Annals of Otology Rhinology and Laryngology 2022-05-24

Flipping the Classroom: An Evaluation of Teaching and Learning Strategies in the Operating Room

Jared Johnson,Emily Misch,Michael T. Chung,Jeffrey Hotaling,Adam Folbe,Peter F. Svider,Cristina Cabrera-Muffly,Andrew P. Johnson

Publication date 05-08-2021


With increasing restraints on resident's experiences in the operating room, with causes ranging from decreased time available to increasing operating room costs, focus has been placed on how to improve resident's education. The objectives of our study are to (1) determine barriers in education in the operating room, (2) identify effective learning and teaching strategies for residents in the operating room with a focus on the tonsillectomy procedure. An online survey was sent to all otolaryngology residents and residency programs for which contact information was available from January 2016 to March 2016 with 139 respondents. The 12-question survey focused on information regarding limitations to learning how to perform tonsillectomies as well as difficulties with teaching the same procedure. Resident responses were separated based on PGY level, and analysis was performed using Common themes emerged from responses for both teaching and learning how to perform tonsillectomies. A significant limitation in learning the procedure was lack of visualization during the surgery (57% learning vs 60% teaching). For both learners and teachers, the monopolar cautery instrument was found to be the most preferred instrument to use during tonsillectomy (80% each). The majority of resident respondents (93%) felt that an instructional video would be beneficial for both learning and teaching the procedure. Significant limitations for learning and teaching in the operating room were identified for performing tonsillectomies. Future endeavors will focus on resolving these limitations to improve surgical education. Level IV.

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Determining Medical Urgency of Voice Disorders Using Auditory-Perceptual Voice Assessments Performed by Speech-Language Pathologists

Robert Brinton Fujiki,Peter W. Sanders,M. Preeti Sivasankar,Stacey Halum

Publication date 20-07-2021


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Recovery of Vocal Cord Motion Among Pediatric Patients

Courtney Ann Prestwood,Ashley F. Brown,Romaine F. Johnson

Publication date 20-07-2021


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Systematic Review and Meta-Analysis of Post-Treatment PET/CT in HPV-Associated Oropharyngeal Cancer

Fasil Mathews,Rachel Irizarry,Richard Rosenfeld,Krishnamurthi Sundaram

Publication date 06-08-2021


To perform a systematic review with meta-analysis to investigate the utility of post-treatment PET/CT specifically in HPV-associated oropharyngeal squamous cell carcinoma following curative intent treatment. Random-effects meta-analysis was used to pool data from 7 observational studies (2013-2019) obtained from a database search of Pub Med, Web of Science, and EMBASE using an a priori protocol with dual independent evaluation for inclusion, risk of bias assessment for acceptable methodology, and extraction of data for analysis. PET/CT results, treatment failure, imaging and interventions subsequent to PET/CT findings, and efficacy of salvage therapy were extracted. Of the 907 post-treatment scans, PET/CT results were largely negative (76.2%; 95% CI, 63.4-85.6) and least often positive (11.3%; 95% CI, 8.8-14.4). PET/CT results were equivocal for 22.5% (95% CI, 12.5-36.9) and equivocal/positive for 34.2% of patients (95% CI, 25.1-44.5). Patients with an initial positive scan had the highest treatment failure rates (43.1%; 95% CI, 21.4-67.7) and those with an initial negative scan had the lowest rates (7.4%; 95% CI, 5.7-9.7). The equivocal and equivocal/positive scans had intermediate prevalence of 16.5% (95% CI, 9.4-27.6) and 16.7% (95% CI, 9.1-28.7), respectively. The low treatment failure rate following a negative PET/CT scan is reassuring, but the data are consistent with treatment failure rates up to 9.7% suggesting follow-up of these patients is prudent. Additionally, the low positive predictive value for treatment failure observed alludes to use of post-treatment PET/CT in HPV-associated disease frequently leading to unnecessary subsequent imaging and intervention.

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Vascular Loops: The Innocent Bystander for Vestibular Paroxysmia

Carren Sui-Lin Teh,Siti Hajar Noordiana,Shanmugalingam Shamini,Narayanan Prepageran

Publication date 06-08-2021


Vestibular paroxysmia (VP) is a condition with recurrent short bouts of vertigo and is thought to be part of a neurovascular compression syndrome caused by the vascular loop. However, this is still being debated as vascular loops are considered as normal variants with limited studies involving vertiginous patients. The aim of this paper is to study the association between audiovestibular symptoms and the presence of vascular loops and to study the association between vestibular paroxysmia and vascular loops. This is a retrospective analysis of clinical, audiological and MRI findings of patients with and without vascular loops and vestibular paroxysmia from 2000 to 2020. A total of 470 MRI Internal Auditory Meatus scans were performed during the study period of which, 71 (15.1%) had vascular loops and 162 (34.5%) had normal MRI which were used as controls. From the 233 subjects recruited, there were 37 subjects with VP and 196 non VP subjects were used as controls. There was no association between the vascular loop and control groups in terms of co-morbidity and audiovestibular symptoms. The VP group had a significantly older mean age of 51.8 (SD ± 10.3) as compared to the non VP group with the mean age of 45.6 (SD ± 15.5). The VP group had higher number of patients presenting with hearing loss at 97.3% when compared with those without VP (80.1%) ( The vascular loop is a normal variant which may or may not give rise to audiovestibular symptoms or vestibular paroxysmia. Clinical assessment is still most important tool in deriving a diagnosis of VP and MRI may be useful to rule out other central causes.

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A Consideration for Surgical Management in Select T4b Oral Cavity Squamous Cell Carcinoma

Michelle M. Chen,Clifford M. Chang,Sarah Dermody,Andrew J. Rosko,Michelle L. Mierzwa,Paul L. Swiecicki,Matthew E. Spector,Francis P. Worden,Mark E. P. Prince,Steven B. Chinn

Publication date 07-08-2021


The role of surgery for conventionally "unresectable" (cT4b) oral cavity squamous cell carcinoma is unclear. We analyzed factors associated with overall survival in cT4b relative to cT4a oral cavity squamous cell carcinoma. We identified 6830 cT4a and 522 cT4b oral cavity squamous cell carcinoma chemoradiation or surgery + adjuvant therapy patients in the National Cancer Data Base from 2004 to 2016. The main outcome was overall survival. Statistical analysis was performed using chi-squared tests, univariable and multivariable regression analysis. The cT4b group had a higher rate of positive margins (30.4% vs 21.3%, Clinical T4b staging is a poor predictor of pathologic staging given a high rate of downstaging on final pathology. Surgical resection with adjuvant chemoradiation is an option in select cT4b oral cavity squamous cell carcinoma patients.

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Development of a Decision Aid for Parents Who Elect Tonsillectomy for Obstructive Sleep Apnea

Adrian Williamson,Maxwell Newby,Drew Phillips,Michele Carr

Publication date 07-08-2021


To develop a novel patient decision aid (PtDA) for parents considering tonsillectomy for their children diagnosed with obstructive sleep apnea (OSA) and compare it to validated scales related to decision making in this context. These included scales for decisional conflict (DC) and shared decision making (SDM). A parental survey during 2017 to 2018 in a tertiary care pediatric otolaryngology clinic was conducted comparing a validated Decisional Conflict Scale (DCS) with a new PtDA that included an SDM scale, parental treatment goals, and knowledge about adenotonsillectomy and OSA. DCS scores range from 0 to 100 with values less than 25 considered to be low DC. The DQ was determined by a score on the PtDA. The PtDA was composed of a knowledge score, SDM score and 5 related values scored along a continuum (these were: resolution of symptoms, avoiding anesthesia, avoiding surgery, avoiding pain/bleeding, and resumption of normal behavior). A high score meant that all answers were consistent with choosing tonsillectomy and imply better DQ. A total of 89 parents or guardians participated in the study. The mean DC score was 4.32 (95% CI: 2.57-6.07). The mean DQ score was 22.69 (95% CI: 21.86-23.51). Mean values score was 5.35 (95% CI: 5.05-5.65). The mean knowledge score was 9.00 (95% CI: 8.60-9.40). SDM score mean was 8.38 (95% CI: 7.85-8.91). Using Spearman's rho, DC versus DQ inversely correlated with a coefficient -.209 via a 2-tailed test ( DC scores overall were low for the group. DQ, as measured with the novel PtDA, had an inverse correlation with DC scores, suggesting validity of the proposed PtDA. Our instrument has potential use as a PtDA for parents who are offered tonsillectomy for their children.

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Otolaryngology Resident Education and Perceptions of e-cigarettes

Elliot Y. Koo,Vivian Jin,Heather M. Weinreich,Barry L. Wenig

Publication date 07-08-2021


To date, there are no reports of otolaryngology residents' knowledge and confidence in discussing e-cigarette use. The purpose of this study was to evaluate otolaryngology resident e-cigarette knowledge and confidence in counseling patients on e-cigarette use. Cross-sectional national survey. Accreditation Council for Graduate Medical Education otolaryngology residents in the United States. US otolaryngology residents were distributed surveys electronically in September 2020. A total of 150 participants replied for a response rate of 8.88%. The majority, 93.10% have not received formal education on e-cigarettes during their residency training. The most common resource of e-cigarette information overall was social media (78.46%). Within academia, the most common resources of e-cigarette education were patient interactions (63.16%) and colleagues (54.74%). Patients commonly inquire residents about e-cigarettes for smoking cessation (85.07%) and their long-term health effects (83.58%). Almost 67% of residents rarely or never ask patients about e-cigarette use. Only 4.35% of residents are not confident discussing traditional cigarette use, while 58.70% are not confident discussing e-cigarettes. Otolaryngology residents have not received formal education in e-cigarettes and are not confident discussing e-cigarettes with their patients. This highlights the need for e-cigarette education during otolaryngology residency to improve patient e-cigarette counseling.

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Trends in Cancer Treatment for Oral Cavity, Oropharynx, and Larynx in 2016 Versus 2009: SEER Patterns of Care Studies

Kristin S. Weeks,Charles F. Lynch,Nitin Pagedar

Publication date 07-08-2021


To determine if there was a higher percentage of patients treated surgically and with advanced radiotherapy in 2016 (N = 897) versus 2009 (N = 1136), the patient and tumor characteristics associated with surgical care and advanced radiotherapy, and if chemotherapy or targeted agent use varied over time for squamous cell carcinoma of the head and neck. We utilized Surveillance Epidemiology and End Results Patterns of Care datasets. Rao-Scott Chi-square tests and logistic regressions were applied to determine differences in surgery, advanced radiotherapy (RT), and chemotherapy by year. There was a lower prevalence of surgery only treatment in 2016 versus 2009 with exception of oral cavity stages IVB/IVC and unknown, and larynx stage unknown. Advanced RT was more common in 2016 for patients receiving definitive RT among all sites, excluding stages I/II glottic larynx. Among each site (oral cavity, oropharynx, and larynx) lower stage was associated with increased odds of surgery. Among each site, advanced RT was more common in patients receiving definitive versus postoperative RT. For the larynx site, 2016 versus 2009 was associated with greater odds of advanced RT. Systemic treatment with fluorouracil, taxanes, or cetuximab was less prevalent in 2016. In 2016 versus 2009, there was largely not a higher percentage of patients treated surgically. There was a higher prevalence of advanced RT for definitive care. Further investigations of these patterns are needed, including trend analysis.

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Parental Views on the Role of Social Media in Pediatric Otolaryngology

Libby M. Ward,Chelsea A. Sykora,Yash Prakash,Michael B. Cohen,Jessica R. Levi

Publication date 09-08-2021


Social media is playing an increasingly important role in medicine as a tool for patients and their families to find information and connect with others. The goal of this study is to understand parental views on if and how social media should be incorporated into pediatric otolaryngology by physicians and hospitals. A survey was distributed to parents of pediatric otolaryngologic patients to assess views on professional social media use by physicians and hospitals. The proportion of parents who answered with specific responses in the survey was computed using the SPSS frequency analysis function. One hundred five parents completed the survey. Ninety-six percent of respondents use social media, of which 92% use social media at least once a day (n = 93). Eighty-five percent of respondents said they definitely or probably would visit their physician's professional social media page (n = 90). Seventy-four percent would be interested in obtaining more information about the physician (n = 76). Forty-one percent would be interested in patient stories (n = 76). Twenty-eight percent would visit out of curiosity (n = 76). Twenty-six percent would want to gather more information about the hospital (n = 76). Seventeen percent would want to connect with other patients and their family members (n = 76). Sixty-seven percent of respondents believe it is important for physicians to have a professional social media page, and 79% of respondents believe it is important for hospitals to have a public social media page (n = 93). The vast majority of parents of pediatric otolaryngologic patients use social media regularly and would want to gather information about their physician and hospital through social media. Therefore, physicians and hospitals should consider using social media as a valuable tool to connect with and relay information to patients and their family members.

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Phosphaturic Mesenchymal Tumors of the Sinonasal Area and Skull Base: Experience at a Single Institution

Davis P. Argersinger,Catherine T. Haring,John E. Hanks,Kevin J. Kovatch,S. Ahmed Ali,Jonathan B. McHugh,Melissa A. Pynnonen,Erin L. McKean

Publication date 09-08-2021


Phosphaturic mesenchymal tumor (PMT) is a rare, polymorphous neoplasm with a highly variable presentation and natural history and unpredictable clinical course. The primary objective was to describe our clinical experience with and management of 4 markedly different cases of sinonasal and skull base PMT. A retrospective case series with chart review, and relevant literature review, was performed at a tertiary academic medical center between 1998 and 2020. Adult patients treated for PMTs of the sinonasal area and skull base were included. Our main outcome measures included postoperative laboratory findings and radiological evidence of disease remission. Four patients (2 Males, 2 Females; Mean Age: 63.5 years) with PMTs of the skull base have been managed at our institution since 1998. Patient presentations varied, ranging from severe phosphorus wasting and osteoporosis to symptoms secondary to mass effect, including nasal obstruction and rhinorrhea. All 4 patients were eventually found to have elevated levels of fibroblast growth factor 23. Tumors were located in the sinonasal area (right frontal sinus, right ethmoid sinus, and right nasal cavity, respectively) in 3 patients and in the lateral skull base (right jugular foramen) in 1 patient. All 4 patients underwent complete surgical resection of their tumors. PMT tissue pathology was confirmed in all cases. Gross total resection was achieved in all patients. There was no chemical or radiological evidence of disease recurrence in any patients at follow-up. The presentation of skull base PMT is variable, and it may mimic other mass pathologies of the head and neck. Complete surgical resection with negative margins is potentially curative.

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Radial Forearm Free Flap Reconstruction of Glossectomy Defects Without Tracheostomy

Tara J. Wu,Satvir Saggi,Karam W. Badran,Albert Y. Han,Jordan P. Sand,Keith E. Blackwell

Publication date 09-08-2021


To assess the feasibility of radial forearm free flap (RFFF) reconstruction of glossectomy defects without tracheostomy tube (TT). Retrospective review of patients with at least oral tongue defects who underwent RFFF reconstruction. Pre- and intra-operative factors were documented. Post-operative respiratory complications included inability to extubate, pneumonia, or need for re-intubation or TT within 30 days. Twenty-one patients underwent RFFF reconstruction without TT, and 36 patients with TT. The average hospital length of stay was 1.5 days shorter in those without TT ( In our experience, RFFF reconstruction of glossectomy defects is feasible without TT among selected patients with small tongue base defects (≤25% resection) and unilateral neck dissection.

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Response of Laryngopharyngeal Symptoms to Transoral Incisionless Fundoplication in Patients with Refractory Proven Gastroesophageal Reflux

Grace E. Snow,Mohamad Dbouk,Lee M. Akst,Glenn Ihde,Rasa Zarnegar,Peter Janu,Michael Murray,Hany Eskarous,Amit Sohagia,Shumon I. Dhar,Marcia Irene Canto

Publication date 11-08-2021


Patients with laryngopharyngeal reflux (LPR) symptoms may not respond to proton pump inhibitors (PPI) if they have an alternative laryngeal diagnosis or high-volume reflux. Transoral incisionless fundoplication (TIF) or TIF with concomitant hiatal hernia repair (cTIF) are effective in decreasing symptoms of gastroesophageal reflux disease (GERD) but are not well studied in patients with LPR symptoms. This prospective multicenter study assessed the patient-reported and clinical outcomes after TIF/cTIF in patients with LPR symptoms and proven GERD. Patients with refractory LPR symptoms (reflux symptom index [RSI] > 13) and with erosive esophagitis, Barrett's esophagus, and/or pathologic acid reflux by distal esophageal pH testing were evaluated before and after a minimum of 6 months after TIF/cTIF. The primary outcome was normalization of RSI. Secondary outcomes were >50% improvement in GERD-Health-Related Quality of Life (GERD-HRQL), normalization of esophageal acid exposure time, discontinuation of PPI, and patient satisfaction. Forty-nine patients had TIF (n = 26) or cTIF (n = 23) with at least 6 months follow-up. Mean pre- and post TIF/cTIF RSI were 23.6 and 5.9 (mean difference: 17.7, In patients with objective evidence of GERD, TIF, or cTIF are safe and effective in controlling LPR symptoms as measured by normalization of RSI and improvement in patient satisfaction after TIF/cTIF. Level 4.

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Decreased Facial Emotion Recognition in Elderly Patients With Hearing Loss Reflects Diminished Social Cognition

Özlem Saatci,Hakan Geden,Halide Güneş Çiftçi,Zafer Çiftçi,Özge Arıcı Düz,Burak Yulug

Publication date 18-08-2021


The main objective of this research was to evaluate the correlation between the severity of hearing loss and the facial emotional recognition as a critical part of social cognition in elderly patients. The prospective study was comprised of 85 individuals. The participants were divided into 3 groups. The first group consisted of 30 subjects older than 65 years with a bilateral pure-tone average mean >30 dB HL. The second group consisted of 30 subjects older than 65 years with a PTA mean ≤30 dB HL. The third group consisted of 25 healthy subjects with ages ranging between 18 and 45 years and a PTA mean ≤25 dB HL. A Facial Emotion Identification Test and a Facial Emotion Discrimination Test were administered to all groups. Elderly subjects with hearing loss performed significantly worse than the other 2 groups on the facial emotion identification and discrimination tests ( Our results suggest that increased age might be associated with decreased facial emotion identification and discrimination scores, which could be deteriorated in the presence of significant hearing loss.

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Non-invasive Fungal Sinusitis as a Complication of a Steroid-Eluting Stent Following Endoscopic Sinus Surgery: A Case Report

Paige Shipman,Julie Highland,Benjamin Witt,Jeremiah Alt

Publication date 05-08-2021


Steroid eluting stents have proven to be a highly useful adjunctive therapy for chronic rhinosinusitis (CRS) and play an important role in the treatment of many inflammatory diseases of the sinuses. Few reports of adverse events were reported in clinical trials and are described in the literature. However, we describe the first known case of an immunocompetent patient developing non-invasive fungal tissue infection as a sequelae of stent-related tissue necrosis requiring surgical debridement. A 69-year-old immunocompetent male with CRS had Propel™ stents placed in the bilateral frontal sinus outflow tracts during revision endoscopic sinus surgery. He presented 2 weeks post-operatively with severe facial pain without vision changes, fevers, mental status changes, or evidence of cranial neuropathies. On rigid nasal endoscopy, necrotic tissue and gross fungal elements were visualized in the left frontal sinus outflow tract at the area of previous steroid stent position. The patient was taken for urgent endoscopic sinus surgery and debridement given significant symptoms and concern for invasive fungal infection. A revision left maxillectomy, ethmoidectomy, and draf 2b frontal sinus drillout were performed, with healthy bleeding tissue encountered beneath necrotic tissue. Pathology revealed tissue necrosis, exudative lumenal debris, and extensive fungal elements with no evidence of tissue invasion, and cultures yielded growth of aspergillus niger. The patient's symptoms improved significantly on post-operative day 1, he had normal post-operative changes at 2 weeks following debridement, and had no recurrence of fungal infection with complete healing at 4 months. While likely rare, steroid-eluting stents may pose a risk of saprophytic tissue infection as a result of tissue necrosis and local immunosuppression. Caution should be taken in using these devices in immunocompromised patients.

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Pulmonary Embolism and Sigmoid Sinus Thrombosis After Translabyrinthine Vestibular Schwannoma Resection: A Retrospective Case Series

Yohan Song,Noel Ayoub,Jenny X. Chen,Jennifer C. Alyono,D. Bradley Welling

Publication date 06-08-2021


To describe the presentation and treatment of patients developing pulmonary embolism following translabyrinthine approach for vestibular schwannoma resection. This was a retrospective case series of patients at 2 academic tertiary medical centers who developed symptomatic pulmonary embolism post-operatively following translabyrinthine approach for vestibular schwannoma resection and were found to have evidence of sigmoid sinus thrombosis. Three patients were identified to have post-operative pulmonary emboli after translabyrinthine approach for vestibular schwannoma resection with sigmoid sinus or internal jugular vein clots in the absence of lower extremity deep vein thrombosis. Caprini scores for these patients were 5 or lower. All patients underwent CT pulmonary angiography and were confirmed to have pulmonary emboli. Two were promptly anticoagulated with heparin drips and transitioned to long-term oral anticoagulation therapy and 1 had delayed anticoagulation. None of these patients suffered from intracranial hemorrhage post-operatively. Patients undergoing translabyrinthine approach for vestibular schwannoma can develop pulmonary embolism from sigmoid sinus entry or thrombosis. No clear guidelines exist for the management of this complication in the setting of recent craniotomy and the risk of intracranial hemorrhage must be considered prior to initiating anticoagulation.

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Impact of Giving Patients Your Personal Phone Number in Otolaryngology—Head & Neck Surgery

Matthew D. Adams,Jeff Wong,Arun Gadre,Joseph Scott Greene,Donna Milligan,Hassan Paknezhad,Nicholas Purdy,Jennifer Rager,Aileen Wertz,Season Whitenight,Thorsen W. Haugen

Publication date 24-05-2022


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Health and Well-Being Needs Among Head and Neck Cancer Caregivers – A Systematic Review

Sarah Benyo,Chandat Phan,Neerav Goyal

Publication date 13-05-2022


This review provides a summary of the current understanding of the health and well-being of the head and neck cancer (HNC) caregiver. Our goal is to understand the healthcare needs required by the caregivers of our oncologic patients, which may ultimately influence quality of care and support that cancer patients require during treatment and recovery. Independent database searches were conducted to identify articles describing HNC caregiver health and healthcare utilization. Search terms included key synonyms for head and neck cancer, caregiver, psychological stress, anxiety, depression, mental health service, and delivery of healthcare in the title/abstract. After following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Protocol, a total of 21 studies were included. Among the 21 studies in the review, a total of 1745 caregivers were included. The average age was 57 years, the majority were female (58%-100%), and spouses/partners of the patients (77%). The literature demonstrates significant anxiety, depression, post-traumatic stress disorder (PTSD), and physical health decline in addition to multifaceted unmet physical and mental health needs among HNC caregivers. There is no standard for examining HNC caregiver healthcare needs, while there is evidence of increased healthcare utilization. The literature is limited regarding medical burdens faced by caregivers. Future research is needed to assess the physical health and comorbidities of HNC caregivers and their engagement with the healthcare system to guide further implementation of support models to address the needs of this population.

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Nasal Nitric Oxide as a Biomarker in the Diagnosis and Treatment of Sinonasal Inflammatory Diseases: A Review of the Literature

Jacob J. Benedict,Matthew Lelegren,Joseph K. Han,Kent Lam

Publication date 13-05-2022


To critically review the literature on nasal nitric oxide (nNO) and its current clinical and research applicability in the diagnosis and treatment of different sinonasal inflammatory diseases, including acute bacterial rhinosinusitis (ABRS), allergic rhinitis (AR), and chronic rhinosinusitis (CRS). A search of the Pub Med database was conducted to include articles on nNO and sinonasal diseases from January 2003 to January 2020. All article titles and abstracts were reviewed to assess their relevance to nNO and ABRS, AR, or CRS. After selection of the manuscripts, full-text reviews were performed to synthesize current understandings of nNO and its applications to the various sinonasal inflammatory diseases. A total of 79 relevant studies from an initial 559 articles were identified using our focused search and review criteria. nNO has been consistently shown to be decreased in ABRS and CRS, especially in cases with nasal polyps. While AR is associated with elevations in nNO, nNO levels have also been found to be lower in AR cases with higher symptom severity. The obstruction of the paranasal sinuses is speculated to be an important variable in the relationship between nNO and the sinonasal diseases. Treatment of these diseases appears to affect nNO through the reduction of inflammatory disease burden and also mitigation of sinus obstruction. nNO has been of increasing interest to researchers and clinicians over the last decade. The most compelling data for nNO as a clinical tool involve CRS. nNO can be used as a marker of ostiomeatal complex patency. Variations in measurement techniques and technology continue to impede standardized interpretation and implementation of nNO as a biomarker for sinonasal inflammatory diseases.

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Evaluation of Preference and Utility Measures for Transoral Thyroidectomy

Vincent Wu,Shireen Samargandy,Justine Philteos,Jesse D. Pasternak,John R. de Almeida,Eric Monteiro

Publication date 03-05-2022


Traditional, trans-cervical thyroidectomy results in the presence of a neck scar, which has been shown to correlate with lower quality of life and lower patient satisfaction. Transoral thyroid surgery (TOTS) has been utilized as an alternative approach to avoid a cutaneous incision and scar by accessing the neck and thyroid through the oral cavity. This study was designed to evaluate patient preference through health-state utility scores for TOTS as compared to conventional trans-cervical thyroidectomy. In this cross-sectional study, patient preferences were elicited for TOTS and trans-cervical thyroidectomy with the use of an online survey. Respondents were asked to consider 4 hypothetical health scenarios involving thyroid surgery with varying approaches. Health-state utility scores were elicited using visual analog scale and standard gamble exercises. Overall, 516 respondents completed the survey, of whom 261 (50.6%) were included for analysis, with a mean age of 41.5 years (SD 14.9 years), including 171 (65.5%) females. Health utility scores were similar for TOTS and conventional transcervical techniques. Statistically significant differences in the standard gamble utility score were noted for gender and ethnicity across all scenarios. Comparisons of visual analog score utilities were not statistically significant based on respondent demographics. Preferences for TOTS and trans-cervical thyroidectomy did not significantly differ in the current study. Females and white ethnicity indicated stronger preference for a TOTs approach compared to males and other ethnicities, respectively. Some literature suggests certain types of patients who might prefer minimally invasive thyroidectomy more so than other patients-in keeping with the current findings of this study.

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Validating a Simulated Emergency Course for Nurses Working in ENT

Catherine de Cates,Chloe Swords,Olivia Kenyon,Karen MacGinley-Kerr, RN,Katy Watson, BSc, RN,Matthew E. Smith,Eishaan Bhargava,James R. Tysome

Publication date 03-05-2022


Nurses are increasingly providing routine and emergency ENT care; yet there are often limited training opportunities. The aim of this study was to validate an intensive 1-day ENT emergency simulation course for nurses. The course included short lectures, practical skills stations and mannequin simulation scenarios. Sixteen nurse participants were video-recorded managing simulated scenarios before and after the course. Two assessors scored individual participant performance on a 15-point competency grid (maximum score 30), blinded to the timing of the recording. Participants also rated their confidence and skill before and immediately following the course across 11 items using a 5-point Likert score (maximum score 55). Blinded assessor ratings for performance were significantly improved after the course compared to baseline (overall score 12 vs 7, respectively; Simulation-based training is an effective and desirable method of teaching ENT emergency management to nurses, with greatest impact on participant confidence. Future courses need to refine the content and increase the validation sample size using a nurse-specific scoring system.

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Resection of Intracochlear Schwannomas With Immediate Cochlear Implantation

Tirth R. Patel,Lindsay Fleischer,R. Mark Wiet,Elias M. Michaelides

Publication date 03-05-2022


Intralabyrinthine schwannomas, including the intracochlear variety, are rare benign tumors. They can cause a number of symptoms and have the potential to grow to involve other critical structures of the inner ear and skull base. While surgical resection is feasible, there is typically permanent hearing dysfunction as a result of resection and subsequent fibrosis. Here, we present 2 cases of intracochlear schwannomas (ICS) that were successfully resected with simultaneous cochlear implant placement. Patient 1 presented with an intravestibulocochlear schwannoma. This patient underwent a translabyrinthine approach. Endoscopic assistance was used to dissect the tumor from the vestibule and basal turn of the cochlea, through an enlarged round window approach. A cochlear implant was placed via a round window cochleostomy. Patient 2 presented with an intracochlear schwannoma involving the basal and middle turns of the cochlea. The patient underwent a trans-otic approach for resection. A large portion of the cochlear promontory required unroofing for complete exposure of the tumor. A cochlear implant was then placed via a round window cochleostomy. Upon cochlear implant activation, Patient 1's sound field thresholds using the implant were near the normal range of hearing, ranging from 25 to 50 dB HL from 250 to 6000 Hz. Patient 2's 6-month post-operative cochlear implant sound field testing ranged from 20 to 30 dB HL from 250 to 6000 Hz and speech recognition testing revealed 59% on AZ Bio sentences compared to 0% pre-operatively. Simultaneous cochlear implantation after resection of intracochlear schwannomas is safe and successful in restoring hearing. Attention to adequate exposure and endoscopic assistance, when required, allow for gross total resection while minimizing trauma to cochlear structures. In such cases, immediate cochlear implantation allows for hearing rehabilitation before likely cochlear fibrosis can occur.

