Otolaryngology Head and Neck Surgery 2020-09-08

Accreditation Information

Publicatie 08-09-2020


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2020 President Duane J. Taylor, MD

Publicatie 08-09-2020


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2020 Annual Meeting Program Committee

Publicatie 08-09-2020


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2020 Star Reviewers

Publicatie 08-09-2020


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2020 Distinguished Service Award Winners

Publicatie 08-09-2020


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2020 Honor Award Recipients

Publicatie 08-09-2020


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Honorary Guest Lecturers 2020

Publicatie 08-09-2020


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Business of Medicine/Practice Management

Publicatie 08-09-2020


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Comprehensive Otolaryngology

Publicatie 08-09-2020


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Endocrine Surgery

Publicatie 08-09-2020


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Facial Plastic and Reconstructive Surgery

Publicatie 08-09-2020


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Head and Neck Surgery

Publicatie 08-09-2020


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Laryngology/Broncho-Esophagology

Publicatie 08-09-2020


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Otology/Neurotology

Publicatie 08-09-2020


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Patient Safety and Quality Improvement

Publicatie 08-09-2020


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Pediatric Otolaryngology

Publicatie 08-09-2020


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Rhinology/Allergy

Publicatie 08-09-2020


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Sleep Medicine

Publicatie 08-09-2020


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Business of Medicine/Practice Management

Publicatie 08-09-2020


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Comprehensive Otolaryngology

Publicatie 08-09-2020


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Endocrine Surgery

Publicatie 08-09-2020


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Facial Plastic and Reconstructive Surgery

Publicatie 08-09-2020


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Head and Neck Surgery

Publicatie 08-09-2020


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Laryngology/Broncho-Esophagology

Publicatie 08-09-2020


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Otology/Neurotology

Publicatie 08-09-2020


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Patient Safety and Quality Improvement

Publicatie 08-09-2020


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Pediatric Otolaryngology

Publicatie 08-09-2020


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Rhinology/Allergy

Publicatie 08-09-2020


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Sleep Medicine

Publicatie 08-09-2020


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Business of Medicine/Practice Management

Publicatie 08-09-2020


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Comprehensive Otolaryngology

Publicatie 08-09-2020


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Endocrine Surgery

Publicatie 08-09-2020


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Facial Plastic and Reconstructive Surgery

Publicatie 08-09-2020


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Head and Neck Surgery

Publicatie 08-09-2020


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Laryngology/Broncho-Esophagology

Publicatie 08-09-2020


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Otology/Neurotology

Publicatie 08-09-2020


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Patient Safety and Quality Improvement

Publicatie 08-09-2020


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Pediatric Otolaryngology

Publicatie 08-09-2020


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Rhinology/Allergy

Publicatie 08-09-2020


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Sleep Medicine

Publicatie 08-09-2020


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Author Index

Publicatie 08-09-2020


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Should I Buy This? A Decision-Making Tool for Surgical Value-Based Purchasing

Ashley M. Nassiri,C. Gaelyn Garrett,Teresa L. Dail,Vikram Tiwari,David S. Haynes,Alejandro Rivas,Alexander J. Langerman

Publicatie 14-04-2020


Many considerations affect the value that a new instrument or product may generate in a surgical practice. This review serves as a guide for surgeons considering new purchases and/or wishing to advocate for hospital acquisition of new items. A summary of data from academic and industry practices is presented, with pertinent examples using relevant surgical devices such as disposable devices, laparoscopic trocars, and otologic endoscopes. Surgeons considering incorporating a new instrument or technology within their practice should weigh the following factors before decision making: patient and clinical care factors, surgeon and care team factors, and hospital factors such as cost, revenue, and sourcing. A surgeon well-versed in stakeholder interests who is involved in the purchase of a new instrument may have significant influence in value-based decision making that not only affects his or her practice but ultimately maximizes value for the patient.

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British Skull Base Society Clinical Consensus Document on Management of Head and Neck Paragangliomas

Simon Lloyd,Rupert Obholzer,James Tysome

Publicatie 28-04-2020


The management of head and neck paragangliomas (HNPGLs) has changed significantly in recent years. There is, however, an absence of guidance in the literature regarding the optimal means of managing this challenging disease. This consensus document, developed by the British Skull Base Society, sets out recommendations for management of HNPGLs. A preliminary document was produced on the basis of current practice in 3 large UK skull base centers, incorporating relevant peer-reviewed evidence. This document was then modified by discussion within these units, through a national survey of British Skull Base Society members, and through discussion with stakeholders. A consensus was reached on the management of all forms of HNPGL. All patients should be managed by a multidisciplinary team and require initial surgical, endocrine, and genetic assessments as well as magnetic resonance imaging of the head, neck, chest, abdomen, and pelvis. Long-term preservation of function is the primary treatment goal, with conservative management the first choice treatment for most tumors. Radiotherapy is a safe, effective treatment for growing tumors in most cases, although there is a limited role for surgery. Screening of family members in high-risk groups is mandatory. These guidelines should help standardize high-quality care for patients with HNPGLs.

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Outcomes and Complications with Topical Epinephrine in Endoscopic Sinus Surgery: A Systematic Review and Meta-analysis

Nicholas B. Nesbitt,Michael W. Noller,Nora L. Watson,Christian P. Soneru,Edward D. McCoul,Charles A. Riley

Publicatie 14-04-2020


To assess the safety and efficacy of topical epinephrine in adults undergoing endoscopic sinus surgery (ESS). PubMed, Embase, and Ovid MEDLINE online databases. Non-case report English articles studying the effects of topical epinephrine as the topical vasoconstrictor used in adult ESS were found from the online databases through January 2019. The PRISMA literature selection process was used (Preferred Reporting Items for Systematic Reviews and Meta-analyses). An overall 2216 articles were identified, with 9 meeting inclusion criteria involving a total of 5043 patients. All 9 studies assessed the safety of topical epinephrine, while 5 examined efficacy. Intraoperative average blood loss (ABL) ranged from 60 to 426 mL. Topical epinephrine concentrations varied from 1:1000 to 1:100,000, and 3 major complications were found for a rate of 0.06%. There were no reports of ophthalmic, orbital, or skull base injury, nor were there reports of cerebrospinal fluid leaks. A meta-analysis was performed on the 4 studies examining ABL. Estimated mean (95% CI) ABL was 119.4 mL (39.1-199.6) in the higher-concentration cohort (>1:10,000) and 372.2 mL (296.8-447.5) in the lower-concentration cohort (≤1:10,000) ( Topical epinephrine is generally safe and provides acceptable hemostasis during ESS, with higher concentrations (>1:10,000) providing improved hemostasis. Caution is advised for its use in patients with preexisting cardiovascular disease or in combination with other topical or injected vasoconstrictive agents. More prospective comparative studies are necessary to determine the ideal hemostatic concentration of epinephrine in ESS.

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Comparing Kadish and Modified Dulguerov Staging Systems for Olfactory Neuroblastoma: An Individual Participant Data Meta-analysis

Mark A. Arnold,Soroush Farnoosh,Mitchell R. Gore

Publicatie 14-04-2020


To compare the Kadish and the modified Dulguerov staging of individual participants to determine the impact of stage and other prognostic factors on disease-free (DFS) and overall survival (OS). Systematic review of EMBASE, MEDLINE, Cochrane Library, and CINAHL databases. The Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) was followed for this study. Articles including patients with olfactory neuroblastoma (ONB) staged with both Kadish and Dulguerov staging systems were reviewed. The raw data from eligible studies were requested to perform an individual participant data (IPD) meta-analysis. Pooled data from 21 studies representing 399 patients with ONB undergoing treatment with curative intent showed that increasing age, treatment with chemotherapy, and positive or unreported margin status portended worse DFS ( This study represents the first IPD meta-analysis of ONB directly comparing the outcomes of Kadish and Dulguerov staging systems in patients treated with primary surgery. Both systems correlated with DFS and OS, with superior performance in the Dulguerov system. Furthermore, the Kadish C group represented a heterogeneous group with regard to outcomes after stratification by the Dulguerov system. Dulguerov T4 patients had the worst outcome, with most being approached with open resection.

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Comparison of Frenotomy Techniques for the Treatment of Ankyloglossia in Children: A Systematic Review

Usman Khan,Jake MacPherson,Michael Bezuhly,Paul Hong

Publicatie 02-06-2020


To compare the effectiveness of conventional (CF), laser (LF), and Z-plasty (ZF) frenotomies for the treatment of ankyloglossia in the pediatric population. A comprehensive search of PUBMED, EMBASE, and COCHRANE databases was performed. Relevant articles were independently assessed by 2 reviewers according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Thirty-five articles assessing CF (27 articles), LF (4 articles), ZF (3 articles), and/or rhomboid plasty frenotomy (1 article) were included. A high level of outcome heterogeneity prevented pooling of data. All 7 randomized controlled trials (RCTs) were of low quality. Both CF (5 articles with 589 patients) and LF (2 articles with 78 patients) were independently shown to reduce maternal nipple pain on a visual analog or numeric rating scale. There were reports of improvement with breastfeeding outcomes as assessed on validated assessment tools for 88% (7/8) of CF articles (588 patients) and 2 LF articles (78 patients). ZF improved breastfeeding outcomes on subjective maternal reports (1 article with 18 infants) only. One RCT with a high risk of bias concluded greater speech articulation improvements with ZF compared to CF. Only minor adverse events were reported for all frenotomy techniques. Current literature does not demonstrate a clear advantage for one frenotomy technique when managing children with ankyloglossia. Recommendations for future research are provided to overcome the methodological shortcomings in the literature. We conclude that all frenotomy techniques are safe and effective for treating symptomatic ankyloglossia.

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The Impact of the Pandemic on Otolaryngology Patients With Negative COVID-19 Status: Commentary and Insights From Orbital Emergencies

Judd H. Fastenberg,Danielle Bottalico,William A. Kennedy,Ahmed Sheikh,Michael Setzen,Rand Rodgers

Publicatie 26-05-2020


Efforts aimed at minimizing the spread of COVID-19 and "flattening the curve" may be affecting clinical care delivery for non-COVID-19 cases that include otolaryngologic and orbital conditions. We are witnessing changes in the manner that patients present, as well as modifications in clinical management strategies. An improved understanding of these phenomena and the contributing factors is essential for otolaryngologists to provide sound clinical care during this unprecedented pandemic.

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Time for a Paradigm Shift in Head and Neck Cancer Management During the COVID-19 Pandemic

Albert Y. Han,Jessa E. Miller,Jennifer L. Long,Maie A. St John

Publicatie 02-06-2020


The coronavirus disease 2019 (COVID-19) pandemic has caused physicians and surgeons to consider restructuring traditional cancer management paradigms. We aim to review the current evidence regarding the diagnosis and management of head and neck cancer, with an emphasis on the role of the multidisciplinary team (MDT) during a pandemic. COVID-19 resources from PubMed, Google Scholar, the American Academy of Otolaryngology-Head and Neck Surgery, and the American Head and Neck Society were examined. Studies and guidelines related to the multidisciplinary management of head and neck cancer in the COVID-19 setting were reviewed. A total of 54 studies were included. Given the continuously evolving body of literature, the sources cited include the latest statements from medical and dental societies. The unpredictable fluctuation of hospital resources and the risk of the nosocomial spread of SARS-CoV-2 have direct effects on head and neck cancer management. Using an MDT approach to help define "essential surgery" for immediately life- or function-threatening disease processes in the context of available hospital resources will help to maximize outcomes. Early enrollment in an MDT is often critical for considering nonsurgical options to protect patients and health care workers. The role of the MDT continues after cancer treatment, if delivered, and the MDT plays an essential role in surveillance and survivorship programs in these challenging times. Head and neck cancer management during the COVID-19 pandemic poses a unique challenge for all specialists involved. Early MDT involvement is important to maximize patient outcomes and satisfaction in the context of public and community safety.

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Virtual Dysphagia Evaluation: Practical Guidelines for Dysphagia Management in the Context of the COVID-19 Pandemic

Liuba Soldatova,Colleen Williams,Gregory N. Postma,Gary W. Falk,Natasha Mirza

Publicatie 26-05-2020


With encouraging signs of pandemic containment nationwide, the promise of return to a full range of clinical practice is on the horizon. Clinicians are starting to prepare for a transition from limited evaluation of emergent and urgent complaints to resumption of elective surgical procedures and routine office visits within the next few weeks to months. Otolaryngology as a specialty faces unique challenges when it comes to the COVID-19 pandemic due to the fact that a comprehensive head and neck examination requires aerosol-generating endoscopic procedures. Since the COVID-19 pandemic is far from being over and the future may hold other highly communicable infectious threats that may require similar precautions, standard approaches to the clinical evaluation of common otolaryngology complaints will have to be modified. In this communication, we present practical recommendations for dysphagia evaluation with modifications to allow a safe and comprehensive assessment.

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Inappropriate Nasopharyngeal Sampling for SARS-CoV-2 Detection Is a Relevant Cause of False-Negative Reports

Antonio Piras,Davide Rizzo,Sergio Uzzau,Giacomo De Riu,Salvatore Rubino,Francesco Bussu

Publicatie 26-05-2020


Reverse transcriptase polymerase chain reaction (RT-PCR) detection of SARS-CoV-2 mRNA on nasopharyngeal swab is the standard for diagnosing active COVID-19 disease in asymptomatic cases and in symptomatic patients without the typical radiologic findings. For the present COVID-19 outbreak in Italy, we describe 4 symptomatic patients with negative RT-PCR results at the first nasopharyngeal swab, which became positive when collected a few hours later by an otolaryngologist. All the patients showed nasal obstruction. The present report suggests that inadequate nasopharyngeal sampling performed by untrained operators in the presence of nasal obstruction can be a relevant case of false-negative findings at RT-PCR, with a clear negative impact on the efforts to contain the current outbreak.

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Safety and Prognosis in Percutaneous vs Surgical Tracheostomy in 27 Patients With COVID-19

Juan Riestra-Ayora,Joaquin Yanes-Diaz,Oscar Penuelas,Cristina Molina-Quiros,Ricardo Sanz-Fernández,Eduardo Martin-Sanz

Publicatie 26-05-2020


During the SARS-CoV-2 pandemic, patients in intensive care units who are undergoing long-term intubation may require tracheostomy. There is controversy about indication and health care professionals' safety regarding the conventional or percutaneous technique. We performed a prospective analysis of a series of 27 consecutive patients with COVID-19 comparing both tracheostomy techniques, safety, and prognosis clinical markers. The results show that the techniques are equally safe, without cases of infection in surgeons. The Sequential Organ Failure Assessment score before surgery and the progression in ventilation support during the first 72 hours after tracheostomy are optimal prognostic markers for these patients.

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Airborne Aerosol Generation During Endonasal Procedures in the Era of COVID-19: Risks and Recommendations

Alan D. Workman,Aria Jafari,D. Bradley Welling,Mark A. Varvares,Stacey T. Gray,Eric H. Holbrook,George A. Scangas,Roy Xiao,Bob S. Carter,William T. Curry,Benjamin S. Bleier

Publicatie 26-05-2020


In the era of SARS-CoV-2, the risk of infectious airborne aerosol generation during otolaryngologic procedures has been an area of increasing concern. The objective of this investigation was to quantify airborne aerosol production under clinical and surgical conditions and examine efficacy of mask mitigation strategies. Prospective quantification of airborne aerosol generation during surgical and clinical simulation. Cadaver laboratory and clinical examination room. Airborne aerosol quantification with an optical particle sizer was performed in real time during cadaveric simulated endoscopic surgical conditions, including hand instrumentation, microdebrider use, high-speed drilling, and cautery. Aerosol sampling was additionally performed in simulated clinical and diagnostic settings. All clinical and surgical procedures were evaluated for propensity for significant airborne aerosol generation. Hand instrumentation and microdebridement did not produce detectable airborne aerosols in the range of 1 to 10 μm. Suction drilling at 12,000 rpm, high-speed drilling (4-mm diamond or cutting burs) at 70,000 rpm, and transnasal cautery generated significant airborne aerosols ( Transnasal drill and cautery use is associated with significant airborne particulate matter production in the range of 1 to 10 μm under surgical conditions. During simulated clinical activity, airborne aerosol generation was seen during nasal endoscopy, speech, and sneezing. Intact or VENT-modified N95 respirators mitigated airborne aerosol transmission, while standard surgical masks did not.

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An Otolaryngologist Redeployed to a COVID-19 Intensive Care Unit: Lessons Learned

Shumon Ian Dhar

Publicatie 26-05-2020


The COVID-19 pandemic has placed a significant personnel burden on intensive care units across the globe. Physicians from various specialties, including otolaryngology, have heeded the call and been redeployed to provide support, serving in a capacity outside their usual scope of practice. The author shares personal experience from redeployment and provides a framework for otolaryngologists to maximize their impact while providing high-quality patient care and preserving their personal safety.

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Taste and Smell Impairment in COVID-19: An AAO-HNS Anosmia Reporting Tool-Based Comparative Study

İbrahim Sayin,Kadriye Kart Yaşar,Zahide Mine Yazici

Publicatie 09-06-2020


To identify the taste and smell impairment in coronavirus disease 2019 (COVID-19)-positive subjects and compare the findings with COVID-19-negative subjects using the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) Anosmia Reporting Tool. Tertiary referral center/COVID-19 pandemic hospital. Comparative study. After power analysis, 128 subjects were divided into 2 groups according to real-time polymerase chain reaction (RT-PCR) COVID-19 testing results. Subjects were called via telephone, and the AAO-HNS Anosmia Reporting Tool was used to collect responses. The mean age of the study group was 38.63 ± 10.08 years. At the time of sampling, rhinorrhea was significantly high in the COVID-19-negative group, whereas those complaints described as "other" were significantly high in the COVID-19-positive group. There was a significant difference in the smell/taste impairment rates of the groups (n = 46% [71.9%] for the COVID-19-positive group vs n = 17 [26.6%] for the COVID-19-negative group, COVID-19-positive subjects are strongly associated with smell/taste impairment.

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Telemedicine During the COVID-19 Pandemic: A Pediatric Otolaryngology Perspective

Sarah E. Maurrasse,Jeff C. Rastatter,Stephen R. Hoff,Kathleen R. Billings,Taher S. Valika

Publicatie 26-05-2020


The COVID-19 pandemic has created a situation unparalleled in our lifetime. As the medical community has attempted to navigate a sea of ever-changing information and policies, this uncertainty has instead bred creativity, community, and evolution. Necessity is the mother of invention, and one of the by-products of our rapidly changing environment is the increased reliance on telemedicine. Here, we discuss our experience with incorporating telemedicine into an urban academic pediatric otolaryngology practice, the challenges that we have encountered, and the principles unique to this population.

