Otolaryngology Head and Neck Surgery 2021-02-23

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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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Is a Biological Scaffold Needed for the Repair of Traumatic Tympanic Membrane Perforations?

Zhengcai Lou

Publication date 02-02-2021


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Response to “Is Biological Scaffold Need for Repair of Traumatic Tympanic Membrane Perforation?”

Yi Shen,Bing Mei Teh

Publication date 02-02-2021


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Letter to the Editor Regarding “Reconstruction After Salvage Total Laryngectomy: A Cost-effectiveness Analysis”

Craig A. Bollig,Patrik Pipkorn

Publication date 02-02-2021


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Response to Letter to the Editor Regarding “Reconstruction After Salvage Total Laryngectomy: A Cost-effectiveness Analysis”

Joseph R. Acevedo,Niels C. Kokot

Publication date 02-02-2021


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Neurophysiology in Cranial Neuropathy: Comment on “Cranial Base Manifestations of Granulomatosis With Polyangiitis”

Otto Jesus Hernandez Fustes

Publication date 02-02-2021


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In Response to “Neurophysiologic Testing Utility in Granulomatosis With Polyangiitis”

Patrick T. Kiessling,John P. Marinelli,Pierce A. Peters,David R. DeLone,John I. Lane,Matthew J. Koster,Matthew L. Carlson

Publication date 02-02-2021


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

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

Publication date 23-02-2021


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

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Developmental Anatomy of the Eustachian Tube: Implications for Balloon Dilation

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

Publication date 23-02-2021


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

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Early Tracheostomy Change in Neonates: Feasibility and Benefits

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

Publication date 23-02-2021


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

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

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

Publication date 23-02-2021


Retrospective study.

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

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

Publication date 23-02-2021


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

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

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

Publication date 23-02-2021


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

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

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

Publication date 23-02-2021


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

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

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

Publication date 23-02-2021


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

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National Trends in Opioid Prescriptions Following Outpatient Otologic Surgery, 2005-2017

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

Publication date 23-02-2021


To describe opioid stewardship in ambulatory otologic surgery from 2005 to 2017. Descriptive study of US private insurance claims. Nationwide deidentified private insurance claims database (Clinformatics Data Mart; Optum). A total of 17,431 adult opioid-naïve outpatients were included in the study. Patients were identified from The mean prescribed perioperative dose over the examined period was 203.03 MMEs (95% CI, 200.27-205.79; 5-mg hydrocodone pill equivalents, 40.61). In multivariate analysis, patients undergoing mastoid surgery were prescribed more opioids than those undergoing middle ear surgery (mean difference, 39.89 MME [95% CI, 34.37-45.41], While the amount of opioids prescribed perioperatively has declined in recent years, otologists should continue to be cognizant of potential overprescribing in light of previous studies of patients' relatively low opioid intake.

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The Anatomical and Clinical Significance of the Superior Laryngeal Nerve

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

Publication date 23-02-2021


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

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Challenges in the Delivery of Rural Otolaryngology Care During the COVID-19 Pandemic

Tasher Losenegger,Matthew J. Urban,Ashok J. Jagasia

Publication date 16-02-2021


Though initially spared from the brunt of the COVID-19 pandemic, rural areas in the United States have been ravaged by the disease. With a higher-risk population at baseline and an already strained health care system, rural hospitals face severe challenges in delivering care during the pandemic. In otolaryngology specifically, there has been difficulty in ensuring patient access to care while maintaining safe environments for patients and staff. Partnership between academic medical centers and critical access rural hospitals is urgently needed to help improve care for vulnerable rural populations.

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

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

Publication date 16-02-2021


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

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

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

Publication date 16-02-2021


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

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The Impact of MassPAT on Opioid Prescribing Patterns for Otolaryngology Surgeries

Samuel Rubin,Jacqueline A. Wulu,Heather A. Edwards,Robert W. Dolan,David M. Brams,Bharat B. Yarlagadda

Publication date 16-02-2021


Determine whether opioid prescriber patterns have changed for tonsillectomy, parotidectomy, and thyroidectomy after implementation of the Massachusetts Prescription Awareness Tool (MassPAT). Retrospective cohort study. Single-center tertiary care hospital. Patients were included if they received tonsillectomy, parotidectomy, or thyroid surgery at Lahey Hospital and Medical Center (Burlington, Massachusetts) between October 1, 2015, and October 1, 2019. Prescribing patterns were compared prior to implementation of MassPAT, October 1, 2015, to October 14, 2016, to postimplementation of MassPAT, October 15, 2016, to October 1, 2019. Quantity of opioids prescribed was described using total morphine milligram equivalents (MME). Data were analyzed using univariate analysis, multivariate analysis, and trend line using line of best fit. A total of 737 subjects were included in the study. There was a downward trend in the quantity of opioids prescribed for all 3 surgeries during the study period. There was a significant difference in the quantity of opioids prescribed pre- and postimplementation of MassPAT for tonsillectomy (647.70 ± 218.50 MME vs 474.60 ± 185.90 MME, We have demonstrated that there is an association with state drug monitoring programs and decrease in the amount of opioids prescribed for acute postoperative pain control for common otolaryngology surgeries.

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Dermal Regeneration Template and Staged Skin Grafting for Extirpative Scalp Wound Reconstruction: A 14-Year Experience

Jacob C. Maus,Kshipra Hemal,Mija Khan,Bennett W. Calder,Malcolm W. Marks,Anthony J. Defranzo,Ivo Alexander Pestana

Publication date 16-02-2021


Dermal regeneration template and staged split-thickness skin grafting may mitigate the need for flap coverage of postoncologic scalp defects. This technique has been studied previously in small case series. We examine the effect of risk factors, surgical technique, irradiation, and dressing modalities on reconstructive outcomes in a highly comorbid patient cohort. Retrospective review. Academic medical center. Full- and partial-thickness extirpative scalp wounds reconstructed with dermal regeneration template and staged skin grafting were reviewed over a 14-year period. Stage 1 consisted of template application following burr craniectomy in cases lacking periosteum. Stage 2 consisted of skin grafting. Negative pressure wound therapy (NPWT) was variably used to support adherence. In total, 102 patients were analyzed (average age 74, mean follow-up 18 months). Eighty-one percent were American Society of Anesthesiologists class 3 or 4. Defect size averaged 56 cm Dermal template and staged skin grafting is a reliable option for postcancer scalp reconstruction in poor flap candidates. Radiotherapy is associated with adverse outcomes. Negative pressure wound therapy simplifies postoperative wound care regimens and may accelerate healing.

