Otolaryngology–Head and Neck Surgery

(1) To determine the diagnostic accuracy of tuning fork tests (TFTs; Weber and Rinne) for assessment of hearing loss as compared with standard audiometry. (2) To identify the audiometric threshold at which TFTs transition from normal to abnormal, thus indicating the presence of hearing loss.

PubMed, Ovid Medline, EMBASE, Web of Science, Cochrane, and Scopus and manual bibliographic searches.

A systematic review of studies reporting TFT accuracy was performed according to a standardized protocol. Two independent evaluators corroborated the extracted data and assessed risk of bias.

Seventeen studies with 3158 participants, including adults and children, met inclusion criteria. The sensitivity and specificity of the Rinne test for detecting conductive hearing loss ranged from 43% to 91% and 50% to 100%, respectively, for a 256-Hz fork and from 16% to 87% and 55% to 100% for a 512-Hz fork. The audiometric thresholds at which tests transition from normal to abnormal ranged from 13 to 40 dB of conductive hearing loss for the Rinne test and from 2.5 to 4 dB of asymmetry for the Weber test. Significant heterogeneity in TFT methods and audiometric thresholds to define hearing loss precluded meta-analysis. There is high risk of bias in patient selection for a majority of the studies.

Variability exists in the reported test accuracy measurements of TFTs for clinical screening, surgical candidacy assessments, and estimation of hearing loss severity. Clinicians should remain mindful of these differences and optimize these techniques in specific clinical applications to improve TFT accuracy.

We aimed to evaluate the relationship between nasal eosinophilia and nasal hyperresponsiveness to allergen extract.

Retrospective chart review.

Academic tertiary rhinologic practice.

We performed allergy tests (skin prick test and multiple allergosorbent test) and nasal cytology for 194 patients with rhinitis symptoms (76 males and 118 females; age, 11-69 years). According to the results, they were classified into 4 groups: group A (allergic rhinitis with eosinophilia, n = 26), group B (allergic rhinitis without eosinophilia, n = 77), group C (nonallergic rhinitis with eosinophilia syndrome, n = 20), and group D (nonallergic rhinitis without eosinophilia, n = 71). We performed a nasal provocation test (NPT) using house dust mite extract and assessed the changes in symptoms and the decrease in acoustic parameters (total nasal volume and minimal cross-sectional area [MCA]).

Patients in group C were more likely to have severe rhinorrhea and sneezing than those in group D (P < .001). After NPT, group C had greater aggravation of nasal obstruction than group D (P < .001). Group C also showed markedly greater MCA changes as compared with group D 15 minutes after the antigen challenge (P = .002). There was significant correlation between the number of eosinophils and an increase in nasal obstruction (r = 0.319, P = .0009), rhinorrhea (r = 0.302, P = .0017), sneezing (r = 0.219, P = .0241), change in the total nasal volume 15 minutes after NPT (r = 0.287, P = .0028), and change in the MCA 15 minutes (r = 0.322, P = .0008) and 30 minutes (r = 0.250, P = .0098) after NPT.

In patients with NAR, nasal eosinophilia is associated with provocative response after NPT. Further research should be performed to elucidate the mechanisms that underlie this phenomenon.

To determine if immediate postoperative uncuffed tracheostomy placement following oral cavity or oropharyngeal head and neck free flap reconstruction is associated with shorter hospital length of stay and higher inpatient decannulation rates without an increase in respiratory complications, as compared with immediate placement of cuffed tracheostomy.

Retrospective cohort.

Tertiary referral center.

Patients were included if they underwent free flap reconstruction for oral cavity or oropharyngeal squamous cell carcinoma and had an intraoperative tracheostomy placed between 2005 and 2016. In 2012, head and neck surgeons changed from routine placement of cuffed to uncuffed tracheostomy tubes immediately after free flap reconstruction. This study compares length of hospital stay, inpatient decannulation rates, and respiratory complications between patients who had cuffed and uncuffed tracheostomies. Analysis of variance and chi-square test were used to examine continuous and categorical variables, respectively. Multivariable regression analyses were performed to determine whether cuff status was independently associated with primary outcomes of length of hospital stay, decannulation, and respiratory complications.

