Otolaryngology–Head and Neck Surgery

Program Description: There is significant external pressure on physicians and healthcare organizations to measure physician outcomes (metrics). However, metrics are quite complicated to develop, validate, and implement. Unfortunately, agencies such as The Joint Commission via hospital medical staffs are requiring evaluations of ongoing professional practice (OPPE) and focused professional practice evaluations (FPPE). As a group, surgeons are not very well versed on this topic. It has come to the attention of the Patient Safety and Quality Improvement Committee of the Academy that many members seek education on creation of metrics and to ensure their non-punitive applications. This miniseminar will begin with an overview of the pertinent definitions and organizations involved in the quality landscape. This brief overview will attempt to be a primer for otolaryngologists such that they can understand the priorities of the quality movement and how to prepare for such in their practices. The primer will also help lay the foundation for the discussion on metrics and how they relate back to the mandates of OPPE. The miniseminar will then discuss how to create and implement metrics from three varying perspectives. We will demonstrate this for a large, multi-specialty practice group, an academic department, and an academic hospital. Participants will learn what constitutes an appropriate metric and how these should ideally be designed for implementation in their practices.

Educational Objectives: 1) Understand the priorities of the quality movement and how to meet the requirements of various constituencies. 2) Learn how to create and implement quality improvement metrics within the practice setting (multi-specialty group practice, academic department, and academic hospital).

Program Description: Following errors and adverse events, the traditional legal and risk management advice to physicians has been to refrain from any disclosure or apology which might be used against the physician legally. Other factors which may inhibit disclosure and apology include a medical culture of perfection and a lack of experience with effective communication techniques. An increasing body of work has shown that the traditional technique of stonewalling is naturally infuriating to patients and is much more likely to lead to lawsuits. In addition, it places physicians in an intolerable position, since the natural human impulse of the caregiver is to apologize for mistakes and then to do everything possible to make things right. A number of non-profit organizations and a few forward-thinking malpractice carriers and institutions are now encouraging prompt, honest disclosure of adverse events, and apology when a genuine error has occurred. Experience to date has been that this more honest process is tremendously relieving to patients and physicians, and that malpractice suits and losses are substantially less when patients are treated honestly. In this miniseminar, three national experts on errors, disclosure, and apology, will discuss the ethical imperative for disclosure and the data that support this approach, both from a patient/provider satisfaction standpoint and a risk reduction standpoint. Doug Wojcieszak, the founder of Sorry Works! will speak about the advantages of disclosure and (when appropriate) apology from a patient perspective. Linda Kenney of Medically Induced Trauma Support Services will speak to how a culture of secrecy around errors harms both patients who are kept in the dark and physicians who aren’t able to be honest with their patients. Rob Hanscom, Vice President of Loss Prevention of Risk Management Foundation (a branch of Harvard’s medical malpractice carrier), will explain why insurance carriers may support thoughtful disclosure and apology policies. A discussion period will cover the issues of what and when to disclose to patients about adverse events, and the difficult question of when an apology is and is not appropriate. We will also present effective techniques for both disclosure and (when appropriate) apology.

Educational Objectives: 1) Understand the literature supporting disclosure and apology as the ethically appropriate response to adverse events. 2) Understand the evidence that disclosure and apology reduce the likelihood of litigation. 3) Know strategies to facilitate disclosure and apology after errors and adverse events.

Program Description: The executive committee of the Board of Governors is proud to present its annual miniseminar. There are many topics that are at the forefront of the practice of otolaryngology. This miniseminar will present three topics that are exceptionally important at this time. Reimbursement for Emergency Department coverage, hospital/physician joint ventures, and an update on payments for EHR and meaningful use. Many hospitals are now reimbursing for emergency department (ED) coverage, many are not. Rick Love, MD, headed the BOG Legislative Committee task force on pay for ED call that resulted in the Academy position paper on this matter. He will give us recommendations on how to successfully merge the feeling of obligation to care for hospital emergency room patients in light of increasing overhead, liability, and decreasing physician reimbursement. Dr Love will shed light on how to be remunerated for hospital ED coverage and at the same time stay within OIG regulations. Lawrence Geller, vice president of consulting services for the group Medical Management Associates, is a sought after speaker and consultant on topics related to healthcare. As portions of the new healthcare law become implemented, hospital/physician joint ventures will be a common trend. Mr Geller will present on the implications of such alliances. The government has recommended that our country’s healthcare providers adopt electronic healthcare record keeping. There are multiple monetary incentives attached to meaningful use and 2011 is the first year slated for reimbursement. Michael Koriwchak, MD, an Atlanta-based otolaryngologist is a noted lecturer and consultant on matters of EHR design, implementation, and “meaningful use.” He also has a popular blog dedicated to topics related to EHR and physician practices- “The Wired EMR Practice.” Dr Koriwchak will update attendees on the progress of the EHR initiatives, how you can you stay or get compliant, and whether the government is keeping their end of the bargain.

Educational Objectives: 1) Learn the current opinion, regulations, and AAO-HNS position regarding pay for emergency department coverage. 2) Understand accountable care organizations and the pros and cons of hospital/physician joint ventures. 3) Learn about implementation of an electronic health record strategy that qualifies for government reimbursement.

Program Description: Humanitarian aid offers human, technological, and financial resources to vulnerable people throughout the world. As health care providers, we strive to provide not only quality medical care, but to establish sustainable programs through our global outreach endeavors. Equipped with the proper resources, women have the power to help whole families and entire communities. Women are at the heart of many community-based efforts to improve basic education, prevent the spread of disease, and increase access to medical care. This miniseminar focuses on the role of women in the international community as otolaryngologists, educators, community leaders, and patients. Panelists will discuss the challenges, both locally and abroad, facing women in promoting and administering outreach in developing nations. The importance of empowering women around the world by providing support through resources and education will be explored. Successful outreach missions and partnership programs will be presented to highlight the significance of establishing lasting access to health care through education. Panelists will relate their experiences from disparate areas of the world: the Middle East, Haiti, Africa, India, and Central America. Introduction by AAO-HNS President J. Regan Thomas, MD. Sonya Malekzadeh, MD, and Gregory W. Randolph, MD, will moderate the session which will include four panelists.

Educational Objectives: 1) Comprehend the challenges of women physicians providing sustainable humanitarian aid. 2) Appreciate what it means to be a woman patient in a developing country. 3) Understand the relationship between a US program and a developing country educational program.

Program Description: Declining reimbursement over many years now threatens the viability of physician practices across specialties and practice settings. This miniseminar will outline the efforts of our Academy, specifically the Physician Payment Policy Work Group (3P), to advocate for fair reimbursement for our members in increasingly challenging public and private payer environments. Topics include updates on government health care reform, the Current Procedural Terminology (CPT) and Relative Value Update Committee (RUC) processes, coding and reimbursement for new technology, and new public and private payment models including the Accountable Care Organization concept. Strategies will be described as to how members can become actively involved to make a difference for our specialty.

Educational Objectives: 1) Learn current healthcare reform initiatives, new payment models, and Academy efforts on Capitol Hill. 2) Understand Academy interaction with the AMA’s CPT Editorial Panel and Relative Value Update Committee. 3) Know Academy strategies for interaction with public and private payers, and effective membership involvement.

Program Description: Although head and neck oncologic surgery (HNOS) is time consuming, requires an effective team, and needs allotment of precious resources, financial compensation for the surgeon is relatively low so that financial inducements for a surgeon to do HNOS are diminishing. However, HNOS can generate significant revenue for a hospital. This miniseminar provides information about costs, revenue, profit/ loss analysis of many aspects of HNOS. Parameters pertaining to HNOS that will be defined and discussed include the following: relative value units (RVU’s) contribution margins, case mix index, allocated expenses, opportunity costs, comparative profitability of various different treatment modalities, and the impact of diminishing reimbursements. In addition we will explain the ways that an otolaryngology department can utilize hospital financial data to justify the commitment of the varied resources that are needed to do major HNOS cases and to safely take care of the patients following surgery. In addition, we will discuss the mandate from the Residency Review Committee that requires residency programs to provide experience for residents with HNOS index cases. We will discuss how to prepare financial data, economic projections, and a business plan in a way that is both comprehensible to hospital financial planners and sufficiently compelling to warrant the commitment of resources that is likely to enable a HNOS program to become vibrant and grow. Examples of successful efforts to garner hospital resources for HNOS will be provided. Risk management will be considered in an analysis of safety issues inherent in doing HNOS and providing postoperative care for patients with advanced disease. We will discuss the need to report outcome data to such external data repositories and agencies such as University Healthsystems Consortium (UHC), Consumer Assessment of Healthcare Providers and Systems (CAHPS), and the US Department of Health and Human Services. Finally, we will discuss how imminent health care reform measures are likely to impact financial aspects of doing HNOS within the next few years including Accountable Care organizations and Health Innovation Zones.

Educational Objectives: 1) Understand how to obtain and interpret hospital financial data that is pertinent for HNOS. 2) Discuss how imminent health care reform measures may impact financial aspects of doing HNOS. 3) Understand the constraints for academic success for a head and neck oncologic surgeon.

Program Description: One of the most common problems many physicians struggle with is maintaining work-life balance. As physicians, we all face extraordinary demands on our time and need to learn how to balance the demands of our careers and family, while also allowing time to cultivate personal interests. Dealing with all of these demands creates stress for both physicians and their families. During this interactive miniseminar, practical techniques and pearls regarding time management and work-life balance will be shared by fellow otolaryngologists. The panel will include both private and academic otolaryngologists who manage busy practices and make substantial contributions to their institutions and specialty societies, while maintaining strong relationships with their friends and families and pursuing interests outside of medicine.

Educational Objectives: 1) Identify obstacles to work-life balance and achieving personal and professional goals. 2) Develop time management and efficient communication skills at work such as how to organize your schedule, control the pace of patient encounters, and trim work flow. 3) Streamline personal errands and chores to maximize time spent with family and interests.

Program Description: This miniseminar will analyze and help academic as well as private practice doctors to comply with the current and future criteria of “Meaningful Use” efficiently without interrupting the “patient-doctor encounter.” Features of electronic health record that will help the doctor and the staff as well as pitfalls will be discussed. Time will be allocated for Q&A.

Educational Objectives: 1) Understand “Meaningful Use” criteria. 2) Be able to select and use an EHR/EMR to receive “stimulus money.” 3) Understand Pay for Performance.

Program Description: This presentation will assist the ENT physician in determining the impact ICD-10 will have to their practice and other health care providers and provide a timeline of essential activities for successful implementation. In this session we will delve into what physicians should expect to prepare for during implementation processes. This is the largest change to the healthcare system in our history and careful planning will be necessary in order to successfully implement both ICD-10 and 5010. We will also explore common implementation hurdles, why it is so important to get started now, and how physicians will be impacted by clinical documentations issues. In addition we will go over the most commonly billed ENT diagnosis codes used now and what they will look like in ICD-10-CM.

Educational Objectives: 1) Explore the history of ICD-10-CM and the impact to physicians. 2) Understand why an implementation timeline is important for successful implementation and how the proper steps can lessen impact of implementation. 3) Review ENT case examples for clinical documentation hurdles and specificity required in ICD-10-CM to properly assign codes.

Program Description: Discussions regarding health care (HC) legislation, reform, and costs continue to be in the public conscience. The media in large part have presented little facts and the enacted health care law has been met with mixed responses from the public, HC sector, and politicians. A central philosophical and public health question is should everyone have covered HC? The panel will suppose the answer is yes and present evidence for what systems could succeed in the US. This program presents facts from national and worldwide experiences that have been essentially absent in media discussion forums. It will also provide participants with an analysis of the political environment surrounding the HC debate in the US. The potential implications of a universal health HC system versus a nationalized HC system on otolaryngologists in private and academic practices will be discussed. Health information technology (HIT) beyond the electronic health record is just beginning to become widely implemented. There is evidence of rapid shifts in how HIT and exchanges will change the current models of clinical practice with socioeconomic implications. The various ways HIT has been and will be used to improve quality of care, shift revenues, and impact access to information will be presented. This set of presenters collectively has experience in a wide breadth of health care systems including private, academic, US government, as well as the Canadian and United Kingdom HC systems. They will provide their perspectives on the current challenges and successes associated with their systems. In conclusion, the panelists will have a moderated question and answer session covering questions such as, what is the preferred model for delivering health care for all in the US and how would you fund it? What is the scope of practice considerations in Canada, UK and US? The audience will also be able to provide and view their answers using the interactive audience response system.

Educational Objectives: 1) Understand various government healthcare systems, politics of healthcare, and the impact on otolaryngologists. 2) Understand the current and future status of health information technology and exchanges beyond medical records. 3) Learn about global models of health care delivery from panelists with experience in varied healthcare systems.

Program Description: The ability to mentor and be mentored is important to the individual and collective success of our specialty. Successful organizations have long benefited from the voluntary contributions of individuals stimulated by a mentoring relationship. On a professional level, mentoring is critical to recruit, retain, and promote a diverse and dynamic otolaryngology work force in a time of changing needs. While the apprentice model of mentoring is familiar, understanding the various options available to aid career transitions and professional development is increasingly important. The panel will explore several aspects attributable to the changing environment of the mentor relationship and provide tools for addressing these needs. Generational differences will be discussed as they relate to changing priorities of the younger mentee and transformation of the traditional mentor role. A successful residency-mentoring program will be presented and this model adapted to various practice applications. The concept of mentorship will be explored from the perspective of the mentor and mentee and topics of physician practice, academy involvement, and work-life balance will be covered. The panel, providing tools for those seeking mentoring, will discuss the needs, expectations, and responsibilities of the mentee. Resources available within medicine, the AAO-HNS, and the business world will be provided for use.

Educational Objectives: 1) Understand the changing mentor/mentee relationship and have the tools to apply to those situations. 2) Improve the mentoring process by incorporating systematic methods reviewed and learn about resources available. 3) Identify individual mentor and mentee needs by encouraging an active role.

Program Description: The AAO-HNS Section for Residents and Fellows and Women in Otolaryngology are sponsoring a miniseminar to assist physicians in embarking on or changing a career in otolaryngology. Important decisions regarding the right type of practice, finding practice opportunities, and interviewing insights will be explored. Discussion will include appropriate questions that physicians should ask themselves and their potential employers. Tips for successful interviewing and placement will be provided by an experienced and highly successful private practice employer. Considerations for those seeking an academic position will also be explored. An attorney will provide insight into negotiation of a fair contract and benefits package from both the employer and employee standpoint. Avoidance of common pitfalls will also be discussed. Issues specific to women in otolaryngology contract negotiation will be addressed, as well. This miniseminar will conclude with an interactive question and answer session.

Educational Objectives: 1) Appreciate factors crucial in evaluating a practice opportunity specific to women and young physicians. 2) Be prepared for a successful interview. 3) Understand the basics of and avoid common pitfalls in negotiating medical employment contracts.

Program Description: The Surgical Consumer Assessment of Healthcare Providers and Systems (SCAHPS®) is a standardized tool sponsored by the American College of Surgeons and the Surgical Quality Alliance that asks consumers and patients to report on and evaluate their experiences and satisfaction with their surgical care. The survey covers topics such as communication skills of providers (surgeon, anesthesiologist) and front office staff, and assesses all phases of the surgery (pre-, intra-, postoperative) for inpatient and outpatient settings.

Through presentation of both aggregate data and outlier case analysis from the AAO-HNS pilot, this interactive miniseminar aims to give attendees a practical understanding of the utility of a survey like SCAHPS for assessing patient experience given the upcoming requirements under Part IV of MOC.

Health plans, insurers, and specialty boards may use the data from the SCAHPS for quality improvement activities and other financial incentive programs. Specifically, beginning in 2011, the American Board of Otolaryngology Part IV (Evaluation of Performance in Practice) Maintenance of Certification will require assessment of the interpersonal and communication skills of the surgeon using the SCAHPS or an equivalent survey.

Given this MOC requirement, the AAO-HNSF BOD mandated the undertaking of this pilot in December 2009 to better understand the challenges and utility of assessing physician communication and the patient experience.

Educational Objectives: 1) Describe the tool itself and the utility of the scores that assess surgeon-physician communication. 2) Describe the feasibility and challenges of implementing a patient experience survey in busy academic and private otolaryngology–head and neck surgery practices. 3) Share lessons learned from outlier case analysis.

Program Description: Otolaryngology programs continue to attract some of the best medical student applicants, but there have been increasing challenges placed on residency training. ACGME, medico-legal, public expectations, and financial pressures have changed the methods in which we train residents. This miniseminar will involve an expert panel discussion of the evolving aspects of otolaryngology residency training, which will expand into a town hall–type format using the audience response system and a roaming microphone for active audience contribution. The panel will include initiating perspectives from the ACGME RRC Executive Director, President of the Otolaryngology Program Directors Organization, members of the ABOto Education Council, an Associate Dean for GME and seasoned Program Directors. The discussion will focus on the important decision steps of both the residency applicant and program in the course of training: 1) How to select the right residency program applicant, including what is known and being studied with regard to resident performance and outcomes. 2) A review of match statistics including how we compare with other competing specialties that our applicants consider. 3) The here and now in terms of the new accreditation and duty hour rules, and what remains in the near future for program accreditation (milestones, etc). What does the average otolaryngology program look like (current program accreditation statistics), and what are some best practice solutions to adapt to the changing environment. 4) The use of the In-training examination by programs and residents in preparation for the board certification and re-certification.

Educational Objectives: 1) Learn to improve a program’s resident applicant selection process to maximize resident performance and outcomes. 2) Understand how a program’s match and accreditation outcomes compare nationally. 3) Understand the current and future expectations for program accreditation and training.

Program Description: Our duty as otolaryngologists to provide the best care possible depends on our ability to stay current with the literature. This important task is becoming more difficult in this era of long hours, more clinical demands, and an ever-growing body of medical literature. Additionally, key research findings that influence policies at hospitals and surgical centers are frequently not published in the usual journals read by otolaryngologists. The educational objectives of this miniseminar are to discuss current original research findings, provide a forum for the exchange of scholarly ideas, and highlight examples of best practice as related to new findings in the literature of patient safety and quality improvement. The format will be through the use of PowerPoint presentations with critical appraisal of the articles using the criteria described by SQUIRE (Standards for Quality Improvement Reporting Excellence), and then considering the validity and usefulness of the results in a practical manner toward our clinical practices. Articles will be chosen that have direct relevance and impact on the practice of otolaryngology-head and neck surgery. The articles will be chosen by the members of the Patient Safety and Quality Care Committee.

Educational Objectives: 1) Describe important recent research findings in the fields of patient safety and quality improvement. 2) Understand the relevance of these new findings to the everyday clinical practice of otolaryngology-head and neck surgery. 3) Learn about the SQUIRE guidelines for reporting quality improvement studies.

Program Description: Patients with facial nerve paralysis suffer significant cosmetic and functional morbidity due to lack of eye protection, ectropion, and lack of muscular control of the lower face. These effects can not only socially isolate the patient but may cause devastating complications to the affected organ including corneal ulceration and poor oral intake requiring nutritional supplementation. While the etiology of facial paralysis can be multifactorial, most of these patients eventually require the attention of the facial plastic reconstructive surgeon. Management of the eye involves not only loading the upper eyelid but tightening the lower eyelid. Many procedures are available for this rehabilitation, and these will be discussed. Gold weight versus platinum weight for the upper lid, shortening, tarsal strip, or wedge excision of the lower lid will be compared and contrasted. Mid-face reconstruction can be addressed by mid-face lifting or by nasal valve repair. The high incidence of nasal obstruction following facial nerve paralysis often is not recognized and should not be neglected. Rehabilitation of the nasal valve is straight forward and well received by patients. The lower face functions to allow for proper articulation and deglutition. Without oral competence, drooling and social isolation will occur. The reconstructive options for the lower face can be considered as either dynamic using a temporalis muscle sling or as dynamic with just some form of acellular suspension. The advantages and risks associated with the procedures and the operative results of these techniques will be discussed by the panel. Each panelist in this multidisciplinary presentation will present their preferred method of rehabilitation and then case scenarios will be used to explore subtleties of each surgical approach. This miniseminar will consist of a short presentation by each panelist with a focus on individual case management presentations. Audience participation will be encouraged.

Educational Objectives: 1) Be able to manage the acute and chronic effects of paralysis of the upper eye. 2) Add tarsal strip to their management paradigm of the lower lid. 3) Discuss the benefits and disadvantages of lower face reanimation with dynamic vs adynamic reconstruction.

Program Description: Cosmetic rhinoplasty has grown in demand over the years. Because of migration patterns around the world, specialists who perform rhinoplasties will frequently be performing surgery on patients coming from different ethnic groups. Characteristic ethnic features can be hard to define and it can be very difficult to try and “fit” a patient in a specific geographical group. Rhinoplasty in ethnic patients, no matter where they come from, will involve most of the usual techniques that are employed in rhinoplasty. However, how the patient is evaluated, what problems are encountered, and what possible solutions are offered make it a challenging operation. The goal in rhinoplasty today is to achieve a natural non-operated looking nose that will blend in with the patient’s face preserving its main ethnic features. Radical changes in appearance have been replaced by techniques that offer refinement and will provide stable long term results. This panel of experts coming from different countries around the world will be showing the audience how they approach the different types of ethnic patients. The discussion will focus on specific problems encountered and how they are approached surgically. Demonstrative cases showing pre- and postsurgical results with intraoperative photographs and videos on the different surgical techniques used will be shown. At the end of each presentation panelists will be showing the attendees how they try to prevent complications on their specific patients. Some final controversies regarding patient satisfaction and revision cases will be discussed at the end of the session.

Educational Objectives: 1) Identify the main anatomic and aesthetic differences encountered in ethnic groups around the world. 2) Be able to identify problems encountered in ethnic noses and establish possible surgical solutions. 3) Acquire a general overview on the prevention and management of possible complications.

Program Description: The reconstruction of facial soft tissue defects occurring after cancer surgery and trauma is a cornerstone discipline of facial plastic and reconstructive surgery. Long-standing basic principles exist, however techniques continue to evolve and advance. In this miniseminar the panel of experts relates their experience and recommendations for the approach to and the reconstruction of key facial structures. The speakers and the topics addressed will be: Dr Carniol - Logical Approach to Reconstruction of Facial Defects, Dr Lazor - Reconstruction of Auricular Defects, Dr Dolan - Cheek Reconstruction: Moderate and Large Defects, Dr Shockley - Skin Grafts for Small to Moderate Size Nasal Defects, Dr Weber - Forehead Flap Reconstruction for Nasal Defects, Dr Tatum - My Approach to Lip Reconstruction, Dr Doerr - Scalp Defects. Dr Fedok will serve as moderator for the panel discussions.

Educational Objectives: 1) Evaluate patients with soft tissue defects with firm principles of facial aesthetics and wound healing. 2) Approach patients with soft tissue defects with a variety of credible surgical options. 3) Design and execute optimal facial soft tissue repairs utilizing a variety of techniques.

Program Description: Cleft and craniofacial teams with both pediatric otolaryngology and facial plastic surgery backgrounds continue to develop. Novel approaches in the management of children with cleft lip and palate have contributed to a variety of treatment paradigms. Each institution and individual surgeon brings a unique perspective of treatment preferences that are worthy of discussion. Beginning in the prenatal period, advances in ultrasound technology now allow parents and surgeons to begin early preparation and education. Presurgical orthopedic devices introduced in the 1960s by the late 1990s have developed into nasoalveolar molding. The appliance is created in conjunction with an orthodontist with adjustments leading to approximation of the alveolar segments, as well as to mold the nasal deformity (columellar lengthening). Recently published modifications of the microform, unilateral, and bilateral cleft lip repair will be presented. Other innovations seeking to improve the aesthetic outcomes such as the subunit approach, suture choice, tissue glue, and scar prevention with silicone gel will be justified. Cleft surgeons from five institutions will present their approach to the cleft lip nasal deformity at the time of cleft lip repair. This can range from delaying repair (no rhinoplasty) to bolstering placement, or even direct lower lateral cartilage repositioning with rhinoplasty. This miniseminar will provide the participant a perspective on how different institutions approach common problems in management of the cleft lip, palate, and nasal deformity. This forum supports the goals of the Specialty Surgery Committee of the AAFPRS in fostering collaboration between those cleft surgeons within pediatric otolaryngology and the facial plastic surgery subspecialties. Secondary speech surgery evaluation and treatment will be presented with fluoroscopic and endoscopic examples and panelist discussion. Lastly, difficult cases will also be presented. Audience touchpad interaction will facilitate discussion. The format will include presentations including intraoperative video and subsequent discussion of the following topics: Presurgical nasoalveolar molding, unilateral cleft lip and nasal deformity repair, bilateral cleft lip and nasal deformity repair, primary cleft rhinoplasty options, and management of the extremely wide cleft lip and nasal deformity.

