Annals of Otology Rhinology and Laryngology 2021-04-10

‘Mini-Microsuture Technique’ for Phonosurgery: A New Simplified Method

İsmail İlter Denizoğlu,Engin BaŞer

Publication date 21-08-2020


Phonomicrolaryngeal surgery involves the surgical treatment of benign disorders of the vocal folds. Postoperative scar tissue in vocal fold mucosa is undesired because mucosal hypodynamia may lead to prolonged impairment in voice quality. This study aims to present and share the outcomes of a new endolaryngeal suture technique. This study consists of patients who underwent vocal fold surgery followed by endolaryngeal microscopic suturation with a technique that we call the "mini-microsuture technique" between January 2018-December 2019. Videolaryngoscopic images were examined to observe the tissue healing process (suture elimination time, mucosal scar status, and wave pattern) at the first and the fourth week postoperatively. A retrospective analysis was made in 144 (57 males (39.5%) and 87 females (60.5%)) patients who underwent phonomicrosurgery with "Mini-microsuture technique." Mean age was 40.61 ± 13.54 (10-78) years. There were multiple pathological lesions in 41.66% (n: 60) of our patients, and 58.33% (n: 84) of them had single-lesion. 63.88% (n: 92) of the patients had bilateral vocal fold lesions where 36.22% (n: 52) of the patients had pathology in one vocal fold. The "mini-microsuture technique" is an easy and functional procedure that can be performed by a single surgeon under microscopy, which minimizes tissue trauma, prevents mucosal hypodynamia, and provides a better anatomical structure postoperatively for a symmetrical vibration. The technique does not significantly prolong operation time when mastered and is a cost-effective method in which surgery which can be concluded using a single suture material.

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Reconstruction of Mastoid Cortex Defects with Hydroxyapatite Cement for Negative Sequelae of Mastoidectomy

Julia Marie Naman Thomas,Michael Brian Gluth

Publication date 21-08-2020


Mastoid cortex defects resulting from mastoidectomy surgery can rarely lead to negative sequelae, including unsightly post-auricular depression and discomfort. This study sought to evaluate the use of hydroxyapatite cement (HAC) to reconstruct mastoidectomy cortex defects. Retrospective chart review was undertaken for all patients that underwent reconstruction of the mastoid cortex using HAC at a single tertiary medical center between 2013 and 2019. Collected data included demographics, indications for mastoidectomy, complications, and associated symptom status. Twenty-nine patients that underwent mastoid cortex repair using HAC were included, and ten of these underwent mastoid revision in a secondary procedure to reconstruct the mastoid cortex with a specific goal to eliminate negative signs and symptoms. There were no associated postoperative complications and no instances of post-auricular depression following repair. All cases of secondary reconstruction resolved the primary signs and symptoms that prompted mastoid revision. HAC mastoid cortex reconstruction may be a safe and effective method to resolve negative sequelae resulting from previous mastoidectomy defects. Also, upfront HAC mastoid cortex reconstruction appears viable in select instances as an option to prevent potential future complications.

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Left Ear Hearing Predicts Functional Activity in the Brains of Patients with Alzheimer’s Disease Dementia

Alana Aylward,Susan R. Naidu,Catherine Mellum,Jace B. King,Keith G. Jones,Jeffrey S. Anderson,Norman L. Foster,Richard K. Gurgel

Publication date 21-08-2020


To determine whether central speech processing ability, as measured by hearing in noise, differs between right and left ears in adults with Alzheimer's disease related dementia (AD) as well as whether differences in central speech processing ability correlate with an fMRI-based measurement of global functional brain connectivity. This prospective study was carried out at a tertiary referral center. Patients with an AD diagnosis and pure tone averages 40 dB HL or better were included. They were examined using resting-state fMRI and underwent central audiometric testing using the Dichotic Sentence Identification Test (DSI), the Dichotic Digits Test (DD), and the Synthetic Sentence Identification Test (SS), which test hearing in noise. DSI scores were correlated with resting-state fMRI connectivity between 361 distinct gray matter brain regions of interest (ROIs). Average global connectivity was calculated as mean functional connectivity between an ROI and the other 360 regions, a quantitative marker representing overall functional connectivity in the brain. Sixteen subjects had adequate fMRI and hearing data. The average age was 71.5 years old (±6.0). The average DSI score for the left ear was 40% (±34%) compared to 90% (±10%) in the right ear ( Correlation was noted between left sided DSI and functional connectivity in patients with AD. Auditory input from the left ear was more susceptible to impairment, suggesting that side-specific auditory input may influence central auditory processing.

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General Complications after Endoscopic Sinus Surgery in Smokers: A 2005-2016 NSQIP Analysis

Jordan I. Teitelbaum,Catie Grasse,Dennis Quan,Ralph Abi Hachem,Bradley J. Goldstein,Xiaoyang Hua,David W. Jang

Publication date 21-08-2020


Exposure to cigarette smoke has been associated with a higher incidence of postoperative complications across a variety of surgical specialties. However, it is unclear if smoking increases this risk after endoscopic sinus surgery (ESS). Because complication rates after ESS are relatively low, a large national database allows for a statistically meaningful study of this topic. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) dataset from 2005 to 2016 was analyzed. Patients who underwent ESS were identified. Thirty-day postoperative complication rates between smokers and nonsmokers were compared. Complications included infection, thromboembolic events, reintubation, readmission, acute renal failure, and cardiovascular events. 921 patients who underwent ESS were identified. 182 (20%) were smokers and 739 (80%) were nonsmokers. 609 patients underwent outpatient ESS, while 312 patients underwent inpatient ESS. A total of 12 patients experienced postoperative surgical site infections involving the deeper tissues beyond the wound (organ/space SSI). On univariate analysis, smoking was associated with a higher incidence of organ/space SSI ( This study demonstrates an association between exposure to cigarette smoke and potentially serious surgical site infections in the 30-day postoperative period after ESS. Our findings may help when counseling smokers who are considering ESS. Further study is required to understand the nature of these infections and ways to prevent them.
Level of Evidence: 2c ("health outcomes").

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Occult Malignancy in Adult Tonsillectomy for Benign Indication

Noah Syme,Stefan Brettfeld,Ashley Dorneden,Von Samedi,Therese Bocklage,Orrin Myers,Fred Herzon,Duncan A. Meiklejohn

Publication date 25-08-2020


National pathology guidelines recommend full pathologic analysis for all adult tonsillectomy specimens. We evaluated the available data on occult malignancy in adult tonsillectomy for benign indication, and created a screening system to reduce the risk of missed malignancies if routine histopathologic examination were to be discontinued. Retrospective chart review and systematic review of the literature. Tertiary care academic hospital and multi-hospital private healthcare system. A systematic literature review identified case series of adult tonsillectomy. Retrospective chart review at our institutions from 2000 to 2016 produced an additional case series. The pooled rate of occult malignancy was determined, and re-analyzed using criteria based on preoperative risk factors designed to identify patients requiring full pathologic analysis. The predicted effects of prospective application of the proposed criteria were calculated. Pooled occult malignancy prevalence was estimated. Literature review and our own case series yielded 12,094 total cases. Occult malignancy prevalence in the combined data was 0.033%, representing four occult malignancies. Three out of the four would have been selected for full pathology preoperatively with use of the proposed criteria. Statistical analysis indicates that the predicted frequency of occult malignancy incidence in cases negative for the criteria is 0.01%, or 1/10,000. Application of the proposed criteria to adults undergoing tonsillectomy for benign indication identifies a subset of patients with an estimated incidence of occult malignancy similar to that reported for pediatric tonsillectomy, and potentially may permit safe elimination of pathologic analysis of their tonsil specimens. Pooled analysis of case series from the literature and a single institution, level 4.

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Longitudinal Voice Outcomes Following Serial Potassium Titanyl Phosphate Laser Procedures for Recurrent Respiratory Papillomatosis

Wei-Chen Hung,Wu-Chia Lo,Kai-Min Fang,Po-Wen Cheng,Chi-Te Wang

Publication date 27-08-2020


Repeated surgical interventions are usually required to control recurrent respiratory papillomatosis (RRP), but at considerable risk of worsened postoperative voice quality. Potassium titanyl phosphate (KTP) laser has been reported to effectively manage RRP; however, voice quality after repeated procedures has not been investigated. This study recruited 16 patients with RRP treated using KTP laser between 2013 and 2019. KTP laser procedures were performed under general anesthesia via direct suspension laryngoscope or under local anesthesia via flexible endoscope, depending on the need for pathological proof, patient tolerance, and lesion size and location. Disease control was investigated by videolaryngostroboscopy. Voice outcome was evaluated using a 10-item voice handicap index (VHI-10), acoustic and perceptual analyzes. We reviewed the medical records of 11 male and 5 female patients with RRP (age range: 23-73 years). Five patients received KTP laser once, six patients received it 2 to 5 times, and five patients received 6 to 15 procedures. Median VHI-10 decreased from 28.3 to 12.0 points after the initial procedure and were maintained at 10.1 to 11.0 points following subsequent procedures ( This longitudinal follow-up study revealed that serial KTP laser procedures can effectively control RRP while preserving phonatory function and maintaining adequate voice quality. 4.

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Comparison of Traditional Upper Airway Surgery and Upper Airway Stimulation for Obstructive Sleep Apnea

Colin Huntley,Maurits Boon,Samuel Tschopp,Kurt Tschopp,Carolyn M Jenks,Erica Thaler,Peter Baptista Jardin,Janki Shah,Alan Kominsky,Eric J Kezirian,Clemens Heiser,Jonathan Waxman,Ho-Sheng Lin

Publication date 29-08-2020


To compare patients with moderate-severe obstructive sleep apnea (OSA) undergoing traditional single and multilevel sleep surgery to those undergoing upper airway stimulation (UAS). Case control study comparing retrospective cohort of patients undergoing traditional sleep surgery to patients undergoing UAS enrolled in the ADHERE registry. 8 multinational academic medical centers. 233 patients undergoing prior single or multilevel traditional sleep surgery and meeting study inclusion criteria were compared to 465 patients from the ADHERE registry who underwent UAS. We compared preoperative and postoperative demographic, quality of life, and polysomnographic data. We also evaluated treatment response rates. The pre and postoperative apnea hypopnea index (AHI) was 33.5 and 15 in the traditional sleep surgery group and 32 and 10 in the UAS group. The postoperative AHI in the UAS group was significantly lower. The pre and postoperative Epworth sleepiness scores (ESS) were 12 and 6 in both the traditional sleep surgery and UAS groups. Subgroup analysis evaluated those patients undergoing single level palate and multilevel palate and tongue base traditional sleep surgeries. The UAS group had a significantly lower postoperive AHI than both traditional sleep surgery subgroups. The UAS group had a higher percentage of patients reaching surgical success, defined as a postoperative AHI <20 with a 50% reduction from preoperative severity. UAS offers significantly better control of AHI severity than traditional sleep surgery. Quality life improvements were similar between groups.

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The Role of Speech-Language Pathologists in Otolaryngology Resident Education

Yassmeen Abdel-Aty,Sara Charney,David G. Lott

Publication date 04-09-2020


Laryngology is an expanding field that has been increasingly incorporated into otolaryngology resident training programs nationwide. The exposure to the field is variable across training programs, despite the fact that laryngological complaints comprise a large proportion of consultations to otolaryngologists. Laryngology education is vital for the care of patients with voice, swallowing, and airway complaints as well as for the appropriate referral of patients to the laryngology team for specialized care. Speech-language pathologists (SLPs) specialized in voice and swallowing disorders are well-trained in the assessment and treatment for these populations. This team recently published a paper regarding the experience of laryngology education in residency. During analysis of the results, an interesting beneficial trend developed regarding the positive impact of exposure to SLPs. This appeared to be distinct and deserved further analysis and discussion. We propose that involving SLPs in resident education may greatly enhance their training in laryngology. As per our previous paper, a cross sectional, multi-institutional study was designed to assess the exposure of residents to laryngology. Descriptive statistics were obtained for questions involving exposure to SLPs. Fisher's exact test was used to compare differences between groups. Most respondents (135/151, 89.4%) indicated having SLPs specializing in voice and swallowing disorders in their departments, although only half (77/151, 51.0%) stated that they spent formal time with them during training. Results show that residents with formal training with SLPs were more comfortable interpreting videofluoroscopic swallow studies (VFSS) ( Formal time with SLPs within otolaryngology residency programs varies across the country. Speech-language pathologists are a useful resource for laryngology resident training and should be included in their education.

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Topical Triamcinolone on “Sweet Spots” to Block Dynamic Pain after Tonsillectomy and Uvulo-Palato-Pharyngo-Plasty

Joshua Kuang-Chao Chen,David M. Niddam,Tao-Hsin Tung,Lieber Po-Hung Li

Publication date 10-09-2020


Severe pain on swallowing (or dynamic pain) has long been a problem in patients receiving tonsillectomy and uvulopalatopharyngoplasty for the treatment of obstructive sleep apnea syndrome and/or snoring. We have previously verified that dynamic pain after laser-assisted uvulopalatoplasty could immediately be mitigated by local treatments with topical triamcinolone on the "sweet spots" of the wounds. This study aimed to assess the efficacy of applying triamcinolone on "sweet spot" in surgical incisions instead of whole surgical wounds to alleviate dynamic pain of some oropharyngeal surgeries such as tonsillectomy and uvulopalatopharyngoplasty. This study is a retrospective case series based on chart review of the participants. Forty-five subjects (31 males; 12~68 years, mean 34 years) with obstructive sleep apnea syndrome and/or snoring treated with tonsillectomy or uvulopalatopharyngoplasty were studied. Local treatments were done to sweet spots with triamcinolone on the 1st, 2nd, 3rd, and 7th days after the surgery. Evaluation of dynamic pain relief was performed by using a visual analogous scale. Sweet spots treatment led to instantaneous reduction of dynamic pain. The average improvement level was ≥72% ( Dynamic pain after tonsillectomy and uvulopalatopharyngoplasty could immediately be mitigated by local treatments upon sweet spots. Local treatments upon sweet spots were highly suggested to begin early post-operatively and be included in the take-home routines for patients receiving tonsillectomy and uvulopalatopharyngoplasty.

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Patient-Reported Factors Associated with the Onset of Hyperfunctional Voice Disorders

Samantha Kridgen,Robert E. Hillman,Tara Stadelman-Cohen,Steven Zeitels,James A. Burns,Tiffiny Hron,Carol Krusemark,Jason Muise,Jarrad H. Van Stan

Publication date 10-09-2020


Prevention, diagnosis, and treatment of hyperfunctional voice disorders would be improved by better understanding their etiological contributing factors. Therefore, this study estimated the prevalence of etiological factors using self-reported data about disorder onset from a large cohort of patients with Phonotraumatic Vocal Hyperfunction (PVH) and Non-Phonotraumatic Vocal Hyperfunction (NPVH). Retrospective chart review extracted the self-reported rate (gradual, sudden) and events associated (voice use, anxiety/stress, upper respiratory infection [URI]) with disorder onset from 1,577 patients with PVH and 979 patients with NPVH. Both patient groups reported a gradual onset more than a sudden onset. Voice use was the most frequently reported event for PVH and the NPVH group self-reported all three events at equal frequency. The largest PVH subgroups were associated with voice use while the NPVH subgroups were associated with only voice use, only URI, or only anxiety/stress. The results support the general clinical view that PVH is most strongly related to the gradual accumulated effects of phonotrauma, while NPVH has a more heterogeneous etiology. The identified PVH and NPVH subgroups may have clinical relevance and future work could investigate differences in treatment and outcomes among these subgroups.

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Applications of Electrospinning for Tissue Engineering in Otolaryngology

Ashley Heilingoetter,Sharon Smith,Prashant Malhotra,Jed Johnson,Tendy Chiang

Publication date 25-09-2020


In tissue engineering, biomaterials create a 3D scaffold for cell-to-cell adhesion, proliferation and tissue formation. Because of their similarity to extracellular matrix and architectural adaptability, nanofibers are of particular interest in tissue engineering. Electrospinning is a well-documented technique for nanofiber production for tissue engineering scaffolds. Here we present literature on the applications of electrospinning in the field of otolaryngology. A Pub Med database search was performed to isolate articles published about applications of electrospun nanofibers for tissue engineering in otolaryngology. Study design, size, material tested, site of application within the head and neck, and outcomes were obtained for each study. Almost all data on electrospinning in otolaryngology was published in the last 6 years (84%), highlighting its novelty. A total of 25 pre-clinical studies were identified: 9 in vitro studies, 5 in vivo animal studies, and 11 combination studies.
Sites of application included: tracheal reconstruction (n = 16), tympanic membrane repair (n = 3), cranial nerve regeneration (n = 3), mastoid osteogenesis (n = 1) and ear/nose chondrogenesis (n = 2). Tissue engineering is a burgeoning field, with recent innovative applications in the field of otolaryngology. Electrospun nanofibers specifically have relevant applications in the field of otolaryngology, due in part to their similarity to native extracellular matrix, with emerging areas of interest being tympanic membrane repair, cranial nerve regeneration and tracheal reconstruction.

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Vocal Fold Motion Impairment Following Chemotherapy Administration: Case Reports and Review of the Literature

Guy Talmor,Brandon Nguyen,Melin Tan Geller,Jeffrey Hsu,Rachel Kaye,Christen Caloway

Publication date 27-01-2021


Chemotherapy-induced vocal fold motion impairment (CIVFMI) is a rare complication of cancer therapy with potential for airway compromise. The objective of this review is to present 2 new cases of CIVFMI to add to the literature as well as characterize the demographics, symptoms, exam findings, airway complication rates and prognosis of CIVFMI. A search of Pubmed/MEDLINE (1970 to May 1, 2020), Embase (1970 to May 1, 2020), and Cochrane Library using medical study heading (MeSH) terms related to chemotherapy ( A preliminary search yielded 148 abstracts, review articles and studies. A total of 23 studies met inclusion criteria. There were 35 total cases presented in the literature, with a mean age of 29.5 (0.4-78). The most common cancer diagnosis was acute lymphoblastic leukemia (n = 15, 42.9%), and the most common agent was vincristine (n = 30, 85.7%). Dysphagia, bilateral CIVFMI, and vocal fold immobility rather than hypomobility were more common in pediatric patients. There were 8 cases of surgical airway intervention, including tracheostomy and posterior cordotomy. The duration of symptoms was 7 to 420 days, and spontaneous resolution was reported in 32 cases. CIVFMI has potential for airway complications requiring surgical intervention. Spontaneous resolution after cessation of the offending agent is the most likely outcome. Bilateral CIVFMI, dysphagia and vocal fold immobility are more common in the pediatric population.

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Epithelioid Sarcoma of the Tongue: An Unusual Tumor Mimic for Squamous Cell Carcinoma

Aasif A. Kazi,Nima A. Vahidi,Austin B. Wiles,Evan R. Reiter

Publication date 20-08-2020


Epithelioid sarcoma is a rare soft tissue malignancy that usually presents in the distal extremities along fascial planes, aponeuroses or tendon sheaths. Very rarely, it presents as a primary or metastatic lesion of the head neck. Chart review and comprehensive literature review using Pub Med and Google Scholar. A 17-year-old non-smoker was referred for evaluation of an ulcerative lesion of the right anterior-lateral tongue, progressing over several months. Incisional biopsy was concerning for squamous cell carcinoma. He underwent partial glossectomy and bilateral selective neck dissections, with reconstruction using a radial forearm free flap. Final pathology was consistent with epithelioid sarcoma, proximal type, demonstrating perineural invasion and close margins. Post-operative PET scan showed no persistent nor metastatic disease. He underwent post-operative radiation therapy to a total dose of 56 Gy to the primary site. Epithelioid sarcoma is a rare malignancy usually presenting in the extremities of young adults, which uncommonly presents in the head and neck as a primary or metastatic lesion. The infrequency of these lesions has prevented development of evidence-based treatment recommendations. As with most sarcomas, surgery is the mainstay of therapy for epithelioid sarcoma, while radiation has been used in an adjunctive role. Although a rare lesion, epithelioid sarcoma should be considered in the differential diagnosis for atypical epithelioid lesions of the tongue and oral cavity when patient demographics, gross lesion characteristics, or histopathology are not entirely consistent with more common lesions, such as squamous cell carcinoma.

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Displacement of a Total Ossicular Replacement Prosthesis Following Ossicular Chain Reconstruction

Aparna Govindan,Rohini R. Bahethi,Zachary G. Schwam,George B. Wanna

Publication date 21-08-2020


Herein we describe the diagnosis and management of total ossicular replacement prosthesis (TORP) displacement following tympanoplasty with ossicular chain reconstruction (OCR). Case report with literature review. A 40-year-old male with otorrhea and tympanic membrane perforation underwent a right revision tympanoplasty with OCR using a TORP with a tragal chondroperichondrial graft. On postoperative day (POD) 4, he developed vertigo and profound right-sided hearing loss. Temporal bone computed tomography showed the prosthesis in the vestibule. After a steroid taper with mild improvement in symptoms, the TORP was removed two weeks later and the patient continued to improve. TORP displacement into the vestibule is a very rare complication following OCR. Conservative management with high dose steroids may improve symptoms, however further middle ear exploration and surgical management may be warranted depending on the depth of displacement into the inner ear as well as symptom severity.

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Management of FDG avid Benign Sinonasal Schneiderian Papilloma: A Case Report and Review of the Literature

Iram Shafqat,Allen S. Ho,Daniel Manzoor,Bonnie Balzer,Arthur W. Wu

Publication date 27-08-2020


The inverted and oncocytic subtypes of sinonasal Schneiderian papillomas are benign tumors with possible rare malignant transformation and are typically managed with complete surgical resection and close follow-up. While computed tomography (CT) and magnetic resonance imaging (MRI) are mainstays in preoperative evaluation of bony invasion and soft tissue extension of the lesion, their imaging characteristics by 18F-fluoro-2-deoxy-D-glucose positron emission tomography (FDG-PET) is less well characterized. To describe the clinical presentation and management of a PET positive sinonasal lesion. To conduct a literature review of FDG uptake in benign sinonasal papillomas. Case report (n = 1) and literature review of similar cases (n = 32). We report the case of a 69-year-old man presenting with an isolated left maxillary sinus mass with avid FDG uptake, discovered on PET/CT imaging. An endoscopic left maxillary mega-antrostomy provided successful definitive treatment for final pathologic diagnosis of oncocytic papilloma. Literature review of cases of sinonasal papillomas with avid FDG uptake found that oncocytic papillomas, on average, exhibit greater uptake than inverted papillomas and both may be mistaken as malignancies on PET. While PET imaging demonstrating avid FDG uptake is associated with an increased risk of malignancy, it does not rule out the possibility of a benign sinonasal papilloma nor other benign inflammatory lesions. Particularly, oncocytic papillomas may have very high FDG uptake and mimic malignant lesions.

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Laryngeal Langerhans Cell Histiocytosis: A Case Report and Literature Review

Allen S. Zhou,Lei Li,Thomas L. Carroll

Publication date 31-08-2020


To describe a case of laryngeal Langerhans cell histiocytosis, discuss its characteristic features and management, and provide a review of the available literature. A patient presenting to a tertiary care medical center with dyspnea and hoarseness is described. A literature review of laryngeal Langerhans cell histiocytosis cases was performed through a search of articles indexed in the National Institutes of Health Pub Med system. We report a case of a 69-year old male, who presented with a laryngeal mass highly suspicious for laryngeal squamous cell carcinoma, was treated with laser excision, and was subsequently found to have laryngeal Langerhans cell histiocytosis upon histological analysis. Including our current case, we found six prior reported cases of laryngeal Langerhans cell histiocytosis in the literature. Of the six cases, four were in adults, while two were in children. Dyspnea is a common presenting complaint present in all cases. Smoking may be a potential risk factor. Laryngeal Langerhans cell histiocytosis is a rare condition and an important consideration in the differential diagnosis of patients presenting with a laryngeal mass and symptoms of dyspnea or hoarseness. Biopsy and histopathological analysis are key to the diagnosis. Surgical excision and radiotherapy are successful treatments used in clinical practice.

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Response to Letter to the Editor: Taste and Smell Dysfunction in COVID-19 Patients

Sara Martinelli de Souza,Bárbara Santos Panichelli,Mariana Spitz

Publication date 14-10-2020


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Is Transoral Robotic Surgery the Best Surgical Treatment for Lingual Thyroid?: A Case-Report and Literature Review

Grégoire D’Andréa,Benjamin Vairel,Clair Vandersteen,Emilien Chabrillac,Sébastien Vergez,Guillaume De Bonnecaze

Publication date 10-04-2021


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The Patient Perspective: Evaluating the Accessibility of Transoral Robotic Surgery Online Resources

Monica H. Xing,Raymond L. Chai

Publication date 10-04-2021


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Feel the Burn! Fireworks-related Otolaryngologic Trauma

Alexander J. Straughan,Luke J. Pasick,Vrinda Gupta,Daniel A. Benito,Joseph F. Goodman,Philip E. Zapanta

Publication date 09-04-2021


Fireworks are used commonly for celebrations in the United States, but can lead to severe injury to the head and neck. We aim to assess the incidence, types, and mechanisms of head and neck injuries associated with fireworks use from 2010 to 2019. A retrospective cross-sectional study, using data from the National Electronic Injury Surveillance System, of individuals presenting to United States Emergency Departments with head and neck injuries caused by fireworks and flares from 2010 to 2019. Incidence, types, and mechanisms of injury related to fireworks use in the US population were assessed. A total of 541 patients (349 [64.5%] male, and 294 [54%] under 18 years of age) presented to emergency departments with fireworks-related head and neck injuries; the estimated national total was 20 584 patients (13 279 male, 9170 white, and 11 186 under 18 years of age). The most common injury diagnoses were burns (44.7% of injuries), laceration/avulsion/penetrating trauma (21.1%), and otologic injury (15.2%), which included hearing loss, otalgia, tinnitus, unspecified acoustic trauma, and tympanic membrane perforation. The remaining 19% of injuries were a mix, including contusion, abrasion, hematoma, fracture, and closed head injury. Associations between fireworks type and injury diagnosis (chi-square Fireworks-related head and neck injuries are more likely to occur in young, white, and male individuals. Burns are the most common injury, while otologic injury is a significant contributor. Annual rates of fireworks-related head and neck injuries have not changed or improved significantly in the United States in the past decade, suggesting efforts to identify and prevent these injuries are insufficient.

