Otolaryngology Head and Neck Surgery 2022-05-24

Cultural Competency and Surgical Decision Making in Otolaryngology

Erik Ovrom,Yilkal Zemene,Sophie Gerndt,Victor Andrade,Joshua Wiedermann

Publication date 08-03-2022


Given the high prevalence of otolaryngology infections such as tonsillitis, otitis, and pharyngitis in low and middle income countries, the field of global otolaryngology continues to grow to accommodate patients around the world. This commentary focuses on best practices in transcultural communications between US doctors and foreign patients with an emphasis on cultural competency. We use alternative medicine as an exemplar for how to collaborate with patients to develop treatment plans that respect their cultural beliefs and lifestyles. Rather than assigning value to the patient's alternative medicine practices, we believe that instructing and counseling a patient on how to incorporate follow-up visits and rehabilitation after allopathic medical procedures such as surgical tonsillectomy should be done in a way that respects the patient's preexisting health regimen. By doing so, these new aspects of their health care will take a discrete place in their wellness practices and engender more trust and better health outcomes.

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Comparison of Narrowband Imaging and White-Light Endoscopy for Diagnosis and Screening of Nasopharyngeal Cancer

Do Hyun Kim,Min Hyeong Lee,Seulah Lee,Sung Won Kim,Se Hwan Hwang

Publication date 27-07-2021


We compared the diagnostic accuracies of narrowband imaging and white-light endoscopy in the detection of nasopharyngeal cancer. Six databases (Pub Med, Cochrane Database, Embase, Web of Science, SCOPUS, and Google Scholar). The 6 databases were thoroughly reviewed by 2 authors (working independently) from their dates of inception to December 2019. Nasopharyngeal mucosal or vascular changes detected by narrowband imaging were compared to those detected by white-light endoscopy. The authors extracted true-positive, true-negative, false-positive, and false-negative parameters for each study. Methodological quality was evaluated using the Quality Assessment of Diagnostic Accuracy Studies version 2 tool. The extent of interrater agreement was assessed. Eighteen prospective or retrospective studies were included. The diagnostic odds ratio of narrowband imaging was 77.560 (95% confidence interval [CI], 37.424-160.739). The area under the summary receiver operating characteristic curve was 0.926. The sensitivity, specificity, and negative predictive value were 0.871 (95% CI, 0.808-0.915), 0.905 (95% CI, 0.816-0.953), and 0.955 (95% CI, 0.906-0.979), respectively. The correlation between sensitivity and the false-positive rate was 0.284, indicating that heterogeneity was absent. Narrowband imaging exhibited moderate interrater reliability (0.7037; 95% CI, 0.6558-0.746). Subgroup analysis showed that vascular patterns revealed by endoscopy in a screened subgroup were significantly more diagnostically accurate than mucosal patterns used for surveillance of a recurrent cancer subgroup. Narrowband imaging exhibits high diagnostic accuracy and should be used in the diagnostic workup of nasopharyngeal cancer. However, further studies are necessary to confirm our results.

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Normative Ambulatory Reflux Monitoring Metrics for Laryngopharyngeal Reflux: A Systematic Review of 720 Healthy Individuals

Jerome R. Lechien,Walter W. Chan,Lee M. Akst,Toshitaka Hoppo,Blair A. Jobe,Carlos M. Chiesa-Estomba,Vinciane Muls,Francois Bobin,Sven Saussez,Thomas L. Carroll,Michael F. Vaezi,Jonathan M. Bock

Publication date 27-07-2021


To review the normative data for acid, weakly acid, and nonacid proximal esophageal (PRE) and hypopharyngeal reflux (HRE) events in diagnosing laryngopharyngeal reflux (LPR) using ambulatory reflux monitoring. Pub Med, Cochrane Library, and Scopus. A literature search was conducted about the normative data for PRE and HRE on multichannel intraluminal impedance-pH monitoring (MII-pH), hypopharyngeal-esophageal MII-pH (HEMII-pH), or oropharyngeal pH monitoring using PICOTS (population, intervention, comparison, outcome, timing, and setting) and PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statements. Outcomes reviewed included device characteristics, impedance/pH sensor placements, study duration, number/average and percentiles of PRE or HRE occurrence, and the event characteristics (pH, composition, and position). Of 154 identified studies, 18 met criteria for analysis, including 720 healthy individuals. HEMII-pH, MII-pH, and oropharyngeal pH monitoring were used in 7, 6, and 5 studies, respectively. The definition and inclusion/exclusion criteria of healthy individuals varied substantially across studies, with 6 studies considering only digestive symptoms to exclude potential LPR patients. Substantial heterogeneity across studies was noted, including impedance/pH sensor placements/configurations and definitions of composition (liquid, gas, mixed) and type (acid, weakly acid, nonacid) of PRE/HRE. The 95th percentile thresholds were 10 to 73 events for PRE, 0 to 10 events for HRE on HEMII-pH, and 40 to 128 for events with pH <6.0 on oropharyngeal pH monitoring. Most HREs were nonacid and occurred upright. The mean HRE among healthy individuals was 1. The low number of studies and the heterogeneity in inclusion criteria, definitions, and characterization of PRE and HRE limit the establishment of consensual normative criteria for LPR on ambulatory reflux monitoring. Future large multicenter studies are needed.

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Multimodal Analgesia in Head and Neck Free Flap Reconstruction: A Systematic Review

Beatrice C. Go,Cammille C. Go,Kevin Chorath,Alvaro Moreira,Karthik Rajasekaran

Publication date 10-08-2021


Postoperative pain after head and neck cancer surgery is commonly treated with opioids, which are associated with considerable side effects. The objective of this study is to analyze the safety and efficacy of using multimodal analgesia (MMA) for patients undergoing head and neck cancer surgery with free flap reconstruction. A systematic search was conducted in Pub Med, Cochrane, Embase, Scopus, and clinicaltrials.gov. All studies comparing patients receiving MMA (gabapentin, corticosteroids, local anesthetic, acetaminophen, nonsteroidal anti-inflammatory drugs [NSAIDs]) vs patients receiving opioids for head and neck cancer surgery with free flap reconstruction were screened. The primary outcome was postoperative opioid usage. Secondary outcomes included length of stay, subjective pain scores, surgical/medical complications, adverse effects, and 30-day outcomes. A total of 10 studies representing 1253 patients (MMA, n = 594; non-MMA, n = 659) met inclusion criteria. Gabapentinoids were the most commonly used intervention (72.9%) followed by NSAIDs (44.6%), acetaminophen (44.3%), corticosteroids (25.1%), ketamine (7.2%), and nerve block (3.4%). Eight studies reported a significant decrease in postoperative opioid usage in the MMA groups. Subjective pain had wider variation, with most studies citing significant pain improvement. There were no differences in surgical outcomes, medical complications, adverse effects, or 30-day mortality and readmission rates. With the rise of the opioid epidemic, MMA may play an important role in the treatment of postoperative pain after head and neck cancer surgery. A growing body of literature demonstrates a variety of effective perioperative regimens.

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Indications of Superselective Neck Dissection in Patients With Lateral Node Metastasis of Papillary Thyroid Carcinoma

Yuntao Song,Guohui Xu,Tianxiao Wang,Yabing Zhang,Bin Zhang

Publication date 07-09-2021


The extent of neck dissection in papillary thyroid carcinoma (PTC) patients with lateral neck metastasis is controversial. This work aims to screen the patients suitable for superselective neck dissections including only levels III-IV. Prospective observational cohort study. The study was conducted in a high-volume tertiary care setting. A total of 134 consecutive previously untreated PTC patients with lateral neck metastases and subjected to 154 therapeutic lateral neck dissections (including levels II, III, IV, and VB) between June 2018 and March 2021 were enrolled. Fine-needle aspiration was performed preoperatively at each suspicious neck level. Clinical predictors were analyzed for occult lymph node metastases at levels II and VB. As a result, 44.8% and 5.8% of neck specimens exhibited metastatic lymph nodes at levels II and VB. In addition, univariate and multivariate analyses showed that the primary tumor in the ipsilateral thyroid upper lobe ( A superselective lateral neck dissection including levels III to IV may be considered in patients with PTC when the preoperative evaluation identifies a single lymph node metastasis located at levels III to IV and the primary tumor is not in the upper lobe of the ipsilateral thyroid.

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Ethical Dilemmas in Surgical Mission Trips During the COVID-19 Pandemic

Brianne B. Roby,Zahrah Taufique,Andrew Redmann,Asitha D. L. Jayawardena,Sivakumar Chinnadurai

Publication date 10-08-2021


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Predictors of Success After Furlow Palatoplasty for Repair of Cleft Palate: Does Syndrome Matter?

Sean S. Evans,Randall A. Bly,Kaylee Paulsgrove,Jonathan A. Perkins,Kathleen Sie

Publication date 07-09-2021


To determine predictors of success following Veau 1 and 2 cleft palate repair in patients with and without syndromes. Retrospective review of prospectively collected data. Tertiary care children's hospital. All children <18 months of age undergoing Furlow palatoplasty for Veau 1 and 2 cleft repair between 2000 and 2014 with postoperative perceptual speech assessment (PSA). In total, 368 consecutive patients were identified; 95 were excluded, resulting in 273 patients. Median age at surgery was 13.0 months (interquartile range [IQR], 11-15 months) with postoperative PSA at a median of 32.3 months (IQR, 26.3-44.5 months). Fifty patients (18.3%) had syndrome diagnosis; 59 patients (21.6%) had nonsyndromic Robin sequence. Velopharyngeal insufficiency (VPI) occurred in 27 patients (10.5%); 13 underwent secondary speech surgery. Cleft-related speech errors occurred in 46 patients (17.6%). Non-cleft-related speech errors occurred in 155 patients (59.6%) and reduced intelligibility in 127 patients (47.9%). Oronasal fistula occurred in 23 patients (8.8%) and was exclusive to Veau 2 clefts. In multivariate analysis, age >13 months at palatoplasty demonstrated a 6-fold higher rate of VPI (hazard ratio [HR], 6.64; VPI occurred in 10% of patients undergoing Furlow palatoplasty repair of Veau 1 or 2 clefts. Age <13 months at palatoplasty was associated with improved speech outcomes and lower VPI incidence (2.8% vs 16.2%). Syndromic diagnosis was associated with noncleft speech errors and reduced intelligibility on univariate analysis but not velopharyngeal function after palatoplasty.

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COVID-19 in the Clinic: Aerosol Containment Mask for Endoscopic Otolaryngologic Clinic Procedures

Elisabeth H. Ference,Wihan Kim,John S. Oghalai,Jee-Hong Kim,Brian E. Applegate

Publication date 22-06-2021


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Otolaryngologist Performance in the Merit-Based Incentive Payment System in 2018

Lauren E. Miller,Neil S. Kondamuri,Roy Xiao,Vinay K. Rathi

Publication date 27-07-2021


In 2017, the Centers for Medicare and Medicaid Services transitioned clinicians to the Merit-Based Incentive Payment System (MIPS), the largest mandatory pay-for-performance program in health care history. The first full MIPS program year was 2018, during which the Centers for Medicare and Medicaid Services raised participation requirements and performance thresholds. Using publicly available Medicare data, we conducted a retrospective cross-sectional analysis of otolaryngologist participation and performance in the MIPS in 2017 and 2018. In 2018, otolaryngologists reporting as individuals were less likely (

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Readability of the American, Canadian, and British Otolaryngology–Head and Neck Surgery Societies’ Patient Materials

Joo Hyun Kim,Elysia Grose,Justine Philteos,David Forner,Christopher W. Noel,Vincent Wu,Antoine Eskander

Publication date 10-08-2021


Patient education materials across 3 national English otolaryngology-head and neck surgery (OHNS) societies: the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS), the Canadian Society of Otolaryngology-Head and Neck Surgery (CSOHNS), and Ear, Nose, and Throat United Kingdom (ENT UK) were examined to determine whether they are written at a level suitable for patient comprehension. Cross-sectional study. Online patient materials presented through OHNS national societies. Readability was calculated using the Flesch-Kincaid Grade Level, Flesch-Kincaid Reading Ease Score, and Simple Measure of Gobbledygook Index. All public patient education materials available through the CSOHNS, AAO-HNS, and ENT UK websites were assessed. Patient education materials were grouped into categories by subspecialty. In total, 128 patient materials from the 3 societies were included in the study. All 3 societies required a minimum grade 9 reading comprehension level to understand their online materials. According to Flesch-Kincaid Grade Level, the CSOHNS required a significantly higher reading grade level to comprehend the materials presented when compared to AAO-HNS (11.3 vs 9.9; 95% CI, 0.5-2.4; This study suggests that the reading level of the current patient materials presented through 3 national OHNS societies are written at a level that exceeds current recommendations. Promisingly, it highlights an improvement for the readability of patient materials presented through the AAO-HNS.

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Financial and Intellectual Conflicts of Interest Among Japanese Clinical Practice Guidelines Authors for Allergic Rhinitis

Anju Murayama,Futa Kida,Akihiko Ozaki,Hiroaki Saito,Toyoaki Sawano,Tetsuya Tanimoto

Publication date 17-08-2021


To elucidate financial and intellectual conflicts of interest (COIs) among clinical practice guideline (CPG) authors of allergic rhinitis in Japan and to evaluate the extent of transparency and accuracy in COIs by CPG authors of allergic rhinitis. A cross-sectional analysis of the payment data from all 79 pharmaceutical companies in Japan between 2016 and 2017. Japan. We considered all 27 CPG authors from 2 different versions of the most prominent CPGs for allergic rhinitis in Japan. Using payment data disclosed by 79 major pharmaceutical companies between 2016 and 2017, we assessed the magnitude and characteristics of financial COIs of CPG authors. We also evaluated the intellectual COIs of the CPG authors by counting self-citations of research articles related to CPG statements and recommendations. Of 27 CPG authors, 26 authors (96.3%) received at least 1 payment from a combined total of $1,333,552 between 2016 and 2017. The 2-year combined average and median monetary values per author were $49,391 (SD, $67,438) and $18,400 (interquartile range: $6,216-$72,494), respectively. Pharmaceutical companies with novel drugs predominantly made these payments. The percentage of citations with at least 1 CPG author relative to total citations was 47.6% in 2016 and 27.9% in 2020. There were no formal COI disclosure statements in either version. This study found that allergic rhinitis CPG authors had significant financial relationships with pharmaceutical companies, particularly those marketing novel drugs. In addition, CPG authors had relatively high self-citation rates, a potential marker of intellectual COIs. More rigorous and comprehensive COI management strategies are needed.

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Construct Validity of the EuroQoL–5 Dimension and the Health Utilities Index in Head and Neck Cancer

Christopher W. Noel,Sareh Keshavarzi,David Forner,Robert F. Stephens,Erin Watson,Eric Monteiro,Ali Hosni,Aaron Hansen,David P. Goldstein,John R. de Almeida

Publication date 27-07-2021


The objective of this study was to evaluate the construct validity of 2 health utility instruments-the Euro QoL-5 Dimension (EQ-5D) and the Health Utilities Index-Mark 3 (HUI-3)-and to compare them with disease-specific measures in patients with head and neck cancer. Prospective cross-sectional analysis. Princess Margaret Cancer Centre. Patients were administered the EQ-5D, HUI-3, the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30) and its head and neck cancer module (EORTC QLQ-H&N35), and the University of Washington Quality of Life Questionnaire (UWQoL). Several a priori expected relations were examined. The correlative and discriminative properties of the various instruments were examined. A total of 209 patients completed the 4 questionnaires. A significant ceiling effect was observed among EQ-5D responses (23% reported a maximum score of 1). The EQ-5D (rho = 0.79) and HUI-3 (rho = 0.60) had a strong correlation with the social-emotional domain of the UWQoL. The EQ-5D had a moderate correlation with the physical domain of the UWQoL (rho = 0.42), whereas the HUI-3 had a weak correlation (rho = 0.29). The EQ-5D and HUI-3 were able to distinguish among levels of health severity measured on the EORTC QLQ-C30 though not the QLQ-H&N35. Comparatively, the UWQoL was able to distinguish levels of disease severity on the EORTC QLQ-C30 and QLQ-H&N35. The results of this study demonstrate that disease-specific domains from head and neck quality-of-life instruments are not strongly correlated with the EQ-5D and HUI-3. Consideration should be put toward development of a disease-specific preference-based measure for health economic evaluation. 4.

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National Analysis of Oropharyngeal Salivary Gland Malignancies Treated With Transoral Robotic Surgery

Craig A. Bollig,Kevin Wang,Pablo Llerena,Sidharth V. Puram,Patrik J. Pipkorn,Ryan S. Jackson,Vanessa C. Stubbs

Publication date 27-07-2021


(1) To compare perioperative outcomes and overall survival of patients with oropharyngeal salivary gland malignancies (OPSGMs) treated with transoral robotic surgery (TORS) versus other approaches. (2) To identify clinical factors associated with a robotic surgical approach. Retrospective analysis of the National Cancer Database (NCDB). NCDB. Data obtained from the NCDB were analyzed between 2010 and 2017 for patients with T1-T4a OPSGMs without distant metastases treated surgically. Patients were stratified by surgical approach (TORS vs nonrobotic), and clinicopathologic factors were compared with the A total of 785 patients were analyzed. A non-soft palate primary site (odds ratio, 12.9; 95% CI, 6.6-25.2) and treatment at an academic facility (odds ratio, 2.0; 95% CI, 1.2-3.5) were independently associated with TORS. There were no significant differences in the positive margin rate, 30-day mortality, or overall survival between the groups. The 30-day unplanned readmission rate was higher in patients treated with TORS versus nonrobotic resections (5.8% vs 1.7%, This study suggests that TORS may be a viable treatment modality for appropriately selected patients with OPSGM.

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Role of Thyroidectomy in Recurrent Laryngeal Carcinoma

Aina Brunet,Chrysostomos Tornari,Akunnah Ezebuiro,Robert Kennedy,Steve E. J. Connor,Richard Oakley,Jean-Pierre Jeannon,Asit Arora,Aleix Rovira,Ricard Simo

Publication date 17-08-2021


Management of recurrent laryngeal cancer presents a major challenge, and salvage laryngectomy is complicated by previous oncologic treatments. Thyroidectomy as part of salvage laryngectomy adds a nonnegligible degree of morbidity. The purpose of this study is to assess the rate of thyroid gland invasion in patients undergoing salvage laryngectomy to determine relevant predictive factors. Case series with chart review. Department of Otorhinolaryngology, Head and Neck Surgery, Guy's Hospital, London, United Kingdom. A retrospective review of patients undergoing salvage laryngectomy between 2009 and 2019 was undertaken. Preoperative cross-sectional imaging and histopathological analysis were performed to define evidence and predictors of thyroid gland invasion (TGI). Fifty-one patients had salvage laryngectomy. Histological evidence of TGI was found in 4 patients (7.8%). No significant relationship was found between histological TGI and subsite of primary carcinoma, degree of differentiation, T staging, or radiological TGI. Preoperative computed tomography had a high negative predictive value for TGI. Thyroidectomy should be carefully considered in patients undergoing salvage laryngectomy, and its extent should be defined on an individual basis. Total thyroidectomy should not routinely be performed in salvage laryngectomy or pharyngolaryngectomy in patients with no preoperative radiological evidence of TGI on cross-sectional imaging, unless there is intraoperative evidence of TGI.

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Assessment of Early Stage Glottic Cancer Depth of Resection After Transoral Laser Cordectomy

Jacob T. Cohen,Tal Goldman,Miki Paker,Eran Fridman

Publication date 17-08-2021


Surgeons generally determine depth of resection during transoral laser cordectomy by visual inspection of the surgical field. Our aim was to examine the correlation between early glottic cancer depth of resection as reported by surgeons in the operation report and depth of resection defined by pathology specimens, using various staining techniques intended to differentiate between the distinct vocal fold layers based on particular collagen deposition. Retrospective study. A voice and swallowing clinic at a tertiary referral hospital. We compared depth of cordectomy assessed intraoperatively by surgeons and by pathologists using Picrosirius red stain and collagen I immunohistochemistry stain in 32 patients who underwent transoral laser cordectomy for early glottic cancer. For type I, II, and III cordectomy, the respective proportions of patients were 14 (47%), 9 (30%), and 7 (23%) according to surgeons' estimations; 2 (6%), 17 (55%), and 12 (39%) according to Picrosirius red stain; and 3 (11%), 12 (44%), and 12 (45%) according to immunohistochemistry for collagen I. Surgeons' reported depth of resection did not correlate with depth of resection established by either staining technique. Determining depth of resection necessitates special stains, which should help in the clinical assessment of cordectomy type.

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The Bicentenary of Bell’s Description of the Neuroanatomical Basis of Facial Paralysis: Historical Remarks

Giovanna Cantarella,Riccardo F. Mazzola

Publication date 27-07-2021


Charles Bell was a talented and versatile Scottish anatomist, neurophysiologist, artist, and surgeon. On July 12, 1821, he reported his studies regarding facial innervation in the essay "On the Nerves," read before the Royal Society in London. Since then, idiopathic peripheral facial paralysis has been named "Bell's palsy." He was the first author to describe the neuroanatomical basis of facial paralysis, in an essay enriched by beautifully self-made illustrations. The aim of this article is to trace the history of Bell's description of the neuroanatomy of the facial nerve, reexamining his 1821 article, in which he stated that the lower facial expression muscles were dually innervated by both the fifth and seventh cranial nerves. In 1829, he rectified this conclusion, recognizing the exclusive role of the facial nerve, which he defined as the "respiratory nerve." We offer a tribute to this polymath scientist on the bicentenary of his 1821 publication.

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24-Hour Multichannel Intraluminal Impedance–pH in Proton Pump Inhibitor Nonresponders vs Responders in Patients With Laryngopharyngeal Reflux

Su Il Kim,Su Jin Jeong,Oh Eun Kwon,Jung Min Park,Young Chan Lee,Young-Gyu Eun,Seong-Gyu Ko

Publication date 13-07-2021


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Endoscopic Resection and Mucosal Reconstitution With Epidermal Grafting: A Pilot Study in Idiopathic Subglottic Stenosis

Ruth J. Davis,Ioan Lina,Kevin Motz,Alexander Gelbard,Robert R. Lorenz,Guri S. Sandhu,Alexander T. Hillel

Publication date 13-07-2021


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Videostroboscopy and Voice Profile in Long-Term Combination Inhaler Users With Obstructive Lower Airway Disease

Neethu V. Krishnan,Kailesh Pujary,Ajay M. Bhandarkar,Usha Devadas,Rahul Magazine

Publication date 27-07-2021


Dysphonia is one of the most common side effects of long-term inhaler therapy containing corticosteroids in asthma or asthma-chronic obstructive pulmonary disease overlap (ACO) patients. This common, often reversible side effect is due to the structural changes in the vocal folds resulting from steroid deposition. This study determines the structural changes and voice profile of patients on long-term inhaler therapy by videostroboscopy and perceptual voice profile analysis. It also determines the duration, formulation, and drug delivery system producing the least side effects during therapy. Prospective case-control study. Tertiary care hospital. In total, 196 patients diagnosed with moderate to severe asthma or ACO were divided into cases (patients on at least 6-month combination inhaler therapy) and controls (newly diagnosed patients not on inhaler therapy) and recruited in the study. They were assessed by videostroboscopy for structural changes and GRBAS (grade of hoarseness, roughness, breathiness, asthenia, and strain) perceptual scale for voice profile changes. The prevalence of dysphonia was significantly higher in cases (62.2%) than controls (27.6%). Prevalence of laryngeal structural changes and voice profile changes were higher in cases. The prevalence of dysphonia and structural changes among cases was much lower when a spacer was used ( This study adds evidence to the long-term side effects of combination inhaler therapy containing corticosteroids on the larynx as demonstrated by videostroboscopy and perceptual voice profile analysis. It also propagates the use of spacers in drug delivery to reduce the prevalence of side effects during long-term inhaler therapy.

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Retrospective Investigation of Contralateral Hearing Thresholds of Patients With Sporadic Vestibular Schwannoma

Nicole Peter,Alexander Huber,Simon Egli,Ulrike Held,Klaus Steigmiller,Christof Röösli

Publication date 03-08-2021


The aim of this study was to investigate the contralateral hearing of patients with sporadic vestibular schwannoma (VS). Retrospective cohort study. Pure-tone audiograms of the contralateral ear from patients with a wait-and-scan strategy were compared to the ones who received therapy. Due to a possible bias caused by the therapy, hearing thresholds before and after radiotherapy or surgery were compared separately with the wait-and-scan group. From 1979 to 2017, 508 patients with sporadic VS could be included in the study. Of these, 240 received regular controls in the sense of wait-and-scan, 72 underwent radiotherapy (63 audiograms before and 43 after radiotherapy), and 196 had a surgery (186 audiograms before and 146 after surgery). Age-normalized hearing thresholds of the contralateral ear from patients with a wait-and-scan strategy were compared to ones who received therapy. In addition, hearing thresholds were compared to norm values. There was no evidence for a difference in the contralateral hearing of patients with sporadic VS between the wait-and-scan and therapy groups. The mean difference of hearing thresholds in our sample to norm values was found to be larger for the high frequencies and more pronounced in male patients. There was no evidence for a difference in the contralateral hearing loss of patients with sporadic VS between the wait-and-scan and therapy groups. However, there was some indirect indication of poorer contralateral hearing in all patients with sporadic VS compared to normative values.

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Speech Recognition Outcomes in Adults With Slim Straight and Slim Modiolar Cochlear Implant Electrode Arrays

Margaret E. MacPhail,Nathan T. Connell,Douglas J. Totten,Mitchell T. Gray,David Pisoni,Charles W. Yates,Rick F. Nelson

Publication date 17-08-2021


To compare differences in audiologic outcomes between slim modiolar electrode (SME) CI532 and slim lateral wall electrode (SLW) CI522 cochlear implant recipients. Retrospective cohort study. Tertiary academic hospital. Comparison of postoperative Az Bio sentence scores in quiet (percentage correct) in adult cochlear implant recipients with SME or SLW matched for preoperative Az Bio sentence scores in quiet and aided and unaided pure tone average. Patients with SLW (n = 52) and patients with SME (n = 37) had a similar mean (SD) age (62.0 [18.2] vs 62.6 [14.6] years, respectively), mean preoperative aided pure tone average (55.9 [20.4] vs 58.1 [16.4] dB; Cochlear implantation with SLW and SME provides comparable improvement in audiologic functioning. SME does not exhibit superior speech recognition outcomes when compared with SLW.

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Repeat Eustachian Tube Balloon Dilation Outcomes in Adults With Chronic Eustachian Tube Dysfunction

David Keschner,Rohit Garg,Randall Loch,Lauren Joelle Luk

Publication date 17-08-2021


With increased focus on surgical management of the eustachian tube, clarifying management decisions benefits patients and surgeons. In this study, we examine the value of repeating the balloon dilation of the eustachian tube (BDET) procedure in patients who did not improve after the initial BDET. Level IV retrospective review of 145 BDETs performed on 86 patients between January 1, 2014, and May 1, 2019, identified 10 patients who underwent BDET more than once. Managed care community otolaryngology practice. Demographic and outcome data were collected on both single and repeat BDET cohorts. The Eustachian Tube Dysfunction Questionnaire 7 (ETDQ-7) was used as the primary outcome measure when comparing single vs repeat BDET cohorts. Generally, the 2 cohorts were similar in terms of sex and age distribution. Tobacco use and radioallergosorbent test-positive results were greater proportionally in the repeat BDET cohort. Preoperative ETDQ-7 scores were similar in both cohorts. Single BDET patients overall showed significant improvement in ETDQ-7 scores. ETDQ-7 scores for repeat BDET patients who did not improve after the first procedure similarly did not demonstrate improvement after the second procedure. Inevitably, some patients will not improve after an initial BDET procedure. The utility of a repeated BDET procedure should be considered in determining how to manage such failures. The results of this limited study suggest that patients who fail to improve meaningfully on ETDQ-7 scores after the initial procedure are unlikely to show substantial improvements after a repeated procedure.

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Outcomes of Salvage Resection and Radiosurgery Following Failed Primary Treatment of Vestibular Schwannomas

Emily Kay-Rivest,John G. Golfinos,Sean O. McMenomey,David R. Friedmann,Daniel Jethanamest,Douglas Kondziolka,J. Thomas Roland

Publication date 07-09-2021


To evaluate outcomes following salvage microsurgery (MS) and salvage stereotactic radiosurgery (SRS) after failure of primary treatment for vestibular schwannomas (VS). Retrospective chart review. Tertiary referral center.
Patients with more than 1 intervention for their VS were divided into 4 groups: MS followed by SRS (n = 61), MS followed by MS (n = 9), SRS followed by MS (n = 7), and SRS followed by SRS (n = 7), and outcomes were evaluated. A total of 77 patients were included (84 procedures). In group 1 (MS then SRS), 3% developed a decline in facial function, 3% developed trigeminal sensory loss, and 13% patients had gradual improvement of facial nerve function following SRS. Group 2 (MS then MS) had the highest rates of facial nerve deterioration, although all but 1 patient achieved a House-Brackmann score of II or III. Gross-total resection (GTR) was achieved in 56% of patients. When a different approach was used for salvage resection, GTR occurred more commonly, and facial nerve outcomes were similar. In group 3 (SRS then MS), GTR occurred in 43% of cases, and 2 of 7 patients developed worsened facial function. In group 4 (SRS then SRS), no patient developed facial weakness after reirradiation, and 1 developed a trigeminal nerve deficit. For MS recurrences/residuals, SRS is the mainstay of treatment and does not preclude facial function recovery. If salvage microsurgery is required, an alternate approach should be considered. For SRS failures, when MS is required, less-than GTR may be preferable, and reirradiation is a potential safe alternative.

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Diagnosis of Auditory Neuropathy Spectrum Disorder in the Neonatal Intensive Care Unit Population

Chengetai Mahomva,Yi-Chun Carol Liu,Nikhila Raol,Samantha Anne

Publication date 27-07-2021


To determine the incidence of auditory neuropathy spectrum disorder (ANSD) and its risk factors among the neonatal intensive care unit (NICU) population from 2009 to 2018 in the Pediatric Health Information System database. Retrospective national database review. Population-based study. The Pediatric Health Information System database was queried to identify patients ≤18 years old with NICU admission and ANSD diagnosis. Patient demographics, jaundice diagnosis, use of mechanical ventilation, extracorporeal membrane oxygenation, furosemide, and/or aminoglycosides were extracted. Multivariable linear regression was used to assess trends in incidence. Chi-square analysis was used to assess differences between patients with and without ANSD. Logistic regression was used to assess factors associated with ANSD. From 2009 to 2018, there was an increase in (1) NICU admissions from 14,079 to 24,851 ( Despite a statistically significant increase in NICU admissions and total ANSD diagnosis, the incidence of ANSD in the NICU population has not increased from 2009 to 2018. Furosemide and mechanical ventilator use were associated with increased likelihood of ANSD.

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Validation of the Seattle Suprastomal Safety Score (5S): A Novel Measure in Pediatric Tracheostomy-Dependent Patients

Prasanth Pattisapu,Matthew F. Abts,Randall A. Bly,Juliana Bonilla-Velez,John P. Dahl,Sarah C. Hofman DeYoung,David L. Horn,Kaalan E. Johnson,Sanjay R. Parikh

Publication date 07-09-2021


Suprastomal collapse and granulation are common sequelae of pediatric tracheostomy. We present the first measure of suprastomal obstructive pathology, the Seattle Suprastomal Safety Score (5S), an instrument with 2 domains: collapse and granulation. Cross-sectional repeated testing survey. Electronic survey. A library of images was assembled from still pictures of the suprastomal area in 50 patients who previously underwent trachea-bronchoscopy at a quaternary children's hospital. Five pediatric otolaryngologists and 2 pediatric pulmonologists reviewed the images in random, blinded fashion and provided 5S scores. Participants repeated this process 2 to 4 weeks later. Interrater agreement was calculated with an intraclass correlation coefficient (ICC) with a 2-way random-effects model and Fleiss's κ. Intrarater agreement was measured with an ICC using a 2-way mixed-effects model as well as with test-retest correlations using Spearman rank coefficient. All measures were performed separately on collapse and granulation domains. ICC for interrater agreement was 0.88 (95% CI, 0.82-0.93) for collapse and 0.97 (95% CI, 0.96-0.98) for granulation, indicating almost perfect agreement. Fleiss's κ demonstrated moderate agreement for collapse and almost perfect agreement for granulation. ICC for intrarater agreement was 0.95 (95% CI, 0.93-0.97) and 0.99 (95% CI, 0.98-0.99) for collapse and granulation, respectively, indicating almost perfect agreement. Spearman rank correlation for test-retest demonstrated substantial agreement for collapse and almost perfect agreement for granulation. The 5S demonstrates excellent interrater and intrarater agreement, making it highly reliable as a novel measure of suprastomal collapse and granulation in tracheostomy-dependent pediatric patients.

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Objective Improvement After Frenotomy for Posterior Tongue-Tie: A Prospective Randomized Trial

Bobak A. Ghaheri,Douglas Lincoln,Tuyet Nhi T. Mai,Jess C. Mace

Publication date 07-09-2021


Infants with posterior tongue-tie (PTT) can have substantial difficulty with breastfeeding and bottle-feeding. This study aimed to address the dearth in investigational objective data surrounding PTT release to better quantify the postoperative impacts of frenotomy for ankyloglossia. Prospective randomized, controlled trial. Private practice clinic. In a prospective, randomized controlled trial, infants 3 to 16 weeks of age with PTT undergoing frenotomy were examined using a bottle-feeding system capable of objectively measuring tongue function. Validated patient-reported outcome measures were also obtained simultaneously. Forty-seven infants with PTT were enrolled into an observational/control arm (n = 23) or interventional/surgical treatment arm (n = 24). The total cohort consisted of 29 (61.7%) male infants with a median age of 39 days. At the day 10 time point, the interventional arm demonstrated statistically significant improvement in 11 objectively obtained feeding metrics, indicating faster tongue speed, more rhythmic and coordinated sucking motions, and a tongue more capable of adapting to varying feeding demands. Significant improvement in breastfeeding self-efficacy was reported in the interventional group while poor self-confidence persisted in the observational group. Infant reflux symptoms improved in the interventional group while not in the control group. Nipple pain also persisted in the control group but improved in the surgical cohort. When measured 10 days after frenotomy for PTT, infants improve feeding parameters using an objective bottle-feeding system. Similar improvements are seen with patient-reported outcomes when PTT is released. Posterior tongue-tie is a valid clinical concern, and surgical release can improve infant and maternal symptoms.

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Depression and Anxiety: Considerations for Interpretation of the SNOT-22 (22-Item Sinonasal Outcome Test)

Katie M. Phillips,Ahmad R. Sedaghat

Publication date 09-11-2021


The objective of this study was to determine whether depression and anxiety symptoms affect and confound scoring on the 22-item Sinonasal Outcome Test (SNOT-22), a commonly used outcome measure for chronic rhinosinusitis. Prospective cross-sectional. Tertiary care academic center. 240 participants completed the SNOT-22, from which nasal, sleep, ear/facial pain, and emotional subdomain scores were calculated. They also completed the 8-item Patient Health Questionnaire (PHQ-8) as a reflection of depression symptoms and 7-item Generalized Anxiety Disorder (GAD-7) questionnaire as a reflection of anxiety symptoms. Correlations were calculated between the 4 SNOT-22 subdomains and the PHQ-8 and GAD-7. Additionally, the predictive ability of subdomains and individual items of the SNOT-22 to predict depression and anxiety was calculated. The SNOT-22 sleep and emotional subdomains most strongly correlated with the PHQ-8 and the GAD-7. The emotional and sleep subdomain scores were predictive of having depression or anxiety. An emotional subdomain score ≥4 had 62.5% sensitivity and 90.1% specificity for detecting depression and 78.8% sensitivity and 88.9% specificity for detecting anxiety. A sleep subdomain score ≥21 had 81.2% sensitivity and 71.4% specificity for detecting depression and 87.9% sensitivity and 68.6% specificity for detecting anxiety. The emotional subdomain item related to sadness and the sleep subdomain items related to functional impairment were most predictive of depression and anxiety. The SNOT-22 emotional and sleep subdomain scores may be used to predict active depression and anxiety symptoms, especially when items related to sadness or functional impairment are scored with moderate burden.

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Perioperative Antibiotic Use in Sleep Surgery: Clinical Relevance

Mohamed Abdelwahab,Sandro Marques,Isolde Previdelli,Robson Capasso

Publication date 28-09-2021


Upper airway surgery is a common therapeutic approach recommended for patients with obstructive sleep apnea (OSA) to decrease disease burden. We aimed to evaluate the effect of perioperative antibiotic prescription on complication rates. Retrospective cohort (national database). Tertiary referral center. This is a retrospective study of a large national health care insurance database (Truven Market Scan) from 2007 to 2015. Subjects diagnosed with OSA who had uvulopalatopharyngoplasty (UPPP) were included and stratified in single versus multilevel surgery. Other variables included smoking, age, sex, antibiotic prescription, and comorbidities based on the Elixhauser index. Evaluated outcomes were postoperative bleeding, intubation, pneumonia, superficial surgical site infection, tracheostomy, and hospital readmission. A multivariate regression model was created to assess each complication. A total of 5,798,528 subjects received a diagnosis of OSA, of which 39,916 were >18 years old and underwent UPPP, either alone or with additional procedures. The mean age was 43 years, and 73.4% were male. Antibiotic prescription was associated with less bleeding in UPPP alone, UPPP with nasal surgery, and UPPP with nasal and tongue surgery ( Although former studies recommended against the use of antibiotics after tonsillectomy, our results suggest that antibiotic prescription after UPPP for OSA was associated with less bleeding, surgical site infection, pneumonia, intubation, tracheostomy, and hospital readmission 30 days postoperatively.

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Cadaver Surgical Education and Research Under the SARS-CoV-2 Pandemic in Japan

Eiji Kobayashi,Toshiaki Shichinohe,Takane Suzuki

Publication date 03-08-2021


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Response to: “Cadaver Surgical Education and Research Under the SARS-CoV-2 Pandemic in Japan”

Dhruv Sharma,Kolin E. Rubel,Michael J. Ye,Vincent J. Campiti,Jonathan Y. Ting,Sarah J. Burgin,Elisa A. Illing

Publication date 03-08-2021


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HEPA Filters and Airborne Viruses, Bacteria, and Fungi

Luke Curtis

Publication date 27-07-2021


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Response to: HEPA Filters and Airborne Viruses, Bacteria, and Fungi

David T. Liu,Katie M. Phillips,Ahmad R. Sedaghat

Publication date 27-07-2021


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Corrigendum to “A Novel Cough Simulation Device for Education of Risk Mitigation Techniques During Aerosol-Generating Medical Procedures”

Publication date 05-04-2022


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Effect of Hospital Safety Net Burden on Survival for Patients With Sinonasal Squamous Cell Carcinoma

Christopher C. Tseng,Jeff Gao,Gregory L. Barinsky,Christina H. Fang,Jordon G. Grube,Prayag Patel,Wayne D. Hsueh,Jean Anderson Eloy

Publication date 24-05-2022


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Lam Qua and Peter Parker: Portraiture of Head and Neck Surgery in 19th-Century China

Kenric Tam,Jamie A. Kwan

Publication date 24-05-2022


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Infection Control With Topical Antimicrobial Prophylaxis for Mucosal Head and Neck Surgery: A Meta-analysis

Jake J. Lee,Stanley Chibueze,Amit Walia,Lauren H. Yaeger,Joseph Zenga,Sidharth V. Puram,Ryan S. Jackson,Patrik Pipkorn

Publication date 24-05-2022


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Glottic and Subglottic Injury and Development of Pediatric Airway Stenosis

Lauren A. Pinzas,Joshua R. Bedwell,Julina Ongkasuwan

Publication date 24-05-2022


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Sleep Endoscopy and Cine Magnetic Resonance Imaging Evaluation of Children With Persistent Obstructive Sleep Apnea

Carol Li,Yann-Fuu Kou,Michael A. DeMarcantonio,Christine H. Heubi,Robert Fleck,Ali Kandil,David F. Smith,Stacey L. Ishman

Publication date 24-05-2022


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Does the History of Tracheoesophageal Fistula Repair Alter Outcomes of Laryngeal Cleft Repair?

