Otolaryngology–Head and Neck Surgery

Rhinoplasty, a surgical procedure that alters the shape or appearance of the nose while preserving or enhancing the nasal airway, ranks among the most commonly performed cosmetic procedures in the United States, with >200,000 procedures reported in 2014. While it is difficult to calculate the exact economic burden incurred by rhinoplasty patients following surgery with or without complications, the average rhinoplasty procedure typically exceeds $4000. The costs incurred due to complications, infections, or revision surgery may include the cost of long-term antibiotics, hospitalization, or lost revenue from hours/days of missed work.

The resultant psychological impact of rhinoplasty can also be significant. Furthermore, the health care burden from psychological pressures of nasal deformities/aesthetic shortcomings, surgical infections, surgical pain, side effects from antibiotics, and nasal packing materials must also be considered for these patients. Prior to this guideline, limited literature existed on standard care considerations for pre- and postsurgical management and for standard surgical practice to ensure optimal outcomes for patients undergoing rhinoplasty. The impetus for this guideline is to utilize current evidence-based medicine practices and data to build unanimity regarding the peri- and postoperative strategies to maximize patient safety and to optimize surgical results for patients.

The primary purpose of this guideline executive summary is to provide evidence-based recommendations for clinicians who either perform rhinoplasty or are involved in the care of a rhinoplasty candidate, as well as to optimize patient care, promote effective diagnosis and therapy, and reduce harmful or unnecessary variations in care. The target audience is any clinician or individual, in any setting, involved in the management of these patients. The target patient population is all patients aged ≥15 years. The guideline is intended to focus on knowledge gaps, practice variations, and clinical concerns associated with this surgical procedure; it is not intended to be a comprehensive reference for improving nasal form and function after rhinoplasty. Recommendations in this guideline concerning education and counseling to the patient are intended to include the caregiver if the patient is <18 years of age.

The Guideline Development Group made the following recommendations: (1) Clinicians should ask all patients seeking rhinoplasty about their motivations for surgery and their expectations for outcomes, should provide feedback on whether those expectations are a realistic goal of surgery, and should document this discussion in the medical record. (2) Clinicians should assess rhinoplasty candidates for comorbid conditions that could modify or contraindicate surgery, including obstructive sleep apnea, body dysmorphic disorder, bleeding disorders, or chronic use of topical vasoconstrictive intranasal drugs. (3) The surgeon, or the surgeon’s designee, should evaluate the rhinoplasty candidate for nasal airway obstruction during the preoperative assessment. (4) The surgeon, or the surgeon’s designee, should educate rhinoplasty candidates regarding what to expect after surgery, how surgery might affect the ability to breathe through the nose, potential complications of surgery, and the possible need for future nasal surgery. (5) The clinician, or the clinician’s designee, should counsel rhinoplasty candidates with documented obstructive sleep apnea about the impact of surgery on nasal airway obstruction and how obstructive sleep apnea might affect perioperative management. (6) The surgeon, or the surgeon’s designee, should educate rhinoplasty patients before surgery about strategies to manage discomfort after surgery. (7) Clinicians should document patient satisfaction with their nasal appearance and with their nasal function at a minimum of 12 months after rhinoplasty.

The guideline development group made recommendations against certain actions: (1) When a surgeon, or the surgeon’s designee, chooses to administer perioperative antibiotics for rhinoplasty, he or she should not routinely prescribe antibiotic therapy for a duration >24 hours after surgery. (2) Surgeons should not routinely place packing in the nasal cavity of rhinoplasty patients (with or without septoplasty) at the conclusion of surgery.

The panel group made the following statement an option: (1) The surgeon, or the surgeon’s designee, may administer perioperative systemic steroids to the rhinoplasty patient.

Complementary and alternative medicine, or integrative medicine, has become increasingly popular among patients with head and neck cancer. Despite its increasing prevalence, many patients feel uncomfortable discussing such therapies with their physicians, and many physicians are unaware and underequipped to evaluate or discuss their use with patients. The aim of this article is to use recent data to outline the decision making inherent to integrative medicine utilization among patients with head and neck cancer, to discuss the ethical implications inherent to balancing integrative and conventional approaches to treatment, and to highlight available resources to enhance head and neck cancer providers’ understanding of integrative medicine.

Randomized controlled trials involving integrative medicine or complementary and alternative medicine treatment for cancer patients.

Trials were drawn from a systematic PubMed database search categorized into cancer prevention, treatment, and symptom management.

