Otolaryngology
Summary: Perioperative Management of Patients Taking Direct Oral Anticoagulants
19 Sep, 2024 | 21:12h | UTCDirect 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:
- Minimal Risk:
- Minor dental procedures (e.g., cleaning, extractions)
- Minor dermatologic procedures (e.g., skin lesion removal)
- Cataract surgery
- Low to Moderate Risk:
- Endoscopic procedures without high-risk interventions
- Cholecystectomy
- Inguinal hernia repair
- 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:
- 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).
- 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.
- Preoperative:
- 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.
- Preoperative:
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:
- Assess Time Since Last DOAC Dose:
- If within 48 hours, consider that significant anticoagulant effect may persist.
- Laboratory Testing (if available):
- DOAC Level Testing:
- ≥50 ng/mL: Consider using reversal agents.
- <50 ng/mL: May proceed without reversal agents.
- DOAC Level Testing:
- 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.
- For Dabigatran:
- 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.
Guideline: Management of age-related hearing loss – Otolaryngol Head Neck Surg
2 May, 2024 | 23:22h | UTCThis 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):
RCT | Upfront radiosurgery reduces tumor volume vs. a wait-and-scan approach in small- to medium-sized vestibular schwannoma
7 Aug, 2023 | 14:40h | UTCUpfront 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
Among patients with small or medium vestibular schwannoma, a treatment strategy consisting of upfront radiosurgery was more effective at reducing tumor volume at 4 years than was the initial wait-and-scan approach. https://t.co/Qv3YZVsq2Q pic.twitter.com/aNeu7MJfl0
— JAMA (@JAMA_current) August 2, 2023
RCT | Limited antibiotic efficacy in children with sinusitis lacking nasopharyngeal pathogens
27 Jul, 2023 | 13:08h | UTCIdentifying 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
In children with acute sinusitis, antibiotic treatment had minimal benefit for those without nasopharyngeal bacterial pathogens. The antibiotic effect did not depend on the color of nasal discharge. https://t.co/hgRx1Qou53 pic.twitter.com/zYs8Mfbjjp
— JAMA (@JAMA_current) July 26, 2023
RCT | Hearing intervention fails to impact 3-year cognitive decline in older adults
20 Jul, 2023 | 11:09h | UTCHearing 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
#AAIC23 While hearing aids did not have an impact on cognitive decline over 3 years in a general population, treating hearing loss protected against cognitive decline in older adults at greater risk of dementia, finds a new trial: https://t.co/1UjGgDf5m5 pic.twitter.com/kuujeekCWW
— The Lancet (@TheLancet) July 18, 2023
RCT | Semont-plus maneuver yields faster recovery than Epley maneuver in posterior canal BPPV
7 Jul, 2023 | 16:26h | UTCThe 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
RCT | Tonsillectomy shown to be clinically and cost-effective in adults with recurrent acute tonsillitis
23 May, 2023 | 13:06h | UTCSummary: 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.
News Release: Tonsillectomy both clinically and cost effective for adults – Newcastle University
Commentary on Twitter
Compared with conservative management, immediate tonsillectomy is clinically effective and cost-effective in adults with recurrent acute #tonsillitis, suggests trial. https://t.co/LvSjn6XUx0 pic.twitter.com/yKzH9RqY5J
— The Lancet (@TheLancet) May 18, 2023
Ear-related balance disorders: evidence and resources
11 May, 2023 | 12:14h | UTCEar-related balance disorders: evidence and resources – Evidently Cochrane
Olfactory dysfunction: etiology, diagnosis, and treatment
11 May, 2023 | 11:50h | UTCOlfactory 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
RCT | Effectiveness of an over-the-counter self-fitting hearing aid compared with an audiologist-fitted hearing aid
25 Apr, 2023 | 14:47h | UTCAuthor 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