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Pediatric Low-Grade Spindle Cell Neoplasm With A Novel AK5::ALK Fusion: A Case Report

Caroline Kikawa,Tyler G. Ketterl,Yajuan J. Liu PhD,Robyn C. Reed,John P. Dahl

Publication date 03-05-2022


Spindle cell neoplasms (SCN) share a single commonality of spindle-shaped cells on histopathology but are diverse in etiology. Expanding our collective knowledge of these neoplasms could further research in targeted therapies. We present a case of pediatric cutaneous SCN with a novel etiology, and the methods used to identify its origination. A 1.5-year-old child presented with a 7-month history of a rapidly enlarging, erythematous, non-painful scalp mass without ulceration or bleeding. The child underwent ultrasound and magnetic resonance imaging, revealing a 2.9 × 3 × 2 cm vascular mass without intracranial connections. The mass was successfully resected at surgery. Subsequent histopathologic and genetic testing indicated a SCN harboring a previously undescribed gene rearrangement between rearrangements are common amongst many tumor types, but to our knowledge,

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Social Media Use by Residents and Faculty in Otolaryngology Training Programs

Vrinda Gupta,Stephanie J. Braverman,Johnny P. Mai,Michael Noller,Macario Camacho,Anthony M. Tolisano,Philip E. Zapanta

Publication date 02-05-2022


Despite the growth of social media in healthcare, the appropriateness of online friendships between otolaryngological residents and attendings is poorly defined in the current literature. This issue is of growing importance, particularly as residency programs increasingly utilize social media as a means of connecting with and evaluating applicants due to limited in-person experiences during the COVID-19 pandemic. Our objective was to better understand the prevalence of and concerns surrounding social media use between residents and faculty. This study sent out 2 surveys in 2017 to all United States Otolaryngology residency program directors to disperse to their residents and attendings, respectively. We received a response from 72 residents and 98 attendings. Our findings show that social media is commonly used by both residents and attendings, and most residents have at least 1 online friendship with an attending. Resident and attending opinions diverge on topics such as appropriateness of use, privacy settings, and professionalism. We call on residency programs to delineate a transparent social media policy so applicant expectations on social media are clear.

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Auditory and Speech Outcomes of Cochlear Implantation in Children With Auditory Neuropathy Spectrum Disorder: A Systematic Review and Meta-Analysis

Duan Bo,Yue Huang,Bing Wang,Ping Lu,Wen-xia Chen,Zheng-min Xu

Publication date 02-05-2022


The aim of this meta-analysis was to critically assess the effect of cochlear implantation on auditory and speech performance outcomes of children with auditory neuropathy spectrum disorder (ANSD). A systematic literature search was conducted on Pub Med, EMbase, and Web of Science. The outcomes included speech recognition score, Categories of Auditory Performance (CAP), Speech Intelligibility Rating (SIR) score, and open-set speech perception. Results were expressed as standardized mean difference (SMD) or risk ratio (RR) with a 95% confidence interval (95% CI). A total of 15 studies was included in this meta-analysis. Pooled data showed that, there were no significant differences between ANSD and sensorineural hearing loss (SNHL) groups in terms of speech recognition score (SMD = 0.01, 95% CI: -0.45, 0.47; The current evidence suggested that children with ANSD who underwent cochlear implants achieved comparable effects in auditory and speech performance as children with non-ANSD SNHL.

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Comparison of Care Settings for Pediatric External Auditory Canal Foreign Bodies: A Meta-Analysis

Ana C. White,Michael C. Shih,Shaun A. Nguyen,Yi-Chun Carol Liu

Publication date 30-04-2022


To compare the success and complication rates of pediatric external auditory canal foreign body (EAC FB) removal between Emergency Departments (ED), Primary Care Providers (PCP), and Otolaryngologists (ENT). Pub Med, Scopus, and Embase were searched through January 13, 2022. Studies mentioning EAC FB removal success rates and types of healthcare settings were included. Pooled measures included abrasions/lacerations, TM perforations, and success rate stratified by healthcare setting. Thirteen studies and 3891 patients were included in the meta-analysis. Most comparisons between EAC FB removal success rates for EDs versus PCPs versus ENTs were statistically significant. The highest FB removal success rate was in patients who presented to ENTs without previous removal attempts (92.9% [95% CI 84.6-98.2]). EDs had the lowest success rates (64.0% [95% CI 48.3-78.3]). For patients that had a previous attempt at FB removal, ENTs had a success rate of 64.1% [95% CI 42.0-83.5]. For ENTs treating pediatric EAC FB, removal success rates decrease if a different healthcare provider previously attempted EAC FB removal. This effect likely is due to decreased patient cooperativeness or increased FB complications (eg, canal edema and bleeding limiting visualization) after previous removal attempts. Individual institutions should identify conditions that increase EAC FB removal failure rates and necessitate ENT referral. Therefore, the communication and concerted efforts between EDs, PCPs, and ENTs are critical for the improved outcomes of pediatric EAC FBs.

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The Effect of Diabetes Mellitus on Post-Operative Outcomes in Patients Undergoing Endoscopic Sinus Surgery

Kolin E. Rubel,Cole P. Rodman,Alex Jones,Dhruv Sharma,Vince Campiti,Megan Falls,Ife Bolujo,Jonathan Y. Ting,Elisa A. Illing

Publication date 27-04-2022


Diabetes Mellitus (DM) and its associated immune dysfunction are well-studied risk factors for adverse surgical outcomes. The literature regarding endoscopic sinus surgery (ESS) is less robust and there have been conflicting reports on post-operative complications and surgical results in this patient population. The purpose of this study was to analyze the impact of diabetes mellitus on outcomes after ESS via rates of post-operative medical intervention in the first 6 months after surgery. This was a retrospective cohort study of 176 subjects who underwent ESS from 2015 to 2019 at a single institution by 2 fellowship-trained rhinologists. Subjects were divided into 2 groups, those with a documented Hemoglobin A1c (HbA1c) >6.5 or diagnosis of DM and those with HbA1C < 6.5. Patient age, demographics, 6-month preoperative HbA1c, surgical status and extent, and 6-monthpostoperative need for steroids and/or antibiotics were collected. Out of n = 176 total patients, n = 39 (22.2%) were categorized into the DM group, which were older (46.4 vs 53.8 years, Patients with DM do not appear to have worse post-operative outcomes outside of the initial 6-month postoperative period.

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Post-operative Monitoring for Head and Neck Microvascular Reconstruction in the Era of Resident Duty Hour Restrictions: A Retrospective Cohort Study Comparing 2 Monitoring Protocols

Vincent J. Anagnos,Robert M. Brody,Ryan M. Carey,Emma De Ravin,Kendall K. Tasche,Jason G. Newman,Rabie M. Shanti,Ara A. Chalian,Christopher H. Rassekh,Gregory S. Weinstein,Bert W. O’Malley,Steven B. Cannady, MD

Publication date 27-04-2022


To determine whether 2 different methods of post-operative head and neck free flap monitoring affect flap failure and complication rates. A retrospective chart review of 803 free flaps performed for head and neck reconstruction by the same microvascular surgeon between July 2013 and July 2020 at 2 separate hospitals within the same healthcare system. Four-hundred ten free flaps (51%) were performed at Hospital A, a medical center where flap checks were performed at frequent, scheduled intervals by in-house resident physicians and nurses; 393 free flaps (49%) were performed at Hospital B, a medical center where flap checks were performed regularly by nursing staff with resident physician evaluation as needed. Total free flap failure, partial free flap failure, and complications (consisting of wound infection, fistula, and reoperation within 1 month) were assessed. There were no significant differences between Hospitals A and B when comparing rates of total free flap failure, partial free flap failure, complication, or re-operation ( In our series, free flap outcomes did not vary based on the degree of flap monitoring by resident physicians. This data supports the ability of a high-volume, well-trained, nursing-led flap monitoring program to detect flap compromise in an efficient fashion while limiting resident physician obligations in the age of resident duty hour restrictions.

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Should Propranolol Remain the Gold Standard for Treatment of Infantile Hemangioma? A Systematic Review and Meta-Analysis of Propranolol Versus Atenolol

Tiffany Chen,Rachana Gudipudi,Shaun A. Nguyen,William Carroll,Clarice Clemmens

Publication date 25-04-2022


Although propranolol has been established as the gold standard when treatment is sought for infantile hemangioma, concerns over its side effect profile have led to increasing usage of atenolol, a beta-1 selective blocker. A systematic review of Pub Med, Scopus, CINAHL, Google Scholar, and Cochrane was conducted following PRISMA guidelines using MeSH terms and keywords for the terms propranolol, atenolol, and infantile hemangioma, including alternative spellings. All randomized control trials (RCTs) or cohort studies directly comparing outcomes of hemangioma treatment with atenolol and propranolol were included. A meta-analysis with pooled mean differences, pooled odds ratios, and analysis of proportions was performed. A total of 669 participants in 7 studies (3 RCTs and 4 cohort) were included. Propranolol showed a significantly higher rate of complete response compared to atenolol (73.3% vs 85.4%, Propranolol treatment leads to a significantly higher rate of complete response than atenolol. However, its use must be weighed against its greater side effect profile.

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Right Vocal Cord Paralysis Caused by Histoplasmosis: A Case Report

Ashley Diaz,Samuel Auger,Nicole A. Cipriani,Brandon J. Baird

Publication date 22-04-2022


is a prevalent dimorphic fungus, reaching an exposure rate of 90% in endemic areas such as the Midwest and Central United States. We report an unusual presentation of dysphonia due to right vocal cord paralysis caused by mediastinal lymphadenopathy from histoplasmosis. A 73-year-old male presented to an otolaryngology clinic with 4 months of hoarseness. Flexible strobolaryngoscopy demonstrated right vocal cord paralysis in lateral position and a full length glottic gap. Computerized tomography (CT) scan showed enlargement of a right paratracheal node. A lymph node biopsy was obtained and showed histoplasmosis. He was treated with a 3-month course of pozaconazole. He then received a vocal cord medialization injection 2 months after symptom onset, which produced favorable improvement of his symptoms at 8-month follow up. One other case report in the literature has reported left vocal cord paralysis related to histoplasmosis. This first case of right vocal cord paralysis was extremely unusual and is not often included in the differential diagnosis of vocal cord paralysis.

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The Efficacy of Gabapentin+Dexamethasone for Postoperative Analgesia Following Septoplasty: A Prospective Randomized Placebo-Controlled Trial

Süheyla Kandemir,A.Erim Pamuk,Gökçe Özel,Işın Gençay,Rahmi Kılıç

Publication date 22-04-2022


This study aimed to compare the efficacy of gabapentin, dexamethasone, and gabapentin + dexamethasone for pain control after septoplasty.
This prospective randomized trial included 120 patients that underwent septoplasty and were randomly divided into 4 groups: group G (preoperative gabapentin 600 mg p.o.); group D (intraoperative dexamethasone 8 mg i.v.); group GD (preoperative gabapentin 600 mg p.o. + intraoperative dexamethasone 8 mg i.v.); group C (placebo control). The median VAS score was significantly lower in groups G and GD at 1, 2, 4, 6, 12, and 24 hours postsurgery than in group C ( Gabapentin, dexamethasone, and gabapentin + dexamethasone are equally more effective analgesics during the first 4 hours postsurgery than placebo. The addition of dexamethasone to gabapentin does not provide extra analgesia. Both gabapentin and gabapentin + dexamethasone have a more prolonged analgesic effect than dexamethasone alone.

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Late Retropharyngeal and Parapharyngeal Abscess in Patients with a History of Anterior Cervical Discectomy and Fusion

Louis Bivona,Adrian Williamson,Sanford E. Emery,William A. Stokes

Publication date 22-04-2022


Anterior cervical discectomy and fusion is a common procedure performed by spine surgeons with rare complications and high treatment success. Late presentation of retropharyngeal abscess in patients with a history of anterior cervical discectomy and fusion is rare but can have devastating consequences. There is a paucity of data to guide medical and surgical management of retropharyngeal abscess in these patients. We discuss 7 patients who presented to our institution with a late retropharyngeal abscess after having a history of anterior cervical discectomy and fusion. A review and description of the current literature regarding treatment and outcomes is described. Seven patients presented to our institution with a retropharyngeal abscess ranging from 10 months to 7 years after undergoing anterior cervical discectomy and fusion. All patients received at least a 6-week course of appropriate intravenous antibiotics. Only one patient had their initial ACDF instrumentation removed at the time of presentation for the abscess. Four out of the 7 patients were treated with irrigation and debridement in addition to intravenous antibiotics, whereas 3 patients were treated with no surgery and intravenous antibiotics alone. All patients were asymptomatic at final follow up. Late retropharyngeal abscess after anterior cervical discectomy and fusion is a rare complication. Surgical management should be considered along with long term antibiotics. Removal of implants may not be necessary for infection resolution. Antibiotic treatment alone may be indicated for patients who are not septic, do not have airway compromise, or and can be considered for poor surgical candidates.

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Age Alone Is Not a Barrier to Concurrent Chemoradiotherapy for Advanced Head and Neck Cancer

Gerard P. Sexton,Paul Walsh,Frank Moriarty,James Paul O’Neill

Publication date 22-04-2022


Head and Neck Cancer (HNC) is associated with significant morbidity and mortality, especially when high stage disease is present. There exists a range of options for the management of locoregionally advanced HNC, though doubt remains as to the optimal strategy in the elderly population. To evaluate the benefits imparted by concurrent chemoradiotherapy (CCRT) to the elderly population of HNC patients in Ireland. A retrospective cohort study was conducted using 20 years of cancer registry data provided by the National Cancer Registry of Ireland. Cox multivariate regression analysis was applied to test for the benefits of CCRT in HNC. Survival analysis showed an overall benefit to the use of CCRT in patients with advanced disease over 70 years, particularly when used for hypopharyngeal, oropharyngeal, and laryngeal malignancy. There was a benefit to cancer-specific but not all-cause mortality in those over 75 years, and no benefit was observed to the addition of chemotherapy in those over 80 years; only 8 patients over 80 received CCRT. There was no statistically significant difference in the benefits derived by those over 70 years relative to those under 70 years. CCRT confers significant survival benefits to appropriately selected elderly HNC patients and should therefore not be withheld solely on the basis of age.

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Efficacy of Cochlear Implantation in Neurofibromatosis Type 2 Related Hearing Loss

Gabriel Sobczak,Wendy Marchant,Sara Misurelli,Garrold Mark Pyle,Samuel Gubbels,Joseph Roche

Publication date 22-04-2022


To investigate the results of cochlear implantation in subjects with neurofibromatosis type 2 (NF2) and bilateral vestibular schwannomas (VS). Retrospective case series. University-based tertiary referral center. Five subjects with NF2 and severe-to-profound sensorineural hearing loss. Cochlear implantation. Surgical outcomes and audiometric performance after cochlear implantation. Five subjects (3 female, 2 male) were included in the study. The mean age at the time of implantation was 54 years old (range 35-78 years). Follow-up after cochlear implantation averaged 38 months (range 21-106 months). In the 5 implanted ears, 2 had no prior treatment, 1 had undergone prior radiation therapy, 1 underwent prior microsurgical removal, and 1 underwent prior microsurgical removal with adjuvant radiation therapy. The mean ipsilateral VS dimensions at time of implantation were 14 mm × 7.2 mm × 6.1 mm (mediolateral × anteroposterior × craniocaudal). Following cochlear implant activation, all 5 subjects achieved sound awareness, open set speech recognition, and 4 continue to be daily users of the devices. Cochlear implantation is a viable hearing rehabilitation option for subjects with NF2 and severe-to-profound sensorineural hearing loss. All subjects reported benefit with their cochlear implant, including open set speech recognition, enhanced lip-reading skills and environmental awareness of sound. Four subjects continued to demonstrate improved open-set speech recognition at the time of their last evaluations.

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Extreme Sawtooth-Sign in Motor Neuron Disease (MND) suggests Laryngeal Resistance to Forced Expiratory Airflow

Deanna Britton,Alexander Kain,Yu-Wen Chen,Jack Wiedrick,Joshua O. Benditt,Albert L. Merati,Donna Graville

Publication date 18-04-2022


The impact of laryngeal dysfunction on airflow has not been well characterized in motor neuron disease (MND). This study aimed to detect and characterize extreme airflow oscillations informally observed during volitional cough and forced vital capacity (FVC) tasks in individuals with MND who demonstrated neurolaryngeal impairments including reduced speed and extent of vocal fold abduction compared to healthy controls during volitional cough expulsion. The extreme airflow oscillations in the MND group, when viewed as a flow-volume loop, appeared similar to the "sawtooth-sign." If the airflow oscillations are periodic in a range similar to phonation, they may reflect reduced laryngeal patency. Volitional cough and FVC airflow data (3 trials each) from 12 participants with MND with bulbar/laryngeal involvement (3 F; ages 45-76) and 12 healthy controls (6 F; ages 41-68) were analyzed for periodicity. Percent and absolute durations of periodicity of the flow oscillations were calculated by an algorithm applied to the airflow signals. In addition, the frequency, magnitude, and kurtosis of the periodic airflow oscillations were described and compared between groups. In both volitional cough and FVC trials, the percent of airflow periodicity during forced expiration was significantly higher ( The significantly larger-magnitude, lower-kurtosis, and more prominent presence of sawtooth-like airflow periodicity within a frequency range similar to phonation observed in individuals with MND with neurolaryngeal impairments suggests glottic airflow resistance during forced expiration.

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A Nomogram Model for Predicting the Postoperative Recurrence of Localized Laryngeal Amyloidosis

Meiling Mao,Na Liang,Ran Ren,Yihua Zhao,Donglin Ma,Honggang Liu

Publication date 11-04-2022


To analyze the factors related to postoperative recurrence in patients with localized laryngeal amyloidosis (LocLA) and to construct a nomogram prediction model (NPM). We collected the data for LocLA patients diagnosed from March 2000 to May 2019 and clinical characteristics data were extracted. Factors related to recurrence were analyzed using multivariate logistic regression. The NPM was constructed for predicting the recurrence risk of LocLA. The receiver operating characteristic (ROC) curve evaluated the distinguishing ability using the area under curve (AUC). The calibration curve was created to evaluate the consistency of the NPM. A total of 226 confirmed LocLA cases were included. One hundred seventy-five cases (77.4%) had localized single nodule, and 51 cases had more than one lesions. Sixty-three (27.9%) cases had no multinucleated giant cell (MGC) around amyloid, and 163 (72.1%) cases had MGC around amyloid. Multivariate logistic regression analysis showed that more than one lesions (odds ratio [OR] = 3.206 and 95% confidence interval [CI]: 1.492-6.888; More than one lesions, subglottic involvement, and no MGC around amyloid are risk factors for postoperative recurrence of LocLA. The NPM constructed has good applicability.

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Characterizing Cochlear Implant Magnet-Related MRI Artifact

Nathan D. Cass,Douglas J. Totten,John D. Ross,Matthew R. O’Malley

Publication date 06-04-2022


To evaluate cochlear implant (CI) magnet-related MRI artifact shape and size, as well as imaging indications and clinical adequacy of scans. A retrospective chart review was performed for patients undergoing CI and subsequent MRI head imaging from 2014 to 2020 at a single institution. Indications and adequacy of each scan was recorded, and interpretability compared by indication. Magnet-related artifact size was determined by performing ellipsoid modeling at axial slice of greatest signal loss. Artifact radius in centimeters was calculated for 5 sequence categories, and size compared between sequences, manufacturers, and by time from implantation. Twenty patients underwent 58 head MRI scans. Approximately 76% of MRIs (n = 44) for 70% of patients (n = 14) were performed for indications known of prior to implantation; the remainder were performed during workup of new issues. Desired structures were interpretable in 23 (52%) of known-indication MRIs and 8 (57%) of new-indication MRIs, without significant difference ( DWI and T2 GRE sequences are less useful in MRI evaluation of CI patients. With a more favorable artifact profile, T1 FSE, T2 FSE, and T1 GRE sequences more likely yield clinically useful information. The large proportion of scans performed for known pathology represents an opportunity to optimize for magnet location preoperatively.

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Between a Rock and a Hard Place: Anticoagulating an Adolescent with Post-Tonsillectomy Massive PE: A Case Report

Aoi Shimomura,Sullivan Smith,Amir Darki,Natalie Kamberos,Steven Charous

Publication date 04-04-2022


To report a case of a morbidly obese 17-year-old boy who presented 4 days post-tonsillectomy with acute deep venous thromboses and a massive pulmonary embolism. To describe a protocol and decision-making tree for providing anticoagulation in the immediate post-tonsillectomy period. A chart review and review of the literature. The patient ultimately did well and had no bleeding from the tonsil beds or further thromboembolic complications. A review of the literature revealed no available data regarding the safety of anticoagulation in the immediate post-tonsillectomy period. We propose that if anticoagulation is needed within 14 days of tonsillectomy, submaximal anticoagulation with a reversible and titratable anticoagulant may be optimal. A multidisciplinary team approach is needed for these complex cases. Future reporting and investigation of anticoagulation post-tonsillectomy is needed.

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Eight Tales of Cervical Necrotizing Fasciitis and Free Tissue Transfer

Nicholas A. Rapoport,David S. Lee,Jake J. Lee,Sidharth V. Puram,Ryan S. Jackson,Patrik Pipkorn

Publication date 02-04-2022


Aggressive surgical debridement is required in cervical necrotizing fasciitis, and in severe defects, subsequent free tissue transfer might be necessary. However, there is concern that the inflammatory environment of the infection site may threaten free flap viability, particularly with concerns for thrombosis of feeding vessels and compromised tissue integration. Cases in the head and neck area are rare, so there are limited data regarding outcomes of free tissue transfer in these patients. A retrospective chart review assessed patients with cervical necrotizing fasciitis treated at an academic tertiary hospital between 2015 and 2021. Twenty-five patients were identified, and eight required free tissue transfer after adequate surgical debridement. Treatment, hospital course, and demographic data were collected on these eight patients. All flaps had full survival at follow up (median follow up 3 months, range 1-39 months) without concerns for vascular compromise. These data suggest that in patients with large soft tissue defects due to cervical necrotizing fasciitis, free tissue transfer may be a safe treatment modality.

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Epidemiology and Prognostic Indicators of Survival in Tongue Lymphoma

Scott A. Hong,Matthew C. Simpson,Eric Y. Du,Gregory M. Ward

Publication date 02-04-2022


Lymphoma, categorized as either non-Hodgkin's lymphoma or Hodgkin's lymphoma, is the second most common malignancy in the head and neck. Primary tongue lymphoma is exceedingly rare, with only case reports or small case series in the literature. This population-based analysis is the first to report the epidemiology and prognostic factors of survival in patients with primary tongue lymphoma. The Surveillance, Epidemiology, and End Results 18 database from the National Cancer Institute was queried for patients diagnosed between the years 2000 and 2016 with tongue lymphoma. Outcomes of interest were overall and disease-specific survival. Independent variables included age at diagnosis, sex, race, marital status, primary subsite, histologic subtype, stage, and treatment type. Seven hundred forty patients met criteria; the male-female ratio was 1.5:1 and the mean age at diagnosis was 67.8 years. The majority of lesions localized to the base of tongue (90.0%), were histologically diffuse large B-cell lymphoma (59.5%), and presented at stage I or II (77.9%). Most early-stage lymphomas were treated with chemotherapy only (40.5%) or a combination of both chemotherapy and radiation (31.3%), while late-stage cancers were primarily treated with chemotherapy alone (68.5%). In multivariate analysis, younger age at diagnosis, female sex, married/partnered marital status, mucosa-associated lymphoid tissue histologic subtype, and earlier cancer stage were found to be associated with improved survival. Chemotherapy treatment with or without radiation was also associated with better survival compared to no treatment or radiation alone, though data regarding immunotherapy was unavailable.

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Identifying Posterior Fossa Abnormality in Pediatric Aerodigestive Patients, a Case Series

Yvonne Adigwu,Beth Osterbauer,Sampreeti Chowdhuri,Moizza Shabbir,Sally Davidson Ward,Vrinda Bhardwaj,Christian Hochstim,Manvi Bansal

Publication date 02-04-2022


Multidisciplinary clinics like Aerodigestive programs focus on issues associated with airway, pulmonary, and gastrointestinal issues. Rarely, significant neurological issues like posterior fossa abnormality are identified as the primary etiology. We describe 3 such patients and compare their clinical presentation to the other patients seen in Aerodigestive clinic. A retrospective chart review was conducted to review the 3 posterior fossa patients and the remainder of children that were referred to the Aerodigestive Clinic at Children's Hospital Los Angeles from June 2016 to August 2018. Clinical characteristics including triple endoscopies and sleep studies were recorded. Of the 110 patients included for review, 3 patients (3%) had an underlying posterior fossa abnormality; all of whom had symptoms of sleep disordered breathing along with dysphagia compared with 30% incidence of this symptom profile in the remaining Aerodigestive population. Presence of sleep disordered breathing and dysphagia, with underlying vomiting history, warrants considering evaluation for posterior fossa abnormalities in addition to traditional workup for aerodigestive disorders. Due to the rarity of this presentation and small sample size, future studies with multicenter collaboration may help better describe identifiers to delineate this population with similar aerodigestive symptoms and clarify diagnostic algorithms.

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The Effect of Topical Tranexamic Acid in Endoscopic Sinus Surgery: A Triple Blind Randomized Clinical Trial

Imen Achour,Zied Ben Rhaiem,Wadii Thabet,Jihene Jdidi,Malek Mnejja,Bouthaina Hammami,Amine Chakroun,Ilhem Charfeddine

Publication date 02-04-2022


Our aim is to evaluate the effect of topical tranexamic acid (TA) on bleeding and surgical quality field in the functional endoscopic sinus surgery (FESS). A total of 74 patients who underwent FESS due to chronic rhinosinusitis were included. The patients were randomized into 2 groups. TA group (n = 37) received a topical cotton pledget soaked with TA and placebo (PL) group (n = 37) received a pledget soaked with saline solution. A significant effect was noted for the TA group versus the PL group in the grade 1 of the Boezaart scale at 35 minutes (4 for TA group and no case for PL group). This effect was absent for higher grades. We did not notice a significant effect between the 2 groups at 5 minutes. Blood loss was 359 ml in the TA group versus 441 ml in the PL group. No significant change was observed between the 2 groups concerning the blood parameters. No side effects were reported. Despite its safety when administrated locally and its low cost, TA provides limited effect on quality of surgical field after 35 minutes of the start of FESS in the patients with chronic rhinosinusitis. This effect was absent at the start of the intervention and when analyzing the blood loss and hematologic parameters.

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Comments Regarding: Marcus K, et al. “Can Red Blood Cell Distribution Width Predict Laryngectomy Complications or Survival Outcomes?” Ann Otol Rhinol Laryngol. 2021 Oct 29;34894211056117. doi: 10.1177/00034894211056117

John L. Frater

Publication date 26-03-2022


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Response to Letter to the Editor: Can Red Blood Cell Distribution Width Predict Laryngectomy Complications and Survival Outcomes?

Marisa R. Buchakjian

Publication date 26-03-2022


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Rhabdomyosarcoma Arising in an Old Rhytidectomy Scar

Jeremy S. Ruthberg,Joseph B. Meleca,Jennifer S. Ko,Steven D. Billings,Jamie A. Ku

Publication date 21-03-2022


The clinical evaluation and management of an adult with head and neck rhabdomyosarcoma is explored to delineate the diagnostic challenge posed by soft-tissue sarcomas bordering scar tissue. A 59 year old female presents with persistent, evolving paresthesia and burning in the right posterior neck, which was found to be in close proximity to a well-healed rhytidectomy scar. Serial biopsies were non-diagnostic. Six months after initial presentation, rhabdomyosarcoma was diagnosed subsequent to histopathological and immunohistochemistry analysis. A wide local excision with posterolateral neck dissection was performed. A high index of suspicion for soft-tissue sarcoma should be maintained for patients with persistent soft-tissue lesions, especially in areas of scarred tissue, who present with new-onset neurological symptoms in the context of nondiagnostic biopsies.

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Readmission Rates Following Major Head and Neck Surgery With Concurrent Tracheostomy

Philip R. Brauer,Paul C. Bryson,William S. Tierney,Shannon S. Wu,Xuefei Jia,Eric D. Lamarre

Publication date 18-03-2022


To determine the influence of major head and neck procedures on readmission and complication rates following tracheostomy. A retrospective cohort study using the 2005 to 2017 National Surgical Quality Improvement Program (NSQIP) database. Current Procedural Terminology codes were used to identify tracheostomy patients and to define the underlying head and neck procedure. Patients under the age of 18 and with unknown pre-operative variables were excluded. Univariate and multivariable analyses were performed. A total of 3240 tracheostomy patients undergoing major head and neck surgery were identified in NSQIP. The 30-day mortality rate was 104 (3.2%) and 258 (9.0%) patients were readmitted. 637 (19.7%) patients had an unplanned return to the operating room. There were 1606 (49.6%) non-tracheostomy specific complications, which included 850 (26.2%) medical and 1142 (35.2%) surgical complications. On multivariable analysis, we found that the underlying procedures did not impact the risk of readmission ( While almost 1 in every 2 patients had a complication following major head and neck surgery that included creation of a tracheostomy, the rate of readmission is comparatively low and is not associated with the underlying procedure. These findings should reassure head and neck surgeons that properly managed tracheostomies do not constitute a disproportionate risk of readmission.