Educational Objectives: 1) Understand the timing and techniques for cleft lip/palate repair based on evidence-based guidelines. 2) Learn the panelists’ preferred basic and advanced cleft lip repair designs. 3) Be able to interpret and choose treatment for velopharyngeal dysfunction audibly, on fluoroscopy, and nasopharyngoscopy.

Program Description: The modern otolaryngologist has had residency-based, and in many cases, advanced fellowship training in a wide spectrum of facial plastic and reconstructive procedures to correct congenital-, acquired-, and aging-related deformities. Due to advances in technologies, there has been an increase in the ability to offer patients a variety of effective and minimally invasive interventions in the office setting. Among these interventions, the use of injected botulinum toxin has become common in the treatment of rhytids, hyperfunctional lines, and facial dystonias. The treatment of skin and subcutaneous contour deformities is also a common challenge for which patients seek consultation. Although previously the materials used for correction were limited in number, there has now been an increasing number of widely used and newly introduced materials made available to the practitioner. The introduction of hyaluronic acid–based agents created a significant increase in acceptance and demand for filler substances by patients. More recently approved and soon to be approved fillers promise to increase the application. Laser and light technologies, including laser hair removal, offer intervention for an increasingly large number of clinical issues including the treatment of wrinkles, hyperpigmentation, cutaneous vascular lesions, rosacea, unwanted hair, and other aging-related skin conditions. Finally, although not representing new technology, but instead low-cost effective treatments, the practitioner will find the availability of skin care services, particularly the use of various chemical peeling agents, to be a useful adjunct in the office setting. The purpose of the miniseminar is to present an up-to-date review of safe, effective office-based procedures that the otolaryngologist may have available to patients in their office. The presentations will review the pertinent pharmacology, physics where applicable, and anatomy. Technique, preoperative and post procedure issues will be discussed. The clinical photo-rich presentations will demonstrate technique and patient selection. The prevention and management of complications will be reviewed. This miniseminar will update the attendees that have previous training in these procedures and serve as an introduction to those that are exploring these procedures.

Educational Objectives: 1) Learn the indications and techniques for cosmetic botulinum toxin injections. 2) Learn the indications and techniques for facial filler injections. 3) Learn the indications and techniques for chemical peels, lasers, and light-based devices.

Program Description: The Academic Bowl pits four of the top otolaryngology residency programs in the country (Loyola University Medical Center; University of Mississippi Medical Center; Tulane University School of Medicine; and University of Texas Southwest) in a clinically oriented test of knowledge. While the programs compete, the audience can participate with the residents through the audience response system. Audience members can also earn CME/CE credit and review for MOC.

Educational Objectives: 1) Test knowledge of current diagnosis and management of diseases of the head and neck. 2) Identify areas meriting further study before the Maintenance of Certification or Board Certification examinations. 3) Gain familiarity with the question format utilized by Annual Inservice and American Board of Otolaryngology exams.

Program Description: Each speaker will review the evidence-based rationale for integrative therapy of common but difficult to treat ENT ailments. Topics will include: Ear wax: Dangers of ear candling—Eric Mann, MD; Tinnitus: What’s the evidence for gingko biloba, bioflavanoid and antioxidant therapies?—Michael Seidman, MD; Meniere’s Disease & vertigo: Should the FDA approve Betahistamine for Meniere’s Disease in the United States? Can acupuncture and cervical manipulation prevent symptoms? What are the best diet-based regimens?—Gregory Artz, MD; Allergic rhinosinusitis: Do clinical trials support the use of Quercetin, Sinupret, Butterbur, and other herbal remedies? Should patients irrigate their nasal passages and, if so, what should they use?—Marilyn B. Wang, MD; Atypical Facial Pain: Does Acupuncture provide superior analgesia?—Chao T. Nguyen, MD; Perioperative Considerations: Can arnica and bromelain really lessen bruising and speed healing? What herbals and supplements must be avoided before and after surgery?—Edmund Pribitkin, MD; Medicolegal risks and opportunities related to integrative therapies—Udayan Shah, MD

Educational Objectives: 1) Be able to identify harmful and helpful alternative therapies and counsel patients accordingly. 2) Integrate alternative therapies into their treatment regimens for common ENT ailments. 3) Understand medicolegal ramifications of introducing alternative therapies into their practice.

Program Description: The crooked nose—and its aesthetic and functional issues—is a challenge frequently encountered by practicing otolaryngologists. Repair is not always straightforward and residual deformities can be distressing for the patient as well as the surgeon. With the prominence of the nose as a central defining feature of the face, any deviation is easily recognized since it detracts from overall facial symmetry. The purpose of this miniseminar, created by the Facial Plastic and Reconstructive Surgery Education Committee, is to shed light on the diagnostic and technical challenges of repairing the crooked nose. Panelists will focus on careful analysis of the anatomic factors responsible and highlight a repertoire of corrective surgical techniques. Discussion of the topic will be divided into the various thirds of the nose: the bony nasal vault, the cartilaginous mid-vault, and the nasal tip and caudal septum. Management strategies to be discussed include new osteotomy techniques, suture techniques, cartilage grafting, extracorporeal septoplasty, and tip-plasty. In contrast to the external rhinoplasty approach, the endonasal approach provides an alternative strategy—and perhaps a different philosophy—to addressing asymmetries of the nose. The role of endonasal rhinoplasty techniques will be presented. Whenever possible, literature will be referenced to support the discussion. The crooked nose is often caused by a complex interplay between bony and cartilaginous deformities, as well as scarring forces especially in traumatic and revision cases. Surgical strategies combine anatomic restoration with camouflage. A surgical plan requires not only an understanding of operative technique but also an understanding of the surgical expectations of the patient. Therefore, cases and patient scenarios will be presented by the moderator to the panelists (and the audience) for discussion. This miniseminar hopes to provide a nuanced understanding of rhinoplasty concepts and techniques that would be appreciated by seasoned surgeons and provide insight to the novice.

Educational Objectives: 1) Recognize the various deformities and anatomic factors responsible for the crooked nose. 2) Learn to correct the bony nasal vault, cartilaginous mid-vault, and nasal tip and caudal septum. 3) Appreciate benefits and limitations of the external versus endonasal rhinoplasty approach to straighten the nose.

Program Description: Over the past several decades, the numbers of North American physicians and surgeons engaged in international humanitarian missions has increased dramatically. Such trips often provide an opportunity for needy individuals and communities to receive care that would otherwise be unavailable to them. They also provide the opportunity for participants to “give back” through providing direct patient care and teaching in an environment of extreme need. Personal motivations, level of ability of the individual practitioner, sophistication of the mission organization, as well as level of connectedness to “in country” providers varies dramatically among mission groups. This variability has contributed to some unfortunate patient outcomes. Accusations that “surgical safaris” represent a “form of Neo-colonialism” have cast doubt on the motivations of participants and brought significant scrutiny to the true benefits arising from these efforts. This interactive miniseminar will explore “deadly sins” which are common to medical humanitarian efforts as well as issues which are unique to surgical humanitarian missions. Panelists will discuss available data and areas in which there is a lack of data concerning humanitarian efforts. Finally, “best practices” for humanitarian missions will be discussed. Issues to be discussed include appropriate standard of care, duration, follow-up, conduct of research, resident trainee participation in surgical procedures, role of the media, and integration with local care systems.

Educational Objectives: 1) Identify common problems encountered during medical and surgical humanitarian mission trips. 2) Understand ethical concerns arising during international humanitarian efforts. 3) Apply best practices for conduct of humanitarian mission trips in which they are involved.

Program Description: Both acute and chronic cough are responsible for a significant portion of all ambulatory medical visits annually (about 3%), over-the-counter self-medication expenses in excess of $3.6 billion in the United States, and impaired quality of life. According to 2007 data, there were more than 27 million visits to all physicians for cough, but that same year otolaryngologists saw a total of only 17 million visits for all diagnoses. This suggests a large unmet need for otolaryngologists to participate in the care of these patients. The diagnosis of cough can be simple or profoundly challenging, and it may be a sentinel indicator of severe underlying disease. The list of diseases that may induce cough is growing, along with an appreciation of their interrelations. For example, the Unified Airway concept supports our long-held observation that the upper and lower airway diseases are closely related. There is also a spectrum of overlapping asthmatic, non-asthmatic, and suppurative pulmonary disease. Gastroesophageal reflux (both distal and proximal LaryngoPharyngeal Reflux), along with neurologic reflexes and aspiration are similarly important. And the complex interplay of neurologic reflexes for cough in the brainstem may result in paradoxical vocal fold motion and disordered breathing. Otolaryngologists are playing an increasingly important role in the multidisciplinary evaluation of these challenging patients, and mastering many procedures associated with cough patients. The spectrum of medical specialists also includes pulmonology and chest physicians, allergy and immunology, gastroenterology, neurology, cardiology, infectious disease, speech and swallowing pathologists, as well as psychiatry. This miniseminar will involve the use of case presentations, panel discussion and audience participation to emphasize evidence-based practice and “state-of-the-art.” Controversial areas will include the inter-relatedness of the disease, the role of speech therapy in disordered breathing, and the importance of early diagnosis in value-based healthcare.

Educational Objectives: 1) Learn the spectrum of common and uncommon causes of chronic cough. 2) Understand evidence-based treatment guidelines in the evaluation and treatment of these patients. 3) Be prepared to participate in interdisciplinary discussion of these patients at their home institution.

Program Description: Disaster awaits unprepared surgeons at the skull base. Multiple routine surgeries in otolaryngology are in close proximity to the skull base. Potential risks of endoscopic sinus surgery include cerebrospinal fluid leak, loss of olfaction, penetrating brain injury, visual loss, hemorrhage from the internal carotid artery, and loss of trigeminal sensory and motor function. Potential risks of temporal bone and lateral approaches include vascular injuries of the sigmoid sinus, jugular bulb, and internal carotid artery; injury to cranial nerves 7-12; cerebrospinal fluid leak, intra- and extradural hemorrhage; and brain trauma. A thorough understanding of skull base anatomy is essential for avoiding such complications during routine surgical procedures. In this miniseminar, case studies will be used to demonstrate potential risks of standard surgical procedures relative to the skull base. Important anatomical landmarks and relationships will be presented in 3D using cadaveric dissections and intraoperative photographs. Strategies to avoid skull base complications will be discussed with an emphasis on everyday surgical procedures.

Educational Objectives: 1) Understand key anatomical relationships at the skull base. 2) Relate skull base anatomy to anterior and lateral skull base approaches. 3) Apply anatomical knowledge to avoid surgical complications.

Program Description: This miniseminar, taught by leadership from the AAO-HNS and the Cochrane Collaboration, will empower attendees to use Cochrane reviews of interventions as a platform for evidence-based healthcare. Cochrane Reviews are systematic reviews of primary healthcare research on prevention, treatment, rehabilitation, and diagnostic test accuracy. Each review addresses a clearly formulated question; for example: Do perioperative antibiotics improve recovery after tonsillectomy? All the existing primary research on a topic that meets certain criteria is searched for and collated, and then assessed using stringent guidelines, to judge the level of evidence for, or against, a specific intervention. Evidence-based healthcare is the conscientious use of current best evidence, derived ideally from systematic review, in making decisions about the care of individual patients or the delivery of health services. Recognizing the increasing role of evidence-based health care in otolaryngology, the AAO-HNS has partnered with the Cochrane ENT Disorders Group since 2006. This miniseminar is one product of that partnership, along with other efforts to enhance the AAO-HNS journal, annual meeting, research agenda, and quality initiatives. Attendees will learn of these efforts including ways to obtain Academy-sponsored travel grants to the annual meeting of the Cochrane Collaboration. Time is allotted at the end of the session for audience questions to the expert panel.

Educational Objectives: 1) Appreciate how systematic review of interventions facilitates evidence-based healthcare. 2) Understand why Cochrane reviews are important to otolaryngologists and their patients. 3) Learn how to read a systematic review, interpret results, and apply findings to patient care.

Program Description: Both oral and topical corticosteroids are used frequently in the practice of otolaryngology. Their use is often based on historical evidence rather than clinical research. First, we will overview corticosteroids’ mechanisms of action and their adverse effects. We will then present a brief overview on evidence-based medicine and grade the evidence to help the audience understand how the studies which we are discussing fit into the overall scheme of “best evidence.” We will then present short case examples in each of the subspecialty areas of otology/neurotology, rhinology, laryngology/head and neck surgery, and pediatric otolaryngology. We will poll the audience if, and how, they might use corticosteroids in these case examples. We will then have clinician scientists who have expertise in each of these areas review the recent evidence in the literature to see if there is any scientific support for their use. Where possible, we will reference clinical practice guidelines. Representative acute cases might include Bell’s palsy, sudden deafness, nasal polyposis, acute laryngotracheobronchitis, and deep neck space infections. We will then re-poll the audience for any changes of opinions. We will also discuss the general perioperative use of corticosteroids in ear surgery, sinus surgery, laryngeal surgery, and tonsillectomy. We feel that this mini-seminar will be of great importance to the general otolaryngologist, providing them with the knowledge of when and when not to use corticosteroids in both their office and surgical practices.

Educational Objectives: 1) Learn the evidence behind using corticosteroids in various otolaryngological disorders. 2) Understand the different oral and topical corticosteroid regimes. 3) Learn the proper use of corticosteroids in several common disorders.

Program Description: Medical device failures are commonly associated with surgical complications. In late 1997, the US FDA (Food and Drug Administration) reported that it receives approximately 100,000 medical device reports a year, and the agency considers this number just the tip of the medical device problem iceberg. Any surgeon is very likely to experience this complication in his or her operative career. The Pediatric Otolaryngology and the Medical Devices and Drugs Committee decided to organize a miniseminar to provide guidelines to surgeons experiencing this complication and for surgeons wishing to be informed to device failures. The symposium will be divided into two major parts. In the first part, clinical cases associated with medical device failures will be presented. The impact of one of these cases based on a national survey of pediatric otolaryngologists will be highlighted. The second part will then include the medicolegal ramifications, disclosure to patients and families, and resources available for the surgeon to report and receive updates on device failures.

Educational Objectives: 1) Learn the role of the surgeon in disclosing device complications to patients and national reporting agencies. 2) Learn the medicolegal ramifications of a device failure to the surgeon. 3) Learn how an otolaryngologist can keep him or herself informed of device recalls or complications.

Program Description: This international symposium will showcase Academy relationships and activities in seven regions of the world. President J. Regan Thomas, MD, will describe his vision for enhanced international collaboration. Academy Regional Advisors who are on the International Steering Committee will introduce our eminent and wide-ranging visiting speakers.

Educational Objectives: 1) Understand the myriad ways the academy interacts with otolaryngology communities in different regions. 2) Appreciate the opportunities for collaboration in scientific exchange, research, fellowships, and observerships. 3) Learn the Academy’s resources available to members, subscribers, meeting attendees, and web visitors.

Program Description: This miniseminar, taught by editors, staff, and the publisher of the journal Otolaryngology–Head and Neck Surgery, will help attendees maximize their success in getting case reports and case series published. Tips and pointers will be presented on writing and organizing the manuscript, dealing with ethics review and patient privacy concerns, using the right terminology for the right message, and avoiding pitfalls that might delay or prevent manuscript acceptance. The best case reports describe a unique or nearly unique case, an important variation (outlier case), unexpected outcome or adverse event, or unexpected association between diseases or disorders. Manuscripts are most likely to be accepted if they state why the case is worth reading, describe the case and all relevant data, discuss why the case is unique or unexpected, provide alternative explanations for case features, and offer clinical implications. The best case series include a consecutive well-defined sample of subjects, report interventions with enough detail for reproduction, account for all patients initially assessed and enrolled, and provide adequate follow-up with descriptions of dropouts and losses. Manuscripts are most likely to be accepted it they include statistical analysis and reach justifiable conclusions devoid of efficacy claims. The goal of the session is to help attendees publish meaningful and valid research that can help journal readers provide enhanced patient care. Time is allotted at the end of the session for audience questions to the expert panel.

Educational Objectives: 1) Learn strategies to maximize success in publishing case reports and case series. 2) Understand the role of ethics review and informed consent in observational research. 3) Avoid pitfalls that might delay or prevent acceptance of a manuscript for publication.

Program Description: Hearing screening for newborn infants has become commonplace. The Joint Commission on Infant Hearing (JCIH) in its position statements has created goals and guidelines for managing these children in a timely manner. The early hearing detection and intervention (EHDI) process is designed to maximize linguistic and communicative competence and literacy development for children who are deaf or hard of hearing. Without appropriate opportunities to learn language, these children will fall behind their hearing peers in language, cognition, and social-emotional development. Such delays may result in lower educational and employment levels in adulthood. Early diagnosis and treatment of hearing impaired infants in the first year of life has been shown to avoid the detrimental effects of delayed action. Despite this fact and a high screening rate among programs (>95%), almost half of those infants who do not pass the initial screening fail to have appropriate and timely follow-up including audiological and medical assessment by an individual with training in pediatric hearing disorders. Rather, families are often times reassured or misinformed by well-intentioned professionals about this process and the consequences of delayed intervention. This miniseminar will provide the fundamental framework for obtaining timely and accurate audiological and medical diagnosis and hearing instrument fitting (hearing aids or cochlear implants). Recognized professionals in the field will cover topics such as electrophysiological hearing testing, practical application and results of amplification, medical assessment including radiological and genetic evaluation, and the criteria and results of cochlear implantation. Issues relevant to delayed diagnosis and intervention such as organizational structure, awareness, funding, and necessary political activity will be addressed.

Educational Objectives: 1) Understand the significance of a failure result on the newborn infant hearing screening examination. 2) Learn the fundamental, multidisciplinary evaluation, and management paradigm for infants that fail the newborn screen. 3) Understand the cause and consequences of inappropriate or delayed intervention in hearing impaired children.

Program Description: The randomized clinical trial (RCT) represents the pinnacle of the evidence-based medicine (EBM) hierarchy. Although they are far from perfect in actual execution, RCTs do offer the highest quality evidence available and are deserving of careful review to determine the validity of the results and to consider how they may be used to improve clinical care. While not as common as would be desired, many RCTs have been published in the field of otolaryngology over the years. The purpose of this miniseminar is to succinctly, but thoroughly review some of the key RCTs that have been published in the realm of otolaryngology in the past 10 to 20 years to inform the audience of the results and how they could positively influence the evidence basis of their practice. In addition, the key elements of an RCT that make it Level 1 evidence and thus less prone to the problems of error and bias will be reviewed. A four member panel composed of a pediatric otolaryngologist, a rhinologist, a neuro-otologist, and a sleep surgeon will present the miniseminar. The key RCTs that have been published in various areas of otolaryngology including otitis media, tonsillitis, hearing loss, rhinosinusitis, and sleep apnea will be reviewed in brief detail. The strengths and weaknesses of each trial and the potential impact of the results on clinical practice will be discussed. Interactive audience participation technology will be used to reinforce the presented material and stimulate audience interest. The attendee of this miniseminar should walk away having learned about some tangible, key published level 1 evidence which could lead to substantive changes in their clinical practice.

Educational Objectives: 1) Understand the concept of the hierarchy of evidence and the key features of the RCT. 2) Learn about key RCTs that have been published in otolaryngology over the past 10 to 20 years. 3) Apply the findings of key RCTs to improve the evidence basis of one’s practice.

Program Description: Lifelong learning is a process that begins when one enters medical school. It continues throughout residency and practice. With a constantly evolving and changing knowledge base, it provides tools for a continual educational process for the clinician. Lifelong learning has been mandated as a core essential element of both professional training, as well as maintenance of professional standing. The field of continuing medical education has evolved to meet this demand. The tools and methodologies available to the practicing clinician in today’s environment are constantly changing. In the past decade or so we have seen a change from education products being enduring materials, such as textbooks and journals to online on demand materials. This evolution has been brought about by not only improved technology but by advances in the understanding of how we learn. This miniseminar will initiate with a concept of how lifelong learning fits into residency training. The role of this competency and how it is managed in residency will be discussed. The evolution of the ability to measure and the different measurement tools available will be presented. It will then move into CME materials that are currently available on the market. The commonest materials will be demonstrated and an understanding of how online educational activities can contribute to online learning will be shown. A discussion of the new rules of CME that are on the horizon and how they impact physician interaction with pharmaceutical manufacturing and the requirements for measurement of outcomes will be presented. Each of us is soon going to be required to identify practice gaps and then demonstrate how we have addressed them. Finally we will have to demonstrate how we have changed our practice with this knowledge. The miniseminar will end with a discussion on how lifelong learning fits into the maintenance of the Certification Program of the American Board of Otolaryngology. The role of online education and certification of competence will be demonstrated.

Educational Objectives: 1) Learn how to better able relate to the historical and evolutionary change in lifelong learning. 2) Understand online learning materials and how to integrate this teaching into identifying practice gaps and then modifying those gaps to provide the best possible care.

Program Description: Over the past several years new technologies, potentially offering safer or less invasive techniques, have been applied to surgery of the thyroid and parathyroid glands. While these technologies may offer benefits to surgeons and patients, each has an associated learning curve and incremental costs compared to the standard techniques. The purpose of this miniseminar is to examine some of these “advances” (in-office ultrasound, laryngeal nerve monitoring, intra-operative parathyroid hormone measurement, minimally invasive and alternate surgical approaches) and to evaluate the benefits and costs and provide guidance for when these technologies should properly be used. Additionally, guidance for how general otolaryngologists can learn these techniques and how these technologies relate to the concept of “standard-of-care” will be addressed. Audience participation will be used to solicit information about usage of these technologies among the membership and to obtain audience opinion to help facilitate discussion.

Educational Objectives: 1) Describe the indications for using new technology in thyroid and parathyroid surgery. 2) Understand the costs and benefits related to using new technology in thyroid and parathyroid surgery. 3) Determine further training necessary to incorporate new technology into practice.

Program Description: “Outcomes research” in medicine is now about 23 years old, and in otolaryngology almost 20 years old. In this miniseminar, some of the otolaryngologists who were involved in outcomes research from its inception will discuss the history, progress, and future opportunities for outcomes research, both in otolaryngology-head and neck surgery, as well as medicine at large. We will also discuss needed next steps—and barriers—to gather the appropriate data to answer important questions for the future. Outcomes assessment will also become increasingly important at the licensure and regulatory level, and we will address those issues as well. The miniseminar will be organized as follows. First, a couple of speakers will give brief presentations on the history, current status, and potential future impacts of outcomes research in otolaryngology. We will discuss outcomes tool development, diseases studied, and the results from several large outcomes-based studies. Next, there will be a panel discussion moderated by Dr Stewart which will cover the following topics: Which outcomes assessment tools are currently used in clinical practice? Which outcomes instruments should we be using in practice? In which diseases have the findings from outcomes research changed clinical practice? What other diseases/areas are most in need of outcomes assessment, and also the related question of where might outcomes assessment actually change practice significantly? What have we learned about co-morbidity and severity staging? The panel will also discuss the role of outcomes assessment in Maintenance of Certification from the perspective of a state licensing board, and the American Board of Otolaryngology. One of the panelists has experience designing outcomes databases for other organizations, and he will relate his unique experience in this area. In addition, we will discuss the role of the Academy, the Board, and other central organizations in outcomes measurements, as well as how to select the best outcome tool, and how to create a database for outcomes assessment. Finally we will discuss the future of outcomes research. Are we teaching our residents and fellows the principles of outcomes assessment? Are we training enough faculty and non-faculty otolaryngologists on how to do good outcomes research? What opportunities do new training grants offer? What is the funding status for outcomes research overall, and in otolaryngology? What is the potential future of outcomes research in otolaryngology? We will also take questions from the audience.

