Systemic Steroids for Otolaryngology-Head and Neck Surgery Disorders: An Evidence-Based Primer for Clinicians.

OBJECTIVE: To offer pragmatic, evidence-informed guidance on the use of systemic corticosteroids (SCS) for common otolaryngologic disorders. DATA SOURCES: PubMed, Cochrane Library, and American Academy of Otolaryngology-Head and Neck Surgery Foundation clinical practice guidelines. REVIEW METHODS: A comprehensive search of published literature through November 2021 was conducted on the efficacy of SCS, alone or in combination with other treatments, for managing disorders in otolaryngology and the subdisciplines. Clinical practice guidelines, systematic reviews, and randomized controlled trials, when available, were preferentially retrieved. Interventions and outcomes of SCS use were compiled to generate summary tables and narrative synthesis of findings. CONCLUSIONS: Evidence on the effectiveness of SCS varies widely across otolaryngology disorders. High-level evidence supports SCS use for Bell's palsy, sinonasal polyposis, and lower airway disease. Conversely, evidence is weak or absent for upper respiratory tract infection, eustachian tube dysfunction, benign paroxysmal positional vertigo, adenotonsillar hypertrophy, or nonallergic rhinitis. Evidence is indeterminate for acute laryngitis, acute pharyngitis, acute sinusitis, angioedema, chronic rhinosinusitis without polyps, Ménière's disease, postviral olfactory loss, postoperative nerve paresis/paralysis, facial pain, and sudden sensorineural hearing loss. IMPLICATIONS FOR PRACTICE: Clinicians should bring an evidence-informed lens to SCS prescribing to best counsel patients regarding the risks, anticipated benefits, and limited data on long-term effects. Alternate routes of corticosteroid administration-such as sprays, drops, inhalers, and intralesional injections-may be preferable for many disorders, particularly those that are self-limited or require a prolonged duration of therapy. Prudent use of SCS reduces the risk of medication-related adverse effects. Clinicians who are conversant with high-level evidence can achieve optimal outcomes and stewardship when prescribing SCS.

[Unmet medical need in otorhinolaryngology: A challenge for otorhinolaryngologists and head and neck surgeons]. / Unmet medical need in der Hals-Nasen-Ohren-Heilkunde: Die HNO-Ärztinnen und HNO-Ärzte sind gefordert.

BACKGROUND: Otorhinolaryngologists and head and neck surgeons are predestined to scientifically analyze and prioritize the medical needs in ENT medicine under the umbrella of the German Society of Otolaryngology, Head and Neck Surgery (DGHNO-KHC). This medical need assessment is important for targeting research and development of medical innovations to improve ENT patients' care with these needs and to trigger respective research and innovation funding programs at an early stage. METHODS: This is to recommend that the DGHNO-KHC and its working groups and task forces in their specialty disciplines address the issue. The goal is a comprehensive medical need assessment for the fields of otolaryngology as well as head and neck surgery. The parameterization of medical needs is based on the unmet medical need (UMN) concept. Criteria for prioritization should follow the method of multi-criteria decision analysis (MCDA). RECOMMENDATION: The working groups of the DGHNO-KHC familiarize themselves with the concept of UMN. Subsequently, suggestions on ENT diseases with UMN in diagnostics and therapy will be collected considering the medical evidence. The suggestions are evaluated in a standardized way according to MCDA and a ranking is established. The results will be published and used to make research funding institutions aware of UMN in otorhinolaryngology, head and neck surgery. DISCUSSION: The work will contribute to the further development of the UMN concept and will also be able to provide a basis to investigate the evidence of the concept to define the UMN. Through this work, the DGHNO-KHC will be perceived as an important scientific player for the development of need-driven medical innovations in Germany.

[Statement on hospitalization of children after otorhinolaryngologic interventions in Germany : Position paper from the Pediatric Otorhinolaryngology Working Group of the German Society of Otorhinolaryngology, Head and Neck Surgery]. / Stellungnahme zur Hospitalisierung von Kindern anlässlich von HNO-Eingriffen in Deutschland : Positionspapier der Arbeitsgemeinschaft Pädiatrische HNO-Heilkunde der Deutschen Gesellschaft für Hals-Nasen-Ohren-Heilkunde, Kopf- und Hals-Chirurgie.

