Otolaryngology–Head and Neck Surgery

To bring attention to the epidemiology, prevention, management, and consequences of surgical fires in otolaryngology by reviewing the literature.

PubMed, EMBASE, Web of Science, and Scopus.

Comprehensive search terms were developed, and searches were performed from data source inception through August 2016. A total of 4506 articles were identified; 2351 duplicates were removed; and 2155 titles and abstracts were independently reviewed. Reference review was also performed. Eligible manuscripts described surgical fires involving patients undergoing otolaryngologic procedures.

Seventy-two articles describing 87 otolaryngologic surgical fire cases were identified. These occurred during oral cavity or oropharyngeal procedures (11%), endoscopic laryngotracheal procedures (25%), tracheostomies (36%), “other” general anesthesia procedures (3%), and monitored anesthesia care or local procedures (24%). Oxidizing agents consisted of oxygen alone (n = 63 of 81, 78%), oxygen and nitric oxide (n = 17 of 81, 21%), and room air (n = 1 of 81, 1%). The fractional inspired oxygen delivered was >30% in 97% of surgical fires in non–nitrous oxide general anesthesia cases (n = 35 of 36). Laser-safe tubes were used in only 12% of endoscopic laryngotracheal cases with endotracheal tube descriptions (n = 2 of 17). Eighty-six percent of patients experienced acute complications (n = 76 of 87), including 1 intraoperative death, and 22% of patients (n = 17 of 77) experienced long-term complications.

Surgical fires in otolaryngology persist despite aggressive multi-institutional efforts to curb their incidence. Guideline recommendations to minimize the concentration of delivered oxygen and use laser-safe tubes when indicated were not observed in many cases. Improved institutional fire safety practices are needed nationally and internationally.

We aimed to perform a meta-analysis examining balloon dilatation and laser tuboplasty for the treatment of eustachian tube dysfunction (ETD).

PubMed, Cochrane, and Embase search up to April 18, 2016, with the following keywords: eustachian, middle-ear, eustachian tuboplasty, balloon tuboplasty, laser tuboplasty, laser dilatation, and balloon dilatation.

Randomized controlled trials and prospective, retrospective, and 1-arm studies of patients with ETD treated with balloon dilatation or laser tuboplasty were included. Outcome measures were improvement of eustachian tube score (ETS) and tympanometry and Valsalva maneuver results.

Two retrospective and 11 prospective studies were included (1063 patients; 942 treated with balloon and 121 with laser tuboplasty). Balloon tuboplasty resulted in a significant improvement of ETS (pooled standardized mean difference [SMD], 0.94; 95% confidence interval [CI], 0.23-1.66; P = .009) and, compared with laser tuboplasty, a greater tympanometry improvement rate (pooled event rate = 73% vs 13%; P = .001). Valsalva maneuver improvement rate was not different between the group results (pooled event rate = 67% vs 50%; P = .472). The maximum number of studies that provided outcome data for any one measure was only 4, and sensitivity analysis indicated ETS results may have been overly influenced by 2 studies. No balloon tuboplasty studies reported ETS data, preventing comparison between the 2 procedures.

Both procedures can improve symptoms of ETD; however, because of the limited numbers of studies reporting data of the outcomes of interest, it remains unclear if one procedure provides greater benefits.

The aim of this report is to present a cohesive evidence-based approach to reducing venous thromboembolism (VTE) in otolaryngology–head and neck surgery. VTE prevention includes deep venous thrombosis and pulmonary embolism. Despite national efforts in VTE prevention, guidelines do not exist for otolaryngology–head and neck surgery in the United States.

PubMed/MEDLINE.

A comprehensive review of literature pertaining to VTE in otolaryngology–head and neck surgery was performed, identifying data on incidence of thrombotic complications and the outcomes of regimens for thromboprophylaxis. Data were then synthesized and compared with other surgical specialties.

