ORL 2023-04-11

Racial and Ethnic Bias in Letters of Recommendation and Personal Statements for Application to Otolaryngology Residency

Publication date 11-04-2023

Introduction: The persistent lack of racial and ethnic diversity within the field of otolaryngology calls for an analysis of potential bias within the residency application system. Letters of recommendation (LORs) and personal statements (PSs) are the most important subjective application constituents. This subjectivity predisposes these components to implicit bias. In applications to various surgical subspecialties, prior linguistic studies assessing bias in reviews of LOR show race-based differences. Thus far, racial and ethnic linguistic differences in LORs for otolaryngology applicants have not been analyzed in the literature.
Methods: LORs and PSs were abstracted from otolaryngology – head and neck surgery applications in the Electronic Residency Application Service for the 2019–20 and 2020–21 application cycles. Linguistic Inquiry and Word Count 2015 was used for quantitative analysis of emotional, cognitive, and structural components of written text.
Results: Race-pair analysis of the 2019–2021 application cycles revealed higher mean “teaching” scores for LORs for Asian, black, Hispanic, and white applicants when compared to applicants who self-identified as Other. White applicants had lower scores for the terms “research” and “analytic” when compared to Asian and black applicants, respectively. Analysis of PSs revealed greater scores for an “authentic” writing style for white versus Asian applicants. White applicants were found to have higher scores for “tone” compared to black applicants.
Conclusion: Minor racial and ethnic language differences exist in both LORs and PSs. A statistically significant difference was observed among LORs, with the “teaching” term used more frequently for Asian, black, Hispanic, and white applicants compared to self-identified Other individuals. For PSs, statistically significant differences were observed among white applicants, who wrote about themselves using more “authentic” language when compared with Asian applicants and who also had higher scores for “tone” compared to black applicants. Although these differences were statistically significant, the practical impact of the variances is likely small. ORL

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Chinese Expert Consensus on the Use of Biologics in Patients with Chronic Rhinosinusitis (2022, Zhuhai)

HY Hong,TY Chen,QT Yang,YQ Sun,FH Chen,HF Lou,HT Wang,RL Yu,YF An,F Liu,TS Wang,MP Lu,QH Qiu,XD Wang,JJ Chen,CD Meng,ZH Xie,J Meng,M Zeng,CL Xu,Y Wang,YC Yang,WT Zhang,J Tang,YL Yang,R Xu,GD Yu,ZH Shi,X Wei,HP Ye,YN Sun,SQ Yu,TH Zhang,J Yong,W Hang,YT Xu,Y Xu,GL Tan,N Sun,G Yang,YJ Li,J Ye,KJ Zuo,LQ Zhang,XY Wang,AN Yang,YX Xu,W Liao,YP Fan,HB Li

Publication date 05-04-2023

Background: Chronic rhinosinusitis (CRS) is a common inflammatory disease in otolaryngology, mainly manifested as nasal congestion, nasal discharge, facial pain/pressure, and smell disorder. CRS with nasal polyps (CRSwNP), an important phenotype of CRS, has a high recurrence rate even after receiving corticosteroids and/or functional endoscopic sinus surgery. In recent years, clinicians have focused on the application of biological agents in CRSwNP. However, it has not reached a consensus on the timing and selection of biologics for the treatment of CRS so far.
Summary: We reviewed the previous studies of biologics in CRS and summarized the indications, contraindications, efficacy assessment, prognosis, and adverse effects of biologics. Also, we evaluated the treatment response and adverse reactions of dupilumab, omalizumab, and mepolizumab in the management of CRS and made recommendations.
Key Messages: Dupilumab, omalizumab, and mepolizumab have been approved for the treatment of CRSwNP by the US Food and Drug Administration. Type 2 and eosinophilic inflammation, need for systemic steroids or contraindication to systemic steroids, significantly impaired quality of life, anosmia, and comorbid asthma are required for the use of biologics. Based on current evidence, dupilumab has the prominent advantage in improving quality of life and reducing the risk of comorbid asthma in CRSwNP among the approved monoclonal antibodies. Most patients tolerate biological agents well in general with few major or severe adverse effects. Biologics have provided more options for severe uncontrolled CRSwNP patients or patients who refuse to have surgery. In the future, more novel biologics will be assessed in high-quality clinical trials and applied clinically. ORL