Ivanna Nebor,Orna Katz Kadosh,Meredith E. Tabangin,Catherine K. Hart,Charles M. Myer,Matthew M. Smith,Jareen K. Meinzen-Derr,Michael Rutter,Alessandro de Alarcón

Publication date 10-05-2022


Tracheoesophageal fistula and esophageal atresia (TEA) and laryngeal cleft (LC) can coexist in some patients. The surgery-specific success rate of LC repair in children with associated TEA has not been well described. The aim of the study is to determine if the history of TEA alters the LC repair outcomes. Case series with chart review. Single-institution academic medical center. A retrospective review was conducted of patients with LC with and without TEA repair between January 2001 and November 2020. Data collected and analyzed included demographics and clinical characteristics, LC type, and LC with TEA timing of repairs.
An overall 282 patients met the inclusion criteria of LC repair: LC (n = 242, 85.8%) and LC + TEA (n = 40, 14.2%). Revision repair was required in 43 patients (15.2%) with 8 (2.8%) needing a second revision repair. The first LC revision rate in the LC group was 36/242 (14.9%) as compared with 7/40 (17.5%) in the LC + TEA group ( The incidence of TEA and LC was 14.2% in our study. Based on our findings, history of TEA repair is not associated with a higher revision rate vs LC alone. The history of TEA repair did not alter the outcomes of LC repair.

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Risk Factors Associated With Reoperative Surgery for Thyroid Malignancies: A Retrospective Cohort Study

Kelly Ann Hutchinson,André Guerra,Alexandra E. Payne,Sena Turkdogan,Veronique-Isabelle Forest,Michael P. Hier,Richard J. Payne

Publication date 03-05-2022


To examine various factors associated with an increased risk of reoperation for persistent or recurrent malignant thyroid cancers. Retrospective cohort study. Tertiary academic hospital centers. Patients undergoing surgery for thyroid cancer at 2 tertiary academic institutions from 2006 to 2020 were included. Those who underwent a reoperative procedure were compared with patients only requiring 1 procedure. The Pearson chi-square and independent This study included 2266 patients with surgically managed thyroid malignancy, of which 54 (2.4%) necessitated reoperations. Those requiring a second surgical procedure were more likely to be male (40.7% vs 20.9%, This study identified patient- and cancer-related characteristics associated with an increased risk of requiring reoperation for thyroid malignancies.

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Decreasing Incidence of Chemosensory Changes by COVID-19 Variant

Daniel H. Coelho,Evan R. Reiter,Evan French,Richard M. Costanzo

Publication date 03-05-2022


Anecdotal clinical observation suggests that rates of chemosensory dysfunction associated with COVID-19 infection may be decreasing. To investigate, the National COVID Cohort Collaborative database was queried for all patients with and without smell and taste loss within 2 weeks of COVID-19 diagnosis. Six-week periods of peak variant prevalence were selected by using Co Variants.org for analysis. Of 3,678,214 patients with COVID-19 in the database, 616,318 met inclusion criteria during the time intervals of interest, with 3431 having an associated smell or taste disturbance diagnosis. With the initial/untyped variant set as the baseline, the odds ratios for alpha, delta, and omicron (December 27, 2021-February 7, 2022) were 0.50 (95% CI, 0.45-0.55;

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Stensen’s Duct Stenosis Balloon Dilatation: Long-term Evaluation of Clinical Outcomes and Quality of Life Impacts

Marie de Boutray,Mélanie Pons,Nicolas Graillon,Cyrille Chossegros,Anthony Reyre,Christophe Chagnaud,Arthur Varoquaux

Publication date 03-05-2022


To conduct a long-term retrospective evaluation of the safety and effectiveness of sialographic balloon dilatation in Stensen's duct stenosis (SDS). Retrospective cohort. Single-institution academic tertiary referral center. All SDS balloon dilatations (SSBDs) performed from 2011 to 2017 were monitored. Pain relief was evaluated by a numeric rating scale at 3-year follow-up at least. Long-term glandular swelling frequency patterns, quality of life (QoL), and drug consumption were retrospectively assessed. Procedure-related complications were recorded. Twenty-one SSBD procedures were recorded (mean ± SD age, 55 ± 12 years), all performed under local anesthesia. SSBD led to complete dilatation in 7 patients (33%), residual stenosis in 8 (38%), and no dilatation (failure) in 6 (29%). Retrospective analysis of clinical outcomes was possible for 17 patients, 71% of whom presented with long-term pain relief, at a mean relief of 3.2 points on the numeric rating scale ( Despite the advent of sialendoscopy-guided techniques, SSBD should be considered for SDS treatment, as it is a safe procedure and provides sustained pain relief.

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Chronic Granulomatous Invasive Fungal Sinusitis in Patients With Immunocompetence: A Review

Vedantam Rupa,Jayanthi Peter,Joy Sarojini Michael,Meera Thomas,Aparna Irodi,Vedantam Rajshekhar

Publication date 03-05-2022


We aimed to study the literature on chronic granulomatous invasive fungal sinusitis to elucidate the changing trends in the management of the disease. Using specific keywords, we searched the Pub Med, Pub Med Central, and Scopus databases over the past 50 years, which yielded 938 articles in the English language. Scrutiny of 147 relevant articles revealed 15 homogenous case series (255 cases of histologically proven chronic granulomatous fungal sinusitis alone) and 8 heterogeneous case series (patients with other types of fungal sinusitis included), which were analyzed in detail (all with >5 cases each). The disease typically affected middle-aged adults with immunocompetence. Most reports were from Sudan, India, and Saudi Arabia. A slowly progressive orbital, cheek, or palatal mass with proptosis (88.2%) or sinonasal symptoms (39.2%) was typical. Ethmoid (57.2%) and maxillary (51.4%) sinuses were chiefly affected with intracranial extension in 35.1%. Chronic granulomatous fungal sinusitis should be diagnosed on the basis of well-defined histopathologic features. A combination of endoscopic sinus surgery and azole therapy usually yields good outcomes.

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Aerosol Generation During Nasal Airway Instrumentation

Tofigh Sayahi,Alan D. Workman,Kerry E. Kelly,Karin Ardon-Dryer,Albert A. Presto,Benjamin S. Bleier

Publication date 03-05-2022


Airborne aerosol transmission, an established mechanism of SARS-CoV-2 spread, has been successfully mitigated in the health care setting through the adoption of universal masking. Upper airway endoscopy, however, requires direct access to the face, thereby potentially exposing the clinic environment to infectious particles. This study quantifies aerosol production during rigid nasal endoscopy (RNE) and RNE with debridement (RNED) as compared with intubation, a posited gold standard aerosol-generating procedure. Prospective cross-sectional study. Subspecialty single-center clinic and surgical study. Three aerosol detectors (NANOSCAN-3910, OPS-3330, and APS-3321) with a particle size sensitivity of 10 to 20,000 nm were utilized to detect particulate production during the clinical care of 209 patients undergoing RNE/RNED and 25 patients undergoing intubation. RNE and RNED produced statistically significant particles over baseline in 29.3% and 51.0% of subjects ( Instrumentation of nasal airway produces airborne aerosols to a similar degree of those seen during intubation, independent of reactive patient behaviors such as cough or sneeze. These data suggest that an improved understanding is necessary of both the definition of an aerosol-generating procedure and the functional consequences of procedural aerosol generation in clinical settings.

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Changing Epidemiology of Oral Cavity Cancer in the United States

Katelyn O. Stepan,Angela L. Mazul,Jeffrey Larson,Parth Shah,Ryan S. Jackson,Patrik Pipkorn,Stephen Y. Kang,Sidharth V. Puram

Publication date 03-05-2022


We aim to more accurately characterize the current distribution and rates of squamous cell carcinoma (SCC) cases across various oral cavity subsites in the United States. Retrospective cohort. Database study evaluating cancer incidence in the United States from 2001 to 2017. We utilized the US Cancer Statistics Public Use Database, which includes deidentified cancer data reported to the Centers for Disease Control and Prevention's National Program of Cancer Registries and the National Cancer Institute's SEER (Surveillance, Epidemiology, and End Results), capturing 97% of newly diagnosed cancers. We restricted our analysis to SCC arising from oral cavity subsites from 2001 to 2017. We calculated trends in annual cancer incidence rates using SEER*Stat, as well as annual and average annual percentage change and joinpoints with the National Cancer Institute's Joinpoint program. Most oral cavity SCC cases arise from the oral tongue (41.7%), followed equally by lip and floor of mouth (each 16.5%), gingival (10.6%), buccal (6.7%), retromolar trigone (5.6%), and hard palate (2.3%) involvement. The overall incidence of oral tongue SCC continues to rise with an average annual percentage change of 1.8% (95% CI, 1.6%-2.1%; The tongue is the most frequently involved subsite of oral cavity SCC and is increasing in incidence among males and females of all ages.

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Telemedicine Services Provided to Medicare Beneficiaries by Otolaryngologists in 2020

Lauren E. Miller,Vinay K. Rathi,David Xiang,Matthew R. Naunheim,Mark A. Varvares,Stacey T. Gray

Publication date 03-05-2022


Telemedicine utilization among otolaryngologists was rare prior to the COVID-19 pandemic. We sought to understand rates of telemedicine utilization by otolaryngologists amid unprecedented changes in care delivery during the pandemic. Using Medicare Physician/Supplier Procedure Summary data, we performed a retrospective cross-sectional analysis of telemedicine services provided to Medicare beneficiaries by otolaryngologists in 2020. The total number of services and amount of reimbursement received by otolaryngologists for telemedical care increased by 52,989% and 73,147% in 2020 relative to 2019: 139,094 vs 262 services and $9.9 million vs $13,536, respectively. The mean telemedicine revenue per otolaryngologist offset only 8.8% ($9304.69) of losses from the reduction in mean in-person revenue between 2019 and 2020. Further research will be necessary to inform successful adoption of telemedicine within our field amid the ongoing COVID-19 pandemic.

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Outcomes and Trends of Treatments in High-Risk Differentiated Thyroid Cancer

Arash Abiri,Khodayar Goshtasbi,Sina J. Torabi,Edward C. Kuan,William B. Armstrong,Tjoson Tjoa,Yarah M. Haidar

Publication date 26-04-2022


To analyze the variant-specific survival benefits and usage patterns of standardized treatment combinations of surgery (S), radioactive iodine ablation (RAI), and thyroid-stimulating hormone suppression therapy (THST) for high-risk differentiated thyroid cancer. Retrospective cohort study. National Cancer Database. The 2004-2017 National Cancer Database was queried for patients receiving definitive surgery for high-risk papillary, follicular, or Hurthle cell thyroid cancer. Cox proportional hazards and Kaplan-Meier analyses assessed for treatment-associated survival. Of 21,076 cases, 18,214 underwent survival analysis with a mean ± SD age of 50.6 ± 17.1 years (71.3% female). When compared with surgery alone, S + RAI was associated with reduced mortality in papillary (hazard ratio [HR], 0.574; High-risk differentiated thyroid cancer exhibited varying susceptibilities to different treatment combinations depending on histology, with greatest responses to regimens that included RAI. Physician practices have trended toward decreased RAI and increased THST usage.

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Two Cases of Beta-Human Chorionic Gonadotropin–Positive Oral Tongue Cancer Resulting in False-Positive Pregnancy Tests

Elisabeth Wenneker,Ya Xu,David J. Hernandez

Publication date 26-04-2022


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Effect of Local Anesthetic Injections on Subjective Pain Scales in Pediatric Tonsillectomies: A Meta-analysis

Joshua A. Stramiello,Briana Ortega,Matthew Brigger,Javan Jonathon Nation

Publication date 26-04-2022


To assess the effect of local anesthetic injection on subjective pain scores for pediatric tonsillectomies on postoperative days (PODs) 0 and 1. A comprehensive literature search was conducted with the Pub Med, Embase, Web of Science, and Scopus databases. A 2-researcher team following the PRISMA guidelines performed a systematic review and meta-analysis. Studies with original data and a saline injection control arm were selected. Corresponding authors were contacted for missing data. The collated data were analyzed with Rev Man version 5.4 (Review Manager; Cochrane Collaboration). Random effects modeling and standard mean difference were utilized to control for heterogeneity. Surgical technique subgroup analysis was performed. A total of 319 publications were identified, and 8 articles with 13 experimental arms (627 participants) were selected for meta-analysis. Local anesthetic injection was compared with placebo with saline injection. The standard mean difference for POD 0 pain was -0.81 (95% CI, -1.16 to -0.46; A local anesthetic injection during a pediatric tonsillectomy reduces postoperative pain on POD 0 and 1. Further analysis on total narcotic use and postoperative complications would benefit surgeon decision making.

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Clinical Predictors of OSA Treatment Success Following Implantation of a Hypoglossal Nerve Stimulation Device

Avrahan Boroosan,Anna M. Salapatas,Michael Friedman

Publication date 19-04-2022


To identify prognostic indicators associated with successful hypoglossal nerve stimulation (HGNS) therapy to treat obstructive sleep apnea (OSA), focusing on patients' physiologic response to awake tongue protrusion. Retrospective chart review. Tertiary care center. We included consecutive patients with moderate-severe OSA who underwent HGNS implantation from December 2017 to December 2019. Data abstracted include standard demographics, body mass index (BMI), pre- and postoperative apnea-hypopnea index (AHI), and Friedman tongue position (FTP). Additionally, change in hypopharyngeal cross-sectional area on awake tongue protrusion was abstracted. Patients protruded their tongues, and the physician visualized change. Positive change in hypopharyngeal cross-sectional area was documented as +1 and a negative change as -1. Chi-square tests for independence and logistic regression analysis were performed to determine indicators of successful surgery. Thirty-nine patients were included in this study. Mean ± SD AHI decreased significantly from 43.1 ± 17.36 to 9.18 ± 8.18. Surgical success was achieved in 79.5% of patients. Variables analyzed included BMI >32, preoperative AHI, FTP, and change in hypopharyngeal cross-sectional area on awake tongue protrusion (positive, 65.8%; negative, 34.2%). Positive predictors of success were positive change in hypopharyngeal cross-sectional area ( Positive change in hypopharyngeal cross-sectional area on awake tongue protrusion and severe baseline AHI were positive predictors of successful HGNS therapy. Negative change in hypopharyngeal cross-sectional area on awake tongue protrusion and BMI >32 were negative predictors.

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Association of Ear Anomalies and Hearing Loss Among Children With 22q11.2 Deletion Syndrome

Shannon S. Wu,Chengetai Mahomva,Tuleen Sawaf,Katherine L. Reinshagen,Christopher Karakasis,Michael S. Cohen,Stephen Hadford,Samantha Anne

Publication date 19-04-2022


To identify inner and middle ear anomalies in children with 22q11.2 deletion syndrome (22q11DS) and determine associations with hearing thresholds. Retrospective study. Two tertiary care academic centers. Children presenting with 22q11DS between 2010 and 2020 were included. Temporal bone imaging with computed tomography or magnetic resonance imaging was reviewed by 2 neuroradiologists. Twenty-two patients (12 female, 10 male) were identified. Forty-four ears were evaluated on imaging. There were 15 (34%) ears with abnormal semicircular canals, 14 (32%) with abnormal vestibules, 8 (18%) with abnormal ossicles, 6 (14%) with enlarged vestibular aqueducts, 4 (9.1%) with abnormal facial nerve canals, and 4 (9.1%) with cochlear anomalies. There were 25 ears with imaging and audiometric data. The median pure tone average (PTA) for ears with any structural abnormality was 41.0 dB, as compared with 28.5 dB for ears without any structural abnormality ( Semicircular canal, ossicular, vestibular aqueduct, and vestibular anomalies were detected in children with 22q11DS, especially in the setting of hearing loss. Careful evaluation of anatomic anomalies is needed prior to surgical intervention in these patients.

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Cholesteatoma in Congenital Aural Atresia and External Auditory Canal Stenosis: A Systematic Review

Ching Yee Chan,Sarah Amirali Karmali,Brandon Arulanandam,Lily H.P. Nguyen,Melanie Duval

Publication date 19-04-2022


Patients with congenital external auditory canal (EAC) abnormalities are at risk of developing cholesteatoma and often undergo surveillance imaging to detect it. The aims of this systematic review are to determine the incidence of cholesteatoma in patients with congenital aural atresia (CAA) and patients with congenital EAC stenosis and to investigate the most common age of cholesteatoma diagnosis. This information will help clinicians decide which patients require surveillance scanning, as well as the timing of imaging. Ovid MEDLINE, Embase, CENTRAL, and Web of Science databases. A systematic literature review following the PRISMA guidelines was performed. The data sources were searched by 2 independent reviewers, and articles were included that reported on CAA or congenital EAC stenosis with a confirmed diagnosis of cholesteatoma. The selected articles were screened separately by 3 reviewers before reaching a consensus on the final articles to include. Data collection on the number of patients with cholesteatoma and the age of diagnosis was performed for these articles. Eight articles met the inclusion criteria. The incidence of cholesteatoma was 1.7% (4/238) in CAA and 43.0% (203/473) in congenital EAC stenosis. The majority of patients with congenital EAC stenosis that developed cholesteatoma were diagnosed at age <12 years. CAA is associated with a low risk of cholesteatoma formation, and surveillance imaging is unnecessary in asymptomatic patients. EAC stenosis is strongly associated with cholesteatoma, and a surveillance scan for these patients is recommended prior to 12 years of age with close follow-up into adulthood.

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Ototoxicity Review: A Growing Number of Non–Platinum-Based Chemo- and Immunotherapies

James G. Naples,Wyatt Rice-Narusch,Nathan W. Watson,Melissa Ghulam-Smith,Sean Holmes,Daqing Li,Scharukh Jalisi

Publication date 19-04-2022


To raise awareness of the growing list of non-platinum-based chemo- and immunotherapeutic agents that have been associated with ototoxicity and to introduce the possible mechanism of ototoxicity of these agents. Pub Med, Embase, and Web of Science. A systematic review was performed following the PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-analyses). Pub Med, Embase, and Web of Science databases were searched for published reports of ototoxicity from non-platinum-based chemo- and immunotherapeutic agents in adult and pediatric patients. Therapies that utilized any platinum-based agent were excluded. Ototoxicity from non-platinum-based chemo- and immunotherapies is an evolving problem. There were 54 reports-39 case reports and 15 cohort studies-documenting ototoxicity from 7 agents/combination therapies. Of these reports, 37 (69%) were published within the last 15 years (after 2005). No recovery of hearing was documented in 21 of 56 cases (38%). Pretreatment audiograms were uncommon (19/54 studies, 35%), despite documented ototoxic associations. There is a growing number of novel, ototoxic, non-platinum-based chemo- and immunotherapeutic agents with various potential mechanisms of action. Otolaryngologists will need to prioritize awareness of these agents. This growing list of agents, many of which have reversible effects, suggest a need for standardized ototoxicity monitor protocols so that appropriate and timely management options can be implemented.

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Moving Beyond Detection: Charting a Path to Eliminate Health Care Disparities in Otolaryngology

Sarah N. Bowe,Uchechukwu C. Megwalu,Regan W. Bergmark,Karthik Balakrishnan

Publication date 19-04-2022


The coronavirus pandemic has illuminated long-standing inequities in America's health care system and societal structure. While numerous studies have identified health care disparities within our specialty, few have progressed beyond detection. Otolaryngologists have the opportunity and the responsibility to act. Within this article, leaders from otolaryngology share their experience and perspective on health care disparities, including (1) a discussion of disparities in otolaryngology, (2) a summary of health care system design and incentives, (3) an overview of implicit bias, and (4) practical recommendations for providers to advance their awareness of health care disparities and the actions to mitigate them. While the path forward can be daunting, it should not be a deterrent. Throughout the course of this article, numerous resources are provided to support these efforts. To move ahead, our specialty needs to advance our level of understanding and develop, implement, and disseminate successful interventions toward the goal of eliminating health care disparities.

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Strategies to Increase Racial and Ethnic Diversity in the Surgical Workforce: A State of the Art Review

Ciersten A. Burks,Trinity I. Russell,Deborah Goss,Gezzer Ortega,Gregory W. Randolph,Mark A. Varvares,David J. Brown,Stacey T. Gray,Regan W. Bergmark

Publication date 19-04-2022


To evaluate strategies to increase racial and ethnic diversity in the surgical workforce among trainees and faculty across surgical specialties. Embase, OVID/Medline, and Web of Science Core Collection. A review of US-based, peer-reviewed articles examining the effect of targeted strategies on racial and ethnic diversity in the surgical workforce was conducted from 2000 to 2020 with the PRISMA checklist and STROBE tool. Studies without an outlined strategy and associated outcomes were excluded. Eleven studies met inclusion criteria and were completed in general surgery, orthopaedic surgery, and otolaryngology-head and neck surgery. Efforts to increase exposure to surgery through internship programs and required clerkships with efforts to improve mentorship were common (6 of 11 [54.5%] and 3 of 11 [27.3%] studies, respectively). Three (27.3%) studies aimed to diversify the recruitment and selection process for the residency match and faculty hiring, and 2 (18.2%) aimed to increase representation among trainees, faculty, and leadership through holistic review processes paired with departmental commitment. Outcome metrics included surgical residency applications for individuals underrepresented in medicine, interview and match rates, faculty hiring, measures of a successful academic surgical career, and leadership representation. All strategies were successful in increasing diversity in the surgical workforce. A convincing yet limited body of literature exists to describe strategies and outcomes that address racial and ethnic diversity in the surgical workforce. While future inquiry is needed to move this field of interest forward, the evidence presented provides a framework for surgical residency programs/departments to develop approaches to increase racial and ethnic diversity.

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Base of Tongue Surgery and Pediatric Obstructive Sleep Apnea

Adrian Williamson,Erica H. McArdle,Vincent R. Morrow,Habib G. Zalzal,Michele M. Carr,Steven W. Coutras

Publication date 19-04-2022


Drug-induced sleep endoscopy-directed lingual tonsillectomy and midline posterior glossectomy have been employed for the treatment of obstructive sleep apnea in children. The purpose of this study is to evaluate outcomes in children undergoing lingual tonsillectomy, midline posterior glossectomy, or combined base of tongue reduction procedures for obstructive sleep apnea. Case series with chart review. Tertiary care academic medical center. A case series was performed with chart review of pediatric patients with obstructive sleep apnea who underwent base of tongue surgery as directed by drug-induced sleep endoscopy. Pre- and postoperative obstructive apnea-hypopnea index (oAHI) was compared. Age, sex, body mass index A total of 168 children were included, with a mean ± SD age of 8.3 ± 3.6 years. Of these patients, 101 underwent lingual tonsillectomy alone; 25, midline posterior glossectomy alone; and 42, both. Their mean oAHI improvement was 3.52 ± 8.39, 2.55 ± 5.59, and 3.70 ± 6.07, respectively. Each surgical group experienced significant improvement in sleep apnea when pre- and postoperative oAHI was compared ( When guided by drug-induced sleep endoscopy, pediatric tongue base surgery can significantly improve oAHI and thus demonstrates promising success in treating pediatric obstructive sleep apnea.

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Corrigendum to “Optimizing Pulmonary Outcomes After Total Laryngectomy: Crossover Study on New Heat and Moisture Exchangers”

Publication date 18-04-2022


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Quality of Life After Modified Rambo Ear Canal Closure in Pediatric and Adult Patients

Peng You,Benjamin D. Lovin,Akash J. Patel,Kathleen E. Hosek,Angela Peng,Alex D. Sweeney

Publication date 13-04-2022


To present the surgical and quality of life (QOL) outcomes of patients who underwent blind sac closure of the external auditory canal (EAC) via a modified Rambo approach. Retrospective case review. Tertiary academic referral center. All patients who underwent EAC closure with a modified Rambo approach between 2015 and 2021 were evaluated. Complication rates, QOL estimations from a validated survey, and subjective cosmetic reports were analyzed. Thirty-five ears were closed in 31 patients. The most common indication for surgery was related to cochlear implantation and cochlear malformation or cholesteatoma (31.4%). No case involved an immediate complication requiring revision surgery, and 4 ears (11.4%) were suspected of having cholesteatoma within the surgical cavity at a mean 28.6-month follow-up. Adults (≥18 years) had significantly higher QOL scores than children in the medical resource subscale of the Chronic Ear Survey ( Ear canal closure can be a useful technique for select adult and pediatric patients. Patient and surgeon concerns regarding QOL and cosmesis in ear canal closure should be explored prior to employing this surgical technique, though the present data suggest that the modified Rambo approach to closure is generally associated with reasonable outcomes in both areas.

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Repeat Fine-Needle Aspiration With Molecular Analysis in Management of Indeterminate Thyroid Nodules

Michael R. Papazian,Jared C. Dublin,Kepal N. Patel,Thaira Oweity,Adam S. Jacobson,Tamar C. Brandler,Babak Givi

Publication date 12-04-2022


To analyze clinical outcomes in a series of indeterminate thyroid nodules (ITNs) with repeat fine-needle aspiration (FNA) biopsy and results of genomic classifier. Historical chart review. Tertiary care center. We reviewed FNA samples from subjects with Bethesda III or IV diagnoses from January 2015 to December 2018 at a single institution and selected those with repeat FNA and Thyro Seq testing of the same nodule. Patient demographics, Bethesda classifications, Thyro Seq results, treatment detail, and surgical pathology, when available, were analyzed. Ninety-six patients with cytologic diagnosis of ITN, repeat FNA, and Thyro Seq testing were identified. Following repeat FNA, 55 nodules (57%) remained ITN; 40 (42%) were reclassified as benign; and 1 (1%) was reclassified as suspicious for malignancy. In 31 patients with Thyro Seq analysis accompanying initial and repeat FNA, 26 (84%) had the same result on each, while 5 (16%) tested Thyro Seq positive following an initially negative result (κ = 0.24). Most nodules that were downgraded to Bethesda II on repeat FNA (37/40, 93%) were managed nonsurgically. Patients with Thyro Seq-positive results were treated with surgery more often (25/28, 89%) than patients with Thyro Seq-negative results (11/68, 16%; In this case series, repeat FNA helped patients with ITNs avoid diagnostic surgery through reclassification to benign cytology. The risk of high-risk malignancy in Thyro Seq-positive nodules with repeat indeterminate cytology was low.

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High-Dose Celecoxib for Pain After Pediatric Tonsillectomy: A Randomized Controlled Trial

Teresa Giordano,Alexandra Durkin,Andrea Simi,Megan Shannon,Julia Dailey,Hannah Facey,Lance Ballester,Ralph F. Wetmore,John A. Germiller

Publication date 12-04-2022


Pediatric tonsillectomy causes significant postoperative pain. Newer nonsteroidal anti-inflammatory drugs such as celecoxib control pain without increasing bleeding risk, but in prior studies provided only modest pain reduction at standard doses. We aimed to determine if high-dose celecoxib (double the usual pediatric dose) is effective for pain, without increasing bleeding or other risks. Randomized double-blind trial. Pediatric tertiary center. Children aged 3 to 11 years undergoing total tonsillectomy were randomized to receive celecoxib (6 mg/kg/dose) or placebo, twice daily, for up to 10 days. All cases were supplemented with acetaminophen and oxycodone as needed. All participants and personnel were blinded to treatment group. Subjects recorded coanalgesic consumption, pain, diet, and activity. The celecoxib group (n = 68) consumed 0.72 mg/kg of oxycodone, as compared with 1.12 mg/kg in the placebo group (n = 62), a 36% difference that was not significant. However, multivariate analysis by treatment group, separate from pain levels, confirmed that this reduction was due to celecoxib treatment ( High-dose celecoxib is effective in controlling pain after tonsillectomy, with no adverse effects in this relatively small sample. It reduces narcotic consumption, and its impact appears greater in children with higher degrees of pain. Celecoxib can be considered an effective alternative to ibuprofen after tonsillectomy.
This trial was registered at Clinical Trials.
gov: NCT02934191.

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Preoperative Predictors of Free Flap Failure

Madelyn N. Stevens,Michael H. Freeman,Justin R. Shinn,Nicole Kloosterman,Shane Carr,Kyle Mannion,Sarah L. Rohde

Publication date 12-04-2022


Microvascular free tissue transfer is an important reconstructive option for defects of the head and neck. The present study aims to identify preoperative patient- and tumor-specific characteristics, laboratory values, and other risk factors associated with early free flap failure. Retrospective cohort study of 1070 patients. Head and neck surgical oncology service at a tertiary care center from 2005 to 2019. Demographics, comorbidities, preoperative laboratory values, treatment history, and cancer stage were collected for consecutive patients who underwent free flap reconstruction of the head and neck and experienced early free flap failure (<8 days from surgery). In 1070 patients, the prevalence of early free flap failure was 3.8% (n = 41). Female sex (odds ratio [OR], 2.58; 95% CI, 1.36-4.99), presence of peripheral vascular disease (OR, 2.78; 95% CI, 1.05-6.57), and elevated preoperative platelet count (OR, 2.67; 95% CI, 1.20-5.47) were independently associated with risk of early free flap failure. Female sex, peripheral vascular disease, and preoperative thrombocytosis are all strong predictors of early free flap failure. This suggests that hypercoagulability and poor vessel quality may predispose patients to flap loss. Patients with elevated platelets or peripheral vascular disease warrant careful reconstructive decision making and close monitoring in the perioperative period.

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Tackling the Minority Tax: A Roadmap to Redistributing Engagement in Diversity, Equity, and Inclusion Initiatives

Erynne A. Faucett,Michael J. Brenner,Dana M. Thompson,Valerie A. Flanary

Publication date 05-04-2022


Academic medical centers striving to implement diversity, equity, and inclusion (DEI) and antiracism initiatives often ask faculty to volunteer substantial time to committee work, recruitment, mentoring, community, and administrative responsibilities. These requests are not in lieu of current workload and seldom count toward scholarship; the service may go unrecognized, unrewarded, and uncompensated. URiM faculty (underrepresented in medicine) providing such service thus pay a minority tax when precious time is syphoned away from career-advancing activities and personal growth. The resulting strain on available resources has social, psychological, and monetary ramifications that can undermine the long-term objectives of DEI initiatives. We examine the facets of the minority tax, consider the current state of diversity, and present a roadmap to redistribute, reform, and reduce URiM taxation through shared engagement in DEI initiatives. Key interventions include ascribing value to DEI efforts, implementing evidence-based policies to reduce bias, and promoting mentorship, sponsorship, and allyship.

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Impact of Facility Volume on Patient Safety Indicator Events After Transsphenoidal Pituitary Surgery

Mehdi S. Lemdani,Hannaan S. Choudhry,Christopher C. Tseng,Christina H. Fang,Donata Sukyte-Raube,Prayag Patel,Jean Anderson Eloy

Publication date 05-04-2022


To investigate the impact of facility volume on Patient Safety Indicator (PSI) events following transsphenoidal pituitary surgery (TSPS). Retrospective database review. National Inpatient Sample database (2003-2011). The National Inpatient Sample was queried for TSPS cases from 2003 to 2011. Facility volume was defined by tertile of average annual number of TSPS procedures performed. PSIs, based on in-hospital complications identified by the Agency of Healthcare Research and Quality, and poor outcomes, such as mortality and tracheostomy, were analyzed. An overall 16,039 cases were included: 804 had ≥1 PSI and 15,235 had none. A greater proportion of male to female (5.8% vs 4.3%) and Black to White (7.0% vs 4.5%) patients experienced PSIs. There was an increased likelihood of poor outcome (odds ratio [OR], 3.1 [95% CI, 2.5-3.7]; PSIs were associated with a higher likelihood of poor outcome and mortality following TSPS. Patients who experienced PSIs had a lower risk of poor outcome but increased mortality at higher-volume facilities.

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Factors Associated With a Prolonged Diagnosis-to-Treatment Interval in Laryngeal Squamous Cell Carcinoma

Noah Shaikh,Vincent Morrow,Cara Stokes,Jeffson Chung,Tanya Fancy,Meghan T. Turner,William A. Stokes

Publication date 05-04-2022


Evaluate factors associated with treatment delays and their effect on survival in laryngeal squamous cell carcinoma. Retrospective cohort study. National Cancer Database. Patients receiving primary radiation or surgery for laryngeal squamous cell carcinoma were included from 2004 to 2017. The primary outcomes were the diagnosis-to-treatment interval (DTI) and 5-year survival. Variables of prolonged DTI (>30 days) were assessed via logistic regression models. Survival was then assessed through Cox proportional hazards models. Candidate variables for both outcomes included age, sex, race, ethnicity, distance to treatment facility, insurance coverage, treatment facility type, TNM T stage, nodal status, and DTI (in models estimating survival). An overall 136,203 patients with laryngeal cancer were identified, from which 51,747 remained after exclusions were applied: 18,499 received primary surgery and 33,248 received primary radiation. Being a member of a racial or ethnic minority, advanced age, female sex, ≥30 miles from treatment facility, lack of insurance, treatment at an academic cancer center, and primary radiation were associated with a prolonged DTI. However, in spite of a faster DTI, treatment at a community cancer center was independently associated with higher mortality (hazard ratio, 1.2; Despite being associated with prolonged DTI, receiving treatment at a high-volume academic facility was associated with significantly improved survival. Our results indicate that improved referral pathways or outreach may help improve survival in laryngeal cancer, especially in high-risk populations.

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Open Bedside Tracheostomy: Safe and Cost Saving but Underutilized Nationally

Liyang Tang,Jonathan West,Esther Lee,Khush Kharidia,Steven Hasday,Tamara Chambers,Niels Kokot,Mark Swanson,Karla O’Dell

Publication date 05-04-2022


To evaluate open bedside tracheostomy (OBT) and compare it with open operating room (OR) tracheostomy and bedside percutaneous dilatational tracheostomy (PDT) in complications and cost. To determine the tracheostomy practice patterns of academic otolaryngology programs. Retrospective cohort study and cross-sectional study. Public hospital and tertiary care hospital. Otolaryngology program directors were surveyed to determine their institutions' tracheostomy practice patterns and the factors preventing the implementation of open bedside tracheostomies. A retrospective chart review was done of tracheostomies performed at our institutions from 2009 to 2019 for prolonged mechanical ventilation. Complications, length of intubation, comorbidities, body mass index, demographics, mortality rates, and decannulation rates were recorded. A cost analysis between OBT and PDT was conducted. Data from 802 patients were analyzed for 449 OBTs, 206 PDTs, and 147 open OR tracheostomies. Complication rates were low. PDTs were more likely to have perioperative tracheal bleeding ( OBT can be done safely in patients with multiple comorbidities and has a cost that can be less than PDT. Despite these benefits, only 50% of academic institutions routinely performed OBT. 3.

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History of Otolaryngology: Globus Pharyngeus as “Globus Hystericus”

Jerome R. Lechien,Robin Baudouin,Stéphane Hans,Lee M. Akst

Publication date 05-04-2022


Globus pharyngeus is the uncomfortable sensation of a "lump in the throat," and at present it has many recognized pathophysiologic causes. However, until relatively recently, this condition was often labeled "globus hystericus" and was thought to be a manifestation of hysteria or anxiety. In this commentary, we briefly review the history surrounding the initial treatment of globus pharyngeus sensation as a hysterical condition rooted in anxiety/psychological causes; then, we briefly review the emerging evidence that roots globus pharyngeus sensation within a constellation of pathophysiologies that are related to pharyngoesophageal inflammation and irritation rather than psychological disorders.

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Reimbursement Trends in Pediatric Otolaryngology From 2000 to 2020: A CMS Physician Fee Schedule Analysis

Noah M. Yaffe,Humzah A. Quereshy,Brooke A. Quinton,Todd D. Otteson,Jay R. Shah

Publication date 05-04-2022


The aim of this study was to evaluate the financial trends in Medicare reimbursement rates for the most billed procedures at a single institution from 2000 to 2020 within pediatric otolaryngology. Retrospective data analysis. United States. The most billed surgical and in-office procedures in pediatric otolaryngology at our institution were identified in the Physician Fee Schedule Look-up Tool from the Centers for Medicare and Medicaid Services to extract reimbursement data for each From 2000 to 2020, without adjusting for inflation, reimbursement for the most billed procedures increased by 10.9%, while the allocated relative value unit per procedure increased by 15.4%. However, when adjusted for inflation, reimbursement for these procedures decreased by 27.5% over the study period. The study findings identify a downward trend in reimbursement for the most billed procedures in pediatric otolaryngology at our institution. Given the low predominance of pediatric otolaryngology codes within Medicare reimbursement, these codes are rarely reviewed for accurate revaluation. It is imperative that our professional society remain active and engaged within this process to ensure quality delivery of care to our patients.

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Occult Metastases During Salvage Oral Cavity and Oropharyngeal Free Flaps: Oncologic Outcomes

Margaret E. Wieser,Emily S. Sagalow,Alyssa Givens,Joseph M. Curry,Laura M. Dooley,Tabitha L. Galloway,Robert P. Zitsch,Patrick T. Tassone

Publication date 05-04-2022


To define rates of occult metastases in salvage oral cavity and oropharyngeal cancer resection requiring free flap, to examine the location of occult metastases, and to determine associations between occult metastasis and survival. Retrospective cohort study. Two tertiary care referral centers. We identified previous cases of irradiation with recurrent or second primary oral cavity or oropharyngeal squamous cell carcinoma that had no evidence of regional metastasis and required free tissue transfer reconstruction of the primary site. Patients who underwent elective neck dissection or exploration were reviewed. The main outcome measures were the presence and location of occult nodal metastasis. Disease-free survival and overall survival were measured. Odds ratios and hazard ratios were used for analysis.
A total of 83 patients were included: 52 with oral cavity primary tumors and 31 with oropharynx. An overall 78 (94%) underwent elective salvage neck dissection. Occult metastases were found in 9 (11.5%) patients. The most common nodal station for occult metastasis was level 2. Neither elective neck dissection nor the presence of occult metastasis was significantly associated with regional disease-free or overall survival. Oropharyngeal primary tumors were associated with higher risk of occult metastasis (odds ratio, 1.38; There is a low incidence of occult metastasis in postradiated recurrent or second primary oral cavity and oropharyngeal tumors. Elective neck dissection and occult nodal metastases were not associated with regional or overall survival. This series may help surgeons make decisions regarding the extent of neck surgery after prior radiation, especially when free flap reconstruction is required.

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Economic Burden Associated With Nasal Polyposis Recurrence Among Commercially Insured Patients in the United States

Maryia Zhdanava,Briana Ndife,Dominic Pilon,Carmine Rossi,Maude Vermette-Laforme,Patrick Lefebvre,Jeffrey D. Suh

Publication date 29-03-2022


To compare health care resource utilization (HRU) and costs among commercially insured patients with nasal polyposis (NP) with and without recurrence after endoscopic sinus surgery (ESS). Retrospective matched cohort study. Adults with initial ESS or an NP excision after a new NP diagnosis were identified in Optum's Clinformatics Data Mart Database (October 1, 2014-December 31, 2019). The index date was the date of NP recurrence, identified with a claims-based algorithm for the recurrent cohort, or a random date for the nonrecurrent cohort. Patients in both cohorts were matched 1:1 on baseline characteristics (12 months preindex) via propensity scores and exact matching factors. Annual HRU and costs (2019 US$) were compared between the matched cohorts at 12 months postindex. NP recurrence was identified among 3343 of 16,693 patients with initial ESS; after matching, each cohort comprised 1574 patients (median age, 54 years; 40% female) with similar baseline health care costs (recurrent, $34,420; nonrecurrent, $33,737). At 12 months postindex, the recurrent cohort had higher HRU, including 36% and 51% more outpatient and emergency department visits, respectively (all NP recurrence is associated with a substantial economic burden, which appears to be driven by outpatient services.

