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Otolaryngology/Head and Neck (all articles)

Cohort Study: High Rate of Preventable Adverse Events in Surgical Inpatients

16 Nov, 2024 | 17:29h | UTC

Background: Adverse events during hospital admissions, particularly in surgical settings, remain a significant cause of patient harm despite efforts to improve patient safety since the “To Err is Human” report. Advances in surgical techniques and patient care necessitate an updated assessment of the current state of perioperative safety.

Objective: To estimate the frequency, severity, and preventability of adverse events associated with perioperative care in surgical inpatients and to identify the settings and healthcare professionals involved.

Methods: A multicenter retrospective cohort study was conducted across 11 US hospitals in Massachusetts. A weighted random sample of 1,009 patients was selected from 64,121 adults admitted for surgery in 2018. Trained nurses reviewed electronic health records to identify adverse events, which were then adjudicated by physicians. Adverse events were classified by type, severity, preventability, setting, and professions involved.

Results: Adverse events occurred in 38.0% of patients (95% CI, 32.6–43.4%), with major adverse events in 15.9% (12.7–19.0%). Among 593 adverse events identified, 59.5% were potentially preventable, and 20.7% were definitely or probably preventable. The most common events were surgery-related (49.3%), adverse drug events (26.6%), healthcare-associated infections (12.4%), and patient care events (11.2%). Adverse events most frequently occurred in general care units (48.8%) and involved attending physicians (89.5%) and nurses (58.9%).

Conclusions: More than one-third of surgical inpatients experienced adverse events, with nearly half classified as major and most potentially preventable. These findings highlight the critical need for ongoing improvement in patient safety throughout perioperative care involving all healthcare professionals.

Implications for Practice: Healthcare providers should enhance patient safety protocols across all perioperative settings, not just in operating rooms. Emphasis should be placed on preventing surgery-related complications, adverse drug events, and healthcare-associated infections by fostering teamwork and continuous monitoring.

Study Strengths and Limitations: Strengths include a comprehensive review of medical records and systematic classification of adverse events by trained professionals. Limitations involve the study’s confinement to Massachusetts hospitals in 2018, potential variability in documentation practices, and limited sample size affecting generalizability and specialty-specific estimates.

Future Research: Further studies are needed to assess adverse event rates in diverse geographic locations and healthcare systems, explore effective interventions to reduce preventable harm, and evaluate long-term trends in surgical patient safety.

Reference: Duclos A, Frits ML, Iannaccone C, Lipsitz SR, Cooper Z, Weissman JS, Bates DW. Safety of inpatient care in surgical settings: cohort study. BMJ. 2024; DOI: http://doi.org/10.1136/bmj-2024-080480

 

Summary: Perioperative Management of Patients Taking Direct Oral Anticoagulants

19 Sep, 2024 | 21:12h | UTC

Direct oral anticoagulants (DOACs)—including apixaban, rivaroxaban, edoxaban, and dabigatran—are increasingly used for stroke prevention in atrial fibrillation and for treating venous thromboembolism. Effective perioperative management of DOACs is essential to minimize bleeding and thromboembolic risks during surgical and nonsurgical procedures. Below are practical recommendations focused on the perioperative management of patients taking DOACs, based on a recent JAMA review article.

Elective Surgical or Nonsurgical Procedures

Classify Bleeding Risk of Procedures:

  1. Minimal Risk:
    • Minor dental procedures (e.g., cleaning, extractions)
    • Minor dermatologic procedures (e.g., skin lesion removal)
    • Cataract surgery
  2. Low to Moderate Risk:
    • Endoscopic procedures without high-risk interventions
    • Cholecystectomy
    • Inguinal hernia repair
  3. High Risk:
    • Major surgery (e.g., cancer surgery, joint replacement)
    • Procedures involving neuraxial anesthesia
    • Endoscopic procedures with high-risk interventions (e.g., large polyp removal)

DOAC Management Strategies:

  1. Minimal Bleeding Risk Procedures:
    • Option 1: Continue DOACs without interruption.
    • Option 2: For added safety, withhold the morning dose on the day of the procedure (especially for twice-daily DOACs like apixaban and dabigatran).
  2. Low to Moderate Bleeding Risk Procedures:
    • Preoperative:
      • Discontinue DOACs 1 day before the procedure.
      • This allows approximately 2 half-lives for drug clearance.
    • Postoperative:
      • Resume DOACs 1 day after the procedure, ensuring adequate hemostasis.
  3. High Bleeding Risk Procedures:
    • Preoperative:
      • Discontinue DOACs 2 days before the procedure.
      • This allows approximately 4-5 half-lives for drug clearance.
    • Postoperative:
      • Resume DOACs 2-3 days after the procedure, based on bleeding risk and hemostasis.

