There is increasing discussion worldwide on explicitly including cost as part of the clinical practice guideline development process. While this could enhance our understanding of value-based care ...and improve resource utilization, there are many practical challenges for cost inclusion. This commentary explores this issue, examining it from multiple angles and giving pros and cons to inclusion in future guidelines.
Clinical practice guideline: Allergic rhinitis Seidman, Michael D; Gurgel, Richard K; Lin, Sandra Y ...
Otolaryngology-head and neck surgery,
02/2015, Letnik:
152, Številka:
1 Suppl
Journal Article
Recenzirano
Allergic rhinitis (AR) is one of the most common diseases affecting adults. It is the most common chronic disease in children in the United States today and the fifth most common chronic disease in ...the United States overall. AR is estimated to affect nearly 1 in every 6 Americans and generates $2 to $5 billion in direct health expenditures annually. It can impair quality of life and, through loss of work and school attendance, is responsible for as much as $2 to $4 billion in lost productivity annually. Not surprisingly, myriad diagnostic tests and treatments are used in managing this disorder, yet there is considerable variation in their use. This clinical practice guideline was undertaken to optimize the care of patients with AR by addressing quality improvement opportunities through an evaluation of the available evidence and an assessment of the harm-benefit balance of various diagnostic and management options.
The primary purpose of this guideline is to address quality improvement opportunities for all clinicians, in any setting, who are likely to manage patients with AR as well as to optimize patient care, promote effective diagnosis and therapy, and reduce harmful or unnecessary variations in care. The guideline is intended to be applicable for both pediatric and adult patients with AR. Children under the age of 2 years were excluded from the clinical practice guideline because rhinitis in this population may be different than in older patients and is not informed by the same evidence base. The guideline is intended to focus on a limited number of quality improvement opportunities deemed most important by the working group and is not intended to be a comprehensive reference for diagnosing and managing AR. The recommendations outlined in the guideline are not intended to represent the standard of care for patient management, nor are the recommendations intended to limit treatment or care provided to individual patients.
The development group made a strong recommendation that clinicians recommend intranasal steroids for patients with a clinical diagnosis of AR whose symptoms affect their quality of life. The development group also made a strong recommendation that clinicians recommend oral second-generation/less sedating antihistamines for patients with AR and primary complaints of sneezing and itching. The panel made the following recommendations: (1) Clinicians should make the clinical diagnosis of AR when patients present with a history and physical examination consistent with an allergic cause and 1 or more of the following symptoms: nasal congestion, runny nose, itchy nose, or sneezing. Findings of AR consistent with an allergic cause include, but are not limited to, clear rhinorrhea, nasal congestion, pale discoloration of the nasal mucosa, and red and watery eyes. (2) Clinicians should perform and interpret, or refer to a clinician who can perform and interpret, specific IgE (skin or blood) allergy testing for patients with a clinical diagnosis of AR who do not respond to empiric treatment, or when the diagnosis is uncertain, or when knowledge of the specific causative allergen is needed to target therapy. (3) Clinicians should assess patients with a clinical diagnosis of AR for, and document in the medical record, the presence of associated conditions such as asthma, atopic dermatitis, sleep-disordered breathing, conjunctivitis, rhinosinusitis, and otitis media. (4) Clinicians should offer, or refer to a clinician who can offer, immunotherapy (sublingual or subcutaneous) for patients with AR who have inadequate response to symptoms with pharmacologic therapy with or without environmental controls. The panel recommended against (1) clinicians routinely performing sinonasal imaging in patients presenting with symptoms consistent with a diagnosis of AR and (2) clinicians offering oral leukotriene receptor antagonists as primary therapy for patients with AR. The panel group made the following options: (1) Clinicians may advise avoidance of known allergens or may advise environmental controls (ie, removal of pets; the use of air filtration systems, bed covers, and acaricides chemical agents formulated to kill dust mites) in patients with AR who have identified allergens that correlate with clinical symptoms. (2) Clinicians may offer intranasal antihistamines for patients with seasonal, perennial, or episodic AR. (3) Clinicians may offer combination pharmacologic therapy in patients with AR who have inadequate response to pharmacologic monotherapy. (4) Clinicians may offer, or refer to a surgeon who can offer, inferior turbinate reduction in patients with AR with nasal airway obstruction and enlarged inferior turbinates who have failed medical management. (5) Clinicians may offer acupuncture, or refer to a clinician who can offer acupuncture, for patients with AR who are interested in nonpharmacologic therapy. The development group provided no recommendation regarding the use of herbal therapy for patients with AR.
