Analysis of the characteristics of outpatient and emergency diseases in the department of otolaryngology during the "COVID-19" pandemic

The pandemic of "Corona Virus Disease 2019" (COVID-19) has changed the lives of people. There have been changes in common outpatient and emergency cases in otolaryngology, so an analysis of data pertaining to this was completed. This study is to evaluate the impact of viral infection disease in otolaryngological common disease. This study uses the data of common diseases in the outpatient and emergency department during the "COVID-19" pandemic (from February to April 2020) and the same period in the past 3 years from the Department of Otolaryngology. During the "COVID-19" period compared with the same period last year, the ranking of cases by diseases has changed. Diseases such as chronic pharyngitis, allergic rhinitis, sudden deafness, and tinnitus increased, meanwhile acute pharyngitis and acute laryngopharyngitis decreased (p < 0.05). The viral infection has impacted the mental behaviors of people, therefore mental-related disease cases of the department of Otolaryngology have increased indirectly. This study provides real data to illustrate mental-related diseases. It also provides experience and shows the importance of keeping and maintaining mental health.

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.

Best practice recommendations: ENT consultations during the COVID-19 pandemic

These best practice recommendations for ENT consultations during the COVID-19 pandemic have been drawn up because ENT examinations and treatments are at risk of contamination by the SARS-Cov-2 virus in certain instances. Thus, ENT specialists are among the professionals who are most exposed to this infection. During the pandemic, insofar as an asymptomatic patient may be infected and contagious, the same precautions must be employed whether the patient is ill with, suspected of having, or without any clinical evidence of COVID-19 infection. According to the scientific data available, the examinations and procedures potentially exposing to projections/aerosolizations of organic material of human origin are considered to be at risk of staff contamination. For ENT examinations and procedures without exposure to such projections/aerosolizations, the professional is advised to a long sleeve clean outfit, a surgical mask and gloves in case of contact with the patient's mucosa. ENT examinations and procedures with exposure to these projections/aerosolizations require the so-called "airborne", "contact", and "droplets" additional precautions: FFP2/N95 respiratory protection device, eye protection, disposable headwear and long sleeve overgown.

Epistaxis as a marker for severe acute respiratory syndrome coronavirus-2 status - a prospective study

OBJECTIVE

To evaluate the prevalence of severe acute respiratory syndrome coronavirus-2 infection in patients presenting with epistaxis to a tertiary otolaryngology unit.

METHODS

A prospective study was conducted of 40 consecutive patients presenting with epistaxis referred to our tertiary otolaryngology unit. A group of 40 age-matched controls were also included. All patients underwent real-time reverse transcriptase polymerase chain reaction testing for severe acute respiratory syndrome coronavirus-2. Symptoms of fever, cough and anosmia were noted in the study group.

RESULTS

The mean age was 66.5 ± 22.4 years in the study group. There were 22 males (55 per cent) and 18 females (45 per cent). The mean age in the control group was 66.3 ± 22.4 years (p = 0.935). There were six positive cases for severe acute respiratory syndrome coronavirus-2 (15 per cent) in the epistaxis group and one case (2.5 per cent) in the control group. The difference was statistically significant (p = 0.05).

CONCLUSION

Epistaxis may represent a presenting symptom of severe acute respiratory syndrome coronavirus-2 infection. This may serve as a useful additional criterion for screening patients.

Union of the European Phoniatricians' position statement on the exit strategy of phoniatric and laryngological services: staying safe and getting back to normal after the peak of coronavirus disease 2019 (issued on 25th May 2020)

BACKGROUND

The following position statement from the Union of the European Phoniatricians, updated on 25th May 2020 (superseding the previous statement issued on 21st April 2020), contains a series of recommendations for phoniatricians and ENT surgeons who provide and/or run voice, swallowing, speech and language, or paediatric audiology services.

OBJECTIVES

This material specifically aims to inform clinical practices in countries where clinics and operating theatres are reopening for elective work. It endeavours to present a current European view in relation to common procedures, many of which fall under the aegis of aerosol generating procedures.

CONCLUSION

As evidence continues to build, some of the recommended practices will undoubtedly evolve, but it is hoped that the updated position statement will offer clinicians precepts on safe clinical practice.

Restructuring ENT out-patient services during the coronavirus disease 2019 pandemic - an iterative approach

BACKGROUND

Coronavirus disease 2019 has demanded enormous adjustments to National Health Service provisions. Non-urgent out-patient work was initially postponed or performed virtually, but is now being re-established. In ENT surgery, aerosol-generating procedures pose a particular challenge in out-patient settings.

OBJECTIVE

A rapid restructuring of ENT out-patient services is required, to safely accommodate aerosol-generating procedures and increase in-person attendances, whilst coronavirus disease 2019 persists.

METHODS

Data were collected prospectively over four consecutive cycles. Two surveys were conducted. Results were analysed and disseminated, with recommendations for service restructuring implemented at cycle end-points.

