Climate change and environmental sustainability in otolaryngology: A state-of-the-art review.

BACKGROUND: Climate change has been identified by the World Health Organization (WHO) as the greatest existing threat to human health. Given the direct exposure of the upper aerodigestive system to pollutants, patients in otolaryngology are at high risk for increased disease burden in the setting of climate change and worsening air quality. Given this and the environmental impact of surgical care, it is essential for surgeons to understand their role in addressing climate health through quality-driven clinical initiatives, education, advocacy, and research. METHODS: A state-of-the-art review was performed of the existing literature on the otolaryngologic health impacts of climate change and environmental sustainability efforts in surgery with specific attention to studies in otolaryngology - head and neck surgery. FINDINGS: Climate variables including heat and air pollution are associated with increased incidence of allergic rhinitis, chronic rhinosinusitis and head and neck cancer. A number of studies have shown that sustainability initiatives in otolaryngology are safe and provide direct cost benefit. CONCLUSION: Surgeons have the opportunity to lead on climate health and sustainability to address the public health burden of climate change.

Addressing Climate Health: A Practical Guide to Quantifying and Reducing Health Care-Associated Emissions.

OBJECTIVE: The objective was to quantify annual greenhouse gas emissions from a surgical specialty hospital and identify high-yield areas to reduce emissions associated with patient care. STUDY DESIGN: Pre-post study, greenhouse gas inventory. SETTING: Specialty hospital. METHODS: A scope 1 and scope 2 greenhouse gas inventory of the Massachusetts Eye and Ear main campus for calendar years (CY) 2020, 2021, and 2022 was performed by assessing emissions attributable to on-site sources (scope 1) and purchased electricity and steam (scope 2). The associated carbon dioxide equivalent was then calculated using known global warming potentials and emission factors. RESULTS: The major contributors to scope 1 and scope 2 emissions at our institution for CY 2020 to 2022 were waste anesthetic gases and purchased steam. These results were reviewed with hospital leadership and a plan was developed to reduce these emissions. Emission monitoring is ongoing to assess the efficacy of these interventions. CONCLUSION: Measuring scope 1 and scope 2 emissions at the facility level allows health care facilities to develop institution-specific interventions and compare data across health care organizations. Surgeons can lead on health care system sustainability by collaborating with clinical and nonclinical staff to measure emissions, developing targeted emissions-reduction interventions, and tracking progress with yearly assessments.

Environmental sustainability in otolaryngologic surgery.

PURPOSE OF REVIEW: Climate change is an urgent public health crisis that significantly impacts disease development, health outcomes, and access to care. The major approaches to climate change are mitigation and adaptation. The purpose of this review is to discuss the effects of climate change on health and health disparities, review the carbon footprint of surgical care and discuss strategies for surgeons to reduce emissions and advocate for sustainability. RECENT FINDINGS: Recent studies increasingly demonstrate the direct and indirect health effects of climate change, including the relationship between climate and otolaryngologic disease. Within the domain of otolaryngology, we summarize findings related to climate change and health and healthcare delivery; health disparities; healthcare-associated emissions; and the role of otolaryngologists in mitigating and adapting to the climate crisis. There are many recent studies that identify impactful sustainability opportunities and initiatives for healthcare providers. Climate solutions may also reduce cost and have potential clinical benefits. SUMMARY: Climate change and air pollution directly impact disease burden in otolaryngology patients and are underrecognized social determinants of health. Surgeons can lead on climate change by implementing sustainability initiatives in the operating room and engaging in research and advocacy.

Survival of Patients With Non-Rhabdomyosarcoma Soft Tissue Sarcomas of the Head and Neck.

