Otolaryngology Head and Neck Surgery 2021-10-19

Unlearning the ABCs of Tympanometry

Edward D. McCoul

Publication date 09-03-2021


Interpretation of tympanometry commonly relies on the historical convention of classifying findings according to large and arbitrary threshold shifts of tympanometric peak pressure (TPP). This convention had value for prior generations of otolaryngologists in diagnosing severe, chronic middle ear disease requiring surgical intervention but may not be well suited for the present-day evaluation of less severe disease. The existing definition of a type C curve (less than -100 da Pa) is likely insensitive to detect subtle abnormalities, including some presentations of obstructive eustachian tube dysfunction. The accuracy of clinical diagnosis may be improved by reporting the absolute values of TPP and moving beyond classification according to arbitrary thresholds.

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Vestibular Dysfunction and Gross Motor Milestone Acquisition in Children With Hearing Loss: A Systematic Review

Anisha Singh,Eileen M. Raynor,Janet W. Lee,Sherri L. Smith,Hannah Heet,Doug Garrison,Jordan Wrigley,David M. Kaylie,Kristal M. Riska

Publication date 12-01-2021


To describe the impact of vestibular dysfunction on gross motor development in children with hearing loss. MEDLINE (Pub Med), Embase (Elsevier), Web of Science (Clarivate), and the Cumulative Index of Nursing and Allied Health Literature (EBSCO). A systematic review was reported in concordance with the PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-analyses). Articles on children with hearing loss who underwent at least 1 instrumented measure of vestibular function and had gross motor milestones assessed were included. The Downs and Black checklist was used to assess risk of bias and methodological quality. Eleven articles were included in the systematic review. Three articles stratified quantitative results of gross motor milestone acquisition by severity of vestibular impairment. Over half of studies were case series published within the last 5 years. This systematic review showed that children with hearing loss and severe, bilateral vestibular dysfunction demonstrate delayed gross motor milestones. However, it was difficult to draw conclusions on whether milder forms of vestibular dysfunction significantly affect gross motor milestone acquisition in children with hearing loss. The reason is that most studies were of low to moderate quality, used different assessment methods, and contained results that were descriptive in nature. This emerging area would benefit from future research, such as higher-quality studies to assess vestibular function and gross motor milestones. This would allow for better characterization of the impacts of vestibular impairment, especially milder forms, in children with hearing loss.

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Surgical Management of Sialorrhea: A Systematic Review and Meta-analysis

Sam D. Schild,Alisa Timashpolsky,Daniel P. Ballard,Sylvia Horne,Richard M. Rosenfeld,Ann W. Plum

Publication date 26-01-2021


Chronic sialorrhea commonly occurs in patients with neurodevelopmental disorders. While conservative management can provide sufficient symptom control, surgical intervention is often required. One of the most common procedures utilized is submandibular gland excision (SMGE), with or without parotid duct ligation or rerouting (PDL or PDR). This study aims to compare these surgical approaches and their outcomes. Pub Med, Web of Science, and Embase. This systematic review includes studies of patients with chronic sialorrhea treated with SMGE alone or SMGE plus PDR or PDL and reports on postintervention outcomes and complications. Two independent investigators assessed study eligibility, rated quality, and extracted data for analysis. A random effects model was used for meta-analysis of pooled data. Of 3186 studies identified, 21 met inclusion criteria, with 708 patients: 103 underwent SMGE alone (15%); 299 (42%), SMGE and PDL; and 306 (43%), SMGE plus PDR. Overall, a majority of patients had significant improvement, with very good to excellent control of symptoms after surgery: SMGE, 82% (95% CI, 73%-89%); SMGE and PDL, 79% (95% CI, 73%-85%); and SMGE and PDR, 85% (95% CI, 75%-92%). Importantly, there was no significant difference in outcomes with the addition of PDL or PDR. Reported complications included sialocele, parotitis, dental caries, and dry mouth. Our systematic review identified consistent positive outcomes with SMGE for patients with chronic sialorrhea but no additional benefit when PDR or PDL was performed as a concurrent procedure.

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Factors Affecting Central Node Metastasis and Metastatic Lymph Node Ratio in Papillary Thyroid Cancer

Jungirl Seok,Chang Hwan Ryu,Seog Yun Park,Chang Yoon Lee,Young Ki Lee,Yul Hwangbo,Eun Kyung Lee,You Jin Lee,Tae Sung Kim,Seok-ki Kim,Yuh-Seog Jung,Junsun Ryu

Publication date 09-02-2021


Despite the growing evidence that metastatic lymph node ratio (MLNR) is a valuable predictor for the prognosis of papillary thyroid carcinoma, it has not yet been fully determined which factors give the ratio predictive value independent of the number of metastatic lymph nodes (MLNs). Retrospective cohort study. A comprehensive cancer center. Recurrence and clinicopathologic factors were analyzed in 2409 patients with papillary thyroid carcinoma who underwent total thyroidectomy and central node dissection. Cutoff values of MLNs ≥2 and MLNR ≥28.2% increased the recurrence risk (hazard ratio [95% CI], 9.97 [4.73-21.0] and 11.4 [5.53-23.3], respectively). Younger age, male sex, multifocality, tumor size, lymphatic and vascular invasion, and gross extrathyroidal extension positively correlated with MLN and MLNR (all Our study demonstrates that MLN and MLNR are independently observed prognostic markers for tumor recurrence. However, lymphocytic thyroiditis in female patients seems to have lower MLNR by increasing total lymph node yields. In light of their association, a different cutoff for MLNR needs to be applied according to the presence or absence of underlying lymphocytic thyroiditis in the use of MLNR for predicting the recurrence. 4.

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Ambient Noise Levels and Wireless Headsets for Communication in Aerosolizing Otolaryngology Surgery During COVID-19

Marc Levin,Kelvin Zhou,Ethan C. Sommer,Tobial McHugh,Doron D. Sommer

Publication date 12-01-2021


The objective of this short scientific communication is to describe and test a strategy to overcome communication barriers in coronavirus disease 2019 (COVID-19) era otolaryngology operating rooms. Thirteen endoscopic sinus surgeries, 4 skull base surgeries, and 1 tracheotomy were performed with powered air-purifying respirators. During these surgeries, surgical team members donned headsets with microphones linked via conference call. Noise measurements and survey responses were obtained and compared to pre-COVID-19 data. Noise was problematic and caused miscommunication as per 93% and 76% of respondents, respectively. Noise in COVID-19 era operating rooms was significantly higher compared to pre-COVID-19 era data (73.8 vs 70.2 decibels,

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Aerosol Generation During Myringotomy With Tympanostomy Tube Insertion: Implications for Otolaryngology in the COVID-19 Era

Vincent J. Campiti,Michael J. Ye,Dhruv Sharma,Bruce H. Matt,Ryan M. Mitchell,Jonathan Y. Ting,Elisa A. Illing,Jae Hong Park,Sarah J. Burgin

Publication date 09-02-2021


The risk of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission to health care workers during myringotomy and tympanostomy tube (MT) insertion is unknown. To determine the need for enhanced precautions to prevent potential spread via aerosolized particles, we used an optical particle sizer to measure aerosol generation intraoperatively during a case series of MT insertion. We also discuss our institutional experience with safe pandemic-era perioperative practices. There was no measured increase in aerosol particle number during the procedure at a distance of 30 cm from the external auditory canal. These initial data are reassuring regarding the risk of SARS-CoV-2 transmission to the operating room team due to aerosol generation, but further study is necessary before making definitive recommendations.

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Microscopic Extranodal Extension in HPV-Negative Head and Neck Cancer and the Role of Adjuvant Chemoradiation

Flora Yan,Hong Li,John R. de Almeida,John M. Kaczmar,Patrik Pipkorn,Joseph Zenga,Mary S. Richardson,David M. Neskey,Anand K. Sharma,Terry A. Day,Evan M. Graboyes

Publication date 23-02-2021


Pathologic extranodal extension (ENE) is an important adverse feature for human papillomavirus (HPV)-negative head and neck squamous cell carcinoma (HNSCC), but the prognostic significance of microscopic ENE (ENE Retrospective cohort study. Commission on Cancer (CoC)-accredited facilities. This retrospective cohort study included patients in the National Cancer Database from 2009 to 2015 with pathologic node-positive (pN+) HPV-negative HNSCC with either pathologic ENE We included 5483 patients with pN+ HPV-negative HNSCC, of whom 24% had ENE For patients with HPV-negative HNSCC, pN+ with ENE

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Opioid Prescribing Patterns After Head and Neck Surgery

Punam A. Patel,Lavanya Nagappan,Daohai Yu,Xiaoning Liu,Cecelia E. Schmalbach

Publication date 02-03-2021


Postoperative prescription narcotics increase access to opioids and associated abuse among patients, family, and acquaintances. Judicious opioid stewardship is required. Best practice questions remain for larger head and neck surgeries. We aim to review opioid utilization patterns in an urban patient population to identify patients at risk for poor postoperative pain control. Case series with planned chart review for patients undergoing head and neck surgery (2015-2018). Single urban hospital. Outcome measures included postoperative phone calls and emergency room visits as markers for inadequate pain control. Age, sex, race, body mass index (BMI), smoking status, comorbidities, prior narcotic filling behavior, surgery type, and duration were evaluated as potential risk factors for pain control. Chi-square and Wilcoxon tests were used for group comparisons. In total, 215 patients met inclusion criteria: male (22%), white/Hispanic (47%), and African American (44%). Median BMI was 31.6 kg/m Female sex, younger age, smokers, and high inpatient opioid dose requirements are associated with inadequately controlled pain. These patients may benefit from additional education, earlier postoperative visits, and a more comprehensive nonopioid regimen.

