Limitations in Faculty Advancement for Underrepresented Groups in Academic Otolaryngology

OBJECTIVE

Despite the increasing racial diversity of the United States, representation in academic medicine faculty does not reach concordance with the general population and worsens with higher rank. Few studies have examined this within academic Otolaryngology and surgical subspecialties. This project aims to compare rank equity in academic Otolaryngology on self-reported gender and race/ethnicity between the years 2000 and 2020.

METHODS

Publicly available data were obtained from the Association of American Medical Colleges under the "Data & Reports" section for the years 2000 and 2020. The report comprised of full-time faculty from all U.S. medical schools. To determine parity between faculty ranks across gender and race/ethnicity, rank equity index (REI) was calculated for associate/assistant, professor/associate, and professor/assistant professor comparisons.

RESULTS

The percentage of women faculty in Otolaryngology has increased from 21% in 2000 to 37% in 2020; however, they did not achieve parity at all rank comparisons for both years. On the contrary, men were above parity at all rank comparisons. Improvements in rank equity occurred for Black/African American (Black) and Hispanic Latino/Spanish Origin (Latine) faculty between the years 2000 and 2020; however, when accounting for gender, benefits were concentrated among men.

CONCLUSION

Advancement along the academic ladder is limited for women of all racial groups in academic Otolaryngology. While improved rank equity was seen for Black and Latine faculty, these improvements were largely among men. Future directions should aim to identify barriers to recruitment, retention, and promotion for women and underrepresented in medicine (URiM) academic otolaryngologists and create interventions that diversify Otolaryngology faculty at all ranks.

LEVEL OF EVIDENCE

NA Laryngoscope, 134:1625-1632, 2024.

Circulating tumor HPV DNA assessments after surgery for human papilloma virus-associated oropharynx carcinoma

PURPOSE

To understand the utility of circulating tumor human papillomavirus DNA (ctHPVDNA) blood testing for HPV-associated oropharynx squamous cell carcinoma (HPV + OPSCC) after definitive surgery.

MATERIALS AND METHODS

Prospective cohort study of HPV(+)OPSCC patients with ctHPVDNA test data to assess its accuracy in detecting biopsy-confirmed disease at various post-treatment time points. Eligible patients had p16(+)/HPV(+) OPSCC and ctHPVDNA testing performed at any time pre-operatively and/or postoperatively. In cases of recurrence, patients were excluded from analysis if ctHPVDNA testing was not performed within 6 months of biopsy.

RESULTS

196 all-treatment-type patients had at least one PT ctHPVDNA test. The initial post-treatment (PT) ctHPVDNA sensitivity, specificity, PPV, and NPV were 69.2 % (9/13), 96.7 % (177/183), 60.0 % (9/15), and 97.8 % (177/181). 61 surgery alone (SA) patients underwent 128 PT tests. The initial PT SA ctHPVDNA sensitivity, specificity, PPV, and NPV were 100 % (2/2), 96.0 % (48/50), 50 % (2/4), and 100 % (48/48). 35 of 61 (57.4 %) SA patients had NCCN-based histopathologic indications for adjuvant (chemo)radiation but declined. 3 of 35 (8.57 %) had a positive PT ctHPVDNA test of which 1 of 3 (33 %) had biopsy-proven recurrence. Prospectively, ten patients had a PreT positive ctHPVDNA, underwent SA, refused adjuvant treatment, had an undetectable ctHPVDNA within 2 weeks of SA, and remained free of disease (mean 10.3 months).

CONCLUSION

The high specificity and NPV of ctHPVDNA after SA suggest ctHPVDNA may have a role in determining the omission of PT adjuvant (chemo)radiation in select patients.

"Left on their own": Left-handedness among rhinologists and otolaryngology trainees

KEY POINTS

Left-hand-dominant (LHD) respondents reported higher rates of training difficulties because of handedness differences. LHD respondents cited particular difficulty with functional endoscopic sinus surgery. Both LHD and right-hand-dominant respondents perceived a need for laterality-specific training during residency.

Finding the Potholes in Academic Career Pathways for Underrepresented Groups in Otolaryngology

OBJECTIVE

To assess inequities in representation among ranks and odds of promotion by race in academic otolaryngology.

STUDY DESIGN

Cross-sectional study.

SETTING

US academic medical centers.

METHODS

Demographic data was collected for medical students, residents, and faculty in the Association of American Medical Colleges and Accreditation Council for Graduate Medical Education databases for the academic year 2020 to 2021. The rank equity index (REI) was used to make pairwise comparisons between ranks to determine groups' representation between levels. Odds ratios (ORs) and 95% confidence intervals (CIs) demonstrating the likelihood that an individual of a particular rank/race would advance in their academic career were determined.

RESULTS

Representation comparing medical students with full professors for black, Latine, and Asian otolaryngologists was below parity (REI: 0.27, 0.85, 0.85, respectively). Black (OR: 0.20, CI: 0.15, 0.26), Latine (OR: 0.61, CI: 0.50, 0.75), and Asian (OR: 0.62, CI: 0.55, 0.71) medical students all faced lower odds of becoming otolaryngology residents compared to their white counterparts. Similar findings occurred when comparing resident and assistant professor representation. American Indian/Alaskan Native (AIAN) and Native Hawaiian/Pacific Islander (NHPI) REIs and ORs could not be assessed as only 1 self-reported AIAN and no NHPI faculty are present in the studied data.

CONCLUSION

Underrepresented in Medicine and Asian physicians faced worsening representation at each rung of the academic otolaryngology ladder. The greatest losses occurred when medical students transitioned to residents and residents transitioned to assistant professors. AIAN and NH faculty were absent in otolaryngology, indicating vital targets for recruitment efforts.

Availability of Readable Online Spanish Rhinosinusitis Outcome Measures

BACKGROUND

Patient-reported outcome measures (PROMs) are useful instruments that give providers insight into patients' experiences with disease by quantifying the symptoms that matter most to patients. Results of these questionnaires can help guide management in chronic rhinosinusitis. However, these tools are often developed for native English speakers, which disadvantages others, who already have a language barrier to care. The aim of this study is to evaluate accessibility and readability of Spanish PROMs used to evaluate rhinosinusitis.

METHODS

Three Spanish readability measures, Gilliam, Peña & Mountain; SOL; and Fernandez-Huerta were used to evaluate PROMs utilized for rhinosinusitis. PROMs with sixth-grade readability level or easier were considered to meet health literacy recommendations.

RESULTS

Four Spanish PROMs utilized in assessment of rhinosinusitis were identified and evaluated. Cuestionario Español de Calidad de Vida en Rinitis (ESPRINT-15) was the most readable PROM and met readability recommendations in two of three measures. Nasal Obstruction Symptom Evaluation met suggested levels in one measure. The remainder of readability scores were more difficult than recommended.

CONCLUSION

PROMs are powerful clinical tools that help patients communicate their symptoms and self-advocate. For providers to gain accurate and useful information, these measures should be written at appropriate readability levels. Most Spanish PROMs used for assessment of rhinosinusitis were above recommended readability. Development of future PROMs should ensure appropriate readability levels to provide good patient-centered care for our primarily Spanish speaking patients.

