Otolaryngology Head and Neck Surgery

Otolaryngology Head and Neck Surgery

Highlights from the Current Issue: December 2019

02-12-2019 – John H. Krouse

Journal Article

Patient Safety/Quality Improvement Primer, Part II: Prevention of Harm Through Root Cause Analysis and Action (RCA2)

01-10-2019 – Karthik Balakrishnan,Michael J. Brenner,John W. Gosbee,Cecelia E. Schmalbach

Journal Article

With increasing emphasis on patient safety/quality improvement, health care systems are mirroring industry in the implementation of root cause analysis (RCA) for the identification and mitigation of errors. RCA uses a team approach with emphasis on the system, as opposed to the individual, to accrue empirical data on what happened and why. While many otolaryngologists have a broad understanding of RCA, practical experience is often lacking. Part II of this patient safety/quality improvement primer investigates the manner in which RCA is utilized in the prevention of medical errors. Attention is given to identifying system errors, recording adverse events, and determining which events warrant RCA. The primer outlines steps necessary to conduct an effective RCA, with emphasis placed on actions that arise from the RCA process through the

Risk Factors for Blood Transfusion with Neck Dissection

02-04-2019 – Monica C. Azmy,Juanita Pinto,Nirali M. Patel,Aparna Govindan,Evelyne Kalyoussef

Journal Article

To identify risk factors of perioperative blood transfusions (PBTs) for neck dissection and identify the association of PBTs with other postoperative outcomes. This is a retrospective study of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. The database was queried for neck dissection procedures performed by otolaryngologists from 2006 to 2014. Multivariable logistic regression was used to determine associations between demographic and preoperative factors, mortality, unplanned reoperation, and unplanned readmission with PBTs. Of the 3090 patients included in our study, 346 (11.2%) received a PBT, 249 patients (72.0%) received blood intraoperatively or on postoperative day (POD) 0, and 97 patients (28.0%) received blood within 5 PODs. American Society of Anesthesiologists (ASA) class ≥3 (odds ratio [OR], 2.1; 95% confidence interval [CI], 1.4-3.2), preoperative weight loss (OR, 2.2; 95% CI, 1.5-3.2), and anemia (OR, 5.5; 95% CI, 4.1-7.6) were independently associated with PBTs. Free flaps were also significantly associated with PBTs. PBTs were significantly associated with unplanned return to the operating room within 30 days (OR, 4.31; 95% CI, 3.01-6.18) but not with 30-day unplanned readmission or 30-day mortality. Eleven percent of patients undergoing neck dissection receive a PBT. Identifying associated risk factors may reduce PBT among patients with cancer. Comorbid data, such as weight loss, anemia, and ASA class, may be useful in determining risk for transfusion during these procedures. Awareness of preoperative risk factors for PBT may lead surgeons to reduce the risk of PBT, anticipate the need for transfusion, and manage these patients carefully to prevent unplanned reoperation.

A Critical Analysis of Medicare Claims for Otolaryngology Procedures

25-06-2019 – Stephanie J. Youssef,Krishna S. Vyas

Journal Article

This study was performed to outline and analyze the overall Medicare landscape with respect to otolaryngologists and beneficiaries, services, and reimbursements. This is a retrospective analysis of publicly available Medicare utilization and payment data for all otolaryngologists in facility and nonfacility practice settings who provided services to Medicare beneficiaries between January 1, 2012, and December 31, 2016. In 2016, a total of $701,195,375 was distributed to 8572 otolaryngology physician providers for 815 unique Healthcare Common Procedure Coding System codes for 13,942,536 procedure claims. Of specialty care, otolaryngology ranks 20th among 54 subspecialties for total Medicare payments. The average number of services coded per provider was 1627. The average otolaryngologist was paid $81,800.67. Thirty-two percent of otolaryngologists did not receive reimbursement for services from Medicare in 2016. In 2016, the most significant contributors to Medicare payments to otolaryngologists were large-scale, low-cost events that are relatively short procedures done in clinic. Utilization of nasal endoscopy was up trending from 2012 to 2016. Some of the It is increasingly valuable for physicians to know factors that affect reimbursement for procedures and operations in different settings and to be aware of the trends in variation in their specialty. Otolaryngologists should communicate with policy makers in efforts toward sustainable reimbursement models.

Assessments of Otolaryngology Resident Operative Experiences Using Mobile Technology: A Pilot Study

13-08-2019 – Jenny X. Chen,Elliott Kozin,Jordan Bohnen,Brian George,Daniel G. Deschler,Kevin Emerick,Stacey T. Gray

Journal Article

Surgical education has shifted from the Halstedian model of “see one, do one, teach one” to a competency-based model of training. Otolaryngology residency programs can benefit from a fast and simple system to assess residents’ surgical skills. In this quality initiative, we hypothesize that a novel smartphone application called System for Improving and Measuring Procedural Learning (SIMPL) could be applied in an otolaryngology residency to facilitate the assessment of resident operative experiences. The Plan Do Study Act method of quality improvement was used. After researching tools of surgical assessment and trialing SIMPL in a resident-attending pair, we piloted SIMPL across an otolaryngology residency program. Faculty and residents were trained to use SIMPL to rate resident operative performance and autonomy with a previously validated Zwisch Scale. Residents (n = 23) and faculty (n = 17) were trained to use SIMPL using a standardized curriculum. A total of 833 assessments were completed from December 1, 2017, to June 30, 2018. Attendings completed a median 20 assessments, and residents completed a median 14 self-assessments. All evaluations were resident initiated, and attendings had a 78% median response rate. Evaluations took residents a median 22 seconds to complete; 126 unique procedures were logged, representing all 14 key indicator cases for otolaryngology. This is the first residency-wide application of a mobile platform to track the operative experiences of otolaryngology residents. We adapted and implemented a novel assessment tool in a large otolaryngology program. Future multicenter studies will benchmark resident operative experiences nationwide.

Submental Island Flap versus Free Flap Reconstruction for Complex Head and Neck Defects

10-09-2019 – Mads Gustaf Jørgensen,Siavosh Tabatabaeifar,Navid Mohamadpour Toyserkani,Jens Ahm Sørensen

Journal Article

Complex soft tissue reconstruction of the head and neck requires a viable, versatile, and dependable flap. Free flaps, such as the radial forearm and anterolateral thigh flap, have been the mainstay of complex head and neck reconstruction. However, a local pedicled flap, such as the submental island flap (SIF), could be a more effective and less demanding alternative. This systematic review and meta-analysis aim to compare free tissue transfer (FTT) with the SIF for head and neck reconstruction. We performed a systematic search in PubMed and EMBASE databases. Meta-analysis was performed on outcomes reported in ≥3 studies. Candidate articles were assessed for eligibility by 2 authors. Three authors performed data extraction and methodological quality of the included studies using the Newcastle-Ottawa Quality Assessment Form for Cohort Studies. The search strategy resulted in 450 studies, of which 7 were included in the analysis, yielding 155 SIF and 198 FTT cases. Operating time and length of stay were significantly lower for the SIF than for FTT ( These results suggest that the SIF reduces length of stay and operating time as compared with FTT in head and neck reconstruction. These findings suggest that the SIF can be considered an alternative reconstructive option to FTT when evaluating intraoral, lateral facial, skull base, and parotidectomy defects, given comparable defect size and tumor biology.

Pattern of Intraoperative Parathyroid Hormone and Calcium in the Treatment of Tertiary Hyperparathyroidism

30-07-2019 – André Luís Maion Casarim,Fernando Antonio Maria Claret Arcadipane,Antonio Santos Martins,André Del Negro,André Afonso Nimtz Rodrigues,Alfio Jose Tincani,Evaldo Marchi

Journal Article

Tertiary hyperparathyroidism, an autonomous hyperproduction of parathyroid hormone (PTH), has a challenge in its treatment. This study asked whether the intraoperative PTH and calcium drop can confirm the resection of all parathyroid tissues. Case series with planned data collection. Tertiary referral medical center. The study assessed patients with tertiary hyperparathyroidism who were treated at the Hospital of the State University of Campinas from 2007 to 2015. All patients underwent total parathyroidectomy with autotransplantation of parathyroid fragments. PTH and calcium were collected during the preoperative period; at 10, 20, and 240 minutes after resection of the glands; and at 1 year after the procedure. Data were analyzed by analysis of variance and logistic regression analysis with statistical values of Thirty-five patients were assessed: 17 women (48.57%) and 18 men (51.43%). The percentage of PTH drop was statistically significant at all times, unlike the calcium analysis, but only PTH collected at 20 minutes was able to confirm the removal of all parathyroid tissues ( Treatment success can be predicted by analyzing the decrease of intraoperative PTH and not by calcium. The 71.2% PTH drop at 20 minutes after parathyroidectomy had high sensitivity and specificity to predict surgical cure.