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Distribution of Article Citation Frequency, Citation Skew, and Impact Factor in Otolaryngology Journals

Ahmad R. Sedaghat

Publication date 29-03-2022


The objectives of this study were to determine the degree of citation skew in otolaryngology journals and how article citation distribution affects their impact factors (IFs). Forty-one "otorhinolaryngology" journals in the Clarivate Journal Citation Reports database were identified and their article citation data from 2017 to 2020 extracted. Article citation frequency was remarkably similar across most journals, consistent with the narrow distribution of IFs (mean [SD], 1.9 [0.9]). Although the percentage of a journal's articles cited more than its IF during the IF citation window (mean [SD] of 32.4% [7.9%] of journals' articles)-reflecting citation skew-was not correlated with IF, the percentage of a journal's articles that were cited at least once (mean [SD] of 62.5% [15.3%] of articles) was highly correlated (ρ = 0.92,

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Systemic Steroids for Otolaryngology–Head and Neck Surgery Disorders: An Evidence-Based Primer for Clinicians

Edward D. McCoul,Uchechukwu C. Megwalu,Stephanie Joe,Raluca Gray,Daniel C. O’Brien,Elisabeth H. Ference,Victoria S. Lee,Prayag S. Patel,Marco A. Figueroa-Morales,Jennifer J. Shin,Michael J. Brenner

Publication date 29-03-2022


To offer pragmatic, evidence-informed guidance on the use of systemic corticosteroids (SCS) for common otolaryngologic disorders. Pub Med, Cochrane Library, and American Academy of Otolaryngology-Head and Neck Surgery Foundation clinical practice guidelines. A comprehensive search of published literature through November 2021 was conducted on the efficacy of SCS, alone or in combination with other treatments, for managing disorders in otolaryngology and the subdisciplines. Clinical practice guidelines, systematic reviews, and randomized controlled trials, when available, were preferentially retrieved. Interventions and outcomes of SCS use were compiled to generate summary tables and narrative synthesis of findings. Evidence on the effectiveness of SCS varies widely across otolaryngology disorders. High-level evidence supports SCS use for Bell's palsy, sinonasal polyposis, and lower airway disease. Conversely, evidence is weak or absent for upper respiratory tract infection, eustachian tube dysfunction, benign paroxysmal positional vertigo, adenotonsillar hypertrophy, or nonallergic rhinitis. Evidence is indeterminate for acute laryngitis, acute pharyngitis, acute sinusitis, angioedema, chronic rhinosinusitis without polyps, Ménière's disease, postviral olfactory loss, postoperative nerve paresis/paralysis, facial pain, and sudden sensorineural hearing loss. Clinicians should bring an evidence-informed lens to SCS prescribing to best counsel patients regarding the risks, anticipated benefits, and limited data on long-term effects. Alternate routes of corticosteroid administration-such as sprays, drops, inhalers, and intralesional injections-may be preferable for many disorders, particularly those that are self-limited or require a prolonged duration of therapy. Prudent use of SCS reduces the risk of medication-related adverse effects. Clinicians who are conversant with high-level evidence can achieve optimal outcomes and stewardship when prescribing SCS.

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A Novel External Auditory Canal Squamous Cell Carcinoma Cell Line Sensitive to CDK4/6 Inhibition

Rocío García-Marín,Virginia N. Cabal,Carmen Fernández-Cedrón Bermejo,Cristina Riobello,Laura Suárez-Fernández,Helena Codina-Martínez,Ainhoa Navarro-García,Sara Lucila Lorenzo-Guerra,Jorge García-Martínez,Blanca Vivanco,Fernando López,José Luis Llorente,Mario A. Hermsen

Publication date 29-03-2022


To characterize cell line CAE606 derived from a squamous cell carcinoma (SCC) of the external auditory canal (EAC) and to show its usefulness as a model for testing candidate therapeutic agents. Preclinical translational research. Biomedical research institute. The cell line was initiated from a moderately differentiated T2N0M0 EAC SCC. We studied its histologic and genetic features as well as growth and invasion parameters. Sensitivity to cell CDK4/6 cell cycle inhibitor palbociclib was analyzed. CAE606 cells expressed heavy molecular weight cytokeratin, p63, and vimentin. The population doubling time was 25.8 hours, and the cells showed fast collective cell migration in a wound-healing assay. Short tandem repeat analysis confirmed it to be derived from the primary tumor of the patient. Next-generation sequencing revealed alterations in cell cycle regulation genes, including inactivating mutations in This is the first report of a stable EAC SCC cell line. Its genetic features make it a useful tool for preclinical testing of new therapeutic agents for EAC SCC, particularly those targeting cell cycle regulation in combination with radio- and chemotherapy or other specific signaling pathway inhibitors.

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A Protocol for Propofol-Infusion Drug-Induced Sleep Endoscopy

Taylor G. Lackey,James R. Duffy,Katherine K. Green

Publication date 29-03-2022


The objective of this study was to outline a protocol utilizing propofol infusion without an initial bolus during drug-induced sleep endoscopy (DISE). We define normative values for final propofol infusion rate (P Retrospective chart review. Tertiary academic hospital. A review of patients with obstructive sleep apnea who underwent DISE between 2016 and 2020 was performed.
The following patient data were recorded: demographics; DISE procedure details, including P There were 246 patients who met inclusion criteria. P We describe a propofol slow-infusion DISE protocol that demonstrates safe and reproducible outcomes.

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From a Slave to a Surgeon: David Kearney McDonogh, the First Black Otolaryngologist

David A. Gudis,Kibwei A. McKinney,Lawrence R. Lustig

Publication date 29-03-2022


David Mc Donogh, born into chattel slavery in Louisiana in the early 1800s, accomplished the unfathomable by becoming the first Black otolaryngologist in the United States of America. With tireless determination and profound intellect, Dr Mc Donogh surmounted immeasurable adversity along his improbable journey to freedom and success as an eye, ear, nose, and throat doctor in New York. His doctorate in medicine was posthumously awarded to his great-great-granddaughter in 2018 by the Columbia University Vagelos College of Physicians and Surgeons. In this History of Otolaryngology piece, we share his extraordinary story.

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Representation of Race and Sex in Sleep Surgery Studies

Peter Debbaneh,Kimberly Ramirez,Nikolas Block-Wheeler,Megan Durr

Publication date 29-03-2022


Obstructive sleep apnea (OSA) is a highly prevalent disorder with many treatment modalities, including surgical intervention. While OSA is known to be more prevalent in males and Black Americans, the representation of race and sex in sleep surgery studies is unknown. The aim of this systematic review is to assess the race and sex demographics represented in sleep surgery studies relative to known OSA demographics. Pub Med, MEDLINE, and OVID databases. A systematic review was conducted to identify studies published between 2016 and 2020 that investigated sleep outcomes following nonnasal surgical intervention for OSA in adults. Pooled racial, ethnic, and sex data of the enrolled subjects in selected studies were analyzed. The 148 included studies comprised 13,078 patients. Of the 137 studies that reported sex, 84.0% of participants were male, exceeding the population prevalence of OSA in males, which is estimated at 66%. Only 13 studies reported racial/ethnic demographic data. Of these, 87.8% of patients were White. Out of 30 studies of primarily American patients, only 4 reported race demographic data, with an average of 82.8% White participants. There is a racial/ethnic and sex inclusion bias among sleep surgery studies. Future studies should better document the demographics of enrolled participants as well as recruit participants who better represent the demographics of adults with OSA in the general population.

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In-office Bone-Anchored Hearing Implants via Minimally Invasive Punch Technique in a Veteran Population

Jackson King,Isabella Leon,Lane Squires

Publication date 29-03-2022


Describe the feasibility and safety of completing bone-anchored hearing implants via the minimally invasive punch technique in the in-office setting. This single-institution case series included 20 patients who underwent in-office bone-anchored hearing implant placement under local anesthesia from 2018 to 2021. Veterans Affairs Northern California Healthcare System. Following completion of the case series, patients were retrospectively surveyed regarding their satisfaction with this approach via a modified SSQ-8 (Surgical Satisfaction Questionnaire) to fit our purposes. A total of 23 implants were completed in the in-office setting on 20 patients. Intra- and postoperative complication rates, including skin changes, irritation, infection, and poor wound healing, were similar to or better than currently published complication rates in the literature. In addition, patients reported overwhelmingly positive responses on the SSQ-8, almost universally stating that they were "very satisfied" with their clinic experience. This case series suggests that it is feasible and safe to complete this procedure in the clinic under local anesthesia, but further prospective studies are needed to evaluate this in a more generalized population.

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Evaluation and Management of Tinnitus: Are There Opportunities for Improvement?

Kenneth M. Grundfast,Taylor L. Jamil

Publication date 29-03-2022


To review current information about diagnosis and management of tinnitus aiming to identify opportunities for achieving a cost-effective, efficient, evidence-based approach that meets the needs of tinnitus sufferers. Pub Med/MEDLINE. In total, 249 relevant published reports were reviewed. Pertinent keywords and MeSH terms identified reports via Pub Med and EMBASE. Acknowledged experts were consulted on ways to improve tinnitus management. There may be opportunities to improve evaluation and management of patients with tinnitus using modern modes of communication and a multidisciplinary therapeutic approach. Tinnitus can adversely affect quality of life while being time-consuming and costly to evaluate and manage. Based on both personal experience and the reports of others, patients with tinnitus who choose to see a physician primarily want to know two things: (1) that the tinnitus that is so distressing will not remain at the same level of severity forever and (2) that something can be done to help cope with the tinnitus that is so annoying. Recent advancements in internet communications, social media, information technology, artificial intelligence, machine learning, holistic medical care, mind-body integrative health care, and multidisciplinary approaches in medical therapeutics may be possibly making new ways of meeting the needs of patients with tinnitus.

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Oropharyngeal Rehabilitation for Patients With Moderate to Severe Obstructive Sleep Apnea After Transoral Robotic Surgery

Yi-Ju Lai,Po-Lan Su,Chung-Yi Li,Chung-Ying Lin,Ching-Hsia Hung,Cheng-Yu Lin

Publication date 29-03-2022


To determine whether combined transoral robotic surgery and postoperative oropharyngeal rehabilitation are effective for reducing the severity of obstructive sleep apnea. A quasi-experimental study enrolled participants without blinding between May 2019 and April 2021. Single-center study at National Cheng Kung University Hospital. Patients with moderate to severe obstructive sleep apnea who were otherwise healthy were recruited from the ear, nose, and throat department at National Cheng Kung University Hospital. The group undergoing transoral robotic surgery with oropharyngeal rehabilitation (n = 18) received a 12-week intervention consisting of home-based rehabilitation exercises following surgery; the transoral robotic surgery group (n = 17) received surgery only; and the control group (n = 15) received conservative treatment, such as continuous positive airway pressure therapy or other oral appliance therapy. Polysomnography data and tongue muscle performance were measured before and after the interventions. The group that underwent transoral robotic surgery with oropharyngeal rehabilitation exhibited significantly improved tongue protrusion strength as compared with the transoral robotic surgery-only group, as well as significantly improved apnea-hypopnea index in the supine position vs the control group. In this study, we demonstrated the synergistic effects of transoral robotic surgery and postoperative oropharyngeal rehabilitation for adult patients with obstructive sleep apnea. Objective records should be used to monitor home-based rehabilitation exercises and examine the lasting synergistic effects.

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Long-Term Quality of Life of Vestibular Schwannoma Patients: A Longitudinal Analysis

Olaf M. Neve,Jeroen C. Jansen,Radboud W. Koot,Mischa de Ridder,Peter Paul G. van Benthem,Anne M. Stiggelbout,Erik F. Hensen

Publication date 29-03-2022


Vestibular schwannoma management aims to maintain optimal quality of life (QoL) while preventing severe sequelae of the tumor or its treatment. This study assessed long-term QoL of patients with vestibular schwannoma in relation to treatment modality and decisional regret. A longitudinal study, in which clinical and QoL data were used that were cross-sectionally acquired in 2014 and again in 2020 from the same patient group. A tertiary expert center for vestibular schwannoma care in the Netherlands. QoL was measured by the Penn Acoustic Quality of Life (PANQOL) scale. Changes in time were assed using a linear mixed model. In addition, the Decision Regret Scale was analyzed. Of 867 patients, 536 responded (62%), with a median follow-up of 11 years. All PANQOL subdomain scores remained stable over time and did not exceed minimal clinically important difference (MCID) levels. Time since treatment did not affect QoL. Patients had comparable average QoL scores and proportions of patients with changing QoL scores (ie, exceeding the MCID) over time, irrespective of the received initial treatment. Female patients and those who required salvage therapy (either by radiotherapy or surgery) reported a lower QoL. The latter patient group reported the highest decisional regret. On average, the long-term QoL of patients with vestibular schwannoma is comparable for patients under active surveillance and those who have received active treatment, and it remains stable over time. This suggests that, on average, preservation of QoL of patients with vestibular schwannoma is feasible when adequately managed.

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Quality of Life in Patients With Recurrent and Second Primary Head and Neck Cancer

Vaibhav H. Ramprasad,Jinhong Li,Karley Atchison,Dan P. Zandberg,David A. Clump,Jonas T. Johnson,Marci L. Nilsen

Publication date 22-03-2022


In the setting of similar outcomes, quality of life (QOL) measures can be utilized to compare treatment modalities in head and neck squamous cell carcinoma (HNSCC). We evaluate QOL and symptoms in patients treated for primary, second primary, and recurrent HNSCC. Retrospective cohort study. Head and neck cancer survivorship clinic. We identified patients seen between 2016 and 2019. QOL and symptoms were assessed with the University of Washington Quality of Life (UW-QOL) questionnaire, 10-item Eating Assessment Tool, 8-item Patient Health Questionnaire, 7-item Generalized Anxiety Disorder, and Neck Disability Index. Regression analysis was utilized to explore associations and compare QOL outcomes.
Our cohort comprised 662 patients: 546 with primary HNSCC, 34 with second primary HNSCC, and 82 with recurrent HNSCC. Multimodality therapy was associated with lower UW-QOL Physical Subscale (UW-QOL-PS) vs single modality: chemoradiation therapy (-12.17 [95% CI, -16.57 to -7.78]) and surgery + postadjuvant treatment (-12.11 [-16.06 to -8.16]). Multimodality therapy was also associated with lower UW-QOL Social-Emotional Subscale (UW-QOL-SS): chemoradiation therapy (-6.70 [-11.41 to -1.99]) and surgery + postadjuvant treatment (-7.41 [-11.63 to -3.19]). Recurrence (-14.42 [-18.80 to -10.04]) and second primary (-11.15 [-17.71 to -4.59]) demonstrated lower UW-QOL-PS vs primary. Radiation for recurrence or second primary had worse UW-QOL-PS (-10.43 [-19.27 to -1.59]) and UW-QOL-SS (-10.58 [-18.76 to -1.54]) and higher Eating Assessment Tool (6.08 [1.39-10.77]) than surgery alone. Surgery + postadjuvant treatment showed worse UW-QOL-PS (-12.65 [-23.76 to -1.54]) and UW-QOL-SS (-12.20 [-22.38 to -2.03]). Multimodality therapy, particularly with recurrent and second primary HNSCC, is more likely to contribute to diminished QOL and symptoms. This important consideration should play a role in framing informed discussions with patients regarding treatment.

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Evidence-Based Medicine in Otolaryngology, Part XIII: Health Disparities Research and Advancing Health Equity

Uchechukwu C. Megwalu,Nikhila P. Raol,Regan Bergmark,Nosayaba Osazuwa-Peters,Michael J. Brenner

Publication date 22-03-2022


To provide a contemporary resource for clinicians and researchers on health equity research and implementation strategies to mitigate or eliminate disparities in health care. Published studies and literature on health disparities, applicable research methodologies, and social determinants of health in otolaryngology. Literature through October 2021 was reviewed, including consensus statements, guidelines, and scientific publications related to health care equity research. This research focus provides insights into existing disparities, why they occur, and the outcomes of interventions designed to resolve them. Progress toward equity requires intentionality in implementing quality improvement initiatives, tracking data, and fostering culturally competent care. Priority areas include improving access, removing barriers to care, and ensuring appropriate and effective treatment. Although research into health care disparities has advanced significantly in recent years, persistent knowledge gaps remain. Applying the lens of equity to data science can promote evidence-based practices and optimal strategies to reduce health inequities. Health disparities research has a critical role in advancing equity in otolaryngology-head and neck surgery. The phases of disparities research include detection, understanding, and reduction of disparities. A multilevel approach is necessary for understanding disparities, and health equity extensions can improve the rigor of evidence-based data synthesis. Finally, applying an equity lens is essential when designing and evaluating health care interventions, to minimize bias. Understanding the data and practices related to disparities research may help promote an evidence-based approach to care of individual patients and populations, with the potential to eventually surmount the negative effects of health care disparities.

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Evaluation of Agreement Among Frailty Assessment Tools in Head and Neck Surgery

Yash Pandey,Brianna Pandey,Sarah J. Aurit,Oleg Militsakh,William Lydiatt,Daniel Lydiatt,Andrew Coughlin,Robert Lindau,Angela Osmolak,Aru Panwar

Publication date 22-03-2022


To evaluate intertest agreement among hand grip strength (HGS), the modified Frailty Index (mFI), and the Edmonton Frail Scale (EFS) in patients presenting for presurgical assessment in a head and neck surgery clinic. Prospective observational study. Academic tertiary medical center. Prospective data relating to 3 frailty measurements were collected for 96 consecutive adults presenting for presurgical counseling at a single high-volume head and neck surgical oncology clinic. Frailty was determined with previously validated thresholds for the mFI (≥3) and EFS (>7). The highest of 2 HGS measurements performed for the dominant hand was used to determine frail status based on previously validated sex- and body mass index-specific thresholds. Baseline characteristics were identified to determine the association of such variables to each tool. Agreement among frailty assessment tools was examined. The frequency of frailty in the cohort varied among tools, ranging from 29.2% (28/96) for HGS to 12.5% (12/96) for the mFI and 4.2% (4/96) for the EFS. The overall agreement among the 3 frailty tools via the Fleiss index was poor (kappa, 0.088; 95% CI, -0.028 to 0.203). Assessment of frailty is complex, and established frailty assessment tools may not agree on which patients are frail. When assessing a patient as frail, clinicians must be vigilant to the influence of frailty assessment tools on such determinations, which may contribute critical input during shared decision making for patients considering head and neck surgery or nonsurgical alternatives.

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Olfactory Outcomes After Middle Turbinate Resection in Endoscopic Transsphenoidal Surgery: A Prospective Randomized Study

Pei-Yuan Hsu,Li-Chun Hsieh,Yu-Hsuan Wang,Shiu-Jau Chen,Yun-Kai Chan,Kuang-Hsuan Shen,Ying-Piao Wang

Publication date 22-03-2022


Endoscopic endonasal transsphenoidal surgery is safe and effective for sellar and parasellar tumor removal. Partial middle turbinate (MT) resection is sometimes performed to optimize the surgical field and facilitate postoperative care. Disturbances in olfaction are concerning because of the lack of randomized studies in this field. Prospective randomized trial. Single academic medical center. We resected the lower halves of bilateral MTs in the resected group and laterally fractured bilateral MTs in the preserved group. Olfactory outcomes and sinonasal conditions were assessed by using the validated Taiwan Smell Identification Test and Lund-Kennedy Endoscopy Score, respectively. Forty-nine patients were enrolled in the final analysis, of whom 23 underwent partial MT resection. The average Taiwan Smell Identification Test result was 36.9 one month after surgery, with a significant change of -4.4 ± 3.1 (mean ± SD; Endoscopic endonasal transsphenoidal surgery may affect olfaction at 1 month after surgery, and olfactory function is expected to return after 3 months. Partial MT resection did not result in additional olfactory loss. It is safe to perform partial MT resection during surgery without compromising the olfactory outcomes.

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Clinicopathological Predictors of Survival for Parotid Mucoepidermoid Carcinoma: A Systematic Review

Emily YiQin Cheng,Joo Hyun Kim,Elysia M. Grose,Justine Philteos,Marc Levin,John de Almeida,David Goldstein

Publication date 22-03-2022


Various prognostic factors are associated with the survival of patients with parotid mucoepidermoid carcinoma (MEC). The aim of this systematic review is to summarize the clinical and pathologic prognostic factors on survival outcomes in patients with parotid MEC. Articles published from database inception to July 2020 on OVID Medline, OVID Embase, Cochrane Central, and Scopus. Studies were included that reported clinical or pathologic prognostic factors on survival outcomes for adult patients with parotid MEC. Data extraction, risk of bias, and quality assessment were conducted by 2 independent reviewers. A total of 4290 titles were reviewed, 396 retrieved for full-text screening, and 18 included in the review. The average risk of bias was high, and quality assessment for the prognostic factors ranged from very low to moderate. Prognostic factors that were consistently associated with negative survival outcomes on multivariate analysis included histologic grade (hazard ratio [HR], 5.66), nodal status (HR, 2.86), distant metastasis (HR, 3.10-5.80), intraparotid metastasis (HR, 13.52), and age (HR, 1.02-6.86). Prognostic factors that inconsistently reported associations with survival outcomes were TNM stage, T classification, and N classification. Histologic grade, nodal status, distant metastasis, intraparotid metastasis, and age were associated with worse survival outcomes. These prognostic factors should be considered when determining the most appropriate treatment and follow-up plan for patients with parotid MEC.

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Optimizing Pulmonary Outcomes After Total Laryngectomy: Crossover Study on New Heat and Moisture Exchangers

Ylenia Longobardi,Jacopo Galli,Tiziana Di Cesare,Lucia D’Alatri,Stefano Settimi,Dario Mele,Francesco Bussu,Claudio Parrilla

Publication date 22-03-2022


To evaluate the effects of new devices-heat and moisture exchangers (HMEs) and adhesives-on pulmonary symptoms, subject adherence, quality of life, dermatologic symptoms, and patient satisfaction after laryngectomy. Prospective crossover study. Between December 2020 and April 2021, 40 patients were enrolled who had undergone laryngectomy, routinely used HMEs and adhesive, and were followed in our Department of Otolaryngology-Head and Neck Surgery. Patients were allocated into group A (new products) or group B (usual care) for 6 weeks. Then the 2 groups reversed, and each patient acted as his or her own control. Patients kept a diary and cough tally sheet. At baseline and after each 6-week period, 2 questionnaires were administered: EQ-5D (European Quality of Life-5 Dimensions) and CASA-Q (Cough and Sputum Assessment Questionnaire).
Six weeks of using new products resulted in the following effects for both groups: (1) a significant reduction in daily forced expectoration and dry coughs, (2) a significant improvement in all domains of the CASA-Q, (3) an increase in adherence to HME use, (4) a significant reduction in shortness of breath and skin irritation, and (5) significantly better scores in the anxiety/depression domain of the EQ-5D. Achieving this reduction in patients who were already highly adherent to HME use is clinically relevant and underscores the importance of using better-performing HMEs that can compensate for the humidification deficit. Improving pulmonary symptomatology could reduce patient restrictions in daily life and avoidance of social activity, with a consequent positive effect on quality of life.

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Establishing a Multicenter Network for Patients With Thyroid Nodules and Cancer: Effects on Referral Patterns

Sam P.J. van Dijk,Ivona Lončar,Elizabeth van Veen-Berkx,W. Edward Visser,Robin P. Peeters,Charlotte van Noord,Elske T. Massolt,Manuel Castro Cabezas,Marlise Schouten,Erik M. von Meyenfeldt,Tessa M. van Ginhoven

Publication date 15-03-2022


To perform a qualitative evaluation of the Thyroid Network, with a quantitative analysis of second opinion referrals for patients in the southwestern part of the Netherlands who have thyroid nodules and cancer. This prospective observational study registered all patients with thyroid nodules and cancer who were referred to the academic hospital from 2 years before and 4 years after the foundation of the Thyroid Network. We implemented biweekly regional multidisciplinary tumor boards using video conference and a regional patient care pathway for patients with thyroid nodules and cancer. For qualitative evaluation, interviews were conducted with a broad selection of stakeholders via maximum variation sampling. The primary outcome was the change in second opinions after the foundation of the Thyroid Network. Second opinions from Thyroid Network hospitals to the academic hospital decreased from 10 (30%) to 2 (7%) two years after the start of the Thyroid Network ( Establishing a regional network, including multidisciplinary tumor boards and a care pathway for patients with thyroid nodules and cancer, resulted in a decrease in second opinions of in-network hospitals and high satisfaction of participating specialists. The concept of the Thyroid Network could spread to other regions as well as to other specialties in health care. Future steps would be to assess the effect of regional collaboration on quality of care and patient satisfaction.

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Effect of the COVID-19 Pandemic on Otolaryngology Trainee Surgical Case Numbers: A Multi-institutional Review

Scott Mann,James Duffy,Tyler Muffly,Keval Tilva,Stacey Gray,Laura Hetzler,Shannon Kraft,Sonya Malekzadeh,Steven Pletcher,Cristina Cabrera-Muffly

Publication date 15-03-2022


To determine the effect of the initiation of COVID-19-related restrictions on the volume of surgical cases performed by otolaryngology trainees. Multi-institutional retrospective analysis of resident surgical case logs. Accredited residency training programs in otolaryngology head and neck surgery. Resident surgical case logs were combined from 6 residency training programs from different regions of the United States. Case volumes were compared between the calendar year before March 1, 2020, and the year afterward. Subgroup analyses were performed for the type of hospital (university, pediatric, veteran, county) and the key index cases by subspecialty. All 6 participating residency programs had a decrease in resident operative case volume. Surgical volume decreased from a mean of 6014 to 4161 ( In the year following initiation of COVID-19-related restrictions, there was a significant decrease in trainee surgical case volumes within residencies for otolaryngology-head and neck surgery. There were no statistical differences in the volume decreases seen at different institutions, among hospital types, or within various subspecialties.

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Recalls of Moderate- and High-Risk Otolaryngologic Devices Approved by the US Food and Drug Administration, 2003-2019

Ish A. Talati,Keon M. Parsa,William Z. Gao

Publication date 15-03-2022


The US Food and Drug Administration (FDA) regulates the marketing of medical devices based on the premarket approval (PMA) or 510(k) pathway. We investigated the relationship among the regulatory pathway of otolaryngologic devices, the number of recalls, and the recall characteristics. Retrospective cross-sectional analysis. Publicly available FDA databases. The FDA Ear, Nose, and Throat Devices Panel database was queried for 510(k) clearances and PMA approvals from 1976 to 2019. Device recalls from 2003 to 2019 were reviewed. Devices were then categorized by subspecialty, type, supporting evidence, and PMA supplement type. Logistic regression characterized the odds of recall for each device type and subspeciality. A total of 1061 (57.8%) 510(k) and 778 (42.3%) PMA device applications and modifications were approved. There were 120 (11.3%) recall events associated with 42 unique otolaryngologic devices cleared via the 510(k) pathway, as compared with 25 (3.2%) recall events for 5 unique PMA devices. 510(k) device approvals were more likely to be recalled than PMA device approvals (odds ratio, 3.67; 95% CI, 2.38-5.88; Otolaryngologic devices approved by the FDA via the 510(k) pathway exhibit a higher number of recalls than the PMA pathway. Given the balance between regulation and facilitating innovation, postmarket surveillance and ongoing regulatory improvements are critical to ensure optimal safety of medical devices.

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Identifying Olfactory Phenotypes to Differentiate Between COVID-19 Olfactory Dysfunction and Sinonasal Inflammatory Disease

Shaan N. Somani,Nathan Farrokhian,Jamison Macke,Katherine M. Yu,Cody Uhlich,Emma L. Rea,Jennifer A. Villwock

Publication date 15-03-2022


The objective of this study was to identify specific olfactory phenotypes-patterns of olfactory performance-across distinct cohorts with or without olfactory dysfunction (OD).
Adult patients underwent testing via a novel olfactory testing methodology in 1 of 4 groups based on health status: sinonasal inflammatory condition (chronic rhinosinusitis or allergic rhinitis), ≥4 weeks of self-reported OD after resolved COVID-19 infection, Alzheimer's disease, and healthy control. Participants' scores for each scent were normalized on a scale of 0 to 1 relative to their worst and best scores. Agglomerative hierarchal cluster analysis was performed on normalized data for the COVID-19 and sinonasal cohorts. Resulting clusters from the penultimate merger revealed a sensitivity of 81% and specificity of 63% for the detection of patients with COVID-19. These results support that there are olfactory phenotypes that may discriminate COVID-19 OD from sinonasal inflammatory disease. These phenotypes will likely become increasingly leveraged in the workup and treatment of patients with OD.

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Postoperative and 1-Year Functional Outcomes After Free Flap Surgery Among Patients 80 Years or Older

Kyle P. Davis,Anvesh Kompelli,James Reed Gardner,Samantha Mohler,Sarah Gammill,Deanne King,Emre Vural,Jumin Sunde,Mauricio Alejandro Moreno

Publication date 15-03-2022


To evaluate the postoperative and 1-year functional outcomes after free flap surgery among patients ≥80 years old. Retrospective chart review. Single tertiary care center. We conducted a retrospective review of 596 patients who underwent head and neck ablation and reconstruction with free tissue over a 7-year period. Patients ≥80 years of age were included. Fifty patients were ≥80 years old, with an average age of 83.7 years. Ninety-day mortality was 12.0%, and those who died were of older age (87.5 vs 83.1 years, The potential for functional decline and risk of 90-day mortality should be discussed with patients aged ≥80 years.

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Dysphagia Outcomes Following Surgical Management of Unilateral Vocal Fold Immobility in Children: A Systematic Review

Kastley Marvin,Michael Coulter,Christopher Johnson,Tzyynong Friesen,Kimberly Morris,Matthew T. Brigger

Publication date 15-03-2022


To assess dysphagia outcomes following surgical management of unilateral vocal fold immobility in children. Ovid Medline, Embase, Web of Science, and CENTRAL databases. A systematic review of the medical literature was performed following the PRISMA guidelines. An a priori protocol was defined to identify all articles that presented quantifiable outcome data in children aged <18 years who underwent surgical treatment to improve glottal competence for dysphagia. Two authors independently determined references meeting the inclusion criteria, extracted data, and assigned levels of evidence. Data were pooled via a random effects model where possible. The quality of studies was graded with the MINORS criteria. An overall 398 publications were screened, with 9 meeting inclusion criteria. A total of 115 patients were included. Of these, 75% had preoperative swallowing symptoms. Surgical intervention for dysphagia included 61 injection laryngoplasties, 11 medialization laryngoplasties, and 10 reinnervations (ansa cervicalis to recurrent laryngeal nerve). The articles consistently reported success in improving dysphagia symptoms, and limited meta-analysis demonstrated a mean improvement after surgical intervention in 79% (95% CI, 67%-91%) of children. The reported rate of minor and major complications was 15% (95% CI, 1%-29%). The MINORS scores ranged from 5 to 12. Surgical management of unilateral vocal fold immobility in properly selected children can be an effective treatment for dysphagia when symptoms are present. Selection of surgical modalities relies on patient- and surgeon-related factors, and the rate of success is high across different interventions in treating these complex children.

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Enhanced Recovery After Surgery Protocols for Head and Neck Cancer: Systematic Review and Meta-analysis

Nrusheel Kattar,Steven X. Wang,Jeffrey D. Trojan,Craig R. Ballard,Edward D. McCoul,Brian A. Moore

Publication date 15-03-2022


Enhanced recovery after surgery (ERAS) protocols aim to optimize the pre-, intra-, and postoperative care of patients to improve surgery outcomes, reduce complications, decrease length of stay, and more. We aim to perform a systematic review and meta-analysis of ERAS protocols for head and neck cancer surgery with or without microvascular reconstruction. Pub Med, Embase, and Web of Science databases were queried, and abstracts were screened independently by 2 investigators. This review was conducted in accordance with the PRISMA guidelines. We included comparative observational studies but excluded animal studies, case reports, and case series. Of 557 articles initially reviewed by title and/or abstract, we identified 30 for full-text screening, and 9 met the criteria for qualitative synthesis. Meta-analysis of length of stay revealed a mean decrease of 1.37 days (95% CI, 0.77-1.96; Implementation of ERAS protocols can lead to decreases in length of stay and opioid drug utilization. However, further high-quality prospective studies of ERAS protocols are needed, especially with stratified analysis of outcomes based on the type of head and neck cancer surgery.

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Temporal Bone Resection for Squamous Cell Carcinoma of the Lateral Skull Base: Systematic Review and Meta-analysis

Matthew McCracken,Kavya Pai,Claudia I. Cabrera,Benjamin R. Johnson,Akina Tamaki,Paul W. Gidley,Nauman F. Manzoor

Publication date 15-03-2022


Temporal bone squamous cell carcinoma (TBSCC) is rare and often confers a poor prognosis. The aim of this study was to synthesize survival and recurrence outcomes data reported in the literature for patients who underwent temporal bone resection (TBR) for curative management of TBSCC. We considered TBSCC listed as originating from multiple subsites, including the external ear, parotid, and external auditory canal (EAC), or nonspecifically from the temporal bone. Pub Med, Cochrane Library, Embase, and manual search of bibliographies. A systematic literature review conducted in December 2020 according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Survival data were collected from 51 retrospective studies, resulting in a pooled cohort of 501 patients with TBSCC. Compared to patients undergoing lateral TBR (LTBR), patients undergoing subtotal (SBTR) or total (TTBR) TBR exhibited significantly higher rates of stage IV disease ( Recurrent disease was associated with risk of death in patients undergoing TBR. Larger prospective multi-institutional studies are needed to ascertain prognostic factors for a wider array of postoperative outcomes, including histology-specific survival and recurrence outcomes.

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COVID-19 Vaccines and Professional Obligations for Otolaryngologists

Norman D. Hogikyan,Andrew G. Shuman

Publication date 15-03-2022


The American Academy of Otolaryngology-Head and Neck Surgery Foundation recently released a position statement with the following conclusion: "Otolaryngologists have a professional obligation to provide medically indicated care to all patients. They should not use vaccination status as a prerequisite to offer services except in exceptional circumstances. We all have a collective obligation to educate and encourage appropriate best public health practices and evidence-based infection control mitigation strategies including vaccination." We reflect on how this statement is consistent with time-honored principles and professional obligations inherent to the doctor-patient relationship, as well as consonant with the collective lessons that we have learned practicing during the COVID-19 pandemic.

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Advances in Artificial Intelligence to Diagnose Otitis Media: State of the Art Review

Stephany Ngombu,Hamidullah Binol,Metin N. Gurcan,Aaron C. Moberly

Publication date 15-03-2022


Otitis media (OM) is a model disease for developing, validating, and implementing artificial intelligence (AI) techniques. We aim to review the state of the art applications of AI used to diagnose OM in pediatric and adult populations. Several comprehensive databases were searched to identify all articles that applied AI technologies to diagnose OM. Relevant articles from January 2010 through May 2021 were identified by title and abstract. Articles were excluded if they did not discuss AI in conjunction with diagnosing OM. References of included studies and relevant review articles were cross-referenced to identify any additional studies. Title and abstract screening resulted in full-text retrieval of 40 articles that met initial screening parameters. Of this total, secondary review articles (n = 7) and commentary-based articles (n = 2) were removed, as were articles that did not specifically discuss AI and OM diagnosis (n = 5), leaving 25 articles for review. Applications of AI technologies specific to diagnosing OM included machine learning and natural language processing (n = 23) and prototype approaches (n = 2). This review emphasizes the utility of AI techniques to automate and aid in diagnosing OM. Although these techniques are still in the development and testing stages, AI has the potential to improve the practice of otolaryngologists and primary care clinicians by increasing the efficiency and accuracy of diagnoses.

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Nodal Metastases in Pediatric and Adult Acinic Cell Carcinoma of the Major Salivary Glands

Jared C. Dublin,Jamie R. Oliver,Moses M. Tam,Michael J. Persky,Adam S. Jacobson,Cheng Liu,Kenneth S. Hu,Alec E. Vaezi,Luc G.T. Morris,Babak Givi

Publication date 08-03-2022


Acinic cell carcinoma (AciCC) is a rare, usually low-grade salivary malignancy. Evidence on rates of lymph node metastases (LNMs) is limited in pediatric patients and varies significantly (4%-45%) in adults. We set out to determine and compare rates of LNMs in pediatric and adult AciCC and to analyze their impact on survival, using the National Cancer Database. Historical cohort study. National Cancer Database. All AciCCs of the major salivary glands with complete clinical and pathologic nodal staging were selected between 2010 and 2016. Patient demographics, tumor characteristics, treatment, and survival were analyzed. Univariable and multivariable regression were performed to determine factors associated with LNMs and survival. We identified 57 (4.6%) pediatric patients (<18 years) and 1192 (95.4%) adults with AciCC. Clinical LNMs were rare in pediatric patients (n < 10) and adults (n = 88, 7.4%). Occult LNMs were uncommon in pediatric patients (n < 5) and adults (n = 41, 4.6%). Three-year overall survival for pediatric patients was 97.8%. Adults with LNM had worse 3-year overall survival than those without (66.0% vs 96.3%, LNMs in AciCC of the major salivary glands are rare in children and adults. However, high-grade and T3-T4 tumors are associated with an increased risk of LNM. LNM is associated with worse survival.

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Sinonasal Squamous Cell Carcinoma Survival Outcomes Following Induction Chemotherapy vs Standard of Care Therapy

Alexander T. Murr,Nicholas R. Lenze,Jared M. Weiss,Juneko E. Grilley-Olson,Shetal A. Patel,Colette Shen,Bhishamjit S. Chera,Adam M. Zanation,Brian D. Thorp,Siddharth H. Sheth

Publication date 08-03-2022


To compare oncologic outcomes in sinonasal squamous cell carcinoma (SNSCC) treated with standard of care (SOC) definitive therapy, consisting of surgery or chemoradiotherapy, vs induction therapy followed by definitive therapy. Retrospective review. Academic tertiary care hospital. The medical records of patients with biopsy-proven SNSCC treated between 2000 and 2020 were reviewed for demographics, tumor characteristics, staging, treatment details, and oncologic outcomes. Patients were matched 1-to-1 by age, sex, and cancer stage according to treatment received. Time-to-event analyses were conducted. The analysis included 26 patients with locally advanced SNSCC who received either induction therapy (n = 13) or SOC (n = 13). Baseline demographics, Charlson Comorbidity Index, and median follow-up time were well balanced. Weekly cetuximab, carboplatin, and paclitaxel were the most common induction regimen utilized. Tolerance and safety to induction were excellent. Objective responses were observed in 11 of 13 patients receiving induction. No difference in disease-free survival was found between the induction and SOC groups at 1 or 3 years. However, when compared with SOC, induction therapy resulted in significant improvement in overall survival at 2 years (100% vs 65.3%, Induction therapy was safe and effective. When compared with SOC, induction therapy improved 3-year overall survival.

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Examining Associations Between Neighborhood-Level Social Vulnerability and Care for Children With Sleep-Disordered Breathing

Flora Yan,John L. Pearce,Marvella E. Ford,Paul J. Nietert,Phayvanh P. Pecha

Publication date 08-03-2022


We aim to investigate the impact of neighborhood-level social vulnerability on otolaryngology care for children with obstructive sleep-disordered breathing (SDB). Retrospective cohort study. A tertiary children's hospital. Children aged 2 to 17 years with SDB were included. Residential addresses were geocoded with geographic information systems, and spatial overlays were used to assign census tract-level social vulnerability index (SVI) scores to each participant. Multivariable logistic regression models were used to estimate associations of neighborhood SVI scores and individual factors with attendance of otolaryngology referral appointment and interventions. The study included 397 patients (mean ± SD age, 5.9 ± 3.7 years; 51% male, n = 203). After adjustment for age and sex, children with higher overall SVI scores (odds ratio [OR], 0.40; 95% CI, 0.16-0.92) and higher socioeconomic vulnerability scores (OR, 0.34; 95% CI, 0.14-0.86) were less likely to attend their referral appointments. The odds of attending referrals were 83% lower (OR, 0.17; 95% CI, 0.09-0.34) for Black children and 73% lower (OR, 0.27; 95% CI, 0.11-0.65) for Hispanic children than for non-Hispanic White children. Medicaid beneficiaries had lower odds of attending their referrals (OR, 0.20; 95% CI, 0.08-0.48) than privately insured children. Overall SVI score was not associated with receiving recommended polysomnography or tonsillectomy. In our study, children living in areas of greater social vulnerability were less likely to attend their otolaryngology referral appointments for SDB evaluation, as were children of Black race, Hispanic ethnicity, and Medicaid beneficiaries. These results suggest that neighborhood conditions, as well as patient-level factors, influence patient access to SDB care.