OBJECTIVE: To evaluate factors associated with overall survival (OS) of patients with non-rhabdomyosarcoma soft tissue sarcomas of the head and neck. STUDY DESIGN: Retrospective cohort study. METHODS: The National Cancer Database was queried for cases of non-rhabdomyosarcoma soft tissue sarcomas of the head and neck between 2004 and 2014. Cases were categorized according to the World Health Organization classification of soft tissue tumors. A multivariable Cox proportional hazards model was used to evaluate associations with OS. RESULTS: A total of 4,555 patients (63.6% male, 36.4% female, mean age 59.6 years) met inclusion criteria. The majority of tumors were classified as miscellaneous (35.9%), followed by vascular (20.1%), smooth muscle (13.5%), fibroblastic/myofibroblastic (12.1%), peripheral nerve (8.5%), adipocytic (7.4%), and undifferentiated (2.5%) sarcomas. The mean follow-up was 37.9 months, and overall mortality (MR) was 45.3%. The best prognosis was seen with fibroblastic/myofibroblastic sarcomas (MR = 20.6%, P < .001), whereas vascular sarcomas had the worst prognosis (MR = 67.6%, P < .001). Resection with clear margins had better OS than microscopically positive margins (hazard ratio [HR] = 1.43, P < .001) or grossly positive margins (HR = 2.97, P < .001). Radiation therapy was associated with better OS than no radiation (HR = 0.86, P = .001). CONCLUSION: Non-rhabdomyosarcoma soft tissue sarcomas of the head and neck are associated with significant mortality. OS differs based on histologic subcategorization. Resection of the primary tumor with clear margins demonstrates improved OS for all histologies, suggesting this modality remains the preferred primary treatment when feasible. LEVEL OF EVIDENCE: 3 Laryngoscope, 131:E500-E508, 2021.

Unhappy Patients Can Turn into Angry Patients: How to Deal with Both.

Patient satisfaction is the ultimate measure of success in cosmetic facial plastic surgery. A successful outcome depends on patient selection, technical performance, and postoperative care. Patient perception can be influenced by physician-patient interactions. Surgical training focuses on diagnosis-identifying variations in physical condition and treatment. Although these skills are essential to a well-trained and successful facial plastic surgeon, the importance of proper patient selection, management of expectations, and empathetic communication in cosmetic surgery are often overlooked in education and cannot be understated. This article outlines the contributing factors to difficult physician-patient relationships and strategies for mitigating these situations.

Demystifying the Deep Plane Facelift: What It Means Anatomically and Why It Works.

Rhytidectomy is a common procedure performed by facial plastic surgeons. On well-selected patients, rhytidectomy rejuvenates the aging face by repositioning soft tissues and improving facial shape. The fundamental goal of rhytidectomy, or facelift surgery, is to provide a more youthful facial appearance by elevating soft tissues that often descend with aging. The success and longevity of any rhytidectomy procedure are based on the individual patient's anatomy and aging and on the mobilization, elevation, and fixation of the soft tissues during the facelift procedure. Although surgeons often use many terms to describe a given facelift technique, anatomical terms are best used to name the facelift procedure, as the plane of dissection and the vector of elevation are what determines the end result. This paper attempts to simplify and demystify the deep plane facelift procedure and to describe the anatomy that makes this technique successful.

Surgical Facial Esthetics for Gender Affirmation.

The sexual identity of an individual is obvious to most observers with a glance or when only noticing a portion of the face. The overall appearance of the male face is quite different from the female face. Differences in facial structures-such as brow bone, chin, nose, or lips-can be quite small. It is the sum of these differences that creates the obvious dimorphism in facial appearance. This article outlines sexual differences between facial features and discusses surgical procedures designed to alter facial appearance and sexual identity. The diagnosis of facial dimorphism and limitations of these techniques are outlined.

Procalcitonin as a Biomarker in Rhinosinusitis: A Systematic Review.

OBJECTIVES: (1) To describe the existing literature on procalcitonin (PCT) as a biomarker in patients with acute rhinosinusitis (ARS), (2) to analyze outcomes in ARS patients who were treated with PCT-guided therapy versus traditional management, and (3) to compare PCT to other biomarkers used in diagnosis of bacterial ARS. Data Sources: PubMed and Embase. Review Methods: A systematic search in the PubMed and Embase databases was performed to identify studies related to PCT as a biomarker in ARS. After critical appraisal of validity by 2 authors, 6 studies with a total of 313 patients were selected for data extraction and analysis. We identified 2 randomized control trials (RCTs) of PCT-based guidelines for antibiotic management of ARS in outpatient settings and 4 observational studies that compared PCT to other biomarkers in patients with ARS. RESULTS: The 2 RCTs demonstrated a reduction (41.6% in 1 study and 71% in the other) in antibiotic prescription rate in the PCT-guided group versus the control group with no change in the number of days with impaired activity due to illness (9.0 vs 9.0 days [ P = .96]; 8.1 vs 8.2 days [95% confidence interval -0.7 to 0.7]), number of days of work missed, and percentage of patients with persistent symptoms at 28 days. In the observational cohort studies, PCT did not consistently correlate with C-reactive protein, body temperature, and/or white blood cell counts. CONCLUSIONS: The limited existing literature on the role of PCT in diagnosis, management, and prediction of clinical outcomes in ARS suggests that PCT-based guidelines for antibiotic prescription are a safe and effective method of minimizing unnecessary antibiotic use.

