Hospital revisits after paediatric tonsillectomy: a cohort study

Background Tonsillectomy, with or without adenoidectomy, is the leading reason for paediatric unplanned hospital readmission, some of which are potentially avoidable. Reducing unplanned hospital revisits would improve patient safety and decrease use of healthcare resources. This study aimed to describe the incidence, timing and risk factors for any surgery-related hospital revisits (both emergency presentation and readmission) following paediatric tonsillectomy and adenotonsillectomy in a large state-wide cohort. Methods We conducted a population-based cohort study using linked administrative datasets capturing all paediatric tonsillectomy and adenotonsillectomy surgeries performed between 2010 and 2015 in the state of Victoria, Australia. The primary outcome was presentation to the emergency department or hospital readmission within 30-day post-surgery. Results Between 2010 and 2015, 46,583 patients underwent 47,054 surgeries. There was a total of 4758 emergency department presentations (10.11% total surgeries) and 2750 readmissions (5.84% total surgeries). Haemorrhage was the most common reason for both revisit types, associated with 33.02% of ED presentations (3.34% total surgeries) and 67.93% of readmissions (3.97% total surgeries). Day 5 post-surgery was the median revisit time for both ED presentations (IQR 3–7) and readmission (IQR 3–8). Predictors of revisit included older age, public and metropolitan hospitals and peri-operative complications during surgery. Conclusions Haemorrhage was the most common reason for both emergency department presentation and hospital readmission. The higher risk of revisits associated with older children, surgeries performed in public and metropolitan hospitals, and in patients experiencing peri-operative complications, suggest the need for improved education of postoperative care for caregivers, and avoidance of inappropriate early discharge. Graphical Abstract

Contralateral nodal failures in oropharyngeal cancers after TORS and unilateral neck management: a retrospective study

Background Report the incidence of contralateral nodal failure rates in well-lateralized oropharyngeal carcinoma treated with upfront surgery and unilateral neck management. Methods Lateralized oropharyngeal carcinomas treated with upfront surgery using transoral robotic surgery (TORS) and unilateral neck management (unilateral neck dissection ± unilateral radiation treatment) were identified. Primary endpoint was contralateral regional control (CRC). Secondary endpoints were local control (LC), and overall survival (OS). Results Thirty-two patients were included. Pathologic T categories included 66% pT1, 31% pT2 and 3% pT3. Nodal diseases comprised 41% N0 and 47% N1 (AJCC 8th). Twenty-three (72%) patients had HPV related tumors. 3-years CRC, LC and OS were 100%, 96% (89–100) and 96% (CI 89–100). One patient developed a second primary with contralateral nodal disease. Only one patient died from another primary cancer. Conclusion In selected patients with lateralized oropharyngeal cancer, treatment with TORS and ipsilateral management of the neck may be oncologically safe without significant risk of contralateral failure. Level of evidence: Level 2. Graphical abstract

Systematic review of validated parent-reported questionnaires assessing swallowing dysfunction in otherwise healthy infants and toddlers

Objectives There has been increasing interest in the management of oropharyngeal swallowing dysfunction (SwD). Its prevalence, particularly in otherwise healthy infants and toddlers (OHITs), is underappreciated. As the standard diagnostic tests are either invasive or scarce, valid parent-reported outcome (PRO) questionnaires could play a pivotal role in the understanding and managing SwD in this group. This article reviewed the literature on PRO questionnaires pertaining to SwD in OHITs. Data source A librarian searched Prospero, Cochrane Library, Embase, Medline, PsycINFO, HaPI, CINAHL, and SCOPUS until February 2021 using the MeSH terms for deglutition and screening methods. Review method Questionnaires that examined disease-specific or eating and feeding concerns or difficulties were excluded. Two reviewers independently identified PRO questionnaires for SwD that were used in OHITs and extracted the author names, publication year, questionnaire name, the studied population, and the reported psychometric assessments. A quality assessment was performed based on consensus-based standards for the selection of health measurement instruments (COSMIN) and updated criteria for good measurement properties. Results Of the 3488 screened articles, we identified only two questionnaires, the pediatric version of the Eating Assessment Tool (PEDI-EAT-10) and the PRO questionnaire for Swallowing Dysfunction in OHITs. The PEDI-EAT-10 authors assessed the validity and reliability on children with cerebral palsy. However, concerns were identified regarding the developmental process and the internal structure validity. The PRO questionnaire for SwD in OHITs meets criteria but has not yet been validated in the population of interest nor its psychometric properties assessed. Conclusion Two instruments were identified. The PED-EAT-10 exhibits methodological flaws, while Edmonton PRO questionnaire for SwD in OHITs awaits construct validation and could fill the current knowledge gap.

