The diagnosis of nontuberculous cervicofacial lymphadenitis: A systematic review

BACKGROUND

Nontuberculous mycobacterial cervicofacial lymphadenitis (NTMCL) is an uncommon condition detected in young immunocompetent children who typically present with a nontender neck mass. Various tests have been proposed to assist in the work-up of suspected NTMCL, with varying diagnostic utility. This systematic review investigates the sensitivity of the various diagnostic methods used in the work-up of pediatric NTMCL.

METHODS

A systematic review in accordance with PRISMA guidelines was performed using the Pubmed, EMBASE, and Web of Science databases. Searches were filtered for English language studies published prior to 05/10/22. Studies meeting criteria included studies featuring 15+ pediatric patients with confirmed or suspected NTMCL. Studies with any reported diagnostic methodology used in the workup of NTMCL were included.

RESULTS

Of 836 abstracts/articles reviewed, 21 studies met inclusion criteria. Diagnostic methods included culture(n = 11 studies), PPD-Tb(Tuberculin)(n = 12), PPD-Scrofulaceum, -Avium, or -Kansasii(n = 6), staining techniques(n = 4), IGRA(n = 3), and ultrasound(n = 2). All studies had an overall low risk of bias. Among patients confirmed to have NTMCL based on PCR and/or culture, the most sensitive tests were PPD-A(0.94, 95 % CI 0.91 to 0.97; n = 210 patients) and PPD-S(0.75, 95 % CI 0.68 to 0.81; n = 171). Auramine and Ziehl-Neelsen staining techniques had moderately high sensitivity(0.85 and 0.60 respectively), though were limited by low patient numbers(n = 20). PPD-Tb(0.45, 95 % CI 0.39 to 0.50; n = 300) and IGRA(0.02; 95 % CI 0 to 0.06; n = 48) demonstrated poor sensitivity. Among patients suspected to have NTM lymphadenitis based on global assessment, the most sensitive tests included combined PPD-S + A + K(0.92, 95 % CI 0.86 to 0.98; n = 85), PCR(0.82, 95 % CI 0.75 to 0.88; n = 136), and PPD-A(0.72, 95 % CI 0.62 to 0.81; n = 84). Culture showed a sensitivity of 0.54(95 % CI 0.50 to 0.58; n = 494). PPD-K, PPD-S, IGRA, and staining techniques demonstrated lower sensitivity.

CONCLUSIONS

This systematic review is the largest study investigating the sensitivity of the various diagnostic methods used in the work-up of pediatric NTMCL. Patients with clinical suspicion for NTMCL and a positive PPD-Tb should first have tuberculous lymphadenitis ruled out with IGRA. Patients with a positive PPD-Tb and negative IGRA and high clinical suspicion for NTMCL can undergo presumptive surgical intervention. Patients with a negative PPD-Tb can undergo NTM antigen skin testing if available, or if high clinical suspicion exists, surgical intervention to reduce tissue burden and elicit additional tissue data.

Orofacial Myofunctional Therapy for Obstructive Sleep Apnea: A Systematic Review and Meta-Analysis

OBJECTIVE

Orofacial myofunctional therapy (OMT) is an alternative form of treatment of obstructive sleep apnea (OSA), that incorporates various exercises to optimize tongue placement and increase oropharyngeal tone. The objective of this systematic review and meta-analysis is to determine the efficacy of OMT in OSA patients.

DATA SOURCES

PubMed/Medline, EMBASE, Cochrane, Web of Science.

REVIEW METHODS

Using PRISMA guidelines, a directed search strategy was performed for randomized control trials (RCTs) published prior to March 24, 2023, featuring 10+ patients with OSA undergoing mono-therapeutic OMT. The primary outcome of interest was apnea-hypopnea index (AHI). Secondary outcomes included subjective sleepiness, sleep-related quality-of-life, and snoring frequency.

