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Literature Review: A Roundup of Important Recent Studies

Adenotonsillectomy in Obese Children Improves AHI but Not Inflammation

Does adenotonsillectomy in obese children improve OSA and systemic inflammation, as measured by TNF-α and IL-6?

Background: Obese children with obstructive sleep apnea (OSA) are more likely to have excessive daytime sleepiness (EDS) with resultant reduction in learning and growth. Elevated TNF-α and IL-6 levels seen in OSA may augment EDS. It is unknown if these markers decrease with treatment in obese children, however, as persistent OSA is highly likely.

Study design: Prospective evaluation of 90 obese children with OSA before and six months after adenotonsillectomy, by polysomnography and lab analysis over a total of eight months.

Setting: Academic medical center (Children’s Hospital of Chongqing Medical University, China).

Synopsis: Ninety obese children with a mean age 6.6±4.1 years had a mean apnea-hypopnea index (AHI) that decreased from 22.3±9.1 to 8.9±5.9 events/hour and an improvement in oxygen saturation nadir from 74.3±7.5 percent to 86.4±5.6 percent. There was no significant change in body mass index (BMI) after surgery (preoperative mean = 41 kg/m2). Resolution of OSA (AHI <5) occurred in 38.9 percent. TNF-α and IL-6 did not change significantly after surgery, regardless of final OSA status. BMI, but not AHI, correlated with TNF-α (r2 = 0.235, p <0.001) and IL-6 (r2 = 0.663, p <0.001) levels. Children with diabetes, craniofacial disease, neuromuscular disease, excessive daytime sleepiness and inflammation were excluded. Limitations include the fact that excluding children with excessive daytime sleepiness may have removed those children most likely to benefit from adenotonsillectomy with reduction in inflammatory markers. The reduction in AHI and level of persistent pediatric OSA is in keeping with previous studies.

Bottom line: OSA is likely to significantly improve in obese children without EDS, although persistent disease occurs in up to 61.1 percent, and inflammatory markers did not improve after adenotonsillectomy, even in those with resolution of OSA.

Reference: Chu L, Li Q. The evaluation of adenotonsillectomy on TNF-α and IL-6 levels in obese children with obstructive sleep apnea. Int J Pediatr Otorhinolaryngol. 2013;77:690-694.

—Reviewed by Stacey Ishman, MD

Improvements in OSA After Weight Loss in Obese Diabetic Patients Even After Weight Regain

Do improvements in obstructive sleep apnea after initial weight loss persist over time in adults with type 2 diabetes and obesity?

Background: Weight loss has been shown to improve OSA in obese adults; however, there is little data looking at the long-term effect of an initial significant weight loss on these patients.

Study design: Multi-center randomized controlled trial (Look AHEAD-Action for Health in Diabetes) evaluating an intensive behavioral weight management (BWM) program with a diabetes education (DE) program. Patients had body mass index (BMI) higher than 25 kg/m2 and underwent unattended home studies to evaluate the effect of weight loss on OSA over four years.

Setting: Four academic medical centers involved in the Look AHEAD trial.

Synopsis: OSA was seen in 264/305 adults aged 45 to 76 (59 percent female); 165 completed year four follow-up. The overall baseline BMI was 36.6 ± 5.7. The BWM group dropped 10.7 ± 0.7, 7.4 ± 0.7 and 5.2 ± 0.7 kg at one, two and four years, respectively, while the DE group dropped less than 1 kg at each time point (p <0.001). Additionally, the apnea-hypopnea index (AHI) was lower in the BWM group by 9.7 ± 2.0, 8.0 ± 2.0 and 7.7 ± 2.3 events/hour at one, two and four years (p <0.001). Those in the BWM group were significantly more likely to improve AHI than those in the DE group. Few study participants were treated for OSA despite identification in this study. Limitations include the fact that those without baseline OSA were excluded and that there was a 38 percent dropout rate over time; it is also unknown whether these patients developed OSA over time.

Bottom line: Improvements in OSA disease severity appear to persist over time in obese diabetic adults despite moderate weight regain. Behavioral medical interventions are much more likely to result in weight loss than diabetes education programs.

Reference: Kuna ST, Reboussin DM, Borradaile KE, et al. Long-term effect of weight loss on obstructive sleep apnea severity in obese patients with type 2 diabetes. Sleep. 2013;36:641-649.