Evidence Supporting These Strategies:

  • The PAUSE study demonstrated that standardized interruption protocols without heparin bridging result in low rates of:
    • Thromboembolism: 0.2%–0.4%
    • Major Bleeding: 1%–2%

Postoperative DOAC Resumption:

  • Assess surgical-site hemostasis before resuming DOACs.
  • Delay resumption if there is ongoing bleeding or concerns about hemostasis.
  • For high bleeding risk procedures, consider a longer delay (2–3 days).

Perioperative Heparin Bridging:

  • Not recommended for patients on DOACs.
  • Bridging increases bleeding risk without reducing thromboembolism.
  • DOACs have rapid offset and onset, making bridging unnecessary.

Special Considerations

Patients with Impaired Renal Function:

  • For CrCl 30–50 mL/min:
    • Dabigatran: Extend preoperative discontinuation by an additional day.
  • For CrCl <30 mL/min:
    • Dabigatran is contraindicated.
    • For other DOACs, consider extending discontinuation to 3–4 days before surgery.

Patients Undergoing Neuraxial Anesthesia:

  • Discontinue DOACs for 3 days (apixaban, edoxaban, rivaroxaban) or 4 days (dabigatran) before the procedure.
  • Minimizes risk of spinal or epidural hematoma.

Dental Procedures:

  • Generally safe to continue DOACs.
  • For added safety:
    • Omit or delay the dose on the day of the procedure.
    • Employ local hemostatic measures (e.g., tranexamic acid mouthwash).

Endoscopic Procedures:

  • Low-risk procedures (e.g., diagnostic endoscopy without biopsy):
    • Follow standard DOAC interruption for low to moderate bleeding risk.
  • High-risk procedures (e.g., polypectomy of large polyps):
    • Extend DOAC discontinuation by an additional day pre- and post-procedure.

Patients Unable to Resume Oral Medications Postoperatively:

  • Use prophylactic low-molecular-weight heparin (LMWH) until oral intake is possible.
  • Avoid therapeutic-dose LMWH due to bleeding risk.

Emergent, Urgent, or Semiurgent Procedures

Risks:

  • Higher bleeding risk: Up to 23%
  • Thromboembolism risk: Up to 11%

Management Strategies:

  1. Assess Time Since Last DOAC Dose:
    • If within 48 hours, consider that significant anticoagulant effect may persist.
  2. Laboratory Testing (if available):
    • DOAC Level Testing:
      • ≥50 ng/mL: Consider using reversal agents.
      • <50 ng/mL: May proceed without reversal agents.
  3. Use of Reversal Agents:
    • For Dabigatran:
      • Idarucizumab (5 g IV)
    • For Factor Xa Inhibitors (apixaban, rivaroxaban, edoxaban):
      • Andexanet alfa (dosing based on last dose timing and amount)
      • Prothrombin Complex Concentrates (PCCs): If andexanet alfa is unavailable or contraindicated.
  4. Proceeding Without Testing:
    • If testing is unavailable and last DOAC dose was within 48 hours, consider reversal agents.
    • If >48 hours since last dose, may proceed without reversal.

Considerations:

  • Reversal agents are expensive and may carry thrombotic risks.
  • Use should be judicious, weighing risks and benefits.
  • Consult hematology or thrombosis experts when possible.

Key Takeaways

  • Elective Procedures:
    • Utilize standardized protocols based on procedural bleeding risk.
    • Routine preoperative DOAC level testing is unnecessary.
    • Avoid heparin bridging.
  • Emergent/Urgent Procedures:
    • Reversal agents may be appropriate when significant DOAC levels are present.
    • Decision to use reversal agents should consider bleeding risk, time since last dose, and availability of DOAC level testing.
  • Patient Communication:
    • Ensure patients understand the plan for DOAC interruption and resumption.
    • Provide clear instructions regarding timing and dosing.
  • Interdisciplinary Coordination:
    • Collaborate with surgical teams, anesthesiologists, and pharmacists.
    • Use electronic medical records and clinical decision support tools to enhance communication.