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Complications in Pediatric Acute Mastoiditis: HCUP KID Analysis

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

Publication date 16-02-2021


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

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

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

Publication date 16-02-2021


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

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

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

Publication date 16-02-2021


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

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

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

Publication date 16-02-2021


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

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Outcomes in Revision Stapes Surgery

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

Publication date 09-02-2021


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

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

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

Publication date 09-02-2021


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

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Levels of Evidence in Rhinology and Skull Base Surgery Research

Jennifer A. Silver,Marco Mascarella,George Tali,Rickul Varshney,Marc A. Tewfik,Bobby A. Tajudeen,Joseph S. Schwartz

Publication date 09-02-2021


The purpose of this study was to evaluate the quality of evidence of rhinology and rhinologic skull base surgery (RSBS) research and its evolution over the past decade. Review article. We reviewed articles from 2007 to 2019 in 4 leading peer-reviewed otolaryngology journals and 3 rhinology-specific journals. The articles were reviewed and levels of evidence were assigned using the Oxford Centre for Evidence-Based Medicine 2011 guidelines. High quality was defined as level of evidence 1 or 2. In total, 1835 articles were reviewed in this study spanning a 13-year period. Overall, the absolute number of RSBS publications increased significantly 22.6% per year, from 108 articles in 2007 to 481 in 2019 ( The number of overall publications and of high-quality RSBS publications has significantly increased over the past decade. However, the proportion of high-quality studies continues to represent a minority of total RSBS research.

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COVID-19 Preprocedural Testing: What About the False Positives?

Christopher J. Hill,Charles D. Meyer,Marilisa G. Elrod,Gregory G. Capra

Publication date 09-02-2021


In the COVID-19 era, preprocedural patients are almost uniformly screened for symptoms, asked to quarantine preoperatively, and then undergo a test of uncertain validity with very low pretest probability. A small percentage of these tests return positive. As a result, surgical procedures are delayed and patients are required to quarantine. Are these asymptomatic patients truly positive for COVID-19? What are the impacts of these test results on the patient and the health care system? In the following commentary, we review how the uncertain validity of reverse transcription polymerase chain reaction testing combined with a low-prevalence population predisposes for false-positive results. As a mitigation strategy, we ask that readers refocus on the fundamental principal of diagnostic testing: pretest probability.

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

Alberto Paderno,Davide Mattavelli,Cesare Piazza

Publication date 09-02-2021


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Corrigendum to “Airborne Aerosolized Mouse Cytomegalovirus From Common Otolaryngology Procedures: Implications for COVID-19 Infection”

Publication date 09-02-2021


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

Kai Liu,Zhenkun Yu

Publication date 09-02-2021


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

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

Publication date 09-02-2021


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

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

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

Publication date 09-02-2021


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

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Extranodal Extension as an Indicator for Sinonasal Squamous Cell Carcinoma Prognosis

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

Publication date 09-02-2021


Although extranodal extension (ENE) is a known indicator of poor prognosis for head and neck malignancies, its value as an indicator for sinonasal squamous cell carcinoma (SCC) has not been well characterized. This study seeks to assess the usefulness of ENE as a prognostic marker for sinonasal SCC. Retrospective database review. National Cancer Database from 2010 to 2015. The National Cancer Database was queried from 2010 to 2015 for all patients with sinonasal SCC with available ENE status (n = 355). These cases were divided into those with pathologically confirmed ENE (n = 146) and those without ENE (n = 209). Univariate and multivariate analyses were used to examine survival differences and predictors of ENE status. Most patients with ENE were ≥60 years old (61.7%), male (61.6%), and white (83.6%). Patients aged 60 to 69 and 80+ years were more likely to have ENE than those under 60 years ( ENE status did not have a significant effect on survival in patients with sinonasal SCC. Thus, ENE alone may not necessarily be a helpful indicator for sinonasal SCC prognosis.

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Executive Summary: “Evidence-Based Performance Measures for Rhinoplasty: A Multi-disciplinary Performance Measure Set”

Lisa Ishii,Fred Fedok,Benjamin Marcus,Travis T. Tollefson

Publication date 09-02-2021


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

Valentin Favier,Léonie Grimmer,Arnaud Florentin,Patrice Gallet

Publication date 02-02-2021


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

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

Publication date 02-02-2021


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

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

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

Publication date 02-02-2021


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

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

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

Publication date 02-02-2021


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

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

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

Publication date 02-02-2021


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

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Changes in Single-Specialty Postoperative Opioid Prescribing Patterns in Response to Legislation: Single-Institution Analysis Over Time

Andrew P. Katz,Carly Misztal,Michael K. Ghiam,Michael E. Hoffer

Publication date 02-02-2021


To determine changes in the prescriptions of postoperative opioids in response to Florida state legislation restricting the number of days for which these medications could be prescribed to 3 days in most circumstances or 7 days at provider discretion. A retrospective review was performed for all patients undergoing 7 common outpatient otolaryngology surgical procedures. Single-institution academic center in Florida. Query of the state's online prescription drug monitoring program was used to compare prescription habits 3 months before and after the law and then again 1 year later. A total of 561 patients were identified meeting criteria. The number of days that opioids were prescribed decreased significantly, from 6.42 to 4.48 to 3.03 days. There was a significant decrease in the proportion of patients receiving any postoperative opioid prescription, from 0.80 to 0.52 to 0.32. The total morphine milligram equivalents prescribed decreased from 28.4 before the law to 18.4 at 1 year after. Legislative restrictions on the length of opioid prescriptions were associated with significant decreases in the proportion of patients receiving any opioids, the number of days that opioids were prescribed, and the total morphine milligram equivalents 3 months after the law went into effect, with even more dramatic changes at the 1-year time point. We opine that these changes are due to providers learning that many procedures do not require postoperative opioids and therefore increasingly considering and utilizing nonopioid alternatives in this setting.

