Otolaryngology Head and Neck Surgery 2020-12-15

Consortium of Otolaryngology Journal Editors: Collegiality and Contributions

Robert T. Sataloff,Rakesh Chandra,Edward W. Fisher,David Goldenberg,Ehab Y. Hanna,Jonas Johnson,David W. Kennedy,Dennis H. Kraus,John H. Krouse,Michael Link,Lawrence R. Lustig,Bert W. O’Malley,Jay F. Piccirillo,Robert Ruben,Samuel H. Selesnick,Raj Sindwani,Richard J. Smith,Michael G. Stewart,James Tysome,Peter C. Weber,D. Bradley Welling

Publication date 01-12-2020


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With the Incidence of Otosclerosis Declining, Should Stapedectomy Remain a Key-Indicator Case for Otolaryngology Residents?

Douglas J. Totten,John P. Marinelli,Samuel A. Spear,Sarah N. Bowe,Matthew L. Carlson

Publication date 21-07-2020


Stapedectomy remains a joint key-indicator case with ossiculoplasty for otolaryngology residents in the United States. Yet, residents consistently report feeling inadequately prepared to perform stapes surgery following graduation. Applying recently described age- and sex-standardized incidence rates of surgically confirmed cases of otosclerosis to the US populace, upper and lower estimates of residents' case exposure to stapedectomy can be approximated. With this, uppermost projections estimate 6484 new cases of stapes surgery are performed annually nationwide. With approximately 1424 otolaryngology residents nationally, the average case exposure is 7.8 stapedectomies throughout their training, with upper and lower estimates of 17.1 and 4.2 cases, respectively. As such, proficiency in stapedectomy is no longer a realistic expectation for US graduating residents. This reality supports the removal of "stapedectomy" from the list of 14 key-indicator case requirements, leaving ossiculoplasty as its own key-indicator case, thereby reinforcing true competence in this fundamental procedure for the graduating otolaryngologist.

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Building Community Relations and Promoting Cancer Prevention: An Oral Cancer Screening Event

Alexander J. Straughan,Philip E. Zapanta,Joseph F. Goodman

Publication date 14-07-2020


Communities often call upon their university hospitals to help with health screening events. Otolaryngologists can play an important role in prevention and education. We recently evaluated 285 community members at an oral cancer screening event at a community health "expo." An intake form and oral exam identified 67 with conditions that warranted further evaluation: 16 for dental follow-up; 25 for further ear, nose, and throat (ENT) evaluation; and 26 for primary care follow-up. One patient was identified with laryngeal cancer after referral for dysphonia. The event served to increase awareness of oral cancer among high-risk patients via educational materials and podium presentations. There was a positive effect on our university's credibility and reputation in the local community. Medical students interested in ENT received valuable supervised hands-on experience. This screening event identified opportunities for collaboration with local dental societies and primary care physicians for prevention and early detection of oral cancer.

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Reflections on the Value of Participation in Simulation as Young Faculty

Jennifer V. Brinkmeier

Publication date 21-07-2020


As simulation becomes more widely adopted among otolaryngology graduate medical education, faculty have much to contribute and gain from participation in courses. Young faculty in particular are well poised to develop new didactic strategies, as they can bridge recent medical education with real-life specialty experiences. Additionally, participation as faculty leadership in course development is a particularly rich opportunity for professional development.

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Impact of Alcohol Consumption on Snoring and Sleep Apnea: A Systematic Review and Meta-analysis

Christian Burgos-Sanchez,Nolan N. Jones,Michael Avillion,Steven J. Gibson,Jagatkumar A. Patel,John Neighbors,Soroush Zaghi,Macario Camacho

Publication date 09-06-2020


To systematically review the international literature for studies evaluating the effect of alcohol consumption on the occurrence and severity of snoring and obstructive sleep apnea and to use the available data to perform a meta-analysis. MEDLINE, Embase, The Cochrane Library, CINAHL/EBASCO, and Scopus. The protocol was registered in PROSPERO in March 2018. Following PRISMA guidelines, 2 independent researchers conducted a search from their inception through July 2018. Polysomnography (PSG) data were collected for sleep stages, apnea-hypopnea index (AHI), respiratory disturbance index, and/or lowest oxygen saturation (LSAT). Data concerning the frequency and severity of snoring intensity and sleep architecture were also collected. Only studies with PSG data were evaluated, with exclusion of studies with home sleep testing data. A multivariate regression and pooled analysis with forest plot was performed. A total of 1266 manuscripts were screened, and 13 manuscripts with 279 patients met inclusion criteria. Pooled analysis of AHI for control versus alcohol consumption revealed a mean difference (MD) of 3.98 events per hour (95% CI, 3.27 to 4.68; Alcohol consumption is associated with worsening severity of snoring, altered sleep architecture, AHI, as well as lowest oxygen saturation among patients susceptible to snoring and obstructive sleep apnea.

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Intranasal Corticosteroid Therapy: Systematic Review and Meta-analysis of Reported Safety and Adverse Effects in Children

Angela M. Donaldson,Garret Choby,Daniel H. Kim,Lisa A. Marks,Devyani Lal

Publication date 14-07-2020


To address concerns related to the safety profile of both Food and Drug Administration (FDA)-approved and non-FDA-approved intranasal corticosteroid (INCS) use in the pediatric population. Systematic review of MEDLINE, Pub Med, and EMBASE databases using comprehensive search strategy, including all INCS formulations and adverse events. The study design was developed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Additional sources were identified from study references of relevant articles. A structured literature search was conducted. Extracted data included age, population size, study design, drug (dosage, route, and frequency), presence of hypothalamic-pituitary-adrenal (HPA) axis suppression, ocular symptoms, and growth velocity adverse events. A total of 33 studies met inclusion criteria. The studies included use of INCS as nasal sprays and drops. There were no persistent abnormalities noted in cortisol level or intraocular pressure change. Growth velocity reduction was reported in 3 of 10 randomized trials. Meta-analysis of epistaxis and headache showed no significant difference in the incidence of headache or epistaxis when FDA-approved INCSs were compared to placebo, with a relative risk of 1.12 (95% CI, 0.77-1.63; INCSs in FDA-approved routes of administration are generally safe to use in the pediatric population. Use of non-FDA-approved INCS drops may increase risk of iatrogenic Cushing's syndrome. Growth velocity reduction, HPA axis suppression, and visual changes due to INCS are uncommon.

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Intranasal Corticosteroid Therapy: Systematic Review and Meta-analysis of Reported Safety and Adverse Effects in Adults

Angela M. Donaldson,Garret Choby,Daniel H. Kim,Lisa A. Marks,Devyani Lal

Publication date 16-06-2020


To address concerns related to the safety profile of both Food and Drug Administration (FDA)-approved and non-FDA-approved intranasal corticosteroid (INCS) use in the adult population. Systematic review of MEDLINE, Pub Med, and EMBASE databases using a comprehensive search strategy including all INCS formulations and adverse events. The study design was developed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Additional sources were identified from study references of relevant articles. A structured literature search was conducted. Each study was graded for level of evidence using the Oxford Centre for Evidence-Based Medicine. Extracted data included population size, study design, drug (dosage, route, and frequency), presence of hypothalamus pituitary axis suppression, ocular symptoms, and treatment-related adverse events. A total of 60 studies met inclusion criteria. The studies included use of INCS as metered nasal sprays, drops, injections, aerosols, and irrigations. There were no persistent abnormalities in cortisol level or intraocular pressure change. Meta-analysis of epistaxis showed a significantly increased risk in the FDA-approved treatment group in comparison with control (risk ratio 1.56; 95% confidence interval, 1.13-2.14; Overall, it appears that the use of both FDA and published non-FDA application of INCS are safe in the adult population. Meta-analysis demonstrated an increased risk of epistaxis in patients using INCS compared with placebo. Otherwise, there was no significant difference between in adults in the treatment group and placebo group. As an important caveat, the interpretation of safety of nonstandard INCS is restricted to delivery methods and dosages published in the literature.

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Cricopharyngeal Achalasia: Management and Associated Outcomes—A Scoping Review

Karuna Dewan,Chloe Santa Maria,Julia Noel

Publication date 23-06-2020


There is little consensus regarding the efficacy and safety of treatment options for cricopharyngeal (CP) achalasia. The purpose of this scoping review is to assess the literature regarding the various treatments for this disease. Pub Med was searched for all articles addressing treatment of adult CP achalasia between January 1990 and June 2019. In total, 351 peer-reviewed results were reviewed by 3 otolaryngologists for inclusion. After review of titles, abstracts, and full texts, 60 articles were selected. Among included studies, 55% were retrospective and 45% were prospective. Forty-five percent of studies were case series. CP achalasia etiologies included idiopathic (28%), cerebrovascular accident (CVA) (28%), neurologic disease (17%), head and neck radiation treatment (11%), Zenker's diverticulum (10%), and myositis (5%). Most commonly employed treatments were botulinum toxin injection (40%), endoscopic CP myotomy (30%), dilation with either balloon or bougie (25%), and open CP myotomy (15%). A proportion of patients were treated with more than 1 approach. Most studies included both subjective and objective outcome measures. Complications were reported most often in patients with a history of head and neck radiation. Small sample sizes and heterogeneity of causes and treatments of CP achalasia, as well as short duration of follow-up, make it challenging to assess the superiority of one treatment over another. There is a need for a prospective study that more directly compares outcomes of administration of botulinum toxin, dilation, and CP myotomy in patients with CP achalasia of similar etiologies.

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Impact of Smoking on Survival Outcomes in HPV-Related Oropharyngeal Carcinoma: A Meta-analysis

Ryan Ference,David Liao,Qi Gao,Vikas Mehta

Publication date 26-05-2020


Characterize the survival impact of smoking on HPV-related (human papillomavirus) oropharyngeal squamous cell carcinoma. Articles from 2000 to 2019 in the Pub Med, Embase, and Cochrane Library databases were systematically reviewed for content and inclusion/exclusion criteria. Two reviewers independently analyzed the databases for eligibility and quality of the articles. Demographic data, smoking history, and survival outcomes were recorded. Hazard ratios and 95% CIs were collectively analyzed through a random effects meta-analysis model. Fifteen articles were included in the meta-analysis for overall survival, disease-specific survival, disease-free survival, progression-free survival, and locoregional recurrence outcomes. The overall survival hazard ratio was 2.4 for ever having smoked (95% CI, 1.4-4.0; Smoking negatively affects survival in patients with HPV-related oropharyngeal carcinoma across all outcomes. Current smoking during treatment is associated with the greatest reduction in survival, possibly secondary to diminished radiation therapy efficacy.

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Artificial Intelligence Applications in Otology: A State of the Art Review

Eunice You,Vincent Lin,Tamara Mijovic,Antoine Eskander,Matthew G. Crowson

Publication date 09-06-2020


Recent advances in artificial intelligence (AI) are driving innovative new health care solutions. We aim to review the state of the art of AI in otology and provide a discussion of work underway, current limitations, and future directions. Two comprehensive databases, MEDLINE and EMBASE, were mined using a directed search strategy to identify all articles that applied AI to otology. An initial abstract and title screening was completed. Exclusion criteria included nonavailable abstract and full text, language, and nonrelevance. References of included studies and relevant review articles were cross-checked to identify additional studies. The database search identified 1374 articles. Abstract and title screening resulted in full-text retrieval of 96 articles. A total of N = 38 articles were retained. Applications of AI technologies involved the optimization of hearing aid technology (n = 5; 13% of all articles), speech enhancement technologies (n = 4; 11%), diagnosis and management of vestibular disorders (n = 11; 29%), prediction of sensorineural hearing loss outcomes (n = 9; 24%), interpretation of automatic brainstem responses (n = 5; 13%), and imaging modalities and image-processing techniques (n = 4; 10%). Publication counts of the included articles from each decade demonstrated a marked increase in interest in AI in recent years. This review highlights several applications of AI that otologists and otolaryngologists alike should be aware of given the possibility of implementation in mainstream clinical practice. Although there remain significant ethical and regulatory challenges, AI powered systems offer great potential to shape how healthcare systems of the future operate and clinicians are key stakeholders in this process.

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Misconceptions About Negative Pressure Rooms and Their Impact Aboard USNS Comfort in New York City

Christopher J. Hill,Gregory G. Capra,Thomas P. McDonald,Gabriel F. Santiago,J. Paul Radabaugh

Publication date 30-06-2020


The outbreak of novel coronavirus disease 2019 (COVID-19) has had a momentous impact on the field of otolaryngology due to the high number of aerosol-generating procedures involving the upper aerodigestive tract. These procedures bear significant risk to the provider and clinical environment due to the possibility of viral aerosolization. While significant attention has been appropriately paid to personal protective equipment during this pandemic, an understanding of industrial hygiene is also necessary for the safe delivery of health care to mitigate the risk of exposure to other patients and health care workers. We provide a review of air ventilation practices and their role in reducing pathogen spread. In addition, we share our experiences with effectively treating COVID-19-positive patients aboard the USNS

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Reverse-Surge Planning During the COVID-19 Pandemic: A Cautionary Ramp-up for the Otolaryngologist

Taha Z. Shipchandler,B. Ryan Nesemeier,Kaitlyn J. Barnes,Leah R. Kelly,Cecelia E. Schmalbach,Jonathan Y. Ting

Publication date 30-06-2020


As the coronavirus disease 2019 (COVID-19) pandemic continues to evolve through the United States and other countries, differing rates of progression and decline are occurring based on varied population densities. While some health systems are reaching a steady state of new patient cases, others are seeing a leveling off or decline, allowing for restoration of normal practices. This "reverse-surge" planning and implementation process is a colossal undertaking for health systems trying to reacquire patient access and financial stability while preserving necessary resources and maintaining precautions for another potential surge. For the otolaryngologist, reverse-surge planning involves additional workflow adjustments in the outpatient and operating room settings given the abundance of COVID-19 virus in the upper aerodigestive tract. As the reverse-surge best practices are still under development, open communication between otolaryngology colleagues and health system leadership is paramount to optimize efficiency and maintain an adequate measure of safety for patients and our health care teams.

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Should Gender-Affirming Surgery Be Prioritized During the COVID-19 Pandemic?

Anna J. Flaherty,Arun Sharma,Dana L. Crosby,Michael J. Nuara

Publication date 30-06-2020


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Olfactory and Gustatory Outcomes in COVID-19: A Prospective Evaluation in Nonhospitalized Subjects

Alberto Paderno,Davide Mattavelli,Vittorio Rampinelli,Alberto Grammatica,Elena Raffetti,Michele Tomasoni,Tommaso Gualtieri,Stefano Taboni,Silvia Zorzi,Francesca Del Bon,Davide Lombardi,Alberto Deganello,Luca Oscar Redaelli De Zinis,Alberto Schreiber

Publication date 30-06-2020


To prospectively assess the rate and timing of recovery of olfactory (OD) and gustatory (GD) dysfunction in patients affected by COVID-19. Cohort study. Population-based evaluation in a COVID-19 high-prevalence region. We analyzed the clinical course of OD and GD in a cohort of home-quarantined SARS-CoV-2-positive patients from Northern Italy. Physicians administered a survey-based questionnaire at recruitment (T0). During follow-up, patients responded to online dedicated surveys modulated according to symptoms at T0. A total of 151 patients completed the follow-up survey. OD and/or GD were observed in 83% and 89% of subjects, respectively. Resolution rates of OD and GD at 30 days from onset were 87% and 82%, respectively. Risk factors for late resolution were grade of dysfunction at onset (total vs partial), gender, and presence of nasal congestion. Three (2%) patients previously reporting complete resolution of symptoms complained of subsequent recurrence of OD and/or GD after a mean of 19 days from resolution of the previous episode. COVID-19-related OD and GD had high rate of resolution in the first month from onset of symptoms. However, in 10% to 15% of patients, these symptoms showed only partial improvement after this period.

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Early Data From Case Series of Tracheostomy in Patients With SARS-CoV-2

Elizabeth Floyd,Scott S. Harris,Jessica W. Lim,David R. Edelstein,Briana Filangeri,Margherita Bruni

Publication date 30-06-2020


Thirty-eight tracheostomies were performed on patients with respiratory failure secondary to SARS-CoV-2 infection over the month of April at North Shore University Hospital and Lenox Hill Hospital (members of Northwell Health System in Long Island and New York City). Follow-up by May 14 revealed that 21 (55.2%) had been weaned from ventilators and 7 (18.4%) underwent decannulation. Two patients (5.3%) expired in the weeks following tracheostomy. Between the 2 institutions, 10 attending surgeons performed all of the tracheostomies using appropriate personal protective equipment, and none demonstrated seroconversion within 1 to 2 weeks of this article.

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High-Efficiency Particulate Air Filters in the Era of COVID-19: Function and Efficacy

David A. Christopherson,William C. Yao,Mingming Lu,R. Vijayakumar,Ahmad R. Sedaghat

Publication date 14-07-2020


Aerosol-generating procedures in the office represent a major concern for health care-associated infection of patients and health care providers by SARS-CoV-2, the causative agent for coronavirus disease 2019 (COVID-19). Although the Centers for Disease Control and Prevention has not yet provided any recommendations for the use of portable air purifiers, air purifiers with high-efficiency particulate air (HEPA) filters have been discussed as an adjunctive means for decontamination of SARS-CoV-2 aerosols in health care settings. This commentary discusses HEPA filter mechanisms of action, decontamination time based on efficiency and flow rate, theoretical application to SARS-CoV-2, and limitations. HEPA filter functionality and prior guidance from the Centers for Disease Control and Prevention for SARS-CoV-1 suggest theoretical efficacy for HEPA filters to decontaminate airborne SARS-CoV-2, although direct studies for SARS-CoV-2 have not been performed. Any portable HEPA purifier utilization for SARS-CoV-2 should be considered an adjunctive infection control measure and undertaken with knowledge of HEPA filter functionality and limitations in mind.

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Discriminating Malignancy in Thyroid Nodules: The Nomogram Versus the Kwak and ACR TI-RADS

Juan Xiao,Qiang Xiao,Wei Cong,Ting Li,Shouluan Ding,Chunchun Shao,Yuan Zhang,Jianing Liu,Mei Wu,Hongying Jia

Publication date 21-07-2020


To develop an easy-to-use nomogram for discrimination of malignant thyroid nodules and to compare diagnostic efficiency with the Kwak and American College of Radiology (ACR) Thyroid Imaging, Reporting and Data System (TI-RADS). Retrospective diagnostic study. The Second Hospital of Shandong University. From March 2017 to April 2019, 792 patients with 1940 thyroid nodules were included into the training set; from May 2019 to December 2019, 174 patients with 389 nodules were included into the validation set. Multivariable logistic regression model was used to develop a nomogram for discriminating malignant nodules. To compare the diagnostic performance of the nomogram with the Kwak and ACR TI-RADS, the area under the receiver operating characteristic curve, sensitivity, specificity, and positive and negative predictive values were calculated.
The nomogram consisted of 7 factors: composition, orientation, echogenicity, border, margin, extrathyroidal extension, and calcification. In the training set, for all nodules, the area under the curve (AUC) for the nomogram was 0.844, which was higher than the Kwak TI-RADS (0.826, When compared with the Kwak and ACR TI-RADS, the nomogram had a better performance in discriminating malignant thyroid nodules.

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Outcomes of Dog Bite Avulsion Injury Reconstruction With Urinary Bladder Matrix

Adrian A. Ong,Ryan Nagy,Michelle R. Fincham,Mark L. Nagy

Publication date 09-06-2020


Dog bite avulsion injuries of the head and neck are difficult to manage in pediatric patients. This study assesses the outcomes of using porcine urinary bladder extracellular matrix (UBM) for reconstruction of these complete avulsion injuries. Five male pediatric patients underwent reconstruction using UBM. Two (40%) patients underwent reconstruction of the nose; the other 3 patients underwent reconstruction of the forehead, forehead/glabella, and auricle. The average size of the avulsion defect was 7.0 ± 2.4 cm

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Prevalence of Eustachian Tube Dysfunction in the US Elderly Population

Jakob L. Fischer,Charles A. Riley,Mei-Chin Hsieh,Michael J. Marino,Xiao-Cheng Wu,Edward D. McCoul

Publication date 23-06-2020


To investigate the prevalence of eustachian tube dysfunction (ETD) in elderly adults in the United States and its association with other upper aerodigestive inflammatory processes. Cross-sectional study. Population based. In total, 147,805 patients without malignancy were compared to 13,804 demographically matched patients with malignancy of the upper aerodigestive tract (UADT) by querying the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database for patients aged 66 to 99 years between 2003 and 2011. The prevalence of ETD and inflammatory diseases among these patients was compared. Association between ETD, other upper aerodigestive inflammatory processes, and UADT malignancies was evaluated. The prevalence of ETD was 5.44% among patients without malignancy and 9.08% in those with cancer (odds ratio [OR], 1.73; 95% CI, 1.63-1.84). Patients with ETD in the control population were more likely (OR, 95% CI) to be diagnosed with chronic rhinitis (5.00, 4.70-5.33), chronic sinusitis (4.20, 3.98-4.43), allergic rhinitis (4.27, 4.08-4.47), and gastroesophageal reflux disease (GERD) (2.42, 2.31-2.53). Patients with ETD and chronic rhinitis (1.43, 1.24-1.65), chronic sinusitis (1.57, 1.38-1.78), and acute otitis media (1.33, 1.08-1.65) were associated with higher rates of UADT malignancy. Over 5% of patients older than 65 in the United States are diagnosed with ETD in the absence of UADT malignancy. Associations between ETD and chronic rhinitis, chronic sinusitis, allergic rhinitis, and GERD in the absence of UADT malignancy suggest that some patients may benefit from treatment of inflammatory disease as a cause of ETD.

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Pain and Opioid Analgesic Use After Otorhinolaryngologic Surgery

Matthew Kim,Ashutosh Kacker,David I. Kutler,Abtin Tabaee,Michael G. Stewart,Klaus Kjaer,Anthony P. Sclafani

Publication date 14-07-2020


To quantify pain and opioid use after otorhinolaryngologic surgery. To determine the effect of patient and surgical factors on primary outcomes. Prospective cohort. Tertiary academic hospital. Patients undergoing elective otorhinolaryngologic surgery were prospectively enrolled. Patients completed demographic surveys and psychometric questionnaires assessing attitudes toward pain and baseline anxiety and depression before surgery. After surgery, patients documented peak pain levels (0-100 mm, visual analog scale) and daily prescription and nonprescription analgesic requirements over a 2-week period. Average daily and cumulative pain and opioid use were calculated and compared among patient cohorts stratified by procedure and preoperative factors. A total of 134 patients were enrolled. Total tonsillectomy was associated with significantly higher pain scores and opioid consumption, as compared to all other procedures. There was moderate correlation between average cumulative pain and opioid use. Older patients required significantly fewer doses of opioids. There was no effect of sex, marital status, or education level on postoperative pain or opioid use. Psychometric instrument scores and chronic pain or analgesic use were not associated with significant differences in pain or opioid requirements. Most patients were prescribed substantially more opioids than they actually required. Postoperative pain following elective otorhinolaryngologic surgery decreases dramatically within the first week and requires only few days of opioid analgesia, with the exception of tonsillectomy. Almost all patients required fewer than 15 doses of opioids.

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Quantitative Assessment of Surgical Ergonomics in Otolaryngology

Cole Rodman,Natalie Kelly,Weston Niermeyer,Laura Banks,Amanda Onwuka,Eric Mason,Tendy Chiang

Publication date 30-06-2020


Objective evaluation of the ergonomic risk of common otolaryngology procedures and assessment of work-related musculoskeletal pain and injury. Cross-sectional intraoperative assessment and survey. Department of Otolaryngology at a tertiary children's hospital. Sixteen otolaryngology attendings, fellows, and residents participated in a blinded study. Intraoperative ergonomics was assessed for tonsillectomies, adenoidectomies, and tympanostomy tube insertions using the Rapid Upper Limb Assessment (RULA). Follow-up surveys were sent to all participating surgeons to determine the prevalence of musculoskeletal pain and formal ergonomic training. Zero percent (N = 0/275) of intraoperative observations were found to have a negligible level of ergonomic risk, with 47% low risk, 37% high risk, and 16% very high risk. Tympanostomy tube insertions conferred less risk than tonsillectomy and adenoidectomy, while the use of headlamp or loupes conferred increased risk. Eighty percent of respondents reported having musculoskeletal pain and 40% reported experiencing pain while operating within the past year. The most common area of pain was the cervical spine. No surgeons reported formal ergonomic training. Our study demonstrates an unacceptable level of ergonomic risk for common procedures in otolaryngology. Furthermore, most participants reported experiencing musculoskeletal pain despite the duration of examined procedures being relatively short. The high prevalence of work-related musculoskeletal pain and the lack of ergonomic training in our cohort highlight the need for increased awareness of ergonomics as well as the development of formal ergonomic curricula.

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The Role of Age and Merkel Cell Polyomavirus in Oral Cavity Cancers

Melina Windon,Carole Fakhry,Lisa Rooper,Patrick Ha,David Schoppy,Brett Miles,Wayne Koch,Peter Vosler,David Eisele,Gypsyamber D’Souza

Publication date 23-06-2020


The incidence of oral tongue cancer, the majority subsite of oral cavity cancer, is rising among young people with less exposure to tobacco and alcohol. Viral causes have been proposed, including Merkel cell polyomavirus (MCPyV). We evaluated patient and tumor characteristics among 126 incident oral cavity cancers (OCCs). Consistent with generational norms, younger patients had less exposure to tobacco and a greater number of oral sexual partners than older OCCs. In addition, younger patients were more likely to present at an earlier stage and with cancer arising from the oral tongue (each

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Narrowband Imaging for p16+ Unknown Primary Squamous Cell Carcinoma Prior to Transoral Robotic Surgery

Kareem Al-Mulki,James Hamilton,Azeem S. Kaka,Brian J. Boyce,H. Michael Baddour,Mark El-Deiry,C. Arturo Solares,Kelly Magliocca,Kelly Summers,Ashley Aiken,Nabil F. Saba,Jonathan J. Beitler,Mihir R. Patel

Publication date 23-06-2020


Our purpose was to assess the potential utility of narrowband imaging (NBI) as a tool in diagnosing and treating unknown primary oropharyngeal squamous cell carcinoma (OPSCC) in patients prior to diagnostic resection with transoral robotic surgery (TORS). Between 2016 and March 2019, 29 patients with carcinoma of unknown primary meeting inclusion criteria were identified and treated with TORS. NBI was used preoperatively in 9 of 29 patients. A suspected tumor site was delineated by NBI in 8 of 9 patients (89%). Of the patients imaged with NBI, 8 of 9 (89%) patients had a pathologically confirmed tumor following TORS, corresponding to the same 8 suspected tumor sites identified with NBI. In contrast, a primary tumor was localized following TORS in 15 of 20 (75%) patients not evaluated with NBI. Thus, we see NBI as a potentially useful tool for the diagnosis and management of p16+ carcinoma of unknown primary.

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Glycoprotein Nonmetastatic Melanoma Protein B as Potential Imaging Marker in Posttherapeutic Metastatic Head and Neck Cancer

Jeroen E. van Schaik,Saskia H. Hanemaaijer,György B. Halmos,Max J. H. Witjes,Bernard F. A. M. van der Laan,Bert van der Vegt,Boudewijn E. C. Plaat

Publication date 30-06-2020


To evaluate expression of potential molecular imaging targets epidermal growth factor receptor (EGFR), glycoprotein nonmetastatic melanoma protein B (GPNMB), and vascular endothelial growth factor (VEGF) in lymph nodes (LNs) with or without head and neck squamous cell carcinoma (HNSCC) metastases after (chemo)radiation. Retrospective study comparing receptor expression in paired lymph nodes after initial treatment. A tertiary referral hospital. Salvage neck dissection specimens of 40 patients treated with (chemo)radiation were selected. LNs that contained viable tumor, reactive changes after initial treatment, and normal LNs were analyzed using immunohistochemically determined H-scores and by calculating sensitivity and specificity rates and positive/negative predictive values (PPVs/NPVs). EGFR expression was found in 86% and GPNMB expression in 100% of the LNs with viable tumor. VEGF expression was present in all lymph node types. For EGFR, the sensitivity rate was 86%, and specificity rate was 81%. For GPNMB, these were 100% and 75%, respectively. PPV of EGFR was 61.8% and NPV was 98.2%. These were 56.4% and 100% for GPNMB, respectively. In residual or recurrent HNSCC lymph node metastases, both EGFR and GPNMB show tumor-specific expression in immunohistochemistry, which may prove useful in future molecular imaging in salvage neck dissections. Immunohistochemically detected VEGF expression indicates that this target is not feasible for imaging purposes in salvage surgery. Therefore, GPNMB could be a new potential imaging target showing comparable results to EGFR in immunohistochemistry.

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Comparison of Survival Estimates Following Recurrence, Persistence, or Second Primary Malignancy in Oropharyngeal Squamous Cell Carcinoma

Ameya Asarkar,José Miguel Flores,Cherie-Ann O. Nathan

Publication date 07-07-2020


This study investigated survival among patients with oropharyngeal squamous cell carcinoma (OPSCC) after recurrence, persistence, and second primary malignancies (SPMs). Retrospective cohort study. Patients were treated at a tertiary cancer center. Patients with OPSCC who had completed treatment between 2001 and 2017 were included.
Survival estimates of 4 groups of patients were calculated: (1) patients who were disease free after initial treatment, (2) patients who had persistent disease, (3) those with recurrent disease, and (4) patients with SPMs. Cox proportional hazard models and parametric survival analyses (using Weibull distributions) were used to obtain hazard ratios (HRs) and time ratios (TRs). The cohort included 364 patients. The crude overall SPM prevalence was 8.2%. Mean overall survival (OS) time in years for patients who remained disease free after treatment was 4.02 years. Among patients who experienced recurrence, the recurrence-free survival (RFS) was 2.58 years while their mean (SD) OS was 3.67 (2.7) years. Participants who experienced persistence had a mean (SD) OS of 1.67 (1.68) years. Patients with observed SPMs had a mean (SD) OS of 6.39 (4.06) years since their primary cancer but shortened survivals of 1.75 (2.34) years since the secondary diagnosis. Differences were present even after accounting for human papillomavirus (HPV) and smoking status. Our findings stress the importance of active surveillance as per current National Comprehensive Cancer Network guidelines, irrespective of the HPV status or smoking status. Prospective studies with a larger number of SPM cases and longer follow-up are needed to validate survival trends even beyond 5 years.

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Predictors of Postoperative Radiation Following Laser Resection in Early-Stage Glottic Cancer

Dustin A. Silverman,Kevin Y. Zhan,Sidharth V. Puram,Antoine Eskander,Theodoros N. Teknos,James W. Rocco,Matthew O. Old,Stephen Y. Kang

Publication date 07-07-2020


Guideline recommendations for the treatment of early-stage glottic cancer are limited to single-modality therapy with surgery or radiation alone. We sought to investigate the clinicopathologic and treatment factors associated with the use of postoperative radiation therapy (PORT) following laser excision for patients with T1-T2N0 glottic squamous cell carcinoma (SCC). Retrospective observational study of the National Cancer Database. National Cancer Database review from 2004 to 2014. A total of 1338 patients with primary cT1-T2N0M0 glottic SCC undergoing primary laser excision were included. Hospitals were divided into quartiles based on yearly volume of laryngeal laser cases performed. Multivariate logistic regression was performed to identify independent predictors of PORT. The overall rate of PORT was 30.0%. Predictors of PORT included treatment at lower-volume hospitals (adjusted odds ratio [aOR] for quartiles 2-4, 1.32-4.84), positive margins (aOR, 3.83 [95% CI, 2.54-5.78]), and T2 tumors (aOR, 3.58 [95% CI, 2.24-5.74]). PORT utilization demonstrated a strong inverse correlation with hospital volume. Among top-quartile hospitals, the rate of PORT was 11.2%, while rates of PORT at second-, third-, and fourth-quartile institutions were 19.2%, 32.2%, and 37.4%, respectively. Predictors of PORT in multivariable analysis included treatment at lower-volume facilities, positive margins, and T2 disease. This study highlights the importance of treating early-stage glottic carcinoma at high-volume institutions. In addition, there is a need to reevaluate the use of PORT and reduce the rate of dual-modality therapy for patients with early-stage glottic SCC.

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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 23-06-2020


To review the results of a series of patients with glottic insufficiency caused by scarred vocal folds who underwent injection laryngoplasty with centrifuged and emulsified autologous fat. Prospective cohort. Single center, tertiary institution. Examination of the medical records of 21 patients operated on through injection laryngoplasty with fat grafts for the treatment of dysphonia was performed. All patients were operated on between January of 2015 and September of 2019. The voice variables measured were the GRABS (Grade, Roughness, Breathiness, Asthenia, Strain) scale, the Voice Handicap Index-10 (VHI-10), maximum phonation time, jitter, shimmer, and harmonic/noise ratio before surgery and 8 months later. Twenty-six injection laryngoplasties were performed in 21 patients during the reviewed period. Seventeen were men, and 4 were women. Mean age was 57.2 (range, 18-80) years. Mean (SD) follow-up time was 20.7 (9.3) months. Etiology of dysphonia was scarring after tumor resection in 17 patients and sulcus vocalis in 4. Five patients received an additional injection laryngoplasty. Statistically significant improvements were observed in all the parameters evaluated ( Injection laryngoplasty with fat grafts processed through centrifugation and emulsification is an effective technique for the treatment of dysphonia caused by glottic insufficiency related to scarred vocal folds, with minimal complication rates.

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Swallowing Patterns in the HNC Population: Timing of Penetration-Aspiration Events and Residue

Jessica M. Pisegna,Susan E. Langmore,Tanya K. Meyer,Barbara Pauloski

Publication date 07-07-2020


This study described swallowing patterns in a large head/neck cancer (HNC) cohort. In a retrospective review of data from a randomized controlled trial, we studied timing of penetration events as they related to aspiration and oral/pharyngeal residue. Retrospective review of a multicenter randomized controlled trial. In total, 168 patients who were >3 months postradiation received baseline modified barium swallow evaluations. Retrospective analyses of data from these exams were studied, including Penetration-Aspiration Scale (PAS) scores and timing of these events (before, during, or after the swallow), as well as percentage of oral and pharyngeal residue. Aspiration occurred more frequently The predominant pattern for this sample of postradiation patients with HNC with dysphagia was aspiration that occurred after the swallow, rather than before or during the swallow. The aspiration was directly caused by penetration events that occurred during the swallow, resulting in aspiration as the airway reopened. Patients demonstrated more pharyngeal residue than oral residue, but a weak relationship was found between residue and penetration/aspiration events. These results guide clinicians in targeting appropriate swallowing interventions.

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Identifying Type III Sulcus: Patient Characteristics and Endoscopic Findings

Eleni A. Varelas,Paul M. Paddle,Ramon A. Franco,Inna A. Husain

Publication date 23-06-2020


Type III sulcus is a pathologic structural deformity of the vocal folds that is challenging to accurately diagnose without endoscopic examination under anesthesia. This study aims to further define the clinical presentation and examination features shared among a patient cohort intraoperatively diagnosed with type III sulcus. Case series with chart review. Tertiary laryngology practice. All patients diagnosed intraoperatively with type III sulcus from 2002 to 2014 at a tertiary laryngology practice were included. Clinical history of presenting symptoms, videostroboscopy, and intraoperative and histologic findings were reviewed. Twenty-two patients were included in the study. A majority were female (77%) and had a mean age of 32.4 years. All patients endorsed hoarseness, and 86% were defined as professional voice users. Endoscopic examination revealed bilateral type III sulcus in 23% of patients. The most common preoperative stroboscopic findings included decreased mucosal wave (100%), dilated vessel (95%), phase asymmetry (91%), additional benign lesion (91%), and cyst (82%). Histology revealed epithelial changes of atypia and keratosis. Both the severity of dysphonia and the difficulty observing structural malformations of the vocal folds make type III sulcus challenging to preoperatively diagnose. This study reports the clinical and endoscopic features seen within a cohort of patients with type III sulcus.

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National Trends in Surgical Resection of Vestibular Schwannomas

Yin Ren,Rosh K. V. Sethi,Konstantina M. Stankovic

Publication date 23-06-2020


To characterize the national trend for surgical resection of vestibular schwannoma (VS) and to assess changes in demographics, length of stay (LOS), discharge patterns, and hospital charges. Population-based inpatient registry analysis. National Inpatient Sample and SEER database (Surveillance, Epidemiology, and End Results). Retrospective review of the US National Inpatient Sample and the SEER database from 2001 to 2014 of all patients who underwent resection of VS. A total of 24,380 VS resections were performed. While the annual incidence of VS remained stable at 1.38 per 100,000, surgical volume declined by 36.1%, from 2807 in 2001 to 1795 in 2014 ( VS resection has evolved in the United States. While the incidence remained stable, surgical volume decreased by 36%, and hospital charges more than doubled. More cases are being performed at smaller hospitals. Although LOS did not vary significantly, there is an increase in nonroutine discharges. These data may guide future research in resource utilization in neurotology.

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Auditory Quality-of-Life Measures in Patients With Traumatic Brain Injury and Normal Pure Tone Audiometry

Renata M. Knoll,Rory J. Lubner,Jacob R. Brodsky,Kevin Wong,David H. Jung,Aaron K. Remenschneider,Seth D. Herman,Elliott D. Kozin

Publication date 30-06-2020


Auditory complaints are commonly reported following traumatic brain injury (TBI). However, few studies have examined patient-reported auditory symptomatology and quality-of-life metrics in individuals with TBI. We hypothesize that following TBI, individuals can experience auditory symptoms even with hearing thresholds in the normal range. Adult patients with normal auditory thresholds and a history of TBI were evaluated for subjective hearing loss, tinnitus, aural fullness, hyperacusis, and autophony. Hearing Handicap Inventory for Adults, Tinnitus Handicap Inventory, and Hyperacusis Questionnaire were administered. Thirty-one patients were prospectively recruited. Twenty-eight TBI participants (90%) reported ≥1 auditory symptoms at the time of survey intake. Mild to severe handicap in the Hearing Handicap Inventory for Adults and Tinnitus Handicap Inventory was reported in 71.4% and 40% of the participants with hearing loss and tinnitus, respectively. Hyperacusis handicap was considered significant in 41.1% of the participants who complained of hyperacusis and completed the survey. Despite normal hearing thresholds, individuals with TBI experience decrements in auditory quality-of-life metrics.
Level of evidence: 3.

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Subjective vs Computerized Assessment of Surgeon Skill Level During Mastoidectomy

Michaela F. Close,Charmee H. Mehta,Yuan Liu,Mitchell J. Isaac,Mark S. Costello,Kyle D. Kulbarsh,Ted A. Meyer

Publication date 30-06-2020


This pilot study examines the use of surgical instrument tracking and motion analysis in objectively measuring surgical performance. Accuracy of objective measures in distinguishing between surgeons of different levels was compared to that of subjective assessments. Twenty-four intraoperative video clips of mastoidectomies performed by junior residents (n = 12), senior residents (n = 8), and faculty (n = 4) were sent to otolaryngology programs via survey, yielding 708 subjective ratings of surgical experience level. Tracking software captured the total distance traveled by the drill, suction irrigator, and patient's head. Measurements were used to predict surgeon level of training, and accuracy was estimated via area under the curve (AUC) of receiver operating characteristic curves. Key objective metrics proved more accurate than subjective evaluations in determining both faculty vs resident level and senior vs junior resident level. The findings of this study suggest that objective analysis using computer software has the potential to improve the accuracy of surgical skill assessment.

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Long-Term Otitis Media Outcomes in Infants With Early Tympanostomy Tubes

Kimberly Luu,James Park,Amber D. Shaffer,David H. Chi

Publication date 16-06-2020


To review the otologic outcomes of infants who failed the newborn hearing screen (NBHS) and received early tympanostomy tubes for otitis media with effusion (OME). Retrospective case series. Tertiary care pediatric hospital. Consecutive patients (2007-2018) who failed an NBHS and required tympanostomy tubes before 6 months of age were included. Variables including hearing loss and otitis media risk factors, episodes of acute otitis media (AOM), number of subsequent tympanostomy tubes, and posttympanostomy tube audiogram results were recorded. The cohort included 171 patients. Median age at referral to otolaryngology was 2.7 months. Sensorineural hearing loss (SNHL) was subsequently identified in 22 (12.9%) of infants after resolution of the effusion. The peak incidence of AOM was during the second year of life (1-1.9 years), with a median of 1 episode. Ninety-five patients (55.6%) had replacement of tubes, 41 of 171 (24.0%) had 2 or more additional sets of tubes, and long-term tubes were eventually placed in 8 of 95 (8.4%) patients. Craniofacial anomalies were identified in 43.3% of patients. Tube replacement (hazard ratio, 3.00; 95% CI, 1.95-4.63; OME is a common cause of failed NBHS. A notable proportion was subsequently found to have SNHL, reiterating the need for postoperative hearing assessments. Infants meeting indication for early tympanostomy tubes for resolution of OME have a high incidence of recurrent AOM and require subsequent tubes.

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Comparison of Endoscopic and Ultrasonographic Measurements of the Subglottic Airway in Children

Elton M. Lambert,Huy D. Tran,Julina Ongkasuwan

Publication date 30-06-2020


To compare measurements of the pediatric subglottis obtained by surgeon-performed ultrasound and endoscopy. Prospective observational comparison-of-methods study. Tertiary care pediatric hospital. Thirty-one patients who underwent direct laryngoscopy from May 2017 to July 2018 were recruited. Transcervical ultrasound was used to visualize the vocal folds, subglottis, and cervical trachea. The anterior-posterior (AP) and transverse (TV) diameter of the subglottic space were measured endoscopically and via ultrasound by 2 independent evaluators. Measurements were compared for correlation, bias, and agreement. A clinically acceptable bias for subglottic diameter was assumed to be 0.5 mm or less. The median age of enrolled patients was 2.6 years (range, 4 months-13.3 years). Endoscopic subglottic AP and TV measurements ranged from 3.33 mm to 14.81 mm and from 4.44 mm to 11.65 mm, respectively, while ultrasonographic AP and TV measurements ranged from 4.57 mm to 9.85 mm and from 3.77 mm to 8.96 mm. Pearson coefficient showed strong a correlation for both endoscopic and ultrasound AP ( Endoscopic and ultrasonography measurements of the pediatric subglottic airway were strongly correlated. The discrepancy between AP and TV measurements was less than 0.5 mm. Ultrasound of the subglottis may be an alternative to endoscopic assessment of the airway for measurement of the subglottic airway in children in select cases.

