Alan Kominsky

Studying Life Effects & Effectiveness of Palatopharyngoplasty (SLEEP) study: subjective outcomes of isolated uvulopalatopharyngoplasty.

Objective. To test the hypothesis that uvulopalatopharyngoplasty (UPPP) improves sleep apnea–related quality of life (measured on the Functional Outcomes of Sleep Questionnaire [FOSQ]) at 3-month follow-up. Secondary objectives were to test (1) the stability of the outcomes at 6 months, (2) the effect on global sleep apnea quality-of-life change, and (3) the effect on sleep apnea symptoms. Study Design. Multicenter, prospective, longitudinal case series. Setting. Diverse university- and community-based otolaryngology practices. Subjects and Methods. The cohort included 68 patients from 17 practices, with a mean ± standard deviation age of 44 ± 12 years and mean apnea-hypopnea index of 35 ± 32 events/hour. All patients underwent UPPP, defined as an open procedure modifying the shape and size of the palate, pharynx, and uvula, with or without tonsillectomy. Baseline data were collected on site before surgery, and outcome data were collected by mail 3 and 6 months after surgery, with follow-up rates of 51% and 50%, respectively. Results. FOSQ scores improved from 14.3 ± 3.4 (scale 5-20, normal ≥17.9) at baseline to 17.2 ± 2.7 at 3 months (mean improvement 2.9; 95% confidence interval, 1.8-4.0; P < .001) and 17.5 ± 2.5 at 6 months (mean improvement 3.1; 95% confidence interval, 2.0-4.2; P < .001). All quality-of-life and symptom measures improved significantly at 3 and 6 months (all P < .05). Conclusion. This prospective, multicenter, university- and community-based study provides evidence that UPPP significantly improves disease-specific quality of life and sleep apnea symptoms in patients with sleep apnea. Validity may be limited by significant loss to follow-up and absence of an unoperated control group.

Patient reported outcomes in endoscopic and open transcervical treatment for Zenker's diverticulum

To compare long‐term symptomatic outcomes between external transcervical (ET) and endoscopic stapling diverticulotomy (ESD) surgeries for Zenkers diverticulum.

Safety of outpatient surgery for obstructive sleep apnea.

Objective Determine the safety experience of adult obstructive sleep apnea patients undergoing airway surgery. Study Design A retrospective cohort study. Setting The experience of members of a large Medicaid managed care organization between January 10, 2009, and June 30, 2011. Subjects and Methods Four hundred fifty-two adult Medicaid obstructive sleep apnea (OSA) patients (404 ambulatory, 48 inpatient) receiving head and neck airway surgery form the basis of this report. Four safety indicators were reported from administrative data for 30 days: emergency room visit, inpatient admission, observation day, and 3 or more primary care physician visits. The occurrence of myocardial infarction, deep venous thrombosis, stroke, pulmonary embolism, tracheostomy, or transfusion was noted. Results Ninety-four percent of the nasal, 86% of the palatal, and 79% of the nasal/palatal surgeries (89% overall) were ambulatory. The observed catastrophic complication rate among ambulatory patients was zero (95% confidence interval, 0.0%-1.1%). Emergency room visits for pain-related diagnoses were the most common adverse outcome (51%). Administrative data sets can be used to provide insight into practice safety questions. Conclusion Contrary to guidelines, most OSA patients underwent ambulatory head and neck airway surgery. The observed catastrophic complication rate was zero. Administrative data sets can be used to provide insight into practice safety questions. Further study is warranted of ambulatory surgery management of adult sleep apnea patients.

Variability of Ratings in the Otolaryngology Standardized Letter of Recommendation.

Objective To determine the variability of ratings given to students on the otolaryngology standardized letter of recommendation (SLOR). Study Design Retrospective review. Setting Academic otolaryngology training program. Subjects and Methods 496 SLORs to the Cleveland Clinic Otolaryngology Training Program were reviewed. The SLORs were extracted from the applications and analyzed. The distributions of ratings across the 10 categories were statistically analyzed including distribution and standard deviation. Rankings were grouped into deciles for this analysis. Results Ratings across the 10 domains revealed clustering of results across the top 2 deciles. The distribution of the bell-shaped curve was shifted significantly to the left, representing the upper deciles. No evidence of gender or geographic bias was found. Longer length of time of association between the applicant and the letter writer correlated to a higher ranking. Conclusion The explosion of applications being sent out by candidates for otolaryngology residency programs has prompted the implementation of the SLOR. The lack of variation in the ratings across the 10 domains does not allow for differentiation among student applicants. Reliance on the narrative letter of recommendation attached to the SLOR still remains the most significant way to differentiate among applicants. Refinements will need to be made in either the structure or use of the SLOR for it to be a more useful tool.