Effect of Application Screening Methods on Racial and Ethnic Diversity in Otolaryngology

Otolaryngology-head and neck surgery (OHNS) lags behind other surgical subspecialties in the representation of underrepresented minorities in medicine (URMs). Given the recently announced changes to Step 1 scoring, we aimed to assess the effect of alternative application screening methods-Step 2 Clinical Knowledge scores and Alpha Omega Alpha membership-on the racial/ethnic diversity of the OHNS applicant pool. After reviewing OHNS residency applications submitted to our institution for the 2015-2020 matches (N = 2177), we determined that a significantly greater proportion of URM vs non-URM applicants would be screened out from interview consideration if any the following were used as an initial screening method: Step 2 cutoff score of 240, Step 2 cutoff score of 253 or non-Alpha Omega Alpha membership (P < .01 for each). Given that using these metrics to screen applications disproportionately affects URMs, programs should consider implementing alternative application review methods, such as holistic evaluation, which may promote more equitable distribution of interviews.

Outcomes in Pediatric Endoscopic Skull Base Surgery: A Systematic Review

Objectives  The frequency of endoscopic skull base surgery in pediatric patients is increasing. This study aims to systematically review the literature for endoscopic skull base surgery outcomes in children/adolescents aged 0 to 18 years. Design  A systematic review of the literature was performed in PubMed and SCOPUS databases querying studies from 2000 to 2020 using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Final inclusion criteria included: case series with more than 10 patients with pediatric patients aged ≤18 years, endoscopic or endoscopic-assisted skull base surgery, and outcomes reported. Setting  This study was conducted at a tertiary care medical center. Participants  Children/adolescents aged 0 to 18 years who underwent endoscopic skull base surgery were participated in this study. Main Outcome Measures  Patient demographics, pathology, reconstructive technique, intraoperative findings, intraoperative, and postoperative surgical complications were measured through this study. Results  Systematic literature search yielded 287 publications. Of these, 12 studies discussing a total of 399 patients aged 0 to 18 years met inclusion criteria for final analysis. Seven of the 12 studies discussed a single pathology. The most common pathology was a skull base defect causing cerebrospinal fluid (CSF) leak. The majority of skull base repairs were made with free tissue grafts. The most common postoperative complication was CSF leak ( n  = 40). Twelve cases of meningitis occurred postoperatively with two of these episodes resulting in death. Conclusion  Endoscopic skull base surgery has been performed recently in the pediatric population in a variety of disease states. Inconsistent individual-level data and reporting standards are present in existing studies posing challenges for comparative analysis. Standardized reporting will aid future reviews and meta-analysis for rare skull base pathology.

HPV in the malignant transformation of sinonasal inverted papillomas: A meta-analysis

OBJECTIVES

To date, there is still a significant debate on the role of human papilloma virus (HPV) infection in transformation of inverted papillomas (IPs) to squamous cell carcinoma (SCC). This study was designed to determine if the presence of HPV in a sinonasal IP increases the risk of malignant transformation to IPSCC.

METHODS

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, 19 high-quality case-control and cohort studies with tissue-diagnosed IP or IPSCC and HPV diagnosis were analyzed. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using the Mantel-Haenszel method with correction for random effects. Subgroup, publication bias and a sensitivity analyses were also performed.

RESULTS

Nineteen studies with minimal bias met the inclusion criteria for quality and identified HPV infection in an IP. The pooled data revealed a strong association with progression to malignancy with an unweighted, pooled OR of 2.38 (CI₉₅ 1.47 to 3.83) and a weighted OR of 2.80 (CI₉₅ 1.42 to 5.51). Sensitivity analysis revealed that no single study contributed significantly to our pooled OR calculations (ORs 2.52 to 3.57). Subgroup analyses stratified by publication date, nucleic acid target, HPV detection method and type, sample size, and region all demonstrated a positive association of HPV with IPSCC.

CONCLUSIONS

There appears to be a significant association between HPV infection and malignant transformation of IPs. While HPV testing is not currently the standard of care for IPs, these data suggest a link between the two and suggest further studies should be performed to identify a link between the virus and malignant transformation.

Readability analysis of pediatric otolaryngology patient-reported outcome measures

OBJECTIVE

(s): Patient-reported outcome measures (PROMs) are tools that allow patients to directly share information about their health with their healthcare provider. Health literacy experts recommend that health information, such as PROMs, be written at a 6th grade level to ensure patients can read and comprehend it. As the readability of PROMs used in pediatric otolaryngology has yet to be studied, our goal was to analyze the readability of these PROMs and assess their compliance with readability recommendations.

METHODS

The Gunning Fog, the Simple Measure of Gobbledygook (SMOG), and the FORCAST readability formulas were used to determine the readability of disease-specific PROMs for pediatric otolaryngology.

RESULTS

Fourteen PROMs were reviewed in the study. Most were intended for caregiver completion (n = 13, 92.9%). Ten PROMs when measured by Gunning Fog (71.4%), 2 PROMs when measured by SMOG (14.3%), and 0 PROMs when measured by FORCAST (0.0%) were at or below the 6th grade reading level.

CONCLUSION

Most PROMs available for use in pediatric otolaryngology are above the recommended 6th grade reading level when measured by FORCAST, the most appropriate metric for assessing questionnaires. The high reading grade level needed to complete these PROMs can contribute to health disparities among underserved and vulnerable populations, such as children. Pediatric otolaryngology PROMs developed in the future should take readability into account in order to ensure equity in the delivery of care.

Intranasal corticosteroids: patient administration angles and impact of education

INTRODUCTION: Intranasal corticosteroids sprays (INCS) are first line treatment for allergic rhinitis and are frequently used for chronic rhinosinusitis. Improperly aiming INCS increases the risk of epistaxis and may decrease the efficacy of the medication. The goal of this study was to determine how patients position INCS for drug delivery and if verbal or written instructions improve their positioning. METHODS: Patients in rhinology clinics were photographed while administering a generic spray bottle. The angle of the spray bot- tle relative to the patients’ head and a fixed background was determined. RESULTS: A total of 46 participants were included. The average spray angle for the right naris was 10.1o towards the septum and 67.2o below the Frankfurt Horizontal plane. The average spray angle for the left naris was 4.5o towards the septum and 62.2o below the Frankfurt horizontal plane. The angle of the spray bottle ranged from 50o toward the septum to 43o away from the sep- tum. Only 8 patients aimed away from the septum for both nares. Patients who recalled receiving verbal and written instructions aimed the INCS bottle at the lateral wall and inferior turbinate in contrast to patients who only received one form of instruction or no instructions. CONCLUSIONS: Most patients (83%) incorrectly aim INCS when compared to current guidelines. There was statistically significant improvement in the positioning of patients who reported receiving both verbal and written instruction; however, this study high- lights a greater need for patient education.

Readability of patient-reported outcome measures for chronic rhinosinusitis and skull base diseases

OBJECTIVE

Outcome measures in healthcare that presume a higher level of patient health and overall literacy may inadequately estimate the disease experiences of less-educated patients and further disadvantage them. Patient-Reported Outcome Measures (PROMs) are widely used communication tools for clinical practice and are often used to evaluate and guide management for chronic rhinosinusitis (CRS) and skull base diseases. However, their readability and subsequent incomprehensibility for patients have not been assessed. The aim of this study is to evaluate the readability of commonly used PROMs for these conditions and whether they meet recommended readability levels.