Postoperative Opioid Prescribing and Consumption Patterns after Tonsillectomy

30-07-2019 – Stephanie Choo,Stephen Nogan,Laura Matrka

Journal Article

Despite increased concern with the opioid epidemic, literature remains scant regarding narcotic prescription and use following tonsillectomy. Retrospective cohort study with telephone interview. A chart review from January to August 2018 evaluated the difference between prescribed amounts of narcotic and patient-reported usage following tonsillectomy ( Sixty-four patients were enrolled at a mean 4.47 months after tonsillectomy. The mean ± SD prescribed morphine milligram equivalent (MME) was 456.1 ± 281.7, with only 302.8 ± 206.2 consumed. The mean MME prescribed per day was 74.1 ± 44.8, and average days of narcotic usage postoperatively was 9.6 ± 4.6, correlating with a mean MME per day of 49.2 ± 34.3 if the maximum prescribed dose per day was consumed. Fifty-four (84.4%) patients reported pain as well controlled. Forty-three (67.2%) patients reported residual narcotic medication, with 228.1 ± 208.5 MMEs remaining per patient. Narcotic solutions were more completely consumed than tablet forms, with 23.1% and 44.0% remaining, respectively. Patients cited uncertainty about safe disposal and safeguarding for future use as reasons for keeping residual narcotic. Patient-reported narcotic use is significantly lower than the amount prescribed after tonsillectomy for benign disease. Providers can use these data to adjust narcotic-prescribing patterns while maintaining appropriate pain management for patients undergoing tonsillectomy.

Analysis of Potential Conflicts of Interest among Otolaryngologic Patient Advocacy Organizations in 2016

03-09-2019 – Neil S. Kondamuri,Vinay K. Rathi,Matthew R. Naunheim,Rosh V. Sethi,Ashley L. Miller,Mark A. Varvares

Journal Article

Patient advocacy organizations (PAOs) are nonprofits dedicated to benefiting patients and their families through activities such as education/counseling and research funding. Although medical drug/device companies may serve as important partners, industry donations may bias the efforts of PAOs. We conducted a retrospective cross-sectional analysis of the Kaiser Health News nonprofit database to identify and characterize otolaryngologic PAOs (n = 32) active in 2016. Among these PAOs, half (n = 16, 50.0%) focused on otologic diseases, and mean total annual revenue was $3.1 million. Among the 15 PAOs (46.9%) with publicly available donor lists, 10 (66.7%) received donations from industry. Few PAOs publicly reported the total amount donated by industry (n = 3, 9.4%) or published policies for mitigating potential financial conflicts of interest with donors (n = 3, 9.4%). Requiring drug and device companies to publicly report donations to PAOs may help patients, providers, and policy makers to better understand advocacy by these influential stakeholders.

Postoperative Analgesic Requirement and Pain Perceptions after Nonaerodigestive Head and Neck Surgery

03-09-2019 – Elizabeth D. Stephenson,Zainab Farzal,Maryam Jowza,Trevor Hackman,Adam Zanation,Eugenie Du

Journal Article

Little data exist on associations between patient factors and postoperative analgesic requirement after head and neck (H&N) surgeries. Such information is important for optimizing postoperative care considering concerns regarding opioid misuse. We analyzed factors associated with narcotic use and pain perception following H&N surgery sparing the upper aerodigestive tract. Prospective cohort. Tertiary referral center. From May to October 2017, data were collected for patients undergoing nonaerodigestive H&N procedures requiring hospitalization. Patients completed a preoperative survey querying chronic pain history, narcotic usage, and postoperative pain expectation. Demographics, surgical data, postoperative narcotic use defined by morphine milligram equivalents (MME), pain scores, and Overall Benefit of Analgesia Score (OBAS) were analyzed. Seventy-six patients, 44 (57.9%) females and 32 (42.1%) males with a mean age of 54.0 years, met inclusion criteria. The most common procedures were parotidectomy (27.6%) and total thyroidectomy (19.7%). Average cumulative 24-hour postoperative MME and calculated MME per hospital day (MME/HD, cumulative MME for hospitalization divided by length of stay) were 40.5 ± 30.6 and 60.8 ± 60.1, respectively. Average pain score throughout the initial 24 hours after surgery was 3.7/10 ± 2.0. Female sex and prior chronic pain diagnosis were associated with higher OBAS after multivariate linear adjustments. Postoperative narcotic requirement in nonaerodigestive H&N surgery is overall low. Female sex and prior chronic pain diagnosis may be associated with higher postoperative OBAS, a validated assessment of pain and opioid-related side effects. This study may serve as a comparison for future studies evaluating narcotic-sparing analgesia and pain perception in nonaerodigestive H&N surgery.

Predictive Value of First Posttreatment Imaging Using Standardized Reporting in Head and Neck Cancer

23-07-2019 – Derek Hsu,Falgun H. Chokshi,Patricia A. Hudgins,Suprateek Kundu,Jonathan J. Beitler,Mihir R. Patel,Ashley H. Aiken

Journal Article

The Neck Imaging Reporting and Data System (NI-RADS) is a standardized numerical reporting template for surveillance of head and neck squamous cell carcinoma (HNSCC). Our aim was to analyze the accuracy of NI-RADS on the first posttreatment fluorodeoxyglucose positron emission tomography/contrast-enhanced computed tomography (PET/CECT). Retrospective cohort study. Academic tertiary hospital. Patients with HNSCC with a 12-week posttreatment PET/CECT interpreted using the NI-RADS template and 9 months of clinical and radiologic follow-up starting from treatment completion between June 2014 and July 2016 were included. Treatment failure was defined as positive tumor confirmed by biopsy or Response Evaluation Criteria in Solid Tumors criteria. Cox proportional hazards models were performed. This study comprised 199 patients followed for a median of 15.5 months after treatment completion (25% quartile, 11.8 months; 75% quartile, 20.2 months). The rates of treatment failure increased with each incremental increase in NI-RADS category from 1 to 3 (4.3%, 9.1%, and 42.1%, respectively). A Cox proportional hazards model demonstrated a strong association between NI-RADS categories and treatment failure at both primary and neck sites (hazard ratio [HR], 2.60 and 5.22, respectively; Increasing NI-RADS category at the baseline posttreatment PET/CECT is strongly associated with increased risk of treatment failure in patients with HNSCC.

Margins in Laryngeal Squamous Cell Carcinoma Treated with Transoral Laser Microsurgery: A National Database Study

03-09-2019 – Jonathan Hanna,Philip R. Brauer,Elliot Morse,Saral Mehra

Journal Article

To determine national positive margin rates in transoral laser microsurgery, to compare patients with positive and negative margins, and to identify factors associated with positive margins. Retrospective review of the National Cancer Database. Population based. Patients included those with TIS-T3 laryngeal squamous cell carcinoma (2004-2014). Univariable and multivariable logistic regression were used to identify predictors. A total of 1959 patients met inclusion criteria. The national positive margin rate was 22.3%. Sixty-five percent of patients had T1 disease; 94.3% were N-negative; and 74.0% had glottic tumors. Fifty-eight percent of patients were treated at academic centers, and 60.6% were treated at facilities performing <2 cases per year. On multivariable analysis, factors associated with margin status included facility volume (odds ratio [95% CI]; in cases per year: 0.93 [0.89-0.97], The national positive margin rate for laryngeal laser surgery is 22%, which is concerning given the equivalent survival benefit offered by surgery and primary radiation and the increased likelihood of bimodal therapy in the situation of positive margins. Cases treated at nonacademic centers and those with lower caseloads had a higher likelihood of positive margins. There was a linear association between T-stage and likelihood of positive margins, with T3 tumors being 5 times as likely as T1 to yield positive margins. This study highlights the importance of proper patient selection for transoral laser microsurgery resections.

