Reflections: Starting an Otolaryngology Medical Student Interest Group
05-11-2019 – Amanda Hu
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.
The Otolaryngology Match 2019: Why Was This Year Different from Every Other Year?
03-02-2020 – David J. Eisenman,Elizabeth Guardiani
After 2 years with record high numbers of unfilled spots in the otolaryngology National Residency Matching Program-sponsored match, the current match cycle had no open positions available in the Supplemental Offer and Acceptance Program. This article analyzes the historical and present data to try to understand what happened so that we can better avoid repeating the problems of the past.
Laryngotracheal Stenosis in Early vs Late Tracheostomy: A Systematic Review
26-11-2019 – Steven D. Curry,Paul J. Rowan
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.
Adenotonsillectomy for the Treatment of Obstructive Sleep Apnea in Children with Prader-Willi Syndrome: A Meta-analysis
10-12-2019 – Chia-Hsuan Lee,Wei-Chung Hsu,Jenq-Yuh Ko,Te-Huei Yeh,Ming-Tzer Lin,Kun-Tai Kang
Adenotonsillectomy outcomes in obstructive sleep apnea (OSA) treatment among children with Prader-Willi syndrome (PWS) remain unclear. This study aimed to elucidate the effectiveness of adenotonsillectomy in OSA treatment among children with PWS. PubMed, MEDLINE, Embase, and Cochrane Review up to February 2019. The registry number of the protocol published on PROSPERO was CRD42015027053. Two authors independently searched the relevant database. Polysomnography outcomes in these children were examined, including net postoperative changes in the apnea-hypopnea index (AHI), net postoperative changes in the minimum and mean oxygen saturation, the overall success rate for a postoperative AHI <1, and the overall success rate for a postoperative AHI <5. Six studies with 41 patients were analyzed (mean age, 5.0 years; 55% boys; mean sample size, 6.8 patients). All children had PWS and received adenotonsillectomy for the treatment of OSA. The AHI was 13.1 events per hour (95% CI, 11.0-15.1) before surgery and 4.6 events per hour (95% CI, 4.1-5.1) after surgery. The mean change in the AHI was a significant reduction of 8.0 events per hour (95% CI, -10.8 to -5.1). The overall success rate was 21% (95% CI, 11%-38%) for a postoperative AHI <1 and 71% (95% CI, 54%-83%) for a postoperative AHI <5. Some patients developed velopharyngeal insufficiency postoperatively. Adenotonsillectomy was associated with OSA improvement among children with PWS. However, residual OSA was frequently observed postoperatively in these patients.
Navigating the Informed Consent Process When Using Innovative Surgery
24-12-2019 – Daniel Wehrmann,Glenn E. Green,Kevin J. Weatherwax,Andrew G. Shuman
Outcomes of Overlapping Surgery in Otolaryngology
10-12-2019 – Pedrom C. Sioshansi,Robert K. Jackler,Edward J. Damrose
To compare outcomes in otolaryngology between overlapping and nonoverlapping surgeries. Retrospective cohort study. Tertiary referral center. All patients undergoing otolaryngologic procedures at Stanford University Hospital between January 2009 and June 2016 were included (n = 13,479). Cases were divided into 2 cohorts: overlapping (n = 1806, 13.4%) vs nonoverlapping (n = 11,673, 86.6%). Variables reviewed were type of operation performed, multidisciplinary team involvement, complications, reoperations, readmissions, and deaths. The total complication rate over 7.5 years studied was 3.3% (n = 450). Complication rates were lower for overlapping cases (0.77%) compared to nonoverlapping cases (3.73%) with an odds ratio of 0.2014, which was statistically significant ( Patients undergoing overlapping surgery had lower overall complication rates, lower reoperation rates, lower readmission rates, and no mortalities. The institutional experience presented provides evidence that with appropriate patient and case selection, otolaryngologists may safely perform overlapping surgery without increased risk of adverse patient outcomes.
The Utility of Facial Nerve Ultrasonography in Bell’s Palsy
24-12-2019 – Seol-Hee Baek,Yoo Hwan Kim,Ye-Ji Kwon,Joo Hye Sung,Myeong Hun Son,Jung Hun Lee,Byung-Jo Kim
This study aimed to investigate the utility of facial nerve ultrasonography in the functional and structural assessment of early-stage Bell’s palsy and the prognostic value of facial nerve ultrasonography in Bell’s palsy. Prospective longitudinal study. Single center, a university-affiliated neurology clinic. Patients with unilateral Bell’s palsy who had visited our clinic within 3 days of symptom onset were enrolled in this study. Demographic information and House-Brackmann grade were collected. Electrophysiologic studies and facial nerve ultrasonography were then performed. The facial nerves on each side were scanned longitudinally with a 5- to 12-MHz probe. The diameter of the facial nerves with and without the sheath was measured at the proximal and distal portions. Follow-up examinations, including House-Brackmann grade analysis, electrophysiologic studies, and facial nerve ultrasonography, were performed after 2 months. Fifty-four patients with unilateral Bell’s palsy were enrolled, and 22 underwent the follow-up examinations. The diameters of the facial nerves were larger on the affected side than on the unaffected side at the proximal and distal portions ( Ultrasonography could be a useful tool for evaluating the facial nerve in Bell’s palsy. Nevertheless, further studies are needed to demonstrate its prognostic value.
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
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.
Cytotoxicity of Ear Drop Excipients in Human and Mouse Tympanic Membrane Fibroblasts
03-12-2019 – Carolyn O. Dirain,David N. Karnani,Patrick J. Antonelli
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.
Location of Small Intracanalicular Vestibular Schwannomas Based on Magnetic Resonance Imaging
17-12-2019 – Nicholas Koen,Chandler Shapiro,Elliott D. Kozin,Mary E. Cunnane,Aaron K. Remenschneider,Michael J. McKenna,David H. Jung
Vestibular schwannomas (VSs) were proposed to arise from the glial-Schwann cell junction within the internal auditory canal (IAC). However, otopathology studies indicate that VS may arise anywhere along the course of the vestibular nerve. Recent studies suggested that the majority of tumors are located centrally within the IAC with an equal distribution near the porus acusticus and the fundus. However, these studies analyzed tumors of all sizes, obscuring their precise origin. Herein, we aim to quantify the position of small intracanalicular tumors (<5 mm), assessing hearing outcomes and growth patterns in relation to tumor position. Of the 38 small intracanalicular tumors analyzed, 61% originated closest to the fundus, 34% at the midpoint, and only 5% closest to the porus acusticus. Tumors were observed with serial magnetic resonance imaging for 3.37 ± 2.65 years (mean ± SD) without intervention. Our findings indicate a lateral predominance of small VS within the IAC, an independence between tumor location and hearing outcomes, and further support the slow natural progression of VS.
Surgical Instrument Optimization to Reduce Instrument Processing and Operating Room Setup Time
22-10-2019 – Lauren Crosby,Eric Lortie,Brian Rotenberg,Leigh Sowerby
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.
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
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.
Evaluation of Tonsillotomy Effects on Pharyngeal Volume and Compliance in Children
10-12-2019 – Abeer Al Ali,Emilie Bois,Imene Boujemla,Natacha Teissier,Thierry Van den Abbeele,Christophe Delclaux,Plamen Bokov
Our objective was to assess whether adenotonsillotomy improved pharyngeal compliance, which is a risk factor for sleep-disordered breathing. Otherwise healthy children underwent Obstructive Sleep Apnea (OSA)-18 questionnaire and a pre- and postoperative acoustic pharyngometry in both sitting and supine positions, allowing the measurement of the volume of the palatine tonsil region and pharyngeal compliance. Thirty-five children (median age 5.3 years) were enrolled; they were reevaluated at a median of 18 days (25th-75th percentiles, 15-25) after surgery. Participants were compared according to a normal (n = 18) or an increased (n = 17) preoperative pharyngeal compliance. Surgery was associated with a significant decrease in OSA-18 and Brodsky scores, with a median increase in palatine volume of 0.13 cm
Laryngeal Web in the Pediatric Population: Evaluation and Management
17-12-2019 – Claire M. Lawlor,Natasha D. Dombrowski,Roger C. Nuss,Reza Rahbar,Sukgi S. Choi
To discuss the presentation, evaluation, and management of pediatric laryngeal web. Retrospective case series. Single tertiary care center. All patients with laryngeal web at Boston Children’s Hospital in the past 22 years. No exclusion criteria. Charts mined for age at presentation, presenting symptoms, degree/location of web, associated syndromes, number/type of surgical procedures, and postoperative outcomes. Thirty-seven patients were included (13 male, 24 female). Average age at diagnosis was 3.7 years (0-19.5 years). Mean follow-up was 4.4 years (range, 0-16.4 years). There were 26 congenital webs (70.2%) and 11 acquired webs (29.8%). Presenting symptoms were vocal (29 patients, 78.4%) and respiratory (22 patients, 60%). Underlying syndromes or synchronous airway lesions included the following: premature (n = 5), congenital heart disease (n = 18), subglottic stenosis (n = 5), 22q11.2 deletion syndrome (n = 10), and recurrent respiratory papillomatosis (n = 4). There were 20 type 1 webs, 6 type 2 webs, 8 type 3 webs, and 3 type 4 webs; 10 had subglottic extension of the laryngeal web. Twelve patients were managed conservatively with observation. Eighty-four interventions were performed: 18 open and 66 endoscopic (sharp division, 32; dilation, 33; mitomycin C, 14; laser, 5; keel, 6; triamcinolone injection, 8; stent, 15; removal of granulation tissue, 5). Tracheotomy was required in 11 patients, and 5 patients were decannulated. Voice improved in 12 patients, with respiratory symptoms in 12 patients. Web recurred in 17 patients. One patient died due to airway complications. Pediatric laryngeal web is an uncommon but challenging lesion. Patients need to be evaluated for comorbid syndromes and synchronous airway lesions. Management includes open and endoscopic procedures. Procedures should be tailored to the child’s presentation.
