Otolaryngology Service Research Articles

The Impact of COVID-19 on Otolaryngology Community Practice in Massachusetts.

ObjectivesCoronavirus disease 2019 (COVID-19) significantly affected many health care specialties, including otolaryngology. In response to governmental policy changes, many hospitals and private practices in Massachusetts canceled or postponed nonurgent office visits and elective surgeries. The objective of this study was to quantify the impact of COVID-19 on the provision and practice trends of otolaryngology services for 10 private practices in Massachusetts.Study DesignRetrospective review.SettingMultipractice study for community practices in Massachusetts.MethodsElectronic billing records from 10 private otolaryngology practices in Massachusetts were obtained for the first 4 months of 2019 and 2020. Questionnaires from these otolaryngology practices were collected to assess financial and staffing impact of COVID-19.ResultsThe local onset of the COVID-19 pandemic had a significant decrease of 63% of visits in comparison to equivalent weeks in 2019. Virtual visits overtook in-person visits over time. A greater decline in operating room (OR) procedures than for office procedures was recorded. Ninety percent of practices reduced working hours, and 80% furloughed personnel. Seventy percent of practices applied for the Paycheck Protection Program (PPP).ConclusionCOVID-19 has had a multifaceted impact on private otolaryngology practices in Massachusetts. A significant decline in provision of otolaryngology services aligned with the Massachusetts government’s public health policy changes. The combination of limited personnel and personal protective equipment, as well as suspension of nonessential office visits and surgeries, led to decrease in total office visits and even higher decrease in OR procedures.

Resuming otolaryngology services following a COVID-19 lockdown in Singapore

Resuming otolaryngology services following a COVID-19 lockdown in Singapore

EPIDEMILOGY OF ENT DISORDERS IN ADULT POPULATION OF AGRICULTURAL REGION

The aim:TostudyandanalyzeSumy region population morbidity dynamics taking into account current stage of medical reform. Sumy region here is represented as one of the main agricultural regions of Ukraine. The prevalence of ENT disorders (otolaryngologic diseases) was studied. Materials and methods: During the study we used data of statistical report of Public Health Board, Sumy State Administration for the period from 2015 to 2019 years by administrative territories. Obtainedresults wereprocessed, usinggeneral statistics methodsandanalyzed, usingstructural-logicalanalysis. Conclusions: The study found that the morbidity rates of ENT disorders in adult population during the study period increased and had levels of 2113.0 and 122.1 per 100 thousand adult population, respectively, and the prevalence rates and the prevalence rates ofENT disorders among the adult population decreased , respectively to 167.7; 2113,0; 665.1 and 389.9. All indicators have reliable differences in terms of administrative territories of the region. The results of the study should be taken into account in the process of reforming the otolaryngological service in the region.

ANALYSIS OF EFFECTIVENESS OF SPECIALIZED OTOLARYNGOLOGICAL CARE TO CHILDREN OF METROPOLIS AS EXEMPLIFIED BY THE CITY OF KHARKIV

The availability of medical resources to provide an otolaryngological care to children in the metropolis as exemplified by the city of Kharkiv was comparatively analyzed. The indices of medical service density as well as the available otolaryngological beds of the city residents have been established to be stable and on the background of reducing their number in Ukraine by the end of 2017 exceed the latter except reducing thechildren's otolaryngological beds by 19.4 %. The revealed excess in an average number of bed occupancy, its turnover and reduction of the duration of inpatient treatment indicates an active use of the hospital bed capacity. It has been statistically proven that on the background of sufficient medical resources there are decreased as follows: the number of patients' visits to otolaryngologists in polyclinics of the Ministry of Health of Ukraine; relative index of the number of children who left the hospital due to diseases of the ear and mastoid process, coverage of the Kharkiv children aged 0−14 years with reduced hearing acuity with preventive examinations. The Kharkiv region is shown to occupy the first ranking place among the regions of Ukraine in terms of the disability level due to diseases of the ear and mastoid process. It was found that in the structure of primary disability the children aged 3 to 6 years and those with deafness were mainly determined. The described dynamics of indices has been more clearly traced since 2014. The above data indicate the existing shortcomings when treating the upper respiratory tract, ear and mastoid process diseases, mainly due to imperfect interaction of otolaryngological care service elements for children, inefficiency of typical medical routes. All this determines the relevance of developing an effective functional model of specialized otolaryngological care for children in the metropolis based on determining and monitoring of indices of simulated pathology quality treatment, training of doctors at all levels of care providing. Key words: efficiency of specialized otolaryngological care, children of the metropolis, analysis of medical resources, disability.

