Otolaryngology–Head and Neck Surgery

Quality improvement (QI) activities emphasize systems to prevent or detect inevitable errors by fallible humans. Aside from intentional misconduct or impaired judgment, human errors often are attributed to system factors, deemphasizing the role of individual decision making as a potential cause of error. Convincing data show that cognitive and motivational biases affect how providers collect and apply clinical data. Our purpose is to increase audience awareness of cognitive “traps” in medical decision making. We will discuss illustrative case studies, practical ways to incorporate these concepts into QI and patient safety activities, and uses of “debiasing” and other strategies to improve individual decision making.

(1) Describe the importance of individual cognitive processes in medical decision making and error and situations in which these processes might be either beneficial or harmful. (2) Describe cognitive processes, heuristics, and biases that play a role in otolaryngologists’ medical and surgical decision making and how these factors may contribute to medical error. (3) Implement individual and institutional methods to identify and mitigate these factors to improve personal clinical performance.

On the hinge of health care reform, the Board of Governors’ (BOG’s) 2014 hot topic is: will fee for service survive? Expert panelists, consisting of American Academy of Otolaryngology—Head and Neck Surgery presidents, BOG chairs, and physician payment and policy workgroup members, will discuss if fee for service will be superseded by payments based on work relative value units, quality measures, hospital employment, and bundled payments. Presentations will be made on current and past payment structures, bundled payments, quality metrics, and the sustainability of private practice. Time for interaction between the audience and panelists will be ensured through a final round table discussion.

(1) Describe the history of fee for service and how it has changed in the past 10 years. (2) Relate the impact of health care reform on current and future payment systems. (3) Recognize the challenges private practice will have with new reimbursement models.

One of the biggest transitions the healthcare industry has historically ever experienced is around the corner with the ICD-10 implementation deadline less than one week away. As many physician practices finish up last steps for preparation it is important to anticipate errors that may result in delayed payment. This miniseminar focuses on potential problems and the preemptive plans to have in place with your payers along with reactive steps you should take as a provider to quickly resolve these issues and keep your practice running. Learn about practices that have experience with the best ways to handle reimbursement delays.

(1) Understand how the proper steps can lessen impact of implementation to ICD-10 on your practice. (2) Learn about steps that payers are taking to facilitate communication with providers to avoid issues that they are anticipating providers may experience with the transition. (3) Learn about key resources offered through the Academy, the physician community, and from private payers to help you with transition to ICD-10.

The landscape of physician payment is changing, with quality and measures becoming more intertwined with how payment is and will be provided for services. This miniseminar will outline the efforts of our Academy, specifically the Physician Payment Policy Workgroup (3P) and the Ad Hoc Payment Model Workgroup, to prepare members for the implementation of the Affordable Care Act, so that otolaryngologists have the tools to participate in diverse payment systems. Topics include new public and private payment models including bundling and the importance of measures in the future of quality and payment initiatives.

(1) Discuss payment models as they relate to health care reform initiatives, new payment models, and Academy efforts to prepare members for changes in reimbursement. (2) Describe how existing measure sets (adult sinusitis and acute otitis externa) were developed for otolaryngology, tracking, and reporting and how these measures affect reimbursement. (3) Recognize the Academy’s efforts to interact and collaborate with public and private payers related to alternative payment model options and opportunities for otolaryngologists.

Patient satisfaction is an emerging theme in modern health care, and there are myriad federal-, state-, institutional-, and practice-level initiatives that emphasize systematic measurement and public reporting of patient satisfaction scores. Moreover, patient satisfaction scores are increasingly weighted in reimbursement formulas and pay-for-performance initiatives. This course will introduce the significance of patient satisfaction in otolaryngology, review nuts and bolts of patient satisfaction measurement and reporting, and offer effective and simple techniques for providers to better communicate with patients and improve satisfaction scores, even within the time constraints of modern practice.

(1) Recognize patient satisfaction as a quality indicator and learn initiatives surrounding measurement, reporting, and benchmarking of patient satisfaction scores. (2) Explain how patient satisfaction scores affect the bottom line (correlate with productivity, market share, and reimbursement. (3) Practice techniques for communication with patients that will result in greater patient engagement and increased satisfaction scores.

This miniseminar addresses a common knowledge gap regarding the purpose and process of maintenance of certification (MOC) in our field. Expert panelists include representatives from the American Board of Otolaryngology and the American Academy of Otolaryngology—Head and Neck Surgery (AAO-HNS) Education Council. Attendees will understand MOC as a 4-component, lifelong learning and quality improvement program. We will address concerns, anxieties, and misconceptions of part III MOC; 2 panelists who have recently taken and passed the part III examination (1 academic and 1 private practice) will describe their experiences and recommendations. Finally, we will share AAO-HNS educational resources designed for lifelong learning and MOC preparation.

(1) Recognize MOC as a lifelong learning and quality improvement program. (2) Understand the 10-year cycle and the specific requirements for each of the 4 components of MOC. (3) List AAO-HNS educational resources designed for lifelong learning, maintenance of certification, and recertification.

There are many questions about the role of otolaryngologists in an Affordable Care Organization (ACO). Our team of experts from private practice to academia, from administration to technology, will engage the audience. We will incorporate content that focuses on patient care, quality improvement, and access. We will welcome questions and advice from the audience.

(1) Make an informed decision whether to join or not to join an ACO. (2) Recognize the pros and cons to such a decision. (3) Manage the risk involved in this decision.

Unprecedented availability of health-related information on the Internet, television, radio, and print has empowered our patients to play larger roles in medical decision making. Increasingly, to help educate a knowledge-hungry public and to help build their practices, otolaryngologists must interact with journalists. Formal media training is often lacking in residency or fellowship, making this task seem daunting. This miniseminar reveals the multitude of media opportunities, including those on the Academy Web site, and how to best interact with journalists and the public. Speakers include renowned television and print health journalists and otolaryngologists with media experience. Audience participation is encouraged.

(1) Improve their communication with journalists. (2) Recognize the opportunities within and outside the Academy for print, television, radio, and online media exposure. (3) Increase involvement with the media to enhance your practice and educate your patients.

Physicians must confront significant financial issues over the course of their careers. These issues can be especially problematic for young physicians entering practice, although decisions around professional and personal finance must be made throughout one’s career. Matters such as professional liability, asset protection, practice management, employment contracting, and retirement planning all must be addressed proactively and confidently for maximal financial benefit. This miniseminar will include presentations from physicians and financial professionals that highlight these important decisions and considerations for otolaryngologists. Representatives of Academy committees will participate in an interactive discussion around central topics of vital interest to practicing physicians.

(1) Recognize the importance of building and protecting their practices. (2) Preserve their investment in their futures. (3) Examine employment contracts and retirement planning.

Concussions and return to play are public health concerns that are gaining coverage as incidence and public awareness increases. Otolaryngologists play an increasing role in the diagnosis of facial trauma and concussions. Not only does the public and health community look to head and neck surgeons for facial trauma treatment, but there is also increasing need for otolaryngologists to play a role in helping concussed athletes return to play. This miniseminar will present the relationship of facial trauma to concussions, review guidelines for diagnosing concussions, review guidelines for returning athletes to play, and review how otolaryngologists fit into the treatment algorithm.

(1) Consider the relationship between facial trauma and concussions. (2) Cite the criteria for diagnosing concussions and returning athletes back to play. (3) Determine the role the otolaryngologist plays in helping the athlete return to play.

The miniseminar will address regional reconstruction of the head and neck, with attention to surgical options available to the general otolaryngologist–head and neck surgeon. The format will include a descriptive portion of both longstanding and emerging reconstructive flap options that are commonly used today. The remainder will be case based, with depiction of commonly encountered wounds or defects followed by an interactive forum to discuss surgical and/or medical strategies for wound management. Audience participation will be encouraged through the Audience Response System to discuss preferred surgical strategies.

(1) Describe recent advances of commonly used regional flaps for head and neck reconstruction: pectoralis, submental, supraclavicular flaps, temporoparietal, facial artery mucosal muscle, and trapezius. (2) Cite the indications and contraindications for each flap, with consideration of location and size of defect, mobility, and prior irradiation. (3) Incorporate the information provided to develop an algorithmic approach to wound management using regional flaps with awareness of their use and limitations.

Otolaryngologists are frequently faced with the challenges of managing patients who have sustained significant injuries due to maxillofacial trauma. Often, these are associated with injuries to other organ systems that may preclude timely attention to the maxillofacial injuries. Sometimes, patients present for medical care after some delay. It is important for surgeons to be able to decide when it is reasonable to delay intervention and when delay is mandatory, as well as have an understanding of how surgical intervention may change as a result of such delays. This miniseminar will address these issues.