RESULTS

Out-patient activity increased four-fold, associated with a significant rise in aerosol-generating procedures during the study period. Mean aerosol-generating procedure duration dropped weekly, implying a learning curve. Service restructuring occurred at cycle end-points.

CONCLUSION

Iterative data gathering, results analysis and outcome dissemination enabled a swift, data-driven approach to the restructuring of ENT out-patient services. Patient and staff safety was ensured, whilst out-patient capacity was optimised.

Relationship between anosmia and hospitalisation in patients with coronavirus disease 2019: an otolaryngological perspective

OBJECTIVE

A study was carried out to evaluate the relationship between anosmia and hospital admission in coronavirus disease 2019 patients.

METHODS

The clinical data of 1534 patients with confirmed coronavirus disease 2019 virus were analysed. The study was conducted with medical records of 1197 patients (78 per cent). The basic characteristics of patients and symptoms related to otolaryngology practice were examined. The patients were divided into two groups according to their follow up: an out-patient group and an in-patient group.

RESULTS

The majority of patients presented with anosmia (44.2 per cent), dysgeusia (43.9 per cent) and fever (38.7 per cent). Anosmia was observed in 462 patients (47 per cent) in the out-patient group, and in only 67 patients (31.2 per cent) in the in-patient group. Younger age (odds ratio = 1.05, 95 per cent confidence interval = 1.03-1.06) and the presence of anosmia (odds ratio = 2.04, 95 per cent confidence interval = 1.39-3) were significantly related to out-patient treatment.

CONCLUSION

Anosmia could be a symptom in the clinical presentation of the coronavirus disease 2019 infection.

Approaching Otolaryngology Patients During the COVID-19 Pandemic

Objective. To describe coronavirus disease 2019 (COVID-19) patient presentations requiring otolaryngology consultation and provide recommendations for protective measures based on the experience of ear, nose, and throat (ENT) departments in 4 Chinese hospitals during the COVID-19 pandemic. Study Design. Retrospective case series. Setting. Multicenter. Subjects and Methods. Twenty hospitalized COVID-19 patients requiring ENT consultation from 3 designated COVID-19 hospitals in Wuhan, Shanghai, and Shenzhen were identified. Data on demographics, comorbidities, COVID-19 symptoms and severity, consult reason, treatment, and personal protective equipment (PPE) use were collected and analyzed. Infection control strategies implemented for ENT outpatients and emergency room visits at the Eye and ENT Hospital of Fudan University were reported. Results. Median age was 63 years, 55% were male, and 95% were in severe or critical condition. Six tracheotomies were performed. Posttracheotomy outcomes were mixed (2 deaths, 2 patients comatose, all living patients still hospitalized). Other consults included epistaxis, pharyngitis, nasal congestion, hyposmia, rhinitis, otitis externa, dizziness, and tinnitus. At all hospitals, powered air-supply filter respirators (PAPRs) were used for tracheotomy or bleeding control. PAPR or N95-equivalent masks plus full protective clothing were used for other complaints. No inpatient ENT providers were infected. After implementation of infection control strategies for outpatient clinics, emergency visits, and surgeries, no providers were infected at the Eye and ENT Hospital of Fudan University. Conclusions and Relevance. COVID-19 patients require ENT consultation for many reasons, including tracheotomy. Otolaryngologists play an indispensable role in the treatment of COVID-19 patients but, due to their work, are at high risk of exposure. Appropriate protective strategies can prevent infection of otolaryngologists.

Pearls of experience for safe and efficient hospital practices in otorhinolaryngology-head and neck surgery in Hong Kong during the 2019 novel coronavirus disease (COVID-19) pandemic

The 2019 novel coronavirus disease (COVID-19) epidemic originated in Wuhan, China and spread rapidly worldwide, leading the World Health Organization to declare an official global COVID-19 pandemic in March 2020. In Hong Kong, clinicians and other healthcare personnel collaborated closely to combat the outbreak of COVID-19 and minimize the cross-transmission of disease among hospital staff members. In the field of otorhinolaryngology-head and neck surgery (OHNS) and its various subspecialties, contingency plans were required for patient bookings in outpatient clinics, surgeries in operating rooms, protocols in wards and other services. Infected patients may shed severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) particles into their environments via body secretions. Therefore, otolaryngologists and other healthcare personnel in this specialty face a high risk of contracting COVID-19 and must remain vigilant when performing examinations and procedures involving the nose and throat. In this article, we share our experiences of the planning and logistics undertaken to provide safe and efficient OHNS practices over the last 2 months, during the COVID-19 pandemic. We hope that our experiences will serve as pearls for otolaryngologists and other healthcare personnel working in institutes that serve large numbers of patients every day, particularly with regard to the sharing of clinical and administrative tasks during the COVID-19 pandemic.