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Systematic Review and Meta-analysis: Effectiveness of Corticosteroids in Treating Adults With Acute Vestibular Neuritis

Kai-Jing Leong,Timothy Lau,Vicky Stewart,Elisa F. D. Canetti

Publication date 02-02-2021


To determine whether steroids are effective in treating adults with acute vestibular neuritis. Pub Med, Embase, CINAHL, Cochrane CENTRAL, Web of Science, CAB Abstract, ICTRP, LILACS, PEDRO, Clinical Trials.
Gov, Google Scholar, NARIC, and OT Seeker. A systematic review was undertaken for articles reporting subjective and/or objective outcomes of corticosteroids in adults with acute vestibular neuritis between December 2010 and October 2019. Reports of patient recovery from clinical vestibular outcomes at various time points and adverse effects from corticosteroids were of interest. Statistical analysis included qualitative and quantitative assessments. A limited meta-analysis of the data was performed through a random effects model. Eight studies met the criteria, and 6 were included in the meta-analysis. No significant differences between the groups (corticosteroid vs placebo, corticosteroid vs vestibular exercise, or corticosteroid vs combination of vestibular exercise and corticosteroid) were reported in the proportion of patients with complete recovery at 1, 6, and 12 months. The corticosteroid group had significantly better caloric recover at 1 month (95% CI, -16.33 to -0.32); however, there was no significant difference to the overall effect between the groups across 12 months. Subjective recovery did not differ between the groups. Five of the 8 studies reported on adverse effects from corticosteroids. There is insufficient evidence to support the use of corticosteroids in managing acute vestibular neuritis in adults. At present, corticosteroids appear to have short-term benefits in canal paresis but no long-term benefits in canal paresis and symptomatic recovery. Future studies should consider including a wider variety of clinical vestibular tests and frequent acute follow-ups to monitor the effects of corticosteroids.

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The Impact of COVID-19 on Otolaryngology Community Practice in Massachusetts

Timothy Fan,Alan D. Workman,Lauren E. Miller,Mallory Mason Sakats,Karthik Rajasekaran,Jason A. Brant,Arjun K. Parasher,David Huckins,Avner Aliphas,Robin Glicksman,Antoine Eskander,Jordan T. Glicksman

Publication date 02-02-2021


Coronavirus disease 2019 (COVID-19) significantly affected many health care specialties, including otolaryngology. In response to governmental policy changes, many hospitals and private practices in Massachusetts canceled or postponed nonurgent office visits and elective surgeries. The objective of this study was to quantify the impact of COVID-19 on the provision and practice trends of otolaryngology services for 10 private practices in Massachusetts. Retrospective review. Multipractice study for community practices in Massachusetts. Electronic billing records from 10 private otolaryngology practices in Massachusetts were obtained for the first 4 months of 2019 and 2020. Questionnaires from these otolaryngology practices were collected to assess financial and staffing impact of COVID-19. The local onset of the COVID-19 pandemic had a significant decrease of 63% of visits in comparison to equivalent weeks in 2019. Virtual visits overtook in-person visits over time. A greater decline in operating room (OR) procedures than for office procedures was recorded. Ninety percent of practices reduced working hours, and 80% furloughed personnel. Seventy percent of practices applied for the Paycheck Protection Program (PPP). COVID-19 has had a multifaceted impact on private otolaryngology practices in Massachusetts. A significant decline in provision of otolaryngology services aligned with the Massachusetts government's public health policy changes. The combination of limited personnel and personal protective equipment, as well as suspension of nonessential office visits and surgeries, led to decrease in total office visits and even higher decrease in OR procedures.

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Outcomes of Septal Perforation Repair With Concurrent Endoscopic Sinus Surgery

Yassmeen Abdel-Aty,Rachel B. Cain,Cullen Taylor,Michael J. Marino,Devyani Lal,Stephen F. Bansberg

Publication date 26-01-2021


This study reviews a cohort of patients in whom septal perforation repair was performed concurrently with endoscopic sinus surgery. We present an endonasal perforation repair technique using bilateral mucosal flaps with an autogenous interposition graft. Intraoperative and postoperative management of the combined surgical patient is discussed and perforation closure outcomes are reported. Case series. Tertiary care center. In this institutional review board-approved retrospective chart review, adult patients who underwent concurrent bilateral mucosal flap septal perforation repair and endoscopic sinus surgery from March 1992 to March 2020 were identified. Data on demographics, clinical presentations, perforation size, surgical techniques, and outcomes were extracted and analyzed for patients with a minimum of 3 months of follow-up. Fifty-six patients met study inclusion criteria. Nasal obstruction/congestion was the most frequent symptom reported (80.4%), followed by crusting and epistaxis. Mean perforation size measured at the time of surgery was 14.7 (range, 3-41) mm in length by 9.3 (range, 2-23) mm in height. Temporalis fascia was the most frequent (57.9%) interposition graft material used. Complete perforation closure at the time of the last follow-up was noted in 51 (91.1%) patients. Only 1 failure was noted in the last 48 attempted repairs. Patients with a perforated septum may have coexistent chronic sinusitis. The feasibility of attempting concurrent sinus surgery and perforation repair has been questioned. Our review demonstrates a high perforation closure rate when a bilateral mucosal flap procedure is performed after sinus surgery is performed at the same setting.

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

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

Publication date 26-01-2021


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

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Emergency Surgical Airway Algorithm for Difficult Airway Management During the COVID-19 Pandemic

Soham Roy,John D. Cramer,Carol Bier-Laning,Patrick A. Palmieri,Christopher H. Rassekh,Michael J. Brenner

Publication date 26-01-2021


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

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

Publication date 26-01-2021


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Does Treatment of Sudden Sensorineural Hearing Loss in Patients With COVID-19 Require Anticoagulants?

Waldemar Narozny,Andrzej Skorek,Dmitry Tretiakow

Publication date 26-01-2021


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Association of Pediatric Hearing Loss and Head Injury in a Population-Based Study

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

Publication date 26-01-2021


Traumatic brain injury (TBI) is the leading cause of acquired long-term disability during childhood, and it may result in wide range of negative developmental consequences. Auditory dysfunction is generally recognized to be a possible sequela of pediatric TBI. Unfortunately, few contemporary studies have quantified the association between head injury and hearing loss in the pediatric population. The National Survey of Children's Health (NSCH) for the combined years 2017-2018 was used to determine the association of hearing loss with TBI. Deafness or problems with hearing were more commonly reported in children with a history or current brain injury/concussion compared to those without any such history (3.2% [70,000] and 1.2% [830,000] children, respectively; odds ratio, 2.67;

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Barriers to Obtaining a Timely Diagnosis in Human Papillomavirus–Associated Oropharynx Cancer