Prevalence of Pediatric Dizziness and Imbalance in the United States
05-11-2019 – Jacob R. Brodsky,Sophie Lipson,Neil Bhattacharyya
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.
Psychometric Evaluation of the Nasal Obstruction Symptom Evaluation Scale for Pediatric Patients
10-12-2019 – Hena Din,Nour Bundogji,Shelby C. Leuin
To evaluate the psychometric properties of the nasal obstruction symptom scale within a sample of pediatric patients undergoing septoplasty or functional septorhinoplasty. This was a prospective study with nasal obstruction symptom scale evaluations conducted pre- and postoperatively. A tertiary care pediatric hospital. Pediatric patients underwent septoplasty or functional septorhinoplasty (FSR) from January 2013 to January 2017. Reliability of the scale was assessed through measures of internal consistency. In addition, item response models of each item were evaluated to assess how well each item captured individuals with varying levels of nasal obstruction. Study authors assessed face validity, and construct validity was assessed by correlation measures between items and exploratory factor analysis. A total of 136 patients, ages 8 to 18 years with a mean age of 15.7 ± 2.1 years, completed pre- and postoperative evaluations. Internal consistency of the scale was high (Cronbach’s α = 0.83). Predominantly a unidimensional scale resulted from exploratory factor analyses. Item response models indicate questions capture low to moderate levels of nasal obstruction within this population. Additional analyses show the scale functions similarly between septoplasty and FSR patients. The Nasal Obstruction Symptom Evaluation scale is a robust tool that may be incorporated as a subjective evaluation of severity of nasal obstruction among pediatric patients undergoing a septoplasty or functional septorhinoplasty.
The Role of Genioglossus Activity in Predicting Uvulopalatopharyngoplasty Outcomes
26-11-2019 – Di Zhao,Yanru Li,Yue Qu,Junbo Zhang,Xin Cao,Jingying Ye
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.
Endoscopic Evidence of Canalicular-Lacrimal Sac Mucosal Folds Mimicking Common Canalicular Obstructions
17-12-2019 – Mohammad Javed Ali
Does Ibuprofen Really Increase Tendency to Posttonsillectomy Hemorrhage?
03-02-2020 – Guan-Jiang Huang
Response to a Letter on Postoperative Bleeding Associated with Ibuprofen Use After Tonsillectomy
03-02-2020 – William A. Stokes,Jane Schubart,Michele M. Carr
Risk Factors and Outcomes of Postoperative Recurrent Well-Differentiated Thyroid Cancer: A Single Institution’s 15-Year Experience
18-02-2020 – Shaunak N. Amin,Justin R. Shinn,Mark M. Naguib,James L. Netterville,Sarah L. Rohde
Identify risk factors and outcomes of recurrent well-differentiated thyroid cancer. Retrospective case-control analysis. Tertiary care academic center in Nashville, Tennessee. This single-center analysis reviews 478 patients who underwent initial surgical management of well-differentiated thyroid carcinoma between 2002 and 2017. Patients were dichotomized with or without recurrent well-differentiated thyroid cancer. Demographic and clinicopathologic risk factors were carefully reviewed. Univariate, multiple regression, and survival analyses were used to evaluate predictors of recurrence. Thirty-eight patients (7.9%) who received initial surgical intervention for well-differentiated thyroid carcinoma at our institution recurred, with an average time to recurrence of 24 months. Male sex, tumor size, multifocality, extrathyroidal extension, lymphovascular invasion, number of positive lymph nodes, and low lymph node yield were all significantly associated with locoregional recurrence ( Extrathyroidal extension, number of positive lymph nodes, and low lymph node yield are independent clinicopathologic risk factors for postoperative recurrence of well-differentiated thyroid cancer. Metastatic lymph node ratio is uncommonly used but can be an important prognosticator of recurrence. Patients with metastatic lymph node ratio ≥0.3 should be counseled on their increased risk of recurrence and should undergo close surveillance following surgery.
Implications of Tumor Size, Subsite, and Adjuvant Therapy on Outcomes in pT4aN0 Oral Cavity Carcinoma
18-02-2020 – Arya W. Namin,Craig A. Bollig,Brette C. Harding,Laura M. Dooley
To determine if tumor size, subsite, and adjuvant radiation therapy (AXRT) are associated with overall survival (OS) in patients with p
N0 oral cavity squamous cell carcinoma (OSCC) who underwent mandibulectomy with negative surgical margins (NSMs). Retrospective cohort study. National Cancer Database (NCDB). Retrospective analysis of the NCDB that included patients diagnosed with p
N0 OSCC who underwent mandibulectomy with NSMs between 2004 and 2015. The association of age, Charlson-Deyo score (CDS), tumor size, subsite, and AXRT with OS was analyzed. The cases were divided into 3 subgroups based on maximal tumor dimension for subgroup analysis; tumors ≤2.0 cm, tumors 2.1 to 4.0 cm, and tumors >4.0 cm. For the entire cohort; age ( In patients with p
N0 OSCC who underwent mandibulectomy with NSMs, age, CDS, tongue subsite, floor of mouth subsite, tumor size, and AXRT are associated with OS. AXRT was not significantly associated with overall survival in patients with gingival, hard palate, retromolar trigone, and not specified tumors ≤2.0 cm.
Health Disparities in the Access and Cost of Health Care for Otolaryngologic Conditions
18-02-2020 – Jeremy S. Ruthberg,Hammad A. Khan,Konrad D. Knusel,Nicholas M. Rabah,Todd D. Otteson
To demonstrate whether race, education, income, or insurance status influences where patients seek medical care and the cost of care for a broad range of otolaryngologic diseases in the United States.
Retrospective cohort study using data from the Medical Expenditure Panel Survey, from 2007 to 2015.
Nationally representative database.
Patients with 14 common otolaryngologic conditions were identified using self-reported data and
Of 78,864 respondents with self-reported otolaryngologic conditions, African American and Hispanic patients were significantly less likely to visit outpatient otolaryngologists than Caucasians (African American: adjusted odds ratio [a
OR], 0.57; 95% CI, 0.5-0.65; Hispanic: a
OR, 0.64; 95% CI, 0.56-0.73) and reported lower average costs per emergency department visit than Caucasians (African American: $4013.67; Hispanic: $3906.21; Caucasian: $7606.46; In this study, significant racial and socioeconomic discrepancies exist in the utilization and cost of health care for otolaryngologic conditions in the United States.
Recurrence and Progression of Head and Neck Paragangliomas after Treatment
18-02-2020 – Kevin J. Contrera,Valeda Yong,Chandana A. Reddy,Sara W. Liu,Robert R. Lorenz
To characterize the recurrence of head and neck paragangliomas and the factors associated with disease progression after treatment. Retrospective cohort study. Tertiary care center. In total, 173 adults with 189 paragangliomas (41.3% carotid body, 29.1% glomus jugulare, 19.0% glomus tympanicum, and 10.6% glomus vagale) treated between 1990 and 2010 were evaluated to determine the incidence and risk of recurrence using Cox proportional hazards. The mean (SD) follow-up duration was 8.6 (9.1) years. The incidence was 2.92 recurrences per 100 person-years. The rate of recurrence was 8.2% (95% confidence interval [CI], 3.7-12.7) after 4 years and 17.1% (95% CI, 10.2-24.0) after 10 years. Glomus jugulare tumors were more likely to recur (hazard ratio [HR], 3.69; 95% CI, 1.70-8.01; Recurrence is more common with glomus jugulare tumors and less common with carotid body tumors. Radiation may have a lower risk of recurrence or progression than surgery for some paraganglioma types. Metastasis is rare but more likely with recurrent disease. Surveillance neck imaging is recommended every several years for decades after treatment.