Plasma Ablation–Assisted Endoscopic Management of Postintubation Laryngotracheal Stenosis: An Alternate Tool for Management

08-10-2019 – Ramandeep Singh Virk,Sandeep Bansal,Gyanaranjan Nayak,Lokesh P

Journal Article

The current study was conducted to highlight the use of plasma ablation as a promising method in management of adult laryngotracheal stenosis. We present our institutional experience with a minimum follow-up of 6 months. Seventy adult patients with acquired postintubation laryngotracheal stenosis were included. Efficacy and clinical outcomes of plasma ablation in endoscopic management and eventual decannulation rate were studied. Number of patients with Myer-Cotton stenosis grades 1, 2, 3, and 4 were 20, 25, 18, and 7, respectively. The mean number of surgical interventions required in each grade of stenosis were 1, 2, 3.8, and 4, respectively. Overall, 47 patients (67%) were without tracheotomy by the end of 6 months. Plasma ablation is an effective treatment option for adult laryngotracheal stenosis, with a better success rate for lower-grade stenosis. It has lesser complications and requires fewer surgical interventions.

Association of Midlife Hypertension with Late-Life Hearing Loss

06-08-2019 – Nicholas S. Reed,Matthew G. Huddle,Joshua Betz,Melinda C. Power,James S. Pankow,Rebecca Gottesman,A. Richey Sharrett,Thomas H. Mosley,Frank R. Lin,Jennifer A. Deal

Journal Article

To investigate the association of midlife hypertension with late-life hearing impairment. Data from the Atherosclerosis Risk in Communities study, an ongoing prospective longitudinal population-based study (baseline, 1987-1989). Washington County, Maryland, research field site. Subjects included 248 community-dwelling men and women aged 67 to 89 years in 2013. Systolic blood pressure (SBP) and diastolic blood pressure were measured at each of 5 study visits from 1987-1989 to 2013. Hypertension was defined by elevated systolic or diastolic blood pressure or antihypertensive medication use. A 4-frequency (0.5-4 k
Hz) better-hearing ear pure tone average in decibels hearing loss (d
B HL) was calculated from pure tone audiometry measured in 2013. A cutoff of 40 d
B HL was used to indicate clinically significant moderate to severe hearing impairment. Hearing thresholds at 5 frequencies (0.5-8 k
Hz) were also considered separately. Forty-seven participants (19%) had hypertension at baseline (1987-1989), as opposed to 183 (74%) in 2013. The SBP association with late-life pure tone average differed by the time of measurement, with SBP measured at earlier visits associated with poorer hearing; the difference in pure tone average per 10-mm Hg SBP measured was 1.43 d
B HL (95% CI, 0.32-2.53) at baseline versus -0.43 d
B HL (95% CI, -1.41 to 0.55) in 2013. Baseline hypertension was associated with higher thresholds (poorer hearing) at 4 frequencies (1, 2, 4, 8 k
Hz). Midlife SBP was associated with poorer hearing measured 25 years later. Further analysis into the longitudinal relationship between hypertension and hearing impairment is warranted.

Establishing an Animal Model of Single-Sided Deafness in Chinchilla lanigera

01-10-2019 – Renee M. Banakis Hartl,Nathaniel T. Greene,Victor Benichoux,Anna Dondzillo,Andrew D. Brown,Daniel J. Tollin

Journal Article

(1) To characterize changes in brainstem neural activity following unilateral deafening in an animal model. (2) To compare brainstem neural activity from unilaterally deafened animals with that of normal-hearing controls. Prospective controlled animal study. Vivarium and animal research facilities. The effect of single-sided deafness on brainstem activity was studied in Four animals underwent chemical deafening, with 2 normal-hearing animals as controls. ABRs confirmed unilateral loss of auditory function. Deafened animals demonstrated symmetric local field potential responses that were distinctly different than the contralaterally dominated responses of the inferior colliculus seen in normal-hearing animals. We successfully developed a model for unilateral deafness to investigate effects of single-sided deafness on brainstem plasticity. This preliminary investigation serves as a foundation for more comprehensive studies that will include cochlear implantation and manipulation of binaural cues, as well as functional behavioral tests.

Optimal Head Position Following Intratympanic Injections of Steroids, As Determined by Virtual Reality

24-09-2019 – Omer J. Ungar,Ophir Handzel,Limor Haviv,Solomon Dadia,Oren Cavel,Dan M. Fliss,Yahav Oron

Journal Article

To study optimal head position after intratympanic steroid injections to enhance drug bioavailability. Application of virtual and in vitro models of the intratympanic anatomy. The surgical 3-dimensional printing laboratory of a tertiary academic medical center. A high-resolution computerized tomographic scan of healthy temporal bone and surrounding soft tissue was segmented and reconstructed to a 3-dimensional model. The tympanic membrane was perforated in the posterior-inferior quadrant. Methylene blue-stained 10-mg/m
L dexamethasone was administered to the middle ear cleft, after which a 3-dimensional rotation in space was performed to hypothesize the optimal position in relation to gravity. The same stereolithography file used for the actual model was used for a digital virtual liquid flow simulation. The optimal head position was defined as the one with the maximum vertical distance between the round window membrane and the plane of the aditus ad antrum and eustachian tube orifice. The virtual model yielded the following position of the head as optimal: 53º rotation away from the injected ear in the vertical axis (yaw), 27º rotation toward the noninjected ear in the longitudinal axis (roll), and 10º neck extension in the transverse axis (pitch). Virtual imaging determined that 53º and 27º yaw and roll, respectively, away and 10º pitch were the optimal position for drug delivery after intratympanic injection to the middle ear and that an erect head position provided optimal passage of steroids from the middle ear to the inner ear.

Office-Based Stapes Surgery

01-10-2019 – Béatrice Voizard,Anastasios Maniakas,Issam Saliba

Journal Article

The objective of this study was to provide a proof of concept and to assess the success and safety of stapes surgery for otosclerosis under local anesthesia in an office-based setting (OBS) as compared with a hospital operating room setting (ORS). Retrospective cohort study. We reviewed all patients who underwent stapes surgery by the same surgeon from October 2014 to January 2017 at our tertiary care center (ORS, n = 36, 52%) and in an OBS (n = 33, 48%). The surgical technique was identical in both groups. All patients had a temporal bone computed tomography scan and audiogram within the 6 months prior to surgery. Air-bone gaps (ABGs), bone conduction, and air conduction pure tone average values were calculated. Preoperative results for pure tone average, bone conduction, ABG, and word recognition scores were compared with early (4 months) and late (12 months) follow-up audiograms. Intra- and postoperative complications were compared. Both groups were comparable in terms of demographic characteristics and severity of disease. The mean 1-year postoperative ABG was 5.66 d
B (95% CI = 4.42-6.90) in the ORS group and 6.30 d
B (95% CI = 4.50-8.10) in the OBS group ( In this small group of patients, the success of stapes surgery performed in an OBS and its complications were comparable to those of an ORS, thus providing an alternative to patients on long operating room waiting lists.

The Role for Imaging in the Investigation of Isolated Objective Vestibular Weakness

01-10-2019 – Deanna Gigliotti,Brian Blakley,Paige Moore,Jordan Hochman

Journal Article

Unilateral vestibular weakness has considerable potential etiologies. One source is a vestibular schwannoma. This article evaluates, in the absence of other symptoms and signs, if unilateral vestibular weakness is an analogue to asymmetric sensorineural hearing loss and serves as an indication for lateral skull base imaging. Retrospective chart review. Academic tertiary center. All patients undergoing caloric assessment between January 1, 2012, and June 30, 2018, were investigated. Patients with unilateral vestibular weakness (a left-right difference >25% on electronystagmography) were included in the study. A provincial encompassing image library was surveyed for potential adequate imaging (computed tomography internal auditory canal infused, magnetic resonance imaging [MRI] brain, MRI internal auditory canal) of the target population within the preceding 5 years. Presence/absence of vestibular schwannoma on imaging was determined. Of the 3531 electronystagmography reports reviewed during the period, 864 patients were identified with unilateral vestibular weakness. Of these, 542 had sufficient imaging, and 14 vestibular schwannomas were identified. Only 1 individual had a vestibular weakness in isolation, while the remaining 13 patients also suffered from documented sensorineural hearing loss that would have mandated MRI scanning. The results of our study suggest that, in isolation, vestibular weakness is an insufficient indicator for lateral skull base imaging.

