Attendees at the Combined Otolaryngology Spring Meeting (COSM) in Chicago this May had access to a wealth of information. Concurrent session topics covered everything from rhinology and sleep medicine to head and neck and facial plastic. Here are overviews of some of this year’s sessions.
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August 2024Changes Shortly After Surgery in HGNS and Palate Procedures
In a study evaluating immediate post-operative changes in sleep apnea after hypoglossal nerve stimulation (HGNS) implantation or expansion pharyngoplasty, researchers at Harvard University in Cambridge, Mass., and Massachusetts Eye and Ear in Boston found that HGNS surgery did not lead to a change in apnea-hypopnea index (AHI) scores. But for the palate surgery patients, AHI increased by 19.2 points on the first day after surgery and 25.7 on the second day, when it peaked. These were statistically significant changes.
Because OSA patients have an increased risk for perioperative cardiopulmonary complications and intensive care admissions, data is needed to help guide their perioperative care, said Victoria Wong, an undergraduate researcher at Harvard University, who presented the results.
To be included in the study, participants had to have an AHI of at least five. Researchers found no difference in time under 90% oxygen (T90) in either group. There were 19 HGNS patients and 11 palate surgery patients.
“HGNS is a safe treatment option with minimal changes to sleep measures in the immediate post-operative period,” Ms. Wong said. “Further research is needed to investigate the role of BMI, disease severity, and opioid and anesthetic use.”
Wong V, Yu P, Huyett P. Immediate Postoperative Sleep Changes after Obstructive Sleep Apnea Surgeries. Combined Otolaryngology Spring Meetings; May 13-18, 2024.
Complications for Balloon Sinuplasty Versus FESS
In an analysis of a database on balloon sinuplasty (BSP) procedures and functional endoscopic sinus surgery (FESS), researchers found that epistaxis was the most common complication, seen in 1.7% of BSP cases and about 3% of FESS cases.
The study, based on data from more than 1,700 BSP cases and more than 90,000 FESS cases, comes as BSP is being performed more often both in the operating room and the office setting, said Benjamin Bitner, MD, a resident physician at the University of California in Irvine.
Meningitis was seen in 0.58% of BSP cases, compared to 0.2% of FESS cases, while orbital injury was seen in 0.85% of BSP and 1.54% of FESS patients, Dr. Bitner reported.
Revision BSP was performed in 0.81% of cases, while revision FESS was performed in 2.58% of cases, he said. Readmission occurred in 1.3% of BSP and 3% of FESS cases. There were emergency room visits in 0.94% of BSP cases, compared to 1.83% of FESS cases.
“BSP and FESS surgical volume has steadily increased over time until the COVID-19 pandemic, which caused a drastic reduction in volume without recovery to date,” Dr. Bitner said.
Bitner B, Torabi SJ, Nguyen TV, et al. Trends and Complications in Functional Endoscopic Sinus Surgery and Balloon Sinuplasty: A TriNetX Database Analysis. Combined Otolaryngology Spring Meetings; May 13-18, 2024.
Machine Learning and DISE Predictions of HGNS Success
Deep learning models trained with images from drug-induced sleep endoscopy (DISE) show promise in helping to predict which patients will respond to HGNS, according to findings presented by researchers at the University of Kansas Medical Center in Kansas City.
With areas under the curve (AUC) just under 0.6, models trained with images performed better than models trained only with clinical data, said Rahul Alapati, MD, an incoming intern at UKMC.
The study is an attempt to improve the use of DISE, which has only fair inter-rater reliability.
Five models were trained using clinical data alone from 127 patients who had an average AHI of 35 per hour. Six models were trained using 25,000 DISE images taken from the patients.
VCG-16, a deep learning model trained on images, had the greatest overall accuracy at 0.833, and an AUC of 0.595. Of the models trained with clinical data, the greatest accuracy score was 0.685 and the greatest AUC was 0.531.
All of the deep learning models that were trained only with velopharyngeal data had higher overall accuracy compared to those trained with base of tongue data or a combination of base of tongue and velopharyngeal data, “suggesting that the velopharynx has more discriminative features for identifying overall success,” he said, adding that this dovetails with the U.S. Food and Drug Administration criteria of anterior-posterior wall collapse at the level of the velopharynx in order to be eligible for implantation.
The patient group was mostly white, so there was a limitation in terms of ethnicity, and some were considered nonresponders because they didn’t meet the threshold, even though there might have been some benefit, he said. The issue of the “black box phenomenon” of AI, where “we’re unable to really understand how these AI models come up with their predictions,” was another concern.
Alapati R, Renslo B, Jackson L, et al. Predicting Therapeutic Response to Hypoglossal Nerve Stimulator Using Drug Induced Sleep Endoscopy Images and Deep Learning. Combined Otolaryngology Spring Meetings; May 13-18, 2024.
Aggressive Turbinectomy and Empty Nose Syndrome
Using a virtual endoscopic surgery simulator, researchers have found that isolated aggressive turbinectomy does not create distorted airflow patterns similar to those seen in empty nose syndrome (ENS) patients. The findings support the notion that aggressive turbinate surgery is likely not the only reason for the development of ENS in postnasal airway patients, they said.
The study is an attempt to help understand the cause of ENS, a condition in which the nasal airway is open but feels blocked, a distressing phenomenon particularly because there is no official treatment. It is often attributed to aggressive turbinectomy, but there is no strong data linking the two, said Ahmad Odeh, a fourth-year medical student at St. Louis University in Missouri, who worked on the study during his clinical research year while at Ohio State.
