Discover new updates in otolaryngology.
Made for medical students, by medical students.
Feature Article of The Month
The Conversational Side of Surgery
Grace R. Leu, Anne R. Links, Jenny Park, Mary Catherine Beach, Emily F. Boss. Parental Expression of Emotions and Surgeon Responses During Consultations for Obstructive Sleep-Disordered Breathing in Children. JAMA Otolaryngol Head Neck Surg. 2021 Dec 9. [Article Link]
What factors guide the emotional communication between surgeons and the parent's of their pediatric patients?
There has been a shift in tone of conversation during surgical consultation toward patient-centered communication, as it has been shown to improve patient satisfaction, treatment adherence, and clinical outcome. The unique management of pediatric patients results in this conversation being had with a proxy such as a parent or caregiver, rather than the patient themself. This study highlights the changing pace of medical conversations and explores the factors that influenced conversations between surgeons and parents of patients with obstructive sleep disordered breathing. This cross-sectional study performed by the Johns Hopkins Department of Otolaryngology observed at least 1 emotional expression in 40 out of 59 total parent consultations. The majority of surgeons responded to parents expressing emotion by giving them space for elaboration (69.9%) rather than engaging in an empathy driven conversation. Additionally, this study also noted that surgeons were less likely to engage and explore emotions of parents from racial and ethnic minority groups compared to their White counterparts (OR = 0.47). This study is of the few to highlight not just the scarcity of emotionally driven conversation during surgical consultations, but how implicit biases may exist during surgeon-patient conversations.
Sudeepti Vedula’s Takeaway: This study suggests that implicit biases may be hindering the ability of surgeons to have family-centered, culturally competent conversations during surgical consultations with parents of pediatric patients. As one of the first studies to detail the prevalence and effects of emotional surgical conversations, it calls on us as a community to increase awareness and correct these implicit biases.
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Question of the Week
A 48-year-old woman presents to your office after undergoing a fine needle aspiration biopsy of a 1.7 cm nodule located within her right thyroid lobe. The pathology report states "Suspicious for a follicular neoplasm." Based on these results, which of the following should be considered for the next steps in clinical management?
A. Clinical and sonographic follow-up in 6 months
B. Repeat FNA with ultrasound guidance
C. Molecular testing and lobectomy
D. Near-total thyroidectomy
(Answer at the bottom)
Wednesday, December 15th, 2021
Facial Plastic Surgery
Nicole C. Starr, Liza Creel, Christopher Harryman, Nikita Gupta. Cost Utility Analysis of Costal Cartilage Autografts and Human Cadaveric Allografts in Rhinoplasty. Ann Otol Rhinol Laryngol. 2021 Nov 15;34894211058115. [Article Link]
How expensive is my rhinoplasty going to be?
In order to replace structural support in rhinoplasty operations, facial plastic surgeons can opt to use either allograft or autograft for cartilaginous reconstruction. However, new research seems to suggest the potential for tissue engineering as a disrupting alternative in this reconstructive space. While no option is supported as unequivocally best for clinical outcomes in the literature, Starr et al. conducted a cost analysis of the current options: human cadaveric allograft (HCA) and costal cartilage autograft (CCA). By including cost estimates of not only physician reimbursement, but also graft costs, surgery center payments, and costs of complications, the authors identified that, at baseline, there is little difference in cost of primary repair using the two reconstructive modalities (~$8000). However, when considering revision operations, observation & admissions, and clinical complications associated with harvesting rib cartilage, the costs incrementally skyrocket for CCA ($21099 for admissions complicated by pneumothorax). In the setting of new research for tissue engineering, this data can shed light on cost control targets and strategies for new products to be competitive in the marketplace.
Humzah Quereshy's Takeaway: Methodologically, this study is fascinating as it introduces a new modality of research of cost utility analysis, and explains that in addition to CPT code reimbursement, there are a number of ancillary costs associated with cost of a procedural “episode”. This study sheds light on the consideration of the probability of complications when trying to understand estimated cost of an operation.
