Annals of Otology Rhinology and Laryngology

Microlaryngeal Teaching Courses: A National Survey on Prevalence, Value, and Barriers to Implementation

01-02-2020 – Vaninder K. Dhillon,Seth H. Dailey,Lee M. Akst

Journal Article

To assess the prevalence of microlaryngeal teaching course in Accreditation Council for Graduate Medical Education (ACGME)-accredited otolaryngology residency programs in an effort to evaluate the nature, perceived value and barriers to implementation of microlaryngeal courses. A 14-question survey to all ACGME-accredited otolaryngology programs in the United States. Out of 119 ACGME-accredited otolaryngology programs identified on the ACGME Fellowship and Residency Electronic Interactive Database, responses were received from 67 programs (56%). Although 90% of respondents indicated that instruction courses in one discipline or another existed at their institution for their otolaryngology residents, only 33% indicated that their program offers a hands-on instruction course in microlaryngeal surgery. Of those programs that offered a microlaryngeal surgery course, 100% felt the residents appreciated the course; 95% of those programs that did not have a course felt their residents would appreciate a microlaryngeal course at their institution if they were able to offer one. Among programs without a microlaryngeal teaching course, the largest perceived barriers were cost and availability of appropriate equipment. Microlaryngeal courses for otolaryngology residency training are limited in availability in the United States, and there is variability in training across the country. All respondents in our survey indicated the value in these courses for microlaryngeal surgical skill training. There is a clear role for increasing availability of low-cost microlaryngeal stations and courses.

Revisit Rates for Pediatric Tonsillectomy: An Analysis of Admit and Discharge Times

01-02-2020 – Sapideh Gilani,Neil Bhattacharyya

Journal Article

To determine the association between intraday timing of outpatient pediatric tonsillectomy and revisit outcomes and complications. Cross-sectional analysis of New York databases. Ambulatory surgery, emergency department and inpatient hospital settings. The State Ambulatory Surgery, State Emergency Department and State Inpatient Databases for 2010-2011 were analyzed for revisits. Outcomes assessed were revisits for any reason, bleeding, acute pain or fever, nausea, vomiting and dehydration. The relationships between the hour of admission for surgery, the hour of discharge and the revisit outcomes were analyzed. The study included 33,611 children (mean age, 6.62 years; 45.7% female) and 62.0% were admitted in the early morning. Discharges were most common in the early afternoon (28.3%). Revisit rates were significantly higher for the early evening discharges (6.0%) versus late morning discharges (3.1%) ( Revisit are significantly higher when the patient is discharged late. Late afternoon surgery is also significantly associated with higher revisit rates. Surgeons may wish to consider these findings when a late tonsillectomy or late discharge is anticipated post-tonsillectomy.

Assessment of Tracheostomy and Laryngectomy Knowledge among Non-Otolaryngology Physicians

01-02-2020 – Tsung-yen Hsieh,Leah Timbang,Maggie Kuhn,Hilary Brodie,Lane Squires

Journal Article

Identify knowledge deficits about alternate airways (AAs) (tracheostomy and laryngectomy) among physicians across multiple specialties a tertiary institution and to assess the impact of an educational lecture on improving deficits. : Cross-sectional assessment. Otolaryngology physicians scored an average of 97.8%, while non-otolaryngology physicians scored 58.3% ( The care of patients with AAs requires an understanding of their basic principles. Our findings identify significant knowledge deficits among non-otolaryngologists. Through an instructional lecture, we demonstrated improvement in knowledge among non-otolaryngology physicians and durability of the knowledge after 3 months. Through an instructional lecture, we found tracheostomy and laryngectomy knowledge deficits can be identified and improved upon. Periodic reinforcement of basic principles for non-otolaryngology physicians may be a promising strategy to ensure the proper care of patients with AAs.

Incidence and Radiological Findings of Incidental Sinus Opacifications in Patients Undergoing Septoplasty or Septorhinoplasty

01-02-2020 – Sung Hee Kim,Jin Seok Oh,Yong Ju Jang

Journal Article

Although the routine use of computed tomography (CT) is controversial, it is employed in the preoperative screening of patients undergoing septoplasty or septorhinoplasty. The aim of this study was to evaluate the incidence and radiological characteristics of incidentally found sinus pathologies on screening CT in patients who underwent elective septoplasty or septorhinoplasty. We retrospectively reviewed the patients who underwent septoplasty and septorhinoplasty performed by a single surgeon (Y.
J.) at Asan Medical Center between January 2016 and December 2017. CT images of 372 patients who had agreed to undergo preoperative CT were reviewed to determine the location and extent of incidental sinus opacifications. Of the 372 patients, 107 (28.8%) showed incidental sinus lesions on CT images. Opacifications were mainly found in the maxillary sinus (73, 68.2%), followed by the ethmoid (34, 31.8%), sphenoid (10, 9.3%), and frontal (3, 2.8%) sinuses. The most common sinus lesion was retention cyst (55, 51.4%), and the second most common one was opacification and mucosal thickening (46, 43%). Other lesions such as osteoma (3, 2.8%), dental cyst (2, 1.9%), and mucocele (1, 0.9%) were rarely found. In patients undergoing septoplasty or septorhinoplasty, the incidence of incidental sinus lesions was approximately 28.8% (107/372). This results indicate that preoperative CT in patients undergoing septoplasty or septorhinoplasty might be helpful to surgeons not only for better understanding the anatomical detail but also for detecting hidden paranasal sinus disease.

Does Insurance Status Impact Delivery of Care with Upper Airway Stimulation for OSA?

01-02-2020 – Jena Patel,Michael C. Topf,Colin Huntley,Maurits Boon

Journal Article

To understand differences in patient demographics, insurance-related treatment delays, and average waiting times for Medicare and private insurance patients undergoing upper airway stimulation (UAS) for treatment of obstructive sleep apnea (OSA). Retrospective chart review of all Medicare and private insurance patients undergoing upper airway stimulation (UAS) from 2015 to 2018 at a single academic center. Primary outcomes were insurance-related procedure cancellation rate and time from drug induced sleep endoscopy (DISE) and UAS treatment recommendation to UAS surgery in Medicare versus private insurance patients. In our cohort 207 underwent DISE and were recommended treatment with UAS. Forty-four patients with Medicare and 30 patients with private insurance underwent UAS procedure. Patients with Medicare undergoing UAS were older (67.4 ± 11.1 years) than patients with private insurance (54.9 ± 8.1 years). Medicare patients had a shorter mean wait time of 121.9 ± 75.8 days (range, 15-331 days) from the time of UAS treatment recommendation to UAS surgery when compared to patients with private insurance (201.3 ± 102.2 days; range, 33-477 days). Three patients with Medicare (6.4%) and 8 patients with private insurance (21.1%) were ultimately denied UAS. Medicare patients undergoing UAS have shorter waiting periods, fewer insurance-related treatment delays and may experience fewer procedure cancellations when compared to patients with private insurance. The investigational status of UAS by private insurance companies delays care for patients with OSA. 4.

The Temporoparietal Fascia Flap is an Effective Strategy for Cochlear Implant Wound Coverage

01-02-2020 – Lucas Leonhard,Joseph Roche,Aaron Wieland,G Mark Pyle

Journal Article

To report the rate of major soft tissue complications after cochlear implantation and to describe the use of the temporoparietal fascia (TPF) flap for such complications. Retrospective case series. Tertiary care, University Hospital. Chart review of all patients who underwent cochlear device implantation over a 5-year period to identify patients and to determine the rate of soft tissue complications. Five patients with major soft tissue complications underwent TPF flap with device salvage or explantation/reimplantation. The rate of major skin complications was 6 out of 281 (2.1%) over 5 years, with 5 patients undergoing TPF flap. The average follow-up was 25.8 months (range, 5-58 months). TPF flap represented the definitive, successful solution for all 5 patients. One postoperative hematoma occurred after TPF flap, with no long-term sequelae. The average hospital length of stay was 2.2 nights (range, 1-5 nights). One patient required IV antibiotics for 4 weeks; the remaining patients were treated with a postoperative course of oral antibiotics. The original device remained in place for 4 patients, while one case required device explantation and staged re-implantation. Post-TPF flap hearing results were equal to if not superior to their preoperative results. Major soft tissue complications following cochlear device implantation are rare. The temporoparietal fascia flap is an excellent option for reconstruction of device site soft tissue dehiscences when local wound care and primary closure are not sufficient, and can potentially prevent explantation of a functional implant.

Current Opioid Prescribing Patterns after Microdirect Laryngoscopy

01-02-2020 – Molly N. Huston,Rouya Kamizi,Tanya K. Meyer,Albert L. Merati,John Paul Giliberto

Journal Article

The prevalence of opioid abuse has become epidemic in the United States. Microdirect laryngoscopy (MDL) is a common otolaryngological procedure, yet prescribing practices for opioids following this operation are not well characterized. To characterize current opioid-prescribing patterns among otolaryngologists performing MDL. A cross-sectional survey of otolaryngologists at a national laryngology meeting. Fifty-eight of 205 physician registrants (response rate 28%) completed the survey. Fifty-nine percent of respondents were fellowship-trained in laryngology. Respondents performed an average of 13.3 MDLs per month. Thirty-four percent of surgeons prescribe opioids for over two-thirds of their MDLs, while only 7% of surgeons never prescribe opioids. Eighty-eight percent of surgeons prescribed a combination opioid and acetaminophen compound, hydrocodone being the most common opioid component. Many surgeons prescribe non-opioid analgesics as well, with 70% and 84% of surgeons recommending acetaminophen and ibuprofen after MDL respectively. When opioids were prescribed, patient preference, difficult exposure and history of opioid use were the most influential patient factors. Concerns of opioid abuse, the physician role in the opioid crisis, and literature about postoperative non-opioid analgesia were also underlying themes in influencing opioid prescription patterns after MDL. In this study, over 90% of practicing physicians surveyed are prescribing opioids after MDL, though many are also prescribing non-opioid analgesia as well. Further studies should be completed to investigate the needs of patients following MDL in order to allow physicians to selectively and appropriately prescribe opioid analgesia postoperatively.

Comparing Urban Maxillofacial Trauma Patterns to the National Trauma Data Bank©

01-02-2020 – Jason E. Cohn,Kiara C. Smith,Jordan J. Licata,Alex Michael,Seth Zwillenberg,Tariem Burroughs,Oneida A. Arosarena

Journal Article

We aimed to determine whether certain maxillofacial fracture patterns and injury mechanisms were more prevalent in an urban environment. In addition, we aimed to determine if maxillofacial trauma incidence correlated with income. Data was collected from Einstein Healthcare Network and Temple University Health System. These data were compared to the 2016 National Trauma Data Bank© (NTDB©) using chi-square analysis. Multivariate analysis was used to identify correlations between demographic variables and fracture patterns. Sociodemographic data was further characterized utilizing neighborhood mapping. A total of 252 patients from our urban campuses and 14 447 patients from the NTDB© were identified with facial fractures. Maxillofacial trauma patients in the urban population were more likely to be minorities and less likely to be Caucasian compared to the NTDB© ( Maxillofacial trauma patterns and injury mechanisms were shown to be significantly different in an urban environment as compared to national data.