We identified 29 articles: 1 prospective cohort study and 28 retrospective studies. The overall prevalence of VTE in otolaryngology appears lower than that of most other surgical specialties. The Caprini system allows effective individualized risk stratification for VTE prevention in otolaryngology. Mechanical and chemoprophylaxis (“dual thromboprophylaxis”) is recommended for patients with a Caprini score ≥7 or patients with a Caprini score of 5 or 6 who undergo major head and neck surgery, when prolonged hospital stay is anticipated or mobility is limited. For patients with a Caprini score of 5 or 6, we recommend dual thromboprophylaxis or mechanical prophylaxis alone. Patients with a Caprini score ≤4 should receive mechanical prophylaxis alone.

Otolaryngologists should consider an individualized and risk-stratified plan for perioperative thromboprophylaxis in every patient. The risk of bleeding must be weighed against the risk of VTE when deciding on chemoprophylaxis.

The goal of this study is to determine the effect of primary surgery vs radiotherapy (RT) on overall survival (OS) in patients with early stage oral cavity squamous cell carcinoma (OCSCC). In addition, this study attempts to identify factors associated with receiving primary RT.

Retrospective cohort study.

National Cancer Database (NCDB, 2004-2013).

Reviewing the NCDB from 2004 to 2013, patients with early stage I to II OCSCC were identified. Kaplan-Meier estimates of survival, Cox regression analysis, and propensity score matching were used to examine differences in OS between primary surgery and primary RT. Multivariable logistic regression analysis was performed to identify factors associated with primary RT.

Of the 20,779 patients included in the study, 95.4% (19,823 patients) underwent primary surgery and 4.6% (956 patients) underwent primary RT. After adjusting for covariates, primary RT was associated with an increased risk of mortality (adjusted hazard ratio [aHR], 1.97; 99% confidence interval [CI], 1.74-2.22). On multivariable analysis, factors associated with primary RT included age ≥70 years, black race, Medicaid or Medicare insurance, no insurance, oral cavity subsite other than tongue, clinical stage II disease, low-volume treatment facilities, and earlier treatment year.

Primary RT for early stage OCSCC is associated with increased mortality. Approximately 5% of patients receive primary RT; however, this percentage is decreasing. Patients at highest risk for receiving primary RT include those who are elderly, black, with public insurance, and treated at low-volume facilities.

To compare positive margin rates between the 2 most common subsites of oropharyngeal transoral robotic surgery (TORS), the base of tongue (BOT) and the tonsil, as well as identify preoperative imaging characteristics that predispose toward positive margins.

Case series with chart review.

Tertiary care referral center.

We compared the final and intraoperative positive margin rate between TORS resections for tonsil and BOT oropharyngeal squamous cell carcinoma (OPSCC), as well as the effect of margins on treatment. A blinded neuroradiologist examined the preoperative imaging of BOT tumors to measure their dimensions and patterns of spread and provided a prediction of final margin results.

Between January 2010 and May 2016, a total of 254 patients underwent TORS for OPSCC. A total of 140 patients who underwent TORS for T1/T2 OPSCC met inclusion criteria. A final positive margin is significantly more likely for BOT tumors than tonsil tumors (19.6% vs 4.5%, respectively, P = .004) and likewise for intraoperative margins of BOT and tonsil tumors (35.3% vs 12.4%, respectively; P = .002). A positive final margin is 10 times more likely to receive chemoradiation compared to a negative margin, controlling for extracapsular spread and nodal status (odds ratio, 9.6; 95% confidence interval, 1.6-59.6; P = .02). Preoperative imaging characteristics and subjective radiologic examination of BOT tumors did not correlate with final margin status.

Positive margins are significantly more likely during TORS BOT resections compared to tonsil resections. More research is needed to help surgeons predict which T1/T2 tumors will be difficult to completely extirpate.

Peripheral blood–derived inflammation-based scores, such as the neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), and the combination of platelet count and NLR, have recently been proposed as prognostic markers in solid tumors. The purpose of this study was to investigate the validity of inflammatory markers as predictive prognostic factors for locally advanced oral squamous cell carcinoma (OSCC). In addition, we evaluated the potential correlation between systemic inflammation and local expression of COX2.

Retrospective chart review and histologic analysis.

Tertiary referral academic center.