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Expression of Iron-Regulatory Hormone Hepcidin and Iron Transporters Ferroportin and ZIP8 in Patients With and Without Chronic Rhinosinusitis

David Hsu,Airie Kim,Tomas Ganz,Jeffrey D. Suh,Marilene Wang,Tara J. Wu,Jivianne T. Lee

Publication date 04-08-2020


Airway epithelia express intrinsic antimicrobial and nutrient-sequestering factors, which contribute to the host defense of the respiratory tract. Hepcidin is an endogenous peptide hormone that serves as a key regulator of iron metabolism, and ferroportin and ZIP8 are iron transporters. All exhibit innate antimicrobial activity. The purpose of this pilot study is to determine if molecules involved in iron regulation are expressed within sinus epithelia and to compare levels of expression between patients with and without chronic rhinosinusitis (CRS). Sinus mucosa was obtained from patients with (n = 19) and without (n = 14) CRS. Real-time polymerase chain reaction following RNA extraction was used to quantify expression of hepcidin, ferroportin, and ZIP8 mRNA. Hepcidin, ferroportin, and ZIP8 were all detected in the sinus epithelia of patients with and without CRS. However, only ZIP8 was significantly changed in CRS, with a 2.5-fold mean increase in mRNA expression relative to controls (

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Computer-Assisted Quantitative Analysis of Drug-Induced Sleep Endoscopy for Obstructive Sleep Apnea/Hypopnea Syndrome

Chi-Chih Lai,Pei-Wen Lin,Hsin-Ching Lin,Michael Friedman,Anna M. Salapatas,Ju-Pin Chen,Hsueh-Wen Chang,Sin-Ei Juang,Shao-Chun Wu,Meng-Chih Lin

Publication date 30-06-2020


To use computer-assisted quantitative measurements of upper airway changes during drug-induced sleep endoscopy (DISE) and to correlate these parameters with disease severities and physiologic changes in patients with obstructive sleep apnea/hypopnea syndrome (OSA). A retrospective study. Tertiary academic medical center. A total of 170 patients who failed continuous positive airway pressure therapy and then underwent upper airway surgery were enrolled. All patients received polysomnography and DISE preoperatively. We used ImageJ 1.48v to obtain maximal and minimal measurements, including cross-sectional areas and anterior-posterior and lateral diameters at 4 anatomic levels (retropalatal, oropharyngeal, retroglossal, and retroepiglottic) under DISE, and then computed the percentage changes. We analyzed the clinical values of DISE changes by computer-assisted analysis in patients with OSA and any correlations between these changes and polysomnography parameters. The percentage changes of upper airway showed significant collapses at all 4 anatomic levels (all Computer-assisted quantitative analysis could evaluate upper airway changes of OSA in an objective way and may help identify the sites of obstruction during DISE more accurately. Upper airway showed multilevel collapse with independent significant changes in patients with OSA, with the retropalatal and retroglossal levels playing important roles in particular.

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Labyrinthitis Ossificans and Cholesteatoma Associated With Gardner Syndrome: A Rare Case

James Sullivan,Luke W. Edelmayer,Nazanin Dadfar,Mohammad Seyyedi

Publication date 30-06-2020


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Tracheostomy in the COVID-19 Era: The Apneic Approach

Georgios Papathanakos,Ioannis Andrianopoulos,Xanthi Zikou,Athanasios Papathanasiou,Vasilios Koulouras

Publication date 30-06-2020


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Reply to the Letter to the Editor, “Tracheostomy in the COVID-19 Era: The Apneic Approach”

Juan Riestra-Ayora,Joaquin Yanes-Diaz,Eduardo Martin-Sanz

Publication date 30-06-2020


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The Association Between Reflux and Laryngeal Neoplasia Is Still Not Demonstrated

Jerome R. Lechien,Young-Gyu Eun,Stephane Hans,Sven Saussez

Publication date 01-12-2020


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Response to “The Association Between Reflux and Laryngeal Neoplasia Is Still Not Demonstrated”

Sean M. Parsel,Andrew L. Iarocci,Mariella Gastañaduy,Ryan D. Winters,Jeffrey P. Marino,Edward D. McCoul

Publication date 01-12-2020


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ThyroidEx: Development and Preliminary Validation of a Thyroid Surgery Expectations Measure

Snehal G. Patel,Thomas M. Atkinson,R. Michael Tuttle,Andrea L. Pusic,Jatin P. Shah,Ashok R. Shaha,Kathleen Lynch,Monica DiLorenzo,Safina Ali,Richard J. Wong,Jennifer R. Cracchiolo

Publication date 15-12-2020


To address the lack of validated patient-reported outcome (PRO) instruments that define and quantify patient expectations in thyroid cancer surgery, we developed and initially validated Thyroid Ex, a novel disease-specific PRO instrument. Survey study. Single-institution tertiary care cancer center. An expert panel drafted an initial set of thyroid cancer-specific concepts, which was used in semistructured concept elicitation interviews with patients with thyroid cancer 4 weeks before and 8 weeks after surgery. Candidate items were generated per patient responses and refined via cognitive interviewing and additional review by the expert panel. The draft Thyroid Ex was then preoperatively administered to a separate cohort undergoing thyroid cancer surgery to establish a final item set and initial psychometric evidence. Prospective concept elicitation interviews generated 358 patient-elicited concepts (n = 15 patients). These were then placed into 70 unique subcategories from which 41 items were generated for cognitive interviews with 20 patients preoperatively and 28 postoperatively. After expert panel review, Thyroid Ex included 18 items across 2 scales (Expectations and Concerns), with an additional item about beliefs. In the preoperative cohort in phase 2 (n = 67), internal consistency Cronbach's α values ranged from 0.81 to 0.89. Descriptive analysis showed significant differences between patients' concerns and expectations and clinicians' perceptions. Defining expectations represents an important modifier in the measurement of PROs. Preliminary validation of Thyroid Ex revealed incongruent expectations between expert opinion and patients. Future development and implementation of Thyroid Ex may affect preoperative consultation and the consent process.

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Prevalence and Characteristics of Taste Disorders in Cases of COVID-19: A Meta-analysis of 29,349 Patients

Jeyasakthy Saniasiaya,Md Asiful Islam,Baharudin Abdullah

Publication date 15-12-2020


The purpose of this meta-analysis is to assess the pooled prevalence of taste disorders and their subtypes in patients with COVID-19. Pub Med, Scopus, Web of Science, Embase, and Google Scholar databases were searched to identify studies published between December 1, 2019, and June 23, 2020, without language restrictions. There was no restriction on the study design; therefore, observational studies, clinical trials, and case series were included. In addition, preprints were considered if data of interest were reported. Two authors independently screened articles for eligibility. A random effects model was used to estimate the pooled prevalence with 95% CIs. Quality assessment was done with critical appraisal tools of the Joanna Briggs Institute. The robustness of the pooled estimates was checked by subgroup and sensitivity analyses. Fifty-nine studies were included (N = 29,349 patients, 64.4% female). The pooled prevalence of taste disorders in patients with COVID-19 was 48.1% (95% CI, 41.3%-54.8%). The prevalence of taste disorders in studies with objective assessments was higher as compared with subjective assessments (59.2% vs 47.3%). The disorders were observed in 55.2% of European patients; 61.0%, North American; 27.1%, Asian; 29.5%, South American; and 25.0%, Australian. Ageusia, hypogeusia, and dysgeusia were detected in 28.0%, 33.5%, and 41.3% of patients with COVID-19. We identified 91.5% of the included studies as high quality. The prevalence of taste disorders in patients with COVID-19 was 48.1%. Objective assessments have higher prevalence than subjective assessments. Dysgeusia is the most common subtype, followed by ageusia and hypogeusia.

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Comparison of Tracheal vs Nasopharyngeal Secretions for SARS-CoV-2 RT-PCR Testing in Patients With Tracheostomy

Anya Costeloe,Mohammad-Nadim Samad,Seilesh Babu,Christopher Metz

Publication date 15-12-2020


This study compares nasopharyngeal and tracheal samples for COVID-19 viral testing in patients with a tracheostomy. This was a prospective cohort study done at 2 academic hospitals between March and June 2020. Patients admitted through the emergency department who had a COVID-19 test and an existing tracheostomy or underwent a tracheostomy during the admission period were included. Patients with a positive initial nasopharyngeal swab were placed in the experimental group (n = 8), while those with a negative swab were the control group (n = 7). Nasopharyngeal and tracheal samples underwent COVID-19 testing using the Abbott Real Time SARS-CoV-2 RNA assay. Fourteen patients underwent tracheostomy, and 1 had an existing tracheostomy. The average duration of viral shedding in nasopharyngeal samples was 20.9 days. One patient (6.7%) tested positive in tracheal secretions after a negative nasopharyngeal swab. In the remaining patients (93.3%), the nasopharyngeal and tracheal specimens correlated.

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COVID-19 Vaccines May Not Prevent Nasal SARS-CoV-2 Infection and Asymptomatic Transmission

Benjamin S. Bleier,Murugappan Ramanathan,Andrew P. Lane

Publication date 15-12-2020


Current COVID-19 vaccine candidates are administered by injection and designed to produce an IgG response, preventing viremia and the COVID-19 syndrome. However, systemic respiratory vaccines generally provide limited protection against viral replication and shedding within the airway, as this requires a local mucosal secretory IgA response. Indeed, preclinical studies of adenovirus and mRNA candidate vaccines demonstrated persistent virus in nasal swabs despite preventing COVID-19. This suggests that systemically vaccinated patients, while asymptomatic, may still be become infected and transmit live virus from the upper airway. COVID-19 is known to spread through respiratory droplets and aerosols. Furthermore, significant evidence has shown that many clinic and surgical endonasal procedures are aerosol generating. Until further knowledge is acquired regarding mucosal immunity following systemic vaccination, otolaryngology providers should maintain precautions against viral transmission to protect the proportion of persistently vulnerable patients who exhibit subtotal vaccine efficacy or waning immunity or who defer vaccination.

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Validation of a Hearing-Related Quality-of-Life Questionnaire for Parents and Deaf or Hard-of-Hearing Infants and Toddlers

Ana Marija Sola,Neelaysh Vukkadala,Sonya Giridhar,Jihyun Stephans,Isabel Elaine Allen,Dylan K. Chan

Publication date 15-12-2020


To design and validate a hearing-related quality-of-life questionnaire targeted toward parents and deaf or hard-of-hearing infants and toddlers: the Hearing-Related Infant/Toddler and Parent Quality of Life (HIP-QL) questionnaire. Cross-sectional questionnaire and prospective instrument validation. Academic pediatric otolaryngology clinic. A 67-question questionnaire developed from constructs of a grounded theory analysis was administered to parents of 31 deaf or hard-of-hearing children and 14 typically hearing children. Questionnaire construct validity, reliability, and discriminant validity were tested. Based on exploratory factor analysis, a 32-item construct composed of developmentally appropriate questions was reduced to a 17-item construct with 4 domains addressing quality of life for both child (auditory/communication behavior, temperament) and parent (management, parent-directed factors). Internal consistency measures were appropriate (Cronbach's alpha = 0.65), and test-retest reliability was high (intraclass correlation coefficient = 0.73). Total HIP-QL scores correlated significantly with related total PedsQL scores ( This context-specific questionnaire is the first validated quality-of-life instrument for parents and deaf or hard-of-hearing infants and toddlers. Previously, parental stress and functional disability questionnaires were used as proxies; therefore, this questionnaire has the potential to serve as an important tool for patient- and caregiver-centered outcomes research.

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Bilateral Auditory Brainstem Implants in Patients With Neurofibromatosis 2

Kathryn Y. Noonan,Jordan Rock,Zach Barnard,Gregory P. Lekovic,Derald E. Brackmann,Eric P. Wilkinson

Publication date 15-12-2020


To discuss indications for bilateral auditory brainstem implants (ABIs), compare audiometric outcomes of unilateral vs bilateral ABIs, and determine if patients have improved outcomes with addition of a second-side implant. Retrospective review of 24 patients with neurofibromatosis 2 (NF2) who underwent sequential placement of ABIs from 1989 to 2019. Tertiary referral center. Charts were reviewed for indication for second-side surgery, use of implants, and audiometric outcomes. Implants placed in the past 30 years were included in the study. Northwestern University Children's Perception of Speech (NU-CHIPS) and/or City University of New York (CUNY) sentence scores were compared in unilateral and bilateral conditions. Indications for a second-side implant included first-side implants with severe nonauditory symptoms (11), marginal audiometric results (9), outdated technology (2), or deterioration of first side (2). Seven patients are bilateral users and 1 patient discontinued bilateral use after a year due to no significant improvement over unilateral use. One patient with initial bilateral use was lost to follow-up. Thirteen patients are unilateral users due to nonaudiometric side effects or poor audiometric outcomes with the first side. Two patients are complete nonusers. Seventy-five percent had improved audiometric outcomes after the second-side implant, and 20% had stable findings. Second-side ABIs should be consider in patients with poor performance from a first-side implant. Most patients demonstrate subjective improvement with the second ABI. More research is needed for better objective assessments of improvements.

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Comparative Evaluation and Management of Dysphonia Between Adults <65 and ≥65 Years of Age

Amy Jacks,Hannah Kavookjian,Shannon Kraft

Publication date 08-12-2020


To compare presenting symptoms, etiology, and treatment outcomes among dysphonic adults <65 and ≥65 years of age. Retrospective cohort study. Tertiary care voice center between January 2011 and June 2016.
A total of 755 patients presenting for dysphonia were included in the study: 513 adults <65 years of age and 242 adults ≥65. Data collected included demographics, referral information, prior diagnoses, prior treatments, clinical examination findings, diagnosis, coexisting symptoms, treatments, and pre- and postintervention Voice Handicap Index scores. Statistical analysis was performed with SPSS to determine significant relationships between variables of interest. The most common etiologies of dysphonia were vocal cord atrophy (44.8%) in the ≥65 cohort and benign vocal cord lesions (17.8%) in the <65 cohort. When compared with adults <65 years old, patients ≥65 had a higher incidence of neurologic dysphonia ( There are notable differences in the pathophysiology of dysphonia between patients aged ≥65 and <65 years. Although adults <65 reported slightly better outcomes with surgery, patients ≥65 obtained significant benefit from surgery and voice therapy.

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Predictors of Tracheostomy Decannulation in Adult Laryngotracheal Stenosis

Grace E. Snow,Timothy Brandon Shaver,Taylor B. Teplitzky,Elizabeth Guardiani

Publication date 08-12-2020


Predictors of tracheostomy decannulation in patients with laryngotracheal stenosis are not fully known, making prognosis difficult. The aim was to identify predictors of tracheostomy decannulation in adult patients with acquired stenosis of the larynx and/or trachea who were tracheostomy dependent. Case series. Academic teaching hospital. A total of 103 consecutive adult patients with laryngotracheal stenosis who were tracheostomy dependent and seen by the otolaryngology clinic from January 1, 2013, to August 2, 2018, were included. Exclusion criteria included age <18 years, history of laryngeal cancer or head and neck radiation, or history of laryngeal fracture. The primary outcome was the presence of tracheostomy at last follow-up. The patients' etiology of stenosis, comorbid conditions, and characteristics of the stenosis were analyzed to determine if there was a statistically significant relationship with decannulation.
A total of 103 patients were included: 67% of patients were women and the average age was 53.5 years. Sixty-four patients (62%) were successfully decannulated. In multivariate analysis, patients who were successfully decannulated presented to the otolaryngology clinic earlier after tracheostomy was performed, were more likely to have been intubated due to trauma, and were less likely to have gastroesophageal reflux disease. In patients with subglottic or tracheal stenosis, those with granulation tissue without firm scar were more likely to be decannulated, and those who underwent rigid dilation were less likely to be decannulated. Early evaluation by an otolaryngologist may increase the likelihood of tracheostomy decannulation in patients with laryngotracheal stenosis. Patient comorbidities may assist in predicting which patients will be successfully decannulated.

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Quantitative Assessment of the Immune Microenvironment in Patients With Iatrogenic Laryngotracheal Stenosis

Ruth J. Davis,Ioan Lina,Benjamin Green,Elizabeth L. Engle,Kevin Motz,Dacheng Ding,Janis M. Taube,Alexander Gelbard,Alexander T. Hillel

Publication date 08-12-2020


Iatrogenic laryngotracheal stenosis (iLTS) is characterized by fibroinflammatory narrowing of the upper airway and is most commonly caused by intubation injury. Evidence suggests a key role for CD4 T cells in its pathogenesis. The objective of this study is to validate emerging multiplex immunofluorescence (mIF) technology for use in the larynx and trachea while quantitatively characterizing the immune cell infiltrate in iLTS. In addition to analyzing previously unstudied immune cell subsets, this study aims to validate previously observed elevations in the immune checkpoint PD-1 and its ligand PD-L1 while exploring their spatial and cellular distributions in the iLTS microenvironment. Controlled ex vivo cohort study. Tertiary care center. mIF staining was performed with formalin-fixed, paraffin-embedded slides from 10 patients with iLTS who underwent cricotracheal resection and 10 control specimens derived from rapid autopsy for CD4, CD8, CD20, FoxP3, PD-1, PD-L1, and cytokeratin. There was greater infiltration of CD4 This study leverages the power of mIF to quantify the iLTS immune infiltrate in greater detail. It confirms the highly inflammatory nature of iLTS, with CD4

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Assessment of Pediatric Middle Ear Effusions With Wideband Tympanometry

Sarah Callaham,Maxwell Newby,Aniket A. Saoji,Jad Ramadan,Michele M. Carr

Publication date 08-12-2020


To determine if wideband tympanometry (WBT) can differentiate types of middle ear effusion (MEE): serous, mucoid, and purulent. Prospective cohort study. Tertiary care children's hospital. Children who met American Academy of Otolaryngology-Head and Neck Surgery's guidelines for ventilation tube insertion had WBT after anesthesia induction but before tympanotomy.
MEE was categorized into 1 of 4 comparison groups: serous effusion, mucoid effusion, purulent effusion, or no effusion. WBT measurements were averaged to 16 one-third octave frequency bands, and comparison of the absorbance patterns for each MEE type was performed through a linear mixed effects model. A total of 118 children (211 ears) were included: 47 females (39.8%) and 71 males (60.2%). The mean age was 2.73 years (95% CI, 2.25-3.22); mean weight, 14.35 kg (95% CI, 12.85-15.85); and mean WBT has potential use to differentiate types of MEE and should be studied further as a tool for investigating how the natural history and management of serous and mucoid effusions may differ.

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Preoperative Radiographic Predictors of Hearing Preservation After Retrosigmoid Resection of Vestibular Schwannomas

Yin Ren,Kareem O. Tawfik,Bill J. Mastrodimos,Roberto A. Cueva

Publication date 08-12-2020


To identify preoperative radiographic predictors of hearing preservation (HP) after retrosigmoid resection of vestibular schwannomas (VSs). Retrospective case series with chart review. Tertiary skull base referral center. Adult patients with VSs <3 cm and word recognition scores (WRSs) ≥50% who underwent retrosigmoid resection and attempted HP between February 2008 and December 2018 were identified. Pure tone average (PTA), WRS, and magnetic resonance imaging radiographic data, including tumor diameter and dimensional extension relative to the internal auditory canal (IAC), were examined. A total of 151 patients were included. The average tumor size was 13.8 mm (range, 3-28). Hearing was preserved in 41.7% (n = 63). HP rates were higher for intracanalicular tumors than tumors with cerebellopontine angle (CPA) components (57.6% vs 29.4%, Rates of HP are highest in patients with small intracanalicular VSs and good preoperative hearing. For tumors extending into the CPA, greater posterior and caudal tumor extension relative to the IAC may portend worse hearing outcomes.

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Clinical Characteristics and Surgical Outcomes of Sinonasal Lesions Associated With Tumor-Induced Osteomalacia

Zhenzhen Zhu,Weibo Xia,Fang Qi,Weiqing Wang,Xiaowei Wang,Yang Zha,Fang Li,Hongli Jing,Peipei Wang,Wei Lv

Publication date 08-12-2020


To investigate the clinical characteristics and surgical outcomes of sinonasal tumors associated with tumor-induced osteomalacia (TIO). Retrospective case series. Single tertiary center. We studied the clinical characteristics and surgical outcomes of 43 patients (22 male, 21 female) who had lesions in the nasal cavity and paranasal sinus associated with TIO and underwent surgery between August 2006 and November 2019. The mean ± SD duration between the onset of symptoms and surgery was 3.9 ± 2.6 years. The most common tumor site was the ethmoid sinus (76.7%), and the skull base was involved in 12 cases. Phosphaturic mesenchymal tumors were diagnosed in 41 patients, among whom there was 1 multifocal case. Another 2 cases involved odontogenic fibroma and hemangiofibroma, respectively. Serum phosphorus normalized in 39 cases within 4.4 ± 2.3 days, and serum fibroblastic growth factor 23 normalized within 1 day; clinical symptoms, however, gradually improved within several months after the first operation. There was no significant difference in the recovery rate between endoscopic and open surgery ( Most sinonasal tumors associated with TIO are located in the ethmoid sinus, and the skull base is involved in some cases. Complete excision of the tumor leads to recovery, and endoscopic surgery could achieve recovery rates similar to those of open surgery.

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Relationship Between Parental Intolerance of Uncertainty and Decisional Conflict in Pediatric Otolaryngologic Surgery

Chelsea Cleveland,Vijay A. Patel,Shari A. Steinman,Reena Razdan,Michele M. Carr

Publication date 08-12-2020


To assess the relationship between depression, anxiety, stress, worry, intolerance of uncertainty (IU), and shared decision making (SDM) in parents of pediatric otolaryngology surgical patients with their perceptions of decisional conflict (DC). Cross-sectional. Academic pediatric otolaryngology outpatient clinic. Participants were legal guardians of pediatric patients who met criteria for otolaryngologic surgery. Participants completed a demographic survey as well as validated Decisional Conflict Scale (DCS); Shared Decision-Making Scale (SDMS); Depression, Anxiety and Stress Scale-21 (DASS-21); Penn State Worry Questionnaire (PSWQ); and short form of the Intolerance of Uncertainty Scale (IUS-12). A total of 114 participants were enrolled. Respondents were predominantly female (93.0%) and married (60.5%). Most guardians had not consented previously for otolaryngologic surgery for their child (69.3%). Participants reported low levels of DC and depression as well as moderate levels of anxiety and stress. DC scores were not significantly correlated to DASS-21, PSWQ, or SDM. IUS-12 Total and subscale IUS-12 prospective negatively correlated with Total DC. DC was not related to age, sex, education level, previous otolaryngologic surgery, or type of surgery recommended. In this group, an association was found between IU and DC. Clinicians should be aware that DC is not modified by previous surgical experience. Interventions aimed at addressing parental IU related to surgery may reduce DC. Further research efforts could help us understand how mental health relates to surgical decision making.

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Treatment of Early Stage Tonsil Cancer in the Age of Human Papillomavirus–Associated Malignancies

Evan J. Patel,Angela W. Zhu,Jamie R. Oliver,MacIntosh Cornwell,Adam S. Jacobson,Kenneth S. Hu,Moses Tam,Alec Vaezi,Luc G. T. Morris,Babak Givi

Publication date 08-12-2020


To investigate the patterns of care and outcomes of treatment of early stage tonsil cancers, controlling for human papillomavirus (HPV) status. Historical cohort study. National Cancer Database (NCDB). Review of the NCDB between 2010 and 2017 for all T1-2N0M0 tonsillar squamous cell carcinoma (SCC). Demographics, clinical characteristics, HPV status, treatment regimens, and survival were analyzed. A total of 4720 patients were identified with early stage SCC of the tonsil. Most were tested for HPV (2759 [58.5%]). Among tested patients, 1758 (63.7%) were positive for HPV and 1001 (36.3%) were negative for HPV. HPV-positive patients had higher 3-year survival compared to HPV-negative patients (93.2% vs 77.8%, Surgical- or radiation-based treatment resulted in similar survival in early stage HPV-positive tonsil cancer. Surgical-based treatments were associated with longer survival in HPV-negative cancers. These findings should be further investigated in a randomized prospective trial.

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Skeletal Muscle Index’s Impact on Discharge Disposition After Head and Neck Cancer Free Flap Reconstruction

Alexander Joseph Jones,Vincent Joseph Campiti,Mohamedkazim Alwani,Leah J. Novinger,Andrea Bonetto,Michael W. Sim,Jessica A. Yesensky,Michael G. Moore,Avinash V. Mantravadi

Publication date 08-12-2020


To determine the role of skeletal muscle index (SMI) in the assessment of frailty and determination of discharge to post-acute care facilities (PACF) after head and neck cancer free flap reconstruction (HNCFFR). Retrospective cohort. Single-institution, academic tertiary referral center. Adult patients undergoing HNCFFR from 2014 to 2019 with preoperative abdominal computed tomography imaging were retrospectively analyzed. Patient demographics, 5-factor modified frailty index (5-mFI), body mass index (BMI), SMI at the third lumbar vertebra, oncologic history, perioperative data, and Clavien-Dindo (CD) complications were collected. Binary logistic regression was used to identify independent predictors of discharge disposition. The cohort consisted of 206 patients, 62 (30.1%) of whom were discharged to PACF. Patients discharged to PACF were of older age (65.4 vs 57.1 years, SMI and 5-mFI are independently associated with discharge to PACF after HNCFFR and should be considered in preoperative planning and assessment of frailty.

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30-Day Postoperative Outcomes Following Transcervical Zenker’s Diverticulectomy in the Elderly: Analysis of the NSQIP Database

Annie E. Moroco,Robert A. Saadi,Vijay A. Patel,Erik B. Lehman,John P. Gniady

Publication date 08-12-2020


To compare the effect of patient factors, including age, on 30-day postoperative outcomes and complications for patients undergoing transcervical Zenker's diverticulectomy. Retrospective cross-sectional analysis. American College of Surgeons National Surgical Quality Improvement Program (NSQIP) Database. Patients who underwent open Zenker's diverticulectomy ( A total of 614 patients were identified. Mean age at time of surgery was 71.1 years, with 13.4% older than 85 years. Outpatient procedures were performed in 29.8%. Postoperative complications occurred in 6.7%, with reoperation and readmission rates of 6.4% and 7.2%, respectively. A mortality rate of 0.3% was observed. Only smoking status (odds ratio, 2.94; Smoking status confers a high risk for postoperative complication. Age was not an independent risk factor associated with adverse outcomes following open diverticulectomy, suggesting this procedure can be safely performed in patients with advanced age.

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Effects of Fractional CO2 Laser Treatment on Subglottic Scar in a Rabbit Model

Kastley Marvin,Isaac Schwartz,Edward Utz,Justin Wilson,Christopher Johnson,Philip Gaudreau

Publication date 08-12-2020


The objective of this study was to investigate the effects of fractional CO Randomized controlled animal study. Academic medical center. Subglottic scar was induced in 12 New Zealand white rabbits via an endoscopic brush technique. This was followed by an open airway surgery that included vertical division of the cricoid and proximal trachea. Eight rabbits underwent fractional CO All 12 subjects survived to the study endpoint with no significant respiratory complications, despite 10 of 12 developing some degree of lateral tracheal narrowing. The median ratio of type I collagen to type III collagen in the laser group (1.57) was significantly more favorable than that of the untreated group (2.84; Treatment with fractional CO

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Trends in Use and Timing of Intratympanic Corticosteroid Injections for Sudden Sensorineural Hearing Loss

Michael C. Jin,Z. Jason Qian,Shayna P. Cooperman,Jennifer C. Alyono

Publication date 08-12-2020


Oral corticosteroids are treatment mainstays for idiopathic sudden sensorineural hearing loss (SSNHL). Recent studies suggest that intratympanic (IT) steroid injections may be effective as an alternate or adjunctive therapy. We sought to investigate nationwide trends in treatment patterns for SSNHL. Retrospective cross-sectional study. A large nationwide health care claims database spanning 2007 to 2016. Patients with SSNHL were identified from the IBM Watson Health Market Scan Database. Multivariable logistic, linear, and Cox regression were used for demographic- and comorbidity-adjusted analyses. Overall, 19,670 patients were included. Between 2007 and 2016, use of oral corticosteroids alone decreased (83.6% to 64.6%, SSNHL management increasingly involves early IT steroids as an alternative or adjunctive option to oral steroids. Use of repeat IT corticosteroid injections has also increased but may raise risk of persistent tympanic membrane perforations and subsequent tympanoplasty. Future decision analysis and cost-effectiveness studies are necessary to identify an optimal care pattern for SSNHL.

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Assessment of Pain and Analgesic Use in Children Following Otologic Surgery

Liliya Benchetrit,Megan Kwock,Evette Ronner,Sheli Goldstein,Edina Shu,Daniel J. Lee,Leila A. Mankarious,Christen Caloway,Judith Kempfle,Michael S. Cohen

Publication date 08-12-2020


To compare postoperative pain and analgesic use in children following transcanal endoscopic ear surgery (TEES) vs non-transcanal endoscopic ear surgery (non-TEES). Prospective case series. Tertiary care center. Surveys using the Wong-Baker FACES Pain Rating Scale and recording the frequency and dosage of consumed analgesics were administered prospectively to caregivers of children undergoing otologic surgery between May 2018 to February 2020. Pain intensity and medication use were recorded twice daily for 6 days, starting on postoperative day 0. Mean pain scores and mean number of consumed analgesic doses were compared between groups. Survey response rate was 57.9%. Among 53 patients who completed the survey, 35 (66.0%) underwent TEES and 18 (34.0%) underwent non-TEES. Mean pain ratings on postoperative days 0 and 1 were significantly lower among children undergoing TEES (2.2 and 2.1) vs non-TEES (4.0 and 4.1), Postoperative pain following TEES and non-TEES in children was overall low. Children undergoing TEES had a small but statistically significant decrease in pain on postoperative days 0 and 1 and decreased use of pain medications compared to non-TEES.

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Teaching Middle Ear Anatomy and Basic Ear Surgery Skills: A Qualitative Study Comparing Endoscopic and Microscopic Techniques

Lukas Anschuetz,Till Siggemann,Cilgia Dür,Corinne Dreifuss,Marco Caversaccio,Sören Huwendiek

Publication date 08-12-2020


Endoscopic ear surgery is gaining popularity as a minimally invasive surgical technique for middle ear diseases. Its ongoing implementation into clinical routine has consequences regarding teaching of middle ear anatomy and surgery. To improve undergraduate and postgraduate training, we investigated the perception of and preference for endoscopy as compared with microscopy at different educational levels. Qualitative study based on a thematic analysis approach. Tertiary academic medical center. After a standardized curriculum was run on endoscopic and microscopic anatomy and surgical skills education, 5 focus groups were held. The interviews were conducted, video recorded, transcribed, and analyzed. Analysis of the data gave rise to 11 themes showing the participants' perceptions and preferences. Five medical students, 11 otorhinolaryngology residents, and 3 staff members participated in this qualitative study. For anatomy teaching, there was a clear preference for the endoscopic technique. The main advantages were the enhanced overview and perception of the anatomic details provided through endoscopy. For skills acquisition, the perceived advantages of the techniques were the same view of the surgical field for endoscopy and the 2-handed surgical technique for microscopy. However, there was no clear preference between the techniques for skills acquisition. The endoscopic technique was generally judged more beneficial for teaching anatomy, especially due to the greater visualization of the complex middle ear anatomy. Given that both techniques will remain important to future surgeons, the relative unique benefits of each must be considered when designing and optimizing curricula for otologic education.

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Parent-Reported Outcome Questionnaire for Swallowing Dysfunction in Healthy Infants and Toddlers: Construction and Content Validation

Abdulsalam Baqays,Wendy Johannsen,Marghalara Rashid,Hussein Jaffal,Anne Hicks,Caroline Jeffery,Hadi Seikaly,Hamdy El-Hakim

Publication date 08-12-2020


There is limited epidemiological information on swallowing dysfunction (SwD) in otherwise healthy infants and toddlers (OHITs). Cost, invasiveness, expertise, and resources constrain the repeatability and utility of instrumental diagnostic tests. A parent-reported outcomes (PRO) tool has the potential to mitigate these disadvantages. Hence, we set out to develop and validate a novel PRO tool to assess SwD in OHITs. A mixed-method study. Tertiary pediatric center. We recruited parents of OHITs with SwD and excluded those with a confounding diagnosis (syndromes or neurological impairment). Interviews were conducted and thematically analyzed to extract the relevant domains and items. A similar analytical method was performed on the reports from a systematic review and literature search. Four verification sessions of parents and experts were conducted to maintain rigor. A panel of experts assessed and established the content validity of the items using a modified Delphi technique. We achieved information saturation after interviewing 10 parents and generated 7 domains with 72 items. Over the course of 3 rounds of modified Delphi content validation, the domains were reduced to 3 (swallowing, breathing, and illness) containing 21 items; a content validity index of 82.1% was achieved. We validated the content of a new PRO instrument to assess SwD in OHITs. The instrument is composed of 3 primary domains representing 21 items. This tool has the potential to screen for swallowing dysfunction and can assess management outcomes specifically for this population at a community level.

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Potential Impact of the COVID-19 Pandemic on Communication and Language Skills in Children

Sara A. Charney,Stephen M. Camarata,Alexander Chern

Publication date 01-12-2020


The COVID-19 pandemic has led to many unintended, long-lasting consequences for society. Preventative practices such as mask wearing, social distancing, and virtual meetings and classrooms to address contagion concerns may negatively affect communication, particularly in the pediatric population, as schools have begun to open this fall. Increasing awareness and creating innovative methods to promote communication and language learning in settings both in person and virtual is paramount. Although more studies are needed to characterize the pandemic's impact on pediatric speech and language development, clinicians and parents should be cognizant of this phenomenon and proactive in facilitating an optimal communication environment for children.

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Prognostic Significance of HPV Status in Laryngeal Squamous Cell Carcinoma: A Large-Population Database Study

Bharat A. Panuganti,Andrey Finegersh,Mitchell Flagg,Xin Tu,Ryan Orosco,Philip A. Weissbrod,Joseph Califano

Publication date 01-12-2020


To explore the survival implications of human papillomavirus (HPV) positivity and subtype in larynx cancer through a national cancer database. To investigate staging discrepancies in larynx cancer associated with HPV status. Retrospective observational cohort study. National Cancer Database. Data were extracted concerning adults with known HPV status who were treated between 2010 and 2016 for laryngeal squamous cell carcinoma. Patients without known HPV subtype were excluded. Cox multivariable regression models were fit to evaluate the survival impact of HPV status, characterized as a binary variable (HPV+ vs HPV-) and by subtype. Two- and 5-year survival rates were calculated via the Kaplan-Meier method and compared by stage between the HPV+ and HPV- cohorts per the log-rank test. Patients with HPV+ larynx cancer were younger (60.5 vs 64.3 years, HPV positivity and infection with HPV subtype 16 are correlated with improved overall survival in patients with laryngeal squamous cell carcinoma, manifesting with a 1-stage incremental survival advantage. Future prospective studies are indicated to corroborate the findings from this large-population database retrospective study.

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Idiopathic Sudden Sensorineural Hearing Loss in Children: A Systematic Review and Meta-analysis

Leonardo Franz,Chiara Gallo,Gino Marioni,Cosimo de Filippis,Andrea Lovato

Publication date 24-11-2020


Idiopathic sudden sensorineural hearing loss (ISSNHL) is uncommon in children, and its treatment and outcome are debated. We aimed to critically review evidence in the literature about treatment options and functional outcomes of pediatric ISSNHL. Additionally, we performed a meta-analysis of the results of combined systemic-intratympanic steroid therapy versus solely systemic treatment. A search was run in the Pub Med, Scopus, and Google Scholar databases. Included articles were original ISSNHL case series, written in English, with a population age ranging from 2 to 19 years. Other study types (single case reports, editorials, and reviews) and case series with known etiology of sudden hearing loss were excluded. Descriptive data of patients, treatments, outcomes, and possible prognostic factors were extracted and recorded for every included study. Twelve articles (7 cohort and 5 case-control studies) met all the selection criteria. Based on only the studies that provided sufficient data about clinical outcome, the pooled overall recovery rate was 67.91% (95% CI, 58.34%-77.48%). No studies showed a significant difference between systemic steroid and combined systemic-intratympanic steroid. The pooled odds ratio for combined systemic-intratympanic steroid versus systemic steroid alone was 0.90 (95% CI, 0.36-2.27) based on a random effects model, ruling out any significant difference between these treatment options. The results of our meta-analysis did not support combination therapy more than systemic steroid alone. Further prospective clinical trials are necessary to establish evidence-based therapies.

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A Comprehensive Analysis of Treatment Management and Survival Outcomes in Nasopharyngeal Carcinoma

Khodayar Goshtasbi,Brandon M. Lehrich,Jack L. Birkenbeuel,Arash Abiri,Jeremy P. Harris,Edward C. Kuan

Publication date 24-11-2020


To comprehensively investigate nasopharyngeal carcinoma (NPC) treatment, overall survival (OS), and the influence of clinical/sociodemographic factors on outcome. Retrospective database study. National Cancer Database. The 2004-2015 National Cancer Database was queried for all patients with NPC receiving definitive treatment. Log-rank tests and Cox proportional hazards models were used for statistical analyses. A total of 8260 patients with NPC were included (71.4% male; 42.5% with keratinizing histology; mean ± SD age, 52.1 ± 15.1 years), with a 5-year OS of 63.4%. Multivariate predictors of mortality included age ≥65 years (hazard ratio [HR], 1.81; NPC survival is dependent on a variety of clinical/sociodemographic factors. Stage-specific treatments with optimal OS include CRT or RT for stages I to II and CRT for stage III to IV. The large representation of nonendemic histology is valuable, as these cases are not well characterized.

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Association Between Sudden Sensorineural Hearing Loss and History of Statin Use: A Nested Case-Control Study

So Young Kim,Jee Hye Wee,Chanyang Min,Dae Myoung Yoo,Hyo Geun Choi

Publication date 24-11-2020


The effect of statin on sudden sensorineural hearing loss (SSNHL) remains unclear. Thus, this study aimed to investigate the association between prior statin use and SSNHL. A nested case-control study. Participants aged ≥40 years were enrolled from the 2002-2015 Korean National Health Insurance Service-Health Screening Cohort. A total of 5876 patients with SSNHL were matched with 23,504 control participants for age, sex, income, and region of residence. History of statin use for 2 years before SSNHL onset was investigated between the groups. The odds ratios (ORs) of the length of statin use for SSNHL stratified by age, sex, income, and region of residence were analyzed with conditional logistic regression. Dyslipidemia, total cholesterol, blood pressure, blood glucose, hemoglobin, obesity, smoking, alcohol consumption, and Charlson Comorbidity Index score were adjusted. The adjusted variables were subjected to subgroup analyses. The SSNHL group had a longer duration of statin use than the control group (mean [SD], 81.9 [197.7] days vs 72.7 [188.0] days; Previous statin use was not associated with SSNHL.

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FDG-PET/CT and Pathology in Newly Diagnosed Head and Neck Cancer: ACRIN 6685 Trial, FDG-PET/CT cN0

Brendan C. Stack,Fenghai Duan,Rathan M. Subramaniam,Justin Romanoff,JoRean D. Sicks,Twyla Bartel,Chien Chen,Val J. Lowe

Publication date 24-11-2020


FDG-PET/CT (fluorodeoxyglucose-positron emission tomography/computed tomography) is effective to assess for occult neck nodal disease. We report risks and patterns of nodal disease based on primary site and nodal level from data on the dissected cN0 per the results from ACRIN 6685. Prospective nonrandomized enrollment included participants with first-time head and neck squamous cell carcinoma and at least 1 cN0 neck side to be dissected. Twenty-four ACRIN-certified centers internationally (American College of Radiology Imaging Network). A total of 287 participants were enrolled. Preoperative FDG-PET/CT findings were centrally reviewed and compared with pathology. Incidence, relative risk, pattern of lymph node involvement, and impact upon neck dissection were reported. An overall 983 nodal levels were dissected (n = 261 necks, n = 203 participants). The highest percentages of ipsilateral positive nodes by primary location and nodal level were oral cavity (level I, 17/110, 15.5%), pharynx (level II, 6/30, 20.0%), and larynx (level VI, 1/3, 33.3%). Levels at greatest risk for nodal disease in cN0 in terms of ipsilateral neck dissection are level I (oral cavity), II (pharynx), and VI (larynx). These data should be considered when treating patients presenting with cN0. This is the first study to comprehensively report the incidence, location, and risk of metastases in cN0 in the FDG-PET/CT era.

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Impact of COVID-19 on Presentation of Sudden Sensorineural Hearing Loss at a Single Institution

Divya A. Chari,Ayush Parikh,Elliott D. Kozin,Meaghan Reed,David H. Jung

Publication date 24-11-2020


The coronavirus disease 2019 (COVID-19) pandemic resulted in widespread unprecedented changes to the health care system. Herein, we sought to assess the impact of the viral outbreak on clinical presentations of sudden sensorineural hearing loss (SSNHL) at a single academic center. Our results demonstrate a decrease in the absolute number of patients presenting with SSNHL to our institution during the initial onset of the COVID-19 pandemic compared to an analogous time frame 1 year prior. However, the ratio of patients with SSNHL compared to total patients evaluated was largely similar during the 2 time periods. Based on data from our institution, the COVID-19 virus does not appear to confer a significantly increased risk for the development of SSNHL.

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Recovery After Adenotonsillectomy—Do Steroids Help? Outcomes From a Randomized Controlled Trial

Ariana G. Greenwell,Amal Isaiah,Kevin D. Pereira

Publication date 24-11-2020


The primary objective was to compare pain control following adenotonsillectomy (AT) in children with and without a single postoperative dose of oral dexamethasone in addition to standard analgesic medication. The secondary objective was to compare changes in caregiver-reported snoring, return to normal diet and baseline function, and the number of phone calls and emergency department (ED) visits. Prospective randomized controlled trial. Tertiary care university hospital. Children aged 3 to 10 years with sleep-disordered breathing who were scheduled to undergo AT were randomized to receive standard analgesia with or without dexamethasone (0.6 mg/kg) administered on the third postoperative day. Standard analgesia was defined as alternating weight-based doses of ibuprofen and acetaminophen. A nurse practitioner blinded to the study condition performed telephone surveys postoperatively, and the electronic medical record was reviewed. Enrollment comprised 149 children, of whom 119 were included. When compared with the control group (n = 61, 51%), children who received dexamethasone (n = 58, 49%) had a greater decrease in reported pain score on day 4 (mean ± SD, 2.5 ± 3.1 vs 1.1 ± 3.5, A single dose of dexamethasone administered on day 3 after adenotonsillectomy significantly improved pain control. There were fewer phone calls and ED visits in the steroid arm. These results support the use of oral steroids as an adjunct for postoperative pain control in children undergoing AT.

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Advanced Practice Providers Utilization Trends in Otolaryngology From 2012 to 2017 in the Medicare Population

Marshall Ge,Jee-hong Kim,Stephanie Shintani Smith,Julianna Paul,Christine Park,Peiyi Su,Elisabeth H. Ference

Publication date 24-11-2020


Nurse practitioners and physician assistants form a growing advanced practice provider (APP) group. We aim to analyze the trends and types of services provided by APPs in otolaryngology. Cross-sectional study.
Medicare Provider Utilization and Payment Data: Physician and Other Supplier Public Use Files, 2012-2017. The Medicare database was searched for 13 commonly used otolaryngology-specific From 2012 to 2017, there was a 51% increase in the number of otolaryngology APPs, compared to a 2.2% increase in physician providers. APPs increased their share of new and established patient visits from 4% to 7%d 11% to 15%, respectively. There was not a significant difference over time in number of patient visits performed annually per provider according to provider type. The increase in number of APP vs physician providers was significantly greater for every procedure except for balloon sinus dilation and tympanostomy tube placement. Due to increasing numbers, APPs are accounting for more patient visits and procedures over time. The physician workforce and the numbers of procedures performed per physician have remained relatively stable from 2012 to 2017. Increasing complexity of patients seen and a broader range of procedures offered by work-experienced or postgraduate-trained APPs may further improve access to health care in the face of possible physician shortages.