Computational Fluid Dynamic Analysis of Different Velopharyngeal Closure Patterns

01-02-2020 – Hanyao Huang,Heng Yin,Yang Wang,Nan Chen,Dantong Huang,Xiangyou Luo,Xing Yin,Qian Zheng,Bing Shi,Jingtao Li

Journal Article

Velopharyngeal (VP) closure has high impact on the quality of life, especially in patients with cleft palate. For better understanding the VP closure, it is important to understand the airflow dynamics of different closure patterns, including circular, coronal, sagittal, and circular with a Passavant’s ridge. The purpose of this study was to demonstrate the airflow characteristics of different velopharyngeal closure patterns. Sixteen adults with no notable upper airway abnormality who needed multislice spiral computed tomography scans as part of their clinical care. Airways were reconstructed. A cylinder and a cuboid were used to replace the VP port in three models of VP port patterns. Flow simulations were carried using computational fluid dynamics. Airflow pressures in the VP orifice, oral cavity and nasal cavity, as well as airflow velocity through the velopharyngeal orifice, were calculated. The airflow dynamics at the velopharynx were different among different velopharyngeal patterns as the area of the velopharyngeal port increased from 0 to 25 mm Airflow dynamics of the velopharynx were correlated to the velopharyngeal closure patterns. Different closure patterns had different largest permitted orifice areas for getting the appropriate oral pressures for normal speech.

Should Excess Topical Decongestant Use Raise a Red Flag? Rhinitis Medicamentosa and Opioid Use Disorder

01-02-2020 – Aneesh Patel,Jessica R. Levi,Christopher D. Brook

Journal Article

The objective of this study was to determine whether patients with rhinitis medicamentosa (RM) have an increased odds of having an opioid use disorder (OUD) and which characteristics may predict this association. The authors conducted a retrospective case control study of patients 18 years and older who presented to the otolaryngology clinic at an academic medical center from January 2013 through December 2017. Cases, defined as patients who presented with excessive decongestant nasal spray usage based on history, were matched to control patients who presented with chronic rhinitis and did not report regular nasal decongestant usage. The charts were reviewed for patients that carried a problem of opioid abuse, identified using ICD-9 codes 304.
XX or ICD-10 codes F11.
XX. The primary outcome of this study was the odds of having an OUD. Secondary outcomes were assessed by summary statistics. One hundred and thirty-one cases of RM were matched to 1871 controls of chronic rhinitis. Seven cases (5.3%) and 24 (1.3%) controls had a diagnosis of OUD, consistent with an odds ratio of 3.98 for opioid abuse in patients with RM (95% CI: 1.47-9.71). Oxymetazoline was used by 85.5% (n = 112) of patients with RM. Thirty-six patients (27.1%) with RM underwent nasal surgery following a diagnosis of RM, of which twenty patients (55.6%) were prescribed opioids following the procedure. RM is associated with increased odds of having an OUD.

Electronic Consults in Otolaryngology: A Pilot Study to Evaluate the Use, Content, and Outcomes in an Academic Health System

01-02-2020 – Sapideh Gilani,Krishna Bommakanti,Lawrence Friedman

Journal Article

To categorize the primary reasons for electronic consults (e
Consults) to otolaryngology from primary care physicians (PCPs). To determine how many patients avoided subsequent in-person otolaryngology office visits. This is a retrospective analysis of a pilot study that took place between 2016 and 2017 regarding e
Consults to adult otolaryngology placed by primary care physicians at the University of California, San Diego (UCSD) Medical Center. The complaints were categorized as related to the following: ear, nose, throat or neck. Initial recommendations were classified as (1) providing education only (no intervention), (2) suggesting medical therapy provided by the PCP, or (3) suggesting surgical intervention. Univariate statistics and multinomial logistic regression were used to analyze the association of problem type with the need for follow-up in the otolaryngology offices. The data was analyzed for differences in patient age and gender. The study population included 64 patients (average age 54.6 years, 60.9% male). Within this group, 41% of consults were for ear complaints, 15% for nose complaints, 28% had throat-related complaints, and 16% had neck-related complaints. In-person follow-up was not required for 82.8% of the consults. Overall, 76.9% of ear, 100% of nose, 88.9% of throat, and 70.0% of neck complaints did not require in-person visits. e
Consults to otolaryngology were primarily for ear concerns. Of the e
Consults, 82.4% did not require in-person follow-up. We therefore conclude that the use of e
Consults prevented substantial office visits that would not otherwise be necessary. Efforts should be made to promote the widespread use of e
Consults, which may to the more efficient use of resources.

Postoperative Opioid Use and Pain Management Following Otologic and Neurotologic Surgery

01-02-2020 – Christopher Boyd,Matthew Shew,Joseph Penn,Thomas Muelleman,James Lin,Hinrich Staecker,Helena Wichova

Journal Article

The topic of prescription opioid overuse remains a growing concern in the United States. Our objective is to provide insight into pain perception and opioid use based on a patient cohort undergoing common otologic and neurotologic surgeries. Prospective observational study with patient questionnaire. Single academic medical center. Adult patients undergoing otologic and neurotologic procedures by two fellowship trained neurotologists between June and November of 2018 were included in this study. During first postoperative follow-up, participants completed a questionnaire assessing perceived postoperative pain and its impact on quality of life, pain management techniques, and extent of prescription opioid use. A total of 47 patients met inclusion and exclusion criteria. The median pain score was 3 out of 10 (Interquartile Range [IQR] = 2-6) with no significant gender differences ( This study suggests that practitioners may over-estimate the need for opioid pain medication following otologic and neurotologic surgery. It also demonstrates the need for ongoing patient education regarding opioid risks, alternatives, and measures to prevent diversion.

Improving Tracheostomy Care in Resource-Limited Settings

01-02-2020 – Mykayla L. Sandler,Nohamin Ayele,Isaie Ncogoza,Susan Blanchette,Daphne S. Munhall,Brittanie Marques,Roger C. Nuss

Journal Article

Tracheostomy care in leading pediatric hospitals is both multidisciplinary and comprehensive, including generalized care protocols and thorough family training programs. This level of care is more difficult in resource-limited settings lacking developed healthcare infrastructure and tracheostomy education among nursing and resident staff. The objective of this study was to improve pediatric tracheostomy care in resource-limited settings. In collaboration with a team of otolaryngologists, respiratory therapists, tracheostomy nurses, medical illustrators, and global health educators, image-based tracheostomy education materials and low-cost tracheostomy care kits were developed for use in resource-limited settings. In addition, a pilot study was conducted, implementing the image-based tracheostomy pamphlet, manual suctioning device and low-cost ambulatory supply kit (“Go-Bags”), within a low-fidelity simulated training course for nurses and residents in Kigali, Rwanda. An image-based language and literacy-independent tracheostomy care manual was created and published on OPENPediatrics, an open-access online database of clinician-reviewed learning content. Participants of the training program pilot study reported the course to be of high educational and practical value, and described improved confidence in their ability to perform tracheostomy care procedures. Outpatient tracheostomy care may be improved upon by implementing image-based tracheostomy care manuals, locally-sourced tracheostomy care kits, and tailored educational material into a low-fidelity simulated tracheostomy care course. These materials were effective in improving technical skills and confidence among nurses and residents. These tools are expected to improve knowledge and skills with outpatient tracheostomy care, and ultimately, to reduce tracheostomy-related complications.

Horner Syndrome from a Pediatric Otolaryngology Perspective

01-02-2020 – Kyra N. Folkert,Heather de Beaufort,Nancy M. Bauman

Journal Article

Horner syndrome is described as the clinical triad of miosis, ptosis, and anhidrosis. In pediatric patients the condition may be congenital or acquired from neoplastic, infectious or traumatic conditions, including birth trauma. Most cases of pediatric Horner syndrome present first to a pediatric ophthalmologist however since the neural pathways involve the cervical sympathetic chain otolaryngologists should understand the pathophysiology to avoid delay in management of potentially malignant cases. To aid otolaryngologists in recognizing and managing pediatric Horner syndrome by describing 3 unique cases from malignant, traumatic and/or congenital causes. Case report of 3 pediatric patients with Horner syndrome presenting to our pediatric otolaryngology department. Case #1 is 5-month-old female with ptosis and a left level II 1.5 cm neck mass. Magnetic resonance imaging showed the mass displacing the common carotid artery and excisional biopsy revealed a poorly differentiated neuroblastoma. Case #2 is a 9-year-old female with anisocoria appearing after suffering a severe playground injury. Case #3 is a 3-year-old-male who developed ptosis and anisocoria following re-excision of a recurrent cervical lymphatic malformation. Pediatric Horner syndrome may be a benign finding that is easily overlooked but may reflect a serious underlying condition. Otolaryngologists should be aware of the pathophysiology and differential diagnosis, including malignant causes, to appropriately manage patients.

Sterno-omohyoid Free Flap for Dual-Vector Dynamic Facial Reanimation

01-02-2020 – Aurora G. Vincent,Scott E. Bevans,Jon M. Robitschek,Kelly L. Groom,Marc W. Herr,Marc H. Hohman

Journal Article

Dynamic rehabilitation of longstanding facial palsy with damaged, atrophied, or absent facial muscles requires replacement of neural and muscular components. The ideal reconstruction would include a fast-twitch muscle that is small, a reliable donor vessel and nerve, and the potential to provide a natural, synchronous, dentate smile with minimal donor site morbidity. Many flaps have been successfully used historically, but none has produced ideal rehabilitation. To evaluate the novel sterno-omohyoid, dual-vector flap in rehabilitation of chronic facial paralysis. We performed sterno-omohyoid free tissue transfer for smile reanimation in a 39-year-old male with a history of longstanding right facial palsy following resection of a skull base tumor several years previously. We transferred both muscles with the superior thyroid artery, middle thyroid vein, and ansa cervicalis. The patient developed a dynamic smile by 6 months postoperatively, and he had improved objective facial symmetry. Herein, we demonstrate the first use of the sterno-omohyoid flap for successful facial reanimation. Overall, it is a novel flap in facial reanimation with many advantages over traditional flaps, including the potential to produce a more synchronous, dynamic smile while adding minimal bulk to the face. Future series will better elucidate the potential of the sterno-omohyoid flap.