We conducted a retrospective analysis of 94 patients with advanced OSCC treated with surgery at our hospital between 2007 and 2015. The relationship among patient survival, systemic inflammatory markers, and local COX2 expression was evaluated. Local COX2 expression in surgical specimens was measured by immunohistochemistry.

High NLR and high PLR were associated with significantly shorter overall survival and cancer-specific survival. Multivariate analysis revealed that cN stage, NLR, and postoperative radiation/chemoradiation were significantly associated with overall survival and cancer-specific survival. PLR and combination of platelet count and NLR were significantly correlated with tumor expression of COX2. Finally, patients with cN2 stage disease and high local COX2 expression had a significantly worse prognosis than other patient groups.

Pretreatment inflammatory markers are useful as prognostic factors in advanced OSCC. Our study suggests that local COX2 may be affected by systemic inflammation and that the prognostic impact of COX2 expression depends on host factors and tumor characteristics.

To analyze the patterns of care and survival for pT1-2N1M0 head and neck cancer based on receipt of surgery alone, surgery + postoperative radiotherapy (S + RT), or surgery + postoperative chemoradiotherapy (S + CRT).

Retrospective analysis.

National Cancer Database.

We queried the database for patients with stage pT1-2N1M0 squamous cell carcinoma of the oral cavity, oropharynx, hypopharynx, or larynx between 2004 and 2012 who were treated with surgery with negative margins and no extracapsular extension. Logistic regression was used to assess predictors of receipt of postoperative treatment. Overall survival was assessed by the Kaplan-Meier method, and Cox regression analysis identified covariates that affected it.

There were 1598 patients included in this study: 566 (35.4%) received surgery alone; 726 (45.4%), S + RT; and 306 (19.1%), S + CRT. The 5-year overall survival was 68.8%, 74.0%, and 87.8%, respectively (P = .009 comparing S + RT and surgery alone, P < .001 for all other comparisons). On multivariable logistic regression, academic centers were associated with a decreased likelihood of S + RT (odds ratio = 0.71) and S + CRT (odds ratio = 0.66). Multivariable Cox regression demonstrated no difference in survival for S + RT over surgery alone (hazard ratio = 0.88, 95% CI = 0.70-1.09, P = .24); however, there was a survival benefit associated with S + CRT (hazard ratio = 0.57, 95% CI = 0.39-0.81, P = .002).

Nearly 65% of patients with pT1-2N1 head and neck cancer with negative margins and no extracapsular extension received S + RT or S + CRT. Improvement in survival was noted only for patients who received S + CRT.

To assess the potential of infrared fiber-optic spectroscopy to evaluate the compositional properties of human tracheal cartilage.

Laboratory-based study.

Twenty human cadaveric distal tracheas were harvested (age range 20-78 years; 6 females, 14 males) for compositional analysis. Histologic staining, Fourier transform infrared imaging spectroscopy data on collagen and proteoglycan (PG) content, and near-infrared (NIR) fiber-optic probe spectroscopic data that reflect protein and water content were evaluated. NIR fiber-optic probe data were also obtained from the proximal trachea in 4 human cadavers (age range 51-65 years; 2 females, 2 males) in situ for comparison to distal trachea spectral data.

In the distal trachea cohort, the spectroscopic-determined ratio of PG/amide I, indicative of the relative amount of PG, was significantly higher in the tissues from the younger group compared to the older group (0.37 ± 0.08 vs 0.32 ± 0.05, P = .05). A principal component analysis of the NIR spectral data enabled separation of spectra based on tracheal location, likely due to differences in both protein and water content. The NIR-determined water content based on the 5200-cm⁻¹ peak was significantly higher in the distal trachea compared to the proximal trachea (P < .001).

Establishment of normative compositional values and further elucidating differences between the segments of trachea will enable more directed research toward appropriate compositional end points in regenerative medicine for tracheal repair.

To reevaluate asymmetric sensorineural hearing loss (ASNHL) criteria used to justify magnetic resonance imaging (MRI) in the evaluation of retrocochlear tumors in a military population.

Retrospective case-control study.

Tertiary care military medical center.

