Nicholas J. Scalzitti

How Does TeamSTEPPS Affect Operating Room Efficiency

Objective To evaluate the effect of TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety) on operating room efficiency for the otolaryngology service at a tertiary care medical center. Study Design Retrospective database review. Setting Otolaryngology department at tertiary care medical center. Subjects and Methods To assess the impact of implementing an evidence-based patient safety initiative, TeamSTEPPS, on operating room efficiency in the otolaryngology department, the operative times, time lost to delayed starts, and turnover times during the year following the implementation of TeamSTEPPS were compared with the values from the prior year. Results The study compared 1322 cases and 644 turnovers in the year prior to TeamSTEPPS implementation with 1609 cases and 769 turnovers in the following year. There were no statistically significant decreases in operating room efficiency in the year after the TeamSTEPPS rollout. Conclusion Operating room efficiency was preserved after the rollout of a rigorous evidence-based patient safety initiative that requires active participation from all operating room team members.

Trichobezoar Causing Airway Compromise during Esophagogastroduodenoscopy.

Objectives. (1) Report the case of a 5-year-old female with trichotillomania and trichophagia that suffered airway compromise during esophagogastroduodenoscopy for removal of a trichobezoar. (2) Provide management recommendations for an unusual foreign body causing extubation and partial airway obstruction. Methods. Case report of a rare situation of airway compromise caused by a trichobezoar. Results. A 5-year-old patient underwent endoscopic retrieval of a gastric trichobezoar (hairball) by the gastroenterology service under general endotracheal anesthesia in a sedation unit. During removal, the hairball, due to its large size, dislodged the endotracheal tube, effectively extubating the patient. The bezoar became lodged at the cricopharyngeus muscle. Attempts to remove the bezoar or reintubation were unsuccessful. The child was able to be mask ventilated while the otolaryngology service was called. Direct laryngoscopy revealed a hairball partially obstructing the view of the glottis from its position in the postcricoid area. The hairball, still entrapped in the snare from the esophagoscope, was grasped with Magill forceps and slowly extracted. The patient was then reintubated and the airway and esophagus were reevaluated. Conclusions. Trichobezoar is an uncommon cause of airway foreign body. Careful attention to airway management during these and similar foreign body extractions can prevent inadvertent extubations.

Military Otolaryngology Resident Case Numbers and Board Passing Rates during the Afghanistan and Iraq Wars

Objective During the wars in Iraq and Afghanistan, the US military has continued to train medical residents despite concern that postgraduate medical education at military training facilities has suffered. This study compares the experience of otolaryngology residents at military programs with the experience of their civilian counterparts. Study Design Retrospective review. Setting Academic military medical centers. Subjects and Methods Resident caseload data and board examination passing rates were requested from each of the 6 Department of Defense otolaryngology residency programs for 2001 to 2010. The American Board of Otolaryngology and the Accreditation Council for Graduate Medical Education provided the national averages for resident caseload. National board passing rates from 2004 to 2010 were also obtained. Two-sample t tests were used to compare the pooled caseloads from the military programs with the national averages. Board passing rates were compared with a test of proportions. Results Data were available for all but one military program. Regarding total cases, only 2001 and 2003 showed a significant difference (P < .05), with military residents completing more cases in those years. For individual case categories, the military averages were higher in Otology (299.6 vs 261.2, P = .033) and Plastics/Reconstruction (248.1 vs 149.2, P = .003). Only the Head & Neck category significantly favored the national average over the military (278.3 and 226.0, P = .039). The first-time board passing rates were identical between the groups (93%). Conclusion Our results suggest that the military otolaryngology residency programs are equal in terms of caseload and board passing rates compared with civilian programs over this time period.

Diagnosis and perioperative management in pediatric sleep-disordered breathing

Sleep‐disordered breathing has a prevalence of 12% in the pediatric population. It represents a spectrum of disorders encompassing abnormalities of the upper airway that lead to sleep disruption, including primary snoring, obstructive sleep apnea, central sleep apnea, and sleep‐related hypoventilation. Sleep‐disordered breathing is the most common indication for adenotonsillectomy, one of the most common procedures performed in children. In recent years, the American Academy of Otolaryngology‐Head and Neck Surgery, American Academy of Pediatrics, and the American Society of Anesthesiologists have crafted guidelines to help safely manage children with sleep‐disordered breathing. Each organization recommends in‐laboratory polysomnography for definitive diagnosis of obstructive sleep apnea in certain cases. However, because this test is both costly and inconvenient, there has been significant interest in alternative methods for diagnosing clinically significant sleep‐disordered breathing. Accurate diagnosis is critical because sleep‐disordered breathing confers certain perioperative risks and increased mortality in some instances. Recent studies have elucidated the danger of anesthesia and opioids in worsening obstructive sleep apnea, and recommendations for alternative analgesia are being created. In addition, determining the most appropriate level and duration of monitoring in the postoperative period is actively being evaluated. This article presents an overview of the recent literature on the perioperative care of pediatric patients with sleep‐disordered breathing. It highlights innovative modalities and limitations in diagnosing obstructive sleep apnea, the importance of a tailored anesthetic/analgesic approach to children with obstructive sleep apnea, and the need for postoperative monitoring. It also brings to focus that further studies on the perioperative care of these children are necessary.