Educational Objectives: 1) Learn the history of outcomes research in medicine and in otolaryngology. 2) Understand the results from outcomes studies in otolaryngology and their impact on patient care. 3) Be able to select outcomes tools for research, practice assessment, and maintenance of certification.

Program Description: This miniseminar will illustrate the potential “misdiagnoses” of aging and highlight management of common geriatric symptoms. The presentation format will emphasize key points through illustrative cases. Audience participation will be encouraged through the use of interactive keypads. The population demographics of North America are changing rapidly, with an increasing number of elderly individuals. In otolaryngology, age-related changes in hearing, vestibular function, smell, and phonation are recognized, as are changes in the soft tissues of the head and neck. Some of these changes are compounded by co-morbidities in other organ systems. It is tempting to dismiss a geriatric patient’s complaints as part of “normal aging.” In doing so there is a risk of missing the same correctable pathology we see in younger patients. The presentation in elderly patients may be subtle and/or atypical, resulting in failure to order appropriate diagnostic tests. Symptoms commonly misdiagnosed as “normal” aging include dizziness, dysphonia, and rhinorrhea. Such assumptions may “blind” the otolaryngologist to treatable etiologies, such as benign positional vertigo, polypharmacy, or allergic rhinitis. The consequences of these potential misdiagnoses directly impact both the level of functioning and quality of life of the geriatric patient. Complaints should be attributed to aging only through exclusion or positive evidence. When this is the case, it is important to recognize that many of the symptoms may nonetheless be managed successfully. Presbyphonia may improve significantly with voice therapy and possibly vocal fold augmentation. Hearing loss frequently is amenable to rehabilitation with an appropriate hearing aid. Multiple symptoms are the rule rather than the exception, and treatment results in a more highly functioning patient with an improved quality of life. In some cases intervention may mean the difference between an autonomous individual and one who is dependent or living in a home.

Educational Objectives: 1) Describe the problem of misdiagnosis. 2) Identify frequent misdiagnoses and recognize the subtle and atypical presentations of disorders in elderly patients. 3) Identify treatable complaints attributable to “normal” aging.

Program Description: Office-based ultrasound of the thyroid and neck is now a standard imaging tool for otolaryngologists, endocrinologists, and surgical clinicians. Training courses in the use of ultrasound are now well-structured and available to clinicians in their related disciplines. Yet, as with all standard technology, new applications and refinements have expanded both the resolution of image quality and uses of ultrasound beyond what was initially envisioned. Through the use of both short didactic presentations and directed questions with clinical case examples from the moderator, this panel of experts will discuss several new frontiers of ultrasound. Techniques that optimize cytologic aspiration, indications and use of core biopsy, alcohol ablation of thyroid cysts, and selection of cases of lymph node ablation with papillary carcinoma, elastography, and the evolving use of radiofrequency ablation and contrast enhanced ultrasound are some of the topics that will be covered. An emphasis on how best to improve the standard use of head and neck ultrasound will make this a practical seminar for the otolaryngologist as well as an important glimpse into the near future.

Educational Objectives: 1) The seminar attendee should learn new advances in obtaining cytologic samples with ultrasound. 2) The seminar attendee will understand new advances in destroying malignant lymph nodes and cysts of the thyroid gland including advantages and disadvantages of the technology compared with conventional surgery. 3) The seminar attendee will learn new adjunctive technologies to ultrasound such as elastography and contrast imaging.

Program Description: This miniseminar on sialendoscopy will provide the audience with the latest developments of sialendoscopy, starting from the basics to advanced cases of sialadenitis. A complete description of the actual indications, how best to investigate those patients, how to treat them—under local or general anesthesia, and how to avoid complications will be detailed. All treatment modalities will be explained and videos shown, with the picture in picture system, allowing easy comprehension of both operative and endoscopic field. Results from around 100 centers linked to the European Sialendoscopy Training Center (ESTC) will be presented, allowing the participants to have objective evidence of the success of this technique.

Educational Objectives: 1) Understand the role of sialendoscopy as a new treatment modality, not only for salivary stones, but also for juvenile recurrent parotitis, adult recurrent parotitis, radio-iodine-induced parotitis, or other inflammatory conditions leading to ductal strictures. 2) Appreciate the paradigm shift that is occurring in the whole world for using interventional sialendoscopy instead of removing salivary glands. 3) Consider the results of multicentric studies analyzing the benefits of the technique but also its limitations.

Program Description: This miniseminar will be a general review of professionalism and its importance for practitioners, residents, students, and nurses. It is vitally important and practical for clinicians to have a regular review of appropriate etiquette and behavior at meetings and in interactions with others, students, bosses, and pharmaceutical companies. This miniseminar will equip the attendee with tools for lifelong learning. Speaker and Topic: Jesus Medina, MD: Professionalism in 2011, Definition of professionalism: 20 min. Karen Calhoun, MD: Professionalism in the work place: 15 min. Mark Zacharek, MD: Professionalism in a Residency Program: Core Curriculum: 15 min. Robert J. Stachler, MD: Academic Professionalism, Proper Meeting Etiquette: 15 min. Susan McCammon, MD: Appropriate Vendor, Drug Representative, Pharmaceutical Relationships: 15 min. Question and Answers: 10 min.

Educational Objectives: 1) Define professionalism: in the work place, in an academic environment, and at home. 2) Identify appropriate styles of behavior to be effective role models for residents, students, and colleagues. 3) Demonstrate proper etiquette at social functions and meetings to be an effective leader in your field. 4) Define appropriate relationships with vendors, drug representatives, and pharmaceutical companies. 5) Review appropriate behavioral constructs and skills in core curricula during residency training for lifelong learning and reassessment during your career. 6) To learn how to play appropriately in the sandbox.

Program Description: Iodine deficiency has largely been eradicated in the developed world, but many lower resource countries demonstrate persistent iodine deficiency, goitrogen abundance, or both. In addition, some areas with high rates of thyroid malignancy have not had the resource capacity to fully address the need. Thus, surgical treatment of thyroid disease has comprised a significant proportion of head and neck related humanitarian surgery. This miniseminar, which is endorsed by the Humanitarian Efforts and Endocrine Surgery Committees, will be targeted to an audience of thyroid surgeons and those experienced in humanitarian surgery in low to medium resource settings. The presentations will be didactic, but with opportunity for discussion as well as audience interaction for the potentially controversial aspects. After introductory remarks, the audience will be queried for experience in humanitarian thyroid surgery and current management practices. The ethics of defining standard care with respect to resources and regional standards will be discussed. Evidence-based standards of thyroid surgery in the developed world will be contrasted to those in the variety of settings in which goiter surgery occurs in the developing world. The public health implications of goiter within the larger context of iodine deficiency will be discussed. Management of thyroid surgery in variable-resource settings will be presented in 3 components: 1) Pre-operative workup and patient selection will be discussed with respect to clinical presentation, diagnostic workup (labs and imaging), medical correction of hypothyroidism and iodine deficiency, and preoperative preparation. 2) Intraoperative management will be discussed including controversies in the use of technologies such as recurrent nerve monitoring and various cutting tools. 3) Postoperative management, including use of drains, hospital stay, calcium monitoring, thyroid supplementation, and long-term follow-up will be discussed. Complications of thyroid surgery in variable resource settings, including bleeding/ hematoma, recurrent nerve injury and hypoparathyroidism will be addressed as well as the need and risks for reoperation. In conclusion, a model for evidence-based standardization of thyroid surgery based on resource availability will be presented. The role of the thyroid surgeon as a conduit for population screening and treatment will be introduced. Research opportunities will be suggested, in particular with respect to greater understanding of a region’s iodine and goitrogen levels, medical management as an alternative to surgery, and measuring the impact of higher level management. The audience will again be queried to demonstrate a greater understanding of the topic and to determine if management opinions have been altered.

Educational Objectives: 1) Understand the challenges faced in performing thyroid surgery during international humanitarian mission work. 2) Discuss ethics in surgical decision-making in low-resource settings: what is the minimum standard of care? 3) Be able to tailor treatment plans to the patient and the environment within best practices.

Program Description: The incidence of Human Papilloma Virus (HPV)–related oropharyngeal cancer is increasing at a near-epidemic proportion. As such, otolaryngologists are diagnosing and treating greater numbers of patients, especially younger patients, with this distinct disease. There have been significant strides in our knowledge about the pathophysiology of this disease. Yet despite our increased knowledge, there are still several unanswered questions about the ideal management. The educational objective of this miniseminar is to provide otolaryngologists with up-to-date clinically relevant information about making treatment decisions for patients with oropharyngeal cancer. This will be done using a case-based format in the style of a multidisciplinary tumor board with incorporating audience participation. The cases discussed will incorporate basic concepts and controversial topics within the discussion. These topics will include 1) initial management with surgical techniques versus non-surgical modalities, 2) incorporating biomarkers (HPV, p16, others) and patient-related factors into initial treatment decision making, 3) optimal management of the neck, 4) management of patients with persistent/recurrent primary site disease after completion of initial therapy, and 5) management of patients with an unknown primary site when the neck metastasis is HPV positive. Panel members will provide support for their responses based on the best evidence-based medicine available. Standard available therapies, currently available and upcoming clinical trials, and future research directions will be emphasized. At the conclusion of this miniseminar, the participant will be able to describe the current “state-of-the-art” for evaluation and management of oropharynx cancer and discuss the underlying principles for how treatment decisions are made.

Educational Objectives: 1) Describe the current “state-of-the-art” for evaluation and management of HPV-associated oropharynx cancer. 2) Discuss the underlying principles for making treatment decisions for patients with oropharynx cancer. 3) Describe current standard treatment options, available clinical trials, and future research directions.

Program Description: Neck dissection continues to be an integral part of surgical treatment of head and neck squamous cell carcinoma (HNSCC). The operation has evolved significantly since first described by Crile and others more than 100 years ago. With the development of more precise imaging modalities, chemoradiation treatment protocols, and transoral laser (TLM) and robotic (TORS) surgery, it is important to reexamine guidelines for management of the neck. This miniseminar will focus on several relevant topics pertaining to treatment of the neck in HNSCC: 1) The role of imaging in planning treatment of the neck will be discussed. Pre-treatment imaging with PET, CT, and MRI can yield valuable information regarding subclinical neck metastases and may help in treatment planning, particularly for T1 and T2 primary tumors. The timing and optimal modality for post-chemoradiation imaging remains controversial. 2) The advantages and disadvantages for upfront neck dissection for small and unknown primary HNSCC will be addressed. Elective neck dissection vs radiation vs observation for clinically negative necks will be discussed. 3) Management of the neck in conjunction with TLM/TORS will be examined. With increasing use of TLM/TORS for surgical management of HNSCC, it is essential that the neck is treated appropriately. Guidelines for neck dissection in conjunction with TLM/TORS will be outlined. 4) Paradigms for management of the neck following chemoradiation continue to evolve. Chemoradiation protocols for HNSCC are effective in eradicating advanced nodal disease as well as the primary tumor. Thus, the use of planned neck dissection for N2 and N3 disease following completion of chemoradiation is giving way to the use of salvage neck dissection. Also, concepts have changed toward the use of more limited neck dissections. Finally, challenging cases involving management of neck disease will be presented to the panel of experts, for discussion and audience participation.

Educational Objectives: 1) Understand the role of imaging in planning treatment of the neck. 2) Understand how to manage the neck in conjunction with TLM/TORS. 3) Understand how paradigms for management of the neck following chemoradiation have evolved.

Program Description: Robotic technology has penetrated most surgical disciplines in the past 5 years, and has now been embraced for a number of head and neck applications including transoral resection of aerodigestive tumors and thyroidectomy. Undoubtedly, further expansion of robotic procedures can be anticipated, and it is prudent to learn from challenges encountered during the development process. Experts in the field of robotic surgery will describe the development of this technology as it relates to specific procedures, and the following questions will be addressed by each discussant: 1) What was the compelling motivation to explore robotic application to the specific procedure? 2) What were the principal challenges encountered in refining and exporting the techniques learned? 3) If you had to do it over again, what would you have done differently in either development, training, or early application of the technique? 4) How do the costs compare with the patient benefit? The topics that will be addressed are transoral resection of supraglottic and oropharyngeal tumors, transoral surgery for benign conditions, remote access thyroidectomy, and novel applications under development (including neck dissection and skull base surgery). This will be an interactive session and audience participation will be actively encouraged. The difficult questions regarding this new technology will be asked, including cost-benefit ratios and responsible implementation among general practices.

Educational Objectives: 1) Recognize the transoral application of robotic technology for benign and malignant supraglottic and oropharyngeal conditions. 2) Understand the current state-of-the-art robotic approach to remote access thyroidectomy. 3) Become familiar with novel applications under development (including neck dissection and skull base surgery).

Program Description: A tremendous amount of debate has occurred since the 2006 and 2009 ATA guidelines made recommendation regarding the indications for central and lateral neck lymph node surgery in patients with well-differentiated thyroid cancer. While consensus has yet to be reached, several pivotal issues have been defined and are the target of prospective randomized trials. The panelists will identify these key issues and answer the following questions: 1) What is the prevailing clinical approach in 2011? 2) What is the best evidence available that governs this approach? 3) What are the future opportunities for refining our understanding? Specific issues that will be explored include: 1) Lateral neck surgery - when and how much? Which levels should be addressed? 2) Has there been a change in the epidemiology of well-differentiated thyroid cancer? How has this impacted neck disease and survival? What is the appropriate threshold for nodal surgery after prior thyroidectomy? 3) What is the evidence for elective central neck dissection (pro and con)? 4) How do we best determine where the disease is located? What is the optimal way to define the extent of surgery? 5) Putting it all together, how do I approach the neck in a patient with early and advanced well-differentiated thyroid cancer? This will be an interactive panel with plentiful discussion and questions from the audience and case-based analysis. The panelists will move toward consensus when possible regarding each of these issues and help provide a framework for investigation and validation of proposed management algorithms.

Educational Objectives: 1) Understand which levels should be addressed in undertaking lateral neck surgery for thyroid cancer. 2) Recognize changes in epidemiology of thyroid cancer and impact on neck disease and survival. 3) Become familiar with optimal determination of the location of disease and therefore extent of surgery.

Program Description: The theme of this audience interactive miniseminar is to incorporate what is new and controversial in the management of differentiated thyroid cancer as well as to examine the level that molecular biology is incorporated into the management of thyroid neoplasms. The American Thyroid Guidelines for differentiated thyroid cancer are a widely quoted document. The level of evidence on which these recommendations are made varies extensively leaving considerable room for debate. Some aspects of surgical management such as laryngoscopy, bronchoscopy, and neuro-monitoring are left out of the document. The moderator will provide a brief background power-point presentation on the pertinent ATA guideline as a template. Expert panelists will debate case presentations germane to the given guideline and determine the level of agreement. Audience interactive opinion will be sought. The specific guidelines (where applicable) and case presentations will include: 1) Ultrasound indications for fine needle aspiration and the use of molecular markers from the FNA; 2) Laryngoscopy and neuro-monitoring; 3) Extent of initial surgical therapy for low-risk differentiated thyroid neoplasms and the potential role for molecular markers; 4) Bronchoscopy, preparation for airway management and extent of surgery for high risk patients with extra-thyroidal spread; and 5) Surgery for recurrent differentiated thyroid cancer and the role of molecular targeted therapy. Panelists and the interactive audience will give opinions on the relevance of the ATA guidelines to their thyroid surgical practice.

Educational Objectives: 1) Learn the benefits and limitations of the American Thyroid Association Guidelines. 2) Learn about molecular markers for diagnosis, prognostication, and molecular-targeted therapy. 3) Learn about ultrasound-guided FNA, management of low- and high-risk patients, and recurrence.

Program Description: Transoral robotic head and neck surgery (TORS) has quickly become an accepted alternative approach for treatment of tumors of the upper aerodigestive tract. Specifically, approaches to oropharyngeal tumors have traditionally been through a mandibulotomy or lingual release approach with its associated postoperative morbidity. Because of this potential morbidity and the proven efficacy of chemoradiotherapy, there has been a paradigm shift away from upfront surgical management. With the advent of TORS over the past few years, several reports have documented its safety and improved functional outcomes in the management not only of oropharyngeal tumors but also of hypopharyngeal and laryngeal cancers without sacrificing tumor control or overall survival. As the indications for TORS continue to expand, will there then be an evolving role for robotic-assisted reconstructive surgery? And what are the indications for reconstructions after TORS? The miniseminar will be composed of four parts: First, the moderator will provide a short introduction. The second speaker will review the current literature and their experience with TORS. They will specifically discuss the current indications and functional results without reconstruction. The third speaker will discuss the rationale for robotic free flap reconstruction, its indications and potential improved function. The last speaker will discuss the current research on robotic assisted reconstruction and its future advantages and challenges ahead.

Educational Objectives: 1) Understand the role of transoral robotic surgery in head and neck cancer. 2) Understand the current use of robotic reconstructive surgery. 3) Understand the indications and future potential for robotic-assisted reconstructive surgery.

Program Description: Transoral treatment of larynx and pharynx cancer has been done for over a century. Despite substantial technical innovations such as enhanced imaging, innovative laser technologies, and robotics guidance systems, radiotherapy and/or chemotherapy dominate the treatment strategy at many institutions. In part, this is due to limited familiarity with recent novel endoscopic surgical approaches. Outcomes data on transoral microsurgical management for advanced oropharynx and larynx cancer will be presented to illustrate the efficacy of surgical management of these diseases. Robotics and laser photoangiolysis of laryngeal cancer are two emerging technologies that can enhance endoscopic surgery. These novel and innovative treatment technologies can potentially be combined in the future to expand the indications for endoscopic surgery. This miniseminar will highlight advantages and disadvantages of endoscopic techniques and update the attendees on state-of-the-art procedural innovations.

Educational Objectives: 1) Understand outcomes data on transoral laser microsurgery for advanced oropharyngeal and laryngeal cancer. 2) Understand the emerging role of robotics in endoscopic surgical management of larynx and pharynx cancer. 3) Understand concepts of photoangiolysis in treatment of aerodigestive tract malignancy.

Program Description: Adult laryngotracheal stenosis (LTS) is a very old problem which continues to represent a diagnostic and treatment challenge for the otolaryngologist. It is distinct in many ways from similar disease seen in the pediatric population. The goal of this miniseminar is to outline the evaluation and management of this disorder. Presenters will discuss the diagnosis and treatment of this condition including airway management, as well as office-based, endoscopic and open procedures. In addition, recent information on the molecular basis of LTS will be presented. Challenging cases will be presented for discussion.

Educational Objectives: 1) Be able to list the most common etiologies of laryngotracheal stenosis in adults. 2) Understand the various treatment options available for the treatment of laryngotracheal stenosis. 3) Understand the molecular basis of laryngotracheal stenosis.

Program Description: For the past decade, the management of a cricopharyngeal dysphagia including a Zenker’s Diverticulum has predominantly been endoscopic. Recent literature has suggested that long-term outcomes may not be as successful with the endoscopic technique as once believed. The purpose of this miniseminar is to thoroughly review the literature on this topic and present the most up to date, evidence-based court room style debate on this topic. This 90-min miniseminar will review: 1) the normal anatomy of the cricopharyngeus and the upper esophagus. 2) Methods of assessing this area, ie, radiographic, endoscopic, manometry, pH probe. 3) Medical management and its role in this disease process. 4) Surgical techniques: Open techniques: Diverticulectomy with stapled or hand-sewn closure, diverticuloplasty, +/- cricopharyngeal myotomy. Closed (endoscopic) technique: diverticulotomy utilizing stapled, laser, bovie. 5) What is the appropriate management of the patient with a When to botox? When to dilate? What are the long-term results of this management? This miniseminar will be interactive. At numerous times during the discussion questions will be asked of the audience to keep them involved and entertained. The open vs closed surgical debate will be a court-room style debate with the Moderator acting as the judge or arbitrator. Each presenter will have 8 mins to define their side of the argument and to present the data. Four minutes will be allowed for cross examination or rebuttal, 2 mins for the closing argument if needed. The audience will give the verdict at the end. A series of questions will be asked of the jury (audience) at the end. Events/Schedule: Normal anatomy of the cricopharyngeus and its assessment: 10 min (Robert Stachler, MD). Medical and surgical management of cricopharyngeal dysfunction: 20 min (Milan Amin, MD). Introduction of the debate of surgical management: 7 mins (Milan Amin, MD). Presiding Arbitrator: Robert J. Stachler, MD. Courtroom: 30 mins total. Pro-open diverticulectomy: Al Meroti, MD; Pro-endoscopic diverticulectomy: Phil Song, MD, Ramon Franco, MD. Questions and Answers (Case presentation if time allows): 20 mins. Miniseminar Evaluation for the Audience: This should be an interactive presentation with questions for the audience to answer and an opportunity for the audience to give a verdict on which technique seems to have the best evidence. This is not a question of right or wrong. It is a question of best evidence. The jury will be prompted on this very point. Decisions are rendered based on the best evidence only.

Educational Objectives: 1) Appreciate the newest techniques available to manage cricopharyngeal dysphagia. 2) Evaluate and treat cricopharyngeal dysphagia. 3) Become facile with the medical management currently available to treat CP dysphagia.

Program Description: The diagnosis and management of primary hyperparathyroidism is generally straightforward. Cases referred from endocrinologists for surgery will usually have the classic laboratory findings and the correct diagnosis. An adenoma will be localized by imaging in approximately 80% to 85% of these patients. As increasing referrals are being generated from primary care physicians rather than endocrinologists, surgeons will invariably see only partially worked up patients and diagnostic dilemmas. The first part of this panel, which is composed of expert endocrine surgeons with extensive experience in parathyroid surgery, will address some of the diagnostic challenges and their evaluation. The second portion of the panel will focus on treatment. Minimally invasive parathyroidectomy (MIP) has become the preferred surgical approach for treatment of primary hyperparathyroidism. Localization of an adenoma on preoperative imaging is the key to being able to perform a successful MIP. The panel will discuss pearls and pitfalls in the imaging of parathyroid adenomas, including the use of ultrasound, sestamibi parathyroid scan, and CT scans. Thirdly the panel will present state of the art minimally invasive parathyroidectomy techniques, such as radioguided surgery, lateral approach, performing MIP under local/sedation. Cases will also be presented on how to approach failed explorations.

Educational Objectives: 1) Learn pearls and recognize pitfalls of challenging cases of hyperparathyroidism. 2) Understand the principles and techniques of minimally invasive parathyroidectomy. 3) Learn how to improve the yield of preoperative imaging for primary hyperparathyroidism.

Program Description: This miniseminar is supported by the Airway and Swallowing Committee. It will be an open forum and interactive discussion on the management of dysphagia and aspiration in the pediatric population. The panelists will discuss diagnostic methods as well as medical and surgical treatment options. They will assist the attendee in understanding the pathophysiology and morbidity of chronic aspiration in children. A case presentation format will be used and the audience will be able to help determine the focus of the discussion. Attendees will have the opportunity to submit a case for presentation by emailing to aspirationaao@me.com prior to the meeting. Each case presented will have a set of questions developed regarding differential diagnosis, evaluation, and treatment for the audience to select prior to discussion by the panel. The audience response will be a springboard for more in-depth discussions. Controversies that will be reviewed include the use of videofluoroscopic swallow studies vs fiber optic endoscopic evaluation of swallowing; sialorrhea management options, including botox, ductal ligation, and salivary gland excision, and surgical management options for persistent aspiration following maximal treatment for sialorrhea and GERD.