Patients with military service and a history of ASNHL prompting referral for MRI, with or without retrocochlear tumors, were compared between 2005 and 2016. Predictor variables included pure tone ASNHL, speech audiometry, and a history of noise exposure. Logistic regression models for hearing asymmetries were performed, and receiver operator curves were used to calculate sensitivity and specificity.

Thirty-eight retrocochlear tumors were identified. The MRI diagnosis rate for patients with ASHNL was 0.85%. Patients with tumors were slightly older (42 vs 37 years, P = .021) and had less noise exposure (47% vs 85%, P < .001). A sensitivity of 0.83 and a specificity of 0.58 were calculated for asymmetries ≥10 dB at 2000 Hz without adjusting for noise exposure. Instituting this imaging threshold would have reduced the number of MRI scans by half while missing 16% of tumors.

The tumor diagnosis rate among those undergoing MRI for ASNHL is low in the military population, likely because service-related noise exposure commonly causes ASNHL. Optimal MRI referral criteria should conserve resources while balancing the risks of over- and underdiagnosis. For those with a history of military service, an asymmetry ≥10 dB at 2000 Hz among patients meeting current ANSHL referral criteria is most predictive of a retrocochlear tumor.

To assess disease-specific (Inner EAR) and general (Patient-Reported Outcomes Measurement Information System [PROMIS]) health status in patients reporting hearing loss and whether there is enough correlation between scales such that the general instrument alone could suffice.

Correlation analysis of prospective cohort data.

Tertiary care academic medical center.

Adults presenting with a chief complaint of hearing loss completed the Inner EAR scale and the PROMIS instrument. Summary statistics, including means, percentiles, and measures of variance, were calculated. The Spearman ρ statistic was used to test the null hypothesis that there were no correlations between the Inner EAR composite or global score and PROMIS scores.

The mean Inner EAR composite score was 35.6, while the global item had a mean score of 4.8. Mean PROMIS-10 scores were 16.0 for physical health and 15.3 for mental health. The global item and social item had mean scores of 3.6 and 3.8, respectively. Inner EAR composite scores were significantly correlated with the PROMIS mental health summary scores (Spearman ρ = 0.3, P = .0066) and the PROMIS social item score (Spearman ρ = 0.4, P = .0005). The Inner EAR global item was moderately correlated with the PROMIS social item score (Spearman ρ = 0.3, P = .0118), while there was no significant correlation between the Inner EAR global item and the PROMIS physical health, mental health, or global item scores.

Inner EAR and a subset of PROMIS scores have weak to moderate correlations. Disease-specific assessment still confers independent value.

Vestibular schwannoma (VS) is a benign tumor of the lateral skull base. Different microscopic surgical techniques are described in literature: the retrosigmoid and translabyrinthine approaches are used to treat big tumors located in the cerebellopontine angle, and the middle cranial fossa approach is utilized for small tumors with good hearing preservation. The expanded transcanal transpromontorial (ExpTT) approach is a combined microscopic-endoscopic technique previously indicated for Koos stage I and II VS and now proposed for larger VS, up to 3 cm in diameter, with linear progression into the cerebellopontine angle and touching the brainstem.

The study was a retrospective case series of patients who underwent ExpTT surgery for VS in our ear, nose, and throat department.

We reviewed the surgical videos and electrophysiologic data recorded during the surgical operations.

From January 2015 to January 2017, 20 patients affected by Koos stage II and III VS underwent surgery in our department with the ExpTT approach. This novel technique is described step by step, with a focus on the surgical procedure and anatomic landmarks; outcomes are detailed in terms of early and late complications. The mean follow-up was 15 months.

The ExpTT approach permitted, in all patients, gross total resection of the tumor without any complication and with preservation of facial nerve function. All patients had a good postoperative recovery.

The ExpTT technique is a new approach that combines the advantages of a microscopic technique with the ones offered by the endoscope in removal of VS.

Lateral temporal bone resection (LTBR) has traditionally been performed en bloc in accordance with oncologic principles. Occasionally, this is not possible due to a low tegmen or lateralized vasculature. We sought to determine if outcomes of piecemeal and en bloc LTBR are comparable.

