Otolaryngology Head and Neck Surgery 2022-01-13

Congratulations 2022

John H. Krouse

Publication date 26-10-2021


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Reviewer List

Publication date 28-09-2021


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The Evolving Role of Advanced Practice Providers in Otolaryngology: Improving Patient Access and Patient Satisfaction

Pratyusha Yalamanchi,Meredith Blythe,Kristi S. Gidley,William R. Blythe,Richard W. Waguespack,Michael J. Brenner

Publication date 22-06-2021


The aging US population requires an increasing volume of otolaryngology-head and neck surgery services, yet the otolaryngologist physician workforce remains static. Advanced practice providers (APPs), including physician assistants and nurse practitioners, improve access across the continuum of primary and subspecialty health care. The rapid growth of APP service is evidenced by a 51% increase in APP Medicare billing for otolaryngology procedures over 5 years. APPs increasingly participate in delivering otolaryngology care; however, reaping the benefits of enhanced patient access and modernizing care delivery is predicated on successful integration of APPs into practices. Few data are available on how best to incorporate APPs into team-based models or how to restructure practices to allow graduated responsibility that supports autonomy and effective teamwork. We compare national APP and physician workforce trends in otolaryngology, consider approaches to optimizing efficiency by integrating APPs, and identify opportunities for improving data collection and practice.

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Proposal for the Standardization of Otolaryngology Residency Interview Offer Dates

Taylor C. Standiford,Steven D. Pletcher,Marc C. Thorne

Publication date 29-06-2021


The process of receiving and scheduling residency interviews for otolaryngology-head and neck surgery positions is chaotic, inducing unnecessary anxiety for applicants and introducing inefficiencies for programs. With incomplete information, applicants often accept all invitations they receive, resulting in interview hoarding and late cancellations. Various specialties have attempted to improve the interview offer and scheduling process through standardization of interview offer dates. In this commentary, we propose that otolaryngology programs adopt a uniform interview offer and scheduling date. We also advise programs commit to limiting the number of interview invitations to the number of interview slots available, and we review best practices to optimize the interview offer and scheduling process for both applicants and programs.

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Quality Improvement in Otolaryngology–Head and Neck Surgery: Developing Registry-Enabled Quality Measures From Guidelines for Cerumen Impaction and Allergic Rhinitis Through a Transparent and Systematic Process

Jeremy J. Michel,Seth R. Schwartz,Douglas E. Dawson,James C. Denneny,Eileen Erinoff,Nui Dhepyasuwan,Richard M. Rosenfeld

Publication date 18-05-2021


Quality measurement can drive improvement in clinical care and allow for easy reporting of quality care by clinicians, but creating quality measures is a time-consuming and costly process. ECRI (formerly Emergency Care Research Institute) has pioneered a process to support systematic translation of clinical practice guidelines into electronic quality measures using a transparent and reproducible pathway. This process could be used to augment or support the development of electronic quality measures of the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) and others as the Centers for Medicare and Medicaid Services transitions from the Merit-Based Incentive Payment System (MIPS) to the MIPS Value Pathways for quality reporting. We used a transparent and reproducible process to create electronic quality measures based on recommendations from 2 AAO-HNSF clinical practice guidelines (cerumen impaction and allergic rhinitis). Steps of this process include source material review, electronic content extraction, logic development, implementation barrier analysis, content encoding and structuring, and measure formalization. Proposed measures then go through the standard publication process for AAO-HNSF measures. The 2 guidelines contained 29 recommendation statements, of which 7 were translated into electronic quality measures and published. Intermediate products of the guideline conversion process facilitated development and were retained to support review, updating, and transparency. Of the 7 initially published quality measures, 6 were approved as 2018 MIPS measures, and 2 continued to demonstrate a gap in care after a year of data collection. Developing high-quality, registry-enabled measures from guidelines via a rigorous reproducible process is feasible. The streamlined process was effective in producing quality measures for publication in a timely fashion. Efforts to better identify gaps in care and more quickly recognize recommendations that would not translate well into quality measures could further streamline this process.

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Patient Safety/Quality Improvement Primer, Part III: The Role of Simulation

Ellen S. Deutsch,Sonya Malekzadeh,Cecelia E. Schmalbach

Publication date 18-05-2021


Simulation training has taken a prominent role in otolaryngology-head and neck surgery (OTO-HNS) as a means to ensure patient safety and quality improvement (PS/QI). While it is often equated to resident training, this tool has value in lifelong learning and extends beyond the individual otolaryngologists to include simulation-based learning for teams and health systems processes. Part III of this PS/QI primer provides an overview of simulation in medicine and specific applications within the field of OTO-HNS. The impact of simulation on PS/QI will be presented in an evidence-based fashion to include the use of run and statistical process control charts to assess the impact of simulation-guided initiatives. Last, steps in developing a simulation program focused on PS/QI will be outlined with future opportunities for OTO-HNS simulation.

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Clinical Decision Support Systems in Otolaryngology–Head and Neck Surgery: A State of the Art Review

Taylor C. Standiford,Janice L. Farlow,Michael J. Brenner,Marisa L. Conte,Jeffrey E. Terrell

Publication date 20-04-2021


To offer practical, evidence-informed knowledge on clinical decision support systems (CDSSs) and their utility in improving care and reducing costs in otolaryngology-head and neck surgery. This primer on CDSSs introduces clinicians to both the capabilities and the limitations of this technology, reviews the literature on current state, and seeks to spur further progress in this area. Pub Med/MEDLINE, Embase, and Web of Science. Scoping review of CDSS literature applicable to otolaryngology clinical practice. Investigators identified articles that incorporated knowledge-based computerized CDSSs to aid clinicians in decision making and workflow. Data extraction included level of evidence, Osheroff classification of CDSS intervention type, otolaryngology subspecialty or domain, and impact on provider performance or patient outcomes. Of 3191 studies retrieved, 11 articles met formal inclusion criteria. CDSS interventions included guideline or protocols support (n = 8), forms and templates (n = 5), data presentation aids (n = 2), and reactive alerts, reference information, or order sets (all n = 1); 4 studies had multiple interventions. CDSS studies demonstrated effectiveness across diverse domains, including antibiotic stewardship, cancer survivorship, guideline adherence, data capture, cost reduction, and workflow. Implementing CDSSs often involved collaboration with health information technologists. While the published literature on CDSSs in otolaryngology is finite, CDSS interventions are proliferating in clinical practice, with roles in preventing medical errors, streamlining workflows, and improving adherence to best practices for head and neck disorders. Clinicians may collaborate with information technologists and health systems scientists to develop, implement, and investigate the impact of CDSSs in otolaryngology.

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Otologic Manifestations of Langerhans Cell Histiocytosis: A Systematic Review

Tiffany Chen,Peter E. Ashman,Dennis I. Bojrab,Andrew P. Johnson,Brian Benson,Robert S. Hong,Peter F. Svider

Publication date 04-05-2021


To perform a systematic review to investigate common otologic manifestations of Langerhans cell histiocytosis, the incidence of these findings, methods for diagnosis, as well as medical and surgical management. Pub Med/MEDLINE, Embase, and Cochrane Library. A search of Pub Med/MEDLINE, Embase, and Cochrane Library for all articles published between 1963 to 2020 was performed with variations and combinations of the following search terms: Langerhans cell histiocytosis, eosinophilic granuloma, Letterer-Siwe, Hand-Schüller-Christian, otitis, otologic, ear. A review of the references of all included articles was also conducted. Sixty-two articles encompassing 631 patients met inclusion criteria. Otologic symptoms at presentation were found in 246 (39%) patients in the reported studies with 48% reporting bilaterality. The mean age was 14.8 years with a male predominance (64%). The most common otologic presenting symptom was otorrhea (46%). A majority had the multisystem variant (52%). The most common treatment modalities were chemotherapy (52%), followed by surgery (50%), systemic steroids (45%), and radiotherapy (31%). Surgery was performed in 75.8% with unisystem involvement and in 50.6% with multisystem involvement. The most effective treatments included radiotherapy (56% success rate, 17% of treated patients), systemic steroids (44% success, 20% treated), chemotherapy (41% success, 21% treated), and surgical modalities (36% success, 19% treated). Otologic manifestations that occur with the multisystem variant or are at high risk for central nervous system involvement necessitate systemic treatment. For unifocal lesions, surgery is recommended. Lastly, radiotherapy should be reserved for extensive lesions involving vital structures or presenting in older patients.

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Deep Lobe Parotid Tumors: A Systematic Review and Meta-analysis

Margaret H. Aasen,Michael J. Hutz,Brian T. Yuhan,Christopher J. Britt

Publication date 21-04-2021


We performed a systematic review and meta-analysis of deep lobe parotid tumors to evaluate their unique characteristics. Pub Med/Medline, Embase, Web of Sciences, and Cochrane Library databases were queried for relevant literature. Studies were individually assessed by 2 independent reviewers. Risk of bias was assessed with the Cochrane bias tool, GRADE criteria, and MINORS criteria. Results were reported according to the PRISMA guidelines. Statistical analysis was performed by comparing rates of malignancy between deep and superficial lobe tumors. In total, 8 studies including 379 deep lobe parotid tumors met inclusion criteria. Mean age at diagnosis was 44.9 years. Computed tomography scan was the most common imaging modality. Preoperative diagnostic fine-needle aspiration was utilized in 39.4% of patients and demonstrated high sensitivity for malignant disease. The most common approach was subtotal parotidectomy with facial nerve preservation (58.9%). The rate of malignancy was 26.6%, which was significantly higher than that of the superficial lobe tumors in this study (risk ratio, 1.25; 95% CI, 1.01-1.56). The rate of temporary postoperative facial nerve weakness between deep and superficial lobe tumors was 32.5% and 11.7%, respectively. Deep lobe parotid tumors had a 26.6% rate of malignancy. On meta-analysis, deep lobe tumors appeared to have higher rates of malignancy than superficial lobe tumors. Surgical excision of deep lobe tumors showed increased rates of temporary facial nerve paresis as compared with superficial lobe tumors. Computed tomography scan was the most common imaging modality. There were limited data regarding the utility of fine-needle aspiration.

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Indocyanine Green Fluorescence Angiography of the Transverse Cervical Arterial Supply to Clavicle Flaps: An Anatomical Study

Pichtat Muangsiri,Rungkit Tanjapatkul,Papat Sriswadpong,Pojanan Jomkoh,Supasid Jirawatnotai

Publication date 30-03-2021


To describe the anatomy of the transverse cervical artery and to prove its perfusion to the clavicle using indocyanine green fluorescence angiography as an alternative vascularized bone for head and neck reconstruction. Cadaveric dissection. Anatomy lab. Twenty-two necks and shoulders from 11 fresh-frozen cadavers were dissected. The transverse cervical artery diameter, length, emerging point, and the length of clavicle segment harvested were described. Photographic and near-infrared video recordings of the bone's medial and longitudinal cut surfaces were taken prior to, during, and after indocyanine green injection. The transverse cervical artery originated from the thyrocervical trunk and emerged at the level of the medial one-third of the clavicle in 22 of 22 (100%) specimens. The average length of the pedicle was 3.6 cm (range, 2.2-4.4 cm), and the mean diameter was 2.5 mm (range, 1.8-3.4 mm). The harvested bone had a mean length of 5.1 cm (range, 4.3-5.8 cm). After injecting the indocyanine green, 22 of 22 (100%) specimens showed enhancement in the periosteum, bony cortex, and medulla. The middle third of the clavicle can be reliably harvested as a vascularized bone with its perfusion solely from the transverse cervical artery pedicle, as shown by the near-infrared fluorescence imaging. The pedicle was sizable and constant in origin.

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CANVAS: A New Genetic Entity in the Otorhinolaryngologist’s Differential Diagnosis

María Costales,Rodrigo Casanueva,Vanessa Suárez,José María Asensi,Guadalupe A. Cifuentes,Marta Diñeiro,Juan Cadiñanos,Fernando López,César Álvarez-Marcos,Andrea Otero,Justo Gómez,José Luis Llorente,Rubén Cabanillas

Publication date 04-05-2021


The biallelic inheritance of an expanded intronic pentamer (AAGGG) A retrospective descriptive study from an ataxia database comprising 500 patients. The study was performed at the Otorhinolaryngology Department of a hospital in the north of Spain. Specific genetic testing for CANVAS was performed in 13 patients with clinical suspicion of complete or incomplete syndrome. The clinical diagnosis was supported by quantitative vestibular hypofunction, cerebellar atrophy, and abnormal sensory nerve conduction testing. Nine of 13 (69%) patients met clinical diagnostic criteria for definite CANVAS disease. The first manifestation of the syndrome was lower limb dysesthesia in 8 of 13 patients and gait imbalance in 5 of 13. Eleven of 13 (85%) patients were carriers of the biallelic (AAGGG) A genetic cause of CANVAS has recently been discovered. We propose genetic screening for biallelic expansions of the AAGGG pentamer of

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Urgency of Esophageal Foreign Body Removal: Differentiation Between Coins and Button Cell Batteries

Arash R. Safavi,Christopher D. Brook,Osamu Sakai,Bindu N. Setty,Ann Zumwalt,Mauricio Gonzalez,Michael P. Platt

Publication date 04-05-2021


Coin-shaped button battery foreign bodies have a similar initial presentation to coin ingestion, but delayed retrieval of a battery from the esophagus can have devastating consequences. Variations in timing of retrieval for children with ingestion of coin foreign bodies have been reported. The study assesses the sensitivity and specificity of conventional and digital radiographs to differentiate button batteries from coin foreign bodies. 3B case control study. Tertiary academic medical center. A radiographic study of the 12 most common commercially available button batteries and 66 coins of varying international origins was performed. Foreign bodies were placed at the cervical esophagus of a cadaver, and anteroposterior (AP) and lateral conventional radiographs of the neck were obtained. Digital AP and lateral radiographs of standalone coins and batteries were also obtained. Images were blindly read by 2 otolaryngologists and 2 radiologists. Statistical analysis was performed to determine accuracy in identifying coins vs batteries. Using conventional radiographs to identify button batteries yielded a sensitivity of 0.88 and a specificity of 0.92 (positive predictive value [PPV] = 0.75, negative predictive value [NPV] = 0.97). Digital radiography yielded an overall sensitivity of 0.98 and specificity of 0.97 (PPV = 0.87, NPV = 0.99). Features of button batteries were only seen on AP conventional radiographs using reverse contrast. Neither conventional nor digital radiographic imaging had perfect accuracy in identifying coins vs batteries. Features of common disc batteries were identified, which may aid in diagnosis. With potential devastating consequences from retained battery in the esophagus, emergent removal of any possible disc battery foreign body should be considered.

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Perceptions of Safety Climate and Fatigue Related to ACGME Residency Duty Hour Restrictions in Otolaryngology Residents

Michele M. Carr,Jonathan E. Friedel,Anne M. Foreman,Daniel C. O’Brien,Oliver Wirth

Publication date 04-05-2021


To compare otolaryngology residents' perceptions of safety climate with respect to duty hour compliance and self-perceived fatigue. Cross-sectional study. Forty-one otolaryngology residencies distributed across the United States. A national sample of otolaryngology residents was surveyed electronically in 2019. The survey included demographic details, on-call descriptors, an 18-point Safety Climate Survey (SCS) modified to measure perceptions of program attitudes and practices around resident duty hour compliance, and the 33-point Chalder Fatigue Questionnaire (CFQ). Of 397 surveyed residents, 205 (51.6%) responded. The mean modified SCS score was 11.29 out of 18 (95% CI, 10.76-11.81). Respondents were most likely to disagree with "Residents are told when they are at risk of working beyond ACGME [Accreditation Council for Graduate Medical Education] duty hour restrictions," where 100 (48.8%) disagreed or strongly disagreed. The mean CFQ score was 15.99 of 33 (95% CI, 15.17-16.81). As the modified SCS score improved, CFQ scores decreased, indicating an inverse relationship between duty hour safety climate and fatigue. Having a protected postcall day off and having the program director, chief resident, or senior resident decide that a resident should take a postcall day off were all associated with higher modified SCS scores. Otolaryngology residents perceived a safety climate that is suboptimal with regard to duty hour restriction issues. Additionally, an inverse relationship between fatigue and modified SCS scores suggests that fatigue among residents may be lower in programs where residents perceive that ACGME duty hour compliance is more important.

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Impact of the Novel Coronavirus 2019 (COVID-19) Pandemic on Head and Neck Cancer Care

Joshua Adam Thompson,Joshua E. Lubek,Neha Amin,Reju Joy,Donita Dyalram,Robert A. Ord,Rodney J. Taylor,Jeffrey S. Wolf,Ranee Mehra,Kevin J. Cullen,Jason K. Molitoris,Matthew Witek,John C. Papadimitriou,Robert E. Morales,Kyle M. Hatten

Publication date 30-03-2021


The study aimed to assess the impact of the coronavirus disease 2019 (COVID-19) pandemic on head and neck oncologic care at a tertiary care facility. This was a cross-sectional study conducted between March 18, 2020, and May 20, 2020. The primary planned outcome was the rate of treatment modifications during the study period. Secondary outcome measures were tumor conference volume, operative volume, and outpatient patient procedure and clinic volumes. This single-center study was conducted at a tertiary care academic hospital in a large metropolitan area. The study included a consecutive sample of adult subjects who were presented at a head and neck interdepartmental tumor conference during the study period. Patients were compared to historical controls based on review of operative data, outpatient procedures, and clinic volumes. In total, 117 patients were presented during the review period in 2020, compared to 69 in 2019. There was an 8.4% treatment modification rate among cases presented at the tumor conference. There was a 61.3% (347 from 898) reduction in outpatient clinic visits and a 63.4% (84 from 230) reduction in procedural volume compared to the prior year. Similarly, the operative volume decreased by 27.0% (224 from 307) compared to the previous year. Restrictions related to the COVID-19 pandemic resulted in limited treatment modifications. Transition to virtual tumor board format observed an increase in case presentations. While there were reductions in operative volume, there was a larger proportion of surgical cases for malignancy, reflecting the prioritization of oncologic care during the pandemic.

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Laryngeal Chondrosarcoma Characteristics and Survival Analysis in the National Cancer Database

Vidit M. Talati,Matthew J. Urban,Tirth R. Patel,Christopher Wojcik,Bobby A. Tajudeen,Kerstin Stenson,Mihir K. Bhayani,Samer Al-Khudari,Inna A. Husain

Publication date 13-04-2021


To highlight various patient, tumor, diagnostic, and treatment characteristics of laryngeal chondrosarcoma (LC) as well as elucidate factors that may independently affect overall survival (OS) for LCs. Retrospective cohort study. National Cancer Database (NCDB). All LC cases from 2004 to 2016 were extracted from the NCDB. Several demographic, diagnostic, and treatment variables were compared between LC subgroups using χ There were 348 LCs included in the main cohort. LCs were predominantly non-Hispanic white males with similar rates of private and government insurance (49.4% vs 45.4%). Most LCs (81.6%) underwent primary surgery, particularly partial and total laryngectomy. The 1-, 5-, and 10-year survivals for LC were 95.7%, 88.2%, and 66.3%, respectively. On multivariate analysis, lack of insurance ( This is the first multivariate survival analysis and largest single cohort study of LCs in the literature. Overall, LCs enjoy an excellent prognosis, with insurance status, grade, and histology as the main predictors of survival.

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Human Papillomavirus in Patients With Hypopharyngeal Squamous Cell Carcinoma

Evan J. Patel,Jamie R. Oliver,Adam S. Jacobson,Zujun Li,Kenneth S. Hu,Moses Tam,Alec Vaezi,Luc G. T. Morris,Babak Givi

Publication date 13-04-2021


Assess the testing rates and prognostic significance of human papilloma virus (HPV) status in hypopharynx malignancies. Historical cohort study. National Cancer Database. Review of the National Cancer Database was conducted between 2010 and 2017 for squamous cell carcinomas (SCCs) of the hypopharynx. We investigated how often the tumors were tested for HPV and whether it was associated with survival outcomes. A total of 13,269 patients with hypopharynx malignancies were identified. Most cases were not tested for HPV status (n = 8702, 65.6%). Of those tested, 872 (19.1%) were positive for HPV and 3695 (80.9%) were negative. The proportion of nonoropharyngeal SCCs tested for HPV increased nearly every year during the study, with roughly one-third of cases (31.9%) being tested in 2017. In the facilities classified as high-testing centers of nonoropharyngeal SCCs of the head and neck, 18.7% of hypopharyngeal tumors were HPV positive. HPV-negative status was associated with worse survival on multivariable analysis. In propensity score-matched analysis controlling for all factors significant in multivariable regression, 2-year survival remained higher in the HPV-positive cohort (77.7% vs 63.1%, HPV-positive tumors constitute a sizable minority of hypopharynx tumors and are associated with improved survival. Expansion of HPV testing to hypopharynx malignancies may be warranted.