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Race and Ethnicity in Otolaryngology Academic Publications

Michael Lindeborg,Taseer Din,Cristóbal Araya-Quezada,Sabreena Lawal,Baveena Heer,Praveen Rajaguru,Myriam Joseph,Blake Alkire,Johannes Fagan

Publication date 08-03-2022


Within otolaryngology, race is commonly included as a study covariate; however, its value in clinical practice is unclear. This study sought to explore how race and ethnicity have been used and applied over time in otolaryngology publications. Pub Med database. A systematic review was done to identify original otolaryngology studies between January 1, 1946, and June 25, 2020, with the following search terms: "otolaryngology" AND "race" OR "ethnicity." Of the 1984 yielded studies, 932 were included in the final analysis. Only 2 studies (0.2%) defined race, and 172 (18.5%) gave participants the opportunity to self-identify race. Less than half (n = 322, 43.8%) of studies controlled for confounders. One hundred studies (10.7%) linked race to genetic factors. An overall 564 (60.5%) made conclusions about race, and 232 (24.9%) mentioned that race is relevant for clinical decision making. The majority of studies had first and senior authors from high-income countries (93.9% and 93.8%, respectively). Over time, there was a significant increase in publications that controlled for confounders, the number of race categories used, and studies that highlighted disparities. Race and ethnicity are often poorly defined in otolaryngology publications. Furthermore, publications do not always control for confounding variables or allow participants to self-identify race. On the basis of our findings, we suggest 7 foundational principles that can be used to promote equitable research in otolaryngology publications. Future efforts should focus on incorporating research guidelines for race and ethnicity into journal publication standards.

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Deep Learning for Predictive Analysis of Pediatric Otolaryngology Personal Statements: A Pilot Study

Yeshwant Reddy Chillakuru,Diego A. Preciado,Jeremy Cha,Hannah Mann,Hengameh K. Behzadpour,Alexandra Genevieve Espinel

Publication date 08-03-2022


The personal statement is often an underutilized aspect of pediatric otolaryngology fellowship applications. In this pilot study, we use deep learning language models to cluster personal statements and elucidate their relationship to applicant rank position and postfellowship research output. Retrospective cohort. Single pediatric tertiary care center. Data and personal statements from 115 applicants to our fellowship program were retrieved from San Francisco Match. BERT (Bidirectional Encoder Representations From Transformers) was used to generate document embeddings for clustering. Regression and machine learning models were used to assess the relationship of personal statements to number of postfellowship publications per year when controlling for publications, board scores, Alpha Omega Alpha status, gender, and residency. Document embeddings of personal statements were found to cluster into 4 distinct groups by We demonstrate ability for document embeddings to capture meaningful information in personal statements from pediatric otolaryngology fellowship applicants. A larger study can further differentiate personal statement clusters and assess the predictive potential of document embeddings.

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Comparison of Caregiver- and Child-Reported Quality of Life in Children With Sleep-Disordered Breathing

Phoebe Kuo Yu,Kaitlyn Cook,Jiayan Liu,Raouf S. Amin,Craig Derkay,Lisa M. Elden,Susan L. Garetz,Alisha S. George,Sally Ibrahim,Stacey L. Ishman,Erin M. Kirkham,S. Kamal Naqvi,Jerilynn Radcliffe,Kristie R. Ross,Gopi B. Shah,Ignacio E. Tapia,H. Gerry Taylor,David A. Zopf,Susan Redline,Cristina M. Baldassari

Publication date 08-03-2022


Caregivers frequently report poor quality of life (QOL) in children with sleep-disordered breathing (SDB). Our objective is to assess the correlation between caregiver- and child-reported QOL in children with mild SDB and identify factors associated with differences between caregiver and child report. Analysis of baseline data from a multi-institutional randomized trial. Pediatric Adenotonsillectomy Trial for Snoring, where children with mild SDB (obstructive apnea-hypopnea index <3) were randomized to observation or adenotonsillectomy. The Pediatric Quality of Life Inventory (PedsQL) assessed baseline global QOL in participating children 5 to 12 years old and their caregivers. Caregiver and child scores were compared. Multivariable regression assessed whether clinical factors were associated with differences between caregiver and child report. PedsQL scores were available for 309 families (mean child age, 7.0 years). The mean caregiver-reported PedsQL score was higher at 75.2 (indicating better QOL) than the mean child-reported score of 67.9 ( Caregiver- and child-reported global QOL in children with SDB was weakly correlated, more so for young children. In pediatric SDB, child-perceived QOL may be poorer than that reported by caregivers. Further research is needed to assess whether similar trends exist for disease-specific QOL metrics.

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A Prospective Analysis of Systemic and Local Aeroallergen Sensitivity in Central Compartment Atopic Disease

Thomas S. Edwards,John M. DelGaudio,Joshua M. Levy,Sarah K. Wise

Publication date 01-03-2022


To compare systemic allergen sensitivity and local allergen sensitivity in the sinonasal tissue of patients with a recently identified subtype of chronic rhinosinusitis strongly associated with allergy: central compartment atopic disease (CCAD). Prospective cohort study. Academic tertiary care rhinology clinic. Fifteen participants with endoscopic and radiographic evidence of CCAD underwent systemic allergy testing with skin testing and measurement of serum specific immunoglobulin E (s IgE) to 15 regionally common aeroallergens. Local allergen sensitivity was determined by measuring s IgE to these same 15 allergens in their sinonasal tissue. s IgE testing was performed by ImmunoCAP assay. Of the 15 participants, 14 were sensitive to at least 1 allergen locally in the central compartment and systemically on skin or serum testing. Among all participants, 4 were sensitive to allergens on central compartment s IgE testing that they were not sensitive to on skin and serum s IgE testing (range, 1-8 discordant allergens). Comparisons between local and systemic aeroallergen sensitivity results showed statistically significant correlations ( Systemic allergy testing is recommended in the initial workup for CCAD. Local allergen sensitivities may be present in a subset of patients with CCAD. Further study of the clinical significance of these sensitivities should be undertaken in CCAD, with evaluation of the role of medical therapies and allergen immunotherapy in the treatment of CCAD.

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Cochlear Implantation in Adults With Single-Sided Deafness: A Systematic Review and Meta-analysis

Samuel J. Oh,Maria A. Mavrommatis,Caleb J. Fan,Aislyn C. DiRisio,Dillan F. Villavisanis,Elisa R. Berson,Zachary G. Schwam,George B. Wanna,Maura K. Cosetti

Publication date 01-03-2022


To determine the clinical outcomes of adult patients with single-sided deafness (SSD) undergoing ipsilateral cochlear implantation. An electronic search of Medline and Embase articles. A systematic review was performed with a search strategy developed by a licensed librarian to identify studies of adult patients with SSD who underwent ipsilateral cochlear implantation. Articles were managed in Covidence and evaluated by 2 independent reviewers. Risk of bias was assessed and data were extracted, including patient demographics, etiology of deafness, duration of deafness, and postoperative change in speech recognition, tinnitus, sound localization, and quality of life (QoL). A meta-analysis was performed, and pooled mean differences were calculated for each outcome of interest via random effects models by each outcome, as well as subgroup analyses by the individual clinical score used. Of 2309 studies identified, 185 full texts were evaluated, and 50 were ultimately included involving 674 patients. Speech perception scores in quiet and noise, tinnitus control, sound localization, and QoL all significantly improved after implantation. Pooled outcomes demonstrated score improvements in speech perception (standardized mean difference [SMD], 2.8 [95% CI, 2.16-3.43]), QoL (SMD, 0.68 [95% CI, 0.45-0.91]), sound localization (SMD, -1.13 [95% CI, -1.68 to -0.57]), and tinnitus score reduction (SMD, -1.32 [95% CI, -1.85 to -0.80]). Cochlear implantation in adults with SSD results in significant improvements in speech perception, tinnitus control, sound localization, and QoL.
Level of evidence: 2.

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RAD51 Inhibitor and Radiation Toxicity in Vestibular Schwannoma

Torin P. Thielhelm,Aida Nourbakhsh,Scott M. Welford,Eric A. Mellon,Olena Bracho,Michael E. Ivan,Fred Telischi,Cristina Fernandez-Valle,Christine T. Dinh

Publication date 01-03-2022


To describe the RAD51 response (DNA repair) to radiation-induced DNA damage in patient-derived vestibular schwannoma (VS) cells and investigate the utility of RAD51 inhibitor (RI-1) in enhancing radiation toxicity. Basic and translational science. Tertiary academic facility. VS tumors (n = 10) were cultured on 96-well plates and 16-well slides, exposed to radiation (0, 6, 12, or 18 Gy), and treated with RI-1 (0, 5, or 10 µM). Immunofluorescence was performed at 6 hours for γ-H2AX (DNA damage marker), RAD51 (DNA repair protein), and p21 (cell cycle arrest protein). Viability assays were performed at 96 hours, and capillary Western blotting was utilized to determine RAD51 expression in naïve VS tumors (n = 5). VS tumors expressed RAD51. In cultured VS cells, radiation initiated dose-dependent increases in γ-H2AX and p21 expression. VS cells upregulated RAD51 to repair DNA damage following radiation. Addition of RI-1 reduced RAD51 expression in a dose-dependent manner and was associated with increased γ-H2AX levels and decreased viability in a majority of cultured VS tumors. VS may evade radiation injury by entering cell cycle arrest and upregulating RAD51-dependent repair of radiation-induced double-stranded breaks in DNA. Although there was variability in responses among individual primary VS cells, RAD51 inhibition with RI-1 reduced RAD51-dependent DNA repair to enhance radiation toxicity in VS cells. Further investigations are warranted to understand the mechanisms of radiation resistance in VS and determine whether RI-1 is an effective radiosensitizer in patients with VS.

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Disparities in Index of Care for Otolaryngologic Procedures Performed in Ambulatory and Inpatient Settings

Shekhar K. Gadkaree,Justin C. McCarty,Autefeh Sajjadi,Harley S. Dresner,Robin W. Lindsay,Mark A. Varvares,David F. Friedlander,Regan W. Bergmark

Publication date 01-03-2022


To compare the same surgical procedure performed in ambulatory and inpatient settings to determine the demographics associated with this selection, the differences in 30-day revisit rates, and the total 30-day cost of care. Retrospective cohort analysis. Ambulatory and inpatient centers in Florida, New York, and Maryland. The Healthcare Cost and Utilization Project, the State Ambulatory Surgery and Services Database, and the State Inpatient Database were used to identify patients undergoing commonly performed otolaryngologic procedures in 2016. The State Emergency Department Database and State Inpatient Database were used to identify 30-day revisits. A total of 55,311 patients underwent an otolaryngologic procedure: 51,136 (92.4%) ambulatory and 4175 (7.6%) inpatient. Adjusted odds of receiving care in the ambulatory setting was significantly lower for Black patients (odds ratio, 0.69 [95% CI, 0.55-0.85]; Disparities exist in the use of ambulatory settings to provide otolaryngologic surgery. Additional research is required to ensure equitable triaging of surgical care setting.

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Prevalence of Depression and Anxiety in Patients With Chronic Rhinosinusitis: A Systematic Review and Meta-analysis

Fei Chen,Libo Liu,Yetong Wang,Ke Hu,Bin Ma,Junting Chi

Publication date 01-03-2022


We performed a meta-analysis and estimated the prevalence of depression and anxiety and their related factors among patients with chronic rhinosinusitis (CRS). Pub Med, Embase, Web of Science, Cochrane Library, CINAHL, PsycINFO, and CBM databases. A systematic search was performed for relevant studies published before August 17, 2021. A random effects model was used to estimate the prevalence of depression and anxiety. Subgroup analysis was performed by continent or region, study setting, sex, sample size, diagnosis, and assessment method. Twenty-two articles covering 40,956 patients were included in the meta-analysis. The pooled crude prevalence estimates of depression and anxiety were 25.2% (95% CI, 20.9%-29.6%) and 28.9% (95% CI, 16.1%-41.6%), respectively.
Subgroup analyses revealed the following: (1) continent or region, study setting, sex, sample size, depression assessment method, and CRS diagnosis were significantly correlated with the prevalence of depression, and (2) continent or region, study setting, sample size, anxiety assessment method, and CRS diagnosis were significantly correlated with the prevalence of anxiety. Meta-regression analysis revealed that study setting and sample size were negatively associated with the pooled prevalence of depression. In contrast, CRS diagnosis and anxiety assessment method were positively associated with the pooled prevalence of anxiety. Depression and anxiety are common in patients with CRS, especially among clinics. Therefore, in patients with CRS, screening and early diagnosis of depression and anxiety are necessary for prevention and treatment.

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Effect of Application Screening Methods on Racial and Ethnic Diversity in Otolaryngology

Christina Dorismond,Zainab Farzal,Rupali N. Shah,Charles S. Ebert,Robert A. Buckmire

Publication date 01-03-2022


Otolaryngology-head and neck surgery (OHNS) lags behind other surgical subspecialties in the representation of underrepresented minorities in medicine (URMs). Given the recently announced changes to Step 1 scoring, we aimed to assess the effect of alternative application screening methods-Step 2 Clinical Knowledge scores and Alpha Omega Alpha membership-on the racial/ethnic diversity of the OHNS applicant pool. After reviewing OHNS residency applications submitted to our institution for the 2015-2020 matches (N = 2177), we determined that a significantly greater proportion of URM vs non-URM applicants would be screened out from interview consideration if any the following were used as an initial screening method: Step 2 cutoff score of 240, Step 2 cutoff score of 253 or non-Alpha Omega Alpha membership (

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Success of Implantable Doppler Probes for Monitoring Buried Free Flaps

Mitchell Frye Dunklebarger,Hilary McCrary,Brody King,Patrick Carpenter,Luke Buchmann,Jason Hunt,Richard Cannon

Publication date 22-02-2022


The objective of this study is to describe the operative success of completely buried free flaps and to determine the safety/reliability of using implantable dopplers for postoperative monitoring in completely buried free flaps. A retrospective chart review was conducted from 2014 to 2020. Patients were included who had implantable dopplers placed for monitoring a completely buried free flap without a visible skin paddle. Single academic cancer hospital. Patient charts were reviewed to determine flap viability after surgery, need for reoperation, and ability of implanted doppler probes to detected change in free flap status. A total of 65 patients were included.
Locations of flaps were as follows: pharynx, 76.9%; skull base, 7.7%; trachea, 6.2%; esophagus, 4.6%; and facial reanimation, 4.6%. Types of free flaps performed included radial forearm (50.8%), anterolateral thigh (44.6%), and gracilis (4.6%). One patient (1.5%) returned to the operating room for vascular compromise, which was accurately detected by the implantable doppler and salvaged. All free flaps were viable upon hospital discharge based on clinical examination and implantable doppler signals. There were no complications related to implantable doppler use. Implantable dopplers are an effective method for evaluating postoperative success of completely buried free flaps. In our series utilizing implantable dopplers, buried free flap survival was higher than traditionally thought. The use of implanted dopplers for monitoring buried free flaps allows for an effective, cosmetically appealing, and simplified reconstructive technique.

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Infectious Complications Following Cochlear Implant: Risk Factors, Natural History, and Management Patterns

Peter K. Moon,Z. Jason Qian,Iram N. Ahmad,Konstantina M. Stankovic,Kay W. Chang,Alan G. Cheng

Publication date 22-02-2022


To describe the natural history, detail the treatment patterns, and identify the risk factors for cochlear implant (CI) infections in a large US cohort. Retrospective study based on insurance claims.
Optum Data Mart database: 6101 patients who received CIs from 2003 to 2019. Infections, treatments patterns, and timelines were described. A multivariable logistic regression model was used to assess the association between postoperative oral antibiotics and CI infection. The cohort includes 4736 (77.6%) adults and 1365 (22.4%) children. Between adult and pediatric patients, rates of CI infection (5.1% vs 4.5%, Postoperative oral antibiotics were not associated with lower risk of infection or interventions. Otitis media episodes and lower income were associated with increased risk of infection among adults as well as intervention overall. Infection typically presented within the first 6 months after surgery, with children presenting earlier than adults. Overall, our findings serve as a resource for providers to consider in their care of patients with CIs.

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Long-term Oncologic Results and Voice Outcomes in Patients With Glottic Cancer After Modified Type III Cordectomy

Chin-Hsuan Liu,Pei-Ju Chien,Li-Ting Hung,Li-Mei Wang,Ya-Chuan Kao,Yueh-Ju Tsai,Pen-Yuan Chu

Publication date 15-02-2022


Transoral laser microsurgery and radiotherapy provide high and comparable cure rates for the treatment of early glottic cancer. However, the voice outcomes after treatment remain controversial. A modified type III cordectomy technique was proposed in 2006, and preliminary results showed it to be an oncologically safe method with satisfactory voice outcomes. This study aimed to evaluate oncologic and voice outcomes after long-term follow-up of these patients. Retrospective cohort study. Tertiary care academic center. Between 2006 and 2018, 42 patients with glottic cancer underwent a modified type III cordectomy. This technique resected the tumor and upper part of the vocal folds and preserved the lower part of the vocalis muscle as a scaffold to improve glottis closure. The oncologic results and voice outcomes were evaluated at a median follow-up of 68 months. The primary tumor stages included 13 T1 (31%), 26 T2 (64%), and 3 T3 (7%). Eight patients (19%) had local recurrence, and 6 underwent successful salvage with transoral laser microsurgery with or without postoperative radiotherapy with laryngeal preservation. The 5-year rate of local control was 80%; laryngeal preservation, 95%; overall survival, 89%; and disease-specific survival, 97%. The final laryngeal preservation rate was 95% (40/42). The voice outcomes were satisfactory and comparable to those of patients who underwent type I and II cordectomies. The modified type III cordectomy has been proven to be an oncologically safe method with satisfactory voice outcomes after long-term follow-up in selected cases of early glottic cancer.

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Hurdles in Diversifying Otolaryngology: A Survey of Medical Students

Bria C. Johnson,Jamil Hayden,Jarrett Jackson,Randall Harley,Earl H. Harley

Publication date 08-02-2022


The field of otolaryngology has one of the lowest rates of racial and ethnic diversity. An anonymous survey was distributed to members of the Student National Medical Association at different medical schools to identify factors that may contribute to this disparity. Responses were received from 104 students at 36 allopathic medical schools. Most respondents identified as black (86.5%). One-third of students (34.6%) noted that they were discouraged from pursuing otolaryngology due to lack of mentorship, and among these students, most noted that they lack mentors of the same race (75%). One-fourth of respondents (25%) indicated that they lack a home otolaryngology program. The most common reasons for participants' disinterest in otolaryngology included competitiveness, inadequate exposure, research, and the high board scores needed to match. This hypothesis-generating, proof-of-concept study highlights potential barriers that may discourage underrepresented medical students from pursuing a career in otolaryngology.

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Automated Extraction of Anatomical Measurements From Temporal Bone CT Imaging

Andy S. Ding,Alexander Lu,Zhaoshuo Li,Deepa Galaiya,Masaru Ishii,Jeffrey H. Siewerdsen,Russell H. Taylor,Francis X. Creighton

Publication date 08-02-2022


Proposed methods of minimally invasive and robot-assisted procedures within the temporal bone require measurements of surgically relevant distances and angles, which often require time-consuming manual segmentation of preoperative imaging. This study aims to describe an automatic segmentation and measurement extraction pipeline of temporal bone cone-beam computed tomography (CT) scans. Descriptive study of temporal bone measurements. Academic institution. A propagation template composed of 16 temporal bone CT scans was formed with relevant anatomical structures and landmarks manually segmented. Next, 52 temporal bone CT scans were autonomously segmented using deformable registration techniques from the Advanced Normalization Tools Python package. Anatomical measurements were extracted via in-house Python algorithms. Extracted measurements were compared to ground truth values from manual segmentations. Paired This is the first study to automatically extract relevant temporal bone anatomical measurements from CT scans using segmentation propagation. Measurements from these models can streamline preoperative planning, improve future segmentation techniques, and help develop future image-guided or robot-assisted systems for temporal bone procedures.

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Not in My Backyard: Centering Health Equity in the Quadruple Aim

J. Nwando Olayiwola

Publication date 08-02-2022


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Sex Disparities in Pediatric Acute Rhinosinusitis: A National Perspective

Vraj P. Shah,Sean Z. Haimowitz,Amar D. Desai,Kendyl Barron,Prayag Patel,Christina H. Fang,Jordon G. Grube,Soly Baredes,Jean Anderson Eloy

Publication date 08-02-2022


This study aims to provide an age-stratified analysis of associations with patient sex in pediatric inpatients with acute rhinosinusitis (ARS). Retrospective cohort study. National administrative database. The 2016 Kids' Inpatient Database was queried for pediatric inpatients (<21 years old) with ARS ( Of the 5882 patients identified with ARS, 2404 (40.9%) were female and 3478 (59.1%) were male. Male patients were younger than female patients (mean, 9.3 vs 9.9 years; In a cohort of pediatric inpatients with ARS, males have increased odds for orbital and intracranial sequelae and undergo more procedures than females. However, males and females have similar charges and length of stay. Our study highlights age-stratified differences in ARS across patient sex.

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Female Representation Among CORE Grant Recipients by Research Subspeciality

Kelsey M. Roman,Anh-Tram Bui,Jack Birkenbeuel,Tjoson Tjoa,Yarah M. Haidar,Edward C. Kuan

Publication date 08-02-2022


This study evaluates the gender distribution of Centralized Otolaryngology Research Efforts (CORE) grants by research subspeciality over the past decade. Demographic information on CORE grant recipients from 2010 to 2019 was extracted through an Internet search, and research projects were categorized by subspeciality. Of 343 grants awarded during this period, 127 (37%) were awarded to women. Analysis demonstrated lower absolute rates of CORE funding for women in all fields except pediatrics, but women receive a proportional number of grants for most subspecialities based on their representation within the field.

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A Systematic Review of Head and Neck Cancer Health Disparities: A Call for Innovative Research

Rohit Nallani,Thamara L. Subramanian,Kiatana M. Ferguson-Square,Joshua B. Smith,Jacob White,Alexander G. Chiu,Carrie L. Francis,Kevin J. Sykes

Publication date 08-02-2022


(1) Describe the existing head and neck cancer health disparities literature. (2) Contextualize these studies by using the NIMHD research framework (National Institute on Minority Health and Health Disparities). (3) Explore innovative ideas for further study and intervention. Ovid MEDLINE, Embase, Web of Science, and Google Scholar. Databases were systematically searched from inception to April 20, 2020. The PRISMA checklist was followed (Preferred Reporting Items for Systematic Reviews and Meta-analyses). Two authors reviewed all articles for inclusion. Extracted data included health disparity population and outcomes, study details, and main findings and recommendations. Articles were also classified per the NIMHD research framework. There were 148 articles included for final review. The majority (n = 104) focused on health disparities related to at least race/ethnicity. Greater than two-thirds of studies (n = 105) identified health disparities specific to health behaviors or clinical outcomes. Interaction between the There has been extensive study of health disparities for head and neck cancer, largely focusing on individual patient factors or health care access and quality. This review identifies gaps in this research, with large numbers of retrospective database studies and little discussion of potential contributors and explanations for these disparities. We recommend shifting research on disparities upstream toward a focus on community and societal factors, rather than individual, and an evaluation of interventions to promote health equity.

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Patient-Defined Goals for Obstructive Sleep Apnea Treatment

Yi Cai,Priyanka Tripuraneni,Arushi Gulati,Erika M. Stephens,Dang-Khoa Nguyen,Megan L. Durr,Jolie L. Chang

Publication date 08-02-2022


To characterize the treatment goals and values of adult patients with obstructive sleep apnea (OSA). Mixed methods design based on semistructured interviews followed by cross-sectional surveys. Academic medical center and integrated managed care consortium. Phase 1 involved qualitative analysis of focus groups and interviews to define treatment goal categories. Phase 2 included analysis of cross-sectional surveys on most important treatment goals from patients with OSA presenting to sleep surgery clinic. Positive airway pressure (PAP) use, Epworth Sleepiness Scale score, and apnea-hypopnea index were obtained to determine influences on goal choices. During focus groups and interviews, treatment goal themes identified included improving sleep quality, reducing daytime sleepiness, snoring sound reduction, and health risk reduction. In phase 2, 536 patients were surveyed, and they reported the primary treatment goals of health risk reduction (35%), sleep quality improvement (28%), daytime sleepiness improvement (21%), and snoring sound reduction (16%). The primary treatment goal was associated with age ( Adult OSA treatment goal choices vary with age, symptoms, PAP history, and OSA severity. Understanding patient-specific goals is the essential first step in the shared decision-making process when choosing surgical or nonsurgical treatments. Ultimately, goal-focused discussions ensure alignment of priorities and definitions of success between the patient and the provider.

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Patient Satisfaction With Otolaryngology Care: Stratification by Race, Age, Gender, Income, and Language

Matthew R. Naunheim,Lucy Xu,Guohai Zhou,Aalok Agarwala

Publication date 08-02-2022


To understand how race, gender, income, and language are correlated with patient satisfaction scores. Cross-sectional analysis of patient satisfaction data. An urban/suburban academic otolaryngology practice. Patients presenting for outpatient otolaryngology visits from 2017 to 2020 were surveyed for patient satisfaction following a visit with their otolaryngology provider. Categorical responses and numerical responses were collected regarding overall satisfaction as well as a variety of more specific satisfaction questions. Responses were matched to both provider characteristics and patient demographic data. Differences in satisfaction by demographic data were assessed with descriptive statistics as well as a multivariable mixed-effect model to adjust for repeated responder data and control for confounding factors. In total, 55,469 surveys were included, the majority of which were from white, English-speaking patients. Overall satisfaction levels were very high across all questions. The individual provider was associated highly with satisfaction, but provider gender was not. Race, age, and gender of the patient had a statistically significant impact on patient satisfaction, with higher levels of satisfaction among patients who were older, white, and male; income and language did not. Patient factors including race, age, and gender had a significant impact on ratings on outpatient otolaryngology patient satisfaction surveys, with nonwhite, younger, female patients reporting lower scores.

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Outcomes in Pediatric Thyroidectomy: Results From a Multinational, Multi-institutional Database

Matthew Maksimoski,Andrew J. Bauer,Ken Kazahaya,Scott C. Manning,Sanjay R. Parikh,Jeffrey P. Simons,Jill D’Souza,John Maddalozzo,Matthew R. Purkey,Karen Rychlik,Brian Ho,Michael J. Rutter,Wen Jiang,Jeremy D. Prager,Gillian Diercks,Evan J. Propst,R. Christopher Miyamoto,Brendan C. Stack,Gregory W. Randolph,Jeffrey C. Rastatter

Publication date 08-02-2022


Traditionally, data regarding thyroidectomy were extracted from billing databases, but information may be missed. In this study, a multi-institutional pediatric thyroidectomy database was used to evaluate recurrent laryngeal nerve (RLN) injury and hypoparathyroidism. Retrospective multi-institutional cohort study. Tertiary care pediatric hospital systems throughout North America. Data were individually collected for thyroidectomies, then entered into a centralized database and analyzed using univariate and multivariable regression models. In total, 1025 thyroidectomies from 10 institutions were included. Average age was 13.9 years, and 77.8% were female. Average hospital stay was 1.9 nights and 13.5% of patients spent at least 1 night in the pediatric intensive care unit. The most frequent pathology was papillary thyroid carcinoma (42%), followed by Graves' disease (20.1%) and follicular adenoma (18.2%). Overall, 1.1% of patients experienced RLN injury (0.8% permanent), and 7.2% experienced hypoparathyroidism (3.3% permanent). Lower institutional volume (odds ratio [OR], 3.57; 95% CI, 1.72-7.14) and concurrent hypoparathyroidism (OR, 3.51; 95% CI, 1.64-7.53) correlated with RLN injury on multivariable analysis. Graves' disease (OR, 2.27; 95% CI, 1.35-3.80), Hashimoto's thyroiditis (OR, 4.67; 95% CI, 2.39-9.09), central neck dissection (OR, 3.60; 95% CI, 2.36-5.49), and total vs partial thyroidectomy (OR, 7.14; 95% CI, 4.55-11.11) correlated with hypoparathyroidism. These data present thyroidectomy information and complications pertinent to surgeons, along with preoperative risk factor assessment. Multivariable analysis showed institutional volume and hypoparathyroidism associated with RLN injury, while hypoparathyroidism associated with surgical indication, central neck dissection, and extent of surgery. Low complication rates support the safety of thyroidectomy in pediatric tertiary care centers.

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Sinus Surgery and Balloon Sinuplasty: What Do Patients Want to Know?

Scott N. Fassas,Andrew M. Peterson,Nathan Farrokhian,Jordan G. Zonner,Emily L. Cummings,Zachary Arambula,Alexander G. Chiu,Meha Goyal Fox

Publication date 08-02-2022


Limited knowledge exists regarding the information patients seek online about sinus procedures. The goals of our study were to identify the most searched online queries regarding functional endoscopic sinus surgery (FESS) and balloon sinuplasty and evaluate the sources to which patients are directed. Observational. Online Google Database. Google data were analyzed using the search engine optimization tool Ahrefs. People Also Ask (PAA) questions (extracted from Google searches) helped identify questions for analysis of search query volume. Search results were categorized into specific topics, and the source (eg, academic vs medical practice) of the information was identified. The The most searched term (average monthly queries) on Google was "sinus surgery" (13,190), followed by "balloon sinuplasty" (9212). For FESS and balloon sinuplasty, most questions focused on treatment of sinusitis (71.64% vs 79.19%) and preoperative inquiries about sinus issues (11.50% vs 11.35%). Answers to PAA questions for FESS were obtained from academic sources at a higher frequency compared to balloon sinuplasty (26.7% vs 10.3%, There is a high volume of online search queries regarding FESS and balloon sinuplasty. The quality of the sources could be improved by addressing authorship, attribution, disclosure, and currency. This information may help otolaryngologists better address patient queries.

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Using Machine Learning to Predict Operating Room Case Duration: A Case Study in Otolaryngology

Lauren E. Miller,William Goedicke,Matthew G. Crowson,Vinay K. Rathi,Matthew R. Naunheim,Aalok V. Agarwala

Publication date 08-02-2022


Optimizing operating room (OR) efficiency depends on accurate case duration estimates. Machine learning (ML) methods have been used to predict OR case durations in other subspecialties. We hypothesize that ML methods improve projected case lengths over existing non-ML techniques for otolaryngology-head and neck surgery cases. Deidentified patient information from otolaryngology surgical cases at 1 academic institution were reviewed from 2016 to 2020. Variables collected included patient, surgeon, procedure, and facility data known preoperatively so as to capture all realistic contributors. Available case data were divided into a training and testing data set. Several ML algorithms were evaluated based on best performance of predicted case duration when compared to actual case duration. Performance of all models was compared by the average root mean squared error and mean absolute error (MAE). In total, 50,888 otolaryngology surgical cases were evaluated with an average case duration of 98.3 ± 86.9 minutes. Most cases were general otolaryngology (n = 16,620). Case features closely associated with OR duration included procedure performed, surgeon, subspecialty of case, and postoperative destination of the patient. The best-performing ML models were Cat Boost and XGBoost, which reduced operative time MAE by 9.6 minutes and 8.5 minutes compared to current methods, respectively. The incorporation of other easily identifiable features beyond procedure performed and surgeon meaningfully improved our operative duration prediction accuracy. Cat Boost provided the best-performing ML model. ML algorithms to predict OR case time duration in otolaryngology can improve case duration accuracy and result in financial benefit.

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Examination of Sex Differences in a Chronic Rhinosinusitis Surgical Cohort

Laylaa Ramos,Conner J. Massey,Annapoorani Asokan,John D. Rice,Miranda Kroehl,Vijay R. Ramakrishnan

Publication date 08-02-2022


Sex discrepancies have been reported in chronic rhinosinusitis (CRS), but limited data exist exploring sex-specific biological processes and sinonasal quality of life. Prospective cohort. Academic medical center. Demographics, clinical data, and sinonasal mucus were collected from patients with CRS presenting for surgical consideration over a 5-year period. A random forest model and linear regression were used to assess predictor variables for the 22-item Sino-Nasal Outcome Test (SNOT-22) and subdomains. Enzyme-linked immunosorbent assays were used to measure substance P and tryptase in a subset of mucus samples to explore biological differences by sex. In total, 520 patients were studied (mean age 48.3 years, 50.9% female). Males were older (50.1 vs 46.6 years, Sex differences exist in CRS disease manifestations and presentation for surgical consideration. Detection of mucus (substance P and tryptase) was reliable, but in this exploratory study, we were not able to establish neurogenic or allergic inflammatory processes as a large source of differential disease features between sexes.

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Radiological Analysis of the Facial Recess: Impact on Posterior Tympanotomy Difficulty During Pediatric Cochlear Implantation

Saad Elzayat,Mahmoud Mandour,Haitham H. Elfarargy,Rasha Lotfy,Islam Soltan,Ashraf Lotfy,Valerio Margani,Edoardo Covelli,Simonetta Monini,Maurizio Barbara

Publication date 08-02-2022


We analyzed several radiological features of the facial recess to correlate them with the intraoperative findings to highlight the most reliable predictors of posterior tympanotomy difficulty. Retrospective observational cohort study. Multicenter study at tertiary referral institutions. We included 184 pediatric patients who underwent cochlear implantation through the posterior tympanotomy approach. The correlation was attempted between 8 radiological features in the preoperative high-resolution computed tomography scan and intraoperative surgical difficulty. Posterior tympanotomy was straightforward in 136 (73.9%) patients. In contrast, it was challenging in 48 (26.1%) patients. The facial recess was aerated in 74.5% of patients. The mean (SD) posterior tympanotomy depth was 3.98 (0.867) mm. The mean (SD) chorda-facial angle was 27.67° (3.406°). The mean (SD) chorda-facial to stylomastoid length was 3.898 (0.6304) mm. The mean (SD) facial nerve second genu angle was 94.54° (6.631)°. Deep-unaerated facial recess wall was associated with the most difficulty. There was a statistically significant difference in the unchallenging and challenging posterior tympanotomy groups regarding the surgical duration ( According to this analytic study, the chorda-facial angle, the facial recess aeration, and the chorda-facial to stylomastoid length were respectively the strongest preoperative radiological predictors of the surgical difficulty of posterior tympanotomy during cochlear implantation. Chorda-facial angle <25.5° was associated with difficult posterior tympanotomy. The oblique parasagittal cut was essential for the radiological analysis of the facial recess.

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Hearing Stability in Patients With Unilateral Hearing Loss Due to Congenital CMV

Kristin A. Tissera,Alisha Williams,Julia Perry,Kosuke Kawai,Margaret Kenna,Leila A. Mankarious

Publication date 08-02-2022


To determine the incidence and severity of progressive hearing loss in both ears in a population of longitudinally-tracked patients with unilateral hearing loss due to congenital cytomegalovirus (cCMV). By determining the natural history of unilateral hearing loss due to cCMV infection, we aim to facilitate therapeutic recommendations. Retrospective chart review. Two tertiary care hospitals. Pure-tone averages (PTAs) based on yearly audiograms were calculated for each patient for both ears, and changes were assessed using a linear mixed-effects model. A total of 32 patients with cCMV with congenital, unilateral hearing loss were enrolled. Of these, 4 (12.5%) had progressive losses ≥10 dB by PTA in the initially normal-hearing ear. For the hearing-impaired side, the mean (SD) PTA at initial presentation was 67.9 (29.2) dB. Eight patients initially in this cohort had profound hearing impairment, and of the other 24 patients, 17 (70.8%) had hearing loss progression. Hearing levels stabilized in the initially normal-hearing and hearing-impaired ear when patients were approximately 10 and 2 years old, respectively. In 32 patients with unilateral hearing loss related to cCMV, 4 (12.5%) exhibited a shift in hearing levels in the normal-hearing ear that progressively stabilized by age 10 years. For ears with congenital hearing loss, progressive stabilization of hearing occurred by age 2 years.

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Resident Burnout and Well-being in Otolaryngology and Other Surgical Specialties: Strategies for Change

Hemali P. Shah,Parsa P. Salehi,Jacqueline Ihnat,David D. Kim,Pauniz Salehi,Benjamin L. Judson,Babak Azizzadeh,Yan Ho Lee

Publication date 08-02-2022


To perform a literature review on burnout prevalence, factors that affect burnout and well-being, and solutions to address burnout in otolaryngology-head and neck surgery (OTO-HNS) residents and residents in other surgical specialties. Ovid Medline, Embase, and article reference lists. A literature search was performed to identify articles on resident burnout, distress, wellness, well-being, and quality of life. Articles deemed outside the scope of the current work were excluded. Search was limited to the past 5 years. Moderate to high burnout has been reported in 35% to 86% of OTO-HNS residents. Among other surgical specialties, resident burnout ranges between 58% and 66% in plastics, 11% and 67% in neurosurgery, 38% and 68% in urology, and 31% and 56% in orthopedics. Highest burnout rates were seen in postgraduate year 2 residents. Factors significantly associated with burnout included hours worked (>80 h/wk), level of autonomy, exercise, and program support.
Reported resident work hours have steadily increased: 8% of OTO-HNS residents in 2005 vs 26% in 2019 reported averaging >80 h/wk. Practical implications of resident burnout include decreased empathy, moral distress and injury, poor health, decreased quality of life, increased attrition, decreased desire to pursue fellowship, and increased likelihood of medical errors. Structured mentorship programs, wellness initiatives, and increased ancillary support have been associated with lower burnout rates and improvements in resident well-being across specialties. Addressing burnout, which is prevalent in OTO-HNS residents, is critical to improving patient care and physician well-being. Surgical specialties can share strategies to effectively address resident burnout through institutional interventions, which can be essential quality improvement initiatives, to promote well-being.

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Redefining Perineural Invasion in Head and Neck Cutaneous Squamous Cell Carcinoma

Erin R. Cohen,Carly Misztal,Cortney Dable,Carmen Gomez-Fernandez,Rita G. Bhatia,Patrick Roth,Ruixuan Ma,Samuel Trosman,Carlos Green,Elizabeth Nicolli,Christine T. Dinh,Zoukaa B. Sargi

Publication date 08-02-2022


Perineural invasion (PNI) negatively affects disease-specific survival in patients with head and neck cutaneous squamous cell carcinoma (HNcSCC). We aim to analyze the prognostic implications of PNI-related features. Retrospective cohort study. Academic tertiary care hospital. Retrospective chart review was performed on 104 patients diagnosed with HNcSCC between January 2011 and October 2019 who underwent resection, parotidectomy, and neck dissection with more than 1 year of follow-up. PNI was classified as incidental (identified on histopathology alone) or clinical (present on radiography and/or physical exam). Primary outcome measures were overall survival and disease-free survival (DFS). Kaplan-Meier analysis, logistic regression, and Cox regression were performed. The overall 5-year DFS was 57.9%. Sixty-one patients had PNI. On histopathology, 28 lesions showed complete nerve encirclement, 10 involved >5 nerves, and 12 involved named nerves. Patients with facial weakness ( DFS was significantly worse in patients with PNI, facial nerve weakness, advanced T stage, positive margins, and multiple nerve involvement. Further characterization of PNI features may help improve prognostic predictions and identify patients who may benefit from more aggressive treatment.

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Cost-effectiveness of Canal Wall-Up vs Canal Wall-Down Mastoidectomy: A Modeling Study

Daniel D. Bu,Zachary G. Schwam,Vivian F. Kaul,Kevin Wong,Caleb Fan,George B. Wanna,Maura K. Cosetti,Enrique Perez

Publication date 08-02-2022


To assess the relative lifetime costs, benefits, and cost-effectiveness between the 2 approaches, canal wall-up (CWU) and canal wall-down (CWD) tympanomastoidectomy, used in the treatment of cholesteatomas. Markov state transition model. Tertiary academic health system. A Markov state transition model was used to simulate outcomes across the patient lifetime. Outcome and complication probabilities were obtained from the existing literature. Costs were calculated from the payer perspective, with procedure, hospital, clinic, and physician cost derived from Medicare reimbursement. Quality-adjusted life years (QALYs) were used to represent effectiveness and utility. One-way and probability sensitivity analyses (PSAs) were conducted. The base case analysis, assuming a 40-year-old patient, yielded a lifetime cost of $14,214 for a patient treated with the CWU approach assuming second-look surgery and $22,290 with a CWD approach. CWU and CWD generated a benefit of 17.11 and 17.30 QALYs, respectively. The incremental cost-effectiveness ratio for CWU was $43,237 per QALY. The Monte Carlo PSA validated the base case scenario. Using a standard $50,000 willingness-to-pay threshold, CWD was the more cost-effective approach and was selected 54.8% of the time by the simulation. Both CWU and CWD were found to be cost-effective, with CWD being cost-effective 54.8% of the time at a WTP threshold of $50,000. The assumptions used in the analysis were validated by the results of 1-way and PSA.