(1) Explain the indications for delayed management of maxillofacial injuries. (2) Recognize typical contraindications to early intervention for the management of maxillofacial injuries. (3) Use techniques for delayed intervention and management of maxillofacial injuries and how they differ from acute interventions.

This 3-hour course sponsored by the American Academy of Otolaryngology—Head and Neck Surgery Foundation Facial Plastic and Reconstructive Surgery Education Committee will provide a concise review of facial plastic surgery topics that will provide attendees a starting point in preparing for the recertification examination (maintenance of certification [MOC] part III). Faculty will use a combination of didactic and case-based formats to cover essential content areas including facial trauma, aging face, facial defect repair, and surgical management of chronic facial paralysis. The course will also fulfill the MOC part II requirements by providing continuing medical education credit.

(1) Demonstrate increased understanding of key topics in facial plastic surgery. (2) Guide further study on these topics in facial plastic surgery. (3) Access available resources in facial plastic surgery that will assist in test preparation.

Four experienced rhinoplasty surgeons divulge their 3 techniques that prove useful in almost every case. Every component of rhinoplasty will be covered systematically with tips being offered on the straight dorsum, functional middle vault, and the refined tip. Videos or step-by-step photographs will enable attendees to quickly grasp how and when to use these maneuvers to consistently improve their patient outcomes. Topics to be covered include grafts in rhinoplasty made easy, management of the lateral crus, ultrasonic sculpting of the dorsum, suture fixation techniques revisited, and critical closing steps.

(1) Employ suture techniques such as medial crural fixation stitch and upper lateral cartilage suspension sutures to maintain tip projection and middle vault competency, respectively. (2) Select cartilage grafts that camouflage defects, reinforce projection, and maintain the nasal airway. (3) Choose appropriate tip refinement techniques to consistently improve patient outcomes.

This course is sponsored by the American Academy of Otolaryngology—Head and Neck Surgery CORE Grants program and is designed to provide a practical, “nuts and bolts” guide to incorporating research into your otolaryngology practice. A diverse group of experienced surgeon-scientists will cover all of the relevant topics from how to choose a project, get funding, publish your work, patent your ideas, and more. Whether you are looking to begin a small clinical study or embark on a career in research, this miniseminar will provide you with the tools to avoid common pitfalls and make your research a successful and rewarding experience.

(1) Design a rewarding research project based on your interests, resources, and time. (2) Market your research idea in order to get funding and successfully publish your findings. (3) Determine when and if you should patent your ideas and how to work with industry to bring your research into the clinic.

The academic bowl has been an annual interactive resident competition at the American Academy of Otolaryngology—Head and Neck Surgery Foundation annual meeting for the past 8 years. Four teams from across the country are selected based on strict academic criteria. These programs send 3 residents to represent them in an interactive question-and-answer format. The educational committees of the foundation develop questions. They are presented to the teams and the audience. Each team responds, and the audience is given a chance to pit their knowledge against the residents’. The resident team with the best score at the end of the competition wins a prize.

(1) Attendees will be able to see what the current level of knowledge is in various subspecialties of otolaryngology. (2) Attendees will be able to compare their knowledge base to residents across a wide range of topics. (3) Attendees will be able to determine areas of weakness in their knowledge base as compared with residents.

Patients with facial nerve paralysis suffer significant cosmetic and functional morbidity. Most of these patients eventually require the attention of the facial plastic reconstructive surgeon. Management of the eye involves both loading the upper eyelid and tightening the lower eyelid. Mid-face reconstruction can be addressed by either dynamic sling using a temporalis muscle or adynamic with 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 will present their preferred method of rehabilitation with case scenarios to explore subtleties of each surgical approach.

(1) Upon completion of this session, the attendee will be able to determine the management of the upper and lower eyelid complex. (2) Attendees will be able to discuss the differences in dynamic and adynamic reconstruction of the lower face. (3) Attendees will be able to manage the nasal airway in patients with facial nerve paralysis.

How does a surgeon decide to optimize the outcome after performing a salvage laryngectomy? The goal of this miniseminar is to help the surgeon understand the decision-making process for the reconstruction of the hypopharynx after salvage laryngectomy using evidence from 2 large national retrospective reviews. In addition, the role of withholding neck dissection to reduce morbidity will be discussed. Substantial time will be left at the end of the presentation to discuss specific case examples and have the faculty discuss perioperative and postoperative management.

(1) Cite the current evidence for flap-assisted closure for patients undergoing salvage laryngectomy. (2) Evaluate the risks and benefits of performing neck dissection for salvage patients. (3) Use case examples to demonstrate management relating to choice for neck dissection, use of the salivary bypass tube, and choice of flap-assisted reconstruction.

Our expertise and skill are essential, but not sufficient, for optimal patient outcomes. We work with teams and we work within systems with variable functionality. How can we make sure our team works together effectively? How can we improve the systems within which we work? An expert panel will describe how we can use simulation and the science of human factors to improve the processes, the equipment, and even the spaces in which we work. Examples address emergency response teams, airway carts, and electronic health records. Our keynote speaker, F. Jacob Seagull, PhD, is an expert in human factors applications in health care.

(1) Understand how simulation can be used to improve health care delivery systems and safety. (2) Understand how human factors principles can be applied to improve health care delivery systems and safety.

With the progressive improvements in imaging resolution of ultrasound, concurrent reduction in capital expenditure, and portability, this modality is ideally suited to point-of-care use by most otolaryngology practices. Primary and exported training courses through the American College of Surgeons have provided a clinical starting point. An accreditation process for head and neck ultrasound is now available through a joint project between the American Institute for Ultrasound in Medicine and the Academy. This miniseminar presents the practical application of ultrasound to general, pediatric, endocrinologic, and oncologic conditions through a panel of outstanding experts from radiology and otolaryngology.

(1) Cite the principles of ultrasound and its application to conditions of the head and neck. (2) Recognize the advantages of ultrasound-guided aspiration of samples for cytology and other chemical tests. (3) Learn ultrasound techniques and eventual accreditation of skills.

Humanitarian surgical trips provide an opportunity to deliver care that would otherwise be unavailable. However, there is significant variability among humanitarian missions. This variability has contributed to some unfortunate patient outcomes. This miniseminar will explore “deadly sins” common to medical humanitarian efforts and issues that are unique to surgical humanitarian missions. Panelists with extensive humanitarian experience will discuss available data and areas with a lack of data concerning humanitarian efforts. Best practices will be discussed with respect to appropriate standard of care, duration, follow-up, research, role of the media, and integration with local care systems.

(1) Critically evaluate the existing literature and identify gaps in knowledge regarding humanitarian efforts in otolaryngology. (2) Recognize “best practices” including appropriate standard of care, duration, follow-up, conduct of research, role of the media, and integration with local care systems. (3) Critically evaluate and devise methods to improve existing humanitarian efforts in otolaryngology.

Chronic cough is an increasingly important public health concern, accounts for a large number of ambulatory care visits, and often involves a protracted clinical course. Otolaryngologists play a critical role in the care of these patients because of our interdisciplinary approach to the aerodigestive tract and our mastery of many procedures used to evaluate and treat related conditions. This miniseminar will present challenging cases with panel discussion and audience participation to emphasize evidence-based practice and the “state-of-the-art” for patients with chronic cough. Controversial areas will include prioritization, the use of evidence-based protocols, and the importance of early diagnosis in value-based health care.

(1) Describe evidence-based treatment guidelines in the evaluation and treatment of chronic cough. (2) Use the spectrum of common and uncommon causes of chronic cough with an appreciation of the underlying physiology. (3) Evaluate these complex patients, perform objective testing when indicated, and prescribe appropriate pharmacotherapy for patients with chronic cough.

This miniseminar will provide a multidisciplinary perspective (rhinology, neurotology, head and neck, and neurosurgery) on the pathophysiology and management of cerebrospinal fluid disorders encountered by the practicing otolaryngologist. The program will discuss epidemiologic, radiologic, medical, and surgical aspects of spontaneous and iatrogenic cerebrospinal fluid leaks of the anterior and lateral skull bases and will highlight important considerations in proper diagnosis, workup, and management.

(1) Properly recognize, diagnose, and manage spontaneous and iatrogenic cerebrospinal fluid (CSF) leaks of both the anterior and lateral skull base. (2) Explain various medical and surgical interventions available for the treatment of CSF disorders encountered by the otolaryngologist.

This international symposium will focus on the Academy’s international relations and activities in a variety of key regions around the globe. President Richard W. Waguespack, MD, will welcome the audience, and president-elect Gayle Woodson, MD, will describe her vision for enhanced international collaboration. The American Academy of Otolaryngology—Head and Neck Surgery Foundation Regional Advisors for the Europe, Middle East, Pacific Rim, and Turkey/Greece/the Balkans will introduce eminent speakers to describe the state of otolaryngology in these regions and subject areas, including socioeconomic and workforce issues.