Of 752 patients who underwent free flap reconstruction, 493 patients met inclusion criteria (cuffed, n = 366; uncuffed, n = 127). Patient variables (ie, age, sex, body mass index, prior chemoradiation) and tumor characteristics (ie, location, stage) did not differ significantly between groups. Adjusted analysis showed that an uncuffed tracheostomy (vs a cuffed tracheostomy) was associated with shorter length of stay (7.7 vs 9.7 days, P < .001) and did not increase the rate of respiratory complications.

Immediate placement of a uncuffed tracheostomy after oral cavity or oropharyngeal free flap reconstruction is associated with shorter hospital stays without an increase in respiratory complications.

Proper use of citation and quotation is crucial to the integrity of the medical literature. The purpose of this study was to determine the prevalence of quotation and citation errors in otolaryngology–head and neck surgery (OHNS) journals and how they have changed over time.

Literature review.

Fifty references were randomly selected from the first published issue of 2017 for 8 leading OHNS journals. These were analyzed for errors in citation (data elements by which the article is referenced) and quotation (factual inaccuracies of the reference). Citation errors were categorized as major, intermediate, or minor. Quotation errors were categorized as major or minor. Results were compared with data from 1997 articles.

Citation errors occurred in 17% of all references studied, with 34% classified as major. Quotation errors occurred in 9%, with 69% classified as major. There was no association between journal impact factor and total number of errors (r = −0.33, P = .42). This compares with a 37% citation error rate (32% major) and 17% quotation error rate (65% major) from 1997.

Citation and quotation errors are still prevalent in the OHNS literature albeit decreased from previously reported data. Improvement in citation errors may be due to technological improvements in reference management. However, it is the continued responsibility of the authors, reviewers, and editors to further reduce error rates to maintain the integrity of our publications.

To determine if and how resident emotional health is monitored among otolaryngology training programs and to determine what wellness resources are available to otolaryngology residents.

Survey.

Tertiary academic medical centers.

An anonymous 50-item survey sent via REDCap to the 107 allopathic American otolaryngology program directors (PDs).

The response rate was 44%, of whom 47.7% regularly surveyed emotional health among their residents. A total of 33.3% used the Maslach Burnout Inventory, and 61.9% used another scale or did not know. Eighty-one percent of surveys were anonymous, and 45% surveyed yearly, which was mandatory in only 33.3% of programs. Whether surveys took place was not related to PD or program demographics. In total, 72.7% of programs utilized faculty mentors for their residents; 88.6% had a wellness lecture within the last year; and 74.5% had no-cost mental health resources with extended hours as required by the American Council of Graduate Medical Education. Within the last year, 31.8% had provided seminars in mindfulness or meditation. Seventy-five percent had financially supported social events for their residents; <15% supported athletic or mental wellness activities. Healthy foods were provided by 36.4%, and 67.4% of programs gave their residents days off in addition to vacation days for medical or dental appointments. Residents were allowed a mean 18.76 vacation days and 3.73 additional wellness days.

There is no standard practice for measuring and monitoring emotional health by otolaryngology programs. Programs struggle to offer interventions to prevent burnout, with 25% noncompliant with the wellness requirements mandated by the American Council of Graduate Medical Education.

The purpose of this study was to examine the unique contribution of psychosocial factors, including perceived social support, depression, and resilience to communicative participation, among adult survivors of head and neck cancer (HNC).

Cross-sectional.

University-based laboratory and speech clinic.

Adult survivors of HNC who were at least 2 years posttreatment for HNC completed patient-reported outcome measures, including those related to communicative participation and psychosocial function. Multiple linear regression analysis was conducted to predict communicative participation. Self-rated speech severity, cognitive function, laryngectomy status, and time since diagnosis were entered first as a block of variables (block 1), and psychosocial factors were entered second (block 2).