Reconstruction of medium-size defects of the oral cavity: radial forearm free flap vs facial artery musculo-mucosal flap

Background The radial forearm free flap (RFFF) is the most commonly used flap for defects of the oral cavity. The facial artery musculomucosal (FAMM) is a safe and effective method to reconstruct medium sized defects of the oral cavity. No comparison exists between the FAMM flap and RFFF. Methods 1) Retrospective chart review from 2007 to 2016. 2) Cost difference analysis. Results Thirteen FAMM flap cases and 18 RFFF met inclusion criteria. The FAMM flap showed a tendency to lower rates of return to the operating room (p = 0.065) as well as lower rates of complications not requiring return to the OR with 1 complication in 1 patient as opposed to 10 patients with 15 complications (p = 0.008). Also, FAMM flap had shorter operative times compared to the RFFF group (7.2HR and 8.9 HR respectively, p = 0.002). The average operative room related costs for a FAMM flap were 6510 CAD vs 10,703 CAD for RFFF (p < 0.0005). Speech and swallowing outcomes were similar (p > 0.05). Conclusion The FAMM flap can be used for reconstruction of medium-size defects of the oral cavity with functional outcomes similar to the RFFF while decreasing the associated costs and morbidity. Graphical Abstract

A comparison of endolymphatic duct blockage, endolymphatic sac drainage and endolymphatic sac decompression surgery in reversing endolymphatic hydrops in Meniere’s disease

Background To explore the differences between endolymphatic duct blockage, endolymphatic sac drainage and endolymphatic sac decompression surgery in the reversal of endolymphatic hydrops (EH) in patients with intractable Meniere’s disease (MD). Methods A total of 27 MD patients receiving endolymphatic duct blockage surgery (n = 10), endolymphatic sac drainage surgery (n = 9) and endolymphatic sac decompression surgery (n = 8) underwent gadolinium-enhanced inner ear magnetic resonance imaging (MRI) scans prior to, 2 weeks after and at > 12 months following surgery. Results In the group with endolymphatic duct blockage, the second MRI revealed no changes in EH, whereas the third MRI revealed a reversal of vestibular EH in 3 patients and a downgrading of cochlear hydrops in 2 of these 3 patients, who presented with an improvement in their hearing and complete control of vertigo. In the group with endolymphatic sac drainage, the second MRI showed a reversal of EH in 4 patients, and no changes in EH in the remaining 5 patients, whereas the third MRI showed that those 4 patients who presented with a reversal of EH at the second MRI stage remained unchanged except a recurrence of vestibular hydrops in 1 patient. All 4 patients exhibited a complete control of vertigo, but hearing improved in 1, worsened in 1 and remained unchanged in 2. In the group with endolymphatic sac decompression, both the second and third MRI examination revealed no reversal of EH. Conclusions The present study has shown that both endolymphatic duct blockage surgery and endolymphatic sac drainage surgery have the potential to reduce EH in certain MD patients, but none of the patients receiving endolymphatic sac decompression surgery showed reversal of their EH. Graphical Abstract

The association of genetic polymorphisms in interleukin-1 receptors type 1 and type 2 with sudden sensorineural hearing loss in a Taiwanese population: a case control study