Educational Objectives: 1) Understand diagnostic tests available for children with dysphagia and aspiration. 2) Formulate algorithm for investigation of children who present with symptoms of dysphagia and aspiration. 3) Understand treatment options for mild, moderate, and severe dysphagia and aspiration.

Program Description: Human papilloma virus (HPV) infection is a major cause of disease. It is causal in respiratory papillomatosis and cervical cancer and is etiologically associated with cancers of the oropharynx as well as additional anogenital sites. Our knowledge of the role of HPV in these diseases is evolving and there are yet many unanswered questions. Furthermore, the epidemiology of these diseases may change with trends in increasing promiscuity and the advent of widespread HPV vaccination. Patients have often read extensively about their diagnosis on the internet and may present with incomplete/incorrect knowledge and difficult questions about disease transmission, progression, treatment and transformation. This miniseminar brings together experts that specialize in different manifestations of HPV disease: adult and pediatric clinicians that treat recurrent respiratory papilloma (RRP), a head and neck surgeon that treats oropharyngeal carcinoma and actively researches vaccines targeting HPV related malignancy, and a guest clinician from gynecology to give insights on the treatment of HPV from a different perspective. The format will focus on case presentations to highlight the specific topics selected for discussion to include: basic biology of HPV infection and oncogenesis, treatment strategies for RRP, adjuvant treatments for RRP, counseling regarding contacts of patients with HPV related disease, HPV vaccine indications, and current concepts regarding the role of HPV in oropharyngeal cancer. There will be opportunity for the audience to ask questions throughout the presentation.

Educational Objectives: 1) Understand current RRP management strategies including surgical techniques, adjuvant medications and nutritional supplements. 2) Be able to counsel patients on etiology of RRP, transmission, cancer risk, and vaccination. 3) Understand how RRP fits in the spectrum of HPV-related disease.

Program Description: Objective: Develop a working algorithm that effectively eliminates dangerous conditions while efficiently provides reasonable alternatives to address LPR symptoms. Methods: use an audience response system in combination with a structured set of questions directed to the audience. End result: a real world proposed treatment algorithm. White paper. Possible basis for outcomes assessment study. The overall goal of this session is to define current practice trends on the management of laryngopharyngeal reflux (LPR) based on actual audience participation/input, and the consideration of appropriate management for a typical patient. Using an interactive panel format, the moderator will prompt panelists to present a quick review of epidemiology, symptomatology, and co-morbid conditions impacting laryngopharyngeal reflux (LPR); diagnosis/differential diagnosis; current evidence on diagnostic and therapeutic management; and future research and management implications. After laying out background, the moderator/panel will consider real world patient management algorithms.

Educational Objectives: 1) Who is the typical patient presenting with laryngopharyngeal reflux (LPR) in an otolaryngology practice? 2) What diagnostic testing options are or should be employed? What are the common treatment pathways? 3) What differential data should be considered? What health care costs impact diagnosis/treatment? When is referral recommended?

Program Description: Aspiration pneumonia is a major problem in the geriatric population, in patients who are hospitalized long term, and for people with head and neck cancer. It is the second most common type of nosocomial infection, resulting in massive mortality and morbidity; in the elderly, the mortality rates range from 20% to 50%, with a rate as high as 80% in some studies. The health care costs associated with aspiration pneumonia are staggering. While aspiration pneumonia is often due to oropharyngeal or laryngeal disorders, the role of the otolaryngologist in diagnosing and managing aspiration can vary significantly; this purely clinical miniseminar will focus on how the general otolaryngologist can maximally contribute to the care of patients with aspiration. The panelists will discuss the following: 1) The practical value of multiple diagnostic modalities will be reviewed, including fiberoptic laryngoscopy, transnasal esophagoscopy (TNE), modified barium swallow and other radiological imaging, functional endoscopic evaluation of swallowing (FEES), sensory testing, pH and impedance probes, and high resolution manometry; 2) in-office evaluation for surgical decision making; 3) when to perform a tracheotomy or refer for a gastrostomy tube; 4) nonsurgical treatment including swallowing therapy, stents, salivary control, injection of botulism toxin, and electrical stimulation; 5) surgical treatment including laryngeal framework surgery, cricopharyngeal myotomy, laryngeal suspension, laryngeal closure procedures, and sensory reinnervation. Illustrative cases will also be presented to highlight common dilemmas and challenges.

Educational Objectives: 1) Describe how in-office evaluation and procedures are useful for decision making in medical and surgical treatment. 2) Understand the value of different diagnostic modalities. 3) Describe medical and surgical treatments for aspiration.

Program Description: While tracheotomies are regularly performed by otolaryngologists nationwide and abroad, technique and perioperative management vary widely between surgeons. Recently, the Academy Airway and Swallowing Committee performed a multi-institutional study reviewing the technique, management, and outcomes from a large series of consecutive tracheotomies. We have used our study, as well as national and international databases to construct tracheotomy evidence-based guidelines for the otolaryngologist. We will discuss incorporation of tracheostomy care teams for the merging of quality care, medical economics, and patient safety. Guidelines will be presented in an interactive format (surveying the audience on their current practices) with the goal of optimizing intraoperative patient safety and minimizing early and late postoperative complications.

Educational Objectives: 1) Understand the management factors associated with tracheotomy complications. 2) Understand how tracheostomy care teams can optimize patient management. 3) Information will be presented in an interactive format with audience participation.

Program Description: The field of pediatric laryngology has experienced tremendous growth in the past few years; the increased focus on voice-related quality of life issues in pediatric airway is a prime example of this. Much in the development of pediatric laryngology reflects the complementary efforts of laryngologists and pediatric otolaryngologists supported by key technological advancements. This miniseminar incorporates the viewpoints of several clinicians experienced in the management of pediatric laryngeal disorders, particularly those related to voice. The presenters will focus on clinically relevant matters for both general and specialty otolaryngologists, including diagnosis, common pathologies, as well as both operative and non-operative approaches and techniques. The anatomical and physiological basis for pediatric laryngology care will be reviewed. Specific components of the interactive session will include addressing these questions: What is the role of videostroboscopy in children? What is the role of FEES and FEESST testing in children? What is the role of in-office tracheobronchoscopy? Who should be referred for these tests? Fundamental pathologies impacting pediatric laryngology will be reviewed, including benign vocal lesions, RRP, laryngeal webs, subglottic stenosis, and hemangioma. Non-operative innovations will be discussed including propanolol, mitomycin, steroids, Botulinum toxin, and fillers. Operative innovations will include the use of cold versus laser technique for benign lesions, a brief discussion of open techniques, and recent augmentations to standard open techniques. Differing practical approaches for operative and non-operative techniques will be discussed in a panel format with presentations of challenging cases after the initial diagnostic, pathological, and interventional options have been discussed in a lecture format.

Educational Objectives: 1) Understand the clinical role of specific diagnostic tests in pediatric laryngology. 2) Approach clinical issues in pediatric laryngology and address them with practical non-operative and operative solutions. 3) Understand the clinical advantages and disadvantages of individual non-operative and operative solutions.

Program Description: The miniseminar will consist of a lively panel discussion on the evidence-based recommendations for the diagnosis and treatment of sudden hearing loss. The panel will discuss the newly developed AAO-HNS clinical practice guideline. The primary purpose of the guideline is to improve the diagnosis and management of sudden hearing loss in adults aged 18 years and older. In creating this guideline the AAO-HNSF selected a panel representing the fields of otolaryngology-head and neck surgery, audiology, otology, neurology, neurotology, family medicine, emergency medicine, and consumers.

Educational Objectives: 1) Learn diagnostic criteria for sudden sensorineural hearing loss. 2) Plan treatment based on current best evidence from randomized, controlled trials. 3) Identify management and counseling strategies that improve quality of care.

Program Description: Current prosthetic auditory implants have achieved a high level of success, however, it would be fair to say that performance gains over the past decade have reached a stable plateau. The latest phase of development has centered primarily on increasing stimulus resolution, preserving residual auditory ultrastructure and function, and implanting higher order neural pathways. To serve these objectives, electrodes have been designed to more closely approximate the spiral ganglion and be inserted virtually atraumatically. Implantation of the higher order pathways has already been performed with combinations of penetrating needles or electrode paddles at the brainstem. Prototypes even exist for stimulation as high up as the auditory cortex. We are now also witnessing the development of highly focused fiberoptic delivery systems for infrared laser energy as the stimulus source. A panel of surgeons and scientists, all of whom have been involved in both clinical and basic science of auditory implants, will debate the strategies being developed to foster the next leap in performance gains. The seminar will begin with a candid appraisal of the successes of currently marketed achievements including modiolar hugging electrodes, hearing preservation hybrid implants, compressed and split arrays for severely malformed and obstructed cochleae, and bilateral implantation. Minimally invasive surgical techniques will be examined with the questions posed: What truly constitutes a minimally invasive procedure? What technical features need to be retained in order to maintain necessary safeguards and precautions? The variable successes of auditory brainstem implantation will be reviewed with an eye toward future improvement. The panelists will then present their collective experience with emerging technologies aiming to push the envelope of performance higher into the future. The constant gains in microprocessor speeds will offer opportunities for development of novel processing strategies including current steering. The emerging concept of integrated drug delivery systems will require a careful re-exploration of the well-known design problems of hermeticity, durability, and ultrastructural trauma induction. Changes in stimulus energy source (eg, infrared laser) will undoubtedly require radical changes in device designs and coding strategies. It is the hope of the organizers that this miniseminar will benefit both the attendees and the panelists through the process of evaluative debate and exploration of new ideas.

Educational Objectives: 1) Understand the current status and future direction of hybrid “hearing preservation” cochlear implantation. 2) Understand the newest device and coding strategies including infrared laser optical based devices. 3) Be familiar with the current systems under development including vestibular prostheses, DACS and ABI.

Program Description: Approximately 35% of office visits in a general otolaryngologic practice are otologic in nature. Simple diagnosis such as cerumen impaction, presbycusis, or acute otitis media are very straight forward and rather easily treated. Other ear-related issues can be more challenging and may require additional office time and resources to manage. This miniseminar will discuss the otologic evaluation and management of progressive SNHL, pulsatile tinnitus, referred otalgia, unilateral middle ear effusion, and osteoradionecrosis of the EAC. While the presentation of these issues may appear benign, they may represent a more serious underlying illness. Emphasis will be placed on a detailed differential diagnosis, and appropriate testing that should be considered by the general otolaryngologist. Audience participation will be encouraged through case presentations.

Educational Objectives: 1) Recognize common patient presenting complaints that can be harbingers of a more serious problem. 2) Understand the basic workup that should be performed prior to referring the patient to a subspecialist. 3) Understand the essential treatment protocol that should be instituted prior to a referral.

Program Description: The temporal bone is the home to and neighbor of a variety of critical neural and vascular structures that are at risk for injury during otologic surgery involving the middle ear and mastoid cavity. Their injury can have devastating consequences including hearing loss, facial nerve injury, central nervous system injury, or stroke. The challenge to the otologic surgeon is to eradicate disease, to preserve structure and function, and to avoid injury. Being prepared to handle expected and unexpected situations is the key to success for otologic or any other surgery. In this miniseminar, a panel of experts will specifically review: 1) How to avoid cholesteatoma recurrence; 2) strategies to prevent facial nerve injury; 3) what to do when the brain is injured; 4) avoiding and managing vascular injury; 5) what to do when the unexpected occurs during routine stapes surgery. The goal of the panel is to provide the tools necessary to become a more effective otologic surgeon and guidance for how to handle a variety of potential complications that may be encountered during routine ear surgery.

Educational Objectives: 1) Understand surgical principles and techniques to avoid FN, vascular, and CNS injury during otologic surgery. 2) Understand strategies to effect total removal of cholesteatoma and minimize its recurrence. 3) Understand the state-of-the-art approaches to minimizing and addressing complications of stapes surgery.

Program Description: This miniseminar is designed for otolaryngologists who include cochlear implants in the scope of their practice and would like to learn more about managing various intraoperative and postoperative complications, and special considerations as they inevitably arise. Particularly useful for otologic surgeons who have small to moderate cochlear implant case volumes, this seminar will address common as well as less common complications and provide a framework for systematically and effectively managing them. A panel of experts consists of four otologists who run busy, mature cochlear implant programs and have extensive experience in managing various implant-related issues. During the first hour, each panelist will give a brief presentation. Topics include: analyzing suspected device failures, evaluation and revision of inappropriate electrode placement, management of CSF gushers and leaks, management of skin ulceration, skin breakdown and device exposure, management of wound infection and device infection. The following half hour will be reserved for discussion of individual case scenarios. The moderator will present cases to the expert panel for discussion. Members of the audience are encouraged to participate in the discussion, ask questions, and present their own cases to the panel. Attendees will learn how to avoid common intraoperative complications and how to better manage complications when they do occur. The aim of this miniseminar is to allow the attendees to benefit from the experience of our panelists and provide them with “tried and true” techniques that can be implemented in their own cochlear implant programs, ultimately improving the scope and quality of cochlear implant services available nationally and internationally.

Educational Objectives: 1) Identify and manage a variety of complications related to cochlear implants with more confidence. 2) Learn to evaluate suspected cochlear implant device failures and need for revisions. 3) Learn an operative technique for managing a CSF gusher.

Program Description: Middle ear surgery can generally be performed with the aid of an operating microscope. However, under a potentially minimally invasive trans-canal approach, it is very difficult to operate on several sites using a microscope alone unless the surrounding bone is removed and retro-auricular approaches are performed. Such sites may include the epitympanum as well as the inferior and posterior parts of the mesotympanum. Although it has been more than 15 years since the introduction of operative endoscopy to middle ear surgery there is still a very limited role for the endoscope in the surgical management of middle ear disease across the globe. There are several possible reasons for that, such as the current idea of a limited and marginal role for endoscopes in middle ear surgery, a potentially long learning curve through the hassles and tribulations of adapting newer techniques and newer instrumentation, and some resistance, especially with otologists who are very comfortable with the use of microscopes. The operating microscope provides a very good quality magnified image in a straight line, however, the surgeon’s field of view is limited to the narrowest segment of the ear canal when using a transcanal approach. On the other hand, endoscopes also provide a magnified vision that enables the ability to change rapidly from a close-up to a wide angle view, just by going closer or by withdrawing the instrument. Further, it provides an all-round vision to the surgeon who can rotate angled endoscopes to visualize the deep and hidden structures. In this miniseminar, we are going to discuss, with the help of very nice quality surgical movies, endoscopic anatomic dissection images and videos, virtual reality objects and also augmented reality capability the current techniques for endoscopic middle ear dissection, and surgical management of several middle ear diseases, such as tympanic membrane perforations, cholesteatomas, ossicular chain reconstruction and also stapedotomies, all performed with endoscopes discussing and commenting the equipment needed, surgical indications, also showing the potential advantages and disadvantages of the procedures, postoperative care and results and some interesting tips and pearls regarding this new way to surgically manage middle ear diseases.

Educational Objectives: 1) Learn and review the endoscopic anatomy of the middle ear, discussing anatomic landmarks. 2) Identify the actual indications and limitations of this minimally invasive approach. 3) Describe and demonstrate step-wise endoscopic middle ear approaches for several diseases of this area.

Program Description: Every time the ear surgeon operates, a significant number of events occur and are anticipated. Many of these are routine and predictable. However, sometimes the unexpected occurs, which can be during the preoperative assessment, during surgery, or after surgery. Treatment outcomes are dependent on the surgeon’s handling of unexpected findings or occurrences as well as the decisions made regarding what is best for the patient. This miniseminar presents cases of 4 common otologic diagnoses where the surgeon was faced with unanticipated situations that challenged his diagnostic and surgical skills; where every decision made affected the final outcome. The disease entities presented are Meniere’s disease, otosclerosis, chronic otitis media with cholesteatoma, and chronic otitis media without cholesteatoma. In each case presented, the panelist will discuss his decisions regarding whether or not to image the patient, whether or not to recommend surgery, what was found intraoperatively, and what was encountered that required difficult but necessary intraoperative decisions. The panelists are all expert otologic surgeons with many years of experience in handling complicated otologic problems. The emphasis of the miniseminar is not to present unusual cases, but instead is to present common problems where unexpected findings significantly challenged the surgeon and complicated the case. In Meniere’s disease, various approaches in evaluation and treatment are used by otolaryngologists. It is anticipated that after this miniseminar the attendee will have a better understanding of how to approach Meniere’s disease systematically and be able to anticipate potential problems. Otosclerosis may seem straight forward, but a myriad of anatomical variations exist that may confuse the surgeon. In addition, other entities may mimic otosclerosis. This miniseminar should help the attendee more accurately prepare for otosclerosis surgery and its potential variations. Chronic otitis media with and without cholesteatoma is a continuum of disease that can challenge all ear surgeons. By presenting ways to evaluate these diseases with awareness of possibly encountering unanticipated findings, this miniseminar should help the attendee feel more comfortable handling chronic otitis media and its many presentations. The emphasis of this miniseminar is for both general otolaryngologists and otologists to become aware of and be able to diagnose and treat the unpredictable challenges that are so often seen in common otologic conditions and how to make the correct intraoperative decisions.

Educational Objectives: 1) Understand that common otologic diseases may present unanticipated challenges during diagnosis and treatment. 2) Learn how to anticipate diagnostic dilemmas and be able to make appropriate treatment recommendations. 3) Learn how to recognize unusual surgical presentations and how to make the right intraoperative decision.

Program Description: Tinnitus is one of the most common health problems in the United States and recent figures show that tinnitus is increasing in frequency. As otolaryngologists we are the primary specialty responsible for the diagnosis and management of tinnitus. Despite a great deal of work in this area definitive treatment options for tinnitus are lacking in many cases. Recognizing the importance of this issue the AAO-HNSF and the Martha Entenmann Tinnitus Foundation have endowed a series of miniseminars to address tinnitus. This year’s panel will once again be comprised of national and international experts who will discuss advances in tinnitus treatment using implantable devices. The panel will discuss the use of cochlear implants, implantable hearing aids, and other, more novel, implantable devices. In particular the presenters will focus on the physiologic basis for tinnitus response to electrical or mechanical stimulation, cases series and outcomes, and patient selection for various treatments. The panel will finish by discussing several cases and will provide time for audience questions.

Educational Objectives: 1) Better understand treatment options for tinnitus. 2) Better understand the principals that support the use of electrical stimulation in tinnitus. 3) Provide a more clear understanding of the impact of cochlear implants on tinnitus.

Program Description: Virtually all microbes live in biofilm communities. Within these communities, the microbes assume differing specialized roles which confer survival advantages on the community. These communities cause chronic and device-associated infections. The role of biofilms in the persistence of chronic, mucosal-based ENT-related infections was first recognized in otitis media. Within the field of pediatric otolaryngology, biofilms have now been shown to play a role in many infections, including: recurrent acute otitis media, otitis media with effusion, cholesteatoma, chronic tonsillitis, chronic rhinosinusitis, and infections of tracheostomies, endotracheal tubes, tympanostomy tubes, and cochlear implants. The recognition that chronic ear, nose, and throat bacterial infections are biofilm-related has been the impetus for the development of new technologies for the study of biofilms and their prevention and treatment. Understanding that chronic bacterial infections are biofilm-related is fundamental to developing rationale strategies for treatment and prevention.

Educational Objectives: 1) Appreciate the current state of understanding regarding biofilms in middle ear effusions and recurrent acute otitis media. 2) Understand the contributions that biofilms make toward chronic infections of the tonsils and adenoids. 3) Understand the near and long-term possibilities in treatment and prevention of pediatric otolaryngology infections associated with biofilms.

Program Description: Although there are well-established surgical techniques for tympanoplasty to repair chronic tympanic membrane perforation, surgical methods remain varied, often based more on local traditions than on scientific research. Successful tympanoplasty continues to pose a significant challenge to the otolaryngologist. The goal of this miniseminar is to present the best surgical technique of this common procedure. Toward these ends, we have assembled a panel of respected and experienced otologists from the East coast, Midwest, South, and West coast of the US. Following a brief introduction, each panelist will present his preferred surgical technique of tympanoplasty for tympanic membrane perforation that works best whether media, lateral, medio-lateral, or cartilage graft method. The remaining time will be devoted to case presentations to discuss on best graft method for particular cases. This miniseminar will provide information that should improve the ability of each participant to perform successful tympanoplasty for chronic tympanic membrane perforation in different clinical situations.

Educational Objectives: 1) Learn best grafting method in tympanoplasty for reconstruction of chronic tympanic membrane perforation. 2) Understand to use different method grafting depending on the location of tympanic membrane perforation. 3) Be able to perform better tympanoplasty in different clinical situations.

Program Description: The management of cholesteatoma has been a topic frequently filled with controversy regarding surgical technique and different methods of hearing restoration. Cholesteatoma management has always presented the otolaryngologist with a unique set of challenges, especially in the pediatric population. Challenges in management include access to various areas of the middle ear and surrounding structures, identification of recurrence, and restoration of hearing loss caused by the disease. Within the past decade, novel techniques such as removal/replacement of the canal wall, diffusion weighted MRI for diagnosis of recurrence, and advances in understanding of cholesteatoma biology have resulted in evolving clinical algorithms used to treat this difficult disease. This miniseminar will be organized as a panel discussing current care and novel management of pediatric cholesteatoma. The multi-institutional panel will include experts in cholesteatoma biology, resective surgery for cholesteatoma, hearing restoration, and imaging of cholesteatoma. Each panelist will focus on novel and/or controversial aspects of cholesteatoma management. The miniseminar will use an audience response system to allow interaction between the panel and the audience during the presentations.

Educational Objectives: 1) Identify current theories regarding etiology of pediatric cholesteatoma and biologic factors determining behavior of cholesteatoma. 2) Understand current options for primary and hearing restorative surgery for pediatric cholesteatoma. 3) Learn about current options for identification of recurrent pediatric cholesteatoma.

Program Description: Recent years have seen great advances in our understanding of the molecular genetic basis of many clinical disorders. Building on the success of the Human Genome Project, new technologies are in development to identify disease-causing mutations through genetic testing. However, there is a knowledge gap among otolaryngologists regarding which patients should undergo genetics evaluation and how genetic testing should be utilized in the care of patients. The three participants are clinician-scientists who investigate the genetic factors underlying human disease, and also apply their understanding of genetics to the care of patients. This panel will discuss the state of the art in genetic testing in otolaryngology as well as translation of recent research which will soon be clinically available. Dr Gruber will address cancer genetics, applying his work in cancer in general to head and neck tumors; Dr Runge will discuss the evaluation of auditory neuropathy beyond routine clinical measures and also genetic testing as an example of genetic hearing loss. Dr Lesperance will discuss approaches to genetic evaluation of the pediatric patient, for children with rare genetic disorders, multiple congenital anomalies, and for Mendelian disorders. The emphasis will be on providing the practicing otolaryngologist with the tools to counsel and evaluate their patients with potential genetic disorders.

Educational Objectives: 1) Describe relationships between genotype and phenotype in auditory neuropathy spectrum disorder. 2) List the most common methods of genetic testing and the risks and benefits of each. 3) Understand the role of the geneticist in evaluating patients with otolaryngologic disorders.

Program Description: Clinical practice must change and evolve in response to the regular, systematic review of new high quality evidence, considered alongside the existing knowledge base. Clinical effectiveness and cost-effectiveness must be evaluated and up-to-date practice guidance must reflect these evaluations. The three speakers are practicing clinicians with expertise in the critical appraisal and synthesis of clinical research evidence, including formal systematic review and meta-analysis. They will discuss three important areas of pediatric otolaryngological practice in this session: the use of 1) pneumococcal conjugate vaccination against acute otitis media (AOM) in children, 2) antibiotics for AOM, and 3) ventilation tubes for otitis media with effusion (OME). The session will emphasize the practical implementation of research evidence.