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Prognosis in Head and Neck Cancer: Importance of Nutritional and Biological Inflammatory Status

Nicolas Saroul,Mathilde Puechmaille,Céline Lambert,Achraf Sayed Hassan,Julian Biau,Michel Lapeyre,Thierry Mom,Maureen Bernadach,Laurent Gilain

Publication date 13-04-2021


To determine the importance of nutritional status, social status, and inflammatory status in the prognosis of head and neck cancer. Single-center retrospective study of prospectively collected data. Tertiary referral center. Ninety-two consecutive patients newly diagnosed for cancer of the upper aerodigestive tract without metastases were assessed at time of diagnosis for several prognostic factors. Nutritional status was assessed by the nutritional risk index, social status by the EPICES score, and inflammatory status by the systemic inflammatory response index. The primary endpoint was overall survival. In multivariable analysis, the main prognostic factors were the TNM classification (hazard ratio [HR] = 3.34, Prognosis in head and neck cancer is multifactorial; however, malnutrition and inflammation are important factors that are potentially reversible by early intervention.

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Comparison Between Manual and Automated Analyses in Multichannel Intraluminal Impedance: pH Monitoring for Laryngopharyngeal Reflux

Hee Jin Kang,Jung Min Park,Soo Young Choi,Su Il Kim,Young Chan Lee,Young-Gyu Eun,Seong-Gyu Ko

Publication date 21-04-2021


To evaluate differences between manual and automated analyses of 24-hour multichannel intraluminal impedance-pH monitoring for diagnosis of laryngopharyngeal reflux. Case series with planned data collection. Academic center outpatient clinic. The study group comprised 127 patients with symptoms suspicious of laryngopharyngeal reflux, who underwent 24-hour multichannel intraluminal impedance-pH monitoring. Automated and manual analyses were performed for each patient.
The following parameters were compared between analyses: number of proximal reflux episodes, proximal exposure time, symptom index, and symptom association probability. The number of proximal reflux episodes detected by manual analysis was significantly lower than that detected by automated analysis, except in acid reflux cases. The false positive of automated analysis was 39.8%. In addition, the proximal exposure time for manual analysis was significantly lower than that for automated analysis, except in cases of acid reflux. Symptom index and symptom association probability values based on manual analysis were significantly lower than in automated analysis, except in heartburn cases. Automated analysis demonstrated a tendency of excessive reflux measurement when compared with manual analysis. It is necessary to increase the accuracy of laryngopharyngeal reflux diagnosis through manual analysis.

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Voice Quality and Laryngeal Findings in Patients With Suspected Lung Cancer

Ruth J. Davis,Barbara Messing,Neri M. Cohen,Lee M. Akst

Publication date 20-04-2021


To describe laryngeal findings and voice quality in patients with suspected lung cancer, relative to voice quality and possible laryngeal pathology. Prospective cohort study. Tertiary care center. Patients with known or suspected lung cancer were approached before planned thoracic surgery, and they completed acoustic analysis, the Voice-Related Quality of Life (V-RQOL) questionnaire, and stroboscopy. The prevalence of dysphonia, V-RQOL and Cepstral Spectral Index of Dysphonia (CSID) scores, and laryngeal findings were examined and compared between patients ultimately found to have lung cancer and those without cancer. Sixty-one patients (45 cancer, 16 noncancer) were analyzed. Patients with cancer were older than those without (mean ± SD, 72.3 ± 9.94 vs 62.6 ± 9.30 years; Patients with suspected lung cancer have moderate dysphonia on acoustic measures, though self-reported impact on quality of life is low. While leukoplakia was seen in 4 patients, obvious neoplasm and occult paralysis were not seen in this cohort. Together, these findings suggest that patients with suspected lung cancer should be assessed for subjective voice dysfunction, but routine laryngeal screening may otherwise be unnecessary.

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Association Between Earwax-Determinant Genotypes and Acquired Middle Ear Cholesteatoma in a Japanese Population

Satoshi Hara,Takeshi Kusunoki,Hiroshi Nakagawa,Yu Toyoda,Shuko Nojiri,Kazusaku Kamiya,Masayuki Furukawa,Yusuke Takata,Hiroko Okada,Takashi Anzai,Fumihiko Matsumoto,Katsuhisa Ikeda

Publication date 16-03-2021


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Association Between Serum Vitamin D Level and Ménière’s Disease

Mehdi Bakhshaee,Susan Moradi,Masoud Mohebi,Majid Ghayour-Mobarhan,Payam Sharifan,Razieh Yousefi,Alireza Rezaei,Mohsen Rajati

Publication date 23-03-2021


Ménière's disease (MD) is a well-known inner ear disease; however, the etiopathogenesis is unknown. Several factors may be involved. Meanwhile, vitamin D is reported to have an important role in inner ear physiology. The aim of this study is to evaluate the relation between vitamin D deficiency and MD. This matched case-control study compared serum vitamin D levels between patients with definite MD and those without it. The study was done between August 2018 and December 2019 at Ghaem University Hospital in Mashhad, Iran. Twenty-eight patients with definite MD were matched with a group of 84 healthy individuals, regarding age, sex, body mass index, and occupation (indoor vs outdoor). The serum level of vitamin D (25-hydroxyvitamin D3) was measured in both groups. The mean ± SD vitamin D level was 18.9 ± 9.7 ng/mL in the case group and 25.2 ± 13.7 ng/mL in the control group ( The results of this study show that serum vitamin D level in MD is significantly lower than that of the control group. However, the role of vitamin D supplementation in the management of MD needs further study. 4.

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Determining the Prognosis of Bell’s Palsy Based on Severity at Presentation and Electroneuronography

Derek A. Escalante,Ronit E. Malka,Allison G. Wilson,Zachary S. Nygren,Kristofer A. Radcliffe,Douglas S. Ruhl,Aurora G. Vincent,Marc H. Hohman

Publication date 30-03-2021


To examine the demographics of Bell's palsy and determine how House-Brackmann (HB) grade at nadir and electroneuronography (ENoG) results correlate with HB grade after recovery and development of synkinesis. Retrospective cohort study. Tertiary care military medical center. Patients with acute Bell's palsy and adequate follow-up, defined as 6 months or return to HB grade I function, were included. Demographic information, HB scores at nadir and recovery, and ENoG results were collected. A total of 112 patient records were analyzed. Ages ranged from 8 to 87 years with peaks at 21 to 25 and 61 to 65 years. Among patients, 16.3% reached a nadir at HB II, 41.9% at HB III, 5.4% at HB IV, 16.3% at HB V, and 20.1% at HB VI. The overall recovery rate was 73.2% to HB I function, 17.0% to HB II, and 9.8% to HB III. The chance of recovery to HB I decreased as the severity of paralysis increased ( More severe paralysis increased the chance of recovery to HB II or III function. The granularity of this study provides prognostic insights that may inform the counseling of patients with Bell's palsy with respect to prognosis and recovery timeline.

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Dizziness Diagnostic Pathways: Factors Impacting Setting, Provider, and Diagnosis at Presentation

Meredith E. Adams,Schelomo Marmor

Publication date 13-04-2021


Ensuring that patients with dizziness present to the most appropriate level of care and provider are key goals of quality and cost improvement efforts. Using a symptom-defined cohort of adults presenting for dizziness evaluations, we aimed to identify patient factors associated with ambulatory clinic vs emergency department (ED) presentations, evaluating provider specialty, and assigned diagnoses. Cross-sectional study. Optum Labs Data Warehouse (OLDW), a longitudinal, real-world data asset with deidentified administrative claims. We performed a cross-sectional analysis of adults (older than 18 years) who received new dizziness diagnoses (2006-2015) and identified factors associated with setting and provider at initial presentation using multivariable regression models. Of 805,454 individuals with dizziness (median age 52 years, 62% women, 29% black, Asian, or Hispanic), 23% presented to EDs and 77% to clinics (76% primary care, 7% otolaryngology, 5% cardiology, 3% neurology). Predictors of ED presentation were younger age, male sex, black race, lower education, and medical comorbidity. Predictors of primary care clinic presentation were older age and race/ethnicity other than white. Nonetiologic symptom diagnoses alone were assigned to 51% and were most associated with age older than 75 years (odds ratio, 2.90; 95% CI, 2.86-2.94). Adults with dizziness often present to a level of care that may be higher than is optimal. Differential care seeking and diagnoses by age, sex, and race/ethnicity reflect influences beyond dizziness presentation acuity. Targeted patient resources, triage systems, provider education, and cross-specialty partnerships are needed to direct dizzy patients to appropriate settings and providers to improve care.

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The Effect of the COVID-19 Pandemic on Pediatric Tympanostomy Tube Placement

Gillian R. Diercks,Michael S. Cohen

Publication date 04-05-2021


To evaluate how the coronavirus disease 2019 (COVID-19) pandemic has affected tympanostomy tube placement and practice patterns. A retrospective review of billing data. A large-volume practice with both community and tertiary care providers. As part of a quality initiative, billing data were queried to identify children <18 years of age who underwent tympanostomy tube placement between January 2019 and December 2020. Patient age, practice location, and case numbers were gathered. The study included data from 2652 patients. Prior to state-mandated clinic and operating room restrictions, there were no significant differences in the number of tympanostomy tubes placed ( During the COVID-19 pandemic, the rate of pediatric tympanostomy tube placement has significantly decreased. The age of patients undergoing surgery has increased, and more children are being cared for in a tertiary setting. These findings may reflect changes in the prevalence of acute and chronic otitis media as the result of the pandemic.

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Tracking Home Language Production and Environment in Children Who Are Deaf or Hard of Hearing

Ana Marija Sola,Kara D. Brodie,Jihyun Stephans,Chiara Scarpelli,Dylan K. Chan

Publication date 25-05-2021


To use an automated speech-processing technology to identify patterns in sound environments and language output for deaf or hard-of-hearing infants and toddlers. Observational study based on a convenience sample. Home observation conducted by tertiary children's hospital. The system analyzed 115 naturalistic recordings of 28 children <3.5 years old. Hearing ability was stratified into groups by access to sound. Outcomes were compared across hearing groups, and multivariable linear regression was used to test associations. There was a significant difference in age-adjusted child vocalizations (P = .042), conversational turns (P = .022), and language development scores (P = .05) between hearing groups but no significant difference in adult words (P = .11). Conversational turns were positively associated with each language development measure, while adult words were not. For each hour of electronic media, there were significant reductions in child vocalizations (β = -0.47; 95% CI, -0.71 to -0.19), conversational turns (β = -0.45; 95% CI, -0.65 to -0.22), and language development (β = -0.37; 95% CI, -0.61 to -0.15). Conversational turn scores differ among hearing groups and are positively associated with language development outcomes. Electronic media is associated with reduced discernible adult speech, child vocalizations, conversational turns, and language development scores. This effect was larger in children who are deaf or hard of hearing as compared with other reports in typically hearing populations. These findings underscore the need to optimize early language environments and limit electronic noise exposure in children who are deaf or hard of hearing.

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Adverse Events Associated With Corticosteroid-Eluting Sinus Stents: A MAUDE Database Analysis

Vishal Narwani,Sina J. Torabi,David A. Kasle,Rahul A. Patel,Michael Z. Lerner,R. Peter Manes

Publication date 13-04-2021


Corticosteroid-eluting stents (CESs) are increasingly used after endoscopic sinus surgery to reduce the need for revision surgery, but their use is not without risks. The objective of this study is to describe adverse events related to CESs. Retrospective cross-sectional study. The US Food and Drug Administration's MAUDE database (2011-2020; Manufacturer and User Facility Device Experience). The MAUDE database was queried for reports of adverse events involving the use of CESs approved by the Food and Drug Administration, including Propel, Propel Mini, Propel Contour, and Sinuva (Intersect ENT). There were 28 reported adverse events in total, with all events being related to the Propel family of stents and none related to Sinuva stents. Overall, 22 were categorized as patient-related adverse events and 6 as device-related events. The most common adverse event was related to postoperative infection, accounting for 39% (n = 11) of all complications. Four of these patients developed periorbital cellulitis, and 5 developed a fungal infection. The second-most common adverse event was migration of the stent, representing 21% of all complications (n = 6). Overall, 8 patients (29%) in our cohort required reintervention in the operating room, with subsequent removal of the CES. The most commonly reported adverse events were postoperative infection, including multiple cases of fungal infection, followed by migration of the stent. An increased awareness of the complications associated with CESs can be used to better inform patients during the consenting process as well as surgeons in their surgical decision making.

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Risk of COVID-19 Infection Among Chronic Rhinosinusitis Patients Receiving Oral Corticosteroids

Lauren E. Miller,Neil Bhattacharyya

Publication date 13-04-2021


Chronic rhinosinusitis (CRS) management frequently comprises conservative treatment, including a combination of topical and oral corticosteroids (OCSs). However, in the midst of the coronavirus disease 2019 (COVID-19) pandemic, providers may have been reluctant to prescribe OCSs out of possible concern for an increased risk of contracting COVID-19 or developing more severe COVID-19 symptoms. This study thus sought to explore the association between the use of OCSs and the development of COVID-19 in patients with CRS. We found no statistically significant difference in the rates of patients with a positive diagnosis of COVID-19 who underwent an OCS treatment regimen compared to those who did not, both within 28 days (

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Free Tissue Transfer in a Patient With Hemoglobin S-Beta-Thalassemia Disease and Mandibular Osteomyelitis

Katherine Chang,Craig Bollig,Allen Sclaroff,Patrik Pipkorn

Publication date 23-03-2021


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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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Delays in Infant Hearing Detection and Intervention During the COVID-19 Pandemic: Commentary

Carolyn M. Jenks,Melinda DeSell,Jonathan Walsh

Publication date 22-12-2021


Early detection and intervention for congenital hearing loss are critical for speech and language development. Newborns should receive hearing screening, diagnosis, and intervention by 1, 3, and 6 months, respectively. The COVID-19 pandemic has caused delays in each step of this process. Increased out-of-hospital births and shortages of essential health care services likely reduced the proportion of newborns completing screening. Additional factors have contributed to delayed diagnosis. We estimate that up to 50% of infants born with hearing loss in Maryland in 2021 may be delayed in diagnosis. Hearing loss interventions have been affected due to delayed initiation, reduced availability, and lack of in-person services. Delayed diagnosis and treatment of congenital hearing loss are likely to have significant effects on individual patients and public health, the full magnitude of which will not be known for years. Opportunities exist for providers to mitigate the negative effects of COVID-19 on pediatric hearing health care.

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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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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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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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Chronic Rhinosinusitis and the Risk of Erectile Dysfunction

Lillian W. Dattilo,Alan D. Workman,Neil Bhattacharyya

Publication date 19-10-2021


Chronic rhinosinusitis is a common disease associated with reductions in quality of life across a range of measures, including sexual health. We conducted a case-control study assessing chronic rhinosinusitis prevalence among men with and without clinically significant erectile dysfunction. We found that chronic rhinosinusitis was significantly associated with erectile dysfunction (odds ratio = 2.0, 95% CI = 1.8-2.4,

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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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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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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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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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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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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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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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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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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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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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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 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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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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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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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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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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Impact of Preoperative Risk Factors on Inpatient Stay and Facility Discharge After Free Flap Reconstruction

Michael Hartley Freeman,Justin R. Shinn,Shanik J. Fernando,Douglas Totten,Jaclyn Lee,Jordan A. Malenke,C. Burton Wood,Alexander J. Langerman,Kyle Mannion,Robert J. Sinard,Sarah L. Rohde

Publication date 17-08-2021


To determine the preoperative risk factors most predictive of prolonged length of stay (LOS) or admission to a skilled nursing facility (SNF) or inpatient rehabilitation center (IPR) after free flap reconstruction of the head and neck. Retrospective cohort study. Tertiary academic medical center. Retrospective review of 1008 patients who underwent tumor resection and free flap reconstruction of the head and neck at a tertiary referral center from 2002 to 2019. Of 1008 patients (65.7% male; mean age of 61.4 years, SD 14.0 years), 161 (15.6%) were discharged to SNF/IPR, and the median LOS was 7 days. In multiple linear regression analysis, Charlson Comorbidity Index (CCI; Common tools for assessing frailty and need for additional care may be inadequate in a head and neck reconstructive population. CCI appears to be the best of the aggregate metrics assessed, with significant relationships to both LOS and placement in SNF/IPR.

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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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Hypoglossal Nerve Stimulation Usage by Therapy Nonresponders

Kimberly K. Coca,Clemens Heiser,Colin Huntley,Maurits Boon,Nico de Vries,Madhu Mamidala,M. Boyd Gillespie

Publication date 10-08-2021


The purpose of this study is to examine differences in therapy usage and outcomes of therapy between responder (R) and nonresponder (NR) groups in an international, multicenter prospective registry of patients undergoing hypoglossal nerve stimulation for obstructive sleep apnea (OSA). Database analysis (level III). International, multicenter registry. The studied registry prospectively collects data pre- and postimplantation, including sleep parameters, Epworth score, patient experience, and safety questions, over the course of 12 months. Patients are defined as a "responder" based on Sher criteria, which require a final apnea-hypopnea index (AHI) of ≤20 and a final AHI reduction of >50% at their 12-month follow-up. Overall, there were 497 (69%) R and 220 (31%) NR. Most patients in both groups experienced improvement in quality of life following implantation (96% of R; 77% of NR) with reductions in oxygen desaturation index and Epworth score. At final follow-up, the R group demonstrated significantly better adherence to recommended therapy (>4 hours/night) (P = .001), average hours of nightly use (P = .001), final Epworth scores (P = .001), and degree of subjective improvement (P < .001). Patients classified as NR to upper airway stimulation continue to use therapy with improvement in percent time of sleep with O

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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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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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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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Predictive Pediatric Characteristics for Revision Tonsillectomy After Intracapsular Tonsillectomy

S. Hamad Sagheer,Caroline M. Kolb,Meghan M. Crippen,Andrew Tawfik,Nathan D. Vandjelovic,Heather C. Nardone,Richard J. Schmidt

Publication date 10-08-2021


There is little research on the rate and risk factors for revision tonsillectomy after primary intracapsular tonsillectomy. Our study aimed to determine the revision rate following intracapsular tonsillectomy, identify patient characteristics that may increase the probability of revision surgery, and report the tonsillar hemorrhage rate after revision. Level III, retrospective case-control study. A tertiary care pediatric center (Alfred I. du Pont Hospital for Children, Wilmington, Delaware). A case-control study of pediatric patients who underwent intracapsular tonsillectomy between January 1, 2004, and December 31, 2018, was performed. Patients aged 2 to 20 years were analyzed and compared with matched controls who underwent intracapsular tonsillectomy within 7 days of the same surgeon's case. In total, 169 revision procedures were included with 169 matched controls. A 1.39% revision rate was observed among a total of 12,145 intracapsular tonsillectomies. Among the 169 patients who underwent a revision procedure, the mean time between cases was 3.5 years. Tonsillitis was the most common diagnosis prompting revision tonsillectomy. Four (2.4%) patients underwent operative control of a postoperative tonsillar hemorrhage after revision surgery. Younger patients ( Patients below age 4 years and patients with gastroesophageal reflux disease may be at increased risk of undergoing revision tonsillectomy after primary intracapsular tonsillectomy. These factors should be considered when selecting an intracapsular technique for primary tonsillectomy in pediatric patients.

