Comparative analysis of pain outcomes in hypoglossal nerve stimulation: Avoiding the digastric tendon.

OBJECTIVE: Upper airway stimulation effectively treats patients with obstructive sleep apnea, especially among those with low long-term compliance with continuous positive airway pressure. Traditional methods to implant the hypoglossal nerve stimulator involve retraction of the digastric tendon to identify the nerve and improve exposure for stimulator implantation. Transient submental pain and discomfort are known side effects of the procedure. Placement without retraction provides an alternative approach to minimize postoperative pain. This study compares post-operative pain outcomes of patients in whom the digastric tendon was and was not retracted. METHODS: Retrospective chart review of patients who received the hypoglossal nerve stimulation implant at a single institution between 2017 and 2021. A combination of descriptive and qualitative data, including age, gender, comorbidities, and postoperative symptoms are analyzed to characterize patient outcomes resulting from this intraoperative technique. The categorical and continuous variables were analyzed using chi-squared tests and independent t-tests, respectively. RESULTS: Patients report overall satisfaction after implantation and titration. A total of 108 patients underwent HGNS implantation between September 2017 and January 2021 using the aforementioned techniques. 1.69 % of patients experienced postoperative submental pain as compared to 18.37 % prior to the change in technique (p < 0.01). CONCLUSION: Avoidance of digastric tendon retraction in the implantation of the stimulating lead is a safe and effective technique that reduces postoperative pain and discomfort. Our institution has demonstrated an alternative technique for hypoglossal stimulator implantation which improves perioperative outcomes. LAY SUMMARY: Upper airway stimulation is an effective treatment for obstructive sleep apnea. During surgery, the digastric tendon is often moved to identify the nerve and improve access. This study shows that avoiding digastric tendon movement safely reduces postoperative pain and discomfort. LEVEL OF EVIDENCE: III.

Telemedicine and Otolaryngology in the COVID-19 Era.

OBJECTIVE: The global Coronavirus disease 2019 (COVID-19) pandemic has resulted in an expansion of telemedicine. The purpose of this study is to present our experience with outpatient telemedicine visits within a single institution's Department of Otolaryngology during the initial COVID-19 era. STUDY DESIGN: Retrospective chart review. METHODS: This was a single-institution study conducted within the Department of Otolaryngology at an urban tertiary care center. Data on outpatient visits was obtained from billing and scheduling records from January 6 to May 28, 2020. Visits were divided into "pre-shutdown" and "post-shutdown" based on our state's March 23, 2020 COVID-19 shutdown date. RESULTS: A total of 3447 of 4340 (79.4%) scheduled visits were completed in the pre-shutdown period as compared to 1451 of 1713 (84.7%) in the post-shutdown period. The proportion of telemedicine visits increased (0.7%-81.2%, P < .001). Overall visit completion rate increased following the shutdown (80.2%-84.7%, P < .001). Subspecialties with an increase in visit completion rate were general (76.9%-88.0%, P = .002), otology (77.4%-87.2%, P < .001), and rhinology (80.0%-86.2%, P = .003). Patients with Medicaid and Medicare had higher appointment completion rates following the transition to telemedicine visits (80.7%-85.7%, P = .002; 76.9%-84.7%, P = .001). Older age was associated with decreased appointment cancellation pre-shutdown (OR 0.994 [0.991-0.997], P < .001) but increased appointment cancellation post-shutdown (OR 1.008 [1.001-1.014], P = .015). Mean COVID-19 risk scores were unchanged (P = .654). CONCLUSIONS: COVID-19 has led to major changes in outpatient practice, with a significant shift from in-person to telemedicine visits following the mandatory shutdown. An associated increase in appointment completion rates was observed, reflecting a promising viable alternative to meet patient needs during this unprecedented time.

Tonsillectomy and Adenoidectomy - Pediatric Clinics of North America.

Tonsillectomy and adenoidectomy are among the most commonly performed major pediatric operations in the United States, with more than 500,000 procedures performed annually. This procedure can be performed with or without adenoidectomy. These procedures were traditionally performed for recurrent tonsillitis; however, the vast majority of tonsillectomies are currently performed for obstructive symptoms. When performed for appropriate indications, tonsillectomy and adenoidectomy can greatly improve a child's quality of life and general health. Given the prevalence of these conditions and subsequent surgical procedures, evidence-based recommendations are regularly evaluated and updated. As such, familiarity with these guidelines is necessary for pediatric practitioners. This review summarizes the indications, complications, and outcomes for tonsillectomy and adenoidectomy, as well as provides a brief overview of operative techniques.

Perioperative Analgesia for Sinus and Skull-Base Surgery.

