CSO (Canadian Society of Otolaryngology - Head & Neck Surgery) position paper on rhinologic and skull base surgery during the COVID-19 pandemic

Healthcare services in many countries have been partially or completely disrupted by the Coronavirus (COVID-19) pandemic since its onset in the end of 2019. Amongst the most impacted are the elective medical and surgical services in order to conserve resources to care for COVID-19 patients. As the number of infected patients decrease across Canada, elective surgeries are being restarted in a staged manner. Since Otolaryngologists - Head & Neck Surgeons manage surgical diseases of the upper aerodigestive tract where the highest viral load reside, it is imperative that these surgeries resume in a safe manner. The aim of this document is to compile the current best evidence available and provide expert consensus on the safe restart of rhinologic and skull base surgeries while discussing the pre-operative, intra-operative, and post-operative care and tips. Risk assessment, patient selection, case triage, and pre-operative COVID-19 testing will be analyzed and discussed. These guidelines will also consider the optimal use of personal protective equipment for specific cases, general and specific operative room precautions, and practical tips of intra-operative maneuvers to optimize patient and provider safety. Given that the literature surrounding COVID-19 is rapidly evolving, these recommendations will serve to start our specialty back into elective rhinologic surgeries over the next months and they may change as we learn more about this disease.

Should Oral Corticosteroids be Used in Medical Therapy for Chronic Rhinosinusitis? A Risk Analysis

OBJECTIVES

Oral corticosteroid (OCS) as a part of appropriate medical therapy (AMT) (formerly maximal medical therapy) in chronic rhinosinusitis remains controversial. While the risks of OCS are well known, the benefit remains unclear due the absence of a standardized prescribing regimen. Consequently, it is difficult to characterize whether the risks of OCS and its ability to avert endoscopic sinus surgery (ESS) are helpful in AMT. When OCS is highly effective at averting surgery, the lesser risks of OCS would be justified because it can avoid the greater risks of ESS. When OCS is poorly effective at averting ESS, the risks of OCS would not be justified because many patients will be exposed to both risks. This study seeks to identify the threshold effectiveness of OCS at averting ESS that would minimize risk exposure to patients.

METHODS

A probabilistic risks-based decision analysis was constructed from literature reported incidences and impacts of adverse events of OCS and ESS. Monte Carlo analysis was performed to identify the minimum effectiveness required to avoid further intervention (MERAFI) for chronic sinusitis without nasal polyp (CRSsNP) and chronic sinusitis with nasal polyp (CRSwNP).

RESULTS

The analysis showed MERAFI results of 20.8% (95% CI 20.7-20.9%) for CRSsNP and 16.8% (95% CI 16.7-16.9%) for CRSwNP.

CONCLUSIONS

Given reported OCS effectiveness in the range of 34-71% in CRSsNP and 46-63% in CRSwNP, this analysis suggests that the inclusion of OCS in AMT may be the lower risk strategy.

LEVEL OF EVIDENCE

N/A Laryngoscope, 131:473-481, 2021.

When do the risks of repeated courses of corticosteroids exceed the risks of surgery?

BACKGROUND

The management of chronic rhinosinusitis with nasal polyposis (CRSwNP) becomes unclear when patients require multiple courses of corticosteroids to maintain quality of life. Repeated courses of corticosteroids carry increased risks to patients. Although endoscopic sinus surgery (ESS) is an effective therapeutic modality, it also carries inherent risks. This study aims to identify the threshold at which the risks of repeated courses of corticosteroid exceed the risks of surgery.

METHODS

An evidence-based risk analysis was simulated using literature-reported complication rates, quality of life changes, and Medicare costs. Simulations were performed from the Medicare patient perspective, societal perspective, and the universal healthcare patient perspective.

RESULTS

All 3 simulations demonstrate a breakeven threshold favoring surgery over medical therapy when patients require oral corticosteroids (OCS) more often than once every 2 years in CRSwNP, once per year in CRSwNP/asthma, or twice per year for Samter's triad patients.

CONCLUSION

This represents the first rationalized evidence-based analysis for when surgery should be considered in place of repeated courses of oral corticosteroids. This threshold provides a guide for otolaryngologists to use when making clinical decisions with patients.

Osteomeatal complex obstruction is not associated with adjacent sinus disease in chronic rhinosinusitis with polyps

BACKGROUND

It is universally accepted that osteomeatal complex (OMC) disease is linked to the subsequent development of chronic rhinosinusitis without nasal polyps (CRSsNPs) via postobstructive mechanisms. The role of OMC obstruction in the pathogenesis of CRSwNPs is less clear. This study was designed to identify if there is an association between OMC obstruction and inflammation of the adjacent sinuses, when patients are stratified by polyp status. This is a follow-up and expanded series of a previous pilot study from our group.

METHOD

CT scans of 144 patients with CRSsNPs and 123 patients with CRS with nasal polyps (CRSwNPs) were evaluated for each sinus and OMC. Patients had no previous surgeries for NPs. CT scans were obtained after a trial of maximal medical therapy.

RESULTS

Increasing OMC involvement was associated with increasing Lund-Mackay score for both CRSsNPs and CRSwNPs. In CRSsNP patients, OMC status significantly correlated with adjacent sinus status (p << 0.0001). Meanwhile in CRSwNPs, OMC status does not correlate with adjacent sinus status (p = 0.328).