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TLM Outcomes in Elderly Patients with Glottic Pre-Malignancy and Early Malignancy; A 12-Year Retrospective Study

Heidi Jones,Elizabeth Ross,Jemy Jose

Publication date 09-04-2021


UK population ageing and associated cancer risk predicts an increase in the prevalence of laryngeal cancer in elderly patients. Whilst trans-oral laser microsurgery (TLM) has been demonstrated to achieve excellent control of early disease with few complications, data specifically related to its safety and efficacy in older patients is lacking. We report the largest series to date. To assess the safety and efficacy of TLM in elderly patients with glottic pre-malignancy and early malignancy. A retrospective review and statistical analysis of the clinical records of patients aged 70 or over undergoing TLM for early and premalignant glottic disease. The records of 106 patients over the age of 70 were identified. Thirteen records were excluded, 4 due to failure to meet the inclusion criteria (stage I/II disease, primary site of lesion in the glottis) and 9 due to incomplete follow up data capture. Most surgeries (>70%) were performed as a day case or overnight admission, with only 2 admissions >2 days. One patient required hospital readmission with dysphagia, resulting in an altered diet. No patients required tracheostomy or tube feeding. No treatment related deaths or intensive care admissions were observed. Ten patients had recurrent disease within 5 years; 1 received radiotherapy, 1 underwent salvage laryngectomy, the remainder had further TLM without complication. Five-year disease specific survival rates were >90%. Our results demonstrate that TLM is safe and effective for elderly patients, with outcomes comparable to those reported in large, non-age selected cohorts. Although our patients underwent more conservative cordectomy types (I-III) than those with similar disease stages reported elsewhere, our recurrence rates were not higher. This supports the oncological effectiveness of surgery whilst reducing the risk of associated functional compromise.

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Dural Contact to the Malleus Head in Patients with Superior Semicircular Canal Dehiscence (SSCD): Case Series and Review of SSCD and Tegmen Defects

Carissa Wentland,Joseph Cousins,Jason May,Arnaldo Rivera

Publication date 09-04-2021


Report a series of cases in which patients have concomitant superior semicircular canal dehiscence (SSCD) and a dehiscent tegmen tympani with Dural contact to the malleus head (DCMH). An analysis of radiologic and audiologic data in 4 patients who presented with SSCD and DCMH at a tertiary care institution. A pertinent literature review was performed. Four patients (5 ears) had SSCD and DCMH. In 3 patients with unilateral DCMH, the mean maximum air-bone gap was 15 dB in the ear with DCMH compared to 50 dB in the ear without DCMH. Of the 5 ears with DCMH, the mean air conduction threshold at 250 Hz was 17 dB compared to 42 dB in the 3 ears without DCMH. We report the findings of DCMH in a series of 4 patients with bilateral SSCD. This limited series suggests that ears with SSCD and DCMH have less of an air-bone gap than would be expected, as 1 would expect an additive effect of DCMH and SSCD on the air-bone gap.

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Demographic Characteristics of Children Diagnosed with Bacterial Tracheitis

Jenna H. Barengo,Andrew J. Redmann,Patrick Kennedy,Michael J. Rutter,Matthew M. Smith

Publication date 09-04-2021


Examine the presentation and clinical course of patients with bacterial tracheitis (BT). Identify if socioeconomic differences exist among children who present with BT. This was a retrospective case series from a tertiary care pediatric medical center. The study group included patients less than 18 years old who were diagnosed with BT from January 2011 to March 2019. Patients with a tracheostomy and those who developed BT after prolonged hospitalization were excluded. Patient demographics were compared with the demographics of the counties surrounding the hospital. 33 patients with BT met inclusion criteria. The most common presenting symptoms were difficulty breathing, stridor, and sore throat (81.8% each), followed by cough (78.8%). Median length of stay was 3 days [interquartile range (IQR):2-4]. 19 patients (57.5%) were admitted to the intensive care unit. Intubation was required for 13 patients (39.4%), for a median length of 2 days [IQR:2-2]. Methicillin sensitive staphylococcus aureus was the most common bacterial etiology (33%). Mean presenting age was 8.58 years [95% confidence interval:7.3-9.9] and 14 patients were female (42.4%). 31 patients were white (93.9%), 1 was black (3%), and 1 was Hispanic (3%). BT patients were more likely to have private insurance compared to comparison (81.8% vs 63.4%, Children who presented with BT were more likely to be privately insured than a comparison population.

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Spontaneous Congenital Perilabyrinthine Cerebrospinal Fluid Fistulas

Benjamin D. Lovin,Eric N. Appelbaum,Latifah Makoshi,William E. Whitehead,Alex D. Sweeney

Publication date 09-04-2021


To report a recalcitrant spontaneous cerebrospinal fluid (CSF) fistula arising from multiple, anatomically-linked lateral skull base defects, and to review the available literature to determine optimal techniques for operative repair of congenital CSF fistulae. A patient with recurrent episodes of otologic meningitis was found to have a patent tympanomeningeal fissure, also known as a Hyrtl's fissure, and internal auditory canal (IAC) diverticulum that communicated with the jugular bulb. A systematic review of the literature characterized all reports of spontaneous congenital perilabyrinthine CSF leaks, and all cases of Hyrtl's fissures. An 11-year-old female was referred for recurrent meningitis. Imaging demonstrated a fistulous connection between the middle ear and IAC diverticulum via the jugular foramen. Specifically, a Hyrtl's fissure was identified, as well as demineralized bone around the jugular bulb. Obliteration of the fissure was initially performed, and a fistula reformed 4 months later. Multifocal CSF egress in the hypotympanum was identified on re-exploration, and middle ear obliteration with external auditory canal (EAC) overclosure was performed. A systematic review of the literature demonstrated 19 cases of spontaneous congenital perilabyrinthine CSF leaks. In total, 6 cases had multiple sources of CSF leak and 2 had history suggestive of intracranial hypertension. All of these noted cases demonstrated leak recurrence. Middle ear obliteration with EAC overclosure was successful in 4 recalcitrant cases. Repair of spontaneous congenital perilabyrinthine CSF leaks in cases demonstrating multiple sources of egress or signs of intracranial hypertension should be approached with caution. Middle ear obliteration with EAC overclosure may provide the most definitive management option for these patients, particularly if initial attempt at primary repair is unsuccessful.

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Postoperative Infection Rate and Associated Factors Following Endoscopic Sinus Surgery

Sharan J. Shah,Vivian S. Hawn,Nina Zhu,Christina H. Fang,Qi Gao,Nadeem A. Akbar,Waleed M. Abuzeid

Publication date 09-04-2021


There is a paucity of data on postoperative infections after endoscopic sinus surgery and associated risk factors. Our objective was to evaluate a cohort of patients undergoing endoscopic sinus surgery (ESS) for chronic rhinosinusitis to determine which perioperative factors may be associated with infection in the 30-day postoperative period. A retrospective cohort study of adults who underwent ESS at a tertiary academic medical center from 2015 to 2018 was performed. The primary outcome was incidence of postoperative infection, defined by identification of sinus purulence on nasal endoscopy necessitating antibiotics within 30 days of surgery. Independent variables collated included the result of postoperative cultures and use of perioperative antibiotics, oral corticosteroids, packing, and steroid-eluting stents. Statistical analysis involved bivariate analysis to identify variables that correlated with postoperative infection and subsequent multivariate logistic regression to identify independent risk factors. Three hundred seventy-eight unique ESS cases performed in 356 patients were reviewed. The mean age was 46 years (range, 18-87). The most common indication for surgery was chronic rhinosinusitis without nasal polyposis. The postoperative infection rate was 10.1%. The most commonly cultured pathogen was The incidence of postoperative infection following ESS was 10.1%. The use of postoperative systemic corticosteroids independently increased the risk of infection by 3.47-fold.

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Initial Experience Treating HPV-Related Laryngeal Diseases with Oral Brincidofovir: A Pilot Study

Brent E. Richardson

Publication date 09-04-2021


To determine if brincidofovir, an oral analog of cidofovir that achieves high tissue levels of the active metabolite with low systemic toxicity, has an observable effect on HPV-related disease of the larynx. Two patients with laryngeal recurrent respiratory papillomatosis (one each of genotypes 6 and 11) and 1 with recurring aryepiglottic fold Brincidofovir reduced papilloma burden in 1 patient and markedly attenuated the rate and magnitude of recurrence in both. After surgical intervention, Patient 1 remains disease-free at 10 years (7 years from last intervention) and Patient 2 has no symptoms at 8 years. Patient 3 with recurring Brincidofovir appears to attenuate HPV disease of the larynx in this small pilot study, though further investigation is required because of the highly variable nature of the disease and potential confounding factors.

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Risk Assessment in Thyroid Lobectomy and Total Thyroidectomy using Over 100 Thousand Cases

Philip R. Brauer,Brian B. Burkey,Chandana A. Reddy,Eric D. Lamarre

Publication date 09-04-2021


To assess risk factors and non-thyroid specific postoperative complications for thyroid lobectomy compared to total thyroidectomy. A retrospective, cross-sectional study of adults undergoing a lobectomy or total thyroidectomy using the National Surgical Quality Improvement Program database between 2005 and 2017. Patients not treated by otolaryngologists or general surgeons and with unknown demographic variables were excluded. A total of 106 915 patients were analyzed, 64 763 total thyroidectomies and 42 152 lobectomies. Multivariable analysis demonstrated that total thyroidectomy patients were half as likely to return to the operating room (OR = 0.491 (95%CI 0.445-0.542), Our multi-institutional study indicates specific risk factors for returning to the operating room that may warrant closer follow up after surgery for total thyroidectomy or thyroid lobectomy. We also identified the most common post-operative complications. During pre-operative planning, these findings should be considered by thyroid surgeons to help mitigate risk to patients.

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Endaural Over-Underlay Cartilage Tympanoplasty for Repair of Dry Subtotal Perforations

Yaser Said Çetin,Mehmet Zeki Erdem

Publication date 07-04-2021


We explored the auditory and anatomical success of grafting when the cartilage perichondrium (CP) was prepared using two different methods. Patients with subtotal or total perforation underwent tympanoplasty with a CP graft. A A total of 195 patients were included in the study. The total CP graft integration rate was 96% for both groups. Significant changes were detected in all hearing criteria evaluated 12 months after surgery compared to the preoperative period ( Cartilage slice support offers an extremely reliable method for reconstruction of tympanic membrane in cases of high-risk perforation. Partial failures are rare, but when they occur, they most often involved anterior graft medialization. When a piece of cartilage is removed at the malleus interface there may be a higher rate of partial failure.

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Can Tonsillectomy Be Safely Performed by Residents? A Comparative Retrospective Study

Shorook Na’ara,Michael Aronov,Ziv Gil,Arie Gordin

Publication date 07-04-2021


To assess whether a surgeon's level of training is associated with outcomes in pediatric tonsillectomy. A retrospective cohort study of the outcomes of pediatric tonsillectomies performed between 2006 and 2016 by senior surgeons versus resident surgeons under the supervision of senior surgeons. An otolaryngology department in a tertiary academic hospital. Children younger than 18 years who underwent bilateral tonsillectomy with or without adenoidectomy. Intraoperative bleeding, initiation of oral intake, and intraoperative and postoperative complications. Of 785 children, 397 (50.5%) were operated on by a resident surgeon and 388 (49.5%) by a senior surgeon. Patient demographics and surgical techniques were similar between the groups. The mean surgical time was 33.2 minutes in the residents' group and 27.1 minutes in the seniors' group ( Children undergoing tonsillectomy showed similar short-term outcomes, whether the operations were performed by a senior surgeon or a resident surgeon supervised by an attending surgeon. This study demonstrates the safety of pediatric tonsillectomy performed by resident surgeons supervised by attending physicians.

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Online Reputations: Comparing Hospital- and Patient-Generated Ratings in Academic Otolaryngology

Krystyne Basa,Nicolette Jabbour,Matthew Rohlfing,Sarah Schmoker,Claire M. Lawlor,Jessica Levi,Lindsay Sobin,Jeremiah C. Tracy,Lauren F. Tracy

Publication date 03-04-2021


This study compares hospital-generated online ratings to patient-generated online ratings in academic otolaryngology and evaluates physician factors influencing these results. Websites of academic otolaryngologists were assessed for inclusion of hospital-generated Press Ganey surveys. Corresponding scores on Healthgrades and Vitals.com were identified via internet search. Hospital ratings were compared with patient-generated ratings, including score, demographics, and number of ratings. All data was collected between July 15th 2019 and August 22nd 2019. 742 academic otolaryngologists with hospital-generated ratings were identified. Mean hospital-generated rating was significantly higher ((4.70, 95% CI 4.69-4.72) than patient-generated rating (Vitals:4.26, 95% CI 4.18-4.34, and Healthgrades:4.02, 95% CI 3.87-4.18; Hospital-generated ratings yield higher mean scores than patient-generated platforms. Between sources, Healthgrades.com scores were lower than those of Vitals.com. Professors with >30 years of practice generated more reviews in patient-generated ratings, and these physicians were generally rated lower. Access to patient-generated ratings is universal and physicians should be aware of variability between online rating platforms as scores may affect referrals and practice patterns.

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Sudden Sensorineural Hearing and Vestibular Loss in a Case of Relapsing Polychondritis

Özge Akdoğan,Smirnov Exilus,Bryan K. Ward,Justin C. McArthur,Charles C. Della Santina,John P. Carey

Publication date 03-04-2021


To report a case of profound bilateral sensorineural hearing and vestibular loss from relapsing polychondritis and hearing outcomes after cochlear implantation. Case report and literature review. A 43 year-old woman developed sudden loss of hearing and balance that progressed over several weeks to bilateral, profound hearing and vestibular loss. Steroid treatments were ineffective. She underwent vestibular physical therapy and left cochlear implantation. About 10 months after her initial presentation, she developed erythema, warmth, swelling, and pain of the left auricle sparing the lobule, flattening of the bridge of her nose, and right ankle swelling, warmth, and skin erythema. A biopsy of the left auricle revealed histopathologic findings consistent with relapsing polychondritis. She was treated with high dose prednisolone. The ear inflammation resolved, however, despite excellent auditory response to pure tone thresholds, the patient reported no improvement in speech perception after cochlear implantation. Relapsing polychondritis can present with rapidly progressive, profound loss of hearing and vestibular function. Hearing outcomes after cochlear implantation can include poor speech discrimination despite good pure tone detection thresholds.

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Sleep Dysfunction is an Independent Predictor of Productivity Losses in Patients with Chronic Rhinosinusitis

Gretchen M. Oakley,Kristine A. Smith,Shaelene Ashby,Richard R. Orlandi,Jeremiah A. Alt

Publication date 03-04-2021


Chronic rhinosinusitis (CRS) is known to have a significant impact on economic productivity. Sleep dysfunction is associated with staggering productivity losses and is highly prevalent in patients with CRS. The effect of sleep dysfunction on productivity in CRS has not been elucidated. The objective of this study was to determine the relationship between sleep dysfunction and lost productivity in patients with CRS. Eighty-two adult patients with CRS were prospectively enrolled into a cross-sectional cohort study. Patients with obstructive sleep apnea were excluded. Sleep quality was measured using the Pittsburgh Sleep Quality Index (PSQI). Presenteeism (reduced work efficiency), absenteeism (missed work days), and lost work, household, and overall productivity were analyzed. The primary aim was assessing the correlation between PSQI and productivity. Regression analyses were performed to account for disease severity, pain, and depression. Sleep dysfunction is significantly correlated with overall lost productivity (R Sleep dysfunction has a significant association with lost productivity in patients with CRS, particularly with worsening PSQI scores. More clearly defining those components of CRS that most impact a patient's daily function will allow clinicians to more optimally manage and counsel patients with CRS.

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Adverse Events Associated with Intranasal Sprays: An Analysis of the Food and Drug Administration Database and Literature Review

Salma Ahsanuddin,Roman Povolotskiy,Rahma Tayyab,Wissam Nasser,Gregory L. Barinsky,Jordon G. Grube,Boris Paskhover

Publication date 03-04-2021


Intranasal sprays (INSs) are commonly used medications for the treatment of many rhinologic conditions. Despite their popularity, an analysis of a nationwide reporting database and comparison to the available literature has never been performed. The Food and Drug Administration Adverse Event Reporting System (FAERS) database was accessed to obtain adverse event (AE) records from 2014 to 2019 for varying INSs, including: 10 corticosteroids, 1 alpha adrenergic, and 3 antihistamines. The Proportional Reporting Ratios (PRR) and Reporting Odds Ratios (ROR) were calculated for dyspnea, anosmia, ageusia/dysgeusia, epistaxis, and headache. A PRR ≥ 2 or ROR ≥ 1 was considered significant. Corticosteroids had 98 864 total reported AEs to the database, followed by antihistamines (7011) and alpha adrenergics (2071). In total, dyspnea was reported 5843 times, followed by headache (4230), epistaxis (1205), ageusia/dysgeusia (920), and anosmia (312). Overall, PRR and ROR values for dyspnea ranged from 0.51 to 4.25 and 0.51 to 4.49; for dysgeusia/ageusia from 0.56 to 6.09 and 0.56 to 6.12; and for epistaxis from 1.03 to 27.24 and 1.03 to 30.76, respectively. All medications which listed anosmia within the top AEs had PRR and ROR values exceeding 2 and 1, respectively. The PRR for headache exceeded 2 for 1 medication and the ROR exceeded 1 in 7 medications. The AEs of dyspnea, anosmia, ageusia/dysgeusia, epistaxis, and headache are reported within the FAERS database for commonly prescribed INSs. When compared against the existing scientific literature, the clinical significance of this reporting tool from the FDA for these classes of medications remains unvalidated.

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Migraine Features in Patients with Persistent Postural-Perceptual Dizziness

Brooke Sarna,Adwight Risbud,Ariel Lee,Ethan Muhonen,Mehdi Abouzari,Hamid R. Djalilian

Publication date 03-04-2021


To evaluate the presence of migraine features in patients with persistent postural-perceptual dizziness (PPPD). In a retrospective survey study, consecutive patients presenting to a tertiary care neurotology clinic during an 18-month period were given questionnaires about headache and dizziness symptoms. The survey responses plus history and examination of the patient were used to diagnose patients with PPPD. The prevalence of migraine headache, vestibular migraine (VM), and migraine characteristics was evaluated. In total, 36 subjects with PPPD were included in the study. The mean age of the subjects was 56 ± 16 years with a female (72%) predominance. A total of 19 (53%) patients met the International Classification of Headache Disorders criteria for migraine headache, and 6 of those (17%) met the criteria for definite VM. Of the patients who did not meet full migraine headache criteria, 6 (17%) patients met 4 of 5 criteria, and 5 (14%) patients met 3 of 5 criteria. There was no significant difference between PPPD patients who fulfilled full migraine headache criteria and those who did not in sensitivity to light, sound, smells, weather changes, feelings of mental fog/confusion, and sinus pain/facial pressure. This study demonstrates that a majority of patients with PPPD fulfill the criteria for migraine headache. A large proportion of PPPD patients who do not meet the full criteria for migraine headache still meet a majority of the migraine headache criteria. This suggests an association between the 2 conditions. PPPD may be a part of the spectrum of otologic migraine, where migraine manifests as otologic symptoms.

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Giant Congenital Blue Nevus Presenting as Cutis Verticis Gyrata: A Case Report and Review of the Literature

Melissa E. Cullom,Garth R. Fraga,Alan R. Reeves,Dhaval Bhavsar,Brian T. Andrews

Publication date 03-04-2021


Cerebriform intradermal nevus and giant congenital blue nevi are rarely reported melanocytic nevi with clinical and histopathologic similarities. Both are known to produce cutis verticis gyrata. We report a significantly large occipital scalp congenital blue nevus with secondary cutis verticis gyrata. The aim of this report is to increase clinical awareness of this entity, highlight histopathologic and mutational features of cerebriform intradermal nevi and giant congenital blue nevi, and stress the importance of clinicopathologic correlation for diagnosis. Case report and review of the literature. A 20-year-old Asian male presented with a long-standing, large (20 cm × 30 cm), exophytic tumor at the occipital scalp and posterior neck. The skin overlying the lesion was arranged in thick folds resembling the surface of the brain, devoid of hair follicles, and discolored by salt-and-pepper pattern hyperpigmentation. After correlating the clinical and histopathologic findings, we diagnosed giant congenital blue nevus with secondary cutis verticis gyrata. Staged surgical excision was performed with subsequent treatment for hypertrophic scarring and occipital alopecia. Cerebriform intradermal nevus and giant congenital blue nevus have overlapping histologic and clinical features. Head and neck surgeons should be aware that nomenclature of these tumors is subjective and often imprecise. Diagnosis requires correlation of clinical findings, patient history, and histopathology. Surgical excision is advised due to rare malignant transformation potential.

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Reversible Canalith Jam of the Horizontal Semicircular Canal Mimicking Cupulolithiasis

Olivia A. Kalmanson,Davis M. Aasen,Samuel P. Gubbels,Carol A. Foster

Publication date 03-04-2021


To describe a case of benign paroxysmal positional vertigo (BPPV) resulting in reversible horizontal semicircular canalith jam successfully treated with horizontal canal occlusion. A brief literature review of similar cases was performed. Case report and literature review. A 68-year-old female presented with apogeotropic positional nystagmus, attributed to reversible horizontal canalith jam mimicking cupulolithiasis that was refractory to tailored repositioning maneuvers across months. She was unable to work due to the severity of her symptoms. She underwent surgical occlusion of the affected canal with immediate resolution of her symptoms. A literature review revealed similar cases of canalith jam mimicking cupulolithiasis. Reversible canalith jam, in which particles moving with horizontal head position alternate between obstructing the semicircular canal and resting on the cupula, can mimic signs of cupulolithiasis. This variant of BPPV can be effectively managed with surgical canal occlusion should symptoms fail to resolve after tailored repositioning maneuvers.

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Diagnosis of Retrolingual Obstruction during Drug-Induced Sleep Endoscopy versus Polysomnography with Nasopharyngeal Tube in Patients with Obstructive Sleep Apnea

Jian Qiao,Jie Qin,Dengxiang Xing,Shuhua Li,Dahai Wu

Publication date 29-03-2021


To compare the retrolingual obstruction during drug-induced sleep endoscopy (DISE) with the retrolingual obstruction during polysomnography with nasopharyngeal tube (NPT-PSG). A cross-sectional study of 77 consecutive patients with moderate and severe obstructive sleep apnea (OSA) was conducted. After 15 patients were excluded from the study for not completing DISE or NPT-PSG successfully, 62 patients were included in this study. Retrolingual sites of obstruction grade 2 determined by DISE according to the VOTE (velum, oropharynx lateral wall, tongue base, and epiglottis) classification were considered as retrolingual obstruction, while apnea-hypopnea index (AHI) ≥ 15 events/hour determined by NPT-PSG was considered as retrolingual obstruction. The extent of agreement between DISE and NPT-PSG findings was evaluated using unweighted Cohen's kappa test. The 62 study participants (11 moderate OSA, 51 severe OSA) had a mean (SD) age of 39.8 (9.9) years, and 58 (94%) were men. No statistically significant differences between included and excluded patients were observed in patient characteristics. The extent of agreement in retrolingual obstruction between DISE and NPT-PSG was 80.6% (Cohen Retrolingual obstruction requiring treatment showed good agreement between DISE and NPT-PSG, suggesting that NPT-PSG may also be a reliable method to assess the retrolingual obstruction.

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Otolaryngology Consult Protocols in the Setting of COVID-19: The University of Pittsburgh Approach

Harish Dharmarajan,Michael A. Belsky,Jennifer L. Anderson,Shaum Sridharan

Publication date 29-03-2021


To analyze trends in otolaryngology consultations and provide algorithms to guide management during the COVID-19 pandemic. A retrospective cohort study at a single institution tertiary care hospital. A total of 95 otolaryngology consultations were performed from March 1, 2020 to April 26, 2020 (COVID-era) and 363 were performed from September 1, 2019 to February 29, 2020 (pre-COVID-era) at the UPMC Oakland campus. Data collected included patient demographics, COVID-19 status, reason for consult, location of consult, type of consult, procedures performed, need for surgical intervention, length of hospital stay and recommended follow up. Patient populations in the pre-COVID-era and COVID-era were similar in terms of their distribution of demographics and chief complaints. Craniofacial trauma was the most common reason for consultation in both periods, followed by vocal fold and airway-related consults. We saw a 21.5% decrease in the rate of consults seen per month during the COVID-era compared to the 6 months prior. Review of trends in the consult workflow allowed for development of several algorithms to safely approach otolaryngology consults during the COVID-19 pandemic. Otolaryngology consultations provide valuable services to inpatients and patients in the emergency department ranging from evaluation of routine symptoms to critical airways. Systematic otolaryngology consult service modifications are required in order to reduce risk of exposure to healthcare providers while providing comprehensive patient care.

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Systematic and Other Reviews: Criteria and Complexities

Robert T. Sataloff,Matthew L. Bush,Rakesh Chandra,Douglas Chepeha,Brian Rotenberg,Edward W. Fisher,David Goldenberg,Ehab Y. Hanna,Joseph E. Kerschner,Dennis H. Kraus,John H. Krouse,Daqing Li,Michael Link,Lawrence R. Lustig,Samuel H. Selesnick,Raj Sindwani,Richard J. Smith,James Tysome,Peter C. Weber,D. Bradley Welling

Publication date 24-03-2021


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Scholarly Research Productivity among Otolaryngology Residency Graduates and its Relationship to Future Academic Achievement

Austin L. Johnson,Adam Corcoran,Matthew Ferrell,Bradley S. Johnson,Scott E. Mann,Jennifer A. Villwock,Sydney Ferrell,Matt Vassar

Publication date 24-03-2021


Scholastic activity through research involvement is a fundamental aspect of a physician's training and may have a significant influence on future academic success. Here, we explore publication rates before, during, and after otolaryngology residency training and whether publication efforts correlate with future academic achievement. This cross-sectional analysis included a random sample of 50 otolaryngology residency programs. From these programs, we assembled a list of residents graduating from the years in 2013, 2014, and 2015. Using SCOPUS, Pub Med, and Google Scholar, we compiled the publications for each graduate, and data were extracted in an independent, double-blinded fashion. We included 32 otolaryngology residency programs representing 249 residents in this analysis. Graduates published a mean of 1.3 (SD = 2.7) articles before residency, 3.5 (SD = 4.3) during residency, and 5.3 (SD = 9.3) after residency. Residents who pursued a fellowship had more total publications ( Research productivity correlated with a number of characteristics such as future fellowship training, the pursuit of an academic career, and overall h-index in this study.

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Treatment of Paranasal Sinus Fungus Ball: A Systematic Review and Meta-Analysis

Gian Luca Fadda,Fabiana Allevi,Cecilia Rosso,Federica Martino,Carlotta Pipolo,Giovanni Cavallo,Giovanni Felisati,Alberto Maria Saibene

Publication date 18-03-2021


Paranasal sinus fungus ball is a common non-invasive mycosis with excellent long-term surgical treatment results. The present systematic review and meta-analysis were undertaken to define current treatment concepts and success rates in paranasal sinus fungus ball treatment. Systematic searches were performed in multiple databases with criteria designed to include all studies published until May 2020 focusing on paranasal sinuses fungus ball treatment in humans. We selected studies including at least 10 patients, specifying treatment modalities, providing a minimum 6-month follow-up, and objectivating treatment success. After duplicate removal, abstract and full-text selection, and quality assessment, we reviewed eligible articles for treatment modalities and success rates. Success rates were pooled in a random effect meta-analysis and compared according to the use of intraoperative sinus lavages and postoperative antibiotics. Among 740 unique citations, 14 studies were deemed eligible. Most (n = 11) were retrospective case series. All studies relied on endoscopic sinus surgery. Intraoperative lavages were proposed in 10 studies and postoperative antibiotics in 7 (for all patients in 5 studies and for selected patients in 2). No significant heterogeneity was observed between results (Cochran's Q Endoscopic sinus surgery shows excellent results in fungus ball treatment. Further prospective studies might help further reducing antibiotics prescriptions in these patients and improve their management.

