Impact of COVID-19 versus chronic rhinosinusitis/rhinitis associated olfactory dysfunction on health utility and quality of life.

Background: Olfactory dysfunction (OD) is associated with both post-viral and inflammatory etiologies such as COVID-19 and chronic rhinosinusitis/rhinitis (CRS/R) respectively, to result in reduced quality of life (QoL). However, the former typically induces a sudden-onset OD while the latter has a gradual presentation. This study aims to establish and compare health utility values (HUVs) and olfactory-specific QoL measurements between patients with COVID-19 and CRS/R related OD. Methods: This prospective study surveyed COVID-19 and CRS/R patients with self-reported OD using HUV assessments (EuroQol-visual analog scale [EQ-VAS], EuroQol-5 dimension [EQ-5D], time trade-off [TTO]) and olfactory and sinonasal QoL measures (questionnaire of olfactory disorders -negative and positive statements [QOD-NS + PS] and sino-nasal outcome test [SNOT-22]). A subgroup of subjects completed objective olfactory testing. Intergroup mean scores were compared using Mann-Whitney U tests. Results: One hundred eleven subjects were enrolled: mean age ± SD (43.0 ± 15.4 years), 55.9% female. CRS/R was associated with lower HUVs as measured by EQ-VAS (CRS/R: 0.67 ± 0.18 vs. COVID-19: 0.74 ± 0.19, p = .03) and worse SNOT-22 scores in both overall (CRS/R: 49.03 ± 21.04 vs. COVID-19: 27.58 ± 18.45, p < .001) and subgroup analysis of objectively confirmed OD subjects (CRS/R: 52.40 ± 22.78 vs. COVID-19: 29.84 ± 21.10, p = .01). On the other hand, COVID-19 has greater burden on olfactory-specific QoL (QOD-NS + PS, COVID-19: 23.19 ± 13.73 vs. CRS/R: 17.25 ± 11.38, p = .04). Both groups demonstrated a similar decrease in health using the EQ-5D assessment. Conclusion: CRS/R associated OD has a more severe impact on general health and sinonasal specific QoL outcomes, while COVID-19 associated OD has a greater burden on olfactory-specific QoL. Level of evidence: Level 2c.

Pediatric Mandible Fractures: Mechanism, Pattern of Injury, Fracture Characteristics, and Management by Age.

Background: Development of the craniofacial skeleton and different mechanisms of injury warrant different treatment paradigms for younger children versus those at skeletal maturity. Objective: To characterize the mechanism, fracture patterns, and management of mandible fractures across the pediatric age spectrum. Methods: A 10-year retrospective review of <18-year-old children with mandible fractures at a level 1 trauma center. Characteristics were compared by age subgroup analysis. Results: Of 220 patients meeting inclusion criteria, motor vehicle collision (n = 53, 40.8%), falls (n = 48, 36.9%), and assault (n = 19, 14.6%) were the most common mechanisms with more falls in younger children and more injury by assault in teenagers. Condylar fractures were most common in the 0- to <9-year-old children (n = 27, 38.4%); angle/ramus fractures (56, 62.6%) were most common in 15- to <18-year-old children (p < 0.001). Nonsurgical management was associated with younger age (p < 0.001). Fourteen of 125 patients (8.0%) undergoing surgical intervention experienced complications. Being uninsured was associated with shorter median (interquartile range) follow-up of 5.6 (1.4-10.7) weeks, compared with private [11.9 (4.3-49.0) weeks] and public insurance [11.7 (3.7-218.0) weeks] (p < 0.001). Conclusion: The mechanism, fracture sites, and treatment differed by age with the youngest frequently managed nonoperatively and teenagers treated with adult algorithms. Complications were rare overall within 6-12 weeks after injury, with or without surgical management.

Open and endoscopic surgery improve survival for squamous and nonsquamous cell nasopharyngeal carcinomas: An NCDB cohort study.