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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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Development of the National Otolaryngology Interest Group: Conception to Implementation

Cameron J. Farsar,Jared Sperling,Pompeyo R. Quesada,Roberto N. Solis,Macaulay Ojeaga,Sarah N. Bowe,Matthew L. Carlson,Jason R. Brown,Jessica R. Levi

Publication date 03-08-2021


Otolaryngology is a small and highly sought-after surgical subspecialty with sparse residency positions, making it competitive to match into. Allopathic (MD) students without home otolaryngology residency programs, osteopathic (DO) medical students, and underrepresented minorities have historically faced additional challenges in matching into otolaryngology. These specific populations generally experience limited opportunities in establishing mentors, engaging in scholarly activity, and gaining early exposure to clinical settings. Even though the American Osteopathic Association and the Accreditation Council for Graduate Medical Education merger was in part established to create equity among applicants, there remains a substantial disparity among the match rates of medical students of various educational and cultural backgrounds. The National Otolaryngology Interest Group is a student-led interest group created to provide all medical students, especially those facing barriers, with the resources needed to best prepare for matching into an otolaryngology residency program and ultimately a career in otolaryngology.

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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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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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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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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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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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Face, Content, and Construct Validity of a Virtual Reality Otoscopy Simulator and Applicability to Medical Training

Tobias Albrecht,Christoph Nikendei,Mark Praetorius

Publication date 27-07-2021


Otologic diseases are common in all age groups and can significantly impair the function of this important sensory organ. To make a correct diagnosis, the correct handling of the otoscope and a correctly performed examination are essential. A virtual reality simulator could make it easier to teach this difficult-to-teach skill. The aim of this study was to assess the face, content, and construct validity of the novel virtual reality otoscopy simulator and the applicability to otologic training. Face and content validity was assessed with a questionnaire. Construct validity was assessed in a prospectively designed controlled trial. Training for medical students at a tertiary referral center. The questionnaire used a 6-point Likert scale. The otoscopy was rated with a modified Objective Structured Assessment of Technical Skills. Time to complete the task and the percentage of the assessed eardrum surface were recorded. The realism of the simulator and the applicability to medical training were assessed across several items. The ratings suggested good face and content validity as well as usefulness and functionality of the simulator. The otolaryngologists significantly outperformed the student group in all categories measured (P < .0001), suggesting construct validity of the simulator. In this study, we could demonstrate face, content, and construct validity for a novel high-fidelity virtual reality otoscopy simulator. The results encourage the use of the otoscopy simulator as a complementary tool to traditional teaching methods in a curriculum for medical students.

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Milestones 2.0: Otolaryngology Resident Competency in the Postpandemic Era

Cristina Cabrera-Muffly,Cristen Cusumano,Michael Freeman,Dink Jardine,Judith Lieu,R. Peter Manes,Bradley Marple,Liana Puscas,Maja Svrakic,Marc Thorne,Laura Edgar

Publication date 27-07-2021


The Accreditation Council for Graduate Medical Education and the American Board of Otolaryngology-Head and Neck Surgery Milestones Project grew out of a continued need to document objective outcomes within resident education. Milestones 2.0 began its work in 2016, with an intent to resolve inconsistencies in the original milestones based on an iterative process. Milestones 2.0 retains the original 5 levels of achievement but includes a "not yet assessable" option as well. In addition, Milestones 2.0 has added harmonized milestones across all specialties. Each specialty has incorporated a supplemental guide with examples and resources to improve facility with the tool. There will be further refinement of the Milestones as new research emerges with the ultimate goal of providing programs and trainees with a reliable roadmap that can be used to direct and assess learning.

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

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

Publication date 27-07-2021


Pubmed PDF Web

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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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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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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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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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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HEPA Filters and Airborne Viruses, Bacteria, and Fungi

Luke Curtis

Publication date 27-07-2021


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COVID-19 in the Clinic: Human Testing of an Aerosol Containment Mask for Endoscopic Clinic Procedures

Elisabeth H. Ference,Wihan Kim,John S. Oghalai,Clayton B. Walker,Jee-Hong Kim,Tyler Gallagher,Harrison J. Ma,Brian E. Applegate

Publication date 27-07-2021


To create an aerosol containment mask (ACM) for common otolaryngologic endoscopic procedures that also provides nanoparticle-level protection to patients. Prospective feasibility study . In-person testing with a novel ACM. The mask was designed in Solidworks and 3D printed. Measurements were made on 10 healthy volunteers who wore the ACM while reading the Rainbow Passage repeatedly and performing a forced cough or sneeze at 5-second intervals over 1 minute with an endoscope in place. There was a large variation in the number of aerosol particles generated among the volunteers. Only the sneeze task showed a significant increase compared with normal breathing in the 0.3-µm particle size when compared with a 1-tailed ACM will accommodate rigid and flexible endoscopes plus instruments and may prevent the leakage of patient-generated aerosols, thus avoiding contamination of the room and protecting health care workers from airborne contagions. 2.

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Mechanics of Total Drum Replacement Tympanoplasty Studied With Wideband Acoustic Immittance

Kristine Elisabeth Eberhard,Salwa Fatima Masud,Inge M. Knudson,Keshinisuthan Kirubalingam,Hamza Khalid,Aaron K. Remenschneider,Hideko Heidi Nakajima

Publication date 20-07-2021


Poor hearing outcomes often persist following total drum replacement tympanoplasty. To understand the mechanics of the reconstructed eardrum, we measured wideband acoustic immittance and compared the mechanical characteristics of fascia-grafted ears with the normal tympanic membrane. Prospective comparison study. Tertiary care center. Patients who underwent uncomplicated total drum replacement with temporalis fascia grafts were identified. Ears with healed grafts, an aerated middle ear, and no other conductive abnormalities were included. All patients underwent pre- and postoperative audiometry. Wideband acoustic immittance was measured with absorbance and impedance computed. Fascia-grafted ears were compared with normal unoperated ears. Eleven fascia-grafted ears without complications were included. Postoperatively, the median air-bone gap was 15 dB (250-4000 Hz), with variation across frequency and between ears. Fifty-six control ears were included. Absorbance of fascia-grafted ears was significantly lower than that of normal ears at 1 to 4 k Hz ( The mechanics of fascia-grafted ears differ from the normal tympanic membrane by having lower absorbance at mid- to high frequencies and thus poor sound transmission. The lower resistance in fascia-grafted ears may be due to poor coupling of the graft to the malleus. To improve sound transmission, grafts for tympanic membrane reconstructions would benefit from refined mechanical properties.

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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


Socioeconomic status (SES) is often used to quantify social determinants of health. This study uses the National Cancer Institute SES index to examine the effect of SES on disease-specific survival and 5-year conditional disease-specific survival (CDSS; the change in life expectancy with increasing survivorship) in paranasal sinus cancer. Cross-sectional analysis. National Cancer Institute's Surveillance, Epidemiology and End Results (SEER) program. A study of adults with sinus cancer between 1973 and 2015 was performed. The Yost index, a census tract-level composite score of SES, was used to categorize patients. Kaplan-Meier analysis and Cox regression for disease-specific survival were stratified by SES. CDSS was calculated with simplified models. Logistic regression was conducted to identify risk factors for advanced stage at diagnosis, multimodal therapy, and diagnosis of squamous cell carcinoma. There were 3437 patients analyzed. In Cox models adjusting for patient-specific factors, the lowest SES tertile exhibited worse mortality (hazard ratio, 1.22; 95% CI, 1.07-1.39; Lower SES is associated with worse outcomes in paranasal sinus cancer. Research should be devoted toward understanding factors that contribute to such disparities, including tumor pathology and treatment course.

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Pediatric Bilateral Sensorineural Hearing Loss: Minimum Test Battery and Referral Criteria for Cochlear Implant Candidacy Evaluation

Samantha Anne,Kevin D. Brown,Donald M. Goldberg,Oliver F. Adunka,Margaret Kenna,Wade Chien,Holly Teagle,Teresa A. Zwolan,Sarah A. Sydlowski,Patricia Roush,Craig A. Buchman

Publication date 20-07-2021


Among the various cochlear implant systems approved by the Food and Drug Administration, current labeling for pediatric usage encompasses (1) bilateral profound bilateral sensorineural hearing loss in children aged 9 to 24 months and bilateral severe to profound sensorineural hearing loss in children older than 2 years; (2) use of appropriately fitted hearing aids for 3 months (this can be waived if there is evidence of ossification); and (3) demonstration of limited progress with auditory, speech, and language development. Pediatric guidelines require children to have significantly worse speech understanding before qualifying for cochlear implantation. The early years of life have been shown to be critical for speech and language development, and auditory deprivation is especially detrimental during this crucial time.
Level of evidence: 2.

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A Genome-First Approach to Rare Variants in Dominant Postlingual Hearing Loss Genes in a Large Adult Population

Shadi Ahmadmehrabi,Binglan Li,Daniel Hui,Joseph Park,Marylyn Ritchie,Daniel J. Rader,Michael J. Ruckenstein,Douglas J. Epstein,Jason Brant

Publication date 20-07-2021


To investigate the importance of rare variants in adult-onset hearing loss. Genomic association study. Large biobank from tertiary care center. We investigated rare variants (minor allele frequency <5%) in 42 autosomal dominant (DFNA) postlingual hearing loss (HL) genes in 16,657 unselected individuals in the Penn Medicine Biobank. We determined the prevalence of known pathogenic and predicted deleterious variants in subjects with audiometric-proven sensorineural hearing loss. We scanned across known postlingual DFNA HL genes to determine those most significantly contributing to the phenotype. We replicated findings in an independent cohort (UK Biobank). While rare individually, when considering the accumulation of variants in all postlingual DFNA genes, more than 90% of participants carried at least 1 rare variant. Rare variants predicted to be deleterious were enriched in adults with audiometric-proven hearing loss (pure-tone average >25 dB; Although prior reports have focused on common variants, we find that rare predicted deleterious variants in DFNA postlingual HL genes are enriched in patients with adult-onset HL in a large health care system population. We show the value of investigating rare variants to uncover hearing loss phenotypes related to implicated genes.

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Improving Patient Education of Facial Fractures Using 3-Dimensional Computed Tomography

Peter Wickwire,Sukhraj Kahlon,Soroush Kazemi,Travis Tollefson,Toby Steele,Jennifer Chang,Bradley Strong

Publication date 19-07-2021


Advances in 3-dimensional modeling have revolutionized presurgical planning for maxillofacial reconstruction, yet little is known about how this technology may affect patient education. This study was designed to evaluate the efficacy of 2-dimensional computed tomography versus 3-dimensional computed tomography for patient education in maxillofacial reconstruction. Crossover study. General otolaryngology outpatients from a tertiary referral center were recruited.
A single computed tomography data set of a zygomaticomaxillary complex fracture was used to generate 2 educational video tutorials: one in a 2-dimensional format and one in a 3-dimensional format. The tutorials were embedded into the Qualtrics Group 2 participants (viewing the 3-dimensional tutorial first) scored better on the self-assessment survey than their counterparts in group 1 did ( Three-dimensional patient educational tutorial regarding a zygomaticomaxillary complex fracture resulted in better knowledge retention and was preferred over the 2-dimensional format.

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Ewing Sarcoma of the Craniofacial Bones: A Qualitative Systematic Review

Rafey Rehman,Muhammad Osto,Nathan Parry,Nadeen Awada,Jacob Agemy,Khashayar Arianpour,Adam J. Folbe

Publication date 13-07-2021


To conduct a systematic review on the demographics, characteristics, management, treatment, complications, and outcomes of Ewing sarcomas in the craniofacial bones. Using Cochrane Library, Em Base, and Pub Med, the authors identified 71 studies to be included. The Cochrane Library, Em Base, and Pub Med databases were used to identify literature relating to Ewing sarcomas in the craniofacial bone to conduct a systematic review. Patient demographics, clinical characteristics, and treatment strategies were extracted. Seventy-one studies encompassing 102 patients were identified. The most common craniofacial locations involved were the frontal bone (16.7%, n = 17), nasal cavity (16.7%, n = 17), and temporal bone (14.7%, n = 15). Stratified by location, the most common presenting symptoms were frontal bone (palpable mass, n = 8, 47.1%), nasal cavities (epistaxis, n = 9, 52.9%), and temporal bones (headache, n = 5, 33.3%). The 3 most commonly used treatment strategies were a combination of surgical intervention/radiotherapy/chemotherapy (n = 43, 43%), a combination of radiotherapy/chemotherapy (n = 18, 18%), and a combination of surgical intervention/chemotherapy (n = 15, 15%). Patients who received a combination of surgical intervention/radiotherapy/chemotherapy experienced local recurrence rate of 16.6%. However, other combinations of therapies such as surgical intervention/chemotherapy and radiotherapy/chemotherapy had a lower local recurrence rate but were limited by small sample size. Most patients (79.0%) were disease free without evidence of recurrence. Ewing Sarcoma of the craniofacial bones has a good prognosis when treated appropriately. Given that our study was limited by retrospective data, we advise clinicians to use the findings of this article with their own clinical judgment to determine which treatment strategy they should pursue.

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Implementation of a Novel Protocol for Preventing Venous Thromboembolism in Otolaryngology Patients

Lirit Levi,Galia Spectre,Ofir Nesichi,Avi Leader,Pia Raanani,Yonatan Reuven,Hilla Schindel,Thomas Shpitzer,Ella Reifen,Gideon Bachar,Aviram Mizrachi

Publication date 13-07-2021


Venous thromboembolism (VTE) is a preventable cause of postoperative morbidity and mortality. The Caprini risk assessment model (CRAM) is a validated tool for estimating the risk for postoperative VTE. Previous studies demonstrated a low risk of VTE among otorhinolaryngology-head and neck surgery (ORL-HNS). Hence, our objective was to modify the CRAM-based protocol to be applicable for otolaryngology patients and assess protocol efficacy and safety. Observational pilot study conducted on ORL-HNS patients undergoing surgery. University-affiliated tertiary care center. We constructed a modified protocol based on the CRAM and previous reports in the ORL-HNS literature using a reduced postoperative anticoagulation regimen. Primary end point was symptomatic VTE up to 3 months after surgery. Main secondary outcome was postoperative bleeding. A total of 508 patients were enrolled. Of them, 48% underwent head and neck surgery, 18% direct laryngoscopy and transoral robotic surgery, 15% endoscopic sinus surgery, and 11% otology surgery. Adherence to the protocol was 79%. Mean follow-up time was 115 days (range, 30-448 days). Only 1 patient developed deep vein thrombosis, and none developed pulmonary embolism. Two patients had major bleeding not related to the use of anticoagulation. Our novel CRAM-based protocol appears to be efficacious and safe for VTE prevention in otolaryngology. A larger-scale study is required to validate these findings. Level 2b.

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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


To assess the impact of sociodemographic factors on primary treatment choice (surgery vs radiotherapy) in patients with human papillomavirus-associated (HPV+) oropharyngeal squamous cell carcinoma (OPSCC). Retrospective analysis of the National Cancer Database. Data from >1500 Commission on Cancer institutions (academic and community) via the National Cancer Database. Our sample consists of patients diagnosed with HPV+ OPSCC from 2010 to 2015.
The primary outcome of interest was initial treatment modality: surgery vs radiation. We performed multivariable logistic models to assess the relationship between treatment choice and sociodemographic factors, including sex, race, treatment facility, and insurance status. Of the 16,043 patients identified, 5894 (36.7%) underwent primary surgery while 10,149 (63.3%) received primary radiotherapy. Black patients were less likely than White patients to receive primary surgery (odds ratio [OR], 0.80; 95% CI, 0.66-0.96). When compared with privately insured patients, those who were uninsured or on Medicaid or Medicare were also less likely to receive primary surgery (OR, 0.70 [95% CI, 0.56-0.86]; OR, 0.77 [95% CI, 0.65-0.91]; OR, 0.85 [95% CI, 0.75-0.96], respectively). Patients receiving treatment at an academic/research cancer program were more likely to undergo primary surgery than those treated at comprehensive community cancer programs (OR, 1.33; 95% CI, 1.14-1.56). In this large sample of patients with HPV+ OPSCC, race and insurance status affect primary treatment choice. Specifically, Black and nonprivately insured patients are less likely to receive primary surgery as compared with White or privately insured patients. Our findings illuminate potential disparities in HPV+ OPSCC treatment.

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Are Multiple Tests Necessary for Salivary Pepsin Detection in the Diagnosis of Laryngopharyngeal Reflux?

Jiasen Wang,Jinrang Li,Qian Nie,Ran Zhang

Publication date 13-07-2021


To evaluate the necessity of multiple salivary pepsin tests within a day when diagnosing laryngopharyngeal reflux. Prospective cohort study. Tertiary hospitals. A total of 138 patients with signs and/or symptoms associated with laryngopharyngeal reflux were included. Salivary pepsin was detected on the day of 24-hour pH monitoring, and the results of salivary pepsin detected once in the morning and multiple times in 1 day were compared with the results of pH monitoring. Among the 138 patients, pH monitoring results were positive in 112. Salivary pepsin was positive in 47 cases in the morning, which was not consistent with the results of pH monitoring (kappa value = 0.117). With the pH monitoring results as the standard, the salivary pepsin detected once in the morning had a sensitivity of 38.4% (43/112) and a specificity of 84.6% (22/26) for the diagnosis of laryngopharyngeal reflux. When salivary pepsin was detected multiple times per day, 102 patients tested positive. The consistency with pH monitoring was moderate (kappa value = 0.587). The sensitivity was 86.6% (97/112), and the specificity was 80.8% (21/26). Of the 97 patients with positive results from pH monitoring and salivary pepsin detected multiple times a day, 54 had negative findings for a single detection in the morning, indicating that 55.7% (54/97) of the true positive cases were missed. Although a single detection of salivary pepsin in the morning is more economical, the sensitivity is too low, and it is necessary to detect it multiple times a day.

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Prognostic Factors and Outcomes of De Novo Sinonasal Squamous Cell Carcinoma: A Systematic Review and Meta-analysis

Emily S. Nguyen,Adwight Risbud,Jack L. Birkenbeuel,Linda S. Murphy,Khodayar Goshtasbi,Jonathan C. Pang,Arash Abiri,Brandon M. Lehrich,Yarah M. Haidar,Tjoson Tjoa,Edward C. Kuan

Publication date 13-07-2021


To review overall survival (OS), recurrence patterns, and prognostic factors of de novo sinonasal squamous cell carcinoma (DN-SCC). Pub Med, Scopus, OVID Medline, and Cochrane databases from 2006 to December 23, 2020. The study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Articles were required to report either recurrence patterns or survival outcomes of adults with DN-SCC. Case reports, books, reviews, meta-analyses, and database studies were all excluded. Forty-one studies reported on survival or recurrence outcomes. The aggregate 5-year OS was 54.5% (range, 18%-75%) from 35 studies (n = 1903). Patients undergoing open surgery were more likely to receive radiation therapy and present at an advanced stage compared to those receiving endoscopic surgery (all This systematic review and meta-analysis suggests that the 5-year OS rate for DN-SCC may approach 54.5% and recurrence rate approaches 42.7%. In addition, various tumor characteristics including advanced T stage, positive nodal status, maxillary sinus origin, and negative HPV status are all associated with decreased survival.

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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


This study aimed to evaluate the characteristics of reflux in proton pump inhibitor (PPI) nonresponders vs responders in patients with laryngopharyngeal reflux (LPR) by using 24-hour multichannel intraluminal impedance-pH (MII-pH) monitoring. Prospective cohort study. A tertiary care otolaryngology clinic. Patients with typical LPR symptoms showing >1 proximal reflux episode were considered to have LPR and investigated prospectively. Patients were prescribed high-dose PPI twice daily and followed up for at least 2 months. Patients with LPR showing a ≥50% decrease in the follow-up reflux symptom index score during treatment periods as compared with pretreatment were defined as responders; others were defined as nonresponders. Various parameters in 24-hour MII-pH monitoring between nonresponders and responders with LPR were compared with Student's Eighty patients were diagnosed with LPR and categorized as nonresponders (n = 19) and responders (n = 61). Proximal all reflux time and proximal longest reflux time in various MII parameters were higher in responders than in nonresponders ( Proximal all reflux time in various 24-hour MII-pH monitoring parameters can be helpful to predict the response to PPI therapy in patients with LPR. These findings will help establish a personalized therapeutic scheme for patients with LPR.