Conclusion

By applying standardized perioperative management protocols, clinicians can effectively balance the risks of bleeding and thromboembolism in patients taking DOACs who require surgical or nonsurgical procedures. These strategies simplify decision-making, avoid unnecessary interventions like heparin bridging, and promote patient safety.

Reference: Douketis JD, Spyropoulos AC. Perioperative Management of Patients Taking Direct Oral Anticoagulants: A Review. JAMA. 2024;332(10):825–834. doi:10.1001/jama.2024.12708

 

Cohort Study: GLP1 receptor agonist use not associated with significant increase in thyroid cancer risk – The BMJ

25 May, 2024 | 19:51h | UTC

A large Scandinavian cohort study investigated the association between glucagon-like peptide 1 (GLP1) receptor agonist use and thyroid cancer risk in Denmark, Norway, and Sweden from 2007 to 2021. The study compared 145,410 patients treated with GLP1 receptor agonists to 291,667 patients treated with dipeptidyl peptidase 4 (DPP4) inhibitors and included an additional analysis with sodium-glucose cotransporter 2 (SGLT2) inhibitors. Results showed no significant increase in thyroid cancer risk among GLP1 users over a mean follow-up of 3.9 years, with a hazard ratio of 0.93 (95% CI, 0.66 to 1.31) compared to DPP4 inhibitor users. The study utilized nationwide cancer registers and employed an active-comparator, new user design to minimize confounding, using Cox regression models adjusted by propensity score weighting. The findings suggest that while small risk increases cannot be definitively ruled out, the use of GLP1 receptor agonists does not substantially elevate thyroid cancer risk.

 

Reference (link to free full-text):

Björn Pasternak et al. (2024). Glucagon-like peptide 1 receptor agonist use and risk of thyroid cancer: Scandinavian cohort study. BMJ, 385. DOI: https://doi.org/10.1136/bmj-2023-078225

 

Guideline: Management of age-related hearing loss – Otolaryngol Head Neck Surg

2 May, 2024 | 23:22h | UTC

This guideline by the American Academy of Otolaryngology–Head and Neck Surgery Foundation offers a comprehensive approach for the detection and management of age-related hearing loss (ARHL) in adults aged 50 and older. It stresses the importance of early identification and appropriate intervention to mitigate the effects of ARHL, which is commonly underdiagnosed despite being the most prevalent sensory deficit in the elderly. The guideline includes eleven Key Action Statements that guide clinicians in screening, diagnosis, and management strategies, emphasizing the use of audiograms, otoscopy, and hearing aids, as well as the importance of addressing sociodemographic factors affecting healthcare access. It also highlights the necessity of patient and family education on the impacts of hearing loss and communication strategies. This structured approach aims to enhance healthcare delivery and improve the quality of life for those affected by hearing loss.

 

Reference (link to free-full-text):

Tsai Do. et al. (2024). Clinical Practice Guideline: Age-Related Hearing Loss. Otolaryngology–Head and Neck Surgery. DOI: 10.1002/ohn.750

 

RCT | Upfront radiosurgery reduces tumor volume vs. a wait-and-scan approach in small- to medium-sized vestibular schwannoma

7 Aug, 2023 | 14:40h | UTC

Upfront Radiosurgery vs a Wait-and-Scan Approach for Small- or Medium-Sized Vestibular Schwannoma: The V-REX Randomized Clinical Trial – JAMA (free for a limited period)

See also: Visual Abstract

 

Commentary on Twitter

 

RCT | Limited antibiotic efficacy in children with sinusitis lacking nasopharyngeal pathogens

27 Jul, 2023 | 13:08h | UTC

Identifying Children Likely to Benefit From Antibiotics for Acute Sinusitis: A Randomized Clinical Trial – JAMA (free for a limited period)

Editorial: Acute Bacterial Sinusitis: Limitations of Test-Based Treatment – JAMA (free for a limited period)

News Release: Bacterial testing in kids with sinusitis could slash antibiotic use – University of Pittsburgh

Commentary: Trial suggests bacterial test could reduce antibiotics in kids with sinusitis – CIDRAP

 

Commentary on Twitter

 