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The Iron Henry: How One Sword Swallower Advanced Modern Medicine

Barry D. Long,Harold S. Pine

Publication date 24-11-2020


Sword swallowing is an ancient skill that was developed by the fakirs of India and slowly permeated the globe leading up to the late 19th century. Its rise as a popular circus act in Europe coincided with the surge of inventive young minds in the medical community. This crossroad brought about a working relationship between Dr Adolf Kussmaul and a sword swallower named the "Iron Henry." Together, they developed a scope that could be passed through the esophagus for evaluation of disease states from the upper aerodigestive tract all the way to the antrum of the stomach. The unique abilities refined by years of sword swallowing were vital in the work to develop and perform the first successful esophagoscopy and then disseminate the technology. This story should not be forgotten and can give insight into how historical practices and modern invention can come together to great effect.

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Influence of Surgical Techniques on Endoscopic Dacryocystorhinostomy: A Systematic Review and Meta-analysis

Alessandro Vinciguerra,Alessandro Nonis,Antonio Giordano Resti,Diego Barbieri,Mario Bussi,Matteo Trimarchi

Publication date 24-11-2020


Endoscopic endonasal dacryocystorhinostomy (END-DCR) has increased as a valid alternative to the classic external approach to treat distal lacrimal obstruction. Different surgical varieties of the END-DCR approach have been proposed with no clear understanding of the best surgical technique. A comprehensive research was performed in Pub Med, Embase, SCOPUS, and Cochrane databases with a final search on March 2020. The aim of this search was to identify relevant END-DCR procedures performed with mechanical (Mecn-END-DCR) and powered (Pow-END-DCR) approaches to compare their functional success rate. In addition, the influence of mucosal flaps was evaluated. Articles were selected only if they were published later than 2000 and had at least 50 single-clinician surgical procedures performed. Excluded articles included acute infections, cancers, mixed cohort study, and revision cases. A total of 11,445 publications were identified and 2741 reviewed after screening; 15 articles were included after full-text review (0.6% of the initial articles reviewed). The mean success rate was 91.34% (95% CI, 87.1%-94.3%) for Pow-END-DCR and 89.5% (95% CI, 86.5%-91.9%) for Mecn-END-DCR with no significant difference between the surgical approaches ( Our analyses suggest that there are no differences in outcomes between mechanical and powered approaches in END-DCR and that mucosal flap preservation is not essential to achieve a superior END-DCR outcome.

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High-Risk Human Papillomavirus–Related Oropharyngeal Squamous Cell Carcinoma Among Non-Indigenous and Indigenous Populations: A Systematic Review

Xiangqun Ju,Karen Canfell,Megan Smith,Sneha Sethi,Gail Garvey,Joanne Hedges,Richard M. Logan,Annika Antonsson,Lisa M. Jamieson

Publication date 24-11-2020


To estimate the prevalence of oral high-risk human papillomavirus (hr-HPV) infection and the proportion of hr-HPV-related oropharyngeal squamous cell carcinoma (OPSCC) among Indigenous and non-Indigenous populations. Electronic database searches of Pub Med, Pub Med Central, Embase, MEDLINE, Scope, and Google Scholar were conducted for articles published from January 2000 until November 2019. Studies were included with a minimum of 100 cases assessing hr-HPV infection in either population samples or oropharyngeal cancer tumor series. The objective was to conduct meta-analyses to calculate the pooled prevalence of oral hr-HPV infection by adjusting for age group or sex in primary studies, the incidence of OPSCC, and the proportion of hr-HPV-related OPSCC in Indigenous people and non-Indigenous/general populations. We identified 47 eligible studies from 157 articles for meta-analyses. The pooled prevalence of oral hr-HPV infection was 7.494% (95% CI, 5.699%-9.289%) in a general population, with a higher prevalence among men (10.651%) than women (5.176%). The pooled incidence rate was 13.395 (95% CI, 9.315-17.475) and 7.206 (95% CI, 4.961-9.450) per 100,000 person-years in Indigenous and non-Indigenous populations, respectively. The overall pooled proportion of hr-HPV-related OPSCC was 50.812% (95 CI, 41.656%-59.969%). The highest proportion was in North America (60.221%), while the lowest proportion was in the Asia-Pacific (34.246%). Our findings suggest that in the general population, the prevalence of oral hr-HPV infection is lower among females and those in younger age groups. The incidence of OPSCC was higher among Indigenous than non-Indigenous populations, with the proportion being highest in North America.

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Evaluating a Prototype Nasolaryngoscopy Hood During Aerosol-Generating Procedures in Otolaryngology

Michal J. Plocienniczak,Ravi Patel,Jessica Pisegna,Gregory Grillone,Christopher D. Brook

Publication date 24-11-2020


During the COVID-19 pandemic, there has been considerable interest in identifying aerosol- and droplet-generating procedures, as well as efforts to mitigate the spread of these potentially dangerous particulates. This study evaluated the efficacy of a prototype nasolaryngoscopy hood (PNLH) during various clinical scenarios that are known to generate aerosols and droplets. Prospective detection of airborne aerosol generation during clinical simulation while wearing an PNLH. Clinical examination room. A particle counter was used to calculate the average number of 0.3-µm particles/L detected during various clinical scenarios that included sneezing, nasolaryngoscopy, sneezing during nasolaryngoscopy, and topical spray administration. Experiments were repeated to compare the PNLH versus no protection. During the sneeze experiments, additional measurements with a conventional N95 were documented. There was a significant increase in aerosols detected during sneezing, sneezing during nasolaryngoscopy, and spray administration, as compared with baseline when no patient barrier was used. With the PNLH in place, the level of aerosols returned to comparable baseline levels in each scenario. Of note, routine nasolaryngoscopy did not lead to a statistically significant increase in aerosols. This study demonstrated that the PNLH is a safe and effective form of protection that can be used in clinical practice to help mitigate the generation of aerosols during nasolaryngoscopy. While nasolaryngoscopy itself was not shown to produce significant aerosols, the PNLH managed to lessen the aerosol burden during sneezing episodes associated with nasolaryngoscopy.

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Life-Threatening Oropharyngeal Teratoma

Emilie Bois,Briac Thierry

Publication date 17-11-2020


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Leveraging Advanced Practice Providers in an Otolaryngology Practice

Nita Sharma,David Upjohn,Carrlene Donald,Katie E. Zoske,Chelsea L. Aldridge,Devyani Lal

Publication date 17-11-2020


Advanced practice providers (APPs) may see patients independently or assist in "collaborative" clinics in otolaryngology practices. Our goal was to redesign the collaborative physician-APP clinic model to increase patient access, maintain financial sustainability, and optimize patient and staff experience. The study was performed in a tertiary care academic rhinology clinic seeing adult patients. The DMAIC framework (define, measure, analyze, improve, control) was used to develop the new model. The process shift between old and new models was analyzed by utilizing a statistical process control chart. Patient and staff surveys were tracked. The collaborative physician-APP model was redesigned into 2 parallel and independently run ("concurrent") physician and APP clinics. Patient access increased by 38.9% from a mean of 17.9 patients per collaborative clinic (n = 15 days, 269 patients) to 29.3 patients per concurrent clinic (n = 12 days, 352 patients). Medicare reimbursement rate modeling showed the collaborative clinic to operate at a loss of $1341.51 per day, while the concurrent clinic model operated at a $1309.88 gain (200% positive change). Patient and staff experience tracked positively. Otolaryngology clinics can become overwhelmed by the volume of empaneled established patients. Traditional collaborative physician-APP clinics see the same panel of patients together. However, these can be successfully redesigned to a concurrent model. Concurrent clinics improve patient access and provider satisfaction while maintaining patient satisfaction and fiscal performance. Leveraging an experienced APP to run a parallel and independent clinic alongside the physician (concurrent clinic model) may improve patient access, financial metrics, and patient/staff experience.

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Revisiting the Radiation Therapy Oncology Group 1221 Hypothesis: Treatment for Stage III/IV HPV-Negative Oropharyngeal Cancer

Daniel Jacobs,Sina J. Torabi,Henry S. Park,Rahmatullah Rahmati,Melissa R. Young,Saral Mehra,Benjamin L. Judson

Publication date 17-11-2020


In 2014, the Radiation Therapy Oncology Group 1221 trial was initiated to analyze whether surgery with risk-based radiation therapy or chemoradiation therapy was superior to chemoradiation therapy alone in patients with clinically staged T1-2N1-2bM0 HPV-negative oropharyngeal squamous cell carcinoma. However, the study was prematurely terminated. Given the lack of a randomized controlled trial, we retrospectively approached the same question using large national cancer databases. Retrospective cohort study. The National Cancer Database and Surveillance, Epidemiology, and End Results (SEER) program from 2010 to 2016. We identified 3004 patients in the National Cancer Database and 670 patients in the SEER database. Statistical techniques included Kaplan-Meier survival analysis, binary and multinomial logistic regressions, Cox proportional hazard regressions, and inverse propensity score weighting. On weighted multivariable Cox regression, patients recommended to receive frontline surgery had improved overall survival as compared with those recommended to receive chemoradiation therapy alone (hazard ratio [HR], 0.77; 95% CI, 0.68-0.86). On post hoc multivariable analysis based on therapy actually received, frontline surgery with adjuvant chemoradiation therapy was associated with improved overall survival (HR, 0.59; 95% CI, 0.50-0.71) as compared with chemoradiation therapy without surgery. Analysis of the SEER cohort revealed improved overall survival (HR, 0.69; 95% CI, 0.54-0.87) and head and neck cancer-specific survival (HR, 0.59; 95% CI, 0.41-0.84) in patients recommended to receive frontline surgery over chemoradiation therapy alone. Our findings support the use of surgery with risk-based addition of adjuvant therapy in patients with cT1-2N1-2bM0 HPV-negative oropharyngeal cancer.

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Efficacy and Complications of Microsurgical Neurovascular Decompression in 55 Patients With Hemifacial Spasm

Chloé Compagnon,Marc Labrousse,Esteban Brenet,André Chays,Arnaud Bazin,Jean-Charles Kleiber,Xavier Dubernard

Publication date 17-11-2020


To analyze the efficacy and complications of microvascular decompression for hemifacial spasm. Retrospective study. Regional hospital. Fifty-five patients with hemifacial spasm were treated by microvascular decompression. All patients with hemifacial spasm who underwent retrosigmoid microvascular decompression from May 2004 to January 2017 were included. Patients with no conflict on preoperative magnetic resonance imaging or with an alternate diagnosis were excluded. The overall cure rate was 83.64%, with an average follow-up of 7.4 years. A left-sided hemifacial spasm was a healing-promoting factor ( Microvascular decompression for hemifacial spasm is an effective and lasting technique. Its low rate of complications and the considerable quality-of-life improvement should lead surgeons to propose it to patients as soon as botulinum toxin injections become ineffective or poorly tolerated.

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Gender Representation in Otolaryngology–Head and Neck Surgery Recognition Awards

Wini V. Zambare,Lindsay Sobin,Anna Messner,Jessica R. Levi,Jeremiah C. Tracy,Lauren F. Tracy

Publication date 10-11-2020


The proportion of women in otolaryngology-head and neck surgery (OHNS) has steadily increased in recent years. This study examines gender representation in recognition awards given by OHNS societies between 2009 and 2019. Retrospective analysis of recognition awards given by 10 OHNS societies between 2009 and 2019. Retrospective review of web-based, public records. Data from 19 awards were analyzed for recipient gender ratio, society, subspecialty, award type (research, achievement, or humanitarian), and change over time. Of 184 awards given by societies in otolaryngology-head and neck surgery, 59 (28%) were given to women. Women received 49 (28%) research awards, 9 (31%) humanitarian awards, and 1 (2.8%) achievement award. Women represented 31% of award winners in rhinology/skull base, 30% of award winners in head and neck surgery, 8% in neurotology, and 6% in facial plastic surgery. The American Head and Neck Society Prevention and Early Detection award had the highest representation of women at 43%. Some awards had no female awardees over the past decade. No temporal trends were observed. From 2009 to 2019, women received recognition awards at a higher percentage than overall gender representation in OHNS. Comparison of research, humanitarian, and achievement awards revealed the disparity of women receiving fewer achievement awards relative to men. Gender representation of award recipients varied by subspecialty, which may be partially determined by gender distribution within the fields.

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Does Ibuprofen Increase Bleed Risk for Pediatric Tonsillectomy?

Peggy Leung,Elliana Kirsh DeVore,Kosuke Kawai,Sonia Yuen,Margaret Kenna,Alexandria L. Irace,David Roberson,Eelam Adil

Publication date 10-11-2020


To evaluate risk factors for pediatric posttonsillectomy hemorrhage (PTH) and the need for transfusion using a national database. Retrospective cohort study. The study was conducted using the Pediatric Health Information System (PHIS) database. Children ≤18 years who underwent tonsillectomy with or without adenoidectomy (T±A) between 2004 and 2015 were included. We evaluated the risk of PTH requiring cauterization according to patient demographics, comorbidities, indication for surgery, medications, year of surgery, and geographic region. Of the 551,137 PHIS patients who underwent T±A, 8735 patients (1.58%) experienced a PTH. The risk of PTH increased from 1.33% (95% confidence interval [CI]: 1.15%, 1.53%) in 2010 to 1.91% (95% CI: 1.64%, 2.24%) in 2015 ( The incidence of PTH increased significantly between 2011 and 2015, and ibuprofen appears to be one contributing factor. Given the benefits of ibuprofen, it is unclear whether this increased risk warrants a change in practice.

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What Is the Impact of Prior Authorization on the Incidence of Pediatric Tonsillectomy?

Vanessa F. Torrecillas,Kaden Neuberger,Alexander Ramirez,Paul Krakovitz,Jeremy D. Meier

Publication date 10-11-2020


Third-party payers advocate for prior authorization (PA) to reduce overutilization of health care resources. The impact of PA in elective surgery is understudied, especially in cases where evidence-based clinical practice guidelines define operative candidacy. The objective of this study is to investigate the impact of PA on the incidence of pediatric tonsillectomy. Cross-sectional study. Health claims database from a third-party payer. Any pediatric patient who had evaluation for tonsillectomy from 2016 to 2019 was eligible for inclusion. A time series analysis was used to evaluate the change in incidence of tonsillectomy before and after PA. Lag time from consultation to surgery before and after PA was compared with segmented regression. A total of 10,047 tonsillectomy claims met inclusion and exclusion criteria. Female patients made up 51% of claims, and the mean age was 7.9 years. Just 1.5% of claims were denied after PA implementation. There was no change in the incidence of tonsillectomy for all plan types ( A modest number of tonsillectomy claims were denied approval after implementation of PA. The value of PA for pediatric tonsillectomy is questionable, as it did not result in decreased incidence of tonsillectomy in this cohort.

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Translation and Validation of the Facial Clinimetric Evaluation Scale to Spanish

Leire Garcia-Iza,Carlos Miguel Chiesa-Estomba,Nuria Rosell-Romero,Eneritz Ibarguren-Esnal,Maria Soriano-Reixach,Teresa Rivera-Schmitz,Xabier Altuna,Jose Angel Gonzalez-García

Publication date 10-11-2020


Peripheral facial palsy is a disabling condition; thus, assessing its impact on quality of life is one of the greatest challenges within this discipline. The Facial Clinimetric Evaluation (FaCE) Scale has been validated for this purpose. The aim of this study is to translate and validate the Spanish version of the FaCE Scale. We performed a forward-backward translation of the original English FaCE Scale. A pilot test and a posterior prospective validation study were performed. A pilot test and a posterior prospective validation study were conducted in a specialized facial palsy unit in a tertiary hospital. A validation study was carried out in 85 patients to calculate the scale's internal consistency and validity and to compare outcomes with the Sunnybrook Facial Grading System and the Facial Disability Index (FDI). Internal consistency was evaluated by Cronbach's α coefficient, which showed a value of 0.841 (95% CI, 0.786-0.886). The total FaCE Scale score correlates well with the Sunnybrook, FDI physical function, and FDI social/well-being function scores: The Spanish version of the FaCE Scale demonstrated a high psychometric property that allows it to be used for clinical practice to assess the quality of life of Spanish-speaking patients with peripheral facial palsy.

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Laryngeal Leukoplakia: State of the Art Review

Joseph C. Park,Kenneth W. Altman,Vyas M. N. Prasad,Matthew Broadhurst,Lee M. Akst

Publication date 10-11-2020


This state-of-the-art article reviews the epidemiology, diagnosis, and management of vocal fold leukoplakia, with focus on recent advances. It focuses on the clinical challenges that otolaryngologists face balancing both oncological efficacy and functional outcomes in leukoplakia and presents the current philosophies and techniques to consider when managing such patients. Pub Med/MEDLINE. We conducted a detailed review of publications related to vocal cord and laryngeal leukoplakia, dysplasia, hyperkeratosis, leukoplakia endoscopy, and leukoplakia management focusing specifically on oncologic outcomes, voice preservation, current and emerging diagnosis, and management techniques. There has been a paradigm shift away from performing "vocal cord stripping" procedures that can cause irreversible hoarseness toward voice preservation surgery while achieving comparable oncologic control. Surgical technical and instrumental developments have been designed to maximally treat superficial disease while preserving underling vibratory mucosa. Recent improvements in histopathological grading systems and advances in biomarker classification may allow for improved oncologic risk stratification. Furthermore, improvements in endoscopic imaging capabilities and contact endoscopy are currently being studied for their potential diagnostic significance. To optimally manage vocal fold leukoplakia, the otolaryngologist should become familiar with the oncologic implications of the disease and the importance of obtaining pathologic diagnosis to rule out malignancy. In addition, the surgeon should maintain surgical techniques and knowledge of available instruments and lasers that can assist in surgical management while prioritizing the preservation of vibratory tissue and voice quality. Finally, the surgeon and the patient should understand the clinical importance of routine endoscopic surveillance.

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Hearing Outcomes and Complications in Stapes Surgery for Otosclerosis Performed Under General or Local Anesthesia

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

Publication date 10-11-2020


Stapes surgery is highly successful in reducing or eliminating the audiometric air-bone gap (ABG) related to otosclerosis, and it can be performed under general anesthesia or local anesthesia with sedation. Literature on the relative outcomes of these 2 modalities is lacking. The purpose of this study was to compare hearing outcomes for these 2 modalities in a large patient population. Retrospective review. Large otology referral center. Patients undergoing primary stapes surgery for otosclerosis from 2005 to 2017 were grouped by anesthetic modality and their cases reviewed. Pre- and postoperative ABGs were primary outcomes.
A total of 580 patients undergoing stapes surgery were included: 46% received local anesthesia and 54% received general anesthesia. These 2 groups were similar in demographic and disease characteristics. Mean preoperative ABGs were 25.6 and 26.6 dB for patients undergoing local and general anesthesia, respectively ( Consistent with limited prior data, in this cohort stapes surgery yielded similar hearing outcomes whether performed under general anesthesia or local anesthesia with sedation. While we report the largest sample size to date, this study, like previous work, carries the potential for sampling bias. Prospective study comparing local and general anesthesia for stapes surgery is needed.

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Sinonasal Outcome Scores and Imaging: A Concurrent Assessment of Factors Influencing Their Association

Allen S. Zhou,Anthony A. Prince,Alice Z. Maxfield,C. Eduardo Corrales,Jennifer J. Shin

Publication date 10-11-2020


The overall discriminatory ability of validated instrument scores for computed tomography (CT) findings of chronic rhinosinusitis has limitations and may be modified by multiple factors. To support optimal methods for assessment, we studied which factors could influence this relationship, including the concurrent impact of multiple discrete CT scoring mechanisms, colocalized imaging findings, and nasal comorbid conditions. Observational outcomes study. Academic medical center. Patients with sinonasal complaints who completed the 22-item Sinonasal Outcome Test (SNOT-22) and underwent CT were included. Multivariate ordinal regression was utilized to assess associations. CT data were quantified with the Lund-Mackay system, Zinreich system, and a direct measure of maximal mucosal thickness. The impact of incidental findings (mucous retention cysts, periapical dental disease) and nasal comorbid conditions was also assessed. A total of 233 patients were included. SNOT-22 nasal scores were significantly associated with CT results when those with incidental findings were excluded, regardless of the radiologic scoring mechanism utilized: Lund-Mackay regression coefficient, 0.321 ( SNOT-22 nasal domain scores were associated with all 3 radiologic scoring systems when incidental findings were absent but not when they were present. Delineating the presence or absence of these colocalized findings affected the relationship between SNOT-22 scores and radiological results, beyond other concurrent factors.

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Contemporary Role and Regulation of Over-the-Counter Sinonasal Medications

Edward D. McCoul

Publication date 10-11-2020


Numerous pharmaceutical options are available over-the-counter (OTC) for the relief of sinonasal symptoms. Patients typically utilize these drugs in an unsupervised manner, without appreciation of their relative efficacy or potential for adverse effects. This review covers the scope and regulation of the OTC drug market, the pros and cons of OTC availability, and specific concerns that surround the most common classes of OTC sinonasal drugs. Suggestions are provided for the improvement of patient care and public health. MEDLINE publications and market reports. Literature review. Some of the most commonly used OTC sinonasal remedies, including decongestants and first-generation antihistamines, are less effective than alternative drugs and pose potential safety concerns. Clinicians should advocate to their patients for the appropriate use of alternative agents, such as intranasal corticosteroids and newer-generation antihistamines, and discourage the unsupervised use of oral and topical decongestants. Furthermore, health care practitioners should encourage dialogue with their patients about the use of OTC sinonasal remedies, with the goals of optimizing individual health and health care delivery.

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Medical Student Participation in Otolaryngology Telemedicine Clinic During COVID-19: A Hidden Opportunity

William R. Pellegrini,David O’Neil Danis,Jessica R. Levi

Publication date 10-11-2020


The undergraduate medical student educational experience was greatly altered this year due to coronavirus disease 2019. Many otolaryngology departments increased use of telemedicine technologies to avoid the need for in-person contact. Medical student incorporation into telemedicine clinics is important to increase their comfort with this format of patient care and to continue student exposure to the field of otolaryngology. The technical and logistical aspects of student inclusion in telemedicine clinics at our institution are detailed. While telemedicine is still an evolving tool for experienced practitioners, there are likely advantages to the use of telemedicine patient visits for student learning. These may include closer working relationships between student and preceptor, as well as increased opportunities for student observation and feedback. Medical students should not assume telemedicine experiences are of inferior educational quality to in-person patient interactions. Future research should investigate ways telemedicine could enhance student learning.

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Comprehensive Treatment Strategy for Internal Carotid Artery Blowout Syndrome Caused by Nasopharyngeal Carcinoma

Zhouyang Zhao,Lijin Huang,Jinhua Chen,Weijia Huang,Xiaobin Zhang,Yue Ma,Hongshen Zhu,Zhang Liu

Publication date 10-11-2020


To evaluate a treatment strategy for internal carotid artery blowout syndrome caused by nasopharyngeal carcinoma. A retrospective analysis of a case series was performed. Carotid blowout syndrome is a catastrophic complication caused by malignant tumor of the skull base. A retrospective analysis based on 69 patients with internal carotid artery blowout syndrome admitted to our center between April 2018 and January 2020 was performed.
The patients were divided into 2 groups: an EBBA (internal carotid artery embolization + bypass based on American Society of Intervention and Therapeutic Neuroradiology/Society of Interventional Radiology [ASITN/SIR]) group and an embolization/stent group. The follow-up time was 6 to 9 months. In the EBBA group, 41 patients (41/49, 83.7%) survived. Forty patients had a satisfactory quality of life after 3 months. No death occurred within 3 months. Nonoperative death occurred in 8 cases (8/49, 16.3%). The rate of mortality and disability was 18.4% (9/49). In the embolization/stent group, 16 patients (16/20, 80%) survived. Nonoperative death occurred in 4 cases (4/20, 20%), 3 of which occurred within 1 to 3 months. Four cases reported Modified Rankin Scale ≥2 after 3 months. The rate of mortality and disability was 40% (8/20). A comprehensive revascularization strategy for internal carotid artery (ICA) embolization and intracranial and extracranial bypass grafting based on ASITN/SIR score for ICA blowout syndrome patients not only can prolong the patient survival but also greatly improve the survival probability and quality of life as well as reduce their rate of mortality or disability.

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Potential Influence of Olfactory, Gustatory, and Pharyngolaryngeal Sensory Dysfunctions on Swallowing Physiology in COVID-19

José Vergara,Camila Lirani-Silva,Martin B. Brodsky,Anna Miles,Pere Clavé,Weslania Nascimento,Lúcia Figueiredo Mourão

Publication date 10-11-2020


Persistent smell and taste disorders have been reported as some of the most common symptoms after COVID-19 (coronavirus disease 2019). Sensory, olfactory, and gustatory functions perform an important role in the initiation and modulation of oropharyngeal swallow biomechanics and salivation as well as in mealtime enjoyment and appetite. Yet, the details of this interaction remain relatively unknown in patients who are infected with and recovering from COVID-19. In this commentary, we discuss the possible impacts of SARS-CoV-2 on the central and peripheral nervous system and consider the pathophysiology of olfactory, gustatory, and pharyngolaryngeal sensory deficits and its influence on deglutition, describing hypotheses and offering guidance for future research.

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Feasibility of Implementing Opioid Stewardship Recommendations for Sinonasal Surgery

Jaxon W. Jordan,Christopher Spankovich,Scott P. Stringer

Publication date 03-11-2020


The objective of our study was to review the current literature pertaining to perioperative opioids in sinus surgery and to determine the effects of implementing opioid stewardship recommendations in the setting of endoscopic sinonasal surgery. Single-institution retrospective case-control study. Academic medical center outpatient area. This retrospective review comprised 163 patients who underwent routine functional endoscopic sinus surgery, septoplasty, and/or inferior turbinate reduction before and after implementation of a standardized pain control regimen based on published opioid stewardship recommendations. The regimen consisted of an oral dose of gabapentin (400 mg) and acetaminophen (1000 mg) at least 30 minutes prior to surgery, absorbable nasal packing soaked in 0.5% tetracaine intraoperatively, and a postoperative regimen of acetaminophen and nonsteroidal anti-inflammatory medications. Tramadol tablets (50 mg) were prescribed postoperatively for breakthrough pain. The primary outcome measure for the study was the average number of hydrocodone equivalents (5 mg) prescribed before and after the new protocol. The average number of opioid medications prescribed, measured as hydrocodone equivalents (5 mg), decreased from 24.59 preprotocol to 18.08 after the initiation of the new perioperative regimen ( Opioid stewardship recommendations can be instituted for sinonasal surgery, including multimodal perioperative pain management and substitution of tramadol for breakthrough pain, as a method to decrease the volume of opioids prescribed, without increasing patient phone calls or affecting the likelihood of physician recommendation Press Ganey scores.

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Positive Margins in Cutaneous Melanoma of the Head and Neck: Implications for Timing of Reconstruction

Arya W. Namin,Lauren Welby,Austin T. Baker,Laura M. Dooley

Publication date 03-11-2020


The aim of this study is to identify clinicopathologic features associated with positive margins after surgical treatment of cutaneous melanoma of the head and neck (CMHN). Retrospective cohort study. National Cancer Database. A retrospective analysis of the National Cancer Database was performed of patients diagnosed with CMHN between 2004 and 2016. Univariate and multivariate analyses examining the association of clinicopathologic features with positive margins were performed via logistic regression analysis. A total of 101,560 patients met inclusion criteria. The incidence of positive margins was 5.0% (5128/101,560).
Patients were significantly more likely to have positive margins with the following: increasing age ( The following have been identified as clinicopathologic features associated with positive margins after surgical treatment of CMHN: increasing age, female sex, the lip subsite, the eyelid subsite, the face subsite, ulceration, the lentigo maligna/lentigo maligna melanoma subtype, the desmoplastic subtype, the spindle cell subtype, and increasing pT classification.

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Revisiting the Recommendation for Contralateral Tonsillectomy in HPV-Associated Tonsillar Carcinoma

Harman S. Parhar,David Shimunov,Robert M. Brody,Steven B. Cannady,Jason G. Newman,Bert W. O’Malley,Ara A. Chalian,Christopher H. Rassekh,Gregory S. Weinstein,Karthik Rajasekaran

Publication date 03-11-2020


Despite epidemiologic evidence that second primaries occur infrequently in HPV (human papillomavirus)-associated oropharyngeal squamous cell carcinoma, recent recommendations advocate for elective contralateral palatine tonsillectomy. We aimed to study this discordance and define the necessary extent of up-front surgery in a large contemporary cohort with long-term follow-up treated with unilateral transoral robotic surgery. We hypothesized that second primaries are discovered exceedingly rarely during follow-up and that survival outcomes are not compromised with a unilateral surgical approach. Retrospective cohort analysis. Tertiary care academic center between 2007 and 2017. Records for patients with p16-positive oropharyngeal squamous cell carcinoma of the tonsil and workup suggestive of unilateral disease who underwent ipsilateral transoral robotic surgery were analyzed for timing and distribution of locoregional recurrence, distant metastases, and second primary occurrence as well as survival characteristics. Among 295 included patients, 21 (7.1%) had a locoregional recurrence; 17 (5.8%) had a distant recurrence; and 3 (1.0%) had a second primary during a median follow-up of 48.0 months (interquartile range, 29.5-62.0). Only 1 (0.3%) had a second primary found in the contralateral tonsil. The 2- and 5-year estimates of overall survival were 95.5% (SE, 1.2%) and 90.1% (SE, 2.2%), respectively, while the 2- and 5-year estimates of disease-free survival were 90.0% (SE, 1.8%) and 84.7% (SE, 2.3%). Second primary occurrence in the contralateral tonsil was infrequent, and survival outcomes were encouraging with unilateral surgery. This provides a rationale for not routinely performing elective contralateral tonsillectomy in patients whose workup suggests unilateral disease.

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Tracheostomy During the COVID-19 Pandemic: Comparison of International Perioperative Care Protocols and Practices in 26 Countries

Carol Bier-Laning,John D. Cramer,Soham Roy,Patrick A. Palmieri,Ayman Amin,José Manuel Añon,Cesar A. Bonilla-Asalde,Patrick J. Bradley,Pankaj Chaturvedi,David M. Cognetti,Fernando Dias,Arianna Di Stadio,Johannes J. Fagan,David J. Feller-Kopman,Sheng-Po Hao,Kwang Hyun Kim,Petri Koivunen,Woei Shyang Loh,Jobran Mansour,Matthew R. Naunheim,Marcus J. Schultz,You Shang,Davud B. Sirjani,Maie A. St. John,Joshua K. Tay,Sébastien Vergez,Heather M. Weinreich,Eddy W. Y. Wong,Johannes Zenk,Christopher H. Rassekh,Michael J. Brenner

Publication date 03-11-2020


The coronavirus disease 2019 (COVID-19) pandemic has led to a global surge in critically ill patients requiring invasive mechanical ventilation, some of whom may benefit from tracheostomy. Decisions on if, when, and how to perform tracheostomy in patients with COVID-19 have major implications for patients, clinicians, and hospitals. We investigated the tracheostomy protocols and practices that institutions around the world have put into place in response to the COVID-19 pandemic. Protocols for tracheostomy in patients with severe acute respiratory syndrome coronavirus 2 infection from individual institutions (n = 59) were obtained from the United States and 25 other countries, including data from several low- and middle-income countries, 23 published or society-endorsed protocols, and 36 institutional protocols. The comparative document analysis involved cross-sectional review of institutional protocols and practices. Data sources were analyzed for timing of tracheostomy, contraindications, preoperative testing, personal protective equipment (PPE), surgical technique, and postoperative management. Timing of tracheostomy varied from 3 to >21 days, with over 90% of protocols recommending 14 days of intubation prior to tracheostomy. Most protocols advocate delaying tracheostomy until COVID-19 testing was negative. All protocols involved use of N95 or higher PPE. Both open and percutaneous techniques were reported. Timing of tracheostomy changes ranged from 5 to >30 days postoperatively, sometimes contingent on negative COVID-19 test results. Wide variation exists in tracheostomy protocols, reflecting geographical variation, different resource constraints, and limited data to drive evidence-based care standards. Findings presented herein may provide reference points and a framework for evolving care standards.

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Temporal Bone Fractures Caused by Ballistic Projectiles: A Systematic Review

Kenneth L. Kennedy,Elizabeth Cash,Jessica Petrey,Jerry W. Lin

Publication date 03-11-2020


Ballistic injuries to the temporal bone are uncommon but devastating injuries that damage critical neurovascular structures. This review describes outcomes after ballistic injuries to the temporal bone and offers initiatives for standardized high-quality future research. A systematic search of Pub Med, Embase, and Cochrane. Studies in the review included adults who experienced temporal bone fractures due to gunshot wounds and survived longer than 48 hours. Individual case reports were excluded. The various searches returned 139 results, of which 6 met inclusion criteria. Most of the included studies are case series with low-level evidence that report a wide range of outcomes and follow-up. Outcomes include demographic patient information, audiologic outcomes, vascular injuries, intracranial complications, facial nerve function, and surgical indications. This review is the first to characterize the nature and progression of patients who experienced gunshot wounds to the temporal bone. Although all patients share an etiology of injury, they often have vastly different hospital courses and outcomes. This review provides a basis for future studies to guide care for these injuries, as most of the existing literature includes small dated case series.

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Coagulation States in Patients With Sudden Sensorineural Hearing Loss Evaluated by Thromboelastography

Chunyan Li,Huiqun Zhou,Yanmei Feng,Yan Zhao,Jingjing Wang,Zhengnong Chen,Shankai Yin

Publication date 03-11-2020


The state of coagulation is controversial in patients with sudden sensorineural hearing loss (SSNHL). We used thromboelastography (TEG) to explore the relationships between blood coagulation parameters and SSNHL pathogenesis and recovery. Prospective study. Affiliated Sixth People's Hospital, Shanghai Jiao Tong University. A total of 104 newly diagnosed patients with SSNHL and 29 matched healthy controls were recruited. Hearing assessments, TEG, and conventional coagulation tests (CCTs) were performed, followed by standard treatments and follow-up. The TEG parameters of patients with SSNHL were in the normal range, but the group exhibited a significantly prolonged kinetic time (K; Although the K value and angle were significantly increased and significantly reduced, respectively, in the test group as compared with the control group, the state of coagulation in patients with SSNHL was still within the normal range. No CCT or TEG coagulation parameters (except the angle) differed significantly among patients in each group according to hearing recovery status, which suggested that the coagulation status does not determine the prognosis of patients with SSNHL.

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Quantification and Comparison of Droplet Formation During Endoscopic and Microscopic Ear Surgery: A Cadaveric Model

Lukas Anschuetz,Abraam Yacoub,Tobias Buetzer,Ignacio J. Fernandez,Wilhelm Wimmer,Marco Caversaccio

Publication date 03-11-2020


The COVID-19 pandemic and the disproportional spread of the disease among otorhinolaryngologists raised concerns regarding the safety of health care staff. Therefore, a quantitative risk assessment for otologic surgery would be desirable. This study aims to quantitatively compare the risk of perioperative droplet formation between microscopic and endoscopic approaches. Experimental research. Temporal bone laboratory. The middle ear of whole head specimens was injected with fluorescein (0.2 mg/10 mL) before endoscopic and microscopic epitympanectomy and mastoidectomy. Fluorescent droplet deposition on the surgical table was recorded under ultraviolet light, quantified, and compared among the interventions. Drilling time, droplet proportion, fluorescein intensity, and droplet size were assessed for every procedure.
A total of 12 procedures were performed: 4 endoscopic epitympanectomies, 4 microscopic epitympanectomies, and 4 mastoidectomies. The mean (SD) proportion of fluorescein droplets was 0.14‰ (0.10‰) for endoscopic epitympanectomy and 0.64‰ (0.31‰) for microscopic epitympanectomy. During mastoidectomy, the deposition of droplets was 8.77‰ (6.71‰). Statistical comparison based on a mixed effects model revealed a significant increase (0.50‰) in droplet deposition during microscopic epitympanectomy as compared with endoscopic epitympanectomy (95% CI, 0.16‰ to 0.84‰). There is considerable droplet generation during otologic surgery, and this represents a risk for the spread of airborne infectious diseases. The endoscopic technique offers the lowest risk of droplet formation as compared with microscopic approaches, with a significant 4.5-fold reduction of droplets between endoscopic and microscopic epitympanectomy and a 62-fold reduction between endoscopic epitympanectomy and cortical mastoidectomy.

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Hormonal Outcomes Following Hemithyroidectomy

Lauren Anne Buehler,Nabil Zuhayr Madhun,James Bena,Christian Nasr,Joseph Scharpf,Keren Zhou

Publication date 03-11-2020


To assess hormonal outcomes and thyroid hormone (TH) replacement after hemithyroidectomy (HT). Retrospective chart review. Quaternary care hospital system. A retrospective analysis was performed on patients who had an HT at Cleveland Clinic between 2000 and 2010 with outcomes assessed up to 5 years post-HT. Patients with overt hypothyroidism (OH; thyroid-stimulating hormone [TSH] >10 mIU/L, TSH >4.2 mIU/L on thyroid hormone [TH]), subclinical hypothyroidism (SH; TSH >4.2-10 mIU/L, no TH), or euthyroidism (EU; TSH 0.4-4.2 mIU/L, no TH) were compared. Patients with SH who returned to EU were compared to those who continued to have SH. For immediate start on TH, a receiver operating characteristic analysis was performed to determine dosage of TH above which suppression of TSH <0.4 mIU/L was predicted. We identified 335 patients (average age 51 years, 78% female, median follow-up of 50 months). Of the 210 not immediately started on TH, 32.4% were OH, 13.3% were SH, and 54.3% were EU. EU patients were younger (48 years), had more remaining gland, were less likely to have lymphocytic infiltrate, and had a lower preoperative TSH (1.2 mIU/L). In the SH group, 58.3% of patients normalized their TSH. With immediate TH start, 45% developed suppressed TSH. Those on LT4 >1.05 mcg/kg/d were more likely to suppress (sensitivity 89%). Most patients post-HT will remain EU, and immediate start of TH may lead to TSH suppression. Those with SH may ultimately normalize TSH. These findings together suggest that observation may be a better option than TH replacement after HT.

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Search Trends and Quality of Online Resources Regarding Thyroidectomy

Lena W. Chen,Vandra Chatrice Harris,Justin Lee Jia,Deborah Xingchun Xie,Ralph Patrick Tufano,Jonathon Owen Russell

Publication date 03-11-2020


Thyroidectomy is one of the most common procedures performed in head and neck surgery. The quality of online resources for thyroidectomy is unknown. We aim to evaluate search trends and online resource quality regarding thyroidectomy. Cross-sectional analysis. Websites appearing on Google search. The first 30 Google websites for thyroidectomy were reviewed, excluding research, video, and restricted sites. Search patterns were obtained with Google Trends. Quality was measured by readability (Flesch Reading Ease and Flesch-Kinkaid Grade Level), understandability and actionability (Patient Education Materials Assessment Tool), and clinical practice guideline (CPG) compatibility. Fleiss kappa interrater reliability analysis was performed for 2 raters. Twenty-one sites were evaluated. Search popularity for thyroidectomy has increased since 2004. Median reading ease was 42.2 (range, 15.4-62.7) on a scale from 1 to 100, with 100 indicating maximum readability. Median reading grade level was 12 (range, 7-16). Thyroidectomy resources were poorly understandable (median, 66%; range, 21%-88%) and actionable (median, 10%; range, 0%-60%). Median CPG compatibility was 4 out of 5 (range, 0-5). Interrater reliability ranged from substantial to moderate for understandability (0.78), actionability (0.57), and CPG compatibility (0.58), with Online resources about thyroidectomy vary in quality and reliability and are written at grade levels above the average reading level of the public. Providers should be aware of existing resources and work to create education resources that meet universal health literacy guidelines. The framework provided in this article may also serve as a guide and provide tangible steps that providers can take to help patients access care.

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Targeted Molecular Therapies in Allergy and Rhinology

Cecelia C. Damask,Matthew W. Ryan,Thomas B. Casale,Mario Castro,Christine B. Franzese,Stella E. Lee,Joshua M. Levy,Sandra Y. Lin,Peter A. Lio,Anju T. Peters,Michael P. Platt,Andrew A. White

Publication date 03-11-2020


Biologic agents, monoclonal antibodies that target highly-specific molecular pathways of inflammation, are becoming integrated into care pathways for multiple disorders that are relevant in otolaryngology and allergy. These conditions share common inflammatory mechanisms of so-called Type 2 inflammation with dysregulation of immunoglobulin E production and eosinophil and mast cell degranulation leading to tissue damage. Biologic agents are now available for the treatment of chronic rhinosinusitis with nasal polyps (CRSwNP), asthma, eosinophilic granulomatosis with polyangiitis (EGPA), atopic dermatitis (AD), and chronic spontaneous urticaria (CSU). This paper summarizes the diagnosis and management of these conditions and critically reviews the clinical trial data that has led to regulatory approval of biologic agents for these conditions.

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Pregnancy, Estrogen Exposure, and the Development of Otosclerosis: A Case-Control Study of 1196 Women

Robert J. Macielak,John P. Marinelli,Douglas J. Totten,Christine M. Lohse,Brandon R. Grossardt,Matthew L. Carlson

Publication date 27-10-2020


This study sought to determine whether a history of pregnancy or bilateral oophorectomy is associated with subsequent otosclerosis development or disease severity. Population-based case-control study. Olmsted County, Minnesota. Women diagnosed with otosclerosis were matched to 3 women without otosclerosis based on age and historical depth of medical records. Associations of prior delivery and bilateral oophorectomy with subsequent development of otosclerosis and with pure-tone average (PTA) at the time of otosclerosis diagnosis were evaluated.
We studied 1196 women: 299 cases of otosclerosis and 897 matched controls. The odds ratio for the association of ≥1 delivery with otosclerosis was 1.16 (95% confidence interval [CI] 0.85-1.60; These data do not support a relationship between endogenous estrogen exposure and development of otosclerosis. Women with otosclerosis who had a history of pregnancy did not have significantly worse hearing at the time of diagnosis, suggesting that pregnancy is not associated with disease severity.

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Hearing Loss–Related Issues Affecting Quality of Life in Preschool Children

Miranda Lindburg,Banan Ead,Donna B. Jeffe,Judith E. C. Lieu

Publication date 20-10-2020


The impact of hearing loss (HL) on quality of life (QOL) in young children has not been examined systematically. The objective of this study was to examine patient, parent, and professional perspectives on experiences and situations that affect the QOL in young children with HL and to identify themes that emerged from coded data to develop a parent-proxy QOL measure for young children with HL. Qualitative study with 6 focus groups followed by semistructured interviews with other parents and professionals as stakeholder checks. Academic medical center and local schools for the deaf. Audiology department clinic lists were used to identify eligible participants, who included 5- to 7-year-old children with permanent HL and parents of 2- to 7-year-old children with permanent HL. A sample of 6 children and 12 parents participated in focus groups. An audiology department and multiple schools for the deaf in the area were contacted to recruit for professional participants, resulting in a sample of 10 professionals who participated in focus groups. Focus groups and interviews were audiotaped and transcribed verbatim. Inductive thematic analysis of focus group transcripts identified key concepts and emerging themes of how HL affects young children.
Six themes emerged from the data: behavior, feelings, environments, social/activities, family, and hearing equipment. Child, parent, and professional focus group themes overlapped well, and data saturation was reached. These qualitative data provided insight into HL-related issues affecting young children's QOL and were used to create items for a new parent-proxy QOL questionnaire.