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Feasibility of an Innovative Absorbable Ventilation Tube Designed to Provide Intermediate-Term Middle Ear Ventilation

Sandra Skovlund,Shelagh Cofer,Heather Weinreich

Publication date 13-07-2021


Myringotomy with ventilation tube placement is a common surgical procedure performed in children and adults to remove fluid buildup behind the tympanic membrane. However, retention of tubes beyond achievement of therapeutic response increases risk for complications and additional intervention. This small feasibility study was conducted to demonstrate proof of concept of a novel bioabsorbable ventilation tube that provides the necessary duration of ventilation with absorption shortly thereafter. Tubes were placed in 15 ears of 14 patients meeting indications for short or intermediate duration of middle ear ventilation. Two independent examiners documented tube patency and tube absorption status at 3, 6, and 12 weeks or until absorption was complete. Results indicate that average ventilation time was 12 weeks (range, 3 weeks to 18 months). There was no observation of blockage. These findings support the feasibility of a novel bioabsorbable ventilation tube.

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Concentric vs Anteroposterior-Laterolateral Collapse of the Soft Palate in Patients With Obstructive Sleep Apnea

Eli Van de Perck,Clemens Heiser,Olivier M Vanderveken

Publication date 13-07-2021


The presence of complete concentric collapse of the soft palate (CCCp) during drug-induced sleep endoscopy (DISE) has important therapeutic consequences. However, CCCp may present in various, sometimes doubtful, ways due to the complex anatomy of the upper airway. Herein, we aimed to characterize these doubtful variants by reviewing the DISE recordings of patients with obstructive sleep apnea (n = 332). We observed in some individuals that the soft palate collapsed in an anteroposterior-laterolateral (AP-LL) way, producing a polygonal shape that was distinct from CCCp. Patients with this collapse pattern (n = 29) had a smaller neck circumference and less severe obstructive sleep apnea than patients with CCCp (n = 68). The majority of patients with AP-LL collapse (n = 19) were originally diagnosed with CCCp. Based on these findings, AP-LL collapse of the soft palate might represent a distinct DISE phenotype that is easily confounded with CCCp.

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Laryngeal Adductor Reflex Movement Latency Following Tactile Stimulation

Madeleine P. Strohl,Jolie L. Chang,Christopher D. Dwyer,VyVy N. Young,Clark A. Rosen,Steven W. Cheung

Publication date 13-07-2021


To measure the latency of laryngeal adductor reflex (LAR) motion onset at 2 laryngopharyngeal subsites using calibrated aesthesiometers. Cross-sectional. Academic institution. Twenty-one asymptomatic, healthy subjects (11 male, 10 female) underwent laryngopharyngeal sensory testing with tactile stimuli delivered to the aryepiglottic fold and medial pyriform sinus using 30-mm Cheung-Bearelly monofilaments (4-0 and 5-0 nylon sutures) via channeled flexible laryngoscope. The LAR onset latency, defined as the first visual detection of ipsilateral vocal fold adduction following tactile stimulation, was measured with frame-by-frame analysis of video recordings. The overall mean LAR latency across both subsites and stimulation forces was 176.6 (95% CI, 170.3-183.0) ms, without significant difference between subsites or forces. The critical value for LAR response latency prolongation at the .01 significance level was 244 ms. At 30 frames/s video capture resolution, LAR response latency ≥8 frame intervals would indicate abnormal prolongation. Aesthesiometer-triggered LAR latency appears to be invariant over an 8.7-dB force range and between the aryepiglottic fold and medial pyriform sinus subsites in controls. Laryngeal adductor reflex latency incongruences between stimulation forces or laryngopharyngeal subsites may serve as pathophysiological features to dissect mechanisms of upper aerodigestive tract disorders. Level 3B.

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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


To describe technical aspects and surgical outcomes of endoscopic resection and mucosal reconstitution with epidermal grafting (ie, the Maddern procedure) in the treatment of idiopathic subglottic stenosis. Medical record abstraction. Johns Hopkins Hospital. Retrospective series of 9 adults with idiopathic subglottic stenosis who underwent the Maddern procedure by a single surgeon over a 5-year period. Prespecified outcomes included (1) perioperative outcomes (Clavien-Dindo grade 4/5 complications, need for staged tracheostomy, hospital length of stay), (2) postoperative outcomes (peak expiratory flow rate [PEFR], need for subsequent airway surgery, tracheostomy at follow-up), and (3) patient-reported quality-of-life outcomes (Clinical COPD Questionnaire, Voice Handicap Index-10, Eating Assessment Tool-10, and 12-Item Short Form Version 2). Wilcoxon matched-pairs signed rank test and Kaplan-Meier analysis were performed. There were no Clavien-Dindo grade 4/5 complications; 2 patients required unplanned staged tracheostomy; and the median length of stay was 3 days. Following endoscopic resection and stent removal, a median of 2 laser resurfacing procedures were required. Two patients developed recurrent stenosis requiring cricotracheal resection (CTR). There were significant improvements in PEFR, Clinical COPD Questionnaire, and Voice Handicap Index-10, without significant difference in Eating Assessment Tool-10. The 12-Item Short Form Version 2 approximated the population norm. Kaplan-Meier analysis demonstrated significant improvement in time to surgery after the final laser resurfacing. The Maddern procedure has a low complication rate and offers durable physiologic improvement in PEFR, limiting need for additional procedures. Risks included need for CTR salvage, temporary tracheostomy, phlegm accumulation, and laryngospasm. It is a surgical option for patients with short dilation intervals who prefer to avoid the risks of CTR.

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Immune-Mediated Sensorineural Hearing Loss in the Pediatric Population

Scott Gorthey,Ravi Patel,Andrea Vambutas

Publication date 13-07-2021


A case series with chart review of pediatric patients with immune-mediated sensorineural hearing loss, including sudden sensorineural hearing loss and autoimmune-mediated hearing loss, was performed. Ninety-eight patients with sensorineural hearing loss were reviewed, and 41 patients met the inclusion criteria, which included corticosteroid therapy for a decline in sensorineural hearing.
The primary outcome was the corticosteroid response rate: 61% of patients responded. The secondary outcome was a sustained response following multiple courses of corticosteroids for additional hearing loss, which correlated with timely corticosteroid treatment: 57% showed sustained response with multiple treatments, but as anticipated, patients were more likely to respond when treated promptly. Sustained responses fell over time with multiple treatments. These data demonstrate pediatric immune-mediated sensorineural hearing loss is corticosteroid responsive in at a rate similar to their adult counterparts and should be considered for similar treatment approaches.

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Cost-effectiveness Analysis of Submandibular Gland Preservation With Sialendoscopy for the Management of Sialolithiasis

Joseph R. Acevedo,Ashley C. Hsu,Jeffrey C. Yu,Dale H. Rice,Daniel I. Kwon,Raymond W. Kung,Niels C. Kokot

Publication date 13-07-2021


To compare the cost-effectiveness of sialendoscopy with gland excision for the management of submandibular gland sialolithiasis. Cost-effectiveness analysis. Outpatient surgery centers. A Markov decision model compared the cost-effectiveness of sialendoscopy versus gland excision for managing submandibular gland sialolithiasis. Surgical outcome probabilities were found in the primary literature. The quality of life of patients was represented by health utilities, and costs were estimated from a third-party payer's perspective. The effectiveness of each intervention was measured in quality-adjusted life-years (QALYs). The incremental costs and effectiveness of each intervention were compared, and a willingness-to-pay ratio of $150,000 per QALY was considered cost-effective. One-way, multivariate, and probabilistic sensitivity analyses were performed to challenge model conclusions. Over 10 years, sialendoscopy yielded 9.00 QALYs at an average cost of $8306, while gland excision produced 8.94 QALYs at an average cost of $6103. The ICER for sialendoscopy was $36,717 per QALY gained, making sialendoscopy cost-effective by our best estimates. The model was sensitive to the probability of success and the cost of sialendoscopy. Sialendoscopy must meet a probability-of-success threshold of 0.61 (61%) and cost ≤$11,996 to remain cost-effective. A Monte Carlo simulation revealed sialendoscopy to be cost-effective 60% of the time. Sialendoscopy appears to be a cost-effective management strategy for sialolithiasis of the submandibular gland when certain thresholds are maintained. Further studies elucidating the clinical factors that determine successful sialendoscopy may be aided by these thresholds as well as future comparisons of novel technology.

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Association of Trismus With Quality of Life and Swallowing in Survivors of Head and Neck Cancer

Zeyao Jia,Jinhong Li,Christine Harrison,Elizabeth Pawlowicz,David Anthony Clump,Tamara Wasserman-Wincko,Kelly Moore,Jonas T. Johnson,Marci Lee Nilsen

Publication date 13-07-2021


We aim to (1) determine the prevalence and predictors of trismus and (2) examine the relationship of trismus, swallowing dysfunction, and quality of life (QOL) in survivors of head and neck cancer (HNC). Case series with chart review. Multidisciplinary HNC survivorship clinic. Data on trismus and patient-reported outcomes were obtained from survivors of HNC between December 2016 and October 2019. Trismus was defined as a maximum interincisal opening ≤35 mm. QOL and swallowing dysfunction were measured with the University of Washington Quality of Life questionnaire and EAT-10 (Eating Assessment Tool-10), respectively. Linear regressions were applied to investigate the relationship of trismus with QOL and swallowing dysfunction. Of the 237 survivors, 22.78% (n = 54) had trismus. Advanced stage of cancer (stage III/IV vs Tis-II, Trismus is a common, treatment-related consequence and is associated with increased symptoms of dysphagia and decreased QOL. Early detection and management of trismus in survivors of HNC are essential to optimize QOL and reduce morbidity.

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Current Barriers in Pursuing Otolaryngology as an Osteopathic Applicant and Proposed Goals for the Future

Cameron J. Farsar,Pompeyo R. Quesada,Jason R. Brown

Publication date 13-07-2021


The osteopathic (DO) medical profession has seen a substantial increase in popularity, evident by the drastic increase in the DO physician workforce and increasing number of DO graduates in the United States. Osteopathic medical schools have historically been primary care focused, resulting in a majority of their graduates pursuing practice in those specialties. This focus may be inadvertently creating a disadvantageous environment for DO students who aim to pursue specialized or traditionally competitive fields in medicine. Otolaryngology is a prime example of osteopathic underrepresentation, as there is currently a significantly low percentage of DO residents in otolaryngology residency programs and practicing DO otolaryngologists. Given the recent American Council on Graduate Medical Education (ACGME) and American Osteopathic Association (AOA) merger between osteopathic and allopathic (MD) residency programs, it is of great value to further discuss avenues for progress and mitigation of barriers.

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Accuracy and Reliability of 4D-CT and Flexible Laryngoscopy in Upper Airway Evaluation in Robin Sequence

Austin S. Lam,Michael D. Bindschadler,Kelly N. Evans,Seth D. Friedman,Matthew S. Blessing,Randall Bly,Michael L. Cunningham,Mark A. Egbert,Russell E. Ettinger,Emily R. Gallagher,Richard A. Hopper,Kaalan Johnson,Jonathan A. Perkins,Erin K. Romberg,Kathleen C. Y. Sie,Srinivas M. Susarla,Carlton J. Zdanski,Xing Wang,Jeffrey P. Otjen,Francisco A. Perez,John P. Dahl

Publication date 13-07-2021


To evaluate the performance of 4-dimensional computed tomography (4D-CT) in assessing upper airway obstruction (UAO) in patients with Robin sequence (RS) and compare the accuracy and reliability of 4D-CT and flexible fiber-optic laryngoscopy (FFL). Prospective survey of retrospective clinical data. Single, tertiary care pediatric hospital. At initial and 30-day time points, a multidisciplinary group of 11 clinicians who treat RS rated UAO severity in 32 sets of 4D-CT visualizations and FFL videos (dynamic modalities) and static CT images. Raters assessed UAO at the velopharynx and oropharynx (1 = There was similar intrarater agreement (moderate to substantial) with 4D-CT and FFL, and both demonstrated fair interrater agreement. Both modalities underestimated UAO severity, although 4D-CT ratings were significantly more accurate, as determined by QPC similarity, than FFL (-1.06 and -1.46 vs QPC ratings, Although 4D-CT may be more accurate in assessing the degree of UAO in patients with RS, 4D-CT and FFL assessments demonstrate similar reliability. Additionally, 4D-CT may be interpreted with greater confidence by nonotolaryngologists who care for these patients.

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Extrasinus Complications From Odontogenic Sinusitis: A Systematic Review

John R. Craig,Atif J. Cheema,Raven T. Dunn,Swapna Vemuri,Edward L. Peterson

Publication date 13-07-2021


Odontogenic sinusitis (ODS) can cause infectious orbital, intracranial, and osseous complications. Diagnosis and management of complicated ODS have not been discussed in recent sinusitis guidelines. The purpose of this systematic review was to describe epidemiological and clinical features, as well as management strategies of complicated ODS. Pub Med, EMBASE, and Cochrane Library. A systematic review was performed to describe various features of complicated ODS. All complicated ODS studies were included in qualitative analysis, but studies were only included in quantitative analysis if they reported specific patient-level data. Of 1126 studies identified, 75 studies with 110 complicated ODS cases were included in qualitative analysis, and 47 studies with 62 orbital and intracranial complications were included in quantitative analyses. About 70% of complicated ODS cases were orbital complications. Only 23% of complicated ODS studies were published in otolaryngology journals. Regarding ODS-related orbital and intracranial complications, about 80% occurred in adults, and 75% were male. Complicated ODS occurred most commonly from apical periodontitis of maxillary molars. There were no relationships between sinusitis extent and orbital or intracranial complications. High rates of anaerobic and α-hemolytic streptococcal bacteria were identified in complicated ODS. Management generally included systemic antibiotics covering aerobic and anaerobic bacteria, and surgical interventions were generally performed to address both the complications (orbital and/or intracranial) and possible infectious sources (dentition and sinuses). ODS should be considered in all patients with infectious extrasinus complications. Multidisciplinary management between otolaryngologists, dental specialists, ophthalmologists, and neurosurgeons should be considered to optimize outcomes.

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Children With Down Syndrome and Obstructive Sleep Apnea: Outcomes After Tonsillectomy

Claire A. Abijay,Anna Tomkies,Swathi Rayasam,Romaine F. Johnson,Ron B. Mitchell

Publication date 13-07-2021


To evaluate outcomes of tonsillectomy and predictors for persistent obstructive sleep apnea (OSA) in children with Down syndrome in an ethnically diverse population. Case series with chart review. UT Southwestern/Children's Medical Center Dallas. Polysomnographic, clinical, and demographic characteristics of children with Down syndrome ages 1 to 18 years were collected, including pre- and postoperative polysomnography. Simple and multivariable regression models were used for predictors for persistent OSA. Eighty-one children were included with a mean age of 6.6 years, 44 of 81 (54%) males, and 53 of 81 (65%) Hispanic. Preoperatively, 60 of 81 (74%) patients had severe OSA. Posttonsillectomy improvements occurred for apnea-hypopnea index (27.9 to 14.0, Children with Down syndrome are at high risk for persistent OSA after tonsillectomy with about 20% worsening after tonsillectomy. Asthma and increasing age are predictors for persistent OSA in children with Down syndrome.

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Impact of Treatment for Nasal Cavity Disorders on Sleep Quality: Systematic Review and Meta-analysis

Jacob Fried,Erick Yuen,Kathy Zhang,Andraia Li,Nicholas R. Rowan,Rodney J. Schlosser,Shaun A. Nguyen,David A. Gudis

Publication date 13-07-2021


To determine the impact of treatment for patients with nasal obstruction secondary to allergic rhinitis (AR) and nasal septal deviation (NSD) on sleep quality. Primary studies were identified though Pub Med, Scopus, Cochrane Library, and Web of Science. A systematic review was performed by querying databases for articles published through August 2020. Studies were included that reported on objective sleep parameters (apnea-hypopnea index) and sinonasal and sleep-specific patient-reported outcome measures: Rhinoconjunctivitis Quality of Life Questionnaire, Nasal Obstruction Symptom Evaluation, Epworth Sleepiness Scale (EpSS), and Pittsburgh Sleep Quality Index (PSQI). The database search yielded 1414 unique articles, of which 28 AR and 7 NSD studies were utilized for meta-analysis. A total of 9037 patients (8515 with AR, 522 with NSD) were identified with a mean age of 35.0 years (35.3 for AR, 34.0 for NSD). Treatment for AR and NSD significantly improved subjective sleep quality. For AR, the EpSS mean difference was -1.5 (95% CI, -2.4 to -0.5; Subjective sleep quality significantly improved following treatment for AR and NSD. There were insufficient data to demonstrate that objective metrics of sleep quality similarly improved.

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The Manukau Salivary Symptoms Score for Assessing the Impact of Sialendoscopy in Recurrent Obstructive Sialadenitis

Tim Hardcastle,Usman Rasul,Sandro de Paiva Leite,Kevin Zheng,Gabriella Donaldson,Zahoor Ahmad,Randall P. Morton

Publication date 13-07-2021


To examine the Manukau Salivary Symptom Score (MSSS) questionnaire as a validated tool to assess obstructive sialadenitis-specific symptoms to both indicate disease severity and assess the outcome after sialendoscopic procedures. A prospective observational study was performed from 2010 to 2019 comprising 164 patients undergoing sialendoscopy for nonneoplastic chronic obstructive salivary gland disease (COSGD). Department of Otolaryngology-Head and Neck Surgery at the Manukau Surgical Centre, Auckland, New Zealand, between June 2010 and September 2019. A prospective observational study was performed from 2010 to 2019 comprising 164 patients undergoing sialendoscopy for nonneoplastic COSGD. Patients completed the MSSS preoperatively and at postoperative follow-up. Statistical tests were used to compare pre- and postoperative answers. Cronbach's α was used to measure internal consistency. Finally, construct validity was determined by comparing the 5-question MSSS questionnaire to the preexisting 20-question Chronic Obstructive Sialadenitis Symptoms (COSS) questionnaire. Postoperatively, patients had significant improvements in pain, eating, talking, swelling, and quality of life ( The MSSS questionnaire is a simple, validated questionnaire that is useful for assessing the impact of sialendoscopy in patients with COSGD.

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When Should Patients Receive Mask Exemptions During the COVID-19 Pandemic? Ethics in Practice: Point-Counterpoint

Michael J. Brenner,Ina Roy-Faderman,Soham Roy,Nosayaba Osazuwa-Peters,Robert K. Jackler,G. Richard Holt

Publication date 06-07-2021


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Evaluation of In-Office Volitional Snore as a Screening Tool for Candidacy for Hypoglossal Nerve Stimulation

Pratyusha Yalamanchi,Nicole Mott,Syed Ahmed Ali,Nithin S. Peddireddy,Kevin J. Kovatch,Jeffrey J. Stanley,Paul T. Hoff

Publication date 29-06-2021


Candidacy evaluation for hypoglossal nerve stimulation (HGNS) is resource intensive. This proof-of-concept study investigates use of in-office volitional snore during flexible laryngoscopy as an efficient, cost-effective screening tool for HGNS evaluation. Adults with moderate to severe obstructive sleep apnea that failed continuous positive airway pressure treatment (n = 41) underwent evaluation for HGNS from 2018 to 2019. Volitional snore and drug-induced sleep endoscopy (DISE) data were collected and scored by VOTE classification (velum/palate, oropharynx, tongue base, epiglottis). A chi-square test of independence was performed that demonstrated a significant relationship between volitional snore and DISE (χ

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Sleep Study Measures on Postoperative Night 1 Following Implantation of the Hypoglossal Nerve Stimulator

Phillip Huyett

Publication date 29-06-2021


To examine the changes in measures of sleep apnea severity and hypoxemia on the first postoperative night following implantation of the hypoglossal nerve stimulator. This was a single-arm prospective cohort study. A single academic sleep surgical practice. Subjects with moderate to severe obstructive sleep apnea underwent implantation of the hypoglossal nerve stimulator (HGNS) and were discharged to home the same day as surgery. A single-night WatchPAT study was performed on the night immediately following surgery (PON 1) and was compared to baseline sleep testing. Twenty subjects who were an average of 58.6 ± 2.5 years old, were 25% female, and had a mean body mass index of 28.1 ± 0.9 kg/m Overall, AHI and measures of nocturnal hypoxemia are stable, if not improved, on PON 1 following HGNS implantation. These findings support the safety of same-day discharge following implantation of the hypoglossal nerve stimulator.