Integrative medicine is gaining popularity for the management of cancer and is most commonly used for symptom management. A number of randomized controlled trials provide data to support integrative therapies, yet physicians who treat head and neck cancer may be faced with ethical dilemmas and practical barriers surrounding incorporation of integrative medicine.

In the management of head and neck cancer, there is an increasing demand for awareness of, dialogue about, and research evaluating integrative medicine therapies. It is important for otolaryngologists to become aware of integrative therapy options, their risks and benefits, and resources for further information to effectively counsel their patients.

The effect of botulinum toxin among patients with adductor spasmodic dysphonia (AdSD) is temporary. To optimize long-term treatment outcome, other therapy options should be evaluated. Alternative treatment options for AdSD comprise several surgical treatments, such as thyroarytenoid myotomy, thyroplasty, selective laryngeal adductor denervation-reinnervation, laryngeal nerve crush, and recurrent laryngeal nerve resection. Here, we present the first systematic review comparing the effect of botulinum toxin with surgical treatment among patients diagnosed with AdSD.

MEDLINE (PubMed), EMBASE, and the Cochrane Library.

Articles were reviewed by 2 independent authors, and data were compiled in tables for analysis of the objective outcome (voice expert evaluation after voice recording), the subjective outcome (patient self-assessment scores), and voice-related quality of life (Voice Health Index scores).

No clinical trials comparing both treatment modalities were identified. Single-armed studies evaluated either the effect of botulinum toxin or surgical treatment. Thirteen studies reported outcomes after botulinum toxin treatment (n = 419), and 9 studies reported outcomes after surgical treatment (n = 585 patients). A positive effect of bilateral botulinum toxin injections was found for the objective voice outcome, subjective voice outcome, and quality of life. The duration of the beneficial effect ranged from 15 to 18 weeks. Surgical treatment had an overall positive effect on objective voice improvement, subjective voice improvement, and quality of live.

No preference for one treatment could be demonstrated. Prospective clinical trials comparing treatment modalities are recommended to delineate the optimal outcomes by direct comparison.

The primary objective was to determine the prevalence of Helicobacter pylori among patients with laryngopharyngeal reflux. The secondary objective was determining if H pylori eradication leads to greater symptom improvement in patients with laryngopharyngeal reflux as compared with standard proton pump inhibitor therapy alone.

EMBASE, Cumulative Index to Nursing and Allied Health Literature, MEDLINE, World Health Organization International Clinical Trials Registry Platform, European Union Clinical Trials Register, Cochrane Library databases of clinical trials, and ClinicalTrials.gov.

A systematic review was performed of studies assessing the diagnosis or treatment of H pylori among patients with laryngopharyngeal reflux. Randomized controlled trials, cohort studies, case-control studies, and case series were included. A meta-analysis of prevalence data and assessment of heterogeneity was performed on relevant studies.

Fourteen studies were analyzed in the review, with 13 eligible for the meta-analysis. We determined that the prevalence of H pylori among patients with laryngopharyngeal reflux was 43.9% (95% confidence interval, 32.1-56.5). The heterogeneity of studies was high, with an overall I ² value of 92.3%. We were unable to quantitatively assess findings for our secondary outcome, since H pylori identification and treatment were not the primary focus of the majority of studies.

There is a high rate of H pylori infection among patients with laryngopharyngeal reflux. The infection rate in North America and Western Europe has not been adequately studied. There is insufficient evidence to make a recommendation regarding the testing and treatment of H pylori infection among patients with laryngopharyngeal reflux.

To determine what ultrasonographic features can identify metastatic cervical lymph nodes, both preoperatively and in recurrences after complete thyroidectomy.

Prospective.

Outpatient clinic, Department of Head and Neck Surgery, School of Medicine, University of São Paulo, Brazil.

A total of 1976 lymph nodes were evaluated in 118 patients submitted to total thyroidectomy with or without cervical lymph node dissection. All the patients were examined by cervical ultrasonography, preoperatively and/or postoperatively. The following factors were assessed: number, size, shape, margins, presence of fatty hilum, cortex, echotexture, echogenicity, presence of microcalcification, presence of necrosis, and type of vascularity. The specificity, sensitivity, positive predictive value, and negative predictive value of each variable were calculated. Univariate and multivariate logistic regression analyses were conducted. A receiver operator characteristic (ROC) curve was plotted to determine the best cutoff value for the number of variables to discriminate malignant lymph nodes.