Eighty-eight adults who were on average 12.2 years post–HNC diagnosis participated. The final regression model predicted 58.2% of the variance in communicative participation (full model R² = 0.58, P < .001). Self-rated speech severity, cognitive function, laryngectomy status, and time since diagnosis together significantly predicted 46.1% of the variance in block 1. Perceived social support, depression, resilience, and interactions significantly and uniquely predicted 12.1% of the additional variance in block 2.

For clinicians, psychosocial factors such as perceived depression warrant consideration when counseling patients with HNC about communication outcomes and when designing future studies related to rehabilitation.

To characterize patterns of secondary complications after inpatient head and neck surgery.

Retrospective cohort study.

National Surgical Quality Improvement Program (2005-2015).

We identified 18,584 patients who underwent inpatient otolaryngologic surgery. Four index complications were studied: pneumonia, bleeding or transfusion event (BTE), deep/organ space surgical site infection (SSI), and myocardial infarction (MI). Each patient with an index complication was matched to a control patient based on propensity for the index event and event-free days. Rates of 30-day secondary complications and mortality were compared.

Index pneumonia (n = 254) was associated with several complications, including reintubation (odds ratio [OR], 11.7; 95% confidence interval [CI], 5.2-26.4), sepsis (OR, 8.8; 95% CI, 4.5-17.2), and death (OR, 5.3; 95% CI, 1.9-14.9). Index MI (n = 50) was associated with increased odds of reintubation (OR, 17.2; 95% CI, 3.5-84.1), ventilatory failure (OR, 5.8; 95% CI, 1.8-19.1), and death (OR, 24.8; 95% CI, 2.9-211.4). Index deep/organ space SSI (n = 271) was associated with dehiscence (OR, 7.2; 95% CI, 3.6-14.2) and sepsis (OR, 38.3; 95% CI, 11.6-126.4). Index BTE (n = 1009) increased the odds of cardiac arrest (OR, 3.9; 95% CI, 1.8-8.5) and death (OR, 2.9; 95% CI, 1.6-5.1).

Our study is the first to quantify the effect of index complications on the risk of specific secondary complications following inpatient head and neck surgery. These associations may be used to identify patients most at risk postoperatively and target specific interventions aimed to prevent or interrupt further complications.

To characterize treatment times in salivary cancer; associate treatment times with patient, tumor, and treatment characteristics; and examine the association of treatment times and overall survival.

Retrospective cohort.

Commission-on-Cancer Accredited Hospitals 2004-2013.

In total, 5953 patients with salivary cancer included in the National Cancer Database were identified. For each treatment interval, patients in the fourth quartile (“prolonged”) were compared to patients in the first and second quartiles (“not prolonged”). Patient, tumor, and treatment characteristics were associated with prolonged times via multivariable binary logistic regression. Prolongation of each interval was associated with overall survival via multivariable Cox proportional hazards regression, controlling for clinically relevant factors.

Median durations for diagnosis-to-treatment initiation, surgery-to-radiation treatment (RT), RT duration, total treatment package, and diagnosis-to-treatment end were 31, 44, 47, 92, and 110 days, respectively. Race, insurance status, comorbidities, age, T and N stage, facility volume and location, and a facility care transition from diagnosis to initial treatment were associated with prolonged treatment time. Prolonged RT duration was associated with decreased overall survival (OS) (62% vs 75% 5-year OS, HR = 1.26 [95% confidence interval (CI), 1.09-1.47]; P = .002), but prolonged diagnosis-to-treatment initiation, surgery-to-RT, total treatment package, and diagnosis-to-treatment end intervals were not (70% vs 67% 5-year OS, HR = 1.11 [95% CI, 0.92-1.34], P = .284; 72% vs 68%, HR = 0.93 [95% CI, 0.79-1.09], P = .370; 70% vs 70%, HR = 1.00 [95% CI, 0.84-1.20], P = .974; 66% vs 71%, HR = 0.99 [95% CI, 0.84-1.18], P = .920, respectively).