OBJECTIVESTransoral robotic surgery in adults confers excellent results and decreased morbidity. Application of these techniques has not yet been rigorously investigated in children. The goal of this ...study is to evaluate the feasibility of a flexible robotic surgical system in a pediatric population. METHODSThis was a non-randomized, non-blinded, prospective clinical trial. An Investigational Device Exemption was obtained from the FDA. Patients 8-12 years old scheduled for tonsillectomy and adenoidectomy between February and December 2019 at an academic tertiary care children's hospital were included. Exclusion criteria included pulmonary or vascular conditions posing risks for extended anesthesia, or a smaller mouth opening than the instrumentation (28 mm × 15 mm). Tonsillectomy was completed with standard monopolar cautery. After the surgery was complete, the robot was utilized for evaluation and assessment of exposure. A pediatric anesthesiologist screened patients for tolerance of additional anesthesia (up to 15 min). A flexible robotic surgical system, the MedRobotics Flex® Robotic System, was used to visualize and access the tonsillar fossa, posterior pharynx, base of tongue, epiglottis and false vocal folds. Visualization and access were graded on a five-point Likert scale. RESULTSA total of ten patients, eight males and two females, with obstructive sleep apnea (OSA) or sleep disordered breathing (SDB) were recruited in 2019. One patient did not complete the study due to equipment malfunction. The average patient demographics were: age 10.1 years (8.6-11.8 years), height 142.4 cm (127-164.9 cm), weight 47.5 kg (24.4-84.5 kg), and BMI 22.6 (13.9-31.0). Study time averaged 10.3 min (5-13 min). The tonsillar fossa, base of tongue, and posterior pharynx were visualized completely and easily accessed with the robotic instruments. The epiglottis and false vocal folds were visualized and accessed in 66% and 55% of patients, respectively. There were no adverse effects. CONCLUSIONSThis study demonstrated that a flexible robotic surgical system is feasible for use in children 8-12 years of age when performing otolaryngology - head and neck surgery procedures of the oropharynx and larynx.
To review the impact of coronavirus disease 2019 (COVID-19) on pediatric otolaryngology and provide recommendations for the management of children during the COVID-19 pandemic.
Clinical data were ...derived from peer-reviewed primary literature and published guidelines from national or international medical organizations. Preprint manuscripts and popular media articles provided background information and illustrative examples.
Included manuscripts were identified via searches using PubMed, MEDLINE, and Google Scholar, while organizational guidelines and popular media articles were identified using Google search queries. Practice guidelines were developed via consensus among all authors based on peer-reviewed manuscripts and national or international health care association guidelines. Strict objective criteria for inclusion were not used due to the rapidly changing environment surrounding the COVID-19 pandemic and a paucity of rigorous empirical evidence.
In the face of the COVID-19 pandemic, medical care must be judiciously allocated to treat the most severe conditions while minimizing the risk of long-term sequelae and ensuring patient, physician, and health care worker safety.
The COVID-19 pandemic will have a profound short- and long-term impact on health care worldwide. Although the full repercussions of this disease have yet to be realized, the outlined recommendations will guide otolaryngologists in the treatment of pediatric patients in the face of an unprecedented global health crisis.
Endoscopic endonasal anterior skull base surgery has expanding use in the pediatric population, but the anatomy of pediatric patients can lead to limitations. This study aims to characterize the ...important anatomical implications of the pediatric skull base using computed tomography (CT) scans.
This study is designed as retrospective analysis.
The study setting comprises of tertiary academic medical center.
In total, 506 patients aged 0 to 18 who had undergone maxillofacial and or head CTs between 2009 to 2016 were involved.
Measurements included piriform aperture width, nare to sella distance (NSD), sphenoid pneumatization, olfactory fossa depth, lateral lamella cribriform plate angles, and intercarotid distances (ICD) at the superior clivus and cavernous sinus. These patients were then subdivided into three age groups adjusting for sex. Analysis of covariance (ANCOVA) models were fit comparing between all age groups and by sex.
Piriform aperture width, NSD, sphenoid sinus pneumatization as measured using lateral aeration and anterior sellar wall thickness, olfactory fossa depth, and ICD at the cavernous sinus were significantly different among all age groups (
<0.0001). Our results show that mean piriform aperture width increased with each age group. The mean olfactory fossa depth also had consistent age dependent growth. In addition, ICD at the cavernous sinus showed age dependent changes. When comparing by sexes, females consistently showed smaller measurements.
The process of skull base development is age and sex dependent. During preoperative evaluation of pediatric patients for skull base surgery piriform aperture width, sphenoid pneumatization in both the anterior posterior and lateral directions, and ICD at the cavernous sinus should be carefully reviewed.
To describe and analyze the demographics and academic backgrounds of United States otolaryngology program directors (PD) and assess gender disparity in the field.
This was a cross-sectional study in ...which an online search using publicly available sources was performed to gather information on PDs for 125 United States otolaryngology programs from May 14, 2021, to May 30, 2021. Data collected included PD appointment year, age, gender, resident gender breakdown, degree, as well as training location and graduation year.