BACKGROUND: Nasopharyngeal tumors (NPTs) are primarily treated with nonsurgical therapy. Recent studies have demonstrated endoscopic salvage surgery for NPT recurrences may improve survival relative to reirradiation. However, there are very limited data on open compared with endoscopic approaches for NPTs. We investigated whether endoscopic and open surgical approaches to the nasopharynx improve overall survival for all histologic subtypes of NPTs. METHODS: We performed a retrospective cohort study using the National Cancer Database (NCDB). All adult patients with NPTs from 2004 to 2016 without distant metastasis who underwent treatment with curative intent were included. We extracted clinical and treatment variables to assess our primary outcome of overall survival. RESULTS: On univariate analysis, patients undergoing endoscopic surgery, but not open surgery, had significantly improved overall survival relative to those undergoing nonsurgical treatment. Post hoc analysis demonstrated significantly improved overall survival for surgery in patients with minor salivary gland histology, but not squamous cell carcinoma (SCC) histology or by T or N classification. A Cox proportional hazards model was used for multivariate regression. After adjusting for covariates, both endoscopic and open approaches were associated with improved overall survival relative to nonsurgical treatment for all tumor types. A multivariate regression of SCC found that open surgery, but not endoscopic surgery, was significantly associated with improved overall survival. CONCLUSION: Both endoscopic and open surgical approaches are associated with improved overall survival of patients with NPT. These findings highlight important oncologic validity as endoscopic and robotic platforms to the nasopharynx become more widely adopted.

Clinical factors associated with lower health scores in COVID-19-related persistent olfactory dysfunction.

BACKGROUND: Patients with persistent COVID-19 olfactory dysfunction (OD) commonly report parosmia. Understanding the impact of COVID-19 OD and parosmia is critical to prioritizing research and interventions. In this study we investigate the impact of parosmia and other clinical and disease characteristics on health state utility values (HUVs) for those with persistent COVID-19 OD. METHODS: Patients with a history of COVID-19 diagnosis and persistent OD were recruited from a tertiary medical center and a social media support forum for chemosensory dysfunction. Clinical characteristics and disease-specific symptoms were obtained along with self-reported history of smell function and presence of parosmia. HUVs were calculated using indirect (EuroQol 5-Dimension [EQ-5D]) and direct (VAS) measures. RESULTS: Our study included 286 subjects (75.52% women) with persistent COVID-19-related OD. Results (mean ± standard deviation) of HUVs based on EQ-5D and VAS were 0.81 ± 0.14 and 0.73 ± 0.21, respectively. Mean self-reported smell function (on a 0-10 scale) was 9.67 ± 1.25 pre-COVID-19, 0.93 ± 2.34 at diagnosis, and 3.39 ± 2.32 at most current assessment. A total of 89.16% of the subjects reported parosmia and 24.13% sought medical care for anosmia. Seeing an MD for OD (p < 0.001), female gender (EQ-5D only, p = 0.002), a history of chronic pain (p < 0.05) and depression/anxiety (EQ-5D only, p < 0.001) predicted worse health. Parosmia and persistent symptoms, such as shortness of breath, were associated with lower EQ-5D and VAS scores, but did not independently predict poorer health scores on multivariable analysis. CONCLUSION: Persistent COVID-19 OD results in health states comparable to other chronic diseases.

Assessment of patient recognition of coronavirus disease 2019 (COVID-19)-associated olfactory loss and recovery: a longitudinal study.

BACKGROUND: The clinical course of coronavirus disease 2019 (COVID-19) olfactory dysfunction remains poorly characterized, often limited by self-reported measures. Given the logistical challenges of psychophysical testing, understanding the longitudinal relationship between self-reported and quantitative measures can help accurately identify patients with persistent olfactory dysfunction. This study aimed to longitudinally correlate measured and subjective olfactory function in COVID-19 subjects. METHODS: A prospective, longitudinal study evaluating subjective and measured olfaction was conducted on ambulatory COVID-19 subjects. Olfaction scores were obtained using a visual analogue scale (VAS) (0 = anosmia, 10 = normosmia) and the validated 12-item Brief Smell Identification Test (BSIT). Weekly testing was performed until recovery (BSIT ≥ 9/12 and/or VAS = 10/10) or study completion. RESULTS: Eighty-six polymerase chain reaction (PCR)-positive COVID-19 subjects were recruited ≤3 days from diagnosis and 52 completed longitudinal testing. Among those with self-reported smell loss at recruitment, similar levels (75.8%) of objective (BSIT ≥ 9/12) and subjective recovery were obtained using a VAS cutoff ≥8, yet only 30.3% reported complete subjective recovery (VAS = 10). Median times to objective and complete subjective olfactory recovery were 12 ± 2.3 and 24 ± 3.5 days, respectively. Although both measures showed chemosensory improvement, the distributions of objective and full subjective olfactory recovery differed significantly (log rank test χ2 = 6.46, degrees of freedom [df] = 1, p = 0.011). Overall correlation between BSIT and VAS scores was moderate to strong across longitudinal follow-up (rs = 0.41-0.65). CONCLUSION: Self-reported and psychophysically measured COVID-19 olfactory dysfunction improve at similar levels and are moderately correlated longitudinally, yet there is a significant delay in complete subjective recovery. Psychophysical testing in conjunction with qualitative assessments may be considered for counseling and follow-up of patients with COVID-19 smell loss.