The inpatient care of children after ENT surgery is organized heterogeneously across Germany. In this statement, the working group on Pediatric ENT comments a national survey on the status quo of child care after ENT interventions in German hospitals. The statement should serve as a basis for further interdisciplinary discussion.

The effectiveness of mitomycin C in Otolaryngology procedures: A systematic review.

OBJECTIVE: Many studies have evaluated the effectiveness of topical intraoperative mitomycin (MCC) usage in a wide range of otolaryngologic procedures with variable conclusions on effectiveness. This systematic review aims to provide a qualitative estimation of mitomycin C's treatment effectiveness in maintaining or preventing stenosis after surgical interventions. DESIGN AND SETTING: Following the PRISMA guideline, a comprehensive systematic search of MEDLINE, EMBASE and CINAHL databases was performed including hand-searching and cross-reference checking. PARTICIPANTS: The search was limited to humans, sample size greater than two and study designs including a comparative arm. MAIN OUTCOME MEASURES: Outcome measures varied but included rates of restenosis, number of procedures, and post-surgical patency. RESULTS: A total of 571 unique abstracts and 109 full articles were reviewed. Seventy-seven studies were included in the final analysis. The available evidence ranged from case series to randomized control studies. Meta-analysis was deemed inappropriate due to heterogeneity of study design. Thirty-eight studies assessed the effective of MCC in dacryocystorhinostomy, which is reported in a separate meta-analysis. All other studies were categorized into otolaryngologic site and pathology including choanal atresia (n = 5), endoscopic sinus surgery (n = 12), airway procedures (n = 9), esophageal procedures (n = 8) and other (n = 2). CONCLUSIONS: The published literature on the effectiveness of MMC was mixed, but suggested topical MMC improved surgical outcomes in many otolaryngologic procedures compared to controls. This was the first review to assemble literature on MMC usage for different surgical procedures. Comprehensive interpretation of the data was limited due to heterogeneity in primary outcome, procedure type and study quality. High-quality prospective and randomized controlled studies are required to further confirm the positive effect of MMC use on surgical outcomes.

Otorhinolaryngological Management in Taiwanese Patients with Mucopolysaccharidoses.

Background: Mucopolysaccharidoses (MPSs) are lysosomal storage disorders wherein glycosaminoglycans accumulate because the enzymes that degrade them are insufficient. The earliest symptoms, which are the main reasons for seeking consultation, are otorhinolaryngological and commonly occur in MPS I, II, IV, and VI. This retrospective study aimed to determine the occurrence of otorhinolaryngological manifestations in MPS patients in Taiwan and to analyze the prognosis of surgical intervention, including its effect on symptoms. Methods: We reviewed 42 patients (30 males and 12 females), with a median age of 20.5 years, who had MPS (16.7% type I, 35.7% type II, 19.0% type IIIB, 21.4% type IVA, and 7.2% type VI). The following otorhinolaryngological manifestations were collected: annual number of upper respiratory tract infections (URTIs) and otitis media with effusion (OME) episodes, adenoid size, tonsillar size, and apnea-hypopnea index (AHI). Results: Among 42 patients, we found recurrent otitis media in 42.9% of the patients, hearing loss in 83.3% (mixed: 52.4%, conductive: 21.4%, and sensorineural: 9.5%), frequent URTIs in 47.6%, and obstructive sleep apnea syndrome in 35.7%. Moreover, 76% of the patients underwent ear, nose, and throat (ENT) surgery, including adenoidectomy, tonsillectomy, tympanostomy with ventilation tube insertion, tracheotomy, and supraglottoplasty. Conclusions: MPS patients had a high incidence of ENT problems. ENT surgery reduced the severity of hearing loss, degree of symptoms related to upper airway obstruction, and severity of respiratory tract and otological infections of patients with MPS.

Predictors of Quality-of-Life Improvements Following Global Head and Neck Surgery Trips to Underserved Regions.