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Application of a Computer Vision Tool for Automated Glottic Tracking to Vocal Fold Paralysis Patients

Tiffany V. Wang,Nat Adamian,Phillip C. Song,Ramon A. Franco,Molly N. Huston,Nate Jowett,Matthew R. Naunheim

Publication date 16-02-2021


(1) Demonstrate true vocal fold (TVF) tracking software (AGATI [Automated Glottic Action Tracking by artificial Intelligence]) as a quantitative assessment of unilateral vocal fold paralysis (UVFP) in a large patient cohort. (2) Correlate patient-reported metrics with AGATI measurements of TVF anterior glottic angles, before and after procedural intervention. Retrospective cohort study. Academic medical center. AGATI was used to analyze videolaryngoscopy from healthy adults (n = 72) and patients with UVFP (n = 70). Minimum, 3rd percentile, 97th percentile, and maximum anterior glottic angles (AGAs) were computed for each patient. In patients with UVFP, patient-reported outcomes (Voice Handicap Index 10, Dyspnea Index, and Eating Assessment Tool 10) were assessed, before and after procedural intervention (injection or medialization laryngoplasty). A receiver operating characteristic curve for the logistic fit of paralysis vs control group was used to determine AGA cutoff values for defining UVFP. Mean (SD) 3rd percentile AGA (in degrees) was 2.67 (3.21) in control and 5.64 (5.42) in patients with UVFP ( AGATI demonstrated a difference in AGA measurements between paralysis and control patients. AGATI can predict UVFP with 77% sensitivity and 92% specificity.

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Clinical Profile of Patients With Unilateral Sudden Sensorineural Hearing Loss: Correlation With Hearing Prognosis

Adriana Perez Ferreira Neto,Rafael da Costa Monsanto,Line Dore Saint Jean,Lucas Sonzzini Ribeiro de Souza,Norma de Oliveira Penido

Publication date 09-02-2021


To characterize, with a standard systematic protocol, the clinical and audiometric profile of patients with idiopathic sudden sensorineural hearing loss (ISSNHL) and to correlate the findings with hearing recovery prognosis. Retrospective cohort of patients with ISSNHL. Outpatients of a tertiary referral center followed for 20 years. We collected clinical information, including the presence of tinnitus, vertigo, and comorbidities, as well as initial pure tone averages, degree of hearing loss, audiogram curves, and time between hearing loss onset and treatment. These variables were statistically analyzed for their impact on hearing recovery prognosis. All patients were treated with oral corticosteroids, following a standard treatment protocol. Hearing recovery was defined according to the criteria of the American Academy of Otolaryngology-Head and Neck Surgery Foundation, and hearing outcomes were reported via a standardized method (scattergrams). Our final study group comprised 186 patients. Most patients were between 41 and 60 years of age. Univariate analysis revealed that vertigo; presence of severe or profound initial hearing loss; flat, U-shaped, and descending audiogram curves; and initiating treatment ≥15 days were correlated with worse hearing recovery. However, the multivariate logistic model revealed that only the presence of severe or profound hearing loss (odds ratio, 6.634; 95% CI, 2.714-16.216; This study demonstrated that the presence of severe or profound hearing loss at the first audiogram and initiating treatment after 14 days from ISSNHL onset were independent risk factors associated with a worse hearing recovery prognosis.

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Incidence of Complete Insertion in Cochlear Implant Recipients of Long Lateral Wall Arrays

Michael W. Canfarotta,Margaret T. Dillon,Kevin D. Brown,Harold C. Pillsbury,Matthew M. Dedmon,Brendan P. O’Connell

Publication date 16-02-2021


High rates of partial insertion have been reported for cochlear implant (CI) recipients of long lateral wall electrode arrays, presumably caused by resistance encountered during insertion due to cochlear morphology. With recent advances in long-electrode array design, we sought to investigate (1) the incidence of complete insertions among patients implanted with 31.5-mm flexible arrays and (2) whether complete insertion is limited by cochlear duct length (CDL). Retrospective review. Tertiary referral center. Fifty-one adult CI recipients implanted with 31.5-mm flexible lateral wall arrays underwent postoperative computed tomography to determine the rate of complete insertion, defined as all contacts being intracochlear. CDL and angular insertion depth (AID) were compared between complete and partial insertion cohorts. Most cases had a complete insertion (96.1%, n = 49). Among the complete insertion cohort, the median CDL was 33.6 mm (range, 30.3-37.9 mm), and median AID was 641° (range, 533-751°). Two cases of partial insertion had relatively short CDL (31.8 mm and 32.3 mm) and shallow AID (542° and 575°). Relatively shallow AID for the 2 cases of partial insertion fails to support the idea that CDL alone prevents a complete insertion. Complete insertion of a 31.5-mm flexible array is feasible in most cases and does not appear to be limited by the range of CDL observed in this cohort. Future studies are needed to estimate other variations in cochlear morphology that could predict resistance and failure to achieve complete insertion with long arrays.

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Expert Consensus Statement: Pediatric Drug-Induced Sleep Endoscopy

Cristina M. Baldassari,Derek J. Lam,Stacey L. Ishman,Boris Chernobilsky,Norman R. Friedman,Terri Giordano,Claire Lawlor,Ron B. Mitchell,Heather Nardone,James Ruda,Habib Zalzal,Adrienne Deneal,Nui Dhepyasuwan,Richard M. Rosenfeld

Publication date 05-01-2021


To develop an expert consensus statement on pediatric drug-induced sleep endoscopy (DISE) that clarifies controversies and offers opportunities for quality improvement. Pediatric DISE was defined as flexible endoscopy to examine the upper airway of a child with obstructive sleep apnea who is sedated and asleep. Development group members with expertise in pediatric DISE followed established guidelines for developing consensus statements. A search strategist systematically reviewed the literature, and the best available evidence was used to compose consensus statements regarding DISE in children 0 to 18 years old. Topics with significant practice variation and those that would improve the quality of patient care were prioritized. The development group identified 59 candidate consensus statements, based on 50 initial proposed topics, that focused on addressing the following high-yield topics: (1) indications and utility, (2) protocol, (3) optimal sedation, (4) grading and interpretation, (5) complications and safety, and (6) outcomes for DISE-directed surgery. After 2 iterations of the Delphi survey and removal of duplicative statements, 26 statements met the criteria for consensus; 11 statements were designated as no consensus. Several areas, such as the role of DISE at the time of adenotonsillectomy, were identified as needing further research. Expert consensus was achieved for 26 statements pertaining to indications, protocol, and outcomes for pediatric DISE. Clinicians can use these statements to improve quality of care, inform policy and protocols, and identify areas of uncertainty. Future research, ideally randomized controlled trials, is warranted to address additional controversies related to pediatric DISE.

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Determining the Odds of Difficult Airway Resolution Among Pediatric Patients: A Case Series

Edgar Erold Kiss,Patrick Olomu,Romaine F. Johnson

Publication date 19-01-2021


We sought to determine the patient factors that contribute to the improvement and resolution of difficult airways in pediatric patients. The hospital's Multidisciplinary Airway Registry Committee was created in November 2006 to develop a process for recognition and management of children with difficult airways. A database of these patients is actively maintained, allowing for statistical data analysis. The tertiary care hospital system consists of 2 campuses serving the indigent pediatric population of the greater Dallas metropolitan area and performs an average of 40,000 anesthetic encounters per year. We examined the data from a difficult airway database from a major tertiary care pediatric hospital to determine patient factors that led to airway improvement over time. Patients enrolled in the registry from November 2006 to October 2019 due to difficulties with intubation or mask ventilation were studied through statistical analysis. A total of 579 patients were identified. The Kaplan-Meier estimate of the 5-year deactivation rate was 14%. The most common reason for deactivation in our cohort was resolution of the difficult airway as defined by direct laryngoscopy Cormack and Lehane grade I or IIa/IIb, easy mask ventilation or laryngeal mask placement, or resolution of subglottic stenosis. Advancing age and male sex at the time of enrollment were the most important predictors of an airway remaining difficult.

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Adverse Events Associated With ClariFix Posterior Nasal Nerve Cryoablation: A MAUDE Database Analysis

Amrita K. Singh,David A. Kasle,Sina J. Torabi,R. Peter Manes

Publication date 02-02-2021


Posterior nasal nerve (PNN) cryoablation is a novel surgical technique used to address chronic rhinitis. The purpose of this study is to review the medical device reports (MDRs) submitted to the Food and Drug Administration's (FDA) Manufacturer and User Device Facility Experience (MAUDE) database to identify adverse events related to the use of Clari Fix, a device designed for office-based cryosurgical ablation of the PNN. A total of 12 adverse events associated with Clari Fix from January 2017 to August 2020 were identified and analyzed. The most common adverse events associated with Clari Fix PNN cryoablation include epistaxis and nasal swelling. Further studies are needed to clarify whether PNN cryoablation is associated with epistaxis in certain populations.

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Ansa Cervicalis and Hypoglossal Nerve Stimulation in a Patient With Obstructive Sleep Apnea

David T. Kent,David Zealear,Alan R. Schwartz

Publication date 26-01-2021


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In Reference to “Augmentation of Scarred Vocal Folds With Centrifuged and Emulsified Autologous Fat Grafts”

Giovanna Cantarella,Riccardo F. Mazzola

Publication date 01-10-2021


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Response to “Augmentation of Scarred Vocal Folds With Centrifuged and Emulsified Autologous Fat Grafts”

Enrique Salmerón-González,Elena García-Vilariño,Ignacio Llópez-Carratalá,Diego Collado-Martin,José María Perolada-Valmaña,Miguel Armengot-Carceller

Publication date 01-10-2021


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Withdrawal of Protective Equipment for Nasolaryngoscopy May Be at Risk of Secondary Aerosolization

Valentin Favier,Léonie Grimmer,Arnaud Florentin,Patrice Gallet

Publication date 02-02-2021


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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


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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


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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


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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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Reviewer List

Publication date 28-09-2021


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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


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

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

Publication date 27-07-2021


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

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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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Effectiveness of Prophylactic Preoperative Antibiotics in Mandible Fracture Repair: A National Database Study

Elizabeth H. Wick,Brian Deutsch,Dorina Kallogjeri,John J. Chi,Gregory H. Branham

Publication date 13-04-2021


This is the first database study to assess the effectiveness of prophylactic preoperative antibiotics (PPAs) in mandible fracture repair. Retrospective cohort. Database study using US inpatient and outpatient insurance claims submitted from July 2006 to March 2015. The IBM Market Scan Commercial Database was queried for adults aged 18 to 64 years who had undergone first-time mandible fracture repair according to A total of 2676 patients were included, with 847 (31.7%) filling PPAs and 1829 (68.3%) filling no antibiotics. Rates were 38.9% for revision, 5.8% for local infection, and 2.1% for osteomyelitis. After multivariate analysis, exposure to PPAs was not associated with surgical revision (adjusted relative risk, 1.04; 95% CI, 0.94-1.15), local infection (1.16; 0.82-1.64), or osteomyelitis (1.21; 0.68-2.14). Patients were more likely to fill PPAs if they underwent open repair (35.3%) versus closed (26.6%) (proportion difference, 8.7%; 95% CI, 5.2%-12.2%), but exposure to antibiotics did not predict outcomes on subgroup analysis. PPAs do not improve mandible repair outcomes, regardless of repair type.