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Improving Attendance and Patient Experiences During the Expansion of a Telehealth-Based Pediatric Otolaryngology Practice

Caroline M. Kolb,Kristen Born,Karen Banker,Patrick C. Barth,Nicole Leigh Aaronson

Publication date 20-10-2020


To determine the rates and primary causes of missed appointments (MAs) for telehealth visits and present remedies for improvement. This cross-sectional survey was conducted at a tertiary care pediatric otolaryngology practice during expansion of telehealth-based visits. A review of questionnaire responses was performed for 103 consecutive patients with MAs over 50 business days from March 20, 2020, to May 29, 2020. Families were asked a brief survey regarding the cause of the MA and assisted with technical support and rescheduling. MA rates and causes were analyzed. The overall MA rate during the initiation of telehealth services was significantly increased at 12.4% as compared with clinic-based visits of a similar duration before COVID of 5.2% ( Technical difficulties were the most commonly reported cause of missed telehealth appointments. Optimization of applications by providing patient reminders, determining need for translator assistance, and reducing required upload/download speeds may significantly reduce rates of MAs and conversions to other communication. Clear, concise education materials on the technical aspects of telehealth, platform optimization, and robust technical and administrative support may be necessary to reduced missed telehealth appointments and support large-scale telehealth operations. An assessment of institutional capacity is critical when considering telehealth expansion.

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Primary Treatment Selection for Clinically Node-Negative Merkel Cell Carcinoma of the Head and Neck

Daniel Jacobs,Kelly Olino,Henry S. Park,James Clune,Shayan Cheraghlou,Michael Girardi,Barbara Burtness,Harriet Kluger,Benjamin L. Judson

Publication date 20-10-2020


Merkel cell carcinoma practice guidelines recommend sentinel lymph node biopsy after wide local excision for the initial management of clinically node-negative disease without distant metastases (cN0M0). Despite guideline publication, treatment selection remains variable. We hypothesized that receipt of guideline-recommended care would be more common in patients evaluated at academic centers and institutions with high melanoma case volumes and that such therapy would be associated with improved overall survival. Retrospective cohort analysis. The National Cancer Database from 2004 to 2015. A total of 3500 patients were included. We utilized Kaplan-Meier analysis and logistic and Cox proportional hazard regressions. Survival analysis was performed on inverse probability-weighted cohorts. There has been a trend toward evaluation at academic programs at a rate of 1.58% of patients per year (95% CI, 1.06%-2.11%) since 2004. However, the percentage of patients receiving guideline-compliant primary tumor excision and lymph node evaluation has plateaued at approximately 50% since 2012. Guideline-compliant surgical management was more commonly provided to patients evaluated at academic programs than nonacademic programs but only when those institutions had a high melanoma case volume (odds ratio, 2.01; 95% CI, 1.62-2.48). Receipt of guideline-compliant primary tumor excision and lymph node evaluation was associated with improved overall survival (hazard ratio, 0.70; 95% CI, 0.64-0.76). Facility factors affect rates of receipt of guideline-compliant initial surgical management for patients with node-negative Merkel cell carcinoma. Given the survival benefit of such treatment, patients may benefit from care at hospitals with high melanoma case volumes.

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Radiofrequency Ablation vs Electrocautery Blinded Randomized Trial: Impact on Clinically Meaningful Outcomes

Aaron J. Prussin,Eric Babajanian,Marc Error,J. Fredrik Grimmer,Jessica Ku,Bryan McRae,Jeremy Meier,Heather Thiesset,Jonathan R. Skirko

Publication date 20-10-2020


To analyze patients' return to normal activity, pain scores, narcotic use, and adverse events after undergoing tonsillectomy or adenotonsillectomy with monopolar electrocautery or radiofrequency ablation. Randomized double-blinded clinical trial based on prospective parallel design. Academic medical center and tertiary children's hospital between March 2018 and July 2019. Inclusion criteria included patients aged ≥3 years with surgical indication of recurrent tonsillitis or airway obstruction/sleep-disordered breathing. Patients were randomly assigned to monopolar electrocautery or radiofrequency ablation. Patients were blinded to treatment assignment. Survey questions answered via text or email were collected daily until postoperative day 15. The primary outcome was the patient's return to normal activity. Secondary outcomes included daily pain score, total amount of postoperative narcotic use, and adverse events. Of the 236 patients who met inclusion criteria and were randomly assigned to radiofrequency ablation or monopolar electrocautery, 230 completed the study (radiofrequency ablation, n = 112; monopolar electrocautery, n = 118). There was no statistically significant difference between the groups in the number of days for return to normal activity ( As one of the largest randomized controlled trials examining instrumentation in tonsillectomy, our data do not show a difference between monopolar electrocautery and radiofrequency ablation with regard to return to normal activity, daily pain scores, total postoperative narcotic use, or adverse events.

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Association Between Age and Nodal Metastasis in Papillary Thyroid Carcinoma

Navika Shukla,Nosayaba Osazuwa-Peters,Uchechukwu C. Megwalu

Publication date 20-10-2020


To determine the relationship between age and rate of lymph node metastasis, nodal burden of disease, as well as rate of lateral neck disease in papillary thyroid cancer, especially in patients aged <30 years. Population-based cross-sectional study. Population-based cancer database. Data were extracted from the SEER 18 database (Surveillance, Epidemiology, and End Results) of the National Cancer Institute. The study cohort included 59,330 patients diagnosed with papillary thyroid cancer between 1988 and 2015. Patients aged 0 to 10 years, 11 to 20 years, and 21 to 30 years old were compared with those >30 years. All analyses were adjusted for sex, race, and T classification. The overall rate of lymph node metastasis was 26.11%, which increased with decreasing age. Adjusted odds ratios of lymph node metastasis were 7.19 (95% CI, 3.76-13.75) for the 0- to 10-year-old group, 3.45 (95% CI, 3.08-3.87) for the 11- to 20-year-old group, and 2.28 (95% CI, 2.15-2.41) for the 21- to 30-year-old group, relative to the group >30 years old. Decreased age was also associated with increased total positive nodes, increased lymph node ratio, and increased risk of lateral neck disease. Pediatric and early young adult patients with papillary thyroid carcinoma have a greater risk of lymph node metastasis, greater burden of nodal disease, and a greater risk of lateral neck metastases.

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Ideas and Innovations to Improve the Otolaryngology–Head and Neck Surgery Residency Application and Selection Process

Parsa P. Salehi,Alyssa Heiser,Pauniz Salehi,R. Peter Manes,Benjamin L. Judson,Babak Azizzadeh,Yan Ho Lee

Publication date 20-10-2020


To (1) summarize strategies proposed in the recent otolaryngology-head and neck surgery (OTO-HNS) literature for improving the residency application and selection process, (2) evaluate the effects of recently implemented changes to the OTO-HNS match, and (3) discuss recommendations for future changes to the OTO-HNS residency application and selection process. Pub Med, Medline Ovid database, and article reference lists. A structured literature search was performed to identify current English language articles relating to the objectives of this study using the aforementioned data sources, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) guidelines. The search was limited to submissions published between January 1, 2015, and January 1, 2020. Numerous proposals have been made for improving the otolaryngology residency application and selection process and addressing the competitive nature of the Match. These proposals include but are not limited to mandating a secondary essay, implementing consortia and early match processes, using a signaling system, conducting regional and web-based interviews, offering early engagement with interest groups, instituting a hard cap on applications, increasing costs of applying, counseling self-restraint to prospective applicants, and creating application filters. As the volume of literature surrounding the OTO-HNS Match continues to increase, this review aims to provide a summary of past proposals and serve as a guide for possible future innovations. We propose 3 initiatives that may improve the residency application and selection process for both program and resident, with minimal impact to the current National Resident Matching Program (NRMP) Match structure.

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Preablation Diagnostic Whole-Body Scan vs Empiric Radioactive Iodine Ablation in Differentiated Thyroid Cancer: Cost-effectiveness Analysis

Simran Arjani,Patrick L. Quinn,Ravi J. Chokshi

Publication date 20-10-2020


To perform a comparative analysis of postthyroidectomy radioactive iodine ablation dosing with or without the implementation of a diagnostic whole-body scan in patients with well-differentiated thyroid cancer. Decision analysis model. Hospital or ambulatory center. A decision tree model was created to determine the cost-effectiveness of radioactive iodine ablation dosed with diagnostic whole-body scans versus empiric radioactive iodine ablation in patients with differentiated thyroid cancer undergoing postthyroidectomy ablation. The decision tree was populated with values from the published literature. Costs were represented by 2020 Medicare reimbursement rates (US dollars), and morbidity and survival data were used to calculate quality-adjusted life-years. The incremental cost-effectiveness ratio was the primary outcome. Empiric radioactive iodine dosing was the dominant economic strategy, producing 0.94 more quality-adjusted life-years while costing $1250.07 less than management with a diagnostic whole-body scan. Sensitivity analyses upheld these results except in cases involving a large discrepancy in successful ablation rates between the diagnostic and empiric treatment arms. For patients with differentiated thyroid cancer requiring postthyroidectomy ablation, it is more cost-effective to administer radioactive iodine empirically.

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Interpretation of Normal and Abnormal Tympanogram Findings in Eustachian Tube Dysfunction

Sean M. Parsel,Graham D. Unis,Spenser S. Souza,Heather Bartley,Jeffrey M. Bergeron,Adam N. Master,Edward D. McCoul

Publication date 20-10-2020


To characterize the relationship between objective tympanogram values and patient-reported symptoms and associations with common comorbid conditions. Cross-sectional study with prospective data collection. Tertiary medical center. Patients undergoing routine audiometric evaluation between October 2018 and June 2019 were included. Participants with temporomandibular joint dysfunction, inner ear hydrops, and similar conditions were excluded. Symptoms were assessed with the 7-item Eustachian Tube Dysfunction Questionnaire. Demographics and medical comorbidities were recorded from the medical record. Analysis of tympanometric peak pressure (TPP), demographics, and comorbidities was performed to determine associations with clinically significant eustachian tube dysfunction (ETD) symptoms.
A total of 250 patients were included with similar demographics: 101 (40.4%) in the asymptomatic group and 149 (59.6%) in the symptomatic group. The median (interquartile range) TPP was -10 (20) da Pa and -25 (100) da Pa in the asymptomatic and symptomatic groups, respectively. A diagnosis of rhinitis was more likely to be associated with significant ETD symptoms (adjusted odds ratio, 2.61; 95% CI, 1.23-5.63). A subgroup analysis revealed that symptomatic patients with normal TPP values were negatively skewed as compared with asymptomatic patients. This symptomatic group had a higher prevalence of rhinitis and chronic rhinosinusitis than the asymptomatic group. Patients with symptoms of ETD may have a TPP within a range typically considered normal per conventional standards. This suggests that the currently accepted interpretation of tympanometry findings may be insensitive for the diagnosis of less severe cases of ETD.

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Role of Otorhinolaryngologists During COVID-19 Crisis in Developing Countries

Neha Shakrawal

Publication date 20-10-2020


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Ultrasound Localization and Percutaneous Electrical Stimulation of the Hypoglossal Nerve and Ansa Cervicalis

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

Publication date 20-10-2020


Hypoglossal nerve stimulation for obstructive sleep apnea (OSA) can be effective for appropriately selected patients, but current patient selection criteria are complex and still result in a proportion of nonresponders. Ansa cervicalis stimulation of the infrahyoid cervical strap muscles has recently been proposed as a new form of respiratory neurostimulation (RNS) therapy for OSA treatment. We hypothesized that percutaneous stimulation of both nerves in humans with temporary electrodes would make testing of the physiologic response to different RNS strategies possible. Nonrandomized acute physiology study. Tertiary care hospital. Fifteen participants with OSA underwent ultrasonography and placement of percutaneous electrodes proximal to the medial division of the hypoglossal nerve and the branch of the ansa cervicalis innervating the sternothyroid muscle (AC The hypoglossal nerve was successfully localized in 15 of 15 (100%) participants and successfully stimulated in 13 of 15 (86.7%). The AC The hypoglossal nerve and AC

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Airway Hemangiomas in PHACE Syndrome: A Multicenter Experience

Josephine A. Czechowicz,Tania Benjamin,Randall A. Bly,Sheila N. Ganti,Daniel M. Balkin,Jonathan A. Perkins,Ilona J. Frieden,Kristina W. Rosbe

Publication date 20-10-2020


To describe the prevalence and clinical characteristics of airway findings in a multi-institutional cohort of PHACE patients. Multicenter retrospective case series. Multidisciplinary vascular anomalies clinics at 2 institutions. Data were collected from the electronic medical record, including clinical presentation, airway findings, treatment, and outcomes. Of 55 PHACE patients, 22 (40%) had airway hemangiomas. Patients with airway involvement were more commonly female ( Risk factors for airway involvement in PHACE include female gender, Caucasian ethnicity, and stridor. Since the widespread use of propranolol, fewer patients have required surgical management of their airway disease. Given the high prevalence of airway involvement even in patients without stridor, assessment of the airway is a crucial component of a comprehensive PHACE workup.

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Endoscopic Multipoint Laser System for Objective Pediatric Airway Assessment

Andrew Christopher Hall,Annakan Victor Navaratnam,Elizabeth Maughan,Benjamin Hartley,Richard J. Hewitt,Colin Butler

Publication date 20-10-2020


Recent technological advances within aeronautical engineering have demonstrated the delivery of objective quantitative endoscopic measurements to within one-hundredth of a millimeter. We sought to validate this emerging laser technology in a simulation-based assessment of pediatric airway stenosis. A 4.4-mm flexible endoscope, incorporating a laser measurement system projecting 49 laser points into the endoscopic view, was used to assess a simulated model of subglottic stenosis. Multiple anteroposterior and lateral measurements were obtained for each stenosis and compared with standard airway assessment techniques. Intra- and interobserver reliability was assessed. A total of 240 multipoint laser measurements were obtained of simulated airway stenosis. The mean difference from manual measurement was 0.1886 mm. The Bland-Altman plot showed low bias (0.011) and narrow 95% limits of agreement (-0.46 to 0.48). This advanced endoscopic measurement technique shows great promise for clinical development to benefit ongoing assessment and treatment of evolving pediatric airway stenosis.

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Idiopathic Subglottic Stenosis: An Institutional Review of Outcomes With a Multimodality Surgical Approach

Christopher D. Dwyer,Mehdi Qiabi,Dalilah Fortin,Richard I. Inculet,Anthony C. Nichols,S. Danielle MacNeil,Richard Malthaner,John Yoo,Kevin Fung

Publication date 13-10-2020


This article reports on a unique cohort of patients with idiopathic subglottic stenosis spilt fairly equally between endoscopic and open surgical approaches. Patients' sequence of operations and reinterventions over time are outlined, offering insight to improve surgical counseling and allow for informative, autonomous patient decision making. Retrospective cohort study. Tertiary care academic center. Cases of consecutive adults with idiopathic subglottic stenosis managed surgically over a 12-year period (January 2006-December 2017) were retrospectively reviewed. Surgical workflow, complications, and outcomes, including reinterventions and tracheotomy dependence, are reported. Seventy-two patients (71 women; mean age, 50.4 years) with idiopathic subglottic stenosis requiring surgical airway intervention were identified. Six patients underwent tracheotomy prior to attempt at airway stenosis surgery. Initial surgical approach thereafter included endoscopic (73.5%, n = 53) and open (26.4%, n = 19) procedures. Thirty-one patients underwent cricotracheal resection; the reintervention rate was 22.5%. Sixty patients underwent 147 endoscopic procedures; the reintervention rate was 75.5%, and the mean time between dilations was 83 weeks (range, 5-402). Two (2.8%) patients remain tracheotomy dependent. Adverse events were significantly higher in the cricotracheal group, especially with respect to dysphonia and temporary gastrostomy tube placement ( Endoscopic and open surgical airway intervention can be employed successfully to avoid tracheotomy dependence and maintain airway patency; however, multiple procedures are usually required, regardless of surgical approach. Cricotracheal reintervention rates are lower than endoscopic dilation but with increased morbidity. Quality-of-life outcomes should be clearly discussed with patients before deciding on a surgical management strategy.

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Myringoplasty With an Ultrathin Cartilage-Perichondrium Complex Graft Versus Temporalis Fascia Graft: A Propensity Score–Matched Analysis

Yi-Bo Huang,Lu-lu Hu,Dong-Dong Ren,Zhao Han

Publication date 13-10-2020


To compare endoscopic myringoplasty using the cartilage-perichondrium complex as a graft (test group) with temporalis fascia microscopic myringoplasty (control group). A retrospective cohort study. Department of Otorhinolaryngology in a tertiary Chinese hospital. Data were collected on patients between 2017 and 2019. To balance the baseline characteristics between groups, we performed a propensity score-matched analysis, and 44 patients were included in each group. Hearing improvement and eardrum closure rates were compared, and risk factors affecting them were analyzed. In the control and test groups, 90.90% and 86.36% of patients had a mean air-bone gap ≤20 dB after the surgery, respectively ( Endoscopic myringoplasty using a cartilage-perichondrium complex graft is comparable with traditional surgery. Age, location of the perforation, and middle ear mucosal status did not significantly affect the change in air-bone gap or the drum closure rate. A perforation size ≥50% was always associated with a better air-bone gap improvement.

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Self-perceived Taste and Flavor Perception: Associations With Quality of Life in Patients With Olfactory Loss

David T. Liu,Gerold Besser,Bernhard Prem,Gunjan Sharma,Marlene M. Speth,Ahmad R. Sedaghat,Christian A. Mueller

Publication date 13-10-2020


To evaluate associations between self-perceived chemosensory functions of smell, taste, and flavor perception with olfactory-specific quality of life (QoL) in patients with olfactory dysfunction (OD) and whether these associations would be influenced by other factors, such as duration or etiology of smell loss. Retrospective cohort study. Tertiary care, academic center. Olfactory-specific QoL was measured with the Questionnaire of Olfactory Disorders (QOD). The QOD measures the impact of OD on QoL (QOD-negative statements) and the ability of patients to cope with smell loss (QOD-positive statements). Orthonasal olfactory function, patients' demographics, self-perceived chemosensory perception, and duration and etiology of OD were retrospectively collected in a cohort of patients with quantitative OD. Correlations and multivariable linear regression models were computed to determine possible associations with the outcome measure of QOD-negative and QOD-positive statement scores. A total of 133 patients with OD were included. Analysis revealed a positive correlation between self-perceived taste and flavor perception with QOD-negative statement scores, while self-perceived smell showed no significant correlation. Similarly, longer duration of smell loss and higher age were also correlated with higher QOD-positive statement scores. Multivariable regression models confirmed that self-perceived taste was independently associated with the QOD-negative statement score, while age and duration of OD were independently associated with the QOD-positive statement score. These findings suggest that the impact of diminished flavor perception during eating and drinking has a stronger impact on the QoL of patients with OD as compared with decreased orthonasal olfaction.

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Velcro Ties in Early Postoperative Pediatric Tracheostomy Care: A Systematic Review and Meta-analysis

Brent A. Chang,Joshua Gurberg,Erin Ware,Kimberly Luu

Publication date 13-10-2020


To systematically review the literature to determine the difference in complications between standard twill and Velcro ties following pediatric tracheostomy. MEDLINE, Embase, the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, Web of Science, and CINAHL Plus were searched up to August 2020. Two authors independently screened articles for eligibility. Retrospective and prospective studies were included as long as there was a direct comparison between twill and Velcro ties. Quantitative and qualitative analysis was performed. The main outcomes were skin-related complications and accidental decannulation.
Three studies were included in the final analysis: 1 randomized prospective trial and 2 retrospective studies. There were 238 patients total (137 twill, 101 Velcro). Combined analysis showed skin-related complications in 23% of the Velcro group and 44% of the twill group. Meta-analysis for skin-related complications showed no significant difference when comparing Velcro with standard twill ties (risk ratio, 0.53 [95% CI, 0.24-1.17]; Based on limited data, skin-related complications were not statistically different between Velcro and twill ties. Accidental decannulation is rare with Velcro and standard twill ties, and both are viable options following pediatric tracheostomy.

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Can Computed Tomography Findings Predict the Recurrence of Sinonasal Inverted Papilloma?

Eran Glikson,Alberto Dragonetti,Ethan Soudry,Noa Rozendoren,Roee Landsberg,Lev Bedrin,Francesco Mozzanica,Shay Schneider,Arkadi Yakirevitch

Publication date 13-10-2020


To evaluate the correlation between the ability to predict the attachment site of sinonasal inverted papilloma by computed tomography and the long-term surgical outcome. Retrospective cohort study. Five tertiary medical centers. Study patients underwent attachment-oriented resection of inverted papilloma. The primary outcome was tumor recurrence. Among 195 patients eligible for the study, focal hyperostosis was recognized on computed tomography in 65% (n = 127), in 71% of primary cases (n = 101), and in 50% of revision procedures (n = 26). There was a trend for a higher incidence of squamous cell carcinoma among the patients without detectable hyperostosis ( Detectability of focal hyperostosis on preoperative computed tomography does not affect the long-term outcome of inverted papilloma resection.

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Association Between the Duration of Hearing Loss and Hearing Outcomes in Surgery for Otosclerosis

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

Publication date 13-10-2020


Hearing loss due to otosclerosis is effectively treated with surgery. The association between duration of hearing loss and surgical outcomes is unknown. Retrospective review. Large otology referral center. Patients undergoing primary stapes surgery for otosclerosis from 2005 to 2017 were evaluated according to their self-reported duration of hearing loss. Closure of the air-bone gap (ABG) was the primary outcome measure. A total of 580 stapes operations were included. Sixteen percent of patients reported hearing loss for ≤1 year; 25%, >1 to ≤5 years; 24%, >5 to ≤10 years; 24%, >10 to ≤20 years; and 12%, >20 years, respectively. Average pre- and postoperative ABGs were 26.1 and 9.6 dB ( Otosclerosis is effectively treated with surgery even after a long duration of hearing loss, provided that sensorineural hearing and word recognition are favorable. Although far-advanced otosclerosis has known poorer hearing outcomes after stapes surgery, a long duration of hearing loss is an unreliable surrogate for this.

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Clinical Radiographic Predictors of Response to Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea

Clara H. Lee,Everett G. Seay,James W. Reese,Xin Wu,Richard J. Schwab,Brendan Keenan,Raj C. Dedhia

Publication date 13-10-2020


To determine if clinically acquired cephalometric measurements, specifically soft palate size, can predict hypoglossal nerve stimulation outcomes. Combined prospective cohort study and retrospective review. US sleep otolaryngology training program. Adults with obstructive sleep apnea and apneahypopnea index greater than 15 events/h who underwent hypoglossal nerve stimulation. Eligible subjects had diagnostic preoperative sleep studies and full-night efficacy postoperative studies for analysis. Lateral neck x-rays were obtained as part of routine clinical care and measured for key cephalometric variables by trained head and neck radiologists. Continuous variables were compared using the Student Fifty-one patients met all study criteria. On average, patients were white, middle aged, and overweight. Following hypoglossal nerve stimulation, the overall cohort achieved a significant apnea-hypopnea index reduction from 36.7 events/h to 20.6 events/h ( Patient-specific anatomic factors, specifically soft palate thickness, may help identify optimal candidates for hypoglossal nerve stimulation. A larger, prospective study including both anatomic and physiologic variables is required to validate these findings.

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In-Practice Endocrine Surgery Fellowship: A Novel Training Model

Hien T. Tierney,Leslie S. Eldeiry,Jeffrey R. Garber,Chia A. Haddad,Mark A. Varvares,Ralph A. Iannuzzi,Gregory W. Randolph

Publication date 13-10-2020


Endocrine surgery is an expanding field within otolaryngology. We hypothesized that a novel endocrine surgery fellowship model for in-practice otolaryngologists could result in expert-level training. Qualitative clinical study with chart review. Urban community practice and academic medical center. Two board-certified general otolaryngologists collaborated with a senior endocrine surgeon to increase their endocrine surgery expertise between March 2015 and December 2017. The senior surgeon provided intensive surgical training to both surgeons for all of their endocrine surgeries. Both parties collaborated with endocrinology to coordinate medical care and receive referrals. All patients undergoing endocrine surgery during this time frame were reviewed retrospectively. A total of 235 endocrine surgeries were performed. Of these, 198 thyroid surgeries were performed, including 98 total thyroidectomies (48%), 90 lobectomies (45%), and 10 completion thyroidectomies (5%). Sixty cases demonstrated papillary thyroid carcinoma, 11 follicular thyroid carcinoma, and 4 medullary thyroid carcinoma. Neck dissections were performed in 14 of the cases. Thirty-seven parathyroid explorations were performed. There were no reports of permanent hypoparathyroidism. Thirteen patients (5.5%) developed temporary hypoparathyroidism. Six patients (2.5%) developed postoperative seroma. Three patients (1.3%) developed postoperative hematomas requiring reoperation. One patient (0.4%) developed permanent vocal fold paralysis, and 3 patients (1.3%) had temporary dysphonia. Thirty-five of 37 (94.5%) parathyroid explorations resulted in biochemical resolution of the patient's primary hyperparathyroidism. This is the first description of a new fellowship paradigm where a senior surgeon provides fellowship training to attending surgeons already in practice.

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Clinical Predictors of Facial Nerve Outcomes After Surgical Resection of Vestibular Schwannoma

Yin Ren,Bridget V. MacDonald,Kareem O. Tawfik,Marc S. Schwartz,Rick A. Friedman

Publication date 13-10-2020


To identify clinical predictors of facial nerve (FN) outcomes after microsurgical resection of vestibular schwannoma (VS). Prospective cohort study. Academic medical center. Consecutive patients undergoing VS resection from November 2017 to October 2019 were included. FN function was evaluated with the House-Brackmann (HB) scale and stratified into good (HB I-II) and poor (HB III-VI) function. Analyses included descriptive statistics, correlation, and logistic regression. Of 256 patients who met criteria (mean age, 47.7 years; 62.5% female), 227 (88.7%) achieved good FN function postoperatively and 238 (93.0%) at latest follow-up (mean, 154.8 days). Operative approaches consisted of translabyrinthine (50.8%), retrosigmoid (25.0%), and middle fossa craniotomies (24.2%). Extent of resection was decided intraoperatively, and gross or near total resection was accomplished in 237 (92.6%) cases. Postoperative HB grade correlated with latest HB grade (0.615, Microsurgical resection of VS can be accomplished with excellent FN outcomes. Gross total resection and ≥100-µV intraoperative FN electromyographic response predicted excellent FN outcomes. Immediate postoperative FN function is a prognosticator of long-term FN function.

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Oral Intubation Attempts in Patients With a Laryngectomy: A Significant Safety Threat

Michael J. Brenner,John D. Cramer,Brendan A. McGrath,Karthik Balakrishnan,Katelyn O. Stepan,Vinciya Pandian,David W. Roberson,Rahul K. Shah,Amy Y. Chen,Itzhak Brook,Brian Nussenbaum

Publication date 13-10-2020


It is impossible to secure the airway of a patient with "neck-only" breathing transorally or transnasally. Surgical removal of the larynx (laryngectomy) or tracheal rerouting (tracheoesophageal diversion or laryngotracheal separation) creates anatomic discontinuity. Misguided attempts at oral intubation of neck breathers may cause hypoxic brain injury or death. We present national data from the American Academy of Otolaryngology-Head and Neck Surgery, the American Head and Neck Society, and the United Kingdom's National Reporting and Learning Service. Over half of US otolaryngologist respondents reported instances of attempted oral intubations among patients with laryngectomy, with a mortality rate of 26%. UK audits similarly revealed numerous resuscitation efforts where misunderstanding of neck breather status led to harm or death. Such data underscore the critical importance of staff education, patient engagement, effective signage, and systems-based best practices to reliably clarify neck breather status and provide necessary resources for safe patient airway management.

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Shared Surgical Decision Making in the Era of COVID-19: Lessons From Hurricane Katrina

Isaac D. Erbele,Moisés A. Arriaga,Daniel W. Nuss

Publication date 13-10-2020


The COVID-19 pandemic has challenged every surgical discipline. Lessons learned from Hurricane Katrina have informed our department's management of the current crisis. That experience impressed upon us a profound appreciation for shared decision making in the face of scarce resources, an evolving clinical context, and potential harm to patients and health care workers. To that end, we have formed a Resource Utilization Committee to prospectively review all nonemergent surgical cases during the current crisis. This has allowed "state-of-the-pandemic" otolaryngologic care in a real-time, collaborative, and high-information setting. In addition, to protect our patients and health care workers, it has influenced our institution's thoughtful application of COVID testing and the use of personal protective equipment.

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Orally Inhaled Drug Particle Transport in Computerized Models of Laryngotracheal Stenosis

Dennis Onyeka Frank-Ito,Seth Morris Cohen

Publication date 13-10-2020


Adjuvant management for laryngotracheal stenosis (LTS) may involve inhaled corticosteroids, but metered dose inhalers are designed for pulmonary drug delivery. Comprehensive analyses of drug particle deposition efficiency for orally inhaled corticosteroids in the stenosis of LTS subjects are lacking. Descriptive research. Academic medical center. Anatomically realistic 3-dimensional reconstructions of the upper airway were created from computed tomography images of 4 LTS subjects-2 subglottic stenosis and 2 tracheal stenosis subjects. Computational fluid dynamics modeling was used to simulate airflow and drug particle transport in each airway. Three inhalation pressures were simulated, 10 Pa, 25 Pa, and 40 Pa. Drug particle transport was simulated for 100 to 950 nanoparticles and 1 to 50 micron-particles. Particles were released into the airway to mimic varying inhaler conditions with and without a spacer chamber. Based on smallest to largest cross-sectional area ratio, the laryngotracheal stenotic segment shrunk by 57% and 47%, respectively, for subglottic stenosis models and by 53% for both tracheal stenosis models.
Airflow resistance at the stenotic segment was lower in subglottic stenosis models than in tracheal stenosis models: 0.001 to 0.011 Pa.s/mL vs 0.024 to 0.082 Pa.s/mL. Drug depositions for micron-particles and nanoparticles at stenosis were 0.06% to 2.48% and 0.10% to 2.60% for subglottic stenosis and tracheal stenosis models, respectively. Particle sizes with highest stenotic deposition were 6 to 20 µm for subglottic stenosis models and 1 to 10 µm for tracheal stenosis models. This study suggests that at most, 2.60% of inhaled drug particles deposit at the stenosis. Particle size ranges with highest stenotic deposition may not represent typical sizes emitted by inhalers.

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Olfactory Cleft Measurements and COVID-19–Related Anosmia

Aytug Altundag,Duzgun Yıldırım,Deniz Esin Tekcan Sanli,Melih Cayonu,Sedat Giray Kandemirli,Ahmet Necati Sanli,Ozge Arici Duz,Ozlem Saatci

Publication date 13-10-2020


This study aimed to investigate the differences in olfactory cleft (OC) morphology in coronavirus disease 2019 (COVID-19) anosmia compared to control subjects and postviral anosmia related to infection other than severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Prospective. This study comprises 91 cases, including 24 cases with anosmia due to SARS-CoV-2, 38 patients with olfactory dysfunction (OD) due to viral infection other than SARS-CoV-2, and a control group of 29 normosmic cases. All cases had paranasal sinus computed tomography (CT), and cases with OD had magnetic resonance imaging (MRI) dedicated to the olfactory nerve. The OC width and volumes were measured on CT, and T2-weighted signal intensity (SI), olfactory bulb volumes, and olfactory sulcus depths were assessed on MRI.
This study showed 3 major findings: the right and left OC widths were significantly wider in anosmic patients due to SARS-CoV-2 (group 1) or OD due to non-SARS-CoV-2 viral infection (group 2) when compared to healthy controls. OC volumes were significantly higher in group 1 or 2 than in healthy controls, and T2 SI of OC area was higher in groups 1 and 2 than in healthy controls. There was no significant difference in olfactory bulb volumes and olfactory sulcus depths on MRI among groups 1 and 2. In this study, patients with COVID-19 anosmia had higher OC widths and volumes compared to control subjects. In addition, there was higher T2 SI of the olfactory bulb in COVID-19 anosmia compared to control subjects, suggesting underlying inflammatory changes. There was a significant negative correlation between these morphological findings and threshold discrimination identification scores. Level 4.

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Prioritizing Diversity in Otolaryngology–Head and Neck Surgery: Starting a Conversation

Carl M. Truesdale,Reginald F. Baugh,Michael J. Brenner,Myriam Loyo,Uchechukwu C. Megwalu,Charles E. Moore,Ethan A. Paddock,Mark E. Prince,Mia Strange,Michael J. Sylvester,Dana M. Thompson,Tulio A. Valdez,Yanjun Xie,Carol R. Bradford,Duane J. Taylor

Publication date 13-10-2020


Academic centers embody the ideals of otolaryngology and are the specialty's port of entry. Building a diverse otolaryngology workforce-one that mirrors society-is critical. Otolaryngology continues to have an underrepresentation of racial and ethnic minorities. The specialty must therefore redouble efforts, becoming more purposeful in mentoring, recruiting, and retaining underrepresented minorities. Many programs have never had residents who are Black, Indigenous, or people of color. Improving narrow, leaky, or absent pipelines is a moral imperative, both to mitigate health care disparities and to help build a more just health care system. Diversity supports the tripartite mission of patient care, education, and research. This commentary explores diversity in otolaryngology with attention to the salient role of academic medical centers. Leadership matters deeply in such efforts, from culture to finances. Improving outreach, taking a holistic approach to resident selection, and improving mentorship and sponsorship complement advances in racial disparities to foster diversity.

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Sleep Architecture in Children With Down Syndrome With and Without Obstructive Sleep Apnea

Christine H. Heubi,Philip Knollman,Susan Wiley,Sally R. Shott,David F. Smith,Stacey L. Ishman,Jareen Meinzen-Derr

Publication date 06-10-2020


To characterize polysomnographic sleep architecture in children with Down syndrome and compare findings in those with and without obstructive sleep apnea. Case series with retrospective review. Single tertiary pediatric hospital (2005-2018). We reviewed the electronic health records of patients undergoing polysomnography who were referred from a specialized center for children with Down syndrome (age, ≥12 months). Continuous positive airway pressure titration, oxygen titration, and split-night studies were excluded. A total of 397 children were included (52.4% male, 81.6% Caucasian). Mean age at the time of polysomnography was 4.7 years (range, 1.4-14.7); 79.4% had obstructive sleep apnea. Sleep variables were reported as mean (SD) values: sleep efficiency, 85% (11%); sleep latency, 29.8 minutes (35.6); total sleep time, 426 minutes (74.6); rapid eye movement (REM) latency, 126.8 minutes (66.3); time spent in REM sleep, 22% (7%); arousal index, 13.3 (5); and time spent supine, 44% (28%). There were no significant differences between those with obstructive sleep apnea and those without. Sleep efficiency <80% was seen in 32.5%; 34.3% had a sleep latency >30 minutes; 15.9% had total sleep time <360 minutes; and 75.6% had an arousal index >10/h. Overall, 69.2% had ≥2 metrics of poor sleep architecture. REM sleep time <20% was seen in 35.3%. REM sleep time decreased with age. In children with Down syndrome, 32.5% had sleep efficiency <80%; 75.6% had an elevated arousal index; and 15.9% had total sleep time <360 minutes. More than a third of the patients had ≥3 markers of poor sleep architecture. There was no difference in children with or without obstructive sleep apnea.

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Association Between COVID-19 and Kawasaki Disease: Vigilance Required From Otolaryngologists: Authors’ Response

Henya Sandhaus,Dana Crosby,Arun Sharma,Stacie R. Gregory

Publication date 06-10-2020


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A New Syndrome and Kawasaki Disease Associated With SARS-CoV-2 in Otolaryngology Practice

Ahmet Sert

Publication date 06-10-2020


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Multi-institutional Evaluation of Radiologic Findings Associated With Pediatric Congenital Idiopathic Bilateral Vocal Fold Dysfunction

James Ruda,John Dahl,Wade McClain,Amelia Drake,Kolin Rubel,Amanda Onwuka,Paul Krakovitz,Samantha Anne

Publication date 06-10-2020


To report brain magnetic resonance imaging (MRI) and ultrasonography findings in pediatric patients with congenital idiopathic bilateral vocal fold dysfunction and analyze factors associated with its etiology and resolution. Case series with retrospective review. Tertiary care multi-institutional setting: Nationwide Children's Hospital, Indiana University, University of North Carolina, and Cleveland Clinic. Pediatric patients with congenital idiopathic bilateral vocal fold dysfunction were included in this review. Congenital idiopathic bilateral vocal fold dysfunction was identified in 74 patients from 2000 to 2018. Brain MRI scans were performed in all patients and ultrasonography in 30 (40.5%). Normal imaging results were most commonly found in patients born full-term ( In this multi-institutional study, no specific brain MRI or ultrasound abnormality was associated with patients' bilateral vocal fold dysfunction or subsequent resolution rates. While imaging is often performed to detect and treat any reversible causes of bilateral vocal fold dysfunction, in this series, imaging findings were heterogeneous and did not identify any treatable causes, such as type I Chiari malformation.

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Multi-institutional Comparison of Temporal Bone Models: A Collaboration of the AAO-HNSF 3D-Printed Temporal Bone Working Group

Sarah E. Mowry,Noel Jabbour,Austin S. Rose,Gregory J. Wiet,Maja Svrakic,David A. Zopf,Kyle Vankoevering,Allison Powell,Monika E. Freiser,Jordan Hochman,Richard Smith

Publication date 06-10-2020


The American Academy of Otolaryngology-Head and Neck Surgery Foundation's (AAO-HNSF's) 3D-Printed Temporal Bone Working Group was formed with the goal of sharing information and experience relating to the development of 3D-printed temporal bone models. The group conducted a multi-institutional study to directly compare several recently developed models. Expert opinion survey. Temporal bone laboratory. The working group convened in 2018. The various methods in which 3D virtual models had been created and printed in physical form were then shared and recorded. This allowed for comparison of the advantages, disadvantages, and costs of each method. In addition, a drilling event was held during the October 2018 AAO-HNSF Annual Meeting. Each model was drilled and evaluated by attending-level working group members using an 15-question Likert scale questionnaire. The models were graded on anatomic accuracy as well as their suitability as a simulation of both cadaveric and operative temporal bone drilling. The models produced for this study demonstrate significant anatomic detail and a likeness to human cadaver specimens for drilling and dissection. Models printed in standard resin material with a stereolithography printer scored highest in the evaluation, though the margin of difference was negligible in several categories. Simulated 3D temporal bones created through a number of printing methods have potential benefit in surgical training, preoperative simulation for challenging otologic cases, and the standardized testing of temporal bone surgical skills.

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The Potential for Telemedicine to Reduce Bias in Patients Seeking Facial Plastic Surgery

Parsa P. Salehi,Brian J. F. Wong,Babak Azizzadeh

Publication date 06-10-2020


Telemedicine use among otolaryngologists-head and neck surgeons and facial plastic and reconstructive surgeons has accelerated as a result of the COVID-19 pandemic. Yet, it is unclear what impact the increased adoption of telehealth will have on the doctor-patient relationship, patients' perceptions of individual practices, and the likelihood of patients proceeding with the next steps toward surgery. While an understanding of these complex questions is imperative for all otolaryngologists, it is extremely important for facial plastic surgeons who focus on elective procedures, particularly cosmetic/aesthetic operations. The use of telemedicine has the potential to reduce bias among patients seeking facial plastic surgery, especially cosmetic procedures. As reports of this phenomenon are anecdotal thus far, we recommend further study into the specific criteria that patients consider when selecting a facial plastic surgeon.

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Polysomnographic Outcomes After Observation for Mild Obstructive Sleep Apnea in Children Younger Than 3 Years

Kathleen M. Sarber,Douglas C. von Allmen,Raisa Tikhtman,Javier Howard,Narong Simakajornboon,Wenwen Yu,David F. Smith,Stacey L. Ishman

Publication date 29-09-2020


Mild obstructive sleep apnea (OSA), particularly in young children, is often treated with observation. However, there is little evidence regarding the outcomes with this approach. Our aim was to assess the impact of observation on sleep for children aged <3 years with mild OSA. Case-control study. Pediatric tertiary care center. We reviewed cases of children (<3 years old) diagnosed with mild OSA (obstructive apnea-hypopnea index, 1-5 events/h) who were treated with observation between 2012 and 2017 and had at least 2 polysomnograms performed 3 to 12 months apart. Demographic data and comorbid diagnoses were collected. Twenty-six children met inclusion criteria; their median age was 7.2 months (95% CI, 1.2-22.8). Nine (35%) were female and 24 (92%) were White. Their median body mass index percentile was 39 (95% CI, 1-76). Comorbidities included cardiac disease (42.3%), laryngomalacia (42.3%), allergies (34.6%), reactive airway disease (23.1%), and prematurity (7.7%). The obstructive apnea-hypopnea index significantly decreased from 2.7 events/h (95% CI, 1-4.5) to 1.3 (95% CI, 0-4.5; In our cohort, resolution of mild OSA occurred in 31% of patients treated with 3 to 12 months of observation. The presence of laryngomalacia, asthma, and allergies did not affect resolution. Larger studies are needed to better identify factors (including race) associated with persistent OSA and optimal timing of intervention for these children. 4.

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Sialendoscopy in Chronic Obstructive Sialadenitis Without Sialolithiasis: A Prospective Cohort Study

Karolina A. Plonowska,Edgar Ochoa,William R. Ryan,Jolie L. Chang

Publication date 29-09-2020


To evaluate long-term chronic sialadenitis symptoms in patients without sialolithiasis following sialendoscopy-assisted salivary duct surgery (SASDS) compared to a control group managed conservatively. Prospective cohort study. Tertiary care center. Thirty-six patients (52 glands) with chronic sialadenitis without sialolithiasis completed the Chronic Obstructive Sialadenitis Symptoms (COSS) questionnaire at presentation and at 3-month time intervals thereafter for 1 year. Lower COSS scores represent lower symptom severity. We compared 27 patients who underwent SASDS to 9 control patients who elected conservative management. COSS gland-specific scores from 38 SASDS-treated glands (cases) and 14 control glands were similar at baseline. At 6 to 12 months (mean, 8.4 months), the surgically treated group had significantly lower scores and a greater score reduction from baseline compared to controls (mean score change [95% confidence interval] cases: 20.7 points [15.7-25.8]; controls: 11.7 points [4.9-18.4]; Compared to patients electing for conservative management, patients with sialadenitis without sialolithasis treated with SASDS had improved symptom scores and a greater reduction of symptom severity after 6 months. With SASDS, patients had higher rates of significant overall symptom improvement. In evaluating chronic sialadenitis, assessment at multiple time points is necessary to capture the intermittent and cyclical pattern of obstructive symptoms.