Autologous Fat Injection Pharyngoplasty in Adults with Velopharyngeal Insufficiency

01-02-2020 – Kevin J. Contrera,William S. Tierney,Paul C. Bryson

Journal Article

Understand the utility and technique of injection pharyngoplasty with autologous fat for the treatment of mild to moderate velopharyngeal insufficiency in adults without a history of cleft palate. Consecutive case series of 11 patients (mean [SD] 41 ± 21 years of age) who underwent injection pharyngoplasty with autologous fat from 2012 to 2018 at a tertiary care center. Patients were followed for a mean of 8.6 ± 8 months with pre versus postoperative evaluations of improvement in rhinophonia, dysphagia, and velopharyngeal closure by nasopharyngoscopy (scored: 0, none; 1, mild; 2, moderate; 3, near-complete; 4, complete). Patient selection and surgical techniques are described. Mean improvements were 2.3 ± 0.86 for rhinophonia, 2.0 ± 0.89 for dysphagia, and 3.0 ± 0.95 for velopharyngeal closure by nasopharyngoscopy. Five (45%) patients underwent subsequent intervention, including four repeat fat injections and three sphincter pharyngoplasties. There were two transient complications-donor site hematoma and subjective nasal obstruction. Although objective assessments are lacking to date, this is among the first reports to demonstrate the effectiveness and safety of injection pharyngoplasty with autologous fat for velopharyngeal insufficiency in a population of adults without a history of cleft. We found, on average, moderate improvement in rhinophonia and dysphagia, and near-complete improvement in velopharyngeal closure by nasopharyngoscopy; however, a portion of patients required subsequent intervention.

Image Guided Sclerotherapy of Masseteric Venous Malformations

09-01-2020 – Subhash Kumar,Kranti Bhavana,Bindey Kumar,Amit Kumar Sinha,Prem Kumar

Journal Article

To describe results of image guided sclerotherapy of venous malformations (VM) localized in the masseter muscle. Retrospective review of prospectively maintained data was done to include consecutive cases treated over 5-year period, with minimum 6 months follow-up. Sclerotherapy was done using ultrasound (US) guided needle puncture(s) of the lesions percutaneously, and 3% polidocanol foam injected under image guidance. Seventeen cases (10 male, 7 female) with mean age 15.6 years (range 6-28 years) were identified. Clinical presentation was with facial asymmetry, becoming pronounced on jaw clenching, and three cases had mild local pain. On US, the lesions appeared as partially compressible masses with anechoic spaces, showing color filling on releasing probe pressure. Fourteen had phleboliths. Eight patients had undergone magnetic resonance imaging, lesions appearing as oval, homogenous, lobulated, T2 hyperintense masses, with heterogeneous contrast enhancement. Number of sclerotherapy sessions were-single in four cases, two in eight cases and three in five cases, for total of 35 sessions (average 2.05 session per patient). The mean dose of drug injected per session was 1.85 m
L and total mean dose per patient was 2.79 m
L. Post-procedure vomiting occurred in one patient while all had local swelling and mild pain, lasting between 3 to 7 days. No facial nerve palsy or sloughing/ulceration/skin necrosis was noted. On US follow-up (6-26 months, mean 15.9 months), 12 patients had small echogenic masses without any vascularity, and five had small anechoic areas <25%. All patients had complete resolution of swelling and pain. For VMs localized to the masseter muscle, image guided sclerotherapy is highly effective and safe, and recommended as first line treatment.

Correlation of Nasal Fluid Biomarkers and Symptoms in Patients with Persistent Allergic Rhinitis

09-01-2020 – Su Il Kim,Oh Eun Kwon,Jung Min Park,Jeon Gang Doo,Seok Hyun Kim,Hae Rim Jung,Jin Young Min,Sung Wan Kim,Young Chan Lee,Young-Gyu Eun

Journal Article

This study investigated whether the biomarkers present in nasal fluid reflect the severity of symptoms in patients with persistent allergic rhinitis (PAR). We enrolled 29 PAR patients complaining of nasal symptoms and testing positive to skin prick test. Patients’ total nasal symptom score (TNSS) was measured and their nasal lavage fluid (NALF) was collected. The levels of biomarkers including Clara cell protein 16 (CC16), tryptase, and interleukin 5 (IL-5) in NALF were determined via enzyme-linked immunosorbent assay (ELISA). PAR patients were classified into persistent mild and persistent moderate-to-severe groups according to the Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines. The CC16 alone was significantly negatively correlated with TNSS ( The levels of CC16 alone among several NALF biomarkers showed an inverse correlation with symptoms of PAR patients.

Botulinum Toxin for the Treatment of Motor and Phonic Tics: A Case Report

08-01-2020 – Nikita Kohli,Andrew Blitzer

Journal Article

To present a unique approach to the treatment of motor and phonic tics. A 26-year-old male presented with motor and phonic tics including grunting, coughing, and throat clearing. The patient was treated with 2.5 units of onabotulinum toxin A (Bo
NT) to the facial mimetic musculature and 2.5 units to each supraglottic musculature via a transthyrohyoid membrane approach under fiberoptic visualization. The patient experienced reduction in the frequency, intensity, and interference with daily life of motor and phonic tics on the Yale Global Tic Severity Scale (YGTSS). This patient experienced subjective and objective decreases in tic severity using a unique approach in the treatment of phonic tics. Results suggest a novel approach in the treatment of phonic tics and bolster the data regarding safe and effective use of Bo
NT for tic disorder. Level V, case report.

Dual Coaptation of Facial Nerve Using Masseteric Branch of Trigeminal Nerve for Iatrogenic Facial Palsy: Preliminary Reports

01-01-2020 – Yoon Se Lee,Joong Ho Ahn,Hong Ju Park,Ho Jun Lee,Mi Rye Bae,Jong-Lyel Roh,Seung-Ho Choi,Soon Yuhl Nam,Sang Yoon Kim

Journal Article

Immediate facial nerve substitution or graft technique has been used for the repair of facial nerve defects occurring as a result of tumour dissection. However, some patients report unsatisfactory outcomes, such as difficulty in maintaining resting or smiling symmetry, due to persistent flaccid facial palsy. Here we evaluated the functional outcomes of transferring the masseteric branch of the trigeminal nerve to the facial nerve adjunct to facial nerve graft. We reviewed the medical records of seven patients who underwent facial reanimation surgery between 2014 and 2016. The patients were divided into two groups according to the type of facial reanimation surgery: group A, masseteric nerve innervation with interposition graft; group B, interposition graft only. The postoperative resting symmetry and dynamic movement were compared. Facial contraction was first observed in group A at 4 months and in group B at 7.3 months. Most of the patients achieved reliable resting symmetry; however, one patient in group B exhibited unsatisfactory facial weakness on the affected side. Group A patients showed better dynamic movement than group B patients. Eye closure, oral excursion and oral continence were better in group A than in group B patients. Smile symmetry in both groups was similar due to hyperkinetic movement in group A patients and flaccidity in group B patients. Dual innervation of the masseteric branch of the trigeminal nerve improves the dynamic movement of paralysed facial muscles and shortens the recovery period in patients with iatrogenic facial palsy.

The Association of Serum Eosinophilia with Structured Histopathology in Chronic Rhinosinusitis

01-01-2020 – Ashwin Ganti,Hannah N. Kuhar,Mike Eggerstedt,Mahboobeh Mahdavinia,Paolo Gattuso,Pete S. Batra,Bobby A. Tajudeen

Journal Article

Prior studies have demonstrated associations between serum eosinophilia and chronic rhinosinusitis (CRS) pathogenesis. However, the association of serum eosinophilia with histopathology profiling in CRS has not been fully delineated and may help better characterize CRS disease burden prior to surgery. A structured histopathology report of 13 variables was utilized to analyze sinus tissue removed during functional endoscopic sinus surgery (FESS). Complete blood count (CBC) with differential was drawn within 4 weeks prior to FESS. Serum eosinophilia was defined as >6.0% (>0.60 th/μL). Histopathology variables were compared among patients. A total of 177 CRS patients (37 with serum eosinophilia and 140 with normal serum eosinophilia) were analyzed. Compared to CRS patients with normal serum eosinophil counts, CRS patients with serum eosinophilia demonstrated increased polypoid disease (67.6% vs 35.0%, CRS patients with serum eosinophilia demonstrated severe disease burden on histopathology with high levels of polypoid disease and tissue eosinophilia. However, a considerable number of patients without serum eosinophilia demonstrated eosinophilic disease on histopathology, indicating that preoperative serum eosinophilia alone could not be reliably used to predict eosinophilic CRS. 4.

Effect of Unilateral Cordotomy on Perception of Dysphagia

01-01-2020 – Melissa Conklin,Matthew S. Clary,Elizabeth M. Cuadrado,Marie E. Jetté

Journal Article

CO Retrospective review was performed on sequential patients having undergone unilateral CO Fifteen patients were available for analysis; 10 patients underwent primary unilateral medial transverse cordotomy, 5 patients underwent revision cordotomy, and 20 unique procedures were included in the dataset. The median EAT-10 score during the visit prior to surgery was 3.5, whereas the post-surgery median score was 2. Furthermore, the median difference of 0 was statistically non-significant ( CO

Juvenile Nasopharyngeal Angiofibroma Outcomes and Cost: Analysis of the Kids’ Inpatient Database

27-12-2019 – Justin Yu,Jonathan S. Choi,Carla Giannoni,Akash J. Patel,K. Kelly Gallagher

Journal Article

To report trends in Juvenile Nasopharyngeal Angiofibroma (JNA) hospitalizations and identify key factors affecting treatment outcomes and cost of care in JNA patients. The Healthcare Cost and Utilization Project (HCUP) Kids’ Inpatient Database was queried for all cases of JNA between the years of 1997 and 2016. Key factors extracted were patient demographics, geographic region, hospital size, teaching status, elective admissions, and number of diagnoses and procedures performed during the hospitalization. These elements were correlated to length of stay (LOS) and cost-per-day (CPD) using a multiple linear regression (MLR). Regional variation in JNA diagnosis and changes in LOS and CPD trends over time were also analyzed. A total of 614 JNA patients were hospitalized in this time period, with a majority of patients identifying as male (98%) and Caucasian/White (55%). The average LOS has decreased by 0.14 day per year since 1997 ( These results indicate hospital characteristics, such as teaching status and geographic region, may predict differences in JNA outcomes and cost. Healthcare providers should be cognizant of these variations to ensure optimal patient outcomes and expenditures.

Supraglottoplasty in Neonates under One Month of Age

26-12-2019 – Peter Nagy,Samuel Dudley,Anthony Sheyn

Journal Article

Examine outcomes of patients 1 month of age or less who received supraglottoplasty. Demonstrate the feasibility and safety of supraglottoplasty in neonates <1 month of age. Charts were reviewed from 2015-2017. Patients with previously identified laryngomalacia requiring surgical intervention and age 1 month or less were identified. We collected data on age, gender, surgical technique, other airway lesions, time to extubation and discharge, and comorbidities. Six patients met the inclusion criteria of which four were male and two were female. Average age at time of surgery was 19.5 days. All patients had diagnosis of laryngomalacia made on flexible or direct laryngoscopy with increased work of breathing, reports of cyanotic episodes, or oxygen desaturations. All had feeding difficulties, and three had signs and history consistent with gastroesophageal reflux. Two patients underwent supraglottoplasty by CO Supraglottoplasty in children younger than 1 month of age is rare. Despite the rare occurrence, it appears to be feasible early in life in treating laryngomalacia. Neonates with respiratory failure, apneas, and cyanosis, or difficulty feeding due to laryngomalacia should be evaluated and treated with supraglottoplasty.

