Doron D. Sommer

A 2013 updated systematic review & meta-analysis of 36 randomized controlled trials; no apparent effects of non steroidal anti-inflammatory agents on the risk of bleeding after tonsillectomy.

Although the literature suggests that non‐steroidal anti‐inflammatory drugs (NSAIDs) are effective in controlling post‐operative pain in the paediatric population, physicians have been reluctant to utilise these medications after tonsillectomy due to concerns of increased bleeding rates. While many surgeons prescribe opioid analgesics postoperatively, these are associated with a number of potential adverse side‐effects including nausea, vomiting, constipation, excessive sedation and respiratory compromise.

Sialendoscopy for the Management of Obstructive Salivary Gland Disease A Systematic Review and Meta-analysis

OBJECTIVE To conduct a systematic review with meta-analysis to determine the efficacy and safety of sialendoscopy in the treatment of obstructive diseases of the salivary glands in adults. DATA SOURCES MEDLINE, EMBASE, and the Cochrane Library (no lower limit to October 2010). Reference lists were searched for identification of relevant studies. STUDY SELECTION Prospective or retrospective studies of adult patients treated with interventional sialendoscopy for the management of salivary gland obstruction were selected. Outcome measures included rates of success (symptom-free and absence of residual obstruction), sialadenectomy, and complications. Non-English publications were excluded. DATA EXTRACTION Two independent review authors screened eligible studies, extracted relevant data, and resolved discrepancies by consensus when applicable. Weighted pooled proportion, 95% confidence intervals, and test results for heterogeneity are reported. DATA SYNTHESIS Twenty-nine studies were included in the analysis. The weighted pooled proportion of success rates were 0.86 (95% CI, 0.83-0.89) for studies involving 1213 patients undergoing sialendoscopy alone and 0.93 (95% CI, 0.89-0.96) for the 374 patients undergoing sialendoscopy with a combined surgical approach. Outcomes following interventional sialendoscopy for radioiodine-induced sialadenitis were reported in 3 studies, and success rates were variable. Rates of sialadenectomy were low, and few major complications were reported. CONCLUSION Findings from the present systematic review and meta-analysis suggest that sialendoscopy is efficacious, safe, and gland preserving for the treatment of obstructive major salivary gland disease.

Sensorineural hearing loss in postmeningitic children.

Objective To establish the proportion of children who develop sensorineural hearing loss after bacterial meningitis and to correlate such loss with patient factors. Study Design Retrospective case review. Setting McMaster University Childrens Hospital, a tertiary referral center. Patients Children between the ages of 1 day and 18 years admitted to McMaster University Childrens Hospital with a confirmed diagnosis of bacterial meningitis between January 1, 1991 and December 30, 2000. Interventions Audiological assessment including auditory brainstem responses and cortical electric-response audiometry or standard audiometry. Main Outcome Measures The nature of sensorineural hearing loss was assessed according to the degree (mild to profound) and course (transient versus permanent). Correlations between sensorineural hearing loss and the patients age, sex, duration of illness before admission, use of dexamethasone, concurrent neurologic complications, and types of pathogens were evaluated. Patterns of inpatient and outpatient audiological assessment were determined. Results Seventy-nine children had confirmed bacterial meningitis. Streptococcus pneumoniae accounted for 36.7 percent of all cases, followed-up by Neisseria meningitides (16.5%), group B Streptococcus (15.2%), and Hemophilus influenzae (13.9%). Sixty-eight (86.1%) children underwent hearing assessment, either as inpatients or after discharge. Of the remaining 11 (13.9%) in whom audiological evaluation could not be confirmed, only two made mention of a referral. As such, a nonreferral rate of 11.4 percent was identified. Abnormal auditory brainstem response findings were present in 22 cases (32.3%), with 11 cases (13.9%) of permanent sensorineural hearing loss identified. A statistically significant association between sensorineural hearing loss and Streptococcus pneumoniae was found (p < 0.001). No association between age, sex, duration of illness before admission, use of dexamethasone, and number of concurrent neurologic complications could be established. Conclusions In our series, 11 children (13.9%) experienced permanent sensorineural hearing loss, consistent with previously reported rates of 5 to 35 percent within the pediatric population. Since introduction of the Hemophilus influenzae type B vaccine, Streptococcus pneumoniae has emerged as the dominant causative organism of bacterial meningitis in children. Our study additionally confirms the role of Streptococcus pneumoniae as a precipitant of sensorineural hearing loss (p < 0.001). Audiological assessment in our series (86.1%) exceeds most of the screening rates previously reported in the literature. Because of compliance problems with outpatient audiological assessment and because early identification and expedient amplification lead to better academic and language outcomes, routine inpatient audiological screening of postmeningitic children is advocated.