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Biomarkers for Malignant Potential in Vocal Fold Leukoplakia: A State of the Art Review

Ping Wan,Julina Ongkasuwan,Julian Martinez,Vlad Sandulache,Defeng Deng,Jack Jiang,Andrew Sikora,Kenneth W. Altman

Publication date 29-09-2020


To explore biomarkers that are candidates for understanding potential degeneration to malignancy of vocal fold leukoplakia (VFL), with the goal of guiding future diagnostic and treatment recommendations. Pub Med and Medline search engines.
A systematic review was conducted by searching the following key words: Prognostic biomarkers in the 16 studies are generally divided into 3 categories according to their biological roles: proliferation (Ki-67, CK-1 RS14024 SNP), cell cycle control (P53, p16, cyclin D1, p57kip2, interleukin-10 [IL-10], miR-10a, and miR-34c), cell adhesion, and invasion (neutrophil-to-lymphocyte ratio, OPN/CD44v6 axis, MMP-1, vascular endothelial growth factor A, MMP-9, serpin peptidase inhibitor 1, plasminogen activator, CTNN/B1, β-catenin, NANOG, HERG1). The prognostic use of these biomarkers is limited due to the variable methodologies, study design, assay methods, and statistical analysis performed. Prognostic factors in vocal fold leukoplakia have important clinical implications regarding the potential for malignant degeneration. Although further study is needed, the currently available evidence suggests that p53, p16, cyclin D1, IL-10, NLR, OPN and CD44v6, CTNNB1, and CTTN and FAK might be of particular interest in determining prognosis of VFL as related to malignancy. Future, large, well-designed, prospective studies are expected to determine the prognostic power of these biomarkers before their implementation in routine clinical practice.

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Pectoralis Major Onlay vs Interpositional Reconstruction Fistulation After Salvage Total Laryngectomy: Systematic Review and Meta-analysis

Claudia I. Cabrera,Alexander Joseph Jones,Noah Philleo Parker,Amy Emily Lynn Blevins,Mark S. Weidenbecher

Publication date 29-09-2020


To evaluate the difference in pharygocutaneous fistula (PCF) development between pectoralis major flap onlay and interpositional reconstructions after salvage total laryngectomy (STL). Medline, Cochrane, Embase, Web of Science, CINAHL, and Clinical Trials.gov. A systematic review was performed during January 2020. English articles were included that described minor and major PCF rates after STL reconstructed with pectoralis major onlay or interposition. PCFs were classified as major when conservative therapy was unsuccessful and/or revision surgery was needed. Articles describing total laryngopharyngectomies were excluded. Meta-analyses of the resulting data were performed. Twenty-four articles met final criteria amassing 1304 patients. Three articles compared onlay with interposition, and 18 compared onlay with primary closure. Pectoralis interposition demonstrated elevated odds ratio (OR) of PCF formation as compared with onlay (OR, 2.34; This research shows evidence that pectoralis onlay after STL diminishes the odds of total and major PCF development. Pectoralis interposition reconstruction showed elevated odds of PCF formation as compared with pectoralis onlay.

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Prevalence of and Associations With Distress and Professional Burnout Among Otolaryngologists: Part II, Attending Physicians

Matthew L. Carlson,David P. Larson,Erin K. O’Brien,Christine M. Lohse,Matthew L. Kircher,Richard K. Gurgel,Jacob B. Hunter,Alan G. Micco,Stephen J. Nogan,Brendan P. O’Connell,Sanjeet V. Rangarajan,Alejandro Rivas,Alex D. Sweeney,George B. Wanna,Peter A. Weisskopf,Garret Choby

Publication date 29-09-2020


To ascertain the prevalence of and associations with distress and professional burnout among academic otolaryngology attending physicians. Cross-sectional survey. Twelve US academic otolaryngology programs. A questionnaire was administered that encompassed sociodemographic and professional features, the Expanded Physician Well-being Index for distress, the 2-item Maslach Burnout Inventory for professional burnout, the Patient Health Questionnaire-2 screen for major depressive disorder, and the Generalized Anxiety Disorder-2 screen for generalized anxiety disorder. The survey response rate was 56% and included 186 attending physicians. The average respondent age was 47 years; 72% were men; 93% were married or partnered; and 86% had children. Distress was present in 40%, professional burnout in 26%, positive depression screening in 8%, and positive anxiety screening in 11%. In a univariable setting, age, hours worked in a typical week, nights on call in a typical week, and years of practice were significantly associated with distress, although in a multivariable setting, only hours worked in a typical week remained significantly associated with a positive Expanded Physician Well-being Index screen (odds ratio for each 10-hour increase, 2.61; 95% CI, 1.73-3.93; Distress or professional burnout occurs in more than a quarter of academic otolaryngology attending physicians, whereas the prevalence of depression or anxiety is approximately 10%. The number of hours worked per week had the strongest association with distress and burnout. These findings may be used to develop and implement programs to promote physician well-being and mitigate professional burnout.

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Prevalence of and Associations With Distress and Professional Burnout Among Otolaryngologists: Part I, Trainees

David P. Larson,Matthew L. Carlson,Christine M. Lohse,Erin K. O’Brien,Matthew L. Kircher,Richard K. Gurgel,Jacob B. Hunter,Alan G. Micco,Stephen J. Nogan,Brendan P. O’Connell,Sanjeet V. Rangarajan,Alejandro Rivas,Alex D. Sweeney,George B. Wanna,Peter A. Weisskopf,Garret Choby

Publication date 29-09-2020


To assess the prevalence of distress and burnout in otolaryngology trainees, including associations with relevant sociodemographic and professional factors, and to compare these results with those of attending otolaryngologists. A cross-sectional survey of trainees and attending physicians. Twelve academic otolaryngology programs. Distress and burnout were measured with the Expanded Physician Well-being Index and the 2-item Maslach Burnout Inventory. The Patient Health Questionnaire-2 and Generalized Anxiety Disorder-2 were used to screen for depressive disorders and anxiety disorders, respectively. Associations with sociodemographic and professional characteristics were assessed. Of the 613 surveys administered to trainees and attending physicians, 340 were completed (56%). Among 154 trainees, distress was present in 49%, professional burnout in 35%, positive depressive disorder screening in 5%, and positive anxiety disorder screening in 16%. In univariable analysis, female gender, hours worked in a typical week (HW), and nights on call in a typical week (NOC) were significantly associated with distress. In multivariable analysis, female gender (odds ratio, 3.91; Otolaryngology trainees experience significant work-place distress (49%) and burnout (35%). Gender, HW, and NOC had the strongest associations with distress and burnout.

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Pediatric Basilar Skull Fracture Mechanisms and Trends From 2007 to 2018

Anthony Magit,Joshua A. Stramiello,Raquel Good,Javan Nation

Publication date 29-09-2020


To evaluate the specific mechanism and trend of injury resulting in pediatric basilar skull fractures. Retrospective chart review of a trauma database. Tertiary care children's hospital. Patients ≤18 years old with basilar skull fractures were identified via the trauma database for admissions from 2007 to 2018.
Patients were identified with A total of 729 patients were included: 251 females and 478 males. The 2 most common mechanisms of injury are multilevel falls and unhelmeted rider falls. Multilevel falls occur more in the toddler age group (average age, 4 years), and unhelmeted rider falls are seen in the older age group (average age, 11.2 years). Helmeted rider and motor vehicle accident basilar skull injuries are relatively uncommon. There was a spike in television/entertainment center mechanisms of injury in toddlers from 2007 to 2011 but has since decreased. Pediatric basilar skull fractures are costly to the health care system, as patients spent more time in intensive care unit beds with a charge limited to hospital rooms between $1.7 and $2.7 million per year. The protective effect of helmets is demonstrated by unhelmeted rider injuries being the second-most common mechanism of basilar skull fractures and by helmeted rider injuries being rare. The small proportion of basilar skull fractures from motor vehicle accidents is an example of policy and behavioral changes resulting in decreased injury.

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Prevalence of Tinnitus in an Aging Population and Its Relation to Age and Hearing Loss

Berthe C. Oosterloo,Pauline H. Croll,Robert J. Baatenburg de Jong,M. Kamran Ikram,André Goedegebure

Publication date 29-09-2020


Tinnitus is a common hearing-related disorder, which may have a large impact on daily life. With aging populations worldwide, it is important to gain insight in the occurrence of tinnitus at older ages and to understand its relationship with age-related hearing loss. We investigated the prevalence of tinnitus among a general aging population, across age strata and hearing status. Cross-sectional. The population-based Rotterdam Study. A total of 6098 participants underwent tinnitus assessment, and 4805 had additional hearing assessment. We determined tinnitus prevalence per 5-year age groups. Hearing impairment was defined as ≥25-dB HL worse ear pure tone average (0.5, 1, 2, 4 k Hz). We investigated with multivariable logistic regression the association between hearing impairment and tinnitus. Tinnitus handicap was assessed in 663 participants with daily tinnitus via the Tinnitus Handicap Inventory-screening version (THI-s). Tinnitus was prevalent in 21.4% (n = 1304). Prevalent tinnitus was evenly distributed over 5-year age groups. Participants with hearing impairment were more likely to have tinnitus (odds ratio, 2.27; 95% CI, 1.92-2.69) as compared with those without hearing impairment. The median THI-s score was 4 (interquartile range, 0-10), indicating a slight handicap, and 14.6% of the participants reported a moderate or severe handicap (THI-s ≥16). In a general elderly population, 1 in 5 persons has tinnitus. Of those with tinnitus, for 1 per 10 persons, the presence of tinnitus interfered with daily life. Participants with hearing impairment were twice as likely to have tinnitus. Despite the age-dependent occurrence of hearing impairment, no such age dependency was found for tinnitus.

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Georg von Békésy and Bruce Mer: Early Pioneers of Endoscopic Ear Surgery

Nicholas Koen,Aaron Remenschneider,Daniel J. Lee,Elliott D. Kozin

Publication date 29-09-2020


The binocular operative microscope has been the workhorse of otologic and neurotologic surgeons since the 1950s. Since its advent, however, surgeons recognized that the operative microscope could not "look around corners" and its line-of-sight technology required soft tissue and bony dissection to enable light to reach the surgical plane. Endoscopic technology has evolved to address many of the limitations of operative microscopy. While the endoscope is often viewed as a recent development in otologic surgery, in the following historical article, we highlight the contributions of two mid-20th century pioneers of endoscopic ear surgery: Georg von Békésy and Bruce Mer. In the 1940s, Dr von Békésy envisioned an endoscope for determining stapes mobility. Dr Mer, with a team of engineers, created an otoendoscope to perform some of the first endoscopic ear procedures in the 1960s. Lessons gleaned from von Békésy and Mer's research include the need for counterculture thinking and the challenges of pioneering ideas beyond technical capacity.

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Multidisciplinary Safety Recommendations After Tracheostomy During COVID-19 Pandemic: State of the Art Review

Kara D. Meister,Vinciya Pandian,Alexander T. Hillel,Brian K. Walsh,Martin B. Brodsky,Karthik Balakrishnan,Simon R. Best,Steven B. Chinn,John D. Cramer,Evan M. Graboyes,Brendan A. McGrath,Christopher H. Rassekh,Joshua R. Bedwell,Michael J. Brenner

Publication date 22-09-2020


In the chronic phase of the COVID-19 pandemic, questions have arisen regarding the care of patients with a tracheostomy and downstream management. This review addresses gaps in the literature regarding posttracheostomy care, emphasizing safety of multidisciplinary teams, coordinating complex care needs, and identifying and managing late complications of prolonged intubation and tracheostomy. Pub Med, Cochrane Library, Scopus, Google Scholar, institutional guidance documents. Literature through June 2020 on the care of patients with a tracheostomy was reviewed, including consensus statements, clinical practice guidelines, institutional guidance, and scientific literature on COVID-19 and SARS-CoV-2 virology and immunology. Where data were lacking, expert opinions were aggregated and adjudicated to arrive at consensus recommendations. Best practices in caring for patients after a tracheostomy during the COVID-19 pandemic are multifaceted, encompassing precautions during aerosol-generating procedures; minimizing exposure risks to health care workers, caregivers, and patients; ensuring safe, timely tracheostomy care; and identifying and managing laryngotracheal injury, such as vocal fold injury, posterior glottic stenosis, and subglottic stenosis that may affect speech, swallowing, and airway protection. We present recommended approaches to tracheostomy care, outlining modifications to conventional algorithms, raising vigilance for heightened risks of bleeding or other complications, and offering recommendations for personal protective equipment, equipment, care protocols, and personnel. Treatment of patients with a tracheostomy in the COVID-19 pandemic requires foresight and may rival procedural considerations in tracheostomy in their complexity. By considering patient-specific factors, mitigating transmission risks, optimizing the clinical environment, and detecting late manifestations of severe COVID-19, clinicians can ensure due vigilance and quality care.

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Adenoidectomy Without Tonsillectomy for Pediatric Obstructive Sleep Apnea

Stephen R. Chorney,Karen B. Zur

Publication date 22-09-2020


The primary objective was to determine if obstructive sleep apnea (OSA) can improve after adenoidectomy. Case series with chart review. Tertiary children's hospital between 2016 and 2018. The study included children under 3.5 years with small (1+ or 2+) palatine tonsils, large (3+ or 4+) adenoids, and documented OSA on polysomnogram (PSG). Seventy-one children were included. Age at adenoidectomy was 2.0 years (95% CI, 1.8-2.2) and 71.8% were male. Mean follow-up was 2.5 years (95% CI, 2.3-2.7). Twenty-six children (36.6%) obtained a repeat PSG at a mean of 9.7 months (95% CI, 6.3-13.2) after adenoidectomy. Among those with a postoperative PSG, apnea-hypopnea index decreased in 77.0% (mean, -3.2 events/h; 95% CI, -14.1 to 7.6), and the proportion with moderate to severe OSA decreased from 65.4% to 30.8% ( Adenoidectomy may improve OSA in young children with large adenoids and small tonsils. However, younger age predicted the need for subsequent tonsillectomy. Prospective studies with additional PSG data are necessary to corroborate these findings.

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Effect of Dedicated In-Person Interpreter on Satisfaction and Efficiency in Otolaryngology Ambulatory Clinic

Douglas R. Johnston,Jennifer M. Lavin,Allison Rose Hammer,Abbey Studer,Colin Harding,Dana M. Thompson

Publication date 22-09-2020


In a large academic children's hospital ambulatory clinic, the increasing demand for Spanish interpretation exceeds the Interpreting Services Department capacity, necessitating telephone interpretation. By adding a dedicated Spanish interpreter in the otolaryngology clinic, we aimed to decrease visit times for Spanish-speaking patients and increase satisfaction. Additional aims explored if dedicated Spanish interpreters could increase patients seen per session. A quality improvement initiative investigated baseline state compared to 2 tests of change using video interpretation and dedicated, in-person interpretation. Time permitting, interpreters contacted patients before the visit to decrease missed appointments and late arrivals. Measures included clinic visit times, late arrivals, missed appointments, and family/employee satisfaction scores. Actuarial statistics forecasted if on-site Spanish interpreters would affect patients seen per session and the potential addition of sessions. In-person interpretation reduced visit times for Spanish-speaking patients from 55 to 48 minutes ( Implementing dedicated Spanish interpreters may increase productivity and enhance family experience. Reducing patient visit time by 9 minutes permits 2 additional patients per clinic session (1560 visits, 390 surgeries per year). Applied institution-wide, the intervention could create 29% more capacity in the ambulatory schedule (31,000 additional visits) and reduce actuarial need for ambulatory sessions in the same clinic space.

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Decision Modeling for Economic Evaluation in Otolaryngology–Head and Neck Surgery: Review of Techniques

David Forner,Graeme Hoit,Christopher W. Noel,Antoine Eskander,John R. de Almeida,Matthew H. Rigby,David Naimark

Publication date 22-09-2020


Decision making in health care is complex, and substantial uncertainty can be involved. Structured, systematic approaches to the integration of available evidence, assessment of uncertainty, and determination of choice are of significant benefit in an era of "value-based care." This is especially true for otolaryngology-head and neck surgery, where technological advancements are frequent and applicable to an array of subspecialties. Decision analysis aims to achieve these goals through various modeling techniques, including (1) decision trees, (2) Markov process, (3) microsimulation, and (4) discrete event simulation. While decision models have been used for decades, many clinicians and researchers continue to have difficulty deciphering them. In this review, we present an overview of various decision analysis modeling techniques, their purposes, how they can be interpreted, and commonly used syntax to promote understanding and use of these approaches. Throughout, we provide a sample research question to facilitate discussion of the advantages and disadvantages of each technique.

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Association Between Immunosuppression and Outcomes in Oral Cavity Squamous Cell Carcinoma

Julia Chang,John B. Sunwoo,Jennifer Lobo Shah,Wendy Hara,Jison Hong,A. Dimitrios Colevas,Vasu Divi

Publication date 22-09-2020


To assess the effect of immunosuppression on recurrence and mortality outcomes in oral cavity squamous cell carcinoma (SCC) after initial surgical treatment. Retrospective cohort study. A single academic tertiary referral center. Patients with oral cavity SCC treated with initial surgery were included. Immunosuppressed versus nonimmunosuppressed groups were compared. Primary end points were 5-year overall recurrence and all-cause mortality. Secondary end points were recurrence subtypes (local, regional, and distant) and disease-specific mortality. Of 803 patients with oral cavity SCC, 71 (9%) were immunosuppressed from therapeutic drug use (n = 48) or systemic disease (n = 23). The immunosuppressed group consisted of patients with a history of transplant (21%), autoimmune or pulmonary disorder (45%), hematologic malignancy or myeloproliferative disorder (30%), and HIV infection (3%). After adjusting for baseline variables of age, sex, comorbidities, pathologic tumor characteristics, and adjuvant treatment, all recurrence and mortality outcomes were worse in the immunosuppressed group. The multivariate-adjusted hazard ratio for overall recurrence was 2.16 (95% CI, 1.50-3.12; This study demonstrates that immunosuppression is associated with poor outcomes in oral cavity SCC, with an approximate 2-fold increase in rates of recurrence and mortality. Future studies are needed to assess the risks and benefits of adjusting therapeutic immunosuppression in this population.

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Resumption of Otolaryngology Surgical Practice in the Setting of Regionally Receding COVID-19

Said Izreig,Cheryl K. Zogg,David A. Kasle,Sina J. Torabi,R. Peter Manes

Publication date 22-09-2020


The practice of otolaryngology has been drastically altered as a consequence of the ongoing coronavirus disease 2019 (COVID-19) pandemic. Geographic heterogeneity in COVID-19 burden has meant different regions have experienced the pandemic at different stages. Regional dynamics of COVID-19 incidence has dictated the available resources for the provision of surgical care. As regions navigate their own COVID-19 dynamics, illustrative examples of areas affected early by the COVID-19 pandemic may provide anticipatory guidance. In this commentary, we discuss our experience with performed and canceled surgical procedures across the various otolaryngology specialties at our institution over the course of regionally rising and falling incident COVID-19 cases.

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Subcutaneous Ports for Chronic Nerve Cuff and Intramuscular Electrode Stimulation in Animal Models

James T. Heaton,James B. Kobler,Mark P. Ottensmeyer,Robert H. Petrillo,Monica A. Tynan,Robert E. Hillman,Steven M. Zeitels

Publication date 22-09-2020


Tracking recovery after nerve injury may require many intermittent assessments over long periods, preferably with non- or minimally invasive methods. We developed subcutaneous electrical connection ports (ECPs) for repeated connection to nerve cuff or intramuscular electrodes via transdermal needles and evaluated them during studies of laryngeal reinnervation. Animal experiment. Laboratory. ECPs were designed and 3-dimensionally printed for connection to bipolar electrodes with biocompatible polymers. Dual compartments filled with conductive silicone capped with nonconductive silicone were used to make the connections between electrode leads and transdermally inserted needles. Ten dogs (19-29 kg) were implanted with 22 ECPs. In 7 dogs, 11 electrodes were placed on recurrent laryngeal nerves proximal to transection and suture repair to track laryngeal reinnervation. In 6 dogs, 8 spinal accessory nerve cuff electrodes were used to stimulate neck muscle contraction. In 2 dogs, 3 electrodes were implanted in the thyroarytenoid muscle. Stimulation thresholds, electromyography, and videolaryngoscopic imaging were obtained in 156 tests over survival periods up to 32 months. Stimulation data provided information about ECP performance. ECPs added negligible resistance to electrodes (mean ± SD, 2.14 ± 0.9 Ω). Despite some electrode leads breaking distally, ECPs were reliable and well tolerated at implant sites and enabled periodic assessment of nerve and muscle function over the time course of laryngeal reinnervation. Histology showed ECP encapsulation as thin layers of connective tissue and minimal acute inflammation. Custom ECPs are easily fabricated and cause little tissue reaction over months to years of subcutaneous implantation, facilitating long-term physiologic studies.

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Opioid Prescribing in Patients Undergoing Neck Dissections With Short Hospitalizations

Grace L. Banik,Kristen L. Kraimer,Maisie L. Shindo

Publication date 22-09-2020


To evaluate postoperative opioid prescribing in patients undergoing neck dissections with short hospitalizations. Retrospective cohort study. Tertiary academic hospital. The study population included patients who underwent lateral neck dissections with or without an associated head and neck procedure and required hospitalization for ≤3 days from 2012 to 2019. Interventions to decrease opioid utilization, including preoperative counseling, multimodality pain management, and multidisciplinary collaboration, were implemented in September 2016.
Patients were divided into 2 groups: preintervention (group 1) and postintervention (group 2). The mean quantity of opioids prescribed during hospitalization, at discharge, and in refills was calculated in morphine milligram equivalents (MME).
A total of 407 patients were included in the analysis: 223 patients in group 1 and 184 patients in group 2 (42.3% female, 89.4% white; average age, 55.2 years [95% CI, 53.6-56.9]). The mean opioid quantity prescribed in unilateral neck dissection alone decreased from 353.9 MME (95% CI, 266.7-441.2) in group 1 to 113.3 MME (95% CI, 87.8-138.7) in group 2 ( This study demonstrates that the quantity of opioids prescribed in patients undergoing neck dissections and associated head and neck procedures with short hospitalizations can be reduced to as low as 100 to 125 MME with preoperative counseling, multimodality pain management, and multidisciplinary collaboration.

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Alternating Unilateral Versus Bilateral Injections of Botulinum Toxin for the Treatment of Adductor Spasmodic Dysphonia

Seung Jin Lee,Min Seok Kang,Hong-Shik Choi,Jae-Yol Lim

Publication date 22-09-2020


This study aimed to compare the long-term efficacy, durability, and dose and interval stability between alternating unilateral and bilateral injections of botulinum neurotoxin type A for the treatment of adductor spasmodic dysphonia. Retrospective cohort study. Academic tertiary medical center. A total of 137 patients (105 alternating unilateral and 32 bilateral injections) who were administered ≥5 injections of botulinum neurotoxin type A were included in this study. The mean dosage change, dose adjustment ratio (number of dose increases/total number of injections), and stability of treatment responses were compared between the alternating unilateral and bilateral injection groups. Long-term changes in the mean dosages for alternating unilateral (mean ± SD, -0.010 ± 0.048 IU) and bilateral (-0.042 ± 0.142 IU) injections did not differ between groups ( Both alternating unilateral and bilateral injection methods showed a long-term decreasing dosing trend, with comparable levels of efficacy, durability, and stability for treating adductor spasmodic dysphonia. Our findings indicate that alternating unilateral injections can be routinely performed with fewer side effects, albeit at shorter treatment intervals, than bilateral injections.

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A Model for Undergraduate Medical Student Education in Otolaryngology During the Post–COVID-19 Era

Johanna L. Wickemeyer,Jeffrey Yu

Publication date 22-09-2020


The clinical learning environment is limited for undergraduate medical education in otolaryngology as the result of coronavirus disease 2019. In an effort to foster and rebuild the attending-medical student relationship, we have developed the R4 teaching model. This model encourages the student to read background information, respond to questions, and review online with faculty with the goal of realization of clinical decision making with gained knowledge. Within the R4 model, there are learning environment subtypes, including real patient cases, journal club, interactive quizzes, flipped classroom, and attending-lead discussions. In the absence of a multitude of "live" patients, our curricula reinstate the core of clinical teaching for medical students.

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Implications of Treatment Modality on Chronic Opioid Use Following Treatment for Head and Neck Cancer

Craig A. Bollig,Brian P. Kinealy,David R. Gilley,Andrew D. Clark,Tabitha L.I. Galloway,Robert P. Zitsch,Jeffrey B. Jorgensen,Gregory B. Biedermann

Publication date 22-09-2020


To investigate the relationship between treatment modality and chronic opioid use in a large cohort of patients with head and neck cancer. Retrospective cohort study. Single academic center. There were 388 patients with head and neck cancer treated between January 2011 and December 2017 who met inclusion criteria. Clinical risk factors for opioid use at 3 and 6 months were determined with univariate and multivariate analyses. The prevalence of opioid use was 43.0% at 3 months and 33.2% at 6 months. On multivariate analysis, primary chemoradiation (odds ratio [OR], 4.04; 95% CI, 1.91-8.55) and surgery with adjuvant chemoradiation (OR, 2.39; 95% CI, 1.09-5.26) were associated with opioid use at 3 months. Additional risk factors at that time point included pretreatment opioid use (OR, 7.63; 95% CI, 4.09-14.21) and decreasing age (OR, 1.03; 95% CI, 1.01-1.06). At 6 months, primary chemoradiation (OR, 2.40; 95% CI, 1.34-4.28), pretreatment opioid use (OR, 5.86; 95% CI, 3.30-10.38), current tobacco use (OR, 2.00; 95% CI, 1.18-3.40), and psychiatric disorder (OR, 1.79; 95% CI, 1.02-3.14) were associated with opioid use. Of the patients who receive different treatment modalities, those receiving primary chemoradiation are independently at highest risk for chronic opioid use. Other risk factors include pretreatment opioid use, tobacco use, and a psychiatric disorder. In an effort to reduce their risk of chronic opioid use, preventative strategies should be especially directed to these patients.

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Facial Nerve Outcomes After Vestibular Schwannoma Microsurgical Resection in Neurofibromatosis Type 2

Catherine Sobieski,Daniel E. Killeen,Samuel L. Barnett,Bruce E. Mickey,Jacob B. Hunter,Brandon Isaacson,Joe Walter Kutz

Publication date 22-09-2020


The aim of this study is to investigate facial nerve outcomes after microsurgical resection in neurofibromatosis type 2 (NF2) compared to sporadic tumors. Single institutional retrospective chart review. Tertiary referral center. All adult patients with NF2 vestibular schwannoma (VS) or sporadic VS who underwent microsurgical resection from 2008 to 2019 with preoperative magnetic resonance imaging (MRI) and 1 year of postsurgical follow-up were included. The primary outcome measure was postoperative House-Brackmann (HB) facial nerve score measured at first postoperative visit and after at least 10 months. In total, 161 sporadic VSs and 14 NF2 VSs met inclusion criteria. Both median tumor diameter (NF2, 33.5 mm vs sporadic, 24 mm, Tumor volume >3 cm

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Adverse Events in Hypoglossal Nerve Stimulator Implantation: 5-Year Analysis of the FDA MAUDE Database

Nikhil Bellamkonda,Travis Shiba,Abie H. Mendelsohn

Publication date 22-09-2020


Use of hypoglossal nerve stimulator implantation has dramatically improved the surgical treatment of multilevel airway collapse during obstructive sleep apnea (OSA). Understanding causes of adverse events and their impact on patients undergoing stimulator implantation will help improve patient preparation and surgical practices to avoid future complications. This study is a retrospective review of the US Food and Drug Administration (FDA) Manufacturer and User Facility Device Experience (MAUDE) database, a publicly available voluntary reporting system. National patient event database. The MAUDE database was searched for reports associated with the terms "hypoglossal nerve stimulator" and "Inspire," being the only currently FDA-approved system for upper airway stimulation for OSA. All records were searched with the events limited in dates between May 2014 and September 2019. A total of 132 patient reports were identified over the 5-year inclusion period, containing 134 adverse events. The reported adverse events resulted in 32 device revision procedures as well as 17 explantations. Device migration and infection were 2 of the most commonly reported adverse events. Complications not witnessed in previous large-scale clinical trials included pneumothorax, pleural effusion, and lead migration into the pleural space. Previous data have demonstrated hypoglossal nerve stimulator implantation results in reliable OSA improvement. However, a number of technical difficulties and complications still exist during the perioperative period, which should be communicated to patients during the surgical consent process.

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Truncal vs Branch Ligation of Inferior Thyroid Arteries in Total Thyroidectomy: Does It Affect Postoperative Hypoparathyroidism?

Talat Waseem,Safia Zahir Ahmed,Hadia Baig,Muhammad Hasham Ashraf,Asad Azim,Khawaja M. Azim

Publication date 22-09-2020


Postthyroidectomy hypoparathyroidism remains a significant challenge. Truncal ligation of the inferior thyroid arteries (ITAs) may lead to an increased risk of hypoparathyroidism; however, dissection along the thyroid capsule with branch ligation of the thyroid arteries could be a safer option. This study's objective was to compare the effect of truncal versus branch ligation of the ITAs on the rate of postoperative hypoparathyroidism. Randomized prospective trial in line with the CONSORT guidelines. The study was conducted at a high-volume tertiary care setting.
We randomized 319 patients into 2 groups: truncal ITA ligation (n = 157) and branch ITA ligation (n = 162). The primary outcomes were serum calcium and parathormone levels on the second postoperative day, followed by the levels on months 1, 3, 6, and 12. The need for exogenous replacements was noted. The secondary outcomes, such as operative time, blood loss, and other complications, were also recorded. Our study revealed a significant difference in the incidence of transient hypocalcemia in patients undergoing truncal ITA ligation and branch ITA ligation (22.9% vs 3.1%, This is the largest randomized trial of patients undergoing thyroidectomy, and it shows that dissection along the thyroid capsule with branch ligation of the ITAs is more likely to preserve parathyroid function as opposed to truncal ligation of ITAs.

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Racial and Insurance Inequalities in Access to Early Pediatric Cochlear Implantation

Xinliang Liu,Linda I. Rosa-Lugo,Janel L. Cosby,Cedric V. Pritchett

Publication date 15-09-2020


To evaluate the association between race/ethnicity and insurance status on the access to early cochlear implantation. Population-based retrospective analysis of pediatric cochlear implantation procedures. State Ambulatory Surgery and Services Databases of Florida from 2005 to 2017. All children aged 18 years or younger in the state of Florida undergoing cochlear implantation were identified. The outcome measures were access to early cochlear implantation (before 1 and 2 years of age). Descriptive and multivariate logistic regression analyses were conducted. Among 1511 pediatric cochlear implantation procedures with complete data, 65 (4.3%) procedures were performed by 1 year of age and 348 (23.0%) by 2 years of age. Black children (odds ratio [OR], 0.44; 95% CI, 0.28-0.70), Hispanic children (OR, 0.70; 95% CI, 0.52-0.94), and children with Medicaid (OR, 0.64; 95% CI, 0.48-0.84) were significantly less likely to be implanted before 2 years of age. Even when insured by private insurance, black and Hispanic children were still less likely to be implanted before 2 years of age compared to white children with private insurance. Greater racial and insurance disparities existed in access to cochlear implantation before 1 year of age compared to implantation before 2 years of age. Racial/ethnic and insurance disparities in pediatric cochlear implantation can be observed at the population level. To address these racial and insurance inequalities, a multidisciplinary care team is needed and priorities should be given to research endeavors and policy interventions that target these disparities.

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Timing the First Pediatric Tracheostomy Tube Change: A Randomized Controlled Trial

Stephen R. Chorney,Rosemary C. Patel,Allison E. Boyd,Joanne Stow,Mary M. Schmitt,Deborah Lipman,Julia F. Dailey,Carol Nhan,Terri Giordano,Steven E. Sobol

Publication date 15-09-2020


The first pediatric tracheostomy tube change often occurs within 7 days after placement; however, the optimal timing is not known. The primary objective was to determine the rate of adverse events of an early tube change. Secondary objectives compared rates of significant peristomal wounds, sedation requirements, and expedited intensive care discharges. Prospective randomized controlled trial. Tertiary children's hospital between October 2018 and April 2020. A randomized controlled trial enrolled children under 24 months to early (day 4) or late (day 7) first tracheostomy tube changes. Sixteen children were enrolled with 10 randomized to an early change. Median age was 5.9 months (interquartile range, 5.4-8.3), and 86.7% required tracheostomy for respiratory failure. All tracheostomy tube changes were performed without adverse events. There were no accidental decannulations. Significant wounds developed in 10% of children with early tracheostomy tube changes and 83.3% of children with late tracheostomy tube changes (odds ratio [OR], 45.0; 95% CI, 2.3-885.6; The first tracheostomy tube change in children can occur without adverse events on day 4, resulting in fewer significant peristomal wounds and earlier intensive care discharge.

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Risk Factors for Post–acute care Following Free Flap Reconstruction of the Oral Cavity

Jason Lepse,Kevin J. Sykes,Kiran Kakarala

Publication date 15-09-2020


Identify previously unreported factors that predict the need for post-acute care after free flap reconstruction of the oral cavity. Retrospective cohort study. Single academic medical center. A total of 134 patients with head and neck disease involving the oral cavity underwent free tissue transfer for reconstruction between August 2012 and October 2015. All patients had a tracheostomy placed at the time of surgery. Data were collected, including demographics, perioperative risk factors, and social variables. Univariate and multivariate logistic regression were used to identify risk factors for needing post-acute care. Of 134 patients, 37 (28%) required post-acute care upon discharge, and 97 of 134 (72%) were discharged home with assistance. Multivariate logistic regression revealed that lack of family support (adjusted odds ratio [AOR], 32.12; 95% CI, 13.75-274.90; P = .002), tracheostomy tube at discharge (AOR, 13.70; 95% CI, 3.20-58.44; Lack of family support, tracheostomy tube at discharge, government insurance, hospital stay >10 days, and increasing age are independently associated with the need for post-acute care following free flap reconstruction of the oral cavity. Physicians, social workers, and nurse case managers are positioned to identify patients at high risk for needing post-acute care and to reduce the duration of hospitalizations.

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Systematic Review of Second Primary Oropharyngeal Cancers in Patients With p16+ Oropharyngeal Cancer

Craig A. Bollig,David S. Lee,Angela L. Mazul,Katelyn Stepan,Sidharth V. Puram,Sean T. Massa,Joseph Zenga,Daniel L. Faden,Michelle M. Doering,Ryan S. Jackson,Patrik Pipkorn

Publication date 15-09-2020


To systematically review the literature to determine the prevalence and clinical outcomes of second primary oropharyngeal squamous cell carcinoma (OPSCC). Search strategies created with a medical librarian were implemented using multiple databases in October 2019. The population of interest included adults age >18 years with a p16+ or human papillomavirus-positive OPSCC. The outcome was a synchronous or metachronous second primary OPSCC. Inclusion and exclusion criteria were designed to capture all study designs. In total, 685 records were identified by the search strategy. Two reviewers independently performed the review, extracted data, and performed a quality assessment. Primary Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. A random-effects model was used for the meta-analysis. A total of 2470 patients with 35 second primary OPSCCs from 15 studies were identified. The pooled prevalence of second primary OPSCC was 1.4% (range, 0%-14.3%). In the random-effects model, the prevalence was estimated at 1.3% (95% CI, 0.7%-2.3%; Overall, the rate of second primary OPSCC in patients with an index p16+ OPSCC is low, and most patients are successfully treated. Insufficient evidence currently exists to recommend routine elective tonsillectomy during surgical treatment of p16+ OPSCC.

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Association of Clinicopathological Features With Outcome in Chondrosarcomas of the Head and Neck

Sofia Asioli,Poosit Ruengwanichayakun,Matteo Zoli,Federica Guaraldi,Giacomo Sollini,Paolo Greco,Carla Facco,Dino Gibertoni,Brayan Vega Jiménez,Stefania Benini,Mario Turri-Zanoni,Ernesto Pasquini,Diego Mazzatenta,Maria Pia Foschini,Alberto Righi

Publication date 15-09-2020


The aim of this study is to assess the association between clinical and radiological features as well as of isocitrate dehydrogenase 1 and 2 ( Retrospective study. Tertiary referral center. Clinical, histological, and molecular data of patients with head and neck chondrosarcomas treated by surgery were collected. Forty-six patients were included. The mean age at diagnosis was 56 years (range, 17-78). The tumor originated from the skull base (52.2%), facial bones (28.2%), or laryngotracheal area (19.6%). At last follow-up (median 52.5 months), 38 patients were alive, 30 of which were disease free, whereas 8 had died, 4 of disease progression and 4 of other causes. Fourteen (30.4%) had local recurrence and 2 (4.3%) had lung metastasis. All cases were negative for cytokeratin AE1/AE3, brachyury, and IDH1 at immunohistochemistry, while Sanger sequencing identified IDH1/2 point mutations, typically IDH1 R132C, in 9 (37.5%) tumors arising from the skull base. Margin infiltration on the surgical specimen negatively affected the outcome, whereas no correlation was identified with An adequate margin positively affects survival.

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Auditory Brainstem Response in Preterm Infants in the Neonatal Intensive Care Unit

Diogo Raposo,João Orfão,Marco Menezes,Mafalda Trindade-Soares,Ana Guimarães,Filipe Freire

Publication date 15-09-2020


To analyze auditory brainstem response (ABR) findings of preterm and term infants in the neonatal intensive care unit (NICU) with perinatal problems. Case series with chart review. Secondary care hospital. Analysis consisted of a consecutive series of 101 infants (69 preterm and 32 term) admitted in the NICU of Hospital Fernando Fonseca between 2016 and 2018 with perinatal problems who underwent an ABR evaluation. The major perinatal problems identified were hyperbilirubinemia, intravenous gentamicin >5 days, mechanical ventilation >5 days, congenital cytomegalovirus infection, meningitis, and periventricular hemorrhage. Gentamicin use significantly increased the absolute latency of wave I in preterm infants (95% CI, 0.01-0.37; These findings suggest that perinatal problems in the NICU significantly impair the ABR threshold and the auditory pathway maturational process in preterm but not term infants.

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Communicative Participation and Quality of Life in Pretreatment Oral and Oropharyngeal Head and Neck Cancer

Cara Sauder,Mara Kapsner-Smith,Carolyn Baylor,Kathryn Yorkston,Neal Futran,Tanya Eadie

Publication date 15-09-2020


To determine how communicative participation is affected in patients with oral and oropharyngeal head and neck cancers (HNCs) pretreatment and whether communication function predicts HNC-specific quality of life (QOL) before treatment, beyond known demographic, medical, psychosocial, and swallowing predictors. Cross-sectional study. Tertiary care academic medical center. Eighty-seven patients with primary oral (40.2%) or oropharyngeal (59.8%) HNC were recruited prior to treatment. T stage, tumor site, and p16 status were extracted from medical records. Demographic and patient-reported measures were obtained. Communicative participation was measured using the Communicative Participation Item Bank (CPIB) General short form. A hierarchical regression analysis included demographic, medical, psychosocial, and functional measures of swallowing and communication as predictors; the University of Washington Quality of Life (UW-QOL v4) composite score was the predicted variable. Median (SD) baseline CPIB scores were 71.0 (11.83); patients with oral cancers reported worse scores. A final sequential hierarchical regression model that included all variables explained 71% of variance in QOL scores. Tumor site, T stage, and p16 status accounted for 28% of variance ( Pretreatment communication predicted QOL and was negatively affected in some oral and oropharyngeal patients with HNC.

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Airborne Aerosolized Mouse Cytomegalovirus From Common Otolaryngology Procedures: Implications for COVID-19 Infection

Tofigh Sayahi,Christopher Nielson,Yuan Yu,Kaden Neuberger,Michael Seipp,Matthew A. Firpo,Kerry Kelly,Albert H. Park

Publication date 15-09-2020


To determine whether common otolaryngology procedures generate viable aerosolized virus through a murine cytomegalovirus (mCMV) model for infection. mCMV model of infection. University of Utah laboratory. Three-day-old BALB/c mice were inoculated with mCMV or saline. Five days later, each mouse underwent drilling, microdebrider, coblation, and electrocautery procedures. Particle size distribution and PM As compared with the background aerosol concentrations, coblation and electrocautery showed statistically significant increases in airborne aerosols (Tukey-adjusted Coblation and electrocautery procedures generate >100-fold increases in aerosol concentrations over background; only coblation and drilling produce aerosolized viral DNA. The high concentration of aerosols from coblation and electrocautery suggests the need for appropriate safeguards against particle exposure to health care workers. The presence of viral DNA from drilling and coblation procedures warrants the need for appropriate protection against droplet and aerosol exposure.

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Demographic and Clinical Characteristics Associated With Adherence to Guideline-Based Polysomnography in Children With Down Syndrome

Philip D. Knollman,Christine H. Heubi,Susan Wiley,David F. Smith,Sally R. Shott,Stacey L. Ishman,Jareen Meinzen-Derr

Publication date 15-09-2020


To compare the demographic and clinical characteristics of children with Down syndrome who did and did not receive polysomnography to evaluate for obstructive sleep apnea after publication of the American Academy of Pediatrics' guidelines recommending universal screening by age 4 years. Retrospective cohort study. Single tertiary pediatric hospital. Review was conducted of children with Down syndrome born between 2007 and 2012. Children who obtained polysomnography were compared with children who did not, regarding demographic data, socioeconomic status, and comorbidities. We included 460 children with Down syndrome; 273 (59.3%) received at least 1 polysomnogram, with a median age of 3.6 years (range, 0.1-8.9 years). There was no difference in the distribution of sex, insurance status, or socioeconomic status between children who received polysomnography and those who did not. There was a significant difference in race distribution ( Overall, 60% of children with Down syndrome obtained a polysomnogram. There was no difference between groups by payer status or socioeconomic status. A significant difference in race distribution was noted. Proximity to the medical center and increased medical need appear to be associated with increased likelihood of obtaining a polysomnogram. This study illustrates the need for improvement initiatives to increase the proportion of patients receiving guideline-based screening.

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Unique Challenges for Otolaryngology Patients During the COVID-19 Pandemic

Melissa Ghulam-Smith,Yeyoon Choi,Heather Edwards,Jessica R. Levi

Publication date 15-09-2020


The coronavirus disease 2019 (COVID-19) pandemic has drastically altered health care delivery and utilization. The field of otolaryngology in particular has faced distinct challenges and an increased risk of transmission as day-to-day procedures involve intimate contact with a highly infectious upper respiratory mucosa. While the difficulties for physicians have been thoroughly discussed, the unique challenges of patients have yet to be considered. In this article, we present challenges for patients of otolaryngology that warrant thoughtful consideration and propose solutions to address these challenges to maintain patient-centered care both during and in the aftermath of the COVID-19 pandemic.

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Preoperative Gabapentin Administration and Its Impact on Postoperative Opioid Requirement and Pain in Sinonasal Surgery

Amarbir S. Gill,Farrukh R. Virani,Joshua C. Hwang,Machelle D. Wilson,Angela M. Beliveau,E. Bradley Strong,Toby O. Steele

Publication date 08-09-2020


To determine the efficacy of preoperative gabapentin on patient-reported pain levels and postoperative opioid requirements following sinonasal surgery. Retrospective review. Academic institution. Patients undergoing sinonasal surgery between July 2019 and January 2020 were followed. Groups were divided into those that received 600 mg of oral gabapentin 1 hour preoperatively (gabapentin) and those that did not (control). Postoperatively, each patient was counseled to use acetaminophen, ibuprofen, and oxycodone as needed for pain control. Patients completed a daily postoperative pain and medication log. Pain was measured by the visual analog scale (VAS) and opioid use by morphine equivalent dose (MED). Chi-square test and Wilcoxon test were used for data analysis. Fifty-seven patients were included (control, n = 28; gabapentin, n = 29). There was no significant difference in age, sex, or baseline Sinonasal Outcome Test-22 scores between the groups. The total MED, postoperative day (POD) 1-2 MED, POD 3-4 MED, and POD 5-6 MED did not differ significantly between the control (17.9, 12.2, 4.6, 1.5) and gabapentin (19.0, 8.9, 7.2, 3.5) groups ( Preoperative gabapentin did not significantly reduce postoperative pain or opioid use. Postoperative discomfort following sinonasal surgery is mild, and opioid intake is minimal.