Findings suggest that a self-fitting OTC hearing aid may be an effective intervention option for individuals with mild to moderate #hearingloss and produce self-perceived and clinical outcomes similar to those of an audiologist-fitted #hearingaid. https://t.co/Zbc8URj2uA
— JAMA Otolaryngology – Head & Neck Surgery (@JAMAOto) April 13, 2023
M-A | Test characteristics of ultrasound for the diagnosis of peritonsillar abscess
19 Apr, 2023 | 13:15h | UTCCommentary: 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 | UTCCommentaries: 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
NEW—Hearing aids may protect against a higher risk of #dementia associated with hearing loss, a @TheLancetPH study suggests.https://t.co/Yliq2wT7SR pic.twitter.com/v3iuTuHYVI
— The Lancet (@TheLancet) April 13, 2023
RCT | Targeted hypoglossal nerve stimulation may benefit patients with obstructive sleep apnea
11 Apr, 2023 | 14:07h | UTC
Commentary on Twitter
In this study, proximal targeted hypoglossal nerve responses proved safe and effective in treating sleep apnea and improving sleep architecture and quality of life, while comparing favorably with those in distal hypoglossal nerve stimulation trials. https://t.co/yorNGW9uoi
— JAMA Otolaryngology – Head & Neck Surgery (@JAMAOto) April 6, 2023
Consensus Paper | Best management of patients with an acute sore throat
6 Apr, 2023 | 13:32h | UTC
Cochrane Library | Hearing conditions: evidence, experience and resources
4 Apr, 2023 | 13:36h | UTCHearing conditions: evidence, experience and resources – Evidently Cochrane
SR | Etiologies of vertigo in the elderly
31 Mar, 2023 | 13:38h | UTCVertigo in the Elderly: A Systematic Literature Review – Journal of Clinical Medicine
M-A | Test characteristics of ultrasound for the diagnosis of peritonsillar abscess
30 Mar, 2023 | 14:19h | UTC
International consensus statement on allergy and rhinology: allergic rhinitis
16 Mar, 2023 | 13:19h | UTC
Evidence Analysis | Menière’s disease: experience, evidence gaps & treatment choices
9 Mar, 2023 | 14:21h | UTCMenière’s disease: experience, evidence gaps & treatment choices – Evidently Cochrane
New Cochrane Reviews:
Systemic pharmacological interventions for Ménière’s disease – Cochrane Library
Intratympanic gentamicin for Ménière’s disease – Cochrane Library
Intratympanic corticosteroids for Ménière’s disease – Cochrane Library
Positive pressure therapy for Ménière’s disease – Cochrane Library
Lifestyle and dietary interventions for Ménière’s disease – Cochrane Library
Surgical interventions for Ménière’s disease – Cochrane Library
Cross-sectional study | Risk factors for hearing loss at birth in newborns with congenital CMV infection
28 Feb, 2023 | 13:20h | UTCRisk Factors for Hearing Loss at Birth in Newborns With Congenital Cytomegalovirus Infection – JAMA Pediatrics (link to abstract – $ for full-text)
Commentary: Factors ID’d for Hearing Loss in Newborns With Congenital Cytomegalovirus – HealthDay
Commentaries on Twitter
Findings of this cross-sectional study suggest that newborns with congenital cytomegalovirus infection and petechiae at birth, periventricular cysts on MRI, or a seroconversion in the first trimester had a higher risk of congenital hearing loss. https://t.co/csecGRFjug
— JAMA Otolaryngology – Head & Neck Surgery (@JAMAOto) January 3, 2023
A study in @JAMAOto examines the association of clinical independent risk factors and hearing loss in congenital CMV https://t.co/n0ScC6eMuB#EBNEOalerts #neoEBM #neotwitter pic.twitter.com/j1R5law7bo
— Evidence-Based Neo (@EBNEO) January 18, 2023
Consensus Statement | Standardized imaging and reporting for thyroid ultrasound
24 Feb, 2023 | 13:52h | UTCRelated: ACR Thyroid Imaging, Reporting and Data System (TI-RADS): White Paper of the ACR TI-RADS Committee
SR | Tranexamic acid for the reduction of bleeding during functional endoscopic sinus surgery
24 Feb, 2023 | 13:39h | UTC
M-A | Complications of percutaneous tracheostomy in critically ill adults with obesity
13 Feb, 2023 | 12:37h | UTCComplication Rate of Percutaneous Dilatational Tracheostomy in Critically Ill Adults With Obesity: A Systematic Review and Meta-analysis – JAMA Otolaryngology-Head & Neck Surgery (free for a limited period)
Guideline | Diagnosis and management of otitis media with effusion in children
6 Feb, 2023 | 13:23h | UTC