Patterns of Care and Survival of Cutaneous Angiosarcoma of the Head and Neck
11-02-2020 – Clifford Chang,S. Peter Wu,Kenneth Hu,Zujun Li,David Schreiber,Jamie Oliver,Babak Givi
To analyze the patterns of care and survival of cutaneous angiosarcomas of the head and neck. Retrospective cohort study. National Cancer Database. The National Cancer Database was queried to select patients with cutaneous angiosarcoma of the head and neck between 2004 and 2015. For survival analysis, patients were included only if they received definitive treatment and complete data. Prognostic factors were analyzed by univariate and multivariable Cox regression. We identified 693 patients diagnosed with head and neck angiosarcomas during the study period. The majority were male (n = 489, 70.6%) and elderly (median, 77 years). A total of 421 patients (60.8%) met the criteria for survival analyses. These patients were treated with surgery and radiation (n = 178, 42.3%), surgery alone (n = 138, 32.8%), triple-modality therapy (n = 48, 11.4%), surgery and chemotherapy (n = 29, 6.9%), and chemoradiation (n = 28, 6.7%). With a median follow-up of 29 months, the 3-year survival was 50.1%. Patients undergoing surgery had better median survival than those who did not (38.1 vs 21.0 months, Angiosarcoma of head and neck is a rare malignancy that affects the elderly. Surgical treatment with negative margins is associated with improved survival. Even with curative-intent multimodality treatment, the survival of patients aged ≥75 years is limited.
ICG-Guided Sentinel Lymph Node Sampling during Robotic Retroauricular Neck Dissection in cN0 Oral Cancer
11-02-2020 – Ji Hoon Kim,Hyung Kwon Byeon,Da Hee Kim,Se-Heon Kim,Eun Chang Choi,Yoon Woo Koh
In this study, we sought to evaluate the clinical feasibility of indocyanine green (ICG)-guided sentinel lymph node (SLN) sampling during robotic retroauricular neck dissection (RAND) in patients with c
N0 oral cancer. Nine adult patients diagnosed with T1 to T2 oral squamous cell carcinoma were consecutively recruited. All of them underwent transoral partial glossectomy and robotic RAND (levels I-III) simultaneously. Twelve hours prior to surgery, ICG was injected into the 4 quadrants around primary tongue tumors. During robotic RAND, intraoperative and ex vivo ICG-stained LNs were identified using the Firefly system and examined for the presence of fluorescence. ICG-stained LNs were identified in all patients. Thirty-one ICG-stained LNs were detected in 313 retrieved LNs (9.9%). Occult metastases were detected among the ICG-stained LNs in 2 patients (22.2%). There was no metastasis identified in the ICG-unstained LNs. Upstaging rates, sensitivity, specificity, and negative predictive value of ICG-guided SLN sampling were 22.2%, 100%, 91.5%, and 100%, respectively.
Role of Free Radical Formation in Murine Cytomegalovirus–Induced Hearing Loss
11-02-2020 – Phayvanh P. Pecha,Ali A. Almishaal,Pranav D. Mathur,Elaine Hillas,Taelor Johnson,Melissa S. Price,Travis Haller,Jun Yang,Namakkal S. Rajasekaran,Matthew A. Firpo,Albert H. Park
The goal of the study was to determine whether reactive oxygen species (ROS) mediates cytomegalovirus (CMV)-induced labyrinthitis. Murine model of CMV infection. University of Utah laboratory. Nrf2 knockout mice were inoculated with murine CMV. Auditory brainstem response (ABR) and distortion product otoacoustic emissions (DPOAEs) were then performed on these and uninfected controls. BALB/c mice were inoculated with murine CMV to determine whether a marker for ROS production, dihydroethidium (DHE), is expressed 7 days after inoculation. Finally, 2 antioxidants-D-methionine and ACE-Mg (vitamins A, C, and E with magnesium)-were administered 1 hour before and after infection in inoculated mice for 14 days. Temporal bones were harvested at postnatal day 10 for DHE detection. ABR and DPOAE testing was done at postnatal day 30. Scanning electron microscopy was also performed at postnatal day 30 to evaluate outer hair cell integrity. Nrf2-infected mice had worse hearing than uninfected mice ( These results demonstrate for the first time that excessive ROS mediates CMV-induced hearing loss in a mouse model.
Sentinel Lymph Node Biopsy in Head and Neck Melanoma: Long-term Outcomes, Prognostic Value, Accuracy, and Safety
11-02-2020 – John E. Hanks,Kevin J. Kovatch,S. Ahmed Ali,Emily Roberts,Alison B. Durham,Joshua D. Smith,Carol R. Bradford,Kelly M. Malloy,Philip S. Boonstra,Christopher D. Lao,Scott A. McLean
To evaluate the long-term outcomes of sentinel lymph node biopsy (SLNB) for head and neck cutaneous melanoma (HNCM). Retrospective cohort study. Tertiary academic medical center. Longitudinal review of a 356-patient cohort with HNCM undergoing SLNB from 1997 to 2007. Descriptive characteristics included the following: age, 53.5 ± 19 years (mean ± SD); sex, 26.8% female; median follow-up, 4.9 years; and Breslow depth, 2.52 ± 1.87 mm. Overall, 75 (21.1%) patients had a positive SLNB. Among patients undergoing completion lymph node dissection following positive SLNB, 20 (27.4%) had at least 1 additional positive nonsentinel lymph node. Eighteen patients with local control and negative SLNB developed regional disease, indicating a false omission rate of 6.4%, including 10 recurrences in previously unsampled basins. Ten-year overall survival (OS) and melanoma-specific survival (MSS) were significantly greater in the negative sentinel lymph node (SLN) cohort (OS, 61% [95% CI, 0.549-0.677]; MSS, 81.9% [95% CI, 0.769-0.873]) than the positive SLN cohort (OS, 31% [95% CI, 0.162-0.677]; MSS, 60.3% [95% CI, 0.464-0.785]) and positive SLN/positive nonsentinel lymph node cohort (OS, 8.4% [95% CI, 0.015-0.474]; MSS, 9.6% [95% CI, 0.017-0.536]). OS was significantly associated with SLN positivity (hazard ratio [HR], 2.39; Long-term follow up indicates that SLNB showcases durable accuracy, safety, and prognostic importance for cutaneous HNCM.
Targeting Viral DNA and Promoter Hypermethylation in Salivary Rinses for Recurrent HPV-Positive Oropharyngeal Cancer
11-02-2020 – Sarek Shen,Yuki Saito,Shuling Ren,Chao Liu,Theresa Guo,Jesse Qualliotine,Zubair Khan,Sayed Sadat,Joseph A. Califano
The incidence and survivorship of human papillomavirus (HPV)-associated oropharyngeal squamous cell carcinoma (OPSCC) are increasing. Presence of HPV DNA and epigenetic alterations in salivary rinses are independently associated with clinical prognosis. We evaluated the utility of a combined panel in detecting disease recurrence during surveillance. We also assessed the assay’s applicability in screening for HPV+ OPSCC. Retrospective cohort study. Two tertiary academic hospitals. Forty-nine patients with posttreatment OPSCC were enrolled. Separately, 21 treatment-naive patients and 40 controls were included in the screening analysis. Salivary rinses were obtained from these cohorts and biomarker levels were quantified. Receiver operative characteristic (ROC) curves and multivariate logistic models were used to assess performance of biomarker combinations. Eight patients (16.3%) in the posttreatment cohort developed locoregional recurrence. Recurrence was associated with alcohol use (odds ratio [OR], 6.12; 95% confidence interval [CI], 0.26-3.79) and advanced nodal disease (OR, 2.21; 95% CI, 1.52-3.01). A panel of HPV DNA and methylated Detection of high-risk HPV DNA or aberrant hypermethylation in oral rinses is associated with presence and recurrence of OPSCC. Targeting both markers in saliva may have utility in long-term surveillance.
Prediction of Apnea-Hypopnea Index Using Sound Data Collected by a Noncontact Device
04-02-2020 – Jeong-Whun Kim,Taehoon Kim,Jaeyoung Shin,Kyogu Lee,Sunkyu Choi,Sung-Woo Cho
To predict the apnea-hypopnea index (AHI) in patients with obstructive sleep apnea (OSA) using data from breathing sounds recorded using a noncontact device during sleep. Prospective cohort study. Tertiary referral hospital. Audio recordings during sleep were performed using an air-conduction microphone during polysomnography. Breathing sounds recorded from all sleep stages were analyzed. After noise reduction preprocessing, the audio data were segmented into 5-second windows and sound features were extracted. Estimation of AHI by regression analysis was performed using a Gaussian process, support vector machine, random forest, and simple linear regression, along with 10-fold cross-validation. In total, 116 patients who underwent attended, in-laboratory, full-night polysomnography were included. Overall, random forest resulted in the highest performance with the highest correlation coefficient (0.83) and least mean absolute error (9.64 events/h) and root mean squared error (13.72 events/h). Other models resulted in somewhat lower but similar performances, with correlation coefficients ranging from 0.74 to 0.79. The estimated AHI tended to be underestimated as the severity of OSA increased. Regarding bias and precision, estimation performances in the severe OSA subgroup were the lowest, regardless of the model used. Among sound features, derivative of the area methods of moments of overall standard deviation demonstrated the highest correlation with AHI. AHI was fairly predictable by using data from breathing sounds generated during sleep. The prediction model may be useful not only for prescreening but also for follow-up after treatment in patients with OSA.