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COVID-19 Tracheostomy Outcomes

Nicole Molin,Keith Myers,Ahmed M.S. Soliman,Cecelia E. Schmalbach

Publication date 01-02-2022


(1) Assess overall COVID-19 mortality in ventilated patients with and without tracheostomy. (2) Determine the impact of tracheostomy on mechanical ventilation duration, overall length of stay (LOS), and intensive care unit (ICU) LOS for patients with COVID-19. Case series with planned chart review. Single-institution tertiary care center. Patients with COVID-19 who were ≥18 years old and requiring invasive positive pressure ventilation (IPPV) met inclusion criteria.
Patients were stratified into 2 cohorts: IPPV with tracheostomy and IPPV with intubation only.
Cohorts were analyzed for the following primary outcome measures: mortality, LOS, ICU LOS, and IPPV duration.
An overall 258 patients with IPPV met inclusion criteria: 46 (18%) with tracheostomy and 212 (82%) without (66% male; median age, 63 years [interquartile range, 18.75]). Average LOS, time in ICU, and time receiving IPPV were longer in the tracheostomy cohort ( While tracheostomy placement in patients with COVID-19 did not shorten overall LOS, mechanical ventilation duration, or ICU LOS, patients with a tracheostomy experienced a significantly lower number of deaths vs those without. One goal for tracheostomy is improved pulmonary toilet with associated shortened IPPV requirements. Our study did not identify this advantage among the COVID-19 population. However, this study demonstrates that the need for tracheostomy in the COVID-19 setting does not portent a poor prognostic factor, as patients with a tracheostomy experienced a significantly higher survival rate than their nontracheostomy counterparts.

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Laryngopharyngeal Reflux: Evolution and Predictive Value of Symptoms and pH-Impedance Features on Clinical Evolution

Jerome R. Lechien,Sven Saussez,Vinciane Muls,Didier Dequanter,Lisa G. De Marrez,Stéphane Hans,Alexandra Rodriguez,Quentin Lisan

Publication date 01-02-2022


To investigate the features of patients with laryngopharyngeal reflux (LPR) who did not respond to medical treatment. Prospective uncontrolled study. Multicenter study. Patients with LPR at 24-hour HEMII-pH monitoring (hypopharyngeal-esophageal multichannel intraluminal impedance-pH) were prospectively recruited from 3 European university centers. Patients were treated with 3- to 6-month medication (proton pump inhibitor and alginate) and categorized as mild to moderate responders, high responders, or nonresponders according to Reflux Symptom Score (RSS) changes at 6 months posttreatment.
The predictive value of the following outcomes was studied: epidemiologic data, HEMII-pH, gastrointestinal endoscopy findings, baseline RSS and Reflux Sign Assessment, and early therapeutic response (6-week RSS). A total of 148 patients completed the evaluations, accounting for 40 mild to moderate responders (20%-60% RSS changes), 76 high responders (>60% RSS changes), and 32 nonresponders. Nonresponders presented more often with hiatal hernia and lower esophageal sphincter insufficiency when compared with mild to moderate and high responders ( Hiatal hernia and baseline and 6-week RSS were the most predictive indicators of therapeutic effectiveness in patients with LPR.

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Correlation Between a Diagnosis of Anxiety or Depression and Initial VHI-10 Scores in Benign Dysphonia

Kwasi Enin,Ayush Parikh,Dorina Kallogjeri,Matthew R. Naunheim,Molly N. Huston

Publication date 01-02-2022


Anxiety and depression have demonstrated a positive correlation with vocal handicap among patients with benign causes of dysphonia. Our objective is to explore differences in initial Vocal Handicap Index-10 (VHI-10) scores between patients with a mental health history of anxiety or depression and those without. Retrospective cohort study. Demographic data, diagnoses, and initial VHI-10 scores were collected for patients presenting with dysphonia to 2 tertiary laryngology clinics. A Kruskal-Wallis test and subsequent Mann-Whitney A total of 620 cases of benign dysphonia were analyzed. Forty-two percent of the patient cohort had a preexisting diagnosis of anxiety (n = 121, 20%), depression (n = 64, 10%), or anxiety and depression (n = 74, 12%). VHI-10 scores were higher in patients with depression than in those without anxiety or depression (median difference, 4 [95% CI, 1-8]; Patients with a history of depression who presented with dysphonia had worse vocal handicap than those without anxiety/depression history. Future studies may clarify how optimization of anxiety and depression can affect patient-reported vocal handicap.

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Model of an Advanced Practice Provider–Led Head and Neck Cancer Survivorship Clinic: Evaluation of a 4-Year Experience

Jennifer Silva-Nash,Kyle P. Davis,James Reed Gardner,Jumin Sunde,Emre Vural,Samantha Rose,Mauricio Alejandro Moreno

Publication date 25-01-2022


To report the efficacy and safety of an advanced practice provider-led head and neck cancer survivorship clinic. Retrospective chart review. Tertiary academic medical center. Patients were enrolled into the survivorship clinic after undergoing 1-year follow-up with the primary head and neck surgeon. Those enrolled between December 2016 and October 2020 were retrospectively reviewed for diagnosis, staging, pattern of recurrence, visit frequency, and compliance. Surgical respectability of recurrent disease was used as a surrogate for timely diagnosis. An overall 570 patients were followed within the survivorship clinic. The mean length of follow-up was 13.6 months. Mucosal primaries represented 72.6% of patients. A majority of the primary malignancies were squamous cell carcinoma (77.7%). The most common primary subsites were the oropharynx (26.7%), oral cavity (25.1%), cutaneous (17.0%), and larynx (15.3%). Recurrence was detected in 50 patients (8.8%): 26 local, 12 regional, and 14 distant. Two patients had multiple synchronous recurrences. Twelve (2.1%) second primary cancers were detected. Of the 36 cases of locoregional recurrence, 32 (88.9%) were deemed amenable to salvage surgical intervention, with or without adjuvant therapy. Negative margins were obtained in 21 of the 23 (91.3%) local recurrences that underwent salvage resection. Advanced practice provider-based surveillance of head and neck cancer, without risk stratification, appears to be a sound model but needs further prospective evaluation. Consistent with literature, 88.9% of patients with locoregional recurrence were candidates for curative-intent salvage surgery, emphasizing that recurrences are identified in a timely fashion.

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Identifying Patient Characteristics That Predict Drug-Induced Sleep Endoscopy Anatomy

Thomas Zhang Gao,Xueliang Pan,Akash Naik,Rohan Khandalavala,Stuart Ramsell,Hannah Gibbs,Eugene Chio

Publication date 25-01-2022


To examine if age, sex, body mass index (BMI), neck circumference, or apnea-hypopnea index can predict whether a patient will demonstrate velopharyngeal complete circumferential (CC) collapse on drug-induced sleep endoscopy (DISE). Single-center retrospective review at The Ohio State Wexner Medical Center of 289 patients between March 2014 and June 2020. Quaternary care hospital. Patient characteristic and DISE information was extracted from charts and summarized with mean and standard deviation for continuous variables and count and percentage for categorical.
CC collapse and patient characteristic associations were explored: 2-sample Male and female BMI and female neck circumference were correlated to velopharyngeal CC collapse, with BMI more strongly correlated. CART analysis for males showed that a BMI ≤34.8 kg/m The BMI values for males and females and the female neck circumference values established by the CART model may accurately predict DISE anatomy and possible candidacy for hypoglossal nerve stimulation.

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Impact of Language and Ethnicity on Pediatric Tracheostomy Outcomes

Nathan Garza,Stephen R. Chorney,Yann-Fuu Kou,Romaine F. Johnson

Publication date 25-01-2022


To compare outcomes after tracheostomy between children from Spanish- and English-speaking families. Prospective cohort study. Tertiary care children's hospital. All children <18 years of age who had a tracheostomy placed between 2014 and 2020 were included. Comorbidities and postsurgical outcomes were compared between (1) children whose families preferred speaking Spanish or identified as Hispanic/Latino and (2) children from English-language or non-Hispanic families. A total of 339 children met inclusion, with 11% (37/339) from families identifying Spanish as their primary language and 33% (112/339) identifying as Hispanic. Spanish-speaking families were more likely to have tracheostomy-dependent children with cardiac conditions (65% vs 42%, Spanish language and Hispanic ethnicity appear to have minimal impact on pediatric tracheostomy outcomes.

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Clinical and Biologic Characteristics and Outcomes in Young and Middle-Aged Patients With Laryngeal Cancer: A Retrospective Cohort Analysis

Calvin X. Geng,Priscilla Tanamal,Simone Arvisais-Anhalt,Massimo Tomasino,Tarik Gheit,Justin A. Bishop,Doreen N. Palsgrove,Ellen Wang,Jordan R. Salley,Kathleen M. Tibbetts,Baran D. Sumer,Brittny N. Tillman,Andrew T. Day

Publication date 25-01-2022


To describe the clinical and biologic characteristics and outcomes of young and middle-aged (YMA; <65 years) patients according to the presence or absence of traditional risk factors for laryngeal cancer. Retrospective cohort analysis. Single-institution academic medical center. Patients without a history of clinically significant tobacco use or heavy alcohol use were defined as "nontraditional": ≤5 pack-years, ≤5 years smoked, ≤14 alcoholic drinks per week, and ≥15-year interval from last tobacco abuse use to diagnosis. Remaining patients were categorized as "traditional." Select tumor samples were evaluated for bacterial and viral DNA by multiplex polymerase chain reaction. Seventy-eight YMA patients with primary laryngeal squamous cell carcinoma were identified, 23% (n = 18) of whom were nontraditional. Nontraditional patients were younger than traditional patients (median age, 51 vs 59 years; Almost one-quarter of YMA patients lacked characteristic risk factors for laryngeal squamous cell carcinoma, and their tumors exhibited a higher prevalence of high-risk HPV. The significance of HPV16 and other tumor viruses with outcomes in nontraditional patients should be evaluated further.

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Recurrence Following Endoscopic Laser Wedge Excision and Triple Medical Therapy for Idiopathic Subglottic Stenosis

Andrew Jay Bowen,Katherine Z. Xie,Thomas J. O’Byrne,Semirra L. Bayan,Eric S. Edell,Robert Vassallo,Dale C. Ekbom,Jan L. Kasperbauer

Publication date 25-01-2022


We present the outcomes for patients with idiopathic subglottic stenosis (iSGS) following their first carbon dioxide laser wedge excision (LWE) procedure, additionally examining the effect of compliance with adjuvant medical therapy (triple therapy) after the operation. Retrospective chart review. Tertiary center. A retrospective review was performed on 183 patients with iSGS following their first LWE and their compliance to adjuvant medical therapy (inhaled corticosteroid, proton pump inhibitor, trimethoprim-sulfamethoxazole) following the operation, with all reviewed to December 31, 2020. The primary outcome variable was median time to recurrence (MTR). Patients were stratified by whether the LWE was their first operation (LWE primary or secondary), by compliance to triple therapy, and by compliance with trimethoprim-sulfamethoxazole. Kaplan-Meier analysis and Cox proportional hazards were used to evaluate the MTR across the stratifications. An overall 113 patients underwent their first LWE, while 70 received the procedure after having undergone 1 to 13 procedures. The MTR between LWE primary and secondary was 4.6 and 2.9 years, respectively. Adjusted Cox proportional hazards comparing these 2 groups revealed the number of prior operations to be a confounding variable. A statistically increased MTR was demonstrated with greater degrees of medical compliance. LWE conferred an MTR of 4.1 years in the iSGS cohort. The number of prior procedures preceding LWE behaved as a confounding variable. Patients who were completely or partially compliant to triple therapy appear to demonstrate increased intervals prior to recurrence.

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Delphi Method Consensus on Priority Global Otolaryngology–Head and Neck Surgery Conditions and Procedures

Sarah Nuss,Rolvix H. Patterson,Gabrielle L. Cahill,Blake Alkire,Mary Jue Xu,Valerie Salano,Josh Wiedermann,Samuel Okerosi

Publication date 25-01-2022


The objective of this study was to develop an international expert consensus on priority otolaryngology-head and neck surgery conditions and procedures globally for which national health systems should be capable of caring. The Delphi method was employed via a multiround online survey administered to attending otolaryngologists in an international research collaborative of >180 otolaryngologists in >40 countries. International online survey. In round 1, participants listed the top 15 otolaryngologic conditions and top 15 otolaryngology procedures for their World Bank regions. In round 2, participants ranked round 1 responses in order of global importance on a 5-point Likert scale. In round 3, participants reranked conditions and procedures that did not achieve consensus, defined as 50% of the round 2 Likert responses being ranked as "important" or "very important." Descriptive statistics were calculated for each round. The survey was distributed to 53 experts globally, with a response rate of 38% (n = 20). Fifty percent (n = 10) of participants were from low- and middle-income countries, with at least 1 participant from each World Bank region. Ten consensus surgical procedures and 10 consensus conditions were identified. This study identified a list of priority otolaryngology-head and neck surgery conditions and surgical procedures for which all national health systems around the world should be capable of managing. Acute and infectious conditions with preventative and emergent procedures were highlighted. These findings can direct future research and guide international collaborations.

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Impact of Delay on Hospitalization in Older Patients With Head and Neck Cancer: A Multicenter Study

Rosanne C. Schoonbeek,Suzanne Festen,Roza Rashid,Boukje A.C. van Dijk,György B. Halmos,Lilly-Ann van der Velden

Publication date 19-01-2022


To assess the impact of delay in treatment initiation on hospitalization, overall survival, and recurrence in older patients with head and neck cancer (HNC). Retrospective multicenter study. Two tertiary referral centers. All patients with newly diagnosed HNC (≥60 years) treated between 2015 and 2017 were retrospectively included. Time-to-treatment intervals were assessed (ie, calendar days between first visit and start of treatment). Multiple multivariable models were performed with hospital admission days (>14 days), survival, and recurrence as dependent outcome variables. In total, 525 patients were enrolled. The mean age was 70.7 years and 70.7% were male. Median time to treatment was 34.0 days, and 36.3% started treatment within 30 days ( This study highlights the importance and challenges of ensuring timely treatment initiation in older patients with HNC, as treatment delay was an independent predictor of hospitalization. During oncologic workup, taking time to consider patient-centered outcomes (including minimizing time spent in hospital) while ensuring timely start of treatment requires well-structured, fast-track care pathways.

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Transpharyngeal Approaches for Management of Oropharyngeal Squamous Cell Carcinoma: Mayo Clinic Institution Experience

Joseph N. Badaoui,Linda X. Yin,Adam B. Sauer,Eric J. Moore,Christine M. Lohse,Daniel L. Price,Jan L. Kasperbauer,Daniel B. Noel,Kerry D. Olsen,Kathryn M. Van Abel

Publication date 18-01-2022


Investigate oncologic and functional outcomes associated with transhyoid and lateral pharyngotomy (transpharyngeal) approaches in the treatment of oropharyngeal squamous cell carcinoma (OPSCC). Retrospective review. Single institution (tertiary care center). This is a retrospective case series of patients with OPSCC undergoing transpharyngeal resection from 1990 to 2017 at Mayo Clinic. Oncologic outcomes, postoperative complications, objective swallowing data, and rates of tracheostomy and percutaneous gastrostomy tube dependence were recorded. Of 83 patients meeting inclusion criteria, 56 (68%) were human papillomavirus positive. Overall survival rates at 5 and 10 years following surgery were 85% and 80%, respectively. Cancer-specific survival rates at these same time points were 90% and 88%. Following treatment, 35 of 49 patients (71%) had a Functional Oral Intake Scale score ≥5, indicating total oral intake of multiple consistencies; 79 of 82 (96%) were without tracheostomy or laryngectomy; and 71 of 81 (88%) were on a full oral diet. Transpharyngeal approaches provide adequate functional and oncologic outcomes in the majority of patients with OPSCC. These results may have important implications for patients who are not candidates for, or are unwilling to undergo, nonoperative therapy or for those without access to radiation therapy.

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Using the Craniovertebral Angle to Quantify Intraoperative Ergonomic Risk

Natalie Kelly,Marike Mousset,Abdulrahman Althubaiti,Riddhima Agarwal,Amanda Onwuka,Tendy Chiang

Publication date 18-01-2022


To measure the craniovertebral angle during tonsillectomy, assess the interrater reliability of our methodology, and investigate the correlations of the Rapid Upper Limb Assessment and the craniovertebral angle to quantify ergonomic risk. Prospective, observational study. Tertiary care pediatric institution. Neck posture was evaluated for 92 images with 7 surgeons. Lateral images of the surgeon were captured every minute in a standardized method. Images were assessed by 3 raters, measuring the craniovertebral angle, defined as the angle between a horizontal line through the C7 vertebrae and another line through C7 and the tragus of the ear. Interrater reliability of the craniovertebral angle was evaluated using the κ statistic. Per prior publications, reports of neck pain were frequent when the craniovertebral angle value was <50°; thus, we defined an abnormal posture if the craniovertebral angle was <50°. Mean (SD) craniovertebral angle during tonsillectomy was 26.0° (11.3°). One hundred percent of procedures had at least 1 assessment of abnormal posture. The lowest interrater reliability was 0.77 (CI: 0.67-0.87). Rapid Upper Limb Assessment and craniovertebral angle (CA) correlation was -0.12 ( Poor posture during tonsillectomy places otolaryngologists at intraoperative ergonomic risk. The craniovertebral angle is a predictor of future neck pain, and a pathologic neck position during tonsillectomy was identified. Given the high interrater reliability, our approach to assessing intraoperative surgical ergonomics was validated. Overall, RULA and the CA are not a substitute for one another but complementary.

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Catchment Profile of Large Cochlear Implant Centers in the United States

Ashley M. Nassiri,Meredith A. Holcomb,Elizabeth L. Perkins,Andrea L. Bucker,Sandra M. Prentiss,Christopher M. Welch,Nick S. Andresen,Carla V. Valenzuela,Cameron C. Wick,Simon I. Angeli,Daniel Q. Sun,Stephen P. Bowditch,Kevin D. Brown,Teresa A. Zwolan,David S. Haynes,Aniket A. Saoji,Matthew L. Carlson

Publication date 18-01-2022


To characterize the catchment area and patient profile of large cochlear implant (CI) centers in the United States. Multi-institutional retrospective case series. Tertiary referral CI centers. Patients who underwent CI surgery at 7 participating CI centers between 2015 and 2020 were identified. Patients' residential zip codes were used to approximate travel distances and urban vs rural residential areas. Over the 6-year study period (2015-2020), 6313 unique CI surgical procedures occurred (4529 adult, 1784 pediatric). Between 2015 and 2019, CI procedures increased by 43%. Patients traveled a median 52 miles (interquartile range, 21-110) each way; patients treated at rural CI centers traveled greater distances vs those treated at urban centers (72 vs 46 miles, While large CI centers serve geographically dispersed populations, most patients reside within a 200-mile radius. Strategies to expand CI utilization may leverage remote programming, telemedicine, and strategic placement of new centers and satellite clinics to ameliorate travel burden.

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Dysphagia Outcomes Following Surgical Management of Unilateral Vocal Fold Immobility: A Systematic Review and Meta-analysis

Michael Coulter,Kastley Marvin,Matthew Brigger,Christopher M. Johnson

Publication date 13-01-2022


To assess dysphagia outcomes following surgical management of unilateral vocal fold immobility (UVFI) in adults. Ovid MEDLINE, Embase, Web of Science, and Cochrane Central. A structured literature search was utilized, and a 2-researcher systematic review was performed following PRISMA guidelines. Extractable data were pooled, and a quantitative analysis was performed with a random effects model to analyze treatment outcome and complications by procedure. A total of 416 publications were screened and 26 met inclusion criteria. Subjects encompassed 959 patients with UVFI who underwent 916 procedures (n = 547, injection laryngoplasty; n = 357, laryngeal framework surgery; n = 12, laryngeal reinnervation). An overall 615 were identified as having dysphagia as a result of UVFI and had individually extractable outcome data, which served as the basis for a quantitative meta-analysis. In general, dysphagia outcomes after all medialization procedures were strongly positive. Quantitative analysis demonstrated a success rate estimate of 90% (95% CI, 75%-100%) for injection laryngoplasty and 92% (95% CI, 87%-97%) for laryngeal framework surgery. The estimated complication rate was 7% (95% CI, 2%-13%) for injection laryngoplasty and 15% (95% CI, 10%-20%) for laryngeal framework surgery, with minor complications predominating. Although laryngeal reinnervation could not be assessed quantitatively due to low numbers, qualitative analysis demonstrated consistent benefit for a majority of patients for each procedure. Dysphagia due to UVFI can be improved in a majority of patients with surgical procedures intended to improve glottal competence, with a low risk of complications. Injection laryngoplasty and laryngeal framework surgery appear to be efficacious and safe, and laryngeal reinnervation may be a promising new option for select patients.

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Rural Otolaryngology Care Disparities: A Scoping Review

Matthew J. Urban,Aoi Shimomura,Swapnil Shah,Tasher Losenegger,Jennifer Westrick,Ashok A. Jagasia

Publication date 11-01-2022


To broadly synthesize the literature regarding rural health disparities in otolaryngology, categorize findings, and identify research gaps to stimulate future work. Scoping review.
A comprehensive literature search was performed in the following databases: Pub Med/MEDLINE, Scopus, Cochrane Central Register of Controlled Trials, Google Scholar, and CINAHL. The methods were developed in concordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist. Peer-reviewed, English-language, US-based studies examining a rural disparity in otolaryngology-related disease incidence, prevalence, diagnosis, treatment, or outcome were included. Descriptive studies, commentaries, reviews, and letters to the editor were excluded. Studies published prior to 1980 were excluded. The literature search resulted in 1536 unique abstracts and yielded 79 studies that met final criteria for inclusion. Seventy-five percent were published after 2010.
The distribution of literature was as follows: otology (34.2%), head and neck cancer (20.3%), endocrine surgery (13.9%), rhinology and allergy (8.9%), trauma (5.1%), laryngology (3.8%), other pediatrics (2.5%), and adult sleep (1.3%). Studies on otolaryngology health care systems also accounted for 10.1%. The most common topics studied were practice patterns (41%) and epidemiology (27%), while the Southeast (47%) was the most common US region represented, and database study (42%) was the most common study design. Overall, there was low-quality evidence with large gaps in the literature in all subspecialties, most notably facial plastic surgery, laryngology, adult sleep, and pediatrics. Importantly, there were few studies on intervention and zero studies on resident exposure to rural populations, which will be critical to making rural otolaryngology care more equitable in the future.

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Association of Pediatric Hearing Quality and Sports Participation: A Population-Based Study

Elliott D. Kozin,Renata M. Knoll,Neil Bhattacharyya

Publication date 11-01-2022


Sports-related injuries, such as concussion, during childhood may result in considerable morbidity, including a range of negative developmental consequences. Auditory dysfunction is generally recognized to be a possible sequela of sports-related concussion; however, few epidemiologic studies have quantified the association between hearing quality and sports-related activity in the pediatric population. The National Health and Nutrition Examination Survey for the 2015-2016 cycle was utilized to determine the association of sports activities and hearing quality. Subjective abnormal hearing quality was more frequent among children who played football than those that did not (36.5% vs 26.8%; odds ratio, 1.56 [95% CI, 1.23-2.00];

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Implementation of a Standardized Perioperative Pain Management Protocol to Reduce Opioid Prescriptions in Otolaryngologic Surgery

Michael T. Chang,M. Lauren Lalakea,Kimberly Shepard,Micah Saste,Amanda Munoz,Misha Amoils

Publication date 11-01-2022


To evaluate the efficacy of implementing a standardized multimodal perioperative pain management protocol in reducing opioid prescriptions following otolaryngologic surgery. Retrospective cohort study. County hospital otolaryngology practice. A perioperative pain management protocol was implemented in adults undergoing otolaryngologic surgery.
This protocol included preoperative patient education and a postoperative multimodal pain regimen stratified by pain level: mild, intermediate, and high. Opioid prescriptions were compared between patient cohorts before and after protocol implementation. Patients in the pain protocol were surveyed regarding pain levels and opioid use. We analyzed 210 patients (105 preprotocol and 105 postprotocol). Mean ± SD morphine milligram equivalents (MMEs) prescribed decreased from 132.5 ± 117.8 to 53.6 ± 63.9 ( Preoperative counseling and standardization of a multimodal perioperative pain regimen for otolaryngology procedures can effectively lower amount of opioid prescriptions while maintaining low levels of postoperative pain.

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Utility of Visual Analog Scale of Subdomain Scores of the 22-Item Sinonasal Outcome Test in Chronic Rhinosinusitis

Katie M. Phillips,Firas A. Houssein,Marlene M. Speth,Ahmad R. Sedaghat

Publication date 11-01-2022


The burden of chronic rhinosinusitis (CRS) symptomatology is frequently measured with the 22-item Sinonasal Outcome Test (SNOT-22). In some situations, such as when there is need for frequent sampling, a full SNOT-22 may be impractical, and an abbreviated measure may be useful. Herein, we study 4 questions reflecting the 4 SNOT-22 subdomains as accurate reflections of SNOT-22 content. In total, 250 patients with CRS completed a SNOT-22 and answered 4 questions about their total nasal symptoms, poor sleep quality, ear/facial pain, and mood (reflecting SNOT-22 subdomains) using visual analog scales (VASs). The 4 SNOT-22 subdomain VAS scores each correlated strongly with the corresponding SNOT-22 subdomain scores. The sum of the 4 subdomain question VAS scores was highly correlated with the total SNOT-22 score (

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Medieval Interpretation of Phonation Through the Divine Comedy, by Dante Alighieri

Martha Borraccini,Matteo Marinini,Michele Augusto Riva

Publication date 11-01-2022


The anatomic and medical knowledge of people throughout history is unexpectedly evident in some of the poems and texts written by intellectuals of the time. This article attempts to understand the conception of laryngology in the Middle Ages by analyzing the

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Endoscopic Repair of Spontaneous Cerebrospinal Fluid Leaks in the Lateral Recess of the Sphenoid Sinus

Zhenxiao Huang,Qian Huang,Shunjiu Cui,E. Qiu,Junfang Xian,Bentao Yang,Mingrui Huo,Bing Zhou

Publication date 11-01-2022


This study aimed to assess the effectiveness of 3 endoscopic endonasal approaches for the management of cerebrospinal fluid (CSF) leaks and meningoencephaloceles in the lateral recess of the sphenoid sinus (LRSS). Retrospective study. University hospital. This study retrospectively reviewed 49 patients with CSF leaks and meningoencephaloceles in the LRSS. Three endoscopic surgical repair approaches were indicated based on 5 different Rhoton's types of the LRSS. The postoperative symptoms, complications, and follow-up outcomes were investigated and evaluated. The success rate of endoscopic surgical repair was 100% at a median follow-up of 75.06 (12-203.4) months. Endoscopic approaches to the LRSS included the prelacrimal recess (PLR) (18.37%), transsphenoidal (18.37%), and transpterygoid approaches (64.26%). All patients in the PLR approach (PLRA) group and most of the patients in the transpterygoid approach group had a full lateral type LRSS. Hypoesthesia and dry eyes were reported in 5 patients (55.56%) and 1 (11.12%) patient, respectively, from the PLRA group and in 6 (19.35%) and 5 (16.12%) patients, respectively, from the transpterygoid approach group. Endoscopic closure is a safe and effective method for the treatment of CSF leaks and meningoencephaloceles in the LRSS. The transpterygoid approach and PLRA offer adequate exposure of the LRSS with extensive lateral pneumatization or a full LRSS. The endoscopic route of the PLRA is more direct than that of the transpterygoid approach. Careful preoperative imaging evaluation is crucial while selecting the optimal surgical approach for the repair of a skull base defect.

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Graduating Otolaryngology Residents’ Ideal Practice Expectations: A Longitudinal Analysis

Robert H. Miller,Richard K. Gurgel,Hilary C. McCrary

Publication date 04-01-2022


Prior literature has indicated that the number of trained otolaryngologists required to meet the need of our growing population may be insufficient. Therefore, identifying trends in the subspecialty composition of future otolaryngology practices will elucidate workforce needs. One-page anonymous questionnaire. The survey was completed by examinees at the conclusion of their American Board of Otolaryngology-Head and Neck Surgery oral examination from 2011 to 2019. Data included age, gender, fellowship, practice type, and ideal future practice components.
A total of 2286 examinees were included: 58.1% were male and 57.2% completed a fellowship. Ideal practice specialties included general otolaryngology (19%), rhinology (15%), head and neck (13%), and pediatrics (11%). General and pediatric otolaryngology had a negative correlation over time ( There is a growing trend for more specialized otolaryngology practices. The data demonstrate a decline in considering general and pediatrics otolaryngology as part of practices, which portends a gap in access to comprehensive otolaryngology in the future.

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Sunitinib-Related Osteonecrosis of the External Auditory Canal: Case Report

Arturo Eguia,Eric Jonasch,Paul Gidley

Publication date 04-01-2022


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Safety of Cochlear Implantation in Children 12 Months or Younger: Systematic Review and Meta-analysis

Firas Sbeih,Malek H. Bouzaher,Swathi Appachi,Seth Schwartz,Michael S. Cohen,Daniela Carvalho,Patricia Yoon,Yi-Chun Carol Liu,Samantha Anne

Publication date 04-01-2022


To systematically review the literature to determine safety of cochlear implantation in pediatric patients 12 months and younger. Ovid MEDLINE, EMBASE, CINAHL, and Cochrane Central Register of Controlled Trials (CENTRAL) databases were searched from inception to March 20, 2021. Studies that involved patients 12 months and younger with report of intraoperative or postoperative complication outcomes were included. Studies selected were reviewed for complications, explants, readmissions, and prolonged hospitalizations. Two independent reviewers screened all studies that were selected for the systematic review and meta-analysis. All studies included were assessed for quality and risk of bias. The literature search yielded 269 studies, of which 53 studies underwent full-text screening, and 18 studies were selected for the systematic review and meta-analysis. A total of 449 patients and 625 cochlear implants were assessed. Across all included studies, major complications were noted in 3.1% of patients (95% CI, 0.8-7.1) and 2.3% of cochlear implantations (95% CI, 0.6-5.2), whereas minor complications were noted in 2.4% of patients (95% CI, 0.4-6.0) and 1.8% of cochlear implantations (95% CI, 0.4-4.3). There were no anesthetic complications reported across all included studies. The results of this systematic review and meta-analysis suggest that cochlear implantation in patients 12 months and younger is safe with similar rates of complications to older cohorts.

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Unintended Side Effects of Electronic Cigarettes in Otolaryngology: A Scoping Review

Ameen Amanian,Jobanjit Phulka,Amanda C. Hu

Publication date 04-01-2022


Electronic cigarettes (E-cigs) are nicotine delivery systems with increasing popularity. The US Food and Drug Administration defines side effects as unwanted or unexpected events or reactions. Our objective was to examine the unintended otolaryngology-related side effects associated with E-cigs. Medline, EMBASE, CINAHL, Web of Science, and CENTRAL databases. Study selection was independently performed by 2 authors in accordance with the PRISMA-ScR statement (Preferred Reporting Items for Systematic Reviews and Meta-analyses Extension for Scoping Reviews); discrepancies were resolved by the senior author. English studies from database inception to May 1, 2020, with a sample size >5 were included. In vitro, animal, and lower respiratory tract studies were excluded. The main outcome was defined as otolaryngology-related side effects following E-cig use. Levels of evidence per the Oxford Centre for Evidence-Based Medicine were used to determine study quality. From 1788 articles, 32 studies were included. The most common unintended side effects were throat irritation (n = 16), cough (n = 16), mouth irritation (n = 11), and oral mucosal lesions (n = 8). A large proportion of participants also reported conventional tobacco use in addition to E-cigs. Eight studies investigated the effectiveness of vaping on smoking cessation. The quality of the literature was level 2 to 4. Given the significant heterogeneity in the studies, meta-analysis was not performed. The most reported side effects were throat and mouth irritation, followed by cough. The long-term impact of E-cigs is not known given the recent emergence of this technology. Future studies are warranted.

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Effect of Insurance Type on Postoperative Tympanostomy Tube Follow-up

Terral A. Patel,Jennifer L. McCoy,Michael A. Belsky,Edward S. Sim,Anisha Konanur,Annie Yan,Noel Jabbour,Reema Padia

Publication date 28-12-2021


Bilateral myringotomy with tube insertion (BMT) is a common procedure performed in children. Appropriate follow-up is necessary to ensure management of postoperative sequalae. The objectives are to investigate (1) the relationship between insurance type and postoperative follow-up attendance and (2) the effect of follow-up on need for further care after BMT. Retrospective cohort study. The study included patients <3 years of age undergoing BMT for recurrent acute otitis media at a tertiary care children's hospital within a single year and followed for 3 years. Patients were excluded if they had received a prior BMT; underwent a concurrent otolaryngologic procedure; or had a syndromic diagnosis, craniofacial abnormality, or any significant cardiac or respiratory comorbidity. Number of follow-up appointments, demographics, socioeconomic status, and postoperative outcomes were analyzed. A total of 734 patients were included with mean (SD) age of 1.4 years (0.50). The majority of patients had private insurance (520/734, 70.8%). Patients with public insurance attended fewer postoperative appointments (1.5 vs 1.8, Insurance type is related to outcomes after the treatment of recurrent acute otitis media with BMT. Future studies that survey individuals will help identify barriers that contribute to patient absence at follow-ups and need for subsequent ED visits.

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Trends in HPV Testing for Patients With Sinonasal Squamous Cell Carcinoma: A National Analysis

Christopher C. Tseng,Jeff Gao,Gregory L. Barinsky,Christina H. Fang,Wayne D. Hsueh,Jordon G. Grube,Soly Baredes,Jean Anderson Eloy

Publication date 28-12-2021


The objective of this study was to analyze national trends in human papillomavirus (HPV) testing for patients diagnosed with sinonasal squamous cell carcinoma (SNSCC). Retrospective database study. National Cancer Database (2010-2016). Cases from 2010 to 2016 with a primary SNSCC diagnosis and known HPV testing status were extracted from the National Cancer Database. Univariate and multivariate analyses were then performed to assess differences in socioeconomic, hospital, and tumor characteristics between tested and nontested patients. A total of 2308 SNSCC cases were collected, with 1210 (52.4%) HPV tested and 1098 (47.6%) not tested. On univariate analyses, patient age, insurance, income quartile, population density, treatment facility location, and tumor grade were significantly associated with HPV testing status. After multivariate logistic regression modeling, living in a suburban area had lower odds of HPV testing as compared with living in urban areas (odds ratio, 0.74 [95% CI, 0.55-0.99]; Among patients with SNSCC, those with high-grade tumors were more likely to be tested for HPV, while patients with a suburban area of residence were less likely. Additionally, there was no significant survival benefit to HPV testing, with tested and nontested groups having similar overall survival. 4.

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Including Surgical Resection in the Multimodal Management of Very Locally Advanced Sinonasal Cancer

Jerome M. Karp,Kenneth S. Hu,Michael Persky,Mark Persky,Adam Jacobson,Theresa Tran,Zujun Li,Babak Givi,Moses M. Tam

Publication date 28-12-2021


Sinonasal cancer often presents as locoregionally advanced disease. National guidelines recommend management of stage T4b tumors with systemic therapy and radiotherapy, but recent studies suggest that including surgical resection in the multimodal treatment of these tumors may improve local control and survival. We queried the National Cancer Database to examine patterns of care and outcomes in T4b sinonasal squamous cell carcinoma (SCC). Prospectively gathered data. National Cancer Database. Patients with T4b N0-3 M0 sinonasal squamous cell carcinoma diagnosed in 2004 to 2016 were stratified between those who received chemoradiotherapy and those who underwent surgical resection with neoadjuvant or adjuvant treatment. The overall survival of each cohort was assessed via Kaplan-Meier analysis and Cox proportional hazard models, with repeat analysis after reweighting of data via inverse probability of treatment weighting. Among 805 patients included in analysis, 2-year overall survival for patients undergoing surgical resection was 60.8% (95% CI, 56.1%-65.9%), while for patients undergoing chemoradiotherapy it was 46.7% (95% CI, 41.9%-52.0%). On Cox regression analysis, the inclusion of surgery in management was associated with improved survival in univariate analysis (hazard ratio [HR], 0.723 [95% CI, 0.606-0.862]; Surgical treatment with neoadjuvant or adjuvant treatment for stage T4b sinonasal SCC was associated with promising survival outcomes, suggesting a role for incorporating surgery in treatment of select T4b SCC, particularly when removal of all macroscopic disease is feasible.

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Transcanal Endoscopic Ear Surgery for Congenital Cholesteatoma: A Multi-institutional Series

Carolyn M. Jenks,Patricia L. Purcell,Gaia Federici,Domenico Villari,Livio Presutti,Adrian L. James,Stephen R. Hoff

Publication date 21-12-2021


To assess outcomes of transcanal endoscopic ear surgery (TEES) for congenital cholesteatoma. Case series with chart review of children who underwent TEES for congenital cholesteatoma over a 10-year period. Three tertiary referral centers. Cholesteatoma extent was classified according to Potsic stage; cases with mastoid extension (Potsic IV) were excluded. Disease characteristics, surgical approach, and outcomes were compared among stages. Outcomes measures included residual or recurrent cholesteatoma and audiometric data. Sixty-five cases of congenital cholesteatoma were included. The mean age was 6.5 years (range, 1.2-16), and the mean follow-up was 3.9 years (range, 0.75-9.1). There were 19 cases (29%) of Potsic stage I disease, 10 (15%) stage II, and 36 (55%) stage III. Overall, 24 (37%) patients underwent a second-stage procedure, including 1 with Potsic stage II disease (10%) and 21 (58%) with Potsic stage III disease. Eight cases (12%) of residual cholesteatoma occurred. One patient (2%) developed retraction-type ("recurrent") cholesteatoma. Recidivism occurred only among Potsic stage III cases. Postoperative air conduction hearing thresholds were normal (<25 dB HL) in 93% of Potsic stage I, 88% of stage II, and 36% of stage III cases. TEES is feasible and effective for removal of congenital cholesteatoma not extending into the mastoid. Recidivism rates were lower with the TEES approach in this large series than in previously reported studies. Advanced-stage disease was the primary risk factor for recidivism and worse hearing result. As minimally invasive TEES is possible in the youngest cases, children benefit from early identification and intervention.

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Transoral Complete vs Partial Excision of the Sublingual Gland for Plunging Ranula

Jong-Lyel Roh

Publication date 21-12-2021


Plunging ranula is a pseudocyst of saliva extravasated from the sublingual gland (SLG) to the submandibular space. This is treated by transoral excision of the SLG or transcervical cyst excision that might differently affect surgical morbidity and recurrence. This study compared the clinical outcomes of complete vs partial excision of the SLG for plunging ranula. A nonrandomized comparative study. Academic medical center. This study included 42 patients with plunging ranula who underwent complete or partial excision of the SLG with the evacuation of cystic content. Two surgical methods of complete or partial SLG resection were alternatively allocated to consecutive patients without randomization. The primary outcome was a postoperative recurrence. Secondary outcomes were operation time and complications. Complete and partial excision of the SLG was performed in 22 and 20 patients, respectively, without injury to the Wharton's duct or the lingual nerve.
Postoperative complications in 42 patients were minor with temporary events: hematoma, 1 (5%); tongue numbness, 2 (5%); dysgeusia, 4 (9%); and dysphagia, 2 (5%), which did not differ between patients with complete and partial excision of the SLG ( Complete SLG excision is preferred over partial SLG excision to treat plunging ranula for reducing postsurgical risks of complications and recurrence.