—Reviewed by Stacey Ishman, MD

ESS a Viable Choice for Children with CRS and Failed Therapies

Is endoscopic sinus surgery (ESS) a viable alternative for children with chronic rhinosinusitis (CRS)?

Background: CRS is a common problem in children, and multiple treatment strategies exist. When medical therapies fail, surgical options, including adenoidectomy, balloon catheter sinuplasty (BCS) and ESS, can be used. There are concerns, however, that ESS may cause growth retardation of the face in children.

Study design: Literature review.

Setting: English-language literature published in the PubMed database between January 1990 and July 2012 that discussed the role of ESS in children with CRS.

Synopsis: Eleven articles from PubMed were used after inclusion and exclusion criteria were applied; two Cochrane Library articles were excluded. In one study, both ESS ± adenoidectomy and adenoidectomy alone showed equal quality-of-life improvements. In another study, the ESS/adenoidectomy group had a better success rate than adenoidectomy alone (87 percent vs. 52 percent). In a third study, 75 percent of those who failed with medical treatment received benefit from adenoidectomy, and 100 percent of those who failed with medical treatment and adenoidectomy received benefit from ESS. Other studies showed a success rate of between 82 percent and 97 percent. Only one study added objective outcome data, with a success rate of 87.7 percent and a mean post-operative CT scan score of 2.36 at a four-month follow up. Only one retrospective study compared ESS to BCS in children: 62.5 percent of ESS patients and 80 percent of BCS patients showed improvement in overall sinus symptoms postoperatively. Six complications were reported out of 440 cases in all studies combined. Limitations included a lack of uniformity in the articles and a wide variation in follow-up periods.

Bottom line: Pediatric ESS is a surgical alternative for children suffering from refractory CRS who have failed with other medical intervention. However, there are still questions regarding when ESS is indicated for children.

Citation: Makary CA, Ramadan HH. The role of sinus surgery in children. Laryngoscope. 2013;123:1348-1352.

—Reviewed by Amy Eckner

Otolaryngology Hospitalist Model Can Work for Inpatient Practices

How viable is a clinical otolaryngology hospitalist, and is there a valid paradigm for the practice?

Background: The hospitalist model has been adopted recently by many specialty fields due to a need to treat acutely ill patients in an inpatient setting. This study details a consortium-based model. Each week, a single faculty member was solely responsible for covering inpatient, emergency room and acute care otolaryngology consultations; the on-call faculty member would suspend his or her primary practice and would not see new patients or perform elective surgeries during that time.

Study design: Retrospective administrative database review for the years 2009 to 2011.

Setting: University of California, San Francisco—Parnassus Heights Campus tertiary referral hospital.

Synopsis: Data were collected for 375 unique patients and 951 billable encounters and procedures. The most common diagnoses were respiratory failure, sinusitis, stridor, dysphonia/vocal fold paralysis, tonsillitis/pharyngitis, epistaxis, facial cellulitis, swelling of the head and neck, and otitis. Procedural services were often provided by the hospitalist team; flexible indirect nasolaryngoscopy was the most common. Common upper airway endoscopic interventions included direct laryngoscopy with biopsy, bronchoscopy, injection laryngoplasty and esophagoscopy. General and pediatric otolaryngology were the most common encounters for the first two years (39 percent in year one; 46 percent in year two), followed by laryngology encounters (29 percent in year one; 23 percent in year two) and rhinology consultations (19 percent in year one; 14 percent in year two). Adult and pediatric airway-related cases accounted for 47 percent of consultations. Several complex surgical cases were performed, including maxillectomy with orbital exenteration. The authors speculated on value equations for this position but noted that calculations would require a methodical approach to more rigorous detail. Limitations include the fact that data for emergency room and acute care consultation encounters were not available for analysis and that age data were not always available.

Bottom line: The UCSF otolaryngology hospitalist model has encouraged better communication and collaboration with other services and allows the hospitalist to provide educational opportunities to clinical residents.

Citation: Russell MS, Eisele D, Murr A. The otolaryngology hospitalist: a novel practice paradigm. Laryngoscope. 2013;123:1394-1398.

—Reviewed by Amy Eckner

Enlarged Vestibular Aqueduct Indicates Stronger Risk of Hearing Loss Progression

Is an enlarged vestibular aqueduct (EVA) an indicator of increased hearing loss progression risk?