Risk of Venous Thromboembolism Among Otolaryngology Patients vs General Surgery and Plastic Surgery Patients.

IMPORTANCE: Venous thromboembolism (VTE), which includes deep venous thrombosis or pulmonary embolism, is the number 1 cause of preventable death in surgical patients. Current guidelines from the American College of Chest Physicians provide VTE prevention recommendations that are specific to individual surgical subspecialties; however, no guidelines exist for otolaryngology. OBJECTIVE: To examine the rate of VTE for various otolaryngology procedures compared with an established average-risk field (general surgery) and low-risk field (plastic surgery). DESIGN, SETTING, AND PARTICIPANTS: This cohort study compared the rate of VTE after different otolaryngology procedures with those of general and plastic surgery in the American College of Surgeons National Surgical Quality Improvement Program from January 1, 2005, through December 31, 2013. We used univariate and multivariable logistic regression analysis of clinical characteristics, cancer status, and Caprini score to compare different risk stratification of patients. Data analysis was performed from May 1, 2016, to April 1, 2017. EXPOSURE: Surgery. MAIN OUTCOMES AND MEASURES: Thirty-day rate of VTE. RESULTS: A total of 1 295 291 patients, including 31 896 otolaryngology patients (mean [SD] age, 53.9 [16.7] years; 14 260 [44.7%] male; 21 603 [67.7%] white), 27 280 plastic surgery patients (mean [SD] age, 50.5 [13.9] years; 4835 [17.7%] male; 17 983 [65.9%] white), and 1 236 115 general surgery patients (mean [SD] age, 54.9 [17.2] years; 484 985 [39.2%] male; 867 913 [70.2%] white) were compared. The overall 30-day rate of VTE was 0.5% for otolaryngology compared with 0.7% for plastic surgery and 1.2% for general surgery. We identified a high-risk group for VTE in otolaryngology (n = 3625) that included free or regional tissue transfer, laryngectomy, composite resection, skull base surgery, and incision and drainage. High-risk otolaryngology patients experienced similar rates of VTE as general surgery patients across all Caprini risk levels. Low-risk otolaryngology patients (n = 28 271) experienced lower rates of VTE than plastic surgery patients across all Caprini risk levels. Malignant tumors were associated with VTE; however, the rates varied by cancer type and were 11-fold greater for cancers of the upper aerodigestive tract compared with thyroid cancers (odds ratio, 10.97; 95% CI, 7.38-16.31). Venous thromboembolism was associated with a 14-fold higher 30-day mortality among otolaryngology patients (5.1% mortality with VTE vs 0.4% mortality without VTE; difference, 4.7%; 95% CI of the difference, 2.2%-9.3%). CONCLUSIONS AND RELEVANCE: Most patients undergoing otolaryngology procedures are at low risk of VTE, indicating that guidelines for a low-risk population could be adapted to otolaryngology. Patients undergoing high-risk otolaryngology procedures should be considered as candidates for more aggressive VTE prophylaxis.

The predictive value of single-photon emission computed tomography/computed tomography for sentinel lymph node localization in head and neck cutaneous malignancy.