Educational Objectives: 1) Appreciate the role of high-quality systematic reviews in implementing best clinical practice. 2) Understand the advantages and disadvantages of pneumococcal conjugate vaccines in managing children with acute otitis media (AOM). 3) Understand the benefits and harms of anti-microbial chemotherapy in managing children with AOM and understand the implications and limitations of the evidence-base for ventilation tubes in children with OME derived from randomized controlled trials.

Program Description: Pediatric obstructive sleep apnea (OSA) has been identified in 2% to 4% of children in the United States. While adenotonsillectomy is widely regarded as the primary therapy for pediatric OSA, evidence suggests that anatomy alone is not enough to explain the presence of OSA. With this in mind, evaluation of other factors contributing to OSA has revealed that inflammation, and specifically leukotrienes, may contribute to airway obstruction and that medical treatment of airway inflammation may be effective to treat sleep disordered breathing (SDB). In addition, the evidence regarding accurate diagnosis of sleep-disordered breathing in children is still subject to debate. While sleep studies are unquestionably the gold standard for diagnosis, the use of criteria adapted from adult studies has led to come controversy regarding the correct parameters to use for diagnosis. Additional investigations have found that respiratory patterns in children differ from those in adults and standard sleep study parameters may not be very specific or sensitive. Therefore, flow-based respiratory measures have been developed to help determine which children would benefit from treatment and measure response to treatment after surgery. While accurate measurement of SDB is essential, quantification of the consequences of OSA and SDB is also important and the relationship between neurobehavioral measures and SDB has been explored. Understanding the role of inflammation and the potential for flow-based respiratory measures is critical in advancing the treatment of pediatric OSA. In addition, a better understanding of the relationship between neurocognitive and behavioral measures and SDB is fundamental to developing rationale strategies for treatment.

Educational Objectives: 1) Appreciate the current state of understanding regarding inflammation and biomarkers in pediatric obstructive sleep apnea. 2) Understand how the measurement of airflow in children can best reflect sleep-disordered breathing. 3) Understand the relationship between neurocognition and sleep disordered breathing in children and changes seen with treatment.

Program Description: Pediatric sinusitis is a major source of patient referrals for the otolaryngologist. The issue of diagnosis and treatment differs from the adult with regard to pathophysiology, management, and patient cooperation. This seminar will focus on the current state of drugs and devices used to diagnose and treat pediatric sinusitis. The seminar will begin with the use of devices in children to diagnose chronic rhinosinusitis or differentiate rhinitis from sinusitis. Discussion will include the use of pediatric office endoscopy, endoscopic-guided cultures, CT scanning, pH probe testing and other devices. We will also discuss how they should be used in the office on children. The seminar will then progress to the use of drugs and devices in the management and treatment of pediatric sinusitis. This discussion will include adenoidectomy and associated devices, culture techniques, balloon sinus surgery, and associated minimally invasive devices as well as traditional endoscopic surgical techniques. Further discussion will focus on various endoscopic surgical drugs and devices applied to the pediatric patient both intraoperative and postoperative. Drugs discussed for the treatment and management of pediatric sinusitis will include intravenous antibiotics, topical aerosol therapy, mucolytic agents, steroids, and intranasal packing and stents. Presentations will also occur on the pediatric patient with special issues and sinusitis such as immunologic deficiencies and cystic fibrosis. This will be a presentation based on the current literature, extensive clinical experience and case studies. Panel discussions and opinion by pediatric otolaryngologist with extensive experience will be a major part of this seminar.

Educational Objectives: 1) Discuss and present drugs and medical devices currently used to diagnose and treat pediatric sinusitis. 2) Present current medical devices and techniques used to treat pediatric sinusitis in the operative setting. 3) Present current drugs and devices used to manage children with sinusitis and related medical disorders.

Program Description: Over a decade has passed since the last comprehensive definition of pediatric rhinosinusitis was developed by an expert panel. In this miniseminar, international leaders in the field of pediatric rhinology will provide the latest evidence and experience regarding the definition of pediatric rhinosinusitis. Specifically, panelists will provide state-of-the-art concepts regarding pediatric rhinosinusitis including contributing factors such as allergy, antigens, fungus, biofilms, and reflux. The panel will discuss the differences between acute and chronic pediatric rhinosinusitis and provide the audience with guidelines for the clinical evaluation of both. Finally, with the use of case presentations, the panel will discuss contemporary medical and surgical interventions for acute and chronic pediatric rhinosinusitis.

Educational Objectives: 1) Understand the current definitions of acute and chronic pediatric rhinosinusitis. 2) Understand contributing factors to pediatric rhinosinusitis including allergy, fungus, biofilms, and reflux. 3) Understand contemporary treatment options for acute and chronic pediatric rhinosinusitis.

Program Description: The miniseminar will consist of a lively panel discussion on the evidence-based recommendations for the use of polysomnography in managing patients with sleep-disordered breathing who are candidates for tonsillectomy, with or without adenoidectomy. The panel will discuss the newly developed AAO-HNS clinical practice guideline for otolaryngologists. The primary purpose of this guideline is to improve the referral patterns for polysomnography for candidates for tonsillectomy, 2 to 18 years of age, when tonsillectomy is recommended for SDB. In creating this guideline the AAO-HNSF selected a panel representing the fields of anesthesiology, pulmonology, otolaryngology-head and neck surgery, pediatrics, and sleep medicine. The committee made recommendations that 1) Before performing tonsillectomy, the clinician should refer children with SDB for PSG if they exhibit any of the following: obesity, Down syndrome, craniofacial abnormalities, neuromuscular disorders, sickle cell disease, or mucopolysaccharidoses; 2) The clinician should advocate for PSG prior to tonsillectomy for SDB in children without any of the comorbid conditions listed in statement No. 1 for whom the need for surgery is uncertain or when there is discordance between tonsillar size on physical examination and the reported severity of SDB; 3) Clinicians should communicate the results of PSG to the anesthesiologist prior to the induction of anesthesia for tonsillectomy in a child with SDB; 4) Clinicians should admit children with OSA documented on PSG for inpatient, overnight monitoring after tonsillectomy if they are under age 3 years or have severe OSA (apnea-hypopnea index of 10 or more obstructive events/hour, or have an oxygen saturation nadir less than 80%); and 5) In children for whom PSG is indicated to assess SDB prior to tonsillectomy, clinicians should obtain laboratory based PSG, when available, instead of portable monitoring (PM) with a home device. This guideline is intended to assist otolaryngologists-head and neck surgeons in making evidence-based decisions regarding PSG in children.

Educational Objectives: 1) Understand when clinicians should refer children with SDB for PSG. 2) Use PSG results to identify children with SDB admitted for overnight observation following tonsillectomy. 3) Know why PSG performed in sleep laboratory is preferred over home PSG with portable monitoring devices.

Program Description: Radiation exposure from medical imaging has increased six-fold over the past 30 years, and such imaging has been estimated to provide half of an individual’s radiation exposure. The risk of cancer development from such radiation exposure has been discussed recently in the medical literature and the lay press. These issues are most notable in children, with long life expectancy and the potential for multiple exposures to medical imaging in their future. This symposium will be a multi-speaker symposium, and at the end of the various presentations, specific case scenarios will be presented with the opportunity to use the Audience Response System for audience participation for better understanding of current otolaryngology practice patterns related to imaging study selection in pediatric patients. The speakers will include a pediatric radiologist as well as 3 pediatric otolaryngologists, and presentations will include strategies on how to use reduced radiation doses for select imaging studies, review the current American College of Radiology Appropriateness Criteria for Otolaryngology related image study selection, appropriateness of using the MiniCAT image system in the office setting, as well as risks and benefits for each image modality for specific pediatric head and neck diseases.

Educational Objectives: 1) Discuss current issues related to safety of radiologic imaging studies used most often in children. 2) Review specific case scenarios and discuss imaging options, relative risks, and benefits of each modality. 3) Enhance judicious use of imaging studies for given pathology, and counseling of parents about risks.

Program Description: The miniseminar provides an open forum for interactive discussion of management options and the decision rationale involved in sinus and skull base cases of varying complexity. A case presentation format is utilized with case presentations from each of the panelists. Questions regarding differential diagnosis, evaluation, imaging, and treatment are posed to the audience in multiple choice format. The responses provided by the audience response system are then discussed and expanded upon by the panelists in an interactive discussion. In general, cases are selected that might be encountered by either a general otolaryngologist or a subspecialty rhinologist, but which have important decision and management dilemmas. Each panelist has been chosen because of their depth of knowledge in the field and because of the clarity of their presentations. Particular emphasis is placed on the decision making process and on frontal sinus disease, revision surgery, and fungal sinusitis, as well as the management of more common tumors. The rationale behind each recommendation will be carefully elucidated. Discussion from the floor is encouraged and the use of a touch pad audience response system creates audience participation as an integral aspect of the case discussions.

Educational Objectives: 1) Improve knowledge of the surgical decision making process in chronic sinus disease. 2) Learn different imaging modalities and improve quality of interpretation for both CT and MRI images. 3) Improve understanding of the management of difficult to treat chronic rhinosinusitis.

Program Description: Balloon catheter technology was introduced to otolaryngology in 2005 for management of paranasal sinus inflammatory disease. Since its introduction, it has engendered considerable controversy with proponents for and against adoption of the technology. Over time, alternate balloon devices have been advocated for office-based sinus ostia dilatation. Balloon technology has been promoted to be less invasive resulting in reduced pain and quicker recovery, generating significant press and interest by the lay public looking for new solutions for sinonasal problems. Thus, proper vetting of the balloon devices is essential to elucidate their proper role in the surgical paradigm for management of chronic rhinosinusitis. This miniseminar will objectively evaluate the currently available operative suite and office-based balloon catheter technology. Rhinologists with considerable experience without commercial conflicts on balloons will assess the frank advantages and limitations of the current balloon devices. Evidence-based review will be incorporated to assess the strengths and weaknesses of the existing peer-review literature. The potential complications unique to balloon catheters will be reviewed. The concerns of radiation exposure from fluoroscopy will be discussed. Current coding dilemmas and socioeconomic issues will also be addressed. At the conclusion of the miniseminar, participants should have a better understanding of the potential strengths and weaknesses of the balloon catheter technology in the context of management of paranasal sinus disease. This information will also serve as the foundation for better evaluation of new technologies that are introduced to our specialty. The miniseminar will be presented in a multimedia powerpoint format with video demonstrations, when applicable. Audience participation will be encouraged to stimulate discussion through the course of the miniseminar.

Educational Objectives: 1) Review currently available balloon catheter technologies and to explore implications on the FESS paradigm. 2) Critically appraise the existing peer-review literature and address potential complications and radiation exposure. 3) Assess socioeconomic implications and CPT coding issues related to balloons.

Program Description: The treatment of chronic rhinosinusitis (CRS) requires extensive skill in surgical and medical management strategies. Innovations in this field are constantly evolving. Not uncommonly, payers are hesitant to compensate for technology that is innovated and has not yet stood the test of time. The presentations will provide specific citations for the clinician to effectively communicate with payers, patients, and hospital administrators. The purpose of this miniseminar is to provide a state-of the-art summary of the best scientific evidence available to help clinicians treat patients with CRS. This miniseminar will present the highest level of evidence-based medicine available for: 1) endoscopic sinus surgery, 2) balloon sinuplasty, 3) image-guided sinus surgery, and 4) medical management of CRS. By focusing on strong, well-performed clinical studies, the attendee will learn the research studies that directly impact the surgical and medical treatment of CRS. The miniseminar will conclude with applying this evidence-based research to clinical cases to solidify the applicability and understanding of the research presented.

Educational Objectives: 1) Recognize the state-of-the-art evidence-based research for the management of CRS. 2) Apply evidence-based clinical research to improve medical and surgical treatment of CRS. 3) Understand evidence behind recent advances in the treatment of CRS including image-guidance and balloon sinuplasty.

Program Description: The miniseminar will consist of a lively panel discussion on the newly developed AAO-HNS clinical consensus statement (CS) on the appropriate use of computed tomography (CT) for paranasal sinus disease. There is increasing scrutiny by government, health policy makers, and third-party payers, regarding issues of radiation safety and appropriate utilization with CT imaging. Unlike clinical practice guidelines that could encompass other disciplines, CSs produced by the AAO-HNS are focused on the specialty of otolaryngology-head and neck surgery. Because clinical evidence is lacking, the terms “evidence-based,” and “guideline” should not be used in the context of CSs. Nonetheless, the development panel has conducted a systematic review to ensure that the best available evidence is identified to support decisions, even if this evidence is limited to case series or previously published consensus documents.

Educational Objectives: 1) Learn about the systematic review that was conducted to identify the best available evidence to support decisions on the appropriate use computed tomography (CT) for paranasal sinus disease. 2) Understand when it is most appropriate to use CT for paranasal sinus disease.

Program Description: Functional Endoscopic Sinus Surgery (FESS) is one of the most frequently performed procedures in otorhinolaryngology and is thus responsible for a significant incidence of complications. Thorough knowledge of the paranasal sinuses and their surrounding structures and adequate surgical experience are keys to preventing surgical complications. Special considerations in hemostasis help optimize visualization and increase safety. Meticulous preoperative review of the patient’s imaging studies is critical in successfully identifying the patient’s unique anatomic and surgical issues, thereby facilitating avoidance of complications. Maxillofacial CT is an absolute requirement prior to surgery, and systematic review of danger areas is critical. These will be reviewed and discussed in detail. Despite these preparatory measures, both minor and major complications may still occur. The surgeon must therefore possess the skill set to deal with these complications in order to consider him- or herself a safe surgeon. Specific complications including cerebrospinal fluid leak, neurovascular injuries, and orbital complications will be discussed in a case presentation format. Algorithms on how to address such scenarios will be presented. Finally, the medicolegal aspects of surgical complications will be considered including documentation and discussion with the patient and their families.

Educational Objectives: 1) Learn strategies to avoid complications during FESS. 2) Understand management (both surgical and medicolegal) of FESS-related complications.

Program Description: Background: AAAAI set up a working group for non-allergic rhinitis (NAR) 2 years ago to describe established facts about NAR with the purpose of identifying gaps in our knowledge based on a comprehensive review of existing literature. Dr Toskala is a member of this working group and most of the review data is now available. Methods: A literature search spanning the years 1960-2010 was performed and articles relevant to NAR were assigned into 7 categories. Information from each article was extracted into category-specific databases. Descriptive analyses were conducted. Results: A total of 2000 articles were reviewed out of which 40% were deemed relevant for data extraction. Reviews were excluded. The majority of articles described prospective, controlled studies. Very few articles offered epidemiologic information. The lack of universal terminology and of NAR phenotyping using objective criteria were the most striking knowledge gaps. Pathophysiology research covered areas of nasal hyperreactivity and autonomic nerve dysfunction, but the evidence was inconclusive. The presence of mucosal inflammation may identify distinct NAR syndromes such as local allergy with local IgE production in the absence of systemic sensitization. Medical management studies suggest that intranasal steroids and topical antihistamines are useful in some patients with NAR, but the responder phenotype is unclear. In patients with excessive rhinorrhea, anticholinergic treatment is effective. The use of capsaicin is supported by one randomized, placebo-controlled trial. Few combination trials were found. Many surgical procedures were reviewed, but there are no randomized controlled trials comparing medical versus surgical treatments.

Educational Objectives: 1) Recognize, diagnosed and treat patients with NAR according to the evidence-based data. 2) Give a comprehensive review of published data about NAR with classification of the evidence. 3) Identify the gaps in our knowledge about NAR.

Program Description: Food allergies are difficult for the patient to understand and challenging for the clinician to treat. The CDC has recently reported that the prevalence of reported food allergies increased 18% over the past 10 years in children under 18. In addition, children with food allergies are 2 to 4 times more likely to suffer from asthma and other allergies. Allergic reactions to foods can produce life-threatening anaphylaxis, but have also been associated with other head and neck problems such as Meniere’s disease, migraine headache, chronic rhinitis, and chronic serous otitis media. There is a wide range of symptoms attributed to food allergies, such as nausea, cramping, diarrhea, dermatitis, urticaria, asthma, and joint pain. However, despite the fact that otolaryngologists see a large number of patients with food allergies, diagnosis and treatment strategies still remain controversial. The first part of the miniseminar will focus on the scientific basis of food allergies by taking a critical look at the latest scientific evidence available in the literature. A basic review of the relevant immunology will be provided along with a comparison of IgE-mediated food reactions versus non-IgE-mediated food reactions. The impact that food preparation and food spoiling has on allergic pathways will also be examined. In the second part of the miniseminar, the manifestations of food allergies will be discussed. The recent literature concerning the rise in prevalence of food allergies will be analyzed and the impact of food allergies on the head and neck and airway will be reviewed. We will examine the role of oral tolerance in human evolution and the relationship of failure to achieve oral tolerance on the health of the individual. The next section will be devoted to the current diagnostic modalities available for the diagnosis of food allergies. The use of structured patient-completed surveys to maximize thoroughness and efficiency will be discussed. We will compare the performance and accuracy of the different methods of food allergy testing, including skin and in vitro methods vs. the traditional gold standard of double-blind, placebo-controlled food challenge. The final part of the presentation will be devoted to treatment strategies for food allergies. Traditional methods, such as elimination diets and recognizing emergencies will be reviewed, as well as more cutting-edge techniques, such as oral and sublingual desensitization and genetically modified foods, will also be discussed. Audio-visual materials will be used to help present this information to the audience.

Educational Objectives: 1) Analyze the literature comparing different methods for diagnosing food allergy. 2) Evaluate the scientific basis of IgE and non-IgE mediated food allergy. 3) Understand the currently available treatments for food allergy as well as future directions.

Program Description: Functional Endoscopic Sinus Surgery (FESS) is a well-established technique for treatment of patients with Chronic Rhinosinusitis. Applied in properly selected patients, FESS is associated with an 80% to 90% success rate. However, the remainder 10% to 20% of patients often have recurrence of disease and require subsequent surgery. This seminar will use a case-based approach to evaluate and discuss the common problems and difficulties that are seen by the revision surgeon. In the process of dissecting surgical situations that require revision, the panelists will discuss strategies to avoid recurrent disease and maximize the success of primary FESS. The panelists will be able to draw from years of revision FESS experience, as well as multiple publications. All clinical cases will be accompanied by endoscopic pictures and videos, as well as a complete complement of appropriate radiologic images. Special highlights of the seminar will include an emphasis on frontal and sphenoid sinus disease, as well as methods of perioperative medical treatment to achieve long term surgical success and improvement of outcomes.

Educational Objectives: 1) Identify common areas of post-operative sinus disease. 2) Learn surgical techniques that avoid the need for revision surgery, and revision surgery strategies. 3) Have a greater understanding of peri-operative medical treatments to improve surgical outcomes.

Program Description: There has been an explosion in the understanding of the mechanisms of chronic sinonasal inflammation. Multiple approaches to control and modify the inflammatory reaction in chronic rhinosinusitis have lead to many new agents being introduced topically to the nose. This miniseminar aims to provide an evidence-based approach to the science behind topical management of sinonasal disease. Current research into irrigation dynamics and delivery device will be discussed. There are a range of products available to deliver solutions topically to nose. The scientific basis behind high and low volume along with negative and positive pressure delivery is presented. The general therapeutic goal of topical management often lies between, potentially competing actions of mechanical and pharmaceutical intervention. Distribution research behind nebulizers, sprays, irrigations, and other delivery techniques is discussed within this framework. The over-the-counter (OTC) market for topical sinonasal treatments is likely to exponentially grow over the next few years. Increasingly, the pharmaceutical options have also grown. Antibiotics, such as mupriocin, and steroids are often added to solutions. Novel innate immunity enhancers and modifiers of mucus rheology are also emerging. The science behind the OTC agents and pharmaceutical additions to saline are presented. Potential adverse risks also needs to balanced with greater local intervention. The influence of pre- and postsurgical distribution efficacy is an important factor that significantly changes how these solutions should be used. The miniseminar is presented by rhinologists actively involved in the topical management of chronic sinonasal conditions both clinically and in research. Presentations for delivery, device, saline, and pharmaceutical additives will be given with video used to illustrate research. There is direct clinical application of current research and available products to the management of chronic sinonasal disease in general otolaryngology practice.

Educational Objectives: 1) Define the therapeutic goals of topical therapies. 2) Understand the influence of device and surgical state on topical delivery. 3) Learn about the science behind novel topical agents.

Program Description: This unique seminar will bring together leaders from both the American Rhinologic Society (ARS) and American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS). We will be examining both functional and aesthetic considerations in nasal surgery from workup to revision surgery. When it comes to nasal surgery, all aspects of anatomy and physiology should be considered, especially when functional and aesthetic surgery is combined. A thorough evaluation is important prior to cosmetic rhinoplasty, with or without septoplasty, including an evaluation of the septum, ostiomeatal complex and inferior turbinates, often using fiber optic endoscopy. The indications for CT scanning will be discussed in patients with sinus disease prior to rhinoplasty. Functional endoscopic sinus surgery can be performed at the same time as rhinoplasty precluding the need for a second surgical procedure. Benefits and contraindications for a combined approach will be presented. Prevention and surgical treatment of nasal septal perforations will be presented since nasal septal perforations most commonly occur following nasal surgery or cocaine abuse. Preventative measures to reduce iatrogenic occurrences will be discussed as well as surgical techniques to repair septal perforations of various sizes. “Functionally safe cosmetic rhinoplasty” will address potential functional pitfalls from cosmetic rhinoplasty. The speaker will target reduced cross-sectional area of the internal nasal valve following many standard rhinoplasty techniques. Methods for cosmetic rhinoplasty that preserve and/or enhance nasal valve function will be presented. Revision rhinoplasty is reported in 5% to 15% of patients. Based on a recent study, “Functional and aesthetic concerns of patients seeking revision rhinoplasty,” the most common complaints that patients present with, from the patients’ point of view, will be presented. This will be accompanied by a summary of these problems with tips on how to prevent them from occurring in the first place. Case presentations will highlight the above.

Educational Objectives: 1) Understand the importance of a detailed workup prior to nasal surgery and rhinoplasty. 2) Understand that functional endoscopic sinus surgery can be performed concurrently with cosmetic rhinoplasty. 3) Perform safe septorhinoplasty while maintaining function; prevent sepal perforations; learn why patients seek revision surgery.

Program Description: To describe the various tongue base surgical techniques that are available for patients with OSA. Why we do them, who we do them for, and when? Tongue base obstruction has been known to be one of the levels of obstruction in OSA. Surgical treatment of the palate alone has been shown to be ineffective in patients with high Mallampati grades, Friedman Stage II & III, and tongue base collapse seen on dynamic nasopharyngoscopy. Severity of OSA is currently known to correlate with degree of tongue base and lateral pharyngeal wall collapse. Patients with severe OSA are more likely to have tongue base obstruction. Airway evaluation is vital in the management and assessment of patients with OSA. The indications for tongue base surgery is pivotal in the decision making process. All the indications based on the clinical examination would be explored and discussed. Various tongue base surgical techniques are discussed, ranging from radiofrequency of the tongue base, genioglossus advancement, hyoid suspension, laser midline glossectomy, tongue suspension, coblator channeling techniques, and robotic tongue base surgery. The surgical steps are illustrated, success rates are presented, and complications are discussed.

Educational Objectives: 1) Apply the appropriate airway evaluation. 2) Choose the correct procedure. 3) Understand the technique behind each procedure.