Primary Clear Cell Adenocarcinoma of the Head and Neck: A Population-Based Analysis
04-02-2020 – Laith Mukdad,Albert Y. Han,Karam Badran,Jose E. Alonso,Hassan B. Nasser,Alexander N. Goel,Maie A. St. John
To characterize the epidemiology and clinicopathologic determinants of survival following the diagnosis of clear cell adenocarcinoma in the head and neck region. Retrospective cohort study. The Surveillance, Epidemiology, and End Results registry (1994 to 2014). A total of 173 cases were identified. Study variables included age, sex, race, tumor subsite, tumor stage, tumor grade, surgical excision, and regional and distant metastases. Survival measures included overall survival (OS) and disease-specific survival (DSS). Median age at diagnosis was 63 years, 48% were female, and 80.2% were white. Fourteen percent of patients presented with regional lymph node metastases, while 3.3% of patients presented with distant metastases. Most of the tumors presented in the oral cavity, salivary glands, and pharynx. Kaplan-Meier analysis demonstrated OS and DSS of 77.2% and 83.7% at 5 years, respectively. Median OS after diagnosis was 153 months. Bivariate analysis showed that surgical excision was associated with 5-fold increased OS and DSS, whereas advanced age, high tumor grade, advanced stage, larger tumor size, nodal disease, and distant metastases were all significant predictors of decreased OS and DSS. Clear cell adenocarcinoma is a rare neoplasm that typically affects white individuals in their early 60s, with a generally favorable prognosis. It most commonly arises in the oral cavity, major salivary glands, and pharynx. Surgical excision is associated with 5-fold survival benefit, whereas advanced age, high tumor grade, advanced stage, nodal disease, and distant metastases are independently associated with worse OS and DSS.
The Association of Sleep Apnea and Cancer in Veterans
04-02-2020 – Sebastian M. Jara,Amanda I. Phipps,Charles Maynard,Edward M. Weaver
To test the association between preexisting obstructive sleep apnea (OSA) and subsequent cancer in a large long-term cohort of veteran patients. Retrospective matched cohort study. The Veterans Affairs Health Care System. All veteran patients diagnosed with OSA between 1993 and 2013 by The cohort included 1,377,285 patients (726,008 with and 651,277 without an OSA diagnosis) with mean age of 55 years, predominantly male (94%), a minority obese (32%), and median follow-up of 7.4 years (range, 2.0-25.2). The proportion of patients diagnosed with cancer was higher in those with vs without an OSA diagnosis (8.3% vs 3.6%; mean difference 4.8%; 95% confidence interval [CI], 4.7%-4.8%; Preexisting OSA was strongly associated with subsequent cancer in this veteran cohort, independent of several known cancer risk factors. These findings suggest that OSA may be a strong, independent risk factor for subsequent cancer development.
Cardiovascular Risk Factors and Benign Paroxysmal Positional Vertigo in Community Otolaryngology–Head and Neck Surgery
04-02-2020 – Jeffrey M. Singh,William D. Corser,Edwin M. Monsell
Cardiovascular risk factors have been associated with benign paroxysmal positional vertigo (BPPV), possibly causing degeneration of the utricular epithelium and subepithelium, but supportive evidence is mixed. This is the first study to examine the association between cardiovascular risk factors and BPPV as they present in the community practice of comprehensive otolaryngology-head and neck surgery. Cross-sectional case-matched case-control series. A community practice of otolaryngology-head and neck surgery with 3 clinical offices and a socioeconomically diverse patient population. Clinical data were collected retrospectively from the electronic health records of a continuous 4-year series of 628 patients with BPPV and age- and sex-matched controls. There were no statistically significant associations found between BPPV and diabetes, hypertension, dyslipidemia, or body mass index in the study population in pairwise comparisons or multivariable modeling. This study suggests that BPPV as encountered in a community ear, nose, and throat practice is not generally associated with cardiovascular risk factors. The possibility that these or other cardiovascular risk factors may be causative in some cases cannot be excluded, though most cases of BPPV appear to be caused primarily by shedding of otoconia from the utricle that is idiopathic or at least in part by unconfirmed noncardiovascular factors.
Reconstructing Forearm Free Flap Donor Sites Using Full-Thickness Skin Grafts Harvested from the Ipsilateral Arm
28-01-2020 – Natalie A. Krane,Alia Mowery,James Azzi,Daniel Petrisor,Mark K. Wax
To compare morbidity and aesthetic outcomes of full-thickness skin grafts (FTSGs) and split-thickness skin grafts (STSGs) in the reconstruction of the forearm free flap donor site. Case series, retrospective chart review. Institutional microvascular database. Subjects who underwent forearm free flaps and FTSGs for donor site reconstruction from April 2016 to November 2017 were included. FTSGs were obtained from the donor forearm with a proximal S-shaped incision, thereby avoiding additional wound creation. Morbidity outcomes were compared to 68 consecutive patients with STSG reconstruction from January 2009 to May 2010. Complications, including tendon exposure, subjective functional impairment, complete graft loss, partial graft loss, infection, paresthesias, and hematoma/seroma, were evaluated, as were aesthetic outcomes. Sixty-eight patients underwent FTSG reconstruction. No significant differences between FTSGs and STSGs were demonstrated in terms of graft loss ≥40% (4% vs 4%, Our results advocate for the consideration of FTSGs in the reconstruction of the forearm free flap donor site given superior aesthetic results without additional donor site morbidity or additional wound creation when compared to STSGs.
Metachronous Sudden Sensorineural Hearing Loss: Patient Characteristics and Treatment Outcomes
28-01-2020 – Timothy Cooper,Ronak Dixit,Candace E. Hobson,Barry E. Hirsch,Andrew A. McCall
Idiopathic sudden sensorineural hearing loss (ISSNHL) is a distressing condition that can significantly affect quality of life. Unilateral ISSNHL, occurring first in 1 ear and then the contralateral ear at a separate and discrete time, is a rare presentation that we refer to as Retrospective case series. Otology clinic at an academic tertiary referral center. Patients ≥18 years old presenting with metachronous ISSNHL between April 2008 to November 2017 were identified through review of the clinic electronic medical record. Metachronous ISSNHL was defined as unilateral ISSNHL occurring in temporally discrete episodes (>6 months apart) affecting both ears. Patients with identifiable causes for sudden hearing loss were excluded. Patient demographics, comorbidities, management, and audiologic outcomes were recorded. Eleven patients with metachronous ISSNHL were identified out of 558 patients with ISSNHL. In patients with metachronous ISSNHL, the mean ± standard deviation age at the time of ISSNHL in the second ear was 58.6 ± 15.2 years (range, 31-77 years). The mean interval between episodes was 9.6 ± 7.5 years (range, 1-22 years). Patients were treated with systemic and intratympanic steroids with variable hearing recovery; 5 patients with resultant bilateral severe to profound hearing loss underwent successful cochlear implantation. Metachronous ISSNHL is uncommon. Treatment is similar to ISSNHL, and cochlear implantation can successfully restore hearing in individuals who do not experience recovery.
Subglottic Cryotherapy: A Pilot Study in New Zealand White Rabbits
28-01-2020 – Jeffrey Cheng,Jeffrey Everitt
To describe proof of concept and pilot data for a cryotherapy application in the subglottis in a rabbit airway model. Four New Zealand white rabbits (3 experimental, 1 control) underwent general anesthesia and laryngoscopy and bronchoscopy. Experimental animals had cryotherapy applied with a direct contact 1.9-mm cryoprobe. Animals were euthanized at days 0, 2, and 6 posttreatment. Histologic changes were assessed in the treated subglottic tissues. This preliminary work has demonstrated that, with early cryogenic injury in the subglottis, there is mild mucosal epithelial injury associated with submucosal edema, acute inflammatory infiltrate, and degeneration of venule endothelial cells. Mucosal epithelial repair and resolution of the inflammatory response appear to be relatively rapid. We hope that this may provide a foundation to further explore cryotherapy as a primary or adjuvant treatment option for pediatric subglottis stenosis.