OBJECTIVES/HYPOTHESIS: Preoperative localization of sentinel lymph nodes in head and neck cutaneous malignancies can be aided by single-photon emission computed tomography/computed tomography (SPECT/CT); however, its true predictive value for identifying lymph nodes intraoperatively remains unquantified. This study aims to understand the sensitivity, specificity, and positive and negative predictive values of SPECT/CT in sentinel lymph node biopsy for cutaneous malignancies of the head and neck. STUDY DESIGN: Blinded retrospective imaging review with comparison to intraoperative gamma probe confirmed sentinel lymph nodes. METHODS: A consecutive series of patients with a head and neck cutaneous malignancy underwent preoperative SPECT/CT followed by sentinel lymph node biopsy with a gamma probe. Two nuclear medicine physicians, blinded to clinical data, independently reviewed each SPECT/CT. Activity within radiographically defined nodal basins was recorded and compared to intraoperative gamma probe findings. Sensitivity, specificity, and negative and positive predictive values were calculated with subgroup stratification by primary tumor site. RESULTS: Ninety-two imaging reads were performed on 47 patients with cutaneous malignancy who underwent SPECT/CT followed by sentinel lymph node biopsy. Overall sensitivity was 73%, specificity 92%, positive predictive value 54%, and negative predictive value 96%. The predictive ability of SPECT/CT to identify the basin or an adjacent basin containing the single hottest node was 92%. SPECT/CT overestimated uptake by an average of one nodal basin. In the head and neck, SPECT/CT has higher reliability for primary lesions of the eyelid, scalp, and cheek. CONCLUSIONS: SPECT/CT has high sensitivity, specificity, and negative predictive value, but may overestimate relevant nodal basins in sentinel lymph node biopsy.

Auditory brainstem implantation in a 16-month-old boy with cochlear hypoplasia.

OBJECTIVE: To determine the safety and feasibility of auditory brainstem implantation in children younger than 5 years. PATIENT(S): Patients younger than 5 years who were not candidates for cochlear implantation because of anatomic considerations were included in the analyses. INTERVENTION(S): Auditory brainstem implantation via retrosigmoid craniotomy. MAIN OUTCOME MEASURE(S): Audiologic, speech, quality of life, and safety outcomes were assessed. RESULTS: Auditory brainstem implantation was performed in a 16-month-old male infant with bilateral cochlear hypoplasia and cochlear nerve hypoplasia after a prior aborted attempt at cochlear implantation. Intraoperatively, multiphasic evoked auditory brainstem responses (EABRs) characteristic of synchronized responses of central auditory pathways were obtained on multiple electrodes. There were no complications in the immediate postoperative period, and the child was discharged home on Postoperative Day 4. Audiologic testing 2 and 4 months after activation indicated sound detection between 45 and 70 dB HL for warble tones, improvements in Infant Meaningful Auditory Integration Scale scores, and subjective gains in sound awareness, as well as quality of life measures. There were no major or minor complications of the procedure. CONCLUSION: Based on our experience in combination with the work of others internationally, auditory brainstem implantation is feasible and safe in children younger than 5 years.

Cochlear implant outcomes in patients with superior canal dehiscence.

OBJECTIVE: To determine whether adult cochlear implant (CI) users with superior canal dehiscence syndrome (SCDS) or asymptomatic superior semicircular canal dehiscence (SCD) have different surgical, vestibular, and audiologic outcomes when compared to CI users with normal temporal bone anatomy. METHODS: A retrospective single institution review of CI users with either superior semicircular canal dehiscence syndrome or asymptomatic superior semicircular canal dehiscence identified eight post-lingually deafened adults with unilateral or bilateral cochlear implantation between 2006 and 2010. Preoperative and postoperative speech perception scores as well as medical and epidemiological data were recorded and analyzed. RESULTS: One patient with superior canal dehiscence syndrome and seven patients with asymptomatic superior semicircular canal dehiscence were identified, representing 7% or 8/113 of CI patients that fulfilled selection criteria. Average dehiscence length was 3.3 mm ± 0.79 SEM. Three patients received bilateral implants and five patients received a unilateral implant. Among asymptomatic superior semicircular canal dehiscence patients, subjective rates of post-operative dizziness were similar to those seen in patients with normal temporal bone anatomy (12.5 % vs. 15.9%, respectively). Speech perception abilities after surgery were poorer in SCD patients compared to the non-SCD cohort (Consonant Nucleus Consonant 33.7 ± 7.78 SEM vs. 56.7 ± 2.15 SEM P = 0.011), although both groups improved substantially relative to pre-operative performance. We also completed detailed analyses of auditory and vestibular outcomes in one patient with SCDS who underwent CI surgery in the symptomatic ear, which demonstrated preservation of vestibular function post-operatively, improved quality-of-life measures, and reduced dizziness symptomatology. CONCLUSIONS: Our data suggest that patients with asymptomatic superior canal dehiscence at the time of CI surgery have similar albeit decreased speech perception scores compared to non-SCD adult CI users. Subjective rate of dizziness or vertigo following CI surgery was similar in both asymptomatic SCD and non-SCD cohorts, with detailed analyses of a single symptomatic SCD patient revealing improved vestibular function and reduced SCD symptoms following CI.

