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Literature Review: A Roundup of Important Recent Studies

Routine ICU Admission for All Post-Surgical OSA Patients Unnecessary

Do patients undergoing multi-level airway surgery for obstructive sleep apnea (OSA) require routine intensive care unit admission after surgery?

Background: Patients undergoing surgery for OSA have been identified as high risk for post-operative complications. However, there is no standard with regard to the type of monitoring required after surgery, which ranges from discharging the patient home after recovery room observation to overnight intensive care monitoring.

Study design: Retrospective review of consecutive patients.

Setting: Tertiary care hospital, Singapore.

Synopsis: The records of 487 consecutive adult patients undergoing nasal and palatal surgery with (NPT) and without (NP) tongue base surgery for OSA were reviewed for complications. Those undergoing NP were monitored for six hours after surgery and discharged, while those undergoing NPT were monitored in a step-down unit overnight. In total, 7 percent of patients had complications, including oxygen desaturation (1.2 percent), persistent hypertension (3.1 percent), postobstructive pulmonary edema (0.4 percent), tongue swelling (1.8 percent), airway obstruction (0.2 percent) and bleeding (3.1 percent). All desaturations occurred within 180 minutes after surgery. All of the tongue swelling and airway obstruction complications were secondary to tongue suspension suture placement.

While the authors acknowledge that narcotics make post-operative respiratory complications more likely, they do not document how pain was managed in these patients. They also make a number of suggestions for post-operative care but include no analysis supporting these findings. Finally, they suggest close post-operative monitoring for three hours in the recovery room to determine whether admission to a surgical floor or increased monitoring environment is necessary.

Bottom line: Patients with post-operative desaturations after undergoing multi-level airway surgery for OSA had them within three hours of the surgery and may not require admission if undergoing nasal and palatal surgery alone. Those undergoing tongue procedures and suspension suture placement in particular had an increased likelihood of complications.

Reference: Pang KP, Siow JK, Tseng P. Safety of multilevel surgery in obstructive sleep apnea: a review of 487 cases. Arch Otolaryngol Head Neck Surg. 2012;138(4):353-357.

—Reviewed by Stacey L. Ishman, MD

Parent Education for Adenotonsillectomy Risks

Do parents understand more of the risks of adenotonsillectomy when pre-operative teaching utilizes standard counseling and a handout versus a video?

Background: Adenotonsillectomy is one of the most commonly performed surgical procedures in children, and yet parental understanding of the procedure’s risks is often limited. In addition, little is known about the optimal way to provide patient and parental education.

Study design: Prospective randomized controlled study.

Setting: Military tertiary referral hospital.

Synopsis: Forty-five parents were asked to remember nine risks of adenotonsillectomy, and scores were compared after counseling alone (C), counseling with a handout (CH) and counseling plus a video (CV). Before surgery, parents remembered an average of 6.8, 7.3 and 6.6 risks in the C, CH and CV groups, respectively. After surgery, parents remembered an average of 5.8, 6.5 and 5.2, respectively, with no significant difference between groups. The length of time to surgery was inversely correlated with retention of surgical risks (P=0.02). Despite the fact that there was no significant improvement in parental understanding through use of videos or handouts, 90 percent of the parents felt that these modalities added to their understanding. In addition, these interventions reduced counseling time by 2.9 to 5.4 minutes.

Previous studies have found the use of handouts to improve procedure risk retention, which was not demonstrated here. Limitations include the fact that most of the parents had at least some secondary education and the sample size was small. However, the use of handouts or videos may allow for decreased face-to-face counseling time without reducing parental understanding of surgical risks.

Bottom line: Parents are not able to retain all of the nine common surgical risks of adenotonsillectomy, and the addition of a handout or video did not add any significant benefit when combined with counseling. Longer times between surgery counseling and the procedure itself may contribute to a reduction in retention of risks.