The Relationship Between the Functional Gait Assessment and Quality-of-Life Data in Patients Undergoing Vestibular Schwannoma Resection.

OBJECTIVE: To examine the relationship between the Functional Gait Assessment (FGA) and quality of life (QOL) measurements relating to balance before and after vestibular schwannoma (VS) resection and to assess the role of preoperative FGA in predicting postoperative QOL. STUDY DESIGN: A prospective clinical study of adult patients undergoing VS resection between September 2018 and December 2019. FGA was administered 1 week before and after surgery. Dizziness Handicap Inventory (DHI) and Penn Acoustic Neuroma Quality of Life (PANQOL) were administered preoperatively and at 3 months postoperatively. SETTING: Single tertiary center. PATIENTS: Patients (age ≥ 18 years old) with VS undergoing microsurgical resection. Excluded were patient with previous surgery or radiation. INTERVENTION: VS resection. MAIN OUTCOMES AND MEASURES: Primary outcome: correlation between FGA and QOL surveys. Secondary outcome: correlation between preoperative measurements of balance and postoperative PANQOL. RESULTS: One hundred thirty-eight patients were analyzed (mean age: 48 years old, 65.9% female). The translabyrinthine approach was most commonly performed. Under multivariate analysis, preoperative FGA significantly correlated with preoperative PANQOL balance score (p < 0.0001), preoperative PANQOL total score (p = 0.0002), and preoperative DHI (p < 0.0001). However, postoperative FGA did not significantly correlate with postoperative PANQOL balance or total scores (p = 0.446 and p = 0.4, respectively), or postoperative DHI (p = 0.3). Univariate analysis demonstrated that preoperative DHI and preoperative FGA were predictive of changes in postoperative PANQOL balance and total scores. However under multivariate analysis, preoperative FGA did not predict changes in postoperative PANQOL balance or total score (p = 0.24; p = 0.28, respectively). Preoperative DHI remained predictive of changes in postoperative PANQOL balance (p = 0.03) score but not of postoperative PANQOL total score (p = 0.37). CONCLUSIONS: Although FGA and QOL data significantly correlated in the preoperative setting, our results did not suggest that preoperative FGA can be used to determine postoperative QOL. Additionally, the lack of correlation between FGA and QOL measurements in the acute postoperative setting suggests that further research is needed to determine contributors to postoperative QOL.

Navigating telemedicine for facial trauma during the COVID-19 pandemic.

Importance: The COVID-19 pandemic is changing how health care providers practice. As some telemedicine and telecommunication support tools have been incorporated into the otolaryngology practice in response to safety and access demands, it is essential to review how these tools and services can help facilitate facial trauma evaluation during a time when clinical resources are limited. Objective: To review applications of telemedicine for the evaluation of facial trauma to better direct utilization of these methods and technologies during times of limited access to clinical resources such as the COVID-19 pandemic. Methods: A systematic review was conducted using PubMed, Embase, and Web of Science. Results: After screening 158 titles and abstracts, we identified 16 eligible studies involving facial trauma evaluation using telemedicine. Telemedicine opportunities for facial trauma evaluation have the potential to be developed in the areas of multidisciplinary remote consultations, facial trauma triage, patient engagement, and postoperative follow-up. Conclusion: The COVID-19 pandemic is posing obstacles for both providers and patients in the delivery of health care at a time of limited clinical resources. Telemedicine may provide a potential useful tool in the evaluation and triage of facial injuries and patient engagement.

Comparison of Intraoperative Computed Tomography Scan with Postoperative Magnetic Resonance Imaging for Determining Deep Brain Stimulation Electrode Coordinates.