METHODS

Three readability measures, Gunning Fog, Simple Measure of Gobbledygook (SMOG), and FORCAST were used in the evaluation of commonly used PROMs for CRS and skull base disease. PROMs with sixth-grade readability level or lower were considered to meet health literacy experts' recommendations.

RESULTS

A total of 11 PROMs were reviewed (8 CRS, 3 skull base). Gunning Fog consistently estimated the easiest readability, whereas FORCAST the most difficult. One hundred percent of CRS and 67% of skull base PROMs were above National Institutes of Health and health literacy experts' recommended reading levels. PROMs developed more recently had easier readability.

CONCLUSION

PROMs are important clinical tools in otolaryngology that help guide management of disease for improved patient-centered care. Like many other fields of medicine, those used in otolaryngology are beyond recommended reading levels. Development of PROMs in the future should meet recommended readability levels to fully assess the disease experience of our patients.

LEVEL OF EVIDENCE

4 Laryngoscope, 130:2305-2310, 2020.

Radiologic Analysis of Balloon Sinuplasty in a Human Cadaver Model: Observed Effects on Sinonasal Anatomy

BACKGROUND

Balloon sinuplasty is increasingly used in the outpatient clinic for treatment of chronic rhinosinusitis, but radiologic analysis of its effects on sinonasal anatomy is largely uncharacterized in the known literature.

OBJECTIVE

The purpose of this study is to examine the anatomic effects of balloon sinuplasty in a cadaveric model.

METHODS

Five fresh cadaver heads underwent sequential endoscopic balloon dilation of maxillary ostia, frontal recess outflow tracts, and sphenoid ostia bilaterally by fellowship-trained rhinologists. Pre- and post-procedural CT imaging was obtained. CT scans were imported into Mimics™ software and sinonasal anatomy was analyzed systematically.

RESULTS

Visual confirmation of balloon dilation was achieved in all 3 sites bilaterally in each cadaver. Radiologic analysis demonstrated that the frontal sinus outflow tract was appropriately dilated 60% (6/10 sites) of the time while the agger was inadvertently dilated 30% of the time (3/10). The sphenoid os was successfully dilated 70% (7/10 sites) of the time. In two cases, a posterior sphenoethmoid (Onodi) cell was dilated instead of the sphenoid. Successful dilation of maxillary os was noted 60% of the time (6/10 sites). No significant change in maxillary os was noted after balloon dilation. Normal middle turbinates were significantly medialized following balloon dilation 75% (6/8 sites) of the time.

CONCLUSIONS

While the goal of balloon sinuplasty is to improve natural sinonasal drainage by dilating existing outflow tracts, as evidenced by radiologic evaluation the procedure appears not to achieve this in all cases, while occasionally creating unintended changes in sinonasal anatomy as well. These unrecognized changes in anatomy may be responsible for the post-procedure change in symptomatology that some patients experience.

Numerical evaluation of spray position for improved nasal drug delivery

Topical intra-nasal sprays are amongst the most commonly prescribed therapeutic options for sinonasal diseases in humans. However, inconsistency and ambiguity in instructions show a lack of definitive knowledge on best spray use techniques. In this study, we have identified a new usage strategy for nasal sprays available over-the-counter, that registers an average 8-fold improvement in topical delivery of drugs at diseased sites, when compared to prevalent spray techniques. The protocol involves re-orienting the spray axis to harness inertial motion of particulates and has been developed using computational fluid dynamics simulations of respiratory airflow and droplet transport in medical imaging-based digital models. Simulated dose in representative models is validated through in vitro spray measurements in 3D-printed anatomic replicas using the gamma scintigraphy technique. This work breaks new ground in proposing an alternative user-friendly strategy that can significantly enhance topical delivery inside human nose. While these findings can eventually translate into personalized spray usage instructions and hence merit a change in nasal standard-of-care, this study also demonstrates how relatively simple engineering analysis tools can revolutionize everyday healthcare. Finally, with respiratory mucosa as the initial coronavirus infection site, our findings are relevant to intra-nasal vaccines that are in-development, to mitigate the COVID-19 pandemic.

Long-Term Academic Outcomes of Triological Society Research Career Development Award Recipients

OBJECTIVES/HYPOTHESIS

Each year, the Triological Society awards several Research Career Development Awards (CDAs) to support early-career otolaryngologists. The objective of this study was to evaluate academic outcomes of CDA recipients including National Institutes of Health (NIH) funding acquisition and h-index. A secondary objective was to appraise gender differences in outcomes among awardees.

STUDY DESIGN

Cross-sectional study.

METHODS

Recipients' practice setting, degree type, academic rank, and leadership titles were determined through review of academic and private practice profiles in October 2019. NIH funding was assessed using the NIH Research Portfolio Online Reporting Tool and the h-index was calculated using the Scopus database.

RESULTS

Between 2004 and 2019, 70 investigators received a CDA. Of the 65 awardees prior to 2019, 26 (40.0%) obtained NIH grants after the CDA. Having an MD/PhD or MD/master's was not associated with NIH funding attainment (P = .891) nor with higher funding total (P = .109). However, funding total was significantly higher for full professors compared to assistant professors (P = .022). The median h-index among awardees was 16 (interquartile range = 11-21) and differed significantly by academic rank (P < .001). Moreover, 23 CDAs (32.9%) were awarded to women. However, fewer female recipients obtain NIH funding after the CDA compared to men (10.5% vs. 52.2%, P = .002), and they had significantly lower h-indices than men (10 vs. 17, P < .001).

CONCLUSIONS

As a cohort, CDA awardees achieve higher academic success than academic otolaryngologists in general. However, female CDA recipients lag behind their male colleagues, highlighting the need for more research to uncover contributors to gender differences and ways to foster equity in research.

LEVEL OF EVIDENCE

NA Laryngoscope, 131:288-293, 2021.

Cystic Fibrosis Transmembrane Conductance Regulator Modulator Therapy: A Review for the Otolaryngologist

Background

Cystic fibrosis (CF) is a genetic disease that may result in multiple systemic disorders and potentially fatal severe respiratory compromise. However, the advent of CF transmembrane conductance regulator (CFTR) modulators has changed the management of CF for patients with select mutations. Although clinical trials have highlighted increased pulmonary function and decreased exacerbations as a result of these novel therapies, their effect on the sinuses has not been well-described.

Objective

Our objective is to review the CFTR modulators to provide otolaryngologists, physicians who frequently care for patients with CF, a basic understanding of these drugs and their effects on chronic rhinosinusitis (CRS) in patients with CF.

Methods

The clinically approved and available CFTR modulators and specific indications for their use are reviewed. Additionally, a systematic review of these therapies and effects on CRS in CF was performed.

Results

Four Food and Drug Administration approved CFTR modulators are available for patients with CF. Current drugs are approved for gating, residual function, or F508del mutations. Multiple reports describe CFTR modulators’ increase in transepithelial ion transport in nasal epithelial cultures; however, clinical studies regarding effects of these modulators on sinonasal health are limited to 5 studies that present new data of the effects of CFTR modulators in CRS.