RESULTS

Of the 1244 abstracts that were identified, 7 RCTs involving 310 patients met inclusion criteria. Adult OMT patients had a statistically significant improvement in AHI (MD -10.2; 95% CI, -15.6, -4.8, p < 0.05), subjective sleepiness (Epworth Sleepiness Scale; MD -5.66; 95% CI, -6.82, -4.5, p < 0.05), sleep-related quality-of-life (Pittsburgh Sleep Quality Index; MD -3.00; 95% CI, -4.52, -1.49, p < 0.05), and minimum oxygen saturation (MD 2.71; 95% CI, 0.23, 5.18, p < 0.05) when compared with sham OMT or no therapy. Within the single RCT featuring pediatric OMT patients, patients had poor compliance (<50%) and did not show any improvements in AHI, minimum oxygen saturation, or snoring frequency.

CONCLUSION

OMT may provide a reasonable alternative for OSA patients who cannot tolerate CPAP or other more established treatment options. OMT benefits appear limited in children due to poor compliance. More studies are required to evaluate compliance and the long-term effects of OMT on OSA outcomes.

LEVEL OF EVIDENCE

1 Laryngoscope, 134:480-495, 2024.

Microdebrider complications in sinus surgery: Analysis of the openFDA database

Objective

Functional endoscopic sinus surgery is a commonly performed otolaryngologic procedure that often uses the microdebrider device for tissue removal. Given the ubiquitous nature of the instrument, we sought to better define the patterns of device failure using the postmarket surveillance openFDA database.

Methods

The openFDA database was queried for all microdebrider-related adverse events from January 1, 2000 to November 1, 2020. Descriptive information on the nature of device failure and any associated patient injury was compiled. Reports not directly related to device failure were excluded from the analysis.

Results

A total of 641 events were included in the analysis. The most common device failure was overheating (n = 348, 54.3%), followed by material separation (n = 173, 27%), and inconsistent device activation (n = 52, 8.1%). Of the reported events, the vast majority did not result in patient harm (n = 579, 90.3%). On review of the remaining cases, only 24 events (3.7%) resulted in true harm to the patient, defined as a temporary or permanent injury or >30 min of additional anesthesia time. Of these cases, the need to reschedule surgical cases (n = 5, 0.8%), retained foreign body (n = 5, 0.8%), and thermal tissue injury (n = 3,0.5%) were the most common. Five patients suffered an injury due to surgeon error unrelated to device malfunction (n = 5, 0.8%).

Conclusions

Microdebrider device failures are extremely rare. When they do occur, less than 10% result in patient harm. In cases of patient harm related to microdebrider failure, preoperative testing of the device before use could prevent many of the reported malfunctions.

Steroid Efficacy on Audiologic Recovery in Patients With Sudden Sensorineural Hearing Loss and Vestibular Schwannoma: A Retrospective Review

OBJECTIVES

The objectives of this study are to (i) estimate the incidence of vestibular schwannoma (VS) among patients in an integrated healthcare system who present for evaluation of sudden sensorineural hearing loss (SSNHL) and (ii) evaluate the efficacy of empiric steroid therapy on audiologic recovery among SSNHL patients ultimately diagnosed with VS.

METHODS

A retrospective chart review was performed on patients presenting with SSNHL in 2021 at a multicenter integrated healthcare system serving over 4 million members. Patient demographics, audiometric data, VS diagnosis, therapeutic steroid intervention, and data regarding treatment response were recorded. A clinically significant audiometric improvement was defined as (i) an increase of 15% in word recognition score, (ii) a decrease of 15 dB in four-frequency pure-tone average (PTA) using frequencies of 500, 1000, 2000, and 4000 Hz, or (iii) a PTA of <20 dB on follow-up audiogram.

RESULTS

Six hundred fifty-eight patients were reviewed, of which 309 (56.0% male; mean, 57.5 years) met the inclusion criteria with audiometric data and magnetic resonance imaging data. Ten patients (70.0% male; mean, 51.3 years) were found to have VS. Of these, five patients received oral steroid therapy alone, and five had combination therapy (oral + intratympanic steroid injections). No patients received intratympanic steroid therapy alone. Median PTA improvement with steroid therapy was 3.1-dB hearing loss, and median word recognition score improvement was 16.5%. Six of 10 patients demonstrated clinically significant audiometric improvement with steroid therapy.