Retrospective review.

Two academic medical centers.

Multi-institutional retrospective cohort study. Current Procedural Terminology codes were used to identify patients with T1 to T3 squamous cell carcinoma of the external auditory canal (EAC) who underwent LTBR from 2005 to 2015. Kaplan-Meier curves were constructed to compare total survival between the 2 treatment approaches. Pairwise comparisons were performed using χ² and Fisher exact tests (significance at P = .05), as appropriate.

Twenty-five patients were identified. Ten patients underwent en bloc LTBR; 15 underwent piecemeal LTBR. Median follow-up time was 11 months (range, 1-60 months). There was not a significant difference in overall survival between en bloc (38.9 months; 95% confidence interval [CI], 22.7-55.2) compared to piecemeal (37.5 months; 95% CI, 21.1-53.9) procedures (P = .519). Estimates of disease-free survival also did not reveal statistically significant differences: estimated mean disease-free survival was 48.1 months (95% CI, 33.7-62.6) in en bloc patients and 32.5 months (95% CI, 17.1-47.8) in piecemeal patients (P = .246).

These data suggest that piecemeal resection can be considered for cases of squamous cell carcinoma involving the external auditory canal where anatomic constraints preclude a safe en bloc resection. Larger studies or studies with a longer follow-up time may provide improved insight into survival comparisons.

Endolymphatic sac (ELS) pathophysiology in Ménière’s disease (MD) remains poorly understood. We identified from the literature a group of proteins expressed on the ELS and involved in endolymph volume regulation: aquaporin-2 (AQP2), vasopressin receptor V2R, sodium potassium chloride cotransporter 2 (NKCC2), and transient receptor potential cation channel V4 (TRPV4). Our objective was to determine whether their ELS expression was altered in MD, to better understand the pathophysiology of endolymphatic hydrops.

Prospective case-control study.

Tertiary care center.

Twenty-four patients with definite MD undergoing endolymphatic duct blockage surgery were recruited, as well as 23 controls with no history of MD undergoing surgery for vestibular schwannoma (VS).

ELS biopsies and blood samples for plasma arginine vasopressin (AVP) were obtained. Immunohistochemistry for AQP2, V2R, NKCC2, and TRPV4 was performed. Slides were scanned digitally for highly sensitive pixel density analysis by specialized software (VIS; Visiopharm).

Global scores generated by the software represent total and relative protein expression density of 3 staining intensity levels, exclusively on ELS epithelium. AQP2 expression density was significantly elevated in MD compared to VS (P = .003). There was no significant difference in plasma AVP, V2R, NKCC2, and TRPV4 expression.

This original study evaluates simultaneous in situ expression of AQP2, V2R, NKCC2, and TRPV4 on the human ELS in MD, with a control group. Our results show only AQP2 upregulation on the ELS of patients with MD. We suggest a constitutively increased expression of AQP2 in MD, independent of its regulatory axis (AVP-V2R). Acquired regulator sequence mutations could support this model.

To document the natural growth pattern of unrepaired complete tracheal rings (UCTRs) and describe the patient population managed conservatively.

Case series with chart review.

Tertiary pediatric academic center.

Medical records of patients with confirmed complete tracheal rings on bronchoscopy from 1993 to 2017 were reviewed. Patients aged 0 to 18 who had documented tracheal sizing over time and did not require surgical intervention were included. Exclusion criteria included tracheal stenosis not caused by complete tracheal rings. Comorbidities and airway characteristics were documented in addition to endoscopic findings. These were compared with children requiring surgical repair.

In total, 149 patients with complete tracheal rings were identified. Twenty-five had UCTRs for an overall 16.8% rate of conservative management. Nineteen patients met inclusion criteria and underwent a total of 90 microlaryngoscopy and bronchoscopies (MLBs) with sizing. The growth of the UCTRs over time, based on MLB sizing, was chronicled. The median airway growth noted was 0.38 mm/y. A moderately strong positive correlation was seen between age and airway size (r_s = 0.72, P < .0001). Children with UCTRs were less likely to have long-segment involvement than those who required repair (92%, P = .024).