Emily E. Karp,Linda X. Yin,Eric J. Moore,Anna J. Elias,Thomas J. O’Byrne,Amy E. Glasgow,Elizabeth B. Habermann,Daniel L. Price,Jan L. Kasperbauer,Kathryn M. Van Abel

Publication date 26-01-2021


Failure to recognize symptoms of human papillomavirus-associated oropharyngeal squamous cell carcinoma (HPV(+)OPSCC) at presentation can delay diagnosis and treatment. This study aims to identify patient factors and provider patterns that contribute to delayed diagnosis. Retrospective case series. Tertiary care center. Patients with HPV(+)OPSCC receiving intent-to-cure treatment from 2006 to 2016. Clinical data, workup, and care timelines were abstracted. Univariate and multivariable linear regressions were performed to determine associations. Of 703 included patients, 627 (89%) were male, and mean (SD) age at diagnosis was 59 (9) years. The mean (SD) delay to diagnosis was 148.8 (243.51) days, with an average delay of 63 (154.91) days from symptom onset to first presentation and 82.8 (194.25) days from first presentation to diagnosis. Most patients visited at least 2 providers (n = 546, 78%) before diagnosis and saw their primary care physician at first presentation (n = 496, 71%). The most common imaging and biopsy obtained before diagnosis was neck computed tomography (n = 391, 56%) and neck fine-needle aspiration (n = 423, 60%), respectively. On multivariable linear regression, being a homemaker, being a current smoker, seeing 3 or more providers, and getting a magnetic resonance imaging scan were associated with significant delays in diagnosis ( Patient delays in seeking medical attention and provider delays in recognizing the appropriate diagnosis both contribute to delays of care in HPV(+)OPSCC. Improved patient and provider education is necessary to expedite the diagnosis of HPV(+)OPSCC.

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Impact of Treatment on Vestibular Schwannoma–Associated Symptoms: A Prospective Study Comparing Treatment Modalities

Jason H. Barnes,Neil S. Patel,Christine M. Lohse,Nicole M. Tombers,Michael J. Link,Matthew L. Carlson

Publication date 26-01-2021


The degree to which various treatment modalities modify vestibular schwannoma (VS)-associated symptoms has received limited attention. The purpose of this study was to determine how different treatment modalities affect subjective symptoms in those presenting with VS. Prospective survey. Tertiary neurotology referral center. Patients with sporadic VS who received treatment at our institution were prospectively surveyed with a VS symptom questionnaire. Those who completed a baseline survey prior to treatment and at least 1 posttreatment survey were included. The prospective survey evaluated the severity of self-reported symptoms (Likert scale, 1-10), including tinnitus, dizziness or imbalance, headaches, and hearing loss. A total of 244 patients were included (mean age, 57 years). The mean duration of follow-up was 2.1 years, and the median number of surveys completed was 2 (interquartile range, 1-3). Seventy-eight (32%) cases were managed with observation, 118 (48%) with microsurgery, and 48 (20%) with radiosurgery. Multivariable analyses revealed no statistically significant difference in the change in tinnitus ( Limited prospective data exist regarding the progression or resolution of subjective symptoms in those presenting with VS. This study suggests that tinnitus, dizziness or imbalance, and headaches are unlikely to be significantly modified by treatment modality and generally should not be used to direct treatment choice.

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

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

Publication date 26-01-2021


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

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

Edgar Erold Kiss,Patrick Olomu,Romaine F. Johnson

Publication date 19-01-2021


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

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Persistent Obstructive Sleep Apnea Burden on Family Finances and Quality of Life

Mathieu Bergeron,Stacey L. Ishman

Publication date 19-01-2021


We previously found that financial concerns negatively affect the quality of life of families of children with persistent obstructive sleep apnea (OSA) after tonsillectomy. The goal is to quantify the financial impact on families of children with persistent OSA and assess contributing factors. Cross-sectional survey study with comparison group. Upper airway center at a tertiary pediatric hospital. Participants included consecutive children with persistent OSA from September to October 2017. Healthy children seen in a general otolaryngology clinic served as controls. Families of both groups completed the Family Impact Questionnaire and the modified Comprehensive Score for Financial Toxicity (COST). Families of the 50 patients (25 study and 25 control) completed the surveys: the mean age was 6.4 years (95% CI, 5.0-7.8), and 19 (38%) were female. There were no differences in age, sex, race, or insurance status between groups ( Families of children with persistent OSA reported a high financial burden related to their children's disease and were more likely to report financial toxicity than families of controls. Concern regarding missed work and school associated with appointments and treatment was a significant factor.

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Normocalcemic and Normohormonal Primary Hyperparathyroidism: Laboratory Values and End-Organ Effects

Blake R. Hollowoa,Horace J. Spencer,Brendan C. Stack

Publication date 19-01-2021


Variants of primary hyperparathyroidism (pHPT), described as normocalcemic (NC) and normohormonal (NH), can confuse the diagnosis of classic pHPT. A MEDLINE search was performed for variants of pHPT using the Pub Med database (last queried October 2019). The search was restricted to articles published after 1960 that were specific to humans. Studies were included in our analysis if laboratory values and incidence of end-organ involvement were reported for NCpHPT and NHpHPT variants. The search returned 189 articles; 27 additional studies were identified and included for a total of 216. Non-English-language studies were excluded. Abstracts were screened, full-text articles were then assessed, and 82 articles were excluded. Data were pooled using a random-effects model in studies that compared NC or NH pHPT to classic pHPT. Comparative laboratory values are presented. This analysis compares NCpHPT and NHpHPT to classic pHPT. Nephrolithiasis was 21.7% (NCpHPT), 15.9% (classic pHPT), and 25.4% (NHpHPT). Decreased bone mineral density was 49.7% (NCpHPT), 39.7% (classic pHPT), and 40.3% (NHpHPT). Fractures in the NCpHPT group were not significantly different from the classic pHPT. Hypertension in the NCpHPT group was significantly less than classic pHPT (odds ratio, 0.59; 95% CI, 0.40-0.88). This information may serve to inform clinicians of the laboratory subtleties of these variants that are being seen with greater frequency in contemporary practice.