Perioperative analgesic management is multifaceted, and an individualized approach should be taken with each patient. Preoperative discussion of the plan for pain control and the patient's postoperative expectations is a necessary facet for optimal outcomes of analgesia. There is the potential for significant abuse and development of dependence on opioids. Nonopioids, such as nonsteroidal anti-inflammatory drugs, acetaminophen, and gabapentinoids, provide reliable alternatives for analgesic management following sinus and skull-base surgery. There is a paucity of literature regarding perioperative pain regimens for sinus and skull-base surgery, and the authors hope that this review serves as a valuable tool for otolaryngologists.

Perioperative Analgesia for Patients Undergoing Thyroidectomy and Parathyroidectomy: An Evidence-Based Review.

OBJECTIVE: To perform an evidence-based systematic review evaluating perioperative analgesia, including opioid alternatives, used for patients undergoing thyroidectomy and parathyroidectomy. METHODS: A comprehensive literature search from 1997 to January 2018 of Pubmed, Cochrane, and EmBase libraries was performed for studies reporting analgesic administration following thyroid or parathyroid surgery. This systematic review was based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Studies were evaluated for level of evidence and given a Jadad score to assess for risk of bias. Outcomes gathered included postoperative pain scores, time to rescue analgesia, rescue analgesic consumption, and adverse events. RESULTS: Thirty-eight randomized controlled trials met inclusion criteria. The GRADE criteria determined the overall evidence to be moderate-high. Studies utilizing NSAIDs reported reduced requirements for rescue analgesics. Acetaminophen studies presented with conflicting data on effectiveness. Gabapentinoid studies demonstrated lower pain scores and an increased time to rescue analgesic. Local anesthetics were effective at decreasing Visual Analogue Scale (VAS) and Numeric Rating Scale (NRS) pain scores while also reducing rescue analgesic consumption. Ketamine was shown to increased postoperative nausea and vomiting. NSAIDs and local anesthetic studies had an aggregate grade of evidence A, while all others had grade B evidence. CONCLUSION: There is significant evidence supporting the use of NSAIDs and local anesthetics in the perioperative period for pain management for thyroid and parathyroid surgeries. Acetaminophen, gabapentinoid and ketamine have some supporting evidence and may serve as adequate alternatives. Further multi-institutional RCTs are warranted to delineate optimal analgesic regimens. LEVEL OF EVIDENCE: NA.

Orbital Roof Fractures: An Evidence-Based Approach.

Importance: There is controversy surrounding the management of orbital roof fractures. Guidelines with regard to when to operate and type of reconstruction are lacking. Categorizing these data will help clinicians make informed decisions about the management of orbital roof fractures and avoid preventable complications. Objective: To perform a systematic review evaluating underlying causes, associated complications, and management of orbital roof fractures including reconstructive options in the general population of children and adults. Evidence Review: A systematic review using the PubMed, EmBase, Cochrane, and MEDLINE databases identified relevant studies for inclusion. Studies were included from 1987 to 2017. Demographics, symptoms, management, reconstruction, and outcomes were reported following preferred reporting items for systematic reviews and meta-analyses guidelines. Inclusion criteria included articles discussing management of traumatic orbital roof fractures across all ages. Included studies were assessed for level of evidence. Findings: Forty-seven studies encompassing 526 patients met inclusion criteria. There were 28 case reports, 15 retrospective case series and 4 retrospective cohort studies. The most common etiologies were motor vehicle accidents (39.5%), falls (30.3%), and assault (11.8%). Periorbital ecchymosis, exophthalmos, and dystopia were the most common initial symptoms. In total, 60.0% of patients underwent surgical repair and 40% of patients were managed conservatively. The most common surgical approach was bicoronal (94.8%), followed by a superolateral orbital rim approach and transpalpebral (5.1%). A variety of grafting materials were utilized, including titanium miniplates (46.2%), bone graft (37.7%), porous polyethylene (2.8%), and silastic implants (2.8%). Overall patients undergoing surgery were adults with clinical symptoms including exophthalmos, diplopia, and gaze restriction as well as patients with dura exposure. Most patients undergoing surgery were those with concomitant fractures. The most common fractures among the surgical patients were frontal bone (32.2%), ethmoid (25.2%), and zygomaticomaxillary complex/zygoma (12.2%). Conclusions and Relevance: Management of orbital roof fractures varies based on individual clinical features including the presence of exophthalmos, gaze restriction, and concomitant injuries such as dural tears. Surgically, bicoronal approaches were performed most commonly along with reconstruction utilizing titanium miniplates. Conservative management was more common among the pediatric population. This systematic review demonstrates both conservative and surgical measures can lead to positive outcomes in appropriately selected patients.

Characteristics and management of sinonasal paragangliomas: a systematic review.