Significant differences were found between metastatic and benign lymph nodes with regard to all of the variables evaluated (P < .05). Logistic regression analysis revealed that size and echogenicity were the best combination of altered variables (odds ratio, 40.080 and 7.288, respectively) in discriminating malignancy. The ROC curve analysis showed that 4 was the best cutoff value for the number of altered variables to discriminate malignant lymph nodes, with a combined specificity of 85.7%, sensitivity of 96.4%, and efficiency of 91.0%.

Greater diagnostic accuracy was achieved by associating the ultrasonographic variables assessed rather than by considering them individually.

To determine which teaching method—otoscopy simulation (OS), web-based module (WM), or standard classroom instruction (SI)—produced the best improvement in the diagnosis of middle/external ear pathologies and the development of otoscopy clinical skills.

Prospective randomized controlled nonclinical trial.

Preclerkship undergraduate medical education.

Fifty-four medical students (first year, 26; second year, 28) were randomized to receive 1 of the 3 interventions: OS, WM, or SI. All students underwent baseline testing of diagnostic accuracy (25 ear pathologies) and otoscopy skills. Immediately following each intervention and 3 months later, testing was repeated.

Baseline scores for diagnostic accuracy and otoscopy skills did not differ across intervention groups. Immediately postintervention, all groups showed an improvement in diagnostic accuracy (P < .001). OS scored significantly higher than SI (P < .001), as did WM (P = .003). At 3-month follow-up, all groups continued to demonstrate improved diagnostic accuracy as compared with baseline. Again, OS showed improvement over SI (P = .031). For otoscopy clinical skills, only OS improved immediately postintervention (P < .001). OS had significantly higher scores than WM and SI (P < .001). At 3-month follow-up, OS again showed improvement over WM (P < .001) and SI (P = .009).

All groups showed an improvement in diagnostic accuracy immediately postintervention, with the largest increases coming from OS and WM. Otoscopy clinical skills increased and were retained only in OS. Preclerkship medical student acquisition and retention of otolaryngology diagnostic skills can be greatly improved through web-based teaching modules and otoscopy simulation.

Pediatric eustachian tube dysfunction (ETD), otitis media with effusion (OME), and tympanic membrane retraction (TMR) have been well studied, but no large analyses have described the associated burden beyond childhood. The potential impact and feasibility of prospective trials designed to optimize management of affected adults are thus unclear. Our objectives were therefore (1) to determine the national visit burden associated with ETD/OME/TMR beyond childhood and (2) to examine risk factors specific to adults, highlighting differences in comparison with children.

Cross-sectional analysis of a national database.

Ambulatory visits in the United States.

Epidemiologic analysis of the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey (2005-2012) included data from 761,291 observations representing 9,369,388,092 visits. Chi-square test with Bonferroni adjustment for multiple comparisons was utilized for hypothesis testing.

Visits related to ETD/OME/TMR exceeded 2 million per annum in patients 0 to 20 years of age (mean 2,625,965; range 2,239,288-3,329,858). Among those >20 years old, visits also exceeded 2 million (mean, 2,025,050; range, 1,550,669-2,353,799). Characteristics differed according to age: whereas ETD/OME/TMR affected more males <20 years, females were more frequently diagnosed in the older age group (P < .0001). Patients >20 to 40 years of age were the most likely to visit the emergency department (P = .0022). There were no statistically significant differences per season or region. The related diagnoses of cholesteatoma and chronic otitis media prompted additional visits.

ETD/OME/TMR is associated with a visit burden for adults that extends beyond childhood. Among adults, there may also be age-related differences in patient characteristics.

Total laryngectomy (TL) is a high-cost procedure with patients at risk for significant postoperative health care use. Face-to-face preoperative counseling provided by speech-language pathologists is a relatively inexpensive intervention that may improve care quality and decrease costs. We evaluated if preoperative counseling for patients undergoing TL was associated with differences in length of stay (LOS), use of the emergency department (ED), or unplanned readmissions within 30 days of discharge. A secondary analysis identified predictors of these 3 outcomes.

Case series with chart review.

Academic medical center in the United States.

Patients were included if they underwent TL from 2011 to 2015. Patient demographics and comorbidities, surgical characteristics, and perioperative care data were retrieved and analyzed for 116 patients. Univariate and multivariate models were constructed for 3 outcomes.