Program Description: Media coverage, physician education, and continued research on the long-term sequelae of obstructive sleep apnea/hypopnea syndrome (OSAHS) have created a huge increase in the number of patients seeking treatment. At the same time, disillusionment with the results of classic surgery such as UPPP and genioglossal advancement has deterred many otolaryngologists from attempting to treat this condition. As the demand for treatment increases, diagnosis of OSAHS will become an increasingly significant component of every ENT practice and surgical treatment will remain an option for selected patients. The purpose of this course is to 1) Explain options for attached and unattached PSG or portable system, 2) Review new techniques and new clinical research on OSAHS, 3) Present a clinical staging system that helps identify appropriate treatment and predict the success for individual patients, 4) Identify patients with mild to moderate disease and those who are CPAP intolerant who could benefit from minimally-invasive and non-invasive techniques, 5) Present non-invasive treatment options that can be incorporated into an ENT practice. In addition to classical OSAHS treatment, the course will review a variety of polysomnogram systems and the strengths and weakness of each system. Our experience with Provent, a non-CPAP, non-invasive treatment option, will also be discussed in addition to thermoplastic mandibular advancement devices. Simplified systems to setup a joint venture with dental specialists for custom-made devices will also be presented. Presenters will discuss the economics of establishing a comprehensive sleep apnea center. We will detail startup strategies and costs for establishing a multidisciplinary sleep apnea team and center. In addition, coding and reimbursement procedures will be explained to maximize revenue production. Audience discussion will be encouraged and ample time will be allotted for a question and answer session.

Educational Objectives: 1) Learn how to incorporate sleep testing into an ENT practice. 2) Learn an algorithm for successful treatment of snoring and obstructive sleep apnea. 3) Understand the approach for proper identification and treatment of each anatomic site. 4) Identify patients who can be helped by multilevel minimally invasive techniques rather than classic surgery. 5) Learn how and when to incorporate custom-made mandibular advancement devices into an ENT/OSAHS practice.

Program Description: The American Academy of Sleep Medicine and Agency for Healthcare Research and Quality have recently published controversial systematic reviews of the obstructive sleep apnea (OSA) surgery literature. These are now being used by third-party payors to reconsider coverage policies, including those for soft palate procedures such as uvulopalatopharyngoplasty. The purpose of this miniseminar is to present these reviews and the debates they raise, examine the available higher level studies, and present a framework for evaluating OSA surgery outcomes. AASM and AHRQ reviews. Systematic reviews can synthesize are powerful but challenging tools that can help guide clinical decisions. Any review has general as well as specific strengths and weaknesses, whether related to methods that require oversimplification of each study’s findings, selection of outcome measures to compare results across studies, or the scope of the review that leaves certain studies excluded. This segment will examine the reviews’ methods and findings, highlighting their importance as well as gaps, particularly those regarding multilevel OSA surgery and the evaluation of sleep study outcomes alone. As for most surgical fields, the bulk of the OSA surgery literature consists of case series studies, with all of their inherent limitations. However, there are a number of higher level OSA surgery studies, including randomized trials and cohort studies. The program will review these higher level studies and provide grades for the available evidence concerning OSA surgical interventions. As for every surgical intervention, outcomes after OSA surgery vary widely, not only among various procedures but also for individual patients. There is a tendency to criticize or discard procedures that do not achieve ideal outcomes universally. The alternative is to pursue a nuanced evaluation of whether those patients who appear to respond to surgery achieve meaningful clinical improvements and also to match procedures and patients in order to increase the proportion of treated patients who do respond to surgery. This portion of the miniseminar will review evidence showing that there is a subgroup of patients who obtain meaningful clinical improvements after surgery, strategies to match procedures and patients, and a framework for presenting and reading results of sleep surgery trials that is based on this variation in outcomes.

Educational Objectives: 1) Learn the findings of recent OSA surgery reviews, along with their strengths and weaknesses. 2) Understand the findings of higher-level studies in the field. 3) Appreciate the variation in outcomes across procedures and patients, along with the implications.

Objective: The NHS Cancer Plan sets out a 2-week maximum wait for out-patient appointments for suspected cancers. The NHS Improvement Plan sets an 18-week limit from referral to treatment for noncancer cases. Research on evaluation of adherence to these targets is lacking, and we therefore present data to address this issue.

Method: An audit was performed at a local GP practice over a 4-month period. EMIS database was used to retrieve correspondence with commissioned ENT services. Date of referral, clinic attendance, type of investigations, and date of first definitive treatment were observed. Standards for the 2-week and 18-week target are both 100%.

Results: n = 31.97% (30/31) were compliant with the “2-week rule.” Only 42% (13/31) were compliant with the 18-week pathway. Of the cases that breached the 18-week pathway, 56% (10/18) were pending clinic, 33% (6/18) investigations and 11% (2/18) treatment.

Conclusion: Despite extensive frameworks formulated by the Department of Health for tackling waiting times, our data suggest that the local ENT services are not in compliance with the 2-week or 18-week standards. There is need for wider debate and national review.

Objective: It has been claimed that institutions engaging in academic activities provide better care. The aim of this study was to establish whether there is an association between academic output and mortality rates for NHS Trusts (NT).

Method: Standardized mortality rates for 2010 were obtained from www.drfosterhealth.co.uk. MEDLINE was queried to establish the number of citations credited to NT from 2006 to 2010. Admissions for NT for 2009-2010 were obtained from www.hesonline.nhs.uk. The number of citations per admission was calculated and used as an indicator of academic output.

Results: Spearman rank analysis was performed to identify any correlation between citations per admission and the inverse of 4 types of mortality rates: high risk conditions r = 0.20 (P = .01); low risk conditions r = -0.06 (P = .46); deaths after surgery r = 0.193 (P = .019); overall mortality 0.291 (P < .01).

Conclusion: The results of this preliminary study demonstrate a statistically significant correlation between academic output and mortality rates. However, it should be noted that the correlation coefficients are small, but the findings of this study encourage further debate.

Objective: 1) Understand the significance between the mean and maximum case numbers for surgical procedures among otolaryngology residents nationwide. 2) Understand potential weaknesses of the ACGME resident case log system and possible errors contributing to case inflation. 3) Understand when excessive case load transforms education into service.

Method: Retrospective review of otolaryngology resident national data reports from the ACGME resident case log system for 6 academic years (2004-2010). Maximum, mean, and standard deviation about the mean for total number of cases and for specific surgical procedures were compared. Tracked CPT codes, “unbundling,” and mechanisms for data entry were reviewed.

Results: The total case numbers for residents graduating from 2005 to 2010 remained fairly constant and ranged from a mean of 1699.5 ± 424.2 in 2007 to 1772.2 ± 517 in 2010. The maximum value for total number of cases increased from 3559 in 2007 to 4857 in 2010, and these values surpass the mean by 5 to 6 standard deviations in most years. Comparison of case numbers for other procedures such as parotidectomy, thyroidectomy, mastoidectomy, and endoscopic sinonasal surgeries, among others, yielded similar results.

Conclusion: Large differences between mean and maximum case numbers for resident surgical procedures exist and are expanding. Educational benefit derived from such excessive case load, if accurate, is unclear. Critical examination of the ACGME resident case log system and investigation of resident case log documentation habits are needed to improve accuracy.

Objective: While office based laser surgery (OBLS) for benign laryngeal disease is cost-effective for the patient, the financial impact on the office offering the service has not been characterized. We hypothesize that OBLS offers a savings to the patient which is not widely realized because the technology poses a financial liability.

Method: A 2-part cost analysis study was performed. First, cost and reimbursements for 50 patients undergoing OBLS was compared with 50 patients undergoing operative direct laryngoscopy with laser (DLL). Second, detailed financial comparison was done on a self-paired series of patients who had each undergone both OBLS and DLL.

Results: When compared with DLL, there was over $5,000.00 per case cost savings to the patient/third party payer for OBLS. Mean total reimbursement per DLL was $6,453.44, including hospital, anesthesiologist, and surgeon reimbursements of $5,150.00, $745.66, and $357.78, respectively. Based on a mean hospital DLL cost of $2,069.15, the hospital profited over $3000 per case. For OBLS in a nonfacility office setting, mean total reimbursement was $643.08 with mean procedure and laser fiber reimbursements of $596.52 and $46.56, respectively. Based on mean office expenses of $1,388.06 for equipment expenses and nursing staff, the office lost over $500 per OBLS case.

Conclusion: OBLS offers health care cost savings that are not widely realized because of the financial loss incurred by the office. An ideal reimbursement model is proposed that would cover the cost of OBLS, and could lead to nearly $400 million in health care costs savings annually.

Objective: 1) Understand the significance between the mean and minimum case numbers for surgical procedures among otolaryngology residents nationwide. 2) Understand potential weaknesses of the ACGME resident case log system and possible errors contributing to inaccurate data. 3) Understand educational definitions of competency and proficiency.

Method: Retrospective review of otolaryngology resident national data reports from ACGME resident case log system for three academic years (2007-2010). Minimum, mean, and standard deviation about the mean for total number of cases and for specific surgical procedures were compared. Comparison of “tracked” vs “untracked” CPT codes was also performed.

Results: The total number of cases for residents graduating from 2008 to 2010 remained fairly constant, ranging from a mean of 1701.5 ± 486 in 2008 to 1772.2 ± 517 in 2010. The minimum total number of cases also remained somewhat constant, ranging from 730 in 2009 to 811 in 2008, with these values falling approximately two standard deviations below the mean for most years. Comparison of case numbers for procedures such as parotidectomy, thyroidectomy, mastoidectomy, and endoscopic sinonasal surgeries, among others, yielded similar results. “Tracked” CPT codes tended to be fewer than “untracked” CPT codes for some surgical procedures.

Conclusion: Large differences between the mean and minimum case numbers for resident surgical procedures exist. Establishing minimum case number requirements for otolaryngology residents should be considered. Closer critical examination of the ACGME resident case log system and resident documentation habits is needed to improve accuracy of reporting.

Objective: Patient safety of surgical patients depends on correct identification and tracking in the operating theater. Additionally, surgical resources, presented patient data from the electronic patient chart, and surgical documentation are highly variable depending on the surgical procedure.

Method: We compared the surgical workflow of ENT-surgical patients equipped with a QR-code based OR-Ticket. The ticket provided relevant electronic patient data: name, surname, date of birth, surgical procedure, operative site and side. The time for pre- and postoperative patient tracking and surgical documentation was investigated for 50 exemplary procedures.

Results: The time for the generation of the OR-ticket could be neglected because it was directly printed from the electronic patient documentation system. There were no technical problems with the readout from the OR-ticket. All patients were identified correctly. The time for patient identification was reduced compared with standard procedure. The time for documentation purposes was reduced compared with standard documentation.

Conclusion: The OR-ticket provides the possibility to improve patient safety and ergonomics in the operating theater. Further technical development may provide automatic presentation of relevant patient data in the surgical cockpit and concentrate surgical resources depending on the identified patient and procedure, especially in operating theaters with a high patient turnover.

Objective: Little information is available regarding the frequency of thyroidectomy related malpractice claims. Previous studies have not assessed claims that were settled or dropped before trial, providing only a limited view of the medical-legal environment. We sought to determine the frequency of thyroid surgery related malpractice claims, their causes and outcomes.

Method: The database of the Physician Insurers Association of America (PIAA) was reviewed. This data is estimated to represent 25% of medical malpractice claims in the United States. Claims from 1985 to 2008 with thyroid-related procedure codes were evaluated for claimant information, insured’s specialty, loss description and causation, and claim outcomes.

Results: During the 23-year period reviewed, 381 claims related to thyroid surgery were reported. 128 claims (33.6% of total claims) resulted in an indemnity payment either due to settlement or a finding against the defendant. The average indemnity payment was $185,366 (range $363 to $2,000,000). Among cases in which a specific outcome was reported, 55 were related to laryngeal nerve injury or voice disturbance. No marked change occurred in the incidence of claims across the study period. During this time, approximately 2,585,000 thyroidectomies were performed. Extrapolating from PIAA data, this works out to an estimated 1.5 claims per 10,000 cases.

Conclusion: Malpractice claims related to thyroid surgery are surprisingly infrequent. While the rates of thyroid surgery have risen steadily, there has not been a corresponding increase in related malpractice claims.

Objective: 1) Define practice patterns and perceptions of young otolaryngologists treating maxillofacial trauma. 2) Identify manners in which the AAO-HNS can meet future maxillofacial trauma needs.

Method: A 26-question survey was designed to identify demographic factors, practice patterns, perceptions of facial trauma, and areas for improvement in trauma care. It was distributed anonymously to AAO-HNS members who completed residency from 2005 to 2009 and analyzed using descriptive statistics.

Results: A total of 444 of 1378 (32%) otolaryngologists responded. A total of 85% treat maxillofacial trauma (<1 case/month). A total of 64% identify trauma as part of their ideal practice. Sense of duty (54%) and institutional requirement (33%) are the most common reasons for trauma participation. Major deterrents: patient noncompliance (60%) and lifestyle limitations (47%). While insufficient reimbursement is a major deterrent (52%), only 35% would increase their volume if reimbursement improved. Sixteen (3.7%) have had a trauma-related lawsuit. Increased education represents the most common request to the AAO-HNS (59%), followed by focus on improved reimbursement/tort reform (28%). Topics proposed: practice guidelines, pediatric, laryngeal, and midface trauma.

Conclusion: Most otolaryngologists treat facial trauma, but do so infrequently. A total of 64% of young otolaryngologists identify trauma as a component of their ideal practice. However, universal concerns include inadequate reimbursement, limited pool of treating physicians, and lack of practice guidelines.

Objective: Unplanned hospital re-admissions are a significant source of morbidity and mortality and are a major fiscal burden to the National Health Service. The cost of re-admissions to ENT services has not previously been described. We present an audit, evaluating the cost per patient for ENT re-admissions in our department.

Method: A prospective audit of all ENT patients who were re-admitted within 28 days of initial discharge over a 3-month period was observed. Cost was calculated using the Department of Health reference books.

Results: n = 24 (17 emergencies, 7 elective) Emergencies: 53% otitis externa (7/17) and tonsillitis (2/17); all returned due to pain. Elective: 86% posttonsillectomy, including hemorrhage (3/7) and pain (3/7). Cost: Total: £25’237.50 (£1051.56 per patient) Otitis externa: £8983.61 (£1122.95 per patient) Post-tonsillectomy bleed/pain: £4670.21 (£778.37 per patient) Otitis externa/post tonsillar combo: £9761 (39% of total cost).

Conclusion: Unplanned re-admissions to ENT cost £25,237.50 over three months. Nearly 40% of this was due to otitis externa, tonsillitis, or as a postoperative complication of tonsillectomy due to suboptimal analgesia. We would recommend greater awareness of departmental caseloads as a means to develop targeted strategies in reducing re-admissions.

Objective: 1) Evaluate the aesthetic parameters of Caucasian noses of Curitiba, Brazil, and compare them with standard aesthetic ideals from the literature.

Method: Prospective cohort study through assessment of anthropometric measurements (intercanthal width [IW], alar width [AW], length, nasofrontal angle [NFA], nasolabial angle [NLA], nasal tip projection) of the Caucasian noses from photographs and comparison with the ideal of literature, with statistical analysis.

Results: A total of 100 volunteers were evaluated, including students and employees connected to the Health Department of HC/UFPR. Met IW0 (sd:8), NLA range 105,430 (sd:10,5) and nasal tip projection 0.63 (GoodeMethod) and 2.1:1 (Baum Method). The naso-frontal angle showed statistical significance between genders (p = 0.0008).

Conclusion: Caucasian noses of Curitiba are shorter, with a wider base, and less projected than the aesthetic ideal, showing possible miscegenation of the population and the importance of population studies for evaluation, preoperative counseling, and surgical planning.

Objective: 1) Develop a model to evaluate biocompatibility and integrationof novel porous bioscaffolds for maxillofacial and plastic reconstruction usingsphere-templated angiogenic regeneration (STAR) technology. 2) Demonstrate substrate-independence of STAR technology. 3) Perform a pilot study to compare a novel STAR implant withcurrently available synthetic and biologic soft tissue implants.

Method: Five pigs underwent dorsal subcutaneous implantation of a polypropylene-based material coated with precision pore silicone granules (STAR scaffold), expanded polytetrafluoroethylene, human dermis, and porcine dermis. Sham dissection was also performed. Specimens were harvested 7, 21, 90, and 180 days after surgery and evaluated histologically for inflammation, neovascularization, and collagen deposition.

Results: All materials and sham sites induced a mild to moderate inflammatory response that decreased over time, except for human dermis, which elicited persistent marked inflammation. Overall, expanded polytetrafluoroethylene elicited the most favorable foreign body reaction and demonstrated minimal chronic inflammation. The STAR scaffold demonstrated the greatest number of foreign body giant cells adjacent to the silicone granules, highlighting the importance of using inert biodegradable substances for bioscaffold constructs in future studies. All materials were similarly encapsulated with a layer of poorly vascularized collagen. Porcine dermis, sham dissections, and the STAR scaffolds received the best scores for collagen deposition and encapsulation.

Conclusion: Implantation studies in an in-vivo pig model revealed that polypropylene/silicone-based STAR implants confer no advantage over expanded polytetrafluoroethylene, the current gold standard for soft tissue reconstruction. Future testing of less reactive, biodegradable materials for STAR constructs such as hyaluronic acid may show an improvement over current soft tissue implants.

Objective: Evaluate the methodology and outcome of open structure rhinoplasty after adapting Quality Assurance (QA) principles during planning, surgery and follow-up. Quality assurance broadly means conforming to standards, meeting customer expectations and fulfilling consumer satisfaction.

Method: Retrospective study was conducted on 82 patients who underwent open structure rhinoplasty. Patient expectation was measured by comparing preoperative virtual image with the postoperative real one. Patient satisfaction was measured by validated procedure-specific Quality-of-Life questionnaires. Conforming to standards was evaluated through assessing aesthetic measures and functional parameters.

Results: A total of 91.4% of the surgeries met patient expectations while 93.3% fulfilled patient satisfaction. A total of 85.4% of cases conformed to aesthetic nasal measures while 92.7% to functional clinical parameters.

Conclusion: Adapting QA principles to rhinoplasty allowed standardization of methodology and assessment of results in precise and accurate manner. It enhances education through defining norms, analyzing variants, addressing deviations, and better planning through proper selection of techniques and customized sequencing of steps. It allowed achievement of preoperative goals effectively and efficiently.

Objective: 1) Assess donor site morbidity following harvest of osteocutaneous radial forearm free flaps (OCRFF). 2), Evaluate patient perceived upper limb disability for osteocutaneous vs fasciocutaneous radial forearm free flaps

Method: Retrospective cross-institutional review of OCRFF performed between 2001 and 2010. There were 218 included patients. The primary outcome measure was forearm donor site morbidity. The Disability of the Arm, Shoulder and Hand (DASH) questionnaire was used to compare patient perceived arm disability for osteocutaneous vs fasciocutaneous radial forearm flaps.

Results: Mean patient age was 63 years with a male predominance (63%). The left arm was the donor site in 86%. Median bone length harvested was 8 cm (range, 3-12 cm). Following harvest, the radius was plated in 99% of patients. Recipient sites primarily included the mandible (62%) and maxilla (34%). Donor site morbidity included fracture (2 patients, 0.9%) and sensory neuropathy (5 patients, 2%). Fractures were treated with open reduction and internal fixation without functional deficits. Hardware extrusion was the most common complication at the recipient site (29 patients, 13%).

Conclusion: Reluctance to perform OCRFF by surgeons usually centers on potential donor site morbidity. However, we identified minimal objective or patient perceived donor site morbidity following harvest of OCRFFs.

Objective: Nanofiber-supported, in vitro-generated cartilage may represent an optimal starting material for the development of a cartilage implant for use in microtia reconstruction. We aim to characterize the molecular composition of endogenous auricular cartilage and determine if human umbilical cord mesenchymal stem cells (hUCMSCs) can be differentiated into cartilage in vitro.

Method: Human ear cartilage from normal adults, patients with microtia, and pediatric patients with preauricular appendages were analyzed for collagen I, II, and X, and elastin expression. In parallel, hUCMSCs were cultured on nanofiber scaffolds for 21 days under chondrogenic conditions. Cells were harvested for histologic, biochemical, and quantitative PCR analysis.

Results: Histologic analysis of human ear cartilage revealed similar levels and distribution of collagens I, X, and elastin. Collagen II was not highly expressed in the microtia samples (P ≤ .0001). hUCMSC cultures stained positively for glycosaminosglycans and sulfated proteoglycans. Compared with control cells, hUCMSCs grown on PLGA nanofiber scaffolds had more extensive glycosaminosglycan production (P ≤ .03), a higher differentiation index (P ≤ .02), and higher levels of collagen X mRNA expression (P ≤ .005).

Conclusion: These data provide information regarding the composition of endogenous ear cartilage and suggest that hUCMSCs grown on PLGA nanofiber scaffolds may represent an optimal starting material for the development of a cartilage implant for use in microtia reconstruction.

Objective: 1) Evaluate the feasibility of an automated zonal facial function grading system through comparison with the House-Brackmann II (HBII) scale. 2) Determine whether such a computerized tool for facial analysis patients can provide objective, accurate, and reproducible assessment in both global and zonal regions of the face.

Method: A prospective clinical trial was performed with 77 consecutive new facial paralysis patients undergoing standardized facial videography. Videos were independently scored by 3 facial nerve specialists using the HBII scale. Subsequent digital analysis was performed with Facogram software, and computer-generated scores were recorded and compared.

Results: Interobserver correlation was high using the HBII scale, with correlation coefficients of 0.81, 0.86, and 0.84. Automated Facogram scores correlated well with manual HBII (scores were within 1.0 ± 0.59, 1.4 ± 1.1, 1.1 ± 1.0, 1.1 ± 0.8, and 1.4 ± 0.8 for overall grade, brow, eye closure, nasolabial fold, and oral commissure, respectively). The HBII required more clinician time to calculate, with an average of 72 ± 21 seconds per case, compared with the Facogram which did not require any clinician time. Specific patient characteristics and video techniques that improved accuracy of the software were identified.

Conclusion: An automated, zone-specific facial analysis tool would eliminate inter-rater subjectivity and allow assessment of facial paralysis patients in a standardized manner across geographic regions and medical specialties. Facogram correlates well with the HBII system. Clinicians should understand the ideal patient population and videotaping technique to optimize accuracy of the program.

Objective: The safe and reliable reconstruction of composite mandibulectomy defects is a topic of significant interest. Unfortunately, a well-established small-animal model of the segmental composite mandibulectomy does not exist. We describe a reliable animal model that can be utilized to study mandibular reconstruction techniques, including atuogenous bone grafts and biomaterials.

Method: Prospective analysis of survival-operations in the rat model (4-month Sprague Dawley Rattusnorvegicus). A detailed, stepwise description of surgical technique and relevant intraoperative anatomy is presented, utilizing photographic and radiographic images. Postoperative management, early pitfalls, surgical complications and future applications are discussed.

Results: A total of 72 operations were performed by a single individual between July and October 2010. Two intraoperative and seven postoperative complications were recognized. There were 4 orocutaneous fistulas, 1 abscess, and 1 seroma. There were 3 fatalities; deaths were attributed to anesthetic complications (2, intraoperative) and foreign-body aspiration (1, postoperative).

Conclusion: The novel animal model described here, reliably replicates the en-bloc segmental mandibular defects seen in our patient population. It can be manipulated to achieve a wide variety of research objectives, including the evaluation of biomaterials and tissue engineering techniques.

Objective: Compare surgical and speech outcomes between the double-opposing Z-plasty (Furlow) palatoplasty vs the 2-flap palatoplasty based on the width of the palatal cleft.

Method: A prospective study of 232 patients with cleft palate repair from April 1995 to March 2010 at a tertiary care institution. The cleft palate was measured (mm) and repaired with a Furlow or 2-flap palatoplasty. Outcome measurements include fistula rate and secondary velopharyngeal insufficiency (VPI) repair.

Results: Primary cleft palate repair was performed on 232 patients by Furlow palatoplasty (n = 96) or 2-flap palatoplasty (n = 136). Patients were subdivided into 4 groups based on width: Group A 1 to 5 mm (n = 57), Group B 6 to 10 mm (n = 38), Group C 11 to 15 mm (n = 72), Group D 16 to 30 mm (n = 4). Fistula rates increase as the width of the palatal cleft increases. Fistula rates are similar between the Furlow and the 2-flap palatoplasty for each palatal width, except for clefts greater than 16mm. Two-flap palatoplasty has a higher rate of velopharyngeal insufficiency for all groups of cleft patients.