Learning experience on sentinel cases of COVID-19 at a public healthcare institution: sharing on operating room processes.

Learning experience on sentinel cases of COVID-19 at a public healthcare institution: sharing on operating room processes.

Perichondritis: inspect the lobule

Case presentationThis is a brief report of a 57-year-old Caucasian female presented with a 4-day history of worsening left ear pain. Her symptoms began with left otalgia and otorrhea which progressed to helical erythema, prompting a visit to the emergency department. She was noted to have erythema of the left auricle and swelling of the left auditory meatus. Our otolaryngology service observed erythema of the auricle with sparing of the lobule.DiagnosisThe diagnosis to be otitis externa with perichondritis was established, and we recommended otic ciprofloxacin-hydrocortisone, IV vancomycin, and ciprofloxacin. The patient had marked improvement and was discharged on an oral and otic fluoroquinolone. In this case, the diagnosis of perichondritis was made by a classic physical examination finding: erythema and edema with sparing of the fatty lobule. This key finding helps to distinguish perichondritis from otitis externa.

S2023 Mucoepidermoid Carcinoma Presenting as Massive Hematemesis

INTRODUCTION: Among salivary gland tumors, Oropharyngeal Mucoepidermoid carcinoma (OMEC) is the most frequent. The mass is generally solid, single, cyst-like. Microscopy describes principally columnar cells, squamous cells, and polygonal intermediate cells. Its presence may result in massive hematemesis which may be mistaken for other gastrointestinal lesions. Here we present a case of oropharyngeal mucoepidermoid carcinoma resulting in massive hematemesis. CASE DESCRIPTION/METHODS: The patient is a 56 years-old female with a past medical history of cerebrovascular accident, congestive heart failure, hypertension, diabetes, and chronic kidney disease; who presented to our emergency department (ED) complaining of progressive dysphagia to solids, hematemesis, and fatigue. While in the ED a computerized tomography (CT) Scan, shown an exophytic mass located at the base of the tongue measuring 2.4 cm × 2.0 cm x 2.1 cm. The gastroenterology service was then consulted to perform an urgent esophagogastroduodenscopy (EGD). This was done and showed a laryngeal mass consistent with the CT scan findings (Figure 1). Due to the location of the lesion and high risk of bleeding biopsy was not attempted. Later on the otolaryngology service was consulted who performed a laryngoscopy and were able to biopsy the lesion. The results of the biopsy returned showing a mucoepidermoid carcinoma of the larynx (Figure 2). During the hospital stay the patient was transfused with blood products due to persistent bleeding from the lesion. Hemostasis was eventually achieved via embolization of the lingual artery. Subsequently the patient was stabilized and discharged home to follow with an oncologist. DISCUSSION: OMEC becomes evident by signs of obstruction such as dysphagia or dyspnea but rarely presents with bleeding, this rare condition present in 2 out of 100.000 people, factors associated with this condition are female sex, history of radiation from natural or artificial sources, woodwork, mining, and plumbing. Predominant signs and symptoms are weight loss, dysphagia, anemia, and rarely hematemesis. Biopsy is the gold standard for diagnosis, but CT may also aid in its identification. The treatment for OMEC requires a combination of surgery, chemotherapy, and radiation that can be used after the surgery to destroy remaining cells.Figure 1.: Esophagogastroduodenoscopy showing a laryngeal mass.Figure 2.: Biopsy specimen of the laryngeal mass revealing mucoepidermoid carcinoma.