Abscopal Effect Following Immunotherapy and Combined Stereotactic Body Radiation Therapy in Recurrent Metastatic Head and Neck Squamous Cell Carcinoma: A Report of Two Cases and Literature Review

26-12-2019 – Jonathan S. Choi,Eugene R. Sansoni,Benjamin D. Lovin,Nathan R. Lindquist,Jack Phan,Lauren L. Mayo,Renata Ferrarotto,Shirley Y. Su

Journal Article

We present two patients with recurrent, metastatic head and neck squamous cell carcinoma (R/M HNSCC) after platinum-based chemotherapy and radiotherapy (RT) with complete response via abscopal effect following combined immunotherapy (IT) and stereotactic body radiation therapy (SBRT). We review the literature for patients undergoing combined treatment with IT and RT to identify potential cases of abscopal response. This is a case series with a contemporary review of the literature. Retrospective chart review identified two patients with potential abscopal responses after IT and RT for R/M HNSCC. The MEDLINE database was queried using the search terms “abscopal AND head and neck squamous cell carcinoma” and “immunotherapy AND stereotactic body radiation therapy.” Two patients with metastatic HNSCC developed complete responses via a possible abscopal effect following combined SBRT and IT. Interim follow-up of both patients revealed a sustained, complete response. We examine the immunogenic effects of RT and report the first cases of potential abscopal effect for R/M HNSCC. We also review several preclinical studies demonstrating the synergistic efficacy of combined RT and IT with a discussion of possible mechanism. Observation of abscopal effect with combined IT and RT is currently under investigation through several preclinical studies and trials. To the best of our knowledge, these are the first two reported cases of abscopal effect for patients with HNSCC. We report two patients with R/M HNSCC with sustained, complete response after systemic IT and local RT.

Jet Ventilation in the Pregnant Patient with Airway Stenosis: Surgical Safety and Outcomes

24-12-2019 – Philip D. Heichel,Christian P. Jacobsen,Luis L. Llamas,C. Blake Simpson,David G. Lott,Sunil Verma,Laura M. Dominguez

Journal Article

To review pregnancy outcomes and the safety of jet ventilation use in the gravid patient undergoing surgical airway intervention. A multi-institutional retrospective review of medical records was performed to identify women who underwent low-frequency jet ventilation during pregnancy for surgical treatment of airway stenosis. Postoperative complications were noted, and patients were interviewed regarding pregnancy outcomes. Six women were included in this series. No immediate complications relating to anesthesia or surgical intervention were noted in five of the six women. One patient with a well-known history of uncontrolled seizures experienced seizure activity postoperatively. One patient returned to the operating room at a later date for debridement of tracheal crusts. Five mothers delivered via cesarean section and one via spontaneous vaginal delivery. The mean gestation age was 37.3 weeks. One of the six infants delivered prematurely and three were delivered at low birth weight. Three of the six infants required elevated care immediately post-delivery but, at present, all are in good health. Low-frequency jet ventilation and surgical management of airway stenosis should be recognized as a safe treatment option in the gravid patient. Surgical intervention should not be delayed in patients with severe symptoms, particularly given the potential risk associated with prolonged corticosteroid use. 4.

Lateral Neck Radiography in Preoperative Evaluation of Adenoid Hypertrophy

24-12-2019 – Liuba Soldatova,Hansel J. Otero,David A. Saul,Christian A. Barrera,Lisa Elden

Journal Article

To assess the value of lateral neck radiographs in quantifying adenoid hypertrophy to help guide treatment decisions in patients with symptoms of nasal obstruction. Retrospective review. Quantitative radiologic grading of adenoids was correlated with the intraoperative grading to select cases in agreement between the two methods. The percent airway obstruction was calculated as a ratio of adenoid size to the size of the nasopharyngeal airway near the level of the choanae on the lateral neck radiographs for adenoidectomy cases in which radiographic and intraoperative grading of adenoid size were in agreement. A total of 426 adenoidectomy cases with preoperative lateral neck radiographs were reviewed (M:F = 254:172 for age range 9 months to 16 years), and only cases in agreement between radiographic and intraoperative adenoid grading were included in radiographic analysis (N = 234). The percent airway obstruction values were significantly different between “severely obstructive” (N = 137, mean = 94.71, SD = 6.55, range [72.00; 100.00]) and “moderately obstructive” adenoid categories (N = 97, mean = 78.53, SD = 6.91, range [63.67; 98.08]), not only within clinically relevant age groups (1-3 years, 4-7 years, 8-15 years), but also for the entire data set (95% CI [14.41; 17.95], Lateral neck radiographs can provide useful supplemental information on the degree of nasopharyngeal airway obstruction when other clinical findings do not clearly point toward adenoid hypertrophy as a primary cause of nasal obstruction. In our data set, a 65% nasopharyngeal airway obstruction represents a value two standard deviations below the mean for “moderately” obstructive adenoid category, and can be viewed as a simplified cut-off to indicate that the degree of adenoid enlargement is clinically relevant. This cut-off value can assist in evaluation of patients with symptoms of nasal obstruction. 4.

Fiberoptic Endoscopic Evaluation of Swallowing in Infants and Children: Protocol, Safety, and Clinical Efficacy: 25 Years of Experience

18-12-2019 – Claire Kane Miller,Jay Paul Willging

Journal Article

The application of fiberoptic endoscopic evaluation of swallowing (FEES) in the pediatric dysphagia protocol requires specialized knowledge of pediatric conditions that result in dysphagia, recognition of normal and abnormal laryngopharyngeal anatomy and function across ages, and the ability to identify maturational changes in anatomy and function of the aerodigestive tract that pertain to airway protection and swallowing function. Over the past 25 years, we have performed over 7,000 collaborative Otolaryngology and Speech-Language Pathology FEES examinations in patients ranging from 2 days of age to young adults. During this time period, we have monitored the safety of the procedure, explored the feasibility and utility of FEES across conditions, compared and contrasted FEES to the videofluoroscopic evaluation of swallowing (VFSS), and developed specific pediatric FEES protocols with operational definitions for identification and interpretation of swallowing parameters. FEES has proved to be a safe procedure in patients across ages. There have been no significant adverse events. FEES is comparable to the VFSS in the assessment of events before and after the swallow. It provides unique information regarding laryngopharyngeal anatomy and function, airway protection integrity, sensory threshold, and secretion management ability, as well as pharyngeal swallowing dynamics and the efficacy of compensatory swallowing strategies. There are specific indications and contraindications for pediatric FEES, and unique components that characterize the pediatric FEES protocols across ages and conditions. FEES procedures performed jointly by an Otolaryngologist and Speech-Language pathologist offer a team approach to interpretation and management recommendations.

Competitiveness of Otolaryngology Residency Applicants without a Home Program

18-12-2019 – James C. Wang,Pranati Pillutla,Nadia Tello,Rebecca Gabrilska,Mayank Aranke,Terrell Bibb,Philip D. Watkins,Joehassin Cordero

Journal Article

Investigate if otolaryngology residency home programs (HP) are associated with advantages in National Resident Matching Program match compared to applicants without HPs. Surveys were distributed to fourth-year medical students applying to otolaryngology residency (2015-2016 cycle) via OHNS (2015-2016) Applicants Closed Facebook Page and Otomatch. Applicant data analyzed included HP, United States Medical Licensing Examination (USMLE) scores, number of away rotations, and matching at top choice. Applicants were grouped: (1) HP, (2) no HP but have ENT staff (staff), and (3) no HP or staff (none). Ninety-five percent of survey participants matched into otolaryngology (n = 62). A sub-analysis of match preference among matching applicants revealed 63% of participants with HP matched to their first choice compared to 56% (staff) and 14% (none) ( Applicants applying to otolaryngology residency without HPs are as competitive as those who have HPs. However, without HPs, applicants tend to participate in more away rotations and are less likely to match at their top choice.

Cost Analysis of Implants in the Surgical Repair of Orbital Floor Fractures

14-12-2019 – Mark M. Mims,Eric W. Wang

Journal Article

Options for the management of orbital floor fractures continue to evolve offering both potential advantages as well as higher costs. To date, the effect of implant choice on the cost associated with the repair of orbital floor fractures has not been studied. A retrospective review at a tertiary care, level I trauma center examining all adult, uncomplicated orbital floor fractures that underwent open reduction and internal fixation from 2013 to 2016. Patients with concurrent operative facial fractures were excluded. The main outcomes were overall cost of care from injury to last follow-up and operating room-related costs. Costs were determined using computerized records of charges as well as the hospital Charge Description Master. Kruksal-Wallis rank sum tests were used to analyze for differences between groups. Twenty-eight patients fulfilled the inclusion criteria. Eight different stock, non-patient specific, implants were used for repair. The cost of individual types of implants ranged from $70.25 to $7 718.00. Total cost of care per patient across all implant types averaged $35 585.57 (range $25 586.26 to $49 985.74, In the setting of uncomplicated orbital floor fractures, surgeons should select an implant that allows them to carry out the repair in a safe, timely fashion. Additional large-scale studies would help to further delineate cost differences.

Centering a Deviated Nose by Caudal Septal Extension Graft and Unilaterally Extended Spreader Grafts

12-12-2019 – Yung Yuan Chen,Shin Ae Kim,Yong Ju Jang

Journal Article

The deviated nose presents a tremendous challenge for rhinoplasty surgeons, especially the correction of the cartilaginous dorsum deviation. In this study, we introduce the surgical techniques of correcting a deviated cartilaginous vault by creating a new center of the lower third using a caudal septal extension graft combined with unilaterally extended spreader grafts. This retrospective observational study was conducted in a university-based tertiary medical center from December 2014 to January 2018. Thirty-two patients who underwent primary open rhinoplasty for correction of a deviated nose using this method participated in the study. Patient characteristics and surgical records were collected. Anthropometric measurements and analyses were performed based on preoperative and postoperative photographs. The aesthetic outcome consensus of three rhinoplasty surgeons was evaluated specifically for nasal dorsum deviation correction. Postoperative complications were reviewed from the medical records. Among the 32 patients, there were 18 males and 14 females. The mean (SD) age of the patients was 26.7 (8.76) years. Anthropometric measurements showed significant improvements in dorsal deviation angle (a 3.7° change towards midline, Centering the cartilaginous vault using a caudal septal extension graft combined with unilaterally extended spreader grafts is a useful technical option in the correction of a deviated nose, and provides improvement in nasal tip projection and nostril shape.