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The Effect of the Mother’s Participation in Therapy on Children with Vocal Fold Nodules

Nevreste Didem Sonbay Yılmaz,Cansu Afyoncu,Nuray Ensari,Muhammet Yıldız,Özer Erdem Gür

Publication date 18-03-2021


Vocal fold nodules (VFN) are a bilateral epithelial thickening of the membranous vocal folds. In this study, children with VFN and their mothers took part in voice therapy. We then compared acoustic analyzes and subjective evaluations to those in previous literature to determine whether voice therapy is more effective for children with VFN when their mothers also take part in therapy. Children aged eight to 12 years who were diagnosed with bilateral VFN between January 2018 and January 2020 were included in this study. Participating children diagnosed with bilateral VFN were divided into two groups based on the wishes and cooperation of their families. Group 1 consisted of 16 patients; Group 2 included 17 patients. The children in Group 1 received voice therapy alone; children in Group 2 took part in therapy with their mothers. For all participants, the average fundemental frequency (F0), jitter percentages, shimmer percentages, maximum phonation time (MPT) and s/z ratios were measured. Pediatric voice handicap index (p-VHI) values were calculated as well. The two groups' measures pre-treatment and post-treatment were compared. Except for p-VHI, no significant difference was observed between the two groups. However, p-VHI post-treatment was significantly lower in Group 2 than in Group 1. Involving the families and even teachers of children with VFN in voice therapy can increase the effectiveness of therapy. The family's involvement increases the child's motivation in therapy. The mother's presence during therapy, supporting the child or even doing the work with the child, can be a very important source of motivation for the child, who may already be tired from school and other activities. Thus, the mother's involvement increases the child's compliance with and interest in therapy.

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Clinical Practices in Head and Neck Cancer: A Speech-Language Pathologist Practice Pattern Survey

Ashley M. Logan,Mario A. Landera

Publication date 18-03-2021


Clinical practices of speech-language pathologists (SLP) treating head and neck cancer (HNC) patients range widely despite literature trending toward best practices. This survey study was designed to identify current patterns and assess for gaps in clinical implementation of research evidence. A web-based survey was distributed to SLPs via listserv and social media outlets. Descriptive statistics and group calculations were completed to identify trends and associations in responses. Of 152 received surveys, the majority of respondents were hospital-based (86%) and had greater than 5 years of experience (65%). There was group consensus for the use of prophylactic exercise programs (95%), recommendations for SLP intervention during HNC treatment (75%), and use of maintenance programs post-treatment (97%). Conversely, no group consensus was observed for use of pre-treatment swallow evaluations, frequency of service provision, and content of therapy sessions. Variation in clinical decision making was noted in use of prophylactic feeding tubes and number of patients taking nothing by mouth during treatment. No associations were found between years of experience and decision-making practices, nor were any associations found between practice setting and clinical decision making. Despite the growing body of literature outlining evidence-based treatment practices for HNC patients, clinical practice patterns among SLPs continue to vary widely resulting in inconsistent patient care across practice settings. As compared to prior similar data, increased alignment with best practices was observed relative to early referrals, implementation of prophylactic intervention programs, and intervention with the SLP during the period of HNC treatment.

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Aerosol and Droplet Risk of Common Otolaryngology Clinic Procedures

Devi Sai Sri Kavya Boorgu,Harish Dharmarajan,Edward S. Sim,Lindsey Goyal,Monika E. Freiser,Michael Weinstock,Rachel Whelan,Timothy E. Corcoran,Noel Jabbour,Eric Wang,David H. Chi

Publication date 18-03-2021


Define aerosol and droplet risks associated with routine otolaryngology clinic procedures during the COVID-19 era. Clinical procedures were simulated in cadaveric heads whose oral and nasal cavities were coated with fluorescent tracer (vitamin B2) and breathing was manually simulated through retrograde intubation. A cascade impactor placed adjacent to the nares collected generated particles with aerodynamic diameters ≤14.1 µm. The 3D printed models and syringes were used to simulate middle and external ear suctioning as well as open suctioning, respectively. Provider's personal protective equipment (PPE) and procedural field contamination were also recorded for all trials using vitamin B2 fluorescent tracer. The positive controls of nebulized vitamin B2 produced aerosol particles ≤3.30 µm and endonasal drilling of a 3D model generated particles ≤14.1 µm. As compared with positive controls, aerosols and small droplets with aerodynamic diameter ≤14.1 µm were not detected during rigid nasal endoscopy, flexible fiberoptic laryngoscopy, and rigid nasal suction of cadavers with simulated breathing. There was minimal to no field contamination in all 3 scenarios. Middle and external ear suctioning and open container suctioning did not result in any detectable droplet contamination. The clinic suction unit contained all fluorescent material without surrounding environmental contamination. While patients' coughing and sneezing may create a baseline risk for providers, this study demonstrates that nasal endoscopy, flexible laryngoscopy, and suctioning inherently do not pose an additional risk in terms of aerosol and small droplet generation. An overarching generalization cannot be made about endoscopy or suctioning being an aerosol generating procedure. 3.

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Spin the Abstracts of Systematic Reviews and Meta-Analyses Regarding the Treatment of Ménière’s Disease

Benjamin Heigle,Micah Kee,Ryan Ottwell,Wade Arthur,Lacy Brame,Drew N. Wright,Micah Hartwell,Jam Khojasteh,Matt Vassar

Publication date 18-03-2021


To identify, quantify, and characterize the presence of spin-specific strategies leading to misrepresentation of study results-in the abstracts of systematic reviews and meta-analyses of Ménière's disease treatment. Using a cross-sectional design, we searched MEDLINE and Embase on May 28, 2020, for systematic reviews and meta-analyses focused on Ménière's disease treatment. Returned searches were screened, and data were extracted in a masked, duplicate fashion. Our sample included 36 systematic reviews and meta-analyses. Of the 36 included studies, 22 (61.1%) abstracts contained spin while 14 (38.9%) did not. The most common spin types were selective reporting of benefit (10/36, 27.8%) or harm (8/36, 22.2%). Other types of spin occurred when findings were extrapolated to the global improvement of the disease (5/36, 13.9%), beneficial effects were reported with high risk of bias in primary studies (3/36, 8.3%), and when beneficial effects were extrapolated to an entire class of interventions (1/36, 2.8%). No instances of other spin types occurred. Abstracts containing spin were substantively associated with studies of critically low methodological quality compared with studies with low and moderate quality. No studies had a methodological rating of high quality. No associations were observed between spin and intervention types, journal recommendation of adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses, or funding. We found a negative correlation ( Our study highlights that spin in the abstracts of systematic reviews of Ménière's disease is common, and it further enhances the discussion surrounding spin in abstracts of scientific research. Spin in an abstract does not discredit a study's findings; however, its occurrence should be eliminated.

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Characteristics of Benign Paroxysmal Positional Vertigo Following an Earthquake

Muhammed Gazi Yildiz,Nagihan Bilal,Irfan Kara,Saime Sagiroglu,Israfil Orhan,Adem Doganer

Publication date 15-03-2021


Benign Paroxysmal Positional Vertigo (BPPV) is a commonly encountered peripheral vestibular disorder. People exposed to massive earthquakes experience intense and long-term problem associated with dizziness. The purpose of our study is to investigate this relationship and to demonstrate the efficacy of the treatment modalities used in the management of patients with post-earthquake dizziness. The study was carried out by examining the retrospective records of patients who presented with dizziness to the otorhinolaryngological outpatient unit before and after the Elazig earthquake that occurred on 24th Jan 2020. Parameters evaluated include patients' age and gender, onset of dizziness, accompanying symptoms and comorbidities, videonystagmography (VNG) findings, pre- and post-treatment Visual Analogue Scale (VAS), Dizziness Handicap Inventory (DHI), and Hospital Anxiety and Depression Scale (HADS). The number of patients who presented with dizziness to our outpatient clinic after the earthquake and were included in our study totaled 84. The number of patients who visited the outpatient clinic before the earthquake was identified to be 75. In the earthquake related group, while there was a statistically significant difference between residual symptoms (RS) and the need for repetitive repositioning maneuvers, there was no statistically significant difference detected for age, gender, and comorbidities. Also, no statistically significant difference was found in the pre- and post-treatment assessments of VAS, DHI, and HADS median values in the earthquake group. There was a remarkable increase in the number of patients presenting with dizziness in the early post-earthquake period. Management of these patients may differ from the classic BPPV. Residual symptoms appearing after performing repositioning maneuvers can be more commonly seen among these patients.

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Removal of Airway Foreign Body in a Premature Neonate

Leighton Reed,Stephen Larson,Anthony Sheyn,Jennifer McLevy

Publication date 04-03-2021


Airway foreign bodies are the leading cause of infantile deaths and fourth among preschool children. Airway foreign bodies in extremely premature neonates represent a rare but potentially lethal entity. There are very few reports in the literature describing the treatment of such a condition in premature neonates. The objectives of this report are to describe the safe removal of an airway foreign body in an extremely premature infant using urologic instruments in a trans-endotracheal tube fashion and to review the literature for other techniques that have proven safe and effective, thereby adding technical options for future cases. We reviewed the case reported and reviewed pertinent literature. A 2-week old, ex-24 3/7-week, 820-g pre-mature infant was intubated with a 2.5 endotracheal tube. After intubation, a 2-cm foreign body was discovered in the distal trachea by chest x-ray. The child's respiratory status continuously deteriorated with increasing oxygen and positive pressure requirements. While remaining intubated, the child underwent direct suspension laryngoscopy, the ventilator circuitry was disconnected, and the object was successfully removed using a 1.2 mm rigid ureteroscope and 1.1 mm grasping forceps through the 2.5 endotracheal tube. This case report demonstrates the effectiveness of using a 1.2 mm ureteroscope and 1.2 mm urologic graspers to extract an airway foreign body from an extremely premature neonate through an endotracheal tube without paralyzing the patient. This method provides a safe and effective means of visualizing and, if necessary, manipulating the airway in a population prone to respiratory complications.

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Laryngeal Manifestations of Crohn’s Disease in a Toddler with Very Early Onset-IBD

Ian A. Schonman,Sona Sehgal,Luv R. Javia,Nancy M. Bauman

Publication date 04-03-2021


We report obstructing laryngeal manifestations of Crohn's disease in a toddler with very early onset-IBD (VEO-IBD) who required tracheotomy tube placement at 27 months of age for relief of recalcitrant airway obstruction unresponsive to maximal medical therapy. We review the literature for the frequency of extra-intestinal laryngeal manifestations of Crohn's disease in adults and children. Case report and literature review of laryngeal manifestations of Crohn's disease. Laryngeal involvement of Crohn's disease is very rare with only 14 other cases reported. Most cases appear in adults, with the supraglottis most commonly affected. This case marks the youngest report and only the second report of a patient requiring a tracheotomy for supraglottic obstruction when intensive medical management, including use of steroids and biologics, failed to relieve obstructing laryngeal inflammation. Despite ongoing Crohn's disease, laryngeal manifestations improved permitting decannulation the following year. Laryngeal manifestations of Crohn's disease are rare and usually affect adults. Most cases are managed with medical therapy, however surgical excision of obstructing lesions or tracheotomy placement is sometimes required for temporary relief of airway obstruction.

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The Sinonasal Outcome Test (SNOT-22) Is a Poor Diagnostic Tool for Chronic Rhinosinusitis

Michael T. Yim,Richard R. Orlandi,Gretchen M. Oakley,Jeremiah A. Alt

Publication date 04-03-2021


The SNOT-22 is a validated and widely used outcomes tool in chronic rhinosinusitis (CRS). We hypothesized that SNOT-22 scores and response patterns could be used as a diagnostic tool to differentiate between patients with CRS and those who present with CRS-like symptoms but prove not to have CRS. SNOT-22 measurements were collected from 311 patients who presented with a chief complaint of sinusitis to a tertiary rhinology practice. Following a full diagnostic evaluation, patients were diagnosed with CRS or determined to have non-CRS diagnoses. A response pattern "heatmap" of the SNOT-22 scores for each group was compared. An optimal cutoff point for total SNOT-22 score in predicting CRS was sought using a receiver operating characteristic (ROC) curve. A total of 109 patients were diagnosed with CRS and 202 patients were assigned to non-CRS. The non-CRS SNOT-22 total score histogram had lower overall scores compared to the CRS group, although there was substantial overlap. The CRS SNOT-22 heatmaps had a distinctive pattern compared to the non-CRS group. As individual measures, 3 of the 4 cardinal symptoms of CRS (nasal congestion, loss of smell, and rhinorrhea) were found to be significantly different between the 2 groups ( Our results cause us to reject our hypothesis and conclude that, while an effective outcomes tool, the SNOT-22 (using total score and response pattern) is a poor differentiator between CRS and non-CRS patients.

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Autologous Free Dermal-Fat-Fascial Graft for Parotidectomy Defects: A Case Series

Aliasghar A. Mianroodi,Sadaf Mohtashami,Nahir Romero,Andrew Fuson,Arjun Joshi,Nader Sadeghi

Publication date 04-03-2021


Frey's syndrome and facial asymmetry from loss of parotid tissue are long-term sequelae of parotid surgeries causing significant morbidity. Various techniques have been used to fill the parotidectomy defect, preserve facial contour symmetry, and prevent Frey's syndrome. Free dermal-fat-fascial graft (DFFG) is one such technique; however, its use is largely undocumented in the literature. In this case series, we investigate the efficacy of free DFFG in reconstructing parotidectomy defects at 2 tertiary care centers. Medical records of 54 patients who underwent primary parotidectomy and immediate reconstruction with autologous abdominal free DFFG by 2 surgeons in George Washington University Hospital and Mc Gill University Health Centre between 2007 and 2019 were collected prospectively. Patients responded to 2 questionnaires addressing postoperative outcomes. Fifty-four patients were included; 32 superficial parotidectomies and 22 total parotidectomies were performed for 39 benign and 15 malignant tumors. Thirty-seven patients could be reached. Out of 37 patients who responded to the first questionnaire, 59% (22) reported complete facial symmetry, 27% (10) reported mild hollowness, and 14% (5) reported mild fullness. None declared noticeable hollowness or fullness. While 81% (30) did not experience Frey's syndrome, 5.4% (2) experienced mild symptoms without disability, and 13.5% (5) experienced debilitating symptoms. Out of 37 patients, 8 patients responded to a second questionnaire addressing the outcome of the abdominal graft donor site. In regard to the donor site, 87.5% (7) were satisfied or very satisfied from its cosmetic appearance, 75% (6) were not bothered by its cosmetic appearance, and 87.5% (7) had no discomfort at the graft donor site. Patients did not report any other symptom at the graft donor site. In this large series of total parotidectomies including malignant pathologies, autologous abdominal free DFFG effectively prevented Frey's syndrome and preserved facial cosmesis in most patients.

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Sublesional Bevacizumab Injection for Recurrent Respiratory Papillomatosis: Evaluation of Utility in a Typical Clinical Practice

Scott Ryan Hall,Mrudula Thiriveedi,Usha Yandrapalli,Nan Zhang,David G. Lott

Publication date 02-03-2021


The goal of this study was to evaluate the benefit of sublesional bevacizumab injection for recurrent respiratory papillomatosis (RRP) as used in a typical clinical practice. A retrospective review of patients with RRP treated between 2011 and 2016 was undertaken. All patients were treated with in-office potassium titanyl phosphate (KTP) laser photoablation. Sublesional bevacizumab injection was used based on joint patient-physician decision making. Papilloma burden was objectively measured on prior recordings by 2 blinded reviewers and described as vocal fold segments affected (VFSA) by papilloma. Each patient served as their own control by comparing times when bevacizumab was or was not used. Mixed model for longitudinal data was used to determine if the previous use of bevacizumab decreased the disease burden. A total of 19 patients met inclusion criteria and all prior laryngoscopic exams were reviewed for VFSA as described above. The mean (SD) number of VFSA when bevacizumab was not used at the prior procedure was 15 (14) as compared to 8 (11) when bevacizumab was used. When adjusted for age, time from initial presentation and baseline disease burden, mixed model showed a decrease of 11 VFSA (95% CI 6.5, 15.5, Using sublesional bevacizumab intermittently based on clinical findings appears to be effective in improving disease control. Papilloma burden is significantly decreased at the subsequent clinical follow-up following injection of sublesional bevacizumab. The beneficial effect of sublesional bevacizumab may be not be dose-dependent.

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Factors Affecting Posterior Glottic Stenosis Surgery Outcomes: Systematic Review and Meta-analysis

Candice Kremer,Roy Jiang,Amrita Singh,Jordan Sukys,Alexandria Brackett,Nikita Kohli

Publication date 01-03-2021


To investigate surgical adjuncts (stents) and previous surgeries on outcomes from posterior glottic stenosis (PGS). PubMED/Medline, CINAHL, EMBASE, and Web of Science were searched for publications on adult patients undergoing surgery for PGS. Decannulation and need for additional surgeries were evaluated as outcomes. Linear mixed-effects (with random effects and fixed effects) models were used for multivariate testing. In total, 516 abstracts were reviewed and 26 articles were considered for systematic review. Of these, 19 articles with 140 pooled patient cases were extracted for meta-analysis. On multivariate meta-analysis analysis accounting for study-specific variation and use of open procedures, prior surgeries were associated with additional surgeries (RR = 3.76 [1.39-3.86], Minimizing repeat surgery is a predictor for avoiding additional future surgeries and use of a stent was correlated with poor outcomes. These 2 findings may assist providers in patient counseling regarding the need for further surgical interventions. Further, this study is the first to compare the efficacy of surgical approaches for the resolution of PGS, and highlights the importance of avoiding repeat procedures and stents for the management of PGS.

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Computer-Aided Rhinoplasty Using a Novel “navigated” Nasal Osteotomy Technique: A Pilot Study

Elizabeth H. Wick,Mark E. Whipple,Marc H. Hohman,Kris S. Moe

Publication date 01-03-2021


To describe the surgical technique of navigation-guided nasal osteotomies and assess feasibility of this technique for treating complex nasal bone deformities in reconstructive rhinoplasty. A retrospective chart review was performed in order to identify patients who underwent computer-aided rhinoplasty from August 2014 to February 2017. Inclusion criteria were nasal bone deformities on computed-tomography (CT) that correlated with specific nasal complaints. All patients underwent computer-aided rhinoplasty with navigation-guided nasal osteotomies using a standard navigation system. Osteotomies were performed using real-time visualization on the navigation screen. Additional soft tissue procedures were performed as needed. Medical records were reviewed for presenting symptoms, radiologic and operative findings, and postoperative course. Cosmetic outcomes were subjectively based on patients' standard 6-view photo-documentation from pre- and post-operative timepoints. Twenty-one patients were included in the study; 8 were revision cases and 3 had mild-to-moderate hemifacial microsomia. Fifteen were completely closed procedures. No cases were opened because of inadequate visualization or difficulty accessing bony pathology. Mean (range) follow up was 98.6 (6-559) days. There were no intra-operative complications, unplanned admissions or re-admissions, or iatrogenic cosmetic complications (ie, "inverted V" or "saddle nose" deformities). Two patients required revision. One was after suffering nasal trauma within 4 weeks of initial rhinoplasty. The second underwent further correction of a deformity that required a costochondral graft. Both experienced good final results. Computer-aided rhinoplasty is safe and feasible for treating complex nasal deformities using standard navigation systems.

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Investigating Long-Term Brow Stabilization by Endotine-Assisted Endoscopic Brow Lift with Concomitant Upper Lid Blepharoplasty

Paloma Belle Perez,Anne Elizabeth Gunter,Minhee Pak Moody,Aurora Grace Vincent,Christian Rene Perez,Renee Makowski Serra,Marc Hale Hohman

Publication date 26-02-2021


To determine whether Endotine-assisted endoscopic brow lift with concomitant upper lid blepharoplasty provides long-term brow elevation. Pre- and post-operative photographs from 35 patients who underwent endoscopic brow lift using Endotine Forehead 3 mm implants with concomitant upper lid blepharoplasty were measured to determine changes in brow height with surgery and up to 55 months post-operatively. Photographs of 20 control subjects who did not undergo periorbital surgery and 11 control subjects who underwent upper blepharoplasty without brow lifting were also measured to provide a basis for comparison. Emotrics software was used to perform automated brow height measurements in order to determine elevation and longevity achieved with endoscopic brow lifting in conjunction with upper lid blepharoplasty. There was a statistically significant increase in brow height post-operatively, averaging 1.6 mm ( Endotine-assisted endoscopic brow lift in conjunction with upper lid blepharoplasty provides modest brow elevation and long-term brow fixation as demonstrated by stable post-operative brow height measurements for up to 55 months.

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Adoption of Telemedicine for Multidisciplinary Care in Pediatric Otolaryngology

Karen K. Hoi,Stuart H. Curtis,Lynn Driver,Erica Wisnosky,David A. Zopf,Lauren A. Bohm

Publication date 25-02-2021


The COVID-19 pandemic has introduced a period of social isolation that has challenged the ability of providers to uphold in-person patient care. Although commonplace in pediatric otolaryngology, multidisciplinary clinics pose a unique challenge during this time due to increased infection risk from multiple patient-provider interactions. Guidance on the application of telemedicine for multidisciplinary clinics in pediatric otolaryngology is limited. We provide comprehensive guidance on best practices for conducting telemedicine visits for a number of multidisciplinary otolaryngology clinics using our experiences at a single tertiary care children's hospital. A review of literature to support the adoption of telemedicine in multidisciplinary pediatric otolaryngology is also incorporated.
Telemedicine was successfully adopted for 7 multidisciplinary pediatric clinics with a variety of specialists: aerodigestive disorders, congenital hearing loss, microtia/aural atresia, orofacial clefting, sleep disorders, tracheostomy care, and velopharyngeal dysfunction. Telemedicine is feasible for a variety of multidisciplinary clinics and its optimization is critical for providing care to complex pediatric otolaryngology patients during the COVID-19 pandemic and beyond.

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Current Status of Handheld Otoscopy Training: A Systematic Review

Andreas Frithioff,Mads Juhl Guldager,Steven Arild Wuyts Andersen

Publication date 25-02-2021


Otoscopy is a frequently performed procedure and competency in this skill is important across many specialties. We aim to systematically review current medical educational evidence for training of handheld otoscopy skills. Following the PRISMA guideline, studies reporting on training and/or assessment of handheld otoscopy were identified searching the following databases: Pub Med, Embase, OVID, the Cochrane Library, PloS Medicine, Directory of Open Access Journal (DOAJ), and Web of Science. Two reviewers extracted data on study design, training intervention, educational outcomes, and results. Quality of educational evidence was assessed along with classification according to Kirkpatrick's model of educational outcomes. The searches yielded a total of 6064 studies with a final inclusion of 33 studies for the qualitative synthesis. Handheld otoscopy training could be divided into workshops, physical simulators, web-based training/e-learning, and smartphone-enabled otoscopy. Workshops were the most commonly described educational intervention and typically consisted of lectures, hands-on demonstrations, and training on peers. Almost all studies reported a favorable effect on either learner attitude, knowledge, or skills. The educational quality of the studies was reasonable but the educational outcomes were mostly evaluated on the lower Kirkpatrick levels with only a single study determining the effects of training on actual change in the learner behavior. Overall, it seems that any systematic approach to training of handheld otoscopy is beneficial in training regardless of learner level, but the heterogeneity of the studies makes comparisons between studies difficult and the relative effect sizes of the interventions could not be determined.

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A Qualitative Study of Developing Competency in Thyroid Surgery: A Resident’s Perspective With 5\u2009Year Follow Up

Gabriela DeVries,Megan Rudolph,Howard David Reines,Philip E. Zapanta

Publication date 25-02-2021


The Accreditation Council for Graduate Medical Education has guidelines on assessing surgical qualifications based on experience. Attending surgeons have various assumptions on how their trainees learn and acquire surgical skills. This study primarily investigates the resident's perspective on gaining experience and achieving competency in thyroid surgical procedures. A qualitative study using semi-structured interviews was designed to derive themes that discuss the acquisition of competency in thyroid surgery. After IRB approval, data was collected from 2012 to 2014 at 4 academic centers in the Washington, DC area. Fourteen chief residents specializing in either general surgery or otolaryngology were interviewed until saturation was achieved. These semi-structured interviews were transcribed and broken up into codes utilizing Moustakas' analysis. A comprehensive list of master themes in regards to achieving competency in thyroid surgery was developed. A follow up survey of the surgeons was undertaken at 5 years to determine if the perceptions during residency persisted in practice. Surgical specialty residents experience and learn thyroid surgery in 5 learning themes:1. Self-directed learning is significant during residency.2. Repetition with graduated autonomy is key.3. Effective mentors are competent surgeons who challenge residents and use positive teaching techniques.4. Residents employ active learning through the "see one, do one, teach one" philosophy.5. Learning from complexity is of importance to residency training.
After several years in practice, the most important theme in learning after residency was repetition of cases. This study demonstrates how residents progress in approaching competency in thyroid surgery. Adult learning strategies are preferred, and programs should incorporate tailored techniques to meet the individual needs of the residents. Perceptions of what is most important shifted in long-term follow up. Further study is needed to assure competency in residency and in practice.

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Gray-Scale Inversion on High Resolution Computed Tomography of the Temporal Bone: An Observational Study

Tyler R. Schwartz,Timothy Logan Lindemann,Gino Mongelluzzo,P. Ashley Wackym,Arun K. Gadre

Publication date 25-02-2021


This is a qualitative study to explore the utility of gray-scale inversion or the "invert" function of high-resolution computed tomography (HRCT) scans in the diagnosis of temporal bone anatomy and pathology. This is a case series describing an innovative application of an existing image processing tool to visualize temporal bone anatomy and pathology. Illustrative patients at a tertiary referral center with otologic symptoms and findings leading to HRCT scans of the temporal bone were included. Diagnostic HRCT scans were evaluated utilizing the gray-scale inversion function (invert function). Nine illustrative cases which demonstrate conditions such as persistent stapedial artery, membranous stapes footplate, total ossicular prosthesis migration into the vestibule, third window syndrome such as superior semicircular canal dehiscence (SSCD) and cochlea-facial nerve dehiscence, otosclerosis, and ossicular chain discontinuity are included. The enhanced visualization was confirmed surgically in 3 cases, and 1 had physiological confirmation using cervical vestibular evoked myogenic potentials (cVEMP). Gray-scale inversion can be used to improve visualization of temporal bone anatomy and pathologic changes when diagnoses are in doubt. The invert function is a useful adjunct in the armamentarium of both radiologists and otologists when evaluating HRCT of the temporal bone.