Conclusion: At our institution the Furlow and 2-flap methods of palatoplasty have similar fistula rates for all cleft widths; however the Furlow method has decreased risk for subsequent velopharyngeal insufficiency compared with the 2-flap method. These data should encourage performance of the Furlow palatoplasty whenever feasible.

Objective: Present a novel technique utilized by the senior author for support of unstable, comminuted nasal bone fractures and its adaptation to rhinoplasty and septal surgery to provide greater stabilization of the nasal septum and bones. Illustrate safe and adequate results with this technique.

Method: Retrospective chart review of the senior author’s past surgical procedures since 2001 utilizing this Double-Doyle intranasal airway splint technique. Patient demographics, diagnoses, surgical procedure, stenting duration, and complications were identified. This technique involves 2 modified Doyle II intranasal airway splints (Medtronic) to provide greater intranasal support.

Results: Eighty-seven cases involving the Double-Doyle intranasal airway splint technique performed for closed nasal reduction, selected cases of open rhinoplasty, and septal procedures revealed overall that this intranasal splint modification was safe, tolerated well by patients, and presented minimal morbidity. All but one patient experienced a successful cosmetic and functional outcome as described by the senior author. Six overall possible complications were noted; 3c cases of minor nasal mucosa damage and 3c cases of possible infection that resolved after removal of the splint and treatment with antibiotics.

Conclusion: We present a safe technique that provides prolonged nasal dorsal support in severely comminuted nasal bone fractures without the need for external suspension devices or additional incisions. Additionally, this technique may be applied to rhinoplasty and septal procedures involving significant septal correction to allow greater stabilization of the septum postoperatively.

Objective: The Facial Artery Mucosa Muscular (FAMM) Flap, described by Pribaz in 1992, can be used in oral surgery on different indications. The primary reconstruction after the resection for an oral cancer is the most evaluated indication.

Method: Thirty-five cases from the University Hospital of Brest Head and Neck Surgery Center between April 2007 and November 2010 were analyzed in a retrospective study. The indication, the status of treatment (post chemoradiotherapy or not), complications (hematoma, infection, necrosis), the weaning delay of the pedicula, and time to an oral feeding were all analyzed.

Results: Twelve cases for primary reconstruction, 7 cases for buccosinusis defect and 16 cases in osteoradionecrosis. One case of hematoma, no infection and no necrosis were observed. One case did not give a good result. There is no difference in terms of viability between postchemoradiotherapy surgery. The weaning delay and the time delay to an oral feeding is twice longer after radiotherapy.

Conclusion: This flap can be used after radiotherapy with a precaution of care. The FAMM flap represents a good solution event after chemoradiotherapy for the loss of medium size substance, it represents a good solution between directed healing and more consistent skin flaps.

Objective: Examine the effect of both local and systemic dexamethasone administration on facial nerve return of function after complete axotomy and immediate microsurgical repair in a rat model. After nerve injury, an exaggerated neuro-inflammatory process may hinder regeneration. Therefore, our hypothesis is that glucocorticoid administration will improve nerve recovery.

Method: A total of 74 Wistar rats underwent facial nerve axotomy with immediate neurorrhaphy. Blinded and randomized, rats were assigned a postoperative group: control (no therapy), systemic dexamethasone 0.5, 1, 5, or 10 mg/kg for 3 doses, or topical dexamethasone 2 or 4 mg/mL. Standardized facial assessments and nerve conduction studies (NCS) were performed.

Results: At 8 weeks, rats receiving systemic dexamethasone at 1 and 5 mg/kg attained greater eye blink closure (P = .014 and P = .018, respectively) and vibrissae motion (P = .018 and P = .023, respectively) compared with controls. Systemic dexamethasone at 0.5 and 10 mg/kg had similar facial motion to controls. Intraoperative topical application of dexamethasone 2 or 4 mg/mL to the neurorrhaphy site was not superior to controls. Gross facial motion assessments were corroborated with vibrissae motion frequency video analysis. NCS’s indicated an increased return of compound muscle action potential amplitude levels to baseline among rats that received systemic dexamethasone 5 mg/kg (P = .048).

Conclusion: In a rat facial nerve axotomy model, postneurorrhaphy systemic dexamethasone therapy improved functional and neurophysiological outcomes at doses of 1 and 5 mg/kg. Locally delivered steroid was not beneficial compared with control groups. Therefore, systemic glucocorticoid administration may provide a substantial recovery benefit after facial nerve injury.

Objective: Investigate the efficacy of graduated compression stockings (GCSs) at improving donor site skin graft take after fibula free flap (FFF).

Method: Retrospective review of 12 patients (13 donor sites) that underwent FFF for mandibular reconstruction over a 1-year period. One-third of the patients were instructed to use graduated compression stockings after removal of the initial wound-vac dressing. Wound healing was followed closely for all patients. Operative and comorbid factors were reviewed.

Results: Two patients reported regular GCS use and 2 were non-compliant. Both patients with regular use had excellent wound healing and 90% to 100% skin graft take. Of the remaining 11 donor sites, 3 had no wound complications, 4 had minor wound complications, 3 had major wound complications, and 1 was lost to follow-up. Skin graft area varied with an average of 25 cm² for GCS patients and 60 cm² for non-GCS. Cardiovascular disease, alcohol use, and smoking were more common among the non-GCS group with strong tendency toward patients with major wound complications. Other operative and comorbid factors were similar between groups.

Conclusion: Graduated compression stocking use demonstrates some promise for use in fibula free flap donor site healing. Patients wearing GCSs had excellent wound healing and no morbidities related to their use. Further studies are warranted to determine if improvement in fibular donor site wound healing occurs with GCS use.

Objective: 1) Examine the outcomes and complications from a single institution experience with free tissue transfer for craniofacial defects involving the orbit. 2) Discuss an algorithm for free flap reconstruction of the orbit and peri-orbital structures.

Method: A review of 42 patients who underwent free flap reconstruction for orbital or peri-orbital defects between September 2006 and January 2011 was performed at a tertiary care facility. Data reviewed included demographics, defect characteristics, free flap used, additional reconstructive techniques employed, length of stay, complications, and follow-up.

Results: Forty-four cases were identified; thirty-five required orbital exenteration. Periorbital defects included those resulting from significant soft tissue or bony removal from the midface, scalp, or skullbase. We present an algorithm for management of such defects. Free flaps used included anterolateral thigh (31), radial forearm (10), latissimus (2), and rectus abdominus (1). Additional reconstructive techniques were performed concurrently in 23 cases, and 4 patients required revision procedures. Fifteen (36%) patients experienced a complication with flap loss occurring in 2 (4.8%). Mean hospital stay and duration of follow-up were 9.9 days and 13 months, respectively.

Conclusion: Free tissue transfer allows for the safe and effective reconstruction of complex defects of the orbit and periorbital structures. Reconstructive choice is dependent upon the extent of soft tissue loss, midfacial bone loss, and skullbase involvement. The anterolateral thigh provides a versatile option to reconstruct the many cranio-orbitofacial defects encountered.

Objective: Investigate the incidence, bacteriology, and clinical outcomes of surgical site infection (SSI) after gracilis transfer for facial reanimation, with a focus on determining the optimal perioperative antibiotics in these clean-contaminated cases.

Method: A retrospective chart review was performed for facial paralysis patients who underwent gracilis free flap reconstruction from 2003 to 2010. Microbiology, medication allergies, type and duration of perioperative prophylactic antibiotics, surgery length, and ASA status were reviewed. Functional smile outcomes were compared between those who developed infections and those who were infection-free.

Results: Since 2003, 110 patients have undergone 116 gracilis free flap operations for facial reanimation, with 6 SSIs. All of the infections occurred in patients receiving clindamycin, levofloxacin, and/or cefazolin perioperative antibiotics. None of the patients who received ampicillin/sulbactam developed a SSI. Surgical site cultures from infected patients grew alpha-hemolytic streptococci, Haemophilus parainfluenzae, Fusobacterium, coagulase-negative staphylococci, and Neisseria. Notably, there were no methicillin-resistant Staphylococcus aureus (MRSA) infections. In the patients with SSIs, the mean oral commissure excursion improved by 7.49 ± 3.83 mm, which was not significantly different from noninfected patients with subjective excellent outcomes of 11.4 ± 7.1 mm.

Conclusion: In gracilis flap infections, the organisms identified were consistent with oral flora. Infections occurred in patients receiving prophylactic clindamycin, levaquin, and/or cefazolin, but not in those receiving prophylactic ampicillin/sulbactam. Infections were not associated with decreased functional outcome. These data may have implications for the optimal choice of prophylactic antibiotics.

Objective: To evaluate outcomes following lateral mandibular defect free flap reconstruction.

Method: Patients undergoing lateral mandibular defect free flap reconstruction from 1999 to 2010 at 2 tertiary care centers were classified into 4 groups based on type of reconstruction: 1) radial forearm swing (n = 8), 2) radial forearm with bar (n = 5), 3) osteocutaneous radial forearm (n = 73) and 4) fibula free flap reconstruction (n = 51).

Results: The majority of patients were male (67%) and presented with advanced T-stage (59%) squamous cell carcinoma (93%) involving the alveolus (26%) retromolar trigone (21%) or oral tongue (25%). The recipient site complication rate approached 35% and included infection and mandibular malunion (n = 9), exposed bone or mandibular plates (n = 7), venous congestion (n = 2), and flap failure (n = 6). Most patients demonstrated little to no trismus following reconstruction (81%) and were able to resume a regular or soft diet (61%). No difference in complication rates, hospital stay or postoperative outcomes was seen between osteocutaneous radial forearm and fibula free flap groups (P > .05).

Conclusion: Free flap reconstruction of lateral mandibular defects results in acceptable functional outcomes for the majority of patients including those who undergo osteocutaneous radial forearm free tissue transfer.

Objective: Silicone augmentation mentoplasty is a common procedure with consistent results in properly selected patients. While many plastic surgeons employ external approachs, the intraoral method affords acceptable aesthetic outcomes while avoiding an external scar. To date, a series of this magnitude involving the intraoral route has yet to be reported.

Method: A total of 125 patients underwent chin augmentation with silicone implants between 2004 and 2010. Among these implants, 105 were placed transorally. 85 patients were followed for at least one year. Demographic information, indications, patient satisfaction questionnaire results, and complications were recorded.

Results: All implants yielded satisfactory results with no displacement, infection, tissue reaction, lower lip incompetence, or mental nerve injury. In addition, no intraoral contamination of implants occured. Two cases of superficial mucosal irritation at suture sites were observed and resolved without consequence. Symmetry, projection, and overall balance of facial components were excellent as well. Although all patients were satisfied with the functional and aesthetic results, 20% stated they would like further augmentation. Patients were extremely satisfied with the lack of an external scar.

Conclusion: Silicone augmentation mentoplasty is a relatively simple, reliable, and aesthetically pleasing procedure associated with minimal morbidity. Based on our series, with the avoidance of excessively large implants, the intraoral technique is recommended for its lack of complications and circumvention of an external scar.

Objective: Determine the effect of vacuum assisted closure (VAC) on massive scapular and latissimus dorsi free flap donor site morbidity, when used over a closed incision line under great tension.

Method: Patients who underwent complex head and neck reconstruction with scapular fasciocutaneous/osteocutaneous and latissimus dorsi myocutaneous free flaps between the years of 2006 and 2010 at a tertiary academic referral center were identified and a retrospective chart review was performed.

Results: Seventy patients who underwent scapular or latissimus dorsi free flap reconstruction were identified. Those with and those without VAC over the closed incision line were identified. The method of application of the VAC dressing was performed by the same team at one institution. None of these patients required skin grafting, and only 1 patient had donor site breakdown secondarily requiring wound care and VAC replacement and 1 patient had an asymptomatic seroma; all others with VAC treatment over the closed incision line were without donor site complications.

Conclusion: Vacuum-assisted closure is a safe technique in the postoperative management of massive back free flap donor sites closed under great tension, and may eliminate the need for skin grafting. In our study, data suggests this approach decreases seroma formation and secondary wound breakdown.

Objective: Determine whether the type (paramedian forehead [PMFF] vs nasolabial [NLF]) or the defect thickness (full vs partial) play a role in take rates of interpolation flaps in nasal reconstruction.

Method: A retrospective chart review was performed on patients who underwent nasal reconstruction with 2-stage paramedian forehead or nasolabial flaps between 2002 and present. Defect characteristics recorded were thickness, size, location; flap type used for repair, utilization of cartilage grafts; and comorbidities, including diabetes, peripheral vascular or coronary artery disease, and smoking habits.

Results: A total of 107 total patients; 82 (76%) reconstructed using 2-stage paramedian forehead flap; 25 (24%) using a 2-stage nasolabial flap (NLF). A total of 47 PMFF and 12 NLF were used for full thickness defects. Overall failure rate was 5%, both partial and complete. Five PMFF failed (7%), 3 full thickness. One NLF failed (4%), also full thickness. Any use of cartilage in reconstruction did not affect failure rates. Both flaps with complete failure were used more distally, while partial failure flaps for more proximal defects. No comorbities were noted to have a significant effect on failure rates, 5 out of 6 failures were in smokers.

Conclusion: This study provides outcome data when interpolation flap reconstruction, with or without cartilage grafts, is offered. Overall success rates for nasal reconstruction using interpolation flaps in this study were 94%. Thickness of defect and type of flap did not affect outcome, while positive smoking status did significantly affect failure rate.

Objective: In orbital floor fractures, the estimation of the herniated orbital content in the maxillary sinus has traditionally been the dividing line between surgical and nonsurgical management. We wanted to evaluate whether a relative change in volume would function as an indicator for surgical vs nonsurgical treatment of orbital floor fractures.

Method: This was a follow-up study in patients with untreated unilateral isolated orbital floor fractures admitted to our department from March 2003 to April 2007. The volume of the orbital contentwas calculated digitally from the patients’ CT scans at the time of their injury. 18 norms were included as controls.

Results: Five of 23 patients showed 2 to 4 mm enophthalmus, and only 3 of them had intermittent diplopia. No statistical correlation was found between the herniated volume and enophthalmus. No statistical correlation supporting the supposition that 1 mL herniated orbital content would result in 1mm enophthalmus was found.

Conclusion: The relative volume change between the fractured and nonfractured orbit in an individual does not appear to be a useful criterion for surgery. The importance of the herniated orbital tissue for the development of enophthalmus is unclear.

Objective: 1) Develop a method for quantification of osteotome sharpness in a rhinoplasty model, using artificial bone; 2) demonstrate changes in osteotome sharpness over multiple uses; and, 3) compare sharpness of osteotomes from different manufacturers at baseline and after multiple uses.

Method: Osteotomes were passed through synthetic bone blocks. Sharpness was measured using the Instron Universal Tester (force required to cut #2 Prolene suture) at baseline and after 1, 4, 7, and 10 osteotomies. Changes in sharpness over time were assessed using within-sample t tests. Comparison of manufacturers was performed with multiway ANOVA.

Results: A novel, prospective surgical model was developed. Osteotomes from 5 manufacturers were tested (Nextedge, Black & Black, Storz, Miltex, and Biomet). Baseline measurements showed that the Storz osteotome was sharpest (1.74 lbs, P < .001), followed by Miltex and Biomet (2.50 lbs, 2.68 lbs), and Nextedge and Black & Black (3.48 lbs, 3.40 lbs). All osteotomes except Nextedge (P = .098) demonstrated a significant decrease in sharpness over time (P = .02 to P < .001), though relative changes and absolute sharpness varied widely between instruments. ANOVA showed the Storz osteotome was significantly sharper across all uses and timepoints (P < .001). The greatest decrease in sharpness over time was seen with Black & Black (-1.28 lbs).

Conclusion: Otolaryngologists use osteotomes in cosmetic and functional rhinoplasty. Millimeter-level accuracy in these procedures is essential to maximize outcome and minimize complications. Multiple similar-appearing instruments are available, but their relative efficacy is infrequently tested. We have demonstrated that, at least in the case of osteotomes, not all instruments are created equally.

Objective: Create a local flap model in the rodent mimicking the rotational flaps used in head and neck reconstruction, secondarily to see if irradiation of this model will result in flap failure and necrosis.

Method: A 3 × 8 cm flap was designed over the right side of the abdomen pedicled off of the inferior epigastric. Left side of the abdomen a 3 × 8 cm defect at 60 degrees from midline was created and the flap was inset. On POD #7 area of necrosis was analyzed.

Results: Eight rats were irradiated with 40 gy in 4 divided doses over 8 days. Field of radiation was restricted to an 8 × 10 cm across the abdomen. One month elapsed for the irradiated group prior to surgery. The control group consisted of 5 rats without radiation. Seven rats in the radiation group completed the study. One rat was sacrificed because of self-mutilation after surgery. Four out of 7 (57%) rats in the irradiated group had necrosis of the distal flap ranging from 1 to 6 cm from the distal edge. No necrosis was seen in the control group. Histology revealed collagen and vascular changes in the irradiated skin.

Conclusion: The irradiated rat model of an axial rotational flap is consistent with what is seen in previously irradiated patients that develop skin necrosis after reconstruction with local rotational flaps.

Objective: 1) Learn how rates of operative facial fractures may have changed between 1996 and 2006. 2) Determine potential impact of such change on otolaryngology residency surgical key indicator cases.

Method: The National Hospital Discharge Survey (NHDS) and National Survey of Ambulatory Surgery (NSAS) 1996 and 2006 cases were reviewed, extracting all cases of nasal, malar/zygomatic, maxillary, and mandibular fracture reductions, in inpatient and outpatient settings, respectively. Procedure rates for each facial fracture were tabulated and compared between 1996 and 2006.

Results: Overall in 1996, there were an estimated 113,041 ± 3,740 operative facial fracture repairs performed. Among the 3 key indicator fracture repairs most relevant to otolaryngologists, there were 15,810 ± 2,143 open nasal fracture reductions, 9,360 ± 1,742 open zygomaticomaxillary (ZMC) fracture reductions, and 20,214 ± 2,585 open mandibular fracture repairs. Overall in 2006, there were 120,463 ± 7,554 total facial fracture procedures, with 11,613 ± 2,846 open nasal fracture reductions, 10,216 ± 2,881 open ZMC fracture reductions, and 17,965 ± 3,171 open mandibular repairs. Comparing cohorts, there was no significant change in number of open nasal, ZMC, or mandibular fractures repairs (P = .24, P = .58, P = .80, respectively).

Conclusion: Despite perceptions, facial fracture procedure rates have remained largely stable over the past 10 years. These data have implications for otolaryngology training programs and could help guide resident education in facial trauma.

Objective: Test the strength of internal fixation of mandibular condyle fractures repaired with titanium miniplates vs titanium intramedullary implants.

Method: Condylar osteotomies were created in 40 urethane hemimandible models and 24 human cadaveric specimens. Half of the samples in each group were repaired with traditional miniplates and the other half were repaired with intramedullary titanium pins. Anteroposterior and mediolateral loads were applied and the displacement across the fracture site was calculated.

Results: When subjected to physiologic and supraphysiologic loads, titanium intramedullary implants provided more resistance to bone fragment displacement than traditional miniplates. This was true for both the urethane model and the cadaveric mandible experimental groups. Mechanical failures in the miniplate groups were due to plate bending and/or screw extrusion. However, a 1.65 mm diameter titanium intramedullary pin did not mechanically fail in any of the cases. Intramedullary implantation failures were due to secondary fracture of the adjacent cortical bone under high forces or rotation of the smooth pin implant.

Conclusion: Mechanical failures which were encountered under physiologic forces with miniplate fixation were not seen with titanium intramedullary implants. These intramedullary implants provide stronger and more durable fixation of mandibular condyle fractures than traditional miniplates in both urethane and cadaveric laboratory models.

Objective: Vacuum-assisted closure of head and neck wounds has been previously described. Negative pressure wound therapy, although efficacious, has practical limitations in the outpatient setting. The purpose of this study is to describe a novel method of treating complex head and neck wounds using an ultraportable mechanical vacuum wound care system.

Method: A cohort study at 2 tertiary care centers. All head and neck patients with complex, low to moderately exudative wounds were treated by the senior author using the SNaP Wound Care System. Patient comorbidities, wound etiology, site, length of treatment, outcomes, and ancillary procedures were recorded.

Results: A variety of wounds was treated with this system and included mucocutaneous fistulas, a tracheocutaneous fistula, soft tissue defects of the head and neck, and tendon exposure of a radial forearm free flap donor site. Outpatient SNaP therapy was utilized in five patients with 6 small- to medium-sized wounds. This system was successful in obtaining wound closure in all patients. These patients were able to complete routine activities of daily living, participate in public social settings, and tolerate therapy without adverse events. One patient required an adjunctive procedure of split thickness skin grafting.

Conclusion: This study demonstrates a novel use of the first FDA-approved ultraportable, mechanical negative pressure device in the treatment of several complex head and neck wounds. The device has utility in the outpatient setting for adjunctive closure of wounds with minimal disturbance to patients’ activities of daily living and lifestyle.

Objective: Describe swallowing disorders encountered after Cerebellopontine Angle (CPA) surgery as well as to explore variables associated with increased incidence of postoperative dysphagia.

Method: Retrospective chart review of 181 consecutive patients undergoing surgical excision of CPA pathology from January 1, 2008, to December 31, 2010, at Johns Hopkins Hospital. Presence and characteristics of dysphagia were determined by speech pathologist reports. Clinical variables were extracted from the electronic medical record.

Results: Postoperative dysphagia was identified in 57 out of 181 patients (31%). Oral, oropharyngeal, and pharyngeal deficits accounted for 49%, 37%, and 12% of dysphagic symptoms respectively. Facial nerve weakness in the immediate postoperative period was noted in 91% of dysphagic subjects (mean House-Brackmann score of 4) compared with 43% of those without dysphagia (mean House-Brackman score of 2). Diet alterations were required for 65% of dysphagic individuals, and an additional 9% required tube-feeding. Common findings during Videofluoroscopic Swallowing Studies (VFSS) were pharyngeal residue, reduced pharyngeal constriction, and anterior bolus loss. Abnormal Penetration-Aspiration Scores (≥3) were found in 59% of those undergoing VFSS.

Conclusion: Oral and pharyngeal swallowing deficits are commonly encountered after CPA surgery. Consultation with a speech-language pathologist appears most critical for any individuals demonstrating postoperative cranial nerve dysfunction, particularly for those with evidence of facial nerve weakness. Early consultation may help to manage short- and long-term functional difficulties.

Objective: Investigate the safety and efficacy of a novel automated tympanostomy tube delivery system for the creation of a myringotomy and the placement of a tympanostomy tube for patients presenting with chronic otitis media with effusion and/or recurrent acute otitis media.

Method: A prospective, multicenter, single arm clinical study enrolled 53 subjects. Tube placement was performed in an operative setting using the Acclarent Tympanostomy Tube Delivery System (TTDS). Patients underwent physical examination and audiometry preoperatively and at one week postoperatively.

Results: A total of 53 subjects (47 subjects 5 years of age and younger) were enrolled in the study at 4 United States centers. From these subjects, 101 ears were enrolled and 5 were excluded because of study criteria related to condition of the tympanic membrane. There were no serious device-related adverse events. The primary efficacy endpoint, successful tube deployment across the tympanic membrane, was achieved: 95 of 101 (94%) attempted deployments in the cohort were successful. Tube retention was also evaluated as a secondary endpoint, and 94 of 95 (99%) tubes placed with the device were retained at follow-up.

Conclusion: The Acclarent TTDS is a safe and effective device for placement of tympanostomy tubes in patients with chronic otitis media with effusion and recurrent acute otitis media. Given the device’s safety, efficacy, and speed of tube delivery, further investigation of its in-office application under local anesthesia is warranted.