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Development and Validation of Instrument for Operative Competency Assessment in Selective Neck Dissection

Eric Dowling,David Larson,Matthew L. Carlson,Daniel L. Price

Publication date 07-03-2022


Instruments to assess surgical skills have been validated for several key indicator procedures in otolaryngology. Selective neck dissection is a core procedure for which trainees must integrate knowledge of complex head and neck anatomy with technical surgical skills. An instrument for assessment of surgical performance in selective neck dissection has not been previously developed. The objective of the current study is to develop and validate an instrument for assessing surgical competency for level II-IV selective neck dissection. A Delphi working group comprised of 23 fellowship trained head and neck surgeons from 17 institutions was assembled. The modified Delphi method encompassed a 3-step process, including 2 anonymous voting rounds to successively refine individual items and establish levels of consensus. Thresholds for achieving strong consensus, at >80% agreement, were determined a priori. The resulting instrument was subsequently validated in a prospective cohort of 17 resident surgeons, spanning postgraduate year 1 to 5 training experience. Participants were asked to perform a level II-IV selective neck dissection on fresh-frozen cadaveric specimens. Performance was scored by 2 independent, blinded observers using the devised instrument and construct validity was assessed. Through the modified Delphi process a final list of 30 items, considered to be the most essential items for achieving the goals of a level II-IV selective neck dissection, was developed. Construct validity was supported by a positive association between instrument scores compared to both resident postgraduate year level and number of head and neck rotations completed. The development and validation of a novel instrument for assessment of surgical competency in level II-IV selective neck dissection, a key indicator case in otolaryngology, is described. This new instrument may be used to provide objective feedback on overall and task-specific competency to identify surgical deficiencies and offer granular feedback to enhance surgical training.

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Olfactory and Gustatory Dysfunction in COVID-19: A Global Bibliometric and Visualized Analysis

Sa’ed H. Zyoud,Muna Shakhshir,Amer Koni,Moyad Shahwan,Ammar A. Jairoun,Samah W. Al-Jabi

Publication date 04-03-2022


Coronavirus illness (COVID-19) has been found to alter infected people's sense of smell and taste. However, the pathobiology of this virus is not yet known. Therefore, it is critical to investigate the influence of COVID-19 infection on olfactory and gustatory processes. Therefore, we use bibliometric analysis on COVID-19 and olfactory and/or gustatory dysfunction publications to provide studies perspective. A bibliometric literature search was performed in the Scopus database. The number and type of publications, countries for publications, institutional sources for publications, journals for publications, citation patterns, and funding agencies were analyzed using Microsoft Excel or VOSviewer. In addition, the VOSviewer 1.6.17 software was used to analyze and visualize hotspots and collaboration patterns between countries. Scopus has published 187 088 documents for COVID-19 in all study fields at the time of data collection (July 26, 2021). A total of 1740 documents related to olfactory and/or gustatory dysfunction were recovered. The countries most relevant by the number of publications were the United States (n = 362, 20.80%), Italy (n = 255, 14.66%), and the United Kingdom (n = 173, 9.94%). By analyzing the terms in the titles and abstracts, we identified 2 clusters related to olfactory and/or gustatory dysfunction research, which are "diagnosis and test methods" and "prognosis and complications of the disease." This is the first bibliometric analysis of publications related to COVID-19 and olfactory and/or gustatory dysfunction. This study provides academics and researchers with useful information on the publishing patterns of the most influential publications on COVID-19 and olfactory and/or gustatory dysfunction. Olfactory and/or gustatory dysfunction as indices of suspicion for the empirical diagnosis of coronavirus infection is a new hotspot in this field.

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Telemedicine in Otolaryngology During COVID-19: An Exploratory Assessment of Provider and Patient Attitudes

Mohamedkazim Alwani,Vincent Campiti,Ryan Nesemeier,Dominic Vernon,Taha Shipchandler,Jonathan Ting,Noah Parker

Publication date 03-03-2022


To determine provider and patient attitudes toward telemedicine in Otolaryngology-Head and Neck Surgery (OHNS). Otolaryngology practitioners conducting outpatient clinics at an academic tertiary referral center were provided with a pre-Study Provider Perception Questionnaire (pre-PPQ) designed to evaluate pre-study perception of telemedicine in otolaryngology. A post-study Provider Perception Questionnaire (post-PPQ) designed to evaluate elements similar to those constituting the PrePPQ was completed at 6 weeks. Additionally, following each visit, providers and patients completed Individual Encounter Survey Questionnaires (IESQ) to evaluate the virtual clinical encounter experience. The pre-PPQ was completed by 29 providers, while the post-PPQ was completed by 12 providers. A total of 236 post-visit provider IESQs were completed, of which 208 were deemed successful. Audio/visual (AV) difficulties and limited server connectivity for the patient were most common causes for unsuccessful encounters. Providers reported that the most appropriate use of telemedicine, on both pre-PPQ and post-PPQ, was triaging patients to determine the need for in-person visits. The inability to perform a physical exam was rated as the primary barrier to telemedicine in OHNS on both pre-PPQ and post-PPQ. Patients strongly agreed with the statements, "My healthcare provider was able to understand my healthcare condition" and, "I felt comfortable communicating with my healthcare provider" 92.0% and 95.4% of the time, respectively. Both providers and patients demonstrated an overall positive attitude toward the use of telemedicine in the provision of otolaryngologic care.

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Telemedicine and Otolaryngology in the COVID-19 Era

Brandon K. Nguyen,Hafiah Z. Eltahir,Gregory L. Barinsky,Yu-Lan Mary Ying,Wayne D. Hsueh

Publication date 01-03-2022


The global Coronavirus disease 2019 (COVID-19) pandemic has resulted in an expansion of telemedicine. The purpose of this study is to present our experience with outpatient telemedicine visits within a single institution's Department of Otolaryngology during the initial COVID-19 era. Retrospective chart review. This was a single-institution study conducted within the Department of Otolaryngology at an urban tertiary care center. Data on outpatient visits was obtained from billing and scheduling records from January 6 to May 28, 2020. Visits were divided into "pre-shutdown" and "post-shutdown" based on our state's March 23, 2020 COVID-19 shutdown date. A total of 3447 of 4340 (79.4%) scheduled visits were completed in the pre-shutdown period as compared to 1451 of 1713 (84.7%) in the post-shutdown period. The proportion of telemedicine visits increased (0.7%-81.2%, COVID-19 has led to major changes in outpatient practice, with a significant shift from in-person to telemedicine visits following the mandatory shutdown. An associated increase in appointment completion rates was observed, reflecting a promising viable alternative to meet patient needs during this unprecedented time.

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Comparison Between Different Approaches Applied in Pediatric Adenoidectomy: A Network Meta-Analysis

Ya-Lei Sun,Bin Yuan,Fei Kong

Publication date 01-03-2022


Adenoidectomy is a surgical procedure most frequently performed by otolaryngologists. However, there are no universally accepted guidelines for the choice of the surgical approach in specific circumstances. Therefore, a network meta-analysis (NMA) is needed to summarize existing studies and provide more evidence-based medical guidelines. A systematic search of the literature was conducted in the Cochrane Central Register of Controlled Trials, Pub Med, and EMBASE databases from inception to 31 July 2021. A network meta-analysis of operating time, intraoperative blood loss, postoperative pain score, and incidence of postoperative residual tissue was performed. A total of 20 studies with 2329 patients were included. Four common surgical approaches, including powered vacuum shaver adenoidectomy (PVSA), plasma field ablation adenoidectomy (PFAA), curettage adenoidectomy (CUA), and suction diathermy adenoidectomy (SDA), were compared for operative time, intraoperative blood loss, postoperative pain score, and incidence of postoperative residual tissue. There were no significant differences between the surgical techniques for the 3 endpoints, operative time, intraoperative blood loss, and incidence of postoperative residual tissue. The data showed lower postoperative pain scores for PFAA than for CUA (MD = -3.45, 95% CI [-6.01, -0.95]). There were no significant differences in other surgical approaches for postoperative pain scores. There were no significant differences between PVSA, PFAA, CUA, and SDA for operative time, intraoperative blood loss, and incidence of postoperative residual tissue. PFAA had advantages over CUA for postoperative pain scores.

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Effects of Soft Tissue Sleep Surgery on Morbidly Obese Patients

Noah Shaikh,Parker Tumlin,Zachery Greathouse,Mustafa G. Bulbul,Steven W. Coutras

Publication date 01-03-2022


Morbidly obese patients with obstructive sleep apnea (OSA) are often intolerant of continuous positive airway pressure (CPAP). The effects of sleep surgery in this population is not well documented, and sleep surgery is generally avoided due to the expectation of poor outcomes, leaving these patients untreated. This retrospective study included 42 patients with a body mass index (BMI) ≥40.0 and OSA with a preoperative apnea hypopnea index (AHI) ≥5. Preoperative BMI ranged from 40.0 to 69.0 kg/m The mean AHI improved from 45.9 ± 31.8 to 31.9 ± 31.6 ( Sleep surgery is effective in reducing OSA burden in most morbidly obese patients and can result in surgical cure for a third of patients.

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Operative Surveillance of Airway Hemangiomas in PHACE Syndrome

Vaibhav H. Ramprasad,Anisha Konanur,Jennifer L. McCoy,Andrew McCormick,Noel Jabbour,Reema Padia

Publication date 01-03-2022


PHACE is a rare syndrome that can present with airway hemangiomas. Management for these patients is variable and the utilization of operative endoscopic airway evaluation has not been described. The objectives of this study were to identify the incidence of airway symptoms in patients being evaluated for PHACE syndrome and determine the utility of operative endoscopy. An IRB-approved retrospective cohort study was conducted on consecutive pediatric patients with head and neck infantile hemangioma (IH) evaluated in a multi-disciplinary vascular anomalies center between 2013 and 2019. Patients were included if they were being worked up for PHACE syndrome and had an otolaryngology evaluation. Demographics, clinical, and surgical variables were collected. There were 317 patients with head and neck IH. Thirty-six patients met inclusion criteria. The majority of patients were female (31/36; 86.1%) and less than half of the patients (15/36; 41.7%) were eventually diagnosed with PHACE syndrome. Median age at presentation was 2 months (range 0-82 months). A total of 28/36 (77.8%) of patients were managed with propranolol. The majority of the patients presented without aerodigestive symptoms; however, 16/36 (44.4%) of patients presented with symptoms such as stridor, hoarseness, and dysphagia. A total of 20/36 (55.6%) of patients underwent operative endoscopy. A total of 8/20 (40.0%) of patients who underwent operative endoscopy had operative intervention. Of the entire cohort, only 2/15 (13.3%) patients diagnosed with PHACE were found to have a subglottic hemangioma. Both patients presented with stridor. Operative endoscopy remains useful in the workup of PHACE syndrome to identify subglottic hemangiomas, however there may be relatively low yield in asymptomatic patients. In office flexible laryngoscopy may be a less invasive means to examine the subglottic region. A multi-center prospective study would be necessary to evaluate incidence of subglottic hemangiomas in asymptomatic patients evaluated for PHACE.

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Chronic Obstructive Sialadenitis due to an Abnormal Wharton’s Duct Draining to the Tonsillar Fossa

Alvaro Sánchez Barrueco,Félix Guerra Gutiérrez, MD,Gonzalo Díaz Tapia,Carlos Cenjor Español

Publication date 22-02-2022


Chronic obstructive sialadenitis (COS) is an entity that causes a marked loss in patient quality of life, including changes in eating habits and a progressive loss of gland function. It is characterized by repeated episodes of painful glandular swelling often requiring emergency care. There are multiple causes of COS, including lithiasis, strictures, anatomical variants, and others. The development of specific imaging tests such as magnetic resonance (MR) sialography or sialendoscopy have increased knowledge of these obstructions and how to specifically treat them. We present an unusual case of a woman with a years-long history of chronic obstructive sialadenitis in which an abnormal path of Wharton's duct was in evidence. This duct, which was atrophic and smaller in diameter, opened in the tonsillar fossa rather than lateral to the lingual frenulum. This case, the first in vivo description of its kind, was confirmed by MR sialography and sialendoscopy. Congenital anomalies of the submandibular duct are a rare finding, but may cause COS. Therefore, COS requires a detailed diagnostic study, usually by ultrasound, MR sialography and sialendoscopy, to rule out complex anatomical variants.

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Long-Term Voice Outcomes After Type I, Type II, or Type V Cordectomy

Eliezer Kinberg,Sarah K. Rapoport,Sarah Brown,Peak Woo

Publication date 22-02-2022


We compare long-term voice outcomes in patients treated with European Laryngeal Society (ELS) classification Type I, Type II, or Type V cordectomy. The aim is to understand the impact of Type V cordectomy on voice outcomes in relation to Type I and Type II cordectomy. A retrospective review of patients treated with Type I, Type II, or Type V cordectomy by a single surgeon over a 20-year period was performed. Voice Handicap Index-10 (VHI-10) scores, Cepstral Spectral Index of Dysphonia (CSID) measures from CAPE-V sentences, and two-rater GRBAS scores were analyzed. Sixty-two patients were identified with a mean follow-up of 52 months. Of these, there were 43 Type I and 19 Type II cordectomies, including 8 in each group with Type V resections. Significant differences in all parameters were noted between the Type I (VHI 5.7, CSID 20.6, Grade 1.3) and the Type II cohorts (VHI 12.6, CSID 36.3, Grade 1.8) who did not undergo Type V cordectomy. Patients undergoing Type V cordectomy demonstrated voice outcomes (VHI 9.4, CSID 35.6, Grade 1.7) which fell between those of Type I and Type II cordectomies. Better long-term subjective, objective, and computer-analyzed voice outcomes are noted for patients undergoing Type I rather than Type II cordectomy. When Type V cordectomy is performed, voice outcomes are comparable to those of both Type I and Type II cordectomy, a surprising finding given the expectation of worsened dysphonia in longer resections. Further work is needed to explain this finding and define voice outcomes after Type V cordectomy.

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Geographic Variation in Otolaryngologist Intranasal Steroid Prescribing Patterns Among Medicare Beneficiaries

Franklin M. Wu,Ruben Ulloa,Ido Badash,Kevin Hur

Publication date 18-02-2022


Intranasal corticosteroids (INCS) are a commonly prescribed medication to treat various rhinological conditions. However, no prior studies have looked at factors and patterns that influence the rates of INCS prescriptions among Medicare beneficiaries in the United States. This study aims to describe the patterns of INCS prescriptions by otolaryngologists for Medicare beneficiaries in the United States between 2013 and 2017.
Data on the most common INCS prescriptions by otolaryngologists for Medicare beneficiaries were obtained from the 2013 to 2017 Medicare Provider Utilization and Payment Data: Physician and Other Supplier Public Use File (PUF) and the Part D Public Use Files from the Centers for Medicare and Medicaid Services (CMS). INCS prescriptions were analyzed by cost, state, provider, and regional temperature. State temperature data was collected through the National Centers for Environmental Information. From 2013 to 2017, the total claims per beneficiary for fluticasone, mometasone, and triamcinolone combined increased from 2.31 to 2.39. Combined cost/beneficiary was similar for mometasone and triamcinolone at 102.47 and 103.60 respectively, while it was much lower for fluticasone at 39.12. There was a strong correlation between otolaryngology providers per beneficiary in each state and total claims per state with a correlation coefficient of .79. Additionally, comparing the average state temperature to the claims/beneficiary yielded a moderately strong correlation coefficient of .44, suggesting that temperature was a possible factor for INCS prescription patterns. INCS prescriptions by otolaryngologists and the number of INCS beneficiaries have increased between 2013 and 2017. Over the same time period, the costs of fluticasone and triamcinolone have decreased while the cost of mometasone increased. Total providers by state correlated with claims per state. Additionally, average annual temperature was positively correlated with INCS claims per beneficiary in each state.

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Botulinum Toxin A in the Management of Pediatric Sialorrhea: A Systematic Review

Tiffany Heikel,Shivam Patel,Kasra Ziai,Sejal J. Shah,Jessyka G. Lighthall

Publication date 18-02-2022


Botulinum toxin A is known to be effective and safe in managing sialorrhea in pediatric patients; however, there is no consensus on a protocol for optimal injection sites and appropriate dosing for injection. This review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocol. Pub Med, EMBASE, and other databases were queried to identify articles that evaluated botulinum toxin type A for the treatment of sialorrhea in the pediatric population. A total of 405 studies were identified. After applying inclusion and exclusion criteria, 31 articles were included for review. A total of 14 studies evaluated 2-gland injections, and 17 studies evaluated 4-gland injections. Of the 31 studies included, one study assessed incobotulinumtoxinA (Xeomin The strength of evidence suggests that the dosing of 50 units total of onabotulinumtoxinA to the submandibular glands is safe and effective in the pediatric population. For 4-gland injections, bilateral submandibular and parotid gland injections of 60 to 100 units total is the safe and effective dosage. There is no substantial evidence comparing 4-gland injections to 2-gland injections, but research thus far suggests 4-gland injections to be superior. Future study is needed to evaluate incobotulinumtoxinA and abobotulinumtoxinA dosages in the pediatric population.

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Impact of Liposomal Bupivacaine on Post-Operative Pain and Opioid Usage in Thyroidectomy

Ryan N. Hellums,Matthew D. Adams,Nicholas C. Purdy,Timothy L. Lindemann

Publication date 17-02-2022


Opioid analgesia has been integral in post-operative pain control for decades. The over-prescription of opioids, commonly in the surgical patient, has contributed to the current opioid epidemic. Liposomal bupivacaine (LB), a long-acting analgesia formulation, has demonstrated decreased post-operative pain and opioid requirements in patients treated across multiple surgical subspecialties. The aims of this retrospective study are to assess post-operative pain and opioid use in patients who received LB at the time of thyroidectomy. A cohort-matched retrospective review of patients who underwent thyroidectomy by 2 surgeons between January 2010 and December 2019 was performed. Patients were divided into those that received LB intraoperatively and those that did not. Statistical analyses were performed using the Chi-square or Fisher's exact test, and 2-sample Of the 201 patients included in this study, 113 patients received LB and 88 did not. Patients who received LB had a lower median visual analog scale (VAS) pain score (2 vs 3, This study suggests a role for incisional infiltration with LB for post-operative pain management in patients undergoing transcervical thyroidectomy. We report reduced post-operative pain scores and opioid analgesia requirements in patients who received LB.

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Children Undergoing Laryngeal Surgery for Obstructive Sleep Apnea: NSQIP Analysis of Length of Stay, Readmissions, and Reoperations

Cathleen C. Kuo,Mohamed Elrakhawy,Michele M. Carr

Publication date 17-02-2022


No national study to date has specifically evaluated the predictive variables associated with extended hospitalization and other postoperative complications following laryngeal surgery in children with obstructive sleep apnea (OSA). The goals of this study were to identify perioperative risk factors and provide a descriptive analysis of surgical outcomes in these children using the National Surgical Quality Improvement Program-Pediatrics (NSQIP-P) database. Patients aged 0 to 18 years who underwent laryngeal surgery with a postoperative diagnosis of OSA were queried via the 2014-2018 NSQIP-P database using Current Procedural Terminology code 31541. Variables collected included age, sex, ethnicity, body mass index (BMI), medical comorbidities, American Society of Anesthesiologists (ASA) physical classification, operative time, and concurrent procedures. Endpoints of interest were length of stay, unplanned reoperation, readmission, reintubation, and postoperative complications. Univariate and multivariate linear regression analyses were performed. A total of 181 cases were identified (57.5% male and 42.5% female, mean age 4.36 years, range 14 days-17.7 years). Body mass index ( In this data set, children with OSA undergoing laryngeal surgery experienced minimal postoperative complications. Recognition of the factors associated with increased LOS could lead to improvement in the quality of care for children with OSA.

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Serratus Anterior-Rib Composite Flap as a Novel Approach for Tracheal Reconstruction

Kyle A. Boudreaux,Roger Bui,Peter Horwich,Brent A. Chang

Publication date 14-02-2022


To report a novel case of tracheal reconstruction using a serratus anterior-rib composite flap. Case report and literature review. A 46-year-old male with a 4 cm anterior tracheal wall defect underwent reconstruction with a serratus anterior-rib composite flap. The patient experienced excellent results regarding phonation, swallowing, and cosmesis. The serratus anterior-rib composite flap appears to be a suitable candidate for tracheal reconstruction and merits further analysis in this context. The flap's intrinsic incorporation of a perfused rib segment allows for reliable reconstruction of the neotrachea and maintenance of proximal dynamic airway support.

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Otolaryngology Program Director, House-Staff, and Student Opinions: Step 1 Pass/Fail Score Reporting

Hannah G. Kay,Alan T. Makhoul,Nishant Ganesh Kumar,Matthew E. Pontell,Brian C. Drolet,Amy S. Whigham

Publication date 12-02-2022


To compare otolaryngology program director, house-staff, and medical student perspectives on the score reporting change of USMLE Step 1 to pass/fail. Separate electronic surveys were sent to program directors of ACGME-accredited otolaryngology programs (Cronbach's alpha = .87), otolaryngology house-staff (Cronbach's alpha = .91), and medical students interested in otolaryngology (Cronbach's alpha = .76). Among the 51 otolaryngology program directors that completed the survey (response rate of 46.8%), 17.6% favored reporting USMLE Step 1 as pass/fail. A majority believed the reporting change would make it more difficult to screen (74.5%) and objectively compare applicants (82.4%). Step 2 CK scores will be more important to most program directors due to the reporting change (83.7%). Of the 93 house-staff that completed surveys, most did not favor the reporting change (61.3%). Over half (54.0%) of the 87 medical students that completed surveys did not support the scoring change, and most (65.5%) did not feel that it would decrease anxiety around residency applications (65.5%). Most house-staff and medical students felt that the scoring change would put non-U.
S. MD students at a disadvantage (65.6% of house-staff, 69.8% of medical students). Most survey respondents do not agree with the decision to report Step 1 as pass/fail. Despite its intended goals, most do not believe pass/fail Step 1 reporting will improve medical student well-being and believe it will put certain student populations at a greater disadvantage.

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Sclerotherapy for Hereditary Hemorrhagic Telangiectasia-Related Epistaxis: A Systematic Review

Brittney Thiele,Yassmeen Abdel-Aty,Lisa Marks,Devyani Lal,Michael Marino

Publication date 12-02-2022


Hereditary hemorrhagic telangiectasia (HHT) is a common inherited condition characterized by mucosal telangiectasias, recurrent epistaxis, and arteriovenous malformations. HHT results in detriment to quality of life. Morbidity and mortality result from severe anemia. Conventional interventions for HHT-related epistaxis include nasal packing, diathermy, lasers, coblation, microdebridement, bevacizumab (topical and systemic), as well as septodermoplasty and nasal closure. Sclerotherapy has been recently described in the literature as a novel approach to HHT-related epistaxis. We hypothesize that sclerotherapy is an effective treatment for HHT-related epistaxis and improves upon the current standard of care for this disease. A systematic review was conducted to study sclerotherapy for treating HHT-related epistaxis. Ovid MEDLINE, Ovid EMBASE, Scopus, and Web of Science were searched. Articles were evaluated and excluded according to PRISMA guidelines and reviewed by 2 authors. Reported variables included number of injections, months of follow up, changes in Epistaxis Severity Score, previous treatments used to control epistaxis, and post-injection side effects. Seven studies with a total of 196 patients met inclusion criteria. Three studies reported significant improvement as measured by the Epistaxis Severity Score scale. One reported improvement through subjective patient surveys and others used the Bergler-Sadick scale to measure frequency and intensity of epistaxis. All studies reported improvement in HHT-related epistaxis. The lack of uniform reporting measures however precluded formal meta-analysis. Based on limited data, sclerotherapy appears to be effective for treating HHT-related epistaxis and offers promise for treating this recalcitrant condition. However, larger, prospective, multi-centered studies using universally validated instruments for epistaxis are needed to definitively evaluate outcomes from sclerotherapy.

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Thyroid Cartilage Compression Causing Bow Hunter’s Syndrome

Xinyuan Hong,Emmanuel D’heygere,Eitan Prisman

Publication date 12-02-2022


We report a unique case of Bow Hunter's syndrome with a dominant aberrantly coursing right vertebral artery (VA), presenting with persistent dizziness and syncope despite previous decompressive surgery at vertebral levels C5-C6. Re-evaluation with computed tomography-scan during provocation of dizziness by neck rotation revealed compression of the right VA at level C6 from against the ipsilateral posterior border and superior cornu of the thyroid cartilage. Laryngoplasty resulted in complete resolution of symptoms. This extremely rare cause of Bow's Hunter's syndrome should be considered, especially in refractory cases after neurosurgical decompression, and surgical management is straightforward and successful.

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Diagnosis and Management of Barosinusitis: A Systematic Review

Tiffany Chen,Shivani Pathak,Ellen M. Hong,Brian Benson,Andrew P. Johnson,Peter F. Svider

Publication date 08-02-2022


To perform a systematic review to investigate the common presenting symptoms of barosinusitis, the incidence of those findings, the methods for diagnosis, as well as the medical and surgical treatment options. A review of Pub Med/MEDLINE, EMBASE, and Cochrane Library for articles published between 1967 and 2020 was conducted with the following search term: aerosinusitis OR "sinus squeeze" OR barosinusitis OR (barotrauma AND sinusitis) OR (barotrauma AND rhinosinusitis). Twenty-seven articles encompassing 232 patients met inclusion criteria and were queried for demographics, etiology, presentation, and medical and surgical treatments. Mean age of patients was 33.3 years, where 21.7% were females and 78.3% were males. Causes of barotrauma include diving (57.3%), airplane descent (26.7%), and general anesthesia (0.4%). The most common presentations were frontal pain (44.0%), epistaxis (25.4%), and maxillary pain (10.3%). Most patients received topical steroids (44.0%), oral steroids (28.4%), decongestants (20.7%), and antibiotics (15.5%). For surgical treatment, most patients received functional endoscopic sinus surgery (FESS) (49.6%). Adjunctive surgeries include middle meatal or maxillary antrostomy (20.7%), septoplasty (15.5%), and turbinate surgery (9.1%).
The most efficacious medical treatments are as follows: 63.6% success rate with oral steroids (66 treated), 50.0% success rate with topical steroids (102 treated), and 50.0% success rate analgesics (10 treated). For surgical treatments received by greater than 10% of the sample, the most efficacious was FESS (91.5% success rate, 108 treated). Oral and topical steroids should be first line therapies. If refractory, then functional endoscopic sinus surgery is an effective treatment.

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Convulsive Syncope From Carotid Sinus Syndrome as a Manifestation of Laryngeal Cancer

Joel Goh Co Ian,Xinyong Huang,Maria Judith Pang,Tee Sin Lee

Publication date 08-02-2022


Carotid sinus syndrome (CSS) is a rare yet serious presentation of head and neck malignancy. To our knowledge, syncope and seizure-like episodes as a manifestation of carotid sinus syndrome secondary to laryngeal cancer has not been reported to date. We report a case of laryngeal cancer causing convulsive syncope masquerading as seizures due to CSS. Case report. The patient's medical record was reviewed for demographic and clinical information. A 62-year-old male presented with multiple episodes of syncope and hoarseness of voice. On nasoendoscopic examination, left vocal cord palsy and left aryepiglottic fold tumor were visualized. Computerized tomography (CT) neck showed a large 2.4 × 3.6 cm left supraglottic tumor with local invasion and extensive cervical lymphadenopathy compressing the carotid sinus. CT guided biopsy of the tumor revealed invasive squamous cell carcinoma. While undergoing evaluation, the patient developed seizure-like episodes. Inpatient telemetry monitoring revealed significant bradycardia and hypotension during these episodes. A permanent pacemaker was inserted which resulted in resolution of the syncopal and seizure-like episodes. In patients with unexplained syncope or seizure-like episodes and a background of head and neck cancer, clinicians should consider the diagnosis of CSS. CSS is a poor prognostic factor due to the associated higher stage of disease.

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Assessment of the Clinical Use of Vestibular Evoked Myogenic Potentials and the Video Head Impulse Test in the Diagnosis of Early-Stage Parkinson’s Disease

Güler Berkiten,Belgin Tutar,Sevgi Atar,Tolgar Lütfi Kumral,Ziya Saltürk,Onur Akan,Hüseyin Sari,Öykü Onaran,Ömür Biltekin Tuna,Yavuz Uyar

Publication date 04-02-2022


To explore the usefulness of vestibular tests including " The study involved 80 participants including 40 patients (24 males, 16 females; age average 63.20 ± 7.94 years) with PD and 40 healthy individuals (18 males and 22 females; age average of 60.36 ± 7.68 years). The Modified Hoehn and Yahr (H&Y) scale was used to measure how Parkinson's symptoms progress and the level of disability. Patients with PD underwent cVEMPs, oVEMPs, and vHIT and the results were compared with those of 40 age-matched healthy control (HC) subjects. vHIT results and VEMP responses were registered in all patients and HCs. One-sided absent cVEMP responses were found in 6 (15%) patients with PD and 8 (20%) patients had bilaterally absent responses. Five (12.5%) patients had 1-sided absent oVEMP responses and it was bilateral in 6 (15%). Patients with PD had significantly shorter cVEMP P1, N1 latency, lower cVEMP amplitudes, and oVEMP amplitudes than the HC group. The cVEMP and oVEMP amplitude asymmetry ratio was significantly higher in the PD group ( The results of this study suggest that cVEMP and vHIT can be used to evaluate the vestibular system in patients with early-stage Parkinson's disease.