Effectiveness of an Advanced Airway Training “Boot Camp” for Family Medicine Physician Trainees
28-01-2020 – Kastley Marvin,Paige Bowman,Matthew W. Keller,Art A. Ambrosio
This course was designed to characterize the impact of a curriculum for training family medicine physicians in advanced airway techniques with respect to intubation performance and learner confidence. A training course was introduced into the curriculum in a single-group pretest-posttest model at a community family medicine residency program. Training consisted of a didactic teaching session on airway management and hands-on skill session with direct laryngoscopy (DL) and video-assisted laryngoscopy (VAL) on normal and difficult airway simulators. Participants were scored with the Intubation Difficulty Scale and completed surveys before and after the training. Twenty-eight residents of all levels participated. The mean time to successful intubation was significantly decreased after training from 51.96 to 23.71 seconds for DL and from 27.89 to 17.07 seconds for VAL. Participant scores with the Intubation Difficulty Scale were also significantly improved for DL and VAL. All participants rated their comfort levels with both techniques as high following training. Advanced airway management is a critical skill for any physician involved in caring for critically ill patients, though few trainees receive formal training. Addition of an airway training course with simulation and hands-on experience can improve trainee proficiency and comfort with advanced airway techniques. Training on airway management should be included in the curriculum for trainees who require the requisite skills and knowledge necessary for advanced airway interventions. This introductory project demonstrates the efficacy and feasibility of a relatively brief training as part of a family medicine residency curriculum.
Down-Expression of Kinin Receptors in Allergic Nasal Polyps Epithelia: An Immunohistochemistry Study
28-01-2020 – Meir Warman,Yonatan Lahav,Monica Huszar,Liad Hadad,Doron Halperin,Oded Cohen
To investigate the expression of B1 and B2 receptors in patients with nasal polyps (NPs) compared to controls. Retrospective case series. Single academic center. Nasal biopsies of patients with NPs were compared to inferior turbinates of control patients. Comparisons included basic demographics and comorbidities, intensity of inflammation, and immunohistochemical staining of B1 and B2 receptors measured by immunohistochemistry staining scores (ISSs). A total of 41 patients were enrolled, with 21 patients (51.2%) in the NP group and 20 patients as controls. No differences were found in the prevalence of allergic comorbidities and smoking between the groups. The NP group demonstrated significantly higher prevalence of moderate and severe mononuclear infiltrates compared to the control group (57.1% vs 5.3%, Patients with NPs exhibit different expression patterns of B1 and B2 compared to control patients. This implies that bradykinin receptor regulation participates in the pathogenesis of NPs.
Intraoperative Primary Tumor Identification and Margin Assessment in Head and Neck Unknown Primary Tumors
28-01-2020 – Jasmijn M. Herruer,S. Mark Taylor,Colin A. MacKay,Kishan M. Ubayasiri,Deanna Lammers,Victoria Kuta,Martin J. Bullock,Martin J. Corsten,Jonathan R. B. Trites,Matthew H. Rigby
Surgical management of the unknown primary head and neck squamous cell carcinoma (UP HNSCC) remains controversial due to challenging clinical diagnosis. This study compares positron emission tomography-computed tomography (PET-CT) findings with intraoperative identification of primary tumors and compares intraoperative frozen-section margins to final histopathology. In addition, adjuvant therapy indications are provided. Prospective cohort study. Academic university hospital. Sixty-one patients with UP HNSCC were included. Patients received PET-CT, followed by oropharyngeal transoral laser microsurgery (TLM). Margins were assessed intraoperatively using frozen sections and afterward by final histopathology. Adjuvant treatment was based on final histopathology. The sensitivity of localizing the primary tumor with PET-CT was 50.9% with a specificity of 82.5%. The primary tumor was found intraoperatively on frozen sections in 82% (n = 50) of patients. Five more tumors were identified on final histopathology, leading to a total of 90% (n = 55). Of the 50 intraoperatively found tumors, 98% (n = 49) had negative margins on frozen sections, and 90% (n = 45) were truly negative on final histopathology. Eighteen patients (29.5%) avoided adjuvant treatment. PET-CT localized the primary tumor in fewer than half the cases. This protocol identified 90% of primary tumors. Intraoperative frozen-section margin assessment has shown potential with a specificity of 92% compared to final histopathology. As a result, adjuvant therapy was avoided in almost one-third of our patients.
The Influence of Vestibular Schwannoma Tumor Volume and Growth on Hearing Loss
28-01-2020 – Neil S. Patel,Alice E. Huang,Eric M. Dowling,Katherine A. Lees,Nicole M. Tombers,Christine M. Lohse,John P. Marinelli,Jamie J. Van Gompel,Brian A. Neff,Colin L. W. Driscoll,Michael J. Link,Matthew L. Carlson
To ascertain the relationship among vestibular schwannoma (VS) tumor volume, growth, and hearing loss. Retrospective cohort study. Single tertiary center. Adults with observed VS and serviceable hearing at diagnosis were included. The primary outcome was the development of nonserviceable hearing as estimated using the Kaplan-Meier method. Associations of tumor volume with baseline hearing were assessed using Spearman rank correlation coefficients. Associations of volume and growth with the development of nonserviceable hearing over time were assessed using Cox proportional hazards models and summarized with hazard ratios (HRs). Of 230 patients with VS and serviceable hearing at diagnosis, 213 had serial volumetric tumor data for analysis. Larger tumor volume at diagnosis was associated with increased pure-tone average (PTA) ( Larger initial VS tumor volume was associated with poorer hearing at baseline. Larger initial tumor volume was also associated with the development of nonserviceable hearing during observation in a univariable setting; however, this association was not statistically significant after adjusting for baseline hearing status.
A Critical Analysis of the Information Available Online for Ménière’s Disease
28-01-2020 – Dennis I. Bojrab,Christian Fritz,Seilesh Babu,Kenny F. Lin
Patients increasingly rely on online resources for medical information; however, the Internet is unregulated and prone to misinformation. This study analyzes the reliability, quality, and readability of websites for Ménière’s disease. A Google search was performed using keywords Ambulatory. None. Forty-two websites were analyzed. Academic institutions were the most common (n = 13, 31%) but scored the lowest using DISCERN at 1.75 ± 0.13. Medical information websites scored highest at 2.24 ± 0.09 ( Most top online search results for Ménière’s disease are deficient in quality and readability. Medical information websites are generally the most reliable and easy to read.
Transoral Robotic Surgery for Oropharyngeal Squamous Cell Carcinoma: Improving Function While Maintaining Oncologic Outcome
21-01-2020 – Daniel W. Scholfield,Dorothy M. Gujral,Zaid Awad
The improved survival in patients with HPV-positive (human papilloma virus) oropharyngeal squamous cell carcinoma as compared with HPV-negative disease calls for treatment that preserves quality of life, particularly a functional swallow. There are several trials currently assessing treatment de-escalation in terms of less invasive transoral robotic surgery, reduced-dose radiotherapy, and omission of chemotherapy in this disease cohort. It is important for head and neck oncology surgeons to stay abreast of developments in this area to offer their patients the most up-to-date treatment and consider recruiting patients to trials at their institutions. For this purpose, we provide a summary of current trials and associated challenges in managing a disease with fast-evolving treatment algorithms.
Leveraging Existing Tools in Electronic Health Record Systems to Automate Clinical Registry Compilation
21-01-2020 – Alisha Williams,William Goedicke,Kristin A. Tissera,Leila A. Mankarious
Clinical registries have proven beneficial by providing a resource to address research questions, monitor care, and identify suitable subjects for clinical studies. Despite a well-organized registry, population is often low because of the human capital required. The increasing prevalence of electronic medical health records provides the opportunity to integrate registry compilation into routine patient encounters. Here we describe how one tool existing within the Epic Medical Record software suite, Smart Phrases, can be adapted to automate population of a hearing loss patient registry. The usage rate of Smart Phrases was high and resulted in a significant reduction in the time burden associated with registry population. Use of Smart Phrases could become an important factor in the design of future registries that allow broad uptake and convenient data input.
A Surgical Simulator for Tympanostomy Tube Insertion Incorporating Capacitive Sensing Technology to Track Instrument Placement
21-01-2020 – Vilija J. Vaitaitis,Michael E. Dunham,Yong-Chan Kwon,Wyatt C. Mayer,Adele K. Evans,Amari J. Baker,Kyla D. Walker,Gabriel D. Cespedes,Abishek Stanley,Michelle Opiri
We describe a device engineered for realistic simulation of myringotomy and tympanostomy tube insertion that tracks instrument placement and objectively measures operator proficiency. A 3-dimensional computer model of the external ear and cartilaginous external auditory canal was created from a normal maxillofacial computed tomography scan, and models for the bony external auditory canal and tympanic cavity were created with computer-aided design software. Physical models were 3-dimensionally printed from the computer reconstructions. The external auditory canal and tympanic cavity surfaces were coated with conductive material and wired to a capacitive sensor interface. A programmable microcontroller with custom embedded software completed the system. Construct validation was completed by comparing the run times and total sensor contact times of otolaryngology faculty and residents.