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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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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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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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Factors Affecting Dilation Interval in Patients With Granulomatosis With Polyangiitis-Associated Subglottic and Glottic Stenosis

Lena W. Chen,Ioan Lina,Kevin Motz,Alexandra J. Berges,Rafael Ospino,Philip Seo,Alexander T. Hillel

Publication date 13-04-2021


Subglottic stenosis (SGS) is a known complication of granulomatosis with polyangiitis (GPA). We investigated the impact of medical and surgical interventions on the surgical dilation interval and characterized patients with glottic involvement. A retrospective chart review of patients with GPA-associated SGS was performed from 2010 to 2019. Tertiary academic medical center. The impact of medical and surgical interventions on dilation interval was assessed. The prevalence of glottic involvement was assessed, and clinical characteristics and outcomes were compared with patients without glottic involvement. A total of 39 patients with GPA-associated SGS were analyzed. Dilation intervals in patients receiving leflunomide (n = 4; median, 484 days; 95% CI, 405-1099) were greater than in those not receiving leflunomide (median, 155 days; 95% CI, 48-305; Although GPA is classically thought to affect the subglottis, it also involves the glottis in a subset of patients. These patients have greater complaints of dysphonia and require more frequent surgery. Systemic therapy may increase dilation intervals. In this preliminary study, patients taking leflunomide demonstrated an improvement, highlighting the need for further study of immunosuppression regimens in the treatment of GPA-associated SGS.

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Further Research Needed to Understand Relationship Between Tubarial Glands and Eustachian Tube Dysfunction

Matthew J. Wu,Renata M. Knoll,Divya A. Chari,Aaron K. Remenschneider,William C. Faquin,Elliott D. Kozin,Dennis S. Poe

Publication date 13-04-2021


The pathophysiology of eustachian tube dysfunction (ETD) remains poorly characterized, and it may result in significant patient morbidity. A recent study has identified a collection of previously unidentified salivary glands in the nasopharynx that overlay the torus tubarius. While salivary gland tissue has been described in the nasopharynx, the newly discovered salivary gland tissue has been denoted tubarial glands (TGs) and theorized to be a distinct organ. The TGs have been suggested to aid in lubrication of the oropharynx and nasopharynx. However, the exact clinical significance of TGs is unknown. Given the proximity of the TG to the eustachian tube, it is possible that the TGs may be related to the development of ETD. Future studies of the TGs and related pathophysiology may improve approaches to developing future ETD treatments.

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Graduate Medical Education in Otolaryngology: Making Dollars and Sense of Reform

Jenny X. Chen,Shivani A. Shah,Vinay K. Rathi,Mark A. Varvares,Stacey T. Gray

Publication date 13-04-2021


Graduate medical education (GME) is funded by the Centers for Medicare and Medicaid Services through both direct and indirect payments. In recent years, stakeholders have raised concerns about the growth of spending on GME and distribution of payment among hospitals. Key stakeholders have proposed reforms to reduce GME funding such as adjustments to statutory payment formulas and absolute caps on annual payments per resident. Otolaryngology departmental leadership should understand the potential effects of proposed reforms, which could have significant implications for the short-term financial performance and the long-term specialty workforce. Although some hospitals and departments may elect to reduce resident salaries or eliminate positions in the face of GME funding cuts, this approach overlooks the substantial Medicare revenue contributed by resident care and high cost of alternative labor sources. Commitment to resident training is necessary to align both the margin and mission of otolaryngology departments and their sponsoring hospitals.

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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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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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Safety and Efficacy of the Draf IIb Procedure: A Systematic Review

Ralph Haddad,Nadim Khoueir,Hussein Smaily,Simon Rassi,Walid Abou Hamad

Publication date 06-04-2021


To systematically review the literature to evaluate the indications, safety, and efficacy of the Draf IIb procedure and to evaluate the added advantages of technical factors such as stents and flaps. Articles published until July 2019 on Medline and Cochrane databases. After a systematic review based on the 2018 PRISMA guidelines was conducted, 26 of 1533 articles were included and reviewed for indications of Draf IIb; surgical technique; use of flaps, stents, grafts, or mitomycin; complications during and after surgery; and success or recurrence rate. The main indication for Draf IIb was chronic frontal rhinosinusitis (61.82%). The postoperative patency rate was 87.85%. When flaps/grafts were applied, the rate was 93.5%, but their added value was not statistically significant. Stents could be an alternative for revision surgery. Treating frontal pathologies other than chronic rhinosinusitis was also satisfying.
Safety was comparable to Draf III: no perioperative complications were reported, only a few postoperative ones (eyelid ecchymosis and periorbital cellulitis in 0.2% of the cases, hyposmia in 1.55%). When properly indicated, Draf IIb frontal drilling is a safe and highly effective surgical technique for frontal pathology treatment, with efficiency and safety comparable to the Draf III, making it a valid option when a bilateral approach is not needed. More studies are required to confirm the added values of flaps, grafts, and stents.

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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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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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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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A Pilot Investigation of the Pediatric Nasal Microbiome

Elish Mahajan,Jeffrey Cheng

Publication date 30-03-2021


This proof-of-concept study demonstrates that sinonasal microbiome sequencing with suctioned nasal secretions in children is technically feasible.
Eighteen children were enrolled: 11 with symptoms of rhinosinusitis and 7 controls. Samples were collected via a sterile flexible respiratory suction catheter into a suction trap. Samples were analyzed with 16S ribosomal RNA sequencing and subsequent phylogenic mapping. The log2-fold differential abundance in class demonstrated significantly higher quantities of bacteria from the classes Negativicutes, Bacilli, Mollicutes, and Alphaproteobacteria as compared with controls, with a false discovery rate-corrected

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Thyroid Eye Disease, Teprotumumab, and Hearing Loss: An Evolving Role for Otolaryngologists

Alexander Chern,Lora R. Dagi Glass,David A. Gudis

Publication date 30-03-2021


Teprotumumab is a human monoclonal antibody and IGF-1R (insulin-like growth factor 1 receptor) inhibitor approved for treatment of thyroid eye disease in adults. Recent clinical trials have demonstrated side effects, notably hearing loss, in the treatment cohort as compared with the placebo cohort. These unexpected otologic side effects may be understood through a mechanistic understanding of IGF-1 (insulin-like growth factor 1). As otolaryngologists who historically play a significant role in the multidisciplinary treatment of thyroid disease and its associated complications, we should be aware of and monitor the otologic side effects of teprotumumab. Clinicians who prescribe teprotumumab should strongly consider monitoring patients' hearing with an audiologist and otolaryngologist.

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Sclerotherapy for Benign Cystic Lesions of the Head and Neck: Systematic Review of 474 Cases

Guy Talmor,Brandon Nguyen,Ghayoour Mir,Ido Badash,Rachel Kaye,Christen Caloway

Publication date 23-03-2021


The role of sclerotherapy for vascular lesions of the head and neck is well established. However, the efficacy of sclerotherapy for benign cystic lesions of the head and neck is less clear. The objective of this review is to determine the efficacy and safety of sclerotherapy for benign cystic lesions of the head and neck. Pub Med/MEDLINE, Cochrane Library, and Embase. The PRISMA guidelines (Preferred Reporting Systems for Systematic Reviews and Meta-analyses) were followed for this systematic review. Studies of patients with benign head and neck cystic masses treated primarily with sclerotherapy were included. Thirty-two studies met criteria for inclusion. A total of 474 cases of sclerotherapy were reviewed. Agents comprised OK-432, ethanol, doxycycline, tetracycline, and bleomycin. Lesions in the analysis were ranula, thyroglossal duct cyst, branchial cleft cyst, benign lymphoepithelial cyst, parotid cyst, thoracic duct cyst, and unspecified lateral neck cyst. A total of 287 patients (60.5%) had a complete response; 132 (27.9%) had a partial response; and 55 (11.6%) had no response. OK-432 was the most widely utilized agent, with a higher rate of complete response than that of ethanol (62.0% vs 39.4%, Sclerotherapy appears to be a safe and efficacious option for benign cystic lesions if malignancy is reliably excluded. Efficacy rates are comparable to those of sclerotherapy for vascular malformations. The rate of serious complications is low, with 1 incident of airway edema reported in the literature.

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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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Quality Improvement in Otolaryngology–Head and Neck Surgery: Age-Related Hearing Loss Measures

Richard K. Gurgel,Selena E. Briggs,Nui Dhepyasuwan,Richard M. Rosenfeld

Publication date 23-03-2021


There is a high and growing prevalence of age-related hearing loss (ARHL), defined as presbycusis or bilateral, symmetric sensorineural hearing loss in older adults. Due to the increasing prevalence of ARHL, the potential delays in its diagnosis and treatment, and the significant disability associated with ARHL, the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) convened a Measures Development Group (MDG) to develop quality measures (QMs) of clinical practice that could be incorporated into the AAO-HNSF's data registry Reg-ent. Although the AAO-HNSF has been engaged in robust clinical practice guideline development since 2006, the development of quality and performance measures is more recent. We report the process, experience, and outcomes in developing a de novo QM set for ARHL in the absence of a preexisting clinical practice guideline on this topic. Steps include the MDG review of evidentiary literature on ARHL, followed by stakeholder discussions to develop measure specifications. Key considerations included discussion on the relative importance, usability, and feasibility of each measure within the Reg-ent or similar databases. The MDG created 4 QMs for the diagnosis and treatment of AHRL. These measures represent the AAO-HNSF's quality initiatives to develop evidence-based QMs and improve patient care and outcomes, and they are intended to assist providers in enhancing quality of care. Development of the ARHL measures is intended for clinicians to evaluate the patient perception, structure, process, and outcomes of care. This process represents a new stage in the AAO-HNSF's measure development efforts to facilitate future efforts in evidence-based QM.