OBJECTIVES/HYPOTHESIS: To conduct longitudinal postoperative follow-up and discern health-related quality-of-life (HR-QoL) changes using a validated questionnaire among patients undergoing head and neck surgeries during a short-term, global surgical trip in a resource-limited setting. To identify clinicodemographic predictors of post-operative HR-QoL improvements in this setting. STUDY DESIGN: Retrospective observational study with prospective follow-up. METHODS: Patients undergoing surgery at Moi Teaching and Referral Hospital in Eldoret, Kenya through the authors' short-term surgical trip (STST) between 2016 and 2019 were asked to complete preoperative Short Form-36 (SF-36) HR-QoL questionnaires, and postoperative SF-36 questionnaires during subsequent follow-up. Preoperative and postoperative SF-36 domain scores, and two composite scores (mental component summary [MCS] and physical component summary [PCS]) were compared. Linear regression models were fit to identify clinicodemographic factors predictors of general health (GH), MCS, and PCS scores. RESULTS: Among the 26 participating patients, significant improvements were seen in post-operative GH (mean change = 19.8) and MCS (mean change = 11.2) scores. Lower pre-operative GH, MCS, and PCS scores were predictive of greater improvement in the corresponding post-operative scores. Longer time to follow-up was associated with greater improvement in GH score. Mean follow-up interval was 23.1 months (SD = 1.8 months). CONCLUSIONS: Utilizing the SF-36 questionnaire, we found that patients' perception of their general and psychosocial health improved after undergoing head and neck surgeries through a global STST. This study provides important, preliminary evidence that that elective surgeries performed in low-resource settings convey substantial benefit to patient QoL. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:2006-2010, 2021.

Patient Safety and Quality Improvement in Otolaryngology-Head and Neck Surgery: A Systematic Review.

OBJECTIVE: The current landscape of patient safety/quality improvement (PS/QI) research dedicated to Otolaryngology-Head and Neck Surgery (OHNS) has not been established. This systematic review aims to define the breadth and depth of PS/QI research dedicated to OHNS and to identify knowledge gaps as well as potential areas of future study. METHODS: The study protocol was developed a priori using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) process. A computerized Ovid/Medline database search was conducted (January 1, 1965-September 30, 2019). Similar computerized searches were conducted using Cochrane Database, PubMed, and Google Scholar. Articles were classified by year, subspecialty, PS/QI category, Institute of Medicine (IOM) Crossing the Chasm categories, and World Health Organization (WHO) subclass. RESULTS: Computerized searches yielded 11,570 eligible articles, 738 (6.4%) of which met otolaryngology PS/QI inclusion criteria; 178 (24.1%) were not specific to any one subspecialty. The most prevalent subspecialty foci were head and neck (29.9%), pediatric otolaryngology (16.9%), and otology/neurotology (11.0%). Studies examining complications or risk factors (32.0%) and outcomes/quality measures (16.3%) were the most common foci. Classification by the IOM included effective care (31.4%), safety (29.9%), and safety/effective care (25.3%). Most research fell into the WHO categories of understanding causes (28.5%) or measuring harm (28.3%). CONCLUSION: Most OHNS PS/QI projects (32.0%) focus on reporting complications or risk factors, followed by outcomes/quality measures (16.3%). Knowledges gaps for future research include healthcare disparities, multidisciplinary care, and the WHO category of studies translating evidence into safer care. LEVEL OF EVIDENCE: NA Laryngoscope, 131:33-40, 2021.

Resumption of Otolaryngology Surgical Practice in the Setting of Regionally Receding COVID-19.

The practice of otolaryngology has been drastically altered as a consequence of the ongoing coronavirus disease 2019 (COVID-19) pandemic. Geographic heterogeneity in COVID-19 burden has meant different regions have experienced the pandemic at different stages. Regional dynamics of COVID-19 incidence has dictated the available resources for the provision of surgical care. As regions navigate their own COVID-19 dynamics, illustrative examples of areas affected early by the COVID-19 pandemic may provide anticipatory guidance. In this commentary, we discuss our experience with performed and canceled surgical procedures across the various otolaryngology specialties at our institution over the course of regionally rising and falling incident COVID-19 cases.