Guidelines of clinical practice for the management of swallowing disorders and recent dysphonia in the context of the COVID-19 pandemic

Procedures putting healthcare workers in close contact with the airway are particularly at risk of contamination by the SARS-Cov-2 virus, especially when exposed to sputum, coughing, or a tracheostomy. In the current pandemic phase, all patients should be considered as potentially infected. Thus, the level of precaution recommended for the caregivers depends more on the type of procedure than on the patient's proved or suspected COVID-19 status. Procedures that are particularly at high risk of contamination are clinical and flexible endoscopic pharyngo-laryngological evaluation, and probably also video fluoroscopic swallowing exams. Voice rehabilitation should not be considered urgent at this time. Therefore, recommendations presented here mainly concern the management of swallowing disorders, which can sometimes be dangerous for the patient, and recent dysphonia. In cases where they are considered possible and useful, teleconsultations should be preferred to face-to-face assessments or rehabilitation sessions. The latter must be maintained only in few selected situations, after team discussions or in accordance with the guidelines provided by health authorities.

COVID-19 and ENT Pediatric otolaryngology during the COVID-19 pandemic. Guidelines of the French Association of Pediatric Otorhinolaryngology (AFOP) and French Society of Otorhinolaryngology (SFORL)

OBJECTIVE

Joint guidelines of the French Pediatric Otolaryngology Society (AFOP) and of the French Society of otorhinolaryngology-head and neck surgery (SFORL) on the management of paediatric otolaryngology patients in the context of the COVID-19 pandemic.

METHODS

A nation-wide workgroup drew guidelines based on clinical experience, national and local recommendations and scientific literature. Proposals may have to be updated on a day-to-day basis.

RESULTS

In children, incidence of symptomatic COVID-19 (1-5%) is low and of good prognosis. The indications for nasal flexible endoscopy should be drastically limited. If undertaken, full Personal Protective Equipment (PPE) including FFP2 masks are required, as well as use of a sheath. Saline nose wash done by caregivers other than parents at home should require PPE. Unless foreign body tracheobronchial aspiration is clinically obvious, CT-scan should be performed to confirm indication of endoscopy. Surgical indications should be limited to emergencies and to cases that cannot be delayed beyond 2 months (especially endonasal, endopharyngeal laryngo-tracheobronchial procedures). Postponement should ideally be a group decision and recorded as such in the medical file. Surgical techniques should be adapted to limit the risk of viral dissemination in the air, avoiding the use of drills, microdebriders, monopolar cautery or lasers. Continuous suction should be placed near the operating field. In case of confirmed Covid-19 cases, or suspected cases (or in some centres systematically), PPE with FFP2 mask should be worn by all staff members present in the operating room.

Comparison of Referral Pathways in Otolaryngology at a Public Versus Private Academic Center

OBJECTIVE

Delayed medical care may be costly and dangerous. Examining referral pathways may provide insight into ways to reduce delays in care. We sought to compare time between initial referral and first clinic visit and referral and surgical intervention for index otolaryngologic procedures between a public safety net hospital (PSNH) and tertiary-care academic center (TAC).

METHODS

Retrospective cohort study of eligible adult patients undergoing one of several general otolaryngologic procedures at a PSNH (n = 216) and a TAC (n = 161) over a 2-year time period.

RESULTS

PSNH patients were younger, less likely to have comorbidities and more likely to be female, Hispanic or Asian, and to lack insurance. Time between referral and first clinic visit was shorter at the PSNH than the TAC (Mean 35.8 ± 47.7 vs 48.3 ± 60.3 days; P = .03). Time between referral and surgical intervention did not differ between groups (129 ± 90 for PSNH vs 141 ± 130 days for TAC, P = .30). On multivariate analysis, the TAC had more patient-related delays in care than the PSNH (OR: 3.75, P < .001). Time from referral to surgery at a PSNH was associated with age, source of referral, type of surgery, diagnostic workup and comorbidities, and at a TAC was associated with gender and type of surgery and comorbidities.

CONCLUSIONS

Sociodemographic differences between PSNH and TAC patients, as well as differences in referral pathways between the types of institutions, influence progression of surgical care in otolaryngology. These differences may be targets for interventions to streamline care.

LEVEL OF EVIDENCE

2c.

Thyroid Surgery: Whose Domain Is It?

In the United States of America (US), most departments of otorhinolaryngology head and neck surgery have been performing thyroid surgery for many years. In contrast to the US, thyroid surgery is still dominated by general surgeons in most European countries. In numerous university centers, there continues to be friction regarding thyroid surgery. The focus of this editorial is to demonstrate that there is objective data in the literature to suggest that otorhinolaryngologists with appropriate training in head and neck surgery are well suited to perform the entire spectrum of thyroid surgery. The question of who is qualified to perform thyroid surgery is not determined by the basic specialty certification of the surgeon—general or otolaryngology; rather it depends on the training, skill and experience in surgery of the neck, of post-surgical and post-irradiated necks, and of neighboring structures.

