A careful look at the literature suggests a variety of clinical best practices, including the use of cochlear implantation to improve cognitive function and olfactory training to help with smell loss after infection, experts said at a Best Practice session at the 2022 Triological Society Combined Sections Meeting.
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June 2022The session was based on the popular “Best Practice” articles in The Laryngoscope, in which authors write concise reviews of the literature to try to answer clinical questions routinely faced by physicians.
Cochlear Implantation
Aaron Moberly, MD, an associate professor of otolaryngology– head and neck surgery at The Ohio State University in Columbus, said that the pattern in the literature shows that cochlear implantation can help improve cognition, but it isn’t a straightforward picture.
In what’s thought to be the largest series on the topic, a study out of France enrolled 93 patients who were 65 and older and assessed their cognition before cochlear implantation and at six and 12 months after implantation (JAMA Otolaryngol Head Neck Surg. 2015;141:442-450). The study’s strengths were that the patients were at a greater risk of cognitive challenges, and it used an array of tests to assess an assortment of cognitive domains, including episodic memory, processing speed, flexibility, and executive function.
As with most studies in this area, however, it didn’t include people with severe cognitive deficits. And, because the patients received rehabilitation therapy for the implants for six months, the cognitive results could have been influenced by that therapy.
Nonetheless, the results suggest that cochlear implants help with cognition, with improvement in some domains at six months, and with additional domains at 12 months, with those patients who had the poorest cognitive function seeming to receive the most benefits.
As otologists, occasionally we see these patients who have obvious cognitive deficits already—what do we do with them, and what’s the best way to clinically manage them? —Aaron Moberly, MD
A study out of Australia that enrolled both cochlear implant recipients and controls who did not have implants but who were on the waiting list for one, found that those who had received the implant showed improvements in attention, processing speed, and working memory at six months, and, additionally, in working memory, general memory, and executive function at 12 months (Otol Neurotol. 2018;39:514-515).
Other studies have also found a tie between cognitive benefits and cochlear implants, showing that patients starting with greater cognitive deficits receive better results.
“It does seem like there are consistent improvements at six months across some domains, and additional gains may be seen at 12 months after cochlear implantation in the same domains or in additional domains,” Dr. Moberly said.
“I take with a grain of salt the actual, specific findings of which domains were affected because all these tests are different.” More consistent tests would help pinpoint the areas that are truly improving, he said.
Enrolling patients who have shown a more serious decline at the time of receiving their implant in similar studies would also help the field, he said. “As otologists, occasionally we see these patients who have obvious cognitive deficits already—what do we do with them, and what’s the best way to clinically manage them?” he said. “And how much do we expect improvement in cognition? We have to be careful about how we talk to our patients about that.”
HPV Vaccination in Older Individuals
Maie St. John, MD, PhD, chair of head and neck surgery at the University of California, Los Angeles, shared evidence to support human papillomavirus (HPV) vaccination in adult individuals.
“Given the demonstrated benefits in women and men age 26 to 45, even in those with prior HPV infection, as well as the high safety profile, we should be recommending the HPV vaccine to all our patients age 26 to 45 who have not yet been vaccinated, based on published evidence,” she said.
In 2018, the FDA expanded the age range for vaccine approval from 9 to 26 years of age to 9 to 45 years of age. Still, uptake of the vaccine is less than ideal— it currently stands at less than 60% for adolescents and young adults, said Dr. St. John.
In 2020, the agency approved the vaccine for preventing oropharyngeal cancer, but the Advisory Committee on Immunization Practices did not expressly recommend routine HPV vaccination for adults 26 to 45 years old, saying it could be given with shared decision-making between physicians and patients. There is concern that this could be seen as a recommendation against the vaccine, Dr. St. John said, but this shouldn’t be the perception.
A phase 3 trial of almost 5,000 women ages 26 to 45 found that the HPV vaccine against the 16 and 18 strains showed 50% to 70% efficacy in reducing persistent infections over a six-month period and in low-grade squamous intraepithelial cervical lesions, regardless of whether the women had been infected with HPV previously. The vaccine also cross-protected against HPV types 31 and 45, which are also oncogenic, Dr. St. John said (Lancet Infect Dis. 2016;16:1154-1168).
Another study, with a prospective cohort of 150 adult men ages 27 to 45, found that the HPV vaccine generated a durable immune response (Vaccine. 2019;37:2864-2869). “The potential benefits of increasing vaccine uptake far outweigh the limited risks,” Dr. St. John said.
Olfactory Training Following Infection
Ralph Metson, MD, a professor of otolaryngology– head and neck surgery at Harvard Medical School in Boston, said that evidence supports the use of olfactory training to help with loss of smell after an infection.
Patients report a loss of smell in 50% to 60% of COVID-19 cases. In 85% of those cases, their sense of smell returns after about four weeks. But in 5% to 10% of these cases, the loss of the sense of smell can go on for three months or longer, and an estimated 700,000 to 1.6 million people have chronic problems with smell because of COVID-19, Dr. Metson said.