The median durations identified here can serve as reference points. Radiation therapy duration is associated with overall survival in salivary cancer and could be considered a quality indicator.

Extent of parotidectomy and neck dissection for metastatic cutaneous squamous cell carcinoma (cSCC) to the parotid is debated. We describe our experience, analyzing outcomes (overall survival and regional recurrence) associated with surgical extent and adjuvant treatment.

A retrospective cohort study of parotidectomy with or without neck dissection for metastatic cSCC.

A tertiary referral cancer center in Australia.

The study group consisted of patients with metastatic cSCC involving the parotid gland who underwent a curative-intent parotidectomy (superficial or total), with or without neck dissection, between 2003 and 2014. Demographic and clinical data, treatment modalities, and outcome parameters were collected from the electronic institutional database.

Of 78 patients, 65 underwent superficial parotidectomy. Median follow-up was 6.5 years. Sixty-four patients (82%) patients received adjuvant radiotherapy. Cervical lymph nodes were involved in 6 (24%) elective neck dissections. Involved preauricular, facial, external jugular, and occipital nodes occurred in 36.9%. Adjuvant radiotherapy was associated with improved 5-year survival—50% (95% CI, 36%-69%) versus 20% (95% CI, 6%-70%)—and improved 2-year regional control: 89% (95% CI, 67%-100%) versus 40% (95% CI, 14%-100%). The ipsilateral parotid bed recurrence rate was 3.7% for those who received adjuvant radiotherapy and 27% for those who did not receive radiotherapy.

This study supports surgery plus adjuvant radiotherapy as a standard of care for metastatic cSCC. The low incidence of parotid bed recurrence with this approach suggests that routine elective deep lobe resection may not be required.

To investigate the prognostic impact of the neutrophil-to-lymphocyte ratio (NLR) for human papillomavirus–positive oropharyngeal cancer (HPV+ OPC).

Retrospective institutional database analysis.

Tertiary referral medical center.

In total, 104 patients with HPV+ OPC were enrolled. From the blood laboratory data checked within 4 weeks before initiation of primary treatment, NLR was calculated. The association between clinicopathological characteristics and NLR was analyzed, and the prognostic role was evaluated based on overall survival (OS) and disease-free survival (DFS).

According to the cutoff value (2.42) for NLR, the patients were classified into the low NLR group (n = 61) or the high NLR group (n = 43). High NLR was associated with a higher rate of advanced T classification (P = .007) and diabetes mellitus (P = .01). The proportion of surgery-based treatment was lower in the high NLR group (20.9% vs 42.6%, P = .02). The high NLR group showed a lower 5-year OS rate (85.3% vs 96.3%, P = .09) and a lower 5-year DFS rate (68.1% vs 94.7%, P = .01) than those in the low NLR group. Multivariate analysis showed that advanced N classification was a significant predictor for worse 5-year OS (hazard ratio [HR], 17.40; 95% confidence interval [CI], 2.36-128.29) and that both advanced N classification (HR, 7.78; 95% CI, 2.33-25.93) and high NLR (HR, 4.16; 95% CI, 1.24-13.95) were important prognosticators for worse 5-year DFS.

Elevated pretreatment NLR was associated with poor DFS in patients with HPV+ OPC.

To determine factors that influence cost variability in septoplasty with inferior turbinate reduction.

Case series with chart review.

Tertiary care hospital and affiliated ambulatory surgical center.

Surgical costs were reviewed for adult patients undergoing septoplasty with inferior turbinate reduction between December 2014 and September 2017. Cases where additional procedures were performed were excluded. Operative supply costs, operative time, room time, and resident involvement were determined. Contribution of these factors to total costs and variability were analyzed.