Morphine or Ibuprofen for Post-Tonsillectomy Analgesia: A Randomized Trial

BACKGROUND: Pediatric sleep disordered breathing is often caused by hypertrophy of the tonsils and is commonly managed by tonsillectomy. There is controversy regarding which postsurgical analgesic agents are safe and efficacious. METHODS: This prospective randomized clinical trial recruited children who had sleep disordered breathing who were scheduled for tonsillectomy +/− adenoid removal. Parents were provided with a pulse oximeter to measure oxygen saturation and apnea events the night before and the night after surgery. Children were randomized to receive acetaminophen with either 0.2–0.5 mg/kg oral morphine or 10 mg/kg of oral ibuprofen. The Objective Pain Scale and Faces Scale were used to assess effectiveness on postoperative day 1 and day 5. The primary endpoint was changes in respiratory parameters during sleep. RESULTS: A total of 91 children aged 1 to 10 years were randomized. On the first postoperative night, with respect to oxygen desaturations, 86% of children did not show improvement in the morphine group, whereas 68% of ibuprofen patients did show improvement (14% vs 68%; P < .01). The number of desaturation events increased substantially in the morphine group, with an average increase of 11.17 ± 15.02 desaturation events per hour (P < .01). There were no differences seen in analgesic effectiveness, tonsillar bleeding, or adverse drug reactions. CONCLUSIONS: Ibuprofen in combination with acetaminophen provides safe and effective analgesia in children undergoing tonsillectomy. Post-tonsillectomy morphine use should be limited, as it may be unsafe in certain children.

Smoking cessation interventions and cessation rates in the oncology population: an updated systematic review and meta-analysis.

Objectives To evaluate tobacco smoking cessation interventions and cessation rates in the oncology population through a systematic review and meta-analysis. Data Sources The literature was searched using PubMed, Google Scholar, Medline, EMBASE, and the Cochrane Library (inception to October 2012) by 3 independent review authors. Review Methods Studies were included if they were randomized controlled trials (RCTs) or prospective cohort (PCs) studies evaluating tobacco smoking cessation interventions with patients assigned to a usual care or an intervention group. The primary outcome measure was smoking cessation rates. Two authors extracted data independently for each study. When applicable, disagreements were resolved by consensus. Results The systematic review identified 10 RCTs and 3 PCs. Statistical analysis was conducted using StatsDirect software (Cheshire, UK). Pooled odds ratios (ORs) for smoking cessation interventions were calculated in 2 groups based on follow-up duration. The therapeutic interventions included counseling, nicotine replacement therapy, buproprion, and varenicline. Smoking cessation interventions had a pooled odds ratio of 1.54 (95% confidence interval [CI], 0.909-2.64) for patients in the shorter follow-up group and 1.31 (95% CI, 0.931-1.84) in the longer follow-up group. Smoking cessation interventions in the perioperative period had a pooled odds ratio of 2.31 (95% CI, 1.32-4.07). Conclusion Our systematic review and meta-analysis demonstrate that tobacco cessation interventions in the oncology population, in both the short-term and long-term follow-up groups, do not significantly affect cessation rates. The perioperative period, though, may represent an important teachable moment with regard to smoking cessation.