Specialists' adherence to guidelines on tympanostomy tube insertion

INTRODUCTION

Tympanostomy tube insertion is very frequent in Denmark. Using electronic patient-reported outcome (ePRO) data, we investigated Danish ear, nose og throat (ENT) specialists' adherence to the 2015 national clinical guideline (NCG) on first-time tympanostomy tube (TT) insertion in children aged 0-5 years with otitis media (OM).

METHODS

Data on children aged 0-5 years with OM undergoing first-time TT insertion were extracted from the Danish ENT Specialists Organisation (DØNHO) database. Pre-operative questionnaires were used to obtain information on symptom duration, and the number of acute OM (AOM) episodes was analysed. The following criteria were established to define NCG adherence: 1) A symptom duration of three months or longer, 2) three or more AOM episodes within six months and 3) four or more AOM episodes within 12 months. These criteria are in accordance with the NCG definition of chronic OM with effusion (COME) and recurrent AOM (RAOM).

RESULTS

A total of 1,495 children were included in the study. In total, 91.0% of the parents reported a symptom duration of three months or more and/or RAOM within 6-12 months prior to TT insertion in accordance with the adherence criteria; 4.6% reported a symptom duration of less than three months with few or no episodes of AOM and did not meet the recommended TT insertion criteria. Finally, 4.4% of the parents were undecided with respect to symptom duration, number of AOM episodes or both at 6-12 months prior to TT insertion.

CONCLUSIONS

Using solely ePRO data, we found that Danish practicing ENT specialists adhere to the 2015 NCG in regard to OM symptom duration and RAOM.

FUNDING

none.

TRIAL REGISTRATION

not relevant.

Validation of the Danish National Tympanostomy Tube Insertion Questionnaires

INTRODUCTION

The objective of the present study was to validate two questionnaires (the Danish National Tympanostomy Tube Insertion Questionnaires (DANTIQ)) intended for use by the DØNHO database in the investigation of the effect of tympanic tube (TT) insertion on ear-related symptoms and the adherence of ear, nose and throat (ENT) specialists in Danish private practice to the Danish National Clinical Guideline on treatment of otitis media (OM) with TT insertion using electronic patient-reported outcome (ePRO) data.

METHODS

The content validity of the questionnaires was assessed through discussion in a group of four active ENT specialists. Face and content validity analyses were conducted using data from semi-structured, single-person interviews with nine subjects. Reliability analysis was conducted as a three-day test/re-test study involving two groups of 117 individuals receiving and answering the same questionnaire twice.

RESULTS

The overall face validity of both questionnaires was satisfactory. The reliability of the answers for both questionnaires was considered acceptable with a proportion of agreement ranging from 1.00 to 0.77. The correlation between first and second scores of the total number of symptoms reported in the test/re-test setup was acceptable with results ranging from 0.93 to 0.84.

CONCLUSIONS

The DANTIQ are valid and reliable for measuring ear-related symptoms in children with OM undergoing TT insertion and for investigating Danish private ENT specialists' adherence to guidelines concerning TT insertion by use of ePRO data.

FUNDING

non.

TRIAL REGISTRATION

not relevant.

Africa's challenged ENT services: highlighting challenges in Zambia

BACKGROUND

Diseases of the ear, nose and throat (ENT) are common and are a major cause of morbidity and mortality. In many low income countries like Zambia, the high ENT disease burden has not received the required resources for treatment. We investigated ENT service provision in hospitals in Zambia by documenting the profile of hospitals offering ENT services and examining the country's ENT services with regards to human resource, infrastructure and availability of equipment based on the levels of care of various hospitals.

METHODS

The study was a cross-sectional descriptive survey conducted using a structured and piloted questionnaire which was administered to the 109 Ministry of Health (MoH) registered hospitals across the country. Ethical clearance was granted by University of KwaZulu-Natal and the Zambia National Health Research Authority. Participation in the study was voluntary and all respondents signed informed consent. Descriptive statistics were used to analyse the data.

RESULTS

Of the 109 hospitals approached to participate in the study, 61 (55.9%) hospitals responded. This represented 83.3% (n = 5) of Third Level Hospitals (TLH), 89.5% (n = 17) of Second Level Hospitals (SLH) and 41.7% (n = 35) of First Level Hospitals (FLH) countrywide. Of the participating hospitals, 6.6% (n = 4) were unclassified. Within this sample, 8.6% (n = 3) FLH, 11.8% (n = 2) SLH and 60.0% (n = 3) TLH had an ENT examination room. Only 2.9% (n = 4) hospitals had an audiology booth and 1.6% (n = 1) had a speech therapy room. Of the second and third level hospitals, 9.1% (n = 2) had flexible rhinolaryngoscopes, 18.2% (n = 4) had operating microscopes and 68.2% (n = 15) adenotonsillectomy sets. The data revealed that there were 4 ENT surgeons, 1 Audiologist and no Speech Therapists across the country.