The Ponticulus Ethmoidalis: A Newly Appreciated Anatomic Landmark in Endoscopic Sinus Surgery

12-12-2019 – William E. Bolger,Masaru Ishii,Meiyappan Solaiyappan,S. James Zinreich

Journal Article

Ethmoid sinus anatomy is so variable it has been referred to as a “labyrinth.” Accordingly, this provides a challenge for surgeons performing ethmoidectomy. Identifying consistent anatomic features or landmarks within the ethmoid sinus can aid surgeons performing sinus surgery. The goal of this investigation was to determine if subtle anatomic features are consistently present within the retrobullar recess and could potentially serve as a reliable landmark for surgeons performing ethmoid surgery. Ethmoid sinus anatomy was studied in 60 sinonasal complexes through several methods including gross anatomic dissection, endoscopic dissection and 3-D CT stereoscopic imaging. Review of gross sagittal sinonasal specimens revealed that the retrobullar recess was present in all specimens and a tissue bridge was noted emanating from the basal lamella deep within the retrobullar recess in 23/24 gross sagittal specimens; in 1/24 specimens it was quite small or difficult to appreciate. In the radiographic analysis, the tissue bridge was noted in 17/18, in 1/18 it was not appreciated. In the endoscopic dissections it was noted in 17/18, in 1/18 it was small or not appreciated. The small tissue bridge, or ponticulus within the retrobulbar recess was seen in nearly all ethmoid sinuses studied leading us to venture that could be used in surgery to orient surgical dissection through the basal lamella into the posterior ethmoid region.

The Impact of Betahistine versus Dimenhydrinate in the Resolution of Residual Dizziness in Patients with Benign Paroxysmal Positional Vertigo: A Randomized Clinical Trial

08-12-2019 – Mir Mohammad Jalali,Hooshang Gerami,Alia Saberi,Siavash Razaghi

Journal Article

The aim of this study was to compare the effects of betahistine with dimenhydrinate on the resolution of residual dizziness (RD) of patients with benign paroxysmal positional vertigo (BPPV) after successful Epley maneuver. In this double-blind, randomized clinical trial, patients with posterior semicircular canal type of BPPV were included. After execution of the Epley maneuver, patients were assigned randomly to one group for 1 week: betahistine, dimenhydrinate or placebo. The primary outcomes were scores of the Dizziness Handicap Inventory (DHI) and the modified Berg balance scale (m
BBS). All patients were asked to describe the characteristics of their subjective residual symptoms. Binary logistic regression analysis was performed to examine the predictors of improved RD. All analyses were conducted using SPSS 19.0. In total, 117 patients (age range: 20-65 years) participated in this study. After the Epley maneuver, 88 participants had RD. After the intervention, 38 patients exhibited an improved RD. Less than 50% of participants in the three groups showed mild to moderate dizziness handicap. However, there was no significant difference between m
BBS scores of groups before or after the intervention. Logistic regression was shown that patients with receiving betahistine were 3.18 times more likely to have no RD than the placebo group. Increasing age was associated with a decreased likelihood of improving RD ( The analysis of data showed that the use of betahistine had more effect on improving RD symptoms. We recommended future studies using objective indicators of residual dizziness.

Pediatric Drug Induced Sleep Endoscopy: A Simple Sedation Recipe

07-12-2019 – Adam C. Adler,Mary F. Musso,Deepak K. Mehta,Arvind Chandrakantan

Journal Article

To describe a minimalist approach to sedating children for DISE procedures. We searched existing literature and derived and tested our algorithm on patients using evidence-based studies. We were able to successfully sedate, without airway intervention, 15 highly complex children with a variety of comorbidities for DISE procedures. We describe a minimalistic sedation approach for DISE procedures in highly complex children. Further studies are required to compare this regimen to natural sleep states.

Efficacy of Multi-Modal Migraine Prophylaxis Therapy on Hyperacusis Patients

04-12-2019 – Mehdi Abouzari,Donald Tan,Brooke Sarna,Yaser Ghavami,Khodayar Goshtasbi,Erica M. Parker,Harrison W. Lin,Hamid R. Djalilian

Journal Article

To evaluate the efficacy of a multi-modal migraine prophylaxis therapy for patients with hyperacusis. In a prospective cohort, patients with hyperacusis were treated with a multi-modal step-wise migraine prophylactic regimen (nortriptyline, verapamil, topiramate, or a combination thereof) as well as lifestyle and dietary modifications. Pre- and post-treatment average loudness discomfort level (LDL), hyperacusis discomfort level measured by a visual analogue scale (VAS), and scores on the modified Khalfa questionnaire for severity of hyperacusis were compared. Twenty-two of the 25 patients (88%) reported subjective resolution of their symptoms following treatment. Post-treatment audiograms showed significant improvement in average LDL from 81.3 ± 3.2 d
B to 86.4 ± 2.6 d
B ( The majority of patients with hyperacusis demonstrated symptomatic improvement from migraine prophylaxis therapy, as indicated by self-reported and audiometric measures. Our findings indicate that, for some patients, hyperacusis may share a pathophysiologic basis with migraine disorder and may be successfully managed with multimodal migraine prophylaxis therapy.

Vagus Associated Neurogenic Cough Occurring Due to Unilateral Vascular Encroachment of Its Root: A Case Report and Proof of Concept of VANCOUVER Syndrome

04-12-2019 – Christopher R. Honey,Marie T. Krüger,Murray D. Morrison,Baljinder S. Dhaliwal,Amanda Hu

Journal Article

A patient is presented with neurogenic cough due to a unilateral vascular compression of a vagus nerve rootlet at the brainstem with complete resolution of cough following microvascular decompression of that nerve. This etiology of a neurogenic cough has not been previously reported to our knowledge. The proportion of patients with neurogenic cough refractory to all current therapies and suffering with this treatable condition remains to be defined. We introduce the concept of Vagus Associated Neurogenic Cough Occurring due to Unilateral Vascular Encroachment of its Root (VANCOUVER syndrome) and present the salient features of this condition. A case review is presented with details of the patient’s history, examination, imaging, laryngoscopy, intraoperative findings, and long-term clinical outcome. A 60-year-old man presented with a 15-year history of non-productive cough refractory to antibiotics, and anti-reflux medications. Investigations by an allergist, a cardiologist, a gastroenterologist, two pulmonologists, and an otolaryngologist were negative. MRI demonstrated a vascular compression of his left vagus nerve and microvascular decompression of that nerve resolved his symptoms. There were no surgical complications and the patient remains asymptomatic at 1 year. Neurogenic cough has been likened to a vagus nerve neuropathy in a similar way that trigeminal neuralgia is a trigeminal nerve neuropathy. Both cause intermittent sensory phenomena in their distribution and can be ameliorated with neuropathic medications. We demonstrate that neurogenic cough, like trigeminal neuralgia, may be caused by a vascular compression of its nerve root. A proposed mechanism of this type of neurogenic cough is presented along with a potential diagnostic paradigm for these patients.

The Usefulness of Respiratory Mechanic Instability in Evaluating the Effect of Continuous Positive Airway Pressure for Obstructive Sleep Apnea

30-11-2019 – Ji Ho Choi,Jae Yeup Jung,Ji Eun Moon,Se-Hwan Hwang

Journal Article

Respiratory mechanics instability (RMI) based on paradoxical movement is correlated with respiratory disturbance such as apnea-hypopnea index (AHI) and reflects the severity of obstructive sleep apnea (OSA). The purpose of this study was to identify RMI as a method for assessing the effectiveness of continuous positive airway pressure (CPAP) in the management for OSA. A total of 71 consecutive OSA patients with CPAP titration were included in this study. We compared sleep (sleep efficiency, arousal index, and sleep stages), respiratory (AHI, oxygen desaturation index ≥3% [ODI3], and lowest oxygen saturation), and RMI parameters (events, index, duration, and % of stage duration) between diagnostic polysomnography and CPAP titration data. All RMI parameters (events [157.5 ± 80.9 vs 80.0 ± 47.1; RMI may be a useful method for evaluating the effect of CPAP in OSA patients.

Experience with Minimally Invasive Ponto Surgery and Linear Incision Approach for Pediatric and Adult Bone Anchored Hearing Implants

28-11-2019 – Aren Bezdjian,Rachel Ann Smith,Nathalie Gabra,Luhe Yang,Marco Bianchi,Sam J. Daniel

Journal Article

To compare intra- and postoperative outcomes between the standard linear incision with tissue preservation and the Minimally Invasive Ponto Surgery (MIPS). A non-randomized retrospective cohort series. Medical files were reviewed of adult and pediatric bone anchored hearing implant recipients. Extracted outcomes included patient characteristics, implant survival, operative time, anesthesia use, intra and postoperative complications, soft tissue tolerability assessed by the Holger’s classification, and implant stability assessed by the Resonance Frequency Analysis (RFA). Outcomes were compared between two surgeries. A total of 59 implants were placed (21 MIPS; 38 linear). Conductive hearing loss was the most common etiology for implantation. Surgery was conducted under local anesthesia in 67% of MIPS patients and 16% of linear patients. No intraoperative complications were reported for both surgical approaches and no implants were lost. Patients undergoing implantation via the MIPS approach displayed less skin reaction postoperatively, however this was not significant ( The MIPS approach seems either similar or superior to the linear approach in all perioperative outcomes evaluated. Outcomes such as surgical duration, anesthesia choice and implant stability measurements support implantation through the MIPS approach for patients meeting eligibility criteria.

Functional and Aesthetic Outcomes of Extracorporeal Septoplasty: A Systematic Review and Meta-Analyses

26-11-2019 – Amishav Bresler,Roman Povolotskiy,Brandon Nguyen,Giancarlo F. Zuliani,Jean Anderson Eloy,Boris Paskhover,Peter Svider

Journal Article

The safety and efficacy of extracorporeal septoplasty (ECS) has long been debated. Our objective was to determine this technique’s functional and aesthetic outcomes and complications through a systematic review of the literature. PubMed/MEDLINE, Embase, Cochrane Library, and Web of Science databases were evaluated for studies detailing functional or aesthetic outcomes of ECS. Bias was evaluated using the Cochrane Risk of Bias Tool and the Methodological Index for Non-randomized Studies (MINORS) score. Aesthetic and functional outcomes in addition to complications were evaluated using subjective and objective measures. Meta-analyses were performed when appropriate. Seventeen studies encompassing 1418 patients were included. The average MINORS score for observational studies was 9.2. Overall there was a significant improvement in subjective nasal function with a preoperative average Nasal Obstruction Symptom Evaluation (NOSE) score of 75 (±16) decreasing to 19.5 (±16.5) postoperatively for a mean difference (MD) of -55 (95% confidence interval (CI): -60 to -49.5). In terms of objective nasal function, at 6 months postoperatively, there was an improvement of nasal flow measured by rhinometry ranging from 70 to 71% across studies. Anthropometric measurements were utilized for objective aesthetic outcomes. There was a significant improvement in I-shaped deviations (MD: -2.7°, 95% CI: -5.6 to -0.16) and C-shaped deviations improved by 11.9° (95% CI +2.8-+21.2). Complication rates ranged from 0 to 18%. ECS can achieve significant improvements in the subjective and objective function of the nose. The associated complication rate is low but variable between surgeons.