LOS was significantly lower for patients receiving counseling (–3.0 days, P = .02). No differences were observed in rates of 30-day ED visits or unplanned readmissions. Care provided by high-volume surgeons was associated with decreased LOS (P = .005), while having postoperative complications increased LOS (P < .001). High rates of ED visits (12.1%) and readmissions (20.6%) were observed. Discharge to inpatient rehabilitation and the patient’s home distance from the institution were predictors of ED visits. TL as salvage therapy and occurrence of postoperative complications were risk factors for readmission.

Preoperative counseling was associated with marked reduction in LOS following TL without increased readmissions, which suggests that it may promote safe, earlier patient readiness for discharge.

To describe the reflections of patients treated for laryngeal cancer with regard to treatment-related decision making.

Cross-sectional survey-based pilot study.

Single-institution tertiary care cancer center.

Adults with laryngeal carcinoma were eligible to participate (N = 57; 46% treated surgically, 54% nonsurgically). Validated surveys measuring decisional conflict and regret explored patients’ reflections on their preferences and priorities regarding treatment-related decision making for laryngeal cancer and how patient-reported functional outcomes, professional referral patterns, and desired provider input influenced these reflections.

When considering the level of involvement of surgeons, radiation oncologists, and medical oncologists in their care, patients were more likely to believe that the specialist whom they saw first was the most important factor in deciding how to treat their cancer (Fisher’s exact, ~χ² = 16.2, df = 6, P = .02). Patients who were treated for laryngeal cancer who reported worse voice-related quality of life recalled more decisional conflict (P = .01) and experienced more decisional regret (P < .001). Of the patients for whom speech was a top priority prior to treatment, better voice-related quality of life overall scores were correlated with less decision regret about treatment decisions (P < .02). Of the patients for whom eating and drinking were top priorities prior to treatment, better MD Anderson Dysphagia Inventory global scores were correlated with less decision regret about treatment decisions (P < .002).

Patient priorities and attitudes, coupled with functional outcomes and professional referral patterns, influence how patients reflect on their choices regarding management of laryngeal cancer. Better understanding of these variables may assist in ensuring that patients’ voices are integrated into individualized laryngeal cancer treatment planning.

The tumor, node, and metastasis staging system of nasopharyngeal carcinoma (NPC) has limitations in predicting prognosis. The aim of this study was to explore the prognostic value of tumor diameter for patients with NPC who were treated with intensity-modulated radiotherapy.

Case series with chart review.

Affiliated Cancer Hospital of Guangxi Medical University.

The cases of 137 NPC patients treated with intensity-modulated radiotherapy were retrospectively reviewed. Tumor diameter was measured on pretreatment magnetic resonance images. Receiver operating characteristic curve was used to find the optimal cutoff value of tumor diameter and to examine the predictive ability of tumor diameter combined with T classification.

The mean tumor diameter increased with the advancing of T classification. The 5-year cumulative survival rates for patients with a tumor diameter <43 mm vs ≥43 mm were 88.4% vs 61.8% (P < .001), respectively. In multivariate analysis, tumor diameter was an independent prognostic factor for 5-year cumulative survival. For patients with T3 + T4, the 5-year cumulative survival rate was higher in the group with a tumor diameter <43 mm vs ≥43 mm (86.2% vs 60.2%, P = .022). The area under the receiver operating characteristic curve was 70.3% for tumor diameter combined with T classification, superior to T classification (area under the curve = 66.2%).

Tumor diameter may be related to the extent of tumor invasion and can provide important information on prognosis. The incorporation of 43 mm as a cutoff value of tumor diameter may help to refine the predictive power of the current staging system for NPC.

There is a lack of consensus regarding the indications for vestibular testing in the evaluation of dizziness and balance disorders. Geographic variation in health services utilization is associated with lack of consensus. To understand the variation in current practice, we investigated the patterns of use of vestibular testing and diagnosis codes for dizziness and balance disorders among individuals ≥65 years of age across different regions of the United States.

Cross-sectional study.

Medicare administrative claims data.

Using the Summarized Denominator file, a sample of the US population linked to the Surveillance, Epidemiology, and End Results (SEER)–Medicare files (years 2000-2010), we identified persons who were ≥65 years of age. We used multivariable analyses to determine the factors associated with vestibular testing and diagnoses.