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Association of Social Determinants of Health with Time to Diagnosis and Treatment Outcomes in Idiopathic Subglottic Stenosis

Jaclyn Lee,Li-Ching Huang,Lynn D. Berry,Catherine Anderson,Milan R. Amin,Michael S. Benninger,Joel H. Blumin,Jonathan M. Bock,Paul C. Bryson,Paul F. Castellanos,Sheau-Chiann Chen,Matthew S. Clary,Seth M. Cohen,Brianna K. Crawley,Seth H. Dailey,James J. Daniero,Alessandro de. Alarcon,Donald T. Donovan,Eric S. Edell,Dale C. Ekbom,Daniel S. Fink,Ramon A. Franco,C. Gaelyn Garrett,Elizabeth A. Guardiani,Alexander T. Hillel,Henry T. Hoffman,Norman D. Hogikyan,Rebecca J. Howell,Lena K. Hussain,Michael M. Johns,Jan L. Kasperbauer,Sid M. Khosla,Cheryl Kinnard,Robbi A. Kupfer,Alexander J. Langerman,Robert J. Lentz,Robert R. Lorenz,David G. Lott,Anne S. Lowery,Samir S. Makani,Fabien Maldonado,Kyle Mannion,Laura Matrka,Andrew J. McWhorter,Albert L. Merati,Matthew Mori,James L. Netterville,Karla O’Dell,Julina Ongkasuwan,Gregory N. Postma,Lindsay S. Reder,Sarah L. Rohde,Brent E. Richardson,Otis B. Rickman,Clark A. Rosen,Michael J. Rutter,Guri S. Sandhu,Joshua S. Schindler,G. Todd Schneider,Rupali N. Shah,Andrew G. Sikora,Robert J. Sinard,Marshall E. Smith,Libby J. Smith,Ahmed M.S. Soliman,Sigríður Sveinsdóttir,Douglas J. Van Daele,David Veivers,Sunil P. Verma,Paul M. Weinberger,Philip A. Weissbrod,Christopher T. Wootten,Yu Shyr,David O. Francis,Alexander Gelbard

Publication date 25-02-2021


To examine whether social determinants of health (SDH) factors are associated with time to diagnosis, treatment selection, and time to recurrent surgical intervention in idiopathic subglottic stenosis (iSGS) patients. Adult patients with diagnosed iSGS were recruited prospectively (2015-2017) via clinical providers as part of the North American Airway Collaborative (NoAAC) and via an online iSGS support community on Facebook. Patient-specific SDH factors included highest educational attainment (self-reported), median household income (matched from home zip code via U.
S. Census data), and number of close friends (self-reported) as a measure of social support. Main outcomes of interest were time to disease diagnosis (years from symptom onset), treatment selection (endoscopic dilation [ED] vs cricotracheal resection [CTR] vs endoscopic resection with adjuvant medical therapy [ERMT]), and time to recurrent surgical intervention (number of days from initial surgical procedure) as a surrogate for disease recurrence. The total 810 participants were 98.5% female, 97.2% Caucasian, and had a median age of 50 years (IQR, 43-58). The cohort had a median household income of $62 307 (IQR, $50 345-$79 773), a median of 7 close friends (IQR, 4-10), and 64.7% of patients completed college or graduate school. Education, income, and number of friends were not associated with time to diagnosis via multivariable linear regression modeling. Univariable multinominal logistic regression demonstrated an association between education and income for selecting ED versus ERMT, but no associations were noted for CTR. No associations were noted for time to recurrent surgical procedure via Kaplan Meier modeling and Cox proportional hazards regression. Patient education, income, and social support were not associated with time to diagnosis or time to disease recurrence. This suggests additional patient, procedure, or disease-specific factors contribute to the observed variations in iSGS surgical outcomes.

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Pilot Study of External Beam Radiotherapy for Recurrent Unremitting Tracheal Stenosis

Aurora G. Vincent,Jerry L. Barker,Yadranko Ducic

Publication date 25-02-2021


Tracheal stenosis can have a variety of presentations, severities, causes, and be a difficult condition to treat. Some patients demonstrate recurrent stenosis after multiple endoscopic treatments and are either poor candidates for open procedures or do not desire open surgery. We sought to evaluate low-dose postoperative external beam radiotherapy (EBRT) as a novel therapy for patients with recurrent tracheal stenosis refractory to endoscopic therapies. We performed a retrospective review of patients with recurrent tracheal stenosis who underwent EBRT in addition to endoscopic dilation. We compared the number of endoscopic procedures required in the 6 months before EBRT to the number required in the 6 months after EBRT. Six patients met criteria for inclusion in our study. The cause of stenosis was variable among the study population. In the 6 months leading up to EBRT, patients underwent an average 6.2 endoscopic procedures. This dropped to an average 1.9 procedures in the 6 months following EBRT ( Herein, we show that low-dose postoperative external beam radiotherapy (EBRT), a novel therapy for patients with recurrent tracheal stenosis refractory to endoscopic therapies, is effective in decreasing the frequency of endoscopic dilations. 4.

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A Systematic Review of the Omohyoid Muscle Syndrome (OMS): Clinical Presentation, Diagnosis, and Treatment Options

Jerome Zhiyi Ong,Alex Chengyao Tham,Jian Li Tan

Publication date 25-02-2021


Omohyoid muscle syndrome (OMS) is a condition that causes a X-shaped lateral neck lump on swallowing, caused by the failure of the central tendon of the omohyoid muscle to restrict movement of the muscle during swallowing. We aim to review the etiology, pathophysiology, diagnostic tests, and management options for this condition. Pubmed, MEDLINE, EMBASE, and Cochrane databases were searched for all articles and abstracts related to OMS up to 29th July 2020. A systematic review was performed, data extracted from relevant full text articles. Both quantitative data and qualitative data were analyzed. Twenty cases of OMS were reported. Patients presented at a mean age of 36.0. All cases were Asian. There is a 7:3 ratio of males to females. The most common symptom was a transient neck mass. Most cases were managed conservatively with good prognosis. Open or endoscopic transection of the muscle and ultrasound-guided botulinum toxin injection were 3 treatment options, with no recurrence at 4 years, 6 months, and 6 months respectively. OMS could be genetic as all cases were Asian in ethnicity. The deep cervical fascia which usually envelopes the omohyoid muscle may be weakened by stress as 20% of cases had a preceding traumatic event. Real-time ultrasonography establishes the diagnosis, demonstrating the anterolateral displacement of the sternocleidomastoid muscle by a thickened omohyoid muscle during swallowing. Surgical transection can achieve cure, but due to limited studies available, they should be reserved for patients who are extremely bothered. Intramuscular injection of botulinum toxin is an effective alternative, but recurrence is expected.

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A National Survey of Robotic Surgery Training Among Otolaryngology—Head and Neck Surgery Residents

Hilary C. McCrary,Sierra R. McLean,Abigail Luman,Patricia O’Sullivan,Brigitte Smith,Richard B. Cannon

Publication date 22-02-2021


The aim of this study is to describe the current state of robotic surgery training among Otolaryngology-Head and Neck Surgery (OHNS) residency programs in the United States. This is a national survey study among OHNS residents. All OHNS residency programs were identified via the Accreditation Council for Graduate Medical Education website. A total of 64/127 (50.3%) of OHNS programs were selected based on a random number generator. The main outcome measure was the number of OHNS residents with access to robotic surgery training and assessment of operative experience in robotic surgery among those residents. A total of 140 OHNS residents participated in the survey, of which 59.3% (n = 83) were male. Response rate was 40.2%. Respondents came from middle 50.0% (n = 70), southern 17.8% (n = 25), western 17.8% (n = 25), and eastern sections 14.3% (n = 20). Most respondents (94.3%, n = 132) reported that their institution utilized a robot for head and neck surgery. Resident experience at the bedside increased in the junior years of training and console experience increased across the years particularly for more senior residents. However, 63.4% of residents reported no operative experience at the console. Only 11.4% of programs have a structured robotics training program. This survey indicated that nearly all OHNS residencies utilize robotic surgery in their clinical practice with residents receiving little formal education in robotics or experience at the console. OHNS residencies should aim to increase access to training opportunities in order to increase resident competency. IV.

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The Effect of Monaurally Fitted Hearing Aid Use on the Evolution of Presbycusis

Gabriel Dunya,Fadi Najem,Aurelie Mailhac,Samer Abou Rizk,Marc Bassim

Publication date 22-02-2021


The effect of hearing aid use on the evolution of presbycusis has not been well described in the literature, with only a handful of publications addressing this topic. This paper aims to evaluate the long-term use of amplification and its effect on pure-tone thresholds and word recognition scores. Monaurally fitted patients were followed with serial audiograms. Data was collected from hearing aid centers. Seventy-seven patients with presbycusis met the inclusion criteria and participated in the present study. The progression of hearing loss in both pure tone thresholds and word recognition scores were compared between the hearing aid ears (HA), and the non-hearing aid ears (NHA). Pure tone thresholds were analyzed by comparing the pure tone average at the initial and last audiograms. Word Recognition Scores (WRS) were analyzed using the model of Thornton and Raffin (1978), and by comparing the change in the absolute values of WRS from the initial to the last audiogram between the HA ear and the NHA ear. No significant difference in pure-tone thresholds between the HA ear and NHA ear was found at the last audiogram ( The present study supports the previously defined auditory deprivation effect on non-fitted ears, which showed worsening of word recognition over time and no effect on pure tone average. It provides an additional argument for the counseling of patients with presbycusis considering amplification, and highlights the importance of bilateral amplification in preserving the residual hearing of hearing impaired patients.

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Office-Based Intralesional Steroid Injection for Treatment of Laryngeal Sarcoidosis

Janice L. Farlow,Jiwon V. Park,Robert J. Morrison,Robbi A. Kupfer

Publication date 15-02-2021


To report preliminary outcomes of a case series of in-office intralesional steroid injections for treatment of laryngeal sarcoidosis. After diagnosis of laryngeal sarcoidosis, 3 patients were offered in-office steroid injections for primary or adjunctive treatment. Triamcinolone 40 was injected into supraglottic sarcoidosis lesions in the office using a channel laryngoscope. Response to treatment and need for further injections was determined based on patient symptoms and repeat flexible laryngoscopy. In-office intralesional steroid injections provided rapid symptom relief within days that lasted for months, thus decreasing the frequency of operative interventions. For one of the patients in this series, these injections even eliminated the need for tracheostomy. No complications were observed. In-office intralesional steroid injection is an emerging adjunctive treatment for laryngeal sarcoidosis. Prospective studies are required to determine efficacy and long-term risk profiles in relation to the current standard of operative management and systemic treatments.

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Intubation-Related Laryngeal Pathology Precluding Tracheostomy Decannulation: Incidence and Associated Risk Factors

Kirsten Meenan,Kavita Bhatnagar,Elizabeth Guardiani

Publication date 15-02-2021


To identify the incidence and risk factors for intubation-related laryngeal lesions that preclude tracheostomy decannulation in a large population. A 3-year retrospective case-control study was performed of tracheotomized adults in acute rehabilitation facilities who underwent routine endoscopic evaluation of the airway as part of the facilities' decannulation protocol. Patients with known upper airway pathology, external laryngeal trauma, cricothyrotomy or emergent tracheostomy, prior head and neck radiation, isolated tracheal lesions, and patients with incomplete reports were excluded. The laryngeal pathologies were classified, and demographics and clinical features were compared between those whose lesions precluded decannulation and all other patients. Three hundred seventy-one patients met inclusion criteria. One hundred six (28.6%) had laryngotracheal lesions. Forty-nine patients (13.2%) had intubation-related lesions of the larynx that precluded decannulation. These lesions included posterior glottic stenosis (30.6%), granulation tissue (24.5%), vocal fold immobility (16.3%), subglottic stenosis (16.3%), a combination of granulation tissue and stenosis (10.2%), and glottic edema (2.0%). A BMI ≥ 25 kg/m BMI ≥ 25 kg/m

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Association of Mast Cell Burden and TIM-3 Expression with Recalcitrant Chronic Rhinosinusitis with Nasal Polyps

Michael A. Belsky,Erica Corredera,Hridesh Banerjee,John Moore,Li Wang,Lawrence P. Kane,Stella E. Lee

Publication date 12-02-2021


Previous work showed that higher polyp mast cell load correlated with worse postoperative endoscopic appearance in patients with chronic rhinosinusitis with nasal polyps (CRSwNP). Polyp epithelial mast cells showed increased expression of T-cell/transmembrane immunoglobulin and mucin domain protein 3 (TIM-3), a receptor that promotes mast cell activation and cytokine production. In this study, CRSwNP patients were followed post-operatively to investigate whether mast cell burden or TIM-3 expression among mast cells can predict recalcitrant disease. Nasal polyp specimens were obtained via functional endoscopic sinus surgery (FESS) and separated into epithelial and stromal layers via enzymatic digestion. Mast cells and TIM-3-expressing mast cells were identified via flow cytometry. Mann-Whitney Twenty-three patients with CRSwNP were studied and followed for 6 months after undergoing FESS.
Higher mast cell levels were associated with earlier recurrence of polypoid edema: epithelial HR = 1.283 ( Mast cell load in polyp epithelium and stroma may predict a more refractory postoperative course for CRSwNP patients. The role of TIM-3 in the chronic inflammatory state seen in CRSwNP remains unclear.

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Radiologic Assessment of the Sinonasal Tract, Nasopharynx and Mastoid Cavity in Patients with SARS-Cov-2 Infection Presenting with Acute Neurological Symptoms

Gul Moonis,Ryan Mitchell,Betsy Szeto,Anil K. Lalwani

Publication date 11-02-2021


Acute neurological sequela in patients with COVID-19 infection include acute thromboembolic infarcts related to cytokine storm and post infectious immune activation resulting in a prothrombotic state. Radiologic imaging studies of the sinonasal tract and mastoid cavity in patients with COVID-19 infection are sparse and limited to case series. In this report, we investigate the radiologic involvement of nasal cavity, nasopharynx, paranasal sinuses, and mastoid cavity in patients with SARS-CoV-2 infection who presented with acute neurological symptoms. Retrospective review of medical records and neuroradiologic imaging in patients diagnosed with acute COVID-19 infection who presented with acute neurological symptoms to assess radiologic prevalence of sinus and mastoid disease and its correlation to upper respiratory tract symptoms. Of the 55 patients, 23 (42%) had partial sinus opacification, with no evidence for complete sinus opacification. The ethmoid sinus was the most commonly affected (16/55 or 29%). An air fluid level was noted in 6/55 (11%) patients, most commonly in the maxillary sinus. Olfactory recess and mastoid opacification were uncommon. There was no evidence of bony destruction in any of the studies, Cough, nasal congestion, rhinorrhea, and sore throat were not significantly associated with any radiological findings. In patients who present with acute neurological symptoms, COVID-19 infection is characterized by limited and mild mucosal disease within the sinuses, nasopharynx and mastoid cavity. 4.

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Diagnostic Lobectomy for Bethesda III Thyroid Nodules: Pathological Outcomes and Risk Factors for Malignancy

Benjamin K. Walters,Samuel L. Garrett,James K. Aden,Grant M. Williams,Samantha L. Butler-Garcia,Travis R. Newberry,Alex J. Mckinlay

Publication date 11-02-2021


An indeterminate thyroid nodule fine-needle aspiration (FNA) presents a unique dilemma. We evaluated our institution's experience with Bethesda III thyroid nodules, including the risk of malignancy (ROM) of these nodules removed for diagnostic lobectomy and radiologic and clinical risk factors for malignancy. Retrospective chart review. San Antonio Military Medical Center (SAMMC; 483 bed Military Treatment Facility and Level 1 Trauma Center). We identified all patients with a Bethesda III thyroid FNA at our institution from 2010 to 2018 and determined which nodules were removed. The final histological diagnosis was recorded. Whether or not age, gender, body mass index (BMI), race, nodule size, margin regularity, rate of nodule growth, vascularity, internal calcifications, family history of thyroid cancer, personal history of radiation, and history of repeated AUS/FLUS on FNA had a significant impact on malignancy risk was evaluated with chi square and rank sum Wilcoxon tests. 492 patients had 1 or more AUS result. 52% (258/492) underwent repeat FNA. This resulted in Bethesda II or III in 90% (232/258). In 10% (26/258), the repeat FNA resulted in a higher Bethesda grade. 183 lobectomies were performed on the side containing an AUS nodule. The malignancy percentage was 38.3% (70/183). Age less than 30 was the only variable showing statistical significance for increased risk of malignancy ( The ROM of nodules characterized as AUS/FLUS on FNA may be higher than expected. Age may be a better predictor of malignancy than repeat FNA.

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Laser Reduction Glottoplasty for Voice Feminization: Experience on 28 Patients

Taner Yılmaz,Furkan Özer,Fatma Esen Aydınlı

Publication date 11-02-2021


Laser reduction glottoplasty is a relatively new surgical procedure for voice feminization on transgender women. This study aims to determine long-term voice results of glottoplasty on transwomen. Nonrandomized, retrospective, cohort. Tertiary referral center. Endoscopic laser reduction glottoplasty was performed on 28 transwomen. Voice Handicap Index (VHI-30), Transsexual Voice Questionnaire (TVQ), acoustic analysis with /a/ for F Mean total VHI and TVQ scores improved significantly postoperatively ( Laser reduction glottoplasty is an accomplished and satisfying operation for feminizing voice of transwomen. Its voice outcome appears to be durable for 5 years. However, secondary operation may be needed to further gratify transwomen.

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Transoral versus Transcervical Drainage of Pharyngeal Abscesses in Children: Post-Operative Complications

Christopher A. Maroun,Habib G. Zalzal,Ayman A. Mustafa,Michele Carr

Publication date 10-02-2021


The objective of this study was to compare complications and other perioperative outcomes between intraoral and transcervical drainage of both retropharyngeal and parapharyngeal abscesses. This was a retrospective study that analyzed data from the 2012 to 2016 National Surgical Quality Improvement Program (NSQIP)-Pediatric public use files. Baseline characteristics and perioperative outcomes including postoperative complications and length of hospital stay (LOS) were compared between intraoral and transcervical drainage groups. Multivariable logistic regression was performed to inspect predictors of having an extended LOS, defined as LOS greater than 3 days. A total of 1174 patients were included. Mean age was 5.1 ± 3.8 years in the intraoral group (N = 1063) and 4.2 ± 4.3 years in the transcervical group (N = 111, There does not appear to be a significant difference in the rate of post-operative complications after intraoral versus transcervical drainage for pharyngeal abscesses in children. However, transcervical drainage was associated with an extended hospital stay. Further prospective studies will be needed to determine the reasons for this.

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Operable, Low-Cost, High-Resolution, Patient-Specific 3D Printed Temporal Bones for Surgical Simulation and Evaluation

Monika E. Freiser,Anish Ghodadra,Andrew A. McCall,Amber D. Shaffer,Michael Magnetta,Noel Jabbour

Publication date 08-02-2021


Three-dimensional printed models created on a consumer level printer can be used to practice mastoidectomy and to discern mastoidectomy experience level. Current models in the literature for mastoidectomy are limited by expense or operability. The aims of this study were (1) to investigate the utility of an inexpensive model for mastoidectomy and (2) to assess whether the model can be used as an evaluation tool to discern the experience level of the surgeon performing mastoidectomy. Three-dimensional printed temporal bone models from the CT scan of a 7-year old patient were created using a consumer-level stereolithography 3D printer for a raw material cost of $10 each. Mastoidectomy with facial recess approach was performed by 4 PGY-2 residents, 4 PGY-5 residents, and 4 attending surgeons on the models who then filled out an evaluation. The drilled models were collected and then graded in a blinded fashion by 6 attending otolaryngologists. Both residents and faculty felt the model was useful for training (mean score 4.7 out of 5; range: 4-5) and case preparation (mean score: 4.3; range: 3-5). Grading of the drilled models revealed significant differences between junior resident, senior resident, and attending surgeon scores ( The described operable model that is patient-specific was rated favorably for pediatric mastoidectomy case preparation and training by residents and faculty. The model may be used to differentiate between experience levels and has promise for use in formative and summative evaluations.

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Prevention of Frey’s Syndrome with the Use of Porcine Dermal Collagen Graft: Retrospective Analysis of 76 “Formal” Parotidectomies for Benign Pathologies

Kostas Vahtsevanos,Angelos Chatziavramidis,Ioannis (Yiannis) Papadiochos,Georgios Koloutsos,Anastasios Stefanidis,Kyriaki Kitikidou,Aris Ntomouchtsis,Anna Patrikidou

Publication date 06-02-2021


Frey's syndrome is a well-known complication of parotid surgery; its prevention may be achieved by the use of an interpositional barrier between the overlying flaps and the exposed parenchymal bed of parotid gland. The aim of this study was to retrospectively evaluate clinical outcomes with and without the interpositional placement of a porcine dermal collagen graft (PDCG) for prevention of syndrome occurrence. We conducted a 20-year retrospective study including the patients who had undergone "formal" (superficial, total, or subtotal) parotidectomies for benign pathologies. The inclusion criteria also involved patients that were (i) regularly monitored about clinical symptoms related to syndrome, and (ii) examined with Minor starch-iodine test. The severity of the diagnosed syndrome was retrospectively evaluated according to the grading score system of Luna-Ortiz. To assess group differences in terms of the extent of dissection in operating sites, we estimated the tumor and histological specimen volumes using the available dimensions. We included Porcine dermal collagen is a safe, practical, and useful means for parotid reconstruction, since it seems to contribute in prevention of Frey's syndrome when increased amount of glandular tissue has to be removed. Additional randomized controlled studies with bigger samples are required to better assess the PDCG use in parotid surgery.

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Predictors of a Normal Sleep Study in Healthy Children with Sleep Disordered Breathing Symptoms

Elizabeth J. Abraham,Ashank Bains,Batsheva R. Rubin,Michael B. Cohen,Jessica R. Levi

Publication date 05-02-2021


To determine the prevalence and characteristics of children with normal elective polysomnography for obstructive sleep disordered breathing (oSDB) based on the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) guidelines. In this retrospective cohort study, we identified patients ages 2 to 18 who underwent diagnostic polysomnography (PSG) ordered by our otolaryngology department for SDB between 2012 and 2018. All patients were seen by otolaryngologists at an urban tertiary safety net hospital. There were a total of 456 patients studied (average age 5.66 ± 3.19; 263 (57.7%) males, 193 (42.3%) females. Demographic factors (age, gender, race, ethnicity, language, insurance status) and clinical findings (symptom severity, tonsil size) were recorded. The data were analyzed by univariate and multivariate analysis. Two hundred four patients (44.7%) had no obstructive sleep apnea (OSA) based on AHI<2 on PSG. Children with a larger tonsil size had 3.18 times the odds of OSA compared to those with a medium tonsil size (95% CI 1.64, 6.19) when adjusting for symptoms, age category, and race ( Among our patient population, 44.7% had normal sleep studies. Younger children (ages 2-3) were less likely to have normal polysomnography. This research demonstrates that obtaining sleep studies in otherwise healthy children with SDB can affect management decisions, and they should be discussed with families with a focus on patient centered decision making.

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Can the Expiratory Disproportion Index Distinguish PVFMD from Subglottic Stenosis in Obese Patients?

Kevin Calamari,Stephen Politano,Laura Matrka

Publication date 01-02-2021


Expiratory disproportion index (EDI) is the ratio of forced expiratory volume in 1 second (FEV1) divided by peak expiratory flow rate (PEFR) multiplied by 100. Prominent EDI (>50) values can differentiate subglottic stenosis (SGS) from paradoxical vocal fold movement disorder (PVFMD), but this has not been verified when considering body habitus. We hypothesize that the predictive value of elevated EDI in differentiating SGS from PVFMD will be lower in obese patients than non-obese patients. Patients ≥ 18 years old with recorded PFT values, BMI, and airway imaging were reviewed retrospectively from 01/2011 to 10/2018.
EDI was recorded for 4 cohorts: non-obese/SGS, non-obese/ PVFMD, obese/SGS, and obese/ PVFMD, to determine the mean EDI and the sensitivity/specificity of an elevated EDI. Mean EDI values were 69.32 and 48.38 in the non-obese SGS and PVFMD groups, respectively ( Prior literature has established that EDI can distinguish SGS from PVFMD in the general population. Our results show that the mean EDI values were significantly different in both cohorts, but an elevated EDI was not as sensitive at identifying SGS cases in obese patients. This suggests that the EDI should be used with caution in obese patients and should not be relied upon to rule out SGS. 3.

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Surgically Treated Advanced Cutaneous Squamous Cell Carcinoma of the Head and Neck: Outcome Predictors and the Role of Adjuvant Radiation Therapy

Liyona Kampel,Alexandra Dorman,Gilad Horowitz,Dan M. Fliss,Orit Gutfeld,Nidal Muhanna

Publication date 30-01-2021


Advanced cutaneous squamous cell carcinoma of the head and neck (CSCCHN) is associated with poor outcome despite multimodality therapy. Comprehensive risk stratification may pinpoint the most suitable adjuvant treatment. This study aimed to evaluate the outcomes of surgically treated locoregional CSCCHN and to identify prognostic indicators of treatment outcomes. We retrospectively analyzed disease variables, pathologic characteristics, and management in association with treatment outcomes of all consecutive advanced CSCCHN patients who underwent surgical resection at Tel Aviv Sourasky Medical Center. From 2008 to 2018, 74 patients met the inclusion criteria. Only perineural invasion (PNI) was significantly associated with worse overall survival (OS) ( PNI was associated with worse OS in surgically treated advanced CSCCHN. Adjuvant RT conferred better outcomes despite high risk features.

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Frequency-Specific Analysis of Hearing Outcomes Associated with Ossiculoplasty Versus Stapedotomy

Denis D. Nguyen,Ryan T. Judd,Terence E. Imbery,Michael B. Gluth

Publication date 29-01-2021


Surgery on the ossicular chain may impact its underlying mechanical properties. This study aims to investigate comparative differences in frequency-specific hearing outcomes for ossiculoplasty versus stapedotomy. A retrospective chart review was conducted on subjects who underwent ossiculoplasty with partial ossicular replacement prosthesis (PORP) or laser stapedotomy with self-crimping nitinol/fluoroplastic piston, and achieved closure of postoperative pure tone average air-bone gap (PTA-ABG) ≤ 15 dB. 45 PORP and 38 stapedotomy cases were included, with mean length of follow-up of 7.6 months. The mean change in PTA-ABG was similar for the 2 procedures (-17.9 dB vs -18.1 dB, Both procedures achieved a similar mean change in PTA-ABG. Stapedotomy was superior to PORP at ABG closure at 1000 Hz and at 4000 Hz, with 1000 Hz the most discrepant. The exact mechanism responsible for these changes is unclear, but the specific frequencies affected suggest that differences in each procedure's respective impact on the native resonant frequency and mass load of the system could be implicated.