Reference: Adams MT, Chen B, Makowski R, Bevans S, Boseley M. Multimedia approach to preoperative adenotonsillectomy couselling. Otolaryngol Head Neck Surg. 2012;146(3):461-466.

—Reviewed by Stacey L. Ishman, MD

Resident Facebook Postings Impact Professionalism

What portion of otolaryngology applicants for residency at a single institution had Facebook profiles that would be considered unprofessional?

Background: Increased Internet-based social networking and connectivity have resulted in increased exposure for physicians who post personal information on websites such as Facebook. Patients routinely search for information on their doctors via the internet. Professionalism is one of the six core competencies stressed by the Accreditation Council of Graduate Medical Education (ACGME) and could be impacted by what is posted on a physician’s publically accessible website.

Study design: Case series.

Setting: Division of Otolaryngology-Head and Neck Surgery, University of Alabama, Birmingham.

Synopsis: Of 234 residency applicants to the otolaryngology program, 119 had Facebook profiles. Of these, 85 profiles contained information beyond simple demographics: 11 percent contained pictures or text that at least one reviewer felt could be perceived as unprofessional, six profiles contained content considered “concerning” and one profile contained clear violations of professional boundaries.

Examples of content perceived as unprofessional were: photos of applicant consuming alcohol and obviously intoxicated; photo of applicant wearing Halloween costume with negative stereotype of a specific ethnicity; profanity in status updates; and a status update detailing a patient encounter in the emergency room, with date and time included in the description.

The authors noted that applicant age, gender, board score, region of residence, number of friends and other factors showed no relationship to a lower professionalism score, thus identifying no way to predict which applicants were at risk.

Bottom line: Physicians and medical students should make themselves thoroughly aware of their online presence.

Reference: Golden JB, Sweeny L, Bush B, Carroll WR. Social networking and professionalism in otolaryngology residency applicants. Laryngoscope. 2012;122(7):1493-1496.

—Reviewed by Sue Pondrom

No Difference in Life Expectancy with HNSCC Imaging Modality

Is life expectancy in head and neck squamous cell carcinoma (HNSCC) patients with distant metastasis altered by the type of imaging used?

Background: The choice of diagnostic modality to detect distant metastasis in HNSCC has included chest X-ray, computed tomography (CT), magnetic resonance imaging (MRI) and, most recently, positron-emission tomography (PET). Recent reports have shown PET to be more sensitive at identifying occult metastatic disease than other radiographic modalities. However, it is unclear whether detection of distant metastasis by PET influences life expectancy in patients with HNSCC.

Study design: Retrospective.

Setting: Department of Otolaryngology-Head and Neck Surgery and Department of Medical Oncology, University of Michigan Health System, Ann Arbor.

Synopsis: Of 115 patients identified as having distant metastasis by surveillance imaging, 38 (33 percent) were identified by PET scan, 57 (50 percent) by CT scan, and 20 (17 percent) by chest X-ray. There were no differences in life expectancy in the patients who were identified to have distant metastasis when stratified by imaging modality.

In 55 patients who were identified as having distant metastasis discovered on imaging due to concerning symptoms, 10 (18 percent) were identified by PET, 24 (44 percent) by CT, six (11 percent) by chest X-ray and 15 (27 percent) by MRI or bone scan. There were no differences in life expectancy when stratified by imaging modality.

Bottom line: PET does not have an added benefit of prolonging life expectancy in patients with distant metastasis in HNSCC.

Reference: Spector ME, Chinn SB, Rosko AJ, et al. Diagnostic modalities for distant metastasis in head and neck squamous cell carcinoma: are we changing life expectancy? Laryngoscope. 122(7):1507-1511.

—Reviewed by Sue Pondrom

Nasal Steroids Effective in Chronic Rhinosinusitis with Polyposis

Do topical nasal steroids improve patient symptomatology in chronic rhinosinusitis with polyposis?