BACKGROUND: Paragangliomas of the nasal cavity and paranasal sinuses, although exceedingly rare, can exhibit frequent and aggressive recurrences. Our objective was to evaluate tumor characteristics, clinical course, management, and associated complications of sinonasal paragangliomas METHODS: A systematic review of the literature was performed utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, searching for sinonasal paraganglioma. Studies meeting inclusion criteria were assessed for level of evidence. Patient demographics, tumor characteristics, primary intervention, and other clinical characteristics were evaluated. RESULTS: Forty-five relevant studies encompassing 54 patients with sinonasal paraganglioma were identified. The most common tumor locations were the nasal cavity (66.7%), ethmoid sinuses (22.2%), maxillary sinuses (7.4%), and sphenoid sinuses (3.7%). Common presenting symptoms included recurrent epistaxis (68.5%), nasal obstruction (53.7%), and headache (13.0%). Tumors were malignant in 28.6% of patients. Only 4 cases (7.4%) involved functional tumors. Initial management was always surgical, via either an open (63.0%) or endoscopic (33.3%) approach. Radiotherapy was used as adjunctive treatment in 10 cases (18.5%). Recurrence rate was 21.7% and occurred between 12 to 156 months after initial resection. The overall survival was 87.0% with a metastatic rate of 8.7%. CONCLUSION: Sinonasal paragangliomas are vascular neoplasms manifesting clinically with recurrent epistaxis and nasal obstruction. Management goals are total resection with clear margins and long-term follow-up due to tendency for local recurrence. Radiotherapy has been utilized as adjuvant therapy with variable results. Further randomized controlled studies may be invaluable in elucidating these findings.

Perioperative Analgesia for Patients Undergoing Septoplasty and Rhinoplasty: An Evidence-Based Review.

OBJECTIVES/HYPOTHESIS: Opioid misuse and diversion is a pressing topic in today's healthcare environment. The objective of this study was to conduct a review of non-opioid perioperative analgesic regimens following septoplasty, rhinoplasty, and septorhinoplasty. STUDY DESIGN: Evidence-based systematic review. METHODS: PubMed, MEDLINE, Cochrane Library, and Embase databases were reviewed for articles related to perioperative analgesic use in septoplasty, rhinoplasty, and septorhinoplasty. Quality of studies were assessed via the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) criteria, Jadad scores, and the Cochrane bias tool. Patient demographic data and clinical outcomes, including medication type, dose, administration time, pain scores, and adverse events, were obtained from included studies. Summary tables detailing the benefits and harms of each investigated regimen are included. RESULTS: Thirty-seven studies met inclusion criteria for this evidence-based review. The quality of the studies was determined to be of moderate quality based off of GRADE standardized criteria with a mean Jadad score of 3.1. A preponderance of evidence showed reduced perioperative pain scores and rescue analgesic requirements, supporting the use of local anesthetics for analgesic control. Nonsteroidal anti-inflammatory drugs (NSAIDs) demonstrated similar decreased visual analog scores and postoperative analgesic demand; however, increased adverse events in this class warrant caution. CONCLUSIONS: Contemporary literature supports the use of NSAIDs, gabapentin, local anesthetics, and α-agonists as effective perioperative analgesic opioid alternatives for septoplasty and septorhinoplasty. Local anesthetic use is a cost-effective option resulting in decreased postoperative pain scores and rescue analgesic requirements. Further large-scale, multi-institutional, controlled studies are needed to provide definitive recommendations. LEVEL OF EVIDENCE: NA Laryngoscope, 129:E200-E212, 2019.

Osteoradionecrosis of the Temporal Bone: An Evidence-Based Approach.

OBJECTIVES: To perform a systematic review evaluating etiologies, associated complications, and management of osteoradionecrosis of the temporal bone (ORNTB). METHODS: The authors searched the PubMed, Embase, and Cochrane Library databases for relevant literature. Patient demographics, etiologies, treatments, and other clinical characteristics were obtained. Treatment success was defined as resolution of symptoms at last follow-up. Results were reported using the preferred reporting systems for systematic reviews and meta-analysis (PRISMA) guidelines. RESULTS: Thirty-eight studies encompassing 364 patients with ORNTB were identified. The most common etiologies necessitating radiotherapy included: nasopharyngeal carcinoma (n = 133 [36.8%]), parotid tumors (n = 73 [20.2%]), and external auditory canal pathology (n = 59 [16.3%]). The mean dose of radiation was 58.0 Gy. The mean lag time between radiotherapy and osteoradionecrosis (ORN) symptoms was 7.9 years. The most common presenting symptoms were purulent otorrhea (33.3%), hearing loss (29.1%), and otalgia (17%). ORNTB complications included tympanic membrane perforation (n = 102 [63.8%]) and chronic otitis media (n = 16 [10%]). Treatments included lateral temporal bone resection (n = 99 [28.3%]), conservative treatment (n = 92 [26.3%]), and mastoidectomy (n = 82 [23.5%]) with 90.9, 89.13, and 59.76% considered successful, respectively. CONCLUSIONS: ORNTB is a rare complication of radiotherapy that may present years after initial radiation exposure. Management should be aimed at relief of presenting symptoms and treatment of ORNTB associated complications. Both conservative and surgical measures may adequately control the disease process and symptomatology; however, randomized controlled studies comparing treatments would serve to further corroborate these findings.