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Endoscopic Skull Base Surgery Protocol From the Frontlines: Transnasal Surgery During the COVID-19 Pandemic

Todd Spock,Remi Kessler,David Lerner,Peter Filip,Anthony Del Signore,Patrick Colley,Peter Morgenstern,Madeleine Schaberg,Joshua Bederson,Satish Govindaraj,Alfred Marc Iloreta,Raj Shrivastava

Publicatie 26-05-2020


The coronavirus disease 2019 (COVID-19) pandemic disrupted the standard management paradigms for care of patients with sinus and skull base presentations due to concern for patient and health care provider safety, given the high aerosol-generating potential of endonasal procedures. We reviewed the relevant literature complied from available sources, including PubMed, Google Scholar, and otolaryngology journals providing electronic manuscripts ahead of indexing or publication. Incorporating available evidence and the projected infection control and resource limitations at our institution, we collectively authored a dynamic set of protocols guiding (1) case stratification, (2) preoperative assessment, (3) operative setup, and (4) postoperative care of patients with sinus or skull base presentations. Due to the rapidly evolving nature of COVID-19 publications, lack of rigorous data, and urgent necessity of standardized protocols, strict inclusion and exclusion criteria were not employed. As scarce hospital resources are diverted to COVID-19 care and staff are redeployed to forward-facing roles, endonasal procedures have largely ceased, leaving patients with ongoing sinonasal and skull base complaints untreated. Skull base teams now weigh the urgency of surgery in this population with the regional availability of resources. The COVID-19 pandemic will have an enduring and unpredictable impact on hospital operations and surgical skull base practices and will require a dynamic set of management protocols responsive to new evidence and changing resources. In the current resource-limited environment, clinicians may utilize these protocols to assist with stratifying patients by acuity, performing preoperative assessment, and guiding peri- and postoperative care.

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Predicting COVID-19 Incidence Using Anosmia and Other COVID-19 Symptomatology: Preliminary Analysis Using Google and Twitter

Bharat A. Panuganti,Aria Jafari,Bridget MacDonald,Adam S. DeConde

Publicatie 02-06-2020


To determine the relative correlations of Twitter and Google Search user trends concerning smell loss with daily coronavirus disease 2019 (COVID-19) incidence in the United States, compared to other severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) symptoms. To describe the effect of mass media communications on Twitter and Google Search user trends. Retrospective observational study. United States. Google Search and "tweet" frequency concerning COVID-19, smell, and nonsmell symptoms of COVID-19 generated between January 1 and April 8, 2020, were collected using Google Trends and Crimson Hexagon, respectively. Spearman coefficients linking each of these user trends to COVID-19 incidence were compared. Correlations obtained after excluding a short timeframe (March 22 to March 24) corresponding to the publication of a widely read lay media publication reporting anosmia as a symptom of infection was performed for comparative analysis. Google searches and tweets concerning all nonsmell symptoms (0.744 and 0.761, respectively) and COVID-19 (0.899 and 0.848) are more strongly correlated with disease incidence than smell loss (0.564 and 0.539). Twitter users tweeting about smell loss during the study period were more likely to be female (52%) than users tweeting about COVID-19 more generally (47%). Tweet and Google Search frequency pertaining to smell loss increased significantly (>2.5 standard deviations) following a widely read media publication linking smell loss and SARS-CoV-2 infection. Google Search and tweet frequency regarding fever and shortness of breath are more robust indicators of COVID-19 incidence than anosmia. Mass media communications represent important confounders that should be considered in future analyses.

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Guidelines for Resident Participation in Otolaryngology Telehealth Clinics During the COVID-19 Pandemic

Michal J. Plocienniczak,J. Pieter Noordzij,Gregory Grillone,Michael Platt,Christopher Brook

Publicatie 02-06-2020


The practice of otolaryngology has changed drastically since the start of the COVID-19 pandemic. To limit exposure and maintain a reserve of caregivers, residency education ceased most clinical activities and shifted to remote lecture consortiums hosted online across the country in lieu of ambulatory and operative experiences. Many practicing university otolaryngologists have transitioned their clinics to telehealth medicine to maintain access to clinical care during the pandemic. The participation of residents in telemedicine visits has not been described. Here we present guidelines and experience-based suggestions for successful resident involvement in telemedicine. While it is unclear what role telehealth medicine may play within the field of otolaryngology beyond the pandemic, our experiences suggest better patient outreach and access. Expanding residents' skill set with telehealth medicine can enhance their education and better prepare them for future practice.

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Vitamin D Status as a Predictor of Postoperative Hypocalcemia after Thyroidectomy

Samuel J. Rubin,Jong H. Park,Elizabeth N. Pearce,Michael F. Holick,David McAneny,J. Pieter Noordzij

Publicatie 21-04-2020


To determine whether perioperative vitamin D levels are predictive of postoperative hypocalcemia in patients receiving thyroidectomy. Single center retrospective study. This study included all patients receiving total or completion thyroidectomy between January 2007 and March 2017 at a single tertiary care hospital. 25-Hydroxyvitamin D (25[OH]D) levels were measured within 42 days prior to surgery or 1 day postoperatively. Hypocalcemia was defined as an adjusted serum calcium <8.0 mg/dL (based on albumin levels) or symptomatic hypocalcemia. Univariate analysis was performed with a 2-sample A total of 517 subjects were included in the study, 15.7% (n = 81) of whom experienced postoperative hypocalcemia with a mean ± SD serum calcium level of 7.6 ± 0.5 mg/dL as compared with 8.9 ± 0.5 mg/dL in the normocalcemic population ( Using a single-center retrospective study design, we demonstrated that 25(OH)D level is a significant predictor of postoperative hypocalcemia after thyroidectomy.

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Surgical Team Exposure to Cautery Smoke and Its Mitigation during Tonsillectomy

Daniel C. O’Brien,Eun Gyung Lee,Jhy-Charm Soo,Sherri Friend,Sarah Callaham,Michele M. Carr

Publicatie 26-05-2020


To assess the exposure of surgical personnel to known carcinogens during pediatric tonsillectomy and adenoidectomy (T&A) and compare the efficacy of surgical smoke evacuation systems during T&A. Prospective, case series. Tertiary children's hospital. The present study assessed operating room workers' exposure to chemical compounds and aerosolized particulates generated during T&A. We also investigated the effect of 3 different smoke-controlling methods: smoke-evacuator pencil cautery (SE), cautery with suction held by an assistant (SA), and cautery without suction (NS). Thirty cases were included: 12 in the SE group, 9 in SA, and 9 in NS. The chemical exposure levels were lower than or similar to baseline background concentrations, with the exception of methylene chloride and acetaldehyde. Within the surgical plume, none of the chemical compounds exceeded the corresponding occupational exposure limit (OEL). The mean particulate number concentration in the breathing zone during tonsillectomy was 508 particles/cm Although the exposure levels to chemicals were considerably lower than the OELs, continuous exposures to these chemicals could cause adverse health effects to surgical personnel. These findings suggest that the use of a smoke-evacuator pencil cautery or an attentive assistant with handheld suction would reduce exposure levels to the aerosolized particles during routine T&A, compared to the use of cautery without suction.

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Pneumatized Crista Galli: A Histopathologic Study

Marcel Marjanovic Kavanagh,Tomislav Tokic,Antonia Jakovcevic,Ranko Smiljanic,Boris Bumber,Ratko Prstacic

Publicatie 05-05-2020


This is the first histopathologic study that investigates the incidence of the pneumatized crista galli. A prospective histopathologic study. Tertiary academic medical center. A total of 109 specimens of crista galli were obtained postmortem during 2018 from randomly chosen patients who died at the University Hospital Centre Zagreb and had an autopsy at our Department of Pathology and Cytology. Specimens were surgically resected during the autopsy and then fixed, decalcinated, dehydrated, and embedded in paraffin. All slides were cut into 5-µm-thin sections and stained with a standard method (hematoxylin and eosin) for light microscope analysis. Specimens were histopathologically analyzed for the existence of pneumatization inside crista galli. The criterion to declare a specimen pneumatized was the presence of mucosa inside the cavity. Pneumatized crista galli was found in 5 of 109 specimens (4.59%). In 5 of 5 cases (100%) of pneumatized crista galli, there was evidence of chronic inflammation. We found that the incidence of pneumatized crista galli is significantly lower in our histopathologic study in comparison with the majority of previous radiologic studies. Our study also found that all 5 specimens with pneumatized crista galli had chronic inflammation in the mucosa, which is a considerably higher incidence than in the previous studies (7.7%-44%). Due to the emerging evidence of pneumatized crista galli being of clinical importance, we suggest that a larger study be conducted before the results are generalized to the general population.

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SimTube: A National Simulation Training and Research Project

Gregory J. Wiet,Ellen S. Deutsch,Sonya Malekzadeh,Amanda J. Onwuka,Nathan W. Callender,Michael D. Seidman,Marvin P. Fried

Publicatie 26-05-2020


To test the feasibility and impact of a simulation training program for myringotomy and tube (M&T) placement. Prospective randomized controlled. Multi-institutional. An M&T simulator was used to assess the impact of simulation training vs no simulation training on the rate of achieving competency. Novice trainees were assessed using posttest simulator Objective Structured Assessment of Technical Skills (OSATS) scores, OSATS score for initial intraoperative tube insertion, and number of procedures to obtain competency. The effect of simulation training was analyzed using χ A total of 101 residents and 105 raters from 65 institutions were enrolled; however, just 63 residents had sufficient data to be analyzed due to substantial breaches in protocol. There was no difference in simulator pretest scores between intervention and control groups; however, the intervention group had better OSATS global scores on the simulator (17.4 vs 13.7, A multi-institutional simulation study is feasible. Novices trained using the M&T simulator achieved higher scores on simulator but not initial intraoperative OSATS, and they did not reach

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Anesthesia for TORS for Oropharyngeal Carcinoma: Factors Associated with Prolonged Phase I Postanesthesia Recovery

Cassandra L. Puccinelli,Eric J. Moore,Linda X. Yin,Daniel L. Price,Jeffrey R. Janus,Toby N. Weingarten,Kathryn M. Van Abel

Publicatie 21-04-2020


Clinical variables affecting anesthetic recovery following transoral robotic surgery (TORS) to resect oropharyngeal squamous cell carcinoma have not been described. We aimed to explore risk factors associated with prolonged postanesthesia recovery following TORS. Retrospective case-control study. Tertiary referral center, January 2010 to November 2016. Patients included adults undergoing primary TORS ± neck dissection for oropharyngeal squamous cell carcinoma. Patients were categorized by phase I recovery time into the "goal" recovery group (75th percentile [lower 3 quartiles], n = 272) and the "prolonged" recovery group (n = 91). Univariate and multivariate logistic regression analyses were performed to assess the associations between clinical characteristics and prolonged phase I recovery. A total of 363 patients were included. Median (interquartile range) duration of postanesthesia recovery was 1.5 hours (1.0-2.0). Prolonged recovery was associated with isoflurane (odds ratio, 2.83 [95% CI, 1.56-5.14], Several anesthetic factors are associated with anesthesia recovery duration, which may be shortened by efforts to reduce postoperative sedation, severe pain, and nausea/vomiting. Shortened anesthesia recovery time may reduce hospital stay.

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MicroRNA Expression Profiling of Cutaneous Squamous Cell Carcinomas Arising in Different Sites

Alexander N. Rock,Mason D. Fisher,Gwenyth Amborski,Dawn C. Allain,Victoria Klee,Sara B. Peters,Stephen Kang,Amanda E. Toland

Publicatie 19-05-2020


To examine the microRNA (miRNA) expression profile of cutaneous squamous cell carcinoma (cSCC) tumors from aggressive head and neck locations compared with nonaggressive anatomic sites and normal controls. Retrospective analysis of miRNA expression. Tertiary care center. Tissue samples were collected from 3 anatomic regions: aggressive head and neck sites (ie, ears/lip), nonaggressive locations (ie, extremities/trunk), and adjacent normal skin. RNA was isolated from tissue cores of 45 samples (18 aggressive sites, 15 nonaggressive sites, and 12 normal-adjacent skin). miRNA expression analysis was completed for approximately 800 miRNAs using the NanoString nCounter panel. Five candidate miRNAs were selected for validation. Quantitative real-time polymerase chain reaction (qRT-PCR) was performed on the original samples plus 30 additional tissue samples (7 aggressive sites, 14 nonaggressive sites, and 9 normal-adjacent skin). Five candidate miRNAs with significant differences in miRNA expression ( cSCC behaves more aggressively when originating from specific anatomical subsites of the head and neck. Of 5 miRNAs evaluated, only

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An Analysis of 1-Year Charges for Head and Neck Cancer: Targets for Value-Based Interventions

John Pang,Kayva Crawford,Farhoud Faraji,Celia Ramsey,Aaron Kemp,Joseph A. Califano

Publicatie 26-05-2020


To identify the dominant clinical factors associated with increased 1-year charges in treating head and neck cancer. Retrospective review. Single academic institution. We retrospectively reviewed 1-year charges for 196 consecutive patients with head and neck cancer (HNC) who were treated exclusively at our institution. We analyzed charges by department as well as factors associated with increased charges per multivariable regression. The mean age was 59.6 years (SD, 14.9). Most of the population was male (64%), white (70%), and commercially insured (46%). The most common primary sites were the oropharynx (25%; 76%, HPV positive), skin (19%), and thyroid (17%). Eighty-three percent of total charges were due to standard-of-care treatment for HNC: surgery ($16 million), radiation therapy ($22 million), or chemotherapy ($11 million). The median total charge per patient was $212,484 (interquartile range, $78,630-$475,823). Multivariable regression demonstrated that the following were associated with increased charges: nasopharynx subsite ($250,929 [95% CI, $93,290-$408,569]; effect size in US dollars, Radiation, followed by surgery and chemotherapy, were the most expensive components of HNC care. In this analysis, we identified the dominant clinical factors associated with increased charges.

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A Bioresorbable Fiducial for Head and Neck Cancer

Victoria Fischman,Vladimir Ivanovic,Scharukh Jalisi

Publicatie 19-05-2020


We aim to evaluate a novel bioresorbable fiducial for marking tumor bed margins in head and neck cancers (HNCs) to improve upon current use of nonresorbable materials. A feasibility test was done placing the marker (L-lactide and ε-caprolactone) in an orange for computed tomography (CT) and applesauce for T1-, T2-, and PD-weighted magnetic resonance imaging (MRI) image acquisition, using routine clinical parameters. The resulting CT and MRI images showed excellent delineation of the marker with all of its margins well seen without adjacent artifact. The marker appeared similar to air on CT and MRI, surrounded by fluid-like appearance of the medium. Surgical bed appearance when radiotherapy is planned should not produce any artifact near the marker, and there should be no inherent marker-related artifact. These pilot CT and MR images show clinical utility for intraoperative marking of positive margins in the skull base or neck to guide future treatment and monitoring.

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Alexander Crum Brown: A Forgotten Pioneer in Vestibular Sciences

Soumit Dasgupta,Marco Mandala,Enis Alpin Guneri

Publicatie 07-07-2020


Although vestibular anatomy was described in the Renaissance period, research in vestibular physiology began in the 1820s and was spearheaded by Purkinje and Flourens. This was subsequently expanded by Ménière, Helmholtz, Goltz, Mach, Breuer, Ewald, and Hogyes, who are regarded as the early pioneers in research on vestibular physiology in the 19th century. The relationship of endolymphatic flow and semicircular canal function is termed the

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Reflux Disease and Laryngeal Neoplasia in Nonsmokers and Nondrinkers

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

Publicatie 28-04-2020


Gastroesophageal reflux disease (GERD) has been hypothesized as a risk factor for development of laryngeal cancer. A case-control study was performed to assess the association of laryngeal neoplasia with GERD. Cases consisted of patients with a history of laryngeal cancer or carcinoma in situ. Controls were patients without neoplasia who matched cases 2:1 on age, sex, race, and smoking history. Univariate and multivariate analyses were performed to assess risk of laryngeal neoplasia and GERD. In total, 2094 patients were included. Cases had higher rates of GERD. Univariate analysis demonstrated a positive association between GERD and laryngeal neoplasia (odds ratio, 1.33; 95% CI, 1.07-1.64). Multivariate analysis controlling for alcohol use history also demonstrated a positive association between GERD and laryngeal neoplasia (adjusted odds ratio, 1.29; 95% CI, 1.04-1.59). These results suggest increased odds of laryngeal carcinoma and carcinoma in situ in patients with GERD when controlling for smoking and drinking history.

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Changes in Pharyngeal Baseline Impedance in Patients With Laryngopharyngeal Reflux

Jeon Gang Doo,Su Il Kim,Jung Min Park,Oh Eun Kwon,Young Chan Lee,Young-Gyu Eun

Publicatie 12-05-2020


Few studies have investigated pharyngeal intraluminal baseline impedance (BI) levels in patients with laryngopharyngeal reflux (LPR). The aim of this study was to compare intraluminal BI levels between patients with LPR and healthy controls. Retrospective case series. Tertiary care medical center. We conducted a retrospective analysis of 24-hour multichannel intraluminal impedance (MII)-pH monitoring results from patients with suspected LPR complaining of reflux symptoms. Patients with suspected LPR were divided into 2 groups according to the 24-hour MII-pH monitoring (LPR group: patients with symptoms with reflux events ≥1, symptom but no reflux [SNR] group: patients with symptoms but no reflux event). Healthy controls were recruited and also underwent 24-hour MII-pH monitoring. We compared the esophageal and pharyngeal BI levels and ratios between 3 groups. Pharyngeal BI levels in the LPR group were significantly higher than in the healthy controls. In addition, the pharyngeal BI levels in the SNR group were significantly higher than in the healthy controls. All ratios of pharyngeal to distal esophageal BI levels in the LPR and SNR group were significantly higher than in the healthy controls. However, there were no significant differences in esophageal BI levels and ratios between the 3 groups. We found that the pharyngeal BI levels were higher in patients with LPR than in healthy controls. In addition, the pharyngeal BI levels measured by 24-hour MII-pH monitoring in patients with LPR symptoms, but without a reflux episode, were higher than in the healthy controls.