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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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Cleft Palate in Newborns Diagnosed With Prematurity

Jennifer N. Shehan,David O’Neil Danis,Ashank Bains,Krystyne Basa,Alexander P. Marston,Jessica R. Levi

Publication date 23-03-2021


Cleft lip and/or palate (CLP) is the most common major congenital malformation of the head and neck. Although numerous genetic features, syndromes, nutritional deficiencies, and maternal exposures have been implicated in the etiology of CLP, the impact of prematurity on the pathogenesis remains incompletely understood. This study seeks to evaluate the associations between prematurity and the development of CLP in the United States. Cross-sectional. Academic medical center. The Kids' Inpatient Database (2016) was used to identify weighted in-hospital births with diagnoses of prematurity or CLP. Demographic information was obtained. Odds ratios were used to determine associations between prematurity and CLP. Among patients included in our data set, 8.653% (n = 326,147) were preterm; 0.136% (n = 5115) had CLP; and 0.021% (n = 808) were preterm and had CLP. Preterm infants had 1.90 times the odds (95% CI, 1.74-2.07) of developing CLP when compared with the nonpreterm population. The binary logistic regression model accounting for possible confounding variables produced an odds ratio of 1.83 (95% CI, 1.66-2.01) for the association between prematurity and CLP. Infants who are born preterm are more likely to have CLP than full-term infants. The current results will allow for improved risk stratification, maternal counseling, and interventions in the case of prematurity. 4.

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Disease Profile and Oncologic Outcomes After Delayed Diagnosis of Human Papillomavirus–Associated Oropharyngeal Cancer

Linda X. Yin,Emily E. Karp,Anna Elias,Thomas J. O’Byrne,David M. Routman,Daniel L. Price,Jan L. Kasperbauer,Michelle Neben-Wittich,Ashish V. Chintakuntlawar,Katharine A. Price,Daniel J. Ma,Robert L. Foote,Eric J. Moore,Kathryn M. Van Abel

Publication date 23-03-2021


Diagnostic delay in human papillomavirus-associated oropharynx squamous cell carcinoma (HPV(+)OPSCC) is common due to nonspecific symptoms. We aim to describe the disease burden and oncologic outcomes of patients with HPV(+)OPSCC diagnosed >12 months after symptom onset. This is a retrospective cohort study of HPV(+)OPSCC patients receiving intent-to-cure treatment (including surgery ± adjuvant therapy or primary chemoradiation). 2006-2016, tertiary care center. Tumor stage was compared between patients with and without delayed diagnosis using χ In total, 664 patients were included. Compared to patients diagnosed <12 months from symptom onset (n = 601), those diagnosed at >12 months (n = 63) were more likely to have T4 disease and higher overall American Joint Committee on Cancer (AJCC) clinical stage at presentation ( Delayed diagnosis of HPV(+)OPSCC is associated with greater burden of disease at presentation, but oncologic outcomes remain favorable across treatment modalities. When appropriate, intent-to-cure therapy should be pursued despite diagnostic delay. Level III.

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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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Viral Infectivity in Patients Undergoing Tracheotomy With COVID-19: A Preliminary Study

Manish M. George,Charlotte J. McIntyre,Jie Zhou,Ruthiran Kugathasan,Dora C. Amos,Ivan J. Dillon,Wendy S. Barclay,Neil S. Tolley

Publication date 23-03-2021


To establish the presence of live virus and its association with polymerase chain reaction (PCR) positivity and antibody status in patients with COVID-19 undergoing tracheotomy. Prospective observational study. Single institution across 3 hospital sites during the first wave of the COVID-19 pandemic. Patients who were intubated for respiratory wean tracheotomy underwent SARS-CoV-2 PCR nasal, throat, and endotracheal tube swabs at the time of the procedure. These were assessed via quantitative real-time reverse transcription PCR. The tracheal tissue excised during the tracheotomy was cultured for SARS-CoV-2 with Vero E6 and Caco2 cells. Serum was assessed for antibody titers against SARS-CoV-2 via neutralization assays. Thirty-seven patients were included in this study. The mean number of days intubated prior to undergoing surgical tracheotomy was 27.8. At the time of the surgical tracheotomy, PCR swab testing yielded 8 positive results, but none of the 35 individuals who underwent tissue culture were positive for SARS-CoV-2. All 18 patients who had serum sampling demonstrated neutralization antibodies, with a minimum titer of 1:80. In our series, irrespective of positive PCR swab, the likelihood of infectivity during tracheotomy remains low given negative tracheal tissue cultures. While our results do not undermine national and international guidance on tracheotomy after day 10 of intubation, given the length of time to procedure in our data, infectivity at 10 days cannot be excluded. We do however suggest that a preoperative negative PCR swab not be a prerequisite and that antibody titer levels may serve as a useful adjunct for assessment of infectivity.

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Outcomes of HPV-Negative Oropharyngeal Cancer Treated With Transoral Robotic Surgery

Ryan S. Jackson,Katelyn Stepan,Craig Bollig,Rahul K. Sharma,Mihir Patel,Sean Massa,Sidharth V. Puram,Jose P. Zevallos,Patrik Pipkorn,Joseph Zenga

Publication date 23-03-2021


The incidence of oropharyngeal squamous cell carcinoma (OPSCC) is increasing secondary to human papillomavirus (HPV)-related disease. Despite this, outcomes of patients with HPV-negative OPSCC undergoing transoral robotic surgery (TORS) are largely unknown. Analysis of the National Cancer Database (NCDB). Not applicable. The 2015 participant user file from the NCDB was analyzed between 2010 and 2015 for patients with OPSCC who underwent TORS and neck dissection. Kaplan-Meier survival analysis was used to estimate overall survival of the study population. Univariable Cox survival analyses was used to determine significant associations between demographic, tumor, and treatment characteristics and overall survival (OS). There were 164 patients (124 male and 40 female) with a mean age of 58 years (30-89 years). Median follow-up was 34 months. Five-year OS was 78% (95% CI, 70%-86%). Patients with early stage disease (pT1-2, N0-1) had significantly improved OS compared to patients with advanced T- or N-stage disease (log-rank 0.011; 5-year OS: 88% [95% CI, 78%-98%] vs 66% [95% CI, 50%-82%]). Very few patients in the NCDB underwent TORS for HPV-negative OPSCC, but those who did had favorable outcomes, especially in early stage disease. Based on these findings, TORS may be considered in the treatment algorithm for patients with HPV-negative OPSCC. Level IV.

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Factors Associated With Unilateral Hearing Loss and Impact on Communication in US Adults

Janet S. Choi,Franklin Wu,Soyun Park,Rick A. Friedman,Elina Kari,Courtney C. J. Volker

Publication date 23-03-2021


To investigate the factors associated with unilateral hearing loss (UHL) and its impact on communication in US adults. Cross-sectional study. Nationally representative sample of US adults. We analyzed data from the 2011-2012 and 2015-2016 National Health and Nutritional Examination Survey, in which participants aged 20 to 69 years completed an audiometric evaluation (n = 8138). UHL was defined as a speech frequency pure-tone average ≥25 dB in the worse hearing ear and <25 dB in the better hearing ear. Logistic regression was used to examine the association between UHL and relevant factors. The prevalence of UHL was 8.1% (95% CI, 7.3%-9.0%) in US adults. Factors associated with UHL included older age, male sex, white race, lower level of education, diabetes, cardiovascular disease, and off-work noise exposure. Among adults with UHL, 40% (95% CI, 32%-48%) reported subjective trouble with hearing, a rate higher than the 12% (95% CI, 11%-14%) among normal-hearing adults. After adjusting for relevant factors, adults with UHL were more likely to report difficulties with following conversations with noise (odds ratio [OR], 1.7; 95% CI, 1.2-2.5) and frustration when talking to family and friends (OR, 3.0; 95% CI, 1.9-4.6). Higher levels of communication difficulties were observed with worsening level of UHL. Adults with UHL report significant communication difficulties in comparison to normal-hearing adults. Further research is needed to understand the psychosocial impact of UHL on adults and ways to improve communication support for adults with UHL.

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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


A single-nucleotide polymorphism 538G>A in the human Case-control study. Single-center academic hospital. We recruited 67 Japanese patients with acquired middle ear cholesteatoma (cholesteatoma group) and 100 Japanese controls with no history of middle ear cholesteatoma. We assessed the The proportion of participants with Our results suggest that the

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

Ernest D. Gomez,John J. Ceremsak,Akiva Leibowitz,Scharukh Jalisi

Publication date 16-03-2021


The COVID-19 pandemic has drawn attention to aerosol-generating medical procedures (AGMPs) in health care environments as a potential mode of transmission. Many organizations and institutions have published AGMP safety guidelines, and several mention the use of simulation in informing their recommendations; however, current methods used to simulate aerosol generation are heterogenous. Creation of a high-fidelity, easily producible aerosol-generating cough simulator would meet a high-priority educational need across all medical specialties. In this communication, we describe the design, construction, and user study of a novel cough simulator, which demonstrates the utility of simulation in raising AGMP safety awareness for providers of all roles, specialties, and training levels.

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Insurance Coverage of Facial Gender Affirmation Surgery: A Review of Medicaid and Commercial Insurance

Enrique Gorbea,Sunder Gidumal,Aki Kozato,John Henry Pang,Joshua D. Safer,Joshua Rosenberg

Publication date 16-03-2021


To provide a portrait of gender affirmation surgery (GAS) insurance coverage across the United States, with attention to procedures of the head and neck. Systematic review. Policy review of US medical insurance companies. State policies on transgender care for Medicaid insurance providers were collected for all 50 states. Each state's policy on GAS and facial gender affirmation surgery (FGAS) was examined. The largest medical insurance companies in the United States were identified using the National Association of Insurance Commissioners Market Share report. Policies of the top 49 primary commercial medical insurance companies were examined. Medicaid policy reviews found that 18 states offer some level of gender-affirming coverage for their patients, but only 3 include FGAS (17%). Thirteen states prohibit Medicaid coverage of all transgender surgery, and 19 states have no published gender-affirming medical care coverage policy. Ninety-two percent of commercial medical insurance providers had a published policy on GAS coverage. Genital reconstruction was described as a medically necessary aspect of transgender care in 100% of the commercial policies reviewed. Ninety-three percent discussed coverage of FGAS, but 51% considered these procedures cosmetic. Thyroid chondroplasty (20%) was the most commonly covered FGAS procedure. Mandibular and frontal bone contouring, rhinoplasty, blepharoplasty, and facial rhytidectomy were each covered by 13% of the medical policies reviewed. While certain surgical aspects of gender-affirming medical care are nearly ubiquitously covered by commercial insurance providers, FGAS is considered cosmetic by most Medicaid and commercial insurance providers, potentially limiting patient access. Level V.