Conclusions

CFTR modulators have changed management of CF. Initial studies of these medications demonstrate promising results in CF; however, there is a paucity of literature describing the effect of CFTR modulators on CF-associated CRS, although initial results are encouraging.

Recent Trends in Female and Racial/Ethnic Minority Groups in U.S. Otolaryngology Residency Programs

OBJECTIVES

Our objectives were to analyze the recent trends in applicants of otolaryngology-head and neck surgery (Oto-HNS) residency programs, including evolutions in sex and racial/ethnic distribution within the applicant pool and subsequent residency cohort.

METHODS

Retrospective database and literature review. Data regarding applicants to Oto-HNS programs as well as Oto-HNS residents in the United States from 2008 to 2017 were analyzed from the Electronic Residency Application Service, National Resident Matching Program, and Journal of the American Medical Association.

RESULTS

Between 2008 and 2018, the number of Oto-HNS residency programs and residency positions offered increased from 105 to 112 and from 273 to 315, respectively. There was no statistically significant difference between applicant sex in 2008 to 2012 compared to 2013 to 2018 (P > .05), but significantly more females made up the residency workforce from 2013 to 2018 compared to 2008 to 2012 (P < .001). However, the percentage increase in female residents from 2008 to 2017 was only 6.1% (29.8% to 35.9%). No statistically significant difference was present between applicant race in 2008 to 2012 compared to 2013 to 2018 (P > .05), but significantly more minority residents made up the residency workforce from 2013 to 2018 compared to 2008 to 2012 (P < .0001). However, the percentage increase in minority residents from 2008 to 2017 was only 4.9% (35.1% to 40%).

CONCLUSION

Women and minority racial and ethnic groups continue to be underrepresented among Oto-HNS applicants. However, the presence of these groups among current residents has increased. Understanding and tracking these national trends yearly is critical for training a diverse future otolaryngology workforce.

LEVEL OF EVIDENCE

VI Laryngoscope, 131:277-281, 2021.

Readability of Patient-Reported Outcome Measures for Head and Neck Oncology

OBJECTIVES/HYPOTHESIS

Patient-reported outcome measures (PROMs) are communication tools to help patients convey their disease experience to medical providers and guide management decisions. However, the utility of healthcare outcome measures is dependent on patient literacy and readability of PROMs. If written for a more advanced literacy level, they can misestimate symptoms and add significant barriers to care, especially in the underserved. However, readability of head and neck (H&N) oncology PROMs has not been assessed. The aim of this study was to evaluate the readability of H&N oncology PROMs to assess whether they meet recommended readability levels.

STUDY DESIGN

Bibliometric review.

METHODS

Three readability measures: Gunning Fog, Simple Measure of Gobbledygook, and FORCAST were used to evaluate the readability level of commonly used H&N PROMs. PROMs with sixth grade readability level or lower were considered to meet the recommendations of health literacy experts.

RESULTS

Eight H&N oncology PROMs were reviewed. None of H&N PROMs met health literacy experts' and National Institutes of Health recommended reading levels. Gunning Fog consistently estimated easiest readability and FORCAST the most difficult.

CONCLUSIONS

PROMs are important clinical tools that drive patient-centric care in H&N oncology. All H&N PROMs are written above recommended reading levels and do not meet suggested standards. Future PROMs should be written with easier readability to accurately convey patients' H&N oncology disease experiences.

LEVEL OF EVIDENCE

4 Laryngoscope, 2020.

Outcomes of Open vs Endoscopic Skull Base Surgery in Patients 70 Years or Older

Importance

The use of skull base surgery in patients 70 years or older is increasing, but its safety in this age group has not been evaluated to date.

Objectives

To describe outcomes in a cohort of patients 70 years or older undergoing skull base surgery and to evaluate whether age, type of disease process, and approach (endoscopic vs traditional open surgery) are associated with increased intraoperative and postoperative complications in this population.

Design, Setting, and Participants

This retrospective cohort study analyzed a population-based sample of 219 patients 70 years or older from a database of 1720 patients who underwent skull base surgery at University of North Carolina Hospitals, Chapel Hill, a tertiary referral center, between October 2007 and June 2017. Data were collected from June 2016 to July 2017 and analyzed in July 2017 and August 2017.

Exposure

Skull base surgery.

Main Outcomes and Measures

Data collected included demographic characteristics, surgical approach, and disease process. Intraoperative findings and postoperative complications were analyzed by age, surgical approach, and malignancy status.

Results

Of the 219 patients, 166 were aged 70.0 to 79.9 years and 53 patients were older than 80 years (mean [SD] age, 76.4 [4.7] years); 120 (54.8%) were men and 160 (73.7%) were white. There were 161 (73.5%) endoscopic and 58 (26.5%) open operations. The most common pathologic processes among the 219 patients were nonsellar malignant (81 [37.0%]), nonsellar benign (53 [24.2%]), and pituitary (49 [22.4%]) tumors. The most common intraoperative and postoperative complications were intraoperative major bleeding (5 of 219 patients [2.3%]) and postoperative bleeding (9 [4.1%]). Thirty-day mortality was zero. There was no clinically meaningful difference in complications between patients aged 70.0 to 79.9 years vs those older than 80 years, endoscopic vs open surgery, or benign vs malignant neoplasms. Specifically, between the endoscopic and open surgery groups, there was no difference in intraoperative major bleeding (3.9%; 95% CI, -0.7% to 12.9%), postoperative cerebrospinal fluid leak (-0.6%; 95% CI, -3.4% to 5.6%), or postoperative bleeding (1.5%; 95% CI, -3.9% to 10.6%).

Conclusions and Relevance

Skull base surgery is a safe option in persons 70 years or older, with similar outcomes across age ranges, surgical approaches, and disease processes.

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

OBJECTIVES

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.

STUDY DESIGN

Prospective cohort.

SETTING

Tertiary referral center.

SUBJECTS AND METHODS

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.

RESULTS

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.

CONCLUSION

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.

A computational fluid dynamics analysis of the effects of size and shape of anterior nasal septal perforations

BACKGROUND

Nasal septal perforations (NSPs) often cause bleeding, crusting, obstruction, and/or whistling. The objective was to analyze the impact of anterior NSP size and shape on nasal physiology using computational fluid dynamics (CFD).

METHODS

A 3-dimensional model of the nasal cavity was constructed from a radiologically normal CT scan using imaging software. Anterior NSPs (ovoid (ONSP): 0.5, 1, 2, and 3 cm long anterior-to-posteriorly and round (RNSP, 0.5 and 1 cm)) were virtually created in the model and divided into ventral, dorsal, anterior, and posterior regions. Steady-state inspiratory airflow, heat, and water vapor transport were simulated using Fluent CFD software. Air crossover through the perforation, wall shear, heat flux, water vapor flux, resistance, and humidification were analyzed.