Application-Based Translaryngeal Ultrasound for the Assessment of Vocal Fold Mobility in Children

24-09-2019 – Zahra Sayyid,Varun Vendra,Kara D. Meister,Catherine D. Krawczeski,Noah J. Speiser,Douglas R. Sidell

Journal Article

To compare the evaluation of vocal fold mobility between flexible nasal laryngoscopy (FNL) and a handheld application-based translaryngeal ultrasound (TLUS) platform. Prospective analysis included patients with unknown vocal fold mobility status who underwent FNL and TLUS. Tertiary referral center. TLUS was performed on 23 consecutive children (<18 years old) presenting for laryngoscopy due to unknown vocal fold mobility status. After the recording of three 10-second TLUS videos as well as FNL, the study was divided into 2 parts: parental assessment of laryngeal ultrasound at the time of patient evaluation and random practitioner assessment of ultrasound videos. We describe 23 patients who underwent TLUS and FNL. Ten patients (43.5%) had normal vocal fold function bilaterally, and 13 (56.5%) had either left or right vocal fold immobility. Family members and physicians correctly identified the presence and laterality of impaired vocal fold mobility in 22 of 23 cases (κ = 0.96). The sensitivity, specificity, positive predictive value, and negative predictive value of FLUS in diagnosing vocal fold immobility were 92.3%, 100%, 100%, and 90.9%, respectively. Random practitioners accurately identified the presence and laterality of vocal fold immobility under all circumstances. A handheld application-based ultrasound platform is both sensitive and specific in its ability to identify vocal fold motion impairment. Portable handheld TLUS has the potential to serve as a validated screening examination, even by inexperienced providers, and in specific cases may obviate the need for an invasive transnasal laryngoscopy.

Clinical Implications of Carcinoma In Situ in Sinonasal Inverted Papilloma

22-10-2019 – Ivy W. Maina,Charles C. L. Tong,Esther Baranov,Neil N. Patel,Vasiliki Triantafillou,Edward C. Kuan,Michael A. Kohanski,Peter Papagiannopoulos,Carol H. Yan,Alan D. Workman,Justina L. Lambert,Noam A. Cohen,David W. Kennedy,Nithin D. Adappa,Michael D. Feldman,James N. Palmer

Journal Article

Sinonasal inverted papilloma (IP) is a typically benign sinonasal tumor with a tendency to recur and the potential for malignant transformation. Varying degrees of dysplasia may be present, of which carcinoma in situ (CIS) is most advanced. We hereby describe the biological and clinical behavior of IP with CIS (IPw
CIS). Retrospective cohort. Tertiary academic referral center. Patients who underwent surgical resection for IP between 2002 and 2017. Pertinent clinical data were obtained, and all IPw
CIS cases were histologically confirmed. In total, 37 of 215 cases (17.2%) were identified with IPw
CIS. Mean age was 57 years and 86.5% of patients were male. Median follow-up was 82 months, and the recurrence rate was 27%. The maxillary sinus was the most common primary site (37.8%) and 14 tumors (37.8%) demonstrated multifocal attachment, which was associated with recurrence (odds ratio [OR], 9.7; 95% confidence interval [CI], 1.4-112.8; IPw
CIS represents the most severe degree of dysplasia prior to malignant transformation and is associated with higher recurrence rate and multifocal involvement but low rate of conversion to invasive carcinoma. The need for adjuvant therapy remains controversial, and further research into the etiology of the disease is warranted.

The Potential of High-Throughput DNA Sequencing of the Paranasal Sinus Microbiome in Diagnosing Odontogenic Sinusitis

06-08-2019 – Asad A. Haider,Michael J. Marino,William C. Yao,Martin J. Citardi,Amber U. Luong

Journal Article

High-throughput DNA sequencing of the paranasal sinus microbiome has potential in the diagnosis and treatment of sinusitis. The objective of this study is to evaluate the use of high-throughput DNA sequencing to diagnose sinusitis of odontogenic origin. Case series with chart review. Single tertiary care academic medical center. A chart review was performed of DNA sequencing results from the sinus aspirates obtained under endoscopic visualization in 142 patients with sinusitis. The identification of any potentially pathogenic bacteria associated with oral flora in a sample was classified as a positive result for sinusitis of odontogenic etiology. The sensitivity, specificity, and predictive values of using high-throughput DNA sequencing to diagnose sinusitis of odontogenic etiology were determined, with the patient’s computed tomography sinus scan as the reference standard. On computed tomography scans, an odontogenic source was determined by the presence of a periapical lucency perforating the schneiderian membrane. Seven of the 142 patients enrolled in this study had an odontogenic source based on computed tomography scans. Relative to this reference standard, high-throughput DNA sequencing produced a sensitivity of 85.7% (95% CI, 42.1%-99.6%), a specificity of 81.5% (95% CI, 73.9%-87.6%), a positive predictive value of 19.4% (95% CI, 13.1%-27.7%), and a negative predictive value of 99.1% (95% CI, 94.7%-99.9%). This study supports the use of high-throughput DNA sequencing in supplementing other methods of investigation for identifying an odontogenic etiology of sinusitis.

Effects of OSA Surgery on Leptin and Metabolic Profiles

01-10-2019 – Chien-Hung Chin,Pei-Wen Lin,Hsin-Ching Lin,Michael Friedman,Meng-Chih Lin

Journal Article

This study is designed to investigate the effects of obstructive sleep apnea/hypopnea syndrome (OSA) surgery on serum leptin levels and metabolic disturbances, both of which contribute to the risk of cardiovascular diseases. Case series with planned data collection. Tertiary referral medical center. A retrospective chart review of 101 consecutive patients with OSA who refused or failed conservative therapy and who then underwent upper airway surgery for OSA treatment was conducted. The personal medical history, anthropometric measurements, subjective symptoms, and objective polysomnographic parameters and fasting morning blood samples for leptin and metabolic biomarkers measurements were collected preoperatively and at a minimum of 3 months postoperatively. Eighty patients with OSA (69 men and 11 women; mean [SD] age of 42.2 [10.2] years) with complete data were included in the final analysis. At least 3 months after surgery, serum leptin, low-density lipoprotein cholesterol (LDL-C), and triglyceride levels and the mean systolic blood pressure (SBP) (night and morning) significantly decreased. According to the classical definition of surgical success, 40 subjects had successful surgery and were categorized as surgical responders, and the other 40 patients who failed surgery were categorized as surgical nonresponders. Significant reductions in serum leptin, total cholesterol, LDL-C, and triglyceride levels and improvement of mean SBP (morning) occurred in surgical responders but not in nonresponders. Effective OSA surgery improves serum leptin, lipid profiles, and SBP. Further studies are needed to investigate the role of serial measurements of these biomarkers in monitoring surgical outcome of OSA treatment.

Plaut-Vincent’s Ulcerative Gingivitis and Tonsillitis

06-08-2019 – Francesco Maccarrone,Matteo Alicandri-Ciufelli

Journal Article

Distance Traveled to Head and Neck Cancer Provider: A Measure of Socioeconomic Status and Access

03-12-2019 – Sean T. Massa,Adam P. Liebendorfer,Jose P. Zevallos,Angela L. Mazul

Journal Article

Improved head and neck cancer survival has been associated with traveling farther distances for treatment, potentially due to patients seeking higher-quality facilities. This study investigates the role of both facility and confounding patient factors on this relationship. Review of national registry data. National Cancer Database. Adults with head and neck cancer diagnosed from 2004 to 2014 were identified. Overall survival was compared among distance-to-facility quartiles via univariate and multivariate survival models. Then, the analysis was stratified by facility and patient factors, and the association between distance and survival was compared among strata. Overall survival was worst in the shortest-distance quartile (<5 miles; median survival, 80.7 months; 95% CI, 79.2-82.3), while other distance groups showed similar survival (range, 96.4-104 months). This finding remained in the multivariate model (adjusted hazard ratio vs first distance quartile: 0.88; 95% CI, 0.87-0.89). The association between survival and distance persisted in all subgroups when stratified by facility volume and type (adjusted hazard ratio range, 0.82-0.91), suggesting that facility quality does not fully account for this association. When stratified by income, distance remained statistically associated with survival but with a smaller effect size than that of income. The association between distance to treating facility and head and neck cancer survival is limited to patients with worse survival outcomes living within 5 miles of the facility and is not fully explained by measures of facility quality.