A select group of children with complete tracheal rings can be managed expectantly without surgical intervention. Conservative management may be less successful in children with long-segment complete tracheal rings. Airway growth does occur in this population and can be monitored over time. Having a standardized method for sizing UCTRs allows for more effective communication between providers and assurance of continued growth of the airway while following these patients.

To compare hearing trajectories among children with symptomatic and asymptomatic congenital cytomegalovirus infection through age 18 years and to identify brain abnormalities associated with sensorineural hearing loss (SNHL) in asymptomatic case patients.

Longitudinal prospective cohort study.

Tertiary medical center.

The study included 96 case patients (4 symptomatic and 92 asymptomatic) identified through hospital-based newborn cytomegalovirus screening from 1982 to 1992 and 72 symptomatic case patients identified through referrals from 1993 to 2005. We used growth curve modeling to analyze hearing thresholds (0.5-8 kHz) by ear with increasing age and Cox regression to determine abnormal findings on head computed tomography scan associated with SNHL (hearing threshold ≥25 dB in any audiometric frequency) among asymptomatic case patients.

Fifty-six (74%) symptomatic and 20 (22%) asymptomatic case patients had SNHL: congenital/early-onset SNHL was diagnosed in 78 (51%) and 10 (5%) ears, respectively, and delayed-onset SNHL in 25 (17%) and 20 (11%) ears; 49 (32%) and 154 (84%) ears had normal hearing. In affected ears, all frequency-specific hearing thresholds worsened with age. Congenital/early-onset SNHL was significantly worse (severe-profound range, >70 dB) than delayed-onset SNHL (mild-moderate range, 26-55 db). Frequency-specific hearing thresholds were significantly different between symptomatic and asymptomatic case patients at 0.5 to 1 kHz but not at higher frequencies (2-8 kHz). Among asymptomatic case patients, white matter lucency was significantly associated with SNHL by age 5 years (hazard ratio, 4.4; 95% CI, 1.3-15.6).

Congenital/early-onset SNHL frequently resulted in severe to profound loss in symptomatic and asymptomatic case patients. White matter lucency in asymptomatic case patients was significantly associated with SNHL by age 5 years.

To determine whether neck:height ratio combined with adenoid and tonsillar size is a good predictive tool for obstructive sleep apnea in obese youth.

Cross-sectional study.

Sleep clinics at the Hospital for Sick Children, Toronto, Canada.

Consented obese individuals aged 8 to 18 years were recruited between 2013 and 2015. Anthropometric measures were obtained by a trained research coordinator in a standardized manner. Otolaryngologists evaluated adenoid and tonsil sizes. Obstructive sleep apnea was diagnosed with an overnight polysomnogram as an obstructive apnea-hypopnea index ≥2. Multivariable logistic regressions investigated the relationship between potential predictors and obstructive sleep apnea. The C-statistic measured the predictive ability.

Of the 53 subjects (median age, 13 years; 55% males), 28 (53%) were diagnosed with obstructive sleep apnea, with a median index of 10.6 per hour. In a logistic regression controlling for adenoid size, enlarged tonsils were significantly associated with the presence of obstructive sleep apnea (P < .01). Adding neck:height ratio into the model improved the model predictive ability (C-index increased from 0.73 to 0.84). Controlling for tonsil and adenoid sizes, an increase in neck:height ratio was significantly associated with the presence of obstructive sleep apnea (P = .01).

Our study suggests that neck:height ratio combined with tonsillar hypertrophy may have a strong predictive ability for obstructive sleep apnea and may be useful in an ambulatory setting to screen obese youth at high risk. These findings should be confirmed in a larger study.

To study the efficacy of budesonide nasal spray on the health-related quality of life and symptoms among children with sleep-disordered breathing.

Randomized, parallel, double-blind, placebo-controlled trial.

Tertiary referral center.