RESULTS

Air crossover and wall shear increased with perforation size. Regionally, wall shear and heat and water vapor flux were highest posteriorly and lowest anteriorly, generally increasing with size in those regions. RNSPs had greater heat and water vapor flux compared to corresponding size ONSPs. Resistance decreased by 10% or more from normal only in the 3 cm ONSP. Maximum water content was achieved more posteriorly in larger NSP nasal cavities.

CONCLUSIONS

High wall shear and heat and water vapor flux in posterior perforation regions may explain the crusting most commonly noted on posterior NSP edges. This preliminary study suggests that larger NSPs have a greater effect on nasal resistance and water content. Decrease in resistance with larger NSP size may be implicated in reported symptomatic improvement following enlargement of NSPs for treatment.

Multimodal Analgesia Protocol after Head and Neck Surgery: Effect on Opioid Use and Pain Control

Objective

To assess the effect that implementation of a multimodal analgesic plan has on opioid requirements and pain control in head and neck (H&N) surgery patients.

Study Design

Prospective cohort.

Setting

Tertiary academic hospital.

Subjects and Methods

An institutional review board (IRB)–approved quality improvement initiative was undertaken to implement a multimodal analgesic protocol for all admitted H&N surgery patients starting November 2017. Postprotocol data from January to May 2018 were compared to preprotocol data from May to October 2017. Data were obtained from the electronic health records as well as through preoperative and postoperative surveys. Average pain scores and opioid use in morphine milligram equivalents (MMEs) before and after protocol implementation were compared.

Results

In total, 139 postprotocol patients were compared to 89 preprotocol patients. The adjusted MMEs in the first 24 hours after surgery decreased significantly from 93.7 mg to 58.6 mg ( P = .026) with protocol implementation. When averaged over the length of stay (MME/hospital day), the change was no longer statistically significant (57.9 vs 46.8 mg, P = .211). The average pain score immediately after surgery and on day of discharge did not change with protocol implementation.

Conclusion

Implementation of a multimodal analgesia plan reduced opioid use immediately after surgery but not over the course of hospitalization without any change in reported pain scores. This study shows that multimodal opioid-sparing analgesia after H&N surgery is feasible. Future studies are needed further refine the optimal analgesic strategy for H&N patients and assess the long-term efficacy, safety, and cost of such regimens.

Comparative study of simulated nebulized and spray particle deposition in chronic rhinosinusitis patients

BACKGROUND

Topical intranasal drugs are widely prescribed for chronic rhinosinusitis (CRS), although delivery can vary with device type and droplet size. The study objective was to compare nebulized and sprayed droplet deposition in the paranasal sinuses and ostiomeatal complex (OMC) across multiple droplet sizes in CRS patients using computational fluid dynamics (CFD).

METHODS

Three-dimensional models of sinonasal cavities were constructed from computed tomography (CT) scans of 3 subjects with CRS refractory to medical therapy using imaging software. Assuming steady-state inspiratory airflow at resting rate, CFD was used to simulate 1-µm to 120-µm sprayed droplet deposition in the left and right sinuses and OMC with spray nozzle positioning as in current nasal spray use instructions. Zero-velocity nebulization simulations were performed for 1-µm to 30-µm droplet sizes, maximal sinus and OMC deposition fractions (MSDF) were obtained, and sizes that achieved at least 50% of MSDF were identified. Nebulized MSDF was compared to sprayed droplet deposition. We also validated CFD framework through in vitro experiments.

RESULTS

Among nebulized droplet sizes, 11-µm to 14-µm droplets achieved at least 50% of MSDF in all 6 sinonasal cavities. Four of 6 sinonasal cavities had greater sinus and OMC deposition with nebulized droplets than with sprayed droplets at optimal sizes.

CONCLUSION

Nebulized droplets may target the sinuses and OMC more effectively than sprayed particles at sizes achieving best deposition. Further studies are needed to confirm our preliminary findings. Several commercial nasal nebulizers have average particle sizes outside the optimal nebulized droplet size range found here, suggesting potential for product enhancement.

Analysis of anterior and posterior maneuvers to enhance intraconal exposure

BACKGROUND

The medial and inferior recti encompass the ideal surgical corridor to approach the intraconal space endonasally. Here, we describe 3 different maneuvers to achieve greater access to orbital contents through an expanded endonasal approach (EEA).

METHODS

Four human cadaver heads were dissected bilaterally (n = 8). EEA to the medial intraconal orbit was executed. The following 3 maneuvers were performed: (1) anterior: extraocular muscles control (EOM); (2) posterior: annulus of Zinn (AZ) release; and (3) anterior/posterior combined. Measurements of the inferior and medial rectus corridor at the level of anterior ethmoidal artery (AEA) and posterior ethmoidal artery (PEA) and extent of optic nerve and medial rectus visualization was performed before and after each maneuver.

RESULTS

Medial rectus length (MRL) and optic nerve length (ONL) achieved were 1.72 ± 0.28 cm and 0.85 ± 0.2 cm, respectively. Mean caudal-rostral distances between the rectus muscles at the level of the AEA and PEA were 3.45 ± 0.7 mm and 1.30 ± 0.3 mm, respectively. After EOM control, mean caudal-rostral distances at the same level were as follows: AEA 4.90 ± 1.15 mm (p = 0.009) and PEA 1.70 ± 0.20 mm (p = 0.016). With AZ release, MRL was 2.20 ± 0.7 cm (p = 0.002) and ONL was 1.30 ± 0.2 cm (p = 0.003), with mean rostral-caudal distance at the level of AEA at 4.03 ± 0.8 mm (p = 0.16) and PEA at 1.71 ± 0.36 mm (p = 0.039). Mean caudal-rostral distances achieved with AZ release and EOM control were as follows: AEA 5.6 ± 1.2 mm (p = 0.001) and PEA 2.15 ± 0.4 mm (p = 0.001).

CONCLUSION

Progressive access to the orbital contents is afforded with the 3 delineated maneuvers. The magnitude of access is optimized with the combined maneuver. The actual anterior/posterior location of the target will determine which maneuvers are required.

Sex bias: Is it pervasive in otolaryngology clinical research?

OBJECTIVES/HYPOTHESIS

Recent initiatives highlight substantial sex bias in biomedical research. The objective was to determine whether sex bias is present in otolaryngology and whether sex is appropriately analyzed as an independent variable in otolaryngology clinical research.

STUDY DESIGN

Literature review.

METHODS

We systematically reviewed all 2016 articles in three major otolaryngology journals: The Laryngoscope, JAMA Otolaryngology-Head and Neck Surgery, and Otolaryngology-Head and Neck Surgery. Extracted data included study origin, location, subspecialty, number/sex of subjects, ≥50% sex matching (SM_≥50 ), and sex-based statistical analysis.

RESULTS

Six hundred of 1,209 articles comprising original clinical research were reviewed including 8,997,345,495 subjects (males: 3,898,559,264 [43.3%]; females: 5,095,592,583 [56.6%]; and unknown: 3,193,648 [0.04%]). There were 533/600 (88.8%) studies that included both sexes, eight (1.3%) included females only, five (0.8%) included males only, and 56 (9.3%) did not document participant sex. Only 280 studies (46.7%) analyzed data by sex, and 330 studies (60.7%) had SM_{≥ 50} . Sex-based statistical analysis and SM_{≥ 50} were similar in domestic and international studies (48.7% vs. 42.8% and 60.9% vs. 62%, respectively). Database studies performed sex-based statistical analysis more frequently than single and multi-institutional studies (79.1% vs. 40.4% and 43.4%, P < .00001). Analysis by sex was more frequently performed in head and neck surgery (53.6%) and pediatric otolaryngology (51.3%), whereas SM_≥50 was highest in pediatric otolaryngology (86.8%) and otology (82.4%).