Of the 231,984 eligible Medicare beneficiaries, 27% were diagnosed with dizziness and balance disorders. Patterns of use of vestibular tests (eye movement recording for spontaneous nystagmus, caloric testing, and rotary chair testing) varied significantly by geographic region. Rotary chair test utilization varied most. We found significant geographic variation in vestibular testing and diagnoses after controlling for age, sex, race, Medicaid participation, and rurality.

There may be opportunities to improve the consistency and efficiency of care for dizziness and balance disorders. It will be important to define appropriate levels of vestibular diagnostic testing and which tests add sufficient value to justify the costs. Further work is needed to better characterize the causes and consequences of variation in vestibular test utilization.

Laryngotracheal stenosis (LTS) is a fibrotic process that narrows the upper airway and has a significant impact on breathing and phonation. Iatrogenic injury from endotracheal and/or tracheostomy tubes is the most common etiology. This study investigates differences in LTS etiologies as they relate to tracheostomy dependence and dilation interval.

Case series with chart review.

Single-center tertiary care facility.

Review of adult patients with LTS was performed between 2004 and 2015. The association of patient demographics, comorbidities, disease etiology, and treatment modalities with patient outcomes was assessed. Multiple logistic regression analysis and Kaplan-Meier analysis were performed to determine factors associated with tracheostomy dependence and time to second procedure, respectively.

A total of 262 patients met inclusion criteria. Iatrogenic patients presented with greater stenosis (P = .023), greater length of stenosis (P = .004), and stenosis farther from the vocal folds (P < .001) as compared with other etiologies. Iatrogenic patients were more likely to be African American, use tobacco, and have obstructive sleep apnea, type II diabetes, hypertension, chronic obstructive pulmonary disease, or a history of stroke. Iatrogenic LTS (odds ratio [OR] = 3.1, 95% confidence interval [95% CI] = 1.2-8.2), Cotton-Myer grade 3-4 (OR = 2.6, 95% CI = 1.1-6.4), and lack of intraoperative steroids (OR = 2.9, 95% CI = 1.2-6.9) were associated with tracheostomy dependence. Nonsmokers, patients without tracheostomy, and idiopathic LTS patients had a significantly longer time to second dilation procedure.

Iatrogenic LTS presents with a greater disease burden and higher risk of tracheostomy dependence when compared with other etiologies of LTS. Comorbid conditions promoting microvascular injury—including smoking, COPD, and diabetes—were prevalent in the iatrogenic cohort. Changes in hospital practice patterns to promote earlier tracheostomy in high-risk patients could reduce the incidence of LTS.

To determine the impact of unilateral vagal sacrifice for vagal schwannoma on postoperative swallowing function.

Case series, chart review.

Academic medical institution.

Ten patients underwent vagus nerve sacrifice for vagal schwannoma resection. Archived pathology records dating from 1985 through 2012 at our institution were retrospectively queried for cases of vagal schwannoma with vagus nerve sacrifice. Medical records were abstracted for demographic and disease information as well as cranial nerve and swallowing function. Preoperative and postoperative cranial nerve function, subjective and objective measures of swallowing function, Functional Oral Intake Scale (FOIS) level, and need for vocal fold medialization were variables collected. Data were analyzed with summary statistics.

The patients who underwent vagal sacrifice for vagal schwannoma at our institution had a mean age of 42.3 years (median, 44 years; range, 15-63 years) and follow-up of 35.6 months (median, 9 months; range, 1-115 months). Most presented with no preoperative cranial nerve deficit or difficulty swallowing. Immediately postoperatively, 90% had a vagus nerve deficit, but 50% had no subjective difficulty swallowing, and 70% had a FOIS level of 7 at postoperative hospital discharge. Within 1 month after surgery, 70% had normal swallowing function according to a modified barium swallow study. A full diet was tolerated by mouth within an average of 2.7 days (median, 2 days; range, 1-6 days) after surgery in this cohort. Seventy percent required vocal fold medialization postoperatively for incomplete glottic closure.

Vagal nerve sacrifice during resection of vagal schwannoma can be performed with normal postoperative swallowing function.

Assess psychometric properties of the Comprehensive Cochlear Implant Questionnaire (CCIQ) as a tool for assessing changes in health-related quality of life (HRQoL) after receiving a second cochlear implant (CI2).

Prospective study.

Academic cochlear implant center.

The CCIQ is a 29-item questionnaire assessing the physical and psychosocial benefits of a CI2 based on a 5-point Likert scale. The CCIQ was administered with the Nijmegen Cochlear Implant Questionnaire and the Short Form–12 Patient Questionnaire (SF-12) to patients with a CI2. Speech perception was tested with the consonant-nucleus-consonant (CNC) word test and AzBio test.