Sixty children (ages, 4-10 years) who were referred because of snoring and/or apneas for >3 months were included between January 2015 and June 2016 and randomized in a double-blind design to treatment with 64 μg/mL of budesonide nasal spray (n = 30) or placebo nasal spray (n = 30) twice daily for 6 weeks. The primary outcome measurement was the change in the mean OSA-18 total score from baseline. Other variables examined were individual OSA-18 domains, a visual analog scale for quality of life, symptoms (snoring, apneas, and nasal obstruction), and adenoid and tonsil size. The trial was investigator initiated and not sponsored by the pharmaceutical industry.

Fifty-five children completed the trial. An intention-to-treat analysis revealed a significantly greater improvement in the mean OSA-18 total score after treatment with budesonide than placebo (19.5 vs 7.5, P = .0014). Intranasal budesonide also improved 2 OSA-18 domains (sleep disturbance, caregivers’ concerns), the visual analog scale score for quality of life, as well as snoring, apneas, and nasal obstruction. No serious adverse events were reported that could be linked to the treatment.

Among children with sleep-disordered breathing, 6 weeks’ treatment with intranasal budesonide significantly improved quality of life and symptoms as compared with placebo nasal spray.

To estimate the prevalence of persistent obstructive sleep apnea postadenotonsillectomy in children with complex chronic conditions.

A retrospective cohort study.

The Hospital for Sick Children Sleep laboratory.

Children ≤18 years of age who had moderate to severe obstructive sleep apnea and had polysomnography pre- and postadenotonsillectomy.

Medical and polysomnographic data were reviewed. The prevalence of persistent obstructive sleep apnea postadenotonsillectomy was determined for the following groups: no complex chronic conditions, single-system complex chronic conditions, and multisystem complex chronic conditions.

We reviewed data of 133 (84 male) children. Their mean (standard deviation) age was 5.5 (3.8) years. The persistent obstructive sleep apnea rate postadenotonsillectomy was highest in children with multisystem complex chronic conditions (57%), intermediate in children with single-system complex chronic conditions (29%), and lowest in children without complex chronic conditions (15%), P = .0004. The odds (confidence interval) of having persistent obstructive sleep apnea postadenotonsillectomy was 7.42 (2.16-25.51) times higher in children with multisystem complex chronic conditions vs no complex chronic conditions and 3.35 (1.16-9.64) times higher in children with multisystem complex chronic conditions vs single-system complex chronic conditions.

Although adenotonsillectomy is considered first-line therapy in healthy children older than 2 years for the treatment of obstructive sleep apnea, there is a significantly greater risk of persistent obstructive sleep apnea postadenotonsillectomy in children with complex chronic conditions. Therefore, other surgical procedures or nonsurgical management may need to be considered as first-line treatment for this cohort.

Venous thromboembolism (VTE) contributes to significant patient morbidity, yet the incidence of VTE following endoscopic sinus surgery (ESS) is unknown. Quality improvement criteria are prompting increased standardization of perioperative VTE prophylaxis. Risk stratification for VTE may better define best practice measures to balance limiting VTE development with avoiding unnecessary chemoprophylaxis.

Retrospective cohort study.

Tertiary institution.

Adult patients who underwent ESS without perioperative chemoprophylaxis from 2008 to 2016 were evaluated. Identification of VTE was performed via screening diagnosis and procedure codes and clinical records, with subsequent confirmation of true-positive VTE. Data for individual Caprini scores were abstracted from electronic medical records. The primary outcome was development of VTE within 30 days following ESS relative to the Caprini score.

A total of 2369 ESS cases were evaluated. While initial screening identified multiple potential VTE events, in-depth medical record review confirmed only 4 true VTE (0.17%). The VTE rate among cases with a Caprini score of <8 (0.09%, 2/2278) was significantly less (P = .008) than the rate with a score of ≥8 (2.2%, 2/91). Beyond overall score, specific risk factors associated with development of postoperative VTE included stroke, central venous access, sepsis, and inpatient status (all P < .025), while prior VTE and hypercoagulability were not associated with postoperative VTE (all P > .5).

In the absence of perioperative chemoprophylaxis, postoperative VTE following ESS is extremely rare, particularly for patients carrying low-to-moderate Caprini scores. Risk stratification based on these data can assist in the design of VTE prophylaxis guidelines for ESS patients.