The study included 116 patients (mean age, 38 years) and 4 faculty surgeons. Total cost was primarily driven by operative time (74%), with a smaller portion of total cost arising from supplies (26%). Time cost (P < .0001) and supply cost (P = .006) varied significantly among surgeons. A resident was involved in 46.6% of cases. When subanalyzed by resident year, no-resident and senior resident (postgraduate years 4 and 5) cases had nearly identical mean times, while junior resident (postgraduate years 1-3) cases had mean times and operative time costs that were 39% greater (P < .001).

For septoplasty with inferior turbinate reduction, the greatest driver of cost variation was operative time. Resident involvement correlated with increased time and cost. Supply costs had a much smaller impact. When subanalyzed by resident year, junior resident–involved cases were significantly longer than no-resident cases.

To describe swallowing outcomes in elderly patients undergoing microvascular reconstruction of the upper aerodigestive tract and identify risk factors for poor postoperative swallowing function.

Case series with chart review.

Academic medical center.

Sixty-six patients aged ≥70 years underwent microvascular reconstruction of the upper aerodigestive tract. The primary outcome measure was the Functional Oral Intake Scale (FOIS); preoperative and postoperative scores were dichotomized to define “good swallowing” and “poor swallowing.” Logistic regression was performed to identify risk factors for poor postoperative swallowing function.

In total, 91% of reconstructions were performed for oncologic defects. The most common defect site was the oral cavity (67%), and the anterolateral thigh (29%) was the most frequently used donor site. At 3-year follow up, 75% of patients had good swallowing function with 95% of patients who achieved good swallowing function doing so within 6 months of surgery. On multivariable analysis, patients with pT4 tumors (odds ratio [OR], 5.2; 95% confidence interval [CI], 1.0-25.6) and those undergoing at least partial glossectomy (OR, 4.7; 95% CI, 1.1-20.7) were more likely to experience poor swallowing function at 6-month follow-up.

Approximately half of elderly patients achieve good swallowing function within 6 months following microvascular reconstruction of the upper aerodigestive tract. Elderly patients with pT4 tumors and those requiring glossectomy are at highest risk for poor swallowing outcomes. These data can be used to inform preoperative patient counseling and design interventions aimed at improving swallowing function in those at high risk for poor outcomes.

To develop a novel sensor capable of dynamically analyzing the force exerted during suspension microlaryngoscopy and to examine the relationship between force and postoperative tongue complications.

Prospective observational study.

Academic tertiary care center.

The laryngeal force sensor is a designed for use during microphonosurgery. Prospectively enrolled patients completed pre- and postoperative surveys to assess the development of tongue-related symptoms (dysgeusia, pain, paresthesia, and paresis) or dysphagia (10-item Eating Assessment Tool [EAT-10]). To prevent operator bias, surgeons were blinded to the force recordings during surgery.

Fifty-six patients completed the study. Of these, 20 (36%) developed postoperative tongue symptoms, and 12 (21%) had abnormal EAT-10 scores. The mean maximum force across all procedures was 164.7 N (95% CI, 141.0-188.4; range, 48.5-402.6), while the mean suspension time was 34.3 minutes (95% CI, 27.4-41.2; range, 7.1-108.1). Multiple logistic regression showed maximum force (odds ratio, 1.15; 95% CI, 1.02-1.29; P = .019) and female sex (30.1%; 95% CI, 22.7%-37.5%; P < .001) as significant predictors for the development of tongue-related symptoms. The only significant predictor of an abnormal postoperative EAT-10 score was an increased maximum force (odds ratio, 1.03; 95% CI, 1.00-1.06; P = .045).

The laryngeal force sensor is capable of providing dynamic force measurements throughout suspension microlaryngoscopy. An increase in maximum force during surgery may be a significant predictor for the development of tongue-related symptoms and an abnormal EAT-10 score. Female patients may also be at greater risk for developing postoperative tongue symptoms.

