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Literature Review: A Roundup of Important Recent Studies

Speech Perception Lower in Older CI Users

Do cochlear implant (CI) users older than 65 years of age have different surgical and audiological outcomes than younger adult CI users?

Background: The number of adults older than 65 is expected to double between 2000 and 2030. Several studies have shown that although older adults benefit from CI, experiencing improved hearing ability and quality of life, current studies are not in agreement as to whether older adults have similar audiological and surgical outcomes to those experienced by younger adults.

Study design: Retrospective single-institution study of medical and audiologic records from 2006 to 2010 of 113 post-lingually deafened adults with unilateral cochlear implants.

Setting: Department of Otolaryngology and Department of Audiology, Massachusetts Eye and Ear Infirmary, Boston.

Synopsis: Records were divided into two primary groups: 1) those younger than age 65 and 2) those aged 65 or older; these groups were also subdivided according to decade of age. Total audiological follow-up time, sex, noise exposure, history of neurological disease, side of implantation and device type were the same between Groups 1 and 2. Speech perception improved in both groups, but octogenarians had poorer speech recognition compared with patients aged 60 to 69. Patients who reported a family history of hearing loss had higher word intelligibility scores compared with those who did not and tended to be younger than age 65. Also, a family history of hearing loss was associated with a trend toward improved post-implantation speech perception in all patients. Patients in both groups were equally likely to experience vertigo/disequilibrium. Group 2 patients trended toward a preference for left-sided implantation; however, this did not influence speech perception. Limitations included a risk of bias and the fact that the data represent a single institution’s experience.

Bottom line: Speech perception ability was significantly poorer in CI users older than age 65 when compared with younger adult patients, and a family history of hearing loss was associated with a trend toward better speech recognition.

Citation: Roberts DS, Lin HW, Hermann BS, Lee DJ. Differential cochlear implant outcomes in older adults. Laryngoscope. 2013;123:1952-1956.

—Reviewed by Amy Eckner

Caseload Volume Predictor of Thyroid Surgery Outcomes

How do surgeon and hospital volume affect the outcome of thyroid surgery in the United States?

Background: Surgeons with a high-volume thyroid caseload have a lower incidence of post-operative complications. However, low-volume thyroid surgeons performing three or fewer cases per year perform the majority of thyroid surgery in the United States. This study seeks to characterize national trends in thyroid surgical care and the effect of hospital and surgeon volume on practice patterns and short-term outcomes.

Study design: Retrospective cross-sectional study of discharge data from 871,644 patients who underwent surgery for thyroid disease from 1993 through 2008.

Setting: Nationwide Inpatient Sample inpatient care database.

Synopsis: Records in the study period were divided into two time intervals: 1) 1993 through 2000 and 2) 2001 through 2008. The average number of annual thyroid surgical cases increased by 39 percent in Interval 2 compared to Interval 1. Thyroid lobectomy, the most common procedure, decreased from 69 percent in Interval 1 to 52 percent in Interval 2, while total thyroidectomy increased from 27 percent to 46 percent. During Interval 1, the largest combined category was very low-volume surgeons operating at very low-volume hospitals. During Interval 2, the largest increase was in cases performed by high-volume surgeons at high-volume hospitals; the proportion of cases performed by very low-volume surgeons and hospitals decreased, although it was still the largest combined category. High-volume surgeons were significantly more likely to be associated with teaching hospitals, to perform total thyroidectomy and to practice in urban areas; they were less likely to operate on patients admitted urgently, with advanced comorbidity, on Medicare, Medicaid or self-pay status, and to be located in Midwestern or Southern states. Surgeon volume was inversely associated with post-operative complications. Limitations included a lack of follow-up data, possible differences in patient or disease type cared for at high-volume hospitals, underreporting of complication incidence and lack of outpatient surgery data.

Bottom line: The proportion of thyroid surgical procedures performed by high-volume surgeons and high-volume hospitals increased significantly over the studied time period, and surgeon volume is a significant predictor of thyroid surgery outcomes.

Citation: Loyo M, Tufano RP, Gourin CG. National trends in thyroid surgery and the effect of volume on short-term outcomes. Laryngoscope. 2013;123:2056-2063.

—Reviewed by Amy Eckner

Younger Patients with Mucosal HNCA Have Better Survival Rates

What are the survival differences between young and older patients who have mucosal head and neck cancer (HNCA)?