Adaptations of a Tertiary Otorhinolaryngology Head and Neck Surgery Department in Singapore during the COVID-19 Outbreak.

PURPOSE: The novel coronavirus 2019 (COVID-19) outbreak which was first reported in Wuhan, China has been declared a pandemic by the World Health Organization on March 11, 2020. Otorhinolaryngologists deal intimately with pathologies of the head and neck region and upper respiratory tract and have been reported as a vulnerable group of healthcare workers who may be more susceptible to COVID-19 nosocomial infection. METHODS: In this article, we provide a comprehensive overview of the adaptations of Singapore's largest tertiary Otorhinolaryngology department during the COVID-19 outbreak. This was undertaken via an evidence-based approach. The relevant medical literature and evidence underlying our adaptations are highlighted. RESULTS: A four-pronged strategy including (1) personnel segregation, (2) triaging and decantment, (3) use of personal protective equipment and (4) changes in clinical practice was employed. The strategy was bolstered by drawing upon a collective learnt experience from the 2003 Severe Acute Respiratory Syndrome (SARS) outbreak. CONCLUSION: A rigorous framework which can preserve operationality while navigating the heightened risks during this outbreak is critical for every Otorhinolaryngology department. As the pandemic continues to evolve and more scientific reports of this disease are made available, approaches will need to be morphed.

Efficient Postoperative Disposition Selection in Pediatric Otolaryngology Patients: A Novel Approach.

OBJECTIVE: Pediatric patients undergoing surgery on the aerodigestive tract require a wide range of postoperative airway support that may be difficult predict in the preoperative period. Inaccurate prediction of postoperative resource needs leads to care inefficiencies in the form of unanticipated intensive care unit (ICU) admissions, ICU bed request cancellations, and overutilization of ICU resources. At our hospital, inefficient utilization of pediatric intensive care unit (PICU) resources was negatively impacting safety, access, throughput, and finances. We hypothesized that actionable key drivers of inefficient ICU utilization at our hospital were operative scheduling errors and the lack of predictability of intermediate-risk patients and that improvement methodology could be used in iterative cycles to enhance efficiency of care. Through testing this hypothesis, we aimed to provide a framework for similar efforts at other hospitals. STUDY DESIGN: Quality improvement initiative. METHODS: Plan, Do, Study, Act methodology (PDSA) was utilized to implement two cycles of change aimed at improving level-of-care efficiency at an academic pediatric hospital. In PDSA cycle 1, we aimed to address scheduling errors with surgical order placement restriction, creation of a standardized list of surgeries requiring PICU admission, and implementation of a hard stop for postoperative location in the electronic medical record surgical order. In the PDSA cycle 2, a new model of care, called the Grey Zone model, was designed and implemented where patients at intermediate risk of airway compromise were observed for 2-5 hours in the post-anesthesia care unit. After this observation period, patients were then transferred to the level of care dictated by their current status. Measures assessed in PDSA cycle 1 were unanticipated ICU admissions and ICU bed request cancellations. In addition to continued analysis of these measures, PDSA cycle 2 measures were ICU beds avoided, safety events, and secondary transfers from extended observation to ICU. RESULTS: In PDSA cycle 1, no significant decrease in unanticipated ICU admissions was observed; however, there was an increase in average monthly ICU bed cancellations from 36.1% to 45.6%. In PDSA cycle 2, average monthly unanticipated ICU admissions and cancelled ICU bed requests decreased from 1.3% to 0.42% and 45.6% to 33.8%, respectively. In patients observed in the Grey Zone, 229/245 (93.5%) were transferred to extended observation, avoiding admission to the ICU. Financial analysis demonstrated a charge differential to payers of $1.1 million over the study period with a charge differential opportunity to the hospital of $51,720 for each additional hospital transfer accepted due to increased PICU bed availability. CONCLUSIONS: Implementation of the Grey Zone model of care improved efficiency of ICU resource utilization through reducing unanticipated ICU admissions and ICU bed cancellations while simultaneously avoiding overutilization of ICU resources for intermediate-risk patients. This was achieved without compromising safety of patient care, and was financially sound in both fee-for-service and value-based reimbursement models. While such a model may not be applicable in all healthcare settings, it may improve efficiency at other pediatric hospitals with high surgical volume and acuity. LEVEL OF EVIDENCE: N/A Laryngoscope, 131:S1-S10, 2021.