This study investigated the ability of implanted human nasal inferior turbinate–derived mesenchymal stem cells (hTMSCs) to repair injured vocal folds. To this end, we used quantitative real-time polymerase chain reaction (PCR) to analyze the early phase of wound healing and histopathological analysis to explore the late phase of wound healing in xenograft animal models.

Prospective animal study.

Research laboratory.

The right-side lamina propria of the vocal fold was injured in 20 rabbits and 30 rats. Next, hTMSCs were implanted into half of the injured vocal folds (hTMSC groups). As a control, phosphate-buffered saline (PBS) was injected into the other half of the injured vocal folds (PBS groups). Rat vocal folds were harvested for polymerase chain reaction (PCR) at 1 week after injury. Rabbit vocal folds were evaluated endoscopically and the larynges harvested for histological and immunohistochemical examination at 2 and 8 weeks after injury.

In the hTMSC group, PCR showed that hyaluronan synthase (HAS) 1, HAS 2, and transforming growth factor (TGF)–β1 were significantly upregulated compared with the PBS group. Procollagen type III (COL III) messenger RNA expression was significantly upregulated in the PBS group compared with the normal group. Histological analyses showed that hTMSC administration afforded more favorable collagen and hyaluronic acid deposition than was evident in the controls. Implanted hTMSCs were observed in injured vocal folds 2 weeks after implantation.

Our results show that hTMSCs implantation into injured vocal folds facilitated vocal fold regeneration, with presenting antifibrotic effects.

We investigated changes in video head impulse test (vHIT) gains and corrective saccades (CSs) at the acute and follow-up stages of vestibular neuritis to assess the diagnostic value of vHIT.

Case series with chart review.

Tertiary medical center.

Sixty-three patients with vestibular neuritis who underwent vHIT at an initial presentation and an approximately 1-month follow-up were included. vHIT gains, gain asymmetry (GA), peak velocities of CS, and interaural difference of CS (CSD) were analyzed.

Mean vHIT gains increased significantly from the acute stage to the follow-up exam. The mean GA, peak velocities of CS, and CSD had decreased significantly at the follow-up. The incidence of CSs was also significantly decreased at the follow-up. The abnormal rate (87%) considering both gain and CS value was significantly higher than that (62%) considering vHIT gain only at the follow-up, although the abnormal rates did not differ at the acute stage (97% vs 87%).

The abnormal rates based on both vHIT gains and CS measurements are similar at the acute stage of VN but are considerably higher at the follow-up stage compared with the abnormal rates based on vHIT gains alone. It is thus advisable to check both CS and vHIT gain while performing vHIT to detect vestibular hypofunction.

The American Academy of Otolaryngology—Head and Neck Surgery Foundation clinical practice guideline (CPG) proposes recommendations regarding sudden sensorineural hearing loss (SSNHL). SSNHL is managed by primary care, emergency medicine, and otolaryngology providers in the Department of Defense (DoD). However, their adherence to this CPG is unknown. We sought to determine provider compliance and identify areas for improvement.

Case series with chart review.

DoD’s electronic medical record.

Patients with SSNHL (N = 204) were treated between March 1, 2012, and September 30, 2015. Time from onset of symptoms to evaluation by primary care, emergency department, audiology, and otolaryngology providers and treatments were analyzed.

The average interval from onset of symptoms to evaluation by a primary care or emergency department provider was 4.86 days (95% CI, 3.46-6.26). Time from presentation to ear, nose, and throat and audiologic evaluation was 15.26 days (95% CI, 12.34-18.20) and 14.16 days (95% CI, 11.31-17.01), respectively. Diagnostic workup included magnetic resonance imaging (n = 150, 73.5%), computed tomography (n = 28, 13.7%), and laboratory testing (n = 50, 24.5%). Oral steroids were used in 137 (67.2%) patients, with 78.8% treated with the recommended dose. Intratympanic steroids were utilized in 65 (31.9%) patients, with variable dosing.