Dexamethasone Use in the Treatment of Pediatric Deep Neck Space Infections

26-11-2019 – James B. Tansey,John Hamblin,Madhu Mamidala,Jerome Thompson,Jennifer Mclevy,Joshua Wood,Anthony Sheyn

Journal Article

Assess the outcome of Intravenous (IV) dexamethasone in the treatment of pediatric deep neck space infections (DNSI) in combination with IV antibiotics. Retrospective chart review of pediatric patients admitted for a DNSI from March 2014 to June 2016. Patient characteristics including demographics, abscess type, antibiotic, dexamethasone, surgery, culture, and length of stay (LOS) were obtained. Patients treated with antibiotics alone versus antibiotics and dexamethasone were compared. Primary outcome measures were rate of surgical drainage and LOS. Overall 153 patients with DNSI were identified, including 62 lateral neck, 18 parapharyngeal, 40 peritonsillar, 32 retropharyngeal, and 1 submandibular. All patients received antibiotics. Dexamethasone was used in 35% of patients. The rate of surgical drainage in the dexamethasone and non-dexamethasone group was 36% and 53% respectively ( Dexamethasone use was associated with a decreased rate of surgical drainage in pediatric patients with DNSI. Further prospective study is needed to determine the role of dexamethasone in treatment.

Comparison of Referral Pathways in Otolaryngology at a Public Versus Private Academic Center

23-11-2019 – Caitlin Bertelsen,Janet S. Choi,Anna Jackanich,Marshall Ge,Gordon H. Sun,Tamara Chambers

Journal Article

Delayed medical care may be costly and dangerous. Examining referral pathways may provide insight into ways to reduce delays in care. We sought to compare time between initial referral and first clinic visit and referral and surgical intervention for index otolaryngologic procedures between a public safety net hospital (PSNH) and tertiary-care academic center (TAC). Retrospective cohort study of eligible adult patients undergoing one of several general otolaryngologic procedures at a PSNH (n = 216) and a TAC (n = 161) over a 2-year time period. PSNH patients were younger, less likely to have comorbidities and more likely to be female, Hispanic or Asian, and to lack insurance. Time between referral and first clinic visit was shorter at the PSNH than the TAC (Mean 35.8 ± 47.7 vs 48.3 ± 60.3 days; Sociodemographic differences between PSNH and TAC patients, as well as differences in referral pathways between the types of institutions, influence progression of surgical care in otolaryngology. These differences may be targets for interventions to streamline care. 2c.

Office-Based Steroid Injections for Idiopathic Subglottic Stenosis: Patient-Reported Outcomes, Effect on Stenosis, and Side Effects

22-11-2019 – Matthew R. Hoffman,David O. Francis,Johnny P. Mai,Seth H. Dailey

Journal Article

Office-based steroid injection has shown promise for idiopathic subglottic stenosis (i
SGS). It is important to understand safety and patient-lived experience. We report patient experience related to airway restriction, voice, and side effects. Sixteen patients (51 ± 14 years) with mild-moderate (20-50%) stenosis undergoing office-based transnasal steroid injections were included; fourteen had prior operations. Patients typically underwent three injections, 1 month apart, followed by transnasal tracheoscopy 1 month later to evaluate outcome; number of injections can vary based on disease severity and response. Outcomes were Dyspnea Index (DI), Modified Medical Research Council (MMRC) dyspnea scale, voice handicap index-10 (VHI-10), and degree of stenosis (estimated from procedural video). At each visit, patients were queried about post-injection airway restriction and side effects. Paired DI decreased ( Steroid injections improved upper airway symptoms. Side effects were mild and transient. Improvement in DI did not correlate with percent stenosis.

The Nerve to Thyrohyoid Muscle as a Novel Donor Nerve for Laryngeal Reinnervation

19-11-2019 – M. Elise Graham,Marshall E. Smith

Journal Article

Recurrent laryngeal nerve (RLN) injury may be a consequence of surgical procedures of the skull base, neck, and chest, with adverse consequences to function and quality of life. Laryngeal reinnervation offers a potentially stable improvement in vocal fold position and tone. The classic donor nerve is the ansa cervicalis, but is not always available due to damage or sacrifice during previous neck surgeries. Our objective was to introduce the nerve to the thyrohyoid (TH) muscle as an alternate donor nerve for reinnervation, which has not previously been described. Case series of two patients using the TH nerve for laryngeal reinnervation after RLN injury, with description of surgical harvest. Follow-up results are available for 10 months (one patient) and 3 years (one patient) demonstrating both subjective and objective improvement in function. GRBAS scores were reduced. Maximal phonation time was improved. Patient rating of voice was stable or improved postoperatively. One patient described significant preoperative dyspnea which was significantly improved postoperatively, from a score of 24 to 10 out of 40 on the dyspnea handicap index. VHI was improved in one patient, but scores elevated in the other, despite a change from “moderately severe impairment” to “normal voice” subjectively. Neither patient experienced significant complications from the procedure. Laryngeal reinnervation procedures provide good outcomes in pediatric patients. When ansa cervicalis is not available as a donor nerve, the nerve to TH provides a reasonable alternative.

Identifying Disadvantaged Groups for Cochlear Implantation: Demographics from a Large Cochlear Implant Program

19-11-2019 – Anthony M. Tolisano,Natalie Schauwecker,Bethany Baumgart,Johanna Whitson,Joe Walter Kutz,Brandon Isaacson,Jacob B. Hunter

Journal Article

To identify demographic predictors of patients undergoing cochlear implantation evaluation and surgery. Consecutive adult patients between 2009 and 2018 who underwent cochlear implantation evaluation at a university cochlear implantation program were retrospectively identified to determine (1) cochlear implantation qualification rate and (2) pursuit of surgery rate with respect to age, gender, race, primary spoken language, marital status, insurance type, and distance to the cochlear implantation center. A total of 823 cochlear implantation evaluations were analyzed. Overall, 76.3% of patients qualified for cochlear implantation and 61.5% of these patients pursued surgery. Age was the only independent predictor for cochlear implantation qualification, such that, for each year younger, the odds of qualifying for cochlear implantation increased by 2.5% (OR 0.98; 95% CI: 0.96-0.99). Age, race, marital status, and insurance type were each independent predictors of the decision to pursue surgery. The odds of pursuing surgery increased by 2.8% for each year younger (OR 1.03; 95% CI: 1.01-1.05). Compared to White patients, non-Whites were half as likely to pursue surgery (OR 0.47; 95% CI: 0.25-0.88). Single (OR 0.49; 95% CI: 0.26-0.94) and widowed patients (OR 0.46; 95% CI: 0.23-0.95) were about half as likely to pursue surgery as compared to married patients. Patients with military insurance were 13 times more likely to pursue surgery as compared to patients with Medicare (OR 13.0; 95% CI: 1.67-101.4). Younger age is an independent predictor for a higher cochlear implantation qualification rate, suggesting the possibility for delayed candidacy referral. Rate of surgical pursuit in qualified cochlear implantation candidates is lower for racial minorities, single and widowed patients, and older patients.

Standard Setting of Competency in Mastoidectomy for the Cross-Institutional Mastoidectomy Assessment Tool

17-11-2019 – Thomas Kerwin,Gregory Wiet,Brad Hittle,Don Stredney,Paul De Boeck,Aaron Moberly,Steven Arild Wuyts Andersen

Journal Article

Competency-based surgical training involves progressive autonomy given to the trainee. This requires systematic and evidence-based assessment with well-defined standards of proficiency. The objective of this study is to develop standards for the cross-institutional mastoidectomy assessment tool to inform decisions regarding whether a resident demonstrates sufficient skill to perform a mastoidectomy with or without supervision. A panel of fellowship-trained content experts in mastoidectomy was surveyed in relation to the 16 items of the assessment tool to determine the skills needed for supervised and unsupervised surgery. We examined the consensus score to investigate the degree of agreement among respondents for each survey item as well as additional analyses to determine whether the reported skill level required for each survey item was significantly different for the supervised versus unsupervised level. Ten panelists representing different US training programs responded. There was considerable consensus on cut-off scores for each item and trainee level between panelists, with moderate (0.62) to very high (0.95) consensus scores depending on assessment item. Further analyses demonstrated that the difference between supervised and unsupervised skill levels was significantly meaningful for all items. Finally, minimum-passing scores for each item was established. We defined performance standards for the cross-institutional mastoidectomy assessment tool using the Angoff method. These cut-off scores that can be used to determine when trainees can progress from performance under supervision to performance without supervision. This can be used to guide training in a competency-based training curriculum.

Utility of Audiometry in the Evaluation of Patients Presenting with Dysphonia

17-11-2019 – Justin Ross,William L. Valentino,Alyssa Calder,David Bigly,Sammy Othman,Brian McKinnon,Robert T. Sataloff

Journal Article

Hearing loss has been implicated in dysphonia secondary to voice misuse, although the data supporting this claim are scant. Determining the prevalence of hearing loss in patients with dysphonia and correlating it with self-perception of vocal handicap may help clarify the value of audiometry in evaluation of patients with dysphonia. This is a retrospective chart review of all new voice patients (n = 405) presenting with dysphonia to the primary investigator between 2015 and 2018. Each new patient routinely undergoes audiometric and voice objective analyses. Main outcomes measured include prevalence, severity of hearing loss, and voice handicap index-10 (VHI-10). Of the 405 subjects reviewed, mean age was 49.0 years (SD = 17.4). 60.7% of subjects were female and 39.3% male. Patients with hearing loss defined as >25 d
B in worse ear with pure tone average (PTA) thresholds at 0.5, 1, 2, and 3 k
Hz (PTA-S) accounted for 18% of the total cohort. The prevalence of previously The prevalence of hearing loss in patients presenting with dysphonia in this cohort is similar to normative population data. This study has also demonstrated that the majority of these patients did not perceive any hearing loss. The reasons behind this may be a result of or associated with the patients’ dysphonia. Furthermore, clinicians should consider performing audiometric evaluation in patients with abnormal VHI-10 scores in the appropriate clinical context.

Pediatric Thyroidectomy: NSQIP-P Analysis of Adverse Perioperative Outcomes

17-11-2019 – Vijay A. Patel,Aliasgher Khaku,Michele M. Carr

Journal Article

This study identifies risk factors and 30-day adverse outcomes of pediatric patients undergoing thyroidectomy. Retrospective analysis utilizing the American College of Surgeons National Surgical Quality Improvement-Pediatric Database (2015-2016). Study population includes pediatric patients (≤18 years) who underwent hemithyroidectomy (HT), total thyroidectomy (TT), and total thyroidectomy with central neck dissection (TT+ND). A total of 720 cases were identified; mean age at time of surgery was 14.1 years, with a female-to-male ratio of 3.4:1. Following hospital discharge, there were 10 related readmissions, with 1 patient requiring reoperation for neck hematoma evacuation. Regression analysis revealed anesthesia time had a significant impact on total length of stay ( Contemporary pediatric thyroidectomy has a low incidence of 30-day general surgical postoperative complications. Future research efforts are necessary once thyroidectomy specific variables are incorporated into ACS-NSQIP-P, which will provide further insights into managing this unique patient population.

