Cannabis related side effects in otolaryngology: a scoping review.

BACKGROUND: Cannabis has been rapidly legalized in North America; however, limited evidence exists around its side effects. Health Canada defines side effect as a harmful and unintended response to a health product. Given drug safety concerns, this study's purpose was to review the unintended side effects of cannabis in otolaryngology. METHODS: The Preferred Reporting Items For Systematic Reviews and Meta-analysis extension for Scoping Reviews (PRISMA-ScR) protocol was used to conduct a scoping review of the MEDLINE, EMBASE, CINAHL, and CENTRAL databases. (PROSPERO: CRD42020153022). English studies in adults were included from inception to the end of 2019. In-vitro, animal, and studies with n < 5 were excluded. Primary outcome was defined as unintended side effects (defined as any Otolaryngology symptom or diagnosis) following cannabis use. Oxford Centre for Evidence-Based Medicine: Levels of Evidence and risk of bias using the Risk of Bias in randomized trials (RoB 2) and Risk of Bias in Non-Randomized Studies of Interventions (ROBINS-I) tools were assessed.. Two authors independently reviewed all studies; the senior author settled any discrepancies. RESULTS: Five hundred and twenty-one studies were screened; 48 studies were analysed. Subspecialties comprised: Head and Neck (32), Otology (8), Rhinology (5), Airway (5), Laryngology (1). Cannabis use was associated with unintended tinnitus, vertigo, hearing loss, infection, malignancy, sinusitis, allergic rhinitis, thyroid dysfunction, and dyspnea. About half (54.1%) of studies showed increased side effects, or no change in symptoms following cannabis use. Oxford Levels of Evidence was 2-4 with substantial heterogeneity. Risk of bias assessment with RoB2 was low to high and ROBINS-1 was moderate to critical. CONCLUSION: This was the first comprehensive scoping review of unintended side effects of cannabis in Otolaryngology. The current literature is limited and lacks high-quality research Future randomized studies are needed to focus on therapeutic effects of cannabis in otolaryngology. Substantial work remains to guide clinicians to suggest safe, evidence-based choices for cannabis use.

Cost-effectiveness analysis comparing dupilumab and aspirin desensitization therapy for chronic rhinosinusitis with nasal polyposis in aspirin-exacerbated respiratory disease.

BACKGROUND: Chronic rhinosinusitis with nasal polyposis (CRSwNP) in the setting of aspirin-exacerbated respiratory disease (AERD) is a disease that is difficult to treat and prone to recurrence. Dupilumab is a promising treatment for these patients, but its cost-effectiveness has not yet been compared with aspirin (acetylsalicyclic acid, or ASA) desensitization, a known and effective treatment. We aimed to compare the cost-effectiveness of ASA desensitization with dupilumab therapy for the treatment of CRSwNP in AERD. METHODS: Analyses of cost-effectiveness, as measured in quality-adjusted life years (QALYs), and cost-utility, as measured in number of required revision endoscopic sinus surgeries (ESSs), were conducted. RESULTS: ASA desensitization after ESS was cost-effective and dominated appropriate medical management. Adding salvage dupilumab was also cost-effective (incremental cost-effectiveness ratio [ICER] $135,517.33), and upfront dupilumab therapy was not cost-effective in any scenario (ICER $273,181.32). The cost-utility analysis demonstrated that, over a 10-year period per patient, appropriate medical management after ESS cost $54,125.31 and resulted in 2.25 revision ESSs, ASA desensitization after ESS cost $53,775.15 and resulted in 2.02 revision ESSs, ASA desensitization with salvage dupilumab cost $121,176.25 and resulted in 1.68 revision ESSs, and upfront dupilumab cost $185,950.34 and resulted in 1.51 revision ESSs. CONCLUSION: Dupilumab for the treatment of severe CRSwNP was found to be cost-effective as salvage therapy under the willingness-to-pay threshold of $150,000. Further analysis highlighted that the cost-effectiveness of dupilumab was most sensitive to drug price and expected gains in quality of life. This suggests that additional investigation into improving patient population selection and tailoring treatment algorithms may improve the cost-effectiveness of dupilumab in specific scenarios.

Treatment and outcomes of nasopharyngeal carcinoma in a unique non-endemic population.