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Salvage Total Laryngectomy Swallowing Outcomes Based on Flap Reconstruction: Onlay vs Incorporated Technique

Andrea Ziegler,Amy Pittman,Eric Thorpe

Publication date 16-03-2021


After a salvage total laryngectomy, one of patients' primary goals is to resume oral intake. This retrospective chart review included all patients who underwent a salvage total laryngectomy with free or pedicled flap reconstruction to compare swallowing outcomes in those with an incorporated flap or primary pharyngeal closure with an onlay flap. There was no significant difference in the ability to achieve complete feeding tube independence or the time that it took to achieve independence. Patients with an onlay flap had significantly lower rates of subjective dysphagia and stricture as compared with patients with incorporated flaps. Incorporated fasciocutaneous flaps showed no significant difference from onlay flaps in terms of outcomes. However, incorporated musculocutaneous flaps showed higher rates of subjective dysphagia and stricture when compared with onlay flaps. Patients undergoing a salvage total laryngectomy and reconstruction with an onlay flap had significantly less postoperative dysphagia and stricture than patients with a musculocutaneous incorporated flap.

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4D Computed Tomography for Dynamic Upper Airway Evaluation in Robin Sequence

Austin S. Lam,Michael D. Bindschadler,Kelly N. Evans,Seth D. Friedman,Jeffrey P. Otjen,Carlton J. Zdanski,Francisco A. Perez,John P. Dahl

Publication date 09-03-2021


Thorough assessment of dynamic upper airway obstruction (UAO) in Robin sequence (RS) is critical, but traditional evaluation modalities have significant limitations. Four-dimensional computed tomography (4D-CT) is promising in that it enables objective and quantitative evaluation throughout all phases of respiration. However, there exist few protocols or analysis tools to assist in obtaining and interpreting the vast amounts of obtained data. A protocol and set of data analysis tools were developed to enable quantification and visualization of dynamic 4D-CT data. This methodology was applied to a sample case at 2 time points. In the patient with RS, overall increases in normalized airway caliber were observed from 5 weeks to 1 year. There was, however, continued dynamic obstruction at all airway levels, though objective measures of UAO did improve at the nasopharynx and oropharynx. Use of 4D-CT and novel analyses provide additional quantitative information to evaluate UAO in patients with RS.

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Surgeon Volume and Complications in Lateral Neck Dissection for Squamous Cell Carcinoma: A Multidatabase Analysis

James C. Campbell,Hui-Jie Lee,Trinitia Cannon,Russel R. Kahmke,Walter T. Lee,Liana Puscas,Daniel J. Rocke

Publication date 09-03-2021


To determine whether annual surgeon volume of lateral neck dissections for squamous cell carcinoma is associated with complication rates. Retrospective review. Two US databases spanning 2000 to 2014. Neck dissections for squamous cell carcinoma from the National Inpatient Sample and State Inpatient Databases were analyzed. The primary outcome was any in-hospital complication common to neck dissection. The principal independent variable was surgeon volume. A multivariable logistic generalized estimating equation with a piecewise linear spline for surgeon volume was fit to assess its association with complication. The National Inpatient Sample had 3517 discharges fitting criteria, a median surgeon volume of 12, and an 11.1% complication rate. A 1-unit increase in surgeon volume was associated with a 7% increase in the odds of complication when volume ranged between 4 and 19 (adjusted odds ratio [AOR], 1.07; 95% CI, 1.04-1.11) and with a 3% decrease in the odds of complication when volume ranged between 19 and 51 (AOR, 0.97; 95% CI, 0.96-0.99). The State Inpatient Databases had 2876 discharges fitting criteria, a median surgeon volume of 30, and a 13.5% complication rate. Surgeon volume was not associated with complication when <27 (AOR, 1.01; 95% CI, 0.99-1.02), but a 5-unit increase in volume was associated with a 7% decrease in the odds of complication with volume ≥27 (AOR, 0.93; 95% CI, 0.88-0.98). Surgeon volume was associated with complications for most volume ranges and with lower odds of complication for high-volume surgeons.

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

Ciersten A. Burks

Publication date 09-03-2021


This commentary emphasizes health disparities related to systemic racism, highlighted by the COVID-19 pandemic, and provides recommendations to mitigate these disparities, including increasing racial and ethnic diversity in the surgical workforce.

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The Adult Neck Mass: Predictors of Malignancy

Rijul S. Kshirsagar,Meredith Anderson,Lauren M. Boeckermann,Jason Gilde,Joseph Y. Shen,Charles Meltzer,Kevin H. Wang

Publication date 09-03-2021


Distinguishing benign from malignant adult neck masses can be challenging because data to guide risk assessment are lacking. We examined patients with neck masses from an integrated health system to identify patient and mass factors associated with malignancy. Retrospective cohort. Kaiser Permanente Northern California. The medical records of adults referred to otolaryngology in 2017 for a neck mass were evaluated. Bivariate and multivariable logistic regression analyses were performed. Malignancy was found in 205 (5.0%) of the cohort's 4103 patients. Patient factors associated with malignancy included sex, age, and race/ethnicity. Males had more than twice the odds of malignancy compared with females (adjusted odds ratio [aOR] = 2.38). Malignancy rates increased with age, ranging from 2.1% for patients younger than 40 years to 8.4% for patients 70 years or older. White non-Hispanic patients had 1.75 times the risk of malignancy compared with patients of other race/ethnicities. The percentage of patients with malignancy increased with increasing minimum mass dimension, from 3.0% in patients with mass size <1 cm to over 31% in patients with mass sizes 2 cm or larger ( Most neck masses referred to otolaryngology were not malignant. Increasing age, male sex, white non-Hispanic ethnicity, increasing minimum mass dimension, multiple neck masses, or heterogeneous architecture/ill-defined borders were associated with malignancy.

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Evaluation of Short-term Outcomes of Tracheostomy Procedures in a NICU Population With High Ventilator Settings

Laura Banks,Noah Worobetz,Erin Hamersley,Amanda Onwuka,Edward Shepherd,Gregory Wiet

Publication date 09-03-2021


To investigate whether tracheostomy placement in infants requiring high ventilator pressure is safe and effective. Case series with chart review. Tertiary children's hospital. Fifty ventilator-dependent neonatal intensive care unit patients who underwent tracheotomy from 2009 to 2018 were included. Patients requiring high ventilator pressures were compared to those requiring low ventilator pressures. Demographics, comorbidities, and surgical and clinical data were recorded. Thirty-two percent (n = 16) had low ventilator settings at the time of tracheostomy tube placement, and 68% (n = 34) had high ventilator settings. The median peak inspiratory pressure of the high ventilator group was 29.5 cm H Few differences in tracheostomy tube placement outcomes were observed for patients with high ventilator settings compared to low ventilator settings. These data demonstrate that patients requiring high ventilator pressures can benefit from tracheostomy tube placement with no additional short-term risks.

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Role and Growth of Independent Medicare-Billing Otolaryngologic Advanced Practice Providers

Rahul A. Patel,Sina J. Torabi,David A. Kasle,Allison Pivirotto,R. Peter Manes

Publication date 09-03-2021


To evaluate the role and growth of independently billing otolaryngology (ORL) advanced practice providers (APPs) within a Medicare population. Retrospective cross-sectional study.
Medicare Provider Utilization and Payment Data: Physician and Other Supplier Data Files, 2012-2017. This retrospective review included data and analysis of independent Medicare-billing ORL APPs. Total sums and medians were gathered for Medicare reimbursements, services performed, number of patients, and unique There has been near-linear growth in number of ORL APPs (13.7% to 18.4% growth per year), with a 115.4% growth from 2012 to 2017. Similarly, total Medicare-allowed reimbursement (2012: $15,568,850; 2017: $35,548,446.8), total number of services performed (2012: 313,676; 2017: 693,693.7), and total number of Medicare fee-for-service (FFS) patients (2012: 108,667; 2017: 238,506) increased. Medians of per APP number of unique Although their scope of practice has remained constant, independently billing ORL APPs are rapidly increasing in number, which has led to increased Medicare reimbursements, services, and patients. ORL APPs tend to be female and are used more heavily in regions with fewer ORL physicians.

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Predictors for Postoperative Chyle Leak Following Neck Dissection, a Technique-Based Comparison

Quinn Dunlap,Matthew Bridges,Kurt Nelson,Deanne King,Brendan C. Stack,Emre Vural,Mauricio Alejandro Moreno

Publication date 09-03-2021


Assess the impact of surgical technique used to address level IV on the rate of postoperative chyle leak. Retrospective chart review. Academic tertiary care center. An analysis of 436 consecutive neck dissections (NDs) in 368 patients was performed by 3 head and neck surgeons between 2014 and 2017. Variation in technique reflects individual approaches to the management of level IV and included suture ligation (SL), monopolar electrocautery (MC), and harmonic scalpel transection (HS). Data points included patient demographics, surgical technique, intraoperative findings, postoperative chyle leaks, and leak management. Correlation between variables was analyzed through χ Overall, 12 patients (3.2%) developed chyle leaks postoperatively. Nine of 12 and 3 of 12 presented with left- and right-sided leaks, respectively. Five of 12 leaks occurred following bilateral ND, 5 of 12 following left ND, and 2 of 12 following right ND. Univariate analysis showed a statistically significant difference ( SL and MC techniques demonstrated superiority over the HS technique in preventative management of chyle leak in level IV, with a significantly higher rate of chyle leak observed in endocrine-related pathology.

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Thermal Conductance Through the Skull Base From Endoscopic Surgery Cauterization Instruments: Cadaver and Goat Model

Peiyi Su,Bozena B. Wrobel,Gabriel Zada,Wendy J. Mack,Marshall Ge,Jee-Hong Kim,Elisabeth D. Ference

Publication date 09-03-2021


Cauterization prevents hemorrhage and optimizes the surgical field during endoscopic sinus surgery but may cause injury to nearby structures. The objective of this study is to examine thermal conductance from cauterization equipment across the skull base. Cadaver and animal model. Surgical skills laboratory of an academic tertiary medical institution. A pilot study was conducted with a deidentified cadaver head and expanded to a goat head animal model. Endoscopic dissection was performed to expose the lamina papyracea, ethmoid roof, sphenoid roof, and frontal sinus. Cautery was applied to the frontal sinus of goat heads, and temperatures were measured via thermocouple sensors placed along the intracranial skull base. Surgical instruments studied included monopolar, bipolar, and endoscopic bipolar devices at various power settings. Temperature increase, as averaged across all cautery powers and measurement positions, was highest for the monopolar cautery (17.55 °C) when compared with the bipolar and endoscopic bipolar devices (<2 °C for bipolar, Endo-Pen, Stammberger, and Wormald; Thermal conductance across the skull base varies depending on equipment and power of cautery, with monopolar resulting in the largest temperature increase. Choice and implementation of cauterization instruments have implications on inadvertent transmission of thermal energy during endoscopic sinus surgery.

