Underreported variation in parathyroid hormone (PTH) assays exists. Using quality improvement methods, we aimed to develop an institution-specific PTH-based protocol to predict hypocalcemia after thyroidectomy.We retrospectively reviewed patients who underwent total/completion thyroidectomy. A receiver operating curve (ROC) determined postoperative PTH cut-offs predictive of hypocalcemia. The stakeholders developed PTH-driven calcium management guidelines. Post-implementation outcomes were prospectively measured.Pre-implementation, 95 patients were assessed. PTH ≤1.5 pmol/L (14.1 pg/ml) predicted hypocalcemia (96%sensitivity), and ≥2.8 pmol/L (26.4 pg/ml) predicted normocalcemia (99%specificity) (area under curve = 0.97, SEM = 0.018). PTH on the day of and morning after surgery were identically predictive. Post-implementation, 64 patients were assessed. Hypocalcemia occurred with PTH >2.8 pmol/L in 2 cases (3.1%). Calcium over-prescribing decreased from 13.7% to 3.1% (p = 0.06). Length of stay (LOS) > 2 nights decreased from 13% to 3.1% (p = 0.05).A PTH-driven calcium management protocol post-thyroidectomy effectively reduces unnecessary calcium replacement and LOS. Given the variability in PTH assays, each institution may need to use individual cut-offs.
Chemical peeling, also known as chemexfoliation or chemical exfoliation, is a procedure where a chemical substance applied to the skin causes controlled destruction of the epidermis with or without part of the dermis, leading to skin regeneration and remodeling. Chemical peels can be used to treat various skin conditions, such as acne vulgaris, photodamage, pigmentary disorders, and scars. Also, dermatologists and facial plastic surgeons commonly employ a chemical peel as a therapeutic or cosmetic intervention to enhance appearance either alone or in combination with other techniques, such as laser or dermabrasion. Chemical peels are commonly classified based on their depth of skin penetration into superficial, medium, and deep peels. The factors affecting the depth of peeling, and thus the degree of its therapeutic effects, include the properties of the chemical agent used (e.g., concentration and pH), the physician's application technique, and the patient's skin condition and sensitivity.
Background: Pituitary adenomas are one of the most common skull base procedures performed by otolaryngology and neurosurgery teams. Although complications are rare, when they occur, they can be devastating to patients. The use of SHERPA (Systematic Human Error Reduction and Prediction Approach) has been used in healthcare to reduce human errors, and it is based on a hierarchical task analysis (HTA) in which the systemic details of a procedure are outlined. HTA approaches can also serve as a foundation for bimodal education. Trainees can utilize HTAs of surgical procedures to understand a global perspective and the granular steps required to perform the surgery safely. Mentors can use HTAs as an outline to provide detailed feedback to trainees so that they can improve their surgical proficiency. Moreover, HTAs can also serve as a model for deliberate practice in surgical simulation, in which trainees can gain experience in surgical procedures without putting patients at risk. To our knowledge, there have not been any published HTA approaches to pituitary adenomas outlining both the otolaryngologic and neurosurgical roles.
To describe the epidemiological characteristics, clinical impact, and adequacy of post-exposure management of occupational exposure to blood and body fluids (BBFs).
Methods:
Retrospective chart review of individuals reporting exposure to BBFs from 2007 to 2013 at King Abdulaziz University Hospital, Jeddah, Kingdom of Saudi Arabia.
Results:
The total number of exposures reported was 326 exposures, of which 302 (92.6%) exposures were percutaneous, 21 (6.5%), mucocutaneous, and 3 (0.9%), bites. Nursing staff/students had the highest rate of exposure (149, or 45.6%), followed by physicians (57, or 17.5%). Surgeons were found to have a significantly higher risk for sharp injuries compared with other physicians (26.3%, or 15 exposures, p<0.005). Most (216, or 72.5%) percutaneous injuries were caused by hollow-bore needles. Majority of exposures (124, or 42.6%) occurred after using the needle/sharp item and before disposal. Two-thirds (219, or 67%) of exposed individuals were immune to hepatitis B at the time of exposure. With appropriate post-exposure management, none of exposed individuals seroconverted to HIV, hepatitis B or C virus infections.
Conclusion:
Occupational exposure to BBFs remains a concern among healthcare workers. Educational programs targeting high-risk groups entailing reinforcement of prevention and adherence to post-exposure management guidelines are needed.
Background Immunodeficiency is a risk factor for recalcitrant chronic rhinosinusitis (CRS). Currently, there is no consensus on effective treatment modalities for immunodeficient CRS patients. This review aims to evaluate the existing evidence on the treatment outcomes and its limitations in patients with CRS and immunodeficiency. Methods MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched from inception to April 2019 for studies reporting measurable medical or surgical treatment outcomes for adult patients with CRS and underlying primary or secondary immunodeficiency. Results Of the 2459 articles screened, 13 studies met the inclusion criteria: 2 prospective double‐blind placebo‐controlled trials, 2 prospective case‐control studies, 2 prospective cohort studies, and 7 case series. The high degree of study heterogeneity precluded a meta‐analysis. Antibiotic monotherapy was not linked with significant improvement in clinical, radiographic, or endoscopic outcomes. Immunoglobulin replacement therapy may potentially reduce the frequency of acute or chronic sinusitis in patients with primary immunodeficiency (PID) but may not improve their sinonasal symptoms. Outcomes from endoscopic sinus surgery (ESS) were reported in 8 studies, which found that surgery was linked with improvement in symptoms, disease‐specific quality of life, endoscopy scores, and radiographic scores. The average reported ESS revision rate was 14%. Conclusion Patients with CRS and immunodeficiency likely benefit from ESS based on the available evidence. Data supporting medical therapy in this targeted population is limited overall, but there may be a potential role for immunoglobulin therapy in patients with PID and CRS.