OBJECTIVE: Nasopharyngeal carcinoma (NPC) is common in Southeast Asia. Due to the influx of immigrants from this region, the incidence in British Columbia is increasing. Current literature from non-endemic populations encompasses heterogeneous cohorts. This study examines NPC in a North American population, with a high incidence, to understand the population's characteristics, treatment outcomes and recurrence patterns. METHODS AND MATERIALS: A retrospective analysis of patients treated for primary and recurrent NPC over 15-years. Regression analyses were used to identify predictors of disease recurrence and death. A subgroup analysis of the locoregional recurrence cohort was conducted. Five-year survival outcomes were determined. RESULTS: 601 patients were included. Asian ethnicity comprised 77% and the majority had non-keratinizing carcinoma (81%). In total, 19.3% of patients experienced recurrence: 58% local, 22% regional and 20% distant. Five-year overall survival was 70%. Smoking, advancing T-stage, poorer performance status and advanced overall stage were all associated with worse overall survival (p < 0.05). Asian ethnicity improved overall survival but not recurrence free survival. Similar features in addition to non-keratinizing histology were associated with increased locoregional recurrence (p < 0.05). Competing risk analysis indicated radiotherapy alone had a higher recurrence relative to chemoradiotherapy (HR 1.91, CI 1.17-3.09, p = 0.01). CONCLUSIONS: We report the largest study evaluating treatment and outcomes of NPC in a non-endemic population. This unique population falls between described endemic and non-endemic populations. Non-keratinizing pathology and primary radiotherapy did not affect survival; however, both had a propensity for recurrence. Finally, patients experienced more locoregional and less distant recurrence, supporting that this cohort may be amenable to curative salvage therapy.

Time to Laryngoscopy for Hoarseness in Canada: Are the American Academy of Otolaryngology Guidelines Feasible?

OBJECTIVES: To determine if a Canadian voice center is meeting the recommended time to laryngoscopy for hoarseness per the clinical practice guideline of the American Academy of Otolaryngology-Head and Neck Surgery. STUDY DESIGN: Retrospective chart audit. SETTING: Tertiary referral Canadian voice center. PARTICIPANTS AND METHODS: A total of 149 adult patients presenting with hoarseness over 6 months were included. Primary outcome measures were the time from onset of symptoms to laryngoscopy and the time from referral to laryngoscopy. Secondary outcome measures included patient- and disease-modifying factors, diagnosis, and clinical management. Analysis was performed to determine what factors were associated with meeting the guideline. RESULTS: Patients were evaluated by the laryngologist after 21.9 ± 37.6 months (mean ± SD) of symptoms. One-third (34.2%) of patients were seen within 3 months; 10.7% were seen within 4 weeks. Logistic regression showed that patients with neurologic symptoms (odds ratio, 4.04; 95% CI, 1.31-12.43; P = .015) and endotracheal intubation (odds ratio, 5.94; 95% CI, 2.21-15.95; P < .001) were associated with being seen within 3 months. Patients who had recent intubation (odds ratio, 6.04; 95% CI, 1.99-18.34; P = .002) were associated with being seen within 4 weeks. CONCLUSION: It is an ongoing challenge for our Canadian voice center to meet the American Academy of Otolaryngology-Head and Neck Surgery's clinical practice guideline for recommended time to laryngoscopy. Patients with more severe pathologies were consistently triaged more urgently. It is debatable whether this 4-week time recommendation is generalizable to a socialized health care system.

Predicting the Number of Fibular Segments to Reconstruct Mandibular Defects.

OBJECTIVES: Several classification schemes have been proposed to categorize mandibular defects following surgical resection; however, there is a paucity of data to guide an optimal reconstruction. This study examines the feasibility of using a geometric algorithm to simplify and determine the optimal reconstruction for a given mandibular defect. This algorithm is then applied to three different mandible defect classification schemes to correlate the defect type and number of bony segments required for reconstruction. METHODS: Computed tomography (CT) scans of 48 mandibles were decomposed into curvilinear representations and analyzed using the Ramer-Douglas-Peucker algorithm. In total, 720 mandibular defects were created and subsequently analyzed utilizing three commonly referenced classification systems. For each defect, the number of bony segments required to reconstruct each defect was computed. RESULTS: A wide variance in the number of segments needed for optimal reconstruction was observed across existing classifications. A six-segment total mandible reconstruction best reconstituted mandibular form in all 48 mandibles. CONCLUSION: Defect classification schemes are not adaptable to predicting the number of fibula segments required for a given defect. Additionally, cephalometric templates may not be applicable in all clinical settings. The Ramer-Douglas-Peucker algorithm is well suited for providing case-specific predictions of reconstruction plans in a reproducible manner. LEVEL OF EVIDENCE: IV Laryngoscope, 130:E619-E624, 2020.

Can Multiple Object Tracking Predict Laparoscopic Surgical Skills?

OBJECTIVE: The purpose of this study was to examine the relationship between multiple object tracking (MOT) and simulated laparoscopic surgery skills. METHODS: A total of 29 second-year medical students were recruited for this study. The participants completed 3 rounds of a three-dimensional MOT and a simulated laparoscopic surgery task. Averages of the performance on the tasks were calculated. Descriptive variables (i.e., age, hours of sleep, caffeine, and video game use) were measured via questionnaires. Data were analyzed using hierarchical regression models with surgical performance as the outcome variable. Predictor variable was the multiple objects tracking score and the descriptive variables. RESULTS: The regression models revealed a significant prediction of simulated laparoscopic surgical skills by the multiple objects tracking score. In particular, 29% of the variance of time to completion and 28% of the average surgical arm movement were explained. In both regressions, the MOT score was the only significant predictor. CONCLUSION: This study demonstrates the potential implications of perceptual-cognitive training for future surgeons. Along with motor skill practice, MOT may aid to better prepare health care professionals for the complex cognitive demands of surgery.