Drug-Induced Sleep Endoscopy Performed in the Endoscopy Suite: A Resource Utilization Analysis
21-01-2020 – Shabnam Ghazizadeh,Kyasha Moore,Kianusch Kiai,Abie H. Mendelsohn
To analyze the resource utilization of performing drug-induced sleep endoscopy (DISE) procedures in an endoscopy suite (ES) setting as compared with the operating room (OR). A retrospective review of DISE procedures performed by a single attending surgeon from 2016 to 2018. Tertiary hospital. All patients undergoing sleep endoscopy without concurrent surgical procedures were included. No exclusion criteria were incorporated. Analysis assessed for differences in procedure-related expenditures, patient characteristics, anesthesia and surgeon time, and access to care. A total of 87 sleep endoscopies were included: 65 (74.7%) performed in the ES and 22 (25.3%) in the OR. Patient groups were similar in age and apnea-hypopnea index severity ( The resource utilization profile of performing DISE can be significantly improved by transferring these procedures from the OR to the ES setting.
The Impact of Hospital Quality on Thyroid Cancer Survival
21-01-2020 – Uchechukwu C. Megwalu,Yifei Ma,Tina Hernandez-Boussard,Vasu Divi,Scarlett Lin Gomez
To develop a composite measure of thyroid cancer-specific hospital quality and to evaluate the association between hospital quality and survival in patients with well-differentiated thyroid cancer. Retrospective cohort study. Population-based cancer database. Data were extracted from the California Cancer Registry data set linked with discharge records and hospital characteristics from the California Office of Statewide Health Planning and Development. The study cohort comprised adult patients with well-differentiated thyroid cancer diagnosed between January 1, 2004, and December 31, 2015. Principal component analysis, incorporating hospital volume, adherence to national guidelines, and accreditation/certification status, was used to generate a composite thyroid cancer-specific hospital quality score. Treatment in hospitals ranked in the highest quartile of quality was associated with improved overall survival (OS) (hazard ratio [HR], 0.81; 95% confidence interval [CI], 0.67-0.98) and disease-specific survival (DSS) (HR, 0.72; 95% CI, 0.54-0.98). Treatment in hospitals meeting the combined metric of 10 or more thyroid cancer cases/year and 80% of patients with high-risk tumors treated with total/near-total thyroidectomy was associated with improved OS (HR, 0.80; 95% CI, 0.70-0.90) and DSS (HR, 0.77; 95% CI, 0.64-0.94). Treatment in high-quality hospitals is associated with improved survival outcomes in patients with thyroid cancer. These findings are important because they help identify hospitals that are better suited to treat patients with thyroid cancer and provide actionable targets for quality improvement.
Preoperative Predictors of Response to Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea
21-01-2020 – Roy Xiao,Douglas K. Trask,Alan H. Kominsky
Hypoglossal nerve stimulation (HGNS) is an effective treatment for patients with obstructive sleep apnea (OSA) who fail continuous positive airway pressure (CPAP). We assessed the relationship between patient characteristics and response to HGNS. Retrospective cohort study. Single tertiary care institution. This study included CPAP-intolerant patients with moderate to severe OSA after HGNS system implantation from November 2015 to December 2017. Patient measures, drug-induced sleep endoscopy (DISE) findings, and apnea-hypopnea indices (AHIs) were recorded. Forty-eight patients underwent implantation with the following median measures: age, 66 years; body mass index, 28.6; and neck circumference, 41.0 cm. Patients were classified by Friedman tongue position (II, 27%; III, 56%; IV, 17%) and Mallampati grade (I, 25%; II, 50%; III, 23%; IV, 2%). By DISE, 71% had anterior-posterior palatal collapse. Additionally, 38% had lateral oropharynx collapse; 50%, tongue base collapse; and 27%, epiglottis collapse. Following implantation, median AHI improved from 38.5 to 2.7 ( This study further confirms HGNS as an effective treatment of CPAP-intolerant OSA. Office measures such as Friedman tongue position IV and Mallampati III/IV were associated with mildly decreased response. DISE findings were not associated with patient response.
Timing of Initial Posttracheostomy Surveillance Endoscopy in Pediatric Patients
21-01-2020 – Matthew M. Smith,Alessandro de Alarcon,Jareen Meinzen-Derr,Aliza P. Cohen,Hayley Born,Lyndy J. Wilcox,Dan T. Benscoter,Catherine K. Hart
To determine the optimal timing of the first posttracheostomy microlaryngoscopy and bronchoscopy (MLB). Case series with chart review. Tertiary pediatric medical center. Patients (<21 years of age) who underwent tracheostomy placement from January 1, 2011, to December 31, 2016. Patients were divided into early and late posttracheostomy surveillance groups (<6 weeks vs 6 to 14 weeks, respectively) based on the timing of their first posttracheostomy MLB. The primary outcome was to ascertain the clinical yield of the initial posttracheostomy MLB by documenting whether a medical or surgical treatment decision was made based on MLB findings. In total, 202 patients were included; of these patients, 162 met criteria for placement in the early group and 40 met criteria for the late group. There was no significant difference between the early and late groups regarding whether a medical or surgical decision was made at the time of the first MLB (21.5% vs 19%, respectively; The presence of tracheostomy-related symptoms was predictive of a medical or surgical decision being made using information obtained at the time of the first posttracheostomy MLB. We thus recommend that surveillance endoscopy be initiated when tracheotomized children start to develop tracheostomy-related symptoms.
Otitis Media Middle Ear Effusion Identification and Characterization Using an Optical Coherence Tomography Otoscope
21-01-2020 – Diego Preciado,Ryan M. Nolan,Radhika Joshi,Gina M. Krakovsky,Anqi Zhang,Nickolas A. Pudik,Nankee K. Kumar,Ryan L. Shelton,Stephen A. Boppart,Nancy M. Bauman
To determine the feasibility of detecting and differentiating middle ear effusions (MEEs) using an optical coherence tomography (OCT) otoscope. Cross-sectional study. US tertiary care children’s hospital. Seventy pediatric patients undergoing tympanostomy tube placement were preoperatively imaged using an OCT otoscope. A blinded reader quiz was conducted using 24 readers from 4 groups of tiered medical expertise. The primary outcome assessed was reader ability to detect presence/absence of MEE. A secondary outcome assessed was reader ability to differentiate serous vs nonserous MEE. OCT image data sets were analyzed from 45 of 70 total subjects. Blinded reader analysis of an OCT data subset for detection of MEE resulted in 90.6% accuracy, 90.9% sensitivity, 90.2% specificity, and intra/interreader agreement of 92.9% and 87.1%, respectively. Differentiating MEE type, reader identification of nonserous MEE had 70.8% accuracy, 53.6% sensitivity, 80.1% specificity, and intra/interreader agreement of 82.9% and 75.1%, respectively. Multivariate analysis revealed that age was the strongest predictor of OCT quality. The mean age of subjects with quality OCT was 5.01 years (n = 45), compared to 2.54 years (n = 25) in the remaining subjects imaged ( OCT otoscopy shows promise for facilitating accurate MEE detection. The imageability with the prototype device was affected by age, with older children being easier to image, similar to current ear diagnostic technologies.
ENT Mentorship Program for Preclinical Medical Students
21-01-2020 – Rishabh Sethia,Cameron C. Sheehan,Douglas Danforth,Garth Essig,Theodoros N. Teknos,Charles A. Elmaraghy
To provide preclinical medical students early access to otolaryngologists to learn about the specialty, facilitate acquisition of clinical skills, and provide one-on-one mentorship. Students are matched with a single otolaryngology faculty mentor from The Ohio State University/Nationwide Children’s Hospital and attend 8 hours per month in the clinic or operating room, monthly lectures, and rounds, and they give a final presentation. Mentors complete performance evaluations, and surveys are administered longitudinally until Match Day. Thirty-five students and 17 faculty members have participated in the program since 2015. All mentors and students found the program to be a valuable experience. When compared to nonparticipating students, participants had significantly higher confidence scores for clinical performance, knowledge of anatomy, and familiarity with the department of interest. All students felt the program prepared them well for third and fourth years, and all 8 of the initial program participants successfully matched into residency with 4 entering otolaryngology. Medical students face a competitive residency application process in otolaryngology with limited exposure, which creates an opportunity for guidance in the pursuit of matching into this field. This novel preclinical mentorship program prepares students for their clinical years and residency by facilitating acquisition of various competencies. Students gain hands-on clinical exposure in a field of interest and support for navigating the application process. The structure of this program can be applied to other medical schools or specialties if the individual departments contain adequate resources of teaching faculty willing to participate.
Facebook Group Use among Parents of Children with Tracheostomy
21-01-2020 – Mikayla J. Huestis,Chase I. Kahn,Lauren F. Tracy,Jessica R. Levi
Tracheotomy in the pediatric population creates unique challenges for parents. Parents often feel underprepared to provide adequate tracheostomy care. Social media is used as a resource for many medical conditions. We looked at Facebook use among parents of children with a tracheostomy to determine how this resource is used as support and to assess common concerns that require improved education prior to discharge. We joined 8 Facebook groups focused on children with a tracheostomy, analyzed the posts for how the groups were used, and identified recurring content. The primary focus of the groups was parental support and general information about tracheostomy care. A common theme identified was patients not receiving medical supplies on time, and groups provided a forum to obtain supplies. Groups also provided general advice about how to travel with a tracheostomy and medical advice, such as when to worry about blood in the tracheostomy tube.