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Surgical Considerations in Addressing Cholesterol Granuloma of the Petrous Apex through an Infracochlear Approach

A Košec,J Prnjak,R Tomljenović,M Ries

Publication date 05-04-2023

Cholesterol granuloma of the petrous bone is a foreign body giant cell reaction to cholesterol deposits with symptoms including hearing loss, vestibular dysfunction, and cranial nerve deficit as a result of cystic mass compression. Surgical treatment is often difficult to plan due to limited access to the lesion and possible injury to surrounding structures. We report on a case of petrous apex cholesterol granuloma drainage through an infracochlear approach. A 27-year-old female patient presented with acute diplopia due to left-sided abducens paralysis. Multislice computed tomography (MSCT) and magnetic resonance (MR) imaging described a 3.5-cm well-marginated lesion in petrous bone apex, compressing the left abducens nerve at the point of entry into the cavernous sinus, corresponding to cholesterol granuloma. The patients was surgically treated through a transcanal infracochlear approach, since preserving the external and middle ear conduction mechanisms was paramount for the patient. The patient was discharged on the second postoperative day and diplopia resolved within 5 days postoperatively. Six months after the surgery, her hearing on the left side is normal, and she remains symptom-free. This case underpins the value of preoperative planning when approaching the petrous apex, an anatomically complex area due to abundance of important neurovascular structures crowded in a narrow and confined region. ORL

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Surgical Approaches for Possible Positions of an Olfactory Implant to Stimulate the Olfactory Bulb

S Menzel,I Konstantinidis,M Valentini,P Battaglia,M Turri-Zanoni,G Sileo,G Monti,PGM Castelnuovo,T Hummel,A Macchi

Publication date 30-03-2023

Introduction: Current scientific developments seem to allow for an “olfactory implant” in analogy to cochlear implants. However, the position and surgical approaches for electrical stimulation of the olfactory system are unclear.
Methods: In a human anatomic cadaver study, we investigated different endoscopic approaches to electrically stimulate the olfactory bulb (OB) based on the following considerations: (1) the stimulating electrode should be close to the OB. (2) The surgical procedure should be as non-invasive and safe as possible and (3) as easy as possible for an experienced ENT surgeon.
Results: In summary, the endoscopic intracranial positioning of the electrode via a widened ostium of the fila olfactoria or a frontal sinus surgery like a Draf IIb procedure is a good option in terms of patients’ risk, degree of difficulty for ENT surgeons, and position to the OB. Endoscopic intranasal positioning appeared to be the best option in terms of patient risk and the degree of difficulty for ENT surgeons. Although a bigger approach to the OB using a drill and the combined intranasal endoscopic and external approach enabled a close placement of the electrode to the OB, they do not seem relevant in practice due to their higher invasiveness.
Conclusion: The study suggested that an intranasal positioning of a stimulating electrode is possible, with placements beneath the cribriform plate, extra- or intracranially, applying elegant surgical techniques with low or medium risk to the patient and a close placement to OB. ORL

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Peripheral Vestibular System Involvement in Multiple Sclerosis and Associations with the Disease Severity