Caracterización de la población que consulta por epistaxis al servicio de otorrinolaringología del Hospital Universitario Mayor Méderi (HUM)

Introducción: La epistaxis es uno de los principales motivos de consulta por urgencias en el servicio de Otorrinolaringología. La mayoría de los episodios se originan en el septo nasal anterior y su manejo tiende a ser conservador. Objetivo: Caracterizar la población que consulta por epistaxis al servicio de Otorrinolaringología del Hospital Universitario Mayor Méderi (HUM) entre marzo de 2017 y febrero de 2018. Metodología: Estudio observacional, descriptivo, de corte transversal, con recolección de datos de forma retrospectiva de pacientes que ingresan a urgencias del HUM por epistaxis, registrados en la base de datos del servicio de Otorrinolaringología. Se analizaron datos demográficos, localización del sangrado, tratamiento, comorbilidades, fármacos y cifras tensionales. 

Ayudas diagnósticas en patología laríngea: imagen de banda estrecha (NBI)

La imagen de banda estrecha (NBI por sus siglas en inglés narrow band imaging) es un sistema de mejora de imagen, desarrollado en Japón en el 2001, que utiliza longitudes de onda filtradas a 415 nm y 540 nm que permiten la visualización de anomalías microvasculares que se han visto asociadas a carcinogenesis. En laringología el NBI es usado para la evaluación de lesiones premalignas, detección de primarios desconocidos en cabeza y cuello, diagnóstico y seguimiento de lesiones malignas posterior a tratamiento endoscópico y/o con radioterapia, entre otros. Se presenta una revisión narrativa de la literatura donde se exponen los fundamentos técnicos del NBI, los principios fisiológicos básicos, las clasificaciones actuales para describir los diferentes patrones vasculares y los usos principales descritos en laringología, así como un atlas de imágenes tomadas en el servicio de Otorrinolaringología del Hospital San José.

The impact of the coronavirus (COVID-19) pandemic on elective paediatric otolaryngology outpatient services – An analysis of virtual outpatient clinics in a tertiary referral centre using the modified paediatric otolaryngology telemedicine satisfaction survey (POTSS)

IntroductionVirtual outpatient clinics (VOPC) have been integrated into both paediatric and based adult outpatient services due to a multitude of factors, including increased demand for services, technological advances and rising morbidity secondary to ageing populations. The novel coronavirus disease (COVID-19) has accentuated pressures on the National Health Service (NHS) infrastructure, particularly elective services, whilst radically altering patterns of practice. AimTo evaluate the impact of the COVID-19 pandemic on paediatric otolaryngology outpatient services whilst collating patient feedback to elicit long-term sustainability post COVID-19. MethodA retrospective analysis of VOPCs was undertaken at a tertiary paediatric referral centre over a 3-month capture period during the COVID-19 pandemic. Demographic, generic clinic (presenting complaint, new vs. follow-up, consultation type), as well as outcome data (medical or surgical intervention, discharge vs. ongoing review, onward referral, investigations, and conversion to face-to-face) was collated. Additionally a modified 15-point patient satisfaction survey was created. The Paediatric Otolaryngology Telemedicine Satisfaction survey (POTSS), was an adaptation of 4 validated patient satisfaction tools including the General Medical Council (GMC) patient questionnaire, the telehealth satisfaction scale (TESS), the telehealth usability questionnaire (TUQ), and the telemedicine satisfaction and usefulness questionnaire (TSUQ). ResultsOf 514 patients reviewed virtually over a 3-month period, 225 (45%) were randomly selected to participate, of which 200 met our inclusion criteria. The most common mode of consultation was telephony (92.5%, n = 185). Non-attendance rates were reduced when compared to face-to-face clinics during an equivalent period prior to the COVID-19 pandemic. A significant proportion of patients (29% compared to 26% pre-VOPC) were discharged to primary care. Nine percent were listed for surgery compared to 19% pre-VOPC. A subsequent face-to-face appointment was required in 10% of participants. Overall, the satisfaction when assessing the doctor-patient relationship, privacy & trust, as well as consultation domains was high, with the overwhelming majority of parents’ content with the future integration and participation in VOPCs. ConclusionAn evolving worldwide pandemic has accelerated the need for healthcare services to reform in order to maintain a steady flow of patients within an elective outpatient setting without compromising patient care. Solutions must be sustainable long-term to account for future disruptions, whilst accounting for evolving patient demographics. Our novel survey has demonstrated the vast potential that the integration of VOPCs can offer paediatric otolaryngology services within a carefully selected cohort of patients.