Effect of Diabetes on the Prognosis of Sudden Sensorineural Hearing Loss: Propensity Score Matching Analysis
21-01-2020 – Hee Won Seo,Jae Ho Chung,Hayoung Byun,Jin-Hyeok Jeong,Seung Hwan Lee
The aim of this study was to investigate the clinical implications of diabetes for the management of idiopathic sudden sensorineural hearing loss (ISSNHL). Retrospective study. Tertiary referral center. ISSNHL patients (N = 403) who received inpatient management between January 2015 and December 2018 were analyzed. All were managed by a uniform treatment protocol of high-dose steroid therapy and salvage intratympanic steroid injections. Treatment results were evaluated according to the American Academy of Otolaryngology-Head and Neck Surgery’s criteria 3 months after the start of treatment. We compared the clinical parameters and treatment outcomes of ISSNHL with and without diabetes. We also evaluated the influence of diabetes on the prognosis of ISSNHL by propensity score matching. Overall, of the 403 ISSNHL patients, 94 (23.3%) had diabetes, and 11 were newly diagnosed with diabetes. The patients with diabetes were older than those without diabetes ( ISSNHL with diabetes usually presents with severe hearing loss and requires longer hospitalization. However, diabetes itself may not influence the prognosis of ISSNHL. Proper management must be provided in ISSNHL with diabetes.
Utilization of Diagnostic Testing for Renal Anomalies and Congenital Heart Disease in Patients with Microtia
21-01-2020 – Vaibhav H. Ramprasad,Amber D. Shaffer,Noel Jabbour
Congenital ear anomalies are associated with congenital cardiac and renal defects. Renal ultrasounds, electrocardiogram, and echocardiogram can be utilized for diagnosis of these concurrent defects. No standard of care exists for the workup of patients with microtia. The goals of this study were to describe the utilization of diagnostic testing for cardiac and renal anomalies and to identify their prevalence in patients with microtia. Case series with chart review. Children’s Hospital of Pittsburgh of the University of Pittsburgh Medical Center. This study is an Institutional Review Board-approved retrospective review of consecutive patients born between 2002 and 2016 who were diagnosed with microtia and seen in the otolaryngology clinic at a tertiary care children’s hospital. Demographics, sidedness and grade of microtia, comorbid diagnoses, and details of renal and cardiovascular evaluations were recorded. Factors associated with retroperitoneal ultrasound and cardiac testing were assessed with logistic regression. Microtia was present in 102 patients, and 98 patients were included as they received follow-up. Microtia was associated with craniofacial syndrome in 34.7% of patients. Renal ultrasound was performed in 64.3% of patients, and 12.9% of patients with ultrasounds had renal aplasia. Cardiac workup (electrocardiogram or echocardiogram) was completed in 60.2% of patients, and of this subset, 54.2% had a congenital heart defect. Diagnostic testing revealed renal anomalies and cardiac defects in patients with isolated microtia at a higher rate than in the general population. This suggests the need for further evaluation of the role of routine screening in patients with microtia.
Occlusion and Functional Outcomes after Complete Temporomandibular Joint Resection with Soft Tissue Reconstruction
21-01-2020 – Jake J. Lee,Daniel P. Lander,Ryan S. Jackson,Joseph Zenga,Patrik Pipkorn
Reconstructive outcomes after complete temporomandibular joint (TMJ) resection, including the condyle and glenoid fossa bone, are poorly defined in the literature. We described our technique and reviewed occlusion and functional outcomes of 6 consecutive patients undergoing complete TMJ resection and reconstruction with anterolateral thigh free tissue transfer and intermaxillary fixation with elastic bands for 6 to 8 weeks. At median follow-up of 14 months, median Mandibular Function Impairment Questionnaire score was 32 (range, 4-38), indicating mild to moderate impairment. Subjective occlusion was normal in 4 of 6 patients. Premature occlusal contact was seen in 2 of 6 patients. Maximal interincisor distance and horizontal mandibular shift with jaw abduction ranged from 29 to 40 mm and 5 to 8 mm, respectively. Four of 6 tolerated regular diets while 2 adhered to mechanical soft diets; no patients were feeding tube dependent. Soft tissue-only reconstruction after complete TMJ resection resulted in good subjective and objective occlusion in 4 of 6 patients and no cases of severe functional impairment.
Benign Vocal Fold Lesions in Patients with Chronic Cough
21-01-2020 – Michelle Adessa,Roy Xiao,Darcey Hull,Andrew J. Bowen,Claudio F. Milstein,Michael S. Benninger,Paul C. Bryson
The objective of this study was to determine the prevalence of benign vocal fold lesions (BVFLs) in patients with chronic cough over a 1-year period. Case series with chart review. Tertiary academic medical center. A retrospective cohort study of patients with chronic cough seen in our tertiary multidisciplinary cough clinic from 2016 to 2017 was conducted. Patient characteristics, presence of BVFLs by laryngoscopy, and Leicester Cough Questionnaire (LCQ) were recorded. A total of 419 patients were included (average age: 61 years), and 67% of patients were female. Ten percent of patients had BVFLs: granuloma (5%), leukoplakia (3%), nodules (2%), and polyps (1%). Median cough duration was 2.9 years (interquartile range [IQR], 0.7-8.5); no significant difference in median cough duration was observed between patients with BVFLs and those with no lesions (2.6 vs 3.0 years, Prevalence of BVFLs in our cohort of patients with chronic cough was 10%, with posterior glottic lesions-granuloma-being the most common (5%). Prevalence of midmembranous lesions was as follows: vocal fold nodules (2%) and vocal fold polyps (1%). BVFLs were not associated with longer cough duration or more severe cough. We cannot determine a causative or noncausative relationship between BVFLs and chronic cough at this time due to lack of a control group.
Letters to the Deaf: Present-Day Relevance of History’s Earliest Social Analysis of Deafness
21-01-2020 – James Naples,Tulio A. Valdez
Harriet Martineau was a 19th-century sociologist who had a progressive form of deafness. Her 1834 essay,
Microscopic vs Endoscopic Ear Surgery for Congenital Ossicular Anomaly
21-01-2020 – Jaein Chung,Jae-Yoon Kang,Min-Su Kim,Bongjik Kim,Jin Woong Choi
To compare surgical outcomes of transcanal endoscopic ear surgery (TEES) for congenital ossicular anomalies with those of conventional microscopic surgery.
Retrospective case review.
Tertiary referral academic center.
From March 2012 to November 2018, 42 consecutive ears in 40 patients with congenital ossicular anomaly who underwent ossiculoplasty or stapes surgery using either ear endoscopes (TEES group) or an operating microscope (microscopic group) were included. Postoperative audiometric results, operation time, switch of approach, and complications were compared between the 2 groups.
Twenty-four ears (66.1%) were in the microscopic group and 18 ears (33.9%) were in the TEES group. The mean (SD) preoperative air-bone gap was 31.8 (10.0) d
B in the microscopic group and 35.2 (11.1) d
B in the TEES group. The mean (SD) postoperative air-bone gap was 7.4 (6.5) d
B in the microscopic group and 5.6 (5.0) d
B in the TEES group. The differences in the preoperative and postoperative air-bone gaps between the 2 groups were not statistically significant ( TEES for congenital ossicular anomaly has comparable audiometric results and complication rates to conventional microscopic surgery. TEES appears to have the advantages of shorter operation times.
Is the Height of the Arcuate Eminence Related to Body Mass Index?
21-01-2020 – Daniel H. Coelho,Bradley Fasulo,Kevin Quinn,Yang Tang,Adam Sima,Brielle Forsthoffer
To determine the relationship, if any, between body mass index (BMI) and attenuation of the arcuate eminence (AE). Case series with chart review. Tertiary neurotologic referral center. Submillimeter distances were recorded from high-resolution temporal bone computed tomography (CT) scans of 50 patients (100 sides). The AE (defined as the superiormost location of the petrous bone over the otic capsule), the bony apex of the superior semicircular canal (SSC), and the geniculate ganglion (GG) were identified and 3-dimensional distances measured. The height of the AE relative to the bony apex of the superior semicircular canal was determined using Euclidean geometry using the fixed anatomical landmark of the GG as the origin. Correlations between AE and BMI were calculated using Pearson’s, linear mixed effects, and sensitivity analysis models. The mean (SD) BMI was 30 (8.1) kg/m Contrary to other structures within the lateral skull base, the relative prominence of the arcuate eminence does not correlate with BMI or any other demographic variables.