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Jugular Bulb Anomalies Involving the Internal Auditory Canal: A Case Series

Tiffany P. Hwa,Qasim Husain,Jason A. Brant,Anil K. Lalwani

Publication date 29-01-2021


Jugular bulb abnormalities (JBA) such as high riding jugular bulb and jugular bulb diverticulum can extend or erode into the middle and inner ear. In this report, we report on a series of 6 patients with jugular bulb anomalies involving the internal auditory canal (IAC). A retrospective case series. Six females, ages 6 to 63 presenting with myriad of otologic symptoms including hearing loss, tinnitus, balance disturbance, fullness, and otalgia were discovered to have JB eroding into IAC. Computerized tomography, but not Magnetic Resonance Imaging, was able to identify IAC erosion by a significantly enlarged JB. A significantly enlarged JB eroding into the IAC maybe congenital or acquired. It can present with a variety of common otologic symptoms. Long term follow-up is needed to determine the natural history of JB anomalies involving the IAC and need for intervention.

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Acoustic Reflexes in Aural Atresia Patients: Evidence of an Intact Efferent System?

Geoffrey C. Casazza,Lincoln C. Gray,Debra Hildebrand,Bradley W. Kesser

Publication date 25-01-2021


To record crossed acoustic reflex thresholds (xART's) postoperatively from patients after surgical repair of unilateral congenital aural atresia (CAA). To seek explanations for when xARTs can and cannot be recorded. We hope to understand the implications for this central auditory reflex despite early afferent deprivation. Patients who underwent surgery to correct unilateral CAA at a tertiary academic medical were prospectively enrolled to evaluate for the presence of xART. Preoperative ARTs in the normal (non-atretic) ear, and postoperative ipsilateral ARTs (stimulus in the normal ear) and contralateral ARTs (stimulus in the newly reconstructed atretic ear; record in the normal ear) were measured at 500, 1000, and 2000 Hz. Four of 11 patients with normal ipsilateral reflex thresholds preoperatively demonstrated crossed acoustic reflexes postoperatively (stimulus in reconstructed ear; record from normal ear). Four other patients demonstrated normal ipsilateral thresholds preoperatively but did not have crossed reflexes postoperatively. No reflexes (pre- or postoperatively) could be recorded in 3 patients. Crossed reflex threshold is significantly correlated with the postoperative audiometric threshold. There was no correlation between ipsilateral and contralateral reflex thresholds. Crossed acoustic reflexes can be recorded from some but not all postoperative atresia patients, and the thresholds for those reflexes correlate with the postoperative pure tone threshold. The presence of acoustic reflexes implies an intact CN VIII-to-opposite CN VII central reflex arc despite early unilateral sound deprivation.

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Subjective Evaluation of Balance by the Dizziness Handicap Inventory Does Not Predict Fall Risk in Older Adults Visiting Otolaryngology Clinics

Iku Abe-Fujisawa,Yukihide Maeda,Soshi Takao,Shin Kariya,Kazunori Nishizaki

Publication date 20-01-2021


Subjective symptoms of dizziness in older adults are affected not only by objective data such as postural balance, but also by complex psychological factors. Published data analyzing how simultaneous evaluations of both objective and subjective assessments of balance can predict fall risk remain lacking. This study examined how fall risk can be predicted based on both objective data for balance and hearing and subjective symptoms of dizziness among older adults visiting otolaryngology clinics. Medical charts of 76 patients ≥65 years old with dizziness/vertigo who visited the otolaryngology clinic were reviewed. Objective data were evaluated by postural balance (posturographic data with eyes open and closed, and one-leg standing test), spontaneous nystagmus, and mean hearing levels. Subjective handicap associated with dizziness/vertigo was assessed using the Dizziness Handicap Inventory (DHI). Subjective mental status of anxiety and depression were assessed using the Hospital Anxiety and Depression Scale (HADS). Information on history (cardiovascular diseases) and fall accidents within the preceding year was collected using an in-house interview sheet. Objective data on postural balance did not correlate with subjective symptoms on DHI or HADS ( Poor postural balance is associated with increased fall risk after adjusting for subjective symptoms in older adults at otolaryngology clinics. Conversely, the self-perceived dizziness handicap of DHI score is an insufficient tool to evaluate their fall risk.

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Does Pepsin Saliva Concentration (Peptest™) Predict the Therapeutic Response of Laryngopharyngeal Reflux Patients?

Jerome R. Lechien,Francois Bobin,Didier Dequanter,Alexandra Rodriguez,Serge Le Bon,Mihaela Horoi,Marie-Paule Thill,Charelle Salem,Vinciane Muls,Sven Saussez

Publication date 20-01-2021


To study the profile and the therapeutic response of patients with laryngopharyngeal reflux (LPR) at the hypopharyngeal-esophageal multichannel intraluminal impedance-pH monitoring (HEMII-pH) according to the initial pepsin saliva concentration. From January 2018 to January 2020, patients with positive LPR diagnosis at the HEMII-pH were consecutively recruited from 3 European Hospitals. Saliva pepsin concentration (Peptest™) was measured during the HEMII-pH testing period and patients were classified into 2 groups: negative versus positive Peptest. The clinical outcomes, that is, gastrointestinal and HEMII-pH findings, reflux symptom score-12 (RSS-12), and 3-month therapeutic response, were compared between groups. A total of 124 patients completed the study. Among them, 30 patients had negative Peptest. Pharyngeal reflux events occurred outside 1-hour post-meal time in 74.0%, after the meals in 20.5% and nighttime in 5.5%. The pepsin saliva level was not significantly associated with the reflux events preceding the sample collection. Patients with positive Peptest had better improvement of RSS-12 digestive and respiratory subscores and oral, pharyngeal, and laryngeal findings compared with patients with negative Peptest. Patients with high saliva pepsin concentration had no stronger gastrointestinal, HEMII-pH, or clinical outcomes compared with those with low or undetectable saliva pepsin concentration.

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The Effect of Lateral Pharyngeal Collapse Patterns on Therapy Response in Upper Airway Stimulation Surgery

John Flynn,Christopher Boyd,Sreeya Yalamanchali,David Rouse,Sara Goodwin,Joseph Penn,Christopher Larsen

Publication date 16-01-2021


Obstructive sleep apnea (OSA) is characterized by repeated upper airway collapse while sleeping which leads to intermittent hypoxemia. Upper airway stimulation (UAS) is a commonly practiced modality for treating OSA in patients who cannot tolerate, or do not benefit from, positive airway pressure (PAP). The purpose of this study is to identify the effect of lateral pharyngeal collapse patterns on therapy response in UAS. A retrospective cohort study from a single, tertiary-care academic center was performed. Patients who underwent UAS between October 2016 and July 2019 were identified and analyzed. Drug-induced Sleep Endoscopy (DISE) outcomes between Apnea-Hypopnea Index (AHI) responders and AHI non-responders were compared. Those with complete concentric collapse at the velopharynx were not candidates for UAS. About 95 patients that underwent UAS were included in this study. Pre- to Post-UAS demonstrated significant improvements in Epworth Sleepiness Scale (12.0 vs 4.0, Demonstration of lateral pharyngeal collapse on DISE, in the absence of complete concentric velopharyngeal obstruction, does not appear to adversely affect AHI outcomes in UAS patients. VI.

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OHNS Residency Program and Applicant Social Media Presence During the COVID-19 Pandemic

Shadi Ahmadmehrabi,Deborah X. Xie,Bryan K. Ward,Paul C. Bryson,Patrick Byrne

Publication date 16-01-2021


In addition to clinical and social disruption, the Coronavirus Disease 2019 (COVID-19) pandemic has affected many aspects of the otolaryngology residency application process. With delays in the 2021 Electronic Residency Applications Service (ERAS) timeline, students and programs have had more time to interact prior to the formal application process. This communication will report recent trends in social media presence by OHNS residency programs, and discuss mechanisms to compensate for decreased applicant-program interactions using social media ahead of the 2021 Match. In a cross-sectional study of the accredited otolaryngology residency programs in the United States, the number of social media profiles on Twitter, Instagram, and Facebook from 2009 to 2019 were recorded and compared. Most programs (61%) have at least 1 social media profile. Over the past 10 years, the number of programs on social media has increased. During the COVID-19 pandemic, Twitter and Instagram showed higher rates of growth compared to Facebook. With the reduction of in-person opportunities for interactions, both applicants and programs are utilizing social media to showcase their values and their research. Twitter, in particular, also serves as a platform for professional networking. Both Twitter and Instagram are growing in popularity among programs and applicants to enhance networking. Social media is a powerful tool for networking and may help compensate for limitations imposed on the residency match process by the COVID-19 pandemic while maintaining professionalism considerations. The impact of social media on the 2021 otolaryngology residency match is an evolving phenomenon.

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Helping Children with Special Needs: Who Receives Tympanostomy Tubes?

David W. Wassef,Nehal Dhaduk,Savannah C. Roy,Gregory L. Barinsky,Evelyne Kalyoussef

Publication date 16-01-2021


Tympanostomy tubes can prevent sequelae of otitis media that adversely affect long term hearing and language development in children. These negative outcomes compound the existing difficulties faced by children who are already diagnosed with developmental disorders. This study aims to characterize this subset of children with developmental disorders undergoing myringotomy and tympanostomy tube insertion. A retrospective review using the Kids' Inpatient Database (KID) was conducted, with codes from In total, 21 945 cases of patients with myringotomy with or without tympanostomy tube insertion were identified, of which 1200 (5.5%) had a diagnosis of a developmental disorder. Children with developmental disorders had a higher mean age (3.3 years vs 2.9 years, The population of children with developmental disorders undergoing myringotomy or tympanostomy tube placement has a different demographic composition than the general population and faces distinct financial and insurance coverage burdens. Further study should be done to assess if these differences impact long term outcomes.

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Clinical and Radiologic Characterization of Frontal Sinusitis in the Pediatric Population

Nathalia Velasquez,William Strober,Amber Shaffer,Amanda Stapleton

Publication date 13-01-2021


Frontal sinusitis in the pediatric population is a disease that has not been thoroughly studied or characterized. The goals of this study are to characterize the clinical presentation, radiologic variables, treatment modalities, complications, and prognosis associated with acute and chronic frontal sinus disease in the pediatric population. IRB-approved retrospective cohort study of pediatric patients who were diagnosed with acute (AFS) or chronic frontal sinusitis (CFS) and underwent frontal sinus surgery at a tertiary level Children's Hospital from 2006 to 2016. Patients with AFS were compared to patients with CFS. Statistical analysis completed using chi-square test or Fisher's exact test, statistical significance set at A total of 19 patients with AFS and 15 patients with CFS were analyzed. There was a male predominance in AFS and female predominance in CFS ( There are 2 distinct presentations of frontal sinus disease in the pediatric population. Patients with AFS vary significantly from those with CFS. Males, ages 13 to 18 years old, who cultured positive for

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Post-Tonsillectomy Bleeding: A National Perspective

Nehal Dhaduk,Ashley Rodgers,Aparna Govindan,Evelyne Kalyoussef

Publication date 13-01-2021


Tonsillectomy is one of the most common otolaryngologic procedures. Hemorrhage after tonsillectomy is one of the most feared complications by surgeons and patients alike. The objective of this study was to analyze the risk factors associated with an increase in post-tonsillectomy hemorrhage in the pediatric population using a large national database. The Kids' Inpatient Database (KID) from 2000 to 2012 was queried for patients between the ages of 1 to 17 years with post-tonsillectomy hemorrhage. Univariate and multivariate analyses were performed to obtain trends in patient demographics, comorbidities, and hospital information. Overall 45 940 pediatric cases of tonsillectomy were identified of which 5470 (11.9%) resulted in postoperative hemorrhage. Patients with postoperative hemorrhage were significantly older with mean age of 8.62 (±4.75) compared to all patients. Females were found to have higher rates of hemorrhage when compared to males 14.6% versus 11.5% ( Postoperative hemorrhage is a common complication following tonsillectomy with a rate of 11.9% in this study. A higher rate of hemorrhage was seen with increasing age, white race, and males overall, as well as patients with fluid and electrolyte disorders. Urban non-teaching hospitals and the Northeast region also saw increased rates of hemorrhage.

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Otolaryngology Applicant Characteristics and Trends: Comparing OTO-HNS with Peer Specialties

Parsa P. Salehi,Alyssa Heiser,Pauniz Salehi,Sina J. Torabi,Rebecca L. Fine,Benjamin Judson,Babak Azizzadeh,Yan H. Lee

Publication date 13-01-2021


To evaluate the recent Otolaryngology-Head and Neck Surgery (OTO-HNS) applicant characteristics, to identify which applicant characteristics are associated with successful match into OTO-HNS, and to compare OTO-HNS applicant trends and characteristics to that of peer surgical specialties (PS). Data were obtained from official reports by the National Residency Matching Program (NRMP) for OTO-HNS, plastic and reconstructive surgery, orthopedic surgery, neurosurgery, and dermatology from 2006 to 2019. Alpha Omega Alpha (AOA) membership, United States Medical Licensing Examination (USMLE) scores, research productivity, graduation from a top-40 NIH-funded U.
S. medical school, and additional graduate degree were recorded. Odds ratios (OR) were calculated to evaluate the relationship between applicant qualifications and match success. From 2014 to 2018, the OTO-HNS applicant pool shrunk from 443 to 333, representing the largest drop of all PS. Furthermore, OTO-HNS reported the most unfilled positions and highest match rates in 2017 (n = 14; 92.1%) and 2018 (n = 12; 94.6%) among any PS. Despite recent trends, 2019 NRMP data revealed a 38.74% increase in OTO-HNS applicant numbers compared to 2018. AOA membership (OR, 7.3; Despite recent fluctuations in application trends, OTO-HNS continues to successfully match highly qualified applicants, including applicants with AOA membership, high Step 2 scores, and high research productivity. An understanding of the qualifications used to evaluate residency applicants may be helpful to both applicants and residency programs of OTO-HNS.

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Spontaneous Abscess of the Posterior Nasal Septum: An Unusual Cause of Nasal Obstruction in Children

Marco Berlucchi,Michele Tomasoni,Roberta Bosio,Vittorio Rampinelli

Publication date 09-01-2021


Nasal septal abscess is a rare disorder in pediatric patients and is mostly diagnosed as a complication of trauma or secondary to dental or sinonasal infection. A 10-year-old girl presented with acute nasal obstruction, otalgia, and headache. Medical history was negative; physical examination and anterior rhinoscopy did not reveal signs of acute rhinosinusitis or septal abscess. A thorough nasal endoscopy was performed to rule out a posterior nasal infection, revealing a bilateral posterior septal bulging, in the absence of purulent discharge. CT scan and contrast-enhanced MRI were performed, confirming the diagnosis of a spontaneous posterior septal abscess. Trans-nasal endoscopic-assisted drainage was conducted under general anesthesia. Although rare, nasal septal abscess in the pediatric age is typically anterior and secondary to local trauma or infection. Accurate medical history and anterior rhinoscopy are usually sufficient to make the diagnosis. In cases where the clinical presentation is consistent with a nasal septal abscess, with no history of recent local trauma or infection, or signs of anterior septal bulging, nasal endoscopy should be performed to rule out spontaneous posterior septal abscess. Delay in diagnosis and treatment could potentially cause the rapid onset of life-threatening complications, including intracranial abscess, meningitis, and cavernous sinus thrombosis.

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Inter-pathologist Agreement on Structured Histopathology Reporting in Chronic Rhinosinusitis

Ashwin Ganti,Hannah J. Brown,Paolo Gattuso,Ritu Ghai,Peter Papagiannopoulos,Pete S. Batra,Bobby A. Tajudeen

Publication date 08-01-2021


Structured histopathology reporting is increasingly being utilized in rhinology to characterize endotypes in chronic rhinosinusitis and guide management decisions after sinus surgery. The goal of this investigation is to evaluate inter-observer agreement in structured histopathology reporting. Two experienced head and neck pathologists independently compiled structured histopathology reports for tissue samples collected during functional endoscopic sinus surgery. Cohen's standard kappa (κ) coefficients were calculated for each histopathologic variable to assess inter-pathologist agreement. A total of 92 cases were analyzed. Substantial inter-pathologist agreement was reached on tissue eosinophil count (κ = 0.64, High inter-pathologist agreement was demonstrated for several salient histopathologic variables, including tissue eosinophil count and the presence of eosinophil aggregates. However, refining the definitions of certain histopathologic variables may improve the reproducibility of structured histopathology reporting.

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Incidental Laryngeal Findings on Bedside Flexible Endoscopic Evaluation of Swallowing in a Community Hospital Setting

James Pazak,Neel K. Bhatt,Alyssa Levy,Susann Schick,Karla O’Dell

Publication date 08-01-2021


The purpose of this study was to evaluate the incidence of laryngeal pathology found during bedside flexible endoscopic evaluation of swallowing (FEES) in a community hospital. A retrospective study among patients who underwent a bedside FEES examination from May 2018 to May 2019. Criteria to perform a bedside FEES exam were patients who were identified through nursing screening swallowing evaluation and failed a bedside clinical evaluation of swallowing by a speech language pathologist. Patient demographics, recent intubation, duration of intubation, dysphonia complaints, laryngeal exam findings, consultation to otolaryngology and intervention were reviewed. Seventy-five patients had an inpatient bedside FEES. All (100%) had subjective complaints of swallowing. 29 (38.66%) had laryngeal pathology identified on FEES examination including unilateral vocal fold immobility (9), fungal infections (6), vocal fold lesion (3), edema (3), erythema (3), vocal process granuloma (2), unilateral TVF Hemorrhage (1), unilateral TVF paresis (1), suspected superior laryngeal nerve palsy (1). Seventeen of the twenty-nine (58.6%) examinations with incidental laryngeal finding received an otolaryngology referral. Twenty-three of the twenty-nine patients with laryngeal findings (79.3%) were intubated during the hospitalization. Bedside FEES is a well-established method to evaluate swallowing function in an inpatient population. Even in a community hospital, routine FEES examinations led to a high rate of detection of clinically significant laryngeal pathology.

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Otolaryngology Resident Wellness, Training, and Education in the Early Phase of the COVID-19 Pandemic

David W. Chou,Giuseppe Staltari,Michael Mullen,Jolie Chang,Megan Durr

Publication date 08-01-2021


To determine changes in the residency experience early in the COVID-19 pandemic and evaluate wellness measures among otolaryngology residents. A web-based survey was administered to U.
S. otolaryngology residents. Responses to the Shirom-Melamed Burnout Measure (SMBM) and the Generalized Anxiety Disorder-7 scale were recorded along with data on burnout, demographics, wellness, sleep, training, and education. 119 U.
S. otolaryngology residents representing 27 of 42 states with otolaryngology residency programs responded to the survey. 24.4% (95% CI 17.0-31.8%) self-reported some level of burnout, while 10.9% met SMBM criteria for "clinically relevant" burnout. 51.3% experienced more stress, and 58.8% reported more anxiety during the COVID-19 pandemic. Compared to males, females had a higher prevalence of burnout (38.9% vs 12.3%, While burnout among otolaryngology residents was low early in the COVID-19 pandemic, likely due to separation from the workplace environment, trainees had higher levels of anxiety and stress. The surgical experience was negatively impacted by the pandemic, but remote didactics and educational opportunities increased. These findings may inform otolaryngology residency programs on the need to promote resident wellness and aid in devising strategies to improve the educational experience during this unique global health crisis as well as in the long term.

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Tracheocutaneous Fistula After Pediatric Open Airway Reconstruction

Stephen R. Chorney,Joanne Stow,Luv R. Javia,Karen B. Zur,Ian N. Jacobs,Steven E. Sobol

Publication date 08-01-2021


Tracheocutaneous fistula (TCF) is a common occurrence after pediatric tracheostomy decannulation. However, the persistence of TCF after staged reconstruction of the pediatric airway is not well-described. The primary objective was to determine the rate of persistent TCF after successful decannulation in children with staged open airway reconstruction. A case series with chart review of children who underwent decannulation after double-stage laryngotracheal reconstruction between 2017 and 2019. A total of 26 children were included. The most common open airway procedure was anterior and posterior costal cartilage grafting (84.6%, 22/26). Median age at decannulation was 3.4 years (IQR: 2.8-4.3) and occurred 7.0 months (IQR: 4.3-10.4) after airway reconstruction. TCF persisted in 84.6% (22/26) of children while 15.4% (4/26) of stomas closed spontaneously. All closures were identified by the one-month follow-up visit. There was no difference in age at tracheostomy ( Persistent TCF occurs in 85% of children who are successfully decannulated after staged open airway reconstruction. Spontaneous closure could be identified by 1 month after decannulation and was more likely when smaller stents and tracheostomy tubes were utilized. Surgeons should counsel families on the frequency of TCF and the potential for additional procedures needed for closure.

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Gender as a Predictor of Complications in Endoscopic Sinus Surgery

Rahul K. Sharma,Sonam Dodhia,Justin S. Golub,Jonathan B. Overdevest,David A. Gudis

Publication date 08-01-2021


Understanding patient-specific risk factors for complications of functional endoscopic sinus surgery (ESS) is critical. Previous work has investigated such risk factors, but a population-based analysis has not been performed to date. This study analyzes the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database to identify patient-specific risk factors associated with complications following ESS. A retrospective cohort study of patients who underwent ESS was conducted using the NSQIP database from 2011 to 2017. Patients were identified using CPT-codes for ESS procedures. The primary outcome analyzed was any postoperative complication. Simultaneous procedures with ESS were controlled for with regression analysis. Post-operative complications and 30-day readmission were evaluated using multivariate logistic regression controlling for age, gender, race, comorbidities (diabetes mellitus, hypertension, chronic obstructive pulmonary disease, congestive heart failure, renal failure, steroid use, and cancer history), smoking history, and intraoperative factors. A total of 1279 patients who underwent ESS were identified. The average age of patients was 46.1 (SD = 16.8). Most patients (58.2%) had no major comorbidities. 594 (46.4%) patients had a tonsillectomy, adenoidectomy, or uvulopharyngoplasty at the same time as ESS. 101 (7.9%) patients experienced a complication post-operatively. 46 (3.6%) patients experienced a readmission postoperatively. The most common complication was reoperation (N = 40, 3.1%). Regression analysis revealed that gender was the only demographic factor associated with risk of post-operative complications, with women having a significantly lower risk than men (OR = 0.61, 95% CI 0.37-0.99, ESS is typically performed on a relatively young and healthy population. Women have a significantly lower risk of complications after controlling for comorbidities. Further analysis of gender-specific differences in surgical outcomes should be evaluated to understand this phenomenon.

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Transmastoid Hydroxyapatite Resurfacing for Sigmoid Sinus Wall Anomalies Causing Pulsatile Tinnitus

Ian Newberry,Julie Highland,Alvin DeTorres,Richard Gurgel

Publication date 08-01-2021


Comprising 4% of tinnitus, pulsatile tinnitus (PT) can be particularly difficult for affected patients as well as surgeons looking to address their symptoms. Often the cause is not identified but can be secondary to turbulent flow in or near the sigmoid sinus, particularly if there is an identifiable sigmoid sinus dehiscence (SSDe) and/or diverticulum (SSDi). These sigmoid sinus wall anomalies (SSWA) may be treated with transmastoid sigmoid sinus resurfacing; however, this intervention remains relatively novel and its technique, materials used, resolution success, and complications need to be continuously reviewed. A retrospective case series of patients with PT due to SSWA at a tertiary referral center was reviewed. A total of 6 patients (7 ears) treated by transmastoid resurfacing using hydroxyapatite (HA) were retrospectively assessed. Pre-operative demographics and symptoms, pre- and post-operative hearing results, and post-operative outcomes were reviewed. All patients were female with an average BMI of 32.9 (±5.4) and a mean age of 45.5 years (±15.3). Mean follow-up was 648 days. Objective tinnitus was noted in all ears with SSDi (100%); however, no objective tinnitus was noted with purely SSDe. In 100% of ears, PT was diminished with ipsilateral jugular compression and was amplified with contralateral head turn. Pre-operative symptoms of PT resolved in all patients, but delayed recurrence (>1 year) occurred in 1 ear (14%). No patient had pre- or post-operative hearing loss. No major complications were encountered. Transmastoid resurfacing for SSWA with HA bone cement is a safe, reliable intervention in properly identified PT patients.

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Critical Evaluation of Trends in Otolaryngology Resident Caseload by Subspecialty from 2005 to 2019

Alexandra Welschmeyer,Kathleen Coerdt,Jason Crossley,Sonya Malekzadeh

Publication date 08-01-2021


Subspecialty caseloads logged by otolaryngology residents over the last 15 years is currently unknown. This study examines the trends at the national level. Otolaryngology case log data was collected from the Accreditation Council for Graduate Medical Education (ACGME) from 2005 to 2019.
Data were categorized according to the following surgical subspecialties: pediatrics, rhinology/skull base, head and neck, facial plastics, otology, and laryngology. Linear regression analyses were performed for each procedure within each subspecialty, total subspecialty means, and total caseload means across all years. Overall surgical volume significantly increased between 2005 and 2019 ( While total mean resident case logs have steadily increased between 2005 and 2019, pediatric cases have declined substantially due to fewer tympanostomy tube insertions and adenotonsillectomies. Rhinology/skull base procedures have increased most significantly secondary to an increase in endoscopic sinus surgeries. Despite changes in case volume amongst specialties, the annual increase in resident case load suggests that otolaryngology residents are meeting the demands of their graduate medical training.

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Evaluation of Scoring Systems for Airway Management After Oral Cancer Surgery: A Retrospective Study

Atsushi Abe,Eri Umemura,Hiroki Hayashi,Yu Ito,Moriyasu Adachi

Publication date 06-01-2021


Postoperative airway obstruction following oral cancer surgery is difficult to predict. Scoring systems used to assess the need for tracheotomy use risk factors as criteria. We aimed to examine whether these clinical scoring systems can predict airway obstruction following oral cancer surgery. We assessed 95 patients who underwent oral cancer surgery without tracheotomy under general anesthesia between January 2007 and April 2019. We reviewed multiple factors from the patients' medical records, including age, sex, tumor site, body mass index, tumor stage, type of surgery, airway management method, Cameron and Gupta scores, and postoperative airway complications. Tumors were located in the maxilla ( Screening based on the Gupta score appears to be effective in predicting postoperative airway obstruction. We propose that this screening tool can be used to better plan tracheotomy and other airway management strategies during preoperative patient assessment.

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The Effect of Language Barriers at Discharge on Pediatric Adenotonsillectomy Outcomes and Healthcare Contact

Xi Dai,Marisa A. Ryan,Anna Christina Clements,David E. Tunkel,Anne R. Links,Emily F. Boss,Jonathan M. Walsh

Publication date 15-12-2020


Effective delivery of discharge instructions and access to postoperative care play a critical role in outcomes after pediatric surgery. Previous studies in the pediatric emergency department suggest that caregivers with language barriers have less comprehension of discharge instructions despite use of interpretation services. However, the impact of language barriers during discharge on surgical outcomes in a pediatric surgical setting has not been studied. This study examined the effect of parental language during discharge on number and mode of healthcare contact following pediatric adenotonsillectomy. A retrospective cohort study was conducted on children who underwent adenotonsillectomy at a tertiary care pediatric academic medical center from July 1, 2016 to June 1, 2018. Data were collected on consecutive patients with non-English-speaking caregivers and a systematic sampling of patients with English-speaking caregiver. Surgery-related complications and healthcare contacts within 90 days after discharge were collected. Two-tailed A total of 136 patients were included: 85 English-speaking and 51 non-English-speaking. The groups were comparable in age, sex, and comorbidities. The non-English group had more patients with public insurance (86% vs. 56%; Language barriers at discharge following pediatric otolaryngology surgery is associated with a meaningful difference in how patients utilized medical care. Interventions to improve comprehension and access may help reduce preventable emergency department visits and healthcare costs.