CONCLUSIONS

Sex bias exists in the clinical otolaryngology literature, with less than half the studies analyzing sex. Acknowledging the intertwinement of sex with disease pathophysiology and outcomes is important. Eliminating sex bias in research and clinical care should become a major focus for otolaryngologists.

LEVEL OF EVIDENCE

NA Laryngoscope, 129:858-864, 2019.

Sex bias in basic science and translational otolaryngology research

OBJECTIVES/HYPOTHESIS

Recent studies revealed sex bias in surgical research. Although many diseases exhibit sex-based clinically relevant differences, otolaryngology research has not been evaluated for sex reporting and sex-based analysis. We postulate that a similar bias is prevalent in otolaryngology literature.

STUDY DESIGN

Literature review.

METHODS

Articles published from 2016 to 2017 in The Laryngoscope, Otolaryngology-Head and Neck Surgery, and JAMA Otolaryngology-Head and Neck Surgery were reviewed. Articles with animal subjects, human subject cells, or commercial cell lines were included. Data collected included study type, cell/animal sex, and sex-based data analysis.

RESULTS

One hundred forty-four basic/translational research articles were identified. Sixty-nine (47.9%) of those lacked sex reporting. Of 75 studies that reported sex, 22 (29.3%) included both sexes, and 11 (14.7%) analyzed data by sex. One hundred five (72.9%) used animal subjects, of which 54 (51.9%) lacked sex breakdown. Among animal studies, 48/105 included only one sex, and three articles analyzed data by sex. Fifty-four studies used commercial cell lines (N = 23) or human/animal subject cells (N = 31). Among cell groups, 28/54 (51.9%) were of unknown sex, and seven were single sex. Eight (14.8%) studies included data analysis by sex. Domestic studies exhibited a lower rate of sex reporting in both animal and cell studies, and a lower rate of sex-based analysis in cell studies.

CONCLUSIONS

Sex may influence outcomes significantly but is underreported and underanalyzed in basic/translational otolaryngology research. Because this research frequently lays the groundwork for clinical trials and standards of care, future research must address these sex-based discrepancies.

LEVEL OF EVIDENCE

NA Laryngoscope, 129:613-618, 2019.

Radiographic muscle invasion not a recurrence predictor in HPV-associated oropharyngeal squamous cell carcinoma

OBJECTIVE

To determine whether muscle invasion evident on pretreatment imaging in p16 + oropharyngeal squamous cell carcinoma (OPSCC) correlates with recurrence.

STUDY DESIGN

Retrospective review.

METHODS

Two-hundred and seventy-six patients with p16 + OPSCC treated at a tertiary referral center from 2003 to 2015 were analyzed. All scans were reviewed by a dedicated neuroradiologist with subspecialty expertise in head and neck imaging. Radiographic evidence of muscle invasion to the genioglossus, hyoglossus, medial pterygoid, and prevertebral muscles was analyzed. Local and regional recurrence rates were compared between the muscle invasion and no muscle invasion groups.

RESULTS

One hundred and ninety patients met inclusion criteria with adequate follow-up data and pretreatment imaging. Patients were predominantly male (87.5% male) and smokers (65.6% smokers) with a mean age of 56.7 (standard deviation: 9.0 years). Most commonly invaded muscles in the muscle invasion group were hyoglossus (57.8%) and genioglossus (56.3%). There was no statistically significant difference in primary site or nodal recurrence between the combined group, including definite or possible muscle invasion and the group without muscle invasion (P = 0.205 and P = 0.569, respectively). Additionally, no statistically significant difference was present in recurrence-free and disease-specific survival between the two groups at 3- and 5-year follow-up (P > 0.05).

CONCLUSION

Radiographic evidence of muscle invasion does not appear to be a predictor of human papilloma virus (+) OPSCC recurrence. Additional studies are needed to validate our findings.

LEVEL OF EVIDENCE

4 Laryngoscope, 129:871-876, 2019.

Sex bias in rhinology research

BACKGROUND

Analysis of general surgery literature has revealed noteworthy sex bias and underreporting. Our objective was to determine the prevalence of sex bias and underreporting in rhinology.

METHODS

All articles in 2016 issues of Rhinology, the American Journal of Rhinology and Allergy (AJRA), and the International Forum of Allergy and Rhinology (IFAR) were reviewed. Of 369 articles, 248 met inclusion criteria. Excluded studies were cadaveric, meta-analysis/review, and editorial. Data collected included study type, demographics, and sex-based statistical analysis.

RESULTS

There were 202 clinical and 46 basic science/translational studies. From 188 of 202 clinical studies with known sex, 1 included participants of a single sex. Sex matching >50% (SM₅₀ ) was found in 81.9%, and 55.9% performed sex-based statistical analysis. Domestic clinical studies performed sex-based analysis more frequently than international (54.9% vs 44.4%) and exhibited a higher rate of SM₅₀ (84.5% vs 80.3%), though these differences were not statistically significant. For basic/translational studies, 54.5% (24/44) provided sex breakdown. Among these, 29.2% included 1 sex, and 8.3% performed sex-based analysis. Of 10 using animals, 70.0% utilized 1 sex. The remaining 30.0% did not report sex. None of 4 cell line studies reported cell sex. Less than half (46.2%) of domestic and 56.3% of international studies reported sex breakdown; 7.7% of domestic and 3.0% of international studies performed sex-based analysis.

CONCLUSION

Although sex may impact outcomes, research without sex reporting and analysis is prevalent, particularly among basic science/translational studies. Future research must account for sex in demographics and analysis to best inform evidence-based clinical guidelines.

Intracranial complications of acute sinusitis in children: The role of endoscopic sinus surgery

OBJECTIVE

To study the role of endoscopic sinus surgery (ESS) in the management of intracranial complications of children with acute rhinosinusitis METHODS: Retrospective chart review at a tertiary care pediatric hospital MAIN OUTCOMES: Demographics, intracranial complications, length of hospital stay (LOS), neurological sequelae, ESS, neurosurgical procedures RESULTS: Twenty-four children with a mean age (SD) of 12.9 years (+/-3.2) with an intracranial complication(s) of acute rhinosinusitis were identified between 2005-2016. A total of 22 were included and 15 (68%) of these were males. The most common complications were: subdural abscess (n=10), epidural abscess (n=10), meningitis (n=5), intraparenchymal abscess (n=5), and cavernous sinus thrombosis (n= 2). Neurologic symptoms included headache (n=12), hemiparesis (n=5) and aphasia (n=3). Average length of stay was 16 (+/- 9.2) days. Average follow up was 7 (+/-5.6) months. One patient had residual seizures and 1 had recurrent rhinosinusitis. Aphasia and hemiparesis resolved in all patients within 1 year. Nineteen (86%) patients had ESS within 4 days of admission. Fourteen patients (63%) had a neurosurgical procedure, 6 (27%) required more than 1 neurosurgical procedure. Six patients (27%) had concurrent neurosurgical drainage and ESS. Four patients (17%) had neurosurgical procedure followed by ESS and 3 patients (13%) were treated only by a neurosurgical procedure. Patients who underwent ESS prior to a neurosurgical procedure had significantly less risk of needing a neurosurgical intervention (OR = .02, p < .01). There was a significantly higher proportion of neurosurgical patients with positive Strep anginosus cultures compared to the ESS only group (85.7% vs 37.5%, p = .02). Studies with larger patient populations are needed to determine the role of ESS in the management of intracranial complications of children with acute rhinosinusitis.