CONCLUSION

This study represents the largest US-based study showcasing the prevalence of VS in patients originally presenting with SSNHL. It also reinforces previous findings that VS does not preclude trials of steroid therapy.

Pediatric vagal nerve stimulator explantation: A comprehensive literature review and tertiary care experience

OBJECTIVE

Patients with medically-refractory epilepsy who undergo vagal nerve stimulator (VNS) implantation to reduce seizure burden sometimes require device removal. Complete explantation refers to the removal of both the generator and vagal nerve leads, and is uncommonly performed by otolaryngologists due to the perceived risk associated with lead removal. This comprehensive literature review and case series studies safety outcomes among pediatric patients undergoing complete VNS explantation.

STUDY DESIGN/SETTING

Literature review and tertiary care case series.

METHODS

PubMed, Embase, Web of Science, and Google Scholar were searched to identify all articles involving VNS explantation prior to January 2023. A retrospective review of pediatric patients undergoing complete VNS explantation from 2009 to 2023 at our tertiary center was also conducted.

RESULTS

After screening, 36 articles were retained involving 399 patients (139 confirmed children) who underwent complete VNS explantation. 26 patients (6.5%) experienced 1+ peri/post-operative complications. These included temporary VF paresis or dysphonia (n = 14; 3.6%), permanent vocal fold (VF) paralysis/paresis (n = 6; 1.5%), internal jugular vein injury (n = 4; 1.0%), temporary dysphagia (n = 2; 0.50%), and cable-bowstring phenomenon (n = 1; 0.25%). Data from our tertiary care center revealed eight patients (6 M: 2 F) with a mean age of 11.4 ± 6.2 years. Devices were removed for clinical ineffectiveness (n = 2), infection (n = 2), lead failures (n = 2), and increased lead impedance (n = 2). Mean total length of implantation was 44.4 ± 40.3 months. Mean follow-up was 44.8 ± 35.2 months. No complications were identified.

CONCLUSIONS

Complete VNS device removal in pediatric patients is technically feasible with low reported complications. Working alongside neurosurgery, otolaryngologists offer unique expertise in dissection along the vagus nerve and may thus add value to the practice of VNS surgery.

Cardiovascular Risk Factors in Patients With Sudden Sensorineural Hearing Loss: A Systematic Review and Meta-Analysis

OBJECTIVE

The interruption of vascular supply to the inner ear is one of several proposed etiologies of sudden sensorineural hearing loss (SSNHL). The increased presence of cardiovascular risk factors may predispose patients to SSNHL through this pathway. This systematic review and meta-analysis studies the presence of cardiovascular risk factors in patients diagnosed with SSNHL.

DATA SOURCES

Databases included PubMed/Medline, OVID, EMBASE, Cochrane, and Web of Science.

REVIEW METHODS

Inclusion criteria included studies featuring SSNHL patients presenting with 1+ cardiovascular risk factors. Exclusion criteria included case reports and studies without outcome measures. Two investigators independently reviewed all manuscripts and performed quality assessments using validated tools.

RESULTS

Of 532 identified abstracts, 27 studies met inclusion criteria (19 case-control, 4 cohorts, 4 case series). Of these, 24 underwent meta-analysis encompassing a total of 77,566 patients (22,620 SSNHL patients, 54,946 matched controls). The mean age was 50.43 years. SSNHL patients were more likely to have concomitant diabetes (odds ratio [OR] 1.61 [95% confidence interval [CI]: 1.31, 1.99; p < .00001]) and hypertension (OR 1.5 [95% CI: 1.16, 1.94; p = .002]). An increased standard mean difference of total cholesterol of 11.09 mg/dL (95% CI; 3.51, 18.67; p = .004) was noted in the SSNHL group compared with the controls. No significant differences in smoking, high-density lipoprotein, triglycerides, or body mass index were detected.