CONCLUSION

OMC obstruction in the setting of CRSwNP may be a barometer of the overall disease process, but in this scenario, paranasal sinus inflammation can not be classified as a postobstructive phenomenon. These findings question the role of minimally invasive procedures in the management of CRSwNPs.

The effect of low-fidelity endoscopic sinus surgery simulators on surgical skill

BACKGROUND

Surgical training models are being increasingly used to provide an environment for surgical trainees to improve their skills without risk to patients. This study uses previously validated, inexpensive, low-fidelity training models to determine how pretraining affects endoscopic sinus surgery (ESS) skills.

METHODS

Fourteen Otolaryngology residents were randomized to 1 of 2 groups that were stratified for training level. The first group took part in a pretraining session where they practiced on all 5 different modules whereas the second group did not receive any pretraining. The following day, all participants took part in a cadaveric ESS course. Participants were instructed to complete a set of tasks and their performances were videotaped. The videos were then evaluated using a Global Rating Scale (GRS) and a Task-Specific Checklist (TSC). The performances of those who trained using the models were compared to the performances of those who did not.

RESULTS

The intervention (pretraining) group performed better than the nonintervention (no pretraining) group on the cadaveric ESS tasks (p < 0.05). As well, there was a statistical difference between the senior residents who had the pretraining with the simulator models performing better than those who did not.

CONCLUSION

The modules appear to have made a positive impact on ESS skills. These low-cost, easily-constructed training modules have the potential to be integrated into Otolaryngology-Head and Neck Surgery resident training. Assessment of long-term training effects with a larger number of participants is planned for future studies.

Electrogustometric assessment of taste after otologic surgery in children

OBJECTIVES/HYPOTHESIS

Long term taste dysfunction after otologic surgery has never been characterized in children. The aim of this study is to determine the rates of gustatory dysfunction in normal and postotologic surgery in children.

STUDY DESIGN

Cross-sectional study.

METHODS

One hundred sixty children visiting a tertiary pediatric otolaryngology clinic, 4 to 18 years of age, were recruited. Surgical groups included patients who had undergone tympanoplasty, combined approach mastoidectomy, modified radical mastoidectomy, and unilateral and bilateral cochlear implantation. They were then tested using a Rion TR-06 electrogustometer (Sensonics, Inc., Haddon Heights, NJ) using a standardized protocol to assess chorda tympani nerve function. An abnormal gustometry result was defined as any recording of > or =16 dB or a difference of 6 dB between ears.

RESULTS

The control group had a 9% (5/61) abnormal electrogustometric threshold rate. Rates of dysfunction after surgery were: tympanoplasty (27%, 4/15), combined approach mastoidectomy (30%, 11/29), modified radical mastoidectomy (50%, 4/8). Unilateral cochlear implantation yielded a 26% (7/27) per ear risk of dysfunction, whereas bilateral cochlear implantation had a 5% (2/40) per ear risk.

CONCLUSIONS

There is a 9% baseline level of electrogustometric abnormality in the pediatric population, which suggests a subclinical level of gustatory dysfunction. Normal electrogustometry was found in 50% of children after modified radical mastoidectomy, suggesting a degree of neural regenerative capacity. Finally, cochlear implantation, using newer surgical techniques (in the bilateral cochlear implant group) has a low risk for causing gustatory dysfunction, reducing concerns over the safety profile of bilateral cochlear implantation.

Construct validation of a low-fidelity endoscopic sinus surgery simulator

BACKGROUND

Before a simulator becomes widely accepted, it must be relevant, affordable, and accessible. We have developed a low-cost model emphasizing the basic skills required for endoscopic sinus surgery (ESS). It is noninvasive, free from risk of infection, and an excellent low-pressure learning opportunity. The current study was designed to assess the construct validity of our simulator.

METHODS

We conducted a stratified randomized crossover-control study. Otolaryngology residents, fellows, and faculty performed predetermined tasks on the model or cadaver, and then switched. Evaluation included hand motion analysis, task time, and blinded expert review.

RESULTS

Sixteen subjects at various levels of training participated. Cadaver performance correlated well with level of training and previous experience with ESS. However, model performance did not demonstrate statistically significant correlation.

CONCLUSION

Our model was unable to demonstrate clear construct validity at this time. Materials and structural modifications are in progress. Pending further validation, its low-cost construction possesses potential for integration into otolaryngology residency curricula. Assessment of the simulator's ability to improve surgical skill is also planned.

An evaluation of the use of hand-held computers for bedside nursing care

Both keyboard-based and pen-based devices for data input have advantages and disadvantages. The suitability of the two input devices for entering different types of clinical data into computers remains unclear. This study aimed to determine the usefulness of different types of technology for nurses' data entry by comparing the utility and efficiency of keyboard and pen-based data input for clinical tasks. The study was conducted in the six largest specialties of an acute care hospital. In each specialty, several wards were randomly selected, and all nurses working in these wards were invited to participate. The input prototype was designed according to the type of text that was to be entered into the system. Task 1 mainly consisted of structured data, Task 2 contained equal amount of structured and textual data, and Task 3 was mainly in textual form. Each nurse was asked to complete the three simulations of nursing records (Tasks 1, 2 and 3). Preliminary findings showed that nurses found the pen-based interface easier to use than the keyboard for completing Tasks 1 and 2, but not Task 3. In terms of accuracy, the nurses preferred the keyboard to the pen when the data were more structured. The pen-based device is not a panacea for all kinds of user interface, and more importantly, the choice of input device should depend on the amount of structured and textual data.