Dysphagia Screening for Pneumonia Prevention in a Cancer Hospital: Results of a Quality/Safety Initiative

03-12-2019 – Barbara Ebersole,Miriam Lango,John Ridge,Elizabeth Handorf,Jeffrey Farma,Sarah Clark,Nausheen Jamal

Journal Article

Hospital-acquired aspiration pneumonia remains a rare but potentially devastating problem. The best means by which to prevent aspiration in a cancer hospital population has not been evaluated. The aim of this study was to evaluate the impact of dysphagia screening on aspiration pneumonia rates in an acute care oncology hospital. A prospective single-institution quality improvement dysphagia screening protocol at a comprehensive cancer center. Effect of dysphagia screening implemented in 2016 on hospital-acquired aspiration pneumonia rates coded “aspiration pneumonitis due to food/vomitus” was compared with rates from 2014 to 2015 prior to implementation. Screening compliance, screening outcomes, patient demographics, and medical data were reviewed as part of a post hoc analysis. Of 12,392 admissions in 2014 to 2016, 97 patients developed aspiration pneumonia during their hospitalization. No significant change in aspiration pneumonia rate was seen during the dysphagia screening year when compared to prior years (baseline, 7.36; screening year, 8.78 per 1000 discharges; Nursing-initiated dysphagia screening did not decrease aspiration pneumonia rates. The causes of aspiration-associated pneumonia were heterogeneous. Aspiration of intestinal contents is a more common source of hospital-acquired pneumonia than oropharyngeal dysphagia.

Cytotoxicity of Ear Drop Excipients in Human and Mouse Tympanic Membrane Fibroblasts

03-12-2019 – Carolyn O. Dirain,David N. Karnani,Patrick J. Antonelli

Journal Article

Commercial ear drops contain ingredients reported to be inactive. We sought to evaluate such excipients for possible cytotoxicity on human and mouse tympanic membrane (TM) fibroblasts. Prospective, in vitro. Tertiary academic center. Mouse and human TM fibroblasts were treated with 1:10 dilutions of benzalkonium chloride (BKC) 0.0025%, 0.006%, or 0.01%; benzyl alcohol 0.9%; polysorbate 80 (PSB) 2.5%; glycerin 2.4%; povidone 0.2%; or water (control), twice within 24 hours or 4 times within 48 hours, for 2 hours each time. Cells were placed back in growth media after the treatments. Cells were observed with phase-contrast microscopy until the cytotoxicity assay was performed. Mouse fibroblasts had lower survival in only the PSB-treated cells compared to the control ( Polysorbate 80 and benzalkonium chloride, at concentrations found in commercial ear drops, may be cytotoxic to human and mouse TM fibroblasts. “Inactive” ingredients may need to be considered when evaluating clinical outcomes with commercial ear drops.

Risks of Neoplasia and Malignancy in Surgically Resected Cystic Parotid Lesions

03-12-2019 – Brian C. Boursiquot,Nancy J. Fischbein,Davud Sirjani,Uchechukwu C. Megwalu

Journal Article

To evaluate the risks of neoplasm and malignancy in surgically treated cystic parotid masses compared with solid or mixed lesions and to evaluate the performance of fine-needle aspiration (FNA) in parotid cysts. Retrospective cross-sectional study. Single-institution academic tertiary care center. Patients without a history of human immunodeficiency virus or head and neck cancer who underwent parotidectomy for parotid masses and had preoperative imaging to characterize lesions as cystic, solid, or mixed (ie, partially cystic and partially solid). We assessed the risks of neoplasia and malignancy, adjusting for age, sex, race/ethnicity, facial nerve weakness, and history of malignancy. We also evaluated the sensitivity and specificity of FNA. We included 308 patients, 27 of whom had cystic parotid masses (5 simple and 22 complex). Cystic masses were less likely to be neoplastic compared to solid or mixed masses (44% vs 97%; odds ratio [OR], 0.03; 95% confidence interval [CI], 0.01-0.07); however, there was no difference in the risk of malignancy (22% vs 26%; OR, 0.81; 95% CI, 0.32-2.10). Cystic masses were more likely to yield nondiagnostic FNA cytology results, but for diagnostic samples, FNA was 86% sensitive and 33% specific for diagnosing neoplasia and 75% sensitive and 83% specific for diagnosing malignancy. In our population, cystic masses undergoing surgery were less likely to be neoplastic but had a similar risk of malignancy as solid masses. The risk of malignancy should be considered in the management of cystic parotid masses.

Preoperative Stellate Ganglion Block for Perioperative Pain in Lateralized Head and Neck Cancer: Preliminary Results

03-12-2019 – Daniel Sharbel,Paramvir Singh,Daniel Blumenthal,James Sullivan,Anterpreet Dua,W. Greer Albergotti,Michael Groves,J. Kenneth Byrd

Journal Article

Patients with head and neck cancer represent a vulnerable population at particular risk of opioid dependence due to frequent histories of substance abuse, requirement of extensive surgery, and the synergistic toxicity of multimodal therapy. Regional anesthetic techniques have been used by other surgical disciplines to facilitate early recovery after surgery and decrease postoperative patient narcotic requirements. This pilot study investigates the efficacy of a preoperative regional analgesia using stellate ganglion block in lateralized head and neck cancer surgery. From our early results, stellate ganglion blockade may hold promise as an effective preoperative intervention for controlling early postoperative pain, lessening narcotic requirements, and improving quality of life.

Ethical Considerations in the Advent of Artificial Intelligence in Otolaryngology

26-11-2019 – Alexandra M. Arambula,Andrés M. Bur

Journal Article

Artificial intelligence (AI) is quickly expanding within the sphere of health care, offering the potential to enhance the efficiency of care delivery, diminish costs, and reduce diagnostic and therapeutic errors. As the field of otolaryngology also explores use of AI technology in patient care, a number of ethical questions warrant attention prior to widespread implementation of AI. This commentary poses many of these ethical questions for consideration by the otolaryngologist specifically, using the 4 pillars of medical ethics-autonomy, beneficence, nonmaleficence, and justice-as a framework and advocating both for the assistive role of AI in health care and for the shared decision-making, empathic approach to patient care.

Laryngotracheal Stenosis in Early vs Late Tracheostomy: A Systematic Review

26-11-2019 – Steven D. Curry,Paul J. Rowan

Journal Article

For critically ill patients undergoing long-term mechanical ventilation, to determine whether early conversion from endotracheal intubation to tracheostomy reduces the incidence of laryngotracheal stenosis. MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, and the Cumulative Index to Nursing and Allied Health Literature. A systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and an assessment of bias were performed. Included studies reported outcomes of patients who were converted from endotracheal intubation to tracheostomy, compared early vs late tracheostomy, and reported the incidence of laryngotracheal stenosis and details of postoperative surveillance. Data were also collected for intensive care setting, method of tracheostomy, and timing of tracheostomy. Seven articles met inclusion criteria: 2 randomized trials, 2 quasi-randomized trials, 1 prospective cohort, and 2 retrospective cohorts. A total of 966 patients were included in this analysis (496 in the early tracheostomy group and 470 in the late tracheostomy group). The mean incidence of laryngotracheal stenosis was 8.9% (range, 0%-20.8%), with a mean incidence of 8.1% in early tracheostomy groups and 10.9% in late tracheostomy groups. In studies with the least risk of bias, there were no differences in the incidence of laryngotracheal stenosis in patients who underwent early vs late tracheostomy. In critically ill patients undergoing long-term mechanical ventilation, early conversion to tracheostomy within 7 days of intubation does not significantly decrease the risk of laryngotracheal stenosis compared to later conversion as defined by the included studies.

The Role of Genioglossus Activity in Predicting Uvulopalatopharyngoplasty Outcomes

26-11-2019 – Di Zhao,Yanru Li,Yue Qu,Junbo Zhang,Xin Cao,Jingying Ye

Journal Article

The aim of this study was to evaluate the association between genioglossus activity during sleep onset and the outcome of uvulopalatopharyngoplasty (UPPP) in patients with obstructive sleep apnea. Case series with planned data collection. Sleep medical center. Forty-four patients with obstructive sleep apnea underwent overnight polysomnography with synchronous genioglossus electromyography (GGEMG) with intraoral electrodes. In addition, all patients underwent revised UPPP with uvula preservation and were followed up with polysomnography at least 3 months after surgery. Twenty-five patients (56.8%) were responders. Multiple regression analysis revealed that increasing tonsil size (odds ratio [OR], 0.086; Sleep-onset GGEMG and tonsil size are both important in deciding outcomes of UPPP. Patients with tonsil size III or IV and higher sleep onset may be more suitable candidates for UPPP because of the higher probability of surgical success.