Background: Temporal bone abnormalities like EVA are recognized as an important factor of sensorineural hearing loss. The otologic phenotype is variable for EVA and can be associated with fluctuating and progressive hearing loss. Although unilateral hearing loss (UHL) in EVA patients has been reported, it is not well described. EVA has also been associated with disorders such as Pendred syndrome, CHARGE syndrome, Waardenburg syndrome and branchio-oto-renal syndrome.

Study design: Retrospective cohort study of all children seen at their center and diagnosed with EVA or unilateral hearing loss without EVA from 1998 to 2010 at one care facility, with a pure tone average (PTA) for each ear, CT scans for temporal bone structure and genomic testing.

Setting: Ear and Hearing Center, Division of Pediatric Otolaryngology, Cincinnati Children’s Hospital Medical Center.

Synopsis: There were 144 patients who met the inclusion criteria. Unilateral EVA was identified in 74 (42 left side, 32 right side); the median age for hearing loss was 59.5 months, and the median follow-up time was 37.8 months. Forty-five patients with EVA had UHL. There was no statistical difference in hearing or the median PTA between unilateral and bilateral EVA patients with hearing loss. There was no significant difference in temporal bone measurements in patients with unilateral EVA and ipsilateral hearing loss, and in all ears with EVA and normal hearing. The proportion of ears with progressive hearing loss was slightly higher for bilateral EVA patients than for unilateral EVA patients. The median change in PTA for all ears was 5.0 dB. Progression rate was significantly correlated with the midpoint but not the operculum in bone measurement. Significantly more patients with bilateral than with unilateral EVA tested positive for Pendred syndrome gene mutation. Patients with UHL and EVA were more likely to suffer contralateral hearing loss than those without EVA. Hearing loss at 250 Hz in EVA patients is strongly correlated with PTA severity and UHL progression. Limitations included possible biases in how data were entered and difficulty assessing the true prevalence of pediatric unilateral EVA.

Bottom line: Because there is a relatively high rate of hearing loss progression in unilateral EVA patients, otolaryngologists should consider offering patients close audiometric monitoring and SLC26A4 genetic testing.

Citation: Greinwald J, deAlarcon A, Cohen A, et al. Significance of unilateral enlarged vestibular aqueduct. Laryngoscope. 2013;123:1537-1546.

—Reviewed by Amy Eckner

Patients with VFP After Thyroidectomy Incur High Cost of Care

Do patients with vocal fold paralysis (VFP) after thyroid surgery incur higher health care costs than those without and, if so, how much?

Background: Thyroidectomies are common in the United States, with bilateral and unilateral VFP occurring at a rate as high as 18.6 percent. The additional treatment that is required incurs a higher cost for patients and insurers that could be avoided without VFP. Actual figures for this cost have not been previously reported.

Study design: Retrospective cohort study of 76 VFP patients and 238 control patients without paralysis through December 2010. Charge analysis ended at 90 days post-operative. Only medical group medical records were used to record charges rather than actual amounts paid.

Setting: Henry Ford Health System, Detroit, Michigan.

Synopsis: Mean tumor weight and

average BMI were not statistically different between VFP and control patients. Proportionally, more VFP patients (8/76) received revision surgeries than control patients (10/238). Serious post-operative morbidity markers (post-operative intubation, tracheotomy, indwelling feeding tube placement, respiratory failure, swallowing study/seophagram) were more common in VFP patients. Length of stay was significantly longer for VFP patients (6.33 days/3.12 days in ICU vs. 2.80 days/0.87 days in ICU). The geometric mean charge for hospitalization for VFP patients was $34,200, compared with $21,600 for the control group, with VFP patients accruing more charges in follow-up costs. Bilateral VFP patients had significantly higher charges than those for unilateral VFP patients only at the 30-day mark. The most expensive hospitalization among VFP patients was $259,480. There were some very expensive charges in the control group but only three bills higher than $100,000. Study limitations included the fact that charge data ended at post-operative day 90 (most surgery related to VFP took place much later), a possibility of coding errors and likely underreporting of transient VFP.

Bottom line: VFP patients incurred a much greater cost for health care in the first 90 days after surgery than those without VFP. The likelihood of VFP was not related to malignancy, BMI or gland weight in this study.

Citation: Gardner GM, Smith MM, Yaremchuk KL, Peterson EL. The cost of vocal fold paralysis after thyroidectomy. Laryngoscope. 2013;123:1455-1463.

—Reviewed by Amy Eckner