CONCLUSION

Zambia's ENT services were deficient at all levels of hospital care. There were deficiencies in infrastructure, human resource and equipment in hospitals. With the current burden of disease, critical intervention is required. These findings should be used to direct national policy on the improvement of ENT service provision in Zambia.

Otolaryngologists adhere to evidence-based guidelines for chronic rhinosinusitis

PURPOSE

To assess awareness of, opinion about and adherence to evidence-based guidelines on chronic rhinosinusitis among Dutch Otolaryngologists.

METHODS

We assessed implementation of two guidelines, one Dutch and one European, that are both intended for diagnosis and treatment of patients with chronic rhinosinusitis. We invited 485 Otolaryngologists to fill out a questionnaire and report on their opinion on and adherence to the guidelines. The adherence was further tested by 4 clinical case scenarios, derived from guideline recommendations.

RESULTS

166 (34%) completed the questionnaire. 99% of the respondents was aware of one or both guidelines. Most respondents (90%) consider the guidelines as directing or supportive for their clinical practice based on the clinical case scenarios, between 62 and 99% of the respondents act according to guidelines. Concerning diagnosis, CT-imaging is performed more and allergy testing less than recommended. Where multiple treatment options are recommended, the responses are more heterogeneous as a result of this. Nonetheless, high recommended treatment was chosen more often. Otolaryngologists were reluctant in surgical treatment as a first option, which is according to the guidelines.

CONCLUSIONS

Overall, both the EPOS and CBO guideline are well known among Dutch Otolaryngologists and 90% indicates that the guideline is important in their daily practice. Adherence to the guidelines is sufficient to high. If multiple treatment or diagnostic options are recommended this leads to a more heterogeneous response pattern. Recommendations with a high grade of recommendation were followed up most often.

Cochlear implant provider awareness of vaccination guidelines

OBJECTIVE

Guidelines for vaccination of cochlear implant (CI) recipients have been promulgated and updated by the Center for Disease Control and Prevention (CDC) to mitigate bacterial meningitis risk. The objective of this study was to survey current CI specialists on: 1) knowledge of current CDC CI recipient immunization recommendations, and 2) impediments to implementation of those guidelines.

METHODS

A survey to assess knowledge of the CI recipient vaccination guidelines was administered to the American Academy of Otolaryngology-Head and Neck surgery (AAO-HNS), the American Cochlear Implant Alliance (ACIA), and the American Neurotology Society (ANS). The members of the AAO-HNS and ACIA were invited to participate in the survey via an e-mail. The members of the ANS were polled during a session of their fall meeting.

RESULTS

A total of 256 individuals participated: 64 from AAO, 59 from ACIA, and 133 from ANS. Participants reported knowledge of the vaccination guidelines as high among all groups and statistically similar. The survey indicated that the participants noted difficulty in obtaining age-group-specific immunizations. Vaccination status was not consistently reported.

CONCLUSION

Cochlear implant providers have high awareness of vaccination guidelines but less detailed knowledge of age-specific recommendations. Obtaining age-specific vaccines is a challenge, as is consistent documentation of vaccination. Future efforts should be focused on improving knowledge of age-specific recommendations, easing access of age-specific vaccines, and improving documentation.

LEVEL OF EVIDENCE

NA. Laryngoscope, 128:2145-2152, 2018.

Otolaryngology Nurses' Awareness of Clinical Practice Guidelines

Clinical practice guidelines (CPG) are developed to inform clinical decision-making and standardize care based on scientific evidence, benefits and harms of treatment, and patient preferences to achieve optimal health outcomes. This survey study explored the level of awareness of otorhinolaryngology (ORL) nurses in using CPGs in clinical practice. The study sought to answer the following: (1) How aware are ORL nurses of CPGs developed by the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF)? (2) Which CPGs are most widely identified by ORL nurses? and (3) Do ORL nurses perceive that AAO-HNSF guidelines can benefit their practice? An online survey was developed, piloted, and launched to all eligible registered nurse SOHN members in October 2015. A total of 146 nurses (29%) completed the survey. Over 60% of respondents were in nursing for more than 20 years, 20% were in ORL for 5 years or less, and 40% worked in the hospital, 25% were aware of one or less of the guidelines, with 75% aware of 2 or more specialty guidelines. Nurses were most aware of the tracheostomy care (64%), tonsillectomy in children (47%), and tympanostomy tubes in children (46%) guidelines. The majority of ORL nurses was aware of specialty CPGs and used them to help guide their clinical practice on a regular basis. They also perceived support by their organizations to engage in evidence-based practice. Increasing nurses' awareness and knowledge of CPGs will likely increase guideline use and advance clinical practices based on these recommendations. Strategies to enhance evidence-based guideline recommendations into practice will also be discussed.