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Diagnostic Utility of Salivary Pepsin as Compared With 24-Hour Dual pH/Impedance Probe in Laryngopharyngeal Reflux

Michael Zhang,Clemente Chia,Claire Stanley,Debra J. Phyland,Paul M. Paddle

Publication date 08-09-2020


Laryngopharyngeal reflux (LPR) is defined as the retropulsion of gastric contents into the larynx, oropharynx, and/or nasopharynx. The 24-hour combined hypopharyngeal-esophageal multichannel intraluminal impedance with dual pH probe (24h-HEMII-pH) is currently the gold standard in LPR diagnosis; however, it is invasive, user dependent, and not always tolerated. This study assesses the diagnostic utility of salivary pepsin (Peptest) at different thresholds and during symptomatic periods as compared with the 24h-HEMII-pH probe in diagnosing LPR. Prospective cohort study. Private laryngology clinic in Melbourne, Australia. Thirty-five patients with a clinical history and endoscopic findings of LPR were recruited and simultaneously evaluated for LPR via 24h-HEMII-pH probe and salivary pepsin analysis at 5 key time points over the same 24-hour period. Salivary pepsin was 76.9% sensitive and had a positive predictive value (PPV) of 87.0% at a threshold of 16 ng/mL when compared with the 24h-HEMII-pH probe. If the pathologic pepsin threshold was raised to 75 ng/mL, salivary pepsin had a sensitivity of 57.7%, a specificity of 75.0%, and a PPV of 93.8%. Symptomatic testing conferred a superior specificity at 16 ng/mL (66.7%) and 75 ng/mL (100.0%) and a superior PPV at 16 ng/mL (92.3%) and 75 ng/mL (100.0%). Salivary pepsin detection is a simpler, more cost-effective, and less traumatic universal first-line alternative to 24h-HEMII-pH probe in diagnosing LPR. Superior specificities conferring greater diagnostic value may be achieved with higher thresholds and symptomatic testing. If clinical suspicion remains high following negative salivary pepsin analysis, a 24h-HEMII-pH study could provide further diagnostic information.

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Tensor Veli Palatinopexy as a Novel Treatment for Eustachian Tube Dysfunction: A Cadaveric Feasibility Study

Eric A. Eisen,Xiaotian Wu,Christiaan A. Rees,David A. Pastel,Joseph A. Paydarfar,James E. Saunders

Publication date 08-09-2020


To demonstrate the feasibility of a novel procedure whereby a suture is placed transorally in the tensor veli palatini muscle to tighten it, thereby dilating the cartilaginous portion of the eustachian tube (ET). The study design was a prospective cadaveric experiment to examine the feasibility of a novel treatment for ET dysfunction. Academic medical center in a research-oriented operating room with intraoperative computed tomography (CT) capabilities. Seven fresh-frozen cadaver heads were obtained, each of which was thawed for 36 hours prior to use. The preprocedural volumes of the cartilaginous ET were measured by filling the ET with an iodine-containing radiocontrast agent via the nasopharynx and then obtaining CT images. Submucosal flaps in the soft palate were raised, and sutures were placed in the tensor veli palatini bilaterally to increase tension. After completion of the procedure, contrast placement and CT imaging were repeated. Three-dimensional models of the ETs were created, and the volumes were measured and compared. Of the 14 ETs evaluated, 13 showed an increase in postprocedure volume. On average, postprocedure volumes showed a 57% increase from preprocedure volumes (mean relative change, 57.1%; Placement of a tension-holding suture in the tensor veli palatini muscle can reliably dilate the cartilaginous portion of the ET. Such a procedure may be useful in the treatment of ET dysfunction.

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Implications of Obesity on Endoscopic Sinus Surgery Postoperative Complications: An Analysis of the NSQIP Database

Robert D. Wardlow,Isaac A. Bernstein,Cinthia P. Orlov,Nicholas R. Rowan

Publication date 08-09-2020


To evaluate the influence of body mass index on postoperative adverse events in adult patients undergoing endoscopic sinus surgery. Retrospective cohort study. Database of the American College of Surgeons NSQIP (National Surgical Quality Improvement Program) from 2006 to 2018. The NSQIP database was queried for adult patients undergoing endoscopic sinus surgery. The total sample (N = 1546) was stratified by nonobese (18.5 kg/m Obese patients accounted for 49.7% (n = 768) of the cohort. Obese patients had a higher American Society of Anesthesiologists classification (class III, 45.1% vs 29.5%; Obesity does not increase the risk of 30-day adverse outcomes following endoscopic sinus surgery and may even be protective against perioperative bleeding.

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Pediatric Aural Foreign Body Extraction: Comparison of Efficacies Among Clinical Settings and Retrieval Methods

Michael Shih,Linda Brock,Yi-Chun Carol Liu

Publication date 08-09-2020


To compare the efficacy of aural foreign body (FB) extractions among medical care settings and determine if certain methods of extraction resulted in higher failure rates and procedural complications. Case series with chart review. Emergency departments (EDs), urgent cares (UCs), pediatric primary care providers (PCPs), and otolaryngologists (ENTs). A total of 366 pediatric patients with EAC foreign bodies at a tertiary children's hospital and associated satellite clinics. The ED/UCs (17.46%), PCPs (75.22%), and ENTs (94.54%) exhibited highly variable success rates for pediatric aural FB extractions. Complications were considerably higher for attempts by ED/UCs (22.22%) as compared with PCPs (2.61%) and those of unclear etiology (2.73% of all attempts). Use of balloon-tipped catheters and adhesive-tipped probes (eg, cyanoacrylate/superglue) for FB extraction exhibited 0% success rates with high severity of complications. Our statistics provide an example in which ED/UCs had higher failure rates at pediatric aural FB removals when compared with PCPs and ENTs. If a single provider (PCP or ED/UC) fails to retrieve an aural FB or if the provider is not comfortable conducting the procedure, then referral to an ENT is preferable to another PCP or ED/UC. Our evidence reveals that balloon-tipped catheters and adhesive-tipped probes for FB removal in the pediatric population are prone to failure and higher rates/severity of complications.

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Venous Flow Coupler in Head and Neck Free Flap Reconstruction

Scott H. Troob,Quinn Self,Deniz Gerecci,Macgregor Hodgson,Javier González-Castro,Daniel Petrisor,Mark K. Wax

Publication date 08-09-2020


To describe the utility of venous flow couplers in monitoring free tissue flaps in the immediate postoperative setting. Retrospective case series. Otolaryngology department at a single tertiary care institution. A retrospective case series of free flap reconstructions in which venous flow couplers were employed to supplement flap monitoring. All free flap cases performed over the past 4 years were reviewed. Inclusion criteria were venous flow coupler and arterial flow Doppler monitored for 5 days postoperatively. From July 2014 through May 2018, the venous flow coupler was used with the arterial flow Doppler and clinical monitoring in 228 cases. Eleven cases did not meet criteria for inclusion; thus, 217 cases were analyzed. Twenty cases (9.2%) returned to the operating room with concern for flap compromise, and 16 were salvaged. The combination of venous flow coupler and arterial flow Doppler identified 19 of these flaps. Venous flow couplers identified 5 compromised flaps before there was an arterial signal change, and all were salvaged. Additionally, there was a 24.1% false-positive rate when 2 venous flow couplers were used in parallel. For the venous flow coupler, the positive predictive value was 64.3% and the negative predictive value, 98.9%. The false-positive rate in the series was 5.1%. The sensitivity was 90% and the specificity, 94.9%. The venous flow coupler is able to detect venous thrombosis in the absence of arterial thrombosis and may contribute to improved flap salvage rates.

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Evidence-Based Medicine in Otolaryngology Part XII: Assessing Patient Preferences

Matthew R. Naunheim,Gregory W. Randolph,Jennifer J. Shin

Publication date 08-09-2020


To provide a contemporary resource to update clinicians and researchers on the current state of assessment of patient preferences. Published studies and literature regarding patient preferences, evidence-based practice, and patient-centered management in otolaryngology. Patients make choices based on both physician input and their own preferences. These preferences are informed by personal values and attitudes, and they ideally result from a deliberative evaluation of the risks, benefits, and other outcomes pertaining to medical care. To date, rigorous evaluation of patient preferences for otolaryngologic conditions has not been integrated into clinical practice or research. This installment of the "Evidence-Based Medicine in Otolaryngology" series focuses on formal assessment of patient preferences and the optimal methods to determine them. Methods have been developed to optimize our understanding of patient preferences. Understanding these patient preferences may help promote an evidence-based approach to the care of individual patients.

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Patterns of Nodal Metastases and Predictors of Occult Disease in HPV-Associated Oropharynx Cancer

Gaelen Britton Stanford-Moore,Edgar Ochoa,Andrew Larson,Mary Han,Kathryn Hoppe,William R. Ryan

Publication date 08-09-2020


For human papilloma virus-associated oropharynx squamous cell carcinoma (HPV+ OPSCC), we evaluated the distribution of neck-level lymph node (LN) metastasis, based on postsurgical histopathology, and the incidence of and risk factors for occult LN metastases, as these patterns need clarification for this newer cancer subset. Retrospective cohort study. National Cancer Database (NCDB). We analyzed 2358 patients in the NCDB with HPV+ OPSCC who underwent neck dissection (ND) from 2010 to 2015. Incidence and distribution of LN metastases were calculated for neck levels I to V. Variables associated with occult LN metastasis were assessed by multivariate logistic regression. In therapeutic NDs (n = 1935), the following proportions of positive LNs were found: level I, 9.0% (n = 175); level II, 81.0% (n = 1568); level III, 29.6% (n = 573); level IV, 11.9% (n = 230); and level V, 4.9% (n = 95). In elective NDs (n = 423), occult-positive LNs were found in 35.8% (n = 152), with the following proportions by level: level I, 3.3% (n = 14); level II, 26.9% (n = 114); level III, 8.7% (n = 37); level IV, 4.0% (n = 17); and level V, 0.2% (n = 1). The presence of occult LNs was independently associated with a Charlson-Deyo score of 1 (odds ratio, 2.26; 95% CI, 1.18-4.31; For HPV+ OPSCC, occult nodal disease is common. Therapeutic NDs should encompass at least levels II, III, and IV and possibly I, whereas elective NDs could possibly encompass levels II and III. 4.

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Otolaryngology Residency Interviews in a Socially Distanced World: Strategies to Recruit and Assess Applicants

David W. Chou,Steven D. Pletcher,David Bruss,C. Kwang Sung,Rodney C. Diaz,Jonathan Liang,Megan L. Durr

Publication date 01-09-2020


Due to concerns surrounding travel during the COVID-19 pandemic, the 2020-2021 otolaryngology residency application cycle will be conducted virtually for the first time. Residency programs should consider the logistics of video interviews, drawing on experiences of other programs that have successfully performed virtual interviews in the past. The lack of in-person interviews will create challenges in assessing applicants, and we recommend that programs develop structured and targeted questions and even consider having candidates answer standardized questions prior to the virtual interview day. From an applicant perspective, gauging the intangibles of individual residency programs, such as resident camaraderie, program culture, and program location, will be difficult. To address this, programs should consider hosting informal virtual gatherings, create videos that highlight the resident experience, and ensure that program websites are up-to-date. Ultimately, adaptability, resilience, and innovation will allow residency programs to achieve a successful 2021 otolaryngology match.

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Recruitment and Networking With Social Media for the Otolaryngology Match in the COVID-19 Pandemic

Jeffrey C. Mecham,Deanna C. Menapace,Sarah N. Bowe,Matthew L. Carlson

Publication date 01-09-2020


COVID-19 has created new challenges and opportunities regarding the way in which programs and applicants will interact in the 2020-2021 otolaryngology residency match cycle. Social media and other virtual platforms offer a flexible and efficient medium for applicants and programs to gain information, communicate, and align interests. In this commentary, we explore ways in which social media may facilitate recruitment and networking in the virtual otolaryngology match.

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Tracheotomy in a High-Volume Center During the COVID-19 Pandemic: Evaluating the Surgeon’s Risk

Arielle G Thal,Bradley A. Schiff,Yasmina Ahmed,Angela Cao,Allen Mo,Vikas Mehta,Richard V. Smith,Hillel W. Cohen,Thomas J. Ow

Publication date 01-09-2020


Performing tracheotomy in patients with COVID-19 carries a risk of transmission to the surgical team due to potential viral particle aerosolization. Few studies have reported transmission rates to tracheotomy surgeons. We describe our safety practices and the transmission rate to our surgical team after performing tracheotomy on patients with COVID-19 during the peak of the pandemic at a US epicenter. Retrospective cohort study. Tertiary academic hospital. Tracheotomy procedures for patients with COVID-19 that were performed April 15 to May 28, 2020, were reviewed, with a focus on the surgical providers involved. Methods of provider protection were recorded. Provider health status was the main outcome measure. Thirty-six open tracheotomies were performed, amounting to 65 surgical provider exposures, and 30 (83.3%) procedures were performed at bedside. The mean time to tracheotomy from hospital admission for SARS-CoV-2 symptoms was 31 days, and the mean time to intubation was 24 days. Standard personal protective equipment, according to Centers for Disease Control and Prevention, was worn for each case. Powered air-purifying respirators were not used. None of the surgical providers involved in tracheotomy for patients with COVID-19 demonstrated positive antibody seroconversion or developed SARS-CoV-2-related symptoms to date. Tracheotomy for patients with COVID-19 can be done with minimal risk to the surgical providers when standard personal protective equipment is used (surgical gown, gloves, eye protection, hair cap, and N95 mask). Whether timing of tracheotomy following onset of symptoms affects the risk of transmission needs further study.

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Chemosensory Dysfunction in COVID-19: Prevalences, Recovery Rates, and Clinical Associations on a Large Brazilian Sample

Deusdedit Brandão Neto,Marco Aurélio Fornazieri,Caroline Dib,Renata Cantisani Di Francesco,Richard L. Doty,Richard Louis Voegels,Fabio de Rezende Pinna

Publication date 01-09-2020


Our study aimed to measure the percentage of reported olfactory or taste losses and their severity, recovery time, and association with other features in a large cohort of patients with COVID-19. Prospective survey. Quaternary medical center and online survey. The perceived chemosensory capacities of 655 patients with confirmed COVID-19 were assessed with 11-point category rating scales (0, no function; 10, normal function). Patients were contacted in hospital, by phone calls, or by internet regarding their ability to smell or taste, and 143 were interviewed by phone 1 to 4 months later to assess the recovery of their chemosensory abilities. The prevalence of self-reported olfactory, general taste, and taste quality-specific disturbances (sweet, sour, bitter, and salty) in the patients with COVID-19 were 82.4% (95% CI, 79.5%-85.3%), 76.2% (95% CI, 72.9%-79.4%), and 52.2% (95% CI, 48.3%-56.1%), respectively. The majority reported anosmia (42.9%). The presence of chemosensory symptoms was not associated with COVID-19 severity. At a median time >2 months after the onset of symptoms, rates of total and partial olfaction recovery were 53.8% and 44.7%, while complete or partial return to previous taste function was 68.3% and 27.6%. Less than 5% of the patients reported no chemosensory function improvement at all. The prevalence of self-reported chemosensory dysfunction is high among patients with COVID-19. Almost all patients seem to recover a significant part of their smell and taste abilities in the first 4 months after the onset of symptoms.

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Establishing an Office-Based Framework for Resuming Otolaryngology Care in Academic Practice During the COVID-19 Pandemic

Aaron N. Pearlman,Abtin Tabaee,Anthony P. Sclafani,Lucian Sulica,Samuel H. Selesnick,David I. Kutler,Joseph J. Montano,Joshua I. Levinger,Maria V. Suurna,Vikash K. Modi,Michael G. Stewart

Publication date 01-09-2020


The COVID-19 health crisis abruptly disrupted the practice of otolaryngology. This article aims to define the changes needed to operate an academic otolaryngology practice safely and efficiently from within the epicenter of the pandemic. We define the areas of normal patient workflow that have been affected by COVID-19, and we offer mitigation strategies with attention paid to the specific needs of subspecialties. The article includes data specific to the office practice metrics of the Weill Cornell Medicine Department of Otolaryngology-Head and Neck Surgery, as well as publically available data from New York Presbyterian Hospital system and the Expert opinion. Through careful planning and execution, it is possible to reestablish safe otolaryngologic patient care during the COVID-19 pandemic. It will require a significant change from prior practice models for successful implementation. Additionally, telemedicine can be positively integrated into the treatment of otolaryngology diseases for new and established patients. The information conveyed in this review can be used as a guide by large and small otolaryngology groups to identify aspects of the patient visit that are "at risk" due to COVID-19, and it suggests sensible responses that can be made without a significant disruption to normal practice. The methods used to identify vulnerabilities with the patient visit process can be applied to future unforeseen crises, such as a resurgence of COVID-19 or a novel pandemic.

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The Sinonasal Outcome Test–22 or European Position Paper: Which Is More Indicative of Imaging Results?

Allen S. Zhou,Anthony A. Prince,Alice Z. Maxfield,C. Eduardo Corrales,Jennifer J. Shin

Publication date 01-09-2020


The 22-item Sinonasal Outcome Test (SNOT-22) is a trusted measure of symptom severity in chronic rhinosinusitis. The European Position Paper on Rhinosinusitis (EPOS) provides widely accepted diagnostic criteria, which include sinonasal symptoms, their duration, and imaging results. Our objective was to compare these approaches to assessing symptoms to determine if either was more indicative of radiologic findings, to support decisions in telehealth. Observational outcomes study. Tertiary care center. In total, 162 consecutive patients provided a structured sinonasal history, completed the SNOT-22, and underwent sinus computed tomography (CT) within 1 month. SNOT-22 scores, EPOS-defined symptom sets, and Lund-Mackay results were assessed. To facilitate direct comparisons, we performed stepwise evaluations of sinonasal symptoms alone and combined with duration. The discriminatory capacity for imaging results was determined through areas under the receiver operating characteristic curves (ROC-AUC) for dichotomous outcomes and ordinal regression for multilevel outcomes. In ROC-AUC analyses, SNOT-22 and EPOS-defined symptoms had similar discriminatory capacity for Lund-Mackay scores, regardless of duration. Within ordinal regression analyses, SNOT-22 nasal scores were significantly associated with Lund-Mackay scores, while EPOS-defined nasal symptoms were not statistically significantly related. SNOT-22 nasal scores and EPOS-defined nasal symptoms may have similar associations with imaging results when assessed via ROC-AUC, while SNOT-22 may have more association within ordinal data. Understanding the implications of discrete patterns of symptoms may confer benefit, particularly when in-person and fiberoptic exams are limited.

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Shared Decision Making for Surgical Care in the Era of COVID-19

David Forner,Christopher W. Noel,Ryan Densmore,David P. Goldstein,Martin Corsten,Arwen H. Pieterse,Andrew G. Shuman,Paul Hong,Valeria E. Rac

Publication date 01-09-2020


The global pandemic caused by severe acute respiratory syndrome coronavirus 2 has upended surgical practice. In an effort to preserve resources, mitigate risk, and maintain health system capacity, nonurgent surgeries have been deferred in many jurisdictions, with urgent procedures facing increasing wait times and unpredictability given potential future surges. Shared decision making, a process that integrates patient values and preferences with the scientific expertise of clinicians, may be of particular benefit during these unprecedented times. Aligning patient choices with their values, reducing unnecessary health care use, and promoting consistency between providers are now more critical than ever before. We review important aspects of shared decision making and provide guidance for its perioperative application during the coronavirus disease 2019 pandemic.

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CARES Act Provider Relief Fund Aid to Otolaryngologists in Small Practices

Roy Xiao,Vinay K. Rathi

Publication date 01-09-2020


The COVID-19 pandemic has placed unprecedented financial strain on otolaryngologists. Otolaryngologists employed by small practices may be particularly vulnerable to the effects of ongoing losses because these organizations often have limited financial reserves. We performed a retrospective cross-sectional analysis of federal direct aid provided to small practices (defined as ≤15 clinicians) employing otolaryngologists, using the Centers for Medicare and Medicaid Services Physician Compare National Downloadable File and the Department of Health and Human Services (HHS) Provider Relief Fund database. As of June 18, 2020, the HHS had allocated nearly $80 million to 966 (88.9%) of 1087 small practices employing 2455 otolaryngologists. The median amount of aid per clinician was $7909 (interquartile range, $4409-$12,710). These findings suggest that the majority of small practices have received direct aid through the HHS Provider Relief Fund, but aid amounts have thus far been modest relative to the fixed costs of practice.

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Pass/Fail Scoring of USMLE Step 1 and the Need for Residency Selection Reform

Parsa P. Salehi,Babak Azizzadeh,Yan Ho Lee

Publication date 25-08-2020


The Federation of State Medical Boards and the National Board of Medical Examiners recently announced a change in the United States Medical Licensing Examination Step 1 scoring convention to take effect, at the earliest, on January 1, 2022. There are many reasons for this change, including decreasing medical student stress and incentivizing students to learn freely without solely focusing on Step 1 performance. The question remains how this will affect the future of the otolaryngology-head and neck surgery match. By eradicating Step 1 grades, other factors, such as research, may garner increased importance in the application process. Such a shift may discriminate against students from less well-known medical schools, international medical graduates, and students from low socioeconomic backgrounds, who have fewer academic resources and access to research. Residency programs should try to anticipate such unintended consequences of the change and work on solutions heading into 2022.

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A National Comparison of Postoperative Outcomes in Completion Thyroidectomy and Total Thyroidectomy

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

Publication date 25-08-2020


To characterize and assess the non-thyroid-specific postoperative complications of completion thyroidectomy as compared with total thyroidectomy.
Retrospective analysis: 2005 to 2017. National Surgical Quality Improvement Program database. Patients aged >18 years receiving a completion or total thyroidectomy were eligible for inclusion. Patients not treated by otolaryngologists or general surgeons and with unknown demographic variables were excluded. A total of 70,638 patients were analyzed, representing 64,763 total thyroidectomies and 5875 completion thyroidectomies. The 30-day mortality rate was 0.1% for both procedures ( National data suggest that total and completion thyroidectomies are relatively safe procedures but that completion thyroidectomies are associated with lower rates of postoperative complications. These findings may play a role in determining treatment plans for patients and optimizing risk reduction.

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Evidence-Based Medicine in Otolaryngology, Part XI: Modeling and Analysis to Support Decisions

Lisa Caulley,Myriam G. Hunink,Gregory W. Randolph,Jennifer J. Shin

Publication date 25-08-2020


To provide a resource to educate clinical decision makers about the analyses and models that can be employed to support data-driven choices. Published studies and literature regarding decision analysis, decision trees, and models used to support clinical decisions. Decision models provide insights into the evidence and its implications for those who make choices about clinical care and resource allocation. Decision models are designed to further our understanding and allow exploration of the common problems that we face, with parameters derived from the best available evidence. Analysis of these models demonstrates critical insights and uncertainties surrounding key problems via a readily interpretable yet quantitative format. This 11th installment of the Evidence-Based Medicine in Otolaryngology series thus provides a step-by-step introduction to decision models, their typical framework, and favored approaches to inform data-driven practice for patient-level decisions, as well as comparative assessments of proposed health interventions for larger populations. Information to support decisions may arise from tools such as decision trees, Markov models, microsimulation models, and dynamic transmission models. These data can help guide choices about competing or alternative approaches to health care. Methods have been developed to support decisions based on data. Understanding the related techniques may help promote an evidence-based approach to clinical management and policy.

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Congenital Absence of Tracheal or Bronchial Rings

Matthew M. Smith,Yann-Fuu Kou,Claudia Schweiger,David G. Lehenbauer,Alessandro de Alarcon,Michael J. Rutter

Publication date 25-08-2020


Congenital airway stenosis secondary to absent tracheal or bronchial rings is a rare congenital anomaly that is difficult to manage both clinically and surgically. This typically manifests as severe segmental tracheomalacia, and only isolated cases with short-term follow-up have been previously described. We aim to describe a series of children with absent tracheal or bronchial rings who underwent surgical management and had long-term follow-up. Case series with chart review. Tertiary care pediatric hospital. Patients with absent tracheal or bronchial rings from 2002 to 2016. Electronic and paper medical records were queried to obtain demographics, age at diagnosis and surgery, pre- and postoperative symptoms, location of absent rings, procedure performed, length of follow-up, and adjunctive procedures performed. Nine subjects were identified who underwent slide tracheoplasty for correction of congenital absent tracheal or bronchial rings. Age at diagnosis ranged from 10 days to 5 years of age (median, 4 weeks). Age at surgery ranged from 3 weeks to 5 years of age (median, 5 weeks). Six out of 9 subjects were extubated on postoperative day 1. Only 1 subject required additional intervention, which included balloon dilation, tracheobronchial stenting, and aortopexy to alleviate the obstruction. Mean follow-up time was 5.89 years. This is the largest series of children with absent tracheal rings who underwent slide tracheoplasty with long-term follow-up presented to date. Slide tracheoplasty is an effective surgical intervention for the treatment of absent tracheal or bronchial rings in infants and young children.

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Prognostic Significance of Extranodal Extension in HPV-Mediated Oropharyngeal Carcinoma: A Systematic Review and Meta-analysis

Liliya Benchetrit,Sina J. Torabi,Babak Givi,Bruce Haughey,Benjamin L. Judson

Publication date 25-08-2020


To determine the prognostic role of extranodal extension (ENE) among patients with human papilloma virus-positive (HPV+) oropharyngeal squamous cell carcinoma (OPSCC) through a systematic review and meta-analysis of institutional studies. MEDLINE, Embase, Scopus, and Pub Med. Two independent authors searched the databases on December 3, 2019, to identify studies of HPV+ OPSCC comparing prognostic outcomes stratified by ENE. The Eighteen observational studies met inclusion criteria, yielding 3603 patients with HPV+ OPSCC (1521 ENE+ and 2082 ENE-) with a median follow-up of 49 months. The presence of pathologic ENE (pENE) and radiologic ENE (rENE) was associated with decreased overall survival (pENE HR, 1.89 [95% CI, 1.15-3.13], pENE and rENE are moderately associated with an increased risk of all-cause mortality and recurrence with distant metastasis in a cohort of patients with HPV+ OPSCC. These findings may be used to inform exclusion criteria for deintensification trials and assist in refined risk stratification.

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Gaps in Training: Misunderstandings of Airway Management in Medical Students and Internal Medicine Residents

Ellen Tokarz,Adam R. Szymanowski,John T. Loree,Joseph Muscarella

Publication date 25-08-2020


(1) Evaluate baseline airway knowledge of medical students (MSs) and internal medicine (IM) residents. (2) Improve MS and IM resident understanding of airway anatomy, general tracheostomy and laryngectomy care, and management of airway emergencies. A before-and-after survey study was carried out over a single academic year. MS and IM resident knowledge was evaluated before and after an educational, grand rounds-style lecture reviewing airway anatomy, tracheostomy tube components, tracheostomy and laryngectomy care, and clinical vignettes. The primary outcome measure was change in pre- and postlecture survey scores. Prelecture surveys were completed by 90 participants, and 83 completed a postlecture assessment. Postlecture scores were statistically improved for all questions on the assessment ( While the majority of participants in our study had previously cared for patients with a tracheostomy or laryngectomy, less than half were able to correctly address basic airway emergencies. Senior IM residents were no more proficient than MSs in addressing airway emergencies. The lack of formal airway training places patients at risk with routine care and in emergencies, demonstrating the need for formal airway education for early medical trainees. Our data demonstrate a serious gap in MS and IM resident knowledge with respect to emergent airway care in patients with tracheostomies and laryngectomies. An interdepartmental collaborative curriculum offers a realistic and potentially life-saving solution for medical trainees.

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The Unseen Global Burden of Disease

Josh Wiedermann,Theodore Klug,Tekleweini Abhra,Biniam Alemayehu,Johanna Sembergman,Carolina Der

Publication date 25-08-2020


Due to geographic-specific patient and institutional-related barriers to care, data extrapolation and expert opinion on global burden of disease in otolaryngology-head and neck surgery may under- or overestimate the presence and effect of common head and neck conditions. The group of conditions that fail to present to local physicians and/or missed in data extrapolation methods is the unseen burden of disease. This article presents opinions from otolaryngology-head and neck surgery physicians in high- and low/middle-income countries to help explain the contributing factors and ultimately how to use this unseen burden of disease.

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Efficacy of Adenoidectomy for the Treatment of Mild Sleep Apnea in Children

Austin Tipold,Turaj Vazifedan,Cristina M. Baldassari

Publication date 25-08-2020


(1) To assess outcomes in children undergoing adenoidectomy for the treatment of mild obstructive sleep apnea (OSA). (2) To identify clinical factors that predict which children will have persistent obstruction following adenoidectomy. Case series with chart review over a 10-year period. Tertiary children's hospital. Children between 2 and 17 years old undergoing adenoidectomy for treatment of mild OSA (obstructive apnea-hypopnea index [AHI] between 1 and 5 on polysomnogram) were included. The need for additional medical or surgical intervention following adenoidectomy was recorded. When available, postoperative polysomnogram data were reviewed. In total, 134 children with a mean age of 5.4 years were included. Fifty-three percent (n = 71) were female and 57% (n = 76) were black. The mean (SD) baseline AHI was 2.2 (1.09). Caregivers reported a moderate impact of sleep disturbance on quality of life with a mean (SD) preoperative total OSA-18 score of 64.1 (19.28). Postadenoidectomy outcomes were reported for 105 patients (78%) with a mean follow-up time of 6 months. Sixty-nine percent (n = 72) of children had resolution of obstructive symptoms. While 31% (n = 33) of children required additional intervention following adenoidectomy, only 6.8% (n = 9) underwent a subsequent tonsillectomy. Demographic factors such as age and baseline AHI did not predict which children required additional treatment following adenoidectomy. Adenoidectomy may be an effective treatment for mild OSA. A randomized trial comparing outcomes for adenoidectomy and adenotonsillectomy is needed to determine the ideal surgical treatment for nonsevere OSA in children.

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The Long “Race” to Diversity in Otolaryngology

Mahbuba Tusty,Brenda Flores,Robert Victor,Magali Fassiotto,Yvonne Maldonado,Javier Howard,Tulio A. Valdez

Publication date 25-08-2020


The number of health disparities disproportionately affecting minority communities continue to rise. Thus, it is imperative to assess whether equity within medical school enrollment and along the academic pipeline has mirrored this growth, especially among elite surgical specialties such as otolaryngology. Census and educational data from 2010 and 2018 were used to assess the current otolaryngology, surgery, and internal medicine physician and faculty workforce diversity across each stage of the academic medicine trajectory by race and ethnicity. We found that disparities exist in medical school enrollment for minority students such that Hispanic/Latinx representation was only 30% and Black representation only 50% of their respective proportions in the US population in 2018. Disparities in achieving full professorship were also observed across all 3 specialties but most prominently in otolaryngology, with 1% Black representation among otolaryngology professors in 2018. A collective strategy toward diversifying the otolaryngology workforce should be explored.

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Complications After Soft Tissue With Plate vs Bony Mandibular Reconstruction: A Systematic Review and Meta-analysis

Eric Bauer,Angela Mazul,Joseph Zenga,Evan M. Graboyes,Ryan Jackson,Sidharth V. Puram,Michelle Doering,Patrik Pipkorn

Publication date 25-08-2020


Mandibular reconstruction for segmental defects is a well-studied topic. However, there are conflicting data on the risks of delayed plate-related complications. The objective of this systematic review and meta-analysis was to assess long-term plate-related complications following reconstruction of the mandible with soft tissue and a plate as compared with immediate vascularized bony reconstruction. A medical librarian created search strategies with a combination of keywords and controlled vocabulary in Ovid Medline (1946-), Embase (1947-), Scopus (1960-), Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Clinicaltrials.gov. Candidate articles were independently reviewed by 2 authors. Inclusion/exclusion criteria were uniformly applied. Articles were considered eligible if they included adequate reporting of plate extrusion and/or fracture and had follow-up ≥12 months. A total of 2379 patients were included. The risk of plate fracture was low in cases of soft tissue with a plate (5%; 95% CI, 0.03-0.08) and osseous reconstruction (1%). The risk of extrusion following soft tissue and plate reconstruction was 20% (95% CI, 0.15-0.27). In the osseous reconstruction group, the risk of extrusion was 10% (95% CI, 0.06-0.18). Revision surgery was performed twice as often following soft tissue with a plate as compared with vascularized bony reconstruction (32% [95% CI, 0.25-0.40] vs 14% [95% CI, 0.09-0.21], respectively). Delayed plate-related complications remain a significant problem following segmental defect reconstruction. Soft tissue and plate reconstruction techniques may increase the risk of plate removal and revision surgery.

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Multispectral Imaging for Automated Tissue Identification of Normal Human Surgical Specimens

Jared A. Shenson,George S. Liu,Joyce Farrell,Nikolas H. Blevins

Publication date 25-08-2020


Safe surgery requires the accurate discrimination of tissue intraoperatively. We assess the feasibility of using multispectral imaging and deep learning to enhance surgical vision by automated identification of normal human head and neck tissues. Construction and feasibility testing of novel multispectral imaging system for surgery. Academic university hospital. Multispectral images of fresh-preserved human cadaveric tissues were captured with our adapted digital operating microscope. Eleven tissue types were sampled, each sequentially exposed to 6 lighting conditions. Two convolutional neural network machine learning models were developed to classify tissues based on multispectral and white-light color images (ARRInet-M and ARRInet-W, respectively). Blinded otolaryngology residents were asked to identify tissue specimens from white-light color images, and their performance was compared with that of the ARRInet models. A novel multispectral imaging system was developed with minimal adaptation to an existing digital operating microscope. With 81.8% accuracy in tissue identification of full-size images, the multispectral ARRInet-M classifier outperformed the white-light-only ARRInet-W model (45.5%) and surgical residents (69.7%). Challenges with discrimination occurred with parotid vs fat and blood vessels vs nerve. A deep learning model using multispectral imaging outperformed a similar model and surgical residents using traditional white-light imaging at the task of classifying normal human head and neck tissue ex vivo. These results suggest that multispectral imaging can enhance surgical vision and augment surgeons' ability to identify tissues during a procedure.

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Droplet Exposure Risk to Providers From In-Office Flexible Laryngoscopy: A COVID-19 Simulation

Michael J. Ye,Dhruv Sharma,Kolin E. Rubel,Nicole L. Lebo,Sarah J. Burgin,Elisa A. Illing,Jonathan Y. Ting,Michael G. Moore,Jessica A. Yesensky,Avinash V. Mantravadi,Michael W. Sim

Publication date 18-08-2020


To provide data on risk of respiratory droplets from common otolaryngologic procedures during the COVID-19 pandemic, a novel simulation of droplet exposure from flexible laryngoscopy was performed. After completion of a nasal symptom questionnaire, topical fluorescein spray was administered into the nasal and oropharynx of 10 healthy volunteers, who then underwent flexible laryngoscopy under 2 conditions: routine without provoked response and with prompted sneeze/cough. After each, droplets on the proceduralist and participant were counted under ultraviolet A light. Droplets were observed on 1 of 10 volunteers after routine laryngoscopy and 4 of 10 during laryngoscopy with sneeze/cough. A nasal symptom score based on congestion and rhinorrhea was significantly elevated among droplet producers after sneeze/cough (

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Tracheostomy in COVID-19 Patients: Why Delay or Avoid?

Paul E. Kwak,Michael J. Persky,Luis Angel,Samaan Rafeq,Milan R. Amin

Publication date 18-08-2020


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Comment on “Tracheostomy in COVID-19 Patients: Why Delay or Avoid?”

Richard A. Goldman,Brian Swendseid,David M. Cognetti

Publication date 18-08-2020


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Management of Type 1 Laryngeal Clefts: A Systematic Review and Meta-analysis

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

Publication date 18-08-2020


Endoscopic surgical management or injection laryngoplasty of type 1 laryngeal clefts in pediatric patients is used in those who do not respond to conservative treatment. This study compares conservative treatment, endoscopic surgical repair, and injection laryngoplasty for the management of type 1 laryngeal clefts. Pub Med, Web of Science, and Embase. This systematic review included studies of patients with type 1 laryngeal clefts who were managed with conservative treatment, injection laryngoplasty, or endoscopic repair, and all studies reported postintervention outcomes. Two independent investigators assessed study eligibility, rated the quality, and extracted data for analysis. A random effects model was used for meta-analysis of pooled data. Of the 1209 studies identified, 27 met inclusion criteria. There were 543 patients with type 1 laryngeal clefts represented in the studies, with outcomes reported for 537. Conservative therapy had a 52% (95% CI, 37%-66%; Our systematic review demonstrated significant improvement and resolution of symptoms for patients with type 1 laryngeal clefts treated with endoscopic repair as compared with other modalities. More prospective and controlled studies comparing treatment strategies with validated instruments to measure outcomes are necessary to determine their efficacy in the management of type 1 laryngeal clefts.

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Nonopioid, Multimodal Analgesia as First-line Therapy After Otolaryngology Operations: Primer on Nonsteroidal Anti-inflammatory Drugs (NSAIDs)

John D. Cramer,Michael L. Barnett,Samantha Anne,Brian T. Bateman,Richard M. Rosenfeld,David E. Tunkel,Michael J. Brenner

Publication date 18-08-2020


To offer pragmatic, evidence-informed advice on nonsteroidal anti-inflammatory drugs (NSAIDs) as first-line therapy after surgery. This companion to the American Academy of Otolaryngology-Head & Neck Surgery (AAO-HNS) clinical practice guideline (CPG), "Opioid Prescribing for Analgesia After Common Otolaryngology Operations," presents data on potency, bleeding risk, and adverse effects for ibuprofen, naproxen, ketorolac, meloxicam, and celecoxib. National Guidelines Clearinghouse, CMA Infobase, National Library of Guidelines, NICE, SIGN, New Zealand Guidelines Group, Australian National Health and Medical, Research Council, TRIP database, Pub Med, Guidelines International Network, Cochrane Library, EMBASE, CINAHL, BIOSIS Previews, ISI Web of Science, AHRQ, and HSTAT. AAO-HNS opioid CPG literature search strategy, supplemented by Pub Med/MEDLINE searches on NSAIDs, emphasizing systematic reviews and randomized controlled trials. NSAIDs provide highly effective analgesia for postoperative pain, particularly when combined with acetaminophen. Inconsistent use of nonopioid regimens arises from common misconceptions that NSAIDs are less potent analgesics than opioids and have an unacceptable risk of bleeding. To the contrary, multimodal analgesia (combining 500 mg acetaminophen and 200 mg ibuprofen) is significantly more effective analgesia than opioid regimens (15 mg oxycodone with acetaminophen). Furthermore, selective cyclooxygenase-2 inhibition reliably circumvents antiplatelet effects. The combination of NSAIDs and acetaminophen provides more effective postoperative pain control with greater safety than opioid-based regimens. The AAO-HNS opioid prescribing CPG therefore prioritizes multimodal, nonopioid analgesia as first-line therapy, recommending that opioids be reserved for severe or refractory pain. This state-of-the-art review provides strategies for safely incorporating NSAIDs into acute postoperative pain regimens.

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Risk Factors for Laryngectomy for Dysfunctional Larynx After Organ Preservation Protocols: A Case-Control Analysis

Michael P. Wu,Tessa Goldsmith,Allison Holman,Rachael Kammer,Anuraag Parikh,Elliana K. Devore,Kevin S. Emerick,Derrick T. Lin,Daniel G. Deschler,Jeremy D. Richmon,Mark A. Varvares,Matthew R. Naunheim

Publication date 18-08-2020


(1) To identify factors associated with severe dysfunctional larynx leading to total laryngectomy after curative treatment of head and neck squamous cell carcinoma and (2) to describe swallowing and voice outcomes. Retrospective single-institution case-control study. Tertiary care referral center. A 10-year chart review was performed for patients who had previously undergone radiation or chemoradiation for head and neck mucosal squamous cell carcinoma and planned to undergo total laryngectomy for dysfunctional larynx, as well as a control group of matched patients. Controls were patients who had undergone radiation or chemoradiation for mucosal squamous cell carcinoma but did not have severe dysfunction warranting laryngectomy; these were matched to cases by tumor subsite, T stage, and time from last treatment to video swallow study. Main outcomes assessed were postoperative diet, alaryngeal voice, pharyngeal dilations, and complications. Twenty-six patients were scheduled for laryngectomy for dysfunctional larynx, of which 23 underwent surgery. Originally treated tumor subsites included the larynx, oropharynx, hypopharynx, oral cavity, and a tumor of unknown origin. The median time from end of cancer treatment to laryngectomy was 11.5 years. All cases were feeding tube or tracheostomy dependent or both prior to laryngectomy. As compared with matched controls, cases were significantly less likely to have undergone IMRT (intensity-modified radiotherapy) and more likely to have pulmonary comorbidities. Eighty-nine percent of cases with follow-up achieved functional alaryngeal voice, and all were able to have oral intake. Non-IMRT approaches and pulmonary comorbidities are associated with laryngectomy for dysfunction after radiation or chemoradiation.

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An Integrated Care Strategy for the Follow-up of Patients With COVID-19–Associated Chemosensory Dysfunction

Luca Giovanni Locatello,Giandomenico Maggiore,Chiara Bruno,Michele Trotta,Oreste Gallo

Publication date 18-08-2020


The proportion of patients with residual olfactory and gustatory dysfunction after COVID-19 is increasing, and practical health care strategies need to be developed to manage this novel situation in otolaryngology services worldwide. Starting from our experience in a large Italian hospital, we estimated that >1500 people will complain of some form of olfactory and gustatory dysfunction in the future months in our region. We want to share our logistical and clinical integrated pathway that is aimed to screen and refer each patient to the most appropriate level of care in order to optimize resources and avoid overwhelming the available clinics.

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Comparative Study of Endoscopic and Microscopic Type I Tympanoplasty in Terms of Delayed Facial Palsy

Kuan-Hui Li,Leong-Perng Chan,Chin-Kuo Chen,Shin-Huei Kuo,Ling-Feng Wang,Ning-Chia Chang,Hsun-Mo Wang,Kuen-Yao Ho,Chen-Yu Chien

Publication date 18-08-2020


Delayed facial palsy is a complication of otologic surgery. Tympanoplasty is commonly employed in chronic otitis media. We compared the incidence and characteristics of delayed facial palsy and hearing restoration between endoscopic and microscopic tympanoplasty for the treatment of simple chronic otitis media. Retrospective cohort study. Tertiary medical center. We retrospectively analyzed 468 patients who underwent type I tympanoplasty from January 2009 to April 2017. Patients were divided into transcanal endoscopic ear surgery and microscopic ear surgery groups. Their epidemiological profiles were reviewed and the outcomes of tympanoplasty were analyzed. Blood sample tests for herpes simplex virus and varicella-zoster virus immunoglobulin M and immunoglobulin G were arranged in patients with delayed facial palsy. Transcanal endoscopic ear surgery exhibited similar benefits to microscopic ear surgery in graft-taking rate and hearing restoration but had a shorter operation time ( Transcanal endoscopic ear surgery is an ideal alternative for simple tympanoplasty. The incidence of delayed facial palsy was not significantly different between the 2 approaches. Because of the favorable prognosis and the absence of direct serological evidence supporting viral reactivation, treatment with antivirals may not be required.