Trends in otolaryngology consult volume at an academic institution from 2014 to 2018.

ObjectiveTo evaluate changes in emergency department and inpatient consult volumes of an otolaryngology service at an academic medical center from 2014 to 2018.MethodsA retrospective review of all otolaryngology consults in the electronic medical record from March 2014 through December 2018 was completed. The total number of consults was recorded to determine changes in consult volume over time. Additional parameters were analyzed including volume of weekday, night and weekend, adult, pediatric, emergency department, and inpatient consults.ResultsFrom 1 March 2014 to 31 December 2018, a total of 8806 consults were seen by the otolaryngology service. In the first year, a total of 990 consults were seen. In the final year of the time period, a total of 2416 consults were seen. This represents a 144% increase in consults over the examined time period. Similar increasing trends were seen when consults were analyzed by weekday, night/weekend, pediatric, adult, emergency department, and inpatient consults.ConclusionsThis is one of the first studies examining trends in otolaryngology consult volumes at an academic medical center in the United States. Our data show that the volume of consults has increased by 144% in a 4‐year time period, predominantly due to an increase in emergency department consultations. This study demonstrates the increasing burden of emergency department consultations on an otolaryngology service at an academic medical center and highlights a potential role for increasing and improving provider availability.Level of evidence4.

Effectiveness and Safety of Advanced Audiology-Led Triage in Pediatric Otolaryngology Services.

Expansion of the scopes of practice of allied health practitioners has the potential to improve the efficiency and cost-effectiveness of healthcare, given the identified shortages in medical personnel. Despite numerous examples in other allied health disciplines, this has yet to be applied to pediatric Audiology. This study aimed to investigate the effectiveness and safety of using audiologists with advanced training to independently triage children referred to otolaryngology (ORL) services, and compare the subsequent use of specialist resources, and postoperative grommet care to a standard medical ORL service. One hundred twenty children consecutively referred to a large ORL outpatient service in Queensland, Australia, for middle ear and hearing concerns were prospectively allocated to either the ORL service or Advanced Audiology-led service. Demographic and clinical data were extracted from electronic medical records and compared between the two services. Clinical incidents and adverse events were recorded for the Advanced Audiology-led service. Approximately half of all children referred to ORL for middle ear or hearing concerns were discharged without requiring any treatment, with the remaining half offered surgical treatment. The Advanced Audiology-led model increased the proportion of children assessed by ORL that proceeded to surgery from 57% to 82% compared with the standard medical ORL model. Children followed up by the audiologists after grommet insertion were more likely to be discharged independently and at the first postoperative review appointment compared with the standard medical ORL service. There were no reports of adverse events or long-term bilateral hearing loss after discharge by the Advanced Audiology-led service. These findings indicate that an Advanced Audiology-led service provides a safe and effective triaging model for the independent management of children not requiring treatment, and children requiring routine postoperative grommet review, and improves the effective use of specialist resource compared with the standard medical ORL service.