Of 56 patients, 32 (57.1%) completed the instruments sent by mail. Of the 32 patients, 22 (68.8%) completed retest CCIQs 6 weeks later. CCIQ scores demonstrated significantly increased HRQoL in all domains. Internal consistency was very good overall (Cronbach’s α = 0.90), with all subdomains exceeding an alpha value of 0.70. Test-retest reliability was good, with an overall intraclass correlation of 0.62. The CCIQ showed a moderate correlation with the Nijmegen Cochlear Implant Questionnaire and a low correlation with the SF-12. Average CNC and AZBio scores significantly improved by 31% ± 29% and 34% ± 33%, respectively. Audiometric data were not significantly correlated with the CCIQ.

The CCIQ shows (1) good reliability and evidence of construct validity, (2) a significant increase in HRQoL and significantly improved speech perception after CI2, and (3) greater sensitivity at detecting CI2 improvements to HRQoL. This promising measure is quick and easy to administer and provides subjective assessments of HRQoL specifically for those with a CI2.

To assess collagen and α-tubulin levels of mouse tympanic membrane fibroblasts treated with quinolone and aminoglycoside antibiotics at concentrations found in eardrops.

Prospective controlled cell culture study.

Academic tertiary medical center.

Mouse tympanic membrane fibroblasts.

In experiment 1, fibroblasts were treated with the following for 24 or 48 hours: phosphate-buffered saline (negative control), dilute hydrochloric acid (positive control), 0.5% gatifloxacin, or commercially available 0.3% ciprofloxacin, 0.3% ciprofloxacin + 0.1% dexamethasone, 0.3% ofloxacin, 0.5% moxifloxacin, 0.3% gentamicin, or 3.5 mg/mL of neomycin + polymyxin B sulfate + hydrocortisone. In experiment 2, cells were treated with the pure form of gatifloxacin, gentamicin, ofloxacin, or ciprofloxacin. Cells were observed with phase-contrast microscope until harvested. Proteins were extracted for Western blotting with antibodies against collagen α1 type I (collagen 1A1) and α-tubulin, and for densitometry to quantify levels.

Collagen and tubulin levels in fibroblasts treated with ofloxacin, moxifloxacin, gatifloxacin, or gentamicin for 24 hours were not different from the saline control. Fibroblasts treated with neomycin + polymyxin B + hydrocortisone, ciprofloxacin + dexamethasone, or ciprofloxacin for 24 hours had lower collagen 1A1 and α-tubulin levels (all P < .001) than the negative control. After 48 hours, fibroblasts treated with neomycin + polymyxin B sulfate + hydrocortisone, ciprofloxacin + dexamethasone, ciprofloxacin, or moxifloxacin had lower collagen 1A1 (P ≤ .007) and α-tubulin (P < .0001; except ciprofloxacin, P = .033) as compared with control. In experiment 2, only cells treated with ciprofloxacin had lower collagen 1A1 and α-tubulin levels and cell viability (all P < .0001) than control. Cytotoxicity assay and phase-contrast images mirrored the protein findings.

The adverse impact of topical antibiotic exposure on tympanic membrane collagen and tubulin protein levels is drug specific. This may be important for selection of ototopical therapy.

To describe characteristics of blast-induced tympanic membrane perforations that do not spontaneously heal, evaluate the outcomes of tympanoplasty techniques, and understand the factors associated with surgical success.

Two tertiary military health care institutions.

Case series with chart review.

This study reviewed the practice of 1 military neurotologist and included all tympanoplasties for combat blast-induced perforations from 2007 to 2012, which comprised a total of 55 patients. Surgical outcomes and associated perioperative factors were examined to include size, location, bilateral involvement, timing of surgery, and surgical technique.

Fifty-five patients (68 ears) met inclusion criteria. Thirty-six (53%) were total or near-total perforations, and 51% of patients had bilateral perforations. The overall success rate was 77%. It was 82% for lateral grafts and 70% for medial grafts, but the difference between these was not statistically significant. Age was a significant factor, with a success rate of 56% for ages 25 to 34 years, compared with 90% for 20 to 24 and >34 years. Patients who had bilateral sequential tympanoplasties also had lower success rates than those who had only unilateral surgery (62% vs 87%, P = .002). Ossicular disruptions were found in 5 ears, and cholesteatoma was discovered in 8. Surgical timing did not predict success, as the average time until repair was 153 days in successful cases and 151 days in failures. The mean conductive hearing improvement was 13.6 dB, and there were no major complications.