Review | The evolving landscape of salivary gland tumors

27 Jul, 2023 | 12:58h | UTC

The evolving landscape of salivary gland tumors – CA: A Cancer Journal for Clinicians

 

RCT | Dysphagia-optimized intensity-modulated radiotherapy better preserves swallowing function in pharyngeal cancer patients

25 Jul, 2023 | 13:52h | UTC

Dysphagia-optimised intensity-modulated radiotherapy versus standard intensity-modulated radiotherapy in patients with head and neck cancer (DARS): a phase 3, multicentre, randomised, controlled trial – The Lancet Oncology

Commentaries:

Dysphagia-Optimized vs Standard IMRT in Newly Diagnosed Patients With Head and Neck Cancer – The ASCO Post

Radiation approach improves swallowing in head, neck cancer – MDedge

 

Commentary on Twitter

 

RCT | Hearing intervention fails to impact 3-year cognitive decline in older adults

20 Jul, 2023 | 11:09h | UTC

Hearing intervention versus health education control to reduce cognitive decline in older adults with hearing loss in the USA (ACHIEVE): a multicentre, randomised controlled trial – The Lancet (link to abstract – $ for full-text)

 

Commentary on Twitter

 

TTMV-HPV DNA testing | Promising diagnostic and surveillance tool for HPV-linked oropharyngeal cancer

17 Jul, 2023 | 13:25h | UTC

Performance of Liquid Biopsy for Diagnosis and Surveillance of Human Papillomavirus–Associated Oropharyngeal Cancer – JAMA Otolaryngology–Head & Neck Surgery (free for a limited period)

Invited Commentary: Circulating Human Papillomavirus Tumor DNA—Ready for Prime Time? –  – JAMA Otolaryngology–Head & Neck Surgery (free for a limited period)

 

2023 ETA clinical practice guidelines for thyroid nodule management

12 Jul, 2023 | 13:48h | UTC

2023 European Thyroid Association clinical practice guidelines for thyroid nodule management – European Thyroid Journal

 

The 2023 Bethesda System for reporting thyroid cytopathology

12 Jul, 2023 | 13:46h | UTC

The 2023 Bethesda System for Reporting Thyroid Cytopathology – Thyroid

 

RCT | Semont-plus maneuver yields faster recovery than Epley maneuver in posterior canal BPPV

7 Jul, 2023 | 16:26h | UTC

The Semont-Plus Maneuver or the Epley Maneuver in Posterior Canal Benign Paroxysmal Positional Vertigo: A Randomized Clinical Study – JAMA Neurology (link to abstract – $ for full-text)

See also: Visual Abstract

Videos:

Demonstration of the Semont-Plus Self-maneuver for Right Posterior Canal Canalithiasis

Semont-Plus Maneuver for Right Posterior Canal Benign Paroxysmal Positional Vertigo

Demonstration of the Epley Self-maneuver for a Right Posterior Canal Canalithiasis

Commentary: Semont-plus Meneuver Offered Faster Recovery for Benign Paroxysmal Positional Vertigo – Neurology Today

 

Editorial | How to become a good surgeon

22 Jun, 2023 | 15:12h | UTC

How to become a good surgeon – Advances in Ophthalmology Practice and Research

 

M-A | Role of chemotherapy in patients with nasopharynx carcinoma treated with radiotherapy

5 Jun, 2023 | 13:29h | UTC

Role of chemotherapy in patients with nasopharynx carcinoma treated with radiotherapy (MAC-NPC): an updated individual patient data network meta-analysis – The Lancet Oncology (free for a limited period)

 

Commentary from the author on Twitter

 

RCT | Tonsillectomy shown to be clinically and cost-effective in adults with recurrent acute tonsillitis

23 May, 2023 | 13:06h | UTC

Summary: The NATTINA trial, a pragmatic multicentre, open-label, randomized controlled study, sought to compare the clinical and cost-effectiveness of conservative management versus tonsillectomy in adults with recurrent acute tonsillitis. Conducted across 27 UK hospitals, 453 participants aged 16 or older were randomly assigned to either undergo immediate tonsillectomy or receive standard non-surgical care.

The main finding was that participants in the immediate tonsillectomy group had fewer days of sore throat over a 24-month period than those in the conservative management group (median 23 vs. 30 days). After adjusting for site and baseline severity, the incident rate ratio of total sore throat days in the immediate tonsillectomy group was significantly lower than in the conservative management group (0.53, 95% CI 0.43 to 0.65, p < 0.0001). The most common adverse event related to tonsillectomy was bleeding, which occurred in 19% of participants.