Validity and Reliability of the Reflux Sign Assessment

16-11-2019 – Jérôme R. Lechien,Alexandra Rodriguez Ruiz,Didier Dequanter,Francois Bobin,Francois Mouawad,Vinciane Muls,Kathy Huet,Bernard Harmegnies,Sarah Remacle,Camille Finck,Sven Saussez

Journal Article

To develop and validate the Reflux Sign Assessment (RSA), a clinical instrument evaluating the physical findings of laryngopharyngeal reflux (LPR). A total of 106 patients completed a 3-month treatment based on the association of diet, pantoprazole, alginate, or magaldrate with the LPR characteristics (acid, nonacid, mixed). Forty-two asymptomatic individuals completed the study (control group). The RSA results and reflux finding score (RFS) were documented for the LPR patients at baseline and after treatment. Intrarater reliability was assessed through a test-retest blinded evaluation of signs (7-day intervals). Interrater reliability was assessed by comparing the RSA evaluations of three blinded otolaryngologists through Kendall’s W. Responsiveness to change was evaluated through a comparison of the baseline and 3-month posttreatment findings. The RSA cutoffs for determining the presence and absence of LPR were examined by receiver operating characteristic (ROC) analysis. A total of 102 LPR patients completed the study (68 females). The mean age was 53 years. The mean RSA at baseline was 25.95 ± 9.58; it significantly improved to 18.96 ± 7.58 after 3 months of therapy ( The RSA is a complete clinical instrument evaluating both laryngeal and extralaryngeal findings associated with LPR. The RSA demonstrated high intra- and interrater reliabilities and responsiveness to change.

Presentation and Management of Killian Jamieson Diverticulum: A Comprehensive Literature Review

12-11-2019 – Narmien Haddad,Pratima Agarwal,Jessica N. Levi,Jeremiah C. Tracy,Lauren F. Tracy

Journal Article

To examine the clinical presentation, diagnostic evaluation, and management of Killian-Jamieson diverticula (KJD) through literature review. A comprehensive literature review was conducted through December 2018 using keywords Killian-Jamieson diverticula/diverticulum. Data extracted included clinical presentation, imaging characteristics, surgical management, and postoperative care. PubMed and Google Scholar. Sixty-eight cases of KJD in 59 reports (29M:39F; median 58 years old) were identified for review. The most common presentation was dysphagia (n = 39), suspected thyroid nodule (n = 24) and globus (n = 14). The majority of KJD (n = 51) occur on the left, with rare reports of right side (n = 11) and bilateral (n = 5) presentation. Thirty-two cases describe surgical management: 22 utilizing a transcervical approach, with (n = 13) or without (n = 9) cricopharyngeal myotomy; and 10 reported endoscopic surgery. Diverticula managed transcervically averaged 3.8 cm in size in comparison to average 2.8 cm in the endoscopic group. Time to diet initiation after transcervical surgery averaged 4 days versus 2 days after endoscopic surgery. Complications were reported in 2/68 cases; both were diverticula recurrence after endoscopic surgery. Killian-Jamieson diverticula is a rare diagnosis that should be considered in the evaluation of dysphagia, globus, and also suspected thyroid nodule. When patient symptoms warrant intervention, a transcervical approach, with or without cricopharyngeal myotomy, is most commonly utilized. In recent years, an endoscopic approach has been presented as an alternative for smaller diverticula. Further understanding of the optimal treatment and postoperative management for KJD requires larger cohorts. 4.

Five-year Survival Data on the Role of Endoscopic Endonasal Nasopharyngectomy in Advanced Recurrent rT3 and rT4 Nasopharyngeal Carcinoma

09-11-2019 – Eugene Hung Chih Wong,Yew Toong Liew,Siow Ping Loong,Narayanan Prepageran

Journal Article

Endoscopic endonasal nasopharyngectomy (EEN) for recurrent nasopharyngeal carcinoma (r
NPC) is being increasingly used due to the added high magnification, reduced morbidities associated with open procedures and good survival outcomes. Most studies looked at usage of EEN in patients with lower recurrent staging (r
T1 and r
T2) although more and more surgeons are studying the outcome of EEN in advanced r
NPC (r
T3 and r
T4). The aims of this study were to report the long-term 5-year survival outcome of EEN performed in patients with advanced r
NPC, and to determine any prognostic factors for patients’ survival. All patients who underwent EEN for advanced r
NPC between January 2003 and December 2015 inclusive were analyzed. All surgeries were performed in University Malaya Medical Centre in Kuala Lumpur and Queen Elizabeth Hospital in Sabah. We reported the 5-year overall survival (OS), disease-free survival (DFS) and disease-specific survival (DSS) and any related complications and significant prognostic factors. Twelve patients with r
NPC (2 r
T3 and 10 r
T4) were followed-up over a mean duration of 44.8 months (range, 40-440 weeks). The 5-year OS was 50.0% (mean 44.75 months), DFS was 25.0% (mean 35.25 months) and the DSS was 58.3% (mean 43.33 months). No severe operative complications were encountered and no independent prognostic factors for survival outcome were identified. This is the first report in English that exclusively described the long-term 5-year survival data in patients with both r
T3 and r
T4 recurrent NPC after EEN. The data suggest that EEN is a feasible treatment to improve survival with minimal morbidities in patients with r
T3 and r
T4 recurrent NPC. However, more studies with larger patient size is recommended.

Quality and Readability of Online Information on In-Office Vocal Fold Injections

09-11-2019 – Grace S. Yi,Amanda Hu

Journal Article

Vocal fold injection augmentations are increasingly being performed in the office setting on awake patients, as opposed to the operating room. These procedures thus require patient cooperation and education. As the Internet is a widely-used resource for patients, our aim was to assess the quality and readability of online resources on in-office awake vocal fold injections. An online Google search using the terms “office vocal fold injection medialization” and “awake vocal fold injection” was conducted. The first 50 English-language websites were categorized into professional- and patient-targeted, and major and minor sources. They were analyzed using the Flesch Reading Ease Score (FRES), Flesch-Kincaid Grade Level (FKGL) test, and DISCERN quality score. Fifty websites were evaluated, and the overall DISCERN score was 2.60 ± 1.01, the mean FRES was 32.16 ± 19.10, and the mean FKGL was 13.76 ± 4.12. Between the 25 professional-targeted and 25 patient-targeted websites, professional-targeted sites had significantly higher DISCERN ( Our study shows that half of the top Google results for our topic were not written for patient education, but rather for health care professionals. The reading level of this information exceeds the recommended grade level for patient education materials, and may be less comprehensible than intended. While patient-targeted materials are easier to read than professional-targeted sites, they are of lower quality. The quality of the available online information on this topic is suboptimal for both patients and health care providers. This research highlights the need for more appropriate patient education materials given low health literacy rates.

“In-Office Balloon Sinus Ostial Dilation with Concurrent Antiplatelet and Anticoagulant Therapy for Chronic Rhinosinusitis without Nasal Polyps”

07-11-2019 – Thomas S. Higgins,Bülent Öcal,Ridwan Adams,Arthur W. Wu

Journal Article

Functional endoscopic sinus surgery (FESS) and balloon sinus ostial dilation (BSD) are well-recognized minimally invasive surgical treatments for chronic rhinosinusitis without nasal polyps (CRSs
NP) refractory symptoms to medical therapy. Patients on antiplatelet and anticoagulant therapies (AAT) usually are recommended to discontinue their medications around the period of endoscopic sinus surgery. The goal of this study is to assess the clinical experience of BSD in CRSs
NP patients with concurrent anticoagulant or antiplatelet therapy. A review of prospectively-collected clinical data from October 2012 to March 2017 were used to perform a cohort study of subjects with CRSs
NP who met criteria for surgical intervention while on antiplatelet and anticoagulant therapy. Data were collected on demographics, details of the procedures, type of AAT used, pre- and postoperative 22-item Sino-Nasal Outcome Test (SNOT-22) scores, and complications. Thirty-five patients underwent in-office BSD while on antiplatelet and/or anticoagulant therapy. The mean difference in pre- and postoperative SNOT-22 scores of 9.9 (SD 14.4, In-office BSD appears to be a safe alternative to endoscopic sinus surgery in select patients who cannot discontinue antiplatelet and anticoagulant therapy. IV.

Endoscopic Transoral Hybrid Supracricoid Partial Laryngectomy with Cricohyoidoepiglottopexy

02-11-2019 – Meijin Nakayama,Ryan K. Orosco,F. Christopher Holsinger,Giuseppe Spriano,Giovanni Succo,Armando De Virgilio,Nobuhiko Oridate

Journal Article

The hybrid supracricoid partial laryngectomy with cricohyoidoepiglottopexy (SCPL-CHEP, that is, open partial horizontal laryngectomies OPHL Type IIa) has been described using a flexible next generation robotic surgical platform for manipulation. We sought to evaluate the feasibility of performing this procedure using endoscopic transoral (Endo
T) surgical techniques without robotics. Preclinical cadaveric study using two human cadavers. Hybrid SCPL-CHEP was performed with a flexible endoscope for visualization and hand-held instruments for manipulation (SILS Hook monopolar and Dissect, HAVAS Laryngo
FIT malleable straight jaw instruments, and Stratafix 4-0 spiral knotless barbed suture). Endo
T hybrid SCPL-CHEP was successfully performed. The hand-manipulated rigid instruments allowed for transoral incisions and mucosal suturing. We provide the procedural steps of Endo
T hybrid techniques. Endo
T hybrid SCPL-CHEP was technically feasible in the preclinical cadaveric laboratory setting and appeared comparable to the hybrid SCPL-CHEP via transoral robotic surgery (TORS). Selected handheld instruments and flexible endoscopy appear to facilitate minimally invasive surgery of the larynx. This novel procedure and technique warrant further clinical study for consideration of feasibility, applicability, and patient benefit.

Risk of Mortality between Untreated and Treated Papillary Thyroid Cancer: A Matched Cohort Analysis

30-10-2019 – Jonathan K. Lin,Lori C. Sakoda,Jeanne Darbinian,Melissa Socarras,Whitney Chiao,Nathaniel Calixto,Charles Quesenberry,Deepak Gurushanthaiah,Kevin H. Wang,Megan Durr

Journal Article

To examine the association between treatment status and mortality risk among patients with papillary thyroid cancer (PTC). We identified 3,679 adults with PTC. Thirty-one untreated patients were matched to 155 treated patients. Hazards ratios (HR) and 95% confidence intervals (CIs) were calculated to estimate all-cause and disease-specific mortality. A low-risk subgroup was analyzed for differences in all-cause mortality. The adjusted HRs (95% CIs) for all-cause mortality at 5 and 10 years were 4.2 (1.7-10.3) and 4.1 (1.9-9.4) and for disease- specific mortality were 14.1 (3.4-59.3) and 10.2 (2.9-36.4), respectively, for untreated versus treated patients. The adjusted HRs (95% CIs) for all- cause mortality was 0.7 (0.1-6.4) for low-risk untreated versus matched treated patients. Compared to treated patients, untreated PTC patients were at higher risk of death while low-risk untreated PTC patients had comparable rate of metastasis and no increased risk of all-cause mortality.