Epidemiology and echinocandin susceptibility of Candida parapsilosis sensu lato species isolated from bloodstream infections at a Spanish university hospital.

OBJECTIVES: The aims of this work were to study the epidemiological profiles, differences in echinocandin susceptibilities and clinical relevance of the Candida parapsilosis sensu lato species isolated from proven fungaemia cases at La Fe University Hospital of Valencia (Spain) from 1995 to 2007. RESULTS: The prevalence of these species was: C. parapsilosis sensu stricto, 74.4%; Candida orthopsilosis, 23.54%; and Candida metapsilosis, 2.05%. The incidence of the species complex as agents of fungaemia remained stationary until 2005 and doubled in 2006. The incidence of C. orthopsilosis showed an increasing trend during the study period, while C. parapsilosis sensu stricto incidence diminished. Also, an important epidemiological change was observed starting in 2004, when 86.5% of the C. parapsilosis sensu lato strains were found in adult patients, while before that year only 13.5% of the isolates were found in this population. CONCLUSIONS: Echinocandin drug susceptibility testing using the CLSI M27-A3 document showed a wide range of MIC values (0.015-4 mg/L), with micafungin being the most potent in vitro inhibitor followed by anidulafungin and caspofungin (MIC geometric mean of 0.68, 0.74 and 0.87 mg/L, respectively). C. metapsilosis was the most susceptible species of the complex to anidulafungin and micafungin in vitro (MIC(50) for anidulafungin and micafungin: 0.06 mg/L), while there were no differences between C. parapsilosis sensu lato species when caspofungin MIC(50)s were compared (MIC(50) 1.00 mg/L). Differences in caspofungin in vitro susceptibility were observed between the different clinical service departments of La Fe Hospital.

Assessment of two new molecular methods for identification of Candida parapsilosis sensu lato species.

Candida parapsilosis sensu stricto, C. orthopsilosis, and C. metapsilosis replaced C. parapsilosis groups I, II, and III in 2005. Since then, an increased interest in studying their epidemiology has arisen based on the observed differences in antifungal susceptibilities and virulence the three species. A strict differentiation of these species cannot be achieved by phenotypic methods. We evaluate two new molecular methodologies to differentiate among these species by the use of a collection of 293 bloodstream infection isolates of C. parapsilosis sensu lato. For the first method, the isolates were studied using PCR amplification of a fragment of the C. parapsilosis sensu lato FKS1 gene and a universal primer pair followed by EcoRI enzyme digestion. The other method used the allele discrimination ability of molecular beacons in a multiplex real-time PCR format. Both methods of identification showed 100% concordance with internal transcribed spacer 1 (ITS1)/ITS2 sequencing and proved to be effective for clinical applications, even with mixed-species DNAs.

Rapid detection of triazole antifungal resistance in Aspergillus fumigatus.

Triazole resistance in Aspergillus fumigatus is an uncommon but rising phenomenon. Susceptibility testing is rarely performed and can take 48 h or longer, which is an impediment to effective therapy. Molecular diagnostic probing of well-defined resistance mechanisms, which serve as surrogate markers, provides an alternative approach to rapidly (within hours) and efficiently identify resistant strains. The mechanisms of triazole resistance in A. fumigatus are limited to amino acid substitutions in the drug target Cyp51A and include amino acid substitutions at the positions Gly 54, Gly 138, Met 220, and Leu 98, coupled with a tandem repetition in the gene promoter. We report the development of a real-time PCR assay utilizing molecular beacons to assess triazole resistance markers in A. fumigatus. When combined in a multiplex platform, the assay provides a comprehensive evaluation of drug resistance in A. fumigatus.