Tympanoplasty can be challenging in this population. Age and bilateral surgery were the only independent variables that showed significance.

To evaluate hospital course and associated complications among pediatric patients undergoing thyroidectomy.

Retrospective database review of the Kids’ Inpatient Database (2009, 2012).

The Kids’ Inpatient Database was evaluated for thyroidectomy patients for the years 2009 and 2012. Surgical procedure, patient demographics, length of stay, hospital charges (in US dollars), and surgical complications were evaluated.

Of an estimated 1099 nationwide partial thyroidectomies and 1654 total thyroidectomies, females accounted for 73.5% and 79.1% of patients, respectively. Children <1 year of age had significantly longer hospital courses (P < .0001), and patients 1 to 5 years of age had a significantly greater length of stay than individuals 6 to 20 years of age (7.8 vs 2.1 days, P < .001). The most common complications overall included hypocalcemia, respiratory complications, vocal cord paresis/paralysis, postoperative infection, and bleeding. Vocal cord paralysis was noted in 1.7% of pediatric thyroidectomy patients. The presence of these complications among total thyroidectomy patients significantly increased one’s length of stay and hospital charges. A neck dissection was reported in 22.9% of malignant thyroidectomy patients.

Nearly 20% of children who underwent total thyroidectomy experienced postoperative hypocalcemia, positing a need for the development of postoperative calcium replacement algorithms to minimize the sequelae of hypocalcemia. A greater incidence of respiratory and infectious complications among younger patients (<6 years) suggests a need for closer monitoring, possibly encompassing routine postoperative intensive care unit utilization, in an attempt to minimize these sequelae.

We evaluated the severity of olfactory impairment according to risk factors, compared responses with risk factors and treatment timing, and investigated prognosis according to treatments.

Case series with chart review.

Tertiary referral center.

We retrospectively reviewed medical records of patients complaining of loss of their sense of smell between January 2006 and May 2016. In total, 491 patients were included. We evaluated olfactory function using the Connecticut Chemosensory Clinical Research Center test (threshold test) and Cross-cultural Smell Identification Test.

Post–upper respiratory infection patients showed better results than those with other risk factors (59.6% recovered). Patients with head trauma (12.5% recovered) and congenital olfactory dysfunction (0% recovered) showed poorer results. Earlier treatment showed better olfactory recovery outcomes for post–upper respiratory infection (P = .001), head trauma (P = .022), and nasal/sinus surgery (P = .009). Xerostomia (P = .73) and idiopathy (P = .365) showed no significant difference in terms of treatment timing. The threshold test better reflected subjective recovery than the identification test. The systemic + topical steroid group and the systemic steroid treatment group both showed better smell recovery outcomes than the group with topical treatment alone (both, P < .001). However, there was no significant difference between the systemic treatment group and the systemic + topical treatment group (P = .978).

Our findings suggest that the duration of smell loss is important for better olfactory outcomes with most etiologies. Also, the effects of systemic steroids were better than those of topical steroids, regardless of combined treatment.

Selective stimulation of the hypoglossal nerve is a new surgical therapy for obstructive sleep apnea, with proven efficacy in well-designed clinical trials. The aim of the study is to obtain additional safety and efficacy data on the use of selective upper airway stimulation during daily clinical routine.

Prospective single-arm study.

Three tertiary hospitals in Germany (Munich, Mannheim, Lübeck).

A multicenter prospective single-arm study under a common implant and follow-up protocol took place in 3 German centers (Mannheim, Munich, Lübeck). Every patient who received an implant of selective upper airway stimulation was included in this trial (apnea-hypopnea index ≥15/h and ≤65/h and body mass index <35 kg/m²). Before and 6 months after surgery, a 2-night home sleep test was performed. Data regarding the safety and efficacy were collected.

From July 2014 through October 2015, 60 patients were included. Every subject reported improvement in sleep and daytime symptoms. The average usage time of the system was 42.9 ± 11.9 h/wk. The median apnea-hypopnea index was significantly reduced at 6 months from 28.6/h to 8.3/h. No patient required surgical revision of the implanted system.

Selective upper airway stimulation is a safe and effective therapy for patients with obstructive sleep apnea and represents a powerful option for its surgical treatment.