BACKGROUND: Deep brain stimulation (DBS) is an effective therapy for a variety of refractory movement disorders. Accurate lead placement in the target nucleus is critical to ensure therapeutic effects and to minimize side effects, and intraoperative computed tomography (iCT) scan has been used to target and confirm lead position. The objective of this study is to compare the accuracy of determining the x, y, and z coordinates of final lead placement using iCT scan relative to postoperative magnetic resonance imaging (MRI). METHODS: We conducted a retrospective study on 83 patients who underwent insertion of 145 DBS leads from 2015 to 2017 at a single institution. iCT scan was merged with the preoperative MRI to determine lead coordinates on both magnetic resonance and computed tomography images independently, and the absolute differences between the x, y, and z coordinates between the 2 scans along with the Euclidean vectors were calculated. RESULTS: The mean absolute differences ± standard error of the mean between iCT scan and postoperative MRI coordinates were as follows: x = 0.01 ± 0.09 mm (P = 0.89), y = 1.67 ± 0.14 mm (P < 0.001), and z = 2.75 ± 0.15 mm (P < 0.001). The average Euclidean vector difference was 3.21 ± 0.15 mm (P < 0.001). CONCLUSIONS: Significant differences exist between iCT scan and postoperative MRI DBS y and z lead coordinates, but not with x coordinates. Based on this series, iCT scan is more accurate when confirming x coordinates, and less accurate for confirming y and z coordinates during DBS operations.

Assessment of the Learning Curve for Virtual Surgical Planning in Orbital Fractures.

Virtual surgical planning (VSP) is becoming more widely used in maxillofacial reconstruction and can be surgeon-based or industry-based. Surgeon-based models require software training but allow surgeon autonomy. We evaluate the learning curve for VSP through a prospective cohort study in which planning times and accuracy of 7 otolaryngology residents with no prior VSP experience were compared to that of a proficient user after a single training protocol and 6 planning sessions for orbital fractures. The average planning time for the first session was 21 minutes 41 seconds ± 6 minutes 11 seconds with an average maximum deviation of 2.5 ± 0.8 mm in the lateral orbit and 2.3 ± 0.6 mm in the superior orbit. The average planning time for the last session was 13 minutes 5 seconds ± 10 minutes and 7 seconds with an average maximum deviation of 1.4 ± 0.5 mm in the lateral orbit and 1.3 ± 0.4 mm in the superior orbit. Novice users reduced planning time by 40% and decreased maximum deviation of plans by 44% and 43% in the lateral and superior orbits, respectively, approaching that of the proficient user. Virtual surgical planning has a quick learning curve and may be incorporated into surgical training.

Eustachian tube dysfunction in children with cleft palate: A tympanometric time-to-event analysis.

OBJECTIVES: To characterize the duration of Eustachian tube dysfunction in children with cleft palate compared to those without cleft palate by performing time-to-event analysis on tympanometric data. To determine predictive characteristics of earlier achievement of normal tympanograms in children with cleft palate. METHODS: Longitudinal tympanometric data from a minimum of 10 years at a single center were reviewed for children with cleft palate born in the years 2003 through 2007. Children with cleft lip without cleft palate born in the same years were used as a reference group to compare children with similar length of follow-up. The association between time to sustained normal (type A) tympanograms with patient demographics, clinical characteristics, and otologic history was evaluated using time-to-event analysis and compared with log rank tests. Adjusted and unadjusted hazard ratios were estimated using Cox proportional hazard models. RESULTS: The median age of achieving a type A tympanogram in children with cleft palate was 9.9 years for one and 12.1 years for both ears, compared to 7.1 and 7.4 years in children with cleft lip only (P < 0.0001). On multivariate analysis, clinical characteristics such as the severity of palatal clefting or the presence of a cleft-associated syndrome/sequence were not predictors of a longer time to a type A tympanogram. CONCLUSION: Our results help characterize the observation that there is delayed time to normal Eustachian tube function in children with cleft palate, which is not associated with the degree of palatal clefting. LEVEL OF EVIDENCE: 3b Laryngoscope, 130:1044-1050, 2020.

Utility of Endoscope-Assisted Orbital Fracture Repair for Atraumatic Reduction of Entrapped Muscle Tissue and Surgical Education.

Trapdoor fractures can result in extraocular muscle entrapment with resultant pain, diplopia, bradycardia, nausea, and vomiting. Urgent repair is required to minimize the risk of permanent muscle injury and long-term diplopia. Complete fracture visualization is imperative to ensure adequate reduction of the herniated tissue and accurate implant placement when necessary. Orbital floor angulation and prolapsed orbital fat can make visualization of the posterior orbit challenging. Inadequate reduction can lead to reoperation in up to 18% of cases. Because the narrow field of view makes visualization difficult, teaching the surgical technique can be very challenging. We demonstrate the reduction of an entrapped inferior rectus muscle using an endoscope-assisted transconjunctival approach, highlighting its advantages in fracture visualization and surgical training.

Update on empty nose syndrome: disease mechanisms, diagnostic tools, and treatment strategies.