136: High-frequency Continuous Objective Tinnitus Caused by Middle Ear Myoclonus

Our Academy has proposed this primer, The Ethical Otolaryngologist, to serve as guide to help individual otolaryngologists determine the ethical nature of technologic advancements. Ultimately, each otolaryngologist will decide for himself or herself what he or she believes to be ethical. However, we otolaryngologists should make these decisions while recalling our sworn responsibility to our patients and our responsibility to our chosen profession in otolaryngology. Examples and questions that were presented are intended to assist each of us in making ethical determinations about the care we render to patients. There are many facets to the ethical implications of new technology touched on in this chapter, and they include the following: 1. Categories of new technology and technology assessment studies. 2. Otolaryngologists adopting or developing new technologies. 3. Otolaryngologists teaching and learning new technologies. 4. Supervision of clinical applications of new technologies. In conclusion, nearly all of us who are otolaryngologists have entered this aspect of health care because we enjoy patient contact, the challenges of surgery, the continuing education process, and above all, we are interested in helping our patients prevent and alleviate disease. Our training has encouraged us to put the patient's best interests above all else. This is our utmost ethical responsibility.

The epistemology of otolaryngology–head and neck surgery: A scientific evaluation of the knowledge base

There are nearly a quarter of a million ENT publications listed in MEDLINE alone and the knowledge within our field continues to accumulate at an increasing rate. Many factors influence publication and the production and dissemination of new knowledge. But the direction of research effort does not always reflect clinical need. A variety of external factors are implicated including-but certainly not limited to-funding, corporate interest and market forces, the political climate, tenacity and resourcefulness of special interest groups, and even fashion. Little detailed information on the current state of knowledge within otolaryngology has been available.

The relationship between evidence and guidelines

This reflection aims to soothe some frustrations, to cool current debates, and to encourage an understanding whereby the relationship between evidence and guidelines can be more productive in future. The relationship of evidence to guidelines, an important link between research and application, is not as simple and unidirectional as is often imagined. The recent emphasis on evidence of high quality and aggregation of evidence is appropriate but can be modified and extended. There are other important elements in guidelines besides the available evidence (which is centered on efficacy and effectiveness). Available evidence may be poor, or not be the most relevant to the decision at hand. To offset the limitations to which this predicament leads, effort is also appropriate to develop more rigorous principles for interpretation and evaluation of evidence, so as to make better use of what is available. The processes for generating guidelines from evidence emphasize reliability, generalizability of a limited kind, and freedom from bias to be achieved via systematic review. If the inclusion criterion for studies is too stringent, there may be little to say from evidence alone, or the evidence that remains may suffer limitations of relevance due to context, or it may be misapplied, simply because it has been endorsed as to quality. Knowledge-based medicine (KBM) would acknowledge a greater role for the scientific principles underlying particular pieces of evidence and deploy a fuller understanding of the health-care context. It should thus make guidelines more professionally accepted and useful in the future.

Evidence-based medicine and otolaryngology–HNS: Passing fashion or permanent solution

Otolaryngologists and head and neck surgeons have not always fully engaged with the evidence-based medicine (EBM) movement. Now that EBM has been identified as one of the most important milestones in medicine in the last 150 years, I hope things will change. In reviewing the tenets of EBM and considering its implementation I explain why we must embrace its principles and argue that optimal medical practice is both “evidence” – and “wisdom”-based, both being necessary but neither alone being sufficient.

[Hygiene in otorhinolaryngology: Requirements and reality]

Considering the physiological contamination of skin and mucous membranes in the ear, nose, and throat region by facultative pathogen microorganisms, as well as the increase in multidrug resistant organisms (MDRO), it is mandatory that hygienic procedures be observed in ENT institutions, in order to prevent transmission of bacteria and infections in patients. General guidelines for hygiene in otorhinolaryngology are presented based on the recommendations published by the German Commission on Hospital Hygiene and Infection Prevention (KRINKO). These encompass hand hygiene, surface disinfection, and reprocessing of medical devices. The correct reprocessing of the various components of ENT treatment units (including endoscopes, water bearing systems) is reported. Although law requires and KRINKO recommends that manufacturers of medical devices publish instructions for reprocessing their products, these reprocessing recommendations are often insufficient. Manufacturers should thus be called upon to improve their recommendations. In this paper, the requirements for handling of ENT treatment units are compared with the observations made by the Public Health Department in 7 ENT clinics and 32 ENT practices in Frankfurt/Main, Germany, in 2014.

American Academy of Otolaryngology-Head and Neck Surgery Foundation Clinical Practice Guidelines

All health care professionals want to provide their patients with the best care possible. In order to accomplish this, the most current research must be incorporated into their daily practice. Many medical specialty societies have developed clinical practice guidelines to help facilitate achievement of safe, high quality patient care. This manuscript highlights the recommendations from the clinical practice guidelines developed and published through the American Academy of Otolaryngology-Head and Neck Surgery Foundation. Dissemination of clinical practice guidelines, to a broad audience, is essential to ensure implementation and adoption into practice. The key action statements and recommendation strength of each from the clinical practice guidelines are highlighted to help achieve these goals.