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Bolus Detection in the Proximal Esophagus Using Pulse-Echo Ultrasound: A Feasibility Study

Andrew Wilcox,Daniel Jackson,Joshua Jones,Samuel Thomas

Publicatie 05-05-2020


Here, the feasibility of using nonimaging pulse-echo ultrasound as a method of noninvasively detecting a bolus in the proximal esophagus was demonstrated. To accomplish this, patient swallows were recorded on a clinical ultrasound device with research interface that allowed for collection of the pulse-echo data. These ultrasound data of the proximal esophagus were processed with a series of signal processing techniques in both the temporal and spectral domains, which revealed characteristic signatures that were unique for both liquid and food boluses compared to the normal collapsed esophageal state. Since substantial amounts of laryngopharyngeal reflux are gaseous in nature, future work will revolve around expanding the data set to include boluses of gaseous refluxate, a standardized methodology for capturing bolus events; developing automated detection tools for identifying laryngopharyngeal reflux for an extended duration; and assessing technology limitations due to user error.

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Additional Benefits of Facial Nerve Monitoring during Otologic Surgery

Kelsey Casano,Gerard Giangrosso,Gauri Mankekar,Alexander Sevy,Rahul Mehta,Moises Arriaga

Publicatie 14-04-2020


This study assesses the role of facial nerve monitoring (FNM) for intraoperative decision making during otologic surgery and possible benefits beyond protecting facial nerve integrity. This prospective study examines intraoperative FNM data and structured interviews collected during 52 otologic procedures. Tertiary referral center. Subjects include adults and children undergoing middle ear or mastoid surgery. Data include intraoperative neuromonitoring activity and structured interviews conducted with the operating surgeon immediately following surgery. Facial nerve stimulation was used to confirm the position of the nerve in 42 of 52 surgical procedures. In 26.9% of cases, the patient became "light" and moved under anesthesia, which was predicted by neuromonitoring 71.4% of the time. Through structured interviews, the operating surgeons reported the following. (1) The facial nerve took an unexpected anatomic course in 7.8% of patients and was difficult to identify in 39.2%. (2) The nerve was at increased risk of injury in 66.7% of cases due to chronic disease or previous surgery. (3) Among these high-risk cases, the monitor helped reduce the risk of nerve damage 100% of the time. (4) Neuromonitoring allowed the surgeon to operate faster 86.5% of the time, and (5) FNM allowed the resident to perform more of the operation 68.9% of the time. No patients experienced postoperative facial weakness. Beyond potentially protecting facial nerve integrity, this study identified additional benefits of FNM, including warning of patient movement during anesthesia, confirming facial nerve anatomic location, reducing operative time, and enhancing resident surgical experience.

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Temporal Bone Encephaloceles: Utility of Preoperative Imaging

Douglas M. Worrall,Akila Pai,Jonathan C. Garneau,Enrique R. Perez,Maura K. Cosetti,Eric E. Smouha,George B. Wanna

Publicatie 28-04-2020


To determine the diagnostic efficacy and clinical value of preoperative computed tomography (CT) and magnetic resonance imaging (MRI) among patients with suspected temporal bone encephaloceles (TBE). Retrospective chart review from 2006 to 2018. Tertiary referral center. The subjects underwent surgery for a clinically suspected TBE or cerebrospinal fluid (CSF) leak. Preoperative imaging test characteristics of CT and MRI, including sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV), were calculated for TBE scans and compared with intraoperative findings. Fifty-seven subjects with otorrhea, middle ear effusion, hearing loss, and/or meningitis with suspected TBE or CSF leak were identified. All had preoperative CT scans, and 61% (35/57) had preoperative MRI scans. Intraoperatively, 37 of 57 patients (65%) were found to have a TBE. CT scans (17% sensitivity, 100% specificity, 100% PPV, 46% NPV) were less sensitive than MRI (58% sensitivity, 100% specificity, 100% PPV, 24% NPV) for detecting TBEs. Furthermore, the time from initial scan to operative repair was significantly longer in those who had a CT followed by MRI scan compared with CT alone or a fused CT-MRI scan (mean = 68 vs 15 days, respectively; CT and MRI provide complementary information that may aid surgical planning. However, imaging cannot always rule out TBE. In cases with high clinical suspicion, surgical confirmation is often required for definitive diagnosis and treatment. The cost of an additional preoperative study should be considered before its use.

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Next-Day Loading of a Bone-Anchored Hearing System: Preliminary Results

John T. McElveen,J. Douglas Green,Moises A. Arriaga,William H. Slattery

Publicatie 14-04-2020


To demonstrate the feasibility and efficacy for next-day loading of a percutaneous bone-anchored hearing device. Multicenter prospective cohort study. Tertiary neurotologic referral centers. In this multicenter prospective study, a 4.5-mm laser-etched bone-anchored hearing device was implanted in adult subjects who had conductive/mixed hearing loss or single-sided deafness. One day following implantation, the surgical site was assessed for soft tissue reaction per the Holgers Scale, and implant stability was evaluated by manual palpation and resonance frequency analysis. On the same day, subjects were fitted with the processor. Follow-up evaluations were at 1 week, 4 weeks, 3 months, 6 months, and 12 months. The Glasgow Benefit Inventory and Abbreviated Profile of Hearing Aid Benefit questionnaires were completed postoperatively. Fourteen devices were implanted in 12 subjects. Two subjects underwent bilateral implantation. Implant stability was rated as firm at every interval for all ears, and the Implant Stability Quotient values at 3 months were stable or increased as compared with day 1 measurements. Skin irritation was limited to Holgers grade 0 and 1, with the majority having no skin irritation. The mean Glasgow Benefit Inventory global score was +43.8, and the mean Abbreviated Profile of Hearing Aid Benefit global benefit score was 60.2%. All 14 implants have remained firmly anchored. Next-day loading of this 4.5-mm-diameter percutaneous bone-anchored hearing device appears to be a feasible alternative to the original 3-month delayed loading. Although this is a preliminary study, the results support continued investigation of a next-day loading strategy.

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Cognitive and Behavioral Functioning in Hearing-Impaired Children with and without Language Delay

Alisha Williams,Margaret Pulsifer,Kristin Tissera,Leila A. Mankarious

Publicatie 14-04-2020


Poor language development in patients with sensorineural hearing loss (SNHL) may be related to an auditory deficit and/or other neurologic condition that influences the ability to communicate. A retrospective chart review of children (mean age = 4.0 years) with congenital, bilateral SNHL was performed to assess for linguistic and nonlinguistic neurodevelopmental differences between those who were language-impaired (LI) versus non-language-impaired (NLI). Language, neurodevelopmental functioning, and behavior were assessed. Twenty-two patients were identified: 12 were LI and 10 were NLI. Average pure-tone thresholds and nonverbal intelligence were not different between the language groups, but the LI group demonstrated significantly lower median overall adaptive skills, personal living skills, and motor skills. Behavioral dysregulation was significantly higher in the LI versus NLI group (58% vs 10%;

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Predictors of Pediatric Tracheostomy Outcomes in the United States

Tzyynong L. Friesen,Steven M. Zamora,Ronak Rahmanian,Nour Bundogji,Matthew T. Brigger

Publicatie 21-04-2020


To investigate the outcomes of pediatric tracheostomy as influenced by demographics and comorbidities. Retrospective national database review. Fifty-two children's hospitals across the United States. Hospitalization records from Pediatric Health Information System database dated 2010 to 2018 with patients younger than 18 years and procedure codes for tracheostomy were extracted. The primary outcome was total length of stay. The secondary outcomes were 30-day readmission, mortality, and posttracheostomy length of stay. A total of 14,155 children were included in the analysis. The median total length of stay was 77 days and increased from 59 to 103 days between 2010 and 2018 ( Pediatric tracheostomy requires substantial health care resources with length of stay escalating over recent years. Age, race, region, discharge destination, and comorbidities were associated with differences in length of stay.

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Epidemiology of Pediatric Tympanostomy Tube Placement in the United States

Neil Bhattacharyya,Sophie G. Shay

Publicatie 14-04-2020


The prevalence of pediatric tympanostomy tube placement (TTP) in the United States has not been reassessed in the past decade. To assess the prevalence of TTP and frequent ear infections (FEI), the National Health Interview Survey for the calendar year 2014 was used. Among 73.1 million children, 6.26 million (8.6%) had TTP. The incidence of FEI was 3.49 million (4.8%). Males (9.6%) were more likely than females (7.5%) to undergo TTP (

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The Effect of Endoscopic Sinus Surgery on Eustachian Tube Dysfunction Symptoms

Michael T. Chang,Davood K. Hosseini,Sun Hee Song,Jayakar V. Nayak,Zara M. Patel,Jennifer Y. Lee,Peter H. Hwang

Publicatie 28-04-2020


We assessed how eustachian tube dysfunction (ETD) changed with endoscopic sinus surgery (ESS) and identified factors associated with improvement. Retrospective chart review. Academic center. Patients undergoing ESS for chronic rhinosinusitis with and without nasal polyposis (CRSwNP, CRSsNP) or recurrent acute rhinosinusitis (RARS) completed the Eustachian Tube Dysfunction Questionnaire 7 (ETDQ-7) preoperatively and postoperatively at 2 weeks, 6 weeks, 3 months, and 6 months. Included in analyses were demographics, comorbidities, Sinonasal Outcome Test 22 (SNOT-22), radiographic score, endoscopy score, procedure, and medication use. Regression analysis identified factors associated with improvement, defined as ΔETDQ-7 >3.5. In total, 302 patients were studied. ETD prevalence was 68% in CRSsNP, 48% in CRSwNP, and 88% in RARS. Patients with ETD had a mean baseline ETDQ-7 of 25.8 ± 8.0 and improved postoperatively at 2 weeks (19.9 ± 8.1, ETD symptoms often improve following ESS. Factors associated with improvement include higher preoperative disease burden, posterior ethmoidectomy, and postoperative corticosteroid spray. 4.

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Frontal Ostium Grade (FOG): A New Computer Tomography Grading System for Endoscopic Frontal Sinus Surgery

Heitham Gheriani,Rami Al-Salman,Al-Rahim R. Habib,Amin Javer

Publicatie 05-05-2020


The location and size of the frontal sinus ostium are critical in determining surgical difficulty. The more anterior the ostium, the more difficult is the surgical access. We propose a novel computed tomography (CT) grading specific to the anatomical position of the frontal ostium. Observational study followed by a prospective part. Tertiary rhinology practice. On a specified sagittal CT cut, a vertical line was drawn through the posterior edge of the frontal process of the maxilla (frontal buttress/beak) along its vertical axis (reference [R-] line). A second (S-) line was placed at the point of upturn of the skull base. Based on if the S-line was posterior or anterior to the R-line, the frontal ostium was graded positive and more easily accessible or negative and thereby more challenging, respectively. If both lines overlapped, then a neutral (0) grading existed. A total of 297 CTs (594 ostia) were analyzed. In total, 394 (65%) ostia were grade positive, 52 (8.75%) were grade negative, and 103 (17.3%) were grade neutral. Ninety frontal sinusotomies were then performed using this grading system: 48 were positive, 21 negative, and 21 neutral. The average time to complete a frontal sinusotomy was 9.96 minutes for grade positive compared to 11.4 minutes for neutral and 16.05 minutes for grade negative ( This novel anatomical CT grading system is designed to be useful in planning and predicting the level of difficulty in endoscopic frontal sinus surgery.

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Surgical Closure of Tracheoesophageal Puncture Without a Flap Interposition

João Fonseca Neves,Ana Rita Nobre,Edite Portugal,Francisco Branquinho

Publicatie 09-06-2020


Tracheoesophageal puncture for voice prosthesis placement is often used in vocal rehabilitation of patients undergoing total laryngectomy. Although its closure can occur spontaneously, some patients require a surgical procedure. We propose a surgical technique, without flap interposition, that begins with careful separation of the esophagus and trachea and identification of the site of tracheoesophageal fistula. After continuous suture closure of the esophagus, the anterior segment of the first tracheal rings is vertically incised to facilitate tracheal closure in a suture without tension. Finally, a small pectoral skin flap is made and mobilized to suture to the free edges of the sectioned tracheal rings, thus reducing the risk of tracheal stenosis. Four patients underwent this procedure with uneventful postoperative evolution and permanent closure of the fistula.

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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

Publicatie 08-09-2020


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

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

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

Publicatie 08-09-2020


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

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

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

Publicatie 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

Publicatie 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

Publicatie 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

Publicatie 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

Publicatie 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

Publicatie 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

Publicatie 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

Publicatie 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

Publicatie 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

Publicatie 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

Publicatie 01-09-2020


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

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

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

Publicatie 01-09-2020


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

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

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

Publicatie 01-09-2020


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

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CARES Act Provider Relief Fund Aid to Otolaryngologists in Small Practices

Roy Xiao,Vinay K. Rathi

Publicatie 01-09-2020


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

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

Parsa P. Salehi,Babak Azizzadeh,Yan Ho Lee

Publicatie 25-08-2020


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

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

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

Publicatie 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

Publicatie 25-08-2020


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

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Congenital Absence of Tracheal or Bronchial Rings

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

Publicatie 25-08-2020


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

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

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

Publicatie 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 PubMed. 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

Publicatie 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

Publicatie 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

Publicatie 25-08-2020


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

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The Long “Race” to Diversity in Otolaryngology

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

Publicatie 25-08-2020


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

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

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

Publicatie 25-08-2020


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

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Multispectral Imaging for Automated Tissue Identification of Normal Human Surgical Specimens

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

Publicatie 25-08-2020


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

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

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

Publicatie 18-08-2020


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

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

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

Publicatie 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

Publicatie 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

Publicatie 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. PubMed, 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

Publicatie 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, PubMed, 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 PubMed/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

Publicatie 18-08-2020


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

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

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

Publicatie 18-08-2020


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

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

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

Publicatie 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

Publicatie 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 PubMed, Scopus, and ISI-Web of Science. Studies addressing the efficacy of AP in reducing the incidence of SSIs in thyroid and parathyroid surgery were included in the systematic review and meta-analysis. The random effects model was assumed to account for different sources of variation among studies. The overall effect size was computed through the inverse variance method. Heterogeneity across studies, possible outlier studies, and publication bias were evaluated. A total of 6 studies with 4428 patients were included in the quantitative analysis. The incidence of SSI was 0.6% in the case group and 0.4% in the control group (odds ratio, 1.07; 95% CI, 0.3-3.81; AP is not effective in reducing the incidence of SSI in thyroid and parathyroid surgery and should be avoided, notwithstanding the negative impact on social costs and the risk of development of antibiotic resistance.

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

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

Publicatie 11-08-2020


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

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

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

Publicatie 11-08-2020


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

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

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

Publicatie 11-08-2020


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

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

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

Publicatie 11-08-2020


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

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

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

Publicatie 11-08-2020


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The Incidence of Pediatric Tracheostomy and Its Association Among Black Children

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

Publicatie 11-08-2020


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

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Drug-Induced Sleep Endoscopy in Pediatric Obstructive Sleep Apnea

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

Publicatie 11-08-2020


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

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

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

Publicatie 11-08-2020


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

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Response to Alfonso Santamaría-Gadea and Colleagues

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

Publicatie 11-08-2020


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

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

Publicatie 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

Publicatie 04-08-2020


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

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

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

Publicatie 04-08-2020


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

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

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

Publicatie 04-08-2020


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

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

Hadar Rotem Betito,Mordechai Himmelfarb,Ophir Handzel

Publicatie 04-08-2020


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

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

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

Publicatie 04-08-2020


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

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

Publicatie 04-08-2020


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

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Predictors of Complications Occurrence Associated With Emergency Surgical Tracheotomy

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

Publicatie 04-08-2020


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

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

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

Publicatie 04-08-2020


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

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

Neha Shakrawal

Publicatie 04-08-2020


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

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

Publicatie 04-08-2020


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

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

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

Publicatie 04-08-2020


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

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

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

Publicatie 04-08-2020


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

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

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

Publicatie 28-07-2020


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

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Hearing Vital Signs: Mobile Audiometry in the Emergency Department for Evaluation of Sudden Hearing Loss

Rory J. Lubner,Eric Barbarite,Neil Kondamuri,Renata M. Knoll,H. Gregory Ota,Rebecca M. Lewis,Kevin Franck,Aaron K. Remenschneider,Elliott D. Kozin

Publicatie 28-07-2020


Emergency departments (EDs) are a common location for patients to present with sudden hearing loss (SHL). Unfortunately, high-quality, rapid quantitative measurement of hearing loss is challenging. Herein, we aim to evaluate the accuracy of tablet-based audiometry in patients complaining of SHL. Prospective tablet-based testing was completed in the ED in patients complaining of SHL. Air conduction thresholds (ACTs) obtained via tablet-based audiometry were compared to same-day measurements with a clinical-grade audiometer. Hearing loss (HL) was defined as >20 dB ACT for any frequency. In participant-level analysis, 30+ dB HL in 3 consecutive frequencies was used to define SHL. In the ED, mobile audiogram ACTs were within 5 dB (77%) and 10 dB (89.6%) of those determined by conventional audiometry. The sensitivity and specificity for mobile audiometry to detect 3 or more consecutive thresholds with 30+ dB HL were 100% and 62.5%, respectively. Findings have implications for increasing access to high-quality audiometry.

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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

Publicatie 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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Reflections on the Value of Participation in Simulation as Young Faculty

Jennifer V. Brinkmeier

Publicatie 21-07-2020


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

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

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

Publicatie 21-07-2020


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

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

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

Publicatie 21-07-2020


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

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Validation of a Sensor-Fitted Simulator for Upper Airway Examination

Nieves Díez,Sofía Pacheco,Marcos Llorente,Secundino Fernández

Publicatie 21-07-2020


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

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

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

Publicatie 21-07-2020


(

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

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

Publicatie 21-07-2020


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

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

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

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

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

Publicatie 21-07-2020


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

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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

Publicatie 21-07-2020


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

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

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

Publicatie 21-07-2020


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

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

Ryan Kendall Thorpe,Sohit Paul Kanotra

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

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

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

Publicatie 21-07-2020


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

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Cleft Lip and Palate in Newborns Diagnosed With Neonatal Abstinence Syndrome

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

Publicatie 21-07-2020


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

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

Scott E. Brietzke,Steven M. Andreoli

Publicatie 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 (PubMed, 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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The Association Between Vitamin D Deficiency and Recurrent Tonsillitis: A Systematic Review and Meta-analysis

Ahmad A. Mirza,Abdulrahman A. Alharbi,Hani Marzouki,Talal Al-Khatib,Faisal Zawawi

Publicatie 21-07-2020


The role of vitamin D deficiency has been linked with recurrent upper respiratory tract infections, but its impact on the frequency of tonsillitis is not yet fully understood. The objective of this study is to determine the association between vitamin D deficiency and recurrent tonsillitis based on current literature. A systematic review was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. Data were collected from online medical databases (PubMed, MEDLINE, EMBASE, and Cochrane Collaboration Registry of Controlled Trials). All studies addressing the association of vitamin D deficiency and recurrent tonsillitis prior to March 2019. The data were collected in different phases: screening review using search words and controlled vocabularies followed by detailed review of screened articles based on inclusion and exclusion criteria, then a full review that included screening the references of selected articles. Fifty-three studies were potentially eligible; of these, 4 publications met the inclusion criteria and were included in the quantitative synthesis. There was a statistically significant reduction of vitamin D levels in patients with recurrent tonsillitis as compared to healthy controls (mean difference, -10.71; 95% CI, -19.12 to -2.31; Vitamin D deficiency was present in patients with recurrent tonsillitis and might be associated with an increase in the risk of recurrent tonsillitis. There is a need to explore these findings via clinical trials based on large populations.