DISCUSSION

Early ESS may be associated with less need for neurosurgical procedures.

The radiation footprint on the pediatric trauma patient

BACKGROUND

The actual baseline of radiation exposure used in evaluating pediatric trauma is not known and has relied on estimates in the literature that may not reflect clinical reality. Our objectives were to determine the baseline amount of radiation delivered in a pediatric trauma evaluation and correlate radiation exposure with trauma activation status to identify the cohort most at risk.

METHODS

We retrospectively evaluated trauma patients (N = 1050) at an independent Level I children's hospital for each level of trauma activation (consults, alerts, stats) from June 2010 to January 2011. Those patients with full dosimetry (N = 215) were analyzed for demographics, mechanism of injury, Injury Severity Score, imaging modalities, and total effective radiation dosages during the full trauma assessment from the time of injury to discharge.

RESULTS

Demographics included gender (143 males, 72 females) and average age (5.5 years [range < 1-16]). The most radiation was conferred from CTs and greatest in trauma stats, followed by alerts, then consults (p < 0.001 for stat and alert doses compared to consults). Repeated imaging was common: 35% of stats had 2-3 CTs and 40% had 4-10 CTs (range 0-10 CTs). The average non-accidental trauma consult utilized four times as many CTs as the average consult (p = 0.002). Most outside hospital CTs (66%) delivered more radiation: 50.0% were at least double the standard pediatric dosage.

CONCLUSIONS

This study is the first to identify the actual baseline of radiation exposure for one trauma evaluation and correlate radiation exposure with trauma activation status. Factors associated with highest radiation include stat activations, suspected non-accidental traumas (NAT), and outside hospital system imaging.

Electrocardiogram Screening in Children with Congenital Sensorineural Hearing Loss: Prevalence and Follow-up of Abnormalities

Objective The purpose is to determine the prevalence of electrocardiogram (ECG) abnormalities, including borderline and prolonged QT, among screened children with sensorineural hearing loss (SNHL) and to analyze their subsequent medical workup. Study Design Institutional Review Board-approved case series with chart review. Setting Tertiary academic center. Subjects and Methods Cases from 1996 to 2014 involving pediatric patients (N = 1994) with SNHL were analyzed. Abnormal ECGs were categorized as borderline/prolonged QT or other. A board-certified pediatric cardiologist retrospectively determined the clinical significance of ECG changes. For follow-up analysis, children with heart disease, known syndromes, or inaccessible records were excluded. Results Among 772 children who had ECGs, 215 (27.8%) had abnormal results: 35 (4.5%) with QT abnormalities and 180 (23.3%) with other abnormalities. For children with QT abnormalities meeting inclusion criteria (n = 30), follow-up measures included cardiology referral (46.6%), repeat ECG by ear, nose, and throat (ENT) specialist (20%), clearance by ENT specialist with clinical correlation and/or comparison with old ECGs (20%), and pediatrician follow-up (6.7%). Documentation of further workup by ENT or referral was absent for 6.7%. For children with other ECG changes meeting inclusion criteria (n = 136), abnormalities were documented for 57 (41.9%); normal QT without other abnormality was documented for 18 (13.2%). The most common follow-up referrals were to pediatricians (16.9%) and cardiologists (10.3%). Among patients with clinically significant non-QT abnormalities mandating further evaluation (n = 122), 38 (31.1%) had documented follow-up in medical records. Conclusion There is a high prevalence of ECG abnormalities among children with congenital SNHL. If findings are confirmed by future studies, screening should be considered for congenital unilateral or bilateral SNHL, regardless of severity. We describe a standardized protocol for ECG screening/follow-up.

The impact of total immunoglobulin E levels on outcomes of maximal medical therapy for chronic rhinosinusitis

INTRODUCTION

The goal of this project was to evaluate the impact of immunoglobulin E (IgE) levels on outcomes in patients with chronic rhinosinusitis (CRS) who received maximal medical therapy (MMT).

STUDY DESIGN

Prospective cohort study.

METHODS

Thirty-eight patients who underwent MMT for CRS were assigned to three different cohorts based on their IgE levels: low IgE (<25 IU), moderate (>25 to <149 IU), and high (≥150 IU). The primary outcome evaluated was MMT failure with a surgical recommendation within each IgE cohort. Secondary outcomes included changes in pre- and post-MMT scores for the Rhinosinusitis Disability Index, Chronic Sinusitis Survey, and computed tomography-based Lund-Mackay evaluation. The cohorts were substratified based on the presence of nasal polyps and nasal allergies.

RESULTS

No significant difference was found when MMT failure was compared between the cohorts in terms of quality of life. When substratified based on the presence of nasal polyps and nasal allergies, there was no significant difference between the cohorts. In the high-IgE cohort, all patients regardless of presence of nasal polyps and nasal allergic disease, frequently failed MMT and were recommended for surgery.

CONCLUSIONS

Overall, IgE levels did not seem to have a significant effect on the quality of life or outcomes of MMT in the patients with CRS. However, the presence of nasal allergies regardless of IgE levels seemed to result in more frequent recommendations for surgery after MMT. In the patients with higher-IgE levels (≥150 IU), MMT seemed to fail at high rates with or without the presence of polyps or allergic disease.

Carotid artery and lower cranial nerve exposure with increasing surgical complexity to the parapharyngeal space

OBJECTIVES/HYPOTHESIS

To investigate the extent of carotid artery exposure attained, including the identification of the external carotid branches and lower cranial nerves in five sequential external approaches to the parapharyngeal space, and to provide an anatomical algorithm.

STUDY DESIGN

Anatomical study.

METHODS

Six latex-injected adult cadaver heads were dissected in five consecutive approaches: transcervical approach with submandibular gland removal, posterior extension of the transcervical approach, transcervical approach with parotidectomy, parotidectomy with lateral mandibulotomy, and parotidectomy with mandibulectomy. The degree of carotid artery exposure attained, external carotid branches, and lower cranial nerves visualized was documented.