The Unseen Global Burden of Disease.

Due to geographic-specific patient and institutional-related barriers to care, data extrapolation and expert opinion on global burden of disease in otolaryngology-head and neck surgery may under- or overestimate the presence and effect of common head and neck conditions. The group of conditions that fail to present to local physicians and/or missed in data extrapolation methods is the unseen burden of disease. This article presents opinions from otolaryngology-head and neck surgery physicians in high- and low/middle-income countries to help explain the contributing factors and ultimately how to use this unseen burden of disease.

CSO (Canadian Society of Otolaryngology - Head & Neck Surgery) position paper on rhinologic and skull base surgery during the COVID-19 pandemic.

Healthcare services in many countries have been partially or completely disrupted by the Coronavirus (COVID-19) pandemic since its onset in the end of 2019. Amongst the most impacted are the elective medical and surgical services in order to conserve resources to care for COVID-19 patients. As the number of infected patients decrease across Canada, elective surgeries are being restarted in a staged manner. Since Otolaryngologists - Head & Neck Surgeons manage surgical diseases of the upper aerodigestive tract where the highest viral load reside, it is imperative that these surgeries resume in a safe manner. The aim of this document is to compile the current best evidence available and provide expert consensus on the safe restart of rhinologic and skull base surgeries while discussing the pre-operative, intra-operative, and post-operative care and tips. Risk assessment, patient selection, case triage, and pre-operative COVID-19 testing will be analyzed and discussed. These guidelines will also consider the optimal use of personal protective equipment for specific cases, general and specific operative room precautions, and practical tips of intra-operative maneuvers to optimize patient and provider safety. Given that the literature surrounding COVID-19 is rapidly evolving, these recommendations will serve to start our specialty back into elective rhinologic surgeries over the next months and they may change as we learn more about this disease.

ENT surgical emergencies during the COVID-19 outbreak.

INTRODUCTION: The restrictive measures adopted by the Italian Government during the COVID-19 outbreak caused dramatic changes in routine public health care. Surprisingly, emergency activity also registered a reduction in frequency. METHODS: This multicentre retrospective study aims to investigate eventual changes in ENT surgical emergencies in a highly populated area of southern Italy during the COVID-19 pandemic. Data concerning the period between the February 1 and the May 31, 2020 were collected from the main three hospitals in the district and compared with the same period of 2019. RESULTS: A substantial reduction was found in the number of ENT emergency interventions in 2020 compared to the same period of 2019, particularly in the main lockdown phase and in the tertiary referral centre. CONCLUSIONS: The reduction in the absolute number of emergency ENT interventions can be only partially explained by social distancing and home confinement. We have reason to believe that some of these patients may have not sought medical support due to fear of nosocomial SARS-CoV2 infection. This study could represent a trigger for further implementation of health system responses to emergencies in a period of transition that is likely to last for a prolonged period of time.

Cost Considerations for Robotic Surgery.

Transoral robotic surgery (TORS) is a rapidly growing diagnostic and therapeutic modality in otolaryngology-head and neck surgery, having already made a large impact in the short time since its inception. Cost-effectiveness analysis is complex, and a thorough cost-effectiveness inquiry should analyze not only financial consequences but also impact on the health state of the patient. The cost-effectiveness of TORS is still under scrutiny, but the early data suggest that TORS is a cost-effective method compared with other available options when used in appropriately selected patients.