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Pediatric Septal Perforation Repair With the Endoscopic Anterior Ethmoid Artery Flap

Samih J. Nassif,Andrew R. Scott

Publicatie 21-07-2020


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

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

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

Publicatie 21-07-2020


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

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

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

Publicatie 21-07-2020


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

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

Christopher T. Breen,Saral Mehra

Publicatie 21-07-2020


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

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

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

Publicatie 21-07-2020


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

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

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

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

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

Publicatie 14-07-2020


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

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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

Publicatie 14-07-2020


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

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

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

Publicatie 14-07-2020


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

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COVID-19 Airway Management Isolation Chamber

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

Publicatie 14-07-2020


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

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

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

Publicatie 14-07-2020


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

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

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

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

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

Publicatie 14-07-2020


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

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Intranasal Antiviral Drug Delivery and Coronavirus Disease 2019 (COVID-19): A State of the Art Review

Thomas S. Higgins,Arthur W. Wu,Elisa A. Illing,Kevin J. Sokoloski,Bree A. Weaver,Benjamin P. Anthony,Nathan Hughes,Jonathan Y. Ting

Publicatie 14-07-2020


To provide a state of the art review of intranasal antiviral drug delivery and to discuss current applications, adverse reactions, and future considerations in the management of coronavirus disease 2019 (COVID-19). PubMed, Embase, and Clinicaltrials.gov search engines. A structured search of the current literature was performed of dates up to and including April 2020. Search terms were queried as related to topics of antiviral agents and intranasal applications. A series of video conferences was convened among experts in otolaryngology, infectious diseases, public health, pharmacology, and virology to review the literature and discuss relevant findings. Intranasal drug delivery for antiviral agents has been studied for many years. Several agents have broad-spectrum antiviral activity, but they still require human safety and efficacy trials prior to implementation. Intranasal drug delivery has potential relevance for future clinical trials in the settings of disease spread prevention and treatment of SARS-CoV-2 and other viral diseases. Intranasal drug delivery represents an important area of research for COVID-19 and other viral diseases. The consideration of any potential adverse reactions is paramount.

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Pain and Opioid Analgesic Use After Otorhinolaryngologic Surgery

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

Publicatie 14-07-2020


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

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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

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

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

Edward D. McCoul

Publicatie 14-07-2020


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

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

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

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

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Adverse Events Associated With Laser Use in the Upper Airway

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

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

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

Publicatie 14-07-2020


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

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

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

Publicatie 14-07-2020


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

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Reconstruction After Salvage Total Laryngectomy: A Cost-effectiveness Analysis

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

Publicatie 14-07-2020


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

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Contemporary Management of Jugular Paragangliomas With Neural Preservation

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

Publicatie 14-07-2020


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

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

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

Publicatie 14-07-2020


To investigate small-particle aerosolization from mastoidectomy relevant to potential viral transmission and to test source-control mitigation strategies. Cadaveric simulation. Surgical simulation laboratory. An optical particle size spectrometer was used to quantify 1- to 10-µm aerosols 30 cm from mastoid cortex drilling. Two barrier drapes were evaluated: OtoTent1, a drape sheet affixed to the microscope; OtoTent2, a custom-structured drape that enclosed the surgical field with specialized ports. Mastoid drilling without a barrier drape, with or without an aerosol-scavenging second suction, generated large amounts of 1- to 10-µm particulate. Drilling under OtoTent1 generated a high density of particles when compared with baseline environmental levels ( Mastoidectomy without a barrier, even when a second suction was added, generated substantial 1- to 10-µm aerosols. During drilling, large amounts of aerosols above baseline levels were detected with OtoTent1 but not OtoTent2. For both drapes, a second suction was an effective mitigation strategy during drilling. Last, the combination of a second suction and a pause before removal prevented aerosol escape during the removal of either drape.

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

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

Publicatie 07-07-2020


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

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Vasodilation by Verapamil-Nitroglycerin Solution in Microvascular Surgery

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

Publicatie 07-07-2020


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

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

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

Publicatie 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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Implications of Change to USMLE Step 1 Scoring for Otolaryngology Residency Programs

Evelyne Kalyoussef,Aatin K. Dhanda,Boris Paskhover

Publicatie 07-07-2020


Otolaryngology is a competitive specialty, with 398 US seniors applying to an offered 328 positions in 2019. Recent changes to US Medical Licensing Exam (USMLE) Step 1 scoring raise many questions for both medical student applicants and program directors. Otolaryngologists are known to be collegial and thoughtful physicians. Focusing on other nonstandardized testing scores may help the specialty "reboot" and refocus on recruiting the best people, not just applicants with a high Step 1 score and Alpha Omega Alpha (AOA) status.

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

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

Publicatie 07-07-2020


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

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

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

Publicatie 07-07-2020


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

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Association of Metformin With the Growth of Vestibular Schwannomas

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

Publicatie 07-07-2020


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

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

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

Publicatie 07-07-2020


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

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Subjective vs Computerized Assessment of Surgeon Skill Level During Mastoidectomy

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

Publicatie 30-06-2020


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

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

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

Publicatie 30-06-2020


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In Vivo Accuracy of Ultrasound for Sizing Salivary Ductal Calculi

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

Publicatie 30-06-2020


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

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Tracheostomy in the COVID-19 Era: The Apneic Approach

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

Publicatie 30-06-2020


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Feasibility of In-office Fine-Needle Aspiration for Base of Tongue Tumors

Allison Reeder,Ricardo Aulet,Mirabelle Sajisevi,William Brundage

Publicatie 30-06-2020


We aim to demonstrate the feasibility of in-office transcervical ultrasound (TCUS)-guided fine-needle aspiration (FNA) of base of tongue (BOT) tumors in a single-institution. Retrospective chart review was performed and 3 patients met criteria, with BOT tumors ≥3 cm . Two patients had no cervical adenopathy, while FNA of a cervical lymph node was inconclusive in patient 3. Two patients had multiple medical comorbidities rendering them high risk for general anesthesia, and 1 patient had a BOT tumor obscuring visualization of the glottis, which would have precluded intubation and potentially required tracheostomy to proceed. All patients underwent successful in-office TCUS-guided FNA, with results showing squamous cell carcinoma. There were no related complications. In-office TCUS-guided FNA can be used for diagnosis of BOT lesions that are evident on ultrasound. This is beneficial in cases where general anesthesia is considered high risk. Additionally, 1 patient safely continued anticoagulation, and another was able to avoid tracheostomy. This technique is cost-effective as it avoids the expenses associated with operative intervention.

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Machine Learning Prediction of Extracapsular Extension in Human Papillomavirus–Associated Oropharyngeal Squamous Cell Carcinoma

Kyle M. Hatten,Julian Amin,Amal Isaiah

Publicatie 30-06-2020


To determine whether machine learning (ML) can predict the presence of extracapsular extension (ECE) prior to treatment, using common oncologic variables, in patients with human papillomavirus (HPV)-associated oropharyngeal squamous cell carcinoma (OPSCC). Retrospective database review. National Cancer Database study. All patients with HPV-associated OPSCC treated surgically between January 1, 2010, and December 31, 2015, were selected from the National Cancer Database. Patients were excluded if surgical pathology reports did not include information regarding primary tumor stage, number of metastatic regional lymph nodes, size of largest metastatic regional lymph node, and tumor grade. The data were split into a random distribution of 80% for training and 20% for testing with ML methods. A total of 3753 adults with surgically treated HPV-associated OPSCC met criteria for inclusion in the study. Approximately 38% of these patients treated with surgical management demonstrated ECE. ML models demonstrated modest accuracy in predicting ECE, with the areas under the receiver operating characteristic curves ranging from 0.58 to 0.68. The conditional inference tree model (0.66) predicted the metastatic lymph node number to be the most important predictor of ECE. Despite a large cohort and the use of ML algorithms, the power of clinical and oncologic variables to predict ECE in HPV-associated OPSCC remains limited.

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Effect of Bumetanide on Facial Nerve Regeneration in Rat Model

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

Publicatie 30-06-2020


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

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Familial Aggregation in Idiopathic Subglottic Stenosis

Virginia E. Drake,Alexander Gelbard,Nara Sobriera,Elizabeth Wohler,Lynne L. Berry,Lena L. Hussain,Alexander Hillel

Publicatie 30-06-2020


To evaluate inheritance patterns and define the familial clustering rate of idiopathic subglottic stenosis (iSGS). Retrospective observational study. International multicenter collaborative of >30 tertiary care centers. Patients with a clinically confirmed iSGS diagnosis within the North American Airway Collaborative's iSGS A total of 810 patients with iSGS were identified. Positive family history for iSGS was reported in 44 patients in 20 families. The rate of familial clustering in iSGS is 2.5%. Mean age of disease onset is 42.6 years. Of the 44 patients with familial aggregation of iSGS, 42 were female and 2 were male; 13 were mother-daughter pairs and 2 were father-daughter pairs. There were 3 sister-sister pairs. There was 1 niece-aunt pair and 2 groups of 3 family members. One pedigree demonstrated 2 affected mother-daughter pairs, with the mothers being first-degree paternal cousins. Inheritance is non-Mendelian, and anticipation is present in 11 of 13 (84%) parent-offspring pairs. The mean age of onset between parents (48.4 years) and offspring (36.1 years) was significantly different ( This study quantifies the rate of familial clustering of iSGS at 2.5%. Inheritance is non-Mendelian, and disease demonstrates anticipation. These data suggest that there may be a genetic contribution in iSGS.

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A Sustainable and Scalable Multidisciplinary Airway Teaching Mission: The Operation Airway 10-Year Experience

Asitha D. L. Jayawardena,Zelda J. Ghersin,Marcos Mirambeaux,Jose A. Bonilla,Ernesto Quiñones,Evelyn Zablah,Kevin Callans,Marina Hartnick,Nita Sahani,Makara Cayer,Cheryl Hersh,Thomas Q. Gallagher,Phoebe H. Yager,Christopher J. Hartnick

Publicatie 30-06-2020


To address whether a multidisciplinary team of pediatric otolaryngologists, anesthesiologists, pediatric intensivists, speech-language pathologists, and nurses can achieve safe and sustainable surgical outcomes in low-resourced settings when conducting a pediatric airway surgical teaching mission that features a program of progressive autonomy. Consecutive case series with chart review. This study reviews 14 consecutive missions from 2010 to 2019 in Ecuador, El Salvador, and the Dominican Republic. Demographic data, diagnostic and operative details, and operative outcomes were collected. A country's program met graduation criteria if its multidisciplinary team developed the ability to autonomously manage the preoperative huddle, operating room discussion and setup, operative procedure, and postoperative multidisciplinary pediatric intensive care unit and floor care decision making. This was assessed by direct observation and assessment of surgical outcomes. A total of 135 procedures were performed on 90 patients in Ecuador (n = 24), the Dominican Republic (n = 51), and El Salvador (n = 39). Five patients required transport to the United States to receive quaternary-level care. Thirty-six laryngotracheal reconstructions were completed: 6 single-stage, 12 one-and-a-half-stage, and 18 double-stage cases. We achieved a decannulation rate of 82%. Two programs (Ecuador and the Dominican Republic) met graduation criteria and have become self-sufficient. No mortalities were recorded. This is the largest longitudinal description of an airway reconstruction teaching mission in low- and middle-income countries. Airway reconstruction can be safe and effective in low-resourced settings with a thoughtful multidisciplinary team led by local champions.

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

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

Publicatie 30-06-2020


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

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

Publicatie 30-06-2020


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

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

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

Publicatie 30-06-2020


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

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

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

Publicatie 30-06-2020


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

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Otopathologic Analysis of Patterns of Postmeningitis Labyrinthitis Ossificans

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

Publicatie 30-06-2020


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

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

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

Publicatie 30-06-2020


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

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Sinonasal Squamous Cell Carcinoma Outcomes: Does Treatment at a High-Volume Center Confer Survival Benefit?

Jordan I. Teitelbaum,Khalil Issa,Ian R. Barak,Feras Y. Ackall,Sin-Ho Jung,David W. Jang,Ralph Abi Hachem

Publicatie 30-06-2020


To determine whether treatment of sinonasal squamous cell carcinoma (SCC) at a high-volume facility affects survival. Retrospective database analysis. National Cancer Database (2004-2014). The National Cancer Database was queried for sinonasal SCC from 2004 to 2014. Patient demographics, tumor characteristics and classification, resection margins, treatment regimen, and facility case-specific volume-averaged per year and grouped in tertiles as low (0%-33%), medium (34%-66%), and high (67%-100%)-were compared. Overall survival was compared with Cox proportional hazards regression analysis. A total of 3835 patients treated for sinonasal SCC between 2004 and 2014 were identified. Therapeutic options included surgery alone (18.6%), radiotherapy (RT) alone (29.1%), definitive chemoradiation (15.4%), surgery with adjuvant RT (22.8%), and combinations (14.1%) of the aforementioned treatments. Patients who underwent surgery with adjuvant RT had better overall survival (hazard ratio [HR], 0.74; This study shows a better overall survival for sinonasal SCC treated at high-volume centers. Further study may be needed to understand the effect of case volume on the paradigms of sinonasal SCC management.

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Quantitative Assessment of Surgical Ergonomics in Otolaryngology

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

Publicatie 30-06-2020


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

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

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

Publicatie 30-06-2020


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

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

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

Publicatie 30-06-2020


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

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

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

Publicatie 30-06-2020


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

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

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

Publicatie 30-06-2020


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

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

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

Publicatie 30-06-2020


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Thyroplasty Type III to Lower the Vocal Pitch in Trans Men

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

Publicatie 30-06-2020


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

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Telemedicine Algorithm for the Management of Dizzy Patients

Divya A. Chari,Matthew J. Wu,Matthew G. Crowson,Elliott D. Kozin,Steven D. Rauch

Publicatie 30-06-2020


As a result of the COVID-19 pandemic, telemedicine has been thrust to the forefront of health care. Despite its inherent limitations, telemedicine offers many advantages to both patient and physician as an alternative to in-person evaluation of select patients. In the near term, telemedicine allows nonpandemic care to proceed while observing appropriate public health concerns to minimize the spread of pandemic pathogens. Thus, it behooves practitioners to use telemedicine consultations for common otolaryngology complaints. Assessment of the dizzy patient is well-suited to an algorithmic approach that can be adapted to a telemedicine setting. As best practices for telemedicine have yet to be defined, we present herein a practical approach to the history and limited physical examination of the dizzy patient in the telemedicine setting for the general otolaryngologist. Indeed, once the acute crisis has abated, we suspect that this approach will continue to be an effective way to manage dizzy patients.

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

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

Publicatie 30-06-2020


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

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

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

Publicatie 30-06-2020


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

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Prevalence of Eustachian Tube Dysfunction in the US Elderly Population

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

Publicatie 23-06-2020


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

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Identifying Type III Sulcus: Patient Characteristics and Endoscopic Findings

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

Publicatie 23-06-2020


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

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Augmentation of Scarred Vocal Folds With Centrifuged and Emulsified Autologous Fat Grafts

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

Publicatie 23-06-2020


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

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

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

Publicatie 23-06-2020


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

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Controversies in the Workup and Surgical Management of Parotid Neoplasms

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

Publicatie 23-06-2020


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

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The Difficult Airway and Aerosol-Generating Procedures in COVID-19: Timeless Principles for Uncertain Times

Joshua D. Smith,Michelle M. Chen,Karthik Balakrishnan,Douglas R. Sidell,Arianna di Stadio,Samuel A. Schechtman,Robert M. Brody,Robbi A. Kupfer,Christopher H. Rassekh,Michael J. Brenner

Publicatie 23-06-2020


The impact of the COVID-19 pandemic on otolaryngology practice is nowhere more evident than in acute airway management. Considerations of preventing SARS-CoV-2 transmission, conserving personal protective equipment, and prioritizing care delivery based on acuity have dictated clinical decision making in the acute phase of the pandemic. With transition to a more chronic state of pandemic, heightened vigilance is necessary to recognize how deferral of care in patients with tenuous airways and COVID-19 infection may lead to acute airway compromise. Furthermore, it is critical to respect the continuing importance of flexible laryngoscopy in diagnosis. Safely managing airways during the pandemic requires thoughtful multidisciplinary planning. Teams should consider trade-offs among aerosol-generating procedures involving direct laryngoscopy, supraglottic airway use, fiberoptic intubation, and tracheostomy. We share clinical cases that illustrate enduring principles of acute airway management. As algorithms evolve, time-honored approaches for diagnosis and management of acute airway pathology remain essential in ensuring patient safety.