Association between Smoking and 30-Day Outcomes in Otologic Surgery

19-11-2019 – Emily Kay-Rivest,Marco Mascarella,Maida J. Sewitch,François Cloutier,Tamara Mijovic

Journal Article

To determine the effect of current smoking status on 30-day postoperative adverse events in patients undergoing otologic surgery. Retrospective cohort study. Database of the American College of Surgeons National Surgical Quality Improvement Program from 2006 to 2016. Adult patients undergoing middle ear and mastoid surgery were included. Preoperative smoking status was determined, and adverse events within 30 days of surgery were recorded. Descriptive statistics were used to characterize the study sample. Multivariable logistic regression was performed to identify the association between sociodemographic and clinical variables and postoperative adverse events. Population-attributable fractions were then calculated. A total of 10,684 patients who underwent otologic surgery were included, of whom 2036 (19.1%) were smokers. The most commonly performed surgery was tympanoplasty with and without ossicular chain reconstruction, followed by canal wall up tympanomastoidectomy. Adverse events occurred in 221 (2.1%) patients; the most common was superficial wound infections (n = 99, 0.9%). In smokers, the odds ratio for any adverse event was 1.97 (95% CI, 1.42-2.71). The odds ratios (95% CIs) for superficial wound infections, wound dehiscence, and 30-day readmission among smokers were 1.89 (1.32-2.86), 3.92 (1.26-11.60), and 1.84 (1.15-2.87), respectively. The population-attributable fraction for any adverse event in smokers was 15.5%. In patients undergoing otologic surgery, smokers are more likely than nonsmokers to have postoperative adverse events-in particular, wound infections, wound dehiscence, and readmission to hospital.

Appropriateness of Otic Quinolone Use among Privately Insured US Patients

19-11-2019 – Phuong T. Tran,Almut G. Winterstein,Xi Wang,Kiyon Rhew,Patrick J. Antonelli

Journal Article

Considering emerging safety concerns involving otic quinolones, we assessed the extent of otic quinolone use for questionable indications. Descriptive cross-sectional study of a national sample of privately insured patients. Outpatient encounters in the United States. Children and adults with outpatient pharmacy-dispensing claims for new prescriptions of otic or ophthalmic quinolones in 2017 were identified within the IBM Market
Scan Commercial Claims & Encounters and the Medicare Supplemental Database. Each dispensing ≥30 days apart constituted a unique episode. Only claims with supporting ear-related diagnoses on outpatient encounters ±3 days of dispensing were considered. Ophthalmic drops were excluded if eye-related diagnoses were found ±30 days. Prescribing was classified as appropriate, questionable, or undetermined. We found 214,897 episodes in 200,270 patients. Adults were twice as likely as children to have otic treatment with questionable indications (6.2% vs 3.0%). Sensitivity analyses with broader time windows to ascertain diagnoses showed similar proportions of questionable use. Otalgia and cerumen impaction constituted 90% of questionable indications. Family physicians (6.8%) and internists (8.0%) had higher percentages of questionable use than other specialties. Based on the demonstrated risks of quinolone ear drops, opportunities exist to decrease otic quinolone use, especially in adults.

Epidemiology of Pediatric Tracheostomy and Risk Factors for Poor Outcomes: An 11-Year Single-Center Experience

19-11-2019 – Aletheia Z. H. Chia,Zhi Min Ng,Yu Xian Pang,Annette H. C. Ang,Cristelle C. T. Chow,Oon Hoe Teoh,Jan Hau Lee

Journal Article

Children with long-term tracheostomies are at higher risk of complications. This study aims to describe the epidemiology, outcomes, and factors associated with successful decannulation in children undergoing tracheostomy. Case series with chart review. Tertiary hospital. A retrospective analysis was conducted on pediatric tracheostomies performed from 2006 to 2016. Demographics, preexisting comorbidities, indications for tracheostomy, and pretracheostomy ventilatory requirements were collected. A multivariate regression model with covariates of age, failure to thrive (FTT), and comorbidities was used to identify factors associated with successful decannulation. Secondary outcomes were ventilation and oxygen requirements at hospital discharge, hospital and intensive care unit length of stay, and complications. In total, 105 patients received a tracheostomy at a median age of 8.0 months (interquartile range, 2.0-45.0). The most common indication was anatomic airway obstruction (55 of 105, 52.5%). Forty-four (41.9%) patients had preexisting FTT. In-hospital mortality was 14 of 105 (13.3%). None were directly related to tracheostomy. At discharge, 40 of 91 (44.0%) and 12 of 91 (13.2%) required home mechanical ventilation and supplemental oxygen, respectively. Forty-one (39%) patients underwent successful decannulation at a median 408 days (interquartile range, 170-1153) posttracheostomy. On adjusted analysis, unsuccessful decannulation was more common in patients with FTT and neurologic comorbidities. Postoperative complications were more common in younger patients and those with a longer time to decannulation. Neurologic comorbidities and FTT were risk factors for unsuccessful decannulation after pediatric tracheostomy. Nutritional interventions may have a role in improving long-term outcomes following pediatric tracheostomies and should be investigated in future studies.

Approximate Weight of 1:1000 Topical Epinephrine on Wrung-Out Epinephrine-Soaked Pledgets

19-11-2019 – Hannah N. Kuhar,Xiaoxia Han,Donald H. Penning,John R. Craig

Journal Article

Topical 1:1000 epinephrine solution is commonly applied intranasally with cottonoid pledgets in endoscopic sinonasal surgery for local vasoconstriction and hemostasis. Pledgets are typically submerged in epinephrine solution and applied without measurement. Hemodynamic complications have been reported when pledgets have been saturated and not wrung out. The amount of epinephrine absorbed per pledget has not been studied methodically. The purpose of this study was to determine the amount of topical 1:1000 epinephrine remaining on a cottonoid pledget after wringing out the pledget, to simulate intraoperative application. Cohort study. Tertiary care center. Sixty 0.5-in × 3-in cottonoid pledgets were submerged in canisters filled with 1:1000 epinephrine solution (1 mg/m
L). Weights of the epinephrine-filled canisters were measured before submerging the pledgets and then after removing and wringing out the pledgets. Measurements were recorded for each pledget after being submerged for 0, 1, and 5 minutes and then wrung out. Mean weights were calculated and compared between the submersion durations. The mean overall weight of epinephrine on a wrung-out pledget was 0.931 mg. Mean weights of epinephrine absorbed onto wrung-out pledgets after submersion for 0, 1, and 5 minutes were 0.914, 0.913, and 0.967 mg, respectively. There were no significant differences in weights based on submersion duration ( Approximately 1 mg of epinephrine was absorbed onto 0.5-in × 3-in cottonoid pledgets when pledgets were wrung out after being submerged in 1:1000 epinephrine, whether being removed from solution immediately or after up to 5 minutes.

PHQ-9 and SNOT-22: Elucidating the Prevalence of Depression in Chronic Rhinosinusitis

12-11-2019 – Laura J. Vandelaar,Zi Yang Jiang,Alok Saini,William C. Yao,Amber U. Luong,Martin J. Citardi

Journal Article

Chronic rhinosinusitis (CRS) has been associated with comorbid depression, yet the prevalence of depression among all patients with CRS is not well described. The Patient Health Questionnaire-9 (PHQ-9), a validated instrument for diagnosing depression, has been used to assess depression in a variety of clinical settings. PHQ-9 scores ≥10 are the threshold for a depression diagnosis. The purpose of this study was to assess the prevalence of depression in a rhinology practice and compare the PHQ-9 with the 22-item Sinonasal Outcome Test (SNOT-22). Retrospective chart review. Tertiary rhinology practice. During the 2-month period ending April 30, 2018, all rhinology patients were asked to complete the PHQ-9 and SNOT-22. Among 216 patients, 46 (21.3%) had a self-reported history of depression, and 39 (18.1%) had a PHQ-9 score ≥10. Of the 39 patients screening positive for depression, 18 (41.9%) had no history of depression. Comparison of PHQ-9 with overall SNOT-22 score had a Pearson’s coefficient of 0.632 ( Depression rates (estimated by PHQ-9 responses) among rhinology patients are similar to chronic disease populations; depression may be underdiagnosed in rhinology patients. Higher SNOT-22 scores were associated with higher PHQ-9 scores. Further studies are warranted to understand the impact of comorbid conditions of depression and CRS in patient quality of life.