PURPOSE OF REVIEW: To discuss the proposed pathophysiology of empty nose syndrome (ENS), summarize and evaluate the role of validated diagnostic tools in the diagnosis of ENS, and review the medical and surgical treatment strategies for patients with ENS. RECENT FINDINGS: Historically, ENS has been associated with a reduction in nasal turbinate size; new data suggest that impaired trigeminal nerve function may also play a role in the pathophysiology of the disease. The newly validated empty nose syndrome 6 item questionnaires and Cotton test are steps forward to standardize the diagnosis of ENS. Finally, there has been a marked increase in surgical treatment strategies to reconstitute turbinate volume with various implant materials. SUMMARY: The diagnosis of ENS remains controversial but the last several years have seen a rejuvenation of interest in this disease entity. The validated empty nose syndrome 6 item questionnaires and Cotton test provide a standardized and objective means by which to characterize ENS. Prevention of iatrogenic ENS through avoidance of excessive turbinate reduction remains critical in preventing paradoxical nasal obstruction. Nasal humidification, patient education, and treatment of possible concomitant medical conditions (e.g., depression) constitute first lines of treatment. We support the cautious use of these screening tools as adjuncts to clinical decision-making. Although injectable implants to augment turbinate volume show promise as a therapeutic surgical technique, there is insufficient data to fully support their use at this time.

Evaluation of the Statewide Variability in the Current Role of Different Specialties in Lower Extremity Endovascular Revascularization for Medicare Beneficiaries.

PURPOSE: To evaluate the statewide variability in the role of different specialties in lower extremity endovascular revascularization (LEER) and associated submitted charges of care and actual reimbursement for Medicare beneficiaries. METHODS: The 2015 "Medicare Provider Utilization and Payment Data: Physician and Other Supplier" data includes provider-specific information regarding the type of service, submitted average charges of care, and actual average Medicare reimbursements per Healthcare Common Procedure Coding System (HCPCS) code per provider. All HCPCS codes related to LEER were identified. The role of vascular surgery (VS), interventional cardiology (IC), and interventional radiology (IR) in each HCPCS-specific intervention was investigated. RESULTS: In 2015, 4113 providers submitted claims for iliac (n = 13,659), femoropopliteal (n = 52,344), and tibioperoneal (n = 32,688) endovascular revascularizations. In the facility setting, VS performed most of these procedures (52%), followed by IC (32%) and IR (8%). In the outpatient-based lab setting, the proportions were 46%, 36%, and 13%, respectively. Substantial statewide variability in the role of different specialties in LEER was noted. In Maine, Vermont, and Hawaii, all facility claims were submitted by VS, while more than 70% of the claims in Arizona and Utah were submitted by IC. The highest share of LEER for IR was observed in Montana and North Dakota (50%). There was substantial statewide variability in the submitted charges. CONCLUSION: Currently, less than 10% of LEER procedures are being performed by IR. The statewide variability in the submitted charges of care by providers and actual reimbursement for Medicare beneficiaries were investigated in this study.

The Prevalence of Cricopharyngeal Webs in Elderly Cadavers.

OBJECTIVE: Cricopharyngeal webs (CPW) are a frequent cause of solid food dysphagia. They are difficult to diagnose and are often missed on swallowing fluoroscopy. The prevalence of CPWs is uncertain. The purpose of this study was to determine the prevalence of CPWs in elderly cadavers. METHODS: Direct laryngoscopy and cervical esophagoscopy were performed in 19 embalmed cadavers by independent two-clinician consensus. Cadaver demographics and the presence and laterality of a CPW were recorded. The prevalence of CPW was calculated, and the size of the cricopharyngeus muscle (CPM) was quantified. RESULTS: The mean age of the cohort was 83 ( ± 12) years. Fifty-three percent were female, and the mean body mass index was 19.7 ( ± 3). The causes of death were cardiovascular disease (10 of 19), cancer (5 of 19), and respiratory failure (4 of 19). A CPW was present in 68% (13 of 19) of cadavers. Forty-seven percent (9 of 19) had a unilateral web, and 21% (4 of 19) had a bilateral web. There was no laterality predominance (P > 0.05). Forty-two percent (8 of 19) had no CPM prominence; 32% (6 of 19) had a small/moderate CPM prominence; and 26% (5 of 19) had a significant CPM prominence. CONCLUSION: The prevalence of cricopharyngeal webs in elderly cadavers is high (68%). The clinician should maintain a high index of suspicion for CPWs in patients with no other identifiable etiology of solid food dysphagia. LEVEL OF EVIDENCE: 3b Laryngoscope, 129:63-66, 2019.