Referral Patterns and Positive Airway Pressure Adherence upon Diagnosis of Obstructive Sleep Apnea

Objective Obstructive sleep apnea (OSA) is a serious medical condition that adds to patient morbidity and mortality. Treatment with positive airway pressure (PAP) is the standard of care, but many patients refuse or do not tolerate PAP. Little is known about the subsequent management of these patients. We sought to understand what types of treatment, if any, adult patients with OSA receive who either fail or refuse PAP therapy within our institution. Study Design Retrospective chart review. Setting Academic hospital. Subjects All adult patients undergoing polysomnogram during the months of March and April 2010 (n = 1174) who were diagnosed with OSA. Methods The electronic medical record was reviewed to determine the subsequent management of patients with a diagnosis of OSA, including tolerance or failure of PAP and referral to specialists upon intolerance. Results Of 1174 patients, 616 met inclusion criteria. Ultimately, 260 (42%) had documented adherence to PAP. Of 241 untreated patients, 84 patients (35%) were referred for further attempts at management of diagnosed OSA. Nearly half of patients with diagnosed OSA did not have continued treatment or referral. Conclusion To our knowledge, this is the first study to define the subsequent management of patients who have failed or refused PAP. Despite the known sequelae of OSA, clinicians are not treating a significant percentage of patients with diagnosed OSA. Those who fail to tolerate PAP therapy are unlikely to be referred for additional treatment. Therapies other than PAP may be warranted in this population.

Electroconvulsive therapy for depression in a patient with an Inspire hypoglossal nerve stimulator device for obstructive sleep apnea: A case report

OUTCOME OBJECTIVES METHODS: This is a case report of a patient who underwent placement and initiation of a hypoglossal nerve stimulator device in the context of receiving electroconvulsive therapy for bipolar depression between February and September 2016. To our knowledge, this has not yet been reported in the literature. Outcome measurements included successful device activation and successful device use throughout electroconvulsive therapy. RESULTS The patient underwent successful device implantation, activation, and use without disruption throughout electroconvulsive therapy sessions. No special device deactivation was required during electroconvulsive therapy sessions. CONCLUSION Obstructive sleep apnea is a common disorder that causes significant reduction in quality of life and is an independent risk factor for multiple comorbidities. Electroconvulsive therapy is an established treatment for medication-refractory depression with minimal risk in most patient populations. This is the first report in the literature of a patient undergoing ECT for bipolar depression with recent activation of Inspire hypoglossal nerve stimulator who had no disruption in the function of his implanted device.

Otolaryngology sleep medicine curriculum objectives as determined by sleep experts

PURPOSE (1) Ascertain the most important concepts and topics for otolaryngology resident education in sleep medicine and surgery, as determined by faculty who teach sleep medicine to otolaryngology residents. (2) Create learning objectives within the area of otolaryngologic sleep medicine in order to design a sleep medicine curriculum for otolaryngology residents. MATERIALS AND METHODS Two web-based surveys were sent to 163 academic otolaryngologists who teach sleep medicine. The first survey determined the topics, and their relative importance, considered most vital to learn during otolaryngology training. Using the Delphi method, the second clarified questions regarding topics determined by the first survey. Sleep medicine learning objectives for residents were ascertained from responses. RESULTS The response rate of first and second surveys were 24.5% and 19%, respectively. Topics ranked most important for resident education included upper airway anatomy, polysomnogram interpretation, and understanding the range of medical and surgical therapies used to treat sleep disorders. Respondents listed surgical therapy as the most critical topic that most residents do not understand well. The second survey clarified the specific anatomic features, surgical techniques, and polysomnography data points deemed most critical for resident learning. CONCLUSIONS Academic otolaryngology sleep experts hold opinions regarding relative value of different topics for teaching sleep medicine, which is useful in creating a curriculum for otolaryngology residents. Otolaryngology learning objectives related to sleep medicine identified during this study are being used to create an online curriculum to supplement resident education.