(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.

This miniseminar is designed to update general otolaryngologists on cutting-edge advances. Dr Nussenbaum will present on human papillomavirus (HPV)–related oropharyngeal cancer, now widely accepted to be a distinct disease. With the increasing incidence of HPV, otolaryngologists need to be familiar with underlying principles that direct comprehensive evaluation and management. Dr Hwang will review the evidence for various methods of drug delivery in treating chronic rhinosinusitis and how the efficacy of topical medical therapy directly relates to the modality of delivery. Dr Wilkinson will give a comprehensive overview of the critical considerations in assessment, diagnosis, and treatment of sudden sensorineural hearing loss.

(1) List current recommendations for diagnosis and management of sudden sensorineural hearing loss. (2) Incorporate into practice with up-to-date clinically relevant information about screening, prevention, diagnosis, and management of HPV-related oropharyngeal cancer. (3) Consider the range of options for topical drug delivery to the paranasal sinuses and the evidence substantiating their use.

Despite adoption of checklists and timeouts in many operating rooms across the country, surgical errors continue to happen. Our program will address some of the myths associated with checklists, including that stand-alone error prevention strategies such as checklists prevent wrong-side surgeries or that checklists should be mandated and will prevent errors. We will then discuss how the checklist process needs to be augmented with specific surgeon-as-leader behaviors: effective team building, communication, and creating a safety focus. We will also discuss some of the challenges around developing and building these techniques and behaviors in our institutions.

(1) At the end of this session, attendee surgeons will demonstrate improved leadership skills. (2) Upon completing this session, attendee surgeons will learn the skills necessary to establish a high-functioning team.

Getting published is a practical, results-oriented miniseminar that emphasizes success strategies for residents, young physicians, and practicing clinicians. Explicit tips are offered to motivate young authors and clinicians to share experience and insights by publishing in peer-reviewed journals. Myriad viewpoints will be presented, including editor-in-chief, managing editor, resident physician, young physician, and practicing clinician. Attendees will learn why publishing is important, how it can prepare them for fellowship and clinical practice, and how it fosters critical thinking skills that lead to better patient care. Time is allowed for questions and answers.

(1) Recognize why publishing in journals is important for young physicians and practicing clinicians. (2) Use best practices associated with successful publishing in biomedical journals. (3) Avoid the top pitfalls when submitting a manuscript for publication consideration.

Otolaryngologists are familiar with the available techniques for establishing an airway. In elective procedures with an anticipated difficult airway, the surgeon, anesthetist, and other members of the team may establish a clear plan of action in the controlled setting of the operating room. Upper airway obstruction may present as a life-threatening emergency in which quick action is essential and discussion time is limited. Some of these cases are extraordinarily challenging. In this miniseminar, we present the options available for establishing an airway through cases in which “standard” plans of action required modification to achieve a successful outcome.

(1) Recognize what makes an airway “difficult.” (2) Weigh the options available for establishing a precarious airway. (3) Establish a decision-making process through case presentations.

The Scary Cases 2014 miniseminar uses a case-base, interactive approach to providing education in patient care and risk management. Exceptionally scary cases presented by well-known experts and community-based clinicians will focus on what could or has gone wrong in the management of otolaryngology patients. Each expert will present a specific case that was difficult to manage, had unexpected morbidity, or resulted in litigation. Attendees will participate using the Audience Response System for key decisions during the case. Difficult cases are often great sources of learning. This miniseminar will provide education on how to anticipate and avoid unwanted outcomes.

(1) Describe potential pitfalls inherent to the practice of otolaryngology that may lead to adverse outcomes or put patients at excessive risk. (2) Recognize legal principles of medical malpractice and learn ways to minimize risk of malpractice in the everyday practice of otolaryngology.

The concept of this miniseminar is to describe how otolaryngology was practiced at the turn of the past century by describing how common otolaryngological diseases were diagnosed and managed and to describe the state of surgical technology and technique

(1) Gain perspective on the antecedents of today’s practice of otolaryngology. (2) Recognize the long tradition in otolaryngology of adapting new ideas and introducing technological innovations.

Seeking an edge in the competitive grant world? This interactive miniseminar will provide a comprehensive review of key elements to a fundable grant. Practical tips on scientific writing, building a productive research team, and maximizing resources will be provided. An overview of basic statistics will help to maximize collaborative efforts with your statistician. Gain insight into the scoring process from an experienced National Institutes of Health reviewer who will highlight common pitfalls. Current 2014 funding mechanisms will also be provided. Residents and faculty new to the grant process, as well as researchers striving to improve their score, will benefit from this course.

(1) Explain key components of a grant to include hypothesis, specific aims, timeline, statistics, budget, and institutional review board. (2) Describe the scoring mechanism, review process, and common pitfalls leading to an unfundable grant. (3) Recognize current grant mechanisms and funding opportunities, with emphasis of American Academy of Otolaryngology—Head and Neck Surgery Foundation CORE grants, K-awards, and R-01 funding.

There are significant technological advances occurring in different otolaryngology subspecialties. In addition, there are many opportunities for cross-pollenization of ideas to envision novel ways to use these technologies. In this miniseminar, the participant will learn about novel technologies being applied in a selected number of technology-heavy areas of otolaryngology. The panel and audience will engage in an interactive discussion about the different technologies and where else these could be employed or changed to solve other clinical problems. Topics include intraoperative computed tomography advances, vascular injury and control, frontiers in robotic surgery, computer-assisted surgery, middle ear gels, 3-dimensional printing, and biomaterials.

(1) Discuss new technologies being applied in different fields within otolaryngology. (2) Review where these technologies have inherent strengths and limits in their current application. (3) Synthesize new and unique applications for these technologies in otolaryngology.

Epistaxis management is rarely discussed in comprehensive detail, and we feel this topic is grossly underrepresented at the annual meeting. Our goal is to thoroughly discuss current epistaxis treatment techniques used by a panel of experts. Each panelist will review personal experience with current advanced management techniques, emphasizing supporting data and best evidence. Modalities discussed include advanced endoscopic techniques, electrosurgical and plasma cautery, directed vessel ligation, endovascular embolization, and large vessel patching for a wide range of scenarios including anterior and posterior epistaxis as well as large vessel hemorrhage. Special considerations such as hereditary hemorrhagic telangiectasia will also be discussed.

(1) Describe the current therapies available to the otolaryngologist to treat epistaxis. (2) Recognize the strengths and weaknesses of each therapy for epistaxis. (3) Implement the various therapies for epistaxis.

Patients with thyroid and parathyroid disease are commonly encountered in a head and neck surgery practice. While the evaluation and management of many patients is relatively straightforward, others are significantly more complicated. The goal of this session is to discuss complex clinical scenarios encountered in the outpatient clinic. The cost-effective use of diagnostic testing as well as the factors critical in treatment planning will be outlined. The entities reviewed will include fine-needle aspiration for thyroid nodules, surveillance of patients with well-differentiated thyroid cancer, and evaluation and decision for surgery in hyperparathyroidism.

(1) Describe the appropriate use of fine-needle aspiration biopsy with a focus on implementing the use of molecular markers into the diagnostic evaluation. (2) Explain the indications for adjuvant radioactive iodine therapy in patients with low-, intermediate-, and high-risk well-differentiated thyroid cancer. (3) Implement a cost-effective approach to preoperative imaging in a patient with primary and recurrent hyperparathyroidism.

Sialendoscopy is recognized as a first-line option in the management of salivary stones. The role of sialendoscopy in nonstone disorders is less clear. This miniseminar focuses on the indications and applications of sialendoscopy for nonstone disorders including ductal scar and trauma, Sjogren disease, radioiodine sialadenitis, and recurrent juvenile parotitis. The moderator will present cases of nonstone disorders to a panel of experts in order to determine their use of sialendoscopy in the management of these disorders. The discussion will conclude with a brief overview of the current best evidence of the role of sialendoscopy in the management of nonstone disorders.

(1) Recognize which nonstone salivary disorders may benefit from sialendoscopy. (2) Learn techniques for applying sialendoscopy to nonstone disorders. (3) Understand the outcomes and limitations of sialendoscopy in the management of nonstone disorders.

In this presentation, the editors-in-chief of several major otolaryngology journals will provide instruction and insight on many aspects of the peer-review process, for current and future reviewers. We will address the roles of peer reviewers, associate editors, and the editorial board and address the importance of voluntary participation in the peer-review process. We will discuss several practical matters, including frequent errors made by authors and reviewers and tips and strategies for improving reviews and papers. We will discuss decisions on revision versus rejection and responding to reviewer critiques/disagreements. We will also discuss how to advance up the editorial ladder.

(1) To educate attendees on the process of peer review and on how to improve their own peer reviews and manuscript submissions. (2) To educate attendees on how editors select associate editors and editorial board members. (3) To allow attendees to learn about the review and publication process.