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Predictive Value of Gross Extranodal Extension for Differentiated Thyroid Carcinoma Persistence/Recurrence

Ying Kou,Guohua Shen,Zhuzhong Cheng,Anren Kuang

Publication date 29-06-2021


We systematically investigated the predictive value of gross extranodal extension (gENE) for differentiated thyroid carcinoma persistence/recurrence. Retrospective study. A tertiary care hospital.
This study was divided into 2 groups according to gENE status: the gENE group and non-gENE group. We compared the disease persistence/recurrence rates of these 2 groups in the entire cohort and by individual risk group (intermediate/high risk), analyzed whether gENE was an independent risk factor for disease persistence/recurrence, and explored the impact of gENE-specific features on disease persistence/recurrence.
There were 989 patients who satisfied the inclusion criteria: 57 patients in the gENE group and 932 in the non-gENE group. The disease persistence/recurrence rate of the gENE group was higher than that of the non-gENE group in the entire cohort and by individual risk group ( Patients with gENE and intermediate risk might be regraded as high risk. Specific features of gENE have no impact on disease persistence/recurrence.

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Modular Approach to Open Partial Horizontal Laryngectomy: Step-by-Step Anatomic Dissection

Gabriele Molteni,Andy Bertolin,Luca Gazzini,Andrea Sacchetto,Daniele Marchioni

Publication date 29-06-2021


Open partial laryngectomies still play an important role in contemporary conservative management of laryngeal cancer. A comprehensive and systematic classification of open partial horizontal laryngectomies (OPHLs) was presented by the European Laryngological Society working committee in 2014. The aim of this video is to show the main surgical steps in OPHL using a cadaveric dissection and to explain the modular approach for removal of laryngeal tumors.

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Impact of Smoking and Primary Tumor Subsite on Recurrence in HPV-Associated Oropharyngeal Squamous Cell Carcinoma

Rex H. Lee,Madeleine Salesky,Tania Benjamin,Ivan H. El-Sayed,Jonathan R. George,Patrick K. Ha,William R. Ryan,Chase M. Heaton

Publication date 29-06-2021


To describe risk of recurrence and recurrence characteristics between ever- and never-smoking patients with human papillomavirus-associated oropharyngeal squamous cell carcinoma (HPV+ OPSCC) when stratified by primary tumor subsite. Retrospective observational study. Tertiary care center. Retrospective chart review of 171 patients with HPV+ OPSCC with primary treatment between 2008 and 2019. Five-year recurrence-free survival and risk of recurrence were evaluated through Kaplan-Meier curves with log-rank test and Cox proportional hazards models, respectively. Of 171 patients with HPV+ OPSCC, 81.9% were male, and the average age was 63.9 years. Eighty patients (46.8%) had a smoking history (average, 17.7 pack-years), including 4 current smokers. Recurrence occurred in 31 patients (18.1%), 19 of whom were ever smokers. The recurrence rate for ever smokers with primary base of tongue (BOT) cancer was 41.7%, while 5.1% of never smokers with BOT primaries had recurrence. For primary tonsillar disease, 9.1% of ever smokers had recurrence versus 19.2% of never smokers. Five-year recurrence-free survival for BOT primaries was lower in ever smokers than never smokers ( Smoking may uniquely interact with tumor subsites within the oropharynx to influence recurrence risk. Understanding the association between smoking and HPV+ OPSCC recurrence could lead to personalized, evidence-based treatments to improve oncologic outcomes.

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Landscape of Centralized Otolaryngology Research Efforts Grant Recipients Over the Past Decade

Savannah C. Roy,David W. Wassef,Wissam A. Nasser,Nicole I. Farber,Christina H. Fang,Soly Baredes,Stacey T. Gray,Jean Anderson Eloy

Publication date 29-06-2021


To investigate the demographics of CORE grant recipients (Centralized Otolaryngology Research Efforts) over the last decade and evaluate disparity among recipients as compared with otolaryngology overall. To assess whether procurement of a grant predicts pursuit of an academic career. Analysis of grant recipients' bibliometrics. Academic medical center. The list of recipients of grants from 2010 to 2019 was obtained from the website of the American Academy of Otolaryngology-Head and Neck Surgery. Demographics of recipients were collected through an internet search, including gender, race, residency program, and The distribution of gender among recipients over the last decade remained nearly constant, with no significant difference versus residents in otolaryngology ( CORE grants are favorably distributed as related to gender and racial disparities, and recipients frequently go on to achieve high levels of academic success.

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Endoscopic Nasopharyngectomy Combined With Internal Carotid Artery Pretreatment for Recurrent Nasopharyngeal Carcinoma

Zhi-Qiang Wang,Yu-Long Xie,You-Ping Liu,Xiong Zou,Jin-Hua Chen,Yi-Jun Hua,Yang-Kui Gu,Yan-Feng Ouyang,Zi-Kun Yu,Rui Sun,Pei-Yu Huang,Ming-Yuan Chen

Publication date 29-06-2021


Salvage endoscopic nasopharyngectomy (ENPG) is a reasonable choice for resectable recurrent nasopharyngeal carcinoma (rNPC). However, in past decades, complete removal of the tumor was not feasible when the recurrent lesion was adjacent to the internal carotid artery (ICA). The present article introduces innovative strategies to ensure sufficient surgical margins while avoiding accidental injury to the ICA. Retrospective study. Tertiary care center. We retrospectively reviewed rT2-3 rNPC patients with tumor lesions adjacent to the ICA (<5 mm) who underwent ENPG at the Sun Yat-sen University Cancer Center between January 2015 and June 2020. Thirty-seven patients were selected for this study. Seventeen patients underwent ENPG using direct dissection, 10 patients underwent endoscopic-assisted transcervical protection of the parapharyngeal ICA combined with ENPG, and 10 patients underwent ICA embolization followed by ENPG. With a median follow-up duration of 31 months (range, 5 to 53 months), the 2-year overall survival, progression-free survival, locoregional recurrence-free survival, and distant metastasis-free survival rates of salvage ENPG for rNPC adjacent to the ICA were 88.7%, 72.0%, 72.0%, and 97.3%, respectively. The incidences of grade 1-2 and grade 3-5 postoperative complications were 16.2% and 13.5%, respectively. Two patients experienced ICA rupture during direct dissection but were out of danger after vascular embolization therapy. One patient had a positive margin. Two patients had severe nasopharyngeal wound infections with mucosal flap necrosis. ENPG combined with ICA pretreatment allows the feasible and effective resection of rNPC lesions adjacent to the ICA.

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Item Response Theory for Psychometric Properties of the SNOT-22 (22-Item Sinonasal Outcome Test)

David T. Liu,Katie M. Phillips,Marlene M. Speth,Gerold Besser,Christian A. Mueller,Ahmad R. Sedaghat

Publication date 29-06-2021


The SNOT-22 (22-item Sinonasal Outcome Test) is a high-quality outcome measure that assesses chronic rhinosinusitis-specific quality of life. The aim of this study was to gain greater insight into the information provided by the SNOT-22 by determining its item-based psychometric properties. Retrospective cohort study. Tertiary care academic centers. This study used a previously described data set of the SNOT-22 completed by 800 patients with chronic rhinosinusitis. Item response theory graded response models were used to determine parameters reflecting item discrimination, difficulty, and information provided by each item toward the SNOT-22 subdomain to which it belonged. The unconstrained graded response model fitted the SNOT-22 data best. Item discrimination parameters and total information provided showed the greatest variability within the nasal subdomain, and the item related to sense of smell/taste demonstrated the lowest discrimination and provided the least amount of information overall. The dizziness item provided disparately lower total information and discrimination in the otologic/facial pain subdomain. Items in the sleep and emotional subdomains generally provided high discrimination. While items in the nasal, sleep, and otologic/facial pain subdomains spanned all levels of difficulty, emotional subdomain items covered higher levels of difficulty, indicating greater information provided at higher levels of disease severity. The item-specific psychometric properties of the SNOT-22 support it as a high-quality instrument. Our results suggest the need and possibility for revision of the smell/taste dysfunction item, for example its wording, to improve its ability to discriminate among the different levels of disease burden.

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Genetic Causes of Hearing Loss in a Large Cohort of Cochlear Implant Recipients

Kristen L. Seligman,A. Eliot Shearer,Kathy Frees,Carla Nishimura,Diana Kolbe,Camille Dunn,Marlan R. Hansen,Bruce J. Gantz,Richard J. H. Smith

Publication date 22-06-2021


Understanding genetic causes of hearing loss can determine the pattern and course of a patient's hearing loss and may also predict outcomes after cochlear implantation. Our goal in this study was to evaluate genetic causes of hearing loss in a large cohort of adults and children with cochlear implants. We performed comprehensive genetic testing on all patients undergoing cochlear implantation. Of the 459 patients included in the study, 128 (28%) had positive genetic testing. In total, 44 genes were identified as causative. The top 5 genes implicated were

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Assessment of Preoperative Functional Status Prior to Major Head and Neck Surgery: A Pilot Study

Ashley L. Miller,Andrew J. Holcomb,Anuraag S. Parikh,Julianne M. Richards,Vinay K. Rathi,Jeremy W. Goldfarb,Aaron K. Remenschneider,Regan W. Bergmark,Donald J. Annino,Laura A. Goguen,Eleni M. Rettig,Daniel G. Deschler,Kevin S. Emerick,Derrick T. Lin,Jeremy D. Richmon,Chiao-Li Chan,Lillian C. Min,Ravindra Uppaluri,Mark A. Varvares

Publication date 22-06-2021


To demonstrate feasibility of a recently developed preoperative assessment tool, the Vulnerable Elders Surgical Pathways and Outcomes Analysis (VESPA), to characterize the baseline functional status of patients undergoing major head and neck surgery and to examine the relationship between preoperative functional status and postoperative outcomes. Case series with planned data collection. Two tertiary care academic hospitals. The VESPA was administered prospectively in the preoperative setting. Data on patient demographics, ablative and reconstructive procedures, and outcomes including total length of stay, discharge disposition, delay in discharge, or complex discharge planning (delay or change in disposition) were collected via retrospective chart review. VESPA scores were calculated and risk categories were used to estimate risk of adverse postoperative outcomes using multivariate logistic regression for categorical outcomes and linear regression for continuous variables. Fifty-eight patients met study inclusion criteria. The mean (SD) age was 66.4 (11.9) years, and 58.4% of patients were male. Nearly one-fourth described preoperative difficulty in either a basic or instrumental activity of daily living, and 17% were classified as low functional status (ie, high risk) according to the VESPA. Low functional status did not independently predict length of stay but was associated with delayed discharge (odds ratio [OR], 5.0; 95% CI, 1.2-21.3; The VESPA can identify major head and neck surgical patients with low preoperative functional status who may be at risk for delayed or complex discharge planning. These patients may benefit from enhanced preoperative counseling and more comprehensive discharge preparation.

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Feeding Tube Placement Following Transoral Robotic Surgery for Oropharyngeal Squamous Cell Carcinoma

Allen L. Feng,Andrew J. Holcomb,Nicholas B. Abt,Tara E. Mokhtari,Krish Suresh,Christopher I. McHugh,Anuraag S. Parikh,Allison Holman,Rachael E. Kammer,Tessa A. Goldsmith,Daniel L. Faden,Daniel G. Deschler,Mark A. Varvares,Derrick T. Lin,Jeremy D. Richmon

Publication date 22-06-2021


To identify factors that may predict the need for feeding tubes in patients undergoing transoral robotic surgery (TORS) in the perioperative setting. Retrospective chart review. Academic tertiary center. A retrospective series of patients undergoing TORS for oropharyngeal squamous cell carcinoma (OPSCC) was identified between October 2016 and November 2019 at a single tertiary academic center. Patient data were gathered, such as frailty information, tumor characteristics, and treatment, including need for adjuvant therapy. Multiple logistic regression was performed to identify factors associated with feeding tube placement following TORS. A total of 138 patients were included in the study. The mean age was 60.2 years (range, 37-88 years) and 81.9% were male. Overall 82.9% of patients had human papilloma virus-associated tumors, while 28.3% were current or former smokers with a smoking history ≥10 pack-years. Eleven patients (8.0%) had a nasogastric or gastrostomy tube placed at some point during their treatment. Five patients (3.6%) had feeding tubes placed perioperatively (<4 weeks after TORS), of which 3 were nasogastric tubes. Six patients (4.3%) had feeding tubes placed in the periadjuvant treatment setting for multifactorial reasons; 5 of which were gastrostomy tubes. Only 1 patient (0.7%) was gastrostomy dependent 1 year after surgery. Multiple logistic regression did not demonstrate any significant predictive variables affecting perioperative feeding tube placement following TORS for OPSCC. Feeding tubes are seldom required after TORS for early-stage OPSCC. With appropriate multidisciplinary planning and care, patients may reliably avoid the need for feeding tube placement following TORS for OPSCC.

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Change in Spontaneous Swallowing Frequency in HNC Patients Undergoing C/RT

Giselle D. Carnaby,Aarthi Madhavan,Ali Barikroo,Michael Crary

Publication date 22-06-2021


This study sought to evaluate the role and trajectory of spontaneous swallowing frequency (SFA) in patients with head and neck cancer (HNC) undergoing chemoradiotherapy (C/RT). University comprehensive cancer center. A prospective cohort of 80 patients with HNC was followed from baseline to 3 months post-C/RT. Subjects were evaluated for performance on swallowing function, functional diet consumed, weight, swallowing frequency rate, perceived xerostomia, perceived pain, and mucositis. Relationships were evaluated using univariate correlations, In general, patients with HNC demonstrated a parabolic decline in most measures over the C/RT trajectory. SFA and perceived xerostomia did not show improved recovery by 3 months. SFA was related to swallow function, xerostomia, and functional diet consumed posttreatment and pain at 3 months. The ability of SFA to correctly identify clinical dysphagia (Mann Assessment of Swallowing-Cancer version [MASA-C]) and reduced oral intake (Functional Oral Intake Scale [FOIS]) at posttreatment was strong (AUROC MASA-C: 0.824 [95% CI, 0.63-1.00], This exploratory study suggests SFA may provide a useful method to identify dysphagia after HNC treatment. Furthermore, SFA may offer a simple, objective measure of swallowing function change in HNC over the C/RT trajectory.

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Rethinking the Definition of High Risk in Pediatric Salivary Gland Carcinoma

Sahaja Acharya,Rebecca N. Sinard,Gustavo Rangel,Jeffrey C. Rastatter,Anthony Sheyn

Publication date 22-06-2021


Indications for adjuvant radiation in pediatric salivary gland carcinoma rely on high-risk criteria extrapolated from adult data. We sought to determine whether adult-derived high-risk criteria were prognostic in children aged ≤21 years or young adults aged 22 to 39 years. Cross-sectional analysis of a hospital-based national registry. Patients were identified from the National Cancer Database between 2004 and 2015. High-risk criteria were defined as adenoid cystic histology, intermediate/high grade, T3/T4, positive margins, and/or lymph node involvement. Exact matching was used to adjust for differences in baseline characteristics between pediatric and young adult patients. We identified 215 pediatric patients aged ≤21 years, 317 patients aged 22 to 30 years, and 466 patients aged 31 to 39 years. Within the pediatric cohort, there was no significant difference in overall survival (OS) between low- and high-risk groups (5-year OS, 100% vs 98.5%; Children have excellent OS, irrespective of adult-derived high-risk status. These findings underscore the need to understand how age modifies clinicopathologic risk factors.

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Influence of Age and Sex on Clinical and Therapeutic Features of Laryngopharyngeal Reflux

Jerome R. Lechien,Thomas L. Carroll,Francois Bobin,Vinciane Muls,Alexandra Rodriguez,Mihaela Horoi,Didier Dequanter,Lise Crevier-Buchman,Stéphane Hans,Sven Saussez

Publication date 22-06-2021


To explore the influence of age and sex on the clinical presentation and therapeutic response of patients with laryngopharyngeal reflux (LPR). Prospective study. Prospective multicenter study of 271 patients with a diagnosis of LPR confirmed by impedance-pH monitoring. Patients were prescribed 6 months of diet changes and a combination of pantoprazole and/or alginate depending on the results of their impedance-pH results. The Reflux Symptom Score (RSS) and Reflux Sign Assessment (RSA) were collected at baseline and at 3 and 6 months posttreatment. Data were explored according to sex and age. A total of 237 patients completed the evaluations (138 females). On the RSS, patients of the oldest group (>60 years) had lower symptom scores (throat pain, ear pain, odynophagia, chest pain, tongue burning, nausea, halitosis, and indigestion) and lower quality-of-life scores than younger individuals. RSS and RSA outcomes significantly improved from pretreatment to 3 months posttreatment in all groups. Scores on the RSS and RSA continued to improve from 3 to 6 months posttreatment in the elderly group. Females with LPR had a higher score on the RSS at baseline as compared with males. On the RSS, scores significantly improved after 3 months in males and females; however, they continued to improve from 3 to 6 months in the female group. Age and sex may influence the clinical presentation and pre- to posttreatment evolution of symptoms and findings. Age and sex differences could be considered in future therapeutic approaches to guide more effective personalized treatment plans for patients with LPR.

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Otolaryngology Manifestations of Primary Ciliary Dyskinesia: A Multicenter Study

Faisal Zawawi,Adam J. Shapiro,Sharon Dell,Nikolaus E. Wolter,Cinzia L. Marchica,Michael R. Knowles,Maimoona A. Zariwala,Margaret W. Leigh,Mariana Smith,Pilar Gajardo,Sam J. Daniel

Publication date 22-06-2021


This project aims to prospectively and objectively assess otolaryngological manifestations and quality of life of children with primary ciliary dyskinesia (PCD) and compare these findings with healthy pediatric controls. Cross-sectional. Two high-volume pediatric PCD specialty centers. Standardized clinical assessment; Sino-Nasal Outcome Test 22 (SNOT-22); Hearing Environment and Reflection Quality of Life (HEAR-QL); Reflux Symptom Index (RSI); standardized physical examination of the sinonasal, laryngeal, and otological systems; and investigations including pure-tone audiograms (PTAs) and sinonasal cultures were collected. Forty-seven children with PCD and 25 control participants were recruited. Children with PCD had more upper airway symptoms than healthy children. They had significantly higher scores in both SNOT-22 and RSI, indicating worse sinonasal and reflux symptoms, with worse quality of life on the HEAR-QL index compared to healthy children ( This multisite cohort highlights the importance of otolaryngology involvement in the management of children with PCD. More rigorous otolaryngological management may lead to reductions in overall morbidity and improve quality of life for children with PCD.

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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


To create an aerosol containment mask (ACM) that contains aerosols during common otolaryngologic endoscopic procedures while protecting patients from environmental aerosols. Bench testing. Mannequin testing. The mask was designed in Solid Works and 3-dimensional printed. Mannequins were fitted with a nebulizer to generate aerosols. Commercial particle counters were used to measure mask performance. The ACM has 2 ports on either side for instruments and endoscopes, a port for a filter, and a port that can evacuate aerosols contained within the mask via a standard suction pump. The mask contained aerosols on a mannequin with and without facial hair when the suction was set to 18.5 L/min. Other types of masks demonstrated substantial aerosol leakage under similar conditions. In a subsequent experiment, the ACM contained aerosols generated by a nebulizer up to the saturation of the particle detector without measurable leakage with or without suction. The ACM will accommodate rigid and flexible endoscopes plus instruments and prevent leakage of patient-generated aerosols, thus avoiding contamination of the room and protecting health care workers from airborne contagions. 2.