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Predictors of Occurrence and Timing of Post-Tonsillectomy Hemorrhage: A Case-Control Study

Jennifer H. Gross,Miranda Lindburg,Dorina Kallogjeri,Michelle Molter,David Molter,Judith E. C. Lieu

Publication date 09-12-2020


To describe cases and timing of pediatric post-tonsillectomy hemorrhage (PTH), to evaluate predictors of PTH, and to determine the optimal amount of postoperative care unit (PACU) monitoring time. Using the Pediatric Health Information System (PHIS) database and electronic medical records, a matched case-control study from 2005 to 2015 was performed. A single, tertiary-care institution.
Each case of PTH was matched with 1 to 4 controls for the following factors: age, sex, surgeon, and time of year. A total of 124 cases of PTH and 479 tonsillectomy controls were included. The rate and timing of postoperative bleeding were assessed, and matched pair analysis was performed using conditional logistic regression. Our institutional PTH rate of 1.9% (130 of 6949) included 124 patients; 15% (19) were primary (≤24 hours), with 50% (9) occurring within 5 hours. Twenty-one percent (4 of 19) of primary PTH patients received operative intervention. Eighty-five percent (105 of 124) of all cases were secondary PTH, and 47% (49) of those patients received operative intervention. Cold steel (OR 1.9, 95% CI 1.1-3.3) and Coblation (OR 1.9, 95% CI 1.2-3.1) techniques and tonsillectomy alone (OR 3.7, 95% CI 1.9-7.2) increased odds of PTH. Patients who developed PTH had 4 times the odds of having a preceding postoperative respiratory event than controls (OR 4.0, 95% CI 1.6-10.0). We conducted a rigorous case-control study for PTH, finding that PTH was associated with use of cold steel and Coblation techniques and with tonsillectomy alone. Patients with a postoperative respiratory event may be more likely to develop a PTH and should be counseled accordingly. A PACU monitoring time of 4 hours is sufficient for outpatient tonsillectomy.

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Characteristics and Outcomes in Head and Neck Sarcomatoid Squamous Cell Carcinoma: The Cleveland Clinic Experience

Katie M. Mingo,Adeeb Derakhshan,Neelab Abdullah,Deborah J. Chute,Shlomo A. Koyfman,Eric D. Lamarre,Brian B. Burkey

Publication date 03-12-2020


To analyze characteristics, treatment outcomes, and prognostic factors of sarcomatoid squamous cell carcinoma of the head and neck. Retrospective chart review. Tertiary care center. Fifty-five patients were treated for sarcomatoid squamous cell carcinoma of the head and neck between 1996 and 2018. Data collection included clinical history, tumor characteristics, pathology, treatment modality, and outcomes. Mean follow up was 17.1 months. Cox univariate analysis was used to evaluate for associations with locoregional recurrence, distant metastasis, and overall survival. Most patients were white males with a smoking history and median age 66 years (range 41-92) at diagnosis. Twenty-two percent had prior head and neck radiation. Tumor site was most frequently oral cavity (41.8%), followed by larynx (29.1%), and oropharynx (16.4%). Half presented with early T stage disease (15.5% T0, 12.7% T1, 30.9% T2) and the remainder with late stage disease (16.4% T3, 34.5% T4). Locoregional recurrence rate was 60.0%, metastatic recurrence was rate 21.8%, with median time to recurrence of 4 months and mean overall survival of 20 months. Presence of lymphovascular space invasion was statistically associated with locoregional recurrence ( Sarcomatoid squamous cell carcinoma remains a rare and aggressive disease variant with high recurrence rates and high mortality. High risk features such as lymphovascular space may indicate the need for more aggressive therapy.

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Corrigendum to Effects of the Number of Muscle-Nerve-Muscle Grafts on Rat Facial Nerve Functional Recovery

Publication date 03-12-2020


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Comparison of Patient Satisfaction Between Virtual Visits During the COVID-19 Pandemic and In-person Visits Pre-pandemic

Kyohei Itamura,Dennis M. Tang,Thomas S. Higgins,Franklin L. Rimell,Elisa A. Illing,Jonathan Y. Ting,Matthew K. Lee,Arthur Wu

Publication date 30-11-2020


To compare the patient experience of a virtual otolaryngology clinic visit to an in-person visit, especially with its significantly increased implementation during the COVID-19 pandemic. Patient satisfaction (PS) metrics from the Clinician and Group Consumer Assessment of Healthcare Providers and Systems survey were queried from March 1, 2020 to May 1, 2020 for telehealth visits and January 1, 2020 to March 1, 2020 for in-person visits. Overlapping and comparable questions were analyzed using Mann-Whitney There were 1284 partial or complete PS surveys from in-person visits and 221 partial or complete virtual PS surveys. There were statistically significantly worse virtual visit evaluations of provider listening, conveyance of information, likelihood to recommend, and overall provider ratings compared to in-person visits. Telehealth has become the new norm for most healthcare providers in the United States. This study demonstrates some of the initial shortcomings of telehealth in an otolaryngology practice and identifies challenges with interpersonal communication that may need to be addressed as telehealth becomes increasingly prevalent. Three.

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Twice as Nice: How Doubling Otolaryngology Rotation Time Affects the Intern Experience Nationwide

Matthew Maksimoski,Sean Mutchnick,Samuel Racette,Karina J. Yu,Alan G. Micco

Publication date 27-11-2020


Describe the current state of otolaryngologic residency training with recent changes to the program requirements by the Accreditation Council for Graduate Medical Education (ACGME) which increased the amount of time on intern year otolaryngology rotations from 3 to 6 months. A cross-sectional study was performed and recruitment was done via personalized email sent to program coordinators of 113 ACGME-accredited otolaryngology training programs within the Unites States. The message requested a breakdown of the amount of time and specialty in which first year otolaryngologic residents rotated. Interval follow ups were sent at 3 and 6 months for coordinators who had not responded. Response rate was 79.7% (90/113). General surgery and surgical intensive care unit were the two most common non-otolaryngologic rotations (92.2% and 96.6% respectively) while ophthalmology and radiation oncology were the least common at 7.8% each. All first year residents spend time on an inpatient otolaryngologic rotation, while 30.7% spend time on outpatient rotations. The most common subspecialties were head and neck oncology (40.0%) followed by pediatric otolaryngology (36.0%). Otolaryngologic training continues to become more slanted towards specialty-specific training and a concurrent reduction in "off-service" rotations. General inpatient services still predominate the intern year both inter- and intra-departmentally. These data provide insight into the training environment of the otolaryngologic trainees set to graduate residency for the first time this year.

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Assessment of Factors Impacting Long-Term Utilization of Tracheoesophageal Speech Among Laryngectomees

Christopher Boyd,James Houghton,Logan Harrold,Justin Bond,James D. Garnett,Shannon Kraft

Publication date 27-11-2020


To evaluate complication rate and abandonment rate after tracheoesophageal puncture and to assess factors associated with these outcome measures. Retrospective review of laryngectomy patients seen at a single academic institution between 1/1/2003 and 12/1/2018. Charts reviewed for demographics, medical comorbidities, tumor characteristics, surgical data, adjuvant treatment history, and complications related to laryngectomy or tracheoesophageal puncture. Complications were divided into minor and major. A total of 293 laryngectomees met inclusion criteria. Of these, 69 patients (23.5%) underwent tracheoesophageal puncture. Average follow up was 64.6 months (SD 58.3). Overall laryngectomy complication rate was 43.3%. Overall tracheoesophageal puncture complication rate was 73.9%, with 39.1% of patients having major complications and 34.8% having minor complications only. Total abandonment rate for tracheoesophageal puncture was 34.8%. No associations were seen between tracheoesophageal puncture complication or abandonment rates based on age, gender, race, or insurance status. An increased rate of laryngectomy complications was seen after primary tracheoesophageal puncture (76.5% vs 41.3%, Tracheoesophageal puncture outcomes were similar in patients with varied demographic, medical, and treatment backgrounds. When considering timing, our findings suggest that patients should be counseled on the possibility of increased complication risk after primary tracheoesophageal puncture. In those in whom the surgeon already has concerns about wound healing, it may be prudent to avoid primary tracheoesophageal puncture. The relatively high abandonment rate emphasizes the value of this measure of tracheoesophageal puncture outcome and highlights the need for appropriate patient counseling and prospective studies assessing the decision to abandon.

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Pediatric Otolaryngology Telehealth in Response to COVID-19 Pandemic: Lessons Learned and Impact on the Future Management of Pediatric Patients

Ryan H. Belcher,James Phillips,Frank Virgin,Jay Werkhaven,Amy Whigham,Lyndy Wilcox,Christopher T. Wootten

Publication date 26-11-2020


Since the start of the COVID-19 pandemic outpatient medicine has drastically been altered how it is delivered. This time period likely represents the largest volume of telehealth visits in the United States health care history. Telehealth presents unique challenges within each subspecialty, and pediatric otolaryngology is no different. This retrospective review was designed to evaluate our division of pediatric otolaryngology's experience with telehealth during the COVID19 pandemic. This study was approved by the Institutional Review Board at Vanderbilt University Medical Center. All telehealth and face-to-face visits for the month of April 2020 completed by the Pediatric Otolaryngology Division were reviewed. A survey, utilizing both open-ended questions and Likert scaled questions was distributed to the 16 pediatric otolaryngology providers in our group to reflect their experience with telehealth during the 1-month study period. In April, 2020 our outpatient clinic performed a total of 877 clinic visits compared to 2260 clinic visits in April 2019. A total of 769 (88%) were telehealth visits. Telemedicine with video comprised 523 (68%) and telephone only comprised 246 (32%). There were 0 telehealth visits in April 2019. Interpretive services were required in 9.3% (N = 211) clinic visits in April 2019 and 7.5% (N = 66) of clinic visits in April 2020. The survey demonstrated a significant difference ( Despite low initial expectations for telehealth, the majority of our providers felt after 1 month of use that telehealth would continue to be a valuable platform post-pandemic clinical practice. Limited physical exam, particularly otoscopy, nasal endoscopy, and nasolaryngoscopy present challenges. However, with adequate information and preparation for the parents and for the physician some of the obstacles can be overcome.

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Non-vascularized Fibular Cortex Grafts with Osteocutaneous Free Fibula Transfer: A Novel Technique in Midface Reconstruction

Paloma I. Perez,Del R. Sloneker,Ashlie G. Bloom,Aurora G. Vincent,Marc H. Hohman,Wayne J. Harsha,Kelly G. Anderson

Publication date 24-11-2020


To present a method to reconstruct the midface using the fibula as both a microvascular free flap and as a free cortex graft. 22-year-old male presented with bilateral maxillary odonotogenic myxoma. Bilateral total maxillectomy defects were reconstructed using an osteocutaneous fibula free flap. The nasomaxillary buttresses were augmented using free cortex grafts to provide additional soft tissue projection and lateral nasal support. The patient received dental implants at 10 months postoperatively and resumed a normal diet. His midface height, nasal and maxillary projection were adequate. At 36 months post-treatment he has no evidence of disease recurrence or resorption of the free bone grafts. The fibula free flap can be used to provide additional support to a patient's reconstruction by means of free cortex grafts. The patient has had successful restoration of pyriform aperture, nasal projection, mastication, and dental restoration using a single donor site.

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Injection Laryngoplasty for the Treatment of Type 1 Laryngeal Clefts: A Single Institution Experience

Mohammad Al-Alawneh,Ladd Caballero,Elijah DeBroux,Michael J. Herr,Amy Claire Petro,Jerome Thompson,Jennifer McLevy,Joshua Wood,Madhu Mamidala,Anthony Sheyn

Publication date 21-11-2020


Standards for treatment of laryngeal clefts remain poorly defined. There are no large case series that report the efficacy of injection laryngoplasty (IL) in the treatment of pediatric Type 1 laryngeal clefts (LC-1). The objective of this study is to measure the effect of IL in young children with LC-1. A retrospective case series of 130 patients was completed over 3 years at a at a single institution included patients aged 1 month to 8 years, diagnosed with aspiration and penetration issues during swallowing based on a Videofluoroscopic Swallow Study (VFSS). Patients underwent surgical evaluation and intervention using carboxymethylcellulose gel injection. Collected data points included age in months at time of first injection, gender, race, pre- and post-operation VFSS scores, number of injections, co-morbidities and post-operative complications. VFSS scores were evaluated pre- and post-operatively to assess efficacy of intervention. A secondary outcome was efficacy in patients with aspiration compared to those with penetration alone. This study included 77 male and 53 female patients. Sixty-two patients (48%) demonstrated a significant post-operative improvement in their swallowing function ( Injecting the inter-arytenoid area in patients with LC-1 appears to confer some benefit to close to half of our patient population. Successful procedures seemed to occur in patients with more severe aspiration and penetration and older age.

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The Effectiveness of Nortriptyline and Tolerability of Side Effects in Neurogenic Cough Patients

Sungjin A. Song,Kanittha Choksawad,Ramon A. Franco

Publication date 21-11-2020


To determine the effectiveness of nortriptyline and tolerability of side effects in the treatment of neurogenic cough. Secondary goal is to evaluate the association between laryngeal asymmetry and clinical response to nortriptyline. Retrospective case series. Consecutive patients diagnosed with neurogenic cough at a quaternary care specialty hospital from 2001 to 2020 were identified. Subjects <18 years old, not treated with nortriptyline, did not have a nasolaryngoscopic examination and were lost to follow-up were excluded. Charts were reviewed for demographic information, clinical history, nasolaryngoscopic findings, medication dosage, side effects, and follow-up time. Forty-two patients met inclusion and exclusion criteria, 7 males and 35 females with an average age of 56.5 (±13.1) years. There were 26/36 (72.2%) responders and 10/36 (27.8%) non-responders; 6 patients stopped nortriptyline due to side effects and were not included in the response comparison. Laryngeal asymmetry was present in 36/42 (85.7%) patients. No factors related to laryngeal asymmetry were significantly different between responders and non-responders. Medication tolerance was observed in 3/42 (7.1%) patients. Side effects were reported in 16/42 (38.1%) patients. The most common side effects were sedation 9/42 (21.4%) and xerostomia 3/42 (7.1%). Nortriptyline is effective for treating neurogenic cough with 72% of patients reporting improvement in cough. Evidence of laryngeal asymmetry was not associated with better treatment response. Although 38% experienced side effects, the majority of patients continued nortriptyline despite side effects. 4.

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Steroid Administration Approach for Idiopathic Sudden Sensorineural Hearing Loss: A National Survey in China

Qingxiu Yao,Zhuang Jiang,Jiajia Zhang,Shujian Huang,Shouhuan He,Yanmei Feng,Hui Wang,Shankai Yin

Publication date 13-11-2020


To optimize a protocol for the steroid administration approach for idiopathic sudden sensorineural hearing loss (ISSNHL) in China. A questionnaire was distributed to otolaryngologists. The data on demographics, indications for first-line and salvage treatment, such as intratympanic administration of steroids (ITS) and postauricular steroids (PAS), and procedures were analyzed. 74 respondents used oral steroids, 112 used intravenous injections, 10 used ITS and 6 used PAS as a monotherapy for first-line treatment, and 135 used ITS or PAS in conjunction with oral or intravenous injection as a first-line treatment. Of the 249 respondents who used ITS, 97.19% adopted it as salvage therapy. The most commonly used steroid was 0.5 ml dexamethasone at 5 mg/ml and the most common side effect was pain. Of the 174 respondents who used PAS, 94.25% used it as salvage therapy. The most commonly used steroid was 0.5 ml methylprednisolone mixed with 0.5 ml lidocaine. The obtained data suggested that intravenous injection of steroids was the most popular treatment for ISSNHL and that ITS or PAS were used as a salvage treatment in China.

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The Epidemiological and Financial Effects of Pneumococcal Vaccination on Otitis Media Related Admissions in the United States

Ariel Grobman,Priyanka Reddy,Amit Wolfovitz,Michael Sylvester,Simon I. Angeli

Publication date 13-11-2020


To quantify the prevalence of hospital admissions, the financial impact, and the trends in surgical procedure rates for AOM and CAOM for all ages before and after 13-valent pneumococcal conjugate vaccine (PCV13) introduction. Retrospective analysis of the National Inpatient Sample (NIS) from 1998 to 2013 to determine the prevalence of AOM/CAOM related admissions and weighted frequencies of AOM/CAOM related International Classification of Diseases, ninth revision (ICD-9) hospital diagnoses. Prevalence of surgical procedures to treat CAOM, cost of admission, length of stay, and cost per day of admission were tabulated. Trend analysis of this data was performed. A total of 46 580 patients were hospitalized with AOM in the designated time period, of which 37 366 had CAOM. The prevalence of hospital admission due to AOM had the most pronounced decrease from pre-vaccine era (1998) to post-PCV13 implementation (2013) in age group 0 to 4 (32%) followed by age group 5 to 19 (7%). Age groups 20-64 and 65+ showed slight increases in prevalence. The trend in prevalence of admissions due to CAOM mirrors that of overall admissions with an 18% and 5.8% decrease in age groups 0-4 and 5-19, respectively, and a 1% increase in ages 20+. The inflation adjusted mean cost of admission did not significantly increase between 2001 and 2013. The total cost per admission was $4428 and $7546 for those with AOM and CAOM, respectively. Mastoidectomy rates increased by 17% in hospitalized children during the post-vaccine era but decreased in the elderly population. The prevalence of AOM/CAOM hospital admissions decreased from the pre-vaccine era (1998) to post-PCV13 implementation (2013) in pediatric patients. Surgical procedure utilization and cost of hospital admission for AOM/CAOM did not increase throughout the study period.

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Bone Cement Fixation of Stapedotomy Prostheses: Long-term Outcomes in Primary and Revision Stapes Surgery

Pedrom C. Sioshansi,Amy Schettino,Seilesh C. Babu,Dennis I. Bojrab,Eric W. Sargent,Elias M. Michaelides,Alexander L. Luryi,Christopher A. Schutt

Publication date 13-11-2020


To describe audiologic outcomes following hydroxyapatite bone cement fixation of stapedotomy prostheses. A retrospective case review at a tertiary neurotology referral center was performed of patients undergoing primary or revision stapedotomy between 2010 and 2017. Patients with hydroxyapatite bone cement fixation of stapes prostheses were assessed. Pre- and postoperative hearing was compared, consisting of air conduction (AC) and bone conduction (BC) pure-tone averages (PTA), air-bone gap (ABG), and word recognition scores (WRS). Short and long-term outcomes were assessed. Forty-six patients with otosclerosis underwent stapedotomy with bone cement fixation: 21 primary cases and 25 revision cases, with an average follow-up time of 17 months. Mean AC PTA was 56 dB preoperatively, and 34 dB postoperatively ( Stapedotomy with bone cement fixation of the prosthesis provides excellent hearing outcomes in both primary and revision treatment of otosclerosis. Results are consistent and stable through long-term follow-up. The use of bone cement should be incorporated into the surgical armamentarium of the otologist for the prevention and treatment of loose-wire syndrome and incus necrosis.

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Combination Surgical Procedure for Fourth Branchial Anomalies: Operative Technique and Outcomes

Matthew Maksimoski,Sarah E. Maurrasse,Matthew Purkey,John Maddalozzo

Publication date 07-11-2020


Branchial apparatus anomalies of the fourth cleft are the rarest subtype of anomaly and occasionally present with suppurative thyroiditis or thyroid abscess due to their relationship with the thyroid gland. Surgical approaches vary and some surgeons favor cauterization of associated pyriform sinus tracts alone versus complete surgical excision. Currently, the literature is scarce and there is limited data on surgical outcomes and procedural steps.
Here we describe a combination surgical technique for fourth branchial anomalies including: (1) surgical excision of the cyst and any external pit, (2) hemithyroidectomy, and (3) direct laryngoscopy with cauterization of pyriform apex tract, if present. A retrospective review was performed on all patients who underwent surgical excision of fourth branchial apparatus lesions (including fistulae, cysts, and sinus tracts) at an urban pediatric university hospital from 2000 to 2019. Data regarding demographics, medical history, surgical methods, complications, and surgical cure rates were collected. A total of 16 patients (9 female, 7 male) underwent a combination surgical procedure for fourth branchial apparatus lesions. Success rate after primary surgery was 94%. One patient had residual disease requiring re-operation. Two patients had post-operative complications: 1 transient vocal fold paresis and 1 seroma, both managed conservatively. A consensus surgical algorithm was created based on operative steps present in the majority of cases. A combination approach to fourth branchial apparatus lesions-including endoscopic cauterization, external excision, and hemithyroidectomy-is safe and provides a high rate of primary cure. Although less invasive options exist, remnants of the branchial lesion, especially in the thyroid, may remain and cause recurrent issues. Therefore, we advocate for complete surgical excision of this rare developmental anomaly, especially when obvious thyroid involvement exists.

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Cartilage Sparing Septal Perforation Repair using Rotation Flaps and a Collagen Interposition Graft: A Case Series

Benjamin G. Hunter

Publication date 07-11-2020


Septal Perforations may be asymptomatic or can cause significant problems including nasal obstruction, crusting, bleeding, whistling and in severe cases a change in nasal shape and even pain. The author would like to present a single surgeon case series of septal perforation repairs, managed using an endo-nasal technique, with no external scars. There were 54 consecutive cases between 2011 and 2017. The repair was carried out using mucosal rotation flaps with an interposition graft of porcine collagen matrix. Patients were grouped according to the size of the perforation as measured at the time of the surgery. The patients were then clinically followed up for 1 year, and the recorded outcome measures were: the success of the surgical repair and the patient reported symptoms. Surgical success was 70% up to 1 cm diameter, 77% from 1 to 2 cm and 82% in perforations from 2 to 3 cm in diameter. No perforation over 3 cm in diameter was successfully closed. Patients were rendered asymptomatic even if the perforation was not closed in between 81% and 91% of patients up to perforations 3 cm in size. Over 3 cm in size 50% of patients reported being asymptomatic. This technique is an effective and low morbidity option for patients with small to medium sized septal perforations. For perforations over 3 cm in diameter other options may be more suitable.

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Biomaterials in the Reconstruction of Nasal Septum Perforation

Izabella Rajzer,Pawel Stręk,Maciej Wiatr,Jacek Skladzien,Anna Kurowska,Jerzy Kopeć,Katarzyna Swiezy,Agnieszka Wiatr

Publication date 04-11-2020


Septal perforations are among the most common craniofacial defects. The causes of septal perforations are varied. The purpose of the study was to develop a septal cartilage implant biomaterial for use in the reconstruction of nasal septal perforations and prepare personalized implants for each patient individually using 3D printing technology. Fragments of septal nasal cartilage from 16 patients undergoing surgery for a deviated nasal septum were analyzed to establish microfeatures in individual samples. A scanning electron microscope was used to estimate the microstructure of the removed septal cartilage. 3D models of porous scaffolds were prepared, and a biomaterial was fabricated in the shape of the collected tissue using a 3D printer. Of the various materials used in the Fused Deposition Modeling (FDM) technology of 3D printing, PLLA was indicated as the most useful to achieve the expected implant features. The implant was designed using the indicated pre-designed shape of the scaffold, and appropriate topography, geometry and pore size were included in the design. The implant's structure allows the use of this device as a framework to carry nanoparticles (antibiotics or bacteriophages). It is possible to create a porous scaffold with an appropriately matched shape and a pre-designed geometry and pore size to close nasal septal perforations even in cases of large septal cartilage defects.

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Corrigendum to Revisit Rates for Pediatric Tonsillectomy: An Analysis of Admit and Discharge Times

Publication date 04-11-2020


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Segmentation of Temporal Bone Anatomy for Patient-Specific Virtual Reality Simulation

Steven Arild Wuyts Andersen,Maxwell Bergman,Jason P. Keith,Kimerly A. Powell,Brad Hittle,Prashant Malhotra,Gregory J. Wiet

Publication date 04-11-2020


Virtual reality (VR) simulation for patient-specific pre-surgical planning and rehearsal requires accurate segmentation of key surgical landmark structures such as the facial nerve, ossicles, and cochlea. The aim of this study was to explore different approaches to segmentation of temporal bone surgical anatomy for patient-specific VR simulation. De-identified, clinical computed tomography imaging of 9 pediatric patients aged 3 months to 12 years were obtained retrospectively. The patients represented normal anatomy and key structures were manually segmented using open source software. The OTOPLAN (CAScination AG, Bern, Switzerland) otological planning software was used for guided segmentation. An atlas-based algorithm was used for computerized, automated segmentation. Experience with the different approaches as well as time and resulting models were compared. Manual segmentation was time consuming but also the most flexible. The OTOPLAN software is not designed specifically for our purpose and therefore the number of structures that can be segmented is limited, there was some user-to-user variation as well as volume differences compared with manual segmentation. The atlas-based automated segmentation potentially allows a full range of structures to be segmented and produces segmentations comparable to those of manual segmentation with a processing time that is acceptable because of the minimal user interaction. Segmentation is fundamental for patient-specific VR simulation for pre-surgical planning and rehearsal in temporal bone surgery. The automated segmentation algorithm currently offers the most flexible and feasible approach and should be implemented. Further research is needed in relation to cases of abnormal anatomy. 4.

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Facial Nerve Paralysis Following Endovascular Embolization: A Case Report and Review of the Literature

Austin Y. Feng,Michael C. Jin,Sandy Wong,Jon-Paul Pepper,Robert Jackler,Yona Vaisbuch

Publication date 02-11-2020


We report a case of facial nerve paralysis post-endovascular embolization of a sigmoid sinus dural arterio-venous fistula from initial presentation to current management and discuss the merits of observation versus decompression through a systematic review of relevant literature. 61 F with right facial palsy. Following a single intravenous dexamethasone injection with oral steroids over 2 months, patient was observed with no additional treatment other than Botox chemodenervation and facial rehabilitation. The patient initially presented with complete right facial palsy (HB 6/6). Post-op CT imaging indicated Onyx (ev3, Irvine, California, USA) particles present at the geniculate segment of the facial nerve. Observation was chosen over surgical intervention. At the most current follow up of 8 months, facial function has improved substantially (HB 2/6). Facial palsy is a serious, though rare, complication of transarterial endovascular embolization. With our case report and literature review, we highlight not only how conservative observation is the recommended treatment, but also that facial nerve recovery should be expected to reach near complete recovery, but not sooner than in 3 months.