The DoD is uniquely positioned to evaluate adherence to CPGs on national and international levels given the robust and standardized electronic medical record. Areas of improvement include timely identification of SSNHL with rapid referral to ear, nose, and throat and audiology providers; minimizing unnecessary imaging, laboratory testing, and medications; and correct dosing of oral and intratympanic steroids.

(1) To describe the demographics and clinical course of children with intracranial complications of sinusitis. (2) To elucidate factors that predict revision surgery in this population, such as type of initial surgery.

Case series with chart review.

Tertiary care academic children’s hospital.

A 15-year retrospective review identified 71 patients with intracranial complications of acute sinusitis. Primary outcome was need for revision surgery. Secondary outcomes were readmission, length of hospitalization, and long-term complications.

This study is the largest to date examining this disease process. Overall, 69 (97%) patients had surgery; 33 (46%) required revision surgery. Half of the patients with frontal sinus opacification underwent frontal sinus surgery at presentation (endoscopic, trephination, or cranialization). There was no difference in revision surgery between patients who had frontal sinus surgery and those who did not. Patients with frontal sinus surgery did not have a higher rate of complications or chronic sinusitis (P > .05). Subdural abscess was associated with multiple surgical procedures (odds ratio, 20.0; P < .01). Thirty-four patients (49%) required neurosurgery. These patients had a longer length of stay (odds ratio, 11.0; P < .01) and a higher readmission rate (P = .02). During the mean 92-month follow-up, 22 patients (33%) had long-term complications, and there was 1 death (1.4%).

Almost half of this cohort required multiple surgical procedures. In particular, patients with subdural abscess had significantly higher rates of revision surgery. Type of frontal sinus surgery was not correlated with need for revision surgery and was not associated with an increased rate of complications.

To review peripheral vestibular disorders in pediatric patients with dizziness following concussion.

Case series with chart review.

Pediatric vestibular clinic and pediatric multidisciplinary concussion clinic at a tertiary level pediatric hospital.

We retrospectively reviewed 109 patients seen for dizziness following a concussion between September 2012 and July 2015. Patients were ≤20 years of age at the time of concussion. Incidences of specific peripheral vestibular disorders were assessed along with timing of diagnosis relative to the date of injury, diagnostic test findings, and treatment interventions associated with those diagnoses.

Twenty-eight patients (25.7%) were diagnosed with peripheral vestibular disorders. None of these disorders were diagnosed prior to evaluation in our pediatric vestibular clinic or our multidisciplinary concussion clinic, which occurred a mean of 133 days (95% confidence interval, 89.2-177.3) after injury. Benign paroxysmal positioning vertigo was diagnosed in 19 patients, all of whom underwent successful canalith repositioning maneuvers. Other diagnoses included temporal bone fracture (n = 3), labyrinthine concussion (n = 2), perilymphatic fistula (n = 2), and superior semicircular canal dehiscence (n = 2). Both patients with perilymphatic fistula and 1 patient with superior semicircular canal dehiscence underwent successful surgical management, while 1 patient with superior semicircular canal dehiscence was managed nonsurgically.

Peripheral vestibular disorders may occur in pediatric patients with dizziness following concussion, but these disorders may not be recognized until symptoms have persisted for several weeks. An algorithm is proposed to guide the diagnosis and management of peripheral vestibular disorders in pediatric patients with concussion.

To evaluate follow-up and timing of sleep-disordered breathing diagnosis and treatment in urban children referred from primary care.

Retrospective longitudinal cohort analysis.

Tertiary health system.

Pediatric outpatients with sleep-disordered breathing, referred from primary care for subspecialty appointment or polysomnography in 2014, followed for 2 years. Timing of polysomnography or subspecialty appointments, loss to follow-up, and sleep-disordered breathing severity were main outcomes. Chi-square and t-test identified differences in children referred for polysomnography, surgery, and loss to follow-up. Logistic regression identified predictors of loss to follow-up. Days to polysomnography or surgery were evaluated using the Kaplan-Meier estimator, with Cox regression comparing estimates by polysomnography receipt and disease severity.