Head and Neck Surgery
Dominic Ku, Michelle Hui, Phylannie Cheung, Oliver Chow, Mark Smith, Faruque Riffat, Niranjan Sritharan, Dipti Kamani, Gregory Randolph. Meta-analysis on continuous nerve monitoring in thyroidectomies. Head Neck. 2021 Dec;43(12):3966-3978. [Article Link]
Is continuous intra-operative nerve monitoring effective in minimizing risk of recurrent laryngeal nerve injury during thyroidectomies?
Intermittent intra-operative nerve monitoring (I-IONM) has been instrumental in reducing risk of recurrent laryngeal nerve (RLN) damage during thyroidectomies. However, I-IONM is not without its drawbacks including the inability to detect RLN injury until after it has taken place. Continuous intra-operative nerve monitoring (C-IONM) via continuous stimulation of the vagal nerve can address this issue by providing information on RLN status in real time. To compare outcomes between C-IONM v. I-IONM, this meta-analysis assessed rates of temporary and permanent vocal cord paralysis along with other adverse events associated with C-IONM during thyroidectomies. A total of 23 studies were included, with 3,040 patients and 5,007 nerves at risk. Among these studies, the rate of temporary vocal cord paralysis was 2.26% and the rate of permanent vocal cord paralysis was 0.05%, with one case of hemodynamic instability reported. Ultimately, this meta-analysis demonstrated that C-IONM during thyroidectomies has low rates of vocal cord paralysis and other nerve monitoring-associated adverse events compared to published data on I-IONM.
Christopher Tseng's Takeaway: Nerve monitoring plays an important role in helping to minimize risk of recurrent laryngeal nerve injury during thyroid surgery. It is certainly exciting to see how these tools continue to be improved upon to optimize outcomes.
Laryngology
Robert Brinton Fujiki, Jessica E Huber, M Preeti Sivasankar. Mitigating the Effects of Acute Vocal Exertion in Individuals With Vocal Fatigue. Laryngoscope. 2021 Dec;131(12):2732-2739. [Article Link]
Are semi-occluded vocal tract exercises more effective than vocal rest?
In this prospective study, 10 individuals with vocal fatigue participated in two 10-minute vocal exertion tasks on two consecutive days. Semi-occluded vocal tract exercises (SOVTEs) and/or vocal rests were integrated between the vocal exertion tasks. Outcome measures included: Phonation Threshold Pressure (PTP) at 80% pitch range, maximum and minimum fundamental frequencies of the frequency range (F0), cepstral peak prominence (CPP) on connected speech, self-perceived vocal effort, lung volume initiation (LVI), lung volume termination (LVT), and a number of syllables per breathe. Both SOVTEs and vocal rest significantly lowered vocal effort to baseline and increased LVT above baseline; however, there were no significant differences found between the effect of SOVTEs and vocal rest. The study authors suggest that their findings may be explained by the short duration of vocal exertion implemented in this study compared to previous studies.
Lauren DiNardo’s Takeaway: Both SOVTE and vocal rest partially restored the changes in vocal function after exertion. Further research is needed to investigate specific circumstances where SOVTE would be preferred over vocal rest.
Otology and Neurotology
Janet S Choi, Franklin Wu, Soyun Park, Rick A Friedman, Elina Kari, Courtney C J Volker. Factors Associated With Unilateral Hearing Loss and Impact on Communication in US Adults. Otolaryngol Head Neck Surg. 2021 Dec;165(6):868-875. [Article Link]
Unilateral hearing loss: hidden repercussions?
Patients with unilateral hearing loss (UHL) often report frustrations related to communication in noisy environments and sound localization that may produce adverse psychosocial effects. The authors of this study sought to identify factors (both non-medical and medical) associated with UHL in adults and also determine how UHL impacts communication. To this end, they analyzed audiometric data, communication survey data, demographics, health care utilization/insurance status, and medical history in participants of the 2011-2012 and 2015-2016 National Health and Nutritional Examination Survey (NHANES). UHL was defined as speech frequency pure-tone average (PTA) (0.5, 1, 1, and 4 kHz) thresholds ≥ 25dB hearing in the affected ear and <25 dB in the unaffected ear. Adults with UHL were more likely to report trouble with hearing (OR: 3.6, 95%CI: 2.7-4.7) and frustration when talking (OR: 3.0, 95%CI: 1.9-4.6). Multivariate analyses revealed UHL was also associated with diabetes (OR: 1.90, 95%CI: 1.31-2.75), cardiovascular disease (OR: 1.75, 95%CI: 1.07-2.87), and off-work noise exposure (OR: 1.49, 95%CI: 1.04-2.14). The authors also note that listening device use remains low in patients with UHL and attribute this to the possibility that patients may not appreciate a subjective hearing loss and/or lack of education on the adverse effects of UHL.