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Subjective Visual Vertical Testing in Patients With Chronic Suppurative Otitis Media

Rafael da Costa Monsanto,Ana Luiza Papi Kasemodel,Andreza Tomaz,Norma de Oliveira Penido

Publicatie 23-06-2020


To analyze the results of the subjective visual vertical test using the "bucket method" in patients with chronic suppurative otitis media (CSOM). Cross-sectional, controlled study. Outpatient otology clinic in a tertiary care hospital. Patients had CSOM, defined as the presence of chronic infection or inflammation of the middle ear cleft, associated with a perforation of the tympanic membrane, frequent or intractable middle ear suppuration, with or without cholesteatoma. Controls were selected using a nonprobability, purposive sampling method. We excluded patients with neurologic or metabolic diseases, cognitive deficits, otosclerosis, vestibular migraine, Ménière's disease, past use of ototoxic medication, or head and neck cancer. The volunteers were subjected to the subjective visual vertical test using the "bucket method." The results obtained in our study and control groups were analyzed using nonparametric tests. Our study comprised 51 patients with CSOM and 50 controls. In the CSOM group, we observed that 72.5% of the patients had vestibular symptoms in the past year, and 70.5% had abnormalities identified in at least 1 vestibular function test. The subjective visual vertical test revealed that patients with CSOM (with and without cholesteatoma) had significantly higher deviations of the true vertical as compared with controls (CSOM, 3.66°; controls, 0.76°; Our results revealed that CSOM was associated with high rates of vestibular symptoms, abnormal vestibular function tests, and abnormal subjective vertical visual results.

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

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

Publicatie 23-06-2020


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

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Identification of 11 Different HPV Subtypes in Adult Patients With Recurrent Respiratory Papillomatosis

Rebecca C. Hoesli,Melissa L. Wingo,Brent E. Richardson,Robert W. Bastian

Publicatie 23-06-2020


To define the human papillomavirus (HPV) subtypes seen in a large adult population with traditionally defined recurrent respiratory papillomatosis. Retrospective review. Tertiary care laryngology practice. All patients had a firm diagnosis of recurrent respiratory papillomatosis defined by (1) visually obvious papillomas, (2) recurrence requiring multiple surgeries, and (3) pathology diagnosis of "papilloma." Each patient had also undergone HPV subtyping. Age, sex, presence of malignancy, and HPV subtypes were tabulated and correlated with long-term patient outcomes. A total of 184 patients were identified who fulfilled the above criteria. In total, 87.0% (160) had a low risk subtype; 9.2% had an alternative subtype. These consisted of subtypes 16, 18, 31, 44, 45, 55, and 70. Four patients (2.2%) had combinations of subtypes, with 1 patient with HPV 11 and 16, 1 patient with HPV 11 and 76, 1 patient with 11 and 84, and 1 patient with 18 and 45. Finally, 3.8% of patients were HPV negative, despite fulfilling all 3 criteria listed above. In the patient population above, almost 10% of patients had an HPV subtype other than 6 and 11. This suggests that traditionally defined recurrent respiratory papillomatosis (RRP) can be caused by HPV subtypes other than 6 and/or 11. In addition, the clinical course of persons with this definition of RRP appears to vary by subtype, and this information may offer the ability to nuance follow-up instructions, reducing in particular the burden placed upon patients who have RRP caused by subtypes 6 and 11.

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National Trends in Surgical Resection of Vestibular Schwannomas

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

Publicatie 23-06-2020


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

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

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

Publicatie 23-06-2020


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

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Cricopharyngeal Achalasia: Management and Associated Outcomes—A Scoping Review

Karuna Dewan,Chloe Santa Maria,Julia Noel

Publicatie 23-06-2020


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

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Randomized Controlled Trial of Balloon Dilation in Treatment of Subglottic Stenosis With a Rabbit Model

Paul Wistermayer,Wesley McIlwain,Derek Escalante,Derek J. Rogers

Publicatie 23-06-2020


Identify the effects of balloon dilation duration and topical ciprofloxacin-dexamethasone application in treatment of subglottic stenosis. Randomized controlled trial. Animal research facility. Forty-four rabbits underwent subglottic injury in an Institutional Animal Care and Use Committee-approved study. One week after injury, the subglottis of each rabbit was measured and treated with endoscopic balloon dilation for 2 rounds of short duration (SBD; 3 seconds), long duration (LBD; 30 seconds), or LBD with topical ciprofloxacin-dexamethasone application (LBD+C). The subglottis of each rabbit was remeasured at the study endpoint: 1 month postdilation or following development of life-threatening respiratory distress. Of 44 rabbits, 35 (80%) survived to endoscopic balloon dilation, with 21 rabbits developing a grade III Cotton-Myer stenosis. Prior to dilation, there was no difference in stenosis rates among groups (all subjects, SBD was inferior to LBD or LBD+C in multiple metrics. LBD+C offered significant improvements in stenosis size and mortality over the SBD group and had the lowest rate of early mortality. Further research is needed to identify optimal balloon dilation treatment duration.

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

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

Publicatie 23-06-2020


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

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Author Reply to: “Comment on ‘The Prevalence of Olfactory and Gustatory Dysfunction in COVID-19 Patients: A Systematic Review and Meta-analysis’”

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

Publicatie 16-06-2020


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Characteristics and Frequency of Children With Severe Obstructive Sleep Apnea Undergoing Elective Polysomnography

Ashank Bains,Elizabeth Abraham,Adam Hsieh,Batsheva R. Rubin,Jessica R. Levi,Michael B. Cohen

Publicatie 16-06-2020


To determine the prevalence and demographics features of pediatric patients with severe obstructive sleep apnea (OSA) who would not undergo preoperative polysomnography (PSG) under current American Academy of Otolaryngology (AAO) guidelines. In this retrospective cohort study, we identified patients from the electronic medical record who underwent elective polysomnography for evaluation of sleep-disordered breathing between 2012 and 2018. Urban tertiary safety net hospital. A total of 456 patients with a mean (SD) age of 5.7 (3.2) years (263 male, 193 female). Demographic factors (age, sex, race, language, insurance status) and clinical findings (symptom severity, tonsil size) were recorded. The data were analyzed by univariate analysis. Of 456 patients identified, 66 (14.5%) were found to have severe OSA. African American patients had 3.7 times the odds of severe OSA compared to white patients (95% CI, 1.2-10.8). Patients aged 2 to 3 years had 2.2 times the odds of severe OSA compared to patients aged 4 to 6 years (95% CI, 1.2-4.0). Sex, ethnicity, language, and insurance type were not significantly associated with severity of OSA. The presence of apneic episodes and tonsil size were not found to be statistically significant. Up to 14.5% of healthy pediatric patients with sleep-disordered breathing may have severe OSA; young age and African American race are statistically significant predictors. Clinical findings, such as tonsil size and symptom severity, were not found to be statistically significant predictors.

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Aerosolization During Common Ventilation Scenarios

Roy Xiao,Alan D. Workman,Elefteria Puka,Jeremy Juang,Matthew R. Naunheim,Phillip C. Song

Publicatie 16-06-2020


Otolaryngologists are at increased risk for exposure to suspected aerosol-generating procedures during the ongoing coronavirus disease 2019 (COVID-19) pandemic. In the present study, we sought to quantify differences in aerosol generation during common ventilation scenarios. We performed a series of 30-second ventilation experiments on porcine larynx-trachea-lung specimens. We used an optical particle sizer to quantify the number of 1- to 10-µm particles observed per 30-second period (PP30). No significant aerosols were observed with ventilation of intubated specimens (10.8 ± 2.4 PP30 vs background 9.5 ± 2.1,

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

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

Publicatie 16-06-2020


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

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Natural History and Consequences of Nonunion in Mandibular and Maxillary Free Flaps

Brian Swendseid,Ayan Kumar,Larissa Sweeny,Tingting Zhan,Richard A. Goldman,Howard Krein,Ryan N. Heffelfinger,Adam J. Luginbuhl,Joseph M. Curry

Publicatie 16-06-2020


To describe the natural history of bone segment union in head and neck free flap procedures and detail the association of poor segment union with postoperative complications. Case series with chart review. Single tertiary care referral center. Patients with mandibular or maxillary defects reconstructed with osseous or osteocutaneous free flaps were analyzed (n = 104). Postoperative computed tomography or positron emission tomography/computed tomography scans were reviewed for signs of osseointegration and nonunion. Postoperative wound complications were correlated with imaging findings. Thirty-seven percent of appositions had partial union on nonunion. Appositions between osteotomized free flap segments form complete unions at a higher rate than appositions with native bone (65% vs 53%, Radiographic evidence of partial union or nonunion of free flap osseous segments greatly exceeds reported rates of clinically evident nonunion. Unions likely form between free flap appositions before unions to the native bone. If initial bone segments are >1-mm apart, the chance of progression to complete union is low. Incomplete osseointegration appears to be a marker for development of wound complications.

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Olfactory and Oral Manifestations of COVID-19: Sex-Related Symptoms—A Potential Pathway to Early Diagnosis

Ameen Biadsee,Ameer Biadsee,Firas Kassem,Or Dagan,Shchada Masarwa,Zeev Ormianer

Publicatie 16-06-2020


The coronavirus disease 2019 (COVID-19) pandemic poses a threat to global health. Early diagnosis is an essential key to limit the outbreak of the virus. Case series, study conducted between March 25, 2020, and April 15, 2020. Ambulatory, nonhospitalized patients who were quarantined in a designated hotel for COVID-19 patients and were recruited by an advertisement at the hotel. In total, 140 patients participated in a web-based questionnaire assessing initial symptoms of common viral diseases, olfactory and taste functions, xerostomia, and orofacial pain. A total of 58 men and 70 women participated. Initial symptoms were cough (59.4%), weakness (47.7%), myalgia (46.9%), fever (42.2%), headache (40.6%), impaired sense of smell (38.3%), impaired sense of taste (32.8%), sore throat (26.6%), runny nose (26.6%), and nasal congestion (22.7%). All symptoms were more frequent among women; however, only runny nose was statistically significant ( A considerable number of patients presented with olfactory and oral disorders. Interestingly, women presented with a different cluster of symptoms than men, which may suggest a new clinical approach to diagnosing COVID-19 disease.

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

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

Publicatie 16-06-2020


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

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Double-Layered (Cartilage Island + Extra Perichondrium) Graft for Type 1 Tympanoplasty

Onur Ismi,Kemal Gorur,Harun Gur,Cengiz Ozcan,Yusuf Vayisoglu

Publicatie 16-06-2020


To compare the graft success rates and hearing results of single-layered (composite island) grafting (SLG) vs double-layered (composite plus second layer of perichondrium) grafting (DLG) for over-under type 1 tympanoplasty techniques. Retrospective chart review. Tertiary center otorhinolaryngology clinic. Medical charts of the patients who underwent type 1 tympanoplasty via the microscopic technique by a single surgeon between 2015 and 2019 were analyzed. A total of 48 patients were included. The DLG (n = 26) group had higher graft take rates as compared to the SLG group (n = 22) for all patients ( DLG tympanoplasty is encouraged, especially for patients with higher MERI scores, to increase the graft success rates. Better hearing outcomes of DLG tympanoplasty were related to the higher graft success status of this technique; DLG had no additional hearing effect for patients with successful grafting. Higher MERI scores and presence of myringosclerosis were related to graft failure.

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Olfactory and Gustatory Dysfunction as an Early Identifier of COVID-19 in Adults and Children: An International Multicenter Study

Chenghao Qiu,Chong Cui,Charlotte Hautefort,Antje Haehner,Jun Zhao,Qi Yao,Hui Zeng,Eric J. Nisenbaum,Li Liu,Yu Zhao,Di Zhang,Corinna G. Levine,Ivette Cejas,Qi Dai,Mei Zeng,Philippe Herman,Clement Jourdaine,Katja de With,Julia Draf,Bing Chen,Dushyantha T. Jayaweera,James C. Denneny,Roy Casiano,Hongmeng Yu,Adrien A. Eshraghi,Thomas Hummel,Xuezhong Liu,Yilai Shu,Hongzhou Lu

Publicatie 16-06-2020


To evaluate the prevalence and characteristics of olfactory or gustatory dysfunction in coronavirus disease 2019 (COVID-19) patients. Multicenter case series. Five tertiary care hospitals (3 in China, 1 in France, 1 in Germany). In total, 394 polymerase chain reaction (PCR)-confirmed COVID-19-positive patients were screened, and those with olfactory or gustatory dysfunction were included. Data including demographics, COVID-19 severity, patient outcome, and the incidence and degree of olfactory and/or gustatory dysfunction were collected and analyzed. The Questionnaire of Olfactory Disorders (QOD) and visual analog scale (VAS) were used to quantify olfactory and gustatory dysfunction, respectively. All subjects at 1 hospital (Shanghai) without subjective olfactory complaints underwent objective testing. Of 394 screened subjects, 161 (41%) reported olfactory and/or gustatory dysfunction and were included. Incidence of olfactory and/or gustatory disorders in Chinese (n = 239), German (n = 39), and French (n = 116) cohorts was 32%, 69%, and 49%, respectively. The median age of included subjects was 39 years, 92 of 161 (57%) were male, and 10 of 161 (6%) were children. Of included subjects, 10% had only olfactory or gustatory symptoms, and 19% had olfactory and/or gustatory complaints prior to any other COVID-19 symptom. Of subjects with objective olfactory testing, 10 of 90 demonstrated abnormal chemosensory function despite reporting normal subjective olfaction. Forty-three percent (44/102) of subjects with follow-up showed symptomatic improvement in olfaction or gustation. Olfactory and/or gustatory disorders may represent early or isolated symptoms of severe acute respiratory syndrome coronavirus 2 infection. They may serve as a useful additional screening criterion, particularly for the identification of patients in the early stages of infection.

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Assessing National Utilization Trends and Outcomes of Robotic and Endoscopic Thyroidectomy in the United States

Daniel Jacobs,Sina J. Torabi,Courtney Gibson,Rahmatullah Rahmati,Saral Mehra,Benjamin L. Judson

Publicatie 16-06-2020


We aimed to evaluate trends and outcomes of surgical approaches to thyroid surgery. We hypothesized that there have been changes over time in the utilization of approaches to thyroidectomy, including endoscopic, robotic, and open approaches, and that patient outcomes may differ between open surgery and endoscopic or robotic approaches. Retrospective analysis. The National Cancer Database (NCDB) was queried between 2010 and 2016. National cohort of patients. Descriptive statistics were performed using χ We identified 217,938 patients within the NCDB. While endoscopic thyroid surgery increased, relatively, in use over time (0.93% to 2.34% of cases in 2010 and 2016, respectively), robotic thyroid surgery started to decline relatively to other approaches from 2013 to 2016 (0.39% to 0.25% of cases, respectively). The endoscopic approach was performed more commonly than the robotic approach within individual facilities that have reported both procedures ( Endoscopic thyroid surgery has increased in utilization since 2004 but may have worse morbidity and mortality outcomes compared to open surgery.

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Utilization of Invasive Procedures for Adult Eustachian Tube Dysfunction

Edward D. McCoul,Heather M. Weinreich,Hillary Mulder,Li-Xing Man,Kristine Schulz,Jennifer J. Shin

Publicatie 11-06-2020


Eustachian tube dysfunction (ETD) is a common diagnosis among adults presenting for outpatient care. We sought to determine national utilization and the associated cost of invasive procedures for adult ETD. Cross-sectional study. National health care database. The Truven Health MarketScan Databases (2010-2014) analytic cohort included health care encounters of patients ≥18 years of age with a diagnosis of ETD or related conditions of otitis media with effusion (OME) or tympanic membrane retraction (TMR). Visits associated with recent diagnoses of acute upper respiratory infection, head and neck cancer, or radiation therapy were excluded. Invasive procedure usage was subdivided into nasal and otologic procedures. ETD, OME, or TMR was diagnosed in 1,298,987 patients, 11.1% of which were chronic. The most common procedure was diagnostic endoscopy (including nasal endoscopy and laryngopharyngoscopy), which was used most frequently in the first 3 months after diagnosis, during which it was performed in 120,971 (9.3%) patients. The most frequent therapeutic nasal procedure was eustachian tube inflation without catheterization, performed in 11,412 patients over 5 years at a total cost of $1,210,939 ($106 per person annually). The most common therapeutic otologic procedure was myringotomy with tympanostomy, performed on 56,137 patients over 5 years at a total cost of $47,713,708 ($810 per person annually). Several nasal and otologic procedures are associated with a diagnosis of adult ETD at substantial cost. Development of therapeutic alternatives should be sought to mitigate the need for invasive procedures to treat this condition.

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Impact of the COVID-19 Global Pandemic on the Otolaryngology Fellowship Application Process

B. Ryan Nesemeier,Nicole L. Lebo,Cecelia E. Schmalbach,Kaitlyn J. Barnes,Dominic Vernon,Jonathan Y. Ting,Taha Z. Shipchandler

Publicatie 09-06-2020


On March 11, 2020, the World Health Organization declared coronavirus disease 2019 a global pandemic. In addition to massive social disruption, this pandemic affected the traditional fellowship interview season for otolaryngology subspecialties, including head and neck surgical oncology, facial plastic and reconstructive surgery, laryngology, rhinology, neurotology, and pediatric otolaryngology. The impact on the fellowship interview process, from the standpoint of the institution and the applicant, necessitated the use of alternative interview processes. This change may alter the future of how interviews and the match proceed for years to come, with nontraditional methods of interviewing becoming a mainstay. While the impact this pandemic has on the fellowship match process is not yet fully realized, this commentary aims to discuss the challenges faced on both sides of the equation and to offer solutions during these unprecedented times.

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A Multimodal Multi-Institutional Solution to Remote Medical Student Education for Otolaryngology During COVID-19

Jeremy S. Ruthberg,Humzah A. Quereshy,Shadi Ahmadmehrabi,Stephen Trudeau,Emaan Chaudry,Bryan Hair,Alan Kominsky,Todd D. Otteson,Paul C. Bryson,Sarah E. Mowry

Publicatie 09-06-2020


During the coronavirus 2019 pandemic, there has been a surge in production of remote learning materials for continued otolaryngology resident education. Medical students traditionally rely on elective and away subinternship experiences for exposure to the specialty. Delays and cancellation of clinical rotations have forced medical students to pursue opportunities outside of the traditional learning paradigm. In this commentary, we discuss the multi-institutional development of a robust syllabus for medical students using a multimodal collection of resources. Medical students collaborated with faculty and residents from 2 major academic centers to identify essential otolaryngology topics. High-quality, publicly available, and open-access content from multiple sources were incorporated into a curriculum that appeals to a variety of learners. Multimodal remote education strategies can be used as a foundation for further innovation aimed at developing tomorrow's otolaryngologists.