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OSA Treatment on Cardio- and Cerebrovascular Comorbidities: A Long-term Nationwide Cohort Study

Kun-Lin Yang,Pei-Wen Lin,Chun-Tuan Chang,Pi-Hua Liu,Hsin-Ching Lin,Michael Friedman,Anna M. Salapatas

Publication date 14-12-2021


To compare the cardio- and cerebrovascular outcomes and survival rates of surgical and nonsurgical interventions for patients with obstructive sleep apnea (OSA) based on a national population-based database. Retrospective cohort study. Taiwan National Health Insurance Research Database. We analyzed all cases of OSA among adults (age >20 years and confirmed with During follow-up, 112 and 92 incident cases of MI occurred in the OSA surgery and CPAP treatment groups, respectively (rates of 327 and 298 per 100,000 person-years). Furthermore, 50 and 39 cases were newly diagnosed with stroke in the OSA surgery and CPAP treatment groups (rates of 144 and 125 per 100,000 person-years). Cox proportional hazard regressions showed that the OSA treatment groups (OSA surgery vs CPAP) were not significantly related to MI (hazard ratio, 1.03 [95% CI, 0.781-1.359]; Our study demonstrated that there was no difference of cardio- and cerebrovascular results between CPAP and surgery for patients with OSA in a 13-year follow-up. 3.

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Comparative Study of ACR TI-RADS and ATA 2015 for Ultrasound Risk Stratification of Thyroid Nodules

William Thedinger,Easwer Raman,Jagdish K. Dhingra

Publication date 14-12-2021


To study the adoption rate of the American College of Radiology Thyroid Imaging Reporting and Data System (ACR TI-RADS) scoring system over a 3-year period in a community setting and compare its performance with that of the American Thyroid Association 2015 (ATA 2015) ultrasound risk scoring system. Case series with prospective data collection and retrospective chart review. Large community-based practice with multiple satellite offices and a dedicated thyroid ultrasound clinic. All patients referred to the thyroid clinic between January 2018 and December 2020 for ultrasound-guided fine-needle biopsy were assigned an ATA 2015 risk score in a prospective manner immediately prior to biopsy. ACR TI-RADS scores were recorded through retrospective chart review of the radiologist report. Performance of the 2 systems was compared with cytology as the gold standard. A total of 949 nodules underwent biopsy, of which 236 had available data for both scoring systems. There was a 33.8% increase in adoption of the ACR TI-RADS over the 3-year study period. The ATA 2015 guidelines yielded sensitivity and specificity of 81.6% and 54.5%, respectively, as opposed to 73.7% and 27.0% for the ACR TI-RADS. In our community, there has been a gradual increase in adoption of the ACR TI-RADS, although the ATA 2015 risk scoring system has performed better.

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Cochlear Implantation and Risk of Falls in Older Adults

David R. Grimm,Shayan Fakurnejad,Jennifer C. Alyono

Publication date 14-12-2021


To examine whether cochlear implantation (CI) increases the risk of clinically significant falls in older adults. Retrospective analysis of deidentified administrative claims from a US commercial insurance database. Nationwide deidentified private insurance claims database (Clinformatics Data Mart; Optum). Patients undergoing CI were identified through Between 2003 and 2019, 3773 patients aged >50 years underwent CI. An overall 139 (3.68%) patients recorded at least 1 fall diagnosis a year pre-CI, and 142 (3.76%) recorded at least 1 fall diagnosis post-CI. The average number of days with fall diagnoses per patient with a recorded fall was 3.12 pre-CI and 2.04 post-CI. In bivariate analysis, age ( CI does not appear to increase the risk of falls in older adults. Patient comorbidities correlate most strongly with fall risk and should be considered in patient selection for CI.

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Robotic Modification of Epiglottis Trimming in the Treatment of Obstructive Sleep Apnea

Mehmet Ali Babademez,Fatih Gul,Kadir Sinasi Bulut,Mecit Sancak,Saliha Kusoglu Atalay

Publication date 14-12-2021


With the widespread use of drug-induced sleep endoscopy, it has been suggested that epiglottis pathologies are present at high rates in patients with sleep apnea. The aim of our study was to evaluate the efficacy of trimming the curled-inward epiglottis as an updated surgical technique in patients with omega epiglottis. Retrospective study. Tertiary hospital. Among the 283 patients with epiglottis pathology, 21 with isolated omega-shaped epiglottis (age, 33-53 years) fulfilled the inclusion criteria between May 2016 and April 2019. Drug-induced sleep endoscopy was used to detect epiglottic collapse compressed by the lateral parts during inspiration. An epiglottoplasty technique was applied as single-level sleep surgery in patients with an isolated omega-shaped epiglottis. The medical data were also reviewed. The mean pre- and postoperative total apnea-hypopnea index (AHI) scores were 27.89 and 10.58, respectively, and this difference was statistically significant ( Trimming the curled-inward epiglottis may represent an excellent option for epiglottis surgery in patients with obstructive sleep apnea by being less invasive than techniques currently in use.

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Independent Role of Nasal Congestion in Positive Airway Pressure Compliance for OSA Treatment

Hao Wu,Fang Fang,Yaxin Guo,Chan Wu,Yongxiang Wei

Publication date 14-12-2021


To determine the independent role of nasal congestion in positive airway pressure (PAP) therapy compliance and factors associated with an unfavorable shift of PAP compliance. Prospective cohort study. Tertiary care center. This follow-up study comprised 174 patients with newly diagnosed obstructive sleep apnea (OSA) who accepted PAP therapy from January 2017 to June 2019. Information was collected on basic demographics, comorbidities, sleep-related symptoms, nasal symptoms, and upper airway assessment. PAP adherence data were collected at the end of the first week and the third month. After 3 months of follow-up, 147 participants were included for final data analysis. The proportion of nasal congestion (29.2% vs 52.0%, Nasal congestion is an independent predictor of PAP noncompliance. Younger patients with lower BMI were more likely to have an unfavorable shift of PAP compliance. Initial and long-term adherence to PAP therapy was affected by OSA severity.

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Centralized Otolaryngology Research Efforts: Stepping-stones to Innovation and Equity in Otolaryngology–Head and Neck Surgery

Michael J. Brenner,Rick F. Nelson,Tulio A. Valdez,Stephanie A. Moody-Antonio,Cherie-Anne O. Nathan,Maie A. St John,Howard W. Francis

Publication date 14-12-2021


The Centralized Otolaryngology Research Efforts (CORE) grant program coordinates research funding initiatives across the subspecialties of otolaryngology-head and neck surgery. Modeled after National Institutes of Health study sections, CORE grant review processes provide comprehensive reviews of scientific proposals. The organizational structure and grant review process support grant-writing skills, attention to study design, and other components of academic maturation toward securing external grants from the National Institutes of Health or other agencies. As a learning community and a catalyst for scientific advances, CORE evaluates clinical, translational, basic science, and health services research. Amid the societal reckoning around long-standing social injustices and health inequities, an important question is to what extent CORE engenders diversity, equity, and inclusion for the otolaryngology workforce. This commentary explores CORE's track record as a stepping-stone for promoting equity and innovation in the specialty. Such insights can help maximize opportunities for cultivating diverse leaders across the career continuum.

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COVID-19 Disparities and Vaccine Hesitancy in Black Americans: What Ethical Lessons Can Be Learned?

Nicolas Restrepo,Helene J. Krouse

Publication date 14-12-2021


This state of the art review focuses on bioethical questions and considerations from research findings and methodological issues, including design and recruitment of participants, in studies related to COVID-19 vaccine hesitation in Black individuals. Ethical concerns identified were applied to otolaryngology with recommendations for improving health inequities within subspecialties. An internet search through Pub Med, CINAHL, and socINDEX was conducted to identify articles on COVID-19 vaccine hesitation among the Black population between 2020 and 2021. A systematic review approach was taken to search and analyze the research on this topic, which was coupled with expert analysis in identifying and classifying vital ethical considerations. The most common COVID-19 vaccine hesitation factors were related to the development of the vaccine, mistrust toward government agencies, and misconceptions about safety and side effects. These findings raised bioethical concerns around mistrust of information, low health literacy, insufficient numbers of Black participants in medical research, and the unique positions of health professionals as trusted sources. These bioethical considerations can be applied in otolaryngology and other health-related areas to aid the public in making informed medical decisions regarding treatments, which may reduce health inequalities among Black Americans and other racial and ethnic minority groups. Addressing ethical questions by decreasing mistrust, tailoring information for specific populations, increasing minority representation in research, and using health professionals as primary sources for communicating health information and recommendations may improve relationships with Black communities and increase acceptance of new knowledge and therapies such as COVID-19 vaccination.

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Pregnancy and Fertility Trends Among Female Otolaryngologists

Makenzie Huguet,Angela Beliveau,Sandra L. Taylor,Debbie A. Aizenberg

Publication date 14-12-2021


This study sought to determine childbearing patterns and decision making among female otolaryngologists. Anonymous survey. An anonymous survey was sent in 2020 to female otolaryngologists identified through their membership with the American Academy of Otolaryngology-Head and Neck Surgery. Data were analyzed concerning individual fertility and childbearing history, reflections regarding decision making, perceptions of workplace support, and estimations of objective childbearing potential. There were 398 responses. The mean age at first pregnancy was 32.3 years. Almost one-third of respondents who attempted to conceive (30.4%) were diagnosed with infertility. Of those who had their first pregnancy during training, 55% reported having substantial workplace support, as opposed to 70% of those whose first pregnancies followed completion of training ( Female otolaryngologist respondents have children later in life than the general population, and a substantial proportion face infertility or have regrets about family planning decisions and career decision making. Increased awareness, further investigation, and targeted programs are needed to support the growing number of female otolaryngologists who desire both a career and a family.

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Sociodemographic Differences in Care Plans and Time to Treatment Among Children Being Considered for Adenotonsillectomy

Maria E. Knaus,Swapna Koppera,Meredith N. Lind,Jennifer N. Cooper

Publication date 14-12-2021


To assess sociodemographic differences in care plans and time to evaluation or treatment after otolaryngologic consultation among children with obstructive sleep-disordered breathing (oSDB). Retrospective cohort study. Single tertiary children's hospital. We included children aged 2 to 9 years with oSDB seen from June to December 2018 as new otolaryngology clinic patients. Logistic regression was used to examine whether sociodemographic factors were associated with having adenotonsillectomy or polysomnography planned at the end of the visit. Kaplan-Meier analyses and Cox proportional hazards models were used to compare times to these events. An overall 1020 children were included, of whom 65% were White and 18% were Black. Approximately 77% were metropolitan residents, 52% were publicly insured, and 88% of caregivers spoke primarily English. Treatment plans included adenotonsillectomy for 62% of patients, polysomnography for 15%, and new medication therapy for 13%. In multivariable analyses, there were no significant differences by child race/ethnicity, metropolitan/nonmetropolitan residence, type of health insurance, or caregiver primary language in the likelihood of having adenotonsillectomy or polysomnography planned. Among children for whom adenotonsillectomy was planned, children from metropolitan areas had greater times to surgery than children from nonmetropolitan areas (hazard ratio, 0.81 [95% CI, 0.66-0.99]; After initial otolaryngology consultation, children with oSDB from metropolitan areas have longer times to adenotonsillectomy than those from nonmetropolitan areas.

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A Review of Noninfectious Diseases Masquerading as Acute Mastoiditis

Kevin Wong,Annie E. Arrighi-Allisan,Caleb J. Fan,George B. Wanna,Maura K. Cosetti,Enrique R. Perez

Publication date 07-12-2021


Acute mastoiditis is commonly attributed to infection. Rarely do clinicians encounter cases that do not respond to traditional antibiotics or surgical management. The goal of this study was to systematically review the literature to characterize diseases masquerading as acute infectious mastoiditis. Pub Med, Embase, and Scopus. A systematic review was performed to identify all publications that reported on diseases with presentations mimicking acute mastoiditis, defined as postauricular redness, swelling, and tenderness. We included clinical prospective studies, retrospective studies, and case series/reports. Exclusion criteria included non-English articles, letters/commentaries, abstracts, and review articles. Out of 3339 results, 35 studies met final inclusion criteria. In children, 11 diseases were reported to mimic mastoiditis, including solid tumors, hematologic diseases, and autoimmune/inflammatory diseases. The most common disease in children was Langerhans cell histiocytosis, followed by rhabdomyosarcoma and acute myelogenous leukemia. In adults, 8 additional diseases were reported. The most common disease in adults was squamous cell carcinoma, followed by nasopharyngeal carcinoma and Langerhans cell histiocytosis. Presenting symptoms are reviewed, as well as characteristic radiographic, laboratory, and intraoperative features that may assist with diagnosis. A diagnostic algorithm for atypical cases of acute mastoiditis is proposed. A small but significant group of diseases in children and adults can mimic acute mastoiditis. In such cases, history and examination alone may be insufficient to reach a diagnosis, and further investigation may be necessary. Otolaryngologists should always be mindful of the possibility that noninfectious pathologies may present with a constellation of symptoms similar to mastoiditis.

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Corticosteroid Use in Otolaryngology: Current Considerations During the COVID-19 Era

C.W. David Chang,Edward D. McCoul,Selena E. Briggs,Elizabeth A. Guardiani,Marlene L. Durand,Tessa A. Hadlock,Alexander T. Hillel,Nrusheel Kattar,Peter J.M. Openshaw,Nosayaba Osazuwa-Peters,David M. Poetker,Jennifer J. Shin,Sujana S. Chandrasekhar,Carol R. Bradford,Michael J. Brenner

Publication date 07-12-2021


To offer pragmatic, evidence-informed advice on administering corticosteroids in otolaryngology during the coronavirus disease 2019 (COVID-19) pandemic, considering therapeutic efficacy, potential adverse effects, susceptibility to COVID-19, and potential effects on efficacy of vaccination against SARS-CoV-2, which causes COVID-19. Pub Med, Cochrane Library, EMBASE, CINAHL, and guideline databases. Guideline search strategies, supplemented by database searches on sudden sensorineural hearing loss (SSNHL), idiopathic facial nerve paralysis (Bell's palsy), sinonasal polyposis, laryngotracheal disorders, head and neck oncology, and pediatric otolaryngology, prioritizing systematic reviews, randomized controlled trials, and COVID-19-specific findings. Systemic corticosteroids (SCSs) reduce long-term morbidity in individuals with SSNHL and Bell's palsy, reduce acute laryngotracheal edema, and have benefit in perioperative management for some procedures. Topical or locally injected corticosteroids are preferable for most other otolaryngologic indications. SCSs have not shown long-term benefit for sinonasal disorders. SCSs are not a contraindication to vaccination with COVID-19 vaccines approved by the US Food and Drug Administration. The Centers for Disease Control and Prevention noted that these vaccines are safe for immunocompromised patients. SCS use for SSNHL, Bell's palsy, laryngotracheal edema, and perioperative care should follow prepandemic standards. Local or topical corticosteroids are preferable for most other otolaryngologic indications. Whether SCSs attenuate response to vaccination against COVID-19 or increase susceptibility to SARS-CoV-2 infection is unknown. Immunosuppression may lower vaccine efficacy, so immunocompromised patients should adhere to recommended infection control practices. COVID-19 vaccination with Pfizer-BioNTech, Moderna, or Johnson & Johnson vaccines is safe for immunocompromised patients.

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Prevalence of Tympanic Membrane Perforations Among Adolescents, Adults, and Older Adults in the United States

Alexander S. Kim,Joshua F. Betz,Nicholas S. Reed,Bryan K. Ward,Carrie L. Nieman

Publication date 07-12-2021


Tympanic membrane (TM) perforations can occur at any age, but limited population-level data are available. Using data from the National Health and Nutrition Examination Survey, we performed a cross-sectional analysis of the prevalence and population estimates for TM perforations among individuals ≥12 years old in the United States. Overall, TM perforations have a prevalence of 2.1% (95% CI, 1.7%-2.6%), corresponding to 5.8 million Americans. Across the life course, older adults have the highest prevalence of TM perforations at 6.1% (95% CI, 4.7%-7.6%), corresponding to nearly 3 million Americans, as opposed to a prevalence of 0.6% (95% CI, 0.3%-0.9%) in adolescents, which equates to 0.2 million Americans. Males and females have a similar prevalence at 2.3% (95% CI, 1.6%-3.0%) among males and 2.0% (95% CI, 1.4%-2.6%) among females. These prevalence and population estimates provide the first US-based population estimates of the burden of TM perforations over the life course.

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Impact of Tonsillectomy on the Life Quality of Parents to Children With Obstructive Sleep-Disordered Breathing

Yair Heskiau Shteinberg,Netanel Eisenbach,Maayan Gruber,Ohad Ronen

Publication date 07-12-2021


Parents of children with any chronic illness may experience increased anxiety and reduced health-related quality of life (QoL). Our objective was to evaluate the change in parental QoL before vs after tonsillectomy. Our hypothesis was that pediatric tonsil surgery with or without adenoidectomy would improve parental QoL. A prospective cohort study. An otolaryngology department in a tertiary academic center. We enrolled parents of 79 children <5 years old. Adenotonsillectomy due to an obstructive airway indication was performed in 45 children. A group of 34 parents to healthy children served as a control group. Initially, we validated a modified version of the PAR-ENT-QoL questionnaire; then, we analyzed QoL parameters among parents of children with obstructive sleep-disordered breathing before and after surgical treatment. We found significant differences between the QoL score before and after surgery ( These results highlight the importance of timely diagnosis and treatment of children with obstructive sleep-disordered breathing, as this condition may affect not only the children themselves but also their caregivers.

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Revision Stapes Surgery: Hearing Symptoms and Associations With Intraoperative Findings and Outcomes

Alexander L. Luryi,Amy Schettino,Elias M. Michaelides,Seilesh Babu,Dennis I. Bojrab,Christopher A. Schutt

Publication date 30-11-2021


Stapes surgery for otosclerosis occasionally requires revision due to recurrent or persistent conductive hearing loss (CHL). This study examines outcomes after revision stapes surgery. Retrospective review. Single tertiary neurotology center. Patients undergoing revision stapes surgery for otosclerosis from 2008 to 2017 were reviewed. Postoperative air-bone gaps (ABGs) were the primary outcome measure. During the study period, 150 patients underwent revision stapes surgery. One hundred patients (67%) had gradually progressive recurrent CHL; 16 (11%), sudden recurrent CHL; 13 (9%), persistent CHL; and 21 (14%), no CHL. For 129 patients with CHL, the mean ABG improved from 23.7 to 9.3 dB ( Revision stapes surgery confers significant improvement in hearing for patients with persistent and recurrent CHL, although patients with persistent CHL after initial surgery see less improvement with revision.

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Hazards and Management of Wire Bristle ingestions: A Systematic Review

Nathaniel Miller,Michael Noller,Matthew Leon,Yonatan Moreh,Nora L. Watson,Justin Costello,Steven Hong

Publication date 30-11-2021


Inadvertently ingested grill brush bristles can lodge in various locations and lead to a variety of injuries. They can also be difficult to identify and remove. Our primary objective was to perform a systematic review of cases reported in the literature, with analysis of trends in clinical presentation and success of diagnostic modalities and treatment approaches. Cases of reported grill brush bristle ingestion reported in Pub Med, Pub Med Central, and Google Scholar databases through April 30, 2021.
Databases were searched for the following terms: ("ingestion" OR "injury" OR "barbeque" OR "BBQ" OR "grill" OR "foreign body" OR "brush" AND "wire" OR "bristle"). Data were collected on patient demographics, clinical presentation, and treatment course. Statistical analysis was performed on characteristics with low risk of confounding. An overall 57 studies involving 91 patients were included. Grill brush bristles presented most commonly in the upper aerodigestive tract (48/91), followed by the abdomen (26/91) and deep neck (17/91). Computed tomography was the most accurate imaging modality for initial diagnosis, identifying 92.8% of bristles. Less invasive or adjunctive techniques such as endoscopy, intraoperative imaging, or minimally invasive surgery may be useful particularly for bristles located in the head and neck given the low rate of success of transoral surgery (66.7%). Although this review of retained bristle may be biased toward complex cases, retained grill brush bristles represent an underrecognized and difficult-to-manage hazard. When cases are suspected, clinicians should obtain computed tomography imaging based on presentation and tailor management appropriately.

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A Noninferiority Analysis of 3- vs 2-Incision Techniques for Hypoglossal Nerve Stimulator Implantation

David T. Kent,Eugene G. Chio,Jordan S. Weiner,Clemens Heiser,Maria V. Suurna,Mark Weidenbecher

Publication date 30-11-2021


The only hypoglossal nerve stimulation (HNS) device available for US clinical use is implanted through 3 incisions. A recently proposed 2-incision modification moved the respiratory sensing lead from the fifth to the second intercostal space to eliminate the third lower chest incision. This study compared perioperative data and therapeutic outcomes between the techniques. Noninferiority cohort analysis of a retrospective and prospective registry study. Tertiary care and community surgical centers. Patients with obstructive sleep apnea underwent HNS implantation via a modified 2-incision technique (I There were 404 I In a multicenter registry, a 2-incision implant technique for a commercially available HNS device had a statistically noninferior therapeutic efficacy profile when compared with the standard 3-incision approach. The 2-incision technique is safe and effective for HNS implantation.

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Consumer Wearables for Patient Monitoring in Otolaryngology: A State of the Art Review

Shaan N. Somani,Katherine M. Yu,Alexander G. Chiu,Kevin J. Sykes,Jennifer A. Villwock

Publication date 23-11-2021


Consumer wearables, such as the Apple Watch or Fitbit devices, have become increasingly commonplace over the past decade. The application of these devices to health care remains an area of significant yet ill-defined promise. This review aims to identify the potential role of consumer wearables for the monitoring of otolaryngology patients. Pub Med. A Pub Med search was conducted to identify the use of consumer wearables for the assessment of clinical outcomes relevant to otolaryngology. Articles were included if they described the use of wearables that were designed for continuous wear and were available for consumer purchase in the United States. Articles meeting inclusion criteria were synthesized into a final narrative review. In the perioperative setting, consumer wearables could facilitate prehabilitation before major surgery and prediction of clinical outcomes. The use of consumer wearables in the inpatient setting could allow for early recognition of parameters suggestive of poor or declining health. The real-time feedback provided by these devices in the remote setting could be incorporated into behavioral interventions to promote patients' engagement with healthy behaviors. Various concerns surrounding the privacy, ownership, and validity of wearable-derived data must be addressed before their widespread adoption in health care. Understanding how to leverage the wealth of biometric data collected by consumer wearables to improve health outcomes will become a high-impact area of research and clinical care. Well-designed comparative studies that elucidate the value and clinical applicability of these data are needed.

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Monitoring Adult Subglottic Stenosis With Spirometry and Dyspnea Index: A Novel Approach

Eleftherios Ntouniadakis,Josefin Sundh,Mathias von Beckerath

Publication date 23-11-2021


The aim was to examine the correlations among the anatomic Cotton-Myer classification, pulmonary function tests (PFTs), and patient-perceived dyspnea or dysphonia in patients with subglottic stenosis and identify measurements accurately reflecting treatment effects. Prospective cohort study. Tertiary referral center. Fifty-two adults receiving endoscopic treatment for isolated subglottic stenosis were consecutively included. Correlations were calculated among the preoperative Cotton-Myer scale, PFTs, the Dyspnea Index (DI), and the Voice Handicap Index. Receiver operating characteristic curves were determined for PFT, DI, and Voice Handicap Index pre- and postoperative measurements. The Cotton-Myer classification correlated weakly with peak expiratory flow ( Expiratory disproportion index or peak expiratory flow combined with DI was a feasible measurement for the monitoring of adult subglottic stenosis. The percentage deterioration of peak expiratory flow and increase in expiratory disproportion index correlated significantly with a proportional percentage increase in DI.

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Utility of the Pediatric Bleeding Questionnaire in Predicting Posttonsillectomy Bleeding

Einat Levy,Amir Kuperman,Eyal Sela,Adham Kashkoush,Abeer Dabbah Miari,Randa Yawer Hana,Ieva Freilich,Ahmad Bader,Maayan Gruber

Publication date 23-11-2021


Posttonsillectomy bleeding is a dreadful complication that may be life-threatening. Preoperative coagulation tests have not been shown to be effective in predicting this complication. The Pediatric Bleeding Questionnaire (PBQ) is a validated and sensitive tool in diagnosing children with abnormal hemostatic functions, and the objective of our study was to assess its utility as a preoperative screening tool for predicting posttonsillectomy bleeding. Prospective single-blinded cohort study. Tertiary care hospital system. All children scheduled for tonsil surgery between 2017 and 2019 in the Galilee Medical Center were included. The PBQ was completed by the caregivers prior to surgery, and all children underwent coagulation tests. Each PBQ item is scored on a scale of -1 to 4, and the total score per candidate is based on summation of all items. An overall 272 patients were included in the study with a mean age of 5.2 years; 57.7% were boys. The main finding was that in a multivariable model adjusted to age, a PBQ score of 2 is correlated with increased postoperative bleeding risk (odds ratio, 10.018 [95% CI, 1.20-82.74]; This study demonstrated that a PBQ score ≥2 has a higher yield for detecting children at risk for posttonsil surgery bleeding as compared with coagulation studies.

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Prevalence of Persistent Olfactory Disorders in Patients With COVID-19: A Psychophysical Case-Control Study With 1-Year Follow-up

Luigi Angelo Vaira,Giovanni Salzano,Serge Daniel Le Bon,Angelantonio Maglio,Marzia Petrocelli,Younes Steffens,Enrica Ligas,Fabio Maglitto,Jerome R. Lechien,Sven Saussez,Alessandro Vatrella,Francesco Antonio Salzano,Paolo Boscolo-Rizzo,Claire Hopkins,Giacomo De Riu

Publication date 23-11-2021


The purpose of this multicenter case-control study was to evaluate a group of patients at least 1 year after coronavirus disease 2019 (COVID-19) with Sniffin' Sticks tests and to compare the results with a control population to quantify the potential bias introduced by the underlying prevalence of olfactory dysfunction (OD) in the general population. The study included 170 cases and 170 controls. In the COVID-19 group, 26.5% of cases had OD (anosmia in 4.7%, hyposmia in 21.8%) versus 3.5% in the control group (6 cases of hyposmia). The TDI score (threshold, discrimination, and identification) in the COVID-19 group was significantly lower than in the control group (32.5 [interquartile range, 29-36.5] vs 36.75 [34-39.5],

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Art and the Audiogram: How Skillful Observation Provides Insights to the History, Present, and Future

Celya Olivia Walker,James G. Naples

Publication date 23-11-2021


Although simple, audiograms are a dynamic tool that, much like fine art, can be used by experts to decipher the history, present, and probable future of its subject. Through close comparison with El Greco's

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Prevalence of Otolaryngology Diseases in an Urban Homeless Population

Massimo Ralli,Alessia Marinelli,Fabio De-Giorgio,Domenico Crescenzi,Marco de Vincentiis,Antonio Greco,Andrea Arcangeli,Lucia Ercoli

Publication date 23-11-2021


Otolaryngology diseases are common among people experiencing homelessness; however, they are seldom evaluated in a specialist setting, and investigations on their prevalence have rarely been conducted. The aim of this retrospective study was to evaluate the prevalence of otolaryngology conditions in an urban homeless population. Retrospective study. Primary health care facility. The clinical records of patients referred to the medical facilities of the Primary Care Services of the Eleemosynaria Apostolica, Vatican City, between October 1, 2019, and July 31, 2021, were retrospectively reviewed; those reporting at least 1 otolaryngology disease were included in the study. A total of 2516 records were retrospectively reviewed, and 484 (19.24%) were included in the study. The most common otolaryngology disease was pharyngotonsillitis (n = 118, 24.13%), followed by rhinitis with nasal obstruction (n = 107, 21.88%), hearing loss (n = 93, 19.01%), otitis (n = 81, 16.56%), abscess (n = 46, 9.40%), and sinusitis (n = 33, 6.74%). Head and neck cancer or precancerous lesions were reported in 34 subjects (7.02%). More than 1 simultaneous otolaryngology disorder was found in nearly 50% of our sample. A wide range of comorbidities was also reported. Our results confirm an elevated otolaryngology demand in the homeless population and encourage the development of more efficient and effective strategies for a population-tailored diagnosis and treatment of these conditions.

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Major Salivary Gland Cancer With Distant Metastasis Upon Presentation: Patterns, Outcomes, and Imaging Implications

Liliya Benchetrit,Saral Mehra,Amit Mahajan,Rahmatullah W. Rahmati,Benjamin L. Judson,Heather A. Edwards

Publication date 16-11-2021


Given limited data availability on distant metastasis (DM) in major salivary gland (MSG) malignancy presentation, we aimed to evaluate the rate, histologic patterns, location, and predictors of DM at first MSG cancer presentation and suggest potential implications on diagnostic workup. Retrospective cohort. Commission on Cancer-accredited hospitals. We included patients in the National Cancer Database (2010-2016) with MSG malignancy. Site and rate of DM were stratified by histologic subtype. Factors predictive of DM at presentation were determined by multivariate regression analysis. Survival analyses were conducted via the Kaplan-Meier method, log-rank test, and Cox regression analysis. Of 5776 patients with MSG carcinoma, 333 (5.8%) presented with DM. The most common DM site was the lung (57.1%), followed by bone (46.8%) and liver (19.5%). DM was most common in adenocarcinoma-not otherwise specified (15.1%, 132/874) and salivary duct carcinoma (10.4%, 30/288). High-grade mucoepidermoid carcinoma had the highest rate of lung metastases (81.6%, 31/38). Conversely, myoepithelial carcinoma had the highest rate of bone metastases (85.7%, 6/7). DM at presentation was independently associated with an increased mortality risk (hazard ratio, 1.62; 95% CI, 1.40-1.90). We identified a DM rate of 5.8% in MSG malignancy at presentation. Overall 43% of patients presented without DM to the lung but with DM to the bones, liver, and/or brain. The most common metastatic sites differed by tumor histology. Staging with computed tomography neck and chest alone may fail to detect sites of DM; this work can be used for patient counseling in the clinical setting.

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Obstructive Sleep Apnea in Underweight Children

Courtney Johnson,Taylor Leavitt,Shiva P. Daram,Romaine F. Johnson,Ron B. Mitchell

Publication date 16-11-2021


To determine predictors of obstructive sleep apnea (OSA) in underweight children and to describe the demographic, clinical, and polysomnographic characteristics of an ethnically diverse population of underweight children with OSA. Case-control study. University of Texas Southwestern Medical Center and Children's Medical Center of Dallas. Underweight children aged 2 to 18 years who underwent a polysomnogram for suspected OSA between January 2014 and December 2020 were included. Underweight was defined as body mass index <5th percentile per Centers for Disease Control and Prevention guidelines. Children with apnea-hypopnea index <1.0 served as a control group. Univariate and multiple logistic regression analysis was used to determine the predictors of OSA.
Significance was set at An overall 124 children met inclusion criteria: mean age, 6.4 years; 50% female; 44% Hispanic, 31% African American, and 18% Caucasian. A total of 83 children had OSA (apnea-hypopnea index ≥1.0). Height was negatively correlated with OSA (odds ratio, 0.94; 95% CI, 0.88-0.99; Underweight children with OSA, as compared with those without OSA, are more likely to have decreased height, tonsillar hypertrophy, and allergic rhinitis. There are no predictors of severe OSA in underweight children. We recommend polysomnography for the diagnosis of OSA in symptomatic underweight children with large tonsils, especially when they have a history of allergies.

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Swallowing After Primary TORS and Unilateral or Bilateral Radiation for Low- to Intermediate-Risk Tonsil Cancer

Carly E.A. Barbon,Christopher M.K. Yao,Christine B. Peterson,Amy C. Moreno,Ryan P. Goepfert,Faye M. Johnson,Gregory M. Chronowski,Clifton D. Fuller,Neil D. Gross,Katherine A. Hutcheson

Publication date 16-11-2021


The primary course of treatment for patients with low- to intermediate-risk tonsil cancer has evolved with a shift toward primary transoral robotic surgery (TORS) or radiation therapy (RT). While favorable outcomes have been reported after deintensification via unilateral TORS or RT (uniRT), comparisons of functional outcomes between these treatments are lacking. We compared clinical outcomes (Dynamic Imaging Grade of Swallowing Toxicity [DIGEST] and feeding tube [FT]) and patient-reported swallowing outcomes (MD Anderson Dysphagia Inventory [MDADI]) based on primary treatment strategy: TORS, uniRT, or bilateral RT (biRT). Secondary analysis of prospective cohort. Single institution. The study sample comprised 135 patients with HPV/p16+ T1-T3, N0-2b (American Joint Committee on Cancer, seventh edition), N0-1 (eighth edition) squamous cell carcinoma of the tonsil were sampled from a prospective registry. Modified barium swallow studies graded per DIGEST, FT placement and duration, and MDADI were collected. Baseline DIGEST grade significantly differed among treatment groups, with higher dysphagia prevalence in the TORS group (34%) vs the biRT group (12%, While TORS and uniRT offer optimal functional outcomes related to dysphagia, results suggest that no measurable clinician-graded or patient-reported differences in swallow outcomes exist among these primary treatment strategies and biRT. Aside from baseline differences that drive treatment selection, differences in FT rate and duration by primary treatment strategy likely reflect diverse toxicities beyond dysphagia.

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Swallowing Function Following Neoadjuvant Chemotherapy and Transoral Robotic Surgery for Oropharyngeal Carcinoma: A 2-Year Follow-up

Esther Lee,Daniel Gorelik,Hannah R. Crowder,Christopher Badger,Jennifer Schottler,Ning-Wei Li,Robert Siegel,Nader Sadeghi,Joseph F. Goodman,Punam G. Thakkar,Arjun S. Joshi

Publication date 09-11-2021


To evaluate 2-year follow-up swallowing function in patients with human papillomavirus-related oropharyngeal squamous cell carcinoma (HPV+ OPSCC) who completed neoadjuvant chemotherapy and transoral robotic surgery (NAC+S). Retrospective analysis of patients with OPSCC treated with NAC+S between 2010 and 2021. A single academic institution. This is a cross-sectional study of patient-reported swallowing function, assessed with the MD Anderson Dysphagia Inventory (MDADI) at least 2 years after completion of treatment. The inclusion criteria are patients with HPV+ OPSCC who underwent NAC+S at least 2 years ago. Those requiring adjuvant radiation or chemoradiation or experiencing relapse were excluded from the study. Completed MDADIs were received from 37 patients at a median 3.8 years posttreatment (interquartile range, 2.0-8.6 years). Of those, 94.6% (n = 35) were male and 81.1% (n = 30) were White. The median age at OPSCC diagnosis was 59.0 years (interquartile range, 41-80 years). The most frequent primary subsite of OPSCC was the base of the tongue (n = 20, 54.1%), followed by the tonsils (n = 16, 43.2%). In addition, 75.7% (n = 28) had stage IVa disease (TNM seventh edition), and 29 (78.4%) had scores ≥80, classified as optimal function. When compared with patients who received bilateral neck dissection, patients who received unilateral neck dissection were associated with an age <65 years old ( Patients with OPSCC who were treated with NAC+S achieved satisfactory long-term swallowing outcomes. Unilateral neck dissection was significantly associated with higher MDADI scores in this patient cohort.

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Cochlear Implantation Outcomes in Children With CDH23 Mutations–Associated Hearing Loss

Kaitian Chen,Bixue Huang,Jincangjian Sun,Yue Liang,Guanxia Xiong

Publication date 09-11-2021


Mutations in the cadherin 23 gene ( Retrospective case review. Tertiary referral center. Targeted deafness-related gene panels were sequenced in Chinese families with profound sensorineural hearing loss. The clinical features of subjects carrying potentially pathogenic Between 2017 and 2019, we identified 5 children with prelinguistically profound hearing loss at our center who harbored 6 variants of This study revealed that children with congenital cochlear defects caused by

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Survival Associated With Consolidated Multidisciplinary Care in Head and Neck Cancer: A Retrospective Cohort Study

Charles Meltzer,Nathalie T. Nguyen,Jie Zhang,Jillian Aguilar,Maruta A. Blatchins,Charles P. Quesenberry,Yan Wang,Lori C. Sakoda

Publication date 09-11-2021


To compare survival among patients with head and neck cancer before and after implementing a weekly multidisciplinary clinic and case conference. A retrospective cohort study with chart review was conducted of 3081 patients (1431 preimplementation, 1650 postimplementation) diagnosed with stage I-IVB tumors in the oral cavity, oropharynx, hypopharynx, nasopharynx, or larynx. Pre- and postimplementation differences in overall and disease-specific survival 1, 2, and 3 years after diagnosis were assessed with unadjusted Kaplan-Meier curves and multivariable Cox proportional hazard regression models adjusted for demographic characteristics, comorbidity burden, smoking status, tumor site and stage, p16 status for oropharyngeal squamous cell cancer, and initial treatment modality. Patients less commonly presented with oropharyngeal squamous cell cancer and advanced tumors (III-IVB) and received primary treatment with surgery alone or with adjuvant therapy preimplementation than postimplementation. Overall survival at 3 years was 77.1% and 79.9% ( A multidisciplinary clinic and case conference were associated with improved outcomes among patients with head and neck cancer, especially those with advanced tumors. All patients with head and neck cancer should receive multidisciplinary team management, especially those with advanced tumors.

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Impact of Powered Air-Purifying Respirator Devices on Word Recognition in Health Care Providers

Emily J. Moldoff,Miranda K. Eubank,Anne Y. Feng,C. Eduardo Corrales,Jennifer J. Shin

Publication date 09-11-2021


The coronavirus 2019 pandemic has increased the use of powered air-purifying respirator (PAPR) devices, which produce appreciable noise levels during filtration. Our objective was to determine if active PAPR usage significantly impairs auditory communication in health care providers. We additionally sought to assess what volume of speech presentation was required for adequate communication with providers wearing a PAPR. In subjects with normal hearing at baseline, audiometric data demonstrated a 93% (95% CI, 86%-99%) decrease in word recognition scores during active PAPR usage. Presentation at 85 to 90 dB was needed to obtain word recognition scores similar to baseline in subjects with normal hearing without a PAPR. Pure tone averages also significantly decreased with PAPR usage, by 54 dB (95% CI, 46-62). Active PAPR usage has a substantial impact on auditory perception when utilized by health care providers. The potential longer-term effect of these devices on providers with regular active usage is of interest for future study.

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Effect of Medialization on Dyspnea Index in Unilateral Vocal Fold Paralysis

Matthew R. Hoffman,Beau Vandiver,Natalie Derise,Edie R. Hapner,Glen Leverson,C. Blake Simpson

Publication date 09-11-2021


Patients with unilateral vocal fold paralysis commonly report dysphonia and dysphagia. Dyspnea also occurs, with studies on treatment-related change producing mixed results. Studies including patient-reported outcomes have focused on single-question global scales. The Dyspnea Index (DI) includes 10 questions, is specific to upper airway-related dyspnea, and may better capture these patients' symptoms. We evaluated change in DI after treatment. Retrospective review. Academic medical center. Forty-three patients with unilateral vocal fold paralysis underwent injection augmentation (n = 25) or framework surgery (n = 18). DI was recorded preprocedure, 2 to 4 weeks afterward, and at approximately 3 months afterward in 19 patients. Voice Handicap Index-10, Glottal Function Index, Cough Severity Index, and Eating Assessment Tool-10 were also recorded. Change in parameters and correlations were assessed. Obesity, cardiac disease, pulmonary disease, and procedure (injection vs framework surgery) were evaluated for effect on DI. Twenty-four patients had an abnormal baseline DI (>10). DI decreased from 14.9 ± 13.8 to 6.5 ± 9.3 after treatment ( Upper airway-related dyspnea is common in unilateral vocal fold paralysis, occurring in half of this cohort. Correcting glottic insufficiency may alleviate symptoms. Treatment decision making should consider postprocedural change in dyspnea, especially in patients for whom dyspnea is a motivating factor for seeking treatment.