An Integrated Care Strategy for the Follow-up of Patients With COVID-19-Associated Chemosensory Dysfunction.

The proportion of patients with residual olfactory and gustatory dysfunction after COVID-19 is increasing, and practical health care strategies need to be developed to manage this novel situation in otolaryngology services worldwide. Starting from our experience in a large Italian hospital, we estimated that >1500 people will complain of some form of olfactory and gustatory dysfunction in the future months in our region. We want to share our logistical and clinical integrated pathway that is aimed to screen and refer each patient to the most appropriate level of care in order to optimize resources and avoid overwhelming the available clinics.

Childhood Obstructive Sleep Apnea: from Diagnosis to Therapy—an Update

Obstructive sleep apnea syndrome (OSAS) is common in childhood and is characterized by recurrent upper airway obstructive events during sleep. It is associated with significant morbidity, potentially influencing long-term neurocognitive and behavioral development, as well as cardiovascular sequelae. Children differ from adults with respect to etiology, clinical presentation, and medical and surgical management. A comprehensive review article concerning the pathophysiology, diagnosis, and treatment of OSAS was undertaken. To date, OSAS is a very common problem in children and is primarily caused by adenotonsillar hypertrophy, and adenotonsillectomy remains the first-line surgical treatment. Clinical and epidemiological studies show that OSAS is a multifactorial and complex disease with a strong genetic basis. OSAS should be recognized as a public health problem due to the increasing incidence of this condition secondary to rising rates of obesity in children. It has a significant impact on the growth and development of a child from a behavioral and neurodevelopmental perspective. This is particularly important in children with secondary medical conditions. It is therefore a crucial tailored approach to pediatric OSAS patients in order to diagnose and treat early this condition with a multidisciplinary team including otolaryngology, respiratory medicine, pediatrics, and clinical nutrition services.

Resection of an Internal Carotid Artery Aneurysm With Extreme Cranial Exposure Maneuvers

This video demonstrates a case of a 63-year-old previously healthy woman with a 5 × 3-cm left internal carotid aneurysm that arose 3 cm cranial to the carotid bifurcation and extended to the cranial portion of the second cervical vertebral body. This was initially treated by a flow-diverting stent that, over time, retracted into the aneurysm sac. Repair of the carotid aneurysm by a multidisciplinary team consisting of vascular surgery, otolaryngology, and oral and maxillofacial surgery services required extreme cranial maneuvers including mandibulotomy for optimal exposure.

Discharge by Noon: A Checklist Initiative by the Otolaryngology Service.

Hospital length of stay (LOS) and throughput are critical issues for hospitals. Late hospital discharges contribute to bottlenecks in the emergency department, overcrowd surgical and procedural areas, and limit patient tertiary-care center transfers. Our goal was to increase discharge by noon (DCBN) percentage from 8% to over 50% in a sustainable manner. Retrospective Review. We used a multiple time series design and a quality improvement approach. An interdisciplinary improvement team (IIT) identified the main causes contributing to late discharge and then developed and implemented multiple interventions to increase the percentage of DCBN. Admissions and discharge information were obtained for all patients in the otolaryngology service (January 2014-September 2017). The intervention was implemented in July 2015. The primary outcome was the percentage of DCBN per month. Secondary outcomes were LOS, case-mix index (CMI), patient experience, and 30-day readmissions. We analyzed the impact of our intervention and outcomes at the preintervention, peri-intervention, and postintervention periods. One thousand four hundred sixty-four admissions to the otolaryngology service were included. Throughout the intervention period, the percentage of patients DCBN increased. Analysis of the intervention showed significant DCBN change of 15% in the first versus 42% in the last 12-months (P < .001), and shorter LOS (-1.4 days, P < .001) and lower CMI (-0.6, P < .001) in the DCBN group. Patient satisfaction scores improved by 4% (P < .05), and no difference in 30-day readmission rates (P = .29) was shown. This multifaceted intervention improved early discharge and patient experience. Our checklist of key behaviors could be applied throughout other services and hospitals with reproducible success. 4 Laryngoscope, 131:E76-E82, 2021.