The myriad lesions that present in the oral cavity can stymie even the most astute otolaryngologist. These may span from the most benign, such as recurrent canker sores, to more ominous malignancies, often with very similar appearances. Furthermore, various systemic illnesses such as Sjogren disease, lichen planus, Crohn disease, lupus, and nutritional deficiencies may present with vexing oral cavity lesions. This evidence-based miniseminar supported by the American Academy of Otolaryngology—Head and Neck Surgery Head and Neck Surgery & Oncology Committee will explore the differential diagnoses, workup, and management of a spectrum of oral lesions as well as early-stage oral cavity cancer.

(1) Describe and identify some of the more unusual oral conditions that present to the otolaryngologist. (2) Identify signs and symptoms of systemic illness in the oral cavity. (3) Examine the management of premalignant oral lesions, the role for screening and biopsy, and the appropriate workup and surgical management of early oral cancer.

Endoscopic approaches to the skull base are being used with increasing frequency in tertiary care centers and in community settings. This miniseminar aims to clarify the current status of endoscopic skull base surgery. The evolving trends have led to controversies regarding the extent of endoscopic resections and utilization for malignancies. The panelists will review surgical techniques, contemporary surgical outcomes for paranasal sinus and spheno-clival cancers, disease-specific approaches, and quality of life after endoscopic surgery.

(1) Recognize the role of endoscopic surgery in the management of skull base malignancies. (2) Describe the technical aspects of expanded endonasal surgical approaches to skull base tumors. (3) Assess the impact of endoscopic surgery on quality of life for skull base tumors.

Despite increased knowledge about head and neck paragangliomas, educational gaps still exist regarding diagnosis, evaluation, and management options. This miniseminar will provide up-to-date clinically relevant information using a case-based format. Best available evidence-based medicine presentations on focused learning points and audience response will be incorporated. Basic concepts and controversial topics will include accurate disease diagnosis; tumor genetics and defining the at risk-population for familial disease; management decision making between surgery, radiation, and observation with expected tumor-control outcomes; identification of patients at particular risk for treatment-related complications; and rehabilitation options to maximize functional outcomes.

(1) Describe the current “state-of-the-art” for evaluation and management of head and neck paragangliomas. (2) Discuss the considerations that affect how treatment decisions are made. (3) Use methods for minimizing complications while maximizing tumor-control and functional outcomes.

Human papillomavirus (HPV)–related oropharyngeal cancer is now recognized as a clinically distinct entity, and data describing the nature of the epidemic, optimal treatment strategies, and survival outcomes are rapidly developing. Our patients are asking pertinent questions about HPV transmission, the role of vaccination, and monitoring recommendations. This miniseminar will update practitioners on the accuracy of testing, how to counsel patients and families regarding the nature of HPV infection (risk and transmissibility), vaccination, the management of benign lesions, and surveillance. This panel will appeal broadly to trainees, general otolaryngologists, and head and neck surgical oncologists.

(1) Advise patients and partners regarding HPV infection and transmission. (2) List the Centers for Disease Control and Prevention recommendations for HPV vaccination. (3) Develop a surveillance plan for patients with HPV and their families.

Transoral robotic surgery (TORS) has become a popular approach for management of oropharyngeal carcinoma. The miniseminar will be organized as a tumor board panel staffed with a head and neck surgeon, radiation oncologist, medical oncologist, and pathologist. Two cases will be presented to highlight 3 controversial topics: (1) What are acceptable surgical margins and does human papillomavirus (HPV) status affect margin status? (2) Following TORS with negative margins, does the primary site require radiotherapy and does HPV status affect that decision? (3) How do “poor prognostic factors” affect decisions regarding adjuvant therapy, radiation dose, and treatment fields?

(1) Differentiate the pathologic characters of HPV-positive and HPV-negative tumors and demonstrate how this finding affects treatment margins. (2) Explain the indication for treating the primary site after TORS resection. (3) Recognize impact of poor prognostic factors of adjuvant therapy decisions, including treatment dose.

Sialendoscopy is a relatively new addition to otolaryngology. It offers the opportunity to work with salivary gland disease with noninvasive procedures that yield potentially superior outcomes to previous techniques. It is exciting but very challenging. This miniseminar is geared toward the beginner. It will give basic techniques and point out potential pitfalls. Additional information will include the appropriate diagnostic workup, operative setting, and patient selection. The interactive format will allow the participant to know if he understands basic techniques and is ready to incorporate sialendoscopy in his practice.

(1) Use basic instrumentation for sialendoscopy. (2) Describe appropriate patient selection for sialendoscopy. (3) Perform sialendoscopy in your practice while recognizing common mistakes and pitfalls.

Human papillomavirus (HPV)–associated head and neck cancer is an epidemic striking a younger and healthier population without the usual risk factors for head and neck cancer. Most patients have an excellent prognosis following treatment with surgery or chemoradiation, and the sequela of long-term morbidity from treatment is of increasing concern as patients are expected to live long enough to experience complications. Failure to identify a subset of patients at high risk for metastasis, recurrence, and decreased survival can lead to undertreatment and poor outcomes. This miniseminar will discuss the epidemiology, workup, treatment, and surveillance of HPV-positive head and neck cancer.

(1) Describe features of HPV-positive head and neck cancer. (2) Recognize the role of surgical and nonsurgical therapy in the treatment of HPV-positive head and neck cancer. (3) Explain the indications for adjuvant treatment in the management of HPV-positive head and neck cancer.

The next breakthrough in surgery will be intraoperative visualization of key normal structures and diseased tissue in real time using biological targeting compounds. Agents for visualizing blood flow are currently available to evaluate flap perfusion or vessel dynamics and sentinel node detection. Both antibody-based agents and small molecules with high-affinity target binding linked to fluorophores can be detected with high sensitivity using currently available cameras. Agents are being developed for imaging nerves. There are active clinical trials to image cancer cells to ensure complete resection. This miniseminar will provide an overview of agents that are currently available and in development.

(1) Describe the utility of optical imaging in head and neck surgery. (2) Implement currently available optical imaging agents in surgical practice. (3) Analyze validity of new agents and instruments that will be coming to the market for surgical optical imaging.

Nasopharyngeal carcinoma (NPC) is a distinct and important cancer of the head and neck. As the incidence is rare in Whites, diagnosis can be challenging. However, ear, nose, and throat specialists should be able to manage NPC; therefore, the aim is to provide the attendee a great opportunity to be familiar with some of the current knowledge of the management of NPC, including using Epstein-Barr virus (EBV) as a biomarker to diagnose and monitor NPC, evolution of treatment guidelines of NPC, and salvage nasopharyngectomy for local recurrence in this miniseminar.

(1) Use EBV as a biomarker to diagnose and monitor patients with NPC. (2) Recognize the evolution and treatment guideline of NPC. (3) Explain the rationale and the various approaches for salvage NPC (open/endoscopic), treatment results, and prognosticators.

Diagnosis and management of hyperparathyroidism represents a rapidly changing field in surgery. Much of the change is technologically driven, with the advent of high-resolution imaging, intraoperative assays, and application of robust neuromonitoring. These have led to a preponderance of targeted, outpatient procedures that have a high rate of success. As the role of the otolaryngologist in treating this condition continues to be established, mastery of fundamental and emerging concepts is essential. This miniseminar will explore the importance of ultrasound, sestamibi, 4-dimensional (4D) computed tomography (CT), and other imaging options as well as proper use of hormone assays, postoperative management techniques, and the recent controversy regarding 4-gland exploration.

(1) To become familiar with the latest refinements in parathyroid imaging, including high-resolution ultrasound, 4D CT scans, and CT-mibi. (2) To understand the strategy behind focused exploration and the principles promoted by surgeons who routinely perform bilateral neck exploration. (3) To appreciate the nuances of modern postoperative management, including calcium prophylaxis and persistent eucalcemic hyperparathyroidism.

This miniseminar will provide a critical, evidence-based review of current practice regarding laryngopharyngeal reflux with focus on improving patient care. Current paradigms often yield uncertain diagnosis, while prolonged treatment and/or extensive testing are time-consuming and costly, have side effects, and yield equivocal benefit in many cases. Through focus on strengths and weaknesses of various diagnostic strategies and with knowledge of current practice patterns, this miniseminar hopes to identify best practices for evaluation of presumed laryngopharyngeal reflux. This miniseminar aims to recall otolaryngologists to a broader patient-based perspective and refocus attention on better evaluation for complaints possibly related to laryngopharyngeal reflux.

(1) Discuss current otolaryngology practice patterns for patients with presumed reflux disease. (2) Compare the strengths and weaknesses of common approaches to reflux diagnosis such as history, examination, response to empiric proton-pump inhibitor trial, and objective reflux testing. (3) Identify current best practices in otolaryngology care of presumed laryngopharyngeal reflux.