Of 216 children, 188 (87%) had public insurance. Half (109 [50%]) were lost to follow-up after primary care referral. More children were lost to follow-up when referred for polysomnography (50 [76%]) compared with subspecialty evaluation (35 [32%]; P < .001). Children referred to both polysomnography and subspecialty were more likely to be lost to follow-up (odds ratio = 2.73, 95% confidence interval = 1.29-5.78; P = .009). For children who obtained polysomnography, an asymmetric distribution of obstructive sleep apnea severity was not observed (P = .152). Median time to polysomnography and surgery was 75 and 226 days, respectively. Obstructive sleep apnea severity did not influence time to surgery (P = .410).

In this urban population, half of the children referred for sleep-disordered breathing evaluation are lost to follow-up from primary care. Obstructive sleep apnea severity did not predict follow-up or timeliness of treatment. These findings suggest social determinants may pose barriers to care in addition to the clinical burden of sleep-disordered breathing.

Upper airway stimulation (UAS) is an alternative treatment option for patients unable to tolerate continuous positive airway pressure (CPAP) for the treatment of obstructive sleep apnea (OSA). Studies support the safety and efficacy of this therapy. The aim of this registry is to collect retrospective and prospective objective and subjective outcome measures across multiple institutions in the United States and Germany. To date, it represents the largest cohort of patients studied with this therapy.

Retrospective and prospective registry study.

Ten tertiary care hospitals in the United States and Germany.

Patients were included who had moderate to severe OSA, were intolerant to CPAP, and were undergoing UAS implantation. Baseline demographic and sleep study data were collected. Objective and subjective treatment outcomes, adverse events, and patient and physician satisfaction were reviewed.

The registry enrolled 301 patients between October 2016 and September 2017. Mean ± SD AHI decreased from 35.6 ± 15.3 to 10.2 ± 12.9 events per hour (P < .0001), and Epworth Sleepiness Scale scores decreased from 11.9 ± 5.5 to 7.5 ± 4.7 (P < .0001) from baseline to the posttitration visit. Patients utilized therapy for 6.5 hours per night. There were low rates of procedure- and device-related complications. Clinical global impression scores demonstrated that the majority of physicians (94%) saw improvement in their patients’ symptoms with therapy. The majority of patients (90%) were more satisfied with UAS than CPAP.

Across a multi-institutional registry, UAS therapy demonstrates significant improvement in subjective and objective OSA outcomes, good therapy adherence, and high patient satisfaction.

The aims of the present study were to evaluate the clinical significance of the delay for surgical treatment and the prognostic value of other clinical, pathologic, and microbiological variables among hematologic patients affected by acute invasive fungal rhinosinusitis (AIFRS). Furthermore, we propose our early diagnosis and treatment protocol, reporting its 10-year results.

Monocentric retrospective analysis.

The study was conducted from 2001 to 2017 at the University Hospital of Bologna, Italy.

The impact of time to treatment and clinical, pathologic, and microbiological variables were analyzed among patients with histologically and microbiologically proven AIFRS. The outcomes of patients treated before the introduction of the early diagnosis protocol were compared with those treated afterward.

Nineteen patients affected by AIFRS were eligible for the study. Treatment delay >4 days (P = .002), infection caused by Mucorales (P = .015), and extension of the disease were negative prognostic variables (P = .017). The application of our protocol significantly reduced the delay for diagnosis and appropriate treatment by an average of 7.3 days (P = .02).

The promptness of the diagnosis and surgical treatment may play a significant role in the management of AIFRS, as it appears to be significantly associated with the disease outcome. Our protocol may help to reduce the time required for diagnosis of high-risk hematologic patients.