İ Aydın Cantürk,BÖ Mutlu,O Yılmaz,YA Bayazıt

Publication date 10-03-2023

Introduction: Multiple sclerosis (MS) is an autoimmune disease that can affect balance, gait, and improve fall risk. The aim of this study was to investigate peripheral vestibular system involvement in MS and associations with the disease severity.
Methods: Thirty-five adult patients with MS and 14 age- and gender-matched healthy controls were evaluated using video head impulse test (v-HIT), cervical vestibular evoked myogenic potential (c-VEMP), ocular vestibular evoked myogenic potentials (o-VEMPs), and sensory organization test (SOT) of computerized dynamic posturography (CDP). The results of both groups were compared, and association with EDSS scores was evaluated.
Results: There was no significant difference between the groups regarding v-HIT and c-VEMP results (p #x3e; 0.05). There was no association of the v-HIT, c-VEMP, and o-VEMP results with EDSS scores (p #x3e; 0.05). There was no significant difference between the o-VEMP results of the groups (p #x3e; 0.05) except for N1-P1 amplitudes (p = 0.01). The amplitudes of N1-P1 were significantly lower in the patients compared to controls (p = 0.01). There was no significant difference between the SOT results of the groups (p #x3e; 0.05). However, significant differences were found within and between groups when the patients were categorized according to their EDSS scores with a cutoff point of 3 (p #x3c; 0.05). There were negative correlations between the EDSS scores and composite (r = −396, p = 0.02) and somatosensory (SOM) scores (r = −487, p = 0.04) of CDP in the MS group.
Conclusion: Although central and peripheral balance-related systems are affected in MS, the impact of disease on the peripheral vestibular end organ is subtle. In particular, the v-HIT, which was mentioned previously as a detector of brainstem dysfunction could not be a reliable tool in the detection of brainstem pathologies in MS patients. The o-VEMP amplitudes may be affected in the early stages of the disease, possibly due to the crossed ventral tegmental tract, oculomotor nuclei, or interstitial nucleus of Cajal involvements. An EDSS score #x3e;3 seems a cutoff level indicating abnormalities in balance integration. ORL

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Hypoglossal Nerve Stimulator Explantation Technique and Outcomes: A Retrospective Case Series

J Taylor Ii,JL Yu

Publication date 16-02-2023

Introduction: Upper airway stimulation via the hypoglossal nerve stimulator (HGNS) implant is a surgical method for treating obstructive sleep apnea. However, patients may need the implant removed for a variety of reasons. The purpose of this case series is to assess surgical experiences with HGNS explantation at our institution. We report on surgical approach, overall operative times, operative and postoperative complications, and discuss relevant patient-specific surgical findings when removing the HGNS.
Methods: We performed a retrospective case series of all patients that underwent HGNS implantation at a single tertiary medical center between January 9, 2021, and January 9, 2022. Subjects included adult patients who presented to the sleep surgery clinic of the senior author for surgical management of previously implanted HGNS. Patient clinical history was reviewed to determine the timing of the patient’s implant, reasons for explant, and postoperative recovery course. Operative reports were reviewed to determine overall duration of surgery and any associated difficulties or deviations from the general approach.
Results: Between January 9, 2021, and January 9, 2022, 5 patients had an explantation of their HGNS implant. Explantation occurred between 8 and 63 months of their original implant surgery. The average operative time from incisional start time to close was 162 min for all cases with a range of 96–345 min. No significant complications were reported including pneumothorax and nerve palsy.
Conclusion: This reported case series outlines the general steps for Inspire HGNS explantation as well as details the experiences in a case series of 5 subjects explanted over the year at a single institution. The results from the cases suggest that the explantation of the device can be performed efficiently and safely. ORL

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Safe Limits of Lateral Nasal Wall Osteotomy at Le Fort I Surgery

M Suzen,M Temiz,K Cesur,S Uckan

Publication date 19-01-2023

Introduction: The aim of this study was to define the difference between lateral nasal wall anatomy and variations as linear and angular in patients with class II and class III dentofacial deformities and to determine a surgical margin for safe entry by establishing an ideal osteotomy line for lateral nasal wall osteotomy during Le Fort I surgery.
Materials and Methods: Eighty-five patients with dentofacial deformities, who were admitted to Medipol Mega University Hospital between September 2018 and February 2021, and 170 regions, including the right and left, were evaluated. In the axial image taken from coronal sections 5 mm above the deepest point of the nasal floor, lateral nasal wall angulations and linear and angular distances to the descending palatine canal were measured. Class II and class III patients were evaluated according to the right and left regions and gender.
Results: The angled right distance values to the descending palatine artery of class III patients are higher than the values of the angled left distance to the descending palatine canal (p = 0.034). The right second angulation levels of class II female patients are higher than those of class II male patients (p = 0.037). Class III male patients have a significantly higher right linear distance to the descending palatine canal and right second angulation levels compared to class III female patients (p1 = 0.009; p2 = 0.003). The right second angulation levels of class II male patients are significantly lower than those of class III male patients (p = 0.003).
Conclusion: This study described the mean angulations and linear distances between anatomic structures of the lateral nasal wall in patients with class II and class III dentofacial deformities for the purpose of a safe osteotomy. The location of the descending palatine canal and the morphology of the lateral nasal wall are not significantly associated with dentofacial deformity. ORL 2023;85:97–103