Background: Epidemiological data have shown that the incidence of head and neck squamous cell carcinoma is rising in young adults, particularly over the last two decades. There is disagreement in the literature about whether young patients at all HNCA sites have better, worse or similar prognoses in comparison with older patients.

Study design: Matched pair (87 cases, aged 45 or younger, matched to 87 controls older than age 45) retrospective cohort study of mucosal HNCA patients between 2003 and 2008.

Setting: Department of Otolaryngology–Head and Neck Surgery and Masonic Cancer Center, Division of Biostatistics, University of Minnesota, Minneapolis.

Synopsis: Individual cases were matched to individual controls on tumor site, tumor stage (I to IV) and gender. The cases had an average diagnosis age of 38.2 years; the controls had an average diagnosis age of 61.3 years. The cases and controls had similar comorbidities (heart disease, stroke, lung disease, arthritis, immunosuppression, previous malignancy), but the control group included more diabetics. Both groups had similar use of alcohol, marijuana and non-cigarette tobacco products. The case group underwent neck dissection at a statistically significant greater rate than controls. Both groups were likely not different in positive margins, perineural invasion, vascular invasion, positive nodes and extracapsular extension; five-year overall survival was not statistically different between the groups. After adjusting for confounding variables, the case group had a higher disease-free survival than the controls, with a risk ratio of 0.43. According to study authors, the data suggest that the cases experienced similar rates of recurrence to those experienced by the controls, but these recurrences took longer to arise. Limitations included too few matched pairs where both cases and controls had data on a second recurrence, a small sample size and possible deficiencies present in the medical record, particularly for HPV information.

Bottom line: Overall survival was marginally better for all young patients, and disease-free survival was significantly better.

Citation: Lassig AA, Lindgren BR, Fernandes P, et al. The effect of young age on outcomes in head and neck cancer. Laryngoscope. 2013;123:1896-1902.

—Reviewed by Amy Eckner

CT Scan Use for Diagnosing CRS Remains Steady

What are the trends in the use of computed tomography (CT) scanning in the diagnosis of chronic rhinosinusitis (CRS)?

Background: Current evidence-based guidelines recommend paranasal sinus CT to verify diagnosis of CRS, but CT involves a number of resources, including patient time, additional costs and patient exposure to ionizing radiation. These factors need to be considered and CT scan use needs to be tracked in all medical specialties, including otolaryngology.

Study design: Cross-sectional analysis of a national health care database from 2005 to 2010. All visits to otolaryngologists with a chronic sinonasal diagnosis code (e.g., chronic sinusitis, chronic rhinitis, allergic rhinitis and septal deviation) were extracted.

Setting: National Ambulatory Medical Care Survey database.

Synopsis: Over the five-year course of the study, there were an estimated 31.1 ± 2.8 million otolaryngology visits for one of the selected sinonasal diagnoses; there were 819 unweighted visits coded for CRS, 639 for allergic rhinitis, 339 for nasal septal deviation, 249 for chronic rhinitis and 53 for nasal polyps. The average patient age was 43.2 ± 0.6 years and patients were predominantly female (57.1 ± 1.8 percent). Overall, 10.4 ± 2.2 percent of sinonasal diagnosis visits involved the use of CT scans, ranging from 8.4 ± 3.0 percent in 2007 to 12.3 ± 2.6 percent in 2008; in 2010, 11.7 ± 2.9 percent of visits included CT scanning. Overall, there was no statistically significant difference in CT rates over the time period of the study, although there was a slight increase in the overall CT scan rate among otolaryngologists from 2007 to 2008. The author hypothesizes that this might have to do with the publication of the adult sinusitis clinical practice guideline in 2007 and the emerging economy after a significant U.S. recession in 2008. Study limitations included the possibility of introduced errors, because the study relies upon diagnosis codes selected by clinicians, the fact that the CT scan ordering rates are based on visit rates and not per individual patient, and the fact that the NAMCS data reflect current practice in nonacademic, noninstitutional otolaryngologic settings.

Bottom line: Although CT imaging is widely available and has been the gold standard for verifying sinonasal diagnoses, the CT ordering patterns of otolaryngologists have not increased over the past six years.

Citation: Bhattacharyya N. Trends in otolaryngologic utilization of computed tomography for sinonasal disorders. Laryngoscope. 2013;123:1837-1839.

—Reviewed by Amy Eckner