Background Sudden sensorineural hearing loss (SSNHL) is a disease with an unknown etiology; damage to the auditory nerve from inflammation due to viral infection or vascular incidents has been implicated. According to several studies, cytokines, including interleukins, are associated with SSNHL in terms of serum expression and genetic polymorphisms. Interleukin-1 (IL-1) plays a key role in inflammation and may be associated with SSNHL. This study analyzed the association of single nucleotide polymorphisms (SNPs) of IL-1 receptor (IL-1R) genes with SSNHL in Taiwan. Methods We conducted a case–control study involving 401 patients with SSNHL and 730 healthy controls. Four SNPs (IL-1R type 1 gene [IL1R1] [rs3917225 and rs2234650] and IL-1R type 2 gene [IL1R2] [rs4141134 and rs2071008]) were selected. The genotypes were determined using the TaqMan assay. The Hardy–Weinberg equilibrium (HWE) was tested for each SNP, and genetic effects were evaluated. Results The TT genotype of rs2234650 had an adjusted odds ratio (OR) of 2.988 (95% confidence interval [95% CI] 1.27–6.82) (P = 0.012) compared with the CC genotype in patients with SSNHL. The SNP rs2234650 was associated with SSNHL in the recessive model (TT vs. CC + CT, P = 0.0206, OR = 2.681). The CT genotype of rs4141134 had an adjusted OR of 3.860 (95% CI 2.01–7.44; P < 0.0001) compared with the TT genotype, in patients with SSNHL. The SNP rs4141134 was associated with SSNHL under the dominant model (CC + CT vs. TT, P < 0.0001, OR = 4.087). Conclusion These findings suggest that IL1R1 and IL1R2 gene polymorphisms may contribute to an increased risk of SSNHL in Taiwan.

Navigation and non-navigation CT scan of the sinuses: comparison of the effective doses of radiation in children and adults

Background The advent of 3D navigation imaging has opened new borders to the endoscopic surgical approaches of naso-sinusal inflammatory and neoplastic disease. This technology has gained in popularity among otolaryngologists for endoscopic sinus and skull base surgeries in both adults and children. However, the increased tissue radiation required for data acquisition associated with 3D navigation protocols CT scans is a source of concern because of its potential health hazards. We aimed to compare the effective doses of radiation between 3D navigation protocols and standard protocols for sinus computed tomography (CT) scans for both the adult and pediatric population. Methods We performed a retrospective cohort study through electronic chart review of patients undergoing sinus CT scans (standard and 3D navigation protocols) from May 2019 to December 2019 using a Siemens Drive (VA62A) CT scanner. The effective dose of radiation was calculated in mSv for all exams. Average irradiation doses were compared using a Student’s T-Test or a Kruskall–Wallis test when appropriate. Results A total of 115 CT scans were selected for analysis, of which 47 were standard protocols and 68 were 3D navigation protocols CT scans. Among these, 31 exams were performed on children and 84 exams on adults. For the total population, mean effective dose in the non-navigation CT scans was 0.37 mSv (SD: 0.16, N = 47) and mean effective dose in the 3D navigation sinus CT group was 2.33 mSv (SD: 0.45, N = 68). The mean difference between the two groups was statistically significant 1.97 mSv (CI 95% − 2.1 to − 1.83; P < 0.0001). There was a sixfold increase in radiation with utilization of 3D navigation protocols. The ratio was identical when the pediatric as well as the adult subset of patients were analyzed. Conclusion In our center, utilization of 3D navigation sinus CT protocols significantly increases radiation exposure. Otolaryngologists should be aware of this significant increase and should attempt to decrease the radiation exposure of their patients by limiting unnecessary scan orders and by evaluating 3D acquisition protocols locally with radiation physicists. Level of evidence: Level IV. Graphical Abstract

Online residency training during the COVID-19 pandemic: a national survey of otolaryngology head and neck surgery program directors

Background The COVID-19 pandemic has deeply impacted healthcare and education systems, including resident education. The impact of the pandemic on the different types of pedagogical activities, and the displacement of pedagogical activities to online modalities have not yet been quantified. We sought to evaluate the impact of the COVID-19 pandemic on formal pedagogic components of otorhinolaryngology–head and neck surgery (ORL–HNS) residency, the switch to distance learning and program director’s perceptions of the future of teaching and learning. Methods A nationwide online survey was conducted on Canadian ORL–HNS program directors. The use of standard didactic activities in-person and online, before and during the pandemic was rated with Likert scales. Perceptions of the pandemic were described with open-ended questions. Results A total of 11 of the 13 program directors contacted responded. The analysis were conducted using nonparametric statistics. There was a significant drop in overall didactic activities during the pandemic, regardless of the teaching format (3.5 ± 0.2 to 3.1 ± 0.3, p < 0.05). The most affected activities were simulation and in-house lectures. Online activities increased dramatically (0.5 ± 0.2 to 5.0 ± 0.5, p < 0.001), including attendance to lectures made by other programs (0.5 ± 0.3 to 4.0 ± 0.8, p < 0.05). Respondents stated their intention to maintain the hybrid online and in-person teaching model. Conclusions These findings suggest that hybrid online and in-person teaching is likely to persist in the post-pandemic setting. A balanced residency curriculum requires diversity in academic activities. The pandemic can have positive consequences if higher education institutions work to better support distance teaching and learning. Graphical Abstract