Prevalence of Pediatric Dizziness and Imbalance in the United States

05-11-2019 – Jacob R. Brodsky,Sophie Lipson,Neil Bhattacharyya

Journal Article

Understand the prevalence of vestibular symptoms in US children. Cross-sectional analysis. 2016 National Health Interview Survey. Responses from the 2016 National Health Interview Survey for children ages 3 to 17 years were examined to determine the prevalence of vestibular symptoms and provider-assigned diagnoses. Dizziness or imbalance was reported in 3.5 (95% confidence interval, 3.1-3.9) million patients (5.6%) with a mean age of 11.5 years. Dizziness was reported in 1.2 million patients (2.0%) with a mean age of 12.7 years and balance impairment in 2.3 million patients (3.7%) with a mean age of 10.6 years. Prevalence of dizziness and imbalance did not vary by sex ( The national prevalence of childhood vestibular symptoms is more common than previously thought. Reported diagnoses varied greatly from the literature, suggesting a need for increased awareness of causes of vestibular symptoms in children.

Quality of Life in Children with Sensorineural Hearing Loss

05-11-2019 – Evette A. Ronner,Liliya Benchetrit,Patricia Levesque,Razan A. Basonbul,Michael S. Cohen

Journal Article

To assess quality of life (QOL) in pediatric patients with sensorineural hearing loss (SNHL) with the Pediatric Quality of Life Inventory 4.0 (Peds
QL 4.0) and the Hearing Environments and Reflection on Quality of Life 26 (HEAR-QL-26) and HEAR-QL-28 surveys. Prospective longitudinal study. Tertiary care center. Surveys were administered to patients with SNHL (ages 2-18 years) from July 2016 to December 2018 at a multidisciplinary hearing loss clinic. Patients aged >7 years completed the HEAR-QL-26, HEAR-QL-28, and Peds
QL 4.0 self-report tool, while parents completed the Peds
QL 4.0 parent proxy report for children aged ≤7 years. Previously published data from children with normal hearing were used for controls. The independent In our cohort of 100 patients, the mean age was 7.7 years (SD, 4.5): 62 participants had bilateral SNHL; 63 had mild to moderate SNHL; and 37 had severe to profound SNHL. Sixty-eight patients used a hearing device. Mean (SD) total survey scores for the Peds
QL 4.0 (ages 2-7 and 8-18 years), HEAR-QL-26 (ages 7-12 years), and HEAR-QL-28 (ages 13-18 years) were 83.9 (14.0), 79.2 (11.1), 81.2 (9.8), and 77.5 (11.3), respectively. Mean QOL scores for patients with SNHL were significantly lower than those for controls on the basis of previously published normative data ( It is feasible to collect QOL data from children with SNHL in a hearing loss clinic. Children with SNHL had significantly lower scores on validated QOL instruments when compared with peers with normal hearing.

Reflections: Starting an Otolaryngology Medical Student Interest Group

05-11-2019 – Amanda Hu

Journal Article

A decline in applicants for otolaryngology residency spots has been reported. Several possible factors include the lack of exposure to otolaryngology, the lack of role models, work-life balance, and the competitiveness of otolaryngology as a deterrent. Our institution started a medical student interest group to address several of these factors. Key stakeholders who were engaged in this process included medical students, otolaryngology residents, and faculty members. Sustainability of the interest group was investigated with funding and succession planning. Early exposure to otolaryngology through shadowing in the operating room and research projects were initiated with a database on a website. Logistics of starting a club and organizing a clinical skills session were discussed. Awareness of our specialty and branding of the interest group as otolaryngology versus ear, nose, and throat were debated. Starting a medical student interest group in otolaryngology may be an excellent way to foster interest in our specialty.

US Medical Trainees’ Knowledge of Human Papilloma Virus and Head and Neck Cancer

29-10-2019 – Benjamin M. Laitman,Lukas Ronner,Kristin Oliver,Eric Genden

Journal Article

Given the increasing incidence of human papilloma virus (HPV)-positive head and neck cancers (HNCs), discussion of this oncologic outcome should be incorporated into HPV vaccine counseling practices. Yet, preliminary evidence shows that knowledge of the association between HPV and HNC is lacking among most medical trainees. To better characterize this deficit, we nationally assessed knowledge of HPV’s association with HNC among medical students and residents across 4 specialties (pediatrics, obstetrics and gynecology, family medicine, and otolaryngology). A total of 3141 responses from 46 states were obtained (n = 402 pediatric residents, n = 346 obstetrics/gynecology residents, n = 260 family medicine residents, n = 87 otolaryngology residents, and n = 2045 medical students). Only 40.3% of surveyed medical students and 56.1% of surveyed obstetrics/gynecology, pediatrics, and family medicine residents identified associations between persistent HPV infection and HNC. When counseling on the vaccine, nonotolaryngology residents more often discussed cervical cancer (99.8%) as compared with HNC (39.7%), commonly because of less HNC knowledge (61.5%). These results suggest that it is imperative to develop educational interventions targeted at medical students and resident trainees on the front line of HPV vaccine counseling and administration.

Recognizing Persistent Disease in Well-Differentiated Thyroid Cancer and Association with Lymph Node Yield and Ratio

29-10-2019 – Julia E. Noel,Lisa A. Orloff

Journal Article

To establish the association between lymph node yield and ratio in neck dissection for well-differentiated thyroid cancer and risk for persistent postoperative disease. Retrospective cohort study of patients undergoing lymphadenectomy for thyroid carcinoma. Tertiary referral center. Included patients underwent central and/or lateral neck dissection for papillary thyroid carcinoma at our institution between 1994 and 2015. They were divided into a persistent disease group with biochemical and structural disease (49 patients) and a disease-free group with no disease after a minimum 2 years of follow-up (175 patients). Demographic characteristics, adjuvant therapy, tumor, and lymph node features were compared. There were no significant differences in demographic characteristics between the groups. The mean nodal yield of patients with central and lateral neck persistence was significantly lower than that of patients remaining disease free (4.8 vs. 11.9: odds ratio [OR] 0.69; 95% CI, 0.59 to 0.8; Lower lymph node yield and higher node ratio from cervical lymph node dissections are associated with persistent disease and have potential applications in surgical adequacy.

Female Authorship of Opinion Pieces in Leading Otolaryngology Journals between 2013 and 2018

29-10-2019 – Ashley L. Miller,Vinay K. Rathi,Stacey T. Gray,Regan W. Bergmark

Journal Article

Although women represent an increasing proportion of the physician workforce, barriers to the professional advancement of women persist, particularly within surgical fields such as otolaryngology. Authorship of scientific opinion articles serves as an important opportunity for professional development. We conducted a retrospective cross-sectional study to characterize the authorship patterns of scientific opinion articles by gender in leading otolaryngology journals between 2013 and 2018. Outcome measures were the number and proportion of female physician first authors and female last authors as compared with the proportion of the otolaryngology workforce. Between 2013 and 2018, female authors accounted for 24.1% of first of multiple authors, 30.4% of sole authors, and 25.3% of last authors. Women were equitably represented in comparison with the proportion of practicing female otolaryngologists (17.1% in 2017). The proportion of female first authorship increased from 20.0% in 2013 to 32.0% in 2018. Additional efforts are necessary to support the equitable advancement of women in otolaryngology.

Surgical Instrument Optimization to Reduce Instrument Processing and Operating Room Setup Time

22-10-2019 – Lauren Crosby,Eric Lortie,Brian Rotenberg,Leigh Sowerby

Journal Article

As health care expenditures rise, novel ways to increase efficiency are sought. The operating room (OR) represents an area where there is opportunity to optimize work flow and supply use. Evidence suggests that instrument redundancy in the OR tends to be high and that direct cost savings can be achieved by “optimizing” surgical trays. The purpose of this study was to quantify the potential time savings associated with surgical tray optimization. Instrument utilization was reviewed for 4 procedures: tonsillectomy, sinus surgery, septoplasty, and septorhinoplasty. Instruments used in <20% of cases were excluded. Data on tray assembly time in the central processing department and instrument setup time in the OR were prospectively collected over a 3-month period before and after tray optimization. Student's Tray assembly times were found to be significantly shorter following optimization, with percentage reduction in time ranging from 58% to 66% ( Tray optimization may reduce stress and adverse events and allow managers to better estimate staffing requirements. Cost-benefits could not be determined given a limited understanding of how departments choose to redistribute time savings. Measurable and significant time savings can be achieved by assessing instrument utilization rates and reducing tray redundancy, leading to lower performance variability and improved efficiency.