Inferior Meatus Augmentation Procedure (IMAP) to Treat Empty Nose Syndrome: A Pilot Study
14-01-2020 – Andrew Thamboo,Sachi S. Dholakia,Nicole A. Borchard,Vishal S. Patel,Navarat Tangbumrungtham,Nathalia Velasquez,Zhenxiao Huang,David Zarabanda,Tsuguhisa Nakayama,Jayakar V. Nayak
Our understanding of empty nose syndrome (ENS) continues to evolve. Prior studies evaluating airway augmentation to treat ENS did not use validated disease-specific questionnaires, making the true impact of these surgeries unclear. We present a case series of 10 patients with ENS (11 procedures) who underwent the inferior meatus augmentation procedure (IMAP) between September 2014 and May 2017. Subjective outcomes of IMAP included comparisons of preoperative and postoperative assessments (1 week, 1 month, 3 months, 6 months) using the Empty Nose Syndrome 6-item Questionnaire (ENS6Q), Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder 7-item Scale (GAD-7), and Sino-Nasal Outcome Test-22 (SNOT-22). The decrement in ENS6Q scores observed maintained statistical significance at 6 months (
Indiscriminate Pathologic Examination of Pediatric Supraglottoplasty Specimens: An Evidence-Based Approach toward Exempt Status
14-01-2020 – Alhasan N. Elghouche,Mohamedkazim M. Alwani,Bruce H. Matt
The primary aim of this study was to demonstrate that indiscriminate pathologic evaluation of supraglottoplasty specimens is unnecessary and does not influence postoperative management. The secondary objective was to determine the costs associated with pathologic evaluation of supraglottoplasty specimens. A planned chart review was conducted to evaluate data from consecutive patients undergoing supraglottoplasty. Demographic data were extracted and pathology reports were reviewed. Projected cost savings were estimated based on 2018 Centers for Medicare & Medicaid Services reimbursement rates for A total of 1417 consecutive patients were identified. All specimens underwent gross and microscopic examination. Pathologic outcomes were categorized into 3 major categories: no diagnostic abnormality (n = 1069), chronic inflammation (n = 346), and other (n = 2). Pathologic evaluation did not alter postoperative management in any patient. Projected yearly and 5-year cost- savings totaled $11,818.08 and $59,173.92, respectively. These findings demonstrate that pathologic examination of supraglottoplasty specimens adds no value to patient management. A more selective approach to pathologic examination of certain surgical specimens is an improvement opportunity to enhance the value of patient care by eliminating direct financial costs and “hidden costs” associated with unnecessarily increased workload. Addressing inappropriate, indiscriminate pathologic examination of certain surgical specimens is a potential quality improvement opportunity that has a meaningful impact on the value of patient care and reduces strains on the workload of surgical and pathology department personnel.
Influence of Gender and Racial Diversity on the Otolaryngology Residency Match
14-01-2020 – Isabel Fairmont,Nyssa Farrell,Andrew P. Johnson,Cristina Cabrera-Muffly
(1) Understand attitudes of otolaryngology residency applicants regarding gender and racial diversity within programs. (2) Examine how program diversity affects applicant decisions during the residency match. (3) Compare the importance of racial and ethnic program diversity among applicants. Web-based survey distributed in February and March 2019. Tertiary care university setting. An anonymous web-based survey was distributed to 418 applicants in the 2019 otolaryngology match. Respondents were queried about the importance of program diversity and its effects on the match process. Ratings were based on a scale of 1 to 5 (with 5 being extremely important or significant effect). The response rate was 35%; 53% of responders were male; and 59% were white, 25% Asian, 6% black, and 6% Hispanic/Latino. Applicants rated the importance of having female faculty and residents as 4.1 (SD = 1.1) and 4.2 (SD = 1.1), respectively. Applicants rated the importance of having diverse faculty and residents as 3.9 (SD = 1.1) and 4 (SD = 1.2). Overall, 7.6% of applicants canceled interviews due to a lack of female residents and 5.5% due to a lack of female faculty; furthermore, 5.5% of applicants canceled interviews due to a lack of diverse residents and 4.9% due to a lack of diverse faculty. Female and nonwhite applicants prioritized females and diversity within programs more so than male and white applicants. Although residency applicants felt that program diversity was important, this did not significantly affect decision making during the match process, likely due to the competitive nature of the match. Women and nonwhite applicants prioritized program diversity more than white male applicants.
Improving On-time Discharge in Otolaryngology Admissions
07-01-2020 – Steven A. Gordon,David Garber,Zahrah Taufique,Qianhui Shao,Milan R. Amin,J. Thomas Roland,Babak Givi
We conducted a quality improvement project to increase the rate of discharges before noon (DBN) in the otolaryngology department at a tertiary care center. Based on a Plan-Do-Study-Act framework, monthly discharge data and observed-to-expected (O:E) length of stay were collected and shared with the department members monthly. A target of 43% DBN was predetermined by the center (Plan). The following interventions were implemented (Do): discharge planning starting at the time of admission, focus on early attending-to-resident team communication, placement of discharge order prior to rounding, and weekly reminders to the entire department. Discharges were monitored for 3 years. For the year prior to this study, a minority of patients were discharged before noon (12 months: 75 of 190, 36%). During the first 6 months of monitoring (Study), no significant improvement was identified (34 of 95, 36%). After interventions, performance significantly improved (31 months: 250 of 548, 68%). The performance was consistently above the predetermined target of 43%. During the study time, O:E length of stay remained below the predetermined target (O:E ratio, 0.90; hospital target, 0.93). Comprehensive discharge planning beginning at the time of admission, weekly reminders, and improved communication (Act) can help to prioritize DBN and increase the percentage of discharges before noon. By utilizing a quality improvement framework, significant improvements in timely discharge can be achieved and sustained with changes in workflow and departmental culture. These changes can be achieved without increases in resources or prolonging the length of stay.
Global Burden of Head and Neck Cancer: Economic Consequences, Health, and the Role of Surgery
07-01-2020 – Rolvix H. Patterson,Victoria G. Fischman,Isaac Wasserman,Jennifer Siu,Mark G. Shrime,Johannes J. Fagan,Wayne Koch,Blake C. Alkire
We aimed to describe the mortality burden and macroeconomic effects of head and neck cancer as well as delineate the role of surgical workforce in improving head and neck cancer outcomes. Statistical and economic analysis. Research group. We conducted a statistical analysis on data from the World Development Indicators and the 2016 Global Burden of Disease study to describe the relationship between surgical workforce and global head and neck cancer mortality-to-incidence ratios. A value of lost output model was used to project the global macroeconomic effects of head and neck cancer. Significant differences in mortality-to-incidence ratios existed between Global Burden of Disease study superregions. An increase of surgical, anesthetic, and obstetric provider density by 10% significantly correlated with a reduction of 0.76% in mortality-to-incidence ratio ( The mortality burden of head and neck cancer is increasing and disproportionately affects those in low- and middle-income countries and regions with limited surgical workforces. This imbalance results in large and growing economic losses in countries that already face significant resource constraints. Urgent investment in the surgical workforce is necessary to ensure access to timely surgical services and reverse these negative trends.
Temporal Trajectory of Body Image Disturbance in Patients with Surgically Treated Head and Neck Cancer
07-01-2020 – Evan M. Graboyes,Elizabeth G. Hill,Courtney H. Marsh,Stacey Maurer,Terry A. Day,Joshua D. Hornig,Eric J. Lentsch,David M. Neskey,Judith Skoner,Katherine R. Sterba
To characterize the temporal trajectory of body image disturbance (BID) in patients with surgically treated head and neck cancer (HNC). Prospective cohort study. Academic medical center. Patients with HNC who were undergoing surgery completed the Body Image Scale (BIS), a validated patient-reported outcome measure of BID, pretreatment and 1, 3, 6, 9, and 12 months posttreatment. Changes in BIS scores (ΔBIS) relative to pretreatment (primary endpoint) were analyzed with a linear mixed model. Associations between demographics, clinical characteristics, psychosocial attributes, and persistently elevated BIS scores and increases in BIS scores ≥5 points relative to pretreatment (secondary endpoints) were analyzed through logistic regression. Of the 68 patients, most were male (n = 43), had oral cavity cancer (n = 37), and underwent microvascular reconstruction (n = 45). Relative to baseline, mean ΔBIS scores were elevated at 1 month postoperatively (2.9; 95% CI, 1.3-4.4) and 3 (3.2; 95% CI, 1.5-4.9) and 6 (1.8; 95% CI, 0.02-3.6) months posttreatment before returning to baseline at 9 months posttreatment (0.9; 95% CI, -0.8 to 2.5). Forty-three percent of patients (19 of 44) had persistently elevated BIS scores at 9 months posttreatment relative to baseline, and 51% (31 of 61) experienced an increase in BIS scores ≥5 relative to baseline. In this cohort of patients surgically treated for HNC, BID worsens posttreatment before returning to pretreatment (baseline) levels at 9 months posttreatment. However, 4 in 10 patients will experience a protracted course with persistent posttreatment body image concerns, and half will experience a significant increase in BIS scores relative to pretreatment levels.