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Bitter Taste Receptors and Chronic Otitis Media

Adam C. Kaufman,Lauren Colquitt,Michael J. Ruckenstein,Douglas C. Bigelow,Steven J. Eliades,Guoxiang Xiong,Cailu Lin,Danielle R. Reed,Noam A. Cohen

Publication date 12-01-2021


To evaluate the presence of bitter taste receptors (T2Rs) in the middle ear and to examine their relationship with chronic ear infections. Cross-sectional study. Tertiary care hospital.
This study enrolled 84 patients being evaluated for otologic surgery: 40 for chronic otitis media (COM) and 44 for other surgical procedures (controls). We collected a small piece of mucosa from 14 patients for mRNA analysis and from 23 patients for immunohistochemistry. A total of 55 patients underwent a double-blind taste test to gauge sensitivity to phenylthiocarbamide, denatonium, quinine, sucrose, and sodium chloride; 47 patients gave a salivary sample for single-nucleotide polymorphism analysis of rs1376251 ( Bitter taste receptors were found in all samples, but the repertoire varied among patients. T2R50 was the most consistently identified receptor by mRNA analysis. Its rs1376251 allele was related to susceptibility to COM but not the expression pattern of T2R50. Ratings of bitterness intensity of phenylthiocarbamide, a ligand for T2R38, differed significantly between the COM and control groups. T2Rs were found within the middle ear of every patient sampled; the rs1376251 allele of

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American Academy of Otolaryngology–Head and Neck Surgery/Foundation Reg-ent Registry: Purpose, Properties, and Priorities

Cecelia E. Schmalbach,Jean Brereton,Cathlin Bowman,James C. Denneny

Publication date 12-01-2021


(1) To describe the patient and membership cohort captured by the otolaryngology-based specialty-specific Reg-ent registry. (2) To outline the capabilities of the Reg-ent registry, including the process by which members can access evidence-based data to address knowledge gaps identified by the American Academy of Otolaryngology-Head and Neck Surgery/Foundation and ultimately define "quality" for our field of otolaryngology-head and neck surgery. Data analytics was performed on Reg-ent (2015-2020). A total of 1629 participants from 239 practices were enrolled in Reg-ent, and 42 health care specialties were represented. Reg-ent encompassed 6,496,477 unique patients and 24,296,713 encounters/visits: the 45- to 64-year age group had the highest representation (n = 1,597,618, 28.1%); 3,867,835 (60.3%) patients identified as Caucasian; and "private" was the most common insurance (33%), followed by Blue Cross/Blue Shield (22%). Allergic rhinitis-unspecified and sensorineural hearing loss-bilateral were the top 2 diagnoses (9% each). Overall, 302 research gaps were identified from 17 clinical practice guidelines. Reg-ent benefits are vast-from monitoring one's practice to defining otolaryngology-head and neck surgery quality, participating in advocacy, and conducting research. Reg-ent provides mechanisms for benchmarking, quality assessment, and performance measure development, with the objective of defining and guiding best practice in otolaryngology-head and neck surgery. To be successful, patient diversity must be achieved to include ethnicity and socioeconomic status. Increasing academic medical center membership will assist in achieving diversity so that the quality domain of equitable care is achieved. Reg-ent provides the first ever registry that is specific to otolaryngology-head and neck surgery and compliant with HIPAA (Health Insurance Portability and Accountability Act) to collect patient outcomes and define evidence-based quality care.

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

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

Publication date 12-01-2021


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

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Emergency Tracheostomy Amid COVID-19

Pirabu Sakthivel,Aswin Chandran,Smriti Panda,Chirom Amit Singh

Publication date 12-01-2021


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

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

Publication date 12-01-2021


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

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Understanding Bias in Surgery: Perceived Cultural Similarity Between Surgeons and Patient Families

Grace R. Leu,Anne R. Links,David E. Tunkel,Jonathan M. Walsh,Marisa A. Ryan,Heather DiCarlo,Eric B. Jelin,Mary Catherine Beach,Emily F. Boss

Publication date 12-01-2021


We describe surgeon and parent perceptions of similarity toward each other and evaluate differences in the perceptions of similarity by race. Observational cohort analysis. Three outpatient sites. Following consultations for children undergoing evaluation for 1 of 3 surgical procedures (tonsillectomy, hernia repair, circumcision), surgeons and parents rated their perception of cultural similarity toward each other on a 6-point Likert scale. Surgeon evaluation of 9 parent characteristics was measured with 7-point Likert scales. Regression analyses were performed to identify predictors of greater surgeon-perceived similarity and to assess associations of perceived similarity with evaluation of parent characteristics. Most parents were women (n = 38, 84%), whereas surgeons were primarily men (n = 7, 54%). Of 45 parents, 23 (51%) were non-White, whereas only 4 of 13 clinicians (31%) were non-White. Mean perceived similarity score was 21.7 for parents (range, 10-24) and 18.2 for surgeons (range, 10-24). There was no difference in parent-perceived similarity based on race (White vs non-White parents, mean [SD] = 22.3 [3.4] vs 21.1 [3.0]; Surgeons perceived similarity more commonly with White parents, while parents' perception of similarity to surgeons was uniform regardless of parent race. Elucidating biases of surgeons may help to tailor interventions promoting culturally competent, equitable communication and decision making for elective surgery.

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Expert Consensus Statement: Pediatric Drug-Induced Sleep Endoscopy

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

Publication date 05-01-2021


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

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Primary Surgical Treatment in Very Advanced (T4b) Oral Cavity Squamous Cell Carcinomas

Evan J. Patel,Jamie R. Oliver,Alec Vaezi,Zujun Li,Michael Persky,Moses Tam,Kenneth S. Hu,Adam S. Jacobson,Babak Givi

Publication date 05-01-2021


To describe patterns of primary surgical treatments in patients with T4b oral cavity squamous cell carcinoma (OCSCC). Historical cohort study. National Cancer Database. Review of the National Cancer Database between 2004 and 2017 for all T4b OCSCCs. Only patients with curative treatment methods were included in the survival analysis. Surgical and nonsurgical outcomes were compared by multivariable and propensity score matching analysis. A total of 1515 cases of T4b OCSCC were identified. A minority of patients (n = 363, 24.0%) underwent curative treatment; among these, 206 (56.7%) underwent primary surgery. Median length of follow-up was 24 months. The 90-day mortality of patients who underwent surgical treatment was 1.0%. The 2-year survival was higher for patients who underwent surgery + chemoradiotherapy (CRT) as compared with CRT (64.6% vs 45.2%, A minority of patients with T4b OCSCC undergo treatments with curative intent. A subset of patients underwent primary surgical treatment, which was associated with longer survival. The T4b classification might entail a heterogenous group, and further studies in revision of this classification might be justified.