Adverse Events Associated with Balloon Sinuplasty: A MAUDE Database Analysis

22-10-2019 – Kevin Hur,Marshall Ge,Jeehong Kim,Elisabeth H. Ference

Journal Article

Balloon sinuplasty utilization has increased significantly since its introduction over a decade ago. However, the most common associated complications are still unknown. The objective of this study was to analyze adverse events related to balloon sinuplasty. Retrospective cross-sectional analysis. Food and Drug Administration’s MAUDE database (Manufacturer and User Facility Device Experience; 2008-2018). The MAUDE database was searched for all reports on adverse events involving balloon sinuplasty devices from the 3 leading manufacturers: Acclarent, Entellus, and Medtronic. Reported events were reviewed and categorized. During the study period, there were 211 adverse events from 208 reports divided into the following categories: patient related (n = 102, 48.3%), device related (n = 101, 47.9%), and packaging related (n = 8, 3.8%). Four periprocedural deaths were reported but were not clearly associated with technical complications. The most common device-related complications were guide catheter malfunction (39.6%), balloon malfunction (38.6%), and imprecise navigation (17.8%). The most common patient-related complications were cerebrospinal fluid leak (36.3%), eye swelling (29.4%), and epistaxis (11.8%). A lateral canthotomy was performed in 30.0% of eye-swelling complications. Sixty percent of eye complications occurred during balloon dilation of the maxillary sinus. The years 2014 (n = 48) and 2012 (n = 32) had the highest number of adverse events reported as compared with all other years. The most common adverse events associated with balloon sinuplasty include balloon malfunction, guide catheter malfunction, cerebrospinal fluid leak, and significant eye swelling. Health care providers should discuss these possible complications when consenting patients for balloon sinuplasty.

Five-Year Objective and Subjective Outcomes of Velopharyngeal Surgery for Patients with Obstructive Sleep Apnea

22-10-2019 – Guoping Yin,Mu He,Xin Cao,Jinkun Xu,Yuhuan Zhang,Dan Kang,Jingying Ye

Journal Article

To assess the long-term effects of velopharyngeal surgery on objective and subjective symptoms in patients with obstructive sleep apnea (OSA). Prospective cohort study. University medical center. Eighty-six patients with OSA underwent velopharyngeal surgery, which consisted of revised uvulopalatopharyngoplasty with uvula preservation, with or without concomitant transpalatal advancement pharyngoplasty. The results from polysomnography and the Epworth Sleep Scale after 6 months and 5 years were compared with baseline. Baseline variables were compared between responders and nonresponders. Sixty-three patients were successfully followed up at the end of study. The surgical success rate after 6 months and 5 years was 66.67% (42 of 63) and 60.32% (38 of 63), respectively, with no significant difference ( Velopharyngeal surgery was effective in improving nocturnal respiration and excessive daytime sleepiness in patients with OSA at 6-month and 5-year follow-up. Tonsil size and CT90 could be predictors for surgery responders.

Impact of Neck Disability on Health-Related Quality of Life among Head and Neck Cancer Survivors

15-10-2019 – Marci L. Nilsen,Lingyun Lyu,Michael A. Belsky,Leila J. Mady,Dan P. Zandberg,David A. Clump,Heath D. Skinner,Shyamal Das Peddada,Susan George,Jonas T. Johnson

Journal Article

Although neck impairment has been described following surgical resection, limited studies have investigated its prevalence in nonsurgical treatment. The purpose of this study is to determine the prevalence and predictors of neck disability following head and neck cancer (HNC) treatment and to explore its association with quality of life (QOL). Cross-sectional study. HNC survivorship clinic. We identified 214 survivors who completed treatment ≥1 year prior to evaluation in the clinic. Self-reported neck impairment was measured using the Neck Disability Index. QOL was measured using the University of Washington QOL Questionnaire, with physical and social subscale scores calculated. Regression analysis and trend tests were employed to explore associations. Over half of survivors (54.2%) reported neck disability. The odds of neck disability in survivors who received nonsurgical treatment and those who received surgery plus adjuvant treatment were 3.46 and 4.98 times higher compared to surgery alone ( This study revealed a high prevalence of neck disability following nonsurgical treatment. While neck disability is an established sequela of surgical resection, the impact of nonsurgical treatment has gone unrecognized. Early identification and intervention to prevent progression of neck disability are crucial to optimize QOL.

Effectiveness of Canal Occlusion for Intractable Posterior Canal Benign Paroxysmal Positional Vertigo: A Systematic Review

15-10-2019 – Britta D. P. J. Maas,Hester J. van der Zaag-Loonen,Peter Paul G. van Benthem,Tjasse D. Bruintjes

Journal Article

A last resort for therapy for intractable benign paroxysmal positional vertigo (BPPV) is mechanical occlusion of the posterior semicircular canal. The aim of this review was to assess the effect of posterior canal occlusion for intractable posterior canal BPPV on vertigo and to determine the risk of loss of auditory or vestibular function. A systematic literature search according to the PRISMA statement was performed on PubMed, the Cochrane Library, Embase, Web of Science, and CINAHL. The last search was conducted in June 2018. Cohort studies with original data and case reports describing >5 cases were included if they analyzed the effect of posterior semicircular canal obliteration in adults with intractable posterior BPPV on vertigo. Two authors screened titles and abstracts for eligibility. The first author screened full texts and analyzed the data. Eight retrospective studies met the eligibility criteria. The quality of all individual studies was rated fair. Canal occlusion was performed on 196 patients. All studies reported complete resolution of BPPV in all patients (100%). Among postoperatively tested patients, total loss of auditory function and vestibular function was reported in 2 of 190 (1%) and 9 of 68 (13%), respectively. Posterior semicircular canal plugging resulted in 100% resolution of BPPV in patients with intractable BPPV in all studies. However, the strength of evidence was weak. Potential serious complications, such as deafness and loss of vestibular function, should be taken into account.

Should You Follow the Better-Hearing Ear for Congenital Cytomegalovirus Infection and Isolated Sensorineural Hearing Loss?

08-10-2019 – Vanessa Torrecillas,Chelsea M. Allen,Tom Greene,Albert Park,Winnie Chung,Tatiana M. Lanzieri,Gail Demmler-Harrison

Journal Article

To describe the progression of sensorineural hearing loss (SNHL) in the better- and poorer-hearing ears in children with asymptomatic congenital cytomegalovirus (CMV) infection with isolated SNHL. Longitudinal prospective cohort study. Tertiary medical center. We analyzed hearing thresholds of the better- and poorer-hearing ears of 16 CMV-infected patients with isolated congenital/early-onset or delayed-onset SNHL identified through hospital-based CMV screening of >30,000 newborns from 1982 to 1992. By 12 months of age, 4 of 7 patients with congenital/early-onset SNHL developed worsening thresholds in the poorer-hearing ear, and 1 had an improvement in the better-hearing ear. By 18 years of age, all 7 patients had worsening thresholds in the poorer-hearing ear and 3 patients had worsening thresholds in the better-hearing ear. Hearing loss first worsened at a mean age of 2 and 6 years in the poorer- and better-hearing ears, respectively. Nine patients were diagnosed with delayed-onset SNHL (mean age of 9 years vs 12 years for the poorer- and better-hearing ears), 6 of whom had worsening thresholds in the poorer-hearing ear and 1 in both ears. In most children with congenital CMV infection and isolated SNHL, the poorer-hearing ear worsened earlier and more precipitously than the better-hearing ear. This study suggests that monitoring individual hearing thresholds in both ears is important for appropriate interventions and future evaluation of efficacy of antiviral treatment.

Surgical Explantation of Bone-Anchored Hearing Devices: A 10-year Single Institution Review

01-10-2019 – Christian G. Fritz,Dennis I. Bojrab,Kenny F. Lin,Christopher A. Schutt,Seilesh C. Babu,Robert S. Hong

Journal Article

To identify clinical variables associated with the decision to surgically discontinue bone-anchored hearing device function. Retrospective chart review. Tertiary neurotology referral center. This study examines surgical interventions performed on existing bone-anchored hearing devices at a single institution from 2008 to 2018. Patient characteristics, indications for implantation, and complications prompting surgical intervention were assessed. Seventy-seven cases were included in this study. Among patients in the younger cohort (<37 years old), 100% (13 of 13) of those discontinuing their device had a contralateral normal-hearing ear. Conversely, 0% (0 of 14) of the younger patients with bilateral hearing loss surgically discontinued their devices. Within the older cohort (≥37 years old), female patients ( Surgical discontinuation is associated with several clinical variables. Targeted interventions that are viable alternatives to removal, such as device relocation, should be presented to younger patients with a contralateral normal-hearing ear who experience persistent complications. Patients with persistent infection in the absence of soft tissue overgrowth would especially benefit from enhanced counseling on proper hygiene.