The NATTINA trial is the largest to date assessing the clinical and cost-effectiveness of tonsillectomy in adults. The results indicate that immediate tonsillectomy is clinically effective and cost-effective for recurrent acute tonsillitis. However, patients should weigh the benefits of fewer sore throat days against the risks of surgery.

Article: Conservative management versus tonsillectomy in adults with recurrent acute tonsillitis in the UK (NATTINA): a multicentre, open-label, randomised controlled trial – The Lancet

News Release: Tonsillectomy both clinically and cost effective for adults – Newcastle University

 

Commentary on Twitter

 

Fluorescence-guided surgery: comprehensive review

18 May, 2023 | 13:34h | UTC

Fluorescence-guided surgery: comprehensive review – BJS Open

 

Commentary on Twitter

 

Ear-related balance disorders: evidence and resources

11 May, 2023 | 12:14h | UTC

Ear-related balance disorders: evidence and resources – Evidently Cochrane

 

Olfactory dysfunction: etiology, diagnosis, and treatment

11 May, 2023 | 11:50h | UTC

Olfactory Dysfunction: Etiology, Diagnosis, and Treatment – Deutsches Ärzteblatt International

 

M-A | Association of SARS-CoV-2 vaccination or infection with Bell palsy

10 May, 2023 | 16:03h | UTC

Association of SARS-CoV-2 Vaccination or Infection With Bell Palsy: A Systematic Review and Meta-analysis – JAMA Otolaryngology–Head & Neck Surgery

 

Review | Updated salivary gland immunohistochemistry

5 May, 2023 | 14:55h | UTC

Updated Salivary Gland Immunohistochemistry: A Review – Archives of Pathology & Laboratory Medicine

 

RCT | Effectiveness of an over-the-counter self-fitting hearing aid compared with an audiologist-fitted hearing aid

25 Apr, 2023 | 14:47h | UTC

Effectiveness of an Over-the-Counter Self-fitting Hearing Aid Compared With an Audiologist-Fitted Hearing Aid: A Randomized Clinical Trial – JAMA Otolaryngology–Head & Neck Surgery

Author Interview: Effectiveness of Self-fitting vs Audiologist-Fitted Hearing Aids – JAMA

Commentaries:

Self-Fitting, Over-the-Counter Hearing Aids Beneficial – HealthDay

How Do Over-the-Counter Hearing Aids Compare with Those Fitted by Audiologists? – NEJM Journal Watch (free for a limited period)

 

Commentary on Twitter

 

Study shows that parathyroidectomy in adults with primary hyperparathyroidism probably has no effect on kidney function

21 Apr, 2023 | 12:57h | UTC

Estimated Effect of Parathyroidectomy on Long-Term Kidney Function in Adults With Primary Hyperparathyroidism – Annals of Internal Medicine (link to abstract – $ for full-text)

News Release: Study: Parathyroidectomy shows no effect on kidney function in older adults with hyperparathyroidism – American College of Physicians

Commentary: Parathyroidectomy for primary hyperparathyroidism didn’t affect kidney function in older patients – ACP Internist

 

Commentary on Twitter

 

M-A | Test characteristics of ultrasound for the diagnosis of peritonsillar abscess

19 Apr, 2023 | 13:15h | UTC

Test characteristics of ultrasound for the diagnosis of peritonsillar abscess: A systematic review and meta-analysis – Academic Emergency Medicine

Commentary: How Good is Ultrasound at Diagnosing PTA? – RebelEM

 

Cohort Study | Association between hearing aid use and all-cause and cause-specific dementia

17 Apr, 2023 | 13:07h | UTC

Association between hearing aid use and all-cause and cause-specific dementia: an analysis of the UK Biobank cohort – The Lancet Public Health

Commentaries: Preventing dementia through correcting hearing: huge progress but more to do – The Lancet Public Health

News Release: Hearing aids may protect against a higher risk of dementia associated with hearing loss, study suggests – Lancet

Related:

M-A | Association of hearing aids and cochlear implants with cognitive decline and dementia

Dementia and hearing-aid use: a two-way street – Age and Ageing

Association of Hearing Loss With Dementia – JAMA Network Open

 

Commentary on Twitter

 

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