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Clinical, Prognostic, and Predictive Value of Olfactory Dysfunction for COVID-19: A Prospective Controlled Study

Esra Kavaz,Emel Tahir,Senem Çengel Kurnaz,Aydın Deveci,Esra Aksakal Tanyel

Publication date 02-11-2021


To evaluate the effect of olfactory dysfunction on the course and severity of COVID-19 and its prognostic and predictive significance for COVID-19. Prospective case-control study. Ondokuz Mayıs University School of Medicine. Reverse transcription polymerase chain reaction (PCR)-positive patients, patients with COVID-19-related symptoms who had a negative PCR result, and healthy controls were included in the study. Clinicodemographic characteristics, inflammatory markers, and computed tomography stages were recorded. Disease progression and intensive care unit admission were registered. The visual analog scale (0, worst; 10, best) was used to evaluate subjective olfactory, taste, and nasal breathing ability, and the Sniffin' Sticks identification (SS-ID) test was used for psychophysical olfactory assessment. Mean SS-ID scores were significantly lower in the positive group (8.77) than in the negative (10.43) and healthy control (12.17) groups. VAS-smell scores were significantly lower and anosmia was more prevalent in PCR-positive patients ( Olfactory dysfunction was detected objectively and subjectively in the PCR-positive group, and no difference was found in terms of taste function and nasal breathing. The severity and prognosis of COVID-19 are not exclusively dependent on olfactory dysfunction. The degree of olfactory dysfunction can be useful in predicting PCR positivity.

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Bedside Neck Exploration for Venous Flow Coupler Signal Loss in Postoperative Free Tissue Transfer Monitoring

Kyle P. Davis,James Reed Gardner,Quinn A. Dunlap,Emre A. Vural,Jumin Sunde,Mauricio Alejandro Moreno

Publication date 26-10-2021


To describe the role and efficacy of bedside neck exploration following free tissue transfer. Retrospective case series. Single tertiary care institution. A retrospective chart review was conducted of 353 patients who underwent free tissue transfer between January 2017 and April 2021. Bedside exploration was performed under mild sedation in patients who had loss of venous Doppler signal with equivocal clinical signs of venous insufficiency. A total of 11 patients underwent bedside assessment of the microvascular pedicle. In 6 cases, a return to the operating room was avoided. Five of these patients had coupler malfunction, and in 1 patient a venous kink was discovered and remedied at the bedside. Five patients required return to the operating room. Venous thrombosis requiring thrombectomy and revision of the venous anastomosis was discovered in 3 patients. One patient had a developing hematoma necessitating evacuation in the operating room, and 1 returned to the operating room due to sternocleidomastoid muscular compression of the venous pedicle. There were no flap failures within the study group. In all cases, broad-spectrum intravenous antibiotic coverage was prophylactically used, and no instances of wound infection were observed. Avoidance of returning to the operating room prevented an estimated $9222 of hospital charges per event. Bedside neck exploration can be incorporated as a safe and cost-effective intermediary for definitive determination of need for return to the operating room.

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Creation of aNovel Preoperative Imaging Review Acronym to Aid in Revision Endoscopic Sinus Surgery

Omar A. Karadaghy,Andrew M. Peterson,Meha Fox,Jacob White,Vidur Bhalla,David Beahm,Jennifer Villwock,Alexander G. Chiu

Publication date 26-10-2021


(1) Identify anatomic contributions to chronic rhinosinusitis (CRS) necessitating revision endoscopic sinus surgery (RESS). (2) Create a clinical acronym to guide imaging review prior to RESS that addresses pertinent sites of disease and potential sites of surgical morbidity. Ovid MEDLINE, Embase and Medline via Embase.com, Web of Science Core Collection, Cochrane Central Register of Controlled Trials (CENTRAL), and Google Scholar. Systematic search was performed using a combination of standardized terms and keywords. Studies were included if they investigated anatomic contributions to persistent CRS requiring RESS or the relationship between anatomic landmarks and surgical morbidity. Identified studies were screened by title/abstract, followed by full-text review. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were strictly followed. In total, 599 articles met screening criteria, 89 were eligible for full-text review, and 27 studies were included in the final review. The identified anatomic sites of interests are broad; the most frequently cited anatomic region was retained anterior ethmoid cells (22/27 studies), followed by posterior ethmoid cells (14/27 studies). Using the consolidated information, a clinical acronym, REVISIONS, was created: Residual uncinate, Ethmoid cells (agger, Haller, supraorbital), Vessels (anterior and posterior ethmoid), Infundibulum, Septal deviation, I (eye) compartment, Onodi cell, Natural os, and Skull base slope and integrity. The REVISIONS acronym was developed as a tool to distill the unique anatomic contributions of primary endoscopic sinus surgery failure into a format that can be easily incorporated in preoperative radiologic review and surgical planning to optimize outcomes and minimize complications.

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Clinical Significance of Mast Cells in the Supraglottic Larynx of Children With Aerodigestive Disease

Emily L. Mace,Shilin Zhao,Brittany Lipscomb,Christopher T. Wootten,Ryan H. Belcher

Publication date 26-10-2021


To analyze the association of mast cells found on supraglottic biopsy of pediatric patients with common aerodigestive diseases. Cross-sectional study. Tertiary care children's hospital. A total of 461 pediatric patients undergoing otolaryngology aerodigestive procedures provided consent between 2014 and 2019, and biopsies of the supraglottic larynx were collected at the time of their surgery. Pathologists reviewed biopsies for the presence and number of mast cells per high-power field. The patients' electronic health records were reviewed for relevant demographic data and clinical diagnoses present at the time of biopsy. Multivariate logistic regression was used to assess the relationship of mast cells with odds of aerodigestive disease. Patients with mast cells in their biopsy had significantly higher odds of asthma (odds ratio [OR], 2.02; 95% CI, 1.17-3.46), gastroesophageal reflux disease (OR, 2.36; 95% CI, 1.47-3.77), laryngomalacia (OR, 2.98; 95% CI, 1.80-4.94), laryngeal anomalies (OR, 2.32; 95% CI, 1.52-3.55), and obstructive sleep apnea (OR, 2.16; 95% CI, 1.35-3.45). When mast cells were evaluated as a continuous variable, there was a nonlinear relationship between increasing mast cell count and odds of disease. Mast cells are known to be associated with inflammatory conditions, though little is known about their presence in laryngeal inflammation. Results from our study demonstrate an association between mast cells in the pediatric larynx and asthma, gastroesophageal reflux disease, laryngomalacia, laryngeal anomalies, and obstructive sleep apnea. Our study also showed a nonlinear relationship between number of mast cells and odds of disease diagnosis.

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The National Cancer Database: Survival Between Head and Neck Melanoma and Melanoma of Other Regions

Claudia I. Cabrera,Shawn Li,Rosalynn Conic,Brian R. Gastman

Publication date 26-10-2021


Primary site is considered an important prognostic factor for cutaneous malignant melanoma (CMM); however, opinions vary regarding its influence on survival. This study compares overall survival between head and neck melanoma (HNM) and melanoma of other regions (MOR), as well as between melanoma of the scalp and neck (MSN) and melanoma of other head regions (MOHR). Level III retrospective cohort study. Patients from Commission on Cancer-accredited cancer programs affiliated to the National Cancer Database (NCDB). Patients with HNM (MSN and MOHR included) and MOR, stages I to IV (n = 39,754), and their linked survival data using the NCDB were identified. Survival was analyzed using propensity score matching methods. After matching using propensity scores, allowing this observational study to mimic a randomized controlled trial, subjects with HNM showed a 22% increased mortality when compared to MOR ( Patients with HNM showed a higher mortality when compared to MOR. The risk of death of primary sites within the head and neck varies over time, showing a higher risk of mortality for scalp and neck during the first 3.5 years of follow-up. This increased risk was not evident after the 3.5-year threshold. Further research is needed to evaluate additional patient factors or differences in treatment approaches.

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Reducing Children’s Preoperative Fear with an Educational Pop-up Book: A Randomized Controlled Trial

Holly Cordray,Chhaya Patel,Kara K. Prickett

Publication date 26-10-2021


Preoperative education empowers children to approach surgery with positive expectations, and providers need efficient, child-focused resources. This study aimed to evaluate an interactive pop-up book as a tool for explaining surgery, managing preoperative anxiety, and strengthening coping strategies. Prospective randomized controlled trial. Pediatric outpatient surgery center. Patients ages 5 to 12 undergoing outpatient surgery read a pop-up book about anesthesia (intervention) or received standard care (control). Patients self-reported their preoperative fear, pain expectations, views of the procedure and preoperative explanations, and coping strategies. Outcomes also included observer-rated behavioral anxiety and caregiver satisfaction. In total, 148 patients completed the study. The pop-up book had a significant, large effect in reducing patients' fear of anesthesia induction (Cohen's The educational pop-up book offers a child-focused resource that helps alleviate children's preoperative fears, encourages positive coping, and improves caregivers' perceptions of the experience. This study was registered at Clinical Trials.gov (NCT04796077).

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Empty Nose Syndrome Pathophysiology: A Systematic Review

Dichapong Kanjanawasee,Raewyn G. Campbell,Janet Rimmer,Raquel Alvarado,Jesada Kanjanaumporn,Kornkiat Snidvongs,Larry Kalish,Richard J. Harvey,Raymond Sacks

Publication date 19-10-2021


The pathophysiology of empty nose syndrome (ENS) remains unclear despite significant research. The pathophysiologic mechanism of ENS was systematically reviewed. MEDLINE and Embase. Data were systematically reviewed for studies that provided original data on pathophysiology. A total of 2476 studies were screened, and 19 met the inclusion criteria: 13 case-control and 6 cross-sectional. Nine pathophysiologic themes were identified.• Demographics: ENS symptoms had no relationship with climatic factors.• Symptomatology: ENS patients demonstrated high symptom severity.• Mental health: Anxiety and depression including hyperventilation were reported in >50% of ENS patients and correlated with ENS symptom severity.• Anatomic features: Structural changes in response to turbinate surgery were similar between ENS and non-ENS patients.• Airflow analysis: Airflow parameters were similar between ENS and non-ENS patients after turbinate surgery. On computational fluid dynamic analysis, differences were found on multiple outcomes.• Diagnostic testing: The menthol detection test was impaired in ENS, and cotton placement in the airway improved ENS symptoms.• Cognitive function: Functional magnetic resonance imaging showed activation in emotional processing area during breathing.• Olfactory function: Subjective impairment was reported in ENS, but quantitative measures were similar to non-ENS patients.• Mucosal physiology/innate immunity: Turbinate histopathology in ENS showed a tissue-remodeling pattern. Nasal nitric oxide level was lower in ENS patients. There is evidence of high comorbid mental health disorders in ENS patients. An abnormal trigeminal-thermoreceptor response may be present in some patients. The influence of altered airflow and the evidence of surgery as the cause for ENS are unclear.

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Effect of Fascia Implantation and Controlled Release of Basic Fibroblast Growth Factor for Muscle Atrophy in Rat Laryngeal Paralysis

Hiromi Nagai,Koichiro Nishiyama,Yutomo Seino,Yasuhiko Tabata,Taku Yamashita

Publication date 19-10-2021


To improve lateral thyroarytenoid (TA) muscle atrophy after laryngeal paralysis, reconstruction of the vascular network of the atrophied muscle is necessary. We therefore evaluated whether the controlled release of basic fibroblast growth factor (bFGF) with autologous fascia implantation could affect vascular reconstruction in the lateral TA muscle. Animal experiment. Laboratory. Unilateral laryngeal paralysis was induced in 20 rats. The rats were implanted with autologous fascia and a gelatin hydrogel sheet with or without 1 µg of bFGF (fascia and bFGF + fascia groups; n = 5 each) and with only a gelatin hydrogel sheet with bFGF (bFGF group: n = 5). Another group remained untreated (n = 5) at 4 months after paralysis. At 3 months since transplantation, intra- and intergroup comparisons of the muscle volumes and total area of blood vessels in the lateral TA muscle were performed. When compared with the untreated group, the bFGF + fascia group showed a significant increase in muscle volume ( bFGF + fascia implantation showed histologic improvement in severe laryngeal paralysis. We demonstrated that the decrease in lateral TA muscle mass after paralysis might be countered by the reconstruction of the vascular network. Our findings indicate that hypovascular and denervated areas of the laryngeal muscle can be regenerated by the implantation of growth factors and scaffolds with surgical stress. 5.

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Intraductal Fragmentation in Sialolithiasis Using Pneumatic Lithotripsy: Initial Experience and Results

Michael Koch,Mirco Schapher,Matti Sievert,Konstantinos Mantsopoulos,Heinrich Iro

Publication date 12-10-2021


To report initial experience in using a pneumatic lithotripter to treat salivary stones. Level IV retrospective study. University hospital and tertiary referral center. A pneumatic lithotripter was used to treat salivary stones after these were diagnosed. Probes with diameters of 0.7 mm were used. Total fragmentation was intended in all stones. Stone fragments were removed using several instruments in serial sialendoscopies to achieve complete stone clearance. A total of 62 patients with 77 stones were treated. Forty-three submandibular stones were treated in 34 patients, and 34 parotid stones were treated in 28 patients. An operating pressure of 2.5 bar and a single frequency mode were used. Complete fragmentation was achieved in all but one of the treated stones in both glands (98.7%). Among the patients, 90.32% became stone free and 100% symptom free. Multiple stones were treated in 24.19% of the patients, and multimodal therapy was also carried out in 24.19%. All of the glands were preserved. The pneumatic lithotripter proved to be effective in the treatment of sialolithiasis. Stone size, location, and the gland involved were important clinical factors. The device was sufficient to achieve success without any increased risk for complications in the patients or damage to the sialendoscopes.

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Novel Surgical Technique in Active Bone Conduction: Minimally Invasive Approach to Fully Implantable Osseointegrated Implant

Tiffany Peng Hwa,Garrett Locketz,Michael J. Ruckenstein

Publication date 12-10-2021


We report our experience using a novel minimally invasive surgical technique for implantation of a fully implantable active bone conduction implant. This was a retrospective review of 16 adults, including 10 women and 6 men. The mean age was 54 years. Hearing loss profiles included 8 with mixed hearing loss, 5 with conductive hearing loss, and 3 with single-sided deafness. Nine patients underwent placement through the standard approach and 7 with the minimally invasive approach. There were no postoperative complications at a mean follow-up of 6.5 months (SD, 4; range, 1.5-12), and all patients received audiologic benefit with objective improvement in sound-field thresholds upon activation. Mean operative time was shorter with the minimally invasive approach (64 vs 41 minutes,

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A Closer Look at “Taller-Than-Wide” Thyroid Nodules: Examining Dimension Ratio to Predict Malignancy

Aviva S. Mattingly,Julia E. Noel,Lisa A. Orloff

Publication date 12-10-2021


To evaluate nodule height-to-width ratio as a continuous variable predicting likelihood of thyroid malignancy. Retrospective cohort study. All study information was collected from a single academic tertiary care hospital. Subjects included adult patients with thyroid nodules who underwent thyroid surgery between 2010 and 2020.
The following variables were collected: patient demographics, nodule dimensions via ultrasound, fine-needle aspiration biopsy results, and surgical pathology results. Statistical analysis included logistic regression modeling malignancy with variables of interest. We used a receiver operating characteristic curve to assess the discriminatory value of variables. Height-to-width ratio, as a continuous variable, was associated with malignancy (with each 0.1 increase in ratio; odds ratio [OR], 1.25; 95% CI, 1.14-1.37). The same relationship was true for height-to-length ratio (OR, 1.36; 95% CI, 1.24-1.56). The area under the receiver operating characteristic curve for height-to-width ratio was 63.7%. In line with current emphasis on the transverse ultrasound view, we determined 4 different height-to-width ratio intervals: <0.8, 0.8 to <1.0, 1.0 to <1.5, and ≥1.5. Likelihood ratios of malignancy for each interval were 0.6, 1.0, 2.3, and 4.9, respectively. Our results support the association between greater height-to-width ratio and malignancy but suggest that a multilevel rather than binary variable improves prediction. The likelihood ratios at different intervals give a more nuanced view of how height-to-width ratio predicts malignancy. With continuing review of guidelines for thyroid nodule biopsy, it is important to consider these data for any point total attributed to shape.

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A Systematic Review of Definitive Treatment for Inverted Papilloma Attachment Site and Associations With Recurrence

Monica S. Trent,Khodayar Goshtasbi,Lily Hui,John A. Gerka Stuyt,Nithin D. Adappa,James N. Palmer,Edward C. Kuan

Publication date 12-10-2021


Inverted papilloma (IP) is the most common benign neoplasm of the nasal cavity with known risk of recurrence. There is no standardized approach to definitive treatment for attachment sites. This systematic review aims to determine whether surgeon choice of technique differs by anatomic attachment site and whether different surgical techniques contribute to reduced rates of recurrence. Pub Med and Ovid Medline. A systematic review was conducted for studies reporting on IP. Those that included IP recurrence rates and primary tumor attachment site were reviewed. Of 122 published studies, 14 met eligibility criteria, representing 585 patients and a recurrence rate of 5.8%. The maxillary sinus (50.9%) was the most common primary attachment site, and the sphenoid sinus was associated with the highest rate of recurrence (10.4%). The most utilized technique included debulking the tumor, removing mucosa over the attachment site, and drilling the underlying bone. The most common Krouse stage represented was T3 (53.3%). No single technique predicted a propensity for recurrence, but certain techniques are favored depending on IP attachment site. Finally, frozen sections to obtain evidence of clear margins intraoperatively significantly reduced rates of recurrence (3.4% vs 7.3%, Based on the current literature, the most common technique to address site of attachment involves resecting mucosa and drilling the tumor base. Choice of technique appears to differ for various sites of attachment. Use of intraoperative frozen section analysis appears to be associated with decreased recurrence overall. 3.

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Objective Assessment of Aerosolization During Transnasal Endoscopy: A Systematic Review

Sophia Matos,Arun Sharma,Dana Crosby

Publication date 12-10-2021


The goal of this systematic review is to assimilate the literature on objective assessment of particulate aerosolization during transnasal endoscopic procedures. Pub Med and hand-searched articles. The Pub Med electronic database was searched using Medical Subject Headings and free-text search terms relating to aerosolization and transnasal endoscopic procedures from inception to November 16, 2020. References were hand-searched to identify additional publications for consideration. Inclusion in the systematic review required quantification of aerosol generation during clinic transnasal endoscopic procedures. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and flowchart were followed during the systematic review. Eight of 900 studies met criteria for inclusion in the systematic review. Five studies tested nasal endoscopy with mixed findings on the risk of aerosol generation during this procedure. Two studies assessed flexible fiberoptic laryngoscopy and also reported mixed findings. Breathing, sneezing, speech, and spray anesthetic/decongestants were found to consistently increase aerosol generation above baseline. A number of studies tested new and general mitigation strategies and were found to be effective in decreasing aerosol generation. The coronavirus disease 2019 pandemic has informed many considerations regarding patient and provider safety. It is valuable to understand the risk during outpatient otolaryngology procedures through the quantification of aerosolization. There are several effective methods to control aerosolization during these procedures. The findings of this systematic review will inform appropriate precautions to protect against spread of infectious agents by aerosolization.

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Long-Term Health Utilization and Outcomes in Chronic Suppurative Otitis Media

Anthony Thai,Ksenia A. Aaron,Adam C. Kaufman,Peter L. Santa Maria

Publication date 12-10-2021


To report health utilization patterns and outcomes of medical and surgical management in patients with chronic suppurative otitis media (CSOM). Retrospective cohort. Academic otology clinic. This study included 175 patients with CSOM with a first clinic visit at our institution between March 2011 and November 2016. All patients displayed a diagnosis of CSOM by Patients had an average of 9.5 ± 0.5 otology visits, 4.7 ± 0.4 prescriptions, and 1.7 ± 0.1 surgeries, with estimated per patient cost ranging from $3927 to $20,776. Under medical management, 69% of patients displayed recurrence of disease, with a median time to recurrence of 4 months. For tympanoplasty and tympanomastoidectomy, median time to recurrence was similar at 5 and 7 years, respectively ( CSOM represents a major public health issue with high health care utilization and associated costs. Surgery is superior to medical therapy for achieving short- to medium-term inactive disease. Patients with CSOM display a high SNHL burden.

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Implementation of Mobile Audiometry During the COVID-19 Pandemic

Alejandro Garcia,Divya A. Chari,Konstantina M. Stankovic,Daniel J. Lee,Elliott D. Kozin,Kevin H. Franck

Publication date 05-10-2021


During the COVID-19 pandemic, the utility of portable audiometry became more apparent as elective procedures were deferred in an effort to limit exposure to health care providers. Herein, we retrospectively evaluated mobile-based audiometry in the emergency department and outpatient otology and audiology clinics. Air conduction thresholds with mobile audiometry were within 5 dB in 66% of tests (95% CI, 62.8%-69.09%) and within 10 dB in 84% of tests (95% CI, 81.4%-86.2%) as compared with conventional audiometry. No significant differences were noted between mobile-based and conventional audiometry at any frequencies, except 8 k Hz (

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Patterns of Failure After Definitive Treatment of T4a Larynx Cancer

Rohith S. Voora,Bharat A. Panuganti,Mitchell Flagg,Tyler Nelson,Nikhil V. Kotha,Edmund M. Qiao,Alexander S. Qian,Abhishek Kumar,Tyler F. Stewart,Brent Rose,Joseph Califano,Philip A. Weissbrod,Loren K. Mell,Ryan K. Orosco

Publication date 05-10-2021


Recurrence is known to predict laryngeal squamous cell cancer (LSCC) survival. Recurrence patterns in T4a LSCC are poorly characterized and represent a possible explanation for observed survival discrepancies by treatment rendered. Retrospective database review. Veterans Affairs national database. Patients with T4a LSCC between 2000 and 2017 were identified and stratified by treatment (chemoradiotherapy [CRT] vs total laryngectomy + neck dissection + adjuvant therapy [surgical]). Primary outcomes were locoregional and distant recurrence. Secondary outcomes of overall mortality, larynx cancer mortality, and noncancer mortality were evaluated in Cox and Fine-Gray models.
A total of 1043 patients had comparable baseline demographics: 438 in the CRT group and 605 in the surgical group. Patients undergoing CRT had higher proportions of node positivity (64.6% vs 53.1%, T4a LSCC survival discrepancies between surgical and nonsurgical treatment are influenced by varying recurrence behaviors. Surgery was associated with superior disease control and improved survival. Beyond the known benefit in locoregional control with surgery, there may be a protective effect on distant recurrence that depends on regional disease burden.

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Multi-institutional Study of Otolaryngology Resident Intraoperative Experiences for Key Indicator Procedures

Jenny X. Chen,Francis Deng,Andrey Filimonov,Elizabeth A. Shuman,Emily Marchiano,Brian C. George,Marc Thorne,Steven D. Pletcher,Michael Platt,Marita S. Teng,Elliott D. Kozin,Stacey T. Gray

Publication date 05-10-2021


There is concern that current otolaryngology residents may not receive adequate surgical training. We aimed to characterize residents' surgical experiences at 5 academic centers performing the 14 key indicator procedures (KIPs) outlined by the Accreditation Council for Graduate Medical Education. Prospective study. Five otolaryngology training programs. Data were gathered from December 2019 to December 2020 with a smartphone application from the Society for Improving Medical Professional Learning. After each operation, residents and faculty rated trainee autonomy on a 4-level Zwisch scale and performance on a 5-level modified Dreyfus scale. Residents and attendings (n = 92 and 78, respectively) logged 2984 evaluations. Attending ratings of resident autonomy and performance increased with training level ( In this multicenter study, resident surgical autonomy and performance varied across otolaryngology KIPs. The development of nationwide benchmarks will help programs and residents set educational goals. 2.

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Development and Characterization of an Electrocochleography-Guided Robotics-Assisted Cochlear Implant Array Insertion System

Allan M. Henslee,Christopher R. Kaufmann,Matt D. Andrick,Parker T. Reineke,Viral D. Tejani,Marlan R. Hansen

Publication date 05-10-2021


Electrocochleography (ECochG) is increasingly being used during cochlear implant (CI) surgery to detect and mitigate insertion-related intracochlear trauma, where a drop in ECochG signal has been shown to correlate with a decline in hearing outcomes. In this study, an ECochG-guided robotics-assisted CI insertion system was developed and characterized that provides controlled and consistent electrode array insertions while monitoring and adapting to real-time ECochG signals. Experimental research. A research laboratory and animal testing facility. A proof-of-concept benchtop study evaluated the ability of the system to detect simulated ECochG signal changes and robotically adapt the insertion. Additionally, the ECochG-guided insertion system was evaluated in a pilot in vivo sheep study to characterize the signal-to-noise ratio and amplitude of ECochG recordings during robotics-assisted insertions. The system comprises an electrode array insertion drive unit, an extracochlear recording electrode module, and a control console that interfaces with both components and the surgeon. The system exhibited a microvolt signal resolution and a response time <100 milliseconds after signal change detection, indicating that the system can detect changes and respond faster than a human. Additionally, animal results demonstrated that the system was capable of recording ECochG signals with a high signal-to-noise ratio and sufficient amplitude. An ECochG-guided robotics-assisted CI insertion system can detect real-time drops in ECochG signals during electrode array insertions and immediately alter the insertion motion. The system may provide a surgeon the means to monitor and reduce CI insertion-related trauma beyond manual insertion techniques for improved CI hearing outcomes.

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Risk Factors for Aspiration Pneumonia After Receiving Liquid-Thickening Recommendations

Hiroaki Masuda,Rumi Ueha,Taku Sato,Takao Goto,Misaki Koyama,Akihito Yamauchi,Asako Kaneoka,Sayaka Suzuki,Tatsuya Yamasoba

Publication date 28-09-2021


We examined the influence of liquid thickness levels on the frequency of liquid penetration-aspiration in patients with dysphagia and evaluated the clinical risk factors for penetration-aspiration and aspiration pneumonia development. A case series. Single-institution academic center. We reviewed medical charts from 2018 to 2019. First, we evaluated whether liquid thickness levels influence the frequency of liquid penetration-aspiration in patients with dysphagia. Penetration-aspiration occurrence in a videofluoroscopic swallowing study was defined as Penetration-Aspiration Scale (PAS) scores ≥3. Second, the association between liquid thickness level and penetration-aspiration was analyzed, and clinical risk factors were identified. Moreover, clinical risk factors for aspiration pneumonia development within 6 months were investigated. Of 483 patients, 159 showed penetration-aspiration. The thickening of liquids significantly decreased the incidence of penetration-aspiration ( Thickening of liquids can reduce the incidence of penetration-aspiration. Vocal fold paralysis, impaired laryngeal sensation, and history of aspiration pneumonia are significant risk factors of penetration-aspiration. Poor performance status, PAS score ≥3, and history of aspiration pneumonia are significantly associated with aspiration pneumonia development following recommendations on thickening liquids. 3.

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Rate of COVID-19 Infection in Patients Following Otolaryngology vs Non-otolaryngology Outpatient Encounters

Alan D. Workman,Mark A. Varvares,Neil Bhattacharyya

Publication date 28-09-2021


Routine outpatient otolaryngology visits have been identified as potential vectors for increased transmission of COVID-19 relative to other medical encounters. This is in part due to the inability of patients to mask during comprehensive otolaryngology examination and potential propensity for aerosolization during upper airway procedures, including endoscopy and nasopharyngoscopy. Using a matched-cohort sampling of >20,000 patients seen between April 2020 and January 2021, we found no increased rate of postvisit COVID-19 positivity following an in-office otolaryngology encounter relative to other non-otolaryngology outpatient encounters. This suggests that the perceived elevated risk of provider-to-patient and patient-to-patient transmission during outpatient otolaryngologic care may be unfounded.

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Opioid Prescriptions Following Otologic Surgery: A Population-Based Study

Keshinisuthan Kirubalingam,Paul Nguyen,Gregory Klar,Joanna M. Dion,Robert J. Campbell,Jason Atkins Beyea

Publication date 28-09-2021


To examine postoperative opioid-prescribing patterns following otologic surgery. Retrospective population-based descriptive study. All hospitals in the Canadian province of Ontario. Of all patients with advanced ear surgery between July 1, 2012, and March 31, 2019, 7 cohorts were constructed: tympanoplasty with or without ossiculoplasty (n = 7812), atticotomy/limited mastoidectomy (n = 1371), mastoidectomy (n = 3717), semicircular canal occlusion (SCO; n = 179), stapedectomy (n = 2735), bone-implanted hearing aid insertion (n = 280), and cochlear implant (n = 2169). Prescriptions filled for narcotics postoperatively were calculated per morphine milligram equivalent (MME) opioid dose. Multivariable regression was used to determine predictors of higher opioid doses. The mean ± SD MMEs prescribed were as follows: tympanoplasty with or without ossiculoplasty, 246.77 ± 1380.78; atticotomy/limited mastoidectomy, 283.32 ± 956.10; mastoidectomy, 280.56 ± 1018.50; SCO, 328.61 ± 1090.86; stapedectomy, 164.64 ± 657.18; bone-implanted hearing aid insertion, 326.11 ± 1054.66; and cochlear implant, 200.87 ± 639.93. SCO (odds ratio [OR], 1.69 [95% CI, 1.16-2.48]) and mastoidectomy (OR, 1.50 [95% CI, 1.36-1.66]) were associated with higher opioid doses than tympanoplasty-ossiculoplasty. Asthma (OR, 1.24 [95% CI, 1.12-1.38]), chronic obstructive pulmonary disease (OR, 1.29 [95% CI, 1.12-1.47]), myocardial infarction (OR, 1.33 [95% CI, 1.05-1.68]), diabetes (OR, 1.22 [95% CI, 1.08-1.39]), and substance-related and addictive disorders (OR, 2.59 [95% CI, 1.67-4.00]) were associated with higher opioid doses prescribed. Overall MME prescribed by year demonstrates a sharp drop from 2017-2018 to 2018-2019. This large comprehensive population study provides insight into the prescribing patterns following otologic surgery. The large amounts prescribed and substantial variation require further study to determine barriers that limit good opioid-prescribing stewardship in the postoperative period.

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Private Payer–Negotiated Prices for Outpatient Otolaryngologic Surgery

Annette A. Wang,Roy Xiao,Rosh K.V. Sethi,Vinay K. Rathi,George A. Scangas

Publication date 28-09-2021


In January 2021, the Centers for Medicare & Medicaid Services began requiring hospitals to publish price transparency files listing all prices negotiated with payers. We performed a cross-sectional analysis of payer-negotiated prices for commonly performed outpatient otolaryngology surgery at all hospitals scored by the

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Cochlear Implantation Outcomes in Observed Vestibular Schwannoma: A Preliminary Report

Elizabeth S. Longino,Nauman F. Manzoor,Nathan D. Cass,Kareem O. Tawfik,Marc L. Bennett,Matthew R. O’Malley,David S. Haynes,Elizabeth L. Perkins

Publication date 21-09-2021


Over the last decade there has been a trend toward observation for small nongrowing vestibular schwannoma (VS). Even without tumor growth, patients commonly experience ipsilateral hearing decline, and hearing rehabilitation remains challenging. This study analyzes hearing and speech performance outcomes after cochlear implantation (CI) in observed VS. Retrospective review. Tertiary referral center. Chart review was used to include patients with observed VS who had undergone ipsilateral CI, pre- and postimplantation audiometry, and speech performance. Tumor size pre- and postimplantation was measured with volumetric analysis. Seven patients with ipsilateral VS and CI were identified. Preimplantation tumor volume was 0.11 to 1.02 cm Our results demonstrate that CI is a successful option for subjects with small nongrowing VS. All subjects had improved performance postimplantation. VS may continue to be observed with serial magnetic resonance imaging given increasing conditionality among CI manufacturers and ability to assess cerebellopontine angle extension despite implant artifact.

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How Do Academic Otolaryngologists Decide to Implement New Procedures Into Practice?

Bethany Powers,Cara Damico Smith,Natalia Arroyo,David O. Francis,Sara Fernandes-Taylor

Publication date 21-09-2021


To identify barriers and facilitators to adoption of a new surgical procedure via an implementation science framework to characterize associated socioemotional, clinical, and decision-making processes. Qualitative study with a semistructured interview approach. Large tertiary care referral center. Academic otolaryngologists with at least 2 years of practice were identified and interviewed. Transcripts were thematically coded and separated into steps in the clinical pathway. Synthesis of major themes characterized facilitators and barriers to uptake of a new surgical technique. Of 22 otolaryngologists, 19 were interviewed (85% male). They had a median 18 years of practice (interquartile range, 7.8-26.3), and 65% were subspecialty trained. In the decision to implement a new procedure, improving patient outcomes and addressing unmet clinical needs facilitated adoption, whereas costs and adopting profit-driven technologies without improved outcomes were barriers. In patient consults, establishing trust facilitated implementation of new techniques; barriers included participants' hesitation to communicate about the unknowns of a new procedure. Intraoperatively, little change to existing workflow or improved efficiency facilitated adoption, while a substantial learning curve for the new procedure was a barrier. Achieving favorable outcomes and patient satisfaction sustained implementation of new procedures. Too few referrals or indications for the new procedure hindered implementation. Our study demonstrates that innovation in otolaryngology is often an individual iterative process that providers pursue to improve patients' outcomes. Although models for the oversight of surgical innovation emphasize the need for evidence, obtaining sufficient numbers of providers and patients to generate evidence remains a challenge in specialty surgical practice.

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Human Papillomavirus–Negative Oropharyngeal Cancer Survival Outcomes Based on Primary Treatment: National Cancer Database Analysis

Mohamed Shama,Zaid Al-Qurayshi,Mohammad Dahl,Robert J. Amdur,James Bates,William Mendenhall,Kathryn Hitchcock,Bianca M. Festa,Tamer Ghanem,Peter T. Dziegielewski

Publication date 21-09-2021


To compare survival outcomes between primary surgery and primary radiation therapy (RT) in patients with human papillomavirus (HPV)-negative oropharyngeal squamous cell carcinoma (OPSCC). A retrospective observational cohort study. National Cancer Database. A National Cancer Database review was conducted of 2635 patients with HPV-negative OPSCC who underwent surgery or RT ± chemotherapy between 2010 and 2014. Univariate analysis was performed on all variables and entered into a multivariate model. The main outcome was overall survival (OS). A total of 2635 patients with HPV-negative OPSCC were organized into 4 groups based on cancer staging. In group 1 (T1-2 N0-1; n = 774), up-front surgery had significantly better 5-year OS (76.2%) than RT (56.8%; adjusted hazard ratio [aHR], 1.76; P = .009; 95% CI, 1.15-2.69) and chemoradiation therapy (CRT; 69.5%; aHR, 1.56; P = .019; 95% CI, 1.08-2.26). In group 2 (T3-4 N0-1; n = 327), no significant difference existed between surgery and CRT (5-year OS, 51.3% vs 52.4%; aHR, 0.96; P = .88; 95% CI, 0.54-1.69). In group 3a (T1-2 N2-3; n = 807), surgery with adjuvant treatment showed significantly better 5-year OS than CRT (78.6% vs 68.8%; aHR, 1.51; P = .027; 95% CI, 1.05-2.18). In group 3b (T3-4 N2-3; n = 737), surgery with adjuvant treatment was not statistically associated with better 5-year OS as compared with CRT (61.0% vs 43.7%; aHR, 1.53; P = .06; 95% CI, 0.98-2.39). Primary surgery may provide improved survival outcomes in many cases of HPV-negative OPSCCs. These data should be used in weighing treatment options and may serve as a basis to better delineate treatment algorithms for HPV-negative disease.

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Autologous Adipose Tissue Injection of Vocal Cords in Presbyphonia

Ramón González-Herranz,Andrés Navarro-Mediano,Estefanía Hernández-García,Guillermo Plaza

Publication date 21-09-2021


This series evaluates the long-term results of autologous adipose injection (AAI) in patients older than 65 years with presbyphonia. Retrospective cohort study. Academic secondary medical center. This was a retrospective study with a minimum follow-up of 12 months. All patients underwent AAI for atrophy of both vocal folds due to presbyphonia. We measured subjective parameters as Voice Handicap Index-10 (VHI-10) or GRBAS scale (grade, roughness, breathiness, asthenia, strain) and objective measures such as maximum phonation time (MPT) or square pixel closure defect. We reviewed the medical records of patients undergoing AAI during the 2011-2018 period. An analysis of the demographic variables of the group was performed, as well as the values of VHI-10, GRBAS, and MPT, and the minimum closure defect measured in square pixels and the number of closed frames in the glottal cycle before and after the intervention. At 12 months, 17 of 18 patients reported subjective and VHI-10 improvement. The mean preoperative VHI-10 (26.7) was significantly higher than the postoperative value (14.4), and the GRBAS scale had a preoperative mean of 8.7 and a postoperative mean of 4.3, both with statistical significance. MPT increased from 7.7 to 12.4 seconds ( AAI improves long-term vocal fold closure, demonstrating utility in patients with presbyphonia.

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Peripheral Auditory Function in Young HIV-Positive Adults With Clinically Normal Hearing

Christopher E. Niemczak,Travis White-Schwoch,Abigail Fellows,Albert Magohe,Jiang Gui,Catherine Rieke,Trent Nicol,Enica R. Massawe,Ndeserua Moshi,Nina Kraus,Jay C. Buckey

Publication date 21-09-2021


Little is known about peripheral auditory function in young adults with HIV, who might be expected to show early evidence of hearing loss if HIV infection or treatment does affect peripheral function. The goal of this study was to compare peripheral auditory function in 2 age- and gender-matched groups of young adults with clinically normal hearing with and without HIV. Matched cohort study with repeated measures. Infectious disease center in Dar es Salaam, Tanzania. Participants included HIV-positive (n = 38) and HIV-negative (n = 38) adults aged 20 to 30 years who had clinically normal hearing, defined as type A tympanograms, air conduction thresholds ≤25 dB HL bilaterally from 0.5 to 8 k Hz, and distortion product otoacoustic emissions (DPOAEs) >6 dB above the noise floor bilaterally from 1.5 to 8 k Hz. Participants were tested multiple times over 6-month intervals (average, 2.7 sessions/participant) for a total of 208 observations. Primary outcome measures included tympanograms, air conduction audiograms, DPOAEs, and click-evoked auditory brainstem responses. HIV groups did not significantly differ in age, static immittance, or air conduction thresholds. HIV-positive status was independently associated with approximately 3.7-dB lower DPOAE amplitudes from 2 to 8 k Hz (95% CI, 1.01-6.82) in both ears and 0.04-µV lower (95% CI, 0.003-0.076) auditory brainstem response wave I amplitudes in the right ear. Young adults living with HIV have slightly but reliably smaller DPOAEs and auditory brainstem response wave I amplitudes than matched HIV-negative controls. The magnitude of these differences is small, but these results support measuring peripheral auditory function in HIV-positive individuals as they age.

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Price Transparency and Compliance With Federal Regulation for Pediatric Tonsillectomy

Noel Fahed Ayoub,Karthik Balakrishnan

Publication date 21-09-2021


To improve hospital price transparency, the Centers for Medicare & Medicaid Services (CMS) requires, as of January 2021, that all hospitals reveal charges for specific items and services. This analysis investigates whether otolaryngology residency-affiliated hospitals have complied with this new regulation, and it evaluates the variability in hospital-reported charges for pediatric tonsillectomy. Cross-sectional analysis. Subset of hospitals affiliated with otolaryngology residency programs.
Hospital websites were searched to determine compliance rates with CMS guidelines by posting a price transparency tool and specific charges for Overall 104 unique hospitals were analyzed: 81 (78%) provided pricing data, but only 28 (27%) complied with CMS guidelines. The median reported total gross charge was $13,239 (range, $600-$41,957); deidentified minimum negotiated charge, $9222 (range, $337-$25,164); and deidentified maximum negotiated charge, $17,355 (range, $1002-$54,987). Hospital fees (median, $11,900; range, $2304-$38,831) were consistently higher than physician fees (median, $1827; range, $420-$5063). All estimates included a disclaimer stating that values likely underrepresent true prices. Hospital compliance with the new regulation remains low, which limits efforts toward improved price transparency. There is wide variability in reported charges for pediatric tonsillectomy and adenoidectomy.