A pioneering study in 2009 was the first to report the usefulness of olfactory training for smell loss after infection. In the prospective study, 24 patients underwent the training, while 11 controls did not. The training consisted of smelling four different scents for about 10 seconds at a time, twice a day for three months. Improvement in detecting scents, telling the difference between scents, and identifying scents at three months was seen in 21% of the treatment group, but in just 6% of the controls (Laryngoscope. 2009;119:496-499).
In another, more recent study, 70 subjects underwent training with therapeutic concentrations of scents, while 74 were exposed to concentrations that were diluted and not considered therapeutic. At four months, 26% of those in the therapeutic group showed significant improvement, while just 11% in the other group showed significant improvement. Those who’d had loss of their sense of smell for less than 12 months were more likely to improve than those who had suffered smell loss for a longer period (Laryngoscope. 2014;124:826-831).
“Olfactory training should be offered to patients who complain of postinfection smell loss,” said Dr. Metson. “It’s low cost and low risk. It makes patients feel good, and it makes you [as a physician] feel good.”
The approach that has been shown to work well for many patients involves deliberate sniffing of each of a floral, citrus, spice, and fresh or effervescent scent—most commonly rose, lemon, clove, and eucalyptus—for about 20 seconds each, twice a day for three months or more. This should not be started within one month of the loss of the sense of smell because the problem so often resolves naturally within the first month, Dr. Metson said. Subglottic Stenosis Management Mona Abaza, MD, MS, a professor of otolaryngology–head and neck surgery
Subglottic Stenosis Management
Mona Abaza, MD, MS, a professor of otolaryngology–head and neck surgery at the University of Colorado in Boulder, said that pulmonary function testing can be helpful in the management of subglottic stenosis.
CT scans, which are “fairly useful” and easy to get, have been widely used by physicians to assess and monitor the condition, Dr. Abaza said. But they do have problems associated with them, she said.
“They can be pretty costly, and if you’re talking about a patient who’s having airway surgery every several months, the cumulative radiation dose can be a challenge as well,” she said. In addition, these measures often aren’t helpful in assessing the dynamics of the airway collapse. Also, visualization of the airway can have subjective aspects to it, she noted.
More recently, pulmonary function testing has emerged as a way to obtain objective measures “to allow us to really understand dynamic changes, as well as the efficiency and effectiveness of the myriad procedures that are used to treat subglottic stenosis,” Dr. Abaza said. In one study, with 32 patients and 271 patient encounters, peak expiratory flow (PEF) was found to significantly correlate with quality of life (Laryngoscope. 2018;128:1398-1402).
Care must be taken with interpretation of peak expiratory flow values, Dr. Abaza cautioned. Because they are dependent on age, height, body type, and gender, a value might be normal in one person but abnormal in another, she said.
Instead, a more useful measure is the percentage change from a given person’s normal PEF, she said. This can be used to assess changes over time clinically and to assess the effect of, and the need for, interventions. PEF is particularly useful because it can be done at home, she added, cautioning that because the tests are effort dependent, they might be of limited value in children or those with cognitive challenges.
“We can use PFTs to help define a patient’s breathing and dyspnea in a more objective manner,” Dr. Abaza said. “You can record them after changes to really begin to define how effective whatever procedure you performed is at improving the patient’s breathing. And you can noninvasively track patients, and they can track themselves.”
Intubation to Tracheostomy Transitions
Edward Damrose, MD, a professor of otolaryngology–head and neck surgery at Stanford University in Stanford, California, said the bulk of the evidence today shows that earlier transition from intubation to tracheostomy leads to the best outcomes.
In a Cochrane review that included eight randomized, controlled trials and 1,977 patients, early conversion to tracheostomy after 10 days or fewer of ventilation performed better than later tracheostomy (Cochrane Database Syst Rev. 2015;1:CD007271). The risk of overall mortality was 17% lower in the early group, and the use of care in the intensive care unit decreased, although that review couldn’t reach conclusions about ventilator-associated pneumonia or laryngotracheal injury because of the heterogeneity of the patients studied, Dr. Damrose said.
In addition, in a meta-analysis, early transition—this time defined as within two to eight days of intubation—led to a shorter intensive care unit stay, lowered the incidence of pneumonia, and lowered the duration of ventilation support, he said (Otolaryngol Head Neck Surg. 2015;152:219-227).
The best practice message to take from the literature, Dr. Damrose said, is that the upper limit of conversion to tracheostomy should be about 10 days. “If you can tracheotomize these folks within that window, there’s generally an overall improvement in mortality and a decreased utilization of ICU care,” he said.
The literature also shows the importance of taking obesity into account, he added. “Certain subpopulations, especially the morbidly obese and those (with large tubes), may also benefit from early tracheotomy to decrease the risk of laryngotracheal injury.”
Thomas R. Collins is a freelance medical writer based in Florida.