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Cephalometric and Functional Mandibular Reconstructive Outcomes Using a Horizontal Scapular Tip Free Flap

Cameron Charles Sheehan,Angela D. Haskins,Andrew T. Huang,David J. Hernandez

Publication date 05-01-2021


Scapula tip free flaps (STFFs) have become an increasingly popular option for head and neck reconstruction. The aim of this study is to demonstrate the feasibility of using the STFF in a horizontal orientation to take advantage of the anatomy of the scapular tip bone to re-create a mandibular symphysis. Eight patients underwent oromandibular reconstruction with a horizontally oriented STFF between October 2016 and June 2020. Virtual surgical planning was used to design the bony reconstruction in 6 cases. Primary outcomes, including flap survival, complications, and return to oral diet, were collected. Cephalometric measurements were obtained to compare preoperative and postoperative mandibular projection and width. All flaps survived without compromise, and no fistulas developed postoperatively. Seven patients returned to taking an oral diet. Cephalometric analysis revealed comparable measurements between preoperative and postoperative mandibles and reconstructed mandibles, respectively. STFFs may be oriented horizontally to reconstruct large anterior mandibular defects with satisfactory results.

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Long-term Oncologic Outcomes of 1188 Tis-T2 Glottic Cancers Treated by Transoral Laser Microsurgery

Cesare Piazza,Alberto Paderno,Francesca Del Bon,Davide Lancini,Milena Fior,Giulia Berretti,Paolo Bosio,Alberto Deganello,Giorgio Peretti

Publication date 05-01-2021


To evaluate long-term disease-specific survival (DSS) and organ preservation (OP) rates in patients affected by Tis-T2 glottic squamous cell carcinoma (SCC) treated by carbon dioxide transoral laser microsurgery (CO Single-center retrospective cohort study. Tertiary academic hospital. The study included patients treated by CO Ten- and 20-year DSS rates were 97.6% and 96.3%, respectively, and 10- and 20-year OP rates were 94.7% and 93%. During the follow-up, 91% of patients were treated by CO Our series validates CO

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Improving Hands-free Speech Rehabilitation in Patients With a Laryngectomy: Proof-of-Concept of an Intratracheal Fixation Device

Maartje Leemans,Maarten J.A. van Alphen,Richard Dirven,Gijsbertus J. Verkerke,Edsko E.G. Hekman,Michiel W.M. van den Brekel

Publication date 05-01-2021


Permanent hands-free speech with the use of an automatic speaking valve (ASV) is regarded as the optimal voice rehabilitation after total laryngectomy. Due to fixation problems, regular ASV use in patients with a laryngectomy is limited. We have developed an intratracheal fixation device (ITFD) composed of an intratracheal button augmented by hydrophilic foam around its shaft. This study evaluates the short-term effectiveness and experienced comfort of this ITFD during hands-free speech in 7 participants with a laryngectomy. We found that 4 of 7 participants had secure ASV fixation inside the tracheostoma during hands-free speech for at least 30 minutes with the ITFD. The ITFD's comfort was perceived positively overall. The insertion was perceived as being mildly uncomfortable but not painful. This proof-of-concept study demonstrates the feasibility of the ITFD that might improve stomal attachment of ASVs, and it provides the basis for further development toward a prototype suitable for long-term daily use.

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Periprosthetic Leakage in Tracheoesophageal Prosthesis: Proposal of a Standardized Therapeutic Algorithm

Claudio Parrilla,Ylenia Longobardi,Jacopo Galli,Mario Rigante,Gaetano Paludetti,Francesco Bussu,Emanuele Scarano

Publication date 05-01-2021


Periprosthetic leakage represents the most demanding long-term complication in the voice prosthesis rehabilitation. The aim of this article is to discuss the various causes of periprosthetic leakage and to propose a systematic management algorithm. Retrospective cohort study. Otolaryngology clinic of the University Polyclinic A. Gemelli-IRCCS Foundation. The study included 115 patients with voice prosthesis who were treated from December 2014 to December 2019. All patients who experienced periprosthetic leakage were treated with the same step-by-step therapeutic approach until it was successful. Incidence, management, and success rate of every attempt are analyzed and discussed. Periprosthetic leakage was reported 330 times by 82 patients in 1374 clinic accesses. Radiotherapy, timing of tracheoesophageal puncture, and type of total laryngectomy (primary or salvage) did not influence the incidence of periprosthetic leakage. Salvage total laryngectomy increases the risk of more clinically relevant leakages. By using a systematic algorithm with a step-by-step standardized approach, periprosthetic leakage management could become a less treacherous issue.

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Association Between Conflict of Interest and Published Position on Hypoglossal Nerve Stimulation for Sleep Apnea

Jason R. Crossley,Katherine Wallerius,Michael Hoa,Bruce Davidson,Jonathan P. Giurintano

Publication date 05-01-2021


To determine if there is an association between authors' financial conflict of interest and published position on clinical use of hypoglossal nerve stimulation for obstructive sleep apnea. Retrospective cross-sectional analysis. International roster of authors and articles analyzed. A Google Scholar search was performed for editorials and reviews citing the 2014 Sixteen articles from 45 independent authors were analyzed. Nine articles by authors were coded as favorable. Among authors of articles with favorable views, 16 (59%) had a financial conflict of interest with the manufacturer of the hypoglossal nerve stimulator device, as opposed to only 1 of 21 (5%) authors of neutral/unfavorable articles. When we included only authors to whom payments could be identified or excluded on Open Payments, 16 of 20 (80%; 95% CI, 62%-98%) authors of favorable articles had a financial conflict, while 1 of 10 (10%; 95% CI, 0%-29.6%) of neutral/unfavorable articles did ( Our study demonstrates an association between published position on hypoglossal nerve stimulator use and financial conflict with the device manufacturer. Several undeclared conflicts were also found, suggesting a role for independent search for conflicts during the review process.