Evaluating Smoking Cessation Interventions and Cessation Rates in Cancer Patients: A Systematic Review and Meta-Analysis

Background. Tobacco smoking cessation interventions in the oncology population are an important part of comprehensive treatment plan. Objectives. To evaluate through a systematic review smoking cessation interventions and cessation rates in cancer patients. Search Strategy. The literature was searched using Medline, EMBASE, and the Cochrane Library (inception to November 2010) by three independent review authors. Selection Criteria. Studies were included if tobacco smoking cessation interventions were evaluated and patients were randomized to usual care or an intervention. The primary outcome measure was cessation rates. Data Collection and Analysis. Two authors extracted data independently for each paper, with disagreements resolved by consensus. Main Results. The systematic review found eight RCTs investigating smoking cessation interventions in the oncology patient population. Pooled relative risks were calculated from two groups of RCTs of smoking cessation interventions based on followup duration. In both groups, the pooled relative risk did not suggest a statistically significant improvement in tobacco cessation compared to usual care. Conclusions. Our review demonstrates that recent interventions in the last decade which are a combination of non-pharmacological and pharmacological approaches yield a statistically significant improvement in smoking cessation rates compared to usual care.

Endoscopic Transnasal Approach to the Craniocervical Junction

Anterior access to the craniocervical junction has traditionally been through a transoral approach. With the advent of newer techniques, recent literature suggests a possible role for a transnasal endoscopic approach to the craniocervical junction. A review of the literature primarily consists of case reports and three anatomic cadaveric studies demonstrating the feasibility of an endonasal approach. In this retrospective review, we report our experience with four patients who underwent an endoscopic transnasal approach to the C1-C2 region. The surgical technique using a binasal endoscopic approach is described. The results indicate that the procedure is well tolerated with no significant deleterious sequelae. Although the use of this technique is in its early stages, the transnasal approach may offer a safe and effective alternative with minimal morbidity. Larger clinical studies are necessary to further explore the risks and benefits of this procedure.

Treatment of Aspirin Exacerbated Respiratory Disease with a Low Salicylate Diet A Pilot Crossover Study

Objective Aspirin exacerbated respiratory disease (AERD) is comprised of aspirin/acetylsalicylic acid (ASA) sensitivity, bronchial asthma, and nasal polyposis. Treatment of this condition is challenging and may include topical/systemic steroids, endoscopic sinus surgery, and/or aspirin desensitization. Study Design A prospective crossover pilot study (n = 10) was conducted in which patients were randomized into either of 2 groups with 6 weeks of regular diet (R) or 6 weeks of a low salicylate diet (LS). Setting The study was conducted in a tertiary otolaryngology clinic. Subjects Patients with AERD were enrolled in the study. Methods Subjective (Sino-nasal Outcome Test-22 [SNOT-22], Nasal Sinus Symptom Scale [NSSS], and the Asthma Control Questionnaire-7 [ACQ-7]) and objective outcome instruments (Peri-Operative Sinus Evaluation [POSE] and Lund-Kennedy Endoscopic Score [LKES]) were used to evaluate patients at baseline, 6 weeks (at crossover), and 12 weeks. Results Wilcoxon rank sum tests demonstrated that patients on the low salicylate diet had improved scores compared to their regular diet when evaluated by 4 of the 5 outcome measures (SNOT-22 pLS = 0.0059, NSSS pLS = 0.0195, LKES pLS = 0.0039, POSE pLS = 0.005). Conclusion Results of the pilot study indicate that implementation of a low salicylate diet improves the nasal symptoms and nasal endoscopy findings of individuals with AERD. Further research is required to support these findings.

Sialendoscopy for the management of juvenile recurrent parotitis: a systematic review and meta-analysis.

To determine the effectiveness and safety of sialendoscopy for the treatment of juvenile recurrent parotitis (JRP). The study was conducted and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses guidelines.

A novel treatment adjunct for aspirin exacerbated respiratory disease: the low-salicylate diet: a multicenter randomized control crossover trial

Aspirin‐exacerbated respiratory disease (AERD) is a clinical triad consisting of aspirin/acetylsalicylic acid (ASA) sensitivity, bronchial asthma, and nasal polyposis. Although respiratory reactions following ingestion of ASA and other nonsteroidal anti‐inflammatory drugs (NSAIDs) are considered a hallmark of the condition, respiratory inflammation persists despite patients’ avoidance of NSAIDs. Treatment of this condition remains challenging and includes both medical and surgical options.