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Nasal Septal Perforation Secondary to Graft-Versus-Host Disease

WP Hoover,CP Wilson,S Hasnie,KA McKinney

Publication date 19-01-2023

Nasal septal perforation is a full-thickness defect of the nasal septum. There are many described etiologies of nasal septal perforation, including trauma, infectious, neoplastic, iatrogenic, and autoimmune. Graft-versus-host disease (GVHD) is a common and potentially life-threatening complication that can occur after an allogenic transplant. GVHD can result in the development of autoantibodies that lead to granulomatous inflammation with necrotizing vasculitis, causing perforation of the nasal septum. In this report, we describe a patient with nasal septal perforation secondary to GVHD and hope to provide novel insights into the association of GVHD and nasal septal perforation. ORL 2023;85:109–111

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Clinical Study on the Risk Factors for the Recurrence of Papillary Thyroid Carcinoma

T Masui,S Adachi,H Uemura,T Kimura,T Kitahara

Publication date 17-01-2023

Introduction: Papillary thyroid carcinoma is the most common endocrine malignancy and the most common type of thyroid cancer, accounting for approximately 85% of all thyroid cancer cases. It usually has a favorable course, with the 10-year survival rate exceeding 90%. However, the literature reports a recurrence rate of 7–23% after initial surgical treatment. It is important to consider medical treatment policies for this recurrence.
Methods: In this study, we examined the risk factors for the recurrence of papillary thyroid carcinoma. We treated 274 patients with thyroid papillary carcinoma at our hospital between 2009 and 2018.
Results: Recurrence occurred in 20 cases (7.3%). Lympho-vascular invasion and lateral cervical lymph node metastasis made significant independent contributions.
Conclusion: The selection of the surgical mode should be based on the recurrence and after comprehensive consideration of the clinical features. ORL 2023;85:104–108

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Taste Alteration in External Auditory Canal Cholesteatoma: Indicator of Impending N VII Affection

L Matosevic,H Friedrich,S Negoias,C Dür,M Caversaccio,P Dubach

Publication date 12-01-2023

Introduction: External auditory canal cholesteatoma (EACC) is a rare disease, with an estimated incidence of approximately 1:1,000 adult and 1.6:1,000 pediatric otologic patients. Systematic studies of chronic ear disease and taste alteration prior to surgery are rare; in fact, there are no such studies for EACCs. Therefore, we describe chorda tympani nerve (CTN) dysfunction and the related clinical consequences in EACC patients. Methods/Study Design: Between 1992 and 2021, we retrospectively analyzed the symptoms, signs, and radiological and intraoperative descriptions of CTN involvement in 73 patients. Liquid taste tests and, since 2009, Taste StripsTM as well as an olfactory screening test (Smell DiskettesTM) have been performed for all symptomatic patients and, when feasible, all other EACC patients.
Level of Evidence: 4.
Results: Ten of 73 patients complained subjectively of dysfunction, and 8 showed abnormal taste test results. Four patients complained of olfactory dysfunction (3 cases with pathological taste tests). Gustatory dysfunction was most frequent in radiogenic EACC cases (n = 4), followed by postoperative EACC (n = 3). Two postoperative patients were asymptomatic despite abnormal test results. Rarely, patients with idiopathic (n = 2) and posttraumatic (n = 1) EACC showed acute taste dysfunction that was confirmed in each with abnormal test results. Discussion/Conclusion: CTN dysfunction often developed asymptomatically in chronic ears, except for idiopathic and posttraumatic EACCs under previous healthy middle ear conditions. Taste disturbance is not a cardinal symptom of EACC, but objective testing suggests that up to one out of 10 EACC patients with advanced disease may experience regional gustatory dysfunction prior to surgery. Especially in context of a new and acute presentation, regional taste dysfunction may alert the clinician of potential progressive EACC invasion and danger to the facial nerve. ORL

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