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Evaluating Risk of Noise-Induced Hearing Loss in Otologic Surgery

Nathan D. Cass,Elizabeth L. Perkins,Marc L. Bennett,Todd A. Ricketts

Publication date 03-02-2022


To evaluate risk for noise-induced hearing damage from otologic surgery-related noise exposure, given recent research indicating that noise levels previously believed to be safe and without long-term consequence may result in cochlear synaptopathy with subsequent degeneration of spiral ganglion neurons, degradation of neural transmission in response to suprathreshold acoustic stimuli, and difficulty understanding in background noise. A prospective observational study of surgeon noise exposure during otologic and neurotologic procedures was performed in a tertiary care center. Surgeon noise exposure was recorded in A- and C-weighted decibel scales (dBA, dBC), including average equivalent (LA Sound measurements taken at the ear with continuous recording equipment during cadaveric otologic surgery demonstrated LA Noise exposure to surgeons, staff, and patients in the operating room is acceptable per NIOSH recommendations. Temporal bone lab noise exposures are greater, possibly due to poorly maintained drill systems and lack of noise shielding from microscope bulk, yet are also within NIOSH recommended levels.

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Association Between Clinical Symptoms, Electrodiagnostic Findings, Clinical Outcome, and Prodromal Symptoms in Patients With Bell’s Palsy

Seon A Chae,Seung Don Yoo,Seung Ah Lee,Yunsoo Soh,Myung Chul Yoo,Yeocheon Yun,Jinmann Chon

Publication date 03-02-2022


This study aimed to determine which prodromal symptoms frequently occur in patients with Bell's palsy and evaluate the association between these symptoms and clinical severity of paresis or the severity of facial nerve injury. The study included 86 patients with Bell's palsy between August 2018 and April 2020. Severity levels of Bell's palsy and facial nerve damage were evaluated using the House-Brackmann (H-B) grading scale and electrodiagnostic study, respectively. Subsequently, a self-reported questionnaire on prodromal symptoms was administered. To assess the degree of recovery, the H-B grade was reported at 9 weeks and 6 months after the onset of paralysis. The most common prodromal symptoms were postauricular pain, sensory decline in the tongue, headache on the affected side, myalgia, facial sensory decline on the affected side, taste impairment, and dry eye. Taste impairment was significantly correlated with severe facial paralysis reported at 9 weeks after onset ( The prodromal symptoms of Bell's palsy were not associated with the severity of facial nerve injury in an electrodiagnostic study. Taste impairment was related to clinical severity of paralysis at subacute stage, 9 weeks after onset, but it was not associated with long-term prognosis.

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Iron Pill-Induced Chemical Laryngitis

Rishabh Sethia,Ryan Bishop,Adlin Gordian-Arroyo,Laura Matrka

Publication date 01-02-2022


To discuss the presentation and management of pill-induced chemical laryngitis by illustrating a rare case. We report a unique case of a patient with iron pill-induced laryngitis. A 71-year-old male presented for evaluation of dysphonia. Five weeks prior, the patient had reportedly aspirated an iron pill. The pill was lodged in his throat for several hours before being coughed up, soft but still intact. Since that event, the patient noted complete voice loss and in clinic was found to have a very breathy and asthenic voice. Stroboscopy revealed aperiodicity with severe false fold compression and significant ulceration of the infraglottic region associated with thick exudate. Vocal folds were mobile but atrophic, with overlying crusted secretions. A sensory deficit was suspected based on scope tolerance. The patient was treated with nebulized ciprodex and humidified air with some improvement in mucosal crusting but had persistent glottic insufficiency and dysphonia, prompting bilateral hyaluronic acid injection. Pill-induced laryngitis is an extremely rare phenomenon. While typically associated with bisphosphonates, this condition should be considered in any patient presenting with dysphonia and history of aspiration of a pill, including iron supplements. Regardless of the inciting medication, pill-induced laryngitis may be treated with humidified air, nebulized steroids, and antibiotics. Injection augmentation of the vocal folds may be made considered when glottic insufficiency and weak cough contribute to the presentation.

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Symptomatic Lingual Thyroglossal Duct Cyst in Children: A Laryngomalacia Phenotype

Christopher M. Shumrick,Alyssa N. Calder,Mark A. Vecchiotti,Andrew R. Scott

Publication date 01-02-2022


Patients with lingual thyroglossal duct cyst (TGDC) can present as symptomatic with obstructive airway and feeding difficulties. We present 3 cases of symptomatic lingual TGDC. All 3 patients were diagnosed with laryngomalacia and underwent further concurrent or delayed airway intervention, in addition to cyst removal. We reason that there is a phenotype of laryngomalacia in the symptomatic lingual thyroglossal duct cyst patients who present with symptoms due to disruption in laryngeal anatomy rather than the cyst itself causing obstructive symptoms. Distinguishing this phenotype, especially in comparison to other pathologies such as vallecular cysts, may better allow for planning of concurrent or delayed airway procedures and overall counseling of parents.

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Attitudes Toward and Acceptability of Medical Marijuana Use Among Head and Neck Cancer Patients

Marc Levin,Han Zhang,Michael K. Gupta

Publication date 29-01-2022


This study aims to understand the attitudes toward marijuana in HNC patients. A 17-question questionnaire regarding medical marijuana (MM) was distributed to HNC patients at a tertiary cancer center. 63 HNC patients completed the questionnaire. Patients that had used or were using marijuana described benefit with symptoms of headache, pain, nausea, and loss of appetite. 83% of all patients considered marijuana as treatment for cancer related pain and 67% as treatment for cancer related anxiety. About 70% of patients actively undergoing cancer treatment believed marijuana medications would help with symptoms during treatment. By understanding how HNC patients perceive MM, HNC teams may be able to prescribe and educate their patients on MM.

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Evaluating Factors That Influence Patient Satisfaction in Otolaryngology Clinics

Taylor S. Redding,Katherine R. Keefe,Andrew R. Stephens,Richard K. Gurgel

Publication date 29-01-2022


To identify factors that influence patient satisfaction during outpatient visits in various settings of otolaryngology clinics in an academic medical center. Retrospective review. Academic medical center. We reviewed Press Ganey patient satisfaction survey responses for new, outpatient visits between January 1, 2014 and December 31, 2018. Self-reported race was identified using electronic medical records. Multivariate binary logistic regression analyses were used to identify continuous and categorical variables associated with patient satisfaction. There were 3998 unique new patient visits with completed surveys. Multivariate analysis revealed that responses for patients <18 years old are less likely to be satisfied with their care compared to patients ≥18 years old (OR 0.66; Wait time, clinic location, patient race, insurance provider, and age were all shown to significantly influence patient-reported satisfaction. Understanding how these variables influence patient satisfaction will hopefully lead to processes that improve patient satisfaction. Level 3.

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Prognosis of Idiopathic Sudden Sensorineural Hearing Loss: The Nomogram Perspective

Huadong Wu,Wei Wan,Hongqun Jiang,Yuanping Xiong

Publication date 27-01-2022


The aim of this study is to create a nomogram for accurately predicting the prognosis of idiopathic sudden sensorineural hearing loss (ISSNHL) and provide a reference for clinical treatment. Three hundred and twenty-three patients with ISSNHL were admitted from September 2014 to November 2020. The clinical data were retrospectively reviewed. Prognostic factors for ISSNHL were assessed based on univariate and multivariate logistic regression analysis and used to create a nomogram. Nomogram performance in terms of predictive and discriminatory ability was evaluated by calculating the concordance index (C-index) and generating calibration plots. The overall hearing improvement rate was 41.4%, comprising complete recovery (13.3%), marked recovery (17.0%), and slight recovery (11.1%). Multivariate logistic regression analysis showed that age, symptoms of vertigo, interval between onset and treatment, low-density lipoprotein, and type of hearing loss were independent predictors of ISSNHL. A nomogram based on these 5 factors had a C index of 0.798 (95% confidence interval 0.750-0.845). Age, vertigo, interval between onset and treatment, low-density lipoprotein level, and type of hearing loss are closely associated with hearing recovery. The nomogram may enable prediction of the prognosis of ISSNHL and facilitate clinical decision-making.

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Obesity as a Risk Factor for Postoperative Adverse Events in Skull Base Surgery

Arash Abiri,Khodayar Goshtasbi,Jack L. Birkenbeue,Harrison W. Lin,Hamid R. Djalilian,Frank P. K. Hsu,Edward C. Kuan

Publication date 27-01-2022


To determine the implications of obesity on postoperative adverse events following skull base surgery. The 2005-2017 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for adverse events in skull base surgery cases. Patients were stratified by body mass index (BMI) into normal weight (18.5 ≤ BMI < 25), overweight (25 ≤ BMI < 30), and obese (BMI ≥ 30) cohorts. Logistic regression was used to assess the association of overweight or obese BMI with various 30-day postoperative adverse events. A total of 2305 patients were included for analysis, of which 732 (31.8%) and 935 (40.6%) were overweight or obese, respectively. The mean age was 53.8 ± 15.3 years and 1214 (52.7%) patients were female. Obese patients were younger ( Obesity was associated with decreased postoperative bleeding and increased deep vein thromboses. Obese patients were otherwise at no higher risk for medical or surgical complications. Elevated BMI did not confer an increased risk for readmission, reoperation, or death. Thus, patient obesity should not be a major determinant in offering skull base surgery in individuals who would otherwise benefit from treatment.

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Did More Otolaryngology Residency Applicants Match at Their Home Institutions in 2021? Investigating the Impact of the COVID-19 Pandemic

Collin F. Mulcahy,Samantha J. Terhaar,Sameh Boulos,Esther Lee,Philip E. Zapanta

Publication date 27-01-2022


To compare the proportion of applicants who matched to their home otolaryngology program during the COVID-19 pandemic compared to the previous 5 years. A "home program match" status was identified for residents in each PGY level and in incoming interns. The "home match proportion" (HMP) was then calculated for each program for each year from 2016 to 2021. The difference in the distribution of home matches between PGY0 and PGY 1, 2, 3, 4, and 5 were analyzed using the chi-square independence test and Fisher's exact test. Statistical significance was declared at A total of 1885 residents were identified from 101 otolaryngology residency programs. The distribution of PGY0s who home matched was statistically higher when separately compared to PGY1-5s. (PGY0 vs PGY 1, 2, 3, 4, 5: 96 [30.1%] vs 63 [19.3%] Nearly a third of applicants matched to their home institution for otolaryngology during the 2021 application cycle, a statistically significant increase compared to an average of the previous 5 years. While there are likely many reasons for this increase, we believe that the severely limited nature of away rotations due to the COVID-19 pandemic played a significant role in this outcome.

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Functional Outcomes Following Total Laryngectomy and Pharyngolaryngectomy: A 20-Year Single Center Study

Thomas Layton,Rachel Thomas,Carol Harris,Sam Holmes,Lisa Fraser,Priy Silva,Stuart C. Winter

Publication date 27-01-2022


Laryngeal cancer accounts for 1% of all cancers in men and 0.3% of all cancers in women. Pharyngolaryngectomy (TPL) and total laryngectomy (TL) are central surgical techniques in the management of advanced laryngeal malignancies but are associated with significant morbidity. In addition, optimal reconstruction following TPL remains an area of active research. Here, we compared speech and swallowing outcomes following circumferential and partial pharyngeal resection alongside total laryngectomy in patients with laryngeal and hypolaryngeal tumors. We performed a systemic analysis of patient demographics, tumor characteristics, treatment modality, and pharyngeal reconstruction technique following TPL and TL, leveraging data collected over a 20-year period at a large tertiary referral center. Analyzing 155 patients the results show circumferential pharyngeal defects and prior radiotherapy have a significant impact on surgical complications. Pharyngeal resection carries a substantial risk of incurring impaired speech and swallowing in patients. Moreover, our results support poorer functional outcomes with more radical pharyngeal resections and show a clear trend toward worse swallowing outcomes in salvage surgery.

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Rhinoplasty in a 3\u2009Week Old: Surgical Challenges in the Setting of Severe Congenital Frontonasal Dysplasia

Alexis Lopez,Daniel A. Lyle,Tara E. Brennan,Erica Bennett

Publication date 19-01-2022


Congenital frontonasal dysplasia (CFND) is a rare heterogeneous collection of facial deformities. Due to the range of complexity, surgical management is not standardized. We present a severe case of CFND and approach to managing multiple defects with a focus on rhinoplasty. This infant was born full term with a large mass instead of a nose, a bilateral cleft lip and palate, and hypertelorbitism. Our primary concerns initially were to address communication with the intracranial cavity, preserve a nasal lining, and improve nasal appearance and airway function in the short term without interfering with subsequent rhinoplasty and adult nasal appearance. This complex case of CFND is more severe than anything we encountered in our literature review and demonstrates the necessity for multidisciplinary approach to multiple craniofacial defects. Future plans for this patient include rhinoplasty with auricular graft, scar revision, and addressing tip support.

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Suture Ligation of Pyriform Sinus Fistulas Following Cauterization to Treat Branchial Cleft Anomalies

In Seong Jeong,Yoon Se Lee,Won Ki Cho,Seung-Ho Choi,Sang Yoon Kim,Soon Yuhl Nam

Publication date 19-01-2022


Obliteration with cauterization of the internal opening of pyriform sinus fistulas, with or without marsupialization, has been a mainstay for preventing recurrence. However, this procedure predisposes patients to recurrence caused by the reopening of the cauterized orifice. We applied suture ligation to secure the closure of the internal orifice following cauterization and evaluated treatment. A total of 42 patients were diagnosed with third or fourth branchial cleft anomaly with internal pyriform sinus fistula and treated either with cauterization or with cauterization and suture ligation, between January 2008 and December 2020. The medical records were reviewed to assess demographic characteristics, clinical presentations, diagnoses, surgical treatment, and outcomes. Treatment flow characteristics for intractable patients were analyzed. The median age of onset was 9 years (range, 0-57 years). Neck swelling (n = 32, 76.2%) was commonly encountered symptom, and a history of neck infection was found in 27 patients (64.3%). After initial treatment, 11 cases (56.2%) recurred. Younger age (≤9 years) and thyroid involvement were associated with recurrence ( Suture ligation with cauterization for an internal orifice of branchial anomaly showed lower recurrence rate than cauterization only. This method was beneficial for refractory cases.

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A Systematic Review of Oral Nutritional Supplement and Wound Healing

Ghazal S. Daher,Karen Y. Choi,Jeffery W. Wells,Neerav Goyal

Publication date 19-01-2022


To explore the current literature for effects of oral nutritional supplement on wound healing rates in humans. A systematic review of the literature was performed using the Medline and Pub Med database following PRISMA guidelines. The Pub Med database was searched using terms relating to oral nutritional supplement and wound healing from 1837 to March 2020.
Study inclusion criteria were: (i) design: randomized controlled trials, clinical studies, observational studies, clinical trials; (ii) population: adults; and (iii) intervention: oral nutritional supplement. The search yielded 2433 studies, 313 of which were clinical trials or clinical studies. After abstract review, 28 studies qualified to be included in the review evaluating the following supplementation categories on wound healing: protein and amino acids (10), mineral, vitamin and antioxidants (9), probiotics (1), and mixed nutrients (8). Arginine and omega-3 supplement were shown to improve wound healing in head and neck cancer patients with surgical wounds by decreasing incidence of postoperative complications and reducing length of hospital stay. Mineral, vitamins, and antioxidants enriched supplements were more beneficial in increasing wound healing than non-enriched protein supplement for diabetic foot and pressure ulcers. Supplementation of a variety of nutrients had variable effects on improving wound healing in different types of wounds. However, further research on the impact of nutritional supplements on surgical wound healing is necessary. The impact of multiple nutrient formulations may also need to be further evaluated for efficacy.

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The Role of Educational Podcast Use Among Otolaryngology Residents

Erik B. Vanstrum,Ido Badash,Franklin M. Wu,Harrison J. Ma,Deepika N. Sarode,Tamara N. Chambers,Michael M. Johns

Publication date 13-01-2022


Medical podcasts are becoming increasingly available; however, it is unclear how these new resources are being used by trainees or whether they influence clinical practice. This study explores the preferences and experiences of otolaryngology residents with otolaryngology-specific podcasts, and the impact of these podcasts on resident education and clinical practice. An 18-question survey was distributed anonymously to a representative junior (up to post-graduate year 3) and senior (post-graduate year 4 or greater) otolaryngology residents at most programs across the US. Along with demographic information, the survey was designed to explore the preferences of educational materials, podcast listening habits and motivations, and influence of podcasts on medical practice. Descriptive statistics and student The survey was distributed to 198 current otolaryngology residents representing 94% of eligible residency programs and was completed by 73 residents (37% response rate). Nearly 3-quarters of respondents reported previous use of otolaryngology podcasts, among which 83% listen at least monthly. Over half of residents changed their overall clinical (53%) and consult (51%) practice based on podcast use. Residents rank-ordered listening to podcasts last among traditional options for asynchronous learning, including reading textbooks and watching online videos. While other asynchronous learning tools remain popular, most residents responding to this survey use podcasts and report that podcasts influence their clinical practice. This study reveals how podcasts are currently used as a supplement to formal otolaryngology education. Results from the survey may inform how medical podcasts could be implemented into resident education in the future.

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Chronic Laryngotracheal Granulomatous Disease Secondary to Sporothrix schenckii in an Immunocompromised Patient

Hannah Kenny,Michael Dougherty,Ian Churnin,Stephen Early,Akriti Gupta,Patrick O. McGarey

Publication date 12-01-2022


To describe a rare presentation of laryngotracheal granulomatous disease secondary to sporotrichosis. The authors report a case of laryngeal sporotrichosis in an immunocompromised patient, with accompanying endoscopic images and pathology. A 72-year-old immunocompromised female with a history of rose-handling presented with a year of hoarseness and breathy voice. Flexible nasolaryngoscopy showed diffuse nodularity; biopsy of the lesions demonstrated granulomatous inflammatory changes, and fungal culture grew When evaluating granulomatous disease of the airway, a broad differential including infectious or inflammatory etiologies should be considered, especially in immunocompromised patients. Adequate tissue samples should be collected to facilitate special staining. The current recommendations for laryngeal sporotrichosis include treatment with a prolonged course of itraconazole.

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Low Pressure Low Frequency Jet Ventilation: Techniques, Safety and Complications

Calvin W. Myint,Stephanie E. Teng,Jennifer J. Butler,Jacline V. Griffeth,Mark A. Fritz,Steffen E. Meiler,Gregory N. Postma

Publication date 12-01-2022


Manual jet ventilation is a specialized oxygenation and ventilation technique that is not available in all facilities due to lack of technical familiarity and fear of complications. The objective is to review our center's 15 year experience with low pressure low frequency jet ventilation (LPLFJV). Retrospective review of procedures utilizing LPLFJV from 2005 to 2019 were performed collecting patient demographic, surgery type and complications. Fisher exact test, Chi square, and Four hundred fifty-seven patients underwent a total of 891 microlaryngeal surgeries-279 cases for voice disorders, 179 for lesions, and 433 for airway stenosis. The peak jet pressure for all cases did not exceed 20 psi and average peak pressure for the last 100 procedures in this case series was 14.9 ± 4.6 psi. The average lowest oxygen saturation for all cases was 95% ± 0.6%. Brief intubation was required in 154 cases (17%). Surgical duration was significantly longer for cases requiring intubation LPLFJV assisted by intermittent endotracheal intubation is an exceedingly safe and effective intraoperative oxygenation and ventilationmodality for a broad variety of laryngeal procedure.

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Factors Affecting Compliance With Myringotomy Tube Follow-up Care

Helen H. Soh,Katherine R. Keefe,Madhav Sambhu,Tithi D. Baul,Dillon B. Karst,Jessica R. Levi

Publication date 12-01-2022


Myringotomy and tube insertion is a commonly practiced procedure within pediatric otolaryngology. Though relatively safe, follow-up appointments are critical in preventing further complications and monitoring for improvement. This study sought to evaluate the factors associated with compliance of post-myringotomy follow-up visits in an urban safety-net tertiary care setting. This study is a retrospective chart review conducted in outpatient otolaryngology clinic at an urban, safety-net, tertiary-care, academic medical center. All patients from ages 0 to 18 who received myringotomy and tube placement between February 3, 2012, to May 30, 2018 at the aforementioned clinic were included. A total of 806 patients had myringotomy tubes placed during this period; 190 patients were excluded due to no visits being scheduled within 1 and 6 month visit windows post-operatively, leaving 616 patients included for analysis. Of 616 patients, 574 patients were seen for the 1-month visit, (42 patients did not have follow-up visits within the 1-month window), and 356 patients were examined for the 6-month visit (260 patients did not schedule follow-up visits within the 6-month window). For the 1-month follow-up visits post-procedure, only race/ethnicity type "Other" was associated with lower no-show rates (OR = 0.330, 95% CI: 0.093-0.968). With the 6-month follow-up visits, having private insurance (OR = 0.446, 95% CI: 0.229-0.867) and not having a 1-month visit scheduled (OR = 0.404, 95% CI: 0.174-0.937) predicted lower no-show rates. No meaningful factors studied were significantly associated with compliance of short-term, 1-month visits post-myringotomy. Compliance of longer-term, 6-month post-operative visits was associated with insurance type and previous visit status.

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Inpatient Type 1 Thyroplasty Versus Injection Laryngoplasty for Vocal Fold Movement Impairment After Extent type I and II Aortic Repair

Lauren A. Pinzas,Diane W. Chen,Nelson Eddie Liou,Donald T. Donovan,Julina Ongkasuwan

Publication date 12-01-2022


Vocal fold motion impairment (VFMI) due to neuronal injury is a known complication following thoracic aortic repair that can impair pulmonary toilet function and post-operative recovery. To demonstrate clinical outcomes of patients undergoing inpatient vocal fold medialization for VFMI after aortic surgery. A 15-year retrospective chart review (2005-2019) of 259 patients with postoperative VFMI after thoracic aortic surgery registry was conducted. Data included demographics, surgery characteristics, laryngology exam, and postoperative clinical outcomes. Medialization procedures consisted of type 1 thyroplasty and injection laryngoplasty. Tertiary care hospital. Two hundred and fifty-nine patients (median age 61, 71% male) with VFMI post-thoracic aortic repair met inclusion criteria; inpatient vocal fold medialization was performed for 203 (78%) patients. One hundred and twenty-six. (49%) received type 1 thyroplasty and 77 (30%) received injection laryngoplasty procedures at a median 7 days (IQR 5-8 days) from extubation. Primary study outcome measurements consisted of median LOS, median ICU LOS, complications intra- and postoperatively, and pulmonary complications (post-medialization bronchoscopies, pneumonia, tracheostomy, etc.). Post-medialization bronchoscopy rates were significantly lower in the medialization (n = 11) versus the non-medialization group (n = 8) (5% vs 14%, Inpatient thyroplasty and injection laryngoplasty are both effective vocal fold medialization techniques after extent I and II aortic repair. Thyroplasty may have a small pulmonary toilet advantage, as measured by need for post-medialization bronchoscopy, compared to injection laryngoplasty.

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Applicant Perspectives on Virtual Otolaryngology Residency Interviews

Daniel O. Kraft,Eve M. R. Bowers,Brandon T. Smith,Noel Jabbour,Barry M. Schaitkin,Miriam A. O’Leary,Jan C. Groblewski,VyVy N. Young,Shaum Sridharan

Publication date 10-01-2022


Residency interviews serve as an opportunity for prospective applicants to evaluate programs and to determine their potential fit within them. The 2019 SARS-CoV2 pandemic mandated programs conduct interviews virtually for the first time. The purpose of this study was to assess applicant perspectives on the virtual interview. A Qualtrics survey assessing applicant characteristics and attitudes toward the virtual interview was designed and disseminated to otorhinolaryngology applicants from 3 large academic institutions in the 2020 to 2021 application cycle. A total of 33% of survey applicants responded. Most applicants were satisfied with the virtual interview process. Applicants reported relatively poor quality of interactions with residents and an inability to assess the "feel" of a geographic area. Most applicants received at least 11 interviews with over a third of applicants receiving >16 interviews. Only 5% of applicants completed >20 interviews. Most applicants believed interviews should be capped between 15 and 20 interviews. Most applicants reported saving >$5000, with over a quarter of applicants saving >$8000, and roughly one-third of applicants saving at least 2 weeks of time with virtual versus in-person interviews. While virtual interviews have limitations, applicants are generally satisfied with the experience. Advantages include cost and time savings for both applicants and programs, as well as easy use of technology. Continuation of the virtual interview format could be considered in future application cycles; geographical limitations may be overcome with in-person second looks, and increased emphasis should be placed on resident interactions during and prior to interview day.

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Acute Herpetic Nasopharyngitis in an Adult Patient: A Case Report and Literature Review

Cathleen C. Kuo,Ellen M. Piccillo,Jason C. DeGiovanni,Matt Kabalan,Gregg Zimmer,Michele M. Carr

Publication date 07-01-2022


To report a case of herpes virus-associated nasopharyngitis in an adult patient. The patient's medical record was reviewed for demographic and clinical data. For literature review, all case reports or other publications published in English literature were identified using Pubmed with the MeSH terms "herpes," "nasopharyngitis," and "upper respiratory infection." A 40-year-old male presented for nasal congestion and a suspected nasal mass. Computed tomography of the sinuses revealed edematous changes in the nasopharynx which exerted a downward mass effect at the right aspect of the soft palate. Flexible fiberoptic laryngoscopy (FFL) revealed a lesion arising from the posterior aspect of the soft palate with extension into the posterior nasal cavity as well as copious mucopurulent secretions consistent with a superimposed acute sinusitis. Rigid nasal endoscopy demonstrated a friable and ulcerated lesion arising from the aforementioned anatomical location. Biopsy of this lesion and subsequent immunohistochemical analysis revealed a diagnosis of herpetic nasopharyngitis. Herpetic infection should be in the differential diagnosis of patients presenting with atypical symptoms of nasopharyngitis. Early accurate diagnosis and appropriate specific management can limit the duration of disease course and prevent further complications.

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Metal Allergy in Tracheostomy Tube Placement Resulting in Complete Subglottic Stenosis: A Case Report

Roger Bui,Lindsay Boven,David Kaufman,Paul Weinberger

Publication date 07-01-2022


Metal hypersensitivity reaction to surgical implants is a well- known phenomenon that is associated with pain, swelling, inflammation, and decreased efficacy of the implant. We present a unique case of a patient with placement a metal Jackson tracheostomy tube that led to expeditious total subglottic stenosis. The patient was a 33-year old, severely atopic woman with history of asthma exacerbations requiring several intubations for acute respiratory failure with several subsequent tracheal dilations with steroid injections, and eventual tracheostomy placement with a metal Jackson tracheostomy tube that led to expeditious total subglottic stenosis. Initial intervention included performing an airway evaluation, CO Metal hypersensitivity reactions are well known phenomena as it relates to surgical implants in other surgical specialties but are seldom reported within the ear, nose and throat literature. Oftentimes, it takes astute observation to diagnose and establish a connection. Prompt recognition and treatment can be acquired from interdisciplinary collaboration with allergy.

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Mucoepidermoid Carcinomas of the Larynx

Holden W. Richards,Caitlin Bertelsen,Bronwyn Hamilton,David Sauer,Joshua Schindler

Publication date 07-01-2022


Discussions regarding the specific management and outcomes for laryngeal MEC are limited to very small, single-institution case series. To look further into the diagnosis and management of these uncommon non-squamous cell carcinomas of the larynx, we present 3 recent cases of laryngeal MEC treated at our institution. Patients at a tertiary hospital treated for MEC between October 2019 and December 2020 were retrospectively identified. Chart review, imaging analysis, and histologic slide creation were completed for all patients. We identified and treated 2 patients with high-grade supraglottic and 1 patient with intermediate-grade glottic MEC. These patients presented to our clinic with a primary complaint of either gradual, worsening dysphonia, dysphagia, or both. All patients underwent laryngovideostroboscopy as well as panendoscopy with directed submucosal biopsy, which was consistent with MEC. MRI was performed in 2 of the cases further elucidating the extent of submucosal spread. PET-CT was performed in all 3 cases, and none demonstrated evidence of regional or distal metastases. Surgically, high-grade MEC lesions were treated with a total laryngectomy. The intermediate MEC lesion was managed with a supracricoid partial laryngectomy (SCPL). Surgical margins were free of tumor in all cases with no nodal metastases by modified radical neck dissection. Radiation therapy was offered to both high-grade MEC patients and declined by one. Radiation was not recommended to the patient with intermediate-grade MEC as we believed that the risk of additional treatment outweighed the benefit. We believe that MEC of the larynx should be considered in patients with atypical submucosal laryngeal masses. Laryngovideostroboscopy, MRI, and PET imaging may be valuable in determining the extent of the lesions and planning appropriate surgery. Postoperative radiation therapy should be considered a per tumor grade in other more studied sites, as there is no data on efficacy in laryngeal MEC.

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A National Analysis of Inpatient Pediatric Adenoidectomy

Flora Yan,Victoria Huang,Shaun A. Nguyen,William W. Carroll,Clarice S. Clemmens,Phayvanh P. Pecha

Publication date 07-01-2022


Hospital admission following pediatric adenoidectomy without tonsillectomy is not well characterized. The objective of our study is to better characterize risk factors for post-operative complications in younger children undergoing inpatient adenoidectomy. A cross-sectional analysis using data derived from the Kid's Inpatient Database (KID) was performed. Study participants included children <3 years of age who underwent an adenoidectomy and were admitted to hospitals participating in the KID for years 1997, 2000, 2003, 2006, 2009, and 2012. Descriptive statistical analysis and a multivariate logistic regression analysis were performed to identify risk factors for post-operative complication. A total of 3406 children (mean age 1.1 ± 0.7 years) were included. The overall post-operative bleeding and respiratory complication rates were 0.6% and 5.4%, respectively. Children less than 18 months of age demonstrated increased rates of post-operative respiratory complications ( This analysis of a national dataset suggests that otherwise healthy children less than 18 months of age and children 18 months to 3 years of age with certain comorbidities may benefit from overnight observation following adenoidectomy.