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Pediatric, Family-Centered, “At-Home” Otologic Physical Examination in the COVID-19 Era

Asitha D. L. Jayawardena,Leila A. Mankarious,Donald G. Keamy,Michael S. Cohen

Publicatie 09-06-2020


SARS-CoV-2, the novel coronavirus resulting in the present COVID-19 pandemic, has increased the otolaryngologist's reliance on telemedicine to manage outpatient pathology. The nature of telemedicine, however, limits a provider's ability to obtain a comprehensive physical examination, specifically of the tympanic membrane. Various smartphone-based otoscopic attachments are now available that facilitate patient-obtained otoscopic image capture of the tympanic membrane. Here, we present 3 cases in which a patient-purchased, over-the-counter otoscope was utilized to alter otologic management during the time of social distancing. Further research is necessary to improve our understanding the safety and efficacy of patient-based "at-home" otoscopic examination and to optimize the use of these devices.

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Outcomes of Dog Bite Avulsion Injury Reconstruction With Urinary Bladder Matrix

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

Publicatie 09-06-2020


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

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The Pandemic Effect: Raising the Bar for Ethics, Empathy, and Professional Collegiality

G. Richard Holt

Publicatie 09-06-2020


The widespread, tragic loss of life and the dedication of health care professionals have characterized the severe acute respiratory syndrome coronavirus 2 pandemic. While we mourn the loss of so many Americans to this novel virus, we also much acknowledge the positive effects to our profession, which are not insignificant. We have witnessed our larger community of otolaryngologist-head and neck surgeons pulling together in a manner not heretofore observed by this author. From the local level of practitioners to our national societies, there has been an amazing effort of collegial unity to develop the most clinically relevant guidelines for providing patient care with maximal safety, in the face of little scientific knowledge or experience with this virus. In addition, we as a specialty and individual otolaryngologists have, through our shared experiences, raised the bar for empathy, ethics, and professional interaction during these difficult times. We must reflect upon our professional growth and capture this renewal of altruism that lives at the heart of our calling.

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A Second Pandemic? Perspective on Information Overload in the COVID-19 Era

Taher S. Valika,Sarah E. Maurrasse,Lara Reichert

Publicatie 09-06-2020


The outbreak of COVID-19 has affected the globe in previously unimaginable ways, with far-reaching economic and social implications. It has also led to an outpouring of daily, ever-changing information. To assess the amount of data that were emerging, a PubMed search related to COVID-19 was performed. Nearly 8000 articles have been published since the virus was defined 4 months ago. This number has grown exponentially every month, potentially hindering our ability to discern what is scientifically important. Unlike previous global pandemics, we exist in a world of instantaneous access. Information, accurate or otherwise, is flowing from one side of the world to the other via word of mouth, social media, news, and medical journals. Changes in practice guidelines should be based on high-quality, well-powered research. Our job as health care providers is to mitigate misinformation and provide reassurance to prevent a second pandemic of misinformation.

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Persistent Smell Loss Following Undetectable SARS-CoV-2

Carol H. Yan,Divya P. Prajapati,Michele L. Ritter,Adam S. DeConde

Publicatie 09-06-2020


The association of smell and taste loss with COVID-19 has been well demonstrated with high prevalence rates. In certain cases, chemosensory loss may be the only symptom of COVID-19 and may linger while other symptoms have resolved. The significance of persistent smell and taste loss and its relationship to ongoing viral shedding has yet to be investigated. In this cross-sectional study, of the 316 laboratory test-confirmed COVID-19 cases at our institution, 46 had subsequent test-based confirmation of viral clearance with 2 consecutive negative RT-PCR test results (reverse transcriptase polymerase chain reaction). Olfactory dysfunction was reported by 50% of the patients (23 of 46), with 78% (18 of 23) having subjective persistent smell loss despite negative RT-PCR test results. These preliminary data demonstrate the persistence of self-reported smell loss despite otherwise clinical resolution and undetectable nasal viral RNA.

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Comment on “The Prevalence of Olfactory and Gustatory Dysfunction in COVID-19 Patients: A Systematic Review and Meta-analysis”

Andrea Lovato,Angelo Antonini,Cosimo de Filippis

Publicatie 09-06-2020


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

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

Publicatie 09-06-2020


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

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

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

Publicatie 09-06-2020


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

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A Lesson on Human Factors in Airway Management Learnt From the Death of George Washington

Ahmad K. Abou-Foul

Publicatie 09-06-2020


On December 14, 1799, 3 prominent physicians-Craik, Brown, and Dick-gathered to examine America's first president, George Washington. He was complaining of severe throat symptoms and was being treated with bloodletting, blistering, and enemas. Dick advised performing an immediate tracheotomy to secure the airway. Both Craik and Brown were not keen on trying tracheotomy and overruled that proposal. Washington was not involved in making that decision. He most likely had acute epiglottitis that proved to be fatal at the end. If Dick had prevailed, a tracheotomy could have saved Washington's life. Human factors analysis of these events shows that his physicians were totally fixated on repeating futile treatments and could not comprehend the need for a radical alternative, like tracheotomy. That was aggravated by an impaired situational awareness and significant resistance to change. Leadership model was also based on hierarchy instead of competency, which might have also contributed to Washington's death.

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Family-Centered Information Dissemination: A Multidisciplinary Virtual COVID-19 “Town Hall”

Asitha D. L. Jayawardena,Sarah Romano,Kevin Callans,M. Shannon Fracchia,Christopher J. Hartnick

Publicatie 09-06-2020


Significant misinformation about COVID-19 has been spread on the internet. Parents of children with complex aerodigestive problems have a hard time understanding the information they encounter on the internet and the news media and interpreting how it relates to their child's complex needs. Our multidisciplinary team, at the suggestion of a parent, hosted 3 virtual "town halls" in which families could ask questions directly of pediatric otolaryngology, pediatric pulmonology and case management in order to efficiently obtain factual evidence-based up-to-date advice. The information discussed at the town halls was then annotated and disseminated via active, parent-run aerodigestive social media forums. The information disseminated via the town halls reached 4787 Facebook participants.

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Creation of a New Educational Podcast: “Headmirror’s ENT in a Nutshell”

Jason H. Barnes,Garret Choby,Alyssa J. Smith,Patrick Kiessling,John P. Marinelli,Sarah Bowe,Matthew L. Carlson

Publicatie 09-06-2020


Podcasts are online digital audio programs that are disseminated via online subscription that are easily accessible through computers or smartphones. Increasingly, residents and medical students are prioritizing podcasts for asynchronous medical education due to ease of use, convenience (eg, use while exercising or commuting), and repeatability. Some trainees have found podcasts more useful than traditional didactic lectures. Given the increasing requirements of social distancing and the need for distance medical education platforms, podcast production can serve as a useful tool to complement resident and medical student education and is a resource that will remain accessible in perpetuity. An otolaryngology specialty podcast, "Headmirror's ENT in a Nutshell," was created to augment asynchronous learning and address the acute need for distance learning opportunities. Over the first 7 weeks of production, 50 episodes were created. Episodes were posted on www.headmirror.com, with subscription services available through Apple Podcast, Spotify, and other platforms.

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Addressing the Impact of COVID-19 on the Residency Application Process Through a Virtual Subinternship

Janice L. Farlow,Emily J. Marchiano,Ilana P. Fischer,Jeffrey S. Moyer,Marc C. Thorne,Lauren A. Bohm

Publicatie 09-06-2020


Senior medical students are facing an unparalleled experiential gap left by COVID-19 restrictions. Due to a shared commitment to safety, equity, and well-being, away rotations are actively being discouraged or even prohibited. As a result, students transitioning to residency encounter reduced clinical training experiences and decreased access to advising, mentorship, and research opportunities. In addition, limited exposure to residency life across subspecialties and institutions poses unique challenges during the current residency application cycle. The otolaryngology-head and neck surgery community has met these unprecedented challenges by producing diverse electronic resources for specialty-specific clinical education, as well as discussing ways to increase access to advising. In this commentary, we review these initiatives and propose an institutional virtual event as a platform for meeting goals previously achieved by visiting subinternships.

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Quantitative Analysis of Saccade Gain in Video Head Impulse Testing

Zhuangzhuang Li,Haiyan Wang,Hui Wang,Dongzhen Yu

Publicatie 09-06-2020


To quantitatively analyze corrective saccade (CS) gain and further characterize the specific relationship between vestibulo-ocular reflex (VOR) gain and CS gain in patients with vestibular loss and healthy controls. Prospective combined with retrospective study. Affiliated Sixth People's Hospital, Shanghai Jiao Tong University. Forty patients with unilateral vestibular loss and 40 participants with normal vestibular function were subjected to video head impulse testing (vHIT). The analysis of the horizontal semicircular canal VOR and CS gains was based on individual head impulses. The patient group had significantly higher CS gain and lower VOR gain than the control group ( In healthy participants, CS was not correlated with VOR gain, suggesting that CS is not due to VOR hypofunction. In patients with unilateral vestibular loss, CS was closely associated with VOR gain and can almost correct gaze position errors required for visual stabilization. CS gain could be an important indicator to diagnose vestibular loss and help physicians identify abnormal vHIT curves caused by artifacts and irregular practices.

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Revaluation of Otolaryngologic Procedures With 10- and 90-Day Global Periods in the Medicare Physician Fee Schedule

Vinay K. Rathi,Ashley L. Miller,Urjeet A. Patel,Mark A. Varvares,Regan W. Bergmark,Roy Xiao,Matthew R. Naunheim

Publicatie 09-06-2020


A recent investigation by the Centers for Medicare and Medicaid Services (CMS) suggests that physicians provide fewer postoperative visits (POVs) than expected for procedures with 10- and 90-day global periods. CMS is now contemplating revaluation of these procedures, which could result in lower Medicare payments to otolaryngologists. To estimate the impact of such reform on otolaryngologic procedures, we conducted a secondary subgroup analysis of CMS-contracted research, which used claims-based estimates of POVs to revalue procedures with 10- and 90-day global periods. Among the top 10 highest volume procedures performed in 2018, the proportion of median physician-reported to CMS-expected POVs ranged between 0.0% (myringotomy ± ventilation tube insertion, mouth biopsy, and complex wound repair) and 40.0% (total thyroidectomy). The top 5 procedures accounted for nearly three-quarters ($6.2 million and $8.6 million; 72.6%) of the estimated Medicare payment reduction. Further study is necessary to guide the development of equitable and effective payment reform.

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Disparate Nasopharyngeal and Tracheal COVID-19 Diagnostic Test Results in a Patient With a Total Laryngectomy

Tirth R. Patel,Joshua E. Teitcher,Bobby A. Tajudeen,Peter C. Revenaugh

Publicatie 09-06-2020


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Rhinologic Practice Special Considerations During COVID-19: Visit Planning, Personal Protective Equipment, Testing, and Environmental Controls

Brittany E. Howard,Devyani Lal

Publicatie 02-06-2020


As rhinologists return to practice amid SARS-CoV-2, special considerations are warranted given the unique features of their subspecialty. Rhinologist manipulation of nasal tissue, proximity, and frequent aerosol-generating procedures (AGPs) create high risk for infection transmission. There are 4 areas of special consideration to mitigate risk: (1) previsit planning for risk stratification/mitigation, (2) appropriate personal protective equipment, (3) preprocedural testing, and (4) environmental controls. During previsit planning, risk factors of the patient and procedures are considered. High-risk AGPs are identified by duration, proximity, manipulation of high-viral load tissue, and use of powered instrumentation. Appropriate personal protective equipment includes selection of respiratory and eye protection. COVID-19 testing can screen for asymptomatic carriers prior to high-risk procedures; however, alternative testing methods are required in rhinologic patients not eligible for nasopharyngeal testing due to nasal obstruction or skull base defects. Last, AGPs in rhinologic practices require considerations of room air handling and environmental controls.

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Telemedicine and the Interdisciplinary Clinic Model: During the COVID-19 Pandemic and Beyond

Lisa A. Zughni,Amanda I. Gillespie,Jeanne L. Hatcher,Adam D. Rubin,John Paul Giliberto

Publicatie 02-06-2020


The emergence of the novel coronavirus disease 2019 (COVID-19) and the subsequent need for physical distancing have necessitated a swift change in health care delivery. Prior to the COVID-19 outbreak, many institutions utilized an interdisciplinary clinic model including both a laryngologist and a speech-language pathologist for the evaluation of patients with voice, swallowing, and upper airway disorders. To improve access, many providers are pursuing the use of interdisciplinary telemedicine to provide individualized patient-centered care while allowing for physical distancing. The purpose of this commentary is to review the current literature regarding telemedicine in laryngology and speech-language pathology as well as the current and future states of practice for interdisciplinary tele-evaluations.

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Alternations of Blood Pressure Before and After OSA Surgery

Ming-Hsien Tsai,Pei-Wen Lin,Hsin-Ching Lin,Michael Friedman,Anna M. Salapatas,Yu-Hao Lu,Mao-Chang Su,Meng-Chih Lin

Publicatie 02-06-2020


To investigate the changes of blood pressure (BP) on patients with obstructive sleep apnea/hypopnea syndrome (OSA) before and after upper airway surgery. Case series with chart review. Tertiary academic medical center. Patients with OSA who underwent upper airway surgery were enrolled. We retrospectively investigated the nighttime and daytime BP before and at least 3 months after OSA surgery. Paired In total, 176 patients with OSA (149 men, 27 women; mean age, 42.9 years; mean apnea/hypopnea index, 43.1/h) were enrolled in this study. The overall nighttime and daytime BP decreased significantly before and after OSA surgery (daytime systolic BP was reduced from 137.3 ± 14.0 mm Hg to 132.7 ± 17.0 mm Hg, Surgical modifications of the upper airways for patients with OSA could benefit blood pressure.

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Implantable Drug Reservoir Devices for Inner Ear Delivery of Pharmacotherapeutics

Ashley Kita,Johnny Saldate,Courtney Chang,Nitika Chellappa,Jeremy Jong,Riley Matsuda,Andrew Schmidt,Brandon Shih,Iram Shafqat,Kari Schoettler,Shiv Acharya,Stephanie Seidlits,Larry Hoffman

Publicatie 02-06-2020


Cisplatin is a platinum-based chemotherapeutic drug that secondarily induces toxicity in inner ear sensory epithelia, contributing to auditory and vestibular dysfunction. We describe the creation of a drug reservoir device (DRD) to combat this ototoxicity for the duration of chemotherapy. As ototoxic side effects of chemotherapy may limit an oncologist's ability to prescribe first-line agents such as cisplatin, mitigating such devastating effects through prolonged topical therapy would be tremendously valuable. We investigated (1) the ability of an electrospun polylactic acid DRD to provide prolonged delivery of the posited otoprotectant metformin and (2) the development of an in vitro model utilizing Sh-Sy5y human neuroblastoma cells to assess the efficacy of metformin in reducing cisplatin-induced toxicity. Neurophysiology laboratory. Basic science experiments were performed to assess DRD properties and metformin's effects on cisplatin toxicity in culture. We found that DRDs with increasing polylactic acid concentrations exhibited metformin release for up to 8 weeks. In modeling elution across the round window in vitro, continued elution of metformin was observed for at least 6 weeks, as quantified by spectrophotometry. Unfortunately, metformin did not exhibit protective efficacy in this model using Sh-Sy5y cells. While metformin was not found to be protective in Sh-Sy5y cells, these results suggest that an electrospun DRD can provide a tailorable drug delivery system providing medication for the duration of chemotherapy treatment. This represents a novel drug delivery system and efficacy screening assay with broad clinical applications in personalized delivery of inner ear therapies.

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Socioeconomic Disparities in Pediatric Single-Sided Deafness

Noga Lipschitz,Gavriel D. Kohlberg,Michael Scott,Matthew M. Smith,John H. Greinwald

Publicatie 02-06-2020


To explore socioeconomic disparities in pediatric single-sided deafness (SSD) treatment. Retrospective chart review. Tertiary referral academic center. The charts of 190 pediatric patients with SSD were reviewed for demographic and clinical characteristics. Socioeconomic variables included race and insurance status. ZIP codes were used to obtain additional socioeconomic data from the American Community Survey, including mean and median income, percentage of families below the poverty level, and employment status. Socioeconomic status (SES) was classified by insurance status and income. Treatment outcomes were analyzed by socioeconomic variables. There were 105 males and 85 females with a mean follow-up of 55.2 months and a mean age at diagnosis of 4.4 years. Sixty-three percent of children received treatment at last follow-up. Thirty-five percent of children had public insurance and 65% had private insurance. Treatment rates were similar in the private and public insurance groups (60.6% vs 66.7%, Insurance type and SES were not associated with SSD treatment outcomes in children, although device use may be higher in children with private insurance and higher SES. Further research should focus on strategies to reduce barriers to treatment and improve adherence.

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Association Between Helicobacter pylori Infection and Otitis Media With Effusion Risk in Children: A Systematic Review and Meta-analysis

Xiaohui Wu,Yun Zheng,Xingqiang Gao,Gang Li,Qiuxue Cao

Publicatie 02-06-2020


To investigate the potential correlation between Electronic databases were searched, including Cochrane Library, PubMed, Embase, China Biology Medicine disc, China Science and Technology Journal Database, Wanfang Database, and China National Knowledge Infrastructure Database. A systematic review and meta-analysis were conducted with Revman 5.3 software. Combined odds ratios (ORs) and 95% confidence intervals (CIs) were calculated to estimate infection-disease association. In total, 11 studies from 9 articles regarding This study indicated the correlation between

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Back to the Future: Principles on Resuming Outpatient Services in the COVID-19 Era

Taher S. Valika,Kathleen R. Billings

Publicatie 02-06-2020


The rapidly changing health care climate related to coronavirus disease 2019 (COVID-19) has resulted in numerous changes to health care systems and in practices that protect both the public and the workers who serve in hospitals around the country. As a result, these past few months have seen a drastic reduction in outpatient visits. With phased reopening and appropriate guidance, health care systems are attempting to return to normal. The experiences and lessons learned are described, and we provide guiding principles to allow for a safe and effective return to outpatient care.

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A Guiding Principles Checklist for Otolaryngologic Surgery in the COVID-19 Era

Taher S. Valika,Sarah E. Maurrasse,Dana M. Thompson

Publicatie 02-06-2020


The COVID-19 pandemic has had a dramatic impact on surgical workflows. There is an abundance of ever-changing information, and protocols are reflexively modified on a daily basis. As many otolaryngologic procedures are shown to have higher risk of viral transmission-so-called aerosol-generating procedures-it is imperative that multidisciplinary care teams be provided updated, timely, and consistent information. A single-page Guiding Principles surgical checklist was developed to discuss 7 key factors: patient information, staff wellness, risk minimization, prioritization, resource utilization, key society criteria, and communication. This was completed for every patient requiring otolaryngologic surgery and was distributed to the care teams involved. It provided the most information for those on the frontline and allowed for cogent pre-, intra-, and postoperative planning.