CONCLUSION

Patients presenting with SSNHL have a significantly higher risk of concomitant diabetes, hypertension, and higher total cholesterol in comparison to matched controls. This may indicate a higher cardiovascular risk profile in this population. More prospective and matched cohort studies are needed to understand the role of cardiovascular risk factors in SSNHL.

Is Continued Perioperative Antithrombotic Therapy Safe When Performing Direct Microlaryngoscopy?

OBJECTIVES/HYPOTHESIS

To evaluate whether antithrombotic status impacts the incidence of perioperative or postoperative bleeding in direct microlaryngoscopy (DML).

STUDY DESIGN

Retrospective chart review.

METHODS

Patients undergoing DML in a single surgeon's practice from September 2012 to September 2017 were studied. Included patients underwent DML with or without biopsy, balloon dilation, microsurgery, laser ablation, or vocal fold injection. Patients were stratified based on perioperative antithrombotic status and assessed for rates of peri- and postoperative bleeding and other complications.

RESULTS

Of the 581 patients meeting inclusion criteria, 179 patients (31%) had a history of baseline antithrombotic therapy. Of these patients, 124 had perioperative continuation of their therapy. Medicated patients were older (P < .01), predominately male (P < .01), and increasingly comorbid (P < .01). Perioperative complications unrelated to bleeding occurred in 22 patients (4%), minor perioperative bleeding occurred in four patients (0.7%), and minor postoperative bleeding occurred in 12 of the 479 patients with recorded follow-up (2.5%). There were no postoperative bleeds requiring intervention or readmission, and no recorded thrombotic events during the peri- and postoperative period. There was no difference in perioperative bleeding based on baseline antithrombotic status (P = .81). Patients on baseline antithrombotic therapy were more likely to have a postoperative bleed in comparison to patients without history of antithrombotic use (P < .01). However, there were no significant differences in postoperative bleeding between patients on baseline anticoagulation who continued or ceased their medication perioperatively (P = .45).

CONCLUSIONS

Perioperative continuation of antithrombotic medications appears to be safe when performing routine DML.

LEVEL OF EVIDENCE

4 Laryngoscope, 2020.

Chronic rhinosinusitis in eosinophilic granulomatosis with polyangiitis: clinical presentation and antineutrophil cytoplasmic antibodies

BACKGROUND

In this study we aim to describe presenting characteristics and identify prognostic factors for disease resolution in patients with chronic rhinosinusitis (CRS) in the setting of eosinophilic granulomatosis with polyangiitis (EGPA).

METHODS

Patients evaluated at a tertiary care center with diagnoses of EGPA and CRS were identified. Descriptive statistics were obtained. Univariate analysis was used to search for prognostic factors associated with higher Lund-Mackay score at presentation and disease resolution.

RESULTS

Forty-four patients were included with a mean age of 52.7 (standard deviation, 14) years. Twenty-one patients (47.7%) were female, all had a diagnosis of asthma, and 36 (83.7%) had eosinophils >10%. Common presenting symptoms for CRS included nasal discharge (87.9%) followed by nasal congestion (83.9%) and facial pain and pressure (83.8%). Medical management of CRS included systemic corticosteroids (93.2%) and systemic antibiotics (75%). Surgical intervention occurred in 29 patients (67%). Nine patients (20.5%) had resolution of sinus symptoms, including 4 with imaging confirmation. Fourteen patients (31.8%) had continued CRS, but with improved symptoms, whereas 9 patients (20.5%) had continued CRS with no improvement in symptoms. Eleven patients (25%) were lost to follow-up and 4 (9.1%) died. Univariate analysis did not show antineutrophil cytoplasmic antibody positivity, presence of peripheral eosinophilia, gender, age, or absence of systemic therapy to be predictive of higher Lund-Mackay score at presentation or predictive of disease resolution.

CONCLUSION

CRS in patients with EGPA is often refractory to medical and surgical management. Treatment of these patients should occur in a multidisciplinary setting.