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Does Mask Usage Worsen Symptoms in Patients With Rhinosinusitis Balloon Sinuplasty Amid the COVID-19 Pandemic?

Arianna Victoria Ramirez,Macaulay Ojeaga,Victor Espinoza,Blake Hensler,Vincent Honrubia

Publication date 09-03-2021


With the onset of the COVID-19 pandemic, social distancing guidelines have reshaped the way that we live our lives. Perhaps the most common and strictly adopted measure has been mask wearing. Mask wearing, whether it be cloth, surgical, or N95, has quickly become the new norm in the ongoing struggle against this pandemic and has been proven to be effective in curbing its high infection rate. There has, however, been growing opposition to these policies by a substantial part of the general population who claims that masks are ineffective and can worsen breathing. To some, the choice to use or not use a mask has morphed into a point of political contention, rather than a choice rooted in concerns for public health. This commentary attempts to investigate the validity of these claims and explore how clinicians can encourage the usage of masks despite the fears and confusion against them.

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Investigating the Impact of Cognitive Training for Individuals With Bothersome Tinnitus: A Randomized Controlled Trial

Maggie Xing,Dorina Kallogjeri,Jay F. Piccirillo

Publication date 02-03-2021


To evaluate the effectiveness of cognitive training in improving tinnitus bother and to identify predictors of patient response. Prospective open-label randomized controlled trial. Online. Participants were adults with subjective idiopathic nonpulsatile tinnitus causing significant tinnitus-related distress. The intervention group trained by using auditory-intensive exercises for 20 minutes per day, 5 days per week, for 8 weeks. The active control group trained on the same schedule with non-auditory intensive games. Surveys were completed at baseline, 8 weeks, and 12 weeks. A total of 64 participants completed the study. The median age was 63 years (range, 25-69) in the intervention group and 61 years (34-68) in the control group. Mixed model analysis revealed that within-subject change in Tinnitus Functional Index in the intervention group was not different than the control group, with marginal mean differences (95% CI): 0.24 (-11.20 to 10.7) and 2.17 (-8.50 to 12.83) at 8 weeks and 2.33 (-8.6 to 13.3) and 3.36 (-7.91 to 14.6) at 12 weeks, respectively. When the 2 study groups were compared, the control group had higher Tinnitus Functional Index scores than the intervention group by 10.5 points at baseline (95% CI, -0.92 to 29.89), 8.1 at 8 weeks (95% CI, -3.27 to 19.42), and 9.4 at 12 weeks (95% CI, -2.45 to 21.34). Auditory-intensive cognitive training was not associated with changes in self-reported tinnitus bother. Given the potential for neuroplasticity to affect tinnitus, we believe that future studies on cognitive training for tinnitus remain relevant.

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Clinical Techniques and Technology: Vestibular Telemetry

John S. Phillips,Jacob L. Newman,Stephen J. Cox

Publication date 02-03-2021


When a patient presents to a clinician with dizziness, it can be difficult for the patient to describe their symptoms in a clear manner, and clinical examination often yields entirely normal results. Ideally, it would be favorable to measure key physiological parameters during their episodes of dizziness. From a clinical perspective, this would allow a more timely and more accurate diagnosis. From a research perspective, it would allow a greater understanding of how the vestibular system malfunctions as a consequence of vestibular disease. The authors of this report have been funded by the UK Medical Research Council to develop and test a novel technology to measure, record, and analyze key physiological parameters provided by the dizzy individual during an episode of dizziness while active in the community. We provide the context to evolving work in this field, the outcome of preliminary studies, and a consideration of future opportunities.

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3D-Printed Models for Temporal Bone Surgical Training: A Systematic Review

Andreas Frithioff,Martin Frendø,David Bue Pedersen,Mads Sølvsten Sørensen,Steven Arild Wuyts Andersen

Publication date 02-03-2021


3D-printed models hold great potential for temporal bone surgical training as a supplement to cadaveric dissection. Nevertheless, critical knowledge on manufacturing remains scattered, and little is known about whether use of these models improves surgical performance. This systematic review aims to explore (1) methods used for manufacturing and (2) how educational evidence supports using 3D-printed temporal bone models. Pub Med, Embase, the Cochrane Library, and Web of Science. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, relevant studies were identified and data on manufacturing and validation and/or training extracted by 2 reviewers. Quality assessment was performed using the Medical Education Research Study Quality Instrument tool; educational outcomes were determined according to Kirkpatrick's model. The search yielded 595 studies; 36 studies were found eligible and included for analysis. The described 3D-printed models were based on computed tomography scans from patients or cadavers. Processing included manual segmentation of key structures such as the facial nerve; postprocessing, for example, consisted of removal of print material inside the model. Overall, educational quality was low, and most studies evaluated their models using only expert and/or trainee opinion (ie, Kirkpatrick level 1). Most studies reported positive attitudes toward the models and their potential for training. Manufacturing and use of 3D-printed temporal bones for surgical training are widely reported in the literature. However, evidence to support their use and knowledge about both manufacturing and the effects on subsequent surgical performance are currently lacking. Therefore, stronger educational evidence and manufacturing knowhow are needed for widespread implementation of 3D-printed temporal bones in surgical curricula.

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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


To assess the impact of rural-urban residence on children with obstructive sleep-disordered breathing (SDB) who were candidates for tonsillectomy with or without adenoidectomy (TA). Retrospective cohort study. Tertiary children's hospital. A cohort of otherwise healthy children aged 2 to 18 years with a diagnosis of obstructive SDB between April 2016 and December 2018 who were recommended TA were included. Rural-urban designation was defined by ZIP code approximation of rural-urban commuting area codes. The main outcome was association of rurality with time to TA and loss to follow-up using Cox and logistic regression analyses. In total, 213 patients were included (mean age 6 ± 2.9 years, 117 [55%] male, 69 [32%] rural dwelling). Rural-dwelling children were more often insured by Medicaid than private insurance ( Rural-dwelling patients experienced longer wait times and driving distance to TA. This study suggests that rurality should be considered a potential barrier to surgical intervention and highlights the need to further investigate geographic access as an important determinant of care in pediatric SDB.

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Pyriform Aperture Enlargement for Internal Nasal Valve Obstruction in Adults: Systematic Review and Surgical Classification

Humoud Hajem,Charles Botter,Mohammad Al Omani,Vincent Sounthakith,Eléonore de Bressieux,Hakim Benkhatar

Publication date 02-03-2021


Pyriform aperture enlargement or "pyriplasty" is an uncommonly used procedure for internal nasal valve obstruction in adults besides functional rhinoplasty, inferior turbinate reduction, and septoplasty. A systematic review of the literature was performed to analyze current surgical techniques, their suggested indications, and their related outcome in terms of success and complications. The search was performed on Pub Med, EMBASE, SCOPUS, and Cochrane databases. The systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies on congenital, traumatic, tumoral, or infectious internal nasal valve obstruction were excluded. Eight articles were finally included.
Three types of pyriplasty have been described according to the level of bone resection: low-level pyriplasty through the sublabial approach, mid-level pyriplasty through endonasal approach, and extended pyriplasty through either approach. Indications included (1) clinically or radiologically narrow pyriform aperture, (2) previously unsuccessful internal nasal valve surgery, (3) lateral nasal wall collapse, and (4) inferior turbinate's head hypertrophy. Subjective improvement of nasal obstruction was reported in these 4 indications. No major complication was encountered. Pyriplasty for nasal obstruction is a simple and safe procedure that could be effective in selected cases. However, level of evidence is currently low, and success rate may vary with indications and pyriplasty techniques. Moreover, there is no clear definition of normal pyriform aperture dimensions to date. Further prospective studies are thereby necessary and should include radiological analysis of pyriform aperture and validated nasal obstruction measurement tools.

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Markup on Services Provided to Medicare Beneficiaries by Otolaryngologists in 2017: Implications for Surprise Billing

Jacob Rha,Vinay K. Rathi,Matthew R. Naunheim,Lauren E. Miller,Shekhar K. Gadkaree,Stacey T. Gray

Publication date 23-02-2021


The degree of markup between provider charges and Medicare prices reflects the potential balance bill for out-of-network commercially insured patients. Using publicly available Medicare data, we performed a retrospective cross-sectional analysis of markup ratios (MRs; ie, the ratio of submitted charges to Medicare-allowed prices) for services commonly performed by otolaryngologists in 2017.
Median MRs were as follows: 2.9 (interquartile range, 2.0-4.3) in facility settings (eg, hospital) and 2.1 (interquartile range, 1.7-2.9) in nonfacility settings (eg, physician office). Among the 10 highest-markup procedures performed by otolaryngologists in facility and nonfacility settings, there was no consistent increase in median MRs between 2012 and 2017 (compound annual growth rates, -4.6% for labyrinthotomy to 24.6% for ultrasound-guided biopsy). Median MRs for these procedures were not consistently lower in states with surprise billing protection laws. These findings may reflect the comparatively low potential to "balance bill" patients for elective otolaryngologic services and the limitations of state-level protections against surprise billing.

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Developmental Anatomy of the Eustachian Tube: Implications for Balloon Dilation

Isabelle Magro,David Pastel,Jace Hilton,Mia Miller,James Saunders,Kathryn Noonan

Publication date 23-02-2021


To describe the developmental anatomy of the eustachian tube (ET) and its relationship to surrounding structures on computed tomography. Case series with chart review. A tertiary care hospital. ET anatomy was assessed with reformatted high-resolution computed tomography scans from 2010 to 2018. Scans (n = 78) were randomly selected from the following age groups: <4, 5 to 7, 8 to 18, and >18 years.
The following were measured and compared between groups: ET length, angles, and relationship between its bony cartilaginous junction and the internal carotid artery and between its nasopharyngeal opening and the nasal floor. The distance between the bony cartilaginous junction and internal carotid artery decreased with age between the <4-year-olds (2.4 ± 0.6 mm) and the 5- to 7-year-olds (2.0 ± 0.3 mm, The ET elongates with age, and its angles and relationship to the nasal floor increase. Although some parameters mature faster, more than half of the ET growth occurs by 8 years of age, and adult morphology is achieved by early adolescence.