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SARS-CoV-2 Infection in Health Care Workers: Cross-sectional Analysis of an Otolaryngology Unit

Alberto Paderno,Milena Fior,Giulia Berretti,Alberto Schreiber,Alberto Grammatica,Davide Mattavelli,Alberto Deganello

Publicatie 02-06-2020


The restart of routine in- and outpatient activity in the COVID-19 postepidemic peak needs to be carefully planned in light of specific patterns of viral diffusion. We evaluated SARS-CoV-2 serology in the entire personnel of a COVID-19-free otolaryngology department in a highly affected area. The aim was to determine the prevalence of SARS-CoV-2 positivity among staff to clarify the impact of different risk factors for infection. The entire staff of the otolaryngology unit was tested for SARS-CoV-2 serology. Symptomatic staff members were tested with nasal/pharyngeal swabs. All answered a survey focused on the number of in- and extrahospital positive contacts and type of activities in the unit. Five (9%) were positive for SARS-CoV-2 infection. The only variable associated with a higher risk of infection was the number of extrahospital contacts without personal protective equipment (

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Care of Patients With a Laryngectomy During the COVID-19 Pandemic

David C. M. Yeung,Ronald Lai,Eddy W. Y. Wong,Jason Y. K. Chan

Publicatie 02-06-2020


Patients with a laryngectomy are at increased risk for droplet-transmitted diseases and, therefore, COVID-19, which has now caused a worldwide pandemic. Adaptive measures to protect patients with a laryngectomy and their families were designed and implemented in the Hong Kong SAR (HK). Driven by the fear of severe acute respiratory syndrome in 2003, hospitals in HK have since modified infection control routines to prevent a repeat public health nightmare. To face COVID-19, caused by SARS-CoV-2, we have adapted guidelines for our patients with a laryngectomy. Contact precautions, droplet precautions with physical barriers, and hand and equipment hygiene are our mainstays of prevention against COVID-19, and sharing these routines is the aim of this article. The COVID-19 pandemic is still roaring ahead. Awareness and precautions for patients with a laryngectomy who may be at higher risk are outlined here and should be maintained during the current pandemic.

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Consequences of Medical Hierarchy on Medical Students, Residents, and Medical Education in Otolaryngology

Parsa P. Salehi,Daniel Jacobs,Timur Suhail-Sindhu,Benjamin L. Judson,Babak Azizzadeh,Yan Ho Lee

Publicatie 02-06-2020


To (1) review concepts of medical hierarchy; (2) examine the role of medical hierarchy in medical education and resident training; (3) discuss potential negative impacts of dysfunctional hierarchy in medical and surgical training programs, focusing on otolaryngology; and (4) investigate solutions to these issues. Ovid Medline, Embase, GoogleScholar, JSTOR, Google, and article reference lists. A literature search was performed to identify articles relating to the objectives of the study using the aforementioned data sources, with subsequent exclusion of articles believed to be outside the scope of the current work. The search was limited to the past 5 years. Two types of hierarchies exist: "functional" and "dysfunctional." While functional medical hierarchies aim to optimize patient care through clinical instruction, dysfunctional hierarchies have been linked to negative impacts by creating learning environments that discourage the voicing of concerns, legitimize trainee mistreatment, and create moral distress through ethical dilemmas. Such an environment endangers patient safety, undermines physician empathy, hampers learning, lowers training satisfaction, and amplifies stress, fatigue, and burnout. On the other hand, functional hierarchies may improve resident education and well-being, as well as patient safety. Otolaryngology-head and neck surgery programs ought to work toward creating healthy systems of hierarchy that emphasize collaboration and improvement of workplace climate for trainees and faculty. The goal should be to identify aspects of dysfunctional hierarchy in one's own environment with the ambition of rebuilding a functional hierarchy where learning, personal health, and patient safety are optimized.

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Medical Intervention Alone vs Surgical Drainage for Treatment of Peritonsillar Abscess: A Systematic Review and Meta-analysis

David Forner,Dennis E. Curry,Kristy Hancock,Colin MacKay,S. Mark Taylor,Martin Corsten,Jonathan R. Trites,Matthew H. Rigby

Publicatie 02-06-2020


Peritonsillar abscesses (PTAs) are common emergency consultations for otolaryngologists. Medical management alone may offer satisfactory treatment without the risk associated with surgical drainage. Therefore, we performed a systematic review of medical treatment alone compared to surgical drainage for the treatment of PTA. MEDLINE, EMBASE, Cochrane CENTRAL, and ClinicalTrials.gov. Studies comparing the outcomes of medically treated to surgically treated patients were included. Risk of bias was assessed using the Newcastle-Ottawa Scale. All screening and data extraction were completed by 2 independent reviewers. Meta-analysis was performed using a random-effects model. Subgroup and sensitivity analyses were performed. Ten cohort studies and 2 randomized studies were included (n Meta-analysis of available studies demonstrated no difference in odds of treatment failure for patients with PTA managed through medical intervention alone compared to surgical intervention. These findings should be interpreted with caution due to high probability of bias and overall low quality of studies.

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Validation of a Novel, Multidomain Head and Neck Cancer Appearance- and Function-Distress Patient-Reported Outcome Measure

Evan M. Graboyes,Brittany N. Hand,Mark A. Ellis,Andrew T. Huang,Marci L. Nilsen,Patrik Pipkorn,Courtney H. Marsh,Stacey Maurer,Terry A. Day,Katherine R. Sterba

Publicatie 02-06-2020


Distress with self-perceived changes in appearance and function can result in body image disturbance (BID), which is common in head and neck cancer (HNC) survivors and a major source of psychosocial morbidity. To address the lack of psychometrically sound patient-reported outcome measures (PROMs) of HNC-related BID, we aim to create and validate the Inventory to Measure and Assess imaGe disturbancE-Head & Neck (IMAGE-HN). Survey study. Multiple academic centers. Following item development, HNC survivors from 4 academic centers completed the IMAGE-HN. Item responses were psychometrically analyzed using confirmatory factor analysis (CFA) and Rasch analysis. Item development resulted in a 31-item PROM consisting of 5 individual domains and a global domain. In total, 305 HNC survivors of diverse ages, HNC subsites, and reconstructive paradigms completed the initial items. After removal of 3 items for local dependence, CFA confirmed the unidimensionality and local independence (item residual correlations <|0.20|) for each domain. Rasch analysis indicated acceptable fit (infit and outfit mean squares <2.0), monotonicity of all rating scale categories, and low person misfit (<4%). Person separation indices and person reliability were adequate for each domain except appearance concealment, which was removed (4 items). This resulted in the IMAGE-HN, a psychometrically acceptable 24-item PROM of HNC-related BID consisting of a global scale and 4 subscales measuring unique constructs and comprised independent items. IMAGE-HN is a novel, psychometrically sound, multidomain PROM of HNC-related BID for use in clinical and research settings.

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Eustachian Tube Balloon Dilation: A Systematic Review and Meta-analysis of Treatment Outcomes

Michael H. Froehlich,Phong T. Le,Shaun A. Nguyen,Theodore R. McRackan,Habib G. Rizk,Ted A. Meyer

Publicatie 02-06-2020


To examine the effectiveness of eustachian tube balloon dilation for the treatment of eustachian tube dysfunction. PubMed, Scopus, and Google Scholar. A systematic review of eustachian tube balloon dilation for the treatment of eustachian tube dysfunction was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines to identify randomized control trials and prospective and retrospective studies published prior to January 31, 2019. Meta-analysis of proportions evaluated 7-item Eustachian Tube Dysfunction Questionnaire (ETDQ7) scores, tympanometry, otoscopy findings, and the ability to perform a Valsalva maneuver. The systematic review identified 35 studies. Twelve studies met inclusion for meta-analysis (448 patients). Mean ETDQ7 scores decreased by 2.13 from baseline to 6 weeks (95% CI, -3.02 to -1.24; Eustachian tube balloon dilation appears to be associated with improvement in subjective and objective treatment outcome metrics. The improvement appears stable at 3 to 12 months after dilation. Patients with eustachian tube dysfunction are likely to benefit from balloon dilation, particularly those with medication-refractory disease.

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Immediate Voice and Swallowing Complaints Following Revision Anterior Cervical Spine Surgery

Madeleine P. Strohl,Winward Choy,Aaron J. Clark,Praveen V. Mummaneni,Sanjay S. Dhall,Bobby K. Tay,Patricia A. Loftus,Ivan H. El-Sayed,Matthew S. Russell

Publicatie 02-06-2020


To report on the incidence of dysphagia, dysphonia, and acute vocal fold motion impairment (VFMI) following revision anterior cervical spine surgery, as well as to identify risk factors associated with acute VFMI in the immediate postoperative period. Retrospective cohort study. Tertiary care center. All patients who underwent 2-team reoperative anterior cervical discectomy and fusion (ACDF) were retrospectively reviewed. Incidence of dysphonia, dysphagia, and acute VFMI was noted. Patient and operative factors were evaluated for association with risk of acute VFMI. The incidence of postoperative dysphonia and dysphagia was 25% (18/72) and 52% (37/72), respectively. The incidence of immediate VFMI was 21% (15/72). Subjective postoperative dysphonia (odds ratio, [OR] 8; 95% CI, 2.2-28; Early involvement of an otolaryngologist in the care of a patient undergoing revision ACDF can be helpful to the patient in anticipation of voice and swallowing changes in the postoperative period. This may be particularly important in those being treated at C7/T1 or those with spinal infections.

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Visual Speech Recognition: Improving Speech Perception in Noise through Artificial Intelligence

Arun M. Raghavan,Noga Lipschitz,Joseph T. Breen,Ravi N. Samy,Gavriel D. Kohlberg

Publicatie 26-05-2020


To compare speech perception (SP) in noise for normal-hearing (NH) individuals and individuals with hearing loss (IWHL) and to demonstrate improvements in SP with use of a visual speech recognition program (VSRP). Single-institution prospective study. Tertiary referral center. Eleven NH and 9 IWHL participants in a sound-isolated booth facing a speaker through a window. In non-VSRP conditions, SP was evaluated on 40 Bamford-Kowal-Bench speech-in-noise test (BKB-SIN) sentences presented by the speaker at 50 A-weighted decibels (dBA) with multiperson babble noise presented from 50 to 75 dBA. SP was defined as the percentage of words correctly identified. In VSRP conditions, an infrared camera was used to track 35 points around the speaker's lips during speech in real time. Lip movement data were translated into speech-text via an in-house developed neural network-based VSRP. SP was evaluated similarly in the non-VSRP condition on 42 BKB-SIN sentences, with the addition of the VSRP output presented on a screen to the listener. In high-noise conditions (70-75 dBA) without VSRP, NH listeners achieved significantly higher speech perception than IWHL listeners (38.7% vs 25.0%, The VSRP significantly increased speech perception in high-noise conditions for NH and IWHL participants and eliminated the difference in SP accuracy between NH and IWHL listeners.

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Lessons Learned From a Single-Surgeon Experience of More Than 1700 Parathyroidectomies

David J. Terris,Ahmad Eltelety,Zachary Zimmerman,Luke Edelmayer

Publicatie 26-05-2020


To define critical elements that contribute to successful parathyroidectomy based on a high-volume single-surgeon experience and explore learning curve characteristics. Systematic analysis of prospectively maintained quality assurance database. Academic tertiary care endocrine surgery practice. In total, 4737 consecutive patients who underwent thyroid or parathyroid surgery from 2004 to 2020 were identified. Demographic data acquisition was undertaken on a subset of these patients who had initial surgery for primary hyperparathyroidism during the academic years 2005 to 2018. Patients with renal or syndromic hyperparathyroidism and those undergoing reoperative surgery were excluded. From 1710 patients who underwent parathyroid surgery, 1082 met inclusion criteria in order to focus on a homogeneous data set. These patients had a mean age of 60.1 ± 12.5 years and 76.4% were female. The overall cure rate was 98.3%, reflecting a success rate that increased from 95.5% during the first 200 cases to 99.7% over the final 300 cases. The complication rate was 1.7%. Over 2 decades, the patient phenotype evolved toward milder disease and smaller adenomas. A learning curve of 200 cases was required to become a proficient parathyroid surgeon; to achieve exceptional results required several hundred additional cases. Parathyroid surgery represents a higher proportion of an endocrine surgery practice than previously (54.0% in 2019 compared with 25.5% in 2004). A focused practice dedicated to endocrine surgery yields surgical volumes exceeding 500 cases annually. There has been a steady shift toward parathyroid surgery. A lengthy learning curve can be shortened by pursuit of several specific strategies that are outlined in detail.

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Quality Indicators of Central Compartment Neck Dissection in Thyroid Surgery

Alexandra E. Quimby,Martin J. Corsten,Elysia Grose,Michael Odell,Stephanie Johnson-Obaseki

Publicatie 26-05-2020


Quality metrics are an increasingly important means of improving patient care. Variability in the number of lymph nodes removed during central compartment lymph node dissection (CCLND) at the time of thyroidectomy has not been studied. A retrospective cohort study was performed using American College of Surgeons National Quality Improvement Program (ACS-NSQIP) data. Centers in North America and worldwide contributing data to ACS-NSQIP and performing thyroidectomy on adults in inpatient and outpatient settings were included. Adult patients undergoing thyroidectomy with or without CCLND were included. Outcomes of interest were number of nodes removed during CCLND and risks of postoperative hypocalcemia. In total, 6108 patients met inclusion criteria (1565 with CCLND). The median number of lymph nodes removed during CCLND was 2. There was no statistically significant association between postoperative hypocalcemia and CCNLD, regardless of number of nodes removed. However, we were underpowered to detect this association based on the overall low nodal yield of many CCLNDs performed. In many cases where CCLND is documented as part of thyroidectomy, very few lymph nodes are removed. Our ability to draw conclusions regarding the effect of CCLND on postoperative hypocalcemia is restricted due to the limited nature of many CCLNDs performed.

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

Ryan Ference,David Liao,Qi Gao,Vikas Mehta

Publicatie 26-05-2020


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

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Adherence to American Academy of Otolaryngology–Head and Neck Surgery Clinical Practice Guidelines: A Systematic Review

Marisa A. Ryan,Grace R. Leu,Emily F. Boss,Eileen M. Raynor,Jonathan M. Walsh

Publicatie 26-05-2020


Clinical practice guidelines synthesize and disseminate the best available evidence to guide clinical decisions and increase high-quality care. Since 2004, the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) has published 16 guidelines. The objective of this review was to evaluate clinicians' adherence to these guidelines' recommendations as measured in the literature. We searched PubMed, Embase, and Web of Science on August 29, 2019, for studies published after June 1, 2004. We systematically identified peer-reviewed studies in English that reported clinician adherence to AAO-HNSF guideline recommendations. Two authors independently reviewed and abstracted study characteristics, including publication date, population, sample size, guideline adherence, and risk of bias. The search yielded 385 studies. We excluded 331 studies during title/abstract screening and 32 more after full-text review. The remaining 22 studies evaluated recommendations from 8 of the 16 guidelines. The Otitis Media with Effusion, Polysomnography, Tonsillectomy, and Sinusitis guidelines were studied most. Study designs included retrospective chart reviews (7, 32%), clinician surveys (7, 32%), and health care database analyses (8, 36%). Studies reported adherence ranging from 0% to 99.8% with a mean of 56%. Adherence varied depending on the recommendation evaluated, type of recommendation, clinician type, and clinical setting. Adherence to the polysomnography recommendations was low (8%-65.3%). Adherence was higher for the otitis media with effusion (76%-90%) and tonsillectomy (43%-98.9%) recommendations. Adherence to recommendations in the AAO-HNSF guidelines varies widely. These findings highlight areas for further guideline dissemination, research about guideline adoption, and quality improvement.

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Methodological Quality of Systematic Reviews and Meta-analyses Published in High-Impact Otolaryngology Journals

Rodrigo Martinez-Monedero,Arman Danielian,Varun Angajala,Jennifer E. Dinalo,Eric J. Kezirian

Publicatie 26-05-2020


To assess the methodological quality of intervention-focused systematic reviews (SRs) and meta-analyses (MAs) published in high-impact otolaryngology journals. Ovid Medline, Embase, and Cochrane Library. A comprehensive search was performed for SR and MA citations from 2012 to 2017 in the 10 highest impact factor otolaryngology journals. Abstracts were screened to identify published manuscripts in which the authors indicated clearly that they were performing an SR or MA. Applying a modified typology of reviews, 4 reviewers characterized the review type as SR, MA, or another review type. A simplified version of the AMSTAR 2 (A MeaSurement Tool to Assess systematic Reviews 2) tool was used to assess the reporting and methodological quality of the SRs and MAs that were focused on interventions. Search and abstract screening generated 499 manuscripts that identified themselves as performing an SR or MA. A substantial number (85/499, 17%) were review types other than SRs or MAs, including 34 (7%) that were literature reviews. In total, 236 SRs and MAs focused on interventions. Over 50% of these SRs and MAs had weaknesses in at least 3 of the 16 items in the AMSTAR 2, and over 40% had weaknesses in at least 2 of the 7 critical domains. Ninety-nine percent of SRs and MAs provided critically low confidence in the results of the reviews. Intervention-focused SRs and MAs published in high-impact otolaryngology journals have important methodological limitations that diminish confidence in the results of these reviews.

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Initial Facial Feminization Surgery Experience in a Multicenter Integrated Health Care System

David W. Chou,Nizar Tejani,Andrew Kleinberger,Charles Shih

Publicatie 26-05-2020


There are few large studies on facial feminization surgery (FFS). We provide the largest comprehensive report to date of an FFS cohort regarding the safety of multilevel surgery, patient-specific considerations with FFS procedures, and complications of surgery. Retrospective cohort study. Multicenter integrated health care system. We examined all patients undergoing FFS within our institution from April 2016 to October 2018. Patients over the age of 18 with a diagnosis of gender dysphoria underwent any combination of scalp advancement, cranioplasty, brow lift, rhinoplasty, upper lip lift, mandibuloplasty, chondrolaryngoplasty, and/or additional cosmetic procedures. Medical records were reviewed for preoperative characteristics, FFS procedures undergone, and postoperative complications. In total, 121 patients underwent a total of 594 FFS procedures. Seventy-five percent of patients had only 1 or no comorbidities, and 90% of patients underwent cranioplasty, scalp advancement, and brow lift. African American patients (n = 5) less commonly underwent cranioplasty compared to those of other ethnicities (white, The population undergoing FFS is generally healthy, the upper third of the face is most commonly addressed, there are age and ethnic considerations in FFS, and major complications after multilevel surgery are uncommon.