Management of obstructive sleep apnea in children: A practical approach

The management of sleep disordered breathing (SDB) in children differs between institutions, and there is a need for an updated review of current practice. Literature was reviewed using the PubMed database from 1995 to 2015 by four tertiary care providers experienced in the management of children with SDB. Articles were selected for clinical applicability, strength of evidence, and practicality for practicing clinicians. Fifty-five articles were identified by tertiary care providers in pediatric anesthesiology, pediatric pulmonology, sleep medicine, and pediatric otolaryngology. Each reviewed and analyzed literature independently based on their specialties, and a consensus document was created. The consensus was that the majority of children with SDB do not undergo polysomnography (PSG) before adenotonsillectomy (T&A). Indications for PSG are presented, with a practical approach recommended for the otolaryngologist. Clinical practice guidelines are available from leading national societies, but their recommendations differ. T&A is the first-line treatment and is highly effective in normal-weight but not in obese children. The perioperative management of children is challenging and needs to be individualized. Young children, those with severe obstructive sleep apnea, and those with significant comorbidities need to be observed overnight.

Diagnosis of Middle Ear Disease using Tympanograms and Digital Imaging

OBJECTIVE: The study investigates the ability of physicians with different levels of training to accurately identify middle ear (ME) pathology using tympanograms and tympanic membrane (TM) digital photographs.

STUDY DESIGN AND SETTING: Groups of medical students, internal medicine residents, and attending and resident otolaryngologists were presented with a set of 50 matched tympanograms and photographs of TMs. The physicians were asked to differentiate between a normal and an abnormal-appearing TM. The sensitivity and specificity of diagnosis of ME pathology by physicians were compared with the gold standard, examining the ME cavity for pathology during myringotomy.

RESULTS: The sensitivity did not vary among physicians with different levels of training; however, specificity improved with an increase in physician experience.

CONCLUSIONS AND SIGNIFICANCE: This study establishes a baseline for accuracy of diagnosis of ME pathology using tympanograms and photographs of TMs as compared with binocular otomicroscopy and the gold standard, myringotomy. EBM rating: B-2.

The Implications of “Pay-for-Performance” Reimbursement for Otolaryngology—Head and Neck Surgery

OBJECTIVE: To introduce otolaryngologists to outcomes-linked reimbursement (“pay-for-performance”), identify clinical practice implications, and recommend changes for successful transition from the traditional “pay-for-effort” reimbursement model.

STUDY DESIGN: Policy review.

RESULTS: Payers are actively linking reimbursement to quality. Since the Institute of Medicine issued its report on medical errors in 1999, there has been much public and private concern over patient safety. In an effort to base health care payment on quality, “pay-for-performance” programs reward or penalize hospitals and physicians for their ability to maintain standards of care established by payers and regulatory groups. More than 100 such programs are operational in the United States today. This reimbursement model relies on detailed documentation in specific patient care areas to facilitate evaluation of outcomes for purposes of determining reimbursement. Because performance criteria for reimbursement have not yet been proposed within otolaryngology—head and neck surgery, otolaryngologists must be involved to ensure the adoption of reasonable goals and development of reasonable systems for documentation.

CONCLUSION: “Pay-for-performance” reimbursement is increasingly common in the current era of outcomes-based medicine. It will assume an even greater role over the next 3 years and will directly affect most otolaryngologists.

Pediatric Microvascular Reconstruction: A Report from the Microvascular Committee

BACKGROUND: Free tissue transfer is an integral part of modern head and neck surgery in the adult population. Its use in the pediatric population has not been well described. Recently, there has been an increase in the application of these techniques in the pediatric population. The morbidity of free tissue transfer in small pediatric patients and its effect on growth has not been well described.

OBJECTIVE: To evaluate the utility of microvascular reconstruction techniques in the pediatric population.

STUDY DESIGN: A consensus study was performed by the microvascular committee of the American Academy of Otolaryngology-Head and Neck Surgery. Thirty active microvascular surgeons reviewed their databases to find patients less than 21 years of age who underwent free tissue transfer.

RESULTS: 49 free tissue transfers performed between 1999 and 2005. The mean age was 12.1 years (age range, 3–21). The types of flaps transferred were radial forearm (10), fibula (21), rectus abdominus (7), scapula (1), latissimus dorsi (3), groin (1), gracillus (4), and jejunum (2). Morbidity at the donor site was relatively minimal. Five patients developed wound breakdown. One of these required return to the operating room. Morbidity at the reconstructed site was also rare. Patients were followed for an average of 49 months (range, 1–131 months), and no problems were noted with growth at the donor or recipient sites.

CONCLUSIONS: Free flaps in the pediatric population have morbidity and survival similar to those in the adult population.

SIGNIFICANCE: While indications differ from those in the adult population, these techniques are viable and valuable and should be considered in the pediatric reconstructive paradigm.