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Antibiotic Prophylaxis for Thyroid and Parathyroid Surgery: A Systematic Review and Meta-analysis

Fabio Medas,Gian Luigi Canu,Federico Cappellacci,Giorgio Romano,Giuseppe Amato,Enrico Erdas,Pietro Giorgio Calò

Publication date 18-08-2020


Although thyroid and parathyroid surgery is considered a clean procedure with a low incidence of surgical site infections (SSIs), a great number of endocrine surgeons use antibiotic prophylaxis (AP). The aim of this study was to assess whether AP is significantly effective in reducing the incidence of SSIs in this kind of surgery. A systematic literature search was performed with Pub Med, Scopus, and ISI-Web of Science. Studies addressing the efficacy of AP in reducing the incidence of SSIs in thyroid and parathyroid surgery were included in the systematic review and meta-analysis. The random effects model was assumed to account for different sources of variation among studies. The overall effect size was computed through the inverse variance method. Heterogeneity across studies, possible outlier studies, and publication bias were evaluated. A total of 6 studies with 4428 patients were included in the quantitative analysis. The incidence of SSI was 0.6% in the case group and 0.4% in the control group (odds ratio, 1.07; 95% CI, 0.3-3.81; AP is not effective in reducing the incidence of SSI in thyroid and parathyroid surgery and should be avoided, notwithstanding the negative impact on social costs and the risk of development of antibiotic resistance.

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Mitigation of Aerosols Generated During Rhinologic Surgery: A Pandemic-Era Cadaveric Simulation

Dhruv Sharma,Michael J. Ye,Vincent J. Campiti,Kolin E. Rubel,Thomas S. Higgins,Arthur W. Wu,Taha Z. Shipchandler,Michael W. Sim,Sarah J. Burgin,Elisa A. Illing,Jae Hong Park,Jonathan Y. Ting

Publication date 11-08-2020


After significant restrictions initially due to the COVID-19 pandemic, otolaryngologists have begun resuming normal clinical practice. However, the risk of SARS-CoV-2 transmission to health care workers through aerosolization and airborne transmission during rhinologic surgery remains incompletely characterized. The objective of this study was to quantify the number concentrations of aerosols generated during rhinologic surgery with and without interventions involving 3 passive suction devices. Cadaver simulation. Dedicated surgical laboratory. In a simulation of rhinologic procedures with and without different passive suction interventions, the concentrations of generated aerosols in the particle size range of 0.30 to 10.0 µm were quantified with an optical particle sizer. Functional endoscopic sinus surgery with and without microdebrider, high-speed powered drilling, use of an ultrasonic aspirator, and electrocautery all produced statistically significant increases in concentrations of aerosols of various sizes ( Significant aerosol concentrations were produced in the range of 0.30 to 10.0 µm during all rhinologic procedures in this cadaver simulation. Rhinologic surgery with a passive suction device results in significant mitigation of generated aerosols.

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Droplet and Aerosol Generation With Endonasal Surgery: Methods to Mitigate Risk During the COVID-19 Pandemic

Harish Dharmarajan,Monika E. Freiser,Edward Sim,Devi Sai Sri Kavya Boorgu,Timothy E. Corcoran,Eric W. Wang,Paul A. Gardner,Carl H. Snyderman

Publication date 11-08-2020


To define the aerosol and droplet risks associated with endonasal drilling and to identify mitigation strategies. Simulation series with fluorescent 3-dimensional (3D) printed sinonasal models and deidentified cadaveric heads. Dedicated surgical laboratory. Cadaveric specimens irrigated with fluorescent tracer and fluorescent 3D-printed models were drilled. A cascade impactor was used to collect aerosols and small droplets of various aerodynamic diameters under 15 µm. Large droplet generation was measured by evaluating the field for fluorescent debris. Aerosol plumes through the nares were generated via nebulizer, and mitigation measures, including suction and SPIWay devices, nasal sheaths, were evaluated regarding reduction of aerosol escape from the nose. The drilling of cadaveric specimens without flexible suction generated aerosols ≤3.30 µm, and drilling of 3D sinonasal models consistently produced aerosols ≤14.1 µm. Mitigation with SPIWay or diameter-restricted SPIWay produced same results. There was minimal field contamination in the cadaveric models, 0% to 2.77% field tarp area, regardless of drill burr type or drilling location; cutting burr drilling without suction in the 3D model yielded the worst contamination field (36.1%), followed by coarse diamond drilling without suction (19.4%). The simple placement of a flexible suction instrument in the nasal cavity or nasopharynx led to complete elimination of all aerosols ≤14.1 µm, as evaluated by a cascade impactor positioned immediately at the nares. Given the findings regarding aerosol risk reduction, we strongly recommend that physicians use a suction instrument in the nasal cavity or nasopharynx during endonasal surgery in the COVID-19 era.

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The Face of COVID-19: Facial Pressure Wounds Related to Prone Positioning in Patients Undergoing Ventilation in the Intensive Care Unit

Sydney T. Jiang,Christina H. Fang,Jen-Ting Chen,Richard V. Smith

Publication date 11-08-2020


In the setting of COVID-19 (coronavirus disease 2019)-associated moderate and severe acute respiratory distress, persistently hypoxemic patients often require prone positioning for >16 hours. We report facial pressure wounds and ear necrosis as a consequence of prone positioning in patients undergoing ventilation in the intensive care unit in a tertiary medical center in New York City.

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Implementation and Evaluation of a Virtual Elective in Otolaryngology in the Time of COVID-19

Andrew J. Steehler,Brian Pettitt-Schieber,Matthew B. Studer,Geetha Mahendran,Barbara J. Pettitt,Oswaldo A. Henriquez

Publication date 11-08-2020


To develop and evaluate a virtual otolaryngology medical student elective created during the COVID-19 crisis with the intention of teaching the basic tenets of otolaryngology and increasing exposure to the specialty. Cross-sectional survey. Emory University School of Medicine. A 1-week virtual otolaryngology curriculum was offered to third- and fourth-year medical students that centered on the American Academy of Otolaryngology-Head and Neck Surgery Foundation's handbook Twelve students participated; 67% reported their baseline precourse understanding of otolaryngology in the "poor-fair" range. After the course, 92% of students reported increased understanding, with 42% and 58% reporting "good" and "very good" understanding, respectively. Following completion of the course, posttest scores on summative assessments were significantly higher than pretest scores ( An otolaryngology elective administered through a virtual format can be effective at providing an educational experience and garnering interest in the field. Positive exposure to otolaryngology can increase medical students' interest in pursuing the specialty and expand their general knowledge of consultation, diagnosis, and management in otolaryngology.

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Errors and Biases in Meta-analysis of the Prevalence of Olfactory Dysfunction in Patients With COVID-19

Alfonso Santamaría-Gadea,Gonzalo de los Santos,Isam Alobid,Joaquim Mullol,Franklin Mariño-Sánchez

Publication date 11-08-2020


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The Incidence of Pediatric Tracheostomy and Its Association Among Black Children

Clarice Brown,Gopi B. Shah,Ron B. Mitchell,Felicity Lenes-Voit,Romaine F. Johnson

Publication date 11-08-2020


In 2012, Black or African American children constituted 21% of pediatric tracheostomies while representing approximately 15% of the US population. It is unclear if this discrepancy is due to differences in associated diagnoses. This study aimed to analyze the incidence of pediatric tracheostomy in the United States from 2003 to 2016 and to determine the odds of placement among Black children when compared with other children. Retrospective. Academic hospital. We used the 2003 to 2016 Kid Inpatient Database to determine the incidence of pediatric tracheostomy in the United States and determine the odds of tracheostomy placement in Black children when compared with other children. A total of 26,034 pediatric tracheostomies were performed between 2003 and 2016, among which, 21% were Black children. The median age was 7 years (interquartile range [IQR] = 0 to 17); 43% were ≤2 years old, and 62% were male. The most common principal diagnosis was respiratory failure (72%). When compared with other children, Black children were more likely to undergo tracheostomy (odds ratio [OR] = 1.2; 95% CI, 1.1-1.3), which increased among children younger than 2 years old (OR = 1.5; 95% CI, 1.4-1.5). Black children with tracheostomies were also more likely to be diagnosed with laryngeal stenosis and bronchopulmonary dysplasia and to have an extended length of stay ( Black children are 1.2 times more likely to undergo tracheostomy in the United States compared with other children. Further investigation is warranted to evaluate if there are underlying anatomical, environmental, or psychosocial factors that contribute to this discrepancy.

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Drug-Induced Sleep Endoscopy in Pediatric Obstructive Sleep Apnea

Diogo Raposo,Marco Menezes,João Rito,Mafalda Trindade-Soares,Cristina Adónis,Helena Cristina Loureiro,Filipe Freire

Publication date 11-08-2020


To describe drug-induced sleep endoscopy (DISE) findings in children with obstructive sleep apnea and to differentiate them between surgically naïve children and children who had adenotonsillectomy performed. Retrospective case series with chart review. Secondary care hospital.
A cohort of 56 children with the diagnosis of obstructive sleep apnea was submitted to DISE and subsequent upper airway surgery: 23 were surgically naïve, and 33 had persistent obstructive sleep apnea after adenotonsillectomy. Comparisons between groups were calculated with chi-square test and Student's In surgically naïve children, the most common sites of obstruction were the adenoids (78.2%) and the lateral pharyngeal walls/tonsils (82.6%). In children with persistent obstructive sleep apnea after adenotonsillectomy, the most common sites of obstruction were the adenoids (54.5%), followed by the supraglottis (48.5%) and the tongue base (45.5%). No correlation was found between obstructive apnea-hypopnea index and DISE findings. Simple linear regression revealed that the degree of obstruction at the tongue base (β = -0.73; 95% CI, -1.22 to -0.25; DISE findings differed between surgically naïve children and children with persistent obstructive sleep apnea after adenotonsillectomy. Increased obstruction at the level of the tongue base and the presence of multilevel obstruction predicted a lower saturation nadir in children with persistent obstructive sleep apnea after adenotonsillectomy.

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Vocal Fold Fat Augmentation for Atrophy, Scarring, and Unilateral Paralysis: Long-term Functional Outcomes

Yonatan Lahav,Liron Malka-Yosef,Yael Shapira-Galitz,Oded Cohen,Doron Halperin,Hagit Shoffel-Havakuk

Publication date 11-08-2020


There is a debate regarding the durability of fat implants. Our experience and recent publications suggest fat implantation may deliver a long-lasting improvement. This study aims to present the long-term outcomes for vocal fold fat augmentation using strict harvesting, preparing, and implantation protocols. A prospective cohort conducted between 2014 and 2020 (recruitment 2014-2017). An academic tertiary referral center. Twenty-two patients with glottic insufficiency were enrolled: 11 had unilateral vocal fold paralysis (UVFP), and 11 had atrophy or scar. Harvested fat was injected unilaterally or bilaterally into multiple sites. Six of these patients also had simultaneous microlaryngoscopic removal of other benign glottic lesions. Outcome measurements included video stroboscopy; Grade, Roughness, Breathiness, Asthenia, Strain (GRBAS) score; Voice Handicap Index (VHI); and acoustic analysis, performed preoperatively, 3, 12, 24, and 36 months after surgery. Ten augmentations were unilateral and 12 bilateral. Comparing the preoperative and 36-month postoperative periods, the mean VHI score improved from 73.45 (±22.78) to 44.88 (±28.93), Fat is an excellent source of autologous graft. With careful patient selection and proper surgical technique, fat is suitable for long-term correction of glottic insufficiency. Fat augmentation should be considered as a long-lasting or even permanent solution, rather than temporary.

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Response to Alfonso Santamaría-Gadea and Colleagues

Jane Y. Tong,Amanda Wong,Daniel Zhu,Judd H. Fastenberg,Tristan Tham

Publication date 11-08-2020


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Virtual Reality as Distraction Analgesia for Office-Based Procedures: A Randomized Crossover-Controlled Trial

Mingyang L. Gray,David Y. Goldrich,Sean McKee,Madeleine Schaberg,Anthony Del Signore,Satish Govindaraj,Alfred Marc Iloreta

Publication date 04-08-2020


The purpose of this study was to explore the use of immersive and interactive virtual reality (VR) for analgesia, anxiety reduction, and overall satisfaction in patients undergoing outpatient postoperative debridements. Randomized crossover-controlled trial. Academic outpatient clinic. Adult patients who had functional endoscopic sinus surgery and skull base surgery and were undergoing office-based postoperative nasal endoscopy and debridement were recruited and followed for 2 consecutive office visits. Participants were randomized to receive either the control or experimental analgesia for the first postoperative visit (PO1) and crossed over into the opposite treatment arm during the second postoperative visit (PO2). Outcomes included procedural pain, anxiety and satisfaction scores, procedural time, and reflexive head movements per minute (RHM). Eighty-two participants were recruited. At PO1, 39 received standard analgesia, and 43 received an immersive VR experience. At PO1, the VR group experienced significantly less anxiety ( VR technology holds promise as a nonpharmacologic analgesic and anxiolytic intervention for otolaryngology office-based procedures. Further study of VR use in other procedures is warranted. 1, randomized controlled trial.

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Standardization and Reduction of Narcotics After Pediatric Tonsillectomy

Daniel C. O’Brien,Habib Zalzal,David Adkins,Christopher Gates,Joedell Gonzaga,Logan Sanders,Michele M. Carr,Brian Kellermeyer

Publication date 04-08-2020


(1) To measure caregiver satisfaction with a nonstandardized postoperative pain regimen after pediatric tonsillectomy. (2) To implement a quality improvement project (QIP) to reduce the number and volume of narcotics prescribed and to describe the effect on caregiver satisfaction. A prospective cohort study at a tertiary children's hospital examined postoperative narcotics prescribed to children following adenotonsillectomy. A QIP was implemented 3 months into the observation, with the goal to standardize nonnarcotic analgesics and reduce the volume of narcotics prescribed. Caregivers were called 2 to 3 weeks postoperatively to assess pain control and caregiver satisfaction. Over an 8-month period, 118 patients were recruited (66 before the QIP, 52 after induction). Prior to the QIP, 47% of patients were prescribed postoperative narcotics, as opposed to 27% after the QIP ( A system shift was identified with the establishment of a posttonsillectomy pain control protocol associated with a reduction in prescribed narcotics without a significant change in caregiver satisfaction. Implementing a standardized plan for the use of nonnarcotic medications was associated with reduced frequency and volume of narcotics prescribed. Future work will further standardize our postoperative pain regimen.

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Role of Biologics in Chronic Rhinosinusitis With Nasal Polyposis: State of the Art Review

Christine Kim,Joseph Han,Tara Wu,Claus Bachert,Wytske Fokkens,Peter Hellings,Claire Hopkins,Stella Lee,Joaquim Mullol,Jivianne T. Lee

Publication date 04-08-2020


To review the current literature regarding the role of biologics in the treatment of chronic rhinosinusitis with nasal polyposis (CRSwNP). Pub Med/MEDLINE, EMBASE, Cochrane Review, Clinical Trials.gov. We conducted a comprehensive review of the literature on clinical studies investigating the efficacy of emerging biologics in CRSwNP, with a focus on randomized controlled trials. There appears to be promising evidence to support the safety and efficacy of biologics in CRSwNP with and without asthma for select patients. However, additional large-scale randomized studies with longer follow-up are necessary to determine which patients would benefit the most from these novel systemic treatments. Chronic rhinosinusitis with nasal polyposis refractory to medical and surgical therapy remains a challenging clinical problem for otolaryngologists. However, emerging biologic therapies may offer a new therapeutic option for such patients with recalcitrant disease.

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Effects of Occlusion and Conductive Hearing Loss on Bone-Conducted cVEMP

Hadar Rotem Betito,Mordechai Himmelfarb,Ophir Handzel

Publication date 04-08-2020


To evaluate the effects of conductive hearing loss and occlusion on bone-conducted cervical vestibular evoked myogenic potentials (cVEMPs). Prospective cohort study conducted in the year 2018. The right ear of each volunteer was evaluated under 3 conditions by using bone-conducted cVEMPs: normal (open external auditory canal), occluded (conductive hearing loss with occlusion effect), and closed (conductive hearing loss without the occlusion effect). Single academic center. The study comprised 30 healthy volunteers aged 20 to 35 years (16 women, 14 men). All had normal hearing and no vestibular or auditory pathologies. The thresholds and amplitudes of cVEMP responses were recorded for the 3 conditions. The results of each condition for a particular participant were compared. As compared with the open condition, the conductive condition increased thresholds by 2.8 dB ( The occlusion effect is present in cVEMP responses. The mechanism is not due to the conductive hearing loss induced. Clinical implications include potentially altering vestibular function with sealed hearing aids and in the surgically modified ears (ie, obliterated ears and open cavity mastoidectomy).

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Reply to “An Approach to Manage Epistaxis in the COVID-19 Pandemic in Resource-Constrained Settings”

Vittorio D’ Aguanno,Massimo Ralli,Lucia Ercoli,Antonio Greco,Marco de Vincentiis

Publication date 04-08-2020


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Patients With Voice Prosthesis Rehabilitation During the COVID-19 Pandemic: Analyzing the Effectiveness of Remote Triage and Management

Ylenia Longobardi,Jacopo Galli,Lucia D’Alatri,Vezio Savoia,Giorgia Mari,Mario Rigante,Giulio Cesare Passali,Francesco Bussu,Claudio Parrilla

Publication date 04-08-2020


To describe a remote approach used with patients with voice prosthesis after laryngectomy during the COVID-19 pandemic and the resulting clinical outcomes in terms of voice prosthesis complications management, oncological monitoring, and psychophysical well-being. Prospective cohort study. Otolaryngology Clinic of the University Polyclinic A. Gemelli, IRCCS Foundation. All patients with voice prosthesis who underwent laryngectomy followed by our institute were offered enrollment. Patients who agreed to participate were interviewed to inquire about the nature of the need and to plan a video call with the appropriate clinician. Before and 1 week after the clinician's call, patients were tested with the Hospital Anxiety and Depression Scale. Degrees of satisfaction were investigated with a visual analog scale. A comparison between those who accepted and refused telematic support was carried out to identify factors that influence patient interest in teleservice. Video call service allowed us to reach 37 (50.68%) of 73 patients. In 23 (62.16%) of 37 cases, the video call was sufficient to manage the problem. In the remaining 14 cases (37.83%), an outpatient visit was necessary. Participants who refused telematic support had a significantly shorter time interval from the last ear, nose, and throat visit than patients who accepted (57.95 vs 96.14 days, Remote approach may be a viable support in the management of patients with voice prosthesis rehabilitation.

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Predictors of Complications Occurrence Associated With Emergency Surgical Tracheotomy

Ana D. Jotic,Jovica P. Milovanovic,Aleksandar S. Trivic,Miljan M. Folic,Sanja B. Krejovic-Trivic,Zorana Z. Radin,Marko N. Buta,Biljana R. Milicic

Publication date 04-08-2020


In emergency airway management, the occurrence of surgical tracheotomy complications is increased and may be fatal for the patient. However, the factors that play a role in complication occurrence and lead to lethal outcome are not known. The objective of this study was to determine predictors associated with the occurrence of complications and mortality after emergency surgical tracheostomy. Retrospective study with a systematic review of the literature. Tertiary medical academic center. We included 402 adult patients who underwent emergency surgical tracheostomy under local anesthesia due to upper airway obstruction. Demographic, clinical, complication occurrence, and mortality data were collected. For statistical analysis, univariable and multivariable logistic regression methods were used. In multivariable analysis, significant positive predictors of complication occurrence were previously performed tracheotomy (odds ratio [OR] 3.67, 95% confidence interval [CI], 0.75-17.88), neck pathology (OR 2.05, 95% CI 1.1-1.77), and tracheotomy performed outside the operating room (OR 5.88, 95% CI, 1.58-20). General in-hospital mortality was 4%, but lethal outcome as a direct result of tracheotomy complications occurred in only 4 patients (1%) because of intraoperative and postoperative complications. The existence of neck pathology and situations in which tracheotomy was performed outside the operating room in uncontrolled conditions were significant prognostic factors for complication occurrence. Tracheotomy-related mortality was greater in patients with intraoperative and early postoperative complications. Clinicians should be aware of the increased risk in specific cases, to prepare, prevent, or manage unwanted outcomes in further treatment and care.

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Methylene Blue as a Diagnosis and Screening Tool for Oral Cancer and Precancer

Se Hwan Hwang,Sung Won Kim,Eun A. Song,Junuk Lee,Do Hyun Kim

Publication date 04-08-2020


To evaluate the accuracy of methylene blue (MB) for diagnosing oral cancer and precancer. Pub Med, Cochrane Database, Embase, Web of Science, SCOPUS, and Google Scholar. Two authors working independently reviewed 6 databases from their dates of inception until April 2020. Studies exploring oral mucosal disorders as detected by MB were assessed. True-positive, true-negative, false-positive, and false-negative data were extracted for each study. Methodological quality was evaluated with the Quality Assessment of Diagnostic Accuracy Studies tool (v 2). Seven prospective and retrospective studies (N = 493) were included. The diagnostic odds ratio of MB was 20.017 (95% CI, 10.65-37.63, Regarding diagnostic accuracy, MB had high sensitivity but low specificity, suggesting that it cannot be recommended as a replacement for the currently used standard of a scalpel biopsy with histologic assessment. Instead, it should be used as an adjunct to conventional assessment because of its low toxicity and price.

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An Approach to Manage Epistaxis in the COVID-19 Pandemic in Resource-Constrained Settings

Neha Shakrawal

Publication date 04-08-2020


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The Utility of the Cl:PO4 Ratio in Patients With Variant Versions of Primary Hyperparathyroidism

Courtney Wright,Deanne King,Mariah Small,Celeste Gibson,Reed Gardner,Brendan C. Stack

Publication date 04-08-2020


To determine the significance and impact of additional chloride testing as part of a diagnostic laboratory test battery for borderline primary hyperparathyroidism (pHPT). Retrospective database review of parathyroidectomy patients. A tertiary care, academic health sciences center. Patients referred to a head and neck endocrine clinic for evaluation and treatment for pHPT. After exclusions, there were a total of 226 patients who underwent parathyroidectomy for primary hyperparathyroidism with the requisite preoperative and postoperative labs. Seventy-seven additional patients who had a thyroid operation for a nonmalignant cause were included as controls. Of the 303 total patients, 166 had normal calcium levels (<10.4 mg/dL), and 54 (32.5%) also exhibited hyperchloremia (>106 mmol/L). Of the 47 patients with normal calcium and parathyroid hormone (PTH) levels (<88 pg/mL), 6 (12.8%) had hyperchloremia, and of the 118 patients with normocalcemic pHPT, 48 (40.7%) were hyperchloremic. The area under the curve for the Cl:PO4 was 0.712. When using a cutoff of 33, the reported sensitivity and specificity of the curve were 58.4% and 28.6%, respectively. The Cl:PO4 ratio was a moderately sensitive test for the diagnosis of the borderline variants of primary hyperparathyroidism. The Ca:PO4 ratio was superior to the Cl:PO4 ratio. Our data also showed the superiority of preoperative calcium and ionized calcium over PTH when predicting the presence of pHPT.

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External Beam Radiotherapy for Medullary Thyroid Cancer Following Total or Near-Total Thyroidectomy

Michael Jin,Uchechukwu C. Megwalu,Julia E. Noel

Publication date 04-08-2020


Medullary thyroid carcinoma (MTC) often presents with advanced disease and takes an aggressive course as compared with more well-differentiated thyroid cancers. The role of adjuvant therapy, specifically external beam radiotherapy (EBRT), remains disputed. This study investigated the impact of EBRT on survival in MTC. Cross-sectional analysis of a national database. Patients with MTC were identified from the SEER program (Surveillance, Epidemiology, and End Results). Collected variables included age, sex, race, T and N stages, lymph node yield, and use of EBRT. Propensity score matching was performed to determine the association of EBRT with overall and disease-specific survival. A total of 2046 patients with locoregional MTC were identified. Of these, 152 received EBRT. Patients receiving EBRT were older and had more advanced disease. EBRT was not associated with differences in overall survival (hazard ratio, 1.12; 95% CI, 0.76-1.65) or disease-specific survival (1.66; 0.93-2.95), as well as in subset analysis of age and disease extent. Long-term overall survival was similar, with 77.3% (95% CI, 70.1%-85.3%) and 58.3% (48.2%-70.5%) of patients without EBRT alive at 5 and 10 years, respectively (vs 70.7% [63.2%-79.1%] and 52.3% [43.3%-63.2%] of patients with EBRT). There were no differences in 5- and 10-year disease-specific survival. EBRT was not associated with improved overall or disease-specific survival in patients with MTC. Decisions regarding EBRT must be made with consideration of morbidity relative to benefit for individual patients.

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Drug-Induced Sleep Endoscopy in Children With Positional Obstructive Sleep Apnea

Erin M. Kirkham,Jonathan B. Melendez,Karen Hoi,Ronald D. Chervin

Publication date 04-08-2020


Positional obstructive sleep apnea (POSA)-defined as obstructive sleep apnea twice as severe supine than nonsupine-may offer clues to the underlying pattern of upper airway collapse in children. We compared drug-induced sleep endoscopy (DISE) findings in children with and without POSA. We hypothesized that children with POSA would have significantly higher obstruction at the gravity-dependent palate and tongue base but not at the adenoid, lateral wall, or supraglottis. Retrospective case series. Tertiary pediatric hospital. We included children aged 1 to 12 years with obstructive sleep apnea diagnosed by polysomnography who underwent DISE from July 2014 to February 2019. Scores were dichotomized as ≥50% obstruction (Chan-Parikh 2 or 3) vs <50% obstruction (Chan-Parikh 0 or 1). Of 99 children included, 32 (32%) had POSA and 67 (68%) did not. Children with POSA did not differ from children without POSA in age, overall apnea-hypopnea index, sex, race, syndromic diagnoses, obesity, or history of adenotonsillectomy. In logistic regression models, odds of ≥50% obstruction were significantly higher at the tongue base (odds ratio, 2.77; 95% CI, 1.04-7.39) after adjustment for age, sex, obesity, previous adenotonsillectomy, and syndrome. No difference was noted at the adenoid, velum, lateral wall, or supraglottis. POSA was associated with higher odds of obstruction on DISE at the tongue base but not at other levels.

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Telemedicine in Minority and Socioeconomically Disadvantaged Communities Amidst COVID-19 Pandemic

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

Publication date 28-07-2020


In the wake of the COVID-19 pandemic, many otolaryngology practices worldwide have chosen to shift their consultations from in-person to telemedicine. The addition of the telemedicine model has allowed many physicians to resume their clinical duties while maintaining social distancing. Access to telemedicine generally relies on the patient's ability to obtain and use technology-factors that are usually dictated by age, education, and socioeconomic status. The Rio Grande Valley, the home of the South Texas Sinus Institute, is a border community situated on the southern tip of Texas. The population is predominantly Hispanic, Spanish speaking, and of a lower socioeconomic level. The aim of this commentary is to describe the effects of the transition to telemedicine in a vulnerable community and the possible improvements that could be made to facilitate access to this resource.

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Assessing the Practice Characteristics of Otolaryngology Same-Day Appointments in an Academic Center

Katie Geelan-Hansen,Vega Were,Kleve Granger,Dwight Jones

Publication date 28-07-2020


to Examine the practice characteristics of same-day clinic appointments and the use of same-day appointment scheduling to provide access to care in an otolaryngology-head and neck surgery clinic. Retrospective chart review of same-day clinic appointments from January 1, 2016, to December 31, 2018, in patients aged >19 years at a single academic center. Demographic data, diagnoses, procedures completed, and operations completed were analyzed. There were 2696 visits by 2324 patients during the 3-year study period. More men than women (57% vs 43%) made same-day appointments. The mean age was 50.7 years (range, 19-99 years). Sinonasal and otologic diagnoses were the most frequently coded. A total of 1452 procedures were completed on the day of the visit, and 239 operations were completed as a result of the visit. Overall, a broad spectrum of otolaryngology care was delivered within the organizational new patient access goals. Access to otolaryngology-head and neck surgery care can be challenging. Many patients will seek care when they feel they need it, and patient conditions can change unexpectedly. Offering same-day scheduling can allow patients timely health care and appropriate care. Same-day appointment scheduling can provide access to care and urgent care for patients. The department of otolaryngology-head and neck surgery has been able to maintain a high rate of providing new patient appointments within 10 days with this method. Further considerations for the impact of same-day scheduling on no-show rates and patient satisfaction can be evaluated.

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Relationship Between Pepsin Expression and Dysplasia Grade in Patients With Vocal Cord Leukoplakia

Ya-Lian Chen,Yang-Yang Bao,Shui-Hong Zhou,Hong-Tian Yao,Zhe Chen

Publication date 21-07-2020


To measure pepsin expression in patients with vocal fold leukoplakia and elucidate its clinical significance. Retrospective analysis of pathologic archive specimens. Affiliated university hospital. The study included 45 patients with vocal fold leukoplakia and 19 with vocal fold polyps who underwent surgical treatment between December 2013 and July 2016. Masses were detected on both vocal cords in 5 patients with vocal fold leukoplakia and in 1 patient with vocal fold polyps. Immunohistochemistry was used to assess pepsin expression. In addition, the relationship of pepsin expression level with clinical characteristics of vocal fold leukoplakia was assessed. The rate of pepsin expression was high in the polyp group (75%) and the leukoplakia group (68%); however, the difference between groups was not significant ( Our study suggests that pepsin was associated with the grade of dysplasia of vocal cord leukoplakia. Further investigation with appropriate control groups and controlling for other risk factors, such as smoking or alcohol consumption, is needed.

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Prediction of Minor Salivary Gland Carcinoma: A Novel Nomogram and Risk Classification System for Overall Survival and Cancer-Specific Survival

Ling-feng lan,Chen-kai Gao,Chao-wu Ma

Publication date 21-07-2020


Minor salivary gland carcinoma (MiSGC) is rare, and the understanding of this disease is insufficient. This study aimed to identify independent risk factors and develop a nomogram for evaluating the overall survival (OS) and cancer-specific survival (CSS) of patients with MiSGC. Retrospective cohort study. SEER database (Surveillance, Epidemiology, and End Results). We collected data from patients diagnosed with MiSGC between 2004 and 2015 from the SEER database. According to patient registration, all patients were randomly allocated to training sets and validation sets (2:1). Then, Kaplan-Meier product limit curves and Cox proportional hazard regressions were performed to estimate the prognostic effect of variables. Nomograms based on Cox proportional hazard regressions were established to estimate 3- and 5-year OS and CSS. Finally, the nomogram was developed by the training set, and validation was performed with the concordance index, calibration curves, and decision curve analyses. In total, 1787 MiSGC cases were registered in SEER. The concordance index for internal validation of OS and CSS prediction was 0.842 and 0.816; that of external validation was 0.871 and 0.831. The calibration plots showed good consistency between nomogram prediction and actual survival. The decision curve analysis showed substantial net benefits of the new predictive model. We constructed nomograms and a corresponding risk classification system predicting the OS and CSS of patients with MiSGC. These tools can generate simple-to-use clinical risk grouping and determine the relationship between adjuvant therapy and active surveillance.

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Validation of a Sensor-Fitted Simulator for Upper Airway Examination

Nieves Díez,Sofía Pacheco,Marcos Llorente,Secundino Fernández

Publication date 21-07-2020


To validate a simulator for upper airway examination, fitted with sensors, for use as an academic tool for learning how to conduct examination of the upper airway and for evaluation of that learning. Validation study. Undergraduate medical education. A group of 18 fifth-year medical students and another of 6 otorhinolaryngology specialists conducted 6 examinations each with the simulator. To investigate concurrent validity, we calculated the correlation between damage scores provided by the simulator and damage assessment by a specialist. To evaluate construct validity, we compared both groups with regard to damage scores, technical procedure, and time spent. To examine content and face validity, we used questionnaires based on a 5-point Likert scale. For concurrent validity, the correlation between the simulator's damage scores and the specialist's damage assessment was high: Spearman's ρ was 0.828 ( Concurrent, construct, content, and face validity have been demonstrated for a sensor-fitted simulator for upper airway examination, which is therefore accurate enough to be used as an academic tool for learning and evaluation of learning.

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An Analysis of the US News & World Report Methodology for Attribution of Specialty Care in Otolaryngology and Urology

Ankur A. Shah,Ryan M. Carey,Jason A. Brant,Gregory E. Tasian,Justin B. Ziemba

Publication date 21-07-2020


(

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Disease-Specific Quality of Life in Vestibular Schwannoma: A National Cross-sectional Study Comparing Microsurgery, Radiosurgery, and Observation

Cynthia M. Chweya,Nicole M. Tombers,Christine M. Lohse,Michael J. Link,Matthew L. Carlson

Publication date 21-07-2020


To examine the impact of treatment on disease-specific health-related quality of life (HRQOL) among patients with sporadic vestibular schwannoma (VS). National cross-sectional study. Tertiary referral center and the Acoustic Neuroma Association. Adult patients with VS who completed the Penn Acoustic Neuroma Quality of Life (PANQOL) survey. Patients were classified by treatment at the most recent survey as microsurgery, radiosurgery, observation, or recently diagnosed (RD). PANQOL scores were compared among VS treatment groups and with nontumor controls using analysis of covariance. A total of 1362 respondents with VS were analyzed. Total PANQOL scores differed significantly by treatment ( Differences in HRQOL among treatment modalities are small and variably exceed the minimal clinically important difference. The impact of a VS diagnosis on HRQOL supersedes that of the treatment type.

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Clinical Implications of the Submental and Sublingual Arteries in Relation to the Mylohyoid Boutonnière

Matthew J. Zdilla,Adam N. Bender-Heine,H. Wayne Lambert,Dawn D. Hunter

Publication date 21-07-2020


Mylohyoid musculature may be included in the submental artery flap to protect perforators. However, blood vessels may pass through the mylohyoid muscle and therefore cause bleeding and risk to pedicle or perforator injury when a mylohyoid-containing flap is lifted. The objectives of this study were to identify the prevalence of the submental and sublingual arteries that traverse the mylohyoid and to assess relationships between vasculature transmitted through mylohyoid muscles and mylohyoid boutonnières. Cross-sectional human cadaveric study. The West Virginia University School of Medicine human gross anatomic laboratories. A total of 43 intact mylohyoid muscles from 22 cadavers were dissected. The prevalence of submental vasculature perforating the mylohyoid was recorded in addition to the prevalence and contents of mylohyoid boutonnières. Of 43 mylohyoid muscles, 21 (48.8%) transmitted the submental or sublingual arteries, and 30 (69.1%) possessed boutonnières. One muscle had 2 boutonnières. Of 31 mylohyoid boutonnières, 21 transmitted blood vessels (67.7%). Specifically, 9 transmitted an artery and a vein (29.0%), and 12 transmitted an artery (38.7%). Ten boutonnières (32.3%) were exclusively occupied by fascia. This report identifies the importance of identifying and carefully ligating branches of the submental artery that pierce the mylohyoid during elevation of the submental island flap. This report also identifies that a boutonnière is often present where a submental or sublingual artery is traversing the mylohyoid to supply sublingual glands, tongue, and anterior mandible.

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Time and Cost of Ultrasound-Guided Fine-Needle Aspiration Biopsy/Core-Needle Biopsy for Primary Laryngohypopharyngeal Squamous Cell Carcinoma

Dongbin Ahn,Gil Joon Lee,Jin Ho Sohn

Publication date 21-07-2020


This study aimed to evaluate benefits in terms of time and cost of percutaneous ultrasound-guided fine-needle aspiration biopsy/core-needle biopsy (US-FNAB/CNB) for the diagnosis of primary laryngeal and hypopharyngeal squamous cell carcinoma (LHSCC) in comparison with direct laryngoscopic biopsy (DLB) under general anesthesia. Retrospective case-control study. Single operator of a single center. From 2018 to 2019, 28 patients who underwent percutaneous US-FNAB/CNB for the diagnosis of untreated LHSCC were enrolled. All US-FNAB/CNBs were performed in the outpatient department by a single head and neck surgeon. Their results were compared with those of 27 patients who underwent DLB under general anesthesia. No major complications occurred in the US-FNAB/CNB and DLB groups. Time to biopsy, time to pathologic diagnosis, and time to treatment initiation in the US-FNAB/CNB and DLB groups were 0 and 14 days ( US-FNAB/CNB offers true benefits in terms of time and cost over those given by conventional DLB for diagnosis of LHSCC in indicated patients.

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Effect of Powered Air-Purifying Respirators on Speech Recognition Among Health Care Workers

Judith S. Kempfle,Ashwin Panda,Mary Hottin,Kevin Vinik,Elliott D. Kozin,Christopher J. Ito,Aaron K. Remenschneider

Publication date 21-07-2020


Powered air-purifying respirators (PAPRs) are used as personalized protective equipment for health care personnel. PAPRs offer health care workers added protection when dealing with patients who have high-risk infectious disease such as COVID-19. Unfortunately, PAPRs can produce notable levels of background noise. We hypothesize that PAPR use may be associated with increased hearing thresholds and impaired word discrimination and may ultimately have a negative impact on effective communication. Herein, we (1) determined sound levels generated by PAPRs and (2) measured hearing thresholds and word discrimination with and without operational PAPRs. All participants had normal hearing. When the PAPR was operational, mean ± SD thresholds increased from 4.5 ± 3.6 to 38.6 ± 5.6 dB HL (

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Surgical Management of Bilateral Vocal Fold Paralysis in Children: A Systematic Review and Meta-analysis

Ryan Kendall Thorpe,Sohit Paul Kanotra

Publication date 21-07-2020


To examine and compare the outcomes of various types of glottic widening surgery (GWS) for initial management of bilateral vocal fold paralysis (BVFP) in children, the outcomes of different GWS procedures in children who underwent initial tracheostomy, and the rate of decannulation in children who underwent tracheostomy alone versus tracheostomy followed by GWS. Pub Med, Web of Science, Cochrane Library, and Embase were searched following the PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-analyses) on September 9, 2019, with no date restriction. Articles focusing on GWS or tracheostomy for initial management of BVFP were included. Articles describing patients who received no surgical intervention for BVFP were excluded.
A total of 5989 articles were reviewed: 67 articles met inclusion criteria, and 240 patients were incorporated into the analysis. Patients who underwent primary GWS had an eventual tracheostomy rate of 6.0% (5/83). There were no statistically significant differences in the rate of tracheostomy, reoperation, or mortality among cricoid split, suture lateralization, and cordectomy/cordotomy. Patients who underwent primary tracheostomy failed to achieve decannulation in 36.9% (58/157) of cases. Decannulation was more likely in tracheostomized children who received GWS than those who did not (odds ratio, 6.336; Most children who undergo primary GWS for BVFP avoid tracheostomy or reoperation. These data demonstrated no differences in surgical outcomes among the most common types of GWS for BVFP. For children who receive a tracheostomy as their first intervention for BVFP, GWS is associated with a significantly improved rate of decannulation.

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Impact of Lymph Node Yield on Survival in Surgically Treated Oropharyngeal Squamous Cell Carcinoma

Ernest D. Gomez,Joyce C. Chang,John J. Ceremsak,Robert M. Brody,Jason A. Brant,Christopher H. Rassekh,Gregory S. Weinstein,Jason G. Newman

Publication date 21-07-2020


(1) To estimate the association between neck dissection lymph node yield (LNY) and survival among patients with surgically treated human papilloma virus (HPV)-associated oropharyngeal squamous cell carcinoma (OPSCC). (2) To identify a clinically relevant quality metric for surgical treatment of HPV-related OPSCC. Retrospective cohort study. National Cancer Database. From the National Cancer Database, 4130 patients were identified with HPV-associated OPSCC treated with primary surgery from 2010 to 2016. Based on prior literature, an adequate neck dissection LNY was defined as ≥18 lymph nodes. To determine whether LNY is associated with survival, univariable and multivariable Cox proportional hazards regression was performed. Analysis was stratified by adjuvant therapy regimen. A total of 2113 patients (51.2%) underwent surgery with or without adjuvant radiation (S ± RT), and 2017 patients (48.8%) underwent surgery with adjuvant chemoradiation. LNY ≥18 was associated with a 5-year survival benefit of 7.15% (91.7% for LNY ≥18, 84.5% for LNY <18, An adequate LNY from a neck dissection may affect survival when HPV-related OPSCC is treated with up-front surgery.

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Cleft Lip and Palate in Newborns Diagnosed With Neonatal Abstinence Syndrome

David O’Neil Danis,Kevin Bachrach,Jacquelyn Piraquive,Alexander P. Marston,Jessica R. Levi

Publication date 21-07-2020


Cleft lip and/or cleft palate (CLP) is the most common major congenital malformation of the head and neck. Previous studies suggested an association between fetal opioid exposure and CLP. This study seeks to evaluate the associations between CLP and neonatal abstinence syndrome (NAS) in the United States. Population-based inpatient registry analysis. Academic medical center. Kids' Inpatient Database (2016) was used to identify weighted in-hospital births with diagnoses of CLP or NAS. Demographic information was obtained. Among 3.8 million weighted in-hospital births, prevalence rates of CLP in the NAS and non-NAS populations were 3.13 and 1.35 per 1000, respectively. The odds ratios for patients with NAS developing CLP, isolated cleft palate, isolated cleft lip, and cleft lip and palate when compared with the reference population were 2.33 (95% CI, 1.87-2.91; Our study found an association between NAS and CLP, specifically isolated cleft palate, suggesting that prenatal exposure to opioids may be an environmental risk factor in the development of CLP.

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Systematic Review and Meta-analysis of the Change in Pharyngeal Bacterial Cultures After Pediatric Tonsillectomy

Scott E. Brietzke,Steven M. Andreoli

Publication date 21-07-2020


To review all available biomedical literature to assess published data regarding the effect of pediatric tonsillectomy on the culture results of potentially pathogenic respiratory pharyngeal bacteria before and after surgery. Biomedical literature databases (Pub Med, Embase, Web of Science) from January 1970 to December 2019. A systematic review of the literature was performed with the assistance of a medical librarian. Inclusion criteria consisted of pediatric patients and extractable data regarding respiratory bacteria culture data before and after tonsillectomy. Meta-analysis with random effects modeling was used on a limited basis. Only 5 studies met the inclusion criteria. The grand mean age was 5.9 years; the sample size range was 31 to 134; and the range of follow-up was 1 to 12 months. Group A beta hemolytic The majority of published evidence shows that pediatric tonsillectomy appears to reduce the quantity of most cultured potentially pathogenic respiratory bacteria in the pharynx after surgery. The implications and possible benefits of this favorable change in the microbiologic environment after surgery require further study.