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Discordance Between Subjective and Objective Measures of Smell and Taste in US Adults

Sophie S. Jang,Janet S. Choi,James H. Kim,Natalie Kim,Elisabeth H. Ference

Publication date 22-06-2021


Examine the rates and factors associated with under- and overreporting of subjective changes in smell or taste as compared with objective measures. Cross-sectional analysis. National Health and Nutrition Examination Survey (2013-2014). We examined participants ≥40 years old who completed subjective questionnaires (smell, n = 3510; taste, n = 3089), validated objective 8-odor pocket smell tests, and Na Cl/quinine taste tests. Over- and underreporting was determined by the difference in subjective and objective results. Univariate and multivariate logistic regression analyses incorporated sampling weights.
A majority of participants correctly classified impairment: smell (73.7%; 95% CI, 71.2%-76.1%) and taste (78.3%; 95% CI, 75.6%-80.7%). Age ≥65 years (odds ratio, 2.23; Although the concordance rate between subjective and objective assessment of smell and taste impairment remains high, we found that older age was associated with incorrect report of impairment. This suggests that the subjective perception of smell varies across demographical and clinical factors, and it is important to not overlook such factors in clinical practice. Potentially using a simplified odor assessment regularly in the clinical setting may aid in early detection and intervention.

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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


The Food and Drug Administration and the National Institutes of Health (NIH) have asserted that diverse demographic representation in clinical trials is essential. In light of these federal guidelines, the objective of this study is to assess the racial, ethnic, and gender demographics of patients enrolled in clinical trials registered with the NIH that evaluate chronic rhinosinusitis with nasal polyposis (CRSwNP) relative to the demographics of the US population. Cross-sectional study. Not applicable. Clinical Trials.gov was queried to identify all prospective clinical trials for CRSwNP. Individual study and pooled data were compared with national US census data. Eighteen studies were included comprising 4125 patients and evaluating dupilumab, mepolizumab, omalizumab, fluticasone/Opti Nose, Medi Honey, mometasone, and SINUVA. Women constituted 42.7% of clinical trial participants. Of the 4125 participants, 69.6% identified as White, 6.6% as Black, 20.8% as Asian, 0.1% as Pacific Islander, 0.4% as American Indian, 8.0% as Hispanic, and 2.4% as other. The racial, ethnic, and gender composition of the pooled study population differs significantly from national US census data, with underrepresentation of Black, Hispanic, Pacific Island, and American Indian individuals, as well as females ( The racial, ethnic, and gender demographics of patients enrolled in CRSwNP clinical trials registered with the NIH differ significantly from the demographics of the US population, despite federal guidelines advising demographically representative participation. Proactive efforts to enroll participants that better represent anticipated treatment populations should be emphasized by researchers, institutions, and editorial boards.

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Assessing the Applicability of the TALK Score: A Modification for Concurrent Tobacco Use During Treatment

Mason Johnson,James Zachary Porterfield,Alexandra Eva Kejner

Publication date 15-06-2021


The previously described TALK score (T-stage, Albumin, Liquor, Karnofsky Performance Status) has been proposed as a method to predict laryngectomy-free survival (LFS) in patients undergoing definitive chemoradiation (CRT). This study assesses its use as well as a modification to include continued tobacco use. Retrospective chart review. Academic institution from 2004 to 2020. Patients diagnosed with larynx or hypopharynx cancer undergoing CRT were reviewed. Clinically relevant variables were collected (TALK), which were dichotomized per previously set cutoffs. Concurrent tobacco use was evaluated and also dichotomized as 0 or 1. Multivariate analysis was conducted to determine which factors were most predictive of the key outcomes of survival and LFS. A total of 2514 patient charts were evaluated. Patients treated for larynx cancer with primary CRT with complete data were included, ultimately totaling 300. Of these, 78 patients required salvage total laryngectomy (TL). Multivariate analysis demonstrated that LFS was best predicted by tobacco use during treatment (odds ratio [OR] 0.3465, 95% confidence interval [CI] 0.1862-0.6300) and Karnofsky Performance Status (OR 0.1646, 95% CI 0.0673-0.3662). Tobacco use during treatment was also strongly predictive of survival. Excluding T4 tumors, the utilization of tobacco in place of T-stage improved the accuracy of the predictive model in this cohort. Given that a T-stage of 4 is typically treated with total laryngectomy, modification of the TALK score to include tobacco use during treatment (tALK) for patients with T < 4 can be used to improve prediction of 3-year LFS and overall survival.

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Microtia Reconstruction and Erector Spinae Block in Children: A Case Series With Chart Review

Gabriel Gomez,Beth Osterbauer,Robert Nguyen,Choo Phei Wee,Amit Kochhar,Tymon Tai,Carl (Yuan-Feng) Lo,Sang Le,Eugene Kim,Shiu-Yi Chen

Publication date 15-06-2021


Autologous reconstruction of microtia is advantageous due to its inherent biocompatibility and long-term stability, but postoperative pain associated with costal harvest is a significant issue. A well-planned pain management approach is imperative. Our objective is to introduce the novel application of erector spinae block anesthesia in pediatric microtia reconstruction and evaluate its impact on pain scores, use of opioids, and hospital length of stay. Case series with chart review. Patients undergoing stage 1 microtia reconstruction at a tertiary pediatric hospital. Data collected included demographics, opioid amounts, Wong-Baker FACES Pain Rating Scale scores, opioid-related side effects, and hospital length of stay. We used generalized estimating equations to examine the effect of erector spinae block use on total opioid use and pain scores and a linear regression model to assess the effect on hospital stay. Forty-seven patients were included: 14 in the erector spinae block group and 33 in the continuous wound pump group. The mean age was 8.3 years (SD, 2; range, 6-13), and 13 (32%) were female. Patients in the erector spinae block group had a 65.44% decrease in adjusted total opioid use (95% CI, -79.72% to -41.10%; This study demonstrates that early experience with an erector spinae block resulted in decreased opioid use and shorter hospital stay as compared with continuous wound infiltration with local anesthetic.

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ERAS Protocols for Thyroid and Parathyroid Surgery: A Systematic Review and Meta-analysis

Kevin Chorath,Neil Luu,Beatrice C. Go,Alvaro Moreira,Karthik Rajasekaran

Publication date 15-06-2021


Enhanced recovery after surgery (ERAS) protocols are evidenced-based multidisciplinary programs implemented in the perioperative setting to improve postoperative recovery and attenuate the surgical stress response. However, evidence on their effectiveness in thyroid and parathyroid surgery remains sparse. Therefore, our goal was to investigate the clinical benefits and cost-effectiveness of ERAS protocols for the perioperative management of thyroidectomy and parathyroidectomy. A systematic review of Medline, Scopus, Embase, and gray literature was performed to identify studies of ERAS or clinical care protocols for thyroidectomy and parathyroidectomy. Two reviewers screened studies using predetermined inclusion criteria. Our primary outcomes included hospital length of stay and hospital costs. Readmission and postoperative complication rates composed our secondary outcomes. Meta-analysis was performed to compare outcomes for patients enrolled in the ERAS protocol versus standard of care. A total of 450 articles were identified; 7 (1.6%) met inclusion criteria with a total of 3082 patients. Perioperative components in ERAS protocols varied across the studies. Nevertheless, patients enrolled in ERAS protocols had reduced hospital length of stay (mean difference, -0.64 days [95% CI, -0.92 to -0.37]) and hospital costs (in US dollars; mean difference, -307.70 [95% CI, -346.49 to -268.90]), without an increase in readmission (odds ratio, 0.75 [95% CI, 0.29-1.94]) or complication rates (odds ratio, 1.14 [95% CI, 0.82-1.57]). There is growing literature supporting the role of ERAS protocols for the perioperative management of thyroidectomy and parathyroidectomy. These protocols significantly reduce hospital length of stay and costs without increasing complications or readmission rates.

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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


Describe the relationship among rurality, socioeconomic status (SES), and patient/tumor characteristics in patients presenting with head and neck cancer. Retrospective single-institution study. Academic tertiary-level medical center. Patients with head and neck cancer presenting between 2011 and 2015 were included. Stage at presentation, insurance status, and demographic characteristics were collected. Rurality was measured through Rural-Urban Continuum Codes. SES was measured by SES index scores of the Agency for Healthcare Research and Quality, which incorporate multiple components of SES. Associations among rurality, SES, and patient/tumor characteristics were assessed with univariate and multivariable statistics. All The study included 266 patients diagnosed with head and neck cancer between 2011 and 2015. Rural residence was associated with lower SES ( Rurality and SES have distinct impacts on patients with head and neck cancer. Specifically, rurality is associated with tumor stage among patients with head and neck cancer. Knowledge of disparities among patients with rural residency may help target interventions to facilitate earlier diagnosis.

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Management of Chronic Rhinosinusitis Prior to Otolaryngology Referral: An Opportunity for Quality Improvement

David W. Jang,Hui-Jie Lee,Philip G. Chen,Seth M. Cohen,Charles D. Scales

Publication date 15-06-2021


The management of chronic rhinosinusitis (CRS) by a nonotolaryngologist prior to otolaryngology referral is an important component of the patient care pathway. The purpose of this study is to characterize CRS management during this period and to identify areas of quality improvement. Retrospective review of a national claims database. Academic institution. Data were analyzed from the IBM Health Market Scan Research Databases (2013-2017). Patients with 3-year enrollment data were identified who were initially diagnosed with CRS by a nonotolaryngologist and subsequently seen by an otolaryngologist. Management of CRS by the nonotolaryngologist was assessed in terms of duration, demographics, health care resource utilization, and health care expenditure. A total of 51,273 patients met inclusion criteria. The median length of the referral period was 142 days, with variations according to geography. Patients with a delayed referral period had higher health care resource utilization in terms of visits for CRS (mean, 1.8 vs 1.2), total visits (mean, 12.6 vs 3.9), and medication prescriptions (especially antibiotics; mean, 5.8 vs 2.1). Health care expenditure was almost twice as high for the delayed referral group (mean, $986 vs $571), mainly due to CRS-related medication costs (mean, $578 vs $214). Our findings suggest that there are wide variations in how CRS is managed prior to referral to an otolaryngologist. The dissemination of clinical practice guidelines to primary care providers may help to increase efficiency of CRS care and offers a unique opportunity for quality improvement that extends beyond the bounds of our own specialty.

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Identifying Phenotypically Distinct Fibroblast Subsets in Type 2 Diabetes–Associated Iatrogenic Laryngotracheal Stenosis

Ioan A. Lina,Alexandra Berges,Rafael Ospino,Ruth J. Davis,Kevin M. Motz,Hsiu-Wen Tsai,Samuel Collins,Alexander T. Hillel

Publication date 15-06-2021


Iatrogenic laryngotracheal stenosis (iLTS) is the pathologic narrowing of the glottis, subglottis, and/or trachea secondary to intubation or tracheostomy related injury. Patients with type 2 diabetes mellitus (T2DM) are more likely to develop iLTS. To date, the metabolomics and phenotypic expression of cell markers in fibroblasts derived from patients with T2DM and iLTS are largely unknown. Controlled in vitro cohort study. Tertiary referral center (2017-2020). This in vitro study assessed samples from 6 patients with iLTS who underwent surgery at a single institution. Fibroblasts were isolated from biopsy specimens of laryngotracheal scar and normal-appearing trachea and compared with controls obtained from the trachea of rapid autopsy specimens. Patients with iLTS were subcategorized into those with and without T2DM. Metabolic substrates were identified by mass spectrometry, and cell protein expression was measured by flow cytometry. T2DM iLTS-scar fibroblasts had a metabolically distinct profile and clustered tightly on a Pearson correlation heat map as compared with non-T2DM iLTS-scar fibroblasts. Levels of itaconate were elevated in T2DM iLTS-scar fibroblasts. Flow cytometry demonstrated that T2DM iLTS-scar fibroblasts were associated with higher CD90 expression (Thy-1; mean, 95%) when compared with non-T2DM iLTS-scar (mean, 83.6%; Scar-derived fibroblasts from patients with T2DM and iLTS have a metabolically distinct profile. These fibroblasts are characterized by an increase in itaconate, a metabolite related to immune-induced scar remodeling, and can be identified by elevated expression of CD90 (Thy-1) in vitro.

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Vascularity Outcomes of Lingual Artery Ligation in Transoral Robotic Base of Tongue Resections

Quinn Dunlap,William M. Mitchell,James Reed Gardner,Deanne King,Rohan Samant,Mauricio Moreno,Emre Vural

Publication date 08-06-2021


To explore the effect of lingual artery ligation on tongue vascularity, we performed an analysis of 25 patients who underwent transoral robotic surgery for base of tongue cancers (May 2011 to December 2019). Hounsfield units of the intrinsic muscles (IMs) and genioglossus muscles (GGs) were measured in postoperative imaging (mean 4 months) as a surrogate for vascularity. In ligated patients (n = 15), the values from the ligated/resected side of the tongue were compared with the contralateral side and the nonligated side of resection. Individually, IMs and GGs on the ligated side demonstrated no significant difference to the contralateral side (

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Portable HEPA Purifiers to Eliminate Airborne SARS-CoV-2: A Systematic Review

David T. Liu,Katie M. Phillips,Marlene M. Speth,Gerold Besser,Christian A. Mueller,Ahmad R. Sedaghat

Publication date 08-06-2021


Current epidemiologic predictions of COVID-19 suggest that SARS-CoV-2 mitigation strategies must be implemented long-term. In-office aerosol-generating procedures pose a risk to staff and patients while necessitating examination room shutdown to allow aerosol decontamination by indwelling ventilation. This review summarizes the current state of knowledge on portable high-efficiency particulate air (HEPA) purifiers' effectiveness in eliminating airborne SARS-CoV-2 from indoor environments. Medline, Embase, Cochrane Databases, and the World Health Organization's COVID-19 Global Literature on Coronavirus Disease. Data sources were systematically searched for original English-language published studies indexed up to January 14, 2021 per the following search strategy: ("HEPA" OR "High-efficiency" OR "High-efficiency particulate air" OR "Efficiency particulate" OR "Purifier" OR "Filter" OR "Cleaner" OR "Filtration") AND ("COVID" OR "COVID-19" OR "SARS-CoV-2" OR "Coronavirus"). Additional relevant studies were identified by searching the reference lists of included articles. Eleven published studies have evaluated the effectiveness of portable HEPA purifiers in eliminating airborne SARS-CoV-2 with relevantly sized surrogate particles. Ten studies evaluated aerosols and submicron particles similar in size to SARS-CoV-2 virions. In all studies, portable HEPA purifiers were able to significantly reduce airborne SARS-CoV-2-surrogate particles. The addition of portable HEPA purifiers augmented other decontamination strategies such as ventilation. Experimental studies provide evidence for portable HEPA purifiers' potential to eliminate airborne SARS-CoV-2 and augment primary decontamination strategies such as ventilation. Based on filtration rates, additional air exchanges provided by portable HEPA purifiers may be calculated and room shutdown times potentially reduced after aerosol-generating procedures.

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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


Surgical procedures that render patients acutely aphonic can cause them to experience significant anxiety and distress. We queried patient perceptions after tracheostomy or laryngectomy and investigated whether introducing augmentative technology was associated with improvement in patient-reported outcomes. Participants included hospitalized patients who acutely lost the ability to speak due to tracheostomy or total laryngectomy from April 2018 to December 2019. We distributed questions regarding the patient communication experience and relevant questions from the validated V-RQOL questionnaire (Voice-Related Quality of Life). Patients were offered a tablet with the electronic communication application Verbally. Pre- and postintervention groups were compared with chi-square analyses. Surveys were completed by 35 patients (n = 18, preintervention; n = 17, postintervention). Prior to using augmentative technology, 89% of patients who were aphonic reported difficulty communicating, specifically noting breathing or suctioning (56%), treatment and discharge plans (78%), or immediate needs, such as pain and using the bathroom (39%). Communication difficulties caused anxiety (55%), depression (44%), or frustration (62%), and 92% of patients were interested in using an electronic communication device. Patients reported less trouble communicating after the intervention versus before (53% vs 89%, Acute loss of phonation arising from surgery can be highly distressing for patients, and use of augmentative technology may alleviate some of these challenges by improving communication. Further studies are needed to identify what additional strategies may improve overall well-being. Electronic communication devices may benefit patients with acute aphonia.

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Outcomes in Head and Neck Free Flap Reconstruction Among Patients With a History of Venous Thromboembolism

Meghan M. Crippen,Rohan S. Ganti,Vivian Xu,Brian Swendseid,Diana L. Tzeng,Joseph Curry

Publication date 01-06-2021


To investigate if a history of venous thromboembolism (VTE) is a risk factor for complications in head and neck free flap surgery by assessing outcomes among patients with a history of deep vein thrombosis (DVT) and/or pulmonary embolism (PE). Retrospective cohort study. Single tertiary care center. All patients undergoing head and neck free flap reconstruction at our institution between September 1, 2006, and April 2, 2020, were assessed for inclusion. Patients with and without a history of DVT or PE preoperatively were identified and grouped for comparison. Groups were compared for demographics, comorbidities, and 30-day complications. Significance was assessed with chi-square and binary logistic regression analyses. Of the 1061 patients meeting inclusion criteria, 40 (3.8%) had a history of VTE. These patients were significantly older (mean [SD], years: 67.8 [11.7] vs 63.0 [14.1], Patients with a history of VTE may be at an increased risk for free flap compromise secondary to postoperative pedicle thrombosis. This risk should be considered in preoperative workup and postoperative monitoring.

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Reduction in Short- and Long-term Pneumonia Rate With Laryngoplasty for Unilateral Vocal Fold Paralysis

Cheng-Ming Hsu,Yao-Te Tsai,Geng-He Chang,Yao-Hsu Yang,Tuan-Jen Fang,Yi-Chan Lee,Chia-Yen Liu,Meng-Hung Lin,Yun-Ting Wang,Ming-Shao Tsai

Publication date 01-06-2021


To examine the association of laryngoplasty, voice therapy, and pneumonia rate in patients with unilateral vocal fold paralysis (UVFP). Population-based retrospective cohort study. Data were collected from the LHID2000 (Longitudinal Health Insurance Database 2000), containing the information of 1 million randomly selected patients in Taiwan. In the LHID2000, we identified 439 patients having new diagnoses of UVFP from 1997 to 2013.
We grouped the aforementioned patients according to UVFP treatment and probed the occurrence of pneumonia: 305 patients underwent laryngoplasty or voice therapy, and 134 patients did not undergo treatment. Follow-up procedures were executed for the enrollees until death or December 31, 2013, representing the end of the study period. We assessed the association of UVFP treatment and pneumonia by executing Cox proportional hazards regression. The pneumonia cumulative incidence was significantly higher among enrolled patients without treatment than in those receiving treatment ( Laryngoplasty was associated with a lower incidence of short- and long-term pneumonia in patients with UVFP. Physicians should encourage patients with UVFP at risk of aspiration to receive prompt evaluation as well as treatment.

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How Does the “Cookie-Bite” Audiogram Shape Perform in Discriminating Genetic Hearing Loss in Adults?

Shadi Ahmadmehrabi,Binglan Li,Douglas J. Epstein,Michael J. Ruckenstein,Jason A. Brant

Publication date 01-06-2021


"Cookie-bite" or U-shaped audiograms-specifically, those showing midfrequency sensorineural hearing loss (HL)-are traditionally taught to be associated with genetic HL; however, their utility as a screening tool has not been reported. We aim to determine the performance of a cookie-bite audiogram shape in stratifying patients carrying putative loss-of-function variants in known HL genes from wild-type controls. We merged audiometric and exome sequencing data from adults enrolled in a large biobank at a tertiary care center. Of 321 patients, 50 carried a putative loss-of-function variant in an HL gene. The cookie-bite shape was present in 9 of those patients, resulting in low sensitivity (18%) and positive predictive value (15%) in stratifying genetic carrier status; 84% of patients with a cookie-bite audiogram did not carry a genetic variant. A cookie-bite audiogram should not be used to screen adults for possible genetic testing.