Pavan S. Krishnan’s Takeaway: At this point, the evolution of hearing interventions only partially addresses patients with UHL. Future interventions must be concurrent with public health interventions to identify and address symptoms associated with UHL to prevent further burdening this specific patient population.
Pediatric Otolaryngology
Leo Gundle, Shilpa Ojhab, Joseph Hendry, Harry Rosen. Stenting versus stentless repair for bilateral choanal atresia: A systematic review of the literature. Int J Pediatr Otorhinolaryngol. 2021 Dec;151:110926. [Article Link]
Which approach for the treatment of bilateral choanal atresia is best: stenting or stentless?
Bilateral choanal atresia (BCA) requires early surgical intervention. This study conducted a systematic review to compare the outcomes of stenting versus stentless repair of BCA, in addition to investigating operative adjuncts. Articles included in the study consisted of a meta-analysis, two randomized control trials, and 45 case series. There was insufficient evidence from randomized control trials (RCTs) to recommend either stenting or stentless repair, but pooled analysis showed a significant reduction in granulation tissue in unstented patients. For case series, the vast majority of studies reported satisfactory outcomes (e.g. >50% choanal patency, absence of nasal symptoms) for both stented and unstented patients. Further analysis demonstrated that restenosis and complication rates were lower in studies that utilized stentless repair. However, the overall data included in the case studies were of mixed quality, therefore factors contributing to positive outcomes were difficult to interpret.
Anastasia Jermihov’s takeaway: Extremely rare conditions, such as BCA, can be difficult to develop evidence-based treatment plans for due to the paucity of high-quality research investigating treatments against a control group. The importance of creating operational definitions for outcomes or other variables particularly in case reports is highlighted by this study and its conclusions.
Rhinology and Sinus Surgery
Lillian W. Dattilo, Alan D. Workman, Neil Bhattacharyya. Chronic Rhinosinusitis and the Risk of Erectile Dysfunction. Otolaryngol Head Neck Surg. 2021 Oct 19;1945998211051934. [Article Link]
When a patient comes to you with chronic rhinosinusitis, is there something else they're not telling you?
Chronic rhinosinusitis (CRS) is negatively associated with many different quality-of-life measures including, sleep, fatigue, work productivity, and psychological well-being. More recent studies have found an association between CRS and sexual health; in particular, CRS patients are at increased risk of developing erectile dysfunction (ED). Therefore, the authors performed a case-control study on 2 years (2018-2019) of institutional records to examine whether ED patients would demonstrate a higher prevalence of CRS compared to their matched control cohorts without ED. Of the case-cohort, comprised of male patients aged 35-75 years who received prescription medication for ED (PDE5 inhibitors, e.g. sildenafil), 3.0% had a diagnosis of CRS as compared to 1.5% in the control group. The authors concluded that a diagnosis of CRS was significantly associated with that of ED, with an odds ratio of 2.0 (95% CI = 1.8-2.4, p<0.001). Moreover, on sensitivity analysis, the odds of having CRS remained significantly higher when examined within both 365 and 180 days of ED prescription.
David Avery Cohen’s Takeaway: As a third-year medical student, I have already seen how patients may understandably avoid discussing uncomfortable topics such as sexual dysfunction with their provider despite symptom severity. As future providers, we must be aware of any conditions our patients might be suffering from so as to ensure they are treated accordingly.
Quiz Answer: C (Bethesda Criteria IV)
According to Bethesda System for Reporting Thyroid Cytopathology, the recommended management of a patient with a diagnosis of follicular nodule or suspicious for follicular nodule (FN/SFN) is surgical excision of the lesion, most often a hemithyroidectomy or lobectomy, but molecular testing may be used to supplement risk assessment rather than proceeding directly to surgery.
SUPER high-yield for sub-I rotations!