Key aspects of thyroid surgery have been addressed by published clinical practice guidelines, consensus statements, and position papers from the American Academy of Otolaryngology—Head and Neck Surgery Foundation (AAO-HSNF), the American Head and Neck Society (AHNS), and the American Thyroid Association (ATA). This miniseminar efficiently presents these society publications, focusing on their content, interpretation, and limitations. Specific topics include surgery for invasive carcinoma, imaging selection, improving postoperative voice outcomes, nerve monitoring, outpatient surgery, and goiter management. These documents will also be used to highlight the important overall differences between practice guidelines, consensus statements, and position papers and their respective influence on clinical decisions.

(1) Differentiate between a clinical practice guideline, clinical consensus statement, and position paper. (2) Analyze the content, interpretation, and limitations of the key publications sponsored by the AAO-HNSF, AHNS, and ATA regarding the management of thyroid surgical disease.

Evaluation of thyroid nodules with surgeon-performed ultrasound and fine-needle aspiration (FNA), armed with molecular testing, is rapidly transforming thyroid surgery. Didactic presentations and case studies including American Thyroid Association (ATA) guidelines will provide participants with risk stratification using ultrasound and pearls for surgeon-performed FNA. Molecular Classifiers have a 95% negative predictive value for indeterminate nodules reducing unnecessary diagnostic lobectomies. Molecular alteration testing from FNA with panels including BRAF is 100% specific for papillary thyroid cancer and has evolved into next-generation sequencing from the cancer genome atlas (TCGA). Combined mutation marker analysis has improved prognostic information. Personalized thyroid cancer surgical management is approaching.

(1) Explain that Molecular Classifier testing for cytologically indeterminate nodules may reduce the number of unnecessary diagnostic thyroid lobectomies. (2) Recognize next-generation sequencing and the cancer genome atlas for cytologically indeterminate nodules will improve the diagnosis of thyroid cancer. (3) Interpret ATA guidelines for ultrasound, FNA, molecular testing, and prognostication.

Airway, voice, and swallowing complaints following radiation present some of the most challenging clinical dilemmas in otolaryngology. This practice-based minisemiar will bridge current scientific knowledge about radiation and its impact on the larynx with decades of clinical experience dealing with vocal fold lesions, vocal fold paralysis, airway obstruction, dysphagia, and chondroradionecrosis of the larynx. Succinct, highly focused presentations on these topics will aim for the shared objective of distilling key elements of clinical care issues that occur in the radiated larynx. Real-life cases will be presented. Panelists are challenged to provide practical advice for the management of this patient population.

(1) Explain the pathophysiology of laryngeal injury following radiation therapy, specifically as it relates to chondroradionecrosis. (2) Examine the limitations that prior radiation places on the otolaryngologist caring for patients with vocal fold lesions and paralysis. (3) Incorporate state-of-the-art surgical and therapeutic options available for airway and swallowing rehabilitation in the radiated larynx.

This miniseminar will address workup and surgical treatment of acute and chronic bilateral vocal fold immobility due to neurological and mechanical injury. Diagnostic challenges will be discussed including how to determine the cause of immobility and whether to use electromyography. Options for acute treatment will include observation, tracheotomy, the use of botulism toxin, and endoscopic lateralization. We will explore how to choose endoscopic versus open procedures for chronic disease and analyze how the choice of procedure depends on the age of the patient and the cause of immobility. There will be an emphasis on case studies and audience participation.

(1) Differentiate between neurological and mechanical causes of bilateral vocal fold immobility. (2) Consider the advantages and disadvantages of all endoscopic and open procedures for bilateral immobility due to a neurological cause. (3) Consider the advantages and disadvantages of all endoscopic and open procedures for bilateral immobility due to cricoarytenoid joint fixation or glottal stenosis.

Laryngopharyngeal reflux (LPR) is commonly diagnosed in patients seen by otolaryngologists. Prescribing of proton pump inhibitors (PPIs) increased 5-fold from 1990 to 2001 and accounts for 10% of costs in evaluation and management of patients with voice disorders. In response, 46.5% of general otolaryngologists feel they are overdiagnosing LPR. Considering this, what diagnoses are otolaryngologists missing due to the reflexive diagnosis of LPR? The goal of this program is to present a clear clinical approach to the diagnosis and treatment of patients complaining of LPR-like symptoms and suggest alternative diagnoses and treatments as well as an approach to patients unresponsive to PPI therapy.

(1) Diagnose efficiently and effectively treat a patient who has LPR-like symptoms but is unresponsive to PPI management. (2) Describe the unified airway concept and how it alters the diagnostic and therapeutic approach to patients with LPR-like symptoms. (3) Implement treatment for postviral vagal neuropathy and irritable larynx syndrome.

Injection laryngoplasty has a long history in vocal fold augmentation, and its use continues to evolve in otolaryngology. This miniseminar will provide a contemporary update on the indications, injectable materials, operative techniques, and potential pitfalls of injection laryngoplasty in modern otolaryngology practice. Particular attention will be paid to the latest developments in injection materials and office-based injection techniques for the general otolaryngologist. In addition, the presentation will include case presentations of pitfalls in injection laryngoplasty with a candid discussion of the inherent risks and possible mistakes that can be made with this technique and how to avoid them.

(1) Define the various indications for injection laryngoplasty in modern otolaryngology practice and recognize the benefits and controversies of currently available injection materials for laryngoplasty. (2) Compare the benefits and indications for clinic or office-based injection techniques, including thorough descriptions of clinic-based injection techniques. (3) Recognize potential patient care risks with injection laryngoplasty and methods to avoid or ameliorate these risks.

The purpose of this miniseminar is to present the contemporary management of cough. This miniseminar will thoroughly cover the most common etiologies of cough and its current management. A description of the sensory receptors, hyperexcitability related to neuropathy (including postviral), pharmacologic suppression of hyperexcitability, and management of pertussis (whooping cough) will be presented. If time allows, a few difficult cases will be presented that highlight the current management strategies.

(1) Explain the multiple etiologies for cough and its management. (2) Examine the complex relationship between the cough receptors and the larynx. (3) Illustrate pertussis resurgence and contemporary management.

This course will provide a comprehensive review of unilateral vocal fold paralysis (UVFP) management. The causes and workup of UVFP will be discussed. Special attention will be paid to office evaluation including utility of stroboscopy and laryngeal electromyography. Intervention including operating room–and office-based injection laryngoplasty will be described. The benefits of thyroplasty, arytenoid adduction, arytenopexy, and reinnervation will be debated. Case presentations will be used to highlight teaching points. Ample time will be allotted for audience participation and questions.

(1) Describe how to perform a vocal fold injection. (2) Compare different methods to treat unilateral vocal fold paralysis.

The goals of cholesteatoma surgery are the complete removal of disease while minimizing the risk of recurrence. A secondary goal is to optimize postoperative hearing. This miniseminar features distinguished experts in the field who will present well-established methods of cholesteatoma surgery. Important topics, such as intact-canal-wall versus canal-wall-down surgery, recurrence prevention, use of cartilage, and management of labyrinthine fistula will then be discussed in a case-based format. The role of endoscopes and use of magnetic resonance imaging for detection of recurrence will be discussed. Finally, ossiculoplasty techniques will be presented.

(1) Perform cholesteatoma surgery as practiced by experts in the field. (2) Examine advantages and disadvantages of endoscopic techniques. (3) Incorporate various methods for preventing recurrence.

The single-sided deafness (SSD) handicap has been underestimated. The purpose of this miniseminar is to present the latest research on the benefits of binaural hearing (Sig Soli, PhD), and the impact of SSD on childhood development and school performance (Nancy Young, MD). The different rehabilitation methods available will be presented, including osseointegrated bone conduction technologies (Jack J. Wazen, MD) and nonsurgical options (John Goddard, MD). Future trends and clinical research on the use of cochlear implants in SSD will be presented (Bruce Gantz, MD, and Tom Roland, MD). Open discussion, questions, and audience participation will follow the presentations.

(1) Recognize the benefits of binaural hearing in children and adults and the potential deficits imposed by SSD. (2) Differentiate between surgical and nonsurgical options in the rehabilitation of SSD. (3) Use developing technologies and clinical research in the rehabilitation of SSD, including the use of cochlear implants.

This miniseminar comprehensively reviews evaluation and management of laryngeal leukoplakia. Although white vocal fold lesions are common, management remains challenging. Doing too little may allow precancerous lesions to progress, while doing too much may create unnecessary dysphonia. Within a framework balancing oncologic with functional outcomes, and using case-based presentations, this miniseminar highlights challenges, controversies, and emerging paradigms in laryngeal leukoplakia care. Perspectives from laryngology, head and neck oncology, and radiation oncology will discuss innovations such as narrow-band imaging, optical coherence tomography, potassium titanyl phosphate (KTP) and CO₂ laser, chemotherapy, radiotherapy, and photodynamic therapy as they apply to current and future state-of-the-art management.