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Early Tracheostomy Change in Neonates: Feasibility and Benefits

Denna Zebda,Brady Anderson,Zhen Huang,Sancak Yuksel,Soham Roy,Zi Yang Jiang

Publication date 23-02-2021


To compare outcomes of early and late tracheostomy change in neonatal patients. Early tracheostomy change (ETC) occurred 3 to 4 days after surgery, and late tracheostomy change (LTC) occurred 5 to 7 days after surgery. Retrospective cohort. Tertiary neonatal/pediatric intensive care unit. A retrospective review of patients who underwent tracheostomy from 2015 to 2019 was performed for infants <1 year old. Data were recorded regarding age at tracheostomy, days until tracheostomy tube change, postoperative complications, and total number of days on sedative or paralytic drugs. Forty-six patients were included: 18 (39%) were male, with a mean age of 140 days (SD, 78). Of these, 28 (61%) received ETC. There were no accidental decannulation events in either group. Wound breakdown developed in 4 (14%) patients with ETC versus 5 (28%) with LTC ( ETC appears to be feasible in children less than a year of age. There does not appear to be an increased risk of accidental decannulation events or false passage tracts. Further investigations are warranted to investigate safety and possible impact on wound breakdown.

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Histopathology of the Incudomalleolar Joint in Cases of “Indeterminate” Presbycusis

Prithwijit Roychowdhury,Melissa Castillo-Bustamante,Marc Polanik,Elliott D. Kozin,Aaron K. Remenschneider

Publication date 23-02-2021


Retrospective study.

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Microvascular Reconstruction of Osteonecrosis: Assessment of Long-term Quality of Life

Larissa Sweeny,Erica Mayland,Brian P. Swendseid,Joseph M. Curry,Alexandra E. Kejner,Carissa M. Thomas,Joshua J. Kain,Steve B. Cannady,Kendall Tasche,Eben L. Rosenthal,Michael DiLeo,Adam J. Luginbuhl,Hailey Theeuwen,Juliana R. Sarwary,Daniel Petrisor,Mark K. Wax

Publication date 23-02-2021


Review long-term clinical and quality-of-life outcomes following free flap reconstruction for osteonecrosis. Retrospective multi-institutional review. Tertiary care centers. Patients included those undergoing free flap reconstructions for osteonecrosis of the head and neck (N = 232). Data included demographics, defect, donor site, radiation history, perioperative management, diet status, recurrence rates, and long-term quality-of-life outcomes. Quality-of-life outcomes were measured using the University of Washington Quality of Life (UW-QOL) survey. Overall flap success rate was 91% (n = 212). Relative to preoperative diet, 15% reported improved diet function at 3 months following reconstruction and 26% at 5 years. Osteonecrosis recurred in 14% of patients (32/232); median time to onset was 11 months. Cancer recurrence occurred in 13% of patients (29/232); median time to onset was 34 months. Results from the UW-QOL questionnaire were as follows: no pain (45%), minor or no change in appearance (69%), return to baseline endurance level (37%), no limitations in recreation (40%), no changes in swallowing following reconstruction (28%), minor or no limitations in mastication (29%), minor or no speech difficulties (93%), no changes in shoulder function (84%), normal taste function (19%), normal saliva production (27%), generally excellent mood (44%), and no or minimal anxiety about cancer (94%). The majority of patients maintained or had advancement in diet following reconstruction, with low rates of osteonecrosis or cancer recurrence and above-average scores on UW-QOL survey suggesting good return of function and quality of life.

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Assessing Trends in Fellowship Training Among Otolaryngology Residents: A National Survey Study

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

Publication date 23-02-2021


To summarize trends in otolaryngology fellowship applications, fellowships selected, and reasons for pursuing a fellowship. One-page anonymous questionnaire. A 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 type, reasons for doing a fellowship, and type of practice that examinees will enter. Spearman correlation and Pearson chi-square tests were completed. Over the 8-year study, 58% of the 2243 responding examinees did fellowships. The most frequently chosen fellowship was facial plastic surgery (25%), followed by pediatric otolaryngology (21%), head and neck surgery (19%), rhinology (13%), laryngology (9%), and neurotology (8%). The 2 most common reasons for doing a fellowship were desire for additional expertise beyond residency training (35%) and intellectual appeal (30%). Over the study period, the number of residents choosing to do a fellowship increased from 45.6% in 2011 to 61.5% in 2019, with a positive correlation between year and number of residents ( There is a statistically significant increasing trend of otolaryngology residents who choose to undergo further training in fellowship. These data from a large, long-term study will be valuable in planning for training and workforce needs in the future.

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Cochlear Implants in Neurologically Impaired Children: A Survey of Health-Related Quality of Life

Samantha Anne,Seth Roslow Schwartz,Jennifer L. McCoy,Thomas Haberkamp,Michael E. Hoffer,David H. Chi

Publication date 23-02-2021


Evaluate health-related quality-of-life (HRQoL) measures in noncommunicative, neurologically impaired, developmentally delayed (NCNIDD) children compared to normally developing children (ND) who undergo cochlear implantation (CI). Cross-sectional survey of parents of NCNIDD and ND children who underwent CI. Two tertiary care medical centers.
Questions comprising the Children With Cochlear Implants: Parental Perspectives survey were used in analysis. Average responses were calculated within 8 domains (communication, general functioning, self-reliance, well-being and happiness, social relationships, education, effects of implantation, and support the child). Groups were compared using Wilcoxon rank-sum test. Impact of individual and collective socioeconomic/family covariates was assessed using analysis of variance. Surveys were returned from 17 of 42 (40%) patients with NCNIDD and 35 of 131 (27%) patients with ND. There were no statistically significant differences between groups in survey response rate, age, sex, age at implantation, current age, or duration of implant use. Overall, parents of children with ND responded more favorably in all domains vs children with NCNIDD. Parents of children with NCNIDD answered neutrally or favorably in all domains, except "support the child" and "self-reliance" domains. Differences between groups in mean domain scores, univariably and almost universally when adjusting for socioeconomic and family variables individually and collectively, were statistically significant. This study suggests that HRQoL benefits of CI are perceived in most domains by parents of children with NCNIDD, albeit less strongly than children with ND. A survey sensitive to challenges of children with NCNIDD may better capture benefits that may not be apparent in this study.

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The Anatomical and Clinical Significance of the Superior Laryngeal Nerve

Kai-ning Lu,Jin-wang Ding,Yu Zhang,Jing-jing Shi,Li Zhou,You Peng,Jie Shen,Si Lu,Si-han Sun,Ye-qin Ni,Huai-rui Cui,Ding-cun Luo

Publication date 23-02-2021


This study summarizes the anatomical features of the superior laryngeal nerve in Chinese to enable the rapid location of the superior laryngeal nerve during an operation. Retrospective analysis of anatomical data. Hangzhou First People's Hospital Affiliated to Nanjing Medical University. A total of 71 embalmed human cadavers (132 heminecks) were examined over 3 months. The length and diameter of the internal and external branches of the superior laryngeal nerve and their relationships with different landmarks were recorded. The total length of the internal branch of the superior laryngeal nerve was 23.4 ± 6.9 mm. The length of the external branch of the superior laryngeal nerve was 47.7 ± 11.0 mm. Considering the midpoint of the lower edge of the thyroid cartilage as the starting point and using that edge as a horizontal line, when the entry point is above that line, the external branch of the superior laryngeal nerve can be found within 41.1 mm and at an angle of 57.2°. When the entry point is below the lower edge of the thyroid cartilage, the external branch of the superior laryngeal nerve can be found within 34.0 mm and at an angle of 36.5°. The superior laryngeal nerve in Chinese people has distinct anatomical characteristics. This article provides a new method of quickly locating the external branch of the superior laryngeal nerve during the operation, which can reduce the probability of damaging the external branch of the superior laryngeal nerve.

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Complications in Pediatric Acute Mastoiditis: HCUP KID Analysis

Nicole Favre,Vijay A. Patel,Michele M. Carr

Publication date 16-02-2021


A small proportion of children with otitis media develop acute mastoiditis, which has the potential to spread intracranially and result in significant morbidity and mortality. The aim of this study was to evaluate the incidence and management of complications related to pediatric acute mastoiditis using a national database. Retrospective review of 2016 Kids' Inpatient Database, part of the Healthcare Cost and Utilization Project. Academic, community, general, and pediatric specialty hospitals in the United States. code H70.
XXX was used to retrieve records for children admitted with a diagnosis of mastoiditis. Data included patient demographics, intracranial infections, procedures (middle ear drainage, mastoidectomy, and intracranial drainage), length of stay (LOS), and total charges. In total, 2061 children aged ≤21 years were identified with a diagnosis of acute mastoiditis. Complications included subperiosteal abscess (6.90%), intracranial thrombophlebitis/thrombosis (5.30%), intracranial abscess (3.90%), otitic hydrocephalus (1.20%), encephalitis (0.90%), subperiosteal abscess with intracranial complication (0.60%), petrositis (0.60%), and meningitis (0.30%). Children with intracranial abscesses were more likely ( Patients with intracranial complications are more likely to undergo surgical procedures; however, there is still wide variability in practice patterns, illustrating that controversies in the management of otitis media complications persist.

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Complications Secondary to Nonsurgical Rhinoplasty: A Systematic Review and Meta-analysis

Sam DeVictor,Adrian A. Ong,David A. Sherris

Publication date 16-02-2021


The popularity of nonsurgical rhinoplasty with injectable fillers continues to rise, and it is important to understand the scope of potential adverse outcomes. The purpose of our study is to determine the prevalence and types of adverse outcomes secondary to nonsurgical rhinoplasty. Pub Med, Cochrane, Embase.
The data sources were explored using the following combination of terms: (("inject*" OR "nonsurgical" OR "augmentation" OR "filler") AND "rhinoplast*") AND ("complication" OR "adverse" OR "embol*"). Studies on human nonsurgical rhinoplasty using injectable fillers were included. A quantitative meta-analysis was performed on articles with low risk of bias. The search yielded 37 publications for review, with 23 included cohort studies and 14 case reports with 8604 patients undergoing nonsurgical rhinoplasty with reported complications. The overall rate of adverse outcome across all cohort studies was 2.52%. The most commonly reported complications were bruising (1.58%) and hematoma (0.13%). While uncommon, there are several reports of major complications including 30 episodes of vessel occlusion (0.35%), 7 reports of skin necrosis (0.08%), 8 reports of vision loss (0.09%), and 6 reports of infection (0.07%). Overall, nonsurgical rhinoplasty with injectable fillers is safe with low rates of complications. However, serious complications, such as vision loss, skin necrosis, and vessel occlusion, can occur. Further studies are needed to optimize delivery of injectable fillers in the nose to decrease the rate of adverse outcomes.