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Critical Quality and Readability Analysis of Online Patient Education Materials on Parotidectomy: A Cross-Sectional Study

Elysia Miriam Grose,Emily YiQin Cheng,Marc Levin,Justine Philteos,Jong Wook Lee,Eric A. Monteiro

Publication date 07-01-2022


Complications related to parotidectomy can cause significant morbidity, and thus, the decision to pursue this surgery needs to be well-informed. Given that information available online plays a critical role in patient education, this study aimed to evaluate the readability and quality of online patient education materials (PEMs) regarding parotidectomy. A Google search was performed using the term "parotidectomy" and the first 10 pages of the search were analyzed. Quality and reliability of the online information was assessed using the DISCERN instrument. Flesch-Kincaid Grade Level (FKGL) and Flesch-Reading Ease Score (FRE) were used to evaluate readability. Thirty-five PEMs met the inclusion criteria. The average FRE score was 59.3 and 16 (46%) of the online PEMs had FRE scores below 60 indicating that they were fairly difficult to very difficult to read. The average grade level of the PEMs was above the eighth grade when evaluated with the FKGL. The average DISCERN score was 41.7, which is indicative of fair quality. There were no significant differences between PEMs originating from medical institutions and PEMs originating from other sources in terms of quality or readability. Online PEMs on parotidectomy may not be comprehensible to the average individual. This study highlights the need for the development of more appropriate PEMs to inform patients about parotidectomy.

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Mucosal Bridge Reconstruction: A Novel Approach for the Vocal Fold Mucosal Bridge

Engin Başer,İsmail İlter Denizoğlu

Publication date 05-01-2022


Mucosal Bridges (MBs) are defined as benign connective tissue abnormalities of unclear etiology that extend over the free surface of the vocal fold, are attached to the front and back of the vocal fold but are not attached to its free surface, and are histologically covered by stratified squamous epithelium. In order to overcome these drawbacks, we aimed to retrospectively evaluate and present the preoperative and postoperative results of patients with MB, who were applied the method we call "Mucosal Bridge Reconstruction" (MBR), which we apply as suturing rather than resection of the MB. Between January 2016 and February 2020, 5 patients who applied to the voice clinic due to dysphonia and were diagnosed with MB via laryngostroboscopic examination and direct laryngoscopy under general anesthesia were included in the study. Dr Speech software was used for acoustic analysis; mean fundamental frequency (fo), jitter %, shimmer %, and noise to harmonic ratio (NHR) were objectively measured and recorded. Voice Handicap Index-10 (VHI-10) was used for positive self-reporting of the severity of vocal symptoms. GRBAS scale (G: Grade, R: Roughness, B: Breathiness, A: Asthenia, and S: Strain) was also used (by the same clinician) for clinic subjective evaluation. Patient age ranged from 33 to 55 years and mean patient age was 42 years. Mean duration of symptoms was 22 months (range 16-30). Mean postoperative follow-up time was 14 months (range 6-24). Unilateral MB was observed in all patients (2 left, 3 right). There was a significant improvement in objective and subjective assessment methods in all our patients after surgery. According to the results of our few patients, MBR offers a physiological and anatomical approach to the treatment of patients with MB. The outcomes of delicate microlaryngeal surgery are promising.

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Prolonged Surgical Interval Following Chemotherapy in a Patient With Idiopathic Subglottic Stenosis (iSGS): Case Report and Brief Review of Literature

Rafael Ospino,Alexandra Berges,Lena W. Chen,Ioan Lina,Alexander T. Hillel

Publication date 04-01-2022


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In-Hospital Costs Associated With an Expanded Endonasal Approach to Anterior Skull Base Tumors

Arjun K. Parasher,David K. Lerner,Jordan T. Glicksman,Theodore Lin,Stephen P. Miranda,Darren Ebesutani,Michael Kohanski,John Y. K. Lee,Phillip B. Storm,Bert W. O’Malley,Daniel Yosher,James N. Palmer,Sean Grady,Nithin D. Adappa

Publication date 04-01-2022


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Postoperative Inhaled Steroids Following Glottic Airway Surgery Reduces Granulation Tissue Formation

Alison N. Hollis,Ameer Ghodke,Douglas Farquhar,Robert A. Buckmire,Rupali N. Shah

Publication date 30-12-2021


Transoral laser surgery for glottic stenosis (transverse cordotomy and anteromedial arytenoidectomy (TCAMA)) is often complicated by granulation tissue (GT) formation. GT can cause dyspnea and may require surgical removal to alleviate airway obstruction. Inhaled corticosteroids (ICS) have been shown to reduce benign vocal fold granulomas, however its use to prevent GT formation has not been described. We aimed to analyze the effect of immediate postoperative ICS on GT formation in patients undergoing transoral laser surgery for glottic stenosis. A retrospective analysis of patients that had transoral laser surgery for glottic stenosis from 2000 to 2019 was conducted. Surgical instances were grouped into those that received postoperative ICS and those that did not. Demographics, diagnosis, comorbidities, intraoperative adjuvant therapy, and perioperative medications were collected. Differences in GT formation and need for surgical removal were compared between groups. A multivariate exact logistic regression model was performed. Forty-four patients were included; 16 required 2 glottic airway surgeries (60 surgical instances). Of the 23 instances where patients received immediate postoperative ICS, 0 patients developed GT; and of the 37 instances that did not receive postoperative ICS, 15 (40.5%) developed GT ( Immediate postoperative use of ICS seems to be a safe and effective method to prevent granulation tissue formation and subsequent surgery in patients following transoral laser airway surgery for glottic stenosis.

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High-Definition 3-D Exoscope for Micro-Laryngeal Surgery: A Preliminary Clinical Experience in 41 Patients

Armando De Virgilio,Andrea Costantino,Giuseppe Mercante,Fabio Ferreli,Phil Yiu,Tiziana Mondello,Daniela Sebastiani,Luca Malvezzi,Raul Pellini,Giuseppe Spriano

Publication date 30-12-2021


The aim of this prospective clinical study is to evaluate the feasibility of the micro-laryngeal surgery (MLS) using a 3D operating exoscope (OE) in substitution to a conventional operating microscope (OM). A total of 41 consecutive patients were included (male: 26; median age: 55.0 years; IQR: 46.0-68.0). After each procedure, the surgeon and the scrub nurse were asked to fill out a tailored questionnaire on a 3-point Likert scale (1-not acceptable, 2-acceptable, 3-good) including 12 items. The majority of the procedures were therapeutic (n = 31, 75.6%), while the remaining were diagnostic (n = 10, 24.4%). All surgeries were successfully completed without the support of the OM, and no complications or unwanted delays were detected. The majority of the individual items were judged "good" either by surgeons (n = 399, 81.1%) and scrub nurses (n = 287, 87.5%). The natural posture during the procedure, and the ease of use the joystick and focusing were the best-rated items by the surgeons. This study demonstrates the feasibility of MLS using the OE. Further comparative clinical studies are needed to clarify its real value in substitution to a conventional operating microscope and to better define advantages and disadvantages.

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Endoscopic Endonasal Treatment of a Sinonasal Vascular Neoplasm in the Postnatal Period: Case Report and Review of Literature

Stephen W. Morvant,Andrew J. Maroda,Leighton F. Reed,Anthony M. Sheyn,Jeremy Peterson,Lucas Elijovich,L. Madison Michael,Julie M. DiNitto,Sanjeet V. Rangarajan

Publication date 17-12-2021


Congenital vascular lesions commonly present in the head and neck, and most are managed conservatively. Location and rapid growth, however, may necessitate surgical intervention. Endoscopic endonasal surgery (EES) in the pediatric population has emerged as a viable option in treating sinonasal and skull base lesions. Utilizing these techniques in newborns carries unique challenges. The objective of this report is to describe the successful use of direct intralesional embolization followed by endoscopic endonasal resection of a venous malformation in a postnatal patient. We reviewed the case reported and reviewed the pertinent literature. A 6-week-old infant was found to have a large right-sided sinonasal lesion confirmed as a venous malformation. Rapid growth, impending orbital compromise, and potential long-term craniofacial abnormalities demanded the need for urgent surgical intervention. Risk of bleeding was mitigated with direct intralesional embolization. Immediately afterward, the patient underwent endoscopic endonasal resection of the lesion. EES in the very young presents multiple challenges both anatomically and behaviorally. A multidisciplinary approach lead to a successful outcome. We report a case of a 6-week-old infant, the youngest reported patient to the authors' knowledge, who successfully underwent direct intralesional embolization followed by endoscopic endonasal resection of a sinonasal vascular malformation. This report highlights the challenges of this technique in the very young and demonstrates it as a viable treatment strategy for sinonasal vascular anomalies in this population.

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ASA Physical Status Classification and Complications Following Facial Fracture Repair

Parisorn Thepmankorn,Chris B. Choi,Sean Z. Haimowitz,Aksha Parray,Jordon G. Grube,Christina H. Fang,Soly Baredes,Jean Anderson Eloy

Publication date 17-12-2021


To investigate the association between American Society of Anesthesiologists (ASA) physical status classification and rates of postoperative complications in patients undergoing facial fracture repair.
Patients were divided into 2 cohorts based on the ASA classification system: Class I/II and Class III/IV. Chi-square and Fisher's exact tests were used for univariate analyses. Multivariate logistic regressions were used to assess the independent associations of covariates on postoperative complication rates. A total of 3575 patients who underwent facial fracture repair with known ASA classification were identified. Class III/IV patients had higher rates of deep surgical site infection ( Higher ASA class is associated with increased length of hospital stay and odds of deep surgical site infection, bleeding, and failure to wean off of ventilator following facial fracture repair. Surgeons should be aware of the increased risk for postoperative complications when performing facial fracture repair in patients with high ASA classification.

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Validation of the Modified Rhinoplasty Assessment Scale (Photographic)

Sinehan B. Bayrak,Joseph Penn,Jinxiang Hu,John David Kriet,Clinton D. Humphrey

Publication date 16-12-2021


To validate the modified Rhinoplasty Assessment Scale (Photographic) (mRASP). Retrospective cohort study. Photographs for 100 rhinoplasty patients from 2 facial plastic surgeons were compiled. Photos included 6 views. Each facial plastic surgeon reviewed all views. Nasal appearance was evaluated using the mRASP. Eighty female (mean RASP score = 14.89, SD = 7.04) and 20 male (mean RASP score = 19.83, SD = 10.09) patients were included. The mean of the total score on the instrument was 15.88 (SD = 7.98). Cronbach's alpha was .81, and inter-rater reliability measured as a Pearson product-moment correlation was .74. The CFA model fit the frontal view (χ The mRASP is a reliable instrument that can be used to assess nasal form via frontal, lateral, and basal photographs of patients. This provides facial plastic surgeons with a validated tool to evaluate rhinoplasty outcomes.

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Impact of Adenotonsillectomy on Homework Performance in Children With Obstructive Sleep-Disordered Breathing

Derek Wu,Vivienne H. Au,Billy Yang,Sylvia J. Horne,Jeremy Weedon,Michelle J. Bernstein,Nira A. Goldstein

Publication date 07-12-2021


As a first line treatment for pediatric obstructive sleep-disordered breathing (SDB), adenotonsillectomy (AT) has been shown to confer physiologic and neurocognitive benefits to a child. However, there is a scarcity of data on how homework performance is affected postoperatively. Our objective was to evaluate the impact of AT on homework performance in children with SDB. Children in grades 1 to 8 undergoing AT for SDB based on clinical criteria with or without preoperative polysomnography along with a control group of children undergoing surgery unrelated to the treatment of SDB were recruited. The primary outcome of interest was the differential change in homework performance between the study group and control at follow-up as measured by the validated Homework Performance Questionnaire (HPQ-P). Adjustments were made for demographics and Pediatric Sleep Questionnaire (PSQ) scores. 116 AT and 47 control subjects were recruited, and follow-up data was obtained in 99 AT and 35 control subjects. There were no significant differences between the general (total) HPQ-P scores and subscale scores between the AT and control subjects at entry and there were no significant differences in the change scores (follow-up minus initial scores) between the groups. Regression modeling also demonstrated that there were no group (AT vs control) by time interactions that predicted differential improvements in the HPQ-P ( Children with SDB experienced improvement in HPQ-P scores postoperatively, but the degree of change was not significant when compared to controls. Further studies incorporating additional educational metrics are encouraged to assess the true scholastic impact of AT in children with SDB.

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Outcome Disparities and Resource Utilization Among Limited English Proficient Patients After Tonsillectomy

Michal Plocienniczak,Batsheva R. Rubin,Alekha Kolli,Jessica Levi,Lauren Tracy

Publication date 07-12-2021


There is evidence to suggest adverse outcomes on patients' medical and surgical care when there is language discordance in patient-physician relationships. No studies have evaluated the impact of limited English proficiency (LEP) on complications after common surgical procedures in otolaryngology. Furthermore, no studies have evaluated how patients with LEP utilize remote resources to connect with otolaryngology providers to better triage such complications. The purpose was to evaluate the incidence of post-tonsillectomy hemorrhage (PTH) comparing patients with LEP to those with English proficiency (EP). Patients with PTH were retrospectively evaluated to identify preceding telephone encounters, a marker of resource utilization. Demographics, English proficiency, and PTH management (surgical vs non-surgical) were evaluated in addition to PTH-associated triage telephone encounters with otolaryngology providers. Of 2466 tonsillectomies, there were 141 episodes of reported hemorrhage (50 LEP vs 91 EP) in the 5 years studied. Rates were not significantly different between LEP and EP patients (4.9% vs 6.3%, Patients with limited English proficiency are not at increased risk for developing PTH. There is equitable access to remote otolaryngologic triage care, although overall the utilization rate of this resource was low for both cohorts.

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Hand Motion Analysis Illustrates Differences When Drilling Cadaveric and Printed Temporal Bone

Jordan B. Hochman,Justyn Pisa,Katrice Kazmerik,Bertram Unger

Publication date 07-12-2021


Temporal bone simulation is now commonly used to augment cadaveric education. Assessment of these tools is ongoing, with haptic modeling illustrating dissimilar motion patterns compared to cadaveric opportunities. This has the potential to result in maladaptive skill development. It is hypothesized that trainee drill motion patterns during printed model dissection may likewise demonstrate dissimilar hand motion patterns. Resident surgeons dissected 3D-printed temporal bones generated from microCT data and cadaveric simulations. A magnetic position tracking system (TrakSTAR Ascension, Yarraville, Australia) captured drill position and orientation. Skill assessment included cortical mastoidectomy, thinning procedures (sigmoid sinus, dural plate, posterior canal wall) and facial recess development. Dissection was performed by 8 trainees (n = 5 < PGY3 > n = 3) using k-cos metrics to analyze drill strokes within position recordings. K-cos metrics define strokes by change in direction, providing metrics for stroke duration, curvature, and length. -tests between models showed no significant difference in drill stroke frequency (cadaveric = 1.36/s, printed = 1.50/s, Significant differences in hand motions were present between simulations, however the significance is unclear. This may indicate that printed bone is not best positioned to be the principal training schema.

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A Longitudinal Comparison of Telemedicine Versus In-Person Otolaryngology Clinic Efficiency and Patient Satisfaction During COVID-19

Karen K. Hoi,Sloane A. Brazina,Rachel Kolar-Anderson,David A. Zopf,Lauren A. Bohm

Publication date 04-12-2021


Telemedicine was increasingly adopted in otolaryngology as a result of the COVID-19 pandemic, but how it compares to in-person visits over the longitudinal course of the pandemic has not been characterized. This study compares telemedicine visits to in-person visits on measures of clinical efficiency and patient satisfaction. We examined all in-person and telemedicine encounters that occurred during the 13-month period from April 1, 2020 to April 30, 2021 at a pediatric otolaryngology clinic associated with a large tertiary care children's hospital. We compared patient demographics, primary encounter diagnoses, completions, cancellations, no-shows, cycle time, and patient satisfaction. A total of 19 541 (90.5%) in-person visits and 2051 (9.5%) telemedicine visits were scheduled over the study period. There was no difference in patient age or gender between the visit types. There was a difference in race (75% White or Caucasian for in-person and 73% for telemedicine, Telemedicine was utilized more during months of heightened COVID-19 cases, with higher completion rates, fewer cancellations, shorter cycle times, saved travel distance, and comparable patient satisfaction to in-person visits. Telemedicine has the potential to remain an efficient mode of care delivery in the post-pandemic era.

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Measurement of Lingual Artery Using Ultrasound Versus Computed Tomography Angiography for Midline Glossectomy in Patients With Obstructive Sleep Apnea

Chenhai Zheng,Lei Shi,Dengxiang Xing,Jie Qin,Peipei Ji,Shuhua Li,Dahai Wu

Publication date 02-12-2021


To clarify the differences in assessing the course of the lingual artery between lingual artery computed tomography angiography (CTA) and ultrasound (US). Twenty-six OSA patients were included in this study and accomplished lingual artery CTA and US, respectively. The differences in the depths of the lingual arteries and the distances between the bilateral lingual arteries on 3 measurement levels based on lingual artery CTA and US were compared. The depths of the lingual arteries on 3 measurement levels by CTA were deeper than those by US ( The parameters of lingual artery measured by lingual artery US were similar to or smaller than those measured by lingual artery CTA. Like lingual artery CTA, lingual artery US could be used as an effective method to ensure the safety of the operation.

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Tracheostomy Outcomes in COVID-19 Patients in a Low Resource Setting

Liyang Tang,Celeste Kim,Connie Paik,Jonathan West,Steven Hasday,Peiyi Su,Eduardo Martinez,Sheng Zhou,Bhavishya Clark,Karla O’Dell,Tamara N. Chambers

Publication date 02-12-2021


COVID-19 predominately affects safety net hospitals. Tracheostomies improve outcomes and decrease length of stay for COVID-19 patients. Our objectives are to determine if (1) COVID-19 tracheostomies have similar complication and mortality rates as non-COVID-19 tracheostomies and (2) to determine the effectiveness of our tracheostomy protocol at a safety net hospital. Patients who underwent tracheostomy at Los Angeles County Hospital between August 2009 and August 2020 were included. Demographics, SARS-CoV-2 status, body mass index (BMI), Charlson Co-morbidity Index (CCI), length of intubation, complication rates, decannulation rates, and 30-day all-cause mortality versus tracheostomy related mortality rates were all collected. Thirty-eight patients with COVID-19 and 130 non-COVID-19 patients underwent tracheostomies. Both groups were predominately male with similar BMI and CCI, though the COVID-19 patients were more likely to be Hispanic and intubated for a longer time ( COVID-19 tracheostomies are safe for patients and healthcare workers. Careful attention should be paid to suctioning to prevent mucus plugging. 3.

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Emergence of Invasive Fungal Rhinosinusitis in Recently Recovered COVID-19 Patients

Vivek Dokania,Ninad Subhash Gaikwad,Vinod Gite,Shashikant Mhashal,Neeraj Shetty,Pravin Shinde,Anju Balakrishnan

Publication date 02-12-2021


The risk of invasive fungal rhinosinusitis is increased in Coronavirus disease 2019 (COVID-19) because of its direct impact in altering innate immunity and is further exacerbated by widespread use of steroids/antibiotics/monoclonal antibodies. The study aims to describe this recently increased clinical entity in association with COVID-19. A prospective, longitudinal study including patients diagnosed with acute invasive fungal rhinosinusitis (AIFRS) who recently recovered from COVID-19 infection or after an asymptomatic carrier state. A single-center, descriptive study investigating demographic details, clinical presentation, radio-pathological aspects, and advocated management. A total of 21 patients were included with a mean age of 49.62 years (SD: 14.24). Diabetes mellitus (DM) was the most common underlying disorder (90.48%), and 63.16% of all patients with DM had a recent onset DM, either diagnosed during or after COVID-19 infection. Nineteen patients (90.48%) had recently recovered from active COVID-19 infection, and all had a history of prior steroid treatment (oral/parenteral). Remaining 2 patients were asymptomatic COVID-19 carriers. Surprisingly, 2 patients had no underlying disorder, and 5 (23.81%) recently received the Covishield vaccine. Fungal analysis exhibited Mucor (95.24%) and Aspergillus species (14.29%). Most common sign/symptom was headache and facial/periorbital pain (85.71%), followed by facial/periorbital swelling (61.90%).
Disease involvement: sinonasal (100%), orbital (47.62%), pterygopalatine fossa (28.58%), infratemporal fossa (14.29%), intracranial (23.81%), and skin (9.52%). Exclusive endoscopic debridement and combined approach were utilized in 61.90% and 38.10%, respectively. Both liposomal amphotericin B and posaconazole were given in all patients except one. A high suspicion of AIFRS should be kept in patients with recent COVID-19 infection who received steroids and presenting with headache, facial pain, and/or facial swelling. Asymptomatic COVID-19 carriers and COVID-19 vaccinated candidates are also observed to develop AIFRS, although the exact immuno-pathogenesis is still unknown. Prompt diagnosis and early management are vital for a favorable outcome.

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Clinical and Microbiological Factors Associated With Abscess Formation in Adult Acute Epiglottitis

Giorgos Sideris,Nikolaos Papadimitriou,Georgios F. Korres,Anastasios Karaganis,Pavlos Maragkoudakis,Thomas Nikolopoulos,Alexander Delides

Publication date 29-11-2021


To evaluate clinical and microbiological findings that are correlated with abscess formation in adult acute epiglottitis (AE). We reviewed 140 cases of adult AE. Demographic, clinical, imaging, and microbiological findings are analyzed for all patients with AE in comparison to those with epiglottic abscess (EA). A total of 113 patients presented with AE and 27 presented or progressed to EA (19.3%). Age, sex, seasonality, smoking, body mass index (BMI), and comorbidities were statistically insignificant between the 2 groups. Muffled voice ( A high level of suspicion for abscess formation is required if clinical examination reveals dyspnea, muffled voice, or an epiglottic cyst in adult with AE. The existence of EA doubles the duration of hospitalization. EA is typically found on the lingual surface of the epiglottis. Supraglottic or deep neck space expansion should be treated surgically. EA is associated with a mixed flora and a higher rate of airway obstruction. Streptococcus is discovered to be the most common pathogen.

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Trends in Nasal Spray Prescribing Patterns by Otolaryngologists in the US Medicare Population

Celeste Kim,Erica Tran,Ian Kim,Kevin Hur

Publication date 26-11-2021


To quantify national and state-level prescribing and cost trends for the 3 most prescribed nasal sprays by otolaryngologists in the Medicare population. Through the Centers for Medicare and Medicaid Services (CMS) database and the Kaiser Family Foundation, we retrieved data on Medicare enrollment and on claims and costs of fluticasone propionate, azelastine HCl, and ipratropium bromide prescribed by otolaryngologists from January 1, 2013 to December 31, 2017. From 2013 to 2017, CMS reimbursed $128.8 million for 5.2 million claims of fluticasone propionate, azelastine HCl, and ipratropium bromide prescribed by otolaryngologists. The national claim rate for fluticasone propionate increased 6.5% per year from 2013 to 2015 and then decreased 4.3% per year from 2015 to 2017 while azelastine HCl and ipratropium bromide consistently increased annually (19.0% and 12.2% respectively) from 2013 to 2017. The cost for fluticasone propionate decreased 33.0% a year from 2013 to 2015 and then increased 5.4% annually to $13.60 per claim in 2017. Azelastine HCl decreased 14.8% annually from $91.30 to $50.23 per claim and ipratropium bromide increased 5.2% annually to $34.78 in 2017. Variations in the claim rate and cost for all 3 nasal sprays were observed in some states. Otolaryngologists are prescribing azelastine HCl and ipratropium at an increasingly higher rate in the Medicare population, while the rate for fluticasone propionate has been decreasing nationally. Utilization and costs of nasal sprays also vary geographically across the United States.

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A Comparison of Near-Infrared Imaging and Computerized Tomography Scan for Detecting Maxillary Sinusitis

Mehdi Abouzari,Brooke Sarna,Joon You,Adwight Risbud,Kotaro Tsutsumi,Khodayar Goshtasbi,Naveen D. Bhandarkar

Publication date 26-11-2021


To investigate the use of near-infrared (NIR) imaging as a tool for outpatient clinicians to quickly and accurately assess for maxillary sinusitis and to characterize its accuracy compared to computerized tomography (CT) scan. In a prospective investigational study, NIR and CT images from 65 patients who presented to a tertiary care rhinology clinic were compared to determine the sensitivity and specificity of NIR as an imaging modality. The sensitivity and specificity of NIR imaging in distinguishing normal versus maxillary sinus disease was found to be 90% and 84%, normal versus mild maxillary sinus disease to be 76% and 91%, and mild versus severe maxillary sinus disease to be 96% and 81%, respectively. The average pixel intensity was also calculated and compared to the modified Lund-Mackay scores from CT scans to assess the ability of NIR imaging to stratify the severity of maxillary sinus disease. Average pixel intensity over a region of interest was significantly different ( Based on this data, NIR shows promise as a tool for identifying patients with potential maxillary sinus disease as well as providing information on severity of disease that may guide administration of appropriate treatments.

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Submental Island Flap After Prior Contralateral Neck Dissection: A Case Series and Technical Considerations

Andrew R. Larson,Nicholas B. Abt,Daniel G. Deschler

Publication date 26-11-2021


The submental island flap is a dependable workhorse in head and neck reconstruction. However, the viability of this flap has not been established for oral cavity reconstruction when a contralateral neck dissection has already been performed in an earlier surgical setting. The aim of this study is to highlight technical considerations and outcomes of this approach with a small case series. Three cases of oral cavity reconstruction with a submental island flap elevated in the context of a prior contralateral neck dissection are presented. In all cases, a doppler was used to identify the maintenance of the submental perforator in the neck opposite the previous neck dissection. In 2 cases, level IA was included within the dissection field of the previous neck dissection. Additionally, the old neck scar was included within the skin paddle of the submental island flap in 2 cases. In all cases, excellent healing of the flap was observed without partial or complete loss. The submental island flap appears to be a reliable reconstruction when a previous contralateral neck dissection has been performed, even when level IA was included in the prior dissection.

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Increased Risk of Postpartum Depression in Women With Allergic Rhinitis During Pregnancy: A Population-Based Case-Control Study

Zhi-Chao Yang,Li-Xin Wang,Yang Yu,Huan-Yu Lin,Liang-Chun Shih

Publication date 15-11-2021


Allergic rhinitis (AR) is associated with increased risk of major depression in the general population, however, no previous study has evaluated its role among pregnant women. We aimed to investigate the potential impact of AR during pregnancy on the development of postpartum depression (PPD). This is a population-based case-control study. Data were retrieved from the National Health Insurance Research Database (NHIRD). Medical records of a total of 199 470 deliveries during 2000 and 2010 were identified. Among which, 1416 women with PPD within 12 months after delivery were classified as the case group, while 198 054 women without PPD after delivery formed the control group. Univariate and multivariate regression analyses were conducted to determine the associations between AR during pregnancies and other study variables with PPD. AR during pregnancy was found in 9.53% women who developed PPD and 5.44% in women without PPD. After adjusting for age at delivery, income level, various pregnancy and delivery-related conditions, asthma, atopic dermatitis and other medical comorbidities in the multivariate analysis, AR was significantly associated with increased odds of PPD (aOR: 1.498, 95% CI: 1.222-1.836). AR during pregnancy was independently and significantly associated with an approximately 50% increased risk of PPD among women giving birth. Closely monitoring of AR is warranted in the future in order to optimize mother and child outcomes after delivery.

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Cost Utility Analysis of Costal Cartilage Autografts and Human Cadaveric Allografts in Rhinoplasty

Nicole C. Starr,Liza Creel,Christopher Harryman,Nikita Gupta

Publication date 15-11-2021


Human cadaveric allograft (HCA) and costal cartilage autograft (CCA) have been described for reconstruction during rhinoplasty. Neither are ideal due to infection, resorption, and donor site morbidity. The clear superiority of 1 graft over the other has not yet been demonstrated. This study assesses comparative costs associated with current grafting materials to better explore the cost ceiling for a theoretical tissue engineered implant. A cost utility analysis was performed. Initial procedure costs include physician fees (CPT 30420), hospital outpatient prospective payments, ambulatory surgical center payments, and fees for the following: rib graft (CPT 20910), hospital observation, and DRG (155) for inpatient admission. Additional costs for revision procedure, included the following fees: physician (CPT 30345), rib graft, hospital outpatient prospective payment, and ambulatory surgical center payments. Total costs under each scenario were calculated with and without the revision procedure. Comparison of total costs for each potential outcome to the estimated health utility value allowed for comparison across rhinoplasty subgroups. The mean cost of primary outpatient rhinoplasty using HCA and CCA were $8075 and $8342 respectively. Revision outpatient rhinoplasty averaged $7447 and increased to $8228 if costal cartilage harvest was required. Hospital admission increased the cost of primary rhinoplasty with CCA to $8609 for observational admission and to $13653 for 1 day inpatient admission. Revision CCA rhinoplasty with an inpatient admission complicated by pneumothorax increased costs to $21 099. Cost of rhinoplasty without hospitalization was similar between HCA and CCA and this cost represents the lower limit of a practical cost for an engineered graft. Considering complications such as need for revision or for admission after CCA due to surgical morbidity, the upper limit of cost for an engineered implant would approximately double.