(1) Understand the risk of progression of laryngeal leukoplakia to carcinoma and need to balance oncologic efficacy with functional outcomes in leukoplakia care. (2) Review current and emerging techniques for accurate diagnosis, staging, and surveillance of laryngeal leukoplakia. (3) Discuss treatment alternatives for laryngeal leukoplakia, emphasizing surgical techniques of KTP, CO₂, and cold-instrument phonosurgery and including potential roles of radiotherapy, photodynamic therapy, and chemotherapy.

Otogenic pain and aural fullness can be some of the more frustrating chief complaints to work up and address. Many patients with this complaint are frustrated with lack of diagnosis and treatment. This leads to multiple visits in search of the answer to their affliction. In this miniseminar, our panel of experts will continue their discussion on how to evaluate and treat these difficult patients. Paradigms for management of these patients will be discussed. Case presentations will highlight proper workup and management of these confusing cases. Sponsored by the Otology and Neurotology Education Committee.

(1) Describe pathologies that may cause otogenic pain or aural fullness. (2) Conduct workup paradigms to avoid missing potentially dangerous processes. (3) Examine possible treatments for the various pathologies.

More than 50 million people in the United States have reported experiencing tinnitus, an estimated prevalence of 10% to 15% in adults. The multidisciplinary American Academy of Otolaryngology—Head and Neck Foundation–developed “Clinical Practice Guideline: Tinnitus,” will be presented. This guideline provides evidence-based recommendations for clinicians managing patients with tinnitus. The guideline discusses evaluation of patients with tinnitus, including selection and timing of diagnostic testing and specialty referral to identify underlying treatable pathology. It then focuses on the evaluation and treatment of patients with persistent primary tinnitus, with recommendations to evaluate and measure its impact, for determining the most appropriate interventions to improve symptoms and quality of life for tinnitus sufferers.

(1) Practice accurate and efficient diagnosis of primary tinnitus. (2) Improve the quality of care and mitigate the personal and social impact of persistent, bothersome tinnitus.

Sponsored by the American Neurotology Society, this interactive presentation aims to provide general practitioners tips and techniques employed by experts in management of intraoperative complications encountered during common otology cases such as tympanoplasty, tympanomastoidectomy, and stapedotomy. The panelists will present illustrative cases and discuss best practice approaches to intraoperative cerebrospinal fluid (CSF) leak and encephaloceles, facial nerve injury, vascular complications, stapedotomy challenges, ossicular chain and external auditory canal damage, and inner ear violation.

(1) Recognize unexpected circumstances and anatomic variations that could lead to complications in otologic surgery. (2) Manage intraoperative complications such as facial nerve palsy, vascular injury, encephaloceles, CSF leaks, postoperative sensorineural hearing loss, and vertigo.

A neurobiology for all clinical types of tinnitus is emerging reflecting advances in the basic science and neuroscience of brain and brain function and the cochleovestibular system. As tinnitus types begin to be objectively identified, treatment modalities can be applied in a more precise manner. The goal of this miniseminar is to examine new and existing tinnitus treatment specifically in reference to how to apply these techniques for the different tinnitus types. Surgery, intratympanic treatment, neuromodulation, and magnetic stimulation will all be examined, allowing the participants to understand the cutting edge of tinnitus therapy.

(1) Cite the clinically applicable methods of tinnitus treatment. (2) Determine the rationale for selection of modality(ies) of treatment based on objective identification. (3) Describe the variety of tinnitus types that can now be diagnosed in an objective manner.

Endoscopic ear surgery (EES) is a current hot topic in our specialty; however, it is not entirely correct to introduce EES as “new.” Although not new, it is clear that during the past few years, endoscopes have proven to be safe and effective instruments to manage ear diseases in a minimally invasive way, preserving important anatomic structures, allowing functional approaches to well-known conditions. Moreover, endoscopes have provided a better view and understanding of traditional middle ear anatomy and physiology, allowing new landmarks, novel concepts of tissue preservation, ventilation routes, and management of other conditions within the middle ear and beyond.

(1) Describe the endoscopic anatomy of the middle and inner ears, discussing the concepts of related physiology. (2) Examine totally endoscopic and combined surgical approaches to middle ear conditions, discussing the possible advantages and disadvantages. (3) Present the instruments needed, system setup, surgical skills, learning curve, and also some important tips and pearls to surgeons to start doing endoscopic ear surgery.

Chronic otitis media is a condition commonly encountered by otolaryngologists. During this miniseminar, we will cover the fundamentals of managing chronic otitis media, medically and surgically, in a case-based, interactive format. Particular emphasis will be given on how to recognize, evaluate, and avoid or treat common complications of chronic otitis media. Specifically, the presentation will include the following topics: managing the tegmen and dura, facial nerve, vascular injury, otic capsule, and ossicular erosion; recurrent disease; and intracranial complications. This presentation will assist the otologic surgeon in the pre-, intra-, and postoperative care of patients with chronic otitis media.

(1) Recognize the most common complications of chronic otitis media. (2) Interpret critical findings that will alert the clinician to the presence of a complication from chronic otitis media. (3) Implement management strategies that will assist in the care of patients with chronic otitis media with attention to intraoperative findings.

The “dizzy” patient can be a diagnostic challenge. Symptoms can be nonspecific and result from numerous etiologies. While most otolaryngologists realize that a complete and accurate history provides the basis for the diagnosis and management of balance disorders, the use and diagnostic significance of balance tests can be unclear. In this miniseminar, we will discuss the use and interpretation of a variety of balance tests including electrocorticography, vestibular evoked myogenic potential, videonystagmography testing, rotational chair testing, head impulse tests, and posturography. The goal of this miniseminar is to educate and discuss the use of these tests in a modern practice.

(1) Identify history and physical examination findings that indicate the need for further diagnostic testing. (2) Decide which balance tests to order when further testing is necessary. (3) Interpret balance function testing for diagnostic and prognostic purposes.

Through this interactive presentation, the audience is exposed to challenging temporal bone radiology cases and offered strategies to improve their interpretation. We will cover key findings for chronic ear disease and conductive hearing loss, lateral skull base lesions, and the petrous apex. The emphasis is placed on subtle but pertinent findings on computed tomography and magnetic resonance imaging examinations and their importance in creating and narrowing a differential diagnoses. We will present guidelines to aid in the efficient acquisition and interpretation of imaging for patients with common otologic symptoms such as vertigo, sudden hearing loss, and pulsatile tinnitus.

(1) Interpret key radiographic findings for common pathologic conditions of the temporal bone. (2) Order appropriate radiographic tests to evaluate common conditions and understand the strengths and limitations of various imaging modalities.

Sudden hearing loss is a complex, frightening condition with a number of possible causes and treatments. There is exciting new research with immediate clinical application. This miniseminar will provide a Clinical Practice Guidelines–based review of targeted evaluation and treatment options and a detailed look at current research, particularly for the problem of the patient with sudden sensorineural hearing loss (SSNHL) who does not respond to first- or second-line treatments.

(1) Demonstrate an evidence-based strategy for workup, evaluation, and counseling of the patient with SSNHL. (2) Compare existing treatment modalities using the available evidence and offer the appropriate treatment for the patient. (3) Recognize the latest research in treating other treatment-resistant SSNHL.

Idiopathic sudden sensorineural hearing loss (ISSHL) has no known etiology. However, numerous studies have addressed this important problem. This miniseminar, sponsored by the American Academy of Otolaryngology—Head and Neck Foundation (AAO-HNSF) Otology and Neurotology Education Committee, will summarize existing literature with regard to the evaluation and treatment of ISSHL. We will review AAO-HNSF guidelines, studies on the efficacy of steroids, antivirals, hyperbaric oxygen, and other treatments. Lastly, we will discuss treatment options when hearing does not recover.

(1) Implement the recommended evaluation of patients with sudden hearing loss. (2) Recognize the benefits of oral versus intratympanic steroids for sudden hearing loss. (3) Analyze the utility of nonsteroidal treatments when steroids and other modalities fail.

Dizziness and balance problems are very common in older adults. These problems can be vexing to manage for the otolaryngologist given that symptoms are often nonspecific, and multiple vestibular and nonvestibular factors are typically involved. In this miniseminar sponsored by the Geriatric Otolaryngology and Equilibrium Committees, we will review the latest evidence on how vestibular function changes with age and how this affects mobility and falls risk in older adults. We will discuss a practical, evidence-based approach to identifying important vestibular and nonvestibular contributing factors (eg, benign paroxysmal positional vertigo in elderly patients, orthostatic hypotension, specific medications), and strategies for managing these factors.