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Tympanic Membrane Perforation After Intratympanic Steroid Injection: A Systematic Review and Meta-analysis

Young Ho Kim,Doh Young Lee,Dong-Han Lee,Sohee Oh

Publication date 01-06-2021


We investigated the incidence of tympanic membrane (TM) perforations induced after intratympanic steroid injection (ITSI) in patients with sudden sensorineural hearing loss (SSNHL) through a systematic review and meta-analysis. Pub Med, Embase, and MEDLINE. Primary database searches were performed, and 1901 records were identified. After removal of 1802 articles through abstract screening, the remaining 99 full-text journals were assessed for eligibility to be included in the study. Fifty-eight studies that used either ventilation tubing (VT) or tympanocentesis (TC) for ITSI were selected for analysis. The subjects were divided into VT and TC groups. The rate of TM perforation after ITSI in 2 groups, sites of ITSI, needle gauge, and influence on residual hearing were investigated. The cohorts comprised patients who underwent VT (n = 257, 9.6%) and TC (n = 2415, 90.4%). The proportion of TM perforation after ITSI in each group was 0.073 (95% CI, 0.0469-0.1113) and 0.010 (95% CI, 0.0045-0.0215), respectively, which suggested that the VT group showed a significantly higher TM perforation rate than the TC group ( ITSI via VT may have a significantly higher risk of TM perforation than ITSI via TC, although those are relatively small overall. ITSI should be performed in the direction to minimize possible adverse effects.

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Surgical Techniques for Tonsillectomy and Perioperative Respiratory Complications in Children

Rahul G. Baijal,Karla E. Wyatt,Teniola Shittu,Eugenia Y. Chen,Eric Z. Wei,Christine J. Tan,Maxwell Lee,Deepak K. Mehta

Publication date 01-06-2021


The aim of this study was to determine the incidence of perioperative respiratory complications in children following tonsillectomy with cold and hot dissection surgical techniques. The study was a retrospective cohort study. Retrospective chart review was performed for all children presenting for a tonsillectomy at Texas Children's Hospital from November 2015 to December 2017. Pre- and intraoperative patient factors, including surgical technique with cold or hot dissection (electrocautery or radiofrequency ablation), and perioperative anesthetic factors were collected to determine the incidence of perioperative respiratory complications. A total of 2437 patients underwent a tonsillectomy at Texas Children's Hospital from November 2015 to December 2017. The incidence of perioperative respiratory complications was 20.0% (n = 487). Sickle cell disease, cardiac disease, reactive airway disease, pulmonary disease, age >2 and <3 years, and obesity, defined as a body mass index >95th percentile for age, were significant for overall perioperative respiratory complications. There was no difference in the incidence of perioperative respiratory complications in children undergoing tonsillectomy by cold or hot dissection. Perioperative respiratory complications following tonsillectomy are more affected by patient factors than surgical technique.

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Dynamic Nomogram for Predicting Lateral Cervical Lymph Node Metastasis in Papillary Thyroid Carcinoma

Xianhua Zhuo,Jiandong Yu,Zhiping Chen,Zeyu Lin,Xiaoming Huang,Qin Chen,Hongquan Zhu,Yunle Wan

Publication date 01-06-2021


To establish a dynamic nomogram based on preoperative clinical data for prediction of lateral lymph node metastasis (LLNM) of papillary thyroid carcinoma. Retrospective study. The Sixth Affiliated Hospital of Sun Yat-Sen University. The data of 477 patients from 2 centers formed the training group and validation group and were retrospectively reviewed. Preoperative clinical factors influencing LLNM were identified by univariable and multivariable analysis and were to construct a predictive dynamic nomogram for LLNM. Receiver operating characteristic analysis and calibration curves were used to evaluate the predictive power of the nomogram.
The following were identified as independent risk factors for LLNM: male sex (odds ratio [OR] = 4.6, The dynamic nomogram for preoperative prediction of LLNM in papillary thyroid carcinoma can help surgeons identify high-risk patients and develop individualized treatment plans.

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Objective Measurement of Listening Device Use and Its Relation to Hearing Acuity

Danique E. Paping,Jantien L. Vroegop,Geert Geleijnse,Carlijn M.P. le Clercq,Simone P.C. Koenraads,Marc P. van der Schroeff

Publication date 25-05-2021


To examine whether adolescents exceed recommended noise exposure limits when using personal listening devices (PLDs) and to investigate the relationship between objectively measured PLD use and hearing thresholds. Cross-sectional study. This study was embedded within an ongoing prospective birth cohort study in Rotterdam, the Netherlands. Data were collected from May 2017 to September 2019. A smartphone application was developed to measure daily noise exposure from PLDs. Listening habits were monitored among 314 adolescents with a mean age of 13 years 7 months (SD, 5 months), of whom 51.6% were male. Hearing acuity was measured by pure tone audiometry, and tympanometry was performed in both ears. Within the study group, 2.2% adolescents exceeded the recommended daily noise dose (85 dBA as an 8-hour time-weighted average) among all days when the application was active and 9.9% when among only the listening days. No significant correlation was found between the daily noise dose from PLDs and pure tone thresholds. The majority of adolescents exhibited listening habits that could be considered safe. As noise-induced hearing loss develops slowly over time, it could be that the effects of PLD use on hearing are not evident yet in this young population with a relatively short duration of PLD use.

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Socioeconomic Influences on Short-term Postoperative Outcomes in Patients With Oral Cavity Cancer Undergoing Free Flap Reconstruction

Jaclyn Lee,Shanik J. Fernando,Jordan A. Malenke,Douglas J. Totten,Nicole Kloosterman,Alexander Langerman,Young J. Kim,Kyle Mannion,Robert Sinard,James Netterville,Sarah L. Rohde

Publication date 25-05-2021


To evaluate the associations between median household income (MHI) and area deprivation index (ADI) on postoperative outcomes in oral cavity cancer. Retrospective review (2000-2019). Single-institution tertiary medical center. MHI and ADI were matched from home zip codes. Main postoperative outcomes of interest were length of tracheostomy use, length of hospital stay, return to oral intake, discharge disposition, and 60-day readmissions. Linear and logistic regression controlled for age, sex, race, body mass index, tobacco and alcohol use history, primary tumor location, disease staging at presentation, and length of surgery. A secondary outcome was clinical disease staging (I-IV) at time of presentation. The cohort (N = 681) was 91.3% White and 38.0% female, and 51.7% presented with stage IV disease. The median age at the time of surgery was 62 years (interquartile range [IQR], 53-71). The median MHI was $47,659 (IQR, $39,324-$58,917), and the median ADI was 67 (IQR, 48-79). ADI and MHI were independently associated with time to return of oral intake (β = 0.130, P = .022; β = -0.092, P = .045, respectively). Neither was associated with length of tracheostomy, hospital stay, discharge disposition, or readmissions. MHI quartiles were associated with a lower risk of presenting with more advanced disease (Q3 vs Q1: adjusted odds ratio, 0.56 [95% CI, 0.32-0.97]). MHI is associated with oral cavity cancer staging at the time of presentation. MHI and ADI are independently associated with postoperative return to oral intake following intraoral tumor resection and free flap reconstruction.

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Evaluation of Cost-effectiveness and Clinical Value of Routine Histopathologic Examination of Septoplasty Specimens

Randall S. Ruffner,Jessica W. Scordino

Publication date 25-05-2021


During septoplasty, normal cartilage and bone are often sent for pathologic examination despite benign appearance. We explored pathology results following septoplasty from April 2016 to April 2018, examining clinical value and relevance, implications, and cost analysis. Retrospective chart review. Single-institution academic medical center. A retrospective chart review was compiled by using A total of 236 consecutive cases were identified spanning a 2-year period. Septoplasty specimens were sent for pathology evaluation in 76 (31%). The decision to send a specimen for histopathology was largely physician dependent. No cases yielded unexpected or significant pathology that changed management. The average total charges for septoplasty were $10,200 at our institution, with 2.2% of procedural charges accounting for pathology preparation and review, averaging $225. Nationally, this results in an estimated charged cost of $58.5 million. The Centers for Medicare and Medicaid Services (CMS) reimbursement for septoplasty pathology charges was $46 in 2018, accounting for 1.3% of hospital-based reimbursements and 2.2% of ambulatory center reimbursements. With CMS as a national model for reimbursement, $11.8 million is spent yearly for septoplasty histopathology. Given that CMS reimbursement is significantly lower than private insurers, national total reimbursement is likely considerably higher. Routine pathology review of routine septoplasty specimens is unnecessary, unremarkable, and wasteful. Correlation of the patient's presentation and intraoperative findings should justify the need for pathology evaluation. This value-based approach can offer significant direct and indirect cost savings. 4.

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Comparison of a Handheld Device vs Endotracheal Tube–Based Neuromonitoring for Recurrent Laryngeal Nerve Stimulation

Derek Kai Kong,Amanda M. Kong,Raymond L. Chai

Publication date 25-05-2021


To measure the effect of thyroidectomy difficulty on intraoperative neuromonitoring false loss of signal (LOS) and to compare intraoperative endotracheal tube-based neuromonitoring (ETNM) and Checkpoint palpation-based direct stimulation (pDS) signals with postoperative laryngoscopy. We hypothesized that pDS has higher a positive predictive value for postdissection confirmation of recurrent laryngeal nerve function than ETNM and that this difference is accentuated with increasing thyroidectomy difficulty. Prospective single-arm cross-sectional study comparing ETNM and pDS for patients undergoing hemi-, total, or completion thyroidectomy from July 2018 to March 2020. Single-surgeon series at a tertiary care hospital. Percentage concordance and positive and negative predictive values were measured. Each thyroidectomy was assigned a validated thyroidectomy difficulty score, and recorded recurrent laryngeal nerve signals were compared with postoperative vocal fold mobility. Percentage concordance was 90.09%. Positive and negative predictive values were 0.19 (95% CI, 0.09-0.31) and 1.0 for ETNM and 0.59 (95% CI, 0.35-0.82) and 1.0 for pDS. The difference in positive predictive value was significant (0.40 [95% CI, 0.33-0.47], ETNM was subject to high rates of postdissection false LOS that increased with thyroidectomy difficulty score. pDS is a reliable alternative that has higher positive predictive value than ETNM, particularly in more challenging cases such as those with posteriorly fixed thyroid cancers and fibrotic glands. 2.

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Tumor-Infiltrating Lymphocytes in Patients With Advanced Laryngeal Cancer Undergoing Bioselection

Molly E. Heft Neal,Joshua D. Smith,Andrew C. Birkeland,Catherine T. Haring,Steven B. Chinn,Andrew G. Shuman,Keith A. Casper,Kelly M. Malloy,Chaz L. Stucken,Scott A. Mclean,Andrew J. Rosko,Michelle L. Mierzwa,Jennifer Shah,Caitlin Schonewolf,Paul L. Swiecicki,Francis P. Worden,Gregory T. Wolf,Carol R. Bradford,Mark E.P. Prince,J. Chad Brenner,Matthew E. Spector

Publication date 25-05-2021


Bioselection to assess tumor response after induction chemotherapy has been introduced as an alternative treatment strategy to total laryngectomy for patients with advanced larynx squamous cell carcinoma (LSCC). Tumor-infiltrating lymphocytes (TILs) have proven to serve as prognostic biomarkers in head and neck cancer but have not been evaluated as a way to select patients for treatment paradigms. The aim of this study is to evaluate the role of pretreatment TILs in patients with advanced LSCC undergoing the bioselection paradigm. Retrospective study. Tertiary care hospital. Patients with advanced LSCC treated with bioselection and available tissue were included (N = 76). Patients were stratified into CD8-low and CD8-high cohorts by using the median TIL count. Kaplan-Meier survival analysis and multivariate cox regression were performed with SPSS version 26 (IBM). After controlling for tobacco use, tumor site, and stage, a high CD8 TIL count was an independent predictor of improved 5-year disease-specific survival (hazard ratio, 0.17 [95% CI, 0.03-0.84]; These findings support prior data published by our group showing that TILs are predictive of disease-specific survival in patients with head and neck cancer. CD8 TIL counts were significantly associated with degree of clinical response after induction chemotherapy. These results suggest that pretreatment assessment of tumor-infiltrating CD8 cells could be useful in selecting patients.

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Association Between Olfactory Dysfunction and Critical Illness and Mortality in COVID-19: A Meta-analysis

Khodayar Goshtasbi,Jonathan Pang,Brandon M. Lehrich,Milind Vasudev,Jack L. Birkenbeuel,Arash Abiri,Edward C. Kuan

Publication date 25-05-2021


4.

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Prediction of Hearing Preservation in Vestibular Schwannoma Surgery According to Tumor Size and Anatomic Extension

Yavor Bozhkov,Julia Shawarba,Julian Feulner,Fabian Winter,Stefan Rampp,Ullrich Hoppe,Arnd Doerfler,Heinrich Iro,Michael Buchfelder,Karl Roessler

Publication date 25-05-2021


Vestibular schwannoma (VS) surgery is feasible for various tumor sizes that are inappropriate for wait and scan or radiosurgery. The predictive value of 2 grading systems was investigated for postoperative hearing preservation (HP) in a large series. Retrospective analysis. Neurosurgical patient database of the University of Erlangen was queried between 2014 and 2017. Retrospective single-center analysis on 138 VSs operated on via a retrosigmoidal approach. The mean tumor size was 20.4 mm (SD, 7.6 mm) with fundal infiltration in 67.4%. The overall resection rate was 93.5%. Tumors were classified preoperatively by the 3-tier Erlangen grading system depending on size or the anatomically based 4-tier Koos grading system. Preoperative hearing preservation was found in 70.3% of patients and was significantly correlated to tumor size ( Surgery on small VSs can achieve excellent hearing preservation. Different grading has a significant influence on and correlates with postoperative hearing preservation. Tumor size seems more important than anatomic relationship.

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Cochlear Implantation Hearing Outcome in Ménière’s Disease

Chen-Yu Chien,Anan Kulthaveesup,Barbara S. Herrmann,Steven D. Rauch

Publication date 18-05-2021


The aim of this study was to evaluate the hearing outcome of cochlear implantation in patients deafened by Ménière's disease. Retrospective single-institution study. Tertiary medical center. Our institutional database of 1400 patients with cochlear implants was reviewed to identify cases with deafness due to Ménière's disease. Twenty-nine patients were identified: 24 with unilateral and 5 with sequential bilateral cochlear implants. Pre- and postoperative speech recognition scores and medical data were extracted from the medical record and analyzed. Overall the mean difference between pre- and postoperative speech recognition after >1 year was 56% (95% CI, 47.08%-64.92%). The mean preoperative monosyllabic word score was 9.5%, and the mean postoperative scores at 1 month, 3 months, 6 months, 1 year, and >1 year were 37.1%, 46.1%, 54.1%, 59.1%, and 66.8%, respectively. Cochlear implantation resulted in improved word scores in all patients regardless of prior medical or surgical treatment (endolymphatic sac, labyrinthectomy). The mean postoperative hearing improvement in patients aged <70 and ≥70 years was 65.26% (95% CI, 54.79%-75.73%) and 40.00% (95% CI, 27.22%-52.77%). Postoperative word scores in patients with bilateral cochlear implants were not significantly different between the first and second implanted ears or between the monoaural and binaural testing conditions. Cochlear implant in patients deafened by Ménière's disease significantly improves word recognition scores regardless of whether medical or surgical treatment is used prior to implantation. The potential improvement in word recognition scores decreases after age 70 years.

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Practice of Telehealth in Otolaryngology: A Scoping Review in the Era of COVID-19

Joseph N. Gonzalez,Lucas G. Axiotakis,Victoria X. Yu,David A. Gudis,Jonathan B. Overdevest

Publication date 18-05-2021


The COVID-19 pandemic has spurred widespread adoption and advancement in telehealth activities, representing a marked change in otolaryngology practice patterns. The present study undertakes a scoping review of research focused on telehealth in otolaryngology (teleotolaryngology) to identify key themes and commonly utilized outcome measures that will assist future development in this growing field. Pub Med, Embase, and Cochrane databases and reference review. Per guidelines of the PRISMA Extension for Scoping Reviews, we performed database queries using a comprehensive search strategy developed in collaboration with research librarians at the Columbia University Irving Medical Center. We identified 596 unique references to undergo title and abstract review by 2 independent reviewers, leaving 439 studies for full-text review. We included 285 studies for extraction of notable findings, leaving 262 unique studies after accounting for content overlap. We identified core outcome measures, including patient and provider satisfaction, costs and benefits, quality of care, feasibility, and access to care. Publication volume increased markedly over time, though only 4% of studies incorporated randomized study group assignment. Using an iterative approach to thematic development, we organized article content across 5 main themes: (1) exploration of teleotolaryngology evolution, (2) role in virtual clinical encounters, (3) applications in interdisciplinary care and educational initiatives, (4) emerging and innovative technologies, and (5) barriers to implementation. This scoping review of teleotolaryngology documents its evolution and identifies current use cases, limitations, and emerging applications, providing a foundation from which to build future studies, inform policy decision making, and facilitate implementation where appropriate.

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Hyaluronic Acid Concentration in Female Vocal Folds With Reinke’s Edema

Cristiana Vanderlei de Melo Lins,João Roberto Maciel Martins,Elsa Yoko Kobayashi,Gustavo Polacow Korn,Sung Woo Park,Welber Chaves Mororó,Noemi Grigoletto De Biase

Publication date 18-05-2021


The aim of the present study was to investigate hyaluronic acid (HA) concentrations in vocal folds among patients with Reinke's edema. Prospective and experimental study. Single tertiary center. An HA binding protein isolated from bovine nasal cartilage was used to identify and isolate the HA from samples. Plates coated with biotin-conjugated binding protein and streptavidin-europium conjugate were sequentially incubated with 18 Reinke's edema samples and 11 female vocal fold cover samples from cadavers (the superficial layer of the lamina propria; control group). After the release of europium from streptavidin in enhancement solution, final fluorescence was measured in a fluorometer. The mean HA concentration in Reinke's edema vocal folds was significantly higher than that in the control vocal folds (9.2 × 10 Vocal fold covers affected by Reinke's edema present a higher concentration of HA than do vocal fold covers with no edema.

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Critical Review and Consensus Statement for Neural Monitoring in Otolaryngologic Head, Neck, and Endocrine Surgery

Joseph Scharpf,Jeffrey C. Liu,Catherine Sinclair,Michael Singer,Whitney Liddy,Lisa Orloff,David Steward,Juliana Bonilla Velez,Gregory W. Randolph

Publication date 18-05-2021


Enhancing patient outcomes in an array of surgical procedures in the head and neck requires the maintenance of complex regional functions through the protection of cranial nerve integrity. This review and consensus statement cover the scope of cranial nerve monitoring of all cranial nerves that are of practical importance in head, neck, and endocrine surgery except for cranial nerves VII and VIII within the temporal bone. Complete and applied understanding of neurophysiologic principles facilitates the surgeon's ability to monitor the at-risk nerve. The American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) identified the need for a consensus statement on cranial nerve monitoring. An AAO-HNS task force was created through soliciting experts on the subject. Relevant domains were identified, including residency education, neurophysiology, application, and various techniques for monitoring pertinent cranial nerves. A document was generated to incorporate and consolidate these domains. The panel used a modified Delphi method for consensus generation. Consensus was achieved in the domains of education needs and anesthesia considerations, as well as setup, troubleshooting, and documentation. Specific cranial nerve monitoring was evaluated and reached consensus for all cranial nerves in statement 4 with the exception of the spinal accessory nerve. Although the spinal accessory nerve's value can never be marginalized, the task force did not feel that the existing literature was as robust to support a recommendation of routine monitoring of this nerve. In contrast, there is robust supporting literature cited and consensus for routine monitoring in certain procedures, such as thyroid surgery, to optimize patient outcomes. The AAO-HNS Cranial Nerve Monitoring Task Force has provided a state-of-the-art review in neural monitoring in otolaryngologic head, neck, and endocrine surgery. The evidence-based review was complemented by consensus statements utilizing a modified Delphi method to prioritize key statements to enhance patient outcomes in an array of surgical procedures in the head and neck. A precise definition of what actually constitutes intraoperative nerve monitoring and its benefits have been provided.

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Vein Graft Tympanoplasty: How a Transiently Used Graft Material Transformed Middle Ear Surgery

Blaine D. Smith,Hannah L. Martin,Howard W. Francis,Calhoun D. Cunningham

Publication date 11-05-2021


The inception of medial grafting as a technique for tympanic membrane repair was a critical milestone in the history of otology. John Shea introduced the medial graft technique and the use of vein grafts for tympanoplasty in 1960 after realizing that the vein grafts that he used to repair the oval window after stapedectomy could also be utilized to repair tympanic membrane perforations. At the time, tympanoplasty often utilized skin grafts, which required placement of the graft lateral to the tympanic membrane annulus. Placement of the graft medial to the tympanic membrane annulus allowed for more efficient surgery and avoided the complications associated with lateral grafting, such as blunting and lateralization. The introduction of vein grafts in tympanoplasty prompted a fundamental shift in technique from lateral to medial grafting, paving the way for decades of innovation in tympanoplasty.