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Salivary HPV Persistence Following Treatment of Oropharyngeal Squamous Cell Carcinoma

Alexandra E. Quimby,Pagona Lagiou,Bibiana Purgina,Martin Corsten,Stephanie Johnson-Obaseki

Publication date 15-11-2021


To determine the persistence of human papillomavirus (HPV) infection following treatment of HPV-positive oropharyngeal squamous cell carcinoma (HPV + OPSCC). A cross-sectional study was undertaken at The Ottawa Hospital (Ottawa, ON, Canada), a tertiary academic hospital and regional cancer center. Adult patients who were diagnosed with HPV + OPSCC between the years of 2014 and 2016 and treated with curative intent, and who were alive and willing to consent were eligible for inclusion. A saliva assay was used to test for the presence of HPV DNA in a random sample of patients. qPCR was used to amplify DNA from saliva samples. Saliva samples were obtained from 69 patients previously treated with HPV + OPSCC. All patients had a minimum of 2 years of follow-up.
5 patients tested positive for HPV: 2 were positive for HPV-16, 2 for HPV-18, and 1 "other" HPV type. No patient in our study cohort had suffered recurrence post-treatment. This study is the first to demonstrate the prevalence of persistent oncogenic HPV DNA in saliva following treatment for HPV + OPSCC. This prevalence appears to be low, despite the fact that persistent HPV infection is a precursor for the development of HPV + OPSCC. This finding raises questions about what factors influence the clearance or persistence of HPV DNA in saliva after treatment for HPV + OPSCC, and may add to our understanding about the longitudinal effects of HPV infection in these cancers.

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Chronic Rhinosinusitis Outcomes of Patients With Aspirin-Exacerbated Respiratory Disease Treated With Budesonide Irrigations: A Case Series

Rehab Talat,Isabelle Gengler,Katie M. Phillips,David S. Caradonna,Stacey T. Gray,Ahmad R. Sedaghat

Publication date 15-11-2021


Pathophysiology-targeting treatments exist for aspirin-exacerbated respiratory disease (AERD) through aspirin desensitization and biologics, such as dupilumab. With increasing attention paid to these treatments, which may be associated with significant side effects and/or cost, there is little description of chronic rhinosinusitis with nasal polyps (CRSwNP) response to treatment with intranasal corticosteroids and saline irrigations in AERD. To determine the effect of intranasal budesonide irrigations for the treatment of CRSwNP in AERD. This is an observational study of 14 AERD patients presenting to a rhinology clinic for CRS who were treated with twice daily high volume, low pressure irrigations with 240 mL of saline to which a 0.5 mg/2 mL respule of budesonide was added. All participants completed a 22-item Sinonasal Outcome Test (SNOT-22) at enrollment and at follow up 1 to 6 months later. Polyp scores were also calculated at each time point. SNOT-22 scores ranged from 26 to 98 (median: 40.5) at enrollment and 3 to 85 (median: 38.5) at follow-up. Polyp scores ranged from 2 to 6 (median: 4) at enrollment at 0 to 6 (median: 2) at follow-up. Over the treatment period, change in SNOT-22 score ranged from -38 to 16 (median: -18) and change in polyp score ranged from -2 to 0 (median: -0.5). Approximately 57% of participants experienced at least 1 minimal clinically important difference in SNOT-22 score and 21% of participants had a SNOT-22 score <20 at follow-up. Medical management with intranasal corticosteroids and saline irrigations alone leads to significant improvement in sinonasal symptomatology in a subset of AERD.

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Otoendoscopes to Enhance Telemedicine During the COVID-19 Pandemic

Evette A. Ronner,Matthew E. Stenerson,Nicole H. Goldschmidt,Divya A. Chari,Gillian R. Diercks,Daniel J. Lee,Donald G. Keamy,Leila A. Mankarious,Michael S. Cohen

Publication date 02-11-2021


As telemedicine has become increasingly utilized during the COVID-19 pandemic, portable otoendoscopy offers a method to perform an ear examination at home. The objective of this pilot study was to assess the quality of otoendoscopic images obtained by non-medical individuals and to determine the effect of a simple training protocol on image quality. Non-medical participants were recruited and asked to capture images of the tympanic membrane before and after completion of a training module, as well as complete a survey about their experience using the otoendoscope. Images were de-identified, randomized, and evaluated by 6 otolaryngologists who were blinded as to whether training had been performed prior to the image capture. Images were rated using a 5-point Likert scale. Completion of a training module resulted in a significantly higher percentage of tympanic membrane visible on otoendoscopic images, as well as increased physician confidence in identifying middle ear effusion/infection, cholesteatoma, and deferring an in-person otoscopy ( At-home otoendoscopes can offer a sufficient view of the tympanic membrane in select cases. The use of a simple training tool can significantly improve image quality, though often not enough to replace an in-person otoscopic exam.

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Can Red Blood Cell Distribution Width Predict Laryngectomy Complications or Survival Outcomes?

Kathryn Marcus,Christopher Blake Sullivan,Zaid Al-Qurayshi,Marisa R. Buchakjian

Publication date 30-10-2021


Red blood cell distribution width (RDW), a reported biomarker for morbidity and mortality in chronic disease and following certain surgeries, has not been well-studied in head and neck cancer patients. The aim of the study was to examine the association of RDW with postoperative complications and survival among patients who underwent primary or salvage laryngectomy. We analyzed a retrospective case series study of patients diagnosed with squamous cell carcinoma of the larynx treated with total laryngectomy. Survival outcomes were examined using Kaplan-Meier analysis. One hundred seventy-seven patients were included in the final analysis. The most common tumor subsite was the supraglottis (60%). On bivariate analysis, patients with RDW ≥14.5 had higher prevalence of non-surgical, systemic complications, including deep venous thrombosis, pneumonia, cardiovascular events, and difficulty weaning from mechanical ventilation. However, there was no significant difference in laryngectomy-specific post-operative complications, including pharyngocutaneous fistula, wound infection, stoma complications, and chyle leak. RDW was not found to be associated with survival outcomes following laryngectomy. Among laryngectomy patients, RDW ≥14.5 is associated with higher prevalence of systemic morbidity, but not with specific local surgical complications or decreased survival.

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Patient Chief Complaint and Otolaryngology Referral Rationale: Discordance and Opportunities for Quality Improvement

Scott E. Mann,Shelby White,Laurel C. Officer,Laylaa Ramos,Scott Hirsch,Geoffrey R. Ferril

Publication date 30-10-2021


As medical systems focus on patient satisfaction as an important care outcome, specialty clinics are tasked with continued improvement of patients' experience. When patient expectations for a consultation differ from that of the specialty provider, dissatisfaction with the experience can occur. One source of differing expectations is discordance between the patient's chief complaint and the clinical rationale for the consultation as requested by the referring provider. We sought to better understand when this discordance occurs, as well as factors contributing to this disorientation of patient and provider expectations in a safety net otolaryngology practice. A retrospective observational study was performed and records were examined from new patient consultations. Patient questionnaires, including self-reported chief concerns, were compared with the electronic referral documentation. A difference between the patient's Chief Complaint (CC) and Referral Reason (RR) was defined as CC-RR Discordance. Medical records, pre-consultation patient communication, and scheduling data were also reviewed to evaluate contributing factors. Of the 1155 consultations examined, 952 were included in the analysis. A CC-RR Discordance was found in 175 (18.4%) of new-patient encounters, including 117 (12.3%) that were unable to articulate a CC (unsure of the reason for the appointment), and 58 (6.1%) that stated a CC that was different than the RR. The rate of CC-RR Discordance was higher in patients with female sex ( Discordance between patient CC and the rationale for a consultation is common in this safety-net otolaryngology practice and may be an important source of patient dissatisfaction. Future opportunities for quality improvement include pre-consultation communication between the specialist and the patient and reducing time intervals between referral and appointment.

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Effects of Age on Delayed Facial Palsy After Otologic Surgery: A Systematic Review and Meta-Analysis

Benjamin D. Lovin,Alex D. Sweeney,Alyssa Claire Chapel,Kristan Alfonso,Nandini Govil,Yi-Chun Carol Liu

Publication date 28-10-2021


To report 4 cases of delayed facial palsy (DFP) after pediatric middle ear (ME) surgery and systematically review and analyze the associated literature to evaluate the effects of age on DFP etiology, management, and prognosis. Systematic review of Pub Med, Cochrane Library, and Embase for articles related to DFP after cochlear implantation (CI) was performed. These articles were assessed for level of evidence, methodological limitations, and number of cases. Meta-analysis was performed to assess the effects of age on DFP incidence. Furthermore, a comprehensive list of all pediatric DFP cases after otologic surgery was assembled through a multi-institutional retrospective review and systematic review of the literature. Twenty-nine articles fit the criteria for inclusion in the meta-analysis. The incidence of DFP after CI was 0.23% and 1.01% for pediatric and adult cases, respectively. This difference was statistically significant ( The systematic review demonstrates that DFP after pediatric CI is rare and occurs at a significantly lower rate than in adults, further supporting the viral reactivation hypothesis of DFP. The prognosis for pediatric DFP after otologic surgery is excellent, with a high rate of full recovery in a short time frame. However, steroid administration can be considered. IIa.

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Adenoid Cystic Carcinoma of the Gingiva: A Case Report and Literature Review

Gabriella T. Seo,Monica H. Xing,Neil Mundi,Ammar Matloob,Azita S. Khorsandi,Mark L. Urken

Publication date 28-10-2021


Adenoid cystic carcinoma (ACC) is a commonly encountered salivary gland malignancy. However, it rarely occurs in the gingiva, an area generally thought to be devoid of minor salivary glands. We present a case occurring in this unusual site and review other reported cases. A 56 year-old male presented with a right-sided mandibular toothache for 1 year and underwent dental extraction. Due to persistent pain, follow up examination revealed a large gingival lesion. A biopsy was positive for adenoid cystic carcinoma. The patient underwent a complete right segmental mandibulectomy and was reconstructed with a fibular osteocutaneous free flap. Three months postoperatively, during the planning for adjuvant radiation therapy, the patient developed pain in the left mandible. Imaging revealed extensive involvement of the left native mandible. Deep bone biopsies in several areas of the left mandible revealed ACC. He then underwent a complete left hemi-mandibulectomy and reconstruction with a fibular osteocutaneous free flap. Tensor fascia lata suspension slings were placed due to concern for an open mouth deformity attributable to disruption of bilateral masticator slings. He will undergo adjuvant radiation therapy. Our review of the literature revealed 50 cases of gingival ACC published since 1972. Disease recurrence and distant metastases were noted in several patients, occurring at the latest after 30 years follow-up. Given its indolent behavior, high proclivity for late recurrence and metastasis, and overall infrequency, ACC represents a pathology that requires early diagnosis and comprehensive long-term surveillance. While ACC is well described in oral cavity sites with high densities of minor salivary glands, it is not commonly seen in the gingiva. As such, gingival ACC may display a unique biological and/or clinical character. We offer the first literature review of this rare entity.

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Continuous Positive Airway Pressure Titration During Pediatric Drug Induced Sleep Endoscopy

Adam C. Adler,Arvind Chandrakantan,Mary Frances Musso

Publication date 28-10-2021


To observe the degree of airway collapse at varying levels of continuous positive airway pressure (CPAP) during drug pediatric induced sleep endoscopy. Using our institutional anesthesia protocol for pediatric DISE procedures, patients were anesthetized followed by evaluation of the nasal airway, nasopharynx, velum, hypopharynx, arytenoids, tongue base, and epiglottis. CPAP titration was performed under vision to evaluate the degree of airway collapse at the level of the velum. Comparison was made with pre-operative polysomnography findings. Twelve pediatric patients underwent DISE with intraoperative CPAP titration. In 7/12 patients, DISE observed CPAP titration was beneficial in elucidating areas of obstruction that were observed at pressures beyond those recommended during preoperative sleep study titrations. In 3 patients, DISE observations provided a basis for evaluation in children not compliant with sleep study CPAP titration testing. With regard to regions effected, airway collapse was observed at the velum and oropharynx to a greater degree when compared with the tongue base and epiglottis. DISE evaluation of the pediatric patient with obstructive sleep apnea may present a source for further patient evaluation with respect to CPAP optimization and severity of OSA assessment, particularly in syndromic patients.

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Rapidly Progressive Complicated Acute Bacterial Sinusitis in the Setting of Severe Pediatric SARS-CoV-2 Infection

Alberto A. Arteaga,Jessica Tran,Hudson Frey,Andrea F. Lewis

Publication date 28-10-2021


This case report presents a case of a rapidly progressive complicated sinus infection in a child with the multisystem inflammatory syndrome in children. Case report with literature review. We present a novel case of severe rapidly progressive complicated sinusitis in a 14-year-old African American male diagnosed with the multisystem inflammatory syndrome in children. Infection was caused by an aggressive pathogen, Streptococcus intermedius (anginosus), and within 48 hours progressed to orbital, subgaleal, and intracranial abscess, requiring multidisciplinary intervention by ophthalmology, neurosurgery, and otolaryngology. Following surgical intervention and a 4-week course of intravenous antibiotic therapy, the patient had resolution of the infection with no neurologic sequelae. Despite the low incidence of multisystem inflammatory syndrome in children, physicians should be aware that immunologic changes and the cytokine storm induced by severe acute respiratory syndrome coronavirus 2 can potentially predispose patients to severe bacterial or opportunistic infections. As more cases of MIS-C develop, associated complications can become evident. Similar cases of SARS-CoV-2 and severe bacterial sinusitis have been published in the literature, but it remains unclear if there is an association between SARS-CoV-2 disease and an increased risk of complicated sinusitis in children.

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A Comprehensive Update of the Incidence and Demographics of Laryngoceles in Adults

Einat Slonimsky,David Goldenberg,Gloria Hwang,Eric Gagnon,Guy Slonimsky

Publication date 28-10-2021


To provide updated data on the incidence, types, and demographics of laryngoceles in the adult population. We searched the medical archives of our institute for computed tomography (CT) studies acquired between January 1, 2007 and December 31, 2017 in which the term "laryngocele" appeared in the radiology reports. Two of the authors reviewed relevant images for the presence, type, distribution, and laterality of true laryngoceles. Demographic and clinical data were extracted from medical records and the incidence was calculated. Laryngoceles were detected in 53 out of the 79 893 patients with relevant CT data, which equates to an incidence of 151 per 2.5 million (0.06:1000) patients per year. The male:female ratio was 3:1, average age was 60 (±18) years, and incidence peaked among patients in the sixth decade of life. Nine patients (17%) had known laryngeal cancer; however, the majority of the cohort did not have follow up clinic visits. Our study demonstrates that the incidence of laryngoceles is much greater than previously reported. In most cases, the diagnosis of a laryngocele was an incidental radiological finding. Male gender predilection and age at presentation are in agreement with previous reports. Association of laryngoceles with laryngeal cancer could not be calculated due to low rates of follow ups. 3.

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Understanding Extremely Elevated Dizziness Handicap Inventory Scores: An Analysis of Predictive Factors

Emily C. Wong,Whitney Chiao,Blaze T. Strangio,Katrina Luong,Lauren Pasquesi,Isabel E. Allen,Jeffrey D. Sharon

Publication date 25-10-2021


The Dizziness Handicap Inventory (DHI) measures impairment in quality of life due to dizziness, with higher scores indicating greater impairment. Little is known about the clinical features that predict extremely elevated DHI scores (eeDHI). To identify clinical features associated with eeDHI. A retrospective analysis was conducted of 217 patients with dizziness between October 2016 and April 2019. Patients with eeDHI had DHI scores 1 standard deviation higher than the mean. Analyses were performed to generate odds ratios (OR) for having eeDHI based on clinical features and exam findings. The cut-off for eeDHI scores was 71. In total, 20.7% had eeDHI.
Logistic regression identified 6 independent predictors for eeDHI scores: numbness in the face or body during dizziness (OR = 5.99, 95% CI 1.77-20.30), history of falls (OR = 4.37, 95% CI 1.74-10.97), female sex (OR = 2.81, 95% CI 1.18-6.66), caloric weakness (OR = 2.61, 95% CI 1.36-5.01), total number of diagnoses associated with dizziness (OR = 2.17, 95% CI 1.11-4.28), and total number of symptoms during dizziness (OR = 1.25, 95% CI 1.07-1.45). These findings suggest that patients with eeDHI have severe disease and should be screened for falls. By understanding the drivers of high DHI scores, we can alleviate disease related suffering for vestibular disorders.

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Intermediate Invasive Fungal Sinusitis, a Distinct Entity From Acute Fulminant and Chronic Invasive Fungal Sinusitis

Andre J. Burnham,Kelly R. Magliocca,Brian Pettitt-Schieber,Thomas S. Edwards,Sonya Marcus,John M. DelGaudio,Sarah K. Wise,Joshua M. Levy,Lauren T. Roland

Publication date 25-10-2021


The current classification system of invasive fungal sinusitis (IFS) includes acute (aIFS) and chronic (cIFS) phenotypes. Both phenotypes display histopathologic evidence of tissue necrosis, but differ by presence of angioinvasion, extent of necrosis, and disease progression. aIFS is defined by a rapid onset of symptoms, while cIFS slowly progresses over ≥12 weeks. However, a subset of IFS patients do not fit into the clinical presentation and histopathologic characteristics of either aIFS or cIFS. To investigate the demographic, clinical, and histopathologic characteristics of a distinct subset of IFS. Retrospective review of patients with IFS from a single tertiary-care institution (2010-2020). Patients with symptoms for ≤4 weeks were classified as aIFS if they displayed endoscopic evidence of mucosal necrosis or fungal angioinvasion on pathology. Patients with slowly progressive IFS for ≥12 weeks were classified as cIFS. Patients with symptom duration between 4 and 12 weeks with evidence of invasive fungal disease were classified as a new entity and were further investigated. Of the 8 patients identified, 50% were immunosuppressed at presentation. The mean symptom duration prior to presentation was 50.5 days (SD 16.8), and common symptoms included facial pain (100%), vision change (87.5%), and blindness (37.5%). Two patients (25%) died of their disease. Sites of fungal involvement confirmed by histopathology included sphenoid (62.5%) and ethmoid sinuses (12.5%), orbital apex (25%), optic nerve (12.5%), pterygopalatine fossa (12.5%), and clivus (12.5%). Fungal elements but without obvious angioinvasion, were identified in all specimens, and fungus balls (50%), granulomas (37.5%), and giant cells (25%) were also observed on histopathology. CT and MRI radiographic imaging showed findings consistent with orbital, intracranial, or skull base involvement in all patients. We propose intermediate IFS as a new subgroup of patients with IFS who do not fit into the standard classification of aIFS or cIFS.

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Opioid Usage and Pain Control in Benign Oropharyngeal Surgery: An Observational Prospective Study

Matthew Stewart,Eric Mastrolonardo,Adeeba Ghias,Joann Butkus,Kealan Hobelmann,Tingting Zhan,Sophia Dang,David Cognetti,David Rosen,Maurits Boon,Colin Huntley

Publication date 25-10-2021


Little data is available on opioid usage in the adult population for benign oropharyngeal surgery. The objective here is to evaluate opioid prescribing patterns, opioid consumption, and patient pain patterns following benign oropharyngeal surgery, specifically tonsillectomy and adenoidectomy, tonsillectomy alone, and expansion sphincter pharyngoplasty. Patients aged ≥18 years old and received a tonsillectomy, tonsillectomy and adenoidectomy, or expansion sphincter pharyngoplasty between November 2019 and August 2020 were included. Patients were provided a survey which included a visual analog scale for recording their pain postoperatively and the amount of opioid they had remaining. About 103 patients completed the post-operative questionnaire.
Patients were prescribed 38 837 morphine milligram equivalents and used 28 644: approximately 26% went unused, which is the equivalent of 1346 5 mg oxycodone pills.
Opioid consumption correlated with the initial dosage: patients consumed 12% more narcotic on average as the initial prescription went upwards by 50 morphine milligram equivalents. Obstructive sleep apnea, history of smoking, and being female predicted increased opioid usage in this cohort. Pain was reported the highest on postoperative day 1. A prescription of approximately 225 morphine milligram equivalents (150 mg oxycodone) was associated with decreased opioid use in this cohort. Larger initial prescriptions did not result in fewer requests for refills. A significant amount of opioid medication went unused in this study. A prescription of 225 morphine milligram equivalents (or 150 mg oxycodone) provided appropriate analgesia for the majority of patients. Larger prescriptions may result in increased opioid consumption and may not reduce the amount of refills. More study is needed to confirm these findings.

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Effects of Tham Nasal Alkalinization on Airway Microbial Communities: A Pilot Study in Non-CF and CF Adults

Zachary M. Holliday,Janice L. Launspach,Lakshmi Durairaj,Pradeep K. Singh,Joseph Zabner,David A. Stoltz

Publication date 22-10-2021


In cystic fibrosis (CF), loss of CFTR-mediated bicarbonate secretion reduces the airway surface liquid (ASL) pH causing airway host defense defects. Aerosolized sodium bicarbonate can reverse these defects, but its effects are short-lived. Aerosolized tromethamine (THAM) also raises the ASL pH but its effects are much longer lasting. In this pilot study, we tested the hypothesis that nasally administered THAM would alter the nasal bacterial composition in adults with and without CF. Subjects (n = 32 total) received intranasally administered normal saline or THAM followed by a wash out period prior to receiving the other treatment. Nasal bacterial cultures were obtained prior to and after each treatment period. At baseline, nasal swab bacterial counts were similar between non-CF and CF subjects, but CF subjects had reduced microbial diversity. Both nasal saline and THAM were well-tolerated. In non-CF subjects, nasal airway alkalinization decreased both the total bacterial density and the gram-positive bacterial species recovered. In both non-CF and CF subjects, THAM decreased the amount of This study shows that aerosolized THAM is safe and well-tolerated and that nasal airway alkalinization alters the composition of mucosal bacterial communities. NCT00928135 (https://clinicaltrials.gov/ct2/show/NCT00928135).

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Electrostatic Discharge (ESD) as a Cause of Facial Nerve Stimulation After Cochlear Implantation: A Case Report

Smruti Rath,Mica Glaun,Claudia Emery,Yi-Chun Carol Liu

Publication date 15-10-2021


To discuss persistent facial nerve stimulation (FNS) related to repeated electrostatic discharge (ESD) shock following cochlear implantation. Single case report with literature review. FNS is a feared complication after cochlear implantation, occurring in approximately 7% of cases, with most patients having anatomic abnormalities. The presented case has no anatomical abnormalities but reported frequent environmental static shock. FNS during the first 1 to 3 seconds of processor attachment caused a significant decrease in the patient's quality of life, requiring subsequent re-implantation with full resolution. FNS is a complication of cochlear implantation that can cause a great deal of distress and discomfort. Frequent electrostatic discharge (ESD) contributed to device malfunctioning and FNS in a patient with otherwise normal anatomy and should be avoided if possible.

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Dyskeratosis Congenita and Squamous Cell Cancer of the Head and Neck: A Case Report and Systematic Review

Alice Q. Liu,Emily C. Deane,Eitan Prisman,J. Scott Durham

Publication date 15-10-2021


Dyskeratosis congenita (DC) is a progressive congenital disorder that predisposes patients to squamous cell cancers (SCC) of the head and neck. We report a case of a patient who underwent primary osteocutaneous free flap for mandibular SCC followed by additional treatments for positive margins and discuss a systematic review on therapeutic management for this patient population. Case report of a 39-year-old male with DC who underwent resection and reconstruction with a fibular free flap for mandible SCC, followed by revision surgery and adjuvant radiotherapy for positive margins.
A systematic review was completed afterward with the following terms: "dyskeratosis congenita" AND "oral cancer" OR "head and neck" OR "otolaryngology" on Medline and Web of Science for articles between 1980 and 2021. In total, 12 articles were included that reported on DC and SCC in the head and neck. Of the case reports that were included in this review, half the patients had recurrence within 1 year of primary treatments. Only 2 patients did not require revision surgery, adjuvant, or salvage therapy. Half of patients that received radiation therapy had severe side effects. This is the largest review of DC and SCC in the head and neck. Based off our case report and review, these patients have aggressive disease that often requires multi-modality treatment. Consideration should be taken in regards to reports of side effects with radiation therapy.

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Acute Vocal Fold Paresis and Paralysis After COVID-19 Infection: A Case Series

Sarah K. Rapoport,Ghiath Alnouri,Robert T. Sataloff,Peak Woo

Publication date 13-10-2021


Evidence demonstrates neurotropism is a common feature of coronaviruses. In our laryngology clinics we have noted an increase in cases of "idiopathic" vocal fold paralysis and paresis in patients with no history of intubation who are recovering from the novel SARS-Cov-2 coronavirus (COVID-19). This finding is concerning for a post-viral vagal neuropathy (PVVN) as a result of infection with COVID-19. Our objective is to raise the possibility that vocal fold paresis may be an additional neuropathic sequela of infection with COVID-19. Retrospective review of patients who tested positive for COVID-19, had no history of intubation as a result of their infection, and subsequently presented with vocal fold paresis between May 2020 and January 2021. Charts were reviewed for demographic information, confirmation of COVID-19 infection, presenting symptoms, laryngoscopy and stroboscopy exam findings, and laryngeal electromyography (LEMG) results. Sixteen patients presented with new-onset dysphonia during and after recovering from a COVID-19 infection and were found to have unilateral or bilateral vocal fold paresis or paralysis. LEMG was performed in 25% of patients and confirmed the diagnosis of neuropathy in these cases. We believe that COVID-19 can cause a PVVN resulting in abnormal vocal fold mobility. This diagnosis should be included in the constellation of morbidities that can result from COVID-19 as the otolaryngologist can identify this entity through careful history and examination.

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Evaluation of Industry Relationships Among Authors of Systematic Reviews and Meta-analyses Regarding Ménières Disease

David Wenger,Ross Nowlin,Austin L. Johnson,Michael Anderson,Michael Weaver,Micah Hartwell,Matt Vassar

Publication date 12-10-2021


To quantify the presence of conflicts of interest (COI) in SRs and MAs of Ménières disease treatment and identify any related secondary characteristics of these articles. A search was conducted on May 28, 2020 to search MEDLINE and Embase databases for SRs or MAs pertaining to Ménières disease published between September 1, 2016 and June 2, 2020. A risk of bias assessment was performed using the Cochrane Collaboration risk of bias assessment criteria. A total of 13 systematic reviews conducted by 49 authors met the inclusion criteria. Of the 49 authors, 7 (14.3%) were found to have some form of COI. Of these 7 authors, 1 (14.3%) completely disclosed all COI within the SR, 1 (14.3%) disclosed one or more COI but were found to have an additional undisclosed COI, and 5 (71.4%) were found to have only undisclosed COI. One of 2 industry funded SRs (50%) had a high risk of bias, and 1 (50%) of the non-industry sponsored SRs were found to have a high risk of bias. Overall authors of SRs pertaining to Ménières disease appear to be properly disclosing COI at higher rates than other fields of medicine; however, further room for improvement has been noted.

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Spending and Utilization on Drugs Prescribed by Otolaryngologists to Medicare Beneficiaries, 2013 to 2017

Shivani A. Shah,Lauren E. Miller,Roy Xiao,Alan Workman,Lucy Xu,Vinay K. Rathi

Publication date 09-10-2021


The significant and rising cost of prescription drugs is a pressing concern for patients and payers. However, little is known about spending on and utilization of drugs prescribed by otolaryngologists. Utilizing publicly available Medicare Part D Prescriber Public Use data, we conducted a retrospective cross-sectional analysis of 34 small-molecule drugs commonly prescribed by otolaryngologists (defined as 2017 Medicare Part D spending ≥$500 000) to Medicare beneficiaries. Prescription data was characterized by drug type (brand name vs generic). Primary outcomes for each prescription drug included the total annual cost and the total annual number of days supplied. From 2013 to 2017, spending on drugs prescribed by otolaryngologists to Medicare beneficiaries decreased by $32.1 million ($131.7-$99.5 million; relative decrease 24.4%; compound annual growth rate [CAGR] -5.4%), while total utilization increased by 24.9 million days supplied (74.6-99.5 million; relative increase 33.3%; CAGR 5.9%). For brand name drugs, there was a decrease in spending ($71.1-$26.7 million; relative decrease -62.4%; CAGR -17.8%) and utilization (11.2-3.1 million days supplied; relative decrease -72.5%; CAGR -22.8%). In contrast, generic drugs demonstrated increased spending ($60.6-$72.8 million; relative increase 20.2%; CAGR 3.7%) and utilization (63.5-96.4 million days supplied; relative increase 51.9%; CAGR 8.7%). Spending on drugs prescribed by otolaryngologists to Medicare Part D beneficiaries declined between 2013 and 2017 in part due to a transition from brand name drugs to lower-cost generic equivalents.

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Understanding the Role of the Otolaryngology Hospitalist: Tracheostomies and Tracheostomy Care

Mohamad Issa,Nadeem El-Kouri,Sara Mater,Jonathan Y. Lee,Carl Snyderman,Yan Lee

Publication date 09-10-2021


The concept of a hospitalist has been well established. This model has been associated with reduced length of stay contributing to reduction in healthcare costs. Minimal literature is available assessing the effects of an otolaryngology (ENT) hospitalist at a tertiary medical center. The aim of this study is to assess the role of an ENT hospitalist on (1) performing tracheostomies and (2) providing care as part of the tracheostomy care team (TCT). Retrospective chart review of all tracheostomies performed by the ENT service over 2 years (July 2015-June 2017), and prospective data collection of all tracheostomy care consults over 1 year (July 2016-June 2017). In year 1 (from July 2015 to June 2016), no ENT hospitalist was employed, and in year 2 (from July 2016 to June 2017), an ENT hospitalist was employed. Compared to other Ear, Nose, and Throat (ENT) surgeons, the ENT hospitalist performed tracheostomies with shorter patient wait times, and performed a greater proportion of percutaneous tracheostomies at the bedside versus open tracheostomies in the operating room. The tracheostomy care team (TCT) received 91 consults over the course of 1 year with an average of 1.1 billable procedures generated per consult. In this study, an ENT hospitalist was decreased patient wait time to tracheostomy and increased bedside percutaneous tracheostomies, which has positive implications for resource utilization and healthcare cost. The average wait time to receive a tracheostomy was reduced when calculated across the entire department due to the availability of the ENT hospitalist to see and perform tracheostomies. The TCT generated many billable bedside procedures in addition to encouraged decannulation of patients. This study highlights the fact that the ENT hospitalist contributes to providing expedient tracheostomies and provides valuable consulting services as part of a TCT at a high-volume tertiary care facility.