(1) Describe multiple contributing factors to dizziness in older adults. (2) Explain how vestibular function changes with aging and how this affects mobility and falls risk. (3) Enhance the diagnosis and management of vestibular dysfunction in older adults.

More than 3500 battery ingestions occur each year in the United States. Over the past 8 years, the number of moderate to severe injuries has increased, including fatalities. A multidisciplinary national button battery task force was set up in 2012 under the American Broncho-Esophagological Association and the American Academy of Pediatrics with the overall mission of reducing button battery injuries in children. This miniseminar aims to outline the current status of the problem, insights into clinical management algorithms, industry involvement, product safety standards, and educational outreach activities. All task force activities will be discussed.

(1) Discuss the incidence of button battery ingestions, mechanisms of injury, clinical presentation, and common household sources of button batteries. (2) Implement treatment algorithms and be able to recognize immediate and delayed complications. (3) Implement solutions with industry collaboration and educational outreach efforts to prevent future button battery injuries.

This clinical consensus statement was developed by a multidisciplinary panel of experts to improve patient care and outcomes for pediatric patients with chronic and recurrent rhinosinusitis. Clinical statements were developed using the modified Delphi technique to optimize expert consensus. Clinical statements were developed to specifically address differences between and within medical disciplines regarding the diagnostic methods for pediatric rhinosinusitis and in both the medical and surgical therapeutic approaches for the management of pediatric rhinosinusitis. This miniseminar will review the key results of the panel’s efforts as well as critically assess the available, supporting evidence.

(1) Review the key clinical factors that distinguish acute and/or chronic rhinosinusitis from other common illnesses such as viral upper respiratory infection or allergic rhinitis. (2) Assess the most useful diagnostic measures to establish the diagnosis of rhinosinusitis in children. (3) Explore the stepwise recommended medical and surgical treatment approaches for pediatric rhinosinusitis.

This panel format miniseminar will provide perspectives on best practices in care of the pediatric tonsillectomy patient with regard to anesthetic practices, criteria for admission, and pain management. The goals of the presentation are to provide guidelines for safe and effective pain management, raise awareness regarding “red flags” in children who may require advanced anesthesia expertise, and propose algorithms for identifying and managing those children who may be at high risk for complications.

(1) Provide safe and effective nonnarcotic postoperative pain management in pediatric tonsillectomy patients. (2) Identify children at increased risk for posttonsillectomy complications. (3) Recognize patients who will most benefit from the expertise of a pediatric anesthesiologist and/or a higher level of postoperative care.

Sleep-disordered breathing (SDB) affects more than 10% of all children, and tonsillectomy and adenoidectomy (T&A) is one of the most common surgeries done nationally. This miniseminar will review available current national guidelines on evaluation of SDB, including the use of polysomnogram and indications for T&A. Outcomes in routine, syndromic, obese, neurologically affected, and other cases will be reviewed. Lastly, surgical options for failures to cure with T&A will be discussed. Case studies will be presented that will demonstrate principles presented and foster discussion among panelists.

(1) Describe patient characteristics that necessitate evaluation with polysomnogram versus proceeding with treatment based on clinical history and examination. (2) Identify common reasons for failure to cure SDB with routine T&A. (3) Demonstrate knowledge of available surgical options for these cases.

In this state-of-the-art miniseminar, 7 experts will share video-based examples of new ideas in pediatric otolaryngology. New knowledge, techniques, and outcomes for emerging concepts will be discussed while ample opportunity for audience questions and answers will be provided. Steven L. Goudy: endoscopic-assisted pharyngeal surgery. Christopher J. Hartnick: optical coherence tomography in the operating room; differentiating cysts from nodules. Sanjay R. Parikh: drug-induced sleep endoscopy: technique and findings. Soham Roy: mechanical models of operating room airway fires. Michael J. Rutter: slide tracheoplasty for difficult tracheoesophageal fistula. David R. White: a new understanding of congenital nasal stenosis. Carlton J. Zdanski: transoral robotic surgery: pearls and pitfalls.

(1) Characterize novel ideas for pediatric airway surgery techniques and concepts. (2) Prevent airway fires during surgery. (3) Practice novel techniques for understanding pediatric sleep apnea evaluation.

Rhinologic diagnostic and treatment problems commonly create dilemmas in practice. This miniseminar provides for interactive discussion of the management options and the decision rationale involved in difficult sinus diagnostic and treatment situations. A case presentation format is used with case presentations from each of the panelists emphasizing questions with regard to differential diagnosis, evaluation, imaging, and treatment. Cases are representative of those encountered by either a general otolaryngologist or a subspecialty rhinologist but have critical decision points for discussion. The session focuses on the decision-making process, frontal sinus disease, revision surgery, and fungal sinusitis, as well as common tumors.

(1) Review the surgical decision-making process in chronic sinus disease. (2) Implement different imaging modalities and improved quality of interpretation for both computed tomography and magnetic resonance images. (3) Improve the management of difficult-to-treat chronic rhinosinusitis.

This miniseminar includes 3 didactic lectures, an audience-interactive section, and Q&A. The lectures will focus on why food allergies develop by taking a critical look at the latest scientific evidence available in the literature, the role of oral tolerance in human evolution, and the relationship of failure to achieve oral tolerance on the health of the individual, relevant immunology, nonimmunologic food reactions versus immunologic reactions, both IgE-mediated and non–IgE-mediated, current methods of diagnosing food allergies, cutting-edge strategies such as component-resolved testing, skin and in vitro methods versus double-blind, placebo-controlled food challenge. Treatment options for food allergy will also be discussed.

(1) Evaluate the scientific basis of IgE- and non–IgE-mediated food allergy. (2) Describe the manifestations of food allergy in the head and neck region. (3) Use the currently available treatments for food allergy as well as future directions.

Chronic sinusitis with nasal polyposis has a detrimental impact on quality of life and may exacerbate coexisting conditions such as asthma. This miniseminar will outline the latest theories on disease pathogenesis as well as promote rational medical and surgical strategies for severe nasal polyposis management. Treatments designed to decrease reliance on systemic steroids including surgical methods and complementary medical therapeutics such as topical steroid irrigations, macrolides, and anti-leukotrienes will be discussed. A panel of international experts will provide the latest innovations in medical and surgical treatments through a case-based approach of difficult patients and strategies for success illustrating these advancements.

(1) Describe current theories on the pathogenesis of nasal polyposis. (2) Recognize the newest medical and surgical treatments for difficult nasal polyposis, including cystic fibrosis. (3) Initiate additional therapeutic measures to appropriately care for patients with severe nasal polyposis.

Allergic rhinitis is a worldwide health problem affecting 30 to 60 million people in the United States annually, including up to 30% of adults and as many as 40% of children. The multidisciplinary, AAO-HNSF-developed Clinical Practice Guideline: Allergic Rhinitis, will be presented. The evidence-based recommendations are designed for clinicians involved in the diagnosis and management of patients with allergic rhinitis.

(1) Properly diagnosis allergic rhinitis. (2) Differentiate between allergic and non-allergic rhinitis. (3) Know when to perform allergy testing; and understand the role of immunotherapy (sublingual and subcutaneous).

Some of the most exciting new research in the field of chronic rhinosinusitis (CRS) relates to topical therapies. These therapies include topical steroids, antibiotics, antifungals, surfactant, and complementary and alternative treatments such as manuka honey and bacteriophage. New research now supports the clinical use of these therapies. However, some topical therapies proposed for treatment of CRS and related disorders should be used with caution due to lack of efficacy and even toxicity. The purpose of this miniseminar is to provide a summary and case studies of the best evidence available to help clinicians treat patients with CRS using topical therapies.

(1) Analyze up-to-date evidence-based research for topical therapy management of CRS including topical steroid, antibiotic, antifungal, surfactant, and other alternative remedies. (2) Apply evidence-based clinical research in this field to directly improve the therapies available for patients with CRS.

Patients with nonallergic rhinitis (NAR) are commonly seen in an otolaryngologist’s practice. These patients may have no allergic triggers, may be negative to routine allergy testing, and are therefore diagnosed with NAR. Recent workgroups both in the United States and internationally have attempted to better classify the pathophysiology and phenotype of patients with NAR, with the goal of facilitating more accurate diagnosis and improved treatment. This panel will review, through brief didactic discussions and case presentations, recent knowledge and current understanding of NAR and will highlight methods to improve the management of these frequently challenging patients.

(1) Discuss the various pathophysiologies and presentations that are grouped under the diagnostic category of nonallergic rhinitis. (2) Review important elements of the diagnostic workup in evaluating the patient with nonallergic rhinitis. (3) Implement treatment strategies for patients diagnosed with nonallergic rhinitis.