Background: Chronic rhinosinusitis (CRS) with nasal polyposis affects 0.5 percent to 4 percent of the world population and is present in approximately 20 percent of patients with chronic rhinosinusitis. A large number of randomized controlled trials have evaluated the efficacy of topical nasal steroids to improve symptomology. While prior studies have used a change in polyp size as a surrogate for a direct clinical benefit, there has been no demonstration of a correlation between endoscopic grading and patient symptom scores.

Study design: Systematic review with meta-analysis using standardized methodology.

Setting: Rhinology and Sinus Surgery, Division of Otolaryngology, Department of Surgery, University of Calgary, Alberta, Canada; Division of Rhinology and Sinus Surgery, Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston; Division of Rhinology and Sinus Surgery, Oregon Sinus Center, Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland.

Synopsis: A total of 19 randomized controlled trials met inclusion and exclusion criteria for a systematic review. The trials were performed from 1993 to 2010, ranging in length from four to 270 weeks. All evaluated three steroid formulations: fluticasone, mometasone and budesonide.

The authors found that gender, age and history of prior polypectomy did not appear to influence steroid efficacy. They did, however, find publication bias in the studies. Topical nasal steroid therapy (all three in the studies) in patients with CRS and nasal polyposis were found to be efficacious. Noting that polyp size reduction is only an indirect measure of clinical success, the authors said one can argue that the most clinically relevant outcome is patient-reported symptoms.

Bottom line: Topical nasal steroids improve patient symptomatology in chronic rhinosinusitis with polyposis.

Reference: Rudmik L, Schlosser RJ, Smith TL, Soler ZM. Impact of topical nasal steroid therapy on symptoms of nasal polyposis: a meta-analysis. Laryngoscope. 122(7):1431-1437.

—Reviewed by Sue Pondrom

Study Looks at Costs of Laryngeal Diseases and Disorders

What are the annual direct costs associated with the evaluation and management of patients with laryngeal disorders, and what is the proportion of annual direct costs related to physician encounters, procedure claims and pharmacy claims?

Background: Approximately one-third of adults experience dysphonia at some point during their lifetime. Dysphonia impacts quality of life and work productivity. Prior studies have focused primarily on specific disease states and populations. One study, by Verdolini and Ramig, estimated costs but only for a teaching population, and it was not clear how cost estimates for voice therapy and surgery were determined.

Study design: Retrospective analysis of data from a large, nationally representative, administrative U.S. claims database.

Setting: Duke Voice Care Center, Division of Otolaryngology-Head and Neck Surgery, Duke University Medical Center, Durham, North Carolina; Division of Public Health and Study Design and Biostatistics Center, Department of Communication Sciences and Disorders, Division of Otolaryngology-Head and Neck Surgery, University of Utah, Salt Lake City; Center for Outcomes Research, Department of Medicine, University of Illinois College of Medicine, Peoria; Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco.

Synopsis: Age, gender, geographic location, employment status, type of medical encounter, physician specialty, pharmacy claims and procedure claims were collected for each of 309,300 patients with 12 months follow-up. Acute and chronic laryngitis, nonspecific causes of dysphonia and benign vocal fold lesions were the most common etiologies. Total direct costs ranged between $178,524,552 and $294,827,671, with mean costs per person between $577.18 and $953.21.

Pharmacy claims accounted for 20.1 percent to 33.3 percent, procedure claims for 50.4 percent to 69.9 percent and medical encounter claims for 16.3 percent to 8.6 percent of overall direct costs. Antireflux medication accounted for roughly 10 percent and antibiotics 6 percent of annual direct costs.

Bottom line: The evaluation and management of patients with laryngeal disorders has associated mean direct costs of $577.18 to $953.21 per patient in 12 months, and national annual cost estimates were comparable to other chronic disease states.

Reference: Cohen SM, Kim J, Roy N, Asche C, Courey M. Direct health care costs of laryngeal diseases and disorders. Laryngoscope. 122(7):1582-1588.

—Reviewed by Sue Pondrom