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Urine Leukotriene E4: Implications as a Biomarker in Chronic Rhinosinusitis

Garret Choby,Christopher M. Low,Joshua M. Levy,Janalee K. Stokken,Carlos Pinheiro-Neto,Kathy Bartemes,Michael Marino,Joseph K. Han,Rohit Divekar,Erin K. O’Brien,Devyani Lal

Publication date 11-05-2021


To provide a comprehensive state-of-the-art review of the emerging role of urine leukotriene E4 (uLTE4) as a biomarker in the diagnosis of chronic rhinosinusitis (CRS), aspirin-exacerbated respiratory disease (AERD), and asthma. Ovid MEDLINE(R), Ovid EMBASE, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, and Scopus. A state-of-the-art review was performed investigating the role of uLTE4 as a diagnostic biomarker, predictor of disease severity, and potential marker of selected therapeutic efficacy. uLTE4 has been shown to be a reliable and clinically relevant biomarker for CRS, AERD, and asthma. uLTE4 is helpful in ongoing efforts to better endotype patients with CRS and to predict disease severity. Aside from being a diagnostic biomarker, uLTE4 is also able to differentiate aspirin-tolerant patients from patients with AERD and has been associated with objective disease severity in patients with CRS with nasal polyposis. uLTE4 levels have also been shown to predict response to medical therapy, particularly leukotriene-modifying agents.

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Association Between 5-Item Modified Frailty Index and Short-term Outcomes in Complex Head and Neck Surgery

Khodayar Goshtasbi,Jack L. Birkenbeuel,Brandon M. Lehrich,Arash Abiri,Yarah M. Haidar,Tjoson Tjoa,Edward C. Kuan

Publication date 11-05-2021


To evaluate the impact of preoperative frailty on short-term outcomes following complex head and neck surgeries (HNSs). Cross-sectional database analysis. American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. The 2005 to 2017 ACS-NSQIP was queried for patients undergoing complex HNS. Five-item modified frailty index (mFI) was calculated based on functional status and history of diabetes, chronic obstructive pulmonary disease, congestive heart failure, and chronic hypertension. A total of 2786 patients (73.1% male) with a mean age of 62.0 ± 11.6 years were included. Compared to nonfrail patients (41.2%), patients with mFI ≥1 (58.8%) had shorter length of operation ( The 5-point mFI can independently predict short-term surgical outcomes following complex HNS. This simple and reliable metric can potentially lead to improved preoperative counseling and postoperative planning for complex HNS patients.

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Audiologic and Otologic Clinical Manifestations of Loeys-Dietz Syndrome: A Heritable Connective Tissue Disorder

Jun W. Jeon,Julie Christensen,Jennifer Chisholm,Christopher Zalewski,Marjohn Rasooly,Caeden Dempsey,Alaina Magnani,Pamela Frischmeyer-Guerrerio,Carmen C. Brewer,Hung Jeffrey Kim

Publication date 11-05-2021


Loeys-Dietz syndrome (LDS) is a rare genetic connective tissue disorder resulting from TGF-ß signaling pathway defects and characterized by a wide spectrum of aortic aneurysm, arterial tortuosity, and various extravascular abnormalities. This study describes the audiologic, otologic, and craniofacial manifestations of LDS. Consecutive cross-sectional study. Tertiary medical research institute. Audiologic and clinical evaluations were conducted among 36 patients (mean ± SD age, 24 ± 17 years; 54% female) with genetically confirmed LDS. Cases were categorized into genetically based LDS types 1 to 4 ( LDS types 1 to 4 included 11, 13, 5, and 7 patients, respectively. In LDS-1, 27% had bilateral conductive hearing loss; 9%, unilateral mixed; and 36%, subclinical. In LDS-2, 38% had conductive hearing loss and 38% subclinical. In LDS-3 and LDS-4, 40% and 43% had bilateral sensorineural hearing loss, respectively. Degree of hearing loss ranged from mild to moderate. Bifid uvula was observed only in LDS-1 (55%) and LDS-2 (62%). Submucosal/hard cleft palates were primarily in LDS-1 and LDS-2. Posttympanostomy tympanic membrane perforations occurred in 45% (10/22 ears) of LDS-1 and LDS-2.
There were 4 cases of cholesteatoma: 3 middle ear (LDS-1 and LDS-2) and 1 external ear canal (LDS-3). Conductive hearing loss, bifid uvula/cleft palate, and posttympanostomy tympanic membrane perforation are more common in LDS-1 and LDS-2 than LDS-3 and LDS-4, while sensorineural hearing loss was present only in LDS-3 and LDS-4. These LDS-associated key clinical presentations may facilitate an early diagnosis of LDS and thus prompt intervention to prevent related detrimental outcomes.

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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


Lengthy wait times for elective surgery is a widespread health care system conundrum that may increase patient distress and jeopardize health outcomes. The primary aim of this quality improvement project was to reduce the surgical wait time in patients undergoing tympanostomy tube insertion. As of January 2018, our tertiary care institution implemented a novel protocol whereby healthy children may undergo tympanostomy tube insertion in a minor procedure room under ketamine sedation administered by pediatric emergency physicians to address lack of both physical and anesthesia staffing resources. A retrospective study of all children undergoing elective tympanostomy tube insertion was conducted between September 1, 2017, and May 8, 2019, to assess wait time to surgery, as well as anesthesia-related and surgical complications. Procedural sedation in minor procedure rooms effectively decreased surgical wait times by 53 days (from 134 to 81 days, Although conscious sedation by emergency physicians has been well studied across a variety of surgical procedures, its novel use in pediatric tympanostomy tube insertion requires careful patient selection to enhance accessibility while maintaining anesthetic safety. This quality improvement project describes a novel combination of processes, using a minor procedure room space and ketamine-based procedural sedation to address surgical wait times in pediatric patients undergoing tympanostomy tube insertion.

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Determining the Impact of Thickened Liquids on Swallowing in Patients Undergoing Irradiation for Oropharynx Cancer

Carly E. A. Barbon,Douglas B. Chepeha,Andrew J. Hope,Melanie Peladeau-Pigeon,Ashley A. Waito,Catriona M. Steele

Publication date 04-05-2021


The current standard for the treatment of oropharynx cancers is radiation therapy. However, patients are frequently left with dysphagia characterized by penetration-aspiration (impaired safety) and residue (impaired efficiency). Although thickened liquids are commonly used to manage dysphagia, we lack evidence to guide the modification of liquids for clinical benefit in the head and neck cancer population. The objective of this study was to assess the impact of slightly and mildly thick liquids on penetration-aspiration and residue in 12 patients with oropharyngeal cancer who displayed penetration-aspiration on thin liquid within 3 to 6 months after completion of radiotherapy. Significantly fewer instances of penetration-aspiration were seen with slightly and mildly thick liquids as compared with thin (

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Effect of Pretreatment Dysphagia on Postchemoradiation Swallowing Function in Head and Neck Cancer

Daniel J. Cates,Lisa M. Evangelista,Peter C. Belafsky

Publication date 04-05-2021


Chemoradiation therapy (CRT) for head and neck cancer can have profound effects on swallowing function. Identification of risk factors for development of swallowing dysfunction after CRT may improve allocation of preventive strategies. The purpose of this study is to determine the association between pre-CRT dysphagia and post-CRT swallowing dysfunction. Retrospective cohort study. Academic medical center. Patients with head and neck cancer were evaluated before and 3 months after CRT. Dysphagia was assessed with the Eating Assessment Tool (EAT-10). Swallowing dysfunction was evaluated by a videofluoroscopic swallow study and the Penetration-Aspiration Scale and swallowing safety was evaluated by the Functional Oral Intake Scale. The association between pre-CRT EAT-10 scores and post-CRT swallowing dysfunction was evaluated. The mean ± SD post-CRT Functional Oral Intake Scale score was 6.5 ± 1.2 for individuals with a pre-CRT EAT-10 score <3 and 5.3 ± 1.9 for those with a pre-CRT EAT-10 score ≥3 ( The presence of dysphagia before chemoradiation for head and neck cancer is an independent predictor of swallowing dysfunction after completion of therapy. These results may help target intervention toward preventing swallowing dysfunction in high-risk individuals.

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Pediatric Hearing Loss Management in the COVID-19 Era: Possible Consequences and Resources for the Next Future

Davide Brotto,Flavia Sorrentino,Niccolò Favaretto,Roberto Bovo,Patrizia Trevisi,Alessandro Martini

Publication date 04-05-2021


Pediatric hearing loss early diagnosis and treatment have been limited by the current restrictions due to the coronavirus disease 2019 pandemic. The difficulty in accessing the multiple facilities required for the rehabilitative process is influencing the timing of each step of the process. Auditory hearing screening programs, etiological characterization, surgical timing, and speech therapies have all been limited in the past year. The current conditions have forced us to adopt different strategies to overcome the necessary social distancing prescriptions. Although their efficacy should be proved over time, some of these resources will be probably useful even in a nonpandemic future.

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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


The objective of this study is to evaluate the impact of high-deductible health plans on elective surgery (tonsillectomy) in the pediatric population. Cross-sectional study. Health claims database from a third-party payer. Data were reviewed for children up to 18 years of age who underwent tonsillectomy or arm fracture repair (nonelective control) from 2016 to 2019. Incidence of surgery by health plan deductible (high, low, or government insured) and met or unmet status of deductibles were compared. A total of 10,047 tonsillectomy claims and 9903 arm fracture repair claims met inclusion and exclusion criteria. The incidence of tonsillectomy was significantly different across deductible plan types. Patients with met deductibles were more likely to undergo tonsillectomy. In patients with deductibles ≥$4000, a 1.75-fold increase in tonsillectomy was observed in those who had met their deductible as compared with those who had not. These findings were not observed in controls (nonelective arm fracture). For those with met deductibles, those with high deductibles were much more likely to undergo tonsillectomy than those with low, moderate, and government deductibles. Unmet high deductibles were least likely to undergo tonsillectomy. Health insurance plan type influences the incidence of pediatric elective surgery such as tonsillectomy but not procedures such as nonelective repair of arm fracture. High deductibles may discourage elective surgery for those deductibles that are unmet, risking inappropriate care of vulnerable pediatric patients. However, meeting the deductible may increase incidence, raising the question of overutilization.

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Impact of Completion Lymphadenectomy on Quality of Life for Head and Neck Cutaneous Melanoma

Janice L. Farlow,Scott A. McLean,Nithin Peddireddy,Carol R. Bradford,Kelly M. Malloy,Chaz L. Stucken,Kyle K. VanKoevering,Matthew E. Spector,Andrew J. Rosko

Publication date 20-04-2021


Recent randomized data suggest that completion lymph node dissection after a positive sentinel lymph node biopsy (SLNB) improves locoregional control but does not improve survival for melanoma patients. Locoregional recurrences of head and neck cutaneous melanoma (HNCM) may result in significant morbidity. A better understanding of morbidity is thus important to inform decisions about whether to pursue completion neck dissection (ND). Cross-sectional study. Academic tertiary care hospital. Clinical data were collected for patients with HNCM seen between 2016 and 2019 who were at least 1-year disease free. Each patient completed the Self-administered Leeds Assessment of Neuropathic Symptoms and Signs (SLANSS), Neck Dissection Impairment Index, and SF-36 (Short Form-36).
Scores were compared by surgical treatment: wide local excision (WLE) only, SLNB, and ND. Univariate and multivariable regression was performed. Of 474 patients, 140 returned questionnaires (29.5% response rate; WLE, n = 49; SLNB, n = 76; ND, n = 15). No significant differences in SLANSS or Neck Dissection Impairment Index scores were found between the WLE and SLNB groups. SLANSS scores differed by 2 SD ( Neuropathy and neck impairment are components of morbidity after ND. These risks must be balanced with potential morbidity of locoregional recurrence in HNCM.

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Frailty and Quality of Life After Cochlear Implantation in Older Adults

Alana Aylward,Morganne Murphy-Meyers,Chelsea McCarty Allen,Neil S. Patel,Richard K. Gurgel

Publication date 20-04-2021


To examine the relationship among frailty index, hearing measures, and hearing-related quality of life (QOL) in older recipients of cochlear implants. Cross-sectional survey. Academic medical center. Adults aged ≥65 years at the time of receiving cochlear implants between July 13, 2000, and April 3, 2019, were asked to complete a questionnaire on hearing-related QOL. Chart review was performed to identify patients' characteristics. Correlations were calculated between frailty index and audiologic outcome measures as well as between speech recognition scores and QOL scores. Linear regression models were developed to examine the impact of clinical characteristics, frailty index, and hearing measures on hearing-related QOL. Data for 143 respondents were included. The mean age was 80.7 years (SD, 7.1), with a mean 27.8 years of hearing loss (SD, 17.4) before implantation. The mean frailty index was 11.1 (SD, 10.6), indicating that patients had 1 or 2 of the measured comorbidities on average. No correlation was found between lower frailty index (better health) and hearing scores, including pure tone averages (PTAs) and speech recognition scores. Lower frailty index and larger improvement in PTA after cochlear implantation predicted better QOL scores on univariate analysis (respectively, Frailty index does not correlate with hearing scores after cochlear implantation in older adults. Lower frailty index and more improvement in PTA predict better QOL scores after cochlear implantation in older adults.

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Otopathologic Abnormalities in CHARGE Syndrome

Rafael da Costa Monsanto,Renata Malimpensa Knoll,Norma de Oliveira Penido,Grace Song,Felipe Santos,Michael Mauro Paparella,Sebahattin Cureoglu

Publication date 20-04-2021


To perform an otopathologic analysis of temporal bones (TBs) with CHARGE syndrome. Otopathologic study of human TB specimens. Otopathology laboratories. From the otopathology laboratories at the University of Minnesota and Massachusetts Eye and Ear Infirmary, we selected TBs from donors with CHARGE syndrome. These TBs were serially sectioned at a thickness of 20 µm, and every 10th section was stained with hematoxylin and eosin. We performed otopathologic analyses of the external ear, middle ear (middle ear cleft, mucosal lining, ossicles, mastoid, and facial nerve), and inner ear (cochlea, vestibule, internal auditory canal, and cochlear and vestibular nerves). The gathered data were statistically analyzed. Our study included 12 TBs from 6 donors. We found a high prevalence of abnormalities affecting the ears. The most frequent findings were stapes malformation (100%), aberrant course of the facial nerve (100%) with narrow facial recess (50%), sclerotic and hypodeveloped mastoids (50%), cochlear (100%) and vestibular (83.3%) hypoplasia with aplasia of the semicircular canals, hypoplasia and aplasia of the cochlear (66.6%) and vestibular (91.6%) nerves, and narrowing of the bony canal of the cochlear nerve (66.6%). The number of spiral ganglion and Scarpa's ganglion neurons were decreased in all specimens (versus normative data). In our study, CHARGE syndrome was associated with multiple TB abnormalities that may severely affect audiovestibular function and rehabilitation.

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Comparative Morbidity Profile of Elective vs Therapeutic Neck Dissection

Quinn Dunlap,James Reed Gardner,Amanda Ederle,Deanne King,Maya Merriweather,Emre Vural,Mauricio Alejandro Moreno

Publication date 20-04-2021


Neck dissection (ND) is one of the most commonly performed procedures in head and neck surgery. We sought to compare the morbidity of elective ND (END) versus therapeutic ND (TND). Retrospective chart review. Academic tertiary care center. Retrospective chart review of 373 NDs performed from January 2015 to December 2018. Patients with radical ND or inadequate chart documentation were excluded. Demographics, clinicopathologic data, complications, and sacrificed structures during ND were retrieved. Statistical analysis was performed with χ Patients examined consisted of 224 males (60%) with a mean age of 60 years. TND accounted for 79% (n = 296) as compared with 21% (n = 77) for END. Other than a significantly higher history of radiation (37% vs 7%, While the significantly higher rate of structure sacrifice among the TND population represents an increased morbidity profile in these patients, no significant difference was found in the rate of surgical complications between groups. The significant difference seen between groups regarding history of radiation and endocrine pathology likely represents selection bias.

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Prognostic Significance of Radiologic Extranodal Extension in Nasopharyngeal Cancer

Melek Karakurt Eryılmaz,Cengiz Kadıyoran

Publication date 20-04-2021


The aim of the present study was to evaluate the prognostic value of radiologic extranodal extension (rENE) in patients with nasopharyngeal cancer. Retrospective review. Tertiary university hospital. We identified patients with nasopharyngeal cancer and lymph node metastasis who underwent pretreatment neck computed tomography or magnetic resonance imaging and evaluated rENE from the involved lymph node. Univariate Kaplan-Meier and multivariate Cox regression analyses were used to compare rENE+ and rENE- groups for local regional relapse-free survival, distant metastasis-free survival, and overall survival. Of 61 cases, 24 (39.3%) were rENE+ and 37 (60.7%) were rENE-. The median follow-up was 65.5 months. The 5-year distant metastasis-free survival and overall survival rates were lower in the rENE+ group than the rENE- group (70.8% vs 89.2%, We showed that rENE is an independent prognostic factor for poor distant control and survival in patients with nasopharyngeal cancer.

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A 2020 Update on Public Awareness of Head and Neck Cancers

Sina J. Torabi,David A. Kasle,Brooke M. Su-Velez,Saral Mehra,Terry A. Day,Wendell G. Yarbrough,Maie St. John,Benjamin L. Judson

Publication date 13-04-2021


To assess knowledge regarding head and neck cancers (HNCs) in 2020, factors associated with knowledge of the role of human papillomavirus (HPV) in HNCs, and factors associated with exposure to Oral, Head and Neck Cancer Awareness Week (OHANCAW). Cross-sectional survey. Online. The survey was distributed to 517 participants via a paid panel and utilized US Census-built quotas to represent the US population. Participants surpassed 50% awareness rates in only 5 of 10 (50.0%), 2 of 6 (33.3%), and 5 of 9 (55.5%) preselected answer choices for subsites, risk factors, and signs/symptoms of HNCs, respectively. Knowledge of HPV's role in oropharyngeal cancer was also low, at 30.6%. However, of the controlled variables, exposure to OHANCAW was closely associated with knowledge of HPV's role in HNC (odds ratio, 10.25; 95% CI, 5.36-19.62). Women and elderly individuals were less likely to be exposed to OHANCAW, while those with higher education, those who drink heavily (>4 drinks/d), and current but not former tobacco users were more likely to be exposed. Knowledge of HNCs and the causal role of HPV remains suboptimal, though our results suggest that OHANCAW remains a viable educational pathway. However, certain at-risk populations, such as former smokers and older individuals, whom we may not be effectively reaching and screening, represent a priority for future outreach efforts.

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Simple Endoscopic Application of Laryngeal Keel Stent

Ahmed Hassan Sweed,Mohamed Mobashir,Abd Elraof Said Mohamed,Ahmed Ibrahim Elsayed,Ashraf Elmalt,Mohamed Elsayed Elshora

Publication date 23-03-2021


This study describes a simple extraendolaryngeal technique to apply laryngeal keel in dealing with anterior commissure web/fibrosis. Standard extraendolaryngeal punctures were applied via 20-gauge needles, 30° from the skin surface, in midline through the cricothyroid and thyrohyoid membranes. These needles were used as a conduit for the passage of 2/0 Prolene threads, which were retrieved through the laryngoscope by crocodile forceps. Both laryngoscopic ends of the Prolene threads were passed through a fabricated silastic sheet (keel stent) via a 22-gauge free needle, and these ends were tied to have a secure internal knot. Steady traction was applied on the other 2 external threads until there was appropriate application of this keel stent within the vicinity of anterior commissure. Finally, these external ends were tied to have a secure external knot. A keel stent could be applied without the need for special instrumentation and with reasonable outcomes (proper healing of anterior commissure, satisfied voice outcome, and patent airway).

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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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