Comments on “Upper Airway Stimulation for Obstructive Sleep Apnea: 5-Year Outcomes”

We enjoyed the article by Woodson et al recently published in this journal. The authors presented an excellent case for upper airway stimulation (UAS) as an alternative treatment for select patients with obstructive sleep apnea (OSA) who are intolerant of positive airway pressure (PAP) therapy. The data demonstrated clinically and statistically significant improvements in apnea-hypopnea index (AHI), oxygen desaturation index, Epworth Sleepiness Scale scores, Functional Outcomes of Sleep Questionnaire scores, and snoring ratings. Perhaps the most impressive finding is the stability of these improvements over the 5-year follow-up with this cohort of patients. While the authors present a well-designed study, the omission of data demonstrating the amount of device usage by the patients is a substantial limitation. A strength of the UAS system is the ability to provide these data objectively. Given the length of follow-up and absence of these data, one is left to speculate if these patients who were not adherent to PAP therapy are similarly not adherent to this therapy. Notably, other studies describing the effectiveness of UAS therapy, with shorter follow-up, presented the usage data. Possibly the greatest advantage that UAS therapy can have over PAP therapy is improved compliance with treatment, as intolerance to or unwillingness to accept PAP therapy is the primary indication for device implantation. The published AHI reductions with UAS are encouraging. However, these reductions are not quite as effective as PAP therapy. Since PAP therapy is effective only for the time that it is used, with a return to the patient’s baseline AHI during periods of nonusage, the “effective AHI” may in fact be improved with UAS. The surgical sleep community has recognized the difference between efficacy and effectiveness in the context of poor PAP compliance and treatment limitations when patients do not use the prescribed therapy. Historically, one of the potential benefits of surgery is that compliance has not been a factor. As highlighted by the “therapy withdrawal” portion of the STAR trial, UAS should be viewed differently than other surgery, since compliance with therapy is required. However, UAS therapy with increased frequency and duration of usage can provide a more substantial disease-altering effect on OSA through more consistent use and thus a lower effective AHI. We look forward to a response from the authors that can clarify this issue of device usage, as we believe that this will strengthen the case for this revolutionary OSA treatment.

Obstructive Sleep Apnea is an Independent Risk Factor for Hospital Readmission

STUDY OBJECTIVES Hospital readmissions are an important metric of quality and safety. This study seeks to characterize the relationship between readmissions and obstructive sleep apnea (OSA). A better understanding of this relationship could be utilized to develop preventative measures and reduce readmission rates. METHODS A retrospective review of patients discharged over a 24-month period to a Department of Defense hospital was conducted. Medical records review provided demographic data, presence of OSA and comorbid diseases, and whether readmission occurred within 30 days of discharge. Statistical analysis assessed risk factors for readmission, and multivariate analysis was performed. Next, 125 readmitted patients with OSA were randomly selected for detailed chart review and compared to a matched cohort that was not readmitted. RESULTS Of 22,261 unique patients discharged, 1,899 (8.5%) were readmitted. Patients with OSA had a readmission rate of 11.4% versus 7.6% for patients without OSA (P < .00001). Multivariable analysis revealed an odds ratio of 1.46 for readmission in patients with OSA (P < .0001). For the detailed chart review of 250 patients, length of hospital stay differed for the readmitted and non-readmitted groups (5.1 versus 3.6 days; P = .007). Apnea-hypopnea index (24.1 versus 27.2 events/h; P = .48) was similar between the groups. Also, inpatient (27.2% versus 26.4%) and outpatient (38.4% versus 37.6%) positive airway pressure (PAP) treatment rates were not different. CONCLUSIONS This study found OSA to be an independent risk factor for readmission within 30 days of discharge. PAP therapy appears to be underutilized in patients with known OSA. Additional studies are needed to define the relationship between OSA, PAP adherence, and hospital readmission.

A Multidisciplinary Approach to Castleman Disease of the Neck.

Abstract Castleman disease (CD) is a rare lymphoproliferative disorder that occurs in adults and rarely in the pediatric population. The disease is characterized by slowly enlarging masses that can form anywhere within the lymphatic system. It is an uncommon cause of a neck mass in both children and adults that presents insidiously and nonspecifically. A 21-year-old woman was referred to the otolaryngology service because of an asymptomatic neck mass found incidentally on computed tomographic imaging 15 months earlier. On repeat imaging, the lesion was characterized as a homogenously enhancing soft tissue mass and appeared stable in size compared with previous studies. Given the nondiagnostic radiologic features, tissue sampling was pursued, first using fine-needle aspiration and ultimately excisional biopsy. The excision revealed histopathology consistent with unicentric, hyaline-vascular CD. Excision is the gold standard for treatment of this variant of CD. The patient was referred to the hematology/oncology service but was subsequently lost to follow-up. This case illustrates a rare cause of a neck mass in a young adult and exemplifies the extremely broad differential in this setting. In addition, it highlights the importance of a systematic and thorough approach to diagnosing neck masses in children and adults.