Evaluación pretrasplante en otorrinolaringología / Pretransplant evaluation in otolaryngology

Resumen Los pacientes trasplantados presentan mayor vulnerabilidad a complicaciones infecciosas, no solo debido al uso de drogas inmunosupresoras, sino que también, a las enfermedades subyacentes que presentan y a la falla de órganos primarios. A pesar de que las infecciones otorrinolaringológicas no son frecuentes en estos pacientes, es importante establecer un adecuado estudio y tratamiento de ellas. A través del siguiente artículo se aportan directrices en el estudio pretrasplante desde un enfoque otorrinolaringológico, generando recomendaciones de acuerdo a la patología del paciente y el órgano a trasplantar. Si bien, las recomendaciones se realizan según evaluación rinosinusal, otológica y faringoamigdalina, una adecuada anamnesis y examen físico son los pilares de la evaluación pretrasplante en otorrinolaringología, reservándose el estudio con imágenes para aquellos pacientes con alteraciones sospechosas.

Abstract Transplanted patients have higher frequency of infectious complications, not only due to the use of immunosuppressive drugs, but also the underlying diseases that present and the failure of primary organs. Although ear, nose and throat (ENT) infections are not frequent in these patients, it is important to establish an adequate study and treatment of them. Through the following article, guidelines are provided in the pretransplant study from an ENT approach, generating recommendations according to the pathology of the patient and the organ to be transplanted. Although, the recommendations are made according to rhinosinusal, otological and pharyngotonsiline evaluation, adequate anamnesis and physical examination are the pillars of the pretransplant evaluation in otolaryngology, reserving the study with images for patients with suspicious alterations.

The impact of COVID-19 on global disparities in surgical training in pediatric otolaryngology.

OBJECTIVE: To assess global trends in otolaryngologic and non-otolaryngologic education in response to COVID-19, specifically with regard to surgical simulation and personnel reallocation needs in case of patient demand. STUDY DESIGN: Online survey. METHODS: A multiple-choice survey regarding operative caseload and impact on resident education was sent to Otolaryngology residents and Pediatric Otolaryngology faculty globally. The survey was open for responses for ten days in March 2020. RESULTS: A total of 96 completed surveys were received across 22 countries. 87.5% of respondents reported that no supplementary operative education is being provided. Despite 71.43% of responses indicating that simulation was useful for all levels of residents, 20.95% of responses indicated that simulation is not possible at their institution, with the majority of these being skewed toward responses from South America. CONCLUSION: Despite the majority of respondents stating that simulation was helpful, there were disparities in access to simulation seen across countries. The results inform the need for a coordinated effort to expand educational efforts outside of the operating room and clinical environment. A major limitation of this study is the low domestic response rate.

Changing paradigms in sinus and skull base surgery as the COVID-19 pandemic evolves: Preliminary experience from a single Italian tertiary care center.

BACKGROUND: Italy was the first European country suffering from COVID-19. Health care resources were redirected to manage the pandemic. We present our initial experience with the management of urgent and nondeferrable surgeries for sinus and skull base diseases during the COVID-19 pandemic. METHODS: A retrospective review of patients treated in a single referral center during the first 2 months of the pandemic was performed. A comparison between the last 2-month period and the same period of the previous year was carried out. RESULTS: Twenty-four patients fulfilled the inclusion criteria. A reduction of surgical activity was observed (-60.7%). A statistically significant difference in pathologies treated was found (P = .016), with malignancies being the most frequent indication for surgery (45.8%). CONCLUSIONS: Although we feel optimistic for the future, we do not feel it is already time to restart elective surgeries. Our experience may serve for other centers who are facing the same challenges.

A Guiding Principles Checklist for Otolaryngologic Surgery in the COVID-19 Era.

The COVID-19 pandemic has had a dramatic impact on surgical workflows. There is an abundance of ever-changing information, and protocols are reflexively modified on a daily basis. As many otolaryngologic procedures are shown to have higher risk of viral transmission-so-called aerosol-generating procedures-it is imperative that multidisciplinary care teams be provided updated, timely, and consistent information. A single-page Guiding Principles surgical checklist was developed to discuss 7 key factors: patient information, staff wellness, risk minimization, prioritization, resource utilization, key society criteria, and communication. This was completed for every patient requiring otolaryngologic surgery and was distributed to the care teams involved. It provided the most information for those on the frontline and allowed for cogent pre-, intra-, and postoperative planning.