Prevalence and incidence of idiopathic subglottic stenosis in southern and central Alberta: a retrospective cohort study

Background Subglottic stenosis (SGS) is a reportedly rare disease that causes recurrent severe airway obstruction. Etiologies reported for SGS include idiopathic, iatrogenic, autoimmune, congenital, and traumatic, with variable ratios among different centres. From empiric observation, southern and central Alberta was hypothesized to have a disproportionate distribution of SGS driven by increased idiopathic SGS (iSGS) compared to previous literature. Identification of causative agents of iSGS will help understand and guide future management options, so this study aimed to characterize the demographics of SGS subtypes, define prevalence and incidence rates of iSGS in southern Alberta, and geographically analyze for clustering of iSGS prevalence. Methods SGS patients from Alberta census divisions No. 1–9 and 15 were retrospectively reviewed. Patients were subtyped according to etiology of SGS and characterized. Idiopathic SGS prevalence and incidence was assessed; prevalence was further geographically segregated by census division and forward sortation area (FSA). Significant clustering patterns were assessed for using a Global Moran’s I analysis. Results From 2010 to 2019 we identified 250 SGS patients, who were substantially overrepresented by idiopathic patients (80.4%) compared to autoimmune (10.0%), iatrogenic (7.6%), congenital (1.2%), and traumatic (0.8%). The total iSGS prevalence was 9.28/100,000 with a mean annual incidence rate of 0.71/100,000 per year. Significant clustering was observed (Moran’s index 0.125; z-score 2.832; p = 0.0046) and the highest rates of prevalence were observed in southern Alberta and in rural communities heterogeneously dispersed around Calgary FSAs. Conclusion In southern and central Alberta, iSGS patients were disproportionately over-represented in contrast to other subtypes with the highest prevalence in southern Alberta. There was a three-fold higher annual incidence compared to previous literature demonstrating the highest rates of disease reported worldwide. Future research aims to expand the geographical scope and to assess for demographic or environmental differences within significant clusters that may contribute to disease pathophysiology. Level of evidence III. Graphical Abstract

BRAF V600E mutation is associated with aggressive features in papillary thyroid carcinomas ≤ 1.5 cm

Background While some studies suggest that the BRAF V600E mutation correlates with a high-risk phenotype in papillary thyroid microcarcinoma (PTMC), more evidence is necessary before this mutation can be used to help guide decision making in the management of small thyroid nodules. This study investigated whether BRAF V600E mutation is associated with aggressive features in PTMC (≤ 1 cm) and small PTC (1–1.5 cm). Methods Retrospective chart review was performed on 121 patient cases. Patients who underwent thyroid surgery for PTMC (≤ 1 cm) or small PTC (1–1.5 cm) were included if molecular testing was done for BRAF V600E mutation. Two study groups were created based on tumour size: PTMC (n = 55) and small PTC (n = 66). The groups were analysed for the presence of a BRAF V600E mutation and aggressive features, including macroscopic extrathyroidal extension (ETE), lymph node metastasis (LNM), and high-risk histological features (tall cell, columnar cell, hobnail, solid/trabecular, and diffuse sclerosing). The Fischer exact test was used to calculate statistical significance. Results BRAF V600E mutations were detected in 43.6% of PTMC and 42.4% of small PTC. Of the mutated PTMC nodules, 54.1% demonstrated aggressive characteristics as compared to 19.4% of the non-mutated PTMCs (p = 0.010). Of the mutated small PTC tumours, 82.1% had aggressive features. In contrast, 28.9% of the non-mutated small PTCs showed aggressive features (p < 0.001). Conclusions Our findings demonstrate an association between a BRAF V600E mutation and aggressive features in PTMC (≤ 1 cm) and small PTC (1–1.5 cm). Therefore, determining the molecular status of these thyroid nodules for the presence of BRAF V600E can help guide patient management. Graphical Abstract