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Impact and Cost Effectiveness of Videonystagmography

Garrett Ni,Christine Kim,Lakshmi Nair,Alexander G. Bien,Daohai Yu,David Foyt

Publication date 30-10-2020


Videonystagmography (VNG) is a commonly ordered test to evaluate patients with vestibular complaints. To date, there are no evidence-based guidelines for evaluating patients presenting with vestibular symptoms. This study evaluates the cost effectiveness of VNG and the impact of VNG findings on patient management. Patient charts were reviewed from 3 institutions to collect the pre- and post-VNG ICD-9/10 diagnosis and treatment plan. VNG findings were recorded to calculate the incidence of abnormal findings and the incidence of change in diagnosis and/or treatment plan. The cost effectiveness of VNG was estimated based on these calculations. A total of 120 patient charts were reviewed. 69/120 (57.5%; 95% CI: 48.2%-66.5%) patients had abnormal findings on their VNG. A change in diagnosis was noted in 24/120 (20.0%; 95% CI: 13.3%-28.3%) patients. A change in treatment plan was noted in 62/120 (51.7%; 95% CI: 42.4%-60.9%) patients, and 11/120 (9.2%; 95% CI: 4.7%-15.8%) had a change in diagnosis that led to change in treatment plan. Using the average Medicare reimbursement for VNG, the cost effectiveness analysis showed a cost of $869.57 per VNG with abnormal findings and a cost of $5454.55 per VNG that lead to a change in diagnosis and treatment plan. VNG findings may not result in changes in clinical diagnosis. However, VNG is impactful at influencing treatment plan changes. VNG results are beneficial for counseling patients, guiding treatment plans, and managing patient expectations. When there is a clear indication, VNG testing can be cost effective in managing patients presenting with vestibular symptoms.

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Prevalence of Hearing Loss, and Middle Ear Disease in 1351 School Age Children in Mekelle, Ethiopia

Betelhem Birhanu,Abel Shimeles,Filmawit Gebremeskel,Gabrielle Cager,Miriam Redleaf

Publication date 30-10-2020


The objective of this study was to begin to measure the prevalence of elevated hearing thresholds in Ethiopia, with audiometric equipment, including bone oscillators and tympanometers. To that end Ethiopian nationals were trained in audiometric techniques to obtain sensorineural hearing loss (SNHL) and conductive hearing loss (CHL) rates in school age children. Five mainstreamed public grade schools in northern Ethiopia were the sites for audiometry campaigns examining 1351 children and testing them with behavioral audiometry. Seven percent of students had SNHL > 20 dB in at least 1 frequency in at least 1 ear, and 0.6% of ears had SNHL > 50 dB. Eighteen percent8% of students had CHL > 20 dB in 1 or both ears. The frequency with the highest incidence of elevated pure tone thresholds was at 8000 Hz. Seven percent of students had an air bone gap at 2000 and/or 4000 Hz of at least 15 dB. Air bone gap is not obtained at 8000 Hz. There were 22 perforated tympanic membranes in 17 children (0.8% of tympanic membranes, 1% of students). This study gives a baseline for the prevalence of hearing loss in school age children in mainstreamed northern Ethiopian schools. It is the first of its kind and perhaps can help in estimated hearing health needs there. 2.

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References Values for the Current Perception Threshold in the Pharynx Based on a Study of a Healthy Population

Wei Chang,Wen Xu,Ran Zhang,Yunsong An

Publication date 28-10-2020


The application of the current perception threshold (CPT) in the diagnosis of pharyngeal sensory abnormalities has rarely been studied, and there is a lack of reference values for this application. This study established a normal reference range for CPT in the pharynx based on a study of a healthy population. The CPT values of the palatoglossal arch, posterior 1/3 of the lingual body and hard palate were measured in 60 healthy individuals at 2000, 250, and 5 Hz. The influencing factors were analyzed, and reference values for the CPT were established. There was no correlation between the CPT value and gender. Age was only correlated at 250 Hz level in the hard palate. The CPT values of the palatoglossal arch were 324.95 ± 82.422 at 2000 Hz, 66.90 ± 38.622 at 250 Hz, and 13 ± 14.93 (7.83-22.75) at 5 Hz. The CPT values of the posterior 1/3 of the lingual body were 359.17 ± 76.299 at 2000 Hz, 86.92 ± 35.151 at 250 Hz, and 19 ± 15.73 (13.03-28.75) at 5 Hz. The CPT values of the hard palate were 157.5 ± 61.75 (124-185.75) at 2000 Hz, 57.63 ± 28.785 at 250 Hz, and 22 ± 25.73 (11.03-36.75) at 5 Hz. The CPT values of the pharynx in healthy people were not related to gender. The CPT values of the hard palate for 250 Hz stimulation were related to age, and there were no relationships between the CPT values and age for the other frequencies and loci. We established a normal reference range of CPT values in the pharynx from measurements obtained from healthy populations.

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Increased Rate of Sexual Dysfunction by Increased Severity of Nasal Obstruction in Patients With Chronic Rhinosinusitis

Ramin Zojaji,Mahnaz Kerachi,Mohammad Mehdi Imani,Seyedeh H. Zojaji,Soheil Shomeiri

Publication date 28-10-2020


Chronic rhinosinusitis (CRS) is a common chronic respiratory disorder. This study aimed to investigate the relation between nasal obstruction and sexual dysfunction in men with CRS. In this case-control study, 100 married men aged 19 to 48 years with CRS and 56 healthy married men were selected, consecutively. For assessment of nasal obstruction severity NOSE scale (Nasal Obstruction Symptom Evaluation) was used and IIEF (International Index of Erectile Function) inventory was used to assess sexual function. Mean age of patients with CRS and controls was 33.25 ± 6.5 and 30.58 ± 7.12 years, respectively. Nasal obstruction was moderate in 70% of patients and 95% of patients had some degrees of erectile dysfunction. A significant association was found between nasal obstruction severity and sexual function and by increasing severity of nasal obstruction, sexual function decreased significantly in CRS patients. Sexual function in total (IIEF score) and in its domains, except for sexual desire, were significantly higher in control group ( There is significant inverse association between severity of nasal obstruction and sexual function. Sexual function decreases with increasing severity of nasal obstruction in CRS. CRS patients also have lower sexual function scores than healthy control males.

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Is EAT-10 Useful to Assess Swallowing during the Chemo-Radiotherapy Phase in Patients with Head and Neck Cancer? A Pilot Study

Neus Bofill-Soler,Anna Guillen-Sola,Ester Marco,Sonia Nieto-Cadalso,Mª Camèlia Barrera,Oscar Pera-Cegarra,Ismael Membrive,Xavier Duran,Palmira Foro

Publication date 23-10-2020


The 10-item Eating-Assessment Tool (EAT-10) is a dysphagia screening test. In HNC patients, screening and diagnosis of dysphagia are not well-established. To determine the metrological properties of the EAT-10 compared with videofluoroscopy in non-surgical HNC-patients and to assess the relationship between EAT-10 scores and patients' self-reported symptoms. Prospective cohort study. Forty-six HNC-patients recently diagnosed and referred to chemoradiotherapy (CRT). Main outcome was evidence of dysphagia according to EAT-10 score, self-perception on a Visual Analog Scale (VAS) of impaired swallowing, severity on the Penetration-Aspiration Scale (PAS), and the Functional Oral Intake Scale (FOIS). Patients were assessed at baseline, before-CRT, after-CRT, and at 3-month follow-up. A strong baseline correlation between EAT-10, VAS, and FOIS was observed. All 3 values decreased in weeks 6 to 9 after CRT initiation; a poor correlation of EAT-10 with VAS was observed at 3-month follow-up. A receiver operating characteristic curve determined new cut-off points (sensitivity/specificity) for safe swallowing: baseline 3 (86%, 77%); post-CRT, 15 (62.5%, 80%); and 3-month follow-up, 4 (83%, 75%). New safe-swallow EAT-10-points are suggested for this population during screening and the oncological follow-up. A poor correlation between EAT10-score and patient self-reported symptoms was observed at the end-RT and at 3-month follow-up, highlighting the need for an objective evaluation instrument.

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Impact of Diabetes Mellitus Following Tonsillectomy in Adults: A National Surgical Quality Improvement Program Analysis

Ishwarya S. Mamidi,Lilun Li,Joel W. Jones,Ryan Lee,Md Sohel Rana,Brian K. Reilly

Publication date 23-10-2020


To identify 30-day complication rates specific to patients with diabetes mellitus following tonsillectomy. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was used to identify patients undergoing tonsillectomy between 2005 and 2018.
Patients were stratified into 3 cohorts: insulin-dependent diabetes mellitus (IDDM), non-insulin-dependent diabetes mellitus (NIDDM), and non-diabetes mellitus (NODM). Coarsened-exact-matching was utilized to account for baseline differences between cohorts. Outcomes studied included post-operate complications, prolonged hospitalization, and unplanned readmissions. A total of 986 DM and 26 774 NODM patients were included, and the mean age of patients undergoing tonsillectomy was 29.5 ± 11.6 and 28.7 ± 11.0 years, respectively. The majority of patients were female (70.5% for both DM and NODM cohorts) and White/Caucasian (89.2% vs 89.3%). Among patients undergoing tonsillectomy, a greater proportion of DM patients experienced an operative time greater than or equal to the 75th percentile (35 minutes; 25.9% vs 22.8%, DM patients are at a heightened risk for complications following tonsillectomy. Standardized protocols, careful pre-operative planning, and stringent glycemic management may help optimize patient outcomes.

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Management of the Embedded Tracheoesophageal Prosthesis: Retrograde Removal and Replacement

Ciersten A. Burks,Allen L. Feng,Daniel G. Deschler

Publication date 23-10-2020


To describe the retrograde removal of a tracheoesophageal (TE) prosthesis embedded in the common wall between the trachea and esophagus with preservation of the original tracheoesophageal puncture (TEP) tract with subsequent placement of new tracheoesophageal prosthesis for voice restoration. The Blom-Singer TEP Set (In Health Technologies, Carpinteria, CA) was used to facilitate this procedure. The coated wire leader cable was threaded through the small opening in the posterior tracheal wall and into the lumen of the old TE prosthesis. The wire was pulled through the mouth in retrograde fashion - bringing the old TE prosthesis out with it and dilating the existing TEP tract. A new prosthesis was then placed over the end of the wire and returned through the stoma, delivering the prosthesis through the TE tract and into the stoma. Safe, voice restoration with avoidance of need for multiple procedures. Removal of an embedded prosthesis and simultaneous replacement of a new prosthesis was safely and efficiently achieved using a retrograde technique which maintained the patency of the prior TE tract and restored voice.

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COVID-19’s Impact on the 2020-2021 Resident Match: A Survey of Otolaryngology Program Directors

David A. Kasle,Sina J. Torabi,Said Izreig,Rahmatullah W. Rahmati,R. Peter Manes

Publication date 22-10-2020


To determine the impact coronavirus disease of 2019 (COVID-19) will have on the 2020-2021 otolaryngology (OTO-HNS) resident application cycle. A cross-sectional survey targeting OTO-HNS program directors (PD) was created and disseminated via email to PDs on May 28th 2020. Descriptive analyses of the 19-question survey was performed, and free text responses for certain suitable questions were thematically categorized into groups determined to be relevant during analysis. Twenty-nine of 123 solicited PDs (23.6%) completed the survey. Nineteen (65.5%) respondents indicated they would not host away rotations (AR) in 2020, and 9 (31.0%) reported that they would consider away rotators without home programs. Regarding the historical importance of AR, 21 (72.4%) PDs stated they were either "extremely" or "very" important in evaluating candidates. Sixteen (55.2%) PDs stated that virtual interviews would impact their ability to properly gauge candidates and 12 (41.4%) were unsure. Eight PDs (27.6%) stated their evaluation of candidates will likely change, with a shift toward an increased reliance on letters of recommendation, research involvement, and clerkship grades. The large majority of PDs-25 (86.2%)-were not worried that the COVID-19 pandemic would affect the abilities of new interns beginning in 2021. Virtual interviews and engagement activities will mostly supplant sub-Is and AR for the 2020-2021 OTO-HNS application cycle. Surveyed PDs largely believe these will be insufficient in providing a comprehensive assessment of candidates, and will similarly limit applicants' ability to gauge residency programs. Criteria utilized to evaluate students is expected to change.

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Muscle Tension Dysphagia: Contributing Factors and Treatment Efficacy

Christina H. Kang,Nan Zhang,David G. Lott

Publication date 22-10-2020


To determine factors contributing to disease etiology and treatment efficacy. Original Report. Tertiary academic center. IRB approved prospective study of 20 patients with reported dysphagia who exhibited normal oropharyngeal and esophageal swallowing function as evidenced by videofluoroscopic swallow study, esophagogastroduodenoscopy, high-resolution esophageal manometry with stationary impedance, and Bravo pH probe off proton pump inhibitor. Patients underwent speech-language pathology intervention. Atypical laryngeal muscle tension was present in 100% of patients. Forty percent of patients had diagnosed positive gastroesophageal reflux disease. Sixty-five percent of patients showed signs of non-specific laryngeal inflammation and laryngeal hyperresponsiveness during strobolaryngoscopy. All patients reported a mean of 90% recovery by the completion of voice therapy directed toward unloading muscle tension. The study results suggest an association between laryngeal muscle tension and these patients' dysphagia symptoms regardless of associated conditions. Speech-language pathology intervention showed high treatment efficacy. 2c- Outcomes research.

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Flexible Endoscopic Evaluation of Swallowing in Breastfeeding Infants With Laryngomalacia: Observed Clinical and Endoscopic Changes With Alteration of Infant Positioning at the Breast

Nikki Mills,Melissa Keesing,Donna Geddes,Seyed Ali Mirjalili

Publication date 22-10-2020


This retrospective cohort study uses endoscopic assessment of the pharyngeal phase of swallowing in infants with laryngomalacia, to ascertain the impact of infant positioning on airway compromise and fluid dynamics during breastfeeding. The study aims to identify whether modification of infant positioning at the breast may improve the possibility of safe, successful breastfeeding in infants with laryngomalacia and concurrent breastfeeding difficulty. Twenty-three infants referred for noisy breathing and difficulty feeding were assessed with flexible endoscopic evaluation of swallowing (FEES) during breastfeeding. All had endoscopically confirmed laryngomalacia. During FEES, observations were made of clinical signs of airway compromise as well as endoscopically observable anatomical features and swallowing dynamics during breastfeeding, including tongue base position, view of laryngeal inlet and vocal folds, dynamic supraglottic soft tissue collapse, timing of milk flow into pyriform fossae/hypopharynx relative to sucking, and presence of penetration and/or aspiration. If airway and/or swallowing compromise was present, the infant's initial position at the breast was altered from supine or semi lateral decubitus position to semi-prone, with a description of the clinical and endoscopically observable changes that subsequently occurred. Signs of dynamic airway obstruction and/or compromised airway protection with swallowing were present in 20 of the 23 infants (87%) in their initial supine or semi lateral decubitus position. These 20 infants were repositioned to semi-prone, with improvement and/or resolution of stridor and an improved ability to maintain latch in all infants. Continued endoscopic evaluation following positional change was possible in 16 infants, identifying anterior positioning of the tongue base, reduced dynamic supraglottic tissue collapse, reduced volume of milk flow into pyriform fossae during pauses in sucking and resolution of penetration and aspiration. This study has shown how alteration of breastfeeding position to semi-prone may improve dynamic airway obstruction and reduce aspiration risk in infants with laryngomalacia.

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Rebuilding survivorship care during Covid-19

Nitin A. Pagedar,Aaron T. Seaman

Publication date 21-10-2020


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Decrease in Respiratory Related Hospitalizations in Tracheostomy-Dependent Children Who Tolerate Passy-Muir Valve Use

Lilun Li,Emily Wikner,Hengameh Behzadpour,Geovanny Perez,Pamela Mudd

Publication date 21-10-2020


To assess the effect of Passy-Muir Retrospective cohort study of 262 patients who underwent tracheostomy placement between 2012 and 2018 at a tertiary free-standing children's hospital. Outcome measures studied were number of reported upper respiratory infections and respiratory related hospitalizations per year (RRH/year). About 135 (51.5%) tracheostomy-dependent children underwent PMV trials, and 106 (78.5%) of these children were able to tolerate PMV for at least 1 hour daily. When comparing children who tolerated PMV versus those who did not, the latter group had significantly higher rates of subglottic stenosis but no significant differences in RRH/year or average age. In those children who tolerated PMV and achieved routine use of PMV > 1 hour/day, an average of 1.14 RRH/year occurred prior to PMV tolerance, as compared with 0.57 RRH/year after PMV tolerance ( In tracheostomy-dependent children who tolerate PMV use routinely >1 hour/day there are decreased rates of respiratory related hospitalizations (RRH). Children <2 years of age have the most impact of RRH, with rates that are significantly lower with routine use of the PMV.

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Two Different Tracts and Origin of Pyriform Sinus Fistula

Koichi Sakakura,Yoshihito Yasuoka,Masato Shino,Minoru Toyoda,Kisho Obi,Kazuaki Chikamatsu

Publication date 21-10-2020


Suppurative acute thyroiditis is caused by pyriform sinus fistula (PSF), and PSF frequently elicits deep neck abscess. However, complete fistulectomy is the ideal management of PSF, and studies on surgical findings of PSF are exceedingly rare. This study aimed to reveal the origins of PSF, each route, and clinical presentation. This is a multicenter study. We have conducted 19 complete fistulectomies of PSF in Japan, analyzed routes of the fistulas, estimated the origins, and investigated their histological and clinical findings. No recurrence was observed in all cases. Five of 12 cases showed thymic and/or parathyroid tissues around the fistulas, passing inside the inferior horn of thyroid cartilage, were regarded as having 3rd pouch origin, and tended to have low frequency of severe deep neck abscess. The remaining 7 cases originated from the 4th pouch running outside of the horn and showed frequent severe infection. PSF have 2 different routes depending on their generation and may present different clinical manifestations.

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Sniffin’ Sticks to Measure Olfactory Function and Recovery Following Bilateral Superior Turbinate Resection as Part of Endoscopic Transsphenoidal Approach

Shaina W. Gong,Sorour Ahmadi,Spiros L. Blackburn,Lindsey Ulin,Martin J. Citardi,Amber Luong,William C. Yao

Publication date 21-10-2020


Extended endoscopic transsphenoidal (EET) approaches can include complete resection of both superior turbinate (ST) for wider exposure. Moreover, ST resection has been associated with postoperative olfactory impairment. We sought to determine the impact of bilateral ST resection on olfaction during a transsphenoidal approach. A prospective observational study was conducted on 29 patients undergoing endoscopic skull base surgery sparing the olfactory tracts at a tertiary academic center. Olfactory function was measured with Sniffin' Sticks at the preoperative visit, 2-weeks and 6 to 8 weeks postoperatively.
All components: odor threshold (OT), odor discrimination (OD), odor identification (OI) and composite scores (TDI = OT+OD+OI) were evaluated. Study was completed in 15 patients with 14 excluded due to a variety of reasons. At 2 weeks, a significant decrease was noted in composite scores (32.3 ± 5.4 vs. 23.8 ± 5.8, Patients undergoing bilateral ST resection during EET procedures experience transient hyposmia postoperatively. However, the olfactory function normalizes to preoperative levels at 6 to 8 weeks. The resection of the bilateral superior turbinate does not appear to decrease olfactory function.

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Exploring the Factor Structure of the Glasgow Children’s Benefit Inventory: New Recommendations for Reporting Results

Haytham Kubba,William M. Whitmer

Publication date 16-10-2020


Patient-reported outcomes can be useful for reporting benefit from non-life-saving interventions, but often they report a single overall score, which means that much information on the specific areas of benefit is lost. Our aim was to perform a new factor analysis on the Glasgow Children's Benefit Inventory (GCBI) to create subscales reflecting domains of benefit. Further aims were to assess the internal consistency of the GCBI, and to develop guidelines for reporting both a total score and sub-scales in future studies. We collected 4 existing datasets of GCBI data from children who have undergone tonsillectomy, ventilation tube insertion, pinnaplasty, and submucous diathermy to the inferior turbinates. We performed exploratory factor analysis with principal axis factoring with varimax rotation, we sought redundancy in question items, and we measured internal consistency. Using the combined dataset of 772 cases, we found 4 factors which accounted for 64% of the variance and which we have labeled "Psycho-social," "Physical health," "Behavior," and "Vitality." Subscale results varied in predictable ways depending on the nature of the intervention. Cronbach's alpha was 0.928. Item-total correlations were high, and no item could be deleted to improve alpha. Floor effects were apparent for various questions but were not consistent between different interventions. The GCBI contains a range of questions which each add value in different clinical interventions. We can now make recommendations for reporting the results of the GCBI and its 4 new subscales.

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Vocal Fold Immobility Following Vaccination

Guy Talmor,Brandon Nguyen,Corina Din-Lovinescu,Boris Paskhover,Rachel Kaye

Publication date 16-10-2020


Vocal fold immobility (VFI) may severely affect quality of life due to dysphonia and respiratory distress. Many etiologies of this disorder have been evaluated, however the relationship between VFI and vaccination has yet to be explored. The objective of this study was to identify the relationship between VFI and vaccine administration. The Vaccine Adverse Event Reporting System (VAERS) database was queried for patients exhibiting symptoms of VFI following vaccination. Patient demographics and clinical information including presenting symptoms, time of symptom onset, laterality, outcomes, and adverse events were documented. Twenty-two patients were found to have VFI following vaccination. Of those reported, 13 patients were female (59.1%) and 8 were male (36.4%) with an average age of 48.4 years. Vaccinations for influenza, shingles, pneumococcus, and hepatitis B were reported. A majority of these cases were unilateral in nature (73.3%). Mean lag time from vaccination to symptom onset was 6.3 days (range 0-45 days). Five adverse events were reported, with 4 patients requiring intubation and tracheostomy. Vaccine administration may be associated with VFI and physicians should be cognizant of this potential adverse event. This is a rare complication with less reported cases than other post-vaccination cranial neuropathies. The difficulty in establishing an initial diagnosis and need for specialized evaluation by an otolaryngologist may result in under-reporting of such events. Further research is needed to delineate the exact pathophysiology of this complication and determine whether a causal relationship exists.

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Safety and Feasibility of a Novel Esophageal Balloon for Circumferential Cytologic Sampling

Nikita Kohli,Andrew Blitzer,Anthony Jahn,Youngnan Jenny Cho,Jay Budrewicz,Karyn Enos,Marshall Strome

Publication date 14-10-2020


A prior publication introduced the Strome-Blitzer balloon's ability to obtain circumferential esophageal cytologic sampling. This GLP study was requisite for FDA approval to determine if equivalent cell capture and cellularity was observed with the balloon compared to surface sampling brushes and to determine the balloon's usability for naive otolaryngologists. Three naïve users tested the Hobbs brush and Strome-Blitzer balloon on 4 Yorkshire swine. Four anatomical sites were sampled, beginning distally and ending proximally. In 2 animals, the balloon was used first distally and in the remaining 2, 4 new Hobbs brushes were used distally first. Moving proximally, the balloon and brushes were sequentially alternated. In follow-the-leader fashion, the balloon was introduced trans-orally followed by an endoscope to the desired site. The balloon was inflated exposing the abrasive strips to contact the esophageal mucosa. Moving the balloon 1 to 2 cm superiorly and inferiorly effected circumferential cell capture. The balloon was collapsed and removed, preserving the cellularity. The Hobbs brush was passed through the scope's channel. Four brushes, 1 per quadrant, obtained the samples at an anatomical site. The balloon was rated as pass/fail on the following: delivery, kinking, usability, and malfunction. A blinded veterinary pathologist evaluated the cytology. There was no device malfunction, mucosal trauma, or difficulty with device use. Balloon cytologic samples were comparable in cellularity and quality to the brush. A single balloon sampling was comparable to 4 brushes in capturing diagnostically relevant cellular volumes and architecture. Naïve users easily performed the procedures after reading the guidelines. 3.

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Impact of Lymph Node Yield in Patients Undergoing Total Laryngectomy and Neck Dissection

Michael C. Topf,Ramez Philips,Joseph Curry,Linda C. Magana,Madalina Tuluc,Voichita Bar-Ad,William Keane,Richard A. Goldman,Adam Luginbuhl,David Cognetti

Publication date 14-10-2020


To determine the impact of lymph node yield (LNY) in patients undergoing neck dissection at the time of total laryngectomy (TL). To determine the impact of radiation therapy (RT) on LNY. Retrospective review of LNY and clinical outcomes in 232 patients undergoing primary or salvage total laryngectomy (TL) with ND. Preoperative RT significantly decreased mean LNY from 31.7 to 23.9 nodes ( Radiotherapy significantly reduces LNY in patients undergoing TL and ND. Within a single institution cohort, positive margins, but not LNY, is associated with survival in both primary and salvage TL patients.

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The Correlation Between Endolymphatic Hydrops and blood-labyrinth barrier Permeability of Meniere Disease

Weidong Zhang,Jiapei Xie,Lian Hui,Songbai Li,Bo Zhang

Publication date 13-10-2020


This study was designed to assess the correlation between the grades of endolymphatic hydrops and the blood-labyrinth barrier permeability in the affected ear in Meniere's disease, following the administration of intravenous gadolinium contrast. Prospective study. The quantitative values of endolymphatic hydrops were determined after intravenous injection of a double-dose of gadobutrol in 39 patients with unilateral definite Meniere's disease. Additionally, the signal intensity ratio of bilateral cochlear basal turns was evaluated and analyzed; The correlation between the grades of the endolymphatic hydrops and the signal intensity ratio of the cochlear basal turns in the affected ear was examined. The grades of the endolymphatic hydrops can be quantitatively evaluated using magnetic resonance imaging (MRI). The signal intensity ratio of the cochlear basal turns in the affected ear was significantly higher than in the unaffected ear ( The increased permeability of the blood-labyrinth barrier may play a role in the process of endolymphatic hydrops in Meniere's disease.

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A Non-inferiority Trial: Safety and Efficacy of Topical 1:1000 versus 1:10\u2009000 Epinephrine in Sino-nasal Surgeries

Cassie L. Dow,Anders W. Sideris,Ravjit Singh,Mitchell H. Giles,Catherine Banks,Catherine Meller,Sim Choroomi,Thomas E. Havas

Publication date 08-10-2020


This study aimed to test the non-inferiority of topical 1:1000 epinephrine compared to topical 1:10 000 with regard to intraoperative hemodynamic stability, and to determine whether it produced superior visibility conditions. A single-blinded, prospective, cross-over non-inferiority trial was performed. Topical 1:1000 or topical 1:10 000 was placed in 1 nasal passage. Hemodynamic parameters (heart rate, systolic and diastolic blood pressures, and mean arterial pressure) were measured prior to insertion then every minute for 10 minutes. This was repeated in the contralateral nasal passage of the same patient with the alternate concentration. The surgeon graded the visualization of each passage using the Boezaart Scale. The medians of the greatest absolute change in parameters were compared using a Wilcoxon Rank-Signed test and confidence intervals were calculated using a Hodges-Lehman test. The non-inferiority margin was pre-determined at 10 bpm for heart rate and 10 mm Hg for blood pressures. A Wilcoxon Rank-Signed test was used to assess superiority in visualization. Thirty-two patients were enrolled and after exclusions, nineteen were assessed (mean age = 35.63 ± 12.49). Differences in means of greatest absolute change between the 2 concentrations were calculated (heart rate = 2.49 ± 1.20; systolic = -1.51 ± 2.16; diastolic = 2.47 ± 1.47; mean arterial pressure = 0.07 ± 1.83). In analyses of medians, 1:1000 was non-inferior to the 1:10 000. There was a significant difference (-0.58 ± 0.84; Topical 1:1000 epinephrine provides no worse intraoperative hemodynamic stability compared to topical 1:10 000 but affords superior visualization and should be used to optimize surgical conditions.