RESULTS

The transcervical approach exposed 1.5 cm (Standard Deviation (SD) 0.5) of internal carotid artery (ICA) and 1.25 cm (SD 0.25) of external carotid artery (ECA). The superior thyroid and facial arteries and cranial nerve XII and XI were identified. The posterior extension exposed 2.9 cm (SD 0.7) of ICA and 2.7 cm (SD 1.0) of ECA. Occipital and ascending pharyngeal arteries were visualized. The transparotid approach exposed 4.0 cm (SD 1.1) of ICA and 3.98 cm (SD 1.8) of ECA. Lateral mandibulotomy exposed the internal maxillary artery, cranial nerve X, the sympathetic trunk, and 4.6 cm (SD 2.4) of ICA. Mandibulectomy allowed for complete ECA exposure, cranial nerve IX, lingual nerve, and 6.9 cm (SD 1.3) of ICA.

CONCLUSION

Approaches for the parapharyngeal space must be based on anatomic and biological patient factors. This study provides a guide for the skull base surgeon for an extended approach based on the desired anatomic exposure.

LEVEL OF EVIDENCE

N/A. Laryngoscope, 127:585-591, 2017.

Endoscopic Resection of Sinonasal Malignancy

Objectives

The use of endoscopic approaches for sinonasal malignancy resection has increased, but survival data are limited secondary to disease rarity and new surgical technique. Here we present a systematic review and meta-analysis of endoscopic endonasal resection of sinonasal malignancy.

Data Sources

MEDLINE, PubMed Central, NCBI Bookshelf, Cochrane Library, clinicaltrials.gov, National Guideline Clearinghouse.

Review Methods

PRISMA/MOOSE guidelines were followed. MeSH terms were “endoscopic” AND (“esthesioneuroblastoma” OR “sinonasal adenocarcinoma” OR “squamous cell carcinoma” OR “sinonasal undifferentiated carcinoma”). For studies in which individual-level data were available, results were obtained by direct pooling. For studies in which only summary Kaplan-Meier curves were available, numerical data were extracted, traced, and aggregated by fitting a Weibull model.

Results

Of 320 studies identified, 35 case series were included (n = 952 patients), with 15 studies analyzed via aggregate modeling and 20 studies analyzed via direct pooling. Two- and 5-year survival rates for patients in aggregate modeling were 87.5% and 72.3%, respectively (mean follow-up: 32.9 months). Two- and 5-year survival for patients in direct pooling were 85.8% and 83.5%, respectively (mean follow-up: 43.0 ± 19.5 months). Significant overall survival difference was found between low- and high-grade cancers ( P = .015) but not between low- and high-stage cancers ( P = .79).

Conclusion

Overall 2- and 5-year survival rates are comparable and sometimes greater than those from open craniofacial resection. Survival rates significantly differ by cancer grade but not stage. Journals and investigators should be encouraged to publish retrospective and prospective case series with staged survival updates based on established guidelines.

The Reverse-Flow Facial Artery Buccinator Flap for Skull Base Reconstruction: Key Anatomical and Technical Considerations

Objective To highlight key anatomical and technical considerations for facial artery identification, and harvest and transposition of the facial artery buccinator (FAB) flap to facilitate its future use in anterior skull base reconstruction. Only a few studies have evaluated the reverse-flow FAB flap for skull base defects. Design Eight FAB flaps were raised in four cadaveric heads and divided into thirds; the facial artery's course at the superior and inferior borders of the flap was measured noting in which incisional third of the flap it laid. The flap's reach to the anterior cranial fossa, sella turcica, clival recess, and contralateral cribriform plate were studied. A clinical case and operative video are also presented. Results The facial artery had a near vertical course and stayed with the middle (⅝) or posterior third (⅜) of the flap in the inferior and superior incisions. Seven of eight flaps covered the sellar/planar regions. Only four of eight flaps covered the contralateral cribriform region. Lastly, none reached the middle third of the clivus. Conclusions The FAB flap requires an understanding of the facial artery's course, generally seen in the middle third of the flap, and is an appropriate alternative for sellar/planar and ipsilateral cribriform defects.

Volumetric nasal cavity analysis in children with unilateral and bilateral cleft lip and palate

OBJECTIVES/HYPOTHESIS

Children with cleft lip and palate (CLP) often suffer from nasal obstruction that may be related to effects on nasal volume. The objective of this study was to compare side:side volume ratios and nasal volume in patients with unilateral (UCLP) and bilateral (BCLP) clefts with age-matched controls.

STUDY DESIGN

Retrospective case-control study using three-dimensional (3D) nasal airway reconstructions.

METHODS

We analyzed 20 subjects (age range = 7-12 years) with UCLP and BCLP from a regional craniofacial center who underwent cone beam computed tomography (CT) prior to alveolar grafting. Ten multislice CT images from age-matched controls were also analyzed. Mimics software (Materialise, Plymouth, MI) was used to create 3D reconstructions of the main nasal cavity and compute total and side-specific nasal volumes. Subjects imaged during active nasal cycling phases were excluded.

RESULTS

There was no statistically significant difference in affected:unaffected side volume ratios in UCLP (P = .48) or left:right ratios in BCLP (P = .25) when compared to left:right ratios in controls. Mean overall nasal volumes were 9,932 ± 1,807, 7,097 ± 2,596, and 6,715 ± 2,115 mm(3) for control, UCLP, and BCLP patients, respectively, with statistically significant volume decreases for both UCLP and BCLP subjects from controls (P < .05).

CONCLUSIONS

This is the first study to analyze total nasal volumes in BCLP patients. Overall nasal volume is compromised in UCLP and BCLP by approximately 30%. Additionally, our finding of no major difference in side:side ratios in UCLP and BCLP compared to controls conflicts with pre-existing literature, likely due to exclusion of actively cycling scans and our measurement of the functional nasal cavity.

LEVEL OF EVIDENCE

3b. Laryngoscope, 126:1475-1480, 2016.

The role of routine hearing screening in children with cystic fibrosis on aminoglycosides: A systematic review

OBJECTIVE

To review the role of routine hearing screening for sensorineural hearing loss (SNHL) in children with cystic fibrosis (CF) who have been on aminoglycoside therapy.

DATA SOURCES

PubMed, Cochrane, Scopus, and Ovid databases.

REVIEW METHODS

A systematic review of the literature was performed in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A comprehensive search was performed from 1970 to 2014. Randomized controlled trials, case-control studies, cohort studies, and case series including pediatric subjects with baseline auditory evaluations were included.

RESULTS

Twelve studies (1979-2014) were reviewed. The study population included 762 children (5 months-20 years). Hearing screening measures included pure-tone audiometry (PTA) at standard ± high frequency threshold (HFPTA) (12/12), distortion product otoacoustic emissions (DPOAE) (4/12), transient-evoked otoacoustic emissions (1/12), and automated auditory brainstem response (1/12). The overall prevalence of SNHL ranged from 0% to 29%. However, on subset analysis of children with greater than 10 courses of intravenous (IV) aminoglycosides, up to 44% had SNHL. Eight studies recommended hearing screening in CF children on aminoglycosides; of these, two studies recommended screening even without aminoglycoside exposure, and four studies made no recommendations. HFPTA was the most commonly recommended screening measure followed by DPOAEs.

CONCLUSION

This systematic review supports a recommendation for clinicians to perform routine hearing screening in children with CF during and after aminoglycoside exposure based on the high prevalence of SNHL in this population. Future studies should define the optimal timing for hearing screening during and after aminoglycoside therapy in children with CF.