Sustaining Otolaryngology Services for the Long Haul during the COVID-19 Pandemic: Experience from a Tertiary Health System.

The impact of the COVID-19 pandemic has been far-reaching and has profoundly affected the practice of otolaryngology in an unprecedented way. In this commentary, we draw from our experience in the first 90 days of the pandemic and discuss a set of workflow measures, personal protection equipment protocols, and strategic goals that can provide a safe environment for patients and staff to continue managing a significant proportion of patients in the otolaryngology service during the pandemic.

Neonatal Vocal Fold Paralysis.

Vocal fold paralysis (VFP) is an important cause of respiratory and feeding compromise in infants. The causes of neonatal VFP are varied and include central nervous system disorders, birth-related trauma, mediastinal masses, iatrogenic injuries, and idiopathic cases. Bilateral VFP often presents with stridor or respiratory distress and can require rapid intervention to stabilize an adequate airway. Unilateral VFP presents more subtly with a weak cry, swallowing dysfunction, and less frequently respiratory distress. The etiology and type of VFP is important for management. Evaluation involves direct visualization of the vocal folds, with additional imaging and testing in select cases. Swallowing dysfunction, also known as dysphagia, is very common in infants with VFP. A clinical assessment of swallowing function is necessary in all cases of VFP, with some patients also requiring an instrumental swallow assessment. Modification of feeding techniques and enteral access for feedings may be necessary. Airway management can vary from close monitoring to noninvasive ventilation, tracheostomy, and laryngeal surgery. Long-term follow-up with otolaryngology and speech-language pathology service is necessary for all children with VFP to ensure adequate breathing, swallowing, and phonation. The short- and long-term health and quality-of-life consequences of VFP can be substantial, especially if not managed early.

Association of Opioid Quantity and Caregiver Education with Pain Control after Pediatric Tonsillectomy.

To examine whether a service guideline reducing postoperative opioid prescription quantities and caregiver-reported education to use nonopioid analgesics first are associated with caregiver-reported pain control after pediatric tonsillectomy. Prospective cohort study (July 2018-April 2019). Pediatric otolaryngology service at a tertiary academic children's hospital. Caregivers of patients aged 1 to 11 years undergoing tonsillectomy (N = 764) were surveyed 7 to 21 days after surgery regarding pain control, education to use nonopioid analgesics first, and opioid use. Respondents who were not prescribed opioids or had missing data were excluded. Logistic regression modeled caregiver-reported pain control as a function of service guideline implementation (December 2018) recommending 20 rather than 30 doses for postoperative opioid prescriptions and caregiver-reported analgesic education, adjusting for patient demographics. Among 430 respondents (56% response), 387 patients were included. The sample was 43% female with a mean age of 5.0 years (SD, 2.5). Pain control was reported as good (226 respondents, 58%) or adequate/poor (161 respondents, 42%). Mean opioid prescription quantity was 27 doses (SD, 7.9) before and 21 doses (SD, 6.1) after guideline implementation (P < .001). Education to use nonopioids first was reported by 308 respondents (80%). In regression, prescribing guideline implementation was not associated with pain control (adjusted odds ratio, 1.3; 95% CI, 0.9-2.0; P = .22), but caregiver-reported education to use nonopioids first was associated with a higher odds of good pain control (adjusted odds ratio, 1.9; 95% CI, 1.1-3.2; P = .02). Caregiver education to use nonopioid analgesics first may be a modifiable health care practice to improve pain control as postoperative opioid prescription quantities are reduced.

Practical Aspects of Otolaryngologic Clinical Services During the 2019 Novel Coronavirus Epidemic

Practical Aspects of Otolaryngologic Clinical Services During the 2019 Novel Coronavirus Epidemic