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Preoperative Predictors and Costs of 30-Day Readmission Following Inpatient Pediatric Tonsillectomy in the United States

Habib Khoury,Shaghauyegh S. Azar,Hannah Boutros,Nina L. Shapiro

Publication date 05-01-2021


To understand national trends in 30-day postoperative readmission following inpatient pediatric tonsillectomy and adenoidectomy. Retrospective cohort study. Nationwide Readmissions Database. We used the Nationwide Readmissions Database to identify and analyze 30-day readmissions following inpatient tonsillectomy from 2010 to 2015. Using the Of 66,652 patients who underwent inpatient tonsillectomy, 2660 (4.0%) experienced a readmission. Readmitted patients were more commonly aged <2 years (23.4 vs 10.6%, Readmission after inpatient tonsillectomy and adenoidectomy places a substantial financial burden on the health care system. Targeted strategies to improve preoperative assessment and optimize postoperative care may prevent readmission, reduce unnecessary health care expenditures, and improve patient outcomes.

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Survival in Middle Ear Malignancy: A Population-Based Analysis Based on the SEER Database

Usman Alam,Iram Shafqat,Sara Ahsan,Jose Alonso,Albert Y. Han,Laith Mukdad,Marilene Wang,Syed F. Ahsan

Publication date 05-01-2021


The purpose of this study was to investigate the clinical features and survival outcomes of patients with middle ear malignancies at a population level. Retrospective cohort study with data from a national database. National database of middle ear malignancy. Records of patients diagnosed with a middle ear malignancy from 1973 to 2016 were extracted from the SEER database (Surveillance, Epidemiology, and End Results). SPSS (version 27; IBM) was used to conduct 5-year survival analysis. The average survival for all 431 patients was 61.4 months. Five-year disease-specific survival for squamous cell carcinoma (SCCA), adenocarcinoma, other carcinoma, and noncarcinoma subtypes varied significantly at 54.6%, 82.1%, 71.8%, and 82.6%, respectively ( Prognosis and treatment outcomes for primary middle ear malignancies depend on histologic subtype and age at diagnosis. The noncarcinoma and adenocarcinoma subtypes carry the best prognoses. Patients with adenocarcinoma were most likely to benefit from surgery.

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Laryngeal Force Sensor for Suspension Microlaryngoscopy: A Prospective Controlled Trial

Allen L. Feng,Elefteria Puka,Alex Ciaramella,Vishwanatha M. Rao,Tiffany V. Wang,Matthew R. Naunheim,Phillip C. Song

Publication date 05-01-2021


The laryngeal force sensor (LFS) provides real-time force data for suspension microlaryngoscopy. This study investigates whether active use of the LFS can prevent the development of complications. Prospective controlled trial. Academic tertiary center. The LFS and custom software were developed to track intraoperative force metrics. A consecutive series of 100 patients had force data collected with operating surgeons blinded to intraoperative readings. The subsequent 100 patients had surgeons actively use the LFS monitoring system. Patients were prospectively enrolled, completing pre- and postoperative surveys to assess the development of tongue pain, paresthesia, paresis, dysgeusia, or dysphagia. On univariate analysis, the active monitoring group had lower total impulse ( Maximum force is predictive of the development postoperative complications. Active monitoring with the LFS is able to mitigate these forces and prevent postoperative complications. 2.

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Hypoglossal Nerve Stimulation in Veterans With Comorbid Insomnia and Sleep Apnea

Reena Dhanda Patil,Michael P. Hong,Stacey L. Ishman

Publication date 05-01-2021


Insomnia and sleep apnea frequently co-occur, with additive effects of both disorders presenting clinicians with unique treatment challenges compared to one disorder alone. The hypoglossal nerve stimulator (HNS) is a promising treatment for patients with comorbid insomnia and sleep apnea (COMISA), many of whom have positive airway pressure (PAP) intolerance. Our aim was to determine adherence to and efficacy of HNS in veterans with COMISA refractory to PAP therapy compared to those with obstructive sleep apnea alone (OSA only). Retrospective case series. A single, academic Veterans Affairs medical center. Review of clinical records, pre- and postoperative polysomnography, and clinical measures of obstructive sleep apnea (OSA), sleepiness, and insomnia was conducted in 53 consecutive cases of veterans with OSA undergoing HNS implantation. HNS adherence was obtained at postoperative visits. HNS adherence and efficacy were compared between individuals with COMISA and OSA only. COMISA was noted in 30 of 53 (56.6%) veterans studied. There was no significant difference between HNS adherence in patients with COMISA and OSA only (5.6 vs 6.4 h/night, HNS was successful in treating a complex veteran population with COMISA refractory to PAP when examining measures of treatment adherence and efficacy. Future studies of patients with COMISA undergoing HNS will examine effective combination therapy targeting insomnia and a multidisciplinary effort to optimize treatment adherence.

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Predicting Adverse Histopathology and Need for Postsurgical Adjuvant Therapy for Human Papilloma Virus–Associated Oropharynx Carcinoma

Edgar Ochoa,Gaelen Stanford-Moore,Carole Fakhry,William R. Ryan

Publication date 05-01-2021


For human papillomavirus-associated oropharynx carcinoma treated with definitive surgery, we aimed to find predictors of adverse histopathology indicating the possible need for adjuvant therapy. Retrospective review. National Cancer Database. We analyzed 2347 eligible patients from 2010 to 2015. We evaluated (1) the ability of clinical nodal staging and extranodal extension designation per the AJCC, seventh edition (American Joint Committee on Cancer), to predict histopathology and (2) the likelihoods for adverse postsurgery histopathology by common clinical stages. Clinical nodal staging predicted pathologic nodal staging 65% of the time, with 24% (569/2347) being upstaged and 11% (251/2347) being downstaged. In patients with cN+ disease, clinical extranodal extension distinction had the following accuracy for pathologic extranodal extension: positive predictive value, 81% (88/109); negative predictive value, 73.1% (505/691); sensitivity, 32.1% (88/274); and specificity, 96.0% (505/526). Patients with cT1-2, N0-N2c, without clinical extranodal extension had the following proportions of pN2+ without pathologic extranodal extension (indicating consideration for adjuvant radiation): cN0, 11%; cN1, 31%; cN2a, 67% (8% downstaged); cN2b, 66% (6% downstaged); and cN2c, 35% (17% downstaged). From this group, patients had the following proportions of pathologic extranodal extension (indicating consideration for adjuvant chemoradiation): cN0, 6%; cN1, 20%; cN2a, 27%; cN2b, 28%; and cN2c, 48%. For human papillomavirus-associated oropharynx carcinoma, nodal clinical staging per the American Joint Committee on Cancer, seventh edition, predicts pathologic stage about two-thirds of the time, leading to up- and downstaging. Clinical extranodal extension assessment has low sensitivity and moderate predictive capability. With careful selection, definitive surgery can allow patients to often avoid adjuvant chemotherapy and sometimes avoid adjuvant radiation.