[On the interdisciplinary S3 guidelines for the treatment of chronic idiopathic tinnitus]

INTRODUCTION

Tinnitus is a frequent symptom, which, particularly in combination with comorbidities, can result in a severe disease-related burden. Chronic idiopathic tinnitus (CIT) is the most frequent type of tinnitus. A considerable number of treatment strategies are used to treat CIT-for many of which there is no evidence of efficacy. In order to enable scientific evidence-based treatment of CIT, German interdisciplinary S3 guidelines have recently been constructed for the first time. Here we present a short form of these S3 guidelines.

MATERIALS AND METHODS

The guidelines were constructed based on a meta-analysis of the treatment of chronic tinnitus performed by the authors. Additionally, a systematic literature search was performed in the PubMed and Cochrane Library databases. Furthermore, a systematic search for international guidelines was performed in Google, as well as in the Guidelines International Network and National Guideline Clearinghouse (USA) database. Evidence was classified according to the Oxford Centre for Evidence-Based Medicine system.

RESULTS

According to the guidelines, alongside counselling, manualized structured tinnitus-specific cognitive behavioral therapy (tCBT) with a validated treatment manual is available as evidence-based therapy. In addition, the guidelines recommend concurrent treatment of comorbidities, including drug-based treatment, where appropriate. Particularly important is treatment of anxiety and depression. Where a psychic or psychiatric comorbidity is suspected, further diagnosis and treatment should be performed by an appropriately qualified specialist (psychiatrist, neurologist, psychosomatic medicine consultant) or psychological psychotherapist. In cases accompanied by deafness or hearing loss bordering on deafness, cochlear implants may be indicated.

CONCLUSION

No recommendations can be made for drug-based treatment of CIT, audiotherapy, transcranial magnetic or electrical stimulation, specific forms of acoustic stimulation or music therapy; or such recommendations must remain open due to the lack of available evidence. Polypragmatic tinnitus treatment with therapeutic strategies for which there is no evidence of efficacy from controlled studies is to be refused.

[Disciplinary decisions about ENT doctors: an overview of the period 1993-2012]

We examined the prevalence and consequences of complaints about ENT doctors lodged with the disciplinary board. In the period 1993-2012, 181 disciplinary decisions were made about ENT doctors. Relatively few complaints were made against ENT doctors compared with other medical professions; 16% of the complaints were upheld. Only the lightest measures were taken, such as warnings or reprimands. Seventy-five complaints concerned a medical-technical procedure. When focussing on surgical treatments, the most serious complaints were about endoscopic sinus surgery. In the study period (1993-2012), 448 claims were filed against ENT doctors at the largest Dutch hospital insurer for medical liability. The biggest claims were also related to endoscopic sinus surgery cases. Recommendations are made to improve the quality policy of the Dutch ENT society.

[The concept of the development of the otorhinolaryngological service in Moscow under conditions of modernization of the healthcare system and single-channel funding]

This paper highlights the complex of organizational and socio-economic measures designed to modify the healthcare system in the city of Moscow, improve the quality of medical aid, and ensure its availability for the urban population. The proposed methods were developed based on the results of analysis of the data obtained in the course of checking the work of the otorhinolaryngological services of the city, analysis of effectiveness of using the hospital stock in the therapeutic and prophylactic facilities of Moscow.

[Current treatment strategies for papillary thyroid microcarcinoma]

The increase in the incidence of thyroid cancer is accompanied by a mortality rate that is stable or perhaps even slightly decreasing. This phenomenon is due to the increased frequency of papillary microcarcinomas (thyroid tumors with a diameter of less than 1 cm), which is presumably attributable to the improved diagnosis enabled by high resolution ultrasound and fine needle aspiration cytology. The American and European Thyroid Associations have recently published new guidelines for the diagnosis and therapy of differentiated thyroid tumors. These guidelines are aimed at minimizing the diagnostic and therapeutic procedures without reducing their effectiveness. This goal is particularly important for papillary thyroid microcarcinoma patients, who have an excellent prognosis and almost normal life expectancy. This article summarizes the history of thyroid surgery and introduces papillary thyroid microcarcinoma--an important topic in modern thyroid oncology. Current methods for diagnosis, treatment and follow-up care of this disease are discussed.

Introducing endoscopic ear surgery into practice

The otolaryngologist will find in this article a direct and frank discussion and useful advice for how to get started performing solely endoscopic ear surgery for abnormalities of the middle ear. The author provides discussion and photos based on his experience with this procedure. Presented herein are selection of the endoscope, how to approach the first fully endoscopic procedure, patient selection, preoperative planning, setting up the operating room, pitfalls typically encountered, and how to gain skills to perform this procedure successfully.

Comment on: The effect of alcohol on surgical skills

Kirby G, Kapoor K, Das-Purkayastha P, Harries M The effect of alcohol on surgical skills.Ann R Coll Surg Engl 2012; 94: 90–93 doi: 10.1308/003588412X13171221501627