There were 69.6% programs with a male PD and 30.4% with a female PD. Ninety percent of PDs have an MD degree and 9.6% have a DO degree. The current average age of PDs was 49.9 years old (range 35-79). Males were older than females PD (51.0 vs 47.1 years,
= 0.045) and have served a longer time as PD (7.1 vs 4.8 years,
= 0.019). There was no significant difference in other variables collected. There were 27.3% of program directors that held the position of professor, 44.5% associate professor, and 28.2% assistant professor. The most common subspecialty practiced by otolaryngology PDs was head and neck oncology.
Disparity in women's representation in otolaryngology still exists, but the program director leadership position demonstrates better parity. There is an equal percent representation when examining female PDs and female otolaryngologists in academic medicine. Continued efforts to encourage women to enter and become leaders in otolaryngology are necessary moving forward.
The risk of expansile hematoma and airway compromise following neck surgery have been used to validate overnight observation. We investigated the outcomes of pediatric patients undergoing a removal ...of second branchial cleft anomalies (BCA) via either same day surgery or overnight observation.
A retrospective review of patients undergoing second BCA removal between January 1, 2008 to January 1, 2019 was performed. 40 cases were identified for review. Bivariate analyses were performed to determine predictive factors for overnight admission as well as associations between overnight observation and adverse outcomes (hematoma, seroma, airway compromise, infection). Factors evaluated for analysis included ASA class, surgeon type, history of pre-operative infection, recurrent case, operation >90 min, pharyngeal violation, intraoperative cyst rupture, cyst size, and drain placement.
There were no life-threatening adverse events. Same day discharge was not associated with adverse events (p = 0.24). Overnight observation was associated with a history of preoperative infection (p = 0.003), cyst > 3.0 cm (p = 0.046), operative time > 90 min (p < 0.001), and drain placement (p = 0.001). There was no association between other investigated variables and adverse events or overnight stay.
Same day discharge following second branchial cleft anomalies appears safe and feasible. Further study is needed to determine the safety profile of same day discharge and etiologies of practice patterns of overnight observation.
Postoperative Outcomes in Pediatric Septoplasty Benyo, Sarah; Moroco, Annie E.; Saadi, Robert A. ...
Annals of otology, rhinology & laryngology,
09/2023, Letnik:
132, Številka:
9
Journal Article
Recenzirano
Objective:
Identify risk factors and perioperative morbidity for pediatric patients undergoing septoplasty.
Methods:
The American College of Surgeons National Surgical Quality Improvement Program ...Pediatric (NSQIP-P) database was retrospectively queried to identify patients who underwent septoplasty (CPT 30520) for a diagnosis of deviated nasal septum (ICD J34.2) from 2018 to 2019. Outcomes analyzed include patient demographics, medical comorbidities, surgical setting, operative characteristics, length of stay, and postoperative outcomes.
Results:
A total of 729 children were identified. Median age at time of surgery was 15.8 years, with most patients (82.8%) >12 years of age; no significant association was identified between age at time of surgery and adverse surgical outcomes. Overall, postoperative complications were uncommon (0.6%), including readmission (0.4%), septic shock (0.1%), and surgical site infection (0.1%). A history of asthma was found to be a significant risk factor for postoperative complications (P = .035) as well as BMI (P = .028).
Conclusion:
The 30-day postoperative complications following pediatric septoplasty in children reported in the NSQIP-P database are infrequent. Special considerations regarding young age, complex sinonasal anatomy, and surgical technique remain important features in considering corrective surgery for the pediatric nose and certainly warrant further investigation in subsequent studies.
Review current literature and guidelines for malignant hyperthermia in the context of neurotologic surgery.
A case of malignant hyperthermia during vestibular schwannoma surgery, in a patient ...previously exposed to anesthesia.
Excision of vestibular schwannoma, acute management of malignant hyperthermia.
Knowledge of the basic pathophysiology, clinical manifestations, and treatment protocols for malignant hyperthermia.
Rapid termination of the procedure and appropriate modifications in surgical technique permitted expeditious treatment of malignant hyperthermia and prevented its lethality.
Malignant hyperthermia is a rare and lethal condition that may arise in neurotologic surgery, even in patients who have previously received general anesthesia. The neurotologic surgeon has a role in early recognition and expeditious termination of surgery to help reduce its mortality.
The American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) has published a supplement to this issue featuring the new Clinical Practice Guideline: Allergic Rhinitis. To assist ...in implementing the guideline recommendations, this article summarizes the rationale, purpose, and key action statements. The 14 recommendations developed address the evaluation of patients with allergic rhinitis, including performing and interpretation of diagnostic testing and assessment and documentation of chronic conditions and comorbidities. It will then focus on the recommendations to guide the evaluation and treatment of patients with allergic rhinitis, to determine the most appropriate interventions to improve symptoms and quality of life for patients with allergic rhinitis.
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