Healthcare usage after uvulopalatopharyngoplasty – Impact of analgesic regimen

OUTCOME OBJECTIVES 1) Analyze differences in healthcare usage between subjects receiving different perioperative analgesic medications after uvulopalatopharyngoplasty (UPPP) surgery. 2) Comment on the impact of perioperative analgesic medication on length of hospital stay and complications after UPPP. METHODS A retrospective cohort study of 120 UPPPs conducted by a single surgeon in the past 5years was conducted. Subjects were grouped based on perioperative pain medication regimen into three groups; narcotics alone (n=83), narcotics with gabapentin (n=27), or narcotics with ketorolac tromethamine (n=10). The primary outcome variable was total number of clinic/emergency room and/or telephone encounters related to post-UPPP pain. Secondary outcomes included length of post-operative hospital stay, number of telephone and/or clinical encounters in which the patient complained specifically of pain or requested a refill for analgesics, and post-operative complications. RESULTS No significant difference was found between the three analgesic regimens in post-operative hospital stay length (p=0.28, median stay 23.5h), number of clinic or telephone encounters related to pain (p=0.26, mean value 0.71 encounters), or post-operative complication rate (p=0.82, 5.9% complication rate). CONCLUSION This study shows no significant difference in post-operative healthcare usage between patients with peri-operative analgesic regimens including narcotics alone, gabapentin with narcotics, or ketorolac with narcotics. Post-operative complication rate and length of stay did not differ between groups. These data suggest that these three medication regimens have similar impact on post-operative course for UPPP patients. Therefore, the most affordable or simplest options have equivalent effects on post-operative healthcare usage.

Voice and swallowing outcomes following hypoglossal nerve stimulation for obstructive sleep apnea

OBJECTIVE Hypoglossal nerve stimulation is an effective treatment for a subset of patients with Obstructive Sleep Apnea (OSA). Although multiple clinical trials demonstrate its efficacy, no previous literature explores the potential impact the stimulator has on swallowing and voice. Our primary objective is to evaluate patient reported post-operative changes in voice or swallowing following hypoglossal nerve stimulator placement. STUDY DESIGN Prospective cohort study. SETTING Tertiary care hospital. SUBJECT AND METHODS Patients scheduled to receive a hypoglossal stimulator were enrolled. Participants completed baseline Voice Handicap Index-10 (VHI-10) and Eating Assessment Tool-10 (EAT-10) questionnaires preoperatively and again at 1week, 3months, and 6months post-operatively following placement of a hypoglossal nerve stimulator. RESULTS 9 males and 5 females completed the study. The mean pre-operative VHI-10 and EAT-10 score was 3 and 0.8 respectively. Using linear mixed models, a clinically and statistically significant increase in the mean EAT-10 score was observed post-operatively at 1week (p=0.007), which was not observed at the time points the stimulator was active. A clinically and statistically significant decrease in VHI-10 score was observed following 2months of active stimulator use (p=0.02), which was not observed at any other time point. CONCLUSION The implantation and use of the hypoglossal nerve stimulator over 5months did not demonstrate any sustained, patient reported changes in voice handicap and swallowing function. While larger studies are warranted, our findings can be used to provide further informed consent for hypoglossal nerve stimulator implantation.

The Impact of Physician Extenders in an Academic Otolaryngology Residency Program: Initial Experiences

Objectives: A physician extender is a licensed health care provider who performs medical activities typically performed by a physician. The term encompasses highly trained health care professionals such as physician assistants, nurse practitioners, and midlevel practitioners. In our academic, tertiary care otolaryngology residency-training program, a physician extender was recently hired. The objective of this study was to evaluate his impact on resident quality of life and education as well as his productivity. Methods: All otolaryngology residents at an academic tertiary care medical center were issued a questionnaire that they answered anonymously. All inpatient consults seen by the physician extenders and residents over an 18-month period between June 2012 and December 2013 were prospectively captured and evaluated. Results: The results of the survey indicated that all residents unanimously agreed that a physician extender had a positive impact on resident education, patient care, and quality of life. There was no statistically significant difference in the types of consults seen by a physician extender and those seen by a resident. The physician extender enhanced departmental productivity on the inpatient consultation service. Conclusions: Physician extenders are valuable assets to academic otolaryngology residency programs. Their presence enhances patient access, care, and departmental productivity. They have a positive impact on resident quality of life and augment resident education.