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Reliability of Measuring Insertion Depth in Cochlear Implanted Infants and Children Using Cochlear View Radiography

Anisha R. Noble,Erin Christianson,Susan J. Norton,Henry C. Ou,Grace S. Phillips,Hedieh Khalatbari,Seth D. Friedman,David L. Horn

Publicatie 26-05-2020


Cochlear implant depth of insertion affects audiologic outcomes and can be measured in adults using plain films obtained in the "cochlear view." The objective of this study was to assess interrater and intrarater reliability of measuring depth of insertion using cochlear view radiography. Prospective, observational. Tertiary referral pediatric hospital. Patients aged 11 months to 20 years (median, 4 years; interquartile range [IQR], 1-8 years) undergoing cochlear implantation at our institution were studied over 1 year. Children underwent cochlear view imaging on postoperative day 1. Films were deidentified and 1 image per ear was selected. Two cochlear implant surgeons and 2 radiologists evaluated each image and determined angular depth of insertion. Images were re-reviewed 6 weeks later by all raters. Inter- and intrarater reliability were calculated with intraclass correlation coefficients (ICCs). Fifty-seven ears were imaged from 42 children. Forty-nine ears (86%) had successful cochlear view x-rays. Median angular depth of insertion was 381° (minimum, 272°; maximum, 450°; IQR, 360°-395°) during the first round of measurement. Measurements of the same images reviewed 6 weeks later showed median depth of insertion of 382° (minimum, 272°; maximum, 449°; IQR, 360°-397°). Interrater and intrarater reliability ICCs ranged between 0.81 and 0.96, indicating excellent reliability. Postoperative cochlear view radiography is a reliable tool for measurement of cochlear implant depth of insertion in infants and children. Further studies are needed to determine reliability of intraoperatively obtained cochlear view radiographs in this population.

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Surgical Field Visualization during Functional Endoscopic Sinus Surgery: Comparison of Propofol- vs Desflurane-Based Anesthesia

Suneeta Gollapudy,Drake A. Gashkoff,David M. Poetker,Todd A. Loehrl,Matthias L. Riess

Publicatie 26-05-2020


To assess if the type of general anesthetic affects bleeding and field visualization during endoscopic sinus surgery. Prospective, randomized, controlled trial. Academic teaching hospital and Veterans Affairs hospital in the United States. Seventy patients were randomized to 1 of 3 anesthetic regimens: (1) the volatile anesthetic desflurane (n = 22), (2) intravenous anesthesia with propofol (n = 25), or (3) a combination of propofol and desflurane (n = 23). Intravenous remifentanil was titrated to decrease the mean arterial pressure to 60 to 70 mm Hg but not ≥30% from baseline. Surgical bleeding scores were recorded along with bleeding rates and hemodynamic parameters, including cardiac output and systemic vascular resistance through pulse contour analysis from a radial arterial line. Statistics: multiple comparison tests and regression analyses; α = .05. There were no differences in bleeding rate (median, 0.58, 0.85, 0.57 mL min When remifentanil is used for controlled hypotension, propofol has no advantage over desflurane to improve surgical field visualization during functional endoscopic sinus surgery.

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Psychological Status as an Effect Modifier of the Association Between Sinonasal Instrument and Imaging Results

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

Publicatie 26-05-2020


To determine whether psychological status is an effect modifier of the previously observed low discriminatory capacity of Sinonasal Outcome Test-22 (SNOT-22) scores for Lund-Mackay computed tomography (CT) results. Observational outcomes study. Tertiary care center. We assessed patients presenting with chronic sinonasal complaints who underwent CT of the sinuses within 1 month of completing the SNOT-22 instrument. SNOT-22 overall and domain scores were calculated, as were Lund-Mackay CT scores. The discriminatory capacity of SNOT-22 scores for CT results was determined using the receiver-operator characteristic area under the curve (ROC-AUC). Patient-Reported Outcome Measurement Information System (PROMIS) mental health T-scores were assessed, and stratified analyses were used to test for effect modification by psychological status. In stratified analyses, patients with better PROMIS mental health scores had SNOT-22 overall (ROC-AUC 0.96) and nasal domain scores (ROC-AUC 0.97-0.98) that were highly discriminatory for Lund-Mackay scores, while those with worse mental health scores did not (ROC-AUC 0.42-0.55, Psychological status is an effect modifier of the relationship between SNOT-22 and Lund-Mackay scores. SNOT-22 scores were discriminatory for Lund-Mackay CT results in patients with better psychological status, while they were nondiscriminatory in those with worse psychological status. When assessing the relationship between subjective and objective measures of chronic rhinosinusitis, accounting for effect modification may have practical utility.

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Impact of AAO-HNS Guideline on Obtaining Polysomnography Prior to Tonsillectomy for Pediatric Sleep-Disordered Breathing

Grace L. Banik,Rebecca M. Empey,Derek J. Lam

Publicatie 19-05-2020


To assess the impact of the 2011 American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) guideline on practice patterns in obtaining preadenotonsillectomy (AT) polysomnography (PSG) for pediatric sleep-disordered breathing (SDB). Retrospective cohort study. Tertiary children's hospital. The study population included all patients referred to our pediatric otolaryngology clinic for consideration of AT for SDB during two 12-month time periods: before (2010-2011) and after (2015-2016) publication of the 2011 AAO-HNS guideline. Demographic, insurance, comorbidity, and Pediatric Sleep Questionnaire (PSQ) variables were assessed for association with pre-AT PSG using bivariate and multivariate logistic regression analysis. A greater percentage of patients underwent pre-AT PSG in 2015-2016 vs 2010-2011 (30% vs 22%, After publication of the 2011 AAO-HNS guideline, there was a significant but modest increase in pre-AT PSG utilization in children with SDB and high-risk comorbidities at our institution, consistent with AAO-HNS guideline recommendations. However, overall guideline adherence remains low and may reflect limitations in PSG testing capacity.

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Weight Gain in Infants With Pierre Robin Sequence in the First Year of Life

Leo Li,Andrew R. Scott

Publicatie 19-05-2020


To compare growth trends among infants with Pierre Robin sequence (PRS) to normal World Health Organization (WHO) growth standards. Case series with chart review. Twenty-four infants with syndromic and nonsyndromic PRS (54% male) treated at an urban academic medical center between 2009 and 2017 were included. Infants with symptomatic hypoventilation underwent mandibular distraction osteogenesis (71%). Weights were recorded at roughly 1- to 3-month intervals from birth to 12 months, with ages adjusted for prematurity. The 50th percentile (P50) for this cohort was calculated and compared to WHO standards. In total, 135 weight entries for 24 subjects were included. The birth weight P50 was similar to the WHO standard (females: 0.09 kg above WHO [95% CI, -0.25 to +0.43; Newborns with and without PRS may have similar birth weights, but the growth rate among male and female infants with PRS may lag behind that of unaffected infants, even when upper airway obstruction has been addressed in early infancy.

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Ankyloglossia: Update on Trends in Diagnosis and Management in the United States, 2012-2016

Eric X. Wei,David Tunkel,Emily Boss,Jonathan Walsh

Publicatie 19-05-2020


Ankyloglossia, or "tongue-tie," refers to limited tongue mobility caused by a restrictive lingual frenulum. Previous studies have demonstrated rapid increases in diagnosis and treatment of ankyloglossia in the United States up to 2012. We performed an updated retrospective review of data from the National Inpatient Sample (NIS), Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality (AHRQ) to evaluate trends in diagnosis of ankyloglossia and use of lingual frenotomy in the hospital setting. From 2012 to 2016, there was an 110.4% increase in reported diagnosis of ankyloglossia in the inpatient setting with similar increases in lingual frenotomy procedures. As seen previously, sex, type of insurance, median income ZIP code, and geographic region were associated with diagnosis of ankyloglossia. The observed trends from prior to 2012 have continued to increase, while unanswered questions about diagnostic criteria and about which infants should undergo frenotomy remain.

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Neck Disability and Swallowing Function in Posttreatment Head and Neck Cancer Patients

Alexandria Harris,Lingyun Lyu,Tamara Wasserman-Winko,Susan George,Jonas T. Johnson,Marci Lee Nilsen

Publicatie 19-05-2020


To examine the relationship between symptoms of neck disability and swallowing dysfunction among head and neck cancer (HNC) survivors. Cross-sectional analysis. Single-center, university-affiliated HNC survivorship clinic. Survivors' patient-reported symptoms of neck disability and swallowing dysfunction were prospectively collected from March 2017 to May 2018. Neck disability and swallowing dysfunction were measured using the Neck Disability Index and Eating Assessment Tool (EAT-10), respectively. Linear regression was used to analyze the association between neck disability and swallowing dysfunction. A total of 179 survivors, predominantly male (n = 130, 72.6%) with an average age of 64.64 ± 9.91 years, were included in the analysis. Primary cancer sites were oropharynx (n = 85, 47.5%), oral cavity (n = 59, 33.0%), and larynx/hypopharynx (n = 35, 19.5%). Mean EAT-10 score was 10.07 ± 10.89 (range = 0-40; >2 indicative of swallowing dysfunction). Survivors treated for early stage cancer had lower EAT-10 scores than those with advanced stage (early = 3.55 ± 7.46; advanced = 11.95 ± 11.02, Swallowing dysfunction is a commonly recognized effect of HNC treatment. The prevalence and burden of neck disability are shown to be highly correlated with swallowing dysfunction. These results support the need for comprehensive, multidisciplinary rehabilitation interventions for patients with HNC.

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Plasma Ablation vs Other Hot Techniques for Tonsillectomy: A Meta-analysis

Guo Liu,Ciyun Xiao,Xu Zhou,Feng Liu

Publicatie 19-05-2020


To evaluate whether plasma ablation tonsillectomy is superior to other hot techniques in reducing postoperative morbidity. The databases of PubMed, EMBASE, and Web of Science were used to search the literature, from inception to January 2, 2020. Randomized controlled trials (RCTs) that compared plasma ablation tonsillectomy with any other hot techniques were eligible. A modified Cochrane tool was used to assess the risk of bias. The standardized mean difference (SMD) and 95% confidence interval (CI) were used to estimate pooled effects of postoperative pain, and the risk ratio (RR) was used for postoperative bleeding. Subgroup analysis was prespecified to explore the source of heterogeneity. The evidence quality of each outcome was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. A total of 15 RCTs were included (n = 1293). Comparing with other hot techniques, plasma ablation tonsillectomy may cause less pain on postoperative day 7 (SMD, -0.53; 95% CI, -0.84 to -0.23). However, the magnitude of the difference may be clinically meaningless. There were no significant differences not only in terms of postoperative pain on day 1 and day 3 but also in the incidence of postoperative bleeding, reoperation hemostasis, and return to normal diet and activities between the 2 groups. There is still substantial uncertainty on postoperative pain, bleeding, and recovery. The current evidence is insufficient to demonstrate that plasma ablation is superior to other hot techniques for tonsillectomy.

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Physician-Assisted Suicide for Patients with Head and Neck Cancer

Maxwell P. Kligerman,Vasu Divi

Publicatie 19-05-2020


A retrospective observational cohort study was conducted using data from Oregon's Death with Dignity Act (DWDA) to characterize patients with head and neck cancer (HNC) who seek physician-assisted suicide (PAS). Between 1998 and 2018, a total of 57 patients with HNC received DWDA prescriptions, of whom 39 (68.4%) died by administration of the prescribed medication. There were no associated complications with medication administration. The most commonly involved subsites were oral cavity (33.3%) and oropharynx (30.8%), and the most commonly cited end-of-life concerns were loss of ability to engage in activities that make life enjoyable (79.5%) and loss of autonomy (74.4%). There were no differences in age, race, marital status, or hospice enrollment rates between patients with HNC who died by administration and those who were prescribed but did not administer the medication. Patients who died by administration were generally less educated as compared to those who were prescribed but did not administer the medication (

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Obesity as a Predictor of Prolonged Mechanical Ventilation

Diana Shao,Jeffrey Straub,Laura Matrka

Publicatie 19-05-2020


To examine the effect of including obesity with parameters of the I-TRACH scale in predicting the need for prolonged mechanical ventilation. A retrospective cohort study. Tertiary care academic medical center. Consecutive patients were identified retrospectively over a 45-month period based on need for mechanical ventilation in the medical intensive care unit. Chart review was performed to collect demographic information as well as clinical data, including duration of mechanical ventilation, body mass index (BMI), and I-TRACH parameters (heart rate >110, serum urea nitrogen >25, serum pH <7.25, serum creatinine >2, serum bicarbonate <20). Statistical analysis was performed to identify any predictors of prolonged mechanical ventilation, defined as ≥14 days and as ≥10 days. In total, 455 patients were identified, with an average duration of mechanical ventilation of 10.4 days (range, 0-248 days). On univariate and multivariate regression analysis, only BMI >30 reached statistical significance with respect to prolonged mechanical ventilation ( This study challenges previous findings regarding the I-TRACH scale and the relation of its parameters to prolonged mechanical ventilation. Furthermore, BMI >30 alone was predictive of prolonged intubation. Inclusion of BMI in predictive models could assist current decision making in determining the likelihood of prolonged mechanical ventilation in medical intensive care unit patients going forward, and obesity should be considered a predictor of prolonged mechanical ventilation.

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Etiology of Prelingual Hearing Loss in the Universal Newborn Hearing Screening Era: A Scoping Review

Ashley Satterfield-Nash,Ayesha Umrigar,Tatiana M. Lanzieri

Publicatie 19-05-2020


To conduct a scoping review on etiologic investigation of prelingual hearing loss among children <2 years of age in the era of universal newborn hearing screening (UNHS). PubMed, Embase, PsycInfo, CINAHL, and Cochrane Library databases. We searched for articles published from January 1, 1998, to February 19, 2020. We reviewed studies that (1) included children identified with either congenital or delayed-onset hearing loss before 2 years of age among cohorts who had undergone UNHS and (2) investigated ≥1 etiologies of hearing loss. We defined hearing loss as congenital when confirmed after UNHS failure and as delayed onset when diagnosed after ≥1 assessments with normal hearing. Among 2069 unique citations, 115 studies met criteria for full-text assessment, and 20 met our inclusion criteria. Six studies tested children diagnosed with hearing loss for genetic etiology, 9 for congenital cytomegalovirus (CMV) infection, and 5 for both. Among 1787 children with congenital hearing loss and etiologic investigation, 933 (52.2%) were tested for genetic mutations and 1021 (57.1%) for congenital CMV infection. The proportion of congenital hearing loss cases attributable to genetic etiology ranged between 7.7% and 83.3% and to congenital CMV infection between 0.0% and 32.0%. Data are lacking on the identification and etiology of delayed-onset hearing loss in children <2 years of age in the UNHS era. The proportion of congenital hearing loss cases attributable to genetic etiologies and congenital CMV infection appears to vary widely.

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Management Patterns in Pediatric Complicated Sinusitis

Sean M. McDermott,Amanda Onwuka,Charles Elmaraghy,Patrick C. Walz

Publicatie 12-05-2020


Sinusitis is a common pediatric illness that can be complicated by periorbital or intracranial extension. Patients can be managed with antimicrobials alone or in conjunction with surgical intervention. This article examines management patterns and outcomes in pediatric patients presenting with complicated sinusitis. Case series with chart review. Tertiary care pediatric hospital. An evaluation of 168 pediatric patients with complicated sinusitis with periorbital complications presenting at a single institution from 2008 to 2018 was performed. Demographics, disease characteristics, in-hospital management, and outcomes were recorded and analyzed. The most common complication was orbital cellulitis, seen in 49% of children. Surgical intervention occurred in 49% of patients, with 36% receiving medical therapy followed by surgery (MTS). Chandler I patients underwent surgical intervention 30% of the time, Chandler II patients 29%, and Chandler III patients 83%. Nineteen percent of initially nonoperative patients started on ampicillin-sulbactam required MTS vs 57% of those started on other antibiotic regimens ( Nonoperative early stage patients started on ampicillin-sulbactam had a lower risk of MTS. MTS did not cost significantly more than SMT, and there were no significant outcome differences seen.

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Transcutaneous Electrical Stimulation Therapy in Obstructive Sleep Apnea: A Systematic Review and Meta-analysis

Young Jae Byun,Flora Yan,Shaun A. Nguyen,Eric J. Lentsch

Publicatie 05-05-2020


To evaluate the treatment efficacy of transcutaneous electrical nerve stimulation (TENS) in patients with obstructive sleep apnea (OSA). Primary studies were identified though PubMed, Scopus, OVID, and Cochrane Library. Systematic review was conducted by querying databases for articles published through July 2019. The search identified randomized controlled trial, randomized comparison, or observational studies pertaining to TENS treatment for OSA. Meta-analysis was performed on pre- and posttreatment apnea-hypopnea index (AHI), mean oxygen saturation (SaO Literature search identified 10 studies that reported sufficient outcome measures to be considered for analysis. A total of 198 patients were identified with a mean age of 50.9 years with a male to female ratio of 1.6:1. Average body mass index (BMI) of the cohort was 29.8 kg/m The TENS treatment of upper airway dilator muscles resulted in reduction of AHI in patients with OSA. However, its effects on SaO

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Palatine Tonsilloliths and Actinomyces: A Multi-institutional Study of Adult Patients Undergoing Tonsillectomy

Simone Arvisais-Anhalt,Andrew Quinn,Justin A. Bishop,Cynthia S. Wang,Ron B. Mitchell,Romaine F. Johnson,Barbara Schultz,Andrew T. Day

Publicatie 05-05-2020


To better characterize associations between Bi-institutional retrospective case-case study. University and county hospital. Adult patients with a clinical history of tonsilloliths who underwent tonsillectomy from January 2006 to December 2018 were included. Patients undergoing tonsillectomy for tonsillar hypertrophy and chronic tonsillitis were identified as comparative cases. Similarly, patients with ipsilateral oropharyngeal cancer (OPC) who underwent contralateral tonsillectomy of a normal-appearing tonsil for prophylaxis against a second primary cancer were also included as comparative cases. The study population comprised 134 patients who underwent tonsillectomy: 62 tonsillolith and 72 nontonsillolith (tonsillar hypertrophy, n = 30; chronic tonsillitis, n = 30; normal-appearing contralateral tonsil in patients with ipsilateral OPC, n = 12). The prevalence of

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