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Adapting Personal Therapies Using a Mobile Application for Tinnitus Rehabilitation: A Preliminary Study

Mehdi Abouzari,Khodayar Goshtasbi,Brooke Sarna,Yaser Ghavami,Erica M. Parker,Pooya Khosravi,Navid Mostaghni,Shahrnaz Jamshidi,Tina Saber,Hamid R. Djalilian

Publication date 08-10-2020


To develop a smartphone application providing sound therapy and cognitive behavioral therapy (CBT) for treating tinnitus and performing a proof-of-concept pilot study evaluating its potential efficacy. An interactive smartphone application available on iOS and Android platforms was developed, which provided an 8-week tinnitus-specific CBT and personalized and frequency-matched sound therapy. Included patients presented to our tertiary clinic between 2017 and 2018, while those waitlisted were regarded as controls.
Three surveys were administrated: Tinnitus Handicap Inventory (THI), Generalized Anxiety Disorder 7-item (GAD-7), and Perceived Stress Scale (PSS). A total of 30 patients enrolled in this study consisting of 20 treatment and 10 control patients and mean age was 55.4 ± 11.6 years. Treatment and control patients had similar age, sex, and pre-enrolment GAD and PSS (all This pilot study demonstrated potentially promising efficacy of a smartphone-based CBT and sound therapy platform for treating tinnitus and encourages future randomized controlled trials on this treatment modality.

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Use of Adenosine to Facilitate Localization and Repair of Internal Carotid Artery Injury during Skull Base Surgery: A Case Report and Literature Review

Obi I. Nwosu,Kolin E. Rubel,Mohamedkazim M. Alwani,Dhruv Sharma,Michael Miller,Jonathan Y. Ting,Troy Payner

Publication date 08-10-2020


Internal carotid artery (ICA) injuries represent a rare, potentially fatal complication of endoscopic endonasal skull base surgery (EESBS). The use of adenosine to induce transient hypotension and facilitate management of high-flow, high-pressure arterial lesions has been well-documented in neuro-endovascular literature. A similar setting in which adenosine-induced hypotension may prove beneficial is during the management of major vascular injury encountered during EESBS. A case of ICA injury and subsequent repair during EESBS is presented. A 74-year-old female underwent endoscopic transsphenoidal resection for a recurrent pituitary adenoma. During suprasellar resection, the right cavernous ICA was inadvertently injured resulting in brisk bleeding. Immediate vascular tamponade was applied, and a crushed muscle graft was obtained. Two intravenous doses of adenosine were administered in quick succession to produce transient hypotension and facilitate repair of the injury with the graft. Neurovascular imaging revealed a small pseudoaneurysm which remained stable throughout the postoperative course. The patient underwent definitive stent embolization of the pseudoaneurysm 1 month following discharge. Prompt repair of ICA injury during EESBS is crucial, but often limited by poor visualization. Adenosine-induced hypotension has demonstrated great efficacy as an adjuvant in neurovascular clipping of intracranial aneurysms and remains a valuable tool for the endoscopic skull-base surgeon as well. In cases with high risk for ICA injury, adenosine should be readily available.

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Tracheal Agenesis: Vertical Division of the Native Esophagus – A Novel Surgical Approach and Review of the Literature

Alexander J. Straughan,Collin F. Mulcahy,Anthony D. Sandler,Nancy M. Bauman,David Steinhorn,Lyuba Gitman

Publication date 08-10-2020


Tracheal agenesis (TA) is rare and usually fatal. Few survivors with concomitant tracheoesophageal fistulae (TEF) who underwent ligation of the distal esophagus with creation of a spit-fistula and neo-trachea from the proximal esophagus exist. We report a novel surgical technique whereby the esophagus is divided longitudinally to preserve a functional alimentation tract and a parallel neo-trachea. We review the literature of reported cases, including survivors beyond 12 months. Case report and literature review. A female infant with prenatal polyhydramnios was born at 35 weeks gestation with immediate respiratory distress and absent cry. Oxygenation was maintained with a laryngeal mask airway. Despite a normal appearing larynx, she could not be intubated and emergent neck exploration disclosed no cervical trachea. The patient was placed on extra corporeal membranous oxygenation (ECMO), and later diagnosed with TA, Floyd Type I. Parental desire for reconstruction but refusal of a spit-fistula necessitated a novel procedure. The esophagus was divided longitudinally via a microstapler to preserve the original alimentary tract and create a parallel neo-trachea originating from the TEF and terminating as a cervical stoma. The healing process was complicated but the baby was ultimately discharged to home where she developed normally neurologically until succumbing one night to accidental decannulation at 16 months of age. We describe a novel surgical approach to manage TA. This includes avoiding creation of a spit fistula and preserving the native esophagus. We then survey the literature, reporting the survivorship duration and operative management of 174 reported cases of TA.

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Olfactory and Gustatory Dysfunctions as a Clinical Manifestation of Coronavirus Disease 2019 in a Malaysian Tertiary Center

Kuganathan Ramasamy,Jeyasakthy Saniasiaya,Norhaslinda Abdul Gani

Publication date 07-10-2020


To investigate the prevalence of olfactory and gustatory dysfunction among patients with COVID-19 infection and the recovery rate. Adult patients (≥18 years) tested positive for COVID-19 via reverse transcription-polymerase chain reaction (RT-PCR) and admitted in Hospital Tuanku Ja'afar Seremban, Malaysia, were recruited in this study.
Patients completed a questionnaire via telephone interview comprising the following details: age, sex, ethnicity, comorbidities, general and otorhinolaryngological symptoms, onset and duration of olfactory and gustatory dysfunction. Patients with persistent olfactory and gustatory dysfunction at the time of the initial interview were followed-up every 3 to 5 days till resolution. A total of 145 patients were included in our study. The mean age of patients was 43.0 ± 17.7 (range: 18-86). Fever (44.1%) and cough (39.3%) were the most prevalent general symptoms. Thirty-one patients (21.4%) reported olfactory dysfunction and 34 (23.4%) reported dysgeusia. There was a significant association between both olfactory and gustatory dysfunction ( Olfactory and gustatory dysfunction is a pertinent manifestation of COVID-19. Most of the affected patients achieve rapid and complete recovery. Sudden onset of olfactory and gustatory dysfunction should be recognized as a major symptom of COVID-19 as we implore to contain this pandemic.

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Recurrent Hemoptysis: A Bronchial Dieulafoy’s Lesion in a Pediatric Patient

Jeremy S. Ruthberg,Anish Abrol,N. Scott Howard

Publication date 07-10-2020


This paper presents a case of a bronchial Dieulafoy's lesion in a pediatric patient with recurrent hemoptysis. A 11-year old female presented multiple times with dry cough and hemoptysis to an outside hospital, each time leading to a diagnosis of epistaxis and subsequent discharge. When she arrived to our tertiary center with heavy hemoptysis and no evidence of epistaxis, the patient was urgently taken to the operating room by both the otolaryngology and pediatric pulmonology services. Active bleeding from a Dieulafoy's lesion on the right lower bronchus was found and selective embolization of two tortuous arteries was subsequently performed. The patient was discharged in stable condition without recurrence of hemoptysis over the last two months. While rare, especially in pediatric patients, bronchial Dieulafoy's lesions may cause severe hemoptysis and should be considered in the differential diagnosis when the etiology for hemoptysis is unclear.

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Early Adverse Events Following Transcervical Hypopharyngeal Diverticulum Surgery

Khodayar Goshtasbi,Sunil P. Verma

Publication date 01-10-2020


To describe rates of short-term morbidity following transcervical surgical treatment of hypopharyngeal diverticulum (HD) and analyze predictors of adverse events. The 2005 to 2017 National Surgical Quality Improvement Program database was queried to identify patients diagnosed with HD undergoing open transcervical diverticulectomy. A total of 597 patients with a mean age of 71.4 ± 12.3 years were included. Thirty-day adverse events were experienced by 63 (10.6%) subjects, including 6.5% unplanned reoperations, 4.2% surgical complications, 4.4% medical complications, 2.7% readmissions, and 0.7% deaths. Medical complications notably included pneumonia (2.0%), reintubation (1.2%), sepsis (1.2%), intubation >48 hours (0.5%), urinary tract infection (0.5%), or deep vein thrombosis (0.5%), while surgical complications included organ/space infection (2.0%) and superficial (1.3%) or deep (1.0%) surgical site infection. Gender, race, functional status, diabetes, dyspnea, hypertension, steroid use, and recent weight loss were not associated with adverse events. Length of operation and hospitalization were both higher among those with adverse events (127.4 ± 107.9 vs 95.7 ± 59.8 minutes, Understanding clinical factors associated with complications following open surgery for HD such as ASA score, smoking status, length of operation, and age can help optimize surgical outcomes for at-risk patients. NA.

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Long-Term Clinical Follow-Up of Patients With Chronic Rhinosinusitis

Ulrica Thunberg,Amanj Saber,Bo Söderquist,Svante Hugosson

Publication date 01-10-2020


This study comprised a long-term follow-up of a cohort of patients with chronic rhinosinusitis (CRS) regarding clinical features and symptomatology. Data from 42 patients with CRS were available from a previous study. Forty of these patients were alive and were contacted for inclusion after approximately 10 years. Patients completed a questionnaire about disease and symptoms, and underwent a clinical examination. Thirty-four patients (85%) responded and could be included and evaluated. For the participants in this follow-up study median length of time between initial inclusion (C1) and follow-up (C2) was 11 years (range: 8-15). In some patients the CRS shifted phenotype over time, from CRS with nasal polyposis to CRS without nasal polyposis or vice versa. The median total visual analogue score for combined sinonasal symptoms for all patients was statistically significantly reduced at follow-up. For individual patients, scores for nasal congestion, nasal discharge, facial pressure, and hyposmia were also statistically significantly reduced. The most frequently reported symptom-relieving treatments were nasal steroids and saline rinsing of the nose. Self-reported general quality of life was statistically significantly improved at C2 compared to C1. At long-term follow-up, symptoms were generally reduced and patients reported an improved quality of life. Patients can be given hope for eventual symptom relief. CRS is a chronic condition that seems to harbor the ability to alter its phenotype after several years. Topical corticosteroids and saline rinsing of the nose should be emphasized, since patients consider these treatments to be of high value.

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Erratum to A Prospective Randomized Trial of N-butyl-cyanoacrylate + Metacryloxysulfolane Adhesive versus Suture Alone for Grafting in Rhinoplasty: 9 year Follow-up

Publication date 18-09-2020


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Hemodynamic Changes with 1:1000 Epinephrine on Wrung-Out Pledgets Before and During Sinus Surgery

John R. Peleman,Pritee Tarwade,Xiaoxia Han,Donald H. Penning,John R. Craig

Publication date 18-09-2020


Intranasal topical 1:1000 epinephrine has been used safely and effectively for hemostasis during endoscopic sinus surgery (ESS). Prior studies assessing hemodynamic changes after intranasal topical epinephrine application have only used soaking wet cottonoid pledgets, and have only assessed for hemodynamic changes before any surgery being performed. The purposes of this study were to determine whether intranasal application of topical 1:1000 epinephrine with wrung-out cottonoid pledgets caused significant hemodynamic changes both before and during ESS, and whether it allowed for adequate hemostasis. A prospective evaluation of 30 patients with eosinophilic chronic rhinosinusitis with nasal polyps (CRSwNP) undergoing complete bilateral ESS was conducted. Heart rate, blood pressure (systolic, diastolic, and mean arterial pressure), and electrocardiography changes were recorded at 0, 1, 2, and 5-minute intervals after placing wrung-out epinephrine-saturated pledgets, both before and at the end of ESS. No submucosal epinephrine injections were performed. Estimated blood loss (EBL) and major intraoperative complications were recorded for all cases. There were no significant hemodynamic changes or electrocardiographic abnormalities after placement of wrung-out epinephrine-soaked pledgets both before and after ESS. After bilateral ESS, there were actually mean decreases in heart rate and blood pressure parameters. Mean EBL was 75.8 ± 32.2 mL, and no major intraoperative complications occurred. Intranasal application of topical 1:1000 epinephrine via wrung-out cottonoid pledgets was effective for intraoperative hemostasis, and did not cause clinically significant alterations in hemodynamic parameters or cardiovascular events, either before or during ESS in patients with CRSwNP.

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Sequelae of Major Trauma Patients with Maxillofacial Fractures

Lasse Østrup Petersen,Emil Ørskov Ipsen,Ulrik Ascanius Felding,Christian von Buchwald,Jacob Steinmetz

Publication date 16-09-2020


Sequelae after maxillofacial fractures are frequent and may affect the patient's quality of life. This study examined sequelae associated with maxillofacial fractures of severely traumatized patients focusing mainly on nerve injuries. A retrospective study including trauma patients with relevant facial fractures admitted to our Trauma Center in the period 2011-2016. Presence of posttraumatic maxillofacial sequelae was identified by examining the medical records of the included patients. Focusing on facial sensory deficits and facial nerve paralysis, but also comprising data on diplopia, blindness, malocclusion, trismus, eye globe malposition, flattening of the malar, facial contour changes, and wound infections. Two-hundred-seventy-five severely traumatized patients were included, comprising 201 men (73%), with a median age of 40 years and ISS of 20. 163 (59%) patients only had assessments within 3 months from trauma of which 79 patients (48.5%) had facial complications at initial examination, mostly malocclusion and trismus. Most patients in this group had no or only minor sequelae at their last clinical assessment, mainly being sensory deficits. 112 (41%) patients had assessments both within and beyond 3 months of which 73 patients (65.2%) had facial complications at initial examination, while 91 patients (81%) had reported sequelae within 3 months decreasing to 47 patients (42%) at their last clinical assessment beyond 3 months from trauma, mostly sensory deficits. An improvement of most sequelae was observed. Objective sequelae were found to be quite common after maxillofacial fractures in severely traumatized patients, especially sensory deficits. However, most of the addressed sequelae seemed to improve over time.

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Evaluation of Surgical Learning Curve Effect on Obstructive Sleep Apnea Outcomes in Upper Airway Stimulation

Christopher Larsen,Christopher Boyd,Mark Villwock,Armin Steffen,Clemens Heiser,Maurits Boon,Colin Huntley,Karl Doghramji,Ryan J. Soose,Alan Kominsky,Tina Waters,Kirk Withrow,Noah Parker,Erica Thaler,Reena Dhanda Patil,Katherine K. Green,Eugene Chio,Maria Suurna,Amy Schell,Kingman Strohl

Publication date 14-09-2020


An increasing number of facilities offer Upper Airway Stimulation (UAS) with varying levels of experience. The goal was to quantify whether a surgical learning curve exists in operative or sleep outcomes in UAS. International multi-center retrospective review of the ADHERE registry, a prospective international multi-center study collecting UAS outcomes. ADHERE registry centers with at least 20 implants and outcomes data through at least 6-month follow-up were reviewed. Cases were divided into two groups based on implant order (the first 10 or second 10 consecutive implants at a given site). Group differences were assessed using Mann-Whitney U-tests, Chi-squared tests, or Fisher's Exact tests, as appropriate. A Mann-Kendall trend test was used to detect if there was a monotonic trend in operative time. Sleep outcome equivalence between experience groups was assessed using the two one-sided tests approach. Thirteen facilities met inclusion criteria, contributing 260 patients. Complication rates did not significantly differ between groups ( Across the centers' first 20 implants, an approximately 11% reduction operative time was identified, however, no learning curve effect was seen for 6-month or 12-month AHI or ESS over the first twenty implants. Ongoing monitoring through the ADHERE registry will help measure the impact of evolving provider and patient specific characteristics as the number of implant centers increases.

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Early Outcomes in an Emerging Facial Nerve Center: The Oregon Health and Science University (OHSU) Experience

Natalie A. Krane,Jimmy S. Chen,Haley Hanseler,Wenelia Baghoomian,John Ng,Mark K. Wax,Myriam Loyo

Publication date 12-09-2020


Nerve transfer (NT) and free gracilis muscle transfer (FGMT) are procedures for reanimation of the paralyzed face. Assessing the surgical outcomes of these procedures is imperative when evaluating the effectiveness of these interventions, especially when establishing a new center focused on the treatment of patients with facial paralysis. We desired to discuss the factors to consider when implementing a facial nerve center and the means by which the specialist can assess and analyze outcomes. Patients with facial palsy secondary to multiple etiologies, including cerebellopontine angle tumors, head and neck carcinoma, and trauma, who underwent NT or FGMT between 2014 and 2019 were included. Primary outcomes were facial symmetry and smile excursion, calculated using FACE-gram and Emotrics software. Subjective quality of life outcomes, including the Facial Clinimetric Evaluation (FaCE) Scale and Synkinesis Assessment Questionnaire (SAQ), were also assessed. 14/22 NT and 6/6 FGMT patients met inclusion criteria having both pre-and postoperative photo documentation. NT increased oral commissure excursion from 0.4 mm (SD 5.3) to 2.9 mm (SD 6.8) ( Measuring outcomes, critical analyses, and a multidisciplinary approach are necessary components when building a facial nerve center. At our emerging facial nerve center, we found NT and FGMT procedures improved smile excursion and symmetry, and improved QOL following NT in patients with facial palsy secondary to multiple etiologies.

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Considerations in Management of Acute Otitis Media in the COVID-19 Era

Suresh Mohan,Alan Workman,Miriam Barshak,D. Bradley Welling,Dunia Abdul-Aziz

Publication date 11-09-2020


To present the otologic findings of a patient with COVID-19 and complicated acute otitis media, evaluate for the presence of SARS-CoV-2 in middle ear fluid, and assess whether suctioning of middle ear fluid may be aerosol- generating. The case of a man with SARS-CoV-2 infection and complicated acute otitis media with facial paralysis is presented to illustrate unique clinical decisions made in context of the COVID-19 pandemic. A cadaveric temporal bone was used to simulate droplet spread during suctioning of fluorescein-labelled middle ear fluid and visualized with a blue-light filter. A 23-year-old male who presented with complicated acute otitis media with facial paralysis was found to have an acute infection with SARS-CoV-2, with positive viral PCR of nasopharyngeal swab, and a negative PCR of the middle ear fluid. He was placed on isolation precautions and treated with myringotomy, topical and systemic antibiotics, and antivirals. Consistent with observations during endonasal suctioning, suctioning of middle ear fluid was not found to be aerosol or droplet generating. The case of a patient with active COVID-19 presenting with complicated acute otitis media in whom middle ear fluid was sampled to evaluate the etiology of the infection and the potential middle ear predilection of SARS-CoV-2 is described. This study has implications for the clinical management of patients with both known and unknown SARS-CoV-2 infection who present with ear disease. While middle ear suctioning may not be aerosol-generating, the risk of coughing or prolonged close contact requires heightened precautions during otologic procedures in patients with suspected or confirmed COVID-19.

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De-Epithelialized Heterotopic Tracheal Allografts without Immunosuppressants in Dogs: Long-Term Results for Cartilage Viability and Structural Integrity

Pengcheng Cui,Pengfei Liu,Shuqin Li,Ruina Ma

Publication date 11-09-2020


Reconstruction of long segmental tracheal defects is difficult because no ideal tracheal substitutes are currently available. Tracheal allotransplantation maintains cartilage and epithelium viability but requires immunosuppression because of epithelial immunogenicity. We aimed to obtain an epithelium-decellularized allograft that maintains cartilage viability and to evaluate long-term outcomes of such allografts implanted on dog backs without immunosuppressants. Twenty-five tracheas harvested from mongrel dogs were used to explore the period of epithelium decellularization by combined use of 1% sodium dodecyl sulfate and an organ preservation solution and to assess the chondrocyte viability and immunogenicity of the tracheas after decellularization. Sixteen epithelium-decellularized tracheal allografts and 10 fresh tracheal segments (6 cm long) were implanted in 26 beagles for durations of 10 days and 1, 3, 6, and 12 months. Macroscopic and microscopic examinations were used to evaluate the morphology, viability, and immune rejection of the allografts. Safranin-O staining was used to detect glycosaminoglycans. The epithelium disappeared after 24 hours of decellularization. At 72 hours, almost no nuclei remained in the mucosa, while the mean survival rate of chondrocytes was 88.1%. Histological analysis demonstrated that the allograft retained intact tracheal rings and viable cartilage after heterotopic implantation for 1 year, with no immunological rejection. There were no significant differences in the glycosaminoglycan contents among the implanted epithelium-decellularized allografts. Epithelium-decellularized tracheal allografts with chondrocyte viability can be achieved by combined use of a detergent and organ preservation solution, which showed satisfactory cartilage viability and structural integrity after long-term heterotopic transplantation. Further studies on orthotopic transplantation are needed to assess the feasibility of allografts in reconstructing long segmental tracheal defects.

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Does Voice Therapy Improve Vocal Outcomes in Vocal Fold Atrophy?

Emma Bick,Lukas D. Dumberger,Douglas R. Farquhar,Heather Davis,Elizabeth Ramsey,Robert A. Buckmire,Rupali N. Shah

Publication date 29-08-2020


Vocal fold atrophy is increasingly identified in the geriatric population. Current literature shows varying outcomes with voice therapy. Our goal was to analyze multidimensional vocal outcomes of these patients who underwent voice therapy. Secondary aims included determining compliance and analyzing differences in patients who undergo surgery. 197 patients with vocal fold atrophy were included and reviewed. Patients were categorized by treatment received. Patient-reported, perceptual, aerodynamic, and acoustic voice outcomes were analyzed before and after therapeutic intervention. Changes were calculated and significance determined using Wilcoxon signed-rank and rank-sum tests. 89(45%) received no therapy, 43(22%) incomplete therapy, 51(26%) complete therapy, 8(4%) surgery only, and 6(3%) therapy followed by surgery. Those who completed voice therapy showed significant improvement in voice related quality of life (VRQOL) ( Only 29% of patients with vocal atrophy completed voice therapy when recommended. Within this patient cohort, voice therapy results in significant improvement in multidimensional voice outcomes. Patients with vocal atrophy that undergo surgical treatment differ from those treated with voice therapy alone in their pre-treatment patient-reported measures.

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Expression of Concern: The clinical significance of IGF-1R and relationship with Epstein-Barr virus markers: LMP1 and EBERs in Tunisian patients with Nasopharyngeal Carcinoma

Publication date 22-08-2020


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Otolaryngology Match 2020-21: Survey of Prospective Applicants in the Setting of COVID-19

Said Izreig,Sina J. Torabi,David A. Kasle,Rahmatullah W. Rahmati,R. Peter Manes

Publication date 20-08-2020


To capture the perspectives of candidates applying for otolaryngology residency positions in the 2020-21 cycle, in the context of disruption caused by the coronavirus disease 2019 (COVID-19) pandemic. Candidates planning to apply to the otolaryngology 2020-21 match were invited to complete a cross-sectional online survey. Distribution was via otomatch.com and word of mouth. Descriptive statistics were performed. Of 85 eligible responses (estimated 18.9% of all applicants), many have had at least one board examination (71.8%) disrupted. A majority (85.9%) believe evaluation of candidates will change due to the pandemic, and 54.1% report they were now less confident in matching. Female applicants (37.6% of respondents) were found to have significantly higher odds of decreased confidence in matching (OR 2.781 [95% CI 1.045-7.4044]; We find that candidates believe their candidacy will be assessed differently in light of the COVID-19 pandemic, are largely less confident in successfully matching, and are planning to apply and interview more broadly. These data are relevant to otolaryngology residency leadership to inform clear dialogue and a smooth transition into an unprecedented application cycle.

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Rationing Rotational Magnet Cochlear Implant Technology in a Single Payer Healthcare System

Justyn Pisa,Colin Andrews,Jordan B. Hochman

Publication date 23-07-2020


In a publicly funded health care system, fiscally responsible management of any program is required. This is especially pertinent as evolving technology and associated incremental costs, places pressure on device availability within a fixed funding envelope. The application of rotational magnet technology and associated escalating surgical wait times must be justified to patients and the single-payer system. We present a single cochlear implant center's attempt at a rationing schema for magnetic resonance compatible cochlear implantation. Contrasting approaches to rationing care are evaluated and deliberated. Based on a comparison of magnetic resonance imaging (MRI) rates within the general population to our cochlear implant (CI) cohort, we attempt the development of a decision-making schema that maximizes the number of patients to receive a CI while rationing the distribution of a rotational magnet technology to similarly situated individuals most likely to benefit. We elect to provide rotational magnet technology to select patient cohorts. This is based on the dominant imaging needs of these populations and the probability of requiring recurrent imaging studies. We consider this an ethical approach grounded in the egalitarian principle of equality of opportunity within cohorts of patients. Given finite resources, increasing per unit cost will unavoidably extend wait times for adult patients. Our approach does not afford similar implant devices for all patients, but rather all similarly situated individuals. Therefore, access to a scare medical resource requires program rigor and a formalized policy around candidacy for emergent technology.

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A Prospective Randomized Trial of N-butyl-cyanoacrylate + Metacryloxysulfolane Adhesive versus Suture Alone for Grafting in Rhinoplasty: 9 year Follow-up

Carmine Martino,Francesco Salzano,Diletta Martino,Massimo Ralli,Marco De Vincentiis,Massimo Maranzano,Antonio Greco,Giovanni Salzano,Arianna Di Stadio

Publication date 22-07-2020


Use of cyanoacrylate glue in facial plastic surgery is still controversial due to the absence of long-term follow up showing the results. Aim of our study is comparing the long-term outcomes of N-butyl-cyanoacrylate + Metacryloxysulfolane versus traditional sutures in rhinoplasty. Prospective comparative study. One hundred forty-two patients affected by ptotic nasal tip were included and randomized in two groups. In group A, the surgeon fixed the graft by using the glue and suture and in group B by using the traditional suture only.
The following data were collected and compared by statistical analysis: nasolabial angle before and after surgery, dimensions of the graft, duration time (in minutes) for graft application during the surgery, number of sutures applied to fix the graft, presence of post-surgery negative outcomes. All patients statistically improved their nasolabial angle after surgery (ANOVA: N-butyl-cyanoacrylate + Metacryloxysulfolane could be a valid tool to reduce the necessary number of sutures and to reduce the time required for graft fixation graft fixation with consistent results in long-term follow-up.

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Outcomes Using a Postoperative Protocol in Pediatric Single-Stage Laryngotracheal Reconstruction

Prasad John Thottam,Taylor Gilliland,Nicholas Ettinger,Rahul Baijal,Deepak Mehta

Publication date 15-02-2019


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