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“A Major Quality of Life Issue”: A Survey-Based Analysis of the Experiences of Adults With Laryngotracheal Stenosis with Mucus and Cough

Gemma M. Clunie,Catherine Anderson,Matthew Savage,Catherine Hughes,Justin W. G. Roe,Gurpreet Sandhu,Alison McGregor,Caroline M. Alexander

Publication date 08-10-2021


To investigate how the symptoms of mucus and cough impact adults living with laryngotracheal stenosis, and to use this information to guide future research and treatment plans. A survey was developed with the support of patient advisors and distributed to people suffering with laryngotracheal stenosis. The survey comprised 15 closed and open questions relating to mucus and cough and included the Leicester Cough Questionnaire (LCQ). Descriptive statistics, In total, 641 participants completed the survey, with 83.62% (n = 536) reporting problems with mucus; 79% having daily issues of varying severity that led to difficulties with cough (46.18%) and breathing (20.90%). Mucus affected voice and swallowing to a lesser degree. Respondents described a range of triggers; they identified smoky air as the worst environmental trigger. Strategies to manage mucus varied widely with drinking water (72.26%), increasing liquid intake in general (49.35%) and avoiding or reducing dairy (45.32%) the most common approaches to control symptoms. The LCQ showed a median total score of 14 (interquartile range 11-17) indicative of cough negatively affecting quality of life. Thematic analysis of free text responses identified 4 key themes-the Mucus Cycle, Social impact, Psychological impact, and Physical impact. This study shows the relevance of research focusing on mucus and cough and its negative impact on quality of life, among adults with laryngotracheal stenosis. It demonstrates the inconsistent advice and management strategies provided by clinicians for this issue. Further research is required to identify clearer treatment options and pathways.

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Recent Laryngology Fellowship Graduates: Where Are They Now?

Benjamin Damazo,Traci Bailey,Daniel R. Fisher,Salem Dehom,Victoria Cress,Thomas Murry,Michael M. Johns,Priya Krishna,Brianna K. Crawley

Publication date 08-10-2021


Over the past 30 years laryngology fellowships have grown in number and diversity. This study investigated the career trajectories of recent laryngology fellowship graduates with the purpose of informing residents considering fellowship. Cross-sectional survey. Academic medical center. The directors of all 27 US laryngology fellowships that graduated/recruited fellows from 2010 to 2019 were contacted, and a list of former fellows was compiled. A short survey was administered in person or via email or phone. Additional data was gathered through internet searches. One hundred eighty-three fellows were identified having completed American laryngology fellowships between 2010 and 2019 (100M:83F). Fifteen percent now practice internationally and 68% are in academic practice. A higher proportion of women than men enter laryngology fellowship after otolaryngology residency. One hundred twenty-nine fellows responded to our survey. Two-thirds of former fellows report current participation in laryngology research. Seventy-two percent of former fellows are still in their first job after fellowship and 53% believe they have their ideal practice. Women were more likely to enter academics than men after laryngology fellowship. Responders were overwhelmingly satisfied with their fellowship experience, with 95% saying they would choose to pursue fellowship training again. Most former laryngology fellows enter academia, contribute to laryngology research, practice away from their training institution, and believe they have found their ideal practice. The results of this study may be useful to residents considering fellowship training, centers considering establishing laryngology fellowships, and practices recruiting fellowship graduates.

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Disparities in Access to Pediatric Otolaryngology Care During the COVID-19 Pandemic

Yvonne Adigwu,Beth Osterbauer,Christian Hochstim

Publication date 08-10-2021


Racial/ethnic minority pediatric otolaryngology patients experience health disparities, including barriers to accessing health care. Our hypothesis for this study is that Hispanic or economically disadvantaged patients would represent a larger percentage of missed appointments and report more barriers to receiving care during the COVID-19 pandemic. A cross-sectional survey utilizing a modified version of the Barriers to Care Questionnaire was administered via telephone to no-show patients, and median income by zip code was collected. Chi-squared, logistic regression, and Student's No-show patients were more likely to be Hispanic than not (OR 2.3, 95% CI: 1.3, 3.9, In our study, we identified ethnic, financial, and logistic concerns that may contribute to patients failing to keep their appointments with the otolaryngology clinic. Future studies are needed to assess the efficacy of measures aimed to reduce these barriers to care such as preventive plans to assist new patients and expanding telehealth services.

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The Digital Dilemma: Perspectives From Otolaryngology Residency Applicants on Social Media

Ankita Patro,Kelly C. Landeen,Madelyn N. Stevens,Nathan D. Cass,David S. Haynes

Publication date 07-10-2021


To evaluate the impact of otolaryngology programs' social media on residency candidates in the 2020 to 2021 application cycle. An anonymous survey was distributed via Otomatch, Headmirror, and word of mouth to otolaryngology residency applicants in the 2021 Match. Survey items included demographics, social media usage, and impact of programs' social media on applicant perception and ranking. Descriptive statistics were performed, and responses based on demographic variables were compared using Fisher's exact and Mann-Whitney Of 64 included respondents, nearly all (61/64, 95%) used Facebook, Instagram, and/or Twitter for personal and/or professional purposes. Applicants (59/64, 92%) most commonly researched otolaryngology residency programs on Instagram (55/59, 93%) and Twitter (36/59, 61%), with younger ( Social media platforms like Instagram and Twitter are frequently used by applicants to assess otolaryngology residency programs. Programs' social media accounts effectively demonstrate program culture and affect applicants' rank lists. As social media usage continues to rise in the medical community, these findings can help otolaryngology residency programs craft a beneficial online presence that aids in recruitment, networking, and education.

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Cricopharyngeal Achalasia Presenting as Acute Dysphagia in a Pediatric Patient

Laura Beth O’Neill,Matthew Magyar,Brian Reilly,Tamara Gayle

Publication date 07-10-2021


To describe a case of idiopathic cricopharyngeal achalasia (CPA) in a pediatric patient with acute onset of dysphagia managed conservatively with supportive care. Sixteen-month-old boy presented with acute onset of gagging and coughing with feeding. His exam was notable for a well-appearing child with pooling of oral secretions and coarse breath sounds. Plain film series did not show radio-opaque foreign body (FB) and an esophagram demonstrated an endoluminal filling defect of the cervical esophagus and aspiration of contrast. He was taken to the operating room for urgent endoscopy but no FB or food impaction was observed. He had persistent symptoms that required further evaluation and a multidisciplinary team approach. Bedside laryngoscopy did not reveal any abnormalities. Modified barium swallow (MBS) study revealed upper esophageal sphincter (UES) dysfunction, consistent with cricopharyngeal achalasia. Repeat upper endoscopy with biopsies demonstrated mucosal irritation overlying the UES but histologic studies were negative for infectious causes. He was treated with supportive care, including nasogastric feedings for nutrition supplementation as he was unable to tolerate oral feedings without aspiration. Over the course of 3 months after discharge, his symptoms resolved and repeat MBS was normal. CPA is a rare cause of dysphagia in the pediatric population. Conservative management with supportive care is a reasonable approach in cases with acute onset in otherwise healthy children without underlying medical problems.

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The Long-term Effect of Inferior Turbinate Surgery Techniques on Nasal Obstruction and Quality of Life

Teemu Harju,Jura Numminen

Publication date 06-10-2021


The aim of the study was to compare the long-term effects of radiofrequency ablation (RFA), microdebrider-assisted inferior turbinoplasty (MAIT), and diode laser techniques on the severity of nasal obstruction and quality of life (QOL) in a 3-year follow-up. The patients filled a Visual Analog Scale (VAS) regarding the severity of nasal obstruction and the Glasgow Health Status Inventory (GHSI) questionnaire preoperatively and during the control visits at 3 months and 3 years. Acoustic rhinometry was also performed. A total of 78 patients attended both control visits. All 3 techniques improved the VAS score for the severity of nasal obstruction and the GHSI total score significantly compared to the preoperative values at both 3 months and 3 years. Compared to the preoperative values, all 3 techniques increased the V2 to 5 cm values significantly at 3 months. After 3 years, compared to the preoperative values, the MAIT ( The RFA, MAIT, and diode laser all improved both the patients' subjective sensation of the severity of nasal obstruction and QOL significantly. The response was sustained during the 3-year follow-up period with all 3 techniques. A weakening in the objective treatment response to RFA was found in the longer follow-up, but that did not cause a weakening of the patients' subjective treatment response.

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Association Between Neonates With Laryngomalacia and Neonatal Abstinence Syndrome

Elizabeth J. Abraham,David O’Neil Danis,Jessica R. Levi

Publication date 01-10-2021


Laryngomalacia (LM) is the most common congenital anomaly of the larynx. The cause of LM is still largely unknown, but a neurological mechanism has gained the most acceptance. There have not been any studies examining the prevalence of LM in infants with Neonatal Abstinence Syndrome (NAS). The aim of our study is to determine if infants with NAS are more likely to be diagnosed with LM. This study was a population-based inpatient registry analysis. We examined nationwide neonatal discharges in 2016 using the Kids' Inpatient Database (KID). Only patients listed as neonates were included. The International Classification of Diseases, 10th revision, Clinical Modification (ICD-10-CM) codes for neonatal withdrawal symptoms from maternal use of drugs of addiction (P96.1) and diagnoses denoting LM were used. To quantify associations between the LM and NAS groups, prevalence rates and odds ratios (ORs) were used. There were 3 970 065 weighted neonatal discharges in the 2016 KID. Among patients included in our dataset, 0.809% (32 128) had NAS and 0.075% (2974) had LM. There was an increased odds ratio for neonates with NAS and LM (OR of 2.85, 95% CI = 2.24-3.63) compared to infants without NAS. Multiple logistic regression accounting for possible confounders produced an adjusted OR of 1.68 (95% CI = 1.29-2.19). Our study found an association between NAS and LM. This suggests that prenatal exposure to opioids or possibly the sequelae of withdrawal symptoms may be risk factors for the development of LM.

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Admission of Patients With Obstructive Sleep Apnea Undergoing Ambulatory Surgery in Otolaryngology—Head and Neck Surgery

Vincent Wu,Nick Lo,R. Jun Lin,Molly Zirkle,Jennifer Anderson,John M. Lee

Publication date 30-09-2021


Within Otolaryngology-Head and Neck Surgery (OHNS), obstructive sleep apnea (OSA) patients are frequently encountered. To implement policies and screening measures for admission of OSA patients undergoing ambulatory surgery, actual rates of admission must first be determined. We aimed to evaluate rates and reasons for admission of OSA patients after ambulatory OHNS surgery. Retrospective chart review was undertaken of all OSA patients undergoing elective day-surgery OHNS procedures at a tertiary center from January 1, 2018 to December 31, 2019. The primary outcome measure was percentage of OSA patients admitted to hospital after ambulatory OHNS surgery. Secondary outcome measures included reasons for admission. American Society of Anesthesiologists (ASA) score, perioperative complications, and patient demographics were captured. There were 118 OSA patients, out of 1942 cases performed during the review period. Thirty-eight were excluded as the procedures were not considered ambulatory. The remaining 80 OSA patients were included for analysis, with an average age of 51.7, SD 13.8, and 30 (38%) females. The admission rate was 47.5% (38/80 patients). Admitted patients were older ( More than half of OSA patients did not require admission to hospital after ambulatory OHNS surgery, unaffected by indications for surgery or type of surgery. Higher ASA score and older age were found in admitted as compared to non-admitted patients.

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Pediatric Otolaryngology During COVID-19: Parental Concern About Elective Surgery

Francesca C. Viola,Lauren DiNardo,Jason C. DeGiovanni,Michele M. Carr

Publication date 25-09-2021


To identify the concerns of parents whose children may need elective surgery during the COVID-19 pandemic. In December 2020, parents of pediatric otolaryngology patients were recruited for a survey about concerns related to elective surgery during the COVID-19 pandemic. A Likert scale quantified concern. The 1 was anchored "Not at all important" and 5 was "Most important." Demographics included gender, age, race, education level, number of children in household, and whether their child had surgery since March 2020. About 253 participants were included. Medians ranged from 1 for concerns about emotional and family support to 4 for concerns about their child being exposed to COVID-19 in the Emergency Room. Black parents were more concerned about the risks of COVID than White parents; they were more concerned about their child contracting COVID-19 during surgery compared to White parents, median was 4 versus 3 ( Parents were most concerned about the risk of seeking Emergency Room care. Black parents were generally more concerned about having their child undergo elective surgery. Whether this is translated into fewer Black children undergoing important but elective surgery requires more study.

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Comparative Treatment Outcome in T3N0 Glottic Cancer With and Without Vocal Fold Fixation Receiving Radiation Therapy and Concurrent Low-Dose Intra-Arterial Cisplatin Infusion

Takeharu Ono,Norimitsu Tanaka,Shun-ichi Chitose,Syuichi Tanoue,Takashi Kurita,Shintarou Sueyoshi,Mioko Fukahori,Yusaku Miyata,Koichiro Muraki,Chiyoko Tsuji,Etsuyo Ogo,Chikayuki Hattori,Kiminobu Sato,Toshi Abe,Hirohito Umeno

Publication date 25-09-2021


Selective radiotherapy and concomitant intra-arterial cisplatin infusion (m-RADPLAT) with a lower cisplatin dosage have been performed for organ and function preservation in patients with locally advanced squamous cell carcinoma of the larynx (SCC-L), and results showing a lower rate of adverse events have been reported. This study evaluated the treatment outcomes of patients with T3N0 glottic SCC-L with or without vocal fold fixation (VFF) who were treated with m-RADPLAT. We retrospectively reviewed the data of 33 patients with T3N0 SCC-L who received m-RADPLAT. The vocal fold in patients with VFF 3 months after completing m-RADPLAT resumed normal movement in 15 patients (83%) and persisted fixation in 3 (17%). The 3-year local control, laryngeal cancer-specific survival, and overall survival rates of patients with or without VFF were 88.9% and 86.7%, 94.1% and 93.3%, and 88.9% and 86.7%, respectively. Additionally, the 3-year freedom from laryngectomy, laryngectomy-free survival, and laryngo-esophageal dysfunction-free survival rates of patients with or without VFF were 94.4% and 86.7%, 88.9% and 73.3%, and 83.3% and 73.3%, respectively.
Grade 3 or higher toxicities were observed in all patients: leukopenia in 4 patients (12%), neutropenia in 5 (15%), anemia in 2 (6%), thrombocytopenia in 3 (9%), and mucositis in 2 (6%). This study demonstrated that m-RADPLAT yielded VFF improvement and a favorable survival while maintaining laryngeal function not only in patients with T3N0 glottic SCC-L without VFF but also in patients with VFF.

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Orocutaneous Fistula After Oral Cavity Resection and Reconstruction: Systematic Review and Meta-Analysis

Patrick Tassone,Tabitha Galloway,Laura Dooley,Robert Zitsch

Publication date 23-09-2021


Orocutaneous fistula (OCF) after reconstruction for oral cavity resection can lead to prolonged hospitalization and adjuvant treatment delay. Few studies have examined factors leading to OCF after oral cavity resection.
Primary objective: evaluate overall incidence and factors associated with OCF after oral cavity reconstruction. Scopus 1960-database was searched for terms: "orocutaneous fistula," "oro cutaneous fistula," "oral cutaneous fistula," "orocervical fistula," "oral cavity salivary fistula." English language studies with >5 patients undergoing reconstruction after oral cavity cancer resection were included. About 1057 records initially screened; 214 full texts assessed; 78 full-texts included. PRISMA guidelines were followed, and MINORS criteria used to assess risk of bias. Data were pooled using random-effects model. Primary outcome was OCF incidence. Meta-analysis to determine the effect of preoperative radiation on OCF conducted on 12 eligible studies. Pre-collection hypothesis was that prior radiation therapy is associated with increased OCF incidence. Post-collection analyses: free versus pedicled flaps; mandible-sparing versus segmental mandibulectomy. Seventy-eight studies were included in meta-analysis of overall OCF incidence. Pooled effect size showed overall incidence of OCF to be 7.71% (95% CI, 6.28%-9.13%) among 5400 patients. Meta-analysis of preoperative radiation therapy on OCF showed a pooled odds ratio of 1.68 (95% CI, 0.93-3.06). OCF incidence was similar between patients undergoing free versus pedicled reconstruction, or segmental mandibulectomy versus mandible-sparing resection. Orocutaneous fistula after oral cavity resection has significant incidence and clinical impact. Risk of OCF persists despite advances in reconstructive options; there is a trend toward higher risk after prior radiation.

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Downward Trend in Resident Myringotomy and Tympanostomy Tube Experience

Sarah M. Dermody,Stephanie Y. Johng,Mariel O. Watkins,Sonya Malekzadeh,Jaeil Ahn,Earl H. Harley

Publication date 23-09-2021


Historically, myringotomy, and the insertion of tympanostomy tubes has served as one of the initial surgical training experiences for residents. Resident experience with this procedure since the introduction of pneumococcal conjugate vaccines has not been well described in the literature. The objective of this study was to identify trends in resident training experience with chronic otitis media-related surgeries, such as myringotomy and tympanostomy tube placement. While multiple factors influence resident experience, we hypothesize that resident experience has decreased since the introduction of the pneumococcal 13-valent conjugate vaccine (PCV13). In a retrospective review of Accreditation Council for Graduate Medical Education (ACGME) National Data Reports, mean number of myringotomy and tympanostomy tube cases logged in the Resident Case Log System from 2006 to 2019 were collated and plotted against years to identify monotonic trends. Mann-Whitney Since the introduction of PCV13, there is a national decreasing trend in the myringotomy and tympanostomy tube placement by otolaryngology residents ( Otologic surgeries are an important part of resident education and historically have served as one of the initial surgical training experiences for residents. There has been a significant reduction in the number of myringotomy and tympanostomy procedures performed by otolaryngology residents in the past decade. While multiple factors influence resident experience, it is possible that introduction of PCV13 has impacted resident exposure to myringotomy and tympanostomy tube placement. Resident proficiency with this procedure has likely not been affected by introduction of PCV13. Data should be reassessed in 5 years to determine if an impact of the PCV13 vaccine on resident training is evident.

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Videofluoroscopic Swallow Studies and Diagnostic Outcomes in Otherwise Healthy Infants With Dysphagia

Michael C. Shih,Christina Rappazzo,Caroline Hudson,Julina Ongkasuwan

Publication date 23-09-2021


To evaluate videofluoroscopic swallow study (VFSS) findings in infants with dysphagia and without prior diagnoses, and to characterize the outcomes and any diagnoses that follow. A chart review of all pediatric patients who received a VFSS at a tertiary children's hospital from November 2008 to March 2017 was performed. There were 106 infants (57 males and 49 females) with 108 VFSS. VFSS was normal in 18 (16.98%) infants. Regarding airway protection, 50 (47.17%) infants had laryngeal penetration, and 8 (7.55%) had tracheal aspiration; 3 (2.83%, 37.5% of all aspirators) exhibited silent aspiration. Of the 75 infants with minimum 2-year follow-up, 35 (46.67%) had no sequelae of disease and received no diagnoses. The most common diagnoses and pathologic sequelae were gastroesophageal reflux (n = 18, 24.00%), asthma (n = 8, 10.67%), laryngomalacia (n = 6, 8.00%), and tracheomalacia (n = 4, 5.33%), all consistent with United States pediatric data on prevalence. All infants (n = 51) with follow-up for dysphagia had resolution of symptoms within 9 months from VFSS order date. Otherwise healthy infants may show signs of dysphagia and not develop later illness. Parents can thus be counseled on the implications of dysphagia in a previously healthy infant. Our findings provide comparative statistics for future research in pediatric dysphagia.

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Traumatic Pediatric Tracheal Rupture After Blunt Force Sporting Injury: Case Report and Review of the Literature

Alon Taylor,Seema Menon,Peter Grant,Bruce Currie,Marlene Soma

Publication date 20-09-2021


This paper presents the case of a traumatic tracheal rupture in a pediatric patient. The body of literature of the clinical features, evaluation, and management of this uncommon presentation is discussed. A 13-year-old boy sustained an intrathoracic tracheal rupture whilst playing Australian Rules football. He developed hallmark clinical features of air extravasation and was intubated prior to transfer to a tertiary pediatric center for further management. After a short trial of conservative management, his respiratory status deteriorated and he was taken to the operating theater for open surgical repair of the defect. Traumatic rupture of the trachea is a rare injury in children. This case demonstrates the dynamic nature of this serious injury and the need for multidisciplinary care in achieving the optimal outcome.

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Efficacy of Adenoidectomy for the Management of Chronic Rhinosinusitis in Children Older Than 7\u2009Years of Age

Chengetai Mahomva,Samantha Anne,Christopher Roxbury

Publication date 18-09-2021


While adenoidectomy is the first-line surgical management of chronic rhinosinusitis (CRS) in young children, evidence regarding its utility in older children is lacking. This study aimed to assess the efficacy of adenoidectomy in children 7 to 18 years old with regard to symptom control, postoperative medication use, and the need for additional surgery. Single-institution retrospective chart review of patients ages 7 to 18 undergoing adenoidectomy for CRS from 2009 to 2019. Patients with cystic fibrosis and ciliary disorders were excluded. Comorbidities, preoperative and postoperative symptoms (rhinorrhea, congestion, anosmia, and facial pain), medication use (antibiotics, antihistamines, nasal steroids, and irrigations), and Lund-Mackay scores were extracted. Mc Nemar's or Wilcoxon Rank Sum Tests were used to assess rates of symptom control and medication use. Fisher's exact or Chi-square tests were used to assess for factors associated with symptom persistence. Ninety-seven patients with a mean age of 9 years (range 7-18) were identified. Patients were shown to experience significantly decreased rates of rhinorrhea (64.9% vs 20.6%, <.001), congestion (95.9% vs 26.8%, <.001), facial pain (17.5% vs 3.1%, .001), use of nasal steroids (79.4% vs 36.1%, <.001), antihistamines (47.4% vs 20.6%, <.001), and number of antibiotics (median 1 vs 0, <.001) after adenoidectomy. No patient or disease factors were associated with symptom persistence. Nine patients (9.3%) required additional nasal surgery. In this cohort of older children with CRS with limited follow up, additional surgery is not routinely done following adenoidectomy, the results suggest that adenoidectomy alone may provide adequate symptom control and medication reduction.

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Silent Sinus Syndrome Secondary to Lymphoma: An Unusual Case With Radiological Evidence of Rapid Progression

Praveena Deekonda,Huw A. S. Jones

Publication date 18-09-2021


To describe a case of silent sinus syndrome secondary to malignancy and discuss the pertinent clinical findings. Silent Sinus Syndrome (SSS) refers to a rare, asymptomatic condition whereby occlusion of the maxillary sinus ostium results in gradual resorption of air, creation of negative pressure and collapse of the maxillary walls. Review of medical records and literature review using NCBI/Pub Med. We describe a case of a 54-year-old gentleman presenting solely with enophthalmos. He had been diagnosed with stage IVa small lymphocytic lymphoma (SLL) 1.5 years prior to this, which was being managed with active surveillance. CT demonstrated severe bowing of the anterior and posterolateral wall, inferior displacement of the floor of the orbit and right enophthalmos, thus supporting a diagnosis of silent sinus syndrome. Compared to previous staging CT at the time of the lymphoma diagnosis these findings were entirely new, and soft tissue in the pterygomaxillary fissure was found to be enlarged. The patient underwent endoscopic sinus surgery and a right maxillary mega-antrostomy was performed to ventilate the maxillary sinus and prevent progression of eye symptoms. A biopsy was taken from the pterygopalatine fossa, which was confirmed to be chronic lymphocytic leukemia (CLL). This case is unique both in being secondary to malignancy, as well as being rapidly progressive given the presence of radiologically normal appearances 1.5 years prior to presentation. Although a rare condition, prompt recognition of SSS is vital to prevent ophthalmological complications. This report highlights malignancy as a potential cause in cases with focal bony remodeling.

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Intermittent Vagal Nerve Stimulation-Associated Vocal Fold Movement Impairment

Jennifer Yan,Julina Ongkasuwan,Elton M. Lambert

Publication date 18-09-2021


Implanted vagal nerve stimulators (VNS) are an accepted therapy for refractory seizures. However, VNS have been shown to affect vocal fold function, leading to voice complaints of hoarseness. We present a case of intermittent VNS-related vocal fold paralysis leading to dysphonia and dysphagia with aspiration in a pediatric patient. This is a case report of a patient at a tertiary hospital evaluated in pediatric swallow and voice clinics. Patient and mother gave verbal consent to be included in this case report. Indirect laryngeal stroboscopy was performed demonstrating full vocal fold mobility with VNS off and left vocal fold paralysis in lateral position and glottic gap with VNS on. Voice measures were performed demonstrating decreased phonation time, lower pitch, and decreased intensity of voice with VNS on. Flexible endoscopic evaluation of swallowing demonstrated deep penetration alone with VNS off and deep penetration with concern for aspiration with VNS on. While the majority of cases of vocal fold movement impairment associated with VNS have been noted to have a medialized vocal fold with VNS activation, we describe a case of intermittent vocal fold lateralization associated with VNS activation with resultant voice changes and aspiration.

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Unilateral Vocal Fold Paralysis With Large Posterior Glottic Gap: Is Arytenoid Procedure Necessary?

Taner Yılmaz,Furkan Özer

Publication date 18-09-2021


For unilateral vocal fold paralysis (UVFP) with large posterior glottic gap medialization laryngoplasty (ML) + arytenoid adduction (AA), ML + adduction arytenopexy (AApexy), and ML alone using prosthesis with posterior extension are possible solutions. This study was carried out to elucidate the controversy among these solution options. Retrospective cohort. Tertiary referral center. One hundred forty patients with UVFP with large posterior glottic gap. Group 1 had 30 patients with ML + AA; Group 2 had 25 patients with ML + AApexy; Group 3 had 29 patients with ML using Isshiki prosthesis; Group 4 had 26 patients with ML using Montgomery prosthesis; Group 5 had 30 patients with ML using prosthesis with large posterior extension. Glottic closure using videolaryngostroboscopy, GRBAS, VHI-30, EAT-10, acoustic and aerodynamic analysis was carried out pre- and 1-year-postoperatively. Preoperatively there was no significant difference in any parameters studied among all study groups ( In patients with UVFP and large posterior glottic gap, ML + AA and ML + AApexy seem to do better subjectively and objectively, acoustically and aerodynamically, when compared to ML using prosthesis with and without large posterior extension. ML alone does not appear to close posterior glottic gap. Therefore, it is a better and more reasonable option to perform arytenoid procedure when there is large posterior glottic gap in UVFP.

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Sleep Endoscopy Findings in Children With Obstructive Sleep Apnea and Small Tonsils

Adrian Williamson,Steven W. Coutras,Michele M. Carr

Publication date 16-09-2021


Obstructive Sleep Apnea (OSA) in children is treated primarily with adenotonsillectomy (AT). When clinical exam demonstrates small tonsils, the success of AT in resolving OSA is uncertain. The purpose of this study is to determine the utility of Drug induced Sleep Endoscopy (DISE) for children with OSA and small tonsils (Brodsky scale 1+) and to identify what obstructive trends exist in this subset of patients and to determine the utility of DISE-directed surgical intervention in patients with small tonsils. A retrospective chart review was performed for patients who underwent DISE at a tertiary care center over a 2-year period. Inclusion criteria were 1+ tonsils and a positive sleep study. Data collected included DISE findings, BMI, comorbid conditions, and pre-op PSG data. Forty children were included with a mean age of 5.0 years (range 8 months-16 years). Mean preoperative AHI was 5.46 and mean oxygen saturation nadir was 87.1%. The most common contributor to airway obstruction was the adenoid (29 patients, 72.5%), followed by the tongue base or lingual tonsil (21 patients, 52.5%). The palatine tonsils (10 patients, 25.0%), epiglottis (10.0%), or obstruction intrinsic to the larynx (10.0%) were significantly less frequently identified as contributors to OSA when compared to the adenoid ( In this group, small palatine tonsils were infrequently identified as a contributor to airway obstruction and tonsillectomy was avoided in most cases. This study illustrates the utility of DISE as a tool to personalize the surgical management of pediatric patients with OSA and small tonsils on physical exam.

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Long-Term Opioid Use in Post-Surgical Management of Patients With Head and Neck Cancer

Judy J. Wang,Samuel J. Rubin,Anand K. Devaiah,Daniel L. Faden,Andrew R. Salama,Heather A. Edwards

Publication date 15-09-2021


This study aims to identify clinical and socioeconomic factors associated with long-term, post-surgical opioid use in the head and neck cancer population. A single center retrospective study was conducted including patients diagnosed with head and neck cancer between January 1, 2014 and July 1, 2019 who underwent primary surgical management. The primary outcome measure was continued opioid use 6 months after treatment completion. Both demographic and cancer-related variables were recorded to determine what factors were associated with prolonged opioid use. Univariate analysis was performed using chi-squared test for categorical variables and 2-sample A total of 359 patients received primary surgical management. Forty-five patients (12.53%) continued to take opioids 6 months after treatment completion. Using univariate analysis, patients less than 65 years of age ( Long-term postoperative opioid use in head and neck cancer patients is significantly associated with adjuvant chemoradiation, and patients with longer length of hospital stay. Therefore, future research should focus on interventions to better manage opioid use during the acute treatment period to decrease long-term use.