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Assessing Patient Symptoms Due to Nasal Septal Perforation: Development and Validation of the NOSE-Perf Scale

Cullen M. Taylor,Stephen F. Bansberg,Michael J. Marino

Publication date 16-02-2021


Reporting patient symptoms due to nasal septal perforation (NSP) has been hindered by the lack of a validated disease-specific symptom score. The purpose of this study was to develop and validate an instrument for assessing patient-reported symptoms related to NSP. Validation study. A tertiary care center. The Nasal Obstruction Symptom Evaluation (NOSE) scale was used as an initial construct to which 7 nonobstruction questions were added to measure septal perforation symptoms. The proposed NOSE-Perf instrument was distributed to consecutive patients evaluated for NSP, those with nasal obstruction without NSP, and a control group without rhinologic complaints. Questionnaires were redistributed to the subgroup with NSP prior to treatment of the perforation. The study instrument was completed by 31 patients with NSP, 17 with only nasal obstruction, and 22 without rhinologic complaint. Internal consistency was high throughout the entire instrument (Cronbach α = 0.935; 95% CI, 0.905-0.954). Test-retest reliability was demonstrated by very strong correlation between questionnaires completed by the same patient at least 1 week apart ( The NOSE-Perf scale is a validated and reliable clinical assessment tool that can be applied to adult patients with NSP.

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A Clinical Decision Analysis for Use of Antibiotic Prophylaxis for Nonabsorbable Nasal Packing

Ximena Maul,Berkay C. Dincer,Arthur W. Wu,Andrew V. Thamboo,Thomas S. Higgins,George A. Scangas,Kristin Oliveira,Allen S. Ho,Jon Mallen-St Clair,Evan Walgama

Publication date 16-02-2021


Nonabsorbable nasal packing is often placed for the treatment of epistaxis or after sinonasal or skull base surgery. Antibiotics are often prescribed to prevent toxic shock syndrome (TSS), a rare, potentially fatal occurrence. However, the risk of TSS must be balanced against the major risk of antibiotic use, specifically A clinical decision analysis was performed using a Markov model to evaluate whether antibiotics should be given. Patients with nonabsorbable nasal packing placed. Utility scores, probabilities, and costs were obtained from the literature. We assess the cost-effectiveness of antibiotic use when the risk of community-acquired CDC is balanced against the risk of TSS from nasal packing. Sensitivity analysis was performed for assumptions used in the model. The incremental cost-effectiveness ratio for antibiotic use was 334,493 US dollars (USD)/quality-adjusted life year (QALY). Probabilistic sensitivity analysis showed that not prescribing antibiotics was cost-effective in 98.0% of iterations at a willingness to pay of 50,000 USD/QALY. Sensitivity analysis showed that when the risk of CDC from antibiotics was greater than 910/100,000 or when the incidence of TSS after nasal packing was less than 49/100,000 cases, the decision to withhold antibiotics was cost-effective. Routine antibiotic prophylaxis in the setting of nasal packing is not cost-effective and should be reconsidered. Even if antibiotics are assumed to prevent TSS, the risk of complications from antibiotic use is of greater consequence. 3a.

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Outcomes in Revision Stapes Surgery

Zachary G. Schwam,Amy Schettino,Seilesh C. Babu,Dennis I. Bojrab,Elias M. Michaelides,Christopher A. Schutt

Publication date 09-02-2021


To compare audiometric outcomes and complication rates between primary and revision stapes surgical cases. Retrospective cohort study. Large single-institution database. Data on 809 patients (including 170 revisions) undergoing primary and revision stapes surgery were reviewed, with Pearson chi-square and multivariable logistic regression analysis performed. Rates of postoperative air-bone gap (ABG) closure to ≤10 dB were significantly worse in the revision group (40.2% vs 61.8%, Revision stapes surgery was found to have less predictable and inferior results as compared with primary cases. 4 (retrospective observational research).

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Long-term Olfactory and Gustatory Dysfunction May Be Related to Neural Damage

Alberto Paderno,Davide Mattavelli,Cesare Piazza

Publication date 09-02-2021


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The Association Between Olfactory/Gustatory Dysfunction and the Course of Infection Is Still Not Demonstrated

Kai Liu,Zhenkun Yu

Publication date 09-02-2021


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Differential Diagnosis of Endolymphatic Hydrops Between “Probable” and “Definite” Ménière’s Disease via Magnetic Resonance Imaging

Jiapei Xie,Weidong Zhang,Jingyi Zhu,Lian Hui,Songbai Li,Ling Ren,Fei Wang,Bo Zhang

Publication date 02-02-2021


To investigate the grade of endolymphatic hydrops in patients with "probable" and "definite" Ménière's disease via magnetic resonance imaging (MRI) and to determine whether MRI could assist clinicians in differential diagnosis between probable and definite Ménière's disease. Prospective study. Three-dimensional FLAIR MRI (fluid-attenuated inversion recovery) to examine endolymphatic hydrops in Ménière's disease. A total of 51 patients diagnosed with probable (n = 20) or definite (n = 31) unilateral Ménière's disease were enrolled. Three-dimensional FLAIR MRI was performed to evaluate the grade of endolymphatic hydrops. The differences in endolymphatic hydrops between the probable and definite groups were analyzed. The grade of endolymphatic hydrops was more severe in the definite group than in the probable group ( MRI revealed a higher grade of endolymphatic hydrops in patients with definite Ménière's disease than in patients with probable Ménière's disease. As a result, it may be clinically useful and an effective tool in the differentiation between definite and probable Ménière's disease.

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Systematic Review and Meta-analysis of Endoscopic vs Microscopic Stapes Surgery for Stapes Fixation

Sandra Ho,Prayag Patel,Daniel Ballard,Richard Rosenfeld,Sujana Chandrasekhar

Publication date 02-02-2021


To systematically review the current literature regarding the operative outcomes of stapes surgery for stapes fixation via the endoscopic and microscopic approaches. Pub Med, Embase, and Web of Science. An electronic search was conducted with the keywords "endoscop* or microscop*" and "stapes surgery or stapedectomy or stapedotomy or otosclerosis or stapes fixation." Studies were included if they compared endoscopy with microscopy for stapes surgery performed for stapes fixation and evaluated hearing outcomes and postoperative complications. Articles focusing on stapes surgery other than for stapes fixation were excluded. The database search yielded 1317 studies; 12 remained after dual-investigator screening for quantitative analysis. The mean MINORS score was 18 of 24, indicating a low risk of bias. A meta-analysis demonstrated no statistically significant difference between the groups with regard to operative time, chorda tympani nerve manipulation or sacrifice, or postoperative vertigo. There was a 2.6-dB mean improvement in the change in air-bone gap in favor of endoscopic stapes surgery and a 15.2% increased incidence in postoperative dysgeusia in the microscopic group, but the studies are heterogeneous. Endoscopic stapes surgery appears to be a reasonable alternative to microscopic stapes surgery, with similar operative times, complications, and hearing outcomes. Superior visibility with the endoscope was consistently reported in all the studies. Future studies should have standardized methods of reporting visibility, hearing outcomes, and postoperative complications to truly establish if endoscopic stapes surgery is equivalent or superior to microscopic stapes surgery.

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The Impact of Socioeconomic Status on Time to Decannulation Among Children With Tracheostomies

Matthew M. Smith,Catherine K. Hart,Dan T. Benscoter,Madison Epperson,Alessandro de Alarcon,Hayley Born,Jareen Meinzen-Derr

Publication date 02-02-2021


To determine if time to tracheostomy decannulation differs among children by socioeconomic status. Case series with chart review. Tertiary pediatric medical center. Patients (≤21 years old) who underwent tracheostomy from January 1, 2011, to December 31, 2016. Patients were divided into 2 groups based on their socioeconomic status (SES), low SES and high SES. Principal components analysis was used to create an index for SES using census data obtained by the US Census Bureau's American Community Survey 5 year data profile from 2013 to 2017. Statistical analysis was performed using a χ In total, 215 patients were included; of these patients, 111 patients (52%) were included in the high-SES group and 104 patients (48%) were included in the low-SES group. There was a significant difference in the time to decannulation for children based on SES status, with those children in the low-SES group taking on average 10 months longer to decannulate (38.7 vs 28.0 months, Health care disparities appear to exist among children undergoing decannulation of their tracheostomy tube. Patients with lower SES had a significantly longer time to decannulation than those with higher SES.

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Effects of COVID-19 Lockdown on Otitis Media With Effusion in Children: Future Therapeutic Implications

Mirko Aldè,Federica Di Berardino,Paola Marchisio,Giovanna Cantarella,Umberto Ambrosetti,Dario Consonni,Diego Zanetti

Publication date 26-01-2021


To evaluate the role of social isolation during the lockdown due to the SARS-CoV-2 outbreak (severe acute respiratory syndrome coronavirus 2) in modifying the prevalence of otitis media with effusion (OME) and the natural history of chronic OME. Retrospective study. Tertiary level referral audiologic center. We assessed the prevalence of OME among children aged 6 months to 12 years who attended the outpatient clinic for hearing or vestibular disorders during 2 periods before the lockdown, May-June 2019 (n = 350) and January-February 2020 (n = 366), and the period immediately after the lockdown, May-June 2020 (n = 216). We also compared the disease resolution rates between a subgroup of children with chronic OME (n = 30) who were diagnosed in summer 2019 and reevaluated in May-June 2020 and a similar subgroup (n = 29) assessed in 2018-2019. The prevalence of OME in this clinic population was 40.6% in May-June 2019, 52.2% in January-February 2020, and 2.3% in May-June 2020. Children with chronic OME had a higher rate of disease resolution in May-June 2020 (93.3%) than those examined in May-June 2019 (20.7%, Closure of schools and the physical distancing rules were correlated with a reduction in the prevalence of OME and favored the resolution of its chronic forms among children who attended the outpatient clinic. These data could suggest that in the presence of chronic OME, keeping young children out of group care settings for a period might be beneficial to allow for OME resolution.

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