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Pediatric Septal Perforation Repair With the Endoscopic Anterior Ethmoid Artery Flap

Samih J. Nassif,Andrew R. Scott

Publication date 21-07-2020


Pediatric nasal septal perforations can lead to crusting, obstruction, whistling, and recurrent epistaxis. Current approaches for pediatric nasal septal repair center on combination endonasal and external approaches. Herein we describe the successful utilization of a purely endoscopic anterior ethmoid artery flap, an established technique in adults, for nasal septal perforation repair in 3 children aged 12 to 13 years who presented with septal perforations ranging in size from 6 to 12 mm. Successful closure was achieved with an endoscopic anterior ethmoid artery flap, with all patients achieving complete closure and symptom resolution. Children with nasal septal defects are typically treated with temporizing measures until early adulthood, when definitive open repair may be performed. Our initial experience with the anterior ethmoid artery flap technique suggests that this surgery may be easily performed in children as young as 12 years, without the use of previously described adjunctive procedures such as turbinate translocation.

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Development and Validation of the Short Version of the Reflux Symptom Score: Reflux Symptom Score–12

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

Publication date 21-07-2020


To develop and validate a short version of the Reflux Symptom Score-the 12-question Reflux Symptom Score-12 (RSS-12)-for patients with laryngopharyngeal reflux disease (LPR). Prospective study. Multicenter academic hospitals. Patients with LPR diagnosed via multichannel intraluminal impedance pH monitoring were enrolled from 3 European hospitals. Healthy individuals completed the study. Individuals completed the Reflux Symptom Score, Reflux Symptom Index (RSI), and Voice Handicap Index (VHI) at baseline and 3 months posttreatment. The Reflux Symptom Score was completed twice within a 7-day period to assess test-retest reliability. Cronbach's α was used for assessing internal consistency. The RSS-12 was developed and validity assessed through a comparison of the RSS-12, RSI, and VHI. Responsiveness to change was evaluated through the pre- to posttreatment evolution of the RSS-12 total score. Receiver operating characteristic analysis was used to determine the RSS-12 threshold that is suggestive of LPR. The RSS-12 was characterized by high test-retest reliability ( The RSS-12 is a shorter, reliable, and valid self-administered patient-reported outcome measure questionnaire that can be used in the outpatient setting to suggest and monitor LPR.

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An Analysis of Otolaryngology Medical Malpractice Payments From the National Practitioner Data Bank

Christopher T. Breen,Saral Mehra

Publication date 21-07-2020


To describe malpractice payments made on behalf of otolaryngologists, analyze trends over time, and test the association of payment amount with severity of alleged malpractice and patient age. Retrospective cross-sectional analysis. National Practitioner Data Bank. This study comprised all payments made on behalf of otolaryngologists from 1991 to 2018 that were reported to the National Practitioner Data Bank. Descriptive statistics were calculated within and across years. Trends in payments were analyzed with the Mann-Kendall test. Generalized linear regression was utilized to test for association of payment amount with severity of the alleged injury and patient age. From 1991 to 2018, there was a significant decrease in the number of payments (272 to 81) and number of otolaryngologists on whose behalf payments were made (250 to 77). Mean and median payments increased significantly from $248,848 to $420,386 and from $96,813 to $275,000, respectively. By severity of alleged injury, mean payments ranged from $39,755 (95% CI, $20,957-$75,412) for insignificant injury to $754,349 (95% CI, $624,847-$910,692) for patients who were left quadriplegic, sustained brain damage, or required lifelong care. By patient age, mean payments for patients ≥60 years old were $191,465 (95% CI, $159,880-$229,292) versus $247,878 (95% CI, $209,416-$293,402) for patients aged 20 to 39 years and $232,225 (95% CI, $197,691-$272,793) for patients aged 40 to 59 years. The annual number and total value of malpractice payments decreased, while the annual mean and median payments increased. Payment amount was associated with severity of alleged malpractice and patient age.

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Cognitive Screening of Adults With Postlingual Hearing Loss: A Systematic Review

Mallory Raymond,Devon Barrett,Daniel Juno Lee,Shenita Peterson,Nikhila Raol,Esther X. Vivas

Publication date 21-07-2020


To systematically review the evidence for the use of cognitive screening tools for adults with postlingual hearing loss. Pub Med, Embase, Scopus, PsycINFO (EBSCO), CINAHL (EBSCO), and CENTRAL (Cochrane Library) electronic databases were searched from inception until October 4, 2018. Articles were reviewed for inclusion by 2 independent reviewers. The references of included articles were hand-searched for additional relevant articles. Data were extracted by 2 independent extractors. Of 2092 articles imported from the search, 81 were included for the review. Nearly a third (31%, n = 25) included patients with profound hearing loss. In total, 23 unique tools were used for 105 unique applications. The Mini Mental Status Exam (MMSE) was the most commonly used (54%, n = 55), followed by the Montreal Cognitive Assessment (MoCA) (19%, n = 10). Nearly half of the tools were used to define patient inclusion or exclusion in a study (48%, n = 50), followed by examination of a change after an intervention (26%, n = 27). Two articles attempted to study the validity of the MMSE and MoCA for screening patients with mild to moderate hearing loss and found mixed effects of the auditory components. There were no validation studies identified from the search. Many different cognitive screening tools have been used to study patients with postlingual hearing loss. The effects of the auditory components of these tools may be deleterious but ultimately remain unclear from the available evidence. To date, there has been no validation of any cognitive screening tool to be used for adults with postlingual hearing loss.

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Human Papillomavirus–Associated Anogenital Pathology in Females With HPV-Positive Oropharyngeal Squamous Cell Carcinoma

Alyssa Larish,Linda Yin,Gretchen Glaser,Eric Moore,Jamie Bakkum-Gamez,David Routman,Daniel Ma,Daniel Price,Jeffrey Janus,Katharine Price,Ashish Chintakuntlawar,Michelle Neben-Wittich,Robert Foote,Kathryn Van Abel

Publication date 14-07-2020


We sought to determine the incidence and location of human papillomavirus (HPV)-associated anogenital disease in women with HPV-positive oropharyngeal squamous cell carcinoma (OPSCC) via a retrospective cohort study with prospective contact to update history at Mayo Clinic in Rochester, Minnesota. Females undergoing treatment for nonmetastatic HPV-positive OPSCC from 2011 to 2019 were identified. Clinical history and outcomes were abstracted from medical records. Patients without documented anogenital history were contacted, consented, and administered a survey, and external records were requested and reviewed. Seventeen of 46 patients (37.0%) had a history of anogenital HPV-associated disease, and 16 of 17 (94.1%) required procedures to diagnose or treat HPV lesions. The cervix was the most common site (16/17, 94.1%). Procedures included colposcopy (n = 6), cervical excision (n = 3), cryotherapy (n = 4), and hysterectomy (n = 3). One case of fatal cervical carcinoma was noted, diagnosed 1 year following OPSCC. Three of 17 (17.6%) had HPV-related vulvovaginal disease, and 1 of 17 had anal disease. Patients with a history of HPV-positive OPSCC may be at elevated risk for HPV-associated anogenital disease.

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MicroRNA Profiling as a Methodology to Diagnose Ménière’s Disease: Potential Application of Machine Learning

Matthew Shew,Helena Wichova,Andres Bur,Devin C. Koestler,Madeleine St Peter,Athanasia Warnecke,Hinrich Staecker

Publication date 14-07-2020


Diagnosis and treatment of Ménière's disease remains a significant challenge because of our inability to understand what is occurring on a molecular level. MicroRNA (miRNA) perilymph profiling is a safe methodology and may serve as a "liquid biopsy" equivalent. We used machine learning (ML) to evaluate miRNA expression profiles of various inner ear pathologies to predict diagnosis of Ménière's disease. Prospective cohort study. Tertiary academic hospital. Perilymph was collected during labyrinthectomy (Ménière's disease, n = 5), stapedotomy (otosclerosis, n = 5), and cochlear implantation (sensorineural hearing loss [SNHL], n = 9). miRNA was isolated and analyzed with the Affymetrix miRNA 4.0 array. Various ML classification models were evaluated with an 80/20 train/test split and cross-validation. Permutation feature importance was performed to understand miRNAs that were critical to the classification models. In terms of miRNA profiles for conductive hearing loss versus Ménière's, 4 models were able to differentiate and identify the 2 disease classes with 100% accuracy. The top-performing models used the same miRNAs in their decision classification model but with different weighted values. All candidate models for SNHL versus Ménière's performed significantly worse, with the best models achieving 66% accuracy. Ménière's models showed unique features distinct from SNHL. We can use ML to build Ménière's-specific prediction models using miRNA profile alone. However, ML models were less accurate in predicting SNHL from Ménière's, likely from overlap of miRNA biomarkers. The power of this technique is that it identifies biomarkers without knowledge of the pathophysiology, potentially leading to identification of novel biomarkers and diagnostic tests.

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Acellular Collagen Scaffold With Basic Fibroblast Growth Factor for Repair of Traumatic Tympanic Membrane Perforation in a Rat Model

Xu Yao,Bing Mei Teh,Huan Li,Yi Hu,Juntao Huang,Cuiting Lv,Shizhong Bu,Minghao Zheng,Yi Shen

Publication date 14-07-2020


To evaluate the efficacy of acellular collagen scaffold (ACS) in combination with basic fibroblast growth factor (bFGF) for the repair of traumatic tympanic membrane (TM) perforation in a rat model. A prospective controlled animal study in a rat model of traumatic TM perforation. Tertiary medical center. Sprague-Dawley rats (N = 84) with unilateral traumatic perforation of the right TMs were randomized to receive ACS, bFGF, ACS in combination with bFGF (ACS/bFGF), or nothing (spontaneous healing without any interventions as a control group). The healing outcomes were evaluated by otoscopy, optical coherence tomography, histology, and transmission electron microscopy at 1, 2, and 4 weeks postoperatively. The hearing outcomes were assessed with auditory brainstem response testing. ACS/bFGF resulted in higher perforation closure rates at an earlier stage than spontaneous healing, ACS, and bFGF. Based on histology, optical coherence tomography, and transmission electron microscopy, a trilaminar structure and uniform thickness with mature, densely packed collagen fibers were seen in the ACS/bFGF group. Auditory brainstem response evaluation also showed that ACS/bFGF treatment promoted faster functional hearing recovery as compared with the control group. ACS is an effective TM scaffold and a carrier for bFGF. ACS/bFGF improves the TM closure rate, results in better-reconstructed TMs, and improves hearing. ACS/bFGF serves as a potential substitute for TM perforations in clinical settings.

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COVID-19 Airway Management Isolation Chamber

Timothy C. Blood,Jonathan N. Perkins,Paul R. Wistermayer,Joseph S. Krivda,Nathan T. Fisher,Charles A. Riley,Douglas S. Ruhl,Steven S. Hong

Publication date 14-07-2020


During the coronavirus pandemic (COVID-19), health care workers are innovating patient care and safety measures. Unfortunately, many of these are not properly tested for efficacy. The objective of this study was to determine the efficacy of the novel COVID-19 Airway Management Isolation Chamber (CAMIC) to contain and evacuate particulate. Multi-institutional proof-of-concept study.
Two academic institutions: Walter Reed National Military Medical Center (WRNMMC) and Madigan Army Medical Center (MAMC). Smoke, saline nebulizer, and simulated working port models were developed to assess the efficacy of the CAMIC to contain and remove ultrafine particles. Particulate counts were collected at set time intervals inside and outside the system. With the CAMIC on, smoke particulate counts inside the chamber significantly decreased over time: The CAMIC system appears to provide a barrier that actively removes particles from within the chamber and limits egress. Further studies are necessary to determine clinical applicability. The CAMIC may serve as an adjunct to improve health care worker safety and patient outcomes.

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Olfactory Dysfunction in COVID-19 Patients: Prevalence and Prognosis for Recovering Sense of Smell

Luca D’Ascanio,Manlio Pandolfini,Cristina Cingolani,Gino Latini,Paolo Gradoni,Maria Capalbo,Gabriele Frausini,Massimo Maranzano,Michael J. Brenner,Arianna Di Stadio

Publication date 14-07-2020


While olfactory dysfunction associated with coronavirus disease 2019 (COVID-19) has attracted considerable interest, few studies have tracked outcomes at serial time points or beyond 2 weeks. Furthermore, data are conflicting regarding whether COVID-19 severity correlates with degree of olfactory dysfunction. This prospective case-control study analyzed prevalence and severity of subjective loss of smell in outpatients (n = 23) and inpatients (n = 20) with confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection vs healthy controls (n = 25). Olfactory dysfunction was reported more commonly in COVID-19 patients than in healthy controls (

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Patient Perceptions of Head and Neck Ambulatory Telemedicine Visits: A Qualitative Study

Vasiliki Triantafillou,Eleanor Layfield,Aman Prasad,Jie Deng,Rabie M. Shanti,Jason G. Newman,Karthik Rajasekaran

Publication date 14-07-2020


During the COVID-19 pandemic, there has been unprecedented use of telemedicine for otolaryngology ambulatory visits. Patient satisfaction with telemedicine is an important metric, but survey-based questionnaires do not capture the nuances of the patient experience. This study aims to understand head and neck patients' perceptions about telemedicine clinic visits during COVID-19. Fifty-six established patients who had video-based telemedicine visits with an otolaryngology-head and neck surgery faculty member between March 25, 2020, and April 24, 2020, completed unstructured telephone interviews. Conventional content analysis was used to analyze the interview data. Retrospective chart reviews were conducted to determine the patients' demographic, disease, and treatment information. The primary benefits of telemedicine were accessibility and cost and time savings. Primary limitations included the ability to perform a physical examination. Most patients expressed a willingness to participate in future remote visits if appropriate or necessitated by social circumstances. Telemedicine is a disruptive process, and long-term adoption requires understanding patient perception of and satisfaction with telemedicine. Head and neck cancer patients were generally satisfied with telemedicine. The study elucidated patient perceived benefits and limitations of telemedicine. Continued implementation of telemedicine in otolaryngology-head and neck ambulatory clinics will require consideration of contextual features surrounding the virtual delivery of care, with particular attention to visit appropriateness for telemedicine and social circumstances.

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Factors Influencing the Development of Pneumonia in Patients With Head and Neck Cancer: A Meta-analysis

Priyanka D. Reddy,Flora Yan,Shaun A. Nguyen,Cherie-Ann O. Nathan

Publication date 14-07-2020


The aim of this study was to identify factors that are associated with the occurrence of pneumonia in patients with head and neck cancer (HNC) after treatment. Pub Med, Scopus, OVID, and Cochrane Library from inception to November 26, 2019. A systematic review in accordance with the PRISMA guidelines and an assessment of bias were performed. Included studies reported on the risk factors of pneumonia development after HNC treatment via odds ratios and subdistribution hazard ratios from regression analysis. Fifteen studies were included, comprising 30,962 patients with a mean age of 70 years (range, 19-95 years). Of these, 71.6% are male.
The results of our study indicate that the following were independent risk factors contributing to the development of pneumonia: male sex, habitual alcohol consumption, poor oral hygiene before treatment, pretreatment dysphagia, hypopharynx and nasopharynx tumor sites, use of radiotherapy with or without chemotherapy versus surgery alone, addition of chemotherapy to radiotherapy, reirradiation, neck dissection, increased duration of tracheotomy, and use of sedatives for sleeping. Multiple patient-, tumor-, and treatment-specific risk factors were identified in predicting pneumonia. Recognition of these risk factors early on may help prevent or at least detect pneumonia in this vulnerable group of patients.

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The Infratemporal Fossa Sign: Pilot Study of a Potential Clue to Eustachian Salpingitis

Edward D. McCoul

Publication date 14-07-2020


Aural discomfort may be the result of obstructive eustachian tube (ET) dysfunction, temporomandibular joint dysfunction, or other causes. The infratemporal fossa (ITF) sign, in which a patient points to a characteristic location below the auricle, is proposed as an indicator of nonobstructive eustachian salpingitis. A preliminary study included patients with a complaint of aural discomfort who were prompted to localize symptoms using a single finger. Group 1 localized by using the ITF sign; group 2 localized deep within the external ear canal (suggesting ET dysfunction); and group 3 localized to the preauricular region (suggesting temporomandibular joint dysfunction). Findings of ET inflammation recorded during nasal endoscopy were greater in groups 1 and 2. Tympanometry and otoscopy were uniformly abnormal for group 2 and uniformly normal for groups 1 and 3. The ITF sign may help to identify eustachian salpingitis as a phenotype of ET disease characterized by symptomatic inflammation without abnormal middle ear pressure.

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Olfactory Training for Postviral Olfactory Dysfunction: Systematic Review and Meta-analysis

Nrusheel Kattar,Triet M. Do,Graham D. Unis,Matthew R. Migneron,Andrew J. Thomas,Edward D. McCoul

Publication date 14-07-2020


Olfactory dysfunction is a common problem that is most frequently attributed to upper respiratory infection. Postviral olfactory dysfunction (PVOD) can be prolonged and clinically challenging to treat. Olfactory training (OT) has demonstrated potential benefit for patients with nonspecific olfactory dysfunction. We sought to evaluate the efficacy of OT specifically for PVOD by pooled analysis of the existing evidence. Pub Med, Embase, and Web of Science. Following PRISMA guidelines, Pub Med, Embase, and Web of Science databases were queried and abstracts screened independently by 2 investigators. We included studies evaluating the efficacy of OT for PVOD and excluded studies evaluating pharmacologic interventions or olfactory loss from other causes. Of the initial 1981 abstracts reviewed, 16 full-text articles were included. Sniffin' Sticks olfactory testing results were reported in 15 (93%) studies as threshold (T), discrimination (D), and identification (I) subscores and TDI total scores. All studies reported clinically significant results after OT, defined as a score improvement of TDI >5.5. Four studies were included in the meta-analysis, in which pooled estimates revealed that patients with PVOD who received OT had a 2.77 (95% confidence interval, 1.67-4.58) higher odds of achieving a clinically important difference in TDI scores compared to controls. Meta-analysis of existing data demonstrates clinically significant improvements in PVOD associated with OT. Variability exists among OT protocols and may benefit from further optimization. Existing data supports the use of OT for the treatment of existing and newly emerging cases of PVOD.

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Adverse Events Associated With Laser Use in the Upper Airway

Jane Y. Tong,Luke J. Pasick,Daniel A. Benito,Robert T. Sataloff

Publication date 14-07-2020


Surgical lasers are used extensively in head and neck surgery. Laser use in the upper airway offers many advantages but also presents risks to patients and operators that are not reported comprehensively. This study aims to summarize device malfunctions, patient complications, and subsequent interventions related to laser use in the upper airway. The US Food and Drug Administration's Manufacturer and User Facility Device Experience database was queried for reports of surgical laser adverse events from January 2010 to March 2020. Data were extracted from reports pertaining to the upper airway. Sixty-two reports involving upper airway laser use in an operating room were identified, from which 95 events were extracted. Of these, 40 (42.1%) were adverse events to patients, 2 (2.1%) adverse events to operators, and 53 (55.8%) device malfunctions. Dislodgement of laser fiber in the airway (23 [57.5%]), burn (8 [20%]), and scar (5 [12.5%]) were the most common adverse events to patients. Two incidents of eye exposure through unfiltered microscope lenses were the only adverse events to operators. Fiber break (26 [49.1%]) and flare (12 [22.6%]) were the most common device malfunctions. Surgical lasers have demonstrated utility in head and neck surgery but are associated with risks. This study discusses adverse events and device malfunctions associated with airway laser surgery and emphasizes shortcomings in current reporting. Standardized reporting and multi-institutional research are needed to better understand adverse events related to surgical laser use and to allow accurate estimation of their prevalence.

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Socioeconomic and Racial Disparities and Survival of Human Papillomavirus–Associated Oropharyngeal Squamous Cell Carcinoma

Janine M. Rotsides,Jamie R. Oliver,Lindsey E. Moses,Moses Tam,Zujun Li,David Schreiber,Adam S. Jacobson,Kenneth S. Hu,Babak Givi

Publication date 14-07-2020


To investigate differences in epidemiology of oropharyngeal squamous cell carcinoma (OPSCC) with regards to human papillomavirus (HPV), race, and socioeconomic status (SES) using the National Cancer Database (NCDB). Population-based cohort study. Racial and socioeconomic disparities in survival of OPSCC have been previously acknowledged. However, the distribution of HPV-related cancers and its influence on survival in conjunction with race and SES remain unclear. All patients with OPSCC in the NCDB with known HPV status from 2010 to 2016 were included. Differences in presentation, HPV status, treatment, and outcomes were compared along racial and socioeconomic lines. Univariable and multivariable Cox regression survival analyses were performed. In total, 45,940 patients met criteria. Most were male (38,038, 82.8%), older than 60 years (23,456, 51.5%), and white (40,156, 87.4%), and lived in higher median income areas (>$48,000, 28,587, 62.2%). Two-thirds were HPV positive (31,007, 67.5%). HPV-negative disease was significantly more common in lower SES (<$38,000, 2937, 41.5%, Significant differences in HPV status exist between socioeconomic and racial groups, with HPV-negative disease more common among blacks and lower SES. When controlling for HPV status, race and SES still influence outcomes in oropharyngeal cancers.

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Reconstruction After Salvage Total Laryngectomy: A Cost-effectiveness Analysis

Joseph R. Acevedo,Jeffrey C. Yu,Brian Cameron,Margaret Nurimba,Joel W. Hay,Niels C. Kokot

Publication date 14-07-2020


To determine the most cost-effective reconstruction method after salvage total laryngectomy. Cost-effectiveness analysis. Tertiary care hospitals with head and neck oncologic and reconstructive surgeons. We constructed a Markov-based decision model to compare reconstruction by primary closure to pectoralis flap and free flap after salvage total laryngectomy. The model simulated disease with transition probabilities and health utilities found in primary literature and estimated the average overall cost of each reconstructive method using Medicare billing codes. Effectiveness was compared using quality-adjusted life years (QALYs). One-way and probabilistic sensitivity analyses were performed to scrutinize the conclusions of our model. Reconstruction methods were compared using incremental cost-effectiveness ratios (ICERs). In the United States, less than $150,000 per QALY gained is considered cost-effective (2019 US dollars). Our base case analysis revealed that primary closure was less expensive ($44,370) and yielded more QALYs (0.91) than both pectoralis ($45,163, 0.81 QALYs) and free flap ($46,244, 0.85 QALYs), making it the most cost-effective option. Between flaps, free flap was cost-effective over pectoralis flap (ICER = $27,025/QALY gained). Sensitivity analyses showed primary closure as cost-effective 69% of the time over either flap. These conclusions were sensitive to the health utilities (quality of life) of each method of reconstruction. Tissue flaps to augment closure after salvage total laryngectomy are not always the most cost-effective reconstructive option. The long-term morbidity of flap surgery oftentimes outweighs the benefit of lowering fistula rates after surgery. Careful consideration must be taken when advising patients of their reconstructive options.

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Contemporary Management of Jugular Paragangliomas With Neural Preservation

Nauman F. Manzoor,Kristen L. Yancey,Joseph M. Aulino,Alexander D. Sherry,Mohamed H. Khattab,Anthony Cmelak,William G. Morrel,David S. Haynes,Marc L. Bennett,Matthew R. O’Malley,James Netterville,George Wanna,Alejandro Rivas

Publication date 14-07-2020


Management of jugular paragangliomas (PGL) has evolved toward subtotal resection (STR). The purpose of this study is to analyze neural preservation and adjuvant treatment for long-term local control. Retrospective chart review. Tertiary neurotology practice. Adults undergoing surgical treatment of jugular PGL between 2006 and 2019. Patients, disease, and treatment variables were collected retrospectively. Single predictor logistic regression was used to ascertain predictors of regrowth or need for salvage radiation. A total of 41 patients (median age, 47 years; 76% female) were identified. Most patients presented with advanced-stage disease (Glasscock-Jackson stage III-IV = 76%). Subtotal resection (STR) was performed in 32 (78%) patients. Extended STR (type 1) was the most commonly performed conservative procedure (n = 19, 59%). Postoperative new low cranial neuropathy (LCN) involving CN X and XII was rare (n = 3 and n = 1, respectively). Seventeen patients (41%) underwent postsurgical therapy for tumor regrowth or recurrence, including 15 patients who underwent adjuvant (n = 4) or salvage (n = 11) radiation. Overall tumor control of 94.7% was achieved at a mean follow-up of 35 months. All patients treated with combined modality treatment had local control at last follow-up. Logistic regression identified no single predictor for postsurgical radiation treatment or salvage-free survival. Management of jugular PGL with a conservative approach is safe and effective with a low rate of new LCN deficit. Active surveillance of residual tumor with salvage radiation for growth results in excellent long-term tumor control.

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Aerosol Dispersion During Mastoidectomy and Custom Mitigation Strategies for Otologic Surgery in the COVID-19 Era

Divya A. Chari,Alan D. Workman,Jenny X. Chen,David H. Jung,Dunia Abdul-Aziz,Elliott D. Kozin,Aaron K. Remenschneider,Daniel J. Lee,D. Bradley Welling,Benjamin S. Bleier,Alicia M. Quesnel

Publication date 14-07-2020


To investigate small-particle aerosolization from mastoidectomy relevant to potential viral transmission and to test source-control mitigation strategies. Cadaveric simulation. Surgical simulation laboratory. An optical particle size spectrometer was used to quantify 1- to 10-µm aerosols 30 cm from mastoid cortex drilling.
Two barrier drapes were evaluated: Oto Tent1, a drape sheet affixed to the microscope; Oto Tent2, a custom-structured drape that enclosed the surgical field with specialized ports. Mastoid drilling without a barrier drape, with or without an aerosol-scavenging second suction, generated large amounts of 1- to 10-µm particulate. Drilling under Oto Tent1 generated a high density of particles when compared with baseline environmental levels ( Mastoidectomy without a barrier, even when a second suction was added, generated substantial 1- to 10-µm aerosols. During drilling, large amounts of aerosols above baseline levels were detected with Oto Tent1 but not Oto Tent2. For both drapes, a second suction was an effective mitigation strategy during drilling. Last, the combination of a second suction and a pause before removal prevented aerosol escape during the removal of either drape.

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National Database Research in Head and Neck Reconstructive Surgery: A Call for Increased Transparency and Reproducibility

Andrés M. Bur,Mark R. Villwock,Rohit Nallani,Ernest D. Gomez,Mark A. Varvares,Jennifer A. Villwock,Steven B. Cannady,Mark K. Wax

Publication date 07-07-2020


To reproduce a published study comparing outcomes of patients who underwent microvascular reconstruction by plastic surgeons and otolaryngologists and to examine how case selection and methodology using the National Surgical Quality Improvement Program (NSQIP) data set can affect results and conclusions. Cross-sectional analysis of US national database. American College of Surgeons National Surgical Quality Improvement Program (NSQIP) from 2005 to 2017. A recently published study that used the NSQIP database to compare outcomes after head and neck free tissue transfer between plastic surgeons and otolaryngologists was reproduced. Different approaches to case selection and statistical analysis were evaluated and their effects on statistical significance and study conclusions were compared. When all cases of free tissue transfer, captured in NSQIP between 2005 and 2017, were compared between plastic surgery and otolaryngology, plastic surgery patients appeared to have lower rates of complications and length of stay. However, a more in-depth analysis demonstrated that these results were confounded by older and sicker otolaryngology patients. A second analysis of the same NSQIP data, limited to only head and neck oncologic reconstructions, demonstrated that otolaryngology patients had fewer complications on univariate and multivariable analysis. We demonstrated how case selection and analysis can significantly affect results. It is incumbent upon researchers who use NSQIP and other publicly available data sets to fully detail their methodology to allow other researchers to reproduce and evaluate their work and for the journal editorial process to carefully evaluate the methodology and conclusions of their contributing authors.

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Vasodilation by Verapamil-Nitroglycerin Solution in Microvascular Surgery

Rahul Seth,Karam W. Badran,Elizabeth Cedars,Karolina Plonowska,Tania Benjamin,Satvir Saggi,P. Daniel Knott,Chase M. Heaton,Keith E. Blackwell

Publication date 07-07-2020


Papaverine is a topical vasodilator commonly used during microvascular surgery to inhibit undesired vasoconstriction. A previous national shortage of papaverine prompted evaluation of an alternative, effective vasodilator. This study aims to assess the experience of a solution of verapamil and nitroglycerin (VG) as a potential alternative pharmacologic vasodilator. Retrospective case series. Two tertiary academic medical centers. Among 298 patients, 306 consecutive free tissue transfers performed between 2014 and 2017 for head and neck defect reconstruction utilized a VG solution. Patient and flap characteristics, intraoperative patient and flap complications, and postoperative complications were reviewed. Diameter of the cervical recipient artery was measured intraoperatively before and after topical application of the VG solution in a subset of 43 patients (44 flaps). Flaps included fibula, radial forearm, subscapular system, and anterolateral thigh. In total, 3 (0.98%) flaps failed with varied etiology unrelated to the VG solution (venous thrombosis, arterial anastomosis thrombosis, physical damage to the perforator). Specific to topical application of the VG solution, the mean recipient artery diameter increased from 2.1 to 3.1 mm, a 48% increase ( We describe the use of a VG solution for pharmacologic vasodilation during microvascular free tissue transfer. Its use was associated with an acceptable incidence of adverse events, none of which were directly attributable to the VG solution. Apparent and sustained vasodilation was demonstrated. The VG solution represents a safe and efficacious alternative to papaverine in microvascular surgery.

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Pathologic Tumor Size as a Predictor of the Survival Outcomes of Patients With Glottic Carcinoma

Hongli Gong,Liang Zhou,Haitao Wu,Lei Tao,Ming Zhang,Xiaoling Chen,Xiaoming Li,Cai Li,Jian Zhou,Shuyi Wang

Publication date 07-07-2020


The purpose of this study was to evaluate the potential predictor of tumor size on rates of overall and disease-free survival (OS and DFS) as determined by postoperative pathologic examination in patients with glottic carcinoma. Retrospective cohort study. Tertiary care university hospital. In this study, 1337 consecutive patients with glottic carcinoma who underwent surgical treatment from 2005 to 2010 were retrospectively reviewed. The influence of tumor size that was evaluated by tumor area (tumor length × tumor width) on OS and DFS outcomes was assessed by Cox regression analyses. In all, 1303 (97.5%) patients were male, and 34 (2.5%) were female, with a mean ± SD age of 60.4 ± 10 years. The 10-year OS and DFS rates were 72.9% and 69.9%, respectively. The tumor area cutoff values that best discriminated OS and DFS rates were both 1.80 cm The results of this study indicate that patients with glottic carcinoma with a tumor area >1.8 cm

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Association of Metformin With the Growth of Vestibular Schwannomas

Sophia Tran,Daniel E. Killeen,Shafeen Qazi,Sanjana Balachandra,Jacob B. Hunter

Publication date 07-07-2020


To assess whether medication use, specifically statin, metformin, and aspirin, affects the growth of vestibular schwannomas (VSs). Retrospective case series. Single tertiary care academic hospital. Patients were enrolled if they were diagnosed with sporadic VS and had at least 2 magnetic resonance imaging (MRI) studies at a minimum of 6 months apart prior to any intervention. Electronic medical records were reviewed for demographic and medication data. Tumor volumes on MRI studies were assessed via Brain Lab i Plan. The primary endpoint was VS tumor growth, defined as a 20% increase in tumor volume, between consecutive MRI studies or between the first and last available MRI study. Predictors of volumetric growth, specifically statin, aspirin, or metformin use, were analyzed with A total of 387 patients met inclusion criteria, 53.5% of whom were women. For all patients, the mean age was 60.6 years (range, 18.2-89.2 years); the mean axial tumor diameter, 11.9 mm (range, 1.7-32.0 mm); and the mean tumor volume, 0.85 cm Metformin use is associated with reduced volumetric VS growth.

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In Vivo Accuracy of Ultrasound for Sizing Salivary Ductal Calculi

Christopher D. Badger,Sahil Patel,Nahir J. Romero,Andrew Fuson,Arjun S. Joshi

Publication date 30-06-2020


The present study was developed to evaluate the accuracy of in vivo ultrasound sizing for parotid and submandibular salivary gland calculi, as compared with ex vivo pathology sizing with a standard plastic ruler after extraction. Retrospective chart review. Ultrasound is frequently used to size salivary calculi and make treatment decisions, but the accuracy of measurements from this modality has not been validated. We evaluated and reviewed the charts and ultrasound examinations of 167 patients who underwent procedures for the treatment of sialolithiasis involving the parotid and submandibular glands. US examinations were performed between 2009 and 2016 in a tertiary-level hospital setting by the senior author. Measurements were collected from ultrasound evaluation before sialolithotomy, and pathology measurements were taken after removal. Ultrasound measurements in millimeters were compared with the measurements collected with a ruler. The differences were calculated and compared. A total of 167 calculi measurements were compared. Good concurrent validity between pathology and ultrasound measurements was suggested by a Pearson correlation of 0.92 (95% CI, 0.887-0.937). On Bland-Altman plot, correlation of the difference between US and pathology measurements showed a mean difference of 0.095 mm (95% CI, -0.19 to 0.38 mm) with a limit of agreement ranging from -3.59 mm (95% CI, -3.84 to -3.34 mm) to +3.78 mm (95% CI, +3.53 to +4.03 mm). Ultrasound is an accurate, relatively precise, and minimally invasive imaging tool for salivary gland sialolithiasis. Preoperative size of calculi can be used to guide management and clinical decision making. 2C.

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Effect of Bumetanide on Facial Nerve Regeneration in Rat Model

Ecem Sevim Longur,Özgür Yiğit,Çiğdem Kalaycık Ertugay,Ela Araz Server,Turgut Adatepe,Dilek Akakın,Oya Orun,Ayça Karagöz Köroğlu

Publication date 30-06-2020


We investigated the effects of bumetanide alone and in combination with dexamethasone on facial nerve regeneration in rats with facial paralysis. A prospective controlled animal study. An animal laboratory.
Facial paralysis was induced in 32 Wistar rats that we then divided into 4 groups: group 1, control; group 2, bumetanide; group 3, dexamethasone; group 4, bumetanide and dexamethasone. Electroneurography was performed 1, 2, and 4 weeks later, and nerve regeneration was evaluated by electron and light microscopy and Western blotting in week 4. Regarding the comparison between preoperative values and week 4, the latency difference in group 1 (1.25 milliseconds) was significantly higher than those of groups 2 to 4 (0.56, 0.34, and 0.10 milliseconds, respectively; After primary neurorrhaphy, dexamethasone and bumetanide alone promoted nerve recovery based on electrophysiologic and histologic measures. Combination therapy was, however, superior.

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Systematic Review of Outcomes After Cochlear Implantation in Children With X-Linked Deafness-2

Joshua D. Smith,Nour El-Kashlan,Owen A. F. Darr,Marc C. Thorne

Publication date 30-06-2020


Outcomes following cochlear implantation in children with X-linked deafness-2 are variable, resulting in challenges in appropriate preoperative counseling. To address this uncertainty, we performed a systematic review and synthesis of the literature on audiologic and speech outcomes after cochlear implantation in these patients to inform prognostic counseling. Pub Med, Embase, and Cochrane Library were queried for articles published between January 2000 and July 2019. We performed a systematic review of all studies published between 2000 and 2019 that reported on (1) children with confirmed X-linked deafness-2 undergoing cochlear implantation and (2) formal assessment of hearing and/or speech capabilities postimplantation. Our initial database search yielded 313 articles. Fourteen articles met inclusion criteria. These studies reported on 61 children with X-linked deafness-2 who underwent implantation at a wide age range (1-29 years) for severe-profound sensorineural hearing loss of prelingual onset. The mean follow-up duration after implant activation was 32 months (range, 12-61). Outcome domains assessed at follow-up were heterogeneous, though each study employed at least 1 assessment of hearing (eg, pure tone audiometry), speech perception (eg, Early Speech Perception Test), or auditory perception (eg, Categories of Auditory Perception scores). In 10 of 14 studies, cochlear implantation afforded significant improvement in hearing and speech capabilities relative to preoperative performance or as compared with age-matched, normal-hearing controls. The majority of studies demonstrate that cochlear implantation provides improvements in hearing and speech performance in patients with X-linked deafness-2. This information is valuable for decision making regarding cochlear implantation in these patients.

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Otopathologic Analysis of Patterns of Postmeningitis Labyrinthitis Ossificans

Danielle R. Trakimas,Renata M. Knoll,Melissa Castillo-Bustamante,Elliott D. Kozin,Aaron K. Remenschneider

Publication date 30-06-2020


Labyrinthitis ossificans (LO) may occur following meningitis and, in cases where cochlear implantation is indicated, complicate electrode insertion. LO is critical to identify for successful cochlear implantation, and histopathology is more sensitive than imaging for identification of LO. Herein we utilize otopathologic techniques to study the timing and location of intracochlear tissue formation following meningitic labyrinthitis (ML). Retrospective review. Academic institution. Temporal bone specimens with a history of bacterial ML were histologically evaluated. The location and extent of intracochlear tissue formation within the scala tympani (ST) and scala vestibuli (SV) were graded, and spiral ganglion neurons were counted. Fifty-one temporal bones were identified: 32 with no intracochlear tissue formation, 9 with fibrosis alone, and 10 with LO. Fibrosis was identified as early as 1.5 weeks after ML, while ossification was found only in specimens that survived multiple years after ML. All LO cases showed ossification of the ST at the round window membrane (RWM) with continuous extension throughout the basal turn. Extent of SV ossification correlated with that in the ST but showed frequent isolated distal involvement of the cochlea. Spiral ganglion neuron counts were lower than those in age-matched controls. In this human temporal bone study, we found that postmeningitic LO results in ossification at the RWM with continuous extension into the ST of the basal turn and variable involvement of the SV. Identification of a patent basal turn beyond RWM ossification of the ST should permit full electrode insertion. Retrospective review.

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Assessing the Educational Quality of Facebook Videos as an Informative Resource on Otitis Media

Chase I. Kahn,Rita Wang,Kunal Shetty,Mikayla J. Huestis,Michael B. Cohen,Jessica R. Levi

Publication date 30-06-2020


This study analyzes the quality and reliability of otitis media (OM) videos on Facebook and investigates whether the videos shared within the Facebook community are considered to be a valuable educational tool. The results of this study are important for providing clinicians with the necessary understanding about the video content that their patients may be exposed to. Cross-sectional analysis of video content. A new Facebook account was created to carry out a search for videos on OM.
Inclusion criteria were as follows: videos intended for educating patients or guardians on OM, videos in the English language, and videos with at least 1 share. A total of 364 videos were screened, and 62 fit our inclusion criteria for analysis. The majority (56%) of OM videos on Facebook focused on complementary and alternative medication without mentioning any current guidelines. A limited amount of videos (29%) made any mention to surgical treatment options for OM. There was a strong positive correlation (rho = 0.8419, The majority of OM videos on Facebook are inadequate for educational value. Clinicians should know about the existence of videos on OM and the quality of information that parents are exposed to.

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Thyroplasty Type III to Lower the Vocal Pitch in Trans Men

Charlotte Bultynck,Marjan Cosyns,Guy T’Sjoen,John Van Borsel,Katrien Bonte

Publication date 30-06-2020


About 20% of trans men do not achieve cisgender male frequencies (F

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Meta-analysis Exploring Sinopulmonary Outcomes of Aspirin Desensitization in Aspirin-Exacerbated Respiratory Disease

Mohamad R. Chaaban,David Moffatt,Alex E. Wright,James A. Cowthran,En Shuo Hsu,Yong-Fang Kuo

Publication date 23-06-2020


The objective of this study is to explore the sinopulmonary outcomes of aspirin desensitization through a systematic review and meta-analysis. Embase and OVID Medline databases. A systematic review of published articles on outcomes following aspirin desensitization in any language for relevant articles was performed in February 2019. Outcomes included sinonasal quality-of-life assessment, sense-of-smell scores, FEV-1 (forced expiratory volume in 1 second), and medication/steroid use. Thirteen studies met the inclusion criteria out of 6055 articles screened. Aspirin desensitization resulted in significant improvement in FEV-1 and reduction in asthma medication/steroid use ( Aspirin desensitization appears to be effective in improving pulmonary outcomes and should be considered in the treatment of patients with aspirin-exacerbated respiratory disease. However, good-quality studies are still needed to determine the ideal protocol tailored to individual patients.

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Controversies in the Workup and Surgical Management of Parotid Neoplasms

Michael G. Moore,Bevan Yueh,Derrick T. Lin,Carol R. Bradford,Richard V. Smith,Samir S. Khariwala

Publication date 23-06-2020


Parotid neoplasms are a rare heterogeneous group of tumors with varied clinical presentation and behavior. Here we provide an evidence-based review of the contemporary approach to evaluation and surgical management of parotid tumors. Pub Med and Web of Science Databases. Searches of the Pub Med and Web of Science databases were performed on subjects related to the diagnosis and surgical management of parotid neoplasms.
Particular emphasis was placed on the following areas: evaluation of parotid tumors, including imaging workup and the utility of fine-needle aspiration; extent of surgery of the primary lesion, including the extent of parotidectomy as well as oncologic management of the facial nerve; the extent of surgery of involved and at-risk cervical lymphatics; and parotid bed reconstruction. Articles published from 2014 to the present were prioritized, supplementing with information from prior studies in areas where data are lacking. A summary of the literature in these areas is outlined to provide an evidence-based approach to evaluation and management of parotid neoplasms. While data are available to help guide many aspects of workup and management of parotid neoplasms, further research is needed to refine protocols for this heterogeneous group of diseases.

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Involvement of Laryngopharyngeal Reflux in Select Nonfunctional Laryngeal Diseases: A Systematic Review

Jerome R. Lechien,Lee M. Akst,Sven Saussez,Lise Crevier-Buchman,Stéphane Hans,Maria Rosaria Barillari,Christian Calvo-Henriquez,Jonathan M. Bock,Thomas L. Carroll

Publication date 23-06-2020


To investigate the existing published evidence supporting the role of laryngopharyngeal reflux (LPR) in the development of the select nonfunctional laryngeal diseases of laryngotracheal stenosis, granuloma, leukoplakia, and laryngeal infections. Pub Med, Cochrane Library, and Scopus. A systematic review was performed by 3 independent investigators for studies providing information about the prevalence and role of LPR in the development of laryngotracheal stenosis, granuloma, leukoplakia, and laryngeal infections. Diagnostic criteria and clinical outcome evaluation of included studies were analyzed with PRISMA criteria. Of the 64 relevant publications, 27 clinical and 4 basic science studies were included. Ten studies used objective reliable examinations for LPR diagnosis (eg, dual- or triple-probe or oropharyngeal pH monitoring, multichannel intraluminal impedance-pH monitoring, or pepsin detection). According to the bias analysis and the results of studies, the association between LPR and laryngotracheal stenosis, leukoplakia, laryngeal papillomatosis, or vocal fold granuloma remains poorly demonstrated. There is a notable heterogeneity among included studies regarding their inclusion criteria, diagnostic methods, and clinical outcome evaluation. Although some experimental findings support the involvement of bile salts and other gastroduodenal proteins active in alkaline pH, no included clinical studies assessed the role of nonacid and mixed reflux through multichannel intraluminal impedance-pH monitoring. The involvement of LPR in the development of leukoplakia, laryngotracheal stenosis, vocal fold granuloma, and laryngeal papillomatosis is currently not demonstrated. The potential relationship between LPR and these select nonfunctional laryngeal diseases must be confirmed through future clinical and experimental studies considering acid, nonacid, and mixed LPR.

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