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The efficacy of Tranexamic Acid Administration in Patients Undergoing Tonsillectomy: An Updated Meta-Analysis

Cathleen C. Kuo,Jason C. DeGiovanni,Michele M. Carr

Publication date 13-09-2021


There is controversy regarding the efficacy and safety of tranexamic acid (TXA) in reducing tonsillectomy-related hemorrhage. We conducted a systematic review and meta-analysis to evaluate the prophylactic role of TXA in tonsillectomy. We searched 6 databases to identify studies that directly compare the effect of TXA versus controls in tonsillectomy patients. Standardized mean difference was applied to summate the findings across the studies. Dichotomous data were expressed as relative risk. Ten studies representing a total of 111 898 patients were included. The pooled results showed a significant reduction of intraoperative blood loss by 39.02 ml (SMD = -1.05, 95% CI: -1.91 to -0.20, Overall, this study indicates that TXA may reduce blood loss and frequency of post-operative hemorrhage associated with tonsillectomy. Further large, high-quality clinical trials are still needed to explore TXA's effect on post-tonsillectomy hemorrhage and the safety of its use.

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Pathological Level VI Lymph Node Metastasis in Clinical N3b Pyriform Sinus Squamous Cell Carcinoma

Hidetoshi Matsui,Shigemichi Iwae,Yuta Yamamura,Yuto Horichi

Publication date 11-09-2021


The frequency of metastasis to level VI lymph nodes in advanced pyriform sinus squamous cell carcinoma (PSSCC) is unknown. We intended to analyze the clinical features and pathological presence or absence of level VI lymph node metastasis in patients with PSSCC. The data of 270 patients with previously untreated hypopharyngeal squamous cell carcinoma from 2006 to 2016 were obtained. Patients who underwent pharyngolaryngectomy for the pyriform sinus subsite with a curative intent with level VI dissection were included. We retrospectively analyzed the clinical Tumor-Node (TN) status (TNM classification of malignant tumors, eighth edition) and the presence or absence of pathological level VI lymph node metastasis. A total of 34 patients were included. Eight patients (24%) had pathological level VI lymph node metastasis. The rate of pathological level VI lymph node metastasis was directly proportional to the clinical N status ( PSSCC with cN3b is prone to bilateral level VI metastasis. We recommend that patients with PSSCC with cN3b should undergo bilateral level VI lymph node dissection.

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I’m All Ears: A Population-Based Analysis of Consumer Product Foreign Bodies of the Ear

Alexandra H. B. Helbing,Alexander J. Straughan,Luke J. Pasick,Daniel A. Benito,Philip E. Zapanta

Publication date 11-09-2021


The purpose of this study was to assess the nationwide incidence of ear foreign body (FB) presentations to the emergency department (ED) and analyze the most common FB consumer products encountered. The National Electronic Injury Surveillance System (NEISS) was evaluated for ED visits that included "ear foreign bodies" from 2010 through 2019. The most frequent foreign bodies were identified and organized by demographics. A total of 20,545 ear FB cases were found, with an estimated 608,860 ED visits nationwide. Female patients (56%) were more likely to have jewelry and first aid equipment FBs. Males between the ages of 5 and 15 years were significantly ( Ear FBs represent a substantial proportion of healthcare expenditures. Although children are the most commonly affected individuals, all ages require further education and preventive measures.

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Association of Quality of Life Measures and Otolaryngologic Care in Cystic Fibrosis Patients

Stephen Leong,Rahul K. Sharma,Chetan Safi,Emily DiMango,Claire Keating,David A. Gudis,Jonathan B. Overdevest

Publication date 11-09-2021


Appropriate management of chronic rhinosinusitis (CRS) among patients with cystic fibrosis (CF) is important in improving quality of life. Otolaryngologists play a critical role in reducing CRS symptom burden. This study seeks to evaluate the role of patient-reported quality-of-life measures in guiding interventions for CF-related sinus disease. We performed a prospective, cross-sectional study of 105 patients presenting to a CF-accredited clinic between July and September 2018. Demographic data and sinus surgery history were collected, in addition to Sino-Nasal Outcome Test (SNOT-22) and Questionnaire of Olfactory Disorders (QOD-NS) scores. Statistical analysis was conducted using correlation and non-parametric Mann-Whitney Baseline well-care visits accounted for 71.4% of all clinical evaluations. Prior otolaryngology intervention was noted in 69 (66%) patients, where the majority of these patients (63/69; 91%) underwent endoscopic sinus surgery (ESS). Patients with a history of otolaryngology intervention had an average SNOT-22 score of 33.2 (SD = 20.6) compared to 24.9 (SD = 18.5) for patients without prior intervention ( CF patients with symptoms resulting in worse quality-of-life assessments were more likely to have established coordinated care with an otolaryngologist. Further validation of the utility of SNOT-22 and QOD-NS questionnaires as care coordination metrics is necessary in the CF population.

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Is Revision Surgery Necessary for Patients With High Risk of Recurrence After Parotidectomy? A Multicenter Retrospective Study

Médarine Roch,Olivier Mauvais,Sebastien Vergez,Esteban Brenet,Pierre Lindas,Bruno Toussaint,Duc Trung Nguyen,Guillaume Gauchotte,Cécile Rumeau,Patrice Gallet

Publication date 09-09-2021


Close margin is a frequent situation after parotidectomy. The need for systematic prophylactic revision surgery is a question that arises regularly for malignant tumors, as it exposes to a high risk of facial palsy, while oncological benefits are unclear. retrospective study. Multicentric. We included all patients operated for systematic revision surgery in case of close margins after parotidectomy for a malignant tumor and analyzed the rate of tumor residue and its risk factors. A tumor residue was identified in 43.5% of 23 cases, but none in case of initial complete excision with supra-millimetric margins. Invaded lymph nodes were identified in 6 cases, but none in case of low-grade tumors. Systematic revision seems mandatory in case of infra-millimetric margins and high-grade tumors or positive lymph node; further studies are needed to confirm whether it can be spared for T1-T2/N0 low-grade tumors, with close margins but complete initial excision.

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Pulmonary Function Tests May Better Predict Dyspnea-Severity in Patients with Subglottic Stenosis Compared to Clinician-Reported Stenosis

Neel K. Bhatt,Valerie P. Huang,Caitlin Bertelsen,William Z. Gao,Lindsay S. Reder,Michael M. Johns,Karla O’Dell

Publication date 09-09-2021


Patients with subglottic stenosis (SGS) present with varied degree of breathing complaints. The dyspnea index (DI) is a 10-question patient-reported outcome measure designed to measure the severity of upper airway obstruction. We set out to determine whether pulmonary function tests or clinician-reported degree of stenosis best predicted DI scores. Thirty patients with SGS were retrospectively reviewed over a 6-year period. One visit from each patient was included. Data including peak expiratory flow rate (PEFR), body-mass index (BMI), clinician-reported degree of stenosis, and DI scores were reviewed. Multiple linear regression was performed to determine how degree of stenosis and PEFR % predicted the variation in DI score. PEFR % better predicted DI scores compared to degree of stenosis (partial correlation -0.32 vs 0.17). After stepwise elimination, PEFR % remained in the regression and was significantly associated with DI scores ( This study suggests that pulmonary function tests may be a better in-office measure to substantiate the severity of symptoms in patients with SGS.

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The Need for Studies on Oral Corticosteroids After Sialendoscopy for Obstructive Salivary Gland Disease: Systematic Review

Gabriella Donaldson,Sandro de Paiva Leite,Tim Hardcastle,Zahoor Ahmad,Randall P. Morton

Publication date 08-09-2021


This qualitative systematic review evaluates the evidence in support of the use of oral corticosteroids in patients undergoing sialendoscopy for the treatment of obstructive sialadenitis. Qualitative systematic review. A literature search was conducted from January 1985 and September 2020. Inclusion criteria embraced peer-reviewed articles in which adult patients undergoing interventional sialendoscopy for obstructive salivary gland disease received oral corticosteroids. The results were initially screened based on title and abstract, and the remaining articles were reviewed for eligibility. About 218 papers were selected by title and abstract, 96 were selected for full-text review, and 9 met the inclusion criteria. Eight published reports were retrospective observational studies and 1 was a prospective comparative study. Overall, the heterogeneity of clinical data stood out in this systematic review. The pooled success rate in the studies was 873/979 (89%). Only 5 studies described a rationale for oral corticosteroid use as part of the post-operative management. In 4 studies, a prednisone total daily dose of 40 to 50 mg was used. One study clearly showed a lower recurrence rate in patients who received oral steroids for more than 7 days in addition to sialendoscopy for management of ductal stenoses. This systematic review showed that most centers that prescribe oral corticosteroids after sialendoscopy are unaware of the specific results with this treatment. For ductal stenoses, only 1 paper clearly showed the benefits of oral corticosteroids after sialendoscopy but more high-quality evidence is required in the form of a comparative study or randomized controlled trial, with appropriate long-term follow up.

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Insurance Status Effect on Laryngeal Cancer Survival: A Population Based Study

Nicholas B. Abt,Lauren E. Miller,Anuraag Parikh,Neil Bhattacharyya

Publication date 04-09-2021


To analyze insurance status effect on overall survival (OS) and disease-specific survival (DSS) in laryngeal cancer. Cross-sectional population analysis. Surveillance, Epidemiology, and End Results (SEER) database. Laryngeal cancer patients from 2007 to 2016. Kaplan-Meier method with log-rank statistic analyzed OS and DSS by insurance status. Multivariable cox proportional hazard modeling generated survival prognostic factors. Of 19 667 laryngeal cancer cases, initial disease presentation was stage I: 7770 patients (39.5%), stage II: 3337 patients (17.0%), stage III: 3289 patients (16.7%), and stage IV: 5226 patients (26.6%). Patients had non-Medicaid insurance (15 523, 78.9%), had Medicaid (3306, 16.8%), or were uninsured (891, 4.5%). Mean and median OS for insured, Medicaid, and uninsured patients were 60.5, 49.6, and 56.6 and 74.0, 40.0, and 65.0 months, respectively. Following multivariable analysis, OS for insured, Medicaid, and uninsured patients was stage I: 87.9, 82.8, and 88.4 ( Insured laryngeal cancer patients had prolonged OS and DSS compared to Medicaid and uninsured patients. Medicaid patients had equivalent survival outcomes to uninsured patients. 2c.

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Iatrogenic Vocal Fold Paralysis: A Population-Based Cohort Study in Taiwan

Ying-Ta Lai,Pin-Zhir Chao,Yu-Kang Chang,Yu-Chun Yen,Yu-Ting Shen,Tzu-Yun Yu,Seth Dailey,Yuan-Hung Wang

Publication date 02-09-2021


Iatrogenic vocal fold paralysis is an important issue in laryngology, yet there are few population-based studies regarding the epidemiology. This study used a nationwide population-based claims database (the National Health Insurance Research Database) to investigate the epidemiology of iatrogenic unilateral and bilateral vocal fold paralysis (UVFP/BVFP) among the general adult population in Taiwan. This study analyzed patients (20-90 years old) who underwent thyroid, parathyroid, thoracic, cardiac, or anterior cervical spine operations with vocal fold paralysis among adults in Taiwan from January 1, 2007 to December 31, 2013. The codes for vocal fold paralysis were defined by International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). Claims data in the Taiwan National Health Insurance Research Database were used. The most commonly performed operations which were related to vocal fold paralysis in Taiwan were, in descending order of frequency, thyroid, cervical spine, cardiac, thoracic (esophagectomy), and parathyroid operations. The operations that put laryngeal nerves at risk (ONRs) most commonly associated with a diagnosis of UVFP were, in descending order of frequency, thoracic, thyroid, parathyroid, cardiac, and cervical spine. For both UVFP and BVFP, the most commonly associated age group was 51 to 60. For both UVFP and BVFP, the more commonly associated sex was women. Increased length of stay was associated with a higher incidence of UVFP and BVFP. Charlson medical co-morbidity index (CCI) was not associated with UVFP but BVFP was associated with higher Charlson medical co-morbidity scores. Thyroid operations, age 51 to 60, longer hospital stays are associated with vocal fold paralysis. Overall women are more surgically affected than men. This is the first population-based study of iatrogenic vocal fold paralysis.

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Sport and Recreational Causes of Nasal Bone Fractures

Christopher C. Xiao,Rijul S. Kshirsagar,Jacob E. Hoerter,Alexander Rivero

Publication date 01-09-2021


Nasal bone fractures are the most common facial bone fractures. However, there is limited literature on the etiology of these fractures, particularly distribution across sports and other recreational activities. The Nationwide Electronic Injury Surveillance System (NEISS) national injury database was queried for emergency department visits involving the diagnosis of nasal or nose fractures associated with sports and recreation activities over the most recent 10 year span available. Demographic, disposition, and weighted incidence were analyzed. Total incidence of nasal fractures across 10 years was 158 979. The mean age of nasal bone fractures was 20.4 years old. Nasal fractures were more common in males (74.6%) and white patients (54.1%). National estimated incidence of nasal fractures decreased from 21 028 in 2009 to 11 108 in 2018, a reduction of 47.2%. The most common causes among all patients were basketball (23.2%), baseball (17.1%), softball (9.8%), soccer (7.4%), and football (7%). In pediatric patients, the most common cause was baseball (25.1%). The majority (98.1%) of patients were discharged from the emergency department, while 0.9% of patients were admitted. The most common recreational causes of nasal fractures are sports, with the most common being non-contact sports like basketball and baseball. However, the incidence of nasal bone fractures due to recreational causes nationwide has decreased significantly over the past 10 years. This may reflect improved safety protocols among athletes.

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Characterizing Medicare Reimbursements and Clinical Activity Among Female Otolaryngologists

Neelima Panth,Sina J. Torabi,David A. Kasle,Emily L. Savoca,Cheryl K. Zogg,Erin K. O’Brien,R. Peter Manes

Publication date 01-09-2021


To evaluate geographic and temporal trends in Medicare fee-for-service (FFS) billing and reimbursements across female otolaryngologists (ORL). We performed a cross-sectional, retrospective analysis of the 2017 Medicare Physician and Other Suppliers Aggregate File. We analyzed differences in the number of services, patients, reimbursements, unique Current Procedural Terminology (CPT) codes used, and services billed per patient among female ORLs. Female ORLs accounted for 15.2% of the 8453 Medicare-reimbursed ORLs. Female ORLs who graduated between 2000 and 2010 were reimbursed a median of $58 031.9 (IQR: $32 286.5-$91 512.2) and performed a median of 702 (IQR: 359.5-1221.5) services, significantly less than those who graduated between 1990 and 1999 (median: $67 508.9; IQR: 37 018.0-110 471.5; Medicare reimbursements and billing patterns across female ORLs varied by graduation decade and geography. Female ORLs further along in their careers may be reimbursed more with greater clinical volume and productivity. Those practicing in urban settings may have practices with decreased procedural diversity and lower clinical volume compared to their counterparts in rural areas.

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Endoscope-Assisted Superior Semicircular Canal Dehiscence Repair: Single Institution Outcomes

Douglas J. Totten,Miriam R. Smetak,Nauman F. Manzoor,Elizabeth L. Perkins,Nathan D. Cass,Kelsey Hatton,Pooja Santapuram,Matthew R. O’Malley,David S. Haynes,Marc L. Bennett,Alejandro Rivas

Publication date 30-08-2021


To compare outcomes of endoscope-assisted middle cranial fossa MCF) repair of superior semicircular canal dehiscence (SSCD) compared to microscopic MCF repair. Retrospective cohort. Tertiary medical center neurotology practice. Retrospective chart review and cohort study of patients who underwent surgical repair of SSCD via MCF approach from 2010 to 2019 at our institution. Patients were categorized according to use of endoscope intraoperatively. Pre- and post-operative symptom number was calculated from 8 patient-reported symptoms. Pre- and post-operative changes in symptom number were assessed using paired Forty-six patients received surgical management for SSCD. Of these, 27 (59%) were male and 19 (41%) were female. Bilateral SSCD was present in 14 cases (29%), of which 3 underwent surgical management bilaterally, for a total of 49 surgical ears. Surgery was performed on the right ear in 19 cases (39%) and on the left in 30 cases (61%). Forty ears (82%) underwent microscopic repair while 9 (18%) underwent endoscope-assisted repair. Microscopic and endoscope-assisted MCF repair both demonstrated significantly improved symptom number postoperatively ( While endoscopic-assisted MCF repair has the potential to provide better visualization of medial and downslope defects, repair via this technique yields similar results and is equivalent to MCF repair utilizing the microscope alone.

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Does Prolonged Use of N95 Masks Affect Nasal Mucociliary Clearance? A Single Group Pre-Post Study

Nikhil Rajan,Bikram Choudhury,Dipika Prakash,Kapil Soni,Darwin Kaushal,Neha Shakrawal,Nithin Prakasan Nair,Amit Goyal

Publication date 28-08-2021


It has been shown that prolonged use of face masks results in physiological changes in the nasal cavity. The objective of this study was to examine the effect of prolonged use of face masks on nasal mucociliary clearance (NMC). A single group pre-post study was conducted to determine the effects of prolonged use of N95 face mask (≥4 hours) on the NMC rates in health care workers. Saccharin transit time (STT) was used to measure the NMC. STT before and after using an N95 mask for at least 4 hours was measured for all participants in controlled conditions of temperature and humidity. Forty-eight volunteers (20 female and 28 male) completed the study after the enrollment of 57 volunteers. The mean STT before mask use was 580.27 ± 193.93 seconds (95% CI; 523.95-636.58 seconds) and after mask use was 667.47 ± 237.42 seconds (95% CI; 598.53-736.42 seconds). There was significant prolongation of the NMC after prolonged use of N95 mask on performing the paired Use of the N95 face masks for 4 hours results in prolongation of the nasal mucociliary clearance as measured by STT. Susceptibility to any respiratory infection may be increased following doffing of the personal protective equipment, including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) itself.

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Laryngotracheobronchial Amyloidosis: Patterns of Presentation and Management

Sarah M. Dermody,Erica L. Campagnaro,Robbi A. Kupfer,Norman D. Hogikyan,Robert J. Morrison

Publication date 28-08-2021


To evaluate the pattern of presentation and management of laryngotracheobronchial amyloidosis at a tertiary care academic center over a 27 year period. In a retrospective review, the electronic medical record at a tertiary care academic center was queried for encounters with 3 laryngologists between 1996 and 2019 which included the ICD-9 or ICD-10 diagnosis of amyloidosis. Demographics, clinical presentation, referral diagnoses, medical history, family history, laboratory values, radiology studies, and treatment modalities of subjects were collated. Results were analyzed using standard univariate descriptive statistics. Seventeen subjects were identified with an average age at diagnosis of 58 years (range 26-76 years). The most common amyloid type on biopsy was immunoglobulin light chain (AL) subtype. The most common location of laryngeal amyloid at diagnosis was the glottis and disease was more likely to be bilateral at the time of diagnosis in this location. Supraglottic disease more often had a unilateral presentation and had a tendency to spread to additional laryngeal subsites. Nearly 25% of subjects had associated systemic disease, including multiple myeloma, auto-immune disease, and familial ATTR mutation. The overall rate of associated systemic disease was low in our study cohort; however, it is higher than typically referenced in extant literature. Our cohort demonstrates that while laryngeal amyloidosis is a chronic condition, the behavior is generally indolent with a low treatment burden.

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Correlations of Radiographic and Endoscopic Observations in Subglottic Stenosis

Alexandra T. Bourdillon,Michael A. Hajek,Mitchel Wride,Mike Lee,Michael Lerner,Nikita Kohli

Publication date 28-08-2021


Subglottic stenosis (SGS) represents a constellation of diverse pathologic processes that ultimately lead to narrowing of the subglottic region and can produce significant morbidity. Existing endoscopic and radiographic assessments may not be consistent in practice. Severity of stenosis was evaluated and reported using the Cotton-Myer classification system from 33 endoscopic procedures from 32 unique subjects. Radiographic imaging within the preceding 3 month period was subsequently reviewed and narrowing was measured by a blinded radiologist. Degree of stenosis was reported as a percentage in 30 out of 33 endoscopic evaluations and subsequently compared to radiographically determined percentage of stenosis. Statistical analyzes were conducted to evaluate concordance between endoscopic and radiographic assessments. About 45.5% (15/33) of the evaluations were in agreement using Cotton-Myer scoring, while 27.3% (9/33) were discrepant by 1 grade and 27.3% (9/33) by 2 grades. Correlation of degree of stenosis as a percentage using Spearman (coefficient: 0.233, Radiographic and endoscopic grading of subglottic stenosis may not be reliably concordant in practice.

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Ototoxicity and Teprotumumab

Julie Highland,Steven Gordon,Deepika Reddy,Neil Patel

Publication date 27-08-2021


Teprotumumab, a novel monoclonal antibody, targets the insulin-like growth factor 1 (IGF-1) receptor. IGF-1 receptors, found in muscle and fat adjacent to the eye and implicated in Graves Ophthalmopathy, are also in the cochlea. In clinical trials, 5 participants reported self-limited audiologic symptoms but there are no objective data in the literature. The aim of this report is to describe one of the first known cases of teprotumumab-induced irreversible sensorineural hearing loss. Case report at a tertiary referral center. A 61 year old female with Graves ophthalmopathy presented with bilateral hearing loss, sound distortion, and tinnitus following treatment with teprotumumab. Audiogram showed mild sloping to moderately-severe sensorineural hearing loss. Repeat audiometry obtained 4 months after cessation of teprotumumab and treatment with oral corticosteroids was unchanged. This is one of the first descriptive cases of ototoxicity resulting in irreversible sensorineural hearing loss in the setting of treatment with teprotumumab. Periodic audiologic evaluations should be recommended to patients on teprotumumab.

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Use of 532\u2009nm Potassium Titanyl Phosphate Laser on Vocal Fold Scars Under Topical Anesthesia: A Pilot Study

Jiajia Wang,Wenjing Mao,Rui Fang,Chunsheng Wei,Peijie He

Publication date 23-08-2021


This pilot study aims to evaluate the efficacy of 532 nm potassium titanyl phosphate (KTP) laser under topical anesthesia in patients with vocal fold scars. A series of 18 patients with vocal fold scars of varying degrees were treated. The KTP laser was used under local anesthesia in the outpatient clinic. It was set to deliver 6 W of power using a continuous output mode. Close-to-contact mode was used for laser irradiation, and contact mode was used for ablation and excision of the lesions. Some of the patients received laser scar ablation on both vocal folds; the scarred vocal fold on one side and the hypertrophic vocal fold on the other. Parameters include glottic closure, amplitude, and mucosal wave pattern were measured using laryngeal stroboscopic examination. Aerodynamic and voice evaluations were carried out using maximum phonation time (MPT), jitter, shimmer, Voice Handicap Index questionnaire (VHI-30), and GRBAS scale. In total, 21 surgeries were performed on 18 patients. Glottic closure, amplitude, and mucosal wave pattern showed improvement 2 months postoperatively ( The 532 nm KTP laser is an effective tool for the treatment of vocal fold scars. Further research is required to determine if serial laser applications could improve outcomes for this challenging condition. Level IV.

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Outcome of Eustachian Tube Balloon Dilation in Children: A Systematic Review

Jeyasakthy Saniasiaya,Jeyanthi Kulasegarah,Prepageran Narayanan

Publication date 23-08-2021


Eustachian tube dysfunction (ETD) is a chronic entity that has been historically managed with adenoidectomy and ventilation tube insertion. Recently, balloon dilation of the eustachian tube has shown promising results in recalcitrant eustachian tube dysfunction. We reviewed the literature to determine the outcome of eustachian tube balloon dilation in children. A literature search was conducted for the period from 1990 to 2020 by searching several databases over a 1-month period (January 2021) according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and the Cochrane Handbook for Systematic Reviews for Interventions. Primary outcome was defined as the success of the intervention determined by the resolution of symptoms, and secondary outcome was determined by revisions surgery and presence of complications. Only 7 articles were identified based on our objectives and selection criteria. All studies included are retrospective cohort case series (Level IV) and 1 cohort of matched controls (Level III). A total of 284 patients were included in this review, with a mean age of 7.8 years. A total of 463 balloon dilation were performed either bilaterally or unilaterally. The most common finding of ETD is middle ear effusion in 5 studies. Balloon dilation of eustachian tube was second-line treatment in 6 studies and first-line treatment in 1 study. Improvement of symptoms was identified in all studies through various assessments performed. Revision surgery was performed in 1 study with no major complications reported. Balloon dilation of the eustachian tube may be considered as an alternative procedure following failed standard treatment in children. The quality of evidence is inadequate to recommend widespread use of the technique until a better-quality study has been completed. Future randomized controlled studies with a large sample size are warranted to determine the efficacy of this procedure amongst children.

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Above and Beyond Age: Prediction of Major Postoperative Adverse Events in Head and Neck Surgery

Marco A. Mascarella,Nikesh Muthukrishnan,Farhad Maleki,Marie-Jeanne Kergoat,Keith Richardson,Alex Mlynarek,Veronique-Isabelle Forest,Caroline Reinhold,Diego R. Martin,Michael Hier,Nader Sadeghi,Reza Forghani

Publication date 21-08-2021


Major postoperative adverse events (MPAEs) following head and neck surgery are not infrequent and lead to significant morbidity. The objective of this study was to ascertain which factors are most predictive of MPAEs in patients undergoing head and neck surgery. A cohort study was carried out based on data from patients registered in the National Surgical Quality Improvement Program (NSQIP) from 2006 to 2018. All patients undergoing non-ambulatory head and neck surgery based on Current Procedural Terminology codes were included. Perioperative factors were evaluated to predict MPAEs within 30-days of surgery. Age was classified as both a continuous and categorical variable. Retained factors were classified by attributable fraction and C-statistic. Multivariate regression and supervised machine learning models were used to quantify the contribution of age as a predictor of MPAEs. A total of 43 701 operations were analyzed with 5106 (11.7%) MPAEs. The results of supervised machine learning indicated that prolonged surgeries, anemia, free tissue transfer, weight loss, wound classification, hypoalbuminemia, wound infection, tracheotomy (concurrent with index head and neck surgery), American Society of Anesthesia (ASA) class, and sex as most predictive of MPAEs. On multivariate regression, ASA class (21.3%), hypertension on medication (15.8%), prolonged operative time (15.3%), sex (13.1%), preoperative anemia (12.8%), and free tissue transfer (9%) had the largest attributable fractions associated with MPAEs. Age was independently associated with MPAEs with an attributable fraction ranging from 0.6% to 4.3% with poor predictive ability (C-statistic 0.60). Surgical, comorbid, and frailty-related factors were most predictive of short-term MPAEs following head and neck surgery. Age alone contributed a small attributable fraction and poor prediction of MPAEs. 3.

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Evaluating the Effect of Recurrent Respiratory Papillomatosis on Work Productivity

Thomas K. Chung,Amanda Hu,Maya G. Sardesai,Haley Wilcox,Lan Jiang,Tanya K. Meyer

Publication date 21-08-2021


Patients with recurrent respiratory papillomatosis (RRP) have significant vocal dysfunction which affects their performance at work. This study aimed to evaluate voice-related work productivity before and after ablative treatment for RRP. This is a prospective case series conducted at 2 academic laryngology outpatient clinics. Adult employed patients with RRP completed the Work Productivity & Activity Impairment instrument (WPAI), Voice Handicap Index (VHI-10), Work Hoarse, Hospital Anxiety and Depression Scale (HADS), and a demographics questionnaire immediately before and 1 month after ablative treatment of papilloma. The primary outcome measure was the change in work productivity impairment domain of the WPAI, and changes in ratings before and after ablation were compared using a Wilcoxon Signed-Rank test. The 32 participants (mean age 45, 84% male) had a median (interquartile range) voice-related work productivity impairment score of 48.8% (30.0) at baseline which was improved to 5.0% (10.0) at 1 month after surgical ablation of papillomata (difference 30.0% (30.0) improvement). For the secondary outcome measures, there were significant improvements in VHI-10 ( Patients with RRP experience significant voice-related work productivity impairment, and ablation of papillomata significantly improves work productivity.

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The Relationship Between Open Access Article Publishing and Short-Term Citations in Otolaryngology

David W. Wassef,Gregory L. Barinsky,Sara Behbahani,Sudeep Peddireddy,Jordon G. Grube,Christina H. Fang,Soly Baredes,Jean Anderson Eloy

Publication date 20-08-2021


The purpose of this study is to compare the number of citations received by open access articles versus subscription access articles in subscription journals in the Otolaryngology literature. Using the Dimensions research database, we examined articles indexed to Pub Med with at least 5 citations published in 2018. Articles were included from 137 open access articles and 337 subscription access articles meeting inclusion criteria were identified, with a median citation number of 8 (IQR 6-11). The most common article type was original investigation (82.5%), and the most common study topic was head and neck (28.9%). Open access articles had a higher median number of citations at 9 (IQR 6-13) when compared to subscription access articles at 7 (IQR 6-10) ( Although comprising a minority of articles examined in this study of subscription journals, open access articles were associated with a higher number of citations than subscription access articles. Open access publishing may facilitate the spread of novel findings in Otolaryngology.

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