Neck Surgery with Hypnosis: An Evaluation Based Upon Patient’s Self Assessment

30-10-2019 – Marie Jaouen,Valentine Parent,Maxime Codet,Véronique Gerard,Anita Chatellier-Miras,Cécile Chaize,Olivier De Crouy Chanel,Franck Jegoux

Journal Article

Surgery with hypnosis avoids the use of general anesthesia (GA). It also shortens hospitalization and promotes outpatient surgery. The objective of this study has been to assess the satisfaction of operated patients. No previous study has focused on patient satisfaction in a prospective design. In this prospective, non-randomized, observational study, all patients operated with hypnosis between 2009 and 2017 in the Ear, Nose, and Throat department of a tertiary care hospital were selected. All patients were asked to fill a questionnaire based on a previously validated questionnaire incremented with complementary questions. Questionnaires were completed immediately after surgery for 31 patients and after 6 months for 20 patients. Global Satisfaction Index (GSI) was self-assessed on a scale ranging from 1 to 10. Patients were asked; whether they felt comfortable during the operation, whether hypnosis helped them, whether the experience matched their expectations, whether they would revisit or recommend it to someone else and whether they considered to have been sufficiently informed before the procedure. The data was analyzed using a linear regression model with During the inclusion period, no patient required conversion to GA. A total of 48 questionnaires were evaluated. The median of the GSI was 8/10. GSI significantly correlated with patient comfort ( This study reveals that patients’ global satisfaction after hypnosis is high. This is significantly related to the quality of preoperative information and to the experience of the surgical team. It also suggests that patients are more likely to benefit from hypnosis if the surgery is longer.

Gene Expression Analysis to Investigate Biological Networks Underlying Nasal Inflammatory Dysfunctions Induced by Diesel Exhaust Particles Using an In Vivo System

28-10-2019 – Hyun Soo Kim,Byeong-Gon Kim,Sohyeon Park,Nahyun Kim,An-Soo Jang,Young Rok Seo,Moo Kyun Park

Journal Article

Diesel exhaust particles (DEP)s are notorious ambient pollutants composed of a complex mixture of a carbon core and diverse chemical irritants. Several studies have demonstrated significant relationships between DEP exposure and serious nasal inflammatory response In the present study, we identified DEP-induced gene expression profiles under short-term and long-term exposure, and identified signaling pathways based on microarray data for understanding effects of DEP exposure in the mouse nasal cavity. Alteration in gene expression due to DEP exposure provokes an imbalance of the immune system via dysregulated inflammatory markers, predicted to disrupt protective responses against harmful exogenous substances in the body. Several candidate markers were identified after validation using q
RT-PCR, including S100A9, CAMP, IL20, and S100A8. Although further mechanistic studies are required for verifying the utility of the potential biomarkers suggested by the present study, our

The Impact of Medical Scribes on Patient Satisfaction in an Academic Otolaryngology Clinic

24-10-2019 – Katherine R. Keefe,Jessica R. Levi,Christopher D. Brook

Journal Article

Evidence shows that scribes can improve provider efficiency and satisfaction in several settings, but is mixed on whether scribes improve patient satisfaction. We studied whether scribes improved patient satisfaction in an academic otolaryngology clinic. The authors performed a retrospective review of patient responses to the Press Ganey survey between 12/2016 and 12/2017. Their responses about satisfaction with the provider and wait times were examined. Three providers worked with scribes during this year; each spent six months with a scribe and six without. The authors compared survey responses from periods with and without scribes using the Fischer exact test. Average overall provider ratings were compared using the Student’s A total of 87 patients filled out Press Ganey surveys for the 3 providers over the year: 54 for visits without scribes, and 33 for visits with scribes. Fischer exact analysis demonstrated no significant difference in satisfaction with providers and wait times for both individual providers and all providers combined (all Patient satisfaction with wait times and providers was high overall and was not affected by the presence of a medical scribe.

Yolk Sac Tumors of the Head and Neck in Aicardi Syndrome

24-10-2019 – Madison V. Epperson,Hayley L. Born,Dehua Wang,Charles M. Myer

Journal Article

To understand that yolk sac tumors (YSTs) of the head and neck (H&N) are exceedingly rare and typically carry a poor prognosis. To acknowledge the possibility of increased incidence in patients with Aicardi Syndrome and the ramifications this has on early diagnosis and treatment in this population. To date, four germ cells tumors of the H&N have been reported in patients with Aicardi Syndrome. This report presents the second known case of a H&N YST in a patient with Aicardi syndrome. In both cases, the patient was initially misdiagnosed given unconvincing radiologic evidence. However, tissue diagnosis and elevated alpha-fetoprotein (AFP) levels were suggestive of a YST. In contrast to the poor prognosis previously described, both patients with Aicardi syndrome had an excellent chemotherapeutic response exhibited by normalization of AFP levels and imaging. Rare germ cell tumors of the H&N, such as YSTs, have now been documented in several patients with Aicardi syndrome, indicating a possible association given the rarity of these tumors in the population. YSTs should be considered in the differential diagnosis of H&N masses in these patients, with emphasis on early tissue diagnosis and treatment.

Surgical Management of Vestibular Schwannoma: Practice Pattern Analysis via NSQIP

23-10-2019 – Vijay A. Patel,Mitchell Dunklebarger,Kalins Banerjee,Tom Shokri,Xiang Zhan,Huseyin Isildak

Journal Article

Characterize current perspectives in the surgical management of vestibular schwannoma (VS) to guide otolaryngologists in understanding United States practice patterns. A retrospective analysis of ACS-NSQIP database was performed to abstract all patients from 2008 to 2016 who underwent VS resection using ICD-9/10 codes 225.1 and D33.3, respectively. The specific surgical approach employed was identified via CPT codes 61520, 61526/61596, and 61591, which represent retrosigmoid (RS), translabyrinthine (TL) and middle cranial fossa (MCF) approaches, respectively. Analyzed outcomes include general surgical complications, total length of stay, and reoperation. A total of 1671 VS cases were identified, 1266 (75.7%) were RS, 292 (17.5%) were TL, and 114 (6.8%) were MCF. The annual number of cases increased over the study period from 15 to 375, which is chiefly attributed to increased institutional participation in ACS-NSQIP. Perioperative variables including BMI ( There is increased employment of RS approach for the operative management of VS, which likely is the result of increased reliance on both stereotactic radiosurgery and observation as alternative treatment strategies.

Detection of Pepsin in Oral Secretions of Infants with and without Laryngomalacia

22-10-2019 – Miles J. Klimara,Tina L. Samuels,Nikki Johnston,Robert H. Chun,Michael E. McCormick

Journal Article

Laryngomalacia is a common cause of stridor in infants and is associated with laryngopharyngeal reflux (LPR). Although pepsin in operative supraglottic lavage specimens is associated with severe laryngomalacia, detection of pepsin in oral secretions has not been demonstrated in an outpatient setting. Children <2 years old with laryngomalacia diagnosed by flexible laryngoscopy and children without stridor were selected. Oral secretion samples were obtained in clinic from all subjects. Pepsin, IL-1β, and IL-8 enzyme-linked immunosorbent assays were performed to determine presence of LPR. Sixteen laryngomalacia and sixteen controls were enrolled. Pepsin was detected more frequently in oral secretions of patients with laryngomalacia (13/16) than in controls (2/16; Pepsin in saliva appears to be associated with laryngomalacia, suggesting a role for salivary pepsin as a noninvasive marker of LPR in patients with laryngomalacia. Future studies will determine the utility of this test in laryngomalacia.

Isolated Congenital Middle Ear Malformations: Comparison of Preoperative High-Resolution CT and Surgical Findings

22-10-2019 – Na Zhang,Yi Li,Xiaobo Ma,Danni Wang,Shuling Li,Fei Yan,Shouqin Zhao

Journal Article

To compare preoperative temporal bone high-resolution computed tomography (HRCT) readings to intraoperative findings during exploratory tympanotomy for suspected cases of isolated congenital middle ear malformations (CMEMs) and summarize the malformations that can and cannot be diagnosed with HRCT. A retrospective study was conducted. All cases were confirmed as isolated CMEMs during surgery. Detailed clinical records were reviewed, with a focus on imaging and surgical findings. One hundred and thirty-two patients and 145 ears were reviewed. Ninety cases (62.1%) could be identified as isolated CMEMs and at least one as middle ear anomaly using preoperative HRCT. Fifty-five cases (37.9%) were reported to be completely normal and the patients underwent exploratory tympanotomy to determine the final diagnosis. Stapes fixation, either alone or associated with other ossicular chain anomalies, contributed to 53.1% of the cases. Most cases of aplasia or dysplasia of the ossicular chain, for example, aplasia/dysplasia of the long process of the incus, aplasia of the stapes’ superstructure, and atresia of the oval window were easily identified in preoperative HRCT. However, fixation of the ossicular chain can be elusive in HRCT, and exploratory tympanotomy is needed for a definitive diagnosis. HRCT provides helpful preoperative clinical information in CMEM and may obviate the need for middle ear exploration in some cases. The negative findings (anomalies that are difficult to identify through preoperative HRCT) and the positive findings (anomalies that are relatively easy to identify through preoperative HRCT) were summarized.

Preoperative Maxillary Sinus Imaging and the Outcome of Sinus Floor Augmentation and Dental Implants in Asymptomatic Patients

22-10-2019 – Amit Ritter,Noa Rozendorn,Gal Avishai,Eli Rosenfeld,Ilan Koren,Ethan Soudry

Journal Article

Preoperative maxillary sinus imaging findings have been suggested to be associated with complications and outcomes of sinus lift and dental implant procedures; nonetheless the evidence is controversial. The aim of this study was to examine the association between preoperative maxillary sinus imaging findings and outcomes of sinus lift and dental implant procedures in asymptomatic patients. We included all patients who underwent maxillary sinus lift and dental implant procedures between 2014 and 2017. Maxillary sinus imaging findings were extracted from pre-procedural dental computed tomography scans, and outcomes of the procedures were assessed. A total of 145 procedures were included. No sinonasal symptoms were reported preoperatively. In 46% of cases maxillary sinus imaging was abnormal. The most common imaging finding was peripheral mucosal thickening (38%). Sinus floor cyst/polyp was identified in 13% of the cases, of which 47% occupied more than 50% of the sinus volume. Partial or complete opacification of the maxillary sinus was documented in 3% of cases. The sinus ostium and ostiomeatal complex were obstructed in 7% and 1%, respectively. Mucosal perforation was documented in 22% of cases and was inversely related to mucosal thickening ( Incidental maxillary sinus imaging findings such as mucosal swelling, cysts or polyps, regardless of their severity or size, and maxillary ostial obstruction may not need to be addressed prior to sinus augmentation and dental implant procedures in asymptomatic patients. Patients with complete sinus opacification should be referred to an otolaryngologist prior to surgery. Further controlled trials, in larger cohorts, are needed to corroborate our findings.