Objective: Recently, the use of low temperature pulsed radiofrequency (RF) energy has emerged as a method for efficient tissue dissection with minimal thermal damage. When used for tonsillectomy, anecdotal reports have cited improved recovery compared with traditional electrosurgery (ie, Bovie). We evaluated this technology in adults undergoing subcapsular tonsillectomy.

Method: Twenty adults were prospectively enrolled in this pilot study. Subjects were randomized to tonsillectomy with the PlasmaBlade (PB) or traditional electrosurgery (ES). Intra-operative time and blood loss were recorded; postoperatively, subjects blindly reported visual analog scale painscores, narcotic consumption, diet volume, and activity level using a validated form.

Results: The population age (34.7 ± 18.7 years, P = .75) and BMI (24.7 ± 3.9 kg/m², P = .44) were equivalent. Operative time was also equivalent for both technologies (7:36 ± 1:58 min, P = .99) with PB subjects demonstrating a 69% reduction in IBL (1.6 ± 1.8 vs 5.3 ± 7.9mL, P = .02) compared with ES. Postoperatively, PB subjects demonstrated a 40% (2.5 ± 1.2 vs 4.1 ± 0.7 Tylenol-Codeine/d, P = .002) reduction in narcotic consumption over the 10-day monitoring period. Modest improvements in activity level (6%; P = .83), diet volume (20%, P = .32), and VAS pain score (12%, P = .41) were also reported. However, these were not statistically significant.

Conclusion: The use of this new low-thermal damage electrosurgical technology for adult tonsillectomy appears to offer several advantages over traditional electrosurgery, notably in reducing narcotic consumption in the postoperative period. Larger population-based studies should be conducted to further examine these endpoints.

Objective: 1) Learn about the epidemiology of recurrent acute rhinosinusitis (RARS). 2) Understand healthcare costs attributable to RARS as a potentially underdiagnosed form of chronic rhinosinusitis.

Method: Medical claims data (2003-2008) from a large payer database were analyzed. Adult patients with RARS (defined as at least 4 acute rhinosinusitis [ARS] claims each with a filled oral antibiotic prescription in a 12-month period) were extracted. Diagnostic procedures, surgery rates, and medical costs were determined.

Results: A total of 4,588 patients were identified (mean age, 43.5 years; 72.1% female) among 13.1 million patients, for a point prevalence of 0.035%, which remained consistent across years. After 1, 2, and 4 years, 2.4%, 5.4%, and 9.2% of patients subsequently received nasal endoscopy and 11.4%, 23.5%, and 39.9% received paranasal sinus computed tomography, respectively. Similarly, 0.2%, 2.0%, and 4.1% underwent endoscopic sinus surgery at these same intervals. Average total healthcare costs related to RARS averaged $1207/patient-year. Antibiotic and nasal prescription costs averaged $210 and $452, and an average of 3.8 antibiotics were filled per patient-year with RARS.

Conclusion: RARS may affect approximately 1 in 3000 adults. Despite significant health care costs over $1000/year per individual patient with RARS, nasal endoscopy and computed tomography are not commonly obtained early after potential diagnosis. RARS is likely an underdiagnosed condition warranting further study.

Objective: One of the more common complications following total thyroidectomy is postoperative hypocalcemia. Numerous protocols have been developed over the years for management including perioperative parathyroid hormone (POPTH) levels and obtaining ionized calcium levels postoperatively with supplementation based on the values. Our goal was to perform a cost analysis of POPTH.

Method: We examined the postoperative hypocalcemia using ICD-9 codes for thyroid nodules and examined those that underwent total thyroidectomy. We excluded revision surgeries and pathology of cancer. The postoperative PTH values, initial ionized calcium, and number of calcium draws were obtained. The patients were then stratified based on initial PTH value.

Results: For initial PTH For initial PTH 21-50, the initial ionized calcium was 3.99 ± 0.38 and the number of laboratory draws was 3.8 ± 3.3. For initial PTH >50, the initial ionized calcium was 4.27 ± 0.37 and the number of laboratory draws was 2.5 ± 1.7. There was no significant difference in the initial ionized calcium between those that had an initial PTH drawn and those that did not.

Conclusion: For total thyroidectomies (benign goiter), there was no difference in the initial ionized calcium for PTH90 (P = .29). This suggests that PTH is not an adequate predictor of postoperative calcium level. Also there is a significant cost burden with obtaining the PTH level where tremendous savings could be achieved.

Objective: Apply a new classification of postoperative hemorrhage using a clear definition and seven grades (A1, A2, B1, B2, C, D, and E) depending on severity and based on the intensity of treatment needed. Postoperative hemorrhage was defined as every bleeding after extubation.

Method: Grade A: anamnestic recorded blood-tinged sputum; A1 dry wound, no coagulum; A2 coagulum, dry wound after removal. Grade B: bleeding actively under examination; B1 noninvasive treatment; B2 treatment in local anaesthesia. Grade C: hemorrhage needing treatment in general anesthesia. Grade D: dramatic hemorrhage requiring blood transfusion. Grade E: fatal hemorrhage.

Results: Of the 4594 patients undergoing tonsillectomy within 9 months evaluation period, 818 bleeding episodes had been recorded (17.8%). A1 bleeding episodes were recorded for 146 patients, A2 for 274 patients, B1 for 104 patients, B2 for 65 patients, C for 221 patients, and D for 8 patients. No fatal hemorrhage occurred. Surgical treatment was necessary in 4.6% of all patients. About half of all bleeding episodes have been anamnestic recorded. For patients with multiple bleeding episodes, light bleedings (grade A1 to B2) increased the risk for severe bleedings of grade C or D (P < .05).

Conclusion: Postoperative hemorrhage is strongly related to the definition of bleeding episodes. A new classification could have been approved for the first time in a large study population.

Objective: Demonstrate the expression of components of the Hedgehog signaling pathway (Hh) in HNSCC. A subsequent over-stimulation of this pathway is described in several types of malignancies and is associated with poor prognosis. Hh inhibition with antagonists like Cyclopamin (Cyc) may reveal a potential therapeutic relevance.

Method: iParaffin-embedded sections of 10 HNSCC were incubated with Alexa 568-labeled antibodies specific for Hh proteins. Further, we tested the effects of Cyc on the growth of KB cells and on HNSCC cells ex vivo in FLAVINO-bioassays alone and in combination with chemotherapeutic agents. Immunofluorescent colonies of epithelial cells were counted.

Results: Epithelial cells in HNSCC expressed components of the Hh-pathway (PTCH-1, PTCH-2, SMO, GLI, andSHH) preferentially at the invading tumor margins. The intensity and distribution of the staining was heterogeneous but significant. Peritumoral stroma cells stained partly positive, too. Cyc alone suppressed mitosis and proliferation of KB cells and suppressed the formation of cytokeratin-positive (CK+) colonies of HNSCC ex vivo in a concentration dependent manner. Further, Cyc enhanced the inhibitory effects of Cisplatin (Cis) and Docetaxel (DTX) on colony formation of CK+ cells in the KB cell line and in HNSCC ex vivo.

Conclusion: Our results underline a potential relevance of Hh in HNSCC. Additional targeting of Hh components may support established therapy regimens in HNSCC-treatment in the future and, therefore, represents a promising aim for drug discovery.

Objective: Evaluate the influence of oral contraceptives on the distribution and concentration of estrogenic receptors in nasal mucosa.

Method: There were selected 2 groups of 32 women, with regular menstrual cycles, who had undergone nasal surgery. One group of women was taking oral contraceptives and the other was not. Samples of mucosa of inferior nasal turbinate were analyzed by immunohistochemical staining for alpha and beta estrogen receptors.

Results: A decrease of beta-receptor in lamina propria cells with the use of oral contraceptives was observed. On the other locations there was not any statistically significant difference. In both groups there was a predominance of beta-receptor presence.

Conclusion: Women taking contraceptive pills had a decrease of beta-receptor in lamina propria cells.

Objective: 99mTc-sestaMIBI SPECT/CT has a proven value for diagnosis and localization of parathyroid adenoma (PTA). Present study compared diagnostic accuracy and image quality of half-time SPECT to standard full-time SPECT.

Method: A total of 90 patients performed 99mTc-sestaMIBI scintigraphy. “H”-mode, 360 degrees SPECT was performed 45 minutes after injection using standard and half-time protocols. The SPECTs were reviewed randomly. Results were graded as negative, probable, and positive. SPECT image quality was graded as poor, good and excellent. PTA detection and image quality were compared.

Results: A total of 85 studies demonstrated cervical 99mTc-sestaMIBI foci and 5 were ectopic. A total of 73 studies (81%) showed congruent PTA detection scoring. In 17 studies a difference of one level in the probability for PTA was found. One of the ectopic foci was demonstrated on standard full-time SPECT only. Image quality was graded as good or excellent in all studies. 64 studies (71.1%) showed the same image quality on full- and half-time SPECT acquisition including 39 graded good, and 25 graded excellent. No significant difference in image quality was found between SPECT techniques.

Conclusion: Significant reduction in acquisition time of 99mTc-sestaMIBI SPECT can be successfully implemented into SPECT/CT for a total study time of 9 min. Diagnosis and precise preoperative localization is obtained without compromising clinically significant information.

Objective: 1) Compare the rate of removal of Champy’s plates vs 8-hole strut plates used for repair of mandible angle fracture. 2) Determine the reason for removal of these plates.

Method: A retrospective chart review was conducted from 2006 to 2010 comparing the removal rate between Champy’s plates and 8-hole strut plates for internal fixation of traumatic angle mandible fractures at a large adult tertiary care hospital. The reason for removal of each plate was then determined from the clinical record.

Results: A total of 104 patients with a total of 106 angle fractures met the inclusion criteria for this study. A total of 73 angle fractures were treated with the 8-hole strut and 33 angle fractures were treated with Champy’s plates. There were 6 plates removed in both groups. This resulted in 8.2% of plates removed in the 8-hole strut plate group and 18.2% in the Champy’s group (P = .133). Loose hardware was determined to be the cause of plate removal in 1 (2.7%) of the 8-hole strut plate group compared with all 6 (18.2%) of the Champy’s group (P = .005).

Conclusion: In our experience, the 8-hole strut plate has a lower rate of plate removal compared to the Champy’s plate in treating mandible angle fractures. The main reason for plate removal was loose hardware. The rate of removal for loose hardware was higher and statistically significant in the Champy’s group.

Objective: Determine if there is any association between the Resident Otolaryngology Training Examination (OTE) score and the pass rate on the American Board of Otolaryngology (ABOto) Written Qualifying Examination.

Method: Data from the 2005 to 2009 OTE and the 2007 to 2010 ABOto Written Examination were available for comparison. Odds ratio, chi-squared test of independence, and logistic regression were used to determine the relationship between OTE score and passage of the written ABOto examination.

Results: The proportion of Board examination failures for those whose OTE score was in the bottom 10th percentile is 25%. Proportion of Board examination failures for those whose OTE score was above the 10th percentile is 7.29% (P = < .0001). Odds ratio analysis revealed that every 10 point increase in percentile corresponds to an estimated 50% increase in odds of passing the examination on the first attempt (OR = 1.54, SE = 0.08; CI = 1.39, 1.71). Logistic modeling showed no significant association for year of exam or cohort of residents.

Conclusion: There is a significant association between a lower score on the OTE and increased failure rate on the first attempt at the ABOto Written Qualifying Examination.

Objective: Despite any cautionary warnings from medical providers, searching internet websites is likely to be a patient’s (or parent’s) first step in obtaining timely information on the treatment of common otolaryngology problems. The quality of the information a patient (parent) may encounter using a Google search for typical otolaryngology ailments was critically examined.

Method: A Google keyword search was performed for 10 common otolaryngology problems including ear infection, hearing loss, tonsillitis, etc. The top 10 search results for each were critically examined using the 16 item (1-5 scale) standardized DISCERN instrument. The DISCERN instrument was developed to assess the quality of patient treatment choice literature.

Results: A total of 100 websites were assessed. Nineteen (19%) were primarily advertisements for products and were excluded from DISCERN scoring. Searches for more typically chronic otolaryngic problems (eg, tinnitus, sleep apnea) resulted in more biased, advertisement results than typically acute problems (eg, ear infection, sinus infection, P = .03). The search for “sleep apnea treatment” produced the highest scoring results (mean overall DISCERN score, 3.49; range, 1.81-4.56), and the search for “hoarseness treatment” produced the lowest scores (mean, 2.49; range, 1.56-3.56). Results from major comprehensive websites (WebMD, EMedicinehealth.com, Wikipedia, etc) scored higher than other websites (Mean DISCERN score, 3.46; vs 2.48; P < .001).

Conclusion: There is marked variability in the quality of website information for the treatment of common otolaryngologic problems. Searches on more chronic problems resulted in a higher proportion of biased advertisement websites. Larger, comprehensive websites generally provided better information but were less than perfect in presenting complete information on treatment options.

Objective: Study the relationship between peritonsillar abscess and minor salivary glands surrounding the palatine tonsils.

Method: Prospective study measuring amylase levels in the pus of patients with peritonsillar abscess compared with the Amylase level in the serum and to the amylase level in pus from other abscesses in the neck. Data regarding age, sex, length of hospitalization, and recurrence were additionally recorded.

Results: A total of 40 patients diagnosed with PTA, 19 male (47.5%) and 21 female (52.5%) with an average age of 19 years. The average level of amylase in the pus of the PTA group was 827 u/dl and 9 u/dl in the control group (P < .001). There were no recurrences in patients with amylase greater than 65 u/dl 0/16 (0%) vs 6/24 (25%) for amylase lower than 65 u/dl (P = .03).

Conclusion: High amylase in the pus lends further support for involvement of minor salivary glands in the pathogenesis of peritonsillar abscess. However, high recurrence rates related to low amylase in the pus imply an additional pathogenesis possibly related to tonsillar infection.

Objective: 1) Learn the histologicdistribution of nasopharyngeal carcinoma (NPC) in a nonendemic European country. 2) Learn epidemiological data of NPC in a nonendemic European country. 3) Understand the implications of some genetic polymorphisms on NPC development.

Method: Using data collected from a retrospective study of 320 NPC patients obtained at the Oporto Portuguese Institute of Oncology during 31 years, a study is made concerning histological characterization, median age, gender profiles, NPC-EBV relationship, and relevance of concerned genetic polymorphisms on probability of disease and age of onset.

Results: A total of 300 out of 320 patients had nonkeratinizing carcinomas (93.75%), with a mean age of 48 years old and twofold male preponderance. Using PCR analysis, EBV-DNA was found in 91.7% of 36 tumor tissue samples. Regarding genetic polymorphisms, 2 case-control studies were performed, including 104 patients and 285 control individuals. TP53 codon 72 pro/pro genotype (P = .012; OR = 2.67; 95% CI 1.21-5.90) and A870G cyclin D1 GG genotype (P = .016; OR = 2.09; 95% CI 1.15-3.79) were associated with increased risk for NPC development. Moreover, cyclin D1 GG genotype was also correlated with earlier disease onset.

Conclusion: The high relative proportion of nonkeratinizing carcinomas is a relevant finding in this nonendemic European country, and so is the association of EBV-DNA with NPC. This study may help to understand the biologic mechanisms of NPC and the correlation of EBV infection with disease in a low-risk nonendemic region.

Objective: Hospitals are increasingly being evaluated for postoperative mortality, which includes intensive care patients who succumb to their medical disease after routine tracheostomy. Here we evaluate the expediency of tracheostomy performance and perioperative mortality over a 6-month period.

Method: Prospective analysis of medical intensive care patients who underwent tracheostomy placement over a 6-month period at a tertiary care hospital. Variables evaluated were time to tracheostomy, time to death, and cause of death.

Results: There were 76 consultations that resulted in 64 patients receiving tracheostomy. Four (5.3%) patients expired the day prior to or the day of planned tracheostomy. Six (7.9%) were extubated prior to tracheostomy. Many were performed within 24 hours from consultation time (37%), and some were performed on the same day as consultation (9.3%). The overall 30-day postoperative mortality rate was 11%. Cause of death in all cases was due to pre-existing conditions and not related to tracheostomy. Thirty-six (57%) survived to discharge. The mean time from consultation to tracheostomy was 2.5 days (range 0 -12).

Conclusion: High rates of mortality after tracheostomy negatively impact hospital postoperative mortality and hospital ratings. Although there were no surgical deaths, only 57% of tracheostomy patients survived to discharge, illustrating the significant disease burden in this patient population and the need to stratify postoperative mortality.

Objective: 1) Assess risk factors for the frequency of postoperative hemorrhage. 2) Apply a new classification of postoperative hemorrhage using a clear definition and 7 grades depending on severity. 3) Assess multiple bleeding episodes after tonsil surgery.

Method: The study is based on a complete census of tonsillectomies (TE), tonsillotomies (TO), and adenoidectomies (AE) within 9 months in Austria. Postoperative hemorrhage was defined as every bleeding episode after extubation and classified in grades A1, A2, B1, B2, C, D, and E according to severity and the treatment needed.

Results: Included were 9,405 patients: 48.5% TE with or without (±) AE, 37.1% AE, and 14.0% TO ± AE. Postoperative hemorrhage was far more frequent for TE than for TO or AE (P < .001). A return to theater was necessary for 4.6% after TE. Adults had a significantly higher risk of postoperative bleeding than children for all types of surgeries (P < .05). Males had a significantly higher risk of postoperative bleeding episodes (P < .05). The “hot” operation techniques (bipolar diathermy or Coblation) showed a significantly increased risk of hemorrhage (P < .05). The evidence of a light bleeding episode increased the risk of a severe bleeding episode (P < .05).

Conclusion: Assessing all grades of postoperative hemorrhage offers a far more precise picture about postoperative bleeding. Risk factors for postoperative hemorrhage have been the type of surgery, age, and operation technique.

Objective: Our aim was to assess the prognostic role of several epidemiological, clinical andbiological factors, related to a higher risk for multiple malignancies in head and neck cancer (HNC) patients.

Method: In 76 consecutive patients treated with curative radiotherapy, p53 gene status, microsatellite instability (MSI) of the index tumor, and inherited chromosome fragility (CF), with epidemiological and clinical characters, were analyzed and correlated with the risk for second primary tumor (SPT). The follow-up was 77 months in mean (2-180 months).

Results: SPT was observed in 22 patients (28.9%). p53 mutation was detected in 36 (47.3%) out of 76 first primary HNC analyzed. MSI was documented in the first primary HNC from 22 out of 63 (34.9%). Susceptibility to bleomycin-induced chromatid breaks (CF+) was found in 26 out of 54 (48.1%). Statistical analysis suggests that MSI, CF and smoking persistence after index tumor treatment were significantly correlated with an increased risk of developing multiple malignancies (P = .05, P < .01 and P = .02).

Conclusion: A genetic susceptibility to DNA damage may play a central role in development of multiple malignancies in HNC patients. Testing for MSI phenotype and CF at the time of the original cancer diagnosis could identify high risk patients.

Objective: Accumulating studies show the role of microRNAs in multiple human cancers. However, little is known about the role of microRNAs in nasopharyngeal cancers (NPC). Given the role of microRNAs in survival and death pathways in cancers, we hypothesized that the microRNAs may regulate the effects of cancer therapeutic agents.

Method: Tumor specific MicroRNA expressions were studied in vitro in primary human NC cells (CCL-30) treated with statins. The effects on cell survival, cell cycle, and apoptosis were examined.

Results: Recently, we showed the promising antitumor effects of statins in NPC via HMG Co-A pathway. Our new study examines the novel role of microRNAs in mediating the effects of statin in the inhibition of survival in NPC. Statins induced apoptosis and decreased survival of NPC. The regulation of tumor suppressor Let-7a was enhanced in cells treated with statins associated with decrease in the cell viability and proliferation, and increase in apoptosis in these cells. Further, we found that the miR-21 and miR-155 played a role in the regulation of apoptotic pathways in NPC.

Conclusion: Tumor-specific microRNAs, Let-7a, miR-21, and miR-155 play a role in the regulation of the disease process and the effects of cancer therapeutic agents in NPC.

Objective: The consequences of perioperative venous thromboembolism (VTE) can be devastating. This study is designed to 1) correlate the incidence of VTE with perioperative risk assessment, 2) determine whether VTE prophylaxis effectively decreases the risk of perioperative VTE, and 3) assess if VTE prophylaxis increases bleeding complications in otolaryngology.

Method: A retrospective case-control study was conducted at a tertiary care medical center among adults presenting for otolaryngologic surgery from 2003 to 2010 (n = 3498). Patients treated before the implementation of guideline-based VTE prophylaxis protocols were compared to patients treated after implementation. Primary outcome variables were Caprini risk level, perioperative VTE, and bleeding complications.

Results: The odds of a VTE increased 1.435 times with each level increase in the Caprini VTE risk level (P = .048). The VTE rate after implementation of prophylactic protocols was significantly lower than prior to implementation (OR 0.286, P = .005). However, the type of VTE prophylaxis had no significant effect on the likelihood of developing a VTE. The likelihood of a bleeding complication was not significantly different before and after implementation. The odds of a bleeding complication increased for patients receiving twice daily enoxaparin (OR 4.546, P = .032) or a treatment (rather than prophylactic) dose of anticoagulant (OR 3.546, P < .001).

Conclusion: Perioperative VTE risk stratification based on Caprini risk assessment in otolaryngology is effective. The odds of VTE decreased after the implementation of guideline-directed VTE prophylaxis. Although perioperative bleeding complications did not increase after the implementation of VTE prophylaxis protocols, therapeutic anticoagulation is associated with a higher incidence of bleeding complications.

Objective: The epidemiology of medication errors (MEs) in ambulatory and inpatient care is well understood, but little is known about ambulatory surgery. This study aims to quantify the incidence and nature of MEs after ambulatory otolaryngologic surgery.

Method: Ambulatory surgery patients were assessed for 1) pre-surgical home medications, 2) clinical history, 3) written prescriptions, 4) discharge instructions, and 5) medication use reported by patients within 48 hours of discharge. Potential MEs were reviewed by an expert panel to determine validity, contributing factors, and potential preventative measures.

Results: From 100 surgeries, 12 postoperative MEs were identified. All were without clinical sequelae, in part due to investigator involvement. Contributing factors included providers (2), patients (5), and the healthcare system (5). Causes for MEs included failure to verify patient information (eg, allergies), failure to accurately reconcile medications, and misunderstanding of instructions by the patients. Discharge instructions and medication reconciliation protocols appeared insufficient for optimal postoperative care and resulted in many after-hours calls for clarification.

Conclusion: MEs are common following ambulatory otolaryngologic surgery even though regimens are simple and limited to few medications. Key targets for quality improvement include fragmentation in information flow and physician-patient communication.

Objective: 1) Analyze current practices and policies of otolaryngologists on tobacco-cessation counseling. 2) Analyze the relationship between formal training in tobacco-cessation and confidence in counseling and prescription therapy behavior by otolaryngologists.

Method: This survey of smoking cessation practices was performed at the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) and associated meetings in September 2010. Attendees were surveyed, and the results were compiled. Regression analysis was performed to further assess the effects of training on otolaryngologists’ confidence in counseling.

Results: A total of 207 surveys were collected; 202 respondents indicated training in otolaryngology. A total of 88.5% of otolaryngologists ask most or all of their patients about tobacco use at an initial encounter; 83.7% advise most to all of their patients to quit at this encounter; 64.5% assess most to all of their patients’ interest in quitting; 49.7% assess their reasons to quit; 22.3% arrange support between visits for most to all of their patients. Regression analysis revealed that training during medical school and after residency were independently associated with higher levels of confidence and higher rates of prescribed therapy for patients (all P < .025).

Conclusion: Otolaryngologists counsel their patients on tobacco at a low rate, and fewer provide patients with the support necessary to assist them in quitting. Formal training in tobacco-cessation was associated with higher levels of confidence. Further research is indicated to assess the utility and cost-effectiveness of tobacco-cessation training programs for otolaryngologists.