The lab uses uploaded computed tomography images and can produce airflow simulations of the nasal cavity using computational fluid dynamic (CFD) modeling. In the study, six patients who had previous turbinate surgery were recruited retrospectively; virtual inferior turbinectomy was performed on their pre-surgery CT scans, and the resulting CFD simulations were compared to a previously studied group of 27 ENS patients.
Researchers found that the ENS patients had a more imbalanced airflow dynamic, with differences in airflow rate and wall shear force—the force exerted by the airflow—between the virtual turbinectomy cases and the cases of ENS, Mr. Odeh said.
“Aggressive turbinate surgery is likely not the sole cause of ENS, and it’s likely a multifactorial process.”
“The use of a surgical simulator and virtual planning could optimize future surgical outcomes and avoid complications like ENS,” said the senior author of the study, Kai Zhao, PhD, professor of otolaryngology–head and neck surgery at The Ohio State University.
Odeh A, Wen R, Wu Z, et al. Does Total Turbinectomy Always Lead to Empty Nose Syndrome? A Computational Virtual Surgery Study. Combined Otolaryngology Spring Meetings; May 13-18, 2024.
Bell’s Palsy and Academy-recommended Treatment
Researchers at Icahn School of Medicine at Mount Sinai in New York found that nearly half of Bell’s palsy patients are not receiving the treatment recommended by the American Academy of Otolaryngology-Head and Neck Surgery.
The academy recommends that patients receive high-dose steroids within 72 hours. In an analysis of the MarketScan database from 2013 to 2020, researchers found that, out of nearly 67,000 Bell’s palsy cases, only 52% received this treatment—34% receiving both high-dose steroids and antivirals, and about 18% receiving high-dose steroids only. About 3% received antivirals only, which is not recommended by the academy, said Sujay Ratna, BS, a second-year medical student at Icahn.
Male sex and patients ages 18 to 34 were factors most associated with receiving combination therapy, he said. Those in the South and West regions of the U.S. were also more likely to get combination therapy.
“Future studies that correlate with nationwide trends with outcomes,” he said, “may have value in validating the academy guidelines.”
Ratna S, Edalati S, Elkersh Y, et al. Evaluating Treatment Patterns, Provider Subspecialty, and Imaging Practices in Individuals with Bell’s Palsy: A Nationwide Employer-Sponsored Healthcare Claims Data Study. Combined Otolaryngology Spring Meetings; May 13-18, 2024.
Delays in Post-op Radiation Quite Common
Delays are still common in post-operative radiation therapy, and this delay is linked with worse survival, researchers reported in an analysis of data from the National Cancer Database.
Data from 2015 to 2021 was pulled from the database, which covered nearly 33,000 patients—about a third each involved the oral cavity, oropharynx, and larynx, said Rahul Sharma, MD, an otolaryngology resident at Vanderbilt University in Nashville, Tenn.
Data showed that 66% of patients received post-op radiation therapy further out than six weeks. After adjusting for factors such as tumor site, tumor characteristics, and demographic traits, researchers found that those treated after six weeks had a 13% worse survival rate.
“The further you get from six weeks, the worse you get in terms of survival,” Dr. Sharma said.
Predictors of delay, they found, were Stage 4 disease, being on Medicaid, Black race, female sex, and a greater number of comorbidities, Dr. Sharma said.
“Future investigations need to be at an institutional level to understand what’s happening in these unique settings,” he said, “and this can help us develop actionable items.”
Sharma RK, Aweeda M, Philips R, et al. Impact and Predictors of Time to Postoperative Radiation Therapy in Head and Neck Squamous Carcinoma. Combined Otolaryngology Spring Meetings; May 13-18, 2024.
Outcomes with Fibrin Sealants in Rhinoplasty
Using fibrin sealants in rhinoplasty procedures appears to reduce bleeding events, particularly in septoplasty, but doesn’t seem to improve other outcomes, according to a systemic review and meta-analysis.
Researchers at Penn State College of Medicine in Hershey did a literature review and found nine articles that fit the criteria for review. The papers included 531 cases that were primary procedures and 112 that were revisions, with 461 external or open procedures and 152 endonasal procedures, said Hanel Eberly, BS, a fourth-year medical student at Penn State.
Six of the nine papers involved graft or skin fixation indications, and one each involved prevention or correction of Polly beak deformity, securing of spreader grafts, and hemostasis.
A lower rate of bleeding was found with the use of fibrin sealants compared to controls, but this was found to be statistically significant only when septoplasty cases were included. Researchers found no differences for edema, ecchymosis, revision, or infection.
Ms. Eberly noted the lack of high-quality randomized trials in the literature. She added that the various interventions and indications in the studies could complicate interpretation and pointed out that researchers could not account for the various formulations of fibrin sealants.
“Fibrin sealants are increasingly used as graft material in rhinoplasty, and previous studies have described the benefits of using fibrin sealants mixed with diced or morselized cartilage,” Ms. Eberly said. “Subjective measures, such as improved aesthetic results and patient satisfaction after using fibrin sealants, may be more relevant to assess in these patients, but current data on these outcomes was inconsistent and unavailable for meta-analysis in our study.”
Eberly H, Sciscient BY, Truong NM, et al. Does Fibrin Sealant Use in Rhinoplasty Alter Outcomes? A Systematic Review and Meta-Analysis. Combined Otolaryngology Spring Meetings; May 13-18, 2024.