Background: To date, there have not been any direct comparative studies assessing clinical outcomes in CRSwNP between biologic and surgical therapies. Objective: To directly compare the effect of dupilumab to FESS using subjective and objective outcomes of CRSwNP patients in a prospective longitudinal study. Methods: We prospectively enrolled 20 CRSwNP patients and counseled them on both biologic and surgical options. Patients were able to decide on either therapy, and data collected at baseline and 3-, 6-, 9-, and 12-months with subjective outcomes including the nasal congestion score (NCS) and SNOT-22 questionnaires, and objectively by degree of smell (UPSIT-40) and nasal polyp score (NPS). Results: All subjects met criteria for either biologic therapy or surgery, with NPS >5, Lund-Mackay score (LMK-CT)>16, SNOT-22>54, and were graded as anosmic/hyposmic. There were no significant differences in age, sex, comorbid asthma/Aspirin Exacerbated Respiratory Disease, or prior FESS between groups. Both dupilumab and FESS significantly improved outcomes by one year in patients with severe CRSwNP when compared to baseline. At one-year, patients on dupilumab had greater improvement in NCS, UPSIT and asthma control relative to one year post FESS. In a subgroup of patients with a history of prior sinus surgery and asthma, dupilumab had lower polyp recurrence rate compared to one year post FESS. Conclusions: Both dupilumab and FESS can significantly improve outcomes by one year in CRSwNP patients. However, in those with a history of asthma and prior surgery, dupilumab is more effective in reducing polyp recurrence and improving sinonasal outcomes than FESS.
Background: Traditional, trans-cervical thyroidectomy results in the presence of a neck scar, which has been shown to correlate with lower quality of life and lower patient satisfaction. Transoral thyroid surgery (TOTS) has been utilized as an alternative approach to avoid a cutaneous incision and scar by accessing the neck and thyroid through the oral cavity. This study was designed to evaluate patient preference through health-state utility scores for TOTS as compared to conventional trans-cervical thyroidectomy. Methods: In this cross-sectional study, patient preferences were elicited for TOTS and trans-cervical thyroidectomy with the use of an online survey. Respondents were asked to consider 4 hypothetical health scenarios involving thyroid surgery with varying approaches. Health-state utility scores were elicited using visual analog scale and standard gamble exercises. Results: Overall, 516 respondents completed the survey, of whom 261 (50.6%) were included for analysis, with a mean age of 41.5 years (SD 14.9 years), including 171 (65.5%) females. Health utility scores were similar for TOTS and conventional transcervical techniques. Statistically significant differences in the standard gamble utility score were noted for gender and ethnicity across all scenarios. Comparisons of visual analog score utilities were not statistically significant based on respondent demographics. Conclusion: Preferences for TOTS and trans-cervical thyroidectomy did not significantly differ in the current study. Females and white ethnicity indicated stronger preference for a TOTs approach compared to males and other ethnicities, respectively. Some literature suggests certain types of patients who might prefer minimally invasive thyroidectomy more so than other patients—in keeping with the current findings of this study.
Abstract Objective To review new drugs and devices relevant to otolaryngology approved by the Food and Drug Administration (FDA) in 2022. Data Sources Publicly available FDA data on drugs and devices approved in 2022. Review Methods A preliminary screen was conducted to identify drugs and devices relevant to otolaryngology. A secondary screen by members of the American Academy of Otolaryngology–Head and Neck Surgery's (AAO‐HNS) Medical Devices and Drugs Committee differentiated between minor updates and new approvals. The final list of drugs and devices was sent to members of each subspecialty for review and analysis. Conclusion A total of 1251 devices and 37 drugs were identified on preliminary screening. Of these, 329 devices and 5 drugs were sent to subspecialists for further review, from which 37 devices and 2 novel drugs were selected for further analysis. The newly approved devices spanned all subspecialties within otolaryngology. Many of the newly approved devices aimed to enhance patient experience, including over‐the‐counter hearing aids, sleep monitoring devices, and refined CPAP devices. Other advances aimed to improve surgical access, convenience, or comfort in the operating room and clinic. Implications for Practice Many new devices and drugs are approved each year to improve patient care and care delivery. By staying up to date with these advances, otolaryngologists can leverage new innovations to improve the safety and quality of care. Given the recent approval of these devices, further studies are needed to assess long‐term impact within the field of otolaryngology.
Though endometrial carcinomas are a relatively common cancer of the female genitourinary tract, they rarely metastasize. Similarly, clival metastases make up a tiny fraction of all brain metastases. To the authors' knowledge, an endometrial carcinoma clival metastasis has never been described in the literature; therefore, the authors present the following unusual case of a 69-year-old female with a history of an initially grade 2 endometrial adenocarcinoma that metastasized to her clivus.