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Tracheotomy in COVID-19 Patients: A Systematic Review and Meta-analysis of Weaning, Decannulation, and Survival

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

Publication date 05-01-2021


A systematic review and meta-analysis was conducted to determine the cumulative incidences of decannulation and mechanical ventilation weaning in patients with coronavirus disease 2019 (COVID-19) who have undergone a tracheotomy. Weighted average mean times to tracheotomy, to decannulation, and to death were calculated from reported or approximated means. Pub Med, SCOPUS, CINAHL, and the Cochrane library. Studies were screened by 3 investigators independently. Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were followed. Studies including patients with COVID-19 who underwent a tracheotomy were identified. Studies without reported mechanical ventilation weaning or decannulation were excluded. Data were pooled using a random-effects model. After identifying 232 unique studies, 18 articles encompassing outcomes for 3234 patients were ultimately included for meta-analysis, with a weighted mean follow-up time of 28.6 ± 6.2 days after tracheotomy. Meta-analysis revealed that 55.0% of tracheotomized patients were weaned successfully from mechanical ventilation (95% CI, 47.4%-62.2%). Approximately 34.9% of patients were decannulated successfully, with a mean decannulation time of 18.6 ± 5.7 days after tracheotomy. The pooled mortality in tracheotomized patients with COVID-19 was 13.1%, with a mean time of death of 13.0 ± 4.0 days following tracheotomy. At the current state of the coronavirus pandemic, over half of patients who have required tracheotomies are being weaned off of mechanical ventilation. While 13.1% patients have died prior to decannulation, over a third of all tracheotomized patients with COVID-19 reported in the literature have undergone successful decannulation.

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The Future of Telemedicine: Revolutionizing Health Care or Flash in the Pan?

Steven D. Losorelli,Varun Vendra,Douglas M. Hildrew,Erika A. Woodson,Michael J. Brenner,Davud B. Sirjani

Publication date 05-01-2021


The meteoric rise of telemedicine early in the COVID-19 pandemic might easily be mistaken for an ephemeral trend-one reaching its zenith in a moment of crisis. To the contrary, momentum has been mounting for telehealth over decades. The recent increase in telecare reveals its potential to deliver efficient, patient-centered, high-quality care in an increasingly technology-dependent landscape. Prior to COVID-19, surgeons lagged behind medical counterparts in embracing telemedicine; however, the pragmatic imperatives for remote care of patients and changes to Medicare removed key barriers to adoption. Otolaryngology-head and neck surgery has innovated across subspecialties, leading in COVID-19 scholarship and year-over-year publications on telemedicine. Yet, improved access to subspecialists is tempered by a digital divide that threatens to exacerbate disparities. Otolaryngology is poised to lead the transformation of procedural specialties while ensuring equitable care.

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Is Postextracapsular Tonsillectomy Bleeding More Common on the Side of the Surgeon’s Nondominant Hand?

Muhamed Masalha,Are DeRowe,Roee Landsberg,Salim Mazzawi,Lev Shlizerman,Firas Kassem,Adam Fadel

Publication date 05-01-2021


To determine the difference in bleeding when extracapsular tonsillectomy with electrocautery is performed on the dominant and nondominant side of the surgeon's hands. Retrospective cohort study. Academic university hospital. Medical record data of patients who were admitted with posttonsillectomy bleeding from January 1, 2000, to July 31, 2017, were reviewed. Included were age, sex, surgical indication, side of posttonsillectomy bleeding, and time of bleeding. Information on the surgeon's dominant hand was also collected. All patients underwent total extracapsular resection with electrocautery. Of 280 patients, 186 met the inclusion criteria, 116 (62.3%) males and 70 (37.7%) females. Ages ranged from 2 to 74 years (mean ± SD, 17 ± 13 years; median, 13 years). In 136 cases (73.1%), bleeding was on the side of the surgeon's nondominant hand ( The risk of bleeding following extracapsular tonsillectomy with electrocautery on the side of the surgeon's nondominant hand is significantly higher than on the side of the dominant hand. Thus, additional caution is required when operating on the nondominant side of the oral cavity in extracapsular tonsillectomy using electrocautery. These findings raise questions regarding dexterity as a risk factor for posttonsillectomy bleeding.

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Nuances and Management of Hilar Submandibular Sialoliths With Combined Transoral Robotic Surgery–Assisted Sialolithotomy and Sialendoscopy

Christopher Z. Wen,Jennifer E. Douglas,Mohamed Elrakhawy,Ellen A. Paul,Christopher H. Rassekh

Publication date 29-12-2020


To describe the management, technical nuances, and success rates of transoral robotic surgery (TORS)-assisted sialolithotomy. Retrospective database review. Quaternary academic medical center. Between the months of January 2015 and May 2019, patients with hilar submandibular gland stones underwent 2 main variations of TORS-assisted sialolithotomy and sialendoscopy: (1) TORS followed by sialendoscopy for patients with palpable predominantly single stones and (2) either sialendoscopy followed by TORS and sialendoscopy or sialendoscopy followed by TORS only for patients with nonpalpable or multiple stones. Clinical charts were reviewed to collect data, including stone size (imaging review, intraoperative measurement), palpability, duration of operation, TORS variation, operative challenges, symptom improvement, gland preservation rate, and complications. Thirty-seven patients were identified. Patients were 26 to 80 years old (mean, 57.2 years), and 40.5% were female. Twenty-four patients (64.9%) underwent TORS followed by sialendoscopy; 10 (27.0%), sialendoscopy followed by TORS and sialendoscopy; and 3 (8.1%), sialendoscopy followed by TORS only. The mean stone size was 12.4 mm (range, 4-28 mm). Eleven patients had multiple stones with a mean 4 stones per patient (range, 2-9). Procedural success was 91.9% (34/37) at a mean follow-up of 34.2 weeks (range, 1.4-262.1), and the gland preservation rate was 97.3% (36/37). No patients reported symptoms of lingual nerve injury at 3-month follow-up. TORS combined with sialendoscopy for hilar submandibular gland sialolithiasis allows for improved visualization of critical anatomy, tissue manipulation, and operative flexibility. In our experience, the operative success rate is high, and duration of surgery compares favorably with conventional combined hilar approaches.

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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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