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Cognitive Impairment and Delirium in Older Patients Undergoing Major Head and Neck Surgery

David P. Goldstein,Michael Blasco,John de Almeida,Jie Su,Wei Xu,Marc Cohen,Michael Sklar,Shabbir Alibhai

Publication date 21-09-2021


The study objective was to measure the prevalence and predictors of cognitive impairment (CI) and delirium. Adults undergoing major head and neck cancer surgery completed the Clock Draw Test to screen for CI, defined as a score of 0 or 1. Postoperative delirium was recorded. Predictors of delirium and length of stay were assessed by univariate logistic regression and the latter with multivariate linear regression. Overall 274 patients were included, of which 47% had a Clock Draw Test score of 0 or 1. Post-operative delirium occurred in 17 (6%). CI was a predictor of postoperative delirium (odds ratio, 3.9; 95% CI, 1.2-12;

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Frailty Index as a Predictor of Readmission in Patients With Head and Neck Cancer

Rohith S. Voora,Alexander S. Qian,Nikhil V. Kotha,Edmund M. Qiao,Minhthy Meineke,James D. Murphy,Ryan K. Orosco

Publication date 14-09-2021


To evaluate the predictive utility of the Hospital Frailty Risk Score (HFRS), a stratification tool based on the Retrospective database review. Nationwide Readmissions Database (2017). Patients with head and neck cancer who underwent major surgical procedures were identified from the 2017 Nationwide Readmissions Database, representing 116 medical centers nationwide. Bivariate and multivariable logistic regression methods were used to identify factors associated with unplanned 30-day readmission, 30-day readmission mortality, and increased length of hospital stay. A total of 14,420 patients underwent major head and neck cancer surgery. Unplanned readmission occurred in 11% of patients. The most common reasons for unplanned readmission were procedural complications (26.5%), sepsis (7.3%), and respiratory failure (3.9%). Elevated frailty index (HFRS ≥5) was identified in 22% of patients. Frailty was associated with higher 30-day readmission rates (18.0% vs 9.5%, In this head and neck cancer surgical population, HFRS significantly predicted unplanned readmission. HFRS is a potential risk stratification tool and should be compared with other methods and explored in other cancer populations. Beyond the challenge of identifying at-risk patients, future work should explore potential interventions aimed at mitigating readmission.

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Pediatric Tracheostomy-Related Complications: A Cross-sectional Analysis

Micah Newton,Romaine F. Johnson,Erin Wynings,Hussein Jaffal,Stephen R. Chorney

Publication date 14-09-2021


To determine the rate of tracheostomy-related complications in pediatric patients from nationally representative databases. Cross-sectional analysis. 2016 Kids' Inpatient Database and 2016 Nationwide Readmission Database. All pediatric tracheostomy procedures were included. Complication type, admission outcomes, and readmission rates were recorded with a logistic regression analysis to determine patient characteristics associated with complications. An estimated 5309 tracheostomies were performed among pediatric patients in 2016, 8% (n = 432) of whom developed tracheostomy-related complications. This group was younger (4.7 vs 8.7 years, Tracheostomy-related complications occur in approximately 8% of pediatric patients and are higher in younger children or those with longer admission lengths. These data have implications for benchmarking standards of posttracheostomy complications across institutions.

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Association Between Twitter Mentions and Academic Citations in Otolaryngology Literature

Nikita Deshpande,Jason R. Crossley,Sonya Malekzadeh

Publication date 14-09-2021


To evaluate the relationship between Twitter mentions and academic citations in otolaryngology literature. Retrospective cross-sectional analysis. Altmetric Twitter mention and Google Scholar citation rosters. Original research articles from 10 leading otolaryngology journals were assessed 26 months after print publication. Article Twitter mentions were tracked through the Altmetric Bookmarklet, and article citation data were determined through the Google Scholar search engine. Twitter mentions and citation metrics of articles were compared through 2-tailed Of all articles, 50.7% (152/300) had at least 1 Twitter mention. Of all article Twitter mentions, 25% (432/1758) happened within the first week of online publication dates, while 64% (1130/1758) occurred between online and print publication dates. Articles mentioned on Twitter had 1.6-fold more Google Scholar citations (8.6 ± 0.7, mean ± SD) than articles with no Twitter mentions (5.4 ± 0.4, Most otolaryngology articles are disseminated over Twitter, with greatest Twitter activity occurring before print publication date of articles. Citations within 2 years of release are positively associated with the number of mentions on Twitter. Article Twitter mentions may augment the academic influence of otolaryngology publications.

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Congenital Cytomegalovirus Targeted Screening Implementation and Outcomes: A Retrospective Chart Review

Evette A. Ronner,Cheryl K. Glovsky,Barbara S. Herrmann,Melissa A. Woythaler,Mark S. Pasternack,Michael S. Cohen

Publication date 14-09-2021


To assess the effectiveness and outcomes of a targeted cytomegalovirus (CMV) testing protocol. Retrospective chart review. Tertiary care institution. Targeted screening for CMV in children who did not pass the newborn hearing screening (NHS) was introduced in July 2015 for the level 2 and 3 nurseries at our hospital. In January 2016, this policy was extended to include all nurseries. Retrospective chart review was performed for all newborns who did not pass their NHS between 2013 and 2020. CMV testing rates and related outcomes were compared before and after rollout.
A total of 891 charts were reviewed for infants who did not pass their NHS: 530 (60%) had CMV testing, of which 8 (1.5%) tested positive. Three cases were detected prior to and 5 occurred after initiation of targeted screening. Six CMV+ infants demonstrated hearing loss on confirmatory auditory brainstem response, all of whom began treatment with oral valganciclovir. Hearing remained stable in 3 patients, progressed in 2, and improved in 1. The rate of CMV testing in children who did not pass their NHS increased from 14% to 88% after full implementation of targeted screening ( Targeted screening is a feasible and effective method to identify CMV+ infants early in life. Implementation of a targeted screening program for CMV in children who do not pass the NHS resulted in significantly higher rates of CMV testing and earlier referral to infectious disease.

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Automated Registration-Based Temporal Bone Computed Tomography Segmentation for Applications in Neurotologic Surgery

Andy S. Ding,Alexander Lu,Zhaoshuo Li,Deepa Galaiya,Jeffrey H. Siewerdsen,Russell H. Taylor,Francis X. Creighton

Publication date 07-09-2021


This study investigates the accuracy of an automated method to rapidly segment relevant temporal bone anatomy from cone beam computed tomography (CT) images. Implementation of this segmentation pipeline has potential to improve surgical safety and decrease operative time by augmenting preoperative planning and interfacing with image-guided robotic surgical systems. Descriptive study of predicted segmentations. Academic institution. We have developed a computational pipeline based on the symmetric normalization registration method that predicts segmentations of anatomic structures in temporal bone CT scans using a labeled atlas. To evaluate accuracy, we created a data set by manually labeling relevant anatomic structures (eg, ossicles, labyrinth, facial nerve, external auditory canal, dura) for 16 deidentified high-resolution cone beam temporal bone CT images. Automated segmentations from this pipeline were compared against ground-truth manual segmentations by using modified Hausdorff distances and Dice scores. Runtimes were documented to determine the computational requirements of this method. Modified Hausdorff distances and Dice scores between predicted and ground-truth labels were as follows: malleus (0.100 ± 0.054 mm; Dice, 0.827 ± 0.068), incus (0.100 ± 0.033 mm; Dice, 0.837 ± 0.068), stapes (0.157 ± 0.048 mm; Dice, 0.358 ± 0.100), labyrinth (0.169 ± 0.100 mm; Dice, 0.838 ± 0.060), and facial nerve (0.522 ± 0.278 mm; Dice, 0.567 ± 0.130). A quad-core 16GB RAM workstation completed this segmentation pipeline in 10 minutes. We demonstrated submillimeter accuracy for automated segmentation of temporal bone anatomy when compared against hand-segmented ground truth using our template registration pipeline. This method is not dependent on the training data volume that plagues many complex deep learning models. Favorable runtime and low computational requirements underscore this method's translational potential.

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Sinogenic Intracranial Suppuration in Children: Systematic Review and Meta-analysis

Kristijonas Milinis,Nathan Thompson,Smadar Cohen Atsmoni,Sunil Dutt Sharma

Publication date 07-09-2021


To evaluate temporal trends in the management of sinogenic intracranial suppuration and its outcomes in children. A systematic search of databases was performed (Medline, Embase, Cochrane, Clinical Trials.gov). Studies in children (age <18 years) with sinogenic subdural empyema, extradural abscess, and intraparenchymal abscess were included. Data on treatment strategies were extracted. Primary outcome was death <90 days. Secondary outcomes were return to theater, neurologic disability at 6 months, and length of stay. Random effects meta-analysis and meta-regression were performed to investigate the effect of time and endoscopic sinus surgery (ESS) on these outcomes. A total of 32 retrospective observational studies involving 533 patients recruited across a 45-year period (1975-2020) were included. The pooled estimates for 90-day mortality, permanent neurologic disability, and return to theater were 2.3% (95% CI, 1.1%-3.6%; The outcomes of sinogenic intracranial complications have not changed over the last 45 years, and ESS was not associated with improved patient outcomes. Further high-quality studies are required to determine the most appropriate treatment modalities to improve the burden of morbidity associated with sinogenic intracranial suppuration in children.

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Management of Flap Failure After Head and Neck Reconstruction: A Systematic Review and Meta-analysis

Amit Walia,Jake J. Lee,Ryan S. Jackson,Angela C. Hardi,Craig A. Bollig,Evan M. Graboyes,Joseph Zenga,Sidharth V. Puram,Patrik Pipkorn

Publication date 07-09-2021


To systematically review management of flap loss in head and neck construction with free tissue transfer as compared with locoregional flap or conservative management. Medline, Embase, Scopus, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Clinical Trials.gov were searched up to October 2019. Candidate articles were independently reviewed by 2 authors. Articles were considered eligible if they included adequate reporting of flap management after flap loss and outcomes for survival of reconstruction, length of hospitalization, and perioperative complications. A total of 429 patients had acute flap failure in the perioperative period. The overall success with a secondary free flap was 93% (95% CI, 0.89-0.97; n = 26 studies, Salvage reconstruction with free tissue transfer has a high success rate. Second free flaps following flap failure had a similar length of hospitalization and lower overall complication rate than locoregional reconstruction or conservative management. A second free tissue transfer, when feasible, is likely a more reliable and effective procedure for salvage reconstruction.

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Survival Predictors of Head and Neck Burkitt’s Lymphoma: An Analysis of the SEER Database

Salma Ahsanuddin,Joshua B. Cadwell,Neel R. Sangal,Jordon G. Grube,Christina H. Fang,Soly Baredes,Jean Anderson Eloy

Publication date 07-09-2021


To analyze population-level data for Burkitt's lymphoma of the head and neck. Retrospective study of a national cancer database. Academic medical center. The SEER database (Surveillance, Epidemiology, and End Results) identified all patients with primary Burkitt's lymphoma of the head and neck from 1975 to 2015. Demographic, clinicopathologic, and treatment characteristics were analyzed. Multivariable Cox regressions analyzed factors associated with survival while controlling for baseline differences. A total of 920 patients with a mean (SD) age of 37.6 years (25.0) were identified. A majority of patients were White (82.8%) and male (72.3%). The most primary common sites included the lymph nodes (61.3%), pharynx (17.7%), and nasal cavity/paranasal sinuses (5.2%). The majority of patients received chemotherapy (90.5%), while fewer underwent surgery (42.1%) or radiotherapy (12.8%). Choice of treatment differed significantly among patients of different ages, year of diagnosis, primary site, nodal status, and Ann Arbor stage. Overall 10-year survival was 67.8%. On multivariable Cox regression, patients with older age (hazard ratio [HR], 1.05 per year; Burkitt's lymphoma of the head and neck diagnosed in more recent years has had improved survival. Factors significantly associated with survival include age, Ann Arbor stage, and treatment regimen. Treatment including surgery and chemotherapy was associated with the highest survival.

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Postoperative Pain After Endoscopic vs Microscopic Otologic Surgery: A Systematic Review and Meta-analysis

Sara Toulouie,Nikolas R. Block-Wheeler,Alexander Rivero

Publication date 07-09-2021


Equivalent outcomes, such as procedural safety and audiometry, have been reported between endoscopic ear surgery (EES) and microscopic ear surgery (MES). This study aims to determine if EES leads to decreased postoperative pain when compared with MES. Pub Med, OVID MEDLINE, Scopus, Web of Science, and Cochrane Central from 2000 to 2020. A systematic review in accordance with the PRISMA guidelines and standardized bias assessment was performed. Studies containing original data on postoperative pain following EES and MES were included.
Fourteen studies fulfilled eligibility: 7 retrospective studies, 6 randomized controlled trials, and 1 case series. Studies included surgery for cholesteatoma (n = 3), tympanoplasty/myringoplasty (n = 6), and stapedotomy (n = 5), pooling data from 974 patients. Postoperative pain was quantitatively described through a variety of numeric pain scores. Meta-analysis was performed on 11 studies. Among the 7 studies utilizing the numeric rating scale or visual analog scale, postoperative pain in the EES cohort was significantly lower than that of the MES cohort (standardized mean difference = -1.45 [95% CI, -2.05 to -0.85], Meta-analysis confirms that EES results in significantly less postoperative pain when compared with MES. This surgical approach should be considered in the armamentarium of otologic surgeons, allowing for improved outcomes.

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Reflecting on the COVID-19 Surgical Literature Surge: A Scoping Review of Pandemic Otolaryngology Publications

Manuela von Sneidern,Ashton E. Lehmann,Aria Jafari,Iliyan K. Vlasakov,Sarek A. Shen,Deborah Goss,Benjamin S. Bleier

Publication date 07-09-2021


To assess the high-volume 2020 COVID-19-related surgical literature, with special attention to otolaryngology articles in regard to content, level of evidence, citations, and public attention. A scoping literature review was performed with Pub Med and Web of Science, including articles pertaining to COVID-19 and surgical specialties (March 20-May 19, 2020) or otolaryngologic subspecialties (March 20-December 31, 2020). Scoping literature review. Otolaryngology-specific COVID-19-related articles were reviewed for publication date, county of origin, subspecialty, content, level of evidence, and Altmetric Attention Score (a weighted approximation of online attention received). Data were analyzed with Pearson correlation coefficients, analysis of variance, independent This review included 773 early COVID-19 surgical articles and 907 otolaryngology-specific COVID-19-related articles from 2020. Otolaryngology was the most represented surgical specialty within the early COVID-19-related surgical literature (30.4%). The otolaryngology-specific COVID-19 surgical literature responsively reflects the unique concerns within each otolaryngologic subspecialty. Although this literature was largely based on expert opinion (64.5%), articles with stronger levels of evidence received significantly more citations (on Web of Science and Google Scholar, Despite concerns of a surge in underrefereed publications during the COVID-19 pandemic, our review of the surgical literature offers some degree of reassurance. Specifically, the COVID-19 otolaryngology literature responsively reflects the unique concerns and needs of the field, and more scholarly citations and greater online attention have been given to articles offering stronger levels of scientific evidence.

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Telemedicine in Otolaryngology During COVID-19: Patient and Physician Satisfaction

Janet S. Choi,James H. Kim,Soyun Park,Matthew Lin,Faiz Abdur-Rahman,Wendy J. Mack,Courtney C.J. Volker

Publication date 07-09-2021


To examine patient and physician satisfaction with telemedicine in otolaryngology during COVID-19 and identify associated factors. Prospective cohort study. Tertiary care center. Patient satisfaction was rated by patients (age ≥18 years) who had encounters from May to July 2020 (n = 407). Physician satisfaction was rated by 15 otolaryngologists for specific encounters delivered from May to June 2020 (n = 1011). Patient satisfaction was measured with a Press Ganey questionnaire and a Telemedicine Satisfaction Questionnaire. Mean Press Ganey satisfaction scores of telemedicine encounters during COVID-19 were compared with the pre-COVID-19 Press Ganey scores from in-person encounters (n = 3059) to test a noninferiority hypothesis. Physician satisfaction was measured with a Provider Satisfaction Questionnaire. The mean Press Ganey patient satisfaction score for telemedicine encounters was 94.5 (SD, 8.8), no worse than that for in-person encounters prior to COVID-19 at 93.7 (SD, 15.5; Δ = 0.8 [95% CI, -0.5 to 2.1, excluding the noninferiority margin of -1]). Encounters with videoconference (vs telephone) and patients reporting higher income were associated with higher Telemedicine Satisfaction Questionnaire scores. Physician satisfaction scores during COVID-19 with telemedicine encounters were overall high at 83.3 (95% CI, 77.5-89.1), slightly lower when compared with the scores with in-person encounters at 88.4 (95% CI, 82.5-94.3; Δ = -5.2 [95% CI, -6.6 to -3.8]). Encounters with videoconference (vs telephone) and patients with English as a preferred language and follow-up visits were associated with higher Provider Satisfaction Questionnaire scores. Telemedicine is a feasible alternative format in otolaryngology during COVID-19 with overall high patient and physician satisfaction. Patient satisfaction with telemedicine encounters during COVID-19 was no worse than in-person encounters prior to the pandemic. Physician satisfaction with telemedicine was relatively lower in comparison with in-person encounters.

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Health Disparities in Otology: A PRISMA-Based Systematic Review

Braeden Lovett,Alexandra Welschmeyer,James Dixon Johns,Sarah Mowry,Michael Hoa

Publication date 07-09-2021


Social determinants of health (SDOHs), including but not limited to sex, race, socioeconomic status, insurance status, and education level, play a significant role in health disparities and affect health outcomes. The purpose of this systematic review is to examine health disparities in otology within the United States and highlight areas warranting further research. Pub Med, Ovid MEDLINE. Our search encompassed all years through January 10, 2021. All peer-reviewed primary literature of any design and publication date regarding health disparities and otology outcomes in the United States was eligible for inclusion. Eligibility assessment was performed via 3 independent investigators. Of the 6326 unique abstracts identified, 188 studies underwent full-text review, and 52 remained in the final review. The most frequently examined otologic condition was hearing loss (36.5%), followed by cochlear implantation (28.8%) and infection/effusion (15.4%). Vertigo/dizziness (1.9%), Ménière's disease (1.9%), and tinnitus (1.9%) were the least represented otologic conditions. Comprehensive articles on multiple disparity topics were the most common (n = 18), followed by articles on race/ethnicity (n = 11) and socioeconomic status (n = 9). Language (n = 2), education (n = 2), and gender (n = 1) were the least discussed. Over 5-fold the number of articles were published between 2011 and 2020 compared to the preceding decade (42 vs 8). This study captures the existing literature regarding health disparities and outcomes in otology. The lack of robust data suggests the need for future quality studies aimed at investigating disparities in otologic care, as well as a broader push for recording and reporting SDOHs.

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Access Challenge Index: A Novel Disparity Measure Predictive of Language Outcomes in Children Who Are Deaf/Hard of Hearing

Michelle M. Florentine,Madeleine P. Strohl,C. Sayard Benvenuti,Molly Eiseman,Melissa Ho,Anna K. Meyer,Chiara Scarpelli,Dylan K. Chan

Publication date 07-09-2021


To evaluate the effect of demographic disparities on language outcomes in a diverse group of children who are deaf or hard of hearing. Retrospective cohort study. UCSF Benioff Children's Hospital (a tertiary care center). Forty-four patients aged <18 years were identified with sensorineural hearing loss managed with a behind-the-ear hearing aid or cochlear implant. Demographic and clinical data were extracted from the medical record. The primary outcome measure was the Preschool Language Scales-5 at least 6 months after intervention.
Predictors of language outcome were assessed: hearing level at the time of hearing intervention, cochlear implant status, age of identification and intervention, travel time to site of hearing care, home language, race/ethnicity, insurance type, and Access Challenge Index-a novel measure of educational environment and family support based on the Child Cochlear Implant Profile. Multivariate and univariate analysis assessed predictors for association with intervention and receptive, expressive, and total language scores. Overall 82% of patients had cochlear implants. The median age at hearing intervention was 12 months. The sample was 59% female, 52% non-White, and 61% publicly insured, and 20% had a non-English primary home language. Accounting for multiple demographic and clinical predictors, a high Access Challenge Index score was independently associated with longer time to intervention ( Access Challenge Index-a novel comprehensive measure of educational and family environment-is a strong independent predictor of language outcomes in children who are deaf or hard of hearing.

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Utilization of Alexandrite Laser for Hair Removal in Pediatric Auricular Reconstruction

Peng You,Tara L. Rosenberg,Yi-Chun Carol Liu

Publication date 31-08-2021


Auricular reconstruction with autologous rib cartilage involves using a soft tissue envelope to cover the cartilage framework. In patients with a low hairline, hair-bearing skin may be incorporated on the reconstructed ear, creating a difficult and conspicuous aesthetic problem. A retrospective chart review was conducted to summarize and share the experience of using the Candela Gentle Max Pro 755-nm alexandrite laser system (Candela Corp) in children following auricular reconstruction. Nine patients received laser hair removal via the alexandrite laser system with good results. The number of completed sessions ranged from 1 to 5. The procedures were completed without the need for premedication or procedural sedation. Laser hair removal with an alexandrite laser system was safe, fast, and effective. With multistage auricular reconstruction, it was feasible to incorporate laser hair removal between the stages.

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Global Incidence of Sporadic Vestibular Schwannoma: A Systematic Review

John P. Marinelli,Cynthia J. Beeler,Matthew L. Carlson,Per Caye-Thomasen,Samuel A. Spear,Isaac D. Erbele

Publication date 31-08-2021


Ubiquitous throughout the literature and during patient counseling, vestibular schwannoma is often quoted to affect about 1 per 100,000 people. Yet, reports from distinct international populations suggest that the incidence is likely much higher. The objective of the current work was to systematically characterize the global incidence of sporadic vestibular schwannoma. Scopus, Embase, and Pub Med. Population-based studies reporting incidence rates of sporadic vestibular schwannoma between January 2010 and August 2020 were searched with language restrictions requiring reports to be published in Chinese, English, German, Italian, or Spanish. The protocol was registered with PROSPERO (CRD42021228208) prior to commencement of data collection. PRISMA guidelines for transparent reporting of systematic reviews were followed. Among 424 citations, 6 publications covering 4 distinct populations from Denmark, the Netherlands, Taiwan, and the United States met inclusion criteria. Most recent incidence rates of among all ages ranged between 3.0 and 5.2 per 100,000 person-years. Highest incidence rates were reported among patients aged ≥70 years, peaking at 20.6 per 100,000 person-years. One study from the United States reported the incidence of asymptomatic, incidentally diagnosed tumors at a rate of 1.3 per 100,000 person-years from 2012 to 2016. Recent international incidence rates of sporadic vestibular schwannoma exceed the commonly quoted "1 per 100,000" figure by up to 5-fold among all ages and by up to 20-fold among age groups at highest risk. Based on modern incidence rates, the lifetime prevalence of developing sporadic vestibular schwannoma likely exceeds 1 per 500 persons.

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Geographic Distribution of Otolaryngology Advance Practice Providers and Physicians

Derek H. Liu,Marshall Ge,Stephanie Shintani Smith,Christine Park,Elisabeth H. Ference

Publication date 24-08-2021


Advanced practice providers (APPs), namely physician assistants (PAs) and nurse practitioners (NPs), play an increasing role in meeting growing demands for otolaryngologic services, particularly in rural communities. This study analyzes the geographic distribution of otolaryngology providers, which is essential to addressing future demands. Cross-sectional study. Medicare Provider Utilization and Payment Data for 2017. codes were used to identify APPs providing 10 common otolaryngologic services. Geographic distribution was evaluated by calculating densities of APPs and otolaryngologists per 100,000 persons in urban versus rural counties as defined by the National Center for Health Statistics Urban-Rural Classification Scheme. We identified cohorts of 8573 otolaryngologists, 1148 NPs, and 895 PAs. There were significantly higher population-controlled densities of otolaryngologists and APPs in urban counties as compared with rural counties. The majority of otolaryngologists (92.1%) and APPs (83.3%) were in urban counties. However, the proportion of APPs (16.7%) in rural counties was significantly higher than the proportion of otolaryngologists (7.9%) in rural counties ( Although otolaryngologists and APPs mostly practiced in urban counties, a relatively higher proportion of APPs practiced in rural counties when compared with otolaryngology physicians. The majority of rural counties did not have any otolaryngologic providers. Given the expected shortages of otolaryngology physicians, APPs may play a critical role in addressing these gaps in access.

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Tonsil Riots and Vaccine Hesitancy: A 100-Year Legacy of Medical Mistrust

James Alrassi,James Cochran,Richard M. Rosenfeld

Publication date 17-08-2021


The "tonsil riots" of 1906 were panics that developed at several public schools in historically immigrant-dominated neighborhoods of New York City (NYC). Per archived newspaper articles, several NYC public schools asked for parental consent to have Board of Health physicians come and perform tonsillectomy and adenoidectomy on their students. When children subsequently returned home from school "drooling mouthfuls of blood and barely able to speak," mothers reacted with panic and flocked to the schools demanding the safe return of their children. Police, ultimately, had to be called in to manage the crowds, and the events of 1906 largely faded from the public eye. However, these events can offer important lessons in communication and cultural humility as the United States continues its mass vaccination against coronavirus disease 2019.

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The Quest for a DISE Protocol

Kristin L. Mooney,Melissa Brooks Peterson,Jonathan R. Skirko,Norman R. Friedman

Publication date 17-08-2021


The objective of this quality initiative project was to modify our existing institutional drug-induced sleep endoscopy (DISE) protocol so that the surgeon could consistently determine obstructive breathing patterns while minimizing children's discomfort. A quality initiative study utilizing the well-described plan-do-study-act (PDSA) process was conducted at a tertiary hospital for children with polysomnogram-documented obstructive sleep apnea who were undergoing DISE. A 4-point Likert measurement tool was created. Change in each Likert rating with subsequent PDSA cycle was tested with the Wilcoxon rank sum test (Mann-Whitney), and change across all PDSA cycles was tested with the Kruskal-Wallis equality-of-populations rank test. After a series of 4 PDSA cycles with 81 children, the DISE protocol was streamlined from 14 to 9 steps. There was significant improvement for all aspects of the DISE, with a final overall median rating of 1 (excellent) for intravenous (IV) placement, scope insertion, and anesthesiologist and surgeon satisfaction ( For sleep surgeons, DISE is quickly becoming what bronchoscopy is to the airway surgeon. Utilizing inhalational agents to obtain IV access and insert the flexible scope in the rapid "on-off" fashion optimizes DISE success regardless of the primary sedation medication and allows ample time for these agents to dissipate. Adoption of a DISE protocol that includes nasal premedication and inhalational volatile gases for IV and scope insertion at the onset provides a more predictable level of sedation that is well tolerated by the patient, enabling the otolaryngologist to create an obstructive sleep apnea treatment plan.

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Impact of Treatment Parameters on Racial Survival Differences in Oropharyngeal Cancer: National Cancer Database Study

Daniel Zhu,Amanda Wong,Eun Jeong Oh,Seungjun Ahn,Michael Wotman,Tanmay Sahai,Danielle Bottalico,Douglas Frank,Tristan Tham

Publication date 17-08-2021


To investigate how differences in treatment parameters account for survival differences between races of patients with oropharyngeal squamous cell carcinoma (OPSCC). Retrospective cohort study. National Cancer Database. Data of patients with OPSCC undergoing radiation therapy (RT) or concurrent chemoradiation therapy as primary treatment were obtained from the National Cancer Database from 2004 to 2016. We analyzed 4 treatment-related time intervals to determine their impact on survival between races when controlling for human papilloma virus (HPV) status. Cox proportional hazards models, stepwise logistic regressions, covariate adjustments, and propensity score matching were performed. A total of 3152 patients were identified (2877 White, 275 Black). In HPV- cases, Black patients with prolonged radiation duration had a significantly worse overall survival as compared with White patients (hazard ratio, 1.77; 95% CI, 1.03-3.05; There is a significant disparity in overall survival between Black and White patients with HPV- OPSCC when RT duration is prolonged. Clinicians should be aware of the negative impact of prolonged RT, especially in Black patients, so that they can attempt to decrease treatment-related time intervals. Facility type was also found to affect the outcomes of patients with OPSCC, and efforts should be made to improve patient access to well-equipped, high-volume facilities.

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Feminization Laryngoplasty: 17-Year Review on Long-Term Outcomes, Safety, and Technique

Brian A. Nuyen,Z. Jason Qian,Ross D. Campbell,Elizabeth Erickson-DiRenzo,James Thomas,C. Kwang Sung

Publication date 17-08-2021


Transfeminine patients can experience significant gender dysphoria in vocal communication. Feminization laryngoplasty (FL) is a gender-affirming surgery developed to elevate speaking vocal range, as well as alter vocal resonance and laryngeal cosmesis. The purpose here was to appraise FL's long-term voice outcomes across a 17-year review period. Level III, retrospective study and description of technique. A single-institution transfeminine voice clinic. Voice data (speaking fundamental frequency [F0], lowest F0, highest F0, F0 range in both Hertz and semitones, and maximum phonation time [MPT]) were collected and assessed. Self-assessment of voice femininity and complications were documented. The 162 patients, all transfeminine women, had a mean age of 40 years with 36-month mean follow-up. There were significant increases in mean speaking F0 (Δ = 50 ± 30 Hz, Δ = 6 ± 3 semitones; P < .001) and mean change in lowest F0 (Δ = 58 ± 31 Hz, Δ = 8 ± 4 semitones; P < .001). There was no significant difference in mean change in highest F0 or MPT. There was significant improvement (Δ = 60% ± 39%; P < .001) in perceptual self-assessment of vocal femininity. There was a 1.2% rate of major postoperative complications requiring inpatient admission or operative intervention. There were no differences in vocal outcomes between those patients who had less than 1-year follow-up and those who had 5-year follow-up. FL in this cohort was a safe and effective technique for increasing mean speaking F0, mean lowest F0, and voice gender perception over a prolonged follow-up period. These findings add to the possible treatments aimed at addressing the morbid dysphoria related to voice and communication for our transfeminine patients.

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A Systematic Review of Clinical Vestibular Symptom Triage, Tools, and Algorithms

Giovanni Lampasona,Erin Piker,Cynthia Ryan,Patricia Gerend,Steven D. Rauch,Joel A. Goebel,Matthew G. Crowson

Publication date 10-08-2021


The evaluation of peripheral vestibular disorders in clinical practice is an especially difficult endeavor, particularly for the inexperienced clinician. The goal of this systematic review is thus to evaluate the design, approaches, and outcomes for clinical vestibular symptom triage and decision support tools reported in contemporary published literature. A comprehensive search of existing literature in August 2020 was conducted using MEDLINE, CINAHL, and EMBASE using terms of desired diagnostic tools such as Study characteristics, tool metrics, and performance were extracted using a standardized form. Quality assessment was conducted using a modified version of the Quality of Diagnostic Accuracy Studies 2 (QUADAS-2) assessment tool. A total of 18 articles each reporting a novel tool for the evaluation of vestibular disorders were identified. Tools were organized into 3 discrete categories, including self-administered questionnaires, health care professional administered tools, and decision support systems. Most tools could differentiate between specific vestibular pathologies, with outcome measures including sensitivity, specificity, and accuracy. A multitude of tools have been published to aid with the evaluation of vertiginous patients. Our systematic review identified several low-evidence reports of triage and decision support tools for the evaluation of vestibular disorders.

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Barriers to Receiving Necessary Hearing Care Among US Children

Brooke M. Su-Velez,Habib Khoury,Shaghauyegh S. Azar,Nina L. Shapiro,Neil Bhattacharyya

Publication date 27-07-2021


We aim to clarify the national scope of unmet pediatric hearing care needs and identify specific barriers to hearing care. Cross-sectional study of a nationally representative data set. This study is based on the combined 2016 and 2017 National Survey of Children's Health. This survey covers the physical and emotional health, access to care, and social context of US children and adolescents aged 0 to 17 years. Analysis of parent-reported responses of children's hearing status, access to care, and perceived barriers. Overall, 0.3% (n = 206,200) of US children surveyed reported needing hearing care, which was not received. A further 1.3% (n = 934,000) reported deafness or problems with hearing, and of these, 6.4% (n = 60,000) reported not receiving necessary hearing care. Rates of insurance coverage between children with deafness/hearing problems and the general population were similar (91.7% vs 93.9%); however, deaf or hard-of-hearing children with unmet hearing care needs were more likely to be from non-White backgrounds (P = .009) and to lack health insurance coverage (P = .001).
Rates of unfulfilled hearing care by reason were as follows: 57.5% without eligibility for the service, 45.4% reporting the service was not available in their area, 53.7% with difficulty obtaining an appointment, and 53.5% reporting issues with cost. Over 200,000 children annually do not receive necessary hearing-related care despite high rates of insurance coverage, and nearly 60,000 of these children are deaf or hard of hearing. Cost, eligibility for and distribution of services, and timely appointments are the primary barriers to hearing health care.

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Sinus Radiological Findings in General Asymptomatic Populations: A Systematic Review of Incidental Mucosal Changes

Basil Razi,Adam Perkovic,Raquel Alvarado,Anna Stroud,Jacqueline Ho,Larry H. Kalish,Raewyn G. Campbell,Raymond Sacks,Richard J. Harvey

Publication date 03-08-2021


To determine the range of incidental mucosal changes in a general sinonasally asymptomatic population on radiology. Medline (1996-present) and Embase (1974-present) were searched on March 14, 2020, to identify articles that reported radiological sinus mucosal findings in asymptomatic population groups. Bibliographic search of included studies was conducted to identify additional articles. The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and Cochrane Handbook for Systematic Reviews of Interventions. A comprehensive search strategy was formulated and articles screened to extract data reporting Lund-Mackay (LM) score, presence of mucous retention cysts, and maxillary mucosal thickening. A random-effects model was used in meta-analysis. A total of 950 articles were identified, of which 33 manuscripts met the inclusion criteria. The included studies involved 16,966 sinonasally asymptomatic subjects. The mean LM score was 2.24 (95% CI, 1.61-2.87), and an LM score of ≥4 in 14.71% (95% CI, 6.86-24.82%) was present across all general asymptomatic population groups. Mucous retention cysts were noted in 13% (95% CI, 8.33-18.55%) and maxillary mucosal thickening of ≥2 mm in 17.73% (95% CI, 8.67-29.08%). The prevalence of incidental mucosal changes in a general asymptomatic population on radiology needs to be considered when making a diagnosis of chronic rhinosinusitis.

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Racial Disparities in Adult Cochlear Implantation

Geethanjeli N. Mahendran,Tyler Rosenbluth,Miriam Featherstone,Esther X. Vivas,Douglas E. Mattox,Candace E. Hobson

Publication date 27-07-2021


To compare rates of cochlear implant referral and cochlear implantation across different races and to compare audiometric profiles of these patients. Retrospective study. Academic tertiary care institution. Demographic and audiometric data were collected for patients who underwent cochlear implant evaluation or cochlear implantation from 2010 to 2020. A total of 504 patients underwent cochlear implant evaluation; 388 met cochlear implant candidacy criteria, and 258 underwent implantation. Of the patients referred for cochlear implant evaluation, 68.5% were White, 18.5% were Black, and 12.3% were Asian, while the institution's primary service area is 46.9% White, 42.3% Black, and 7.7% Asian (P < .001). Black patients referred for cochlear implant evaluation had significantly worse hearing (mean pure-tone average [PTA] 84.5 dB, 26.1% word recognition) than White patients (mean PTA 78.2 dB, P = .005; 35.7% word recognition, P = .015) and Asians patients (mean PTA 77.9 dB, P = .04; 36.5% word recognition, P = .04).
Black patients who underwent cochlear implant evaluation also had significantly worse Az Bio scores than White patients: 24.5% versus 36.7% (P = .003). There was no significant difference in cochlear implantation rates between Black and White candidates (P = .06). Black patients undergo cochlear implant evaluation and cochlear implantation at rates disproportionately lower than expected based on local demographics. In addition, Black patients have significantly worse hearing at the time of cochlear implant referral than White and Asian patients. Identifying and increasing awareness of these disparities are essential steps to improving cochlear implant access for potentially disadvantaged populations.

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Effects of Social Determinants of Health Care on Pediatric Thyroid Cancer Outcomes in the United States

Nelson R. Gruszczynski,Christopher M. Low,Garret Choby,Kara D. Meister,Byron H. Smith,Karthik Balakrishnan

Publication date 27-07-2021


To identify social determinants of health care that are associated with poorer pediatric well-differentiated thyroid cancer (WDTC) outcomes and increased stage at presentation. Using the SEER database (Surveillance, Epidemiology, and End Results), we retrospectively gathered data on pediatric WDTC across the United States between 1973 and 2015. All patients between 0 and 19 years old with a diagnosis of WDTC were included. Patient variables were analyzed for relationships to AJCC stage at presentation (American Joint Committee on Cancer), overall survival, and disease-specific survival. Among 3913 patients with pediatric thyroid cancer, 3185 were female (81.4%), 3366 had papillary thyroid cancer (85.3%), and 367 had follicular thyroid cancer (9.4%). Two- and 5-year overall and disease-specific survival approached 100%. However, when outcomes were analyzed by specific populations, male sex, non-Caucasian race, poverty, and language isolation were linked to worse overall survival. Male sex and poverty were associated with poorer disease-specific survival. Regarding overall AJCC stage at presentation, male sex and Black race were related to higher overall presenting AJCC stage. Later AJCC T stage at presentation was seen in male, Hispanic, Asian, and Black patients. There were no variables significantly related to following through with recommended surgery. Pediatric WDTC continues to carry an excellent prognosis in the United States. However, when we consider specific populations, the social determinants of health care affect survival and disease burden at presentation: male sex, poverty, language isolation, and race affected survival and/or AJCC stage at presentation in pediatric WDTC.

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Impact of Socioeconomic Status on Paranasal Sinus Cancer Disease-Specific and Conditional Survival

Rahul K. Sharma,Anthony Del Signore,Satish Govindaraj,Alfred Iloreta,Jonathan B. Overdevest,David A. Gudis

Publication date 20-07-2021


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Impact of Race and Insurance Status on Primary Treatment for HPV-Associated Oropharyngeal Squamous Cell Carcinoma

Andy M. Habib,Ryan M. Carey,Aman Prasad,Leila J. Mady,Justin R. Shinn,Andrés M. Bur,Robert M. Brody,Steven B. Cannady,Karthik Rajasekaran,Said A. Ibrahim,Jason G. Newman,Jason A. Brant

Publication date 13-07-2021


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Do Federal Regulations Affect Gender, Racial, and Ethnic Disparities in Chronic Rhinosinusitis Research?

Daniel B. Spielman,Rodney J. Schlosser,Andi Liebowitz,Rahul Sharma,Jonathan Overdevest,Jose Mattos,David A. Gudis

Publication date 15-06-2021


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Socioeconomic Status and Rurality Among Patients With Head and Neck Cancer

Lauren A. Lawrence,Mitchell L. Heuermann,Pardis Javadi,Arun Sharma

Publication date 15-06-2021


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Effect of Augmentative Technology on Communication and Quality of Life After Tracheostomy or Total Laryngectomy

Catherine T. Haring,Janice L. Farlow,Marie Leginza,Kaitlin Vance,Anna Blakely,Teresa Lyden,Rebecca C. Hoesli,Molly E. Heft Neal,Michael J. Brenner,Norman D. Hogikyan,Robert J. Morrison,Keith A. Casper

Publication date 01-06-2021


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Procedural Sedation in Minor Procedure Rooms for Pediatric Myringotomy and Tympanostomy: A Quality Improvement Initiative

Catherine F. Roy,Sena Turkdogan,Lily H. P. Nguyen,Jeffrey Yeung

Publication date 04-05-2021


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Deductible Status in the Pediatric Population: A Barrier to Appropriate Care?

Vanessa F. Torrecillas,Kaden Neuberger,Alexander Ramirez,Andrew Knighton,Paul Krakovitz,Nathan G. Richards,Raj Srivastava,Jeremy D. Meier

Publication date 20-04-2021


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Sparked by Tragedy: A Movement to End Systemic Racism in Health Care

Ciersten A. Burks

Publication date 09-03-2021


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Rural Barriers to Surgical Care for Children With Sleep-Disordered Breathing

Flora Yan,Dylan A. Levy,Chun-Che Wen,Cathy L. Melvin,Marvella E. Ford,Paul J. Nietert,Phayvanh P. Pecha

Publication date 02-03-2021


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