The risk of serious complications during endoscopic sinus surgery (ESS) is ever present. It is the responsibility of the operating surgeon to minimize the risks through meticulous preoperative preparation, careful operative technique, and diligent postoperative care. This miniseminar brings together some of the top sinus surgeons from around the world to share some of their technical pearls and experience regarding the treatment and avoidance of complications in ESS, as well as the latest research in the field. Through the use of clinical case-based vignettes, topics that will be covered include CSF leak, orbital injury, and catastrophic hemorrhage.

(1) Identify high-risk situations preoperatively in patients undergoing functional ESS (FESS). (2) Apply intraoperative measures and technical pearls to avoid serious complications during FESS. (3) Elaborate a clear plan for the management of intraoperative emergencies, including orbital hematoma and internal carotid artery injury.

With continual advances in endoscopic instrumentation and technology, a burgeoning number of rhinologic procedures can now be effectively performed in the office environment. Such interventions have provided therapeutic alternatives in the management of primary and recalcitrant sinonasal disease. The purpose of this miniseminar is to describe the principles and techniques involved in successful implementation of rhinologic surgery in the clinic setting. Both fundamental (turbinate surgery, polypectomy) and advanced sinus procedures (frontal sinusotomy, revision surgery) will be discussed. Appropriate setup, anesthesia, and patient selection will be described. This miniseminar will be conducted by academic leading rhinologists using a multimedia, interactive, case-based format.

(1) Discuss current office-based, rhinologic surgical procedures and their role in the management of sinonasal disease. (2) Describe appropriate patient selection, preparation, and optimal anesthetic and surgical techniques for rhinologic clinic procedures. (3) Assess recent technologic innovations and understand their proper application in rhinologic office-based surgical procedures.

Although our understanding of chronic rhinosinusitis (CRS) has improved, patients prove to be a diagnostic and therapeutic challenge. The variability in presentation contributes to the difficulty in providing effective medical and/or surgical therapy for each patient, and straightforward, all-encompassing guidelines are lacking. As more innovative treatments arise, choices available to otolaryngologists become overwhelming. The purpose of this miniseminar is to provide a stepwise approach to the overall management of CRS patients. The panelists will cover aspects of patient care including evaluation and diagnosis, tailored medical management, surgical choice and optimization, and postoperative management.

(1) Evaluate patients presenting with CRS and provide medical/surgical management recommendations for specific categories of CRS. (2) Discuss methods for improving surgical outcomes and recommend appropriate use of surgical devices/products for CRS. (3) Provide recommendations for effective postoperative management, use of subsequent in-office procedures, and continued medical treatments for CRS.

Modification of uvulopalatopharyngoplasty (UPPP) as well as variation in treatment of hypopharyngeal obstruction are numerous. Selecting the right technique for the right patient often becomes the most difficult decision in treatment planning. It is often unclear if the proponents of a particular technique apply their “modifications” for every case or if there is a selection process. The purpose of this miniseminar is to present specific cases and hear the opinion of 5 experts on how they would treat the same patient.

(1) Use the appropriate patient selection for a classic UPPP. (2) Determine when uvula preservation techniques are appropriate. (3) Examine the current thinking in tongue base reduction.

Obstructive sleep apnea (OSA) significantly affects sleep, daytime function, quality of life, public safety, and cardiovascular risk. Although positive pressure remains the primary treatment, suboptimal adherence rates necessitate alternative treatment strategies. Hypoglossal nerve stimulation is a new and emerging treatment option with published prospective clinical trial data. Sleep-boarded otolaryngologists will review the physiology and basic science of upper airway stimulation, demonstrate the current technology and surgical procedure, present safety and efficacy data from recent multicenter clinical trials, and discuss patient selection and cost-effectiveness. A panel will explore future directions and the advantages/disadvantages of this technology as it compares to other sleep apnea treatment options.

(1) Examine the pathophysiology of OSA with a particular focus on the neuromuscular control mechanisms. (2) Interpret the basic science and feasibility studies on hypoglossal nerve stimulation and describe the current technology and surgical procedure. (3) Report the safety, efficacy, and cost-effectiveness data from published prospective multicenter clinical trials.

Since the introduction of endoscopic sinus surgery, surgeons have debated the merits of middle meatus packing. Many surgeons favor a middle meatal spacer, rather than packing, since the former implies an intentional design for better wound healing. Recently, the emphasis has been upon dissolvable or fragmentable materials that may exert positive effects upon wound healing, and a dissolvable stent that provides drug delivery has also been introduced. In addition, some surgeons do not use any materials whatsoever in the middle meatus after surgery. This miniseminar will feature evidence-based reviews of the published trials, as well as practical knowledge from experienced surgeons.

(1) Comprehend the principles of biomaterials selection for placement in the nose and paranasal sinuses. (2) Review principles of postoperative care with an emphasis on integration into the global surgical strategy. (3) Compare various middle meatal spacers, including chitosan, esterified hyaluronic acid, steroid-releasing implant, and synthetic fragmental foam sponge.

Failure of adequate response to endoscopic sinus surgery (ESS) is a frequent cause of frustration to chronic rhinosinusitis patients and their surgeons. Technical execution of ESS may be a factor in some common findings at revision ESS (middle meatal adhesions, lateralized middle turbinate, missed maxillary ostium, residual uncinate process, residual anterior and posterior ethmoid cells, sphenoid ostium stenosis, and frontal recess scarring). Using real-life demonstrative cases, our expert panel will share practical and key technical pearls on optimizing results from ESS. These include simple modifications in surgical techniques, selection of procedure appropriate to disease, and incorporation of state-of-the-art technology (endoscopes, instrumentation, navigation, etc).

(1) Recognize technical causes of failure of satisfactory response from ESS. (2) Implement changes in surgical techniques to optimize technical execution of ESS. (3) Learn to use technology and instrumentation to improve execution and completeness of ESS.

Surgical and medical management of the nasal airway has traditionally not been considered primary indication for sleep disorders’ treatment. Controversy exists over nasal surgery as primary treatment of snoring and sleep apnea. Algorithms to manage sleep-disordered breathing often ignore or dismiss the nasal airway. This miniseminar addresses the following controversies: (1) Is the nasal airway an important contributor to sleep disorders? (2) Does nasal surgery affect sleep? (3) Does nasal treatment affect the use of continuous positive airway pressure? and (4) What is the role and documented effect of nasal surgery sleep apnea treatment in adults and children?

(1) Justify using appropriate evidence-based outcome metrics of medical and surgical treatment of the nose for specific sleep-related breathing disorders. (2) Compare medical outcomes of sleep apnea treatment with and without treatment of nasal obstruction. (3) Describe potential differences and obstacles in treating nasal obstruction using traditional definitions versus treating it as a spectrum of sleep disordered breathing.

Palate surgery is the primary surgical approach for treatment of obstructive sleep apnea. Although uvulopalatopharyngoplasty (UPPP) was described 30 years ago, the past 10 to 15 years have witnessed the development of alternative palatoplasty techniques. This miniseminar draws from leading surgeons who have developed these procedures and/or performed clinical trials related to them. Findings from published studies will enable attendees to learn more about selection from among the procedures for their patients.

(1) Interpret evidence regarding the range of palatoplasty techniques: UPPP, modified expansion sphincter pharyngoplasty (aka functional expansion pharyngoplasty), relocation pharyngoplasty, lateral pharyngoplasty, Z-palatoplasty, and palatal advancement. (2) Identify the key patient characteristics to guide the selection among palate surgery techniques.

Drug-induced sleep endoscopy (DISE) is a novel technique to identify sites of anatomic obstruction that may be amenable to surgery. Although the technical aspect of the procedure is straight forward, the interpretation and management is not. The science of DISE is rapidly expanding, but there are still many gaps. This miniseminar will present a variety of DISE videos. After audience polling, an expert panel will provide their interpretation and management. Both the art and science behind the decision process will be discussed.

(1) Evaluate a DISE video and classify the obstruction. (2) Formulate a management plan for a variety of anatomic sites of obstruction. (3) Predict the best OSA surgical candidates.

Assess the attitude of academic otolaryngology faculty members toward a new electronic medical record (EMR) and determine the impact of implementation on their perspectives.

A longitudinal survey study was conducted from December 2013 to June 2013 at an academic medical center. All otolaryngology and audiology faculty members were serially administered an online, 10-question survey assessing their attitudes toward implementation of a new EMR system. These surveys were completed 3 months prior and 1 and 3 months after implementation. Basic demographic information was also collected.

Thirty faculty members completed all 3 surveys. Compared with respondents over 40 years old, those under 40 years reported being more comfortable with computers (P = .035). Prior to implementation, respondents under 40 years were statistically more likely to believe that the new EMR documentation would be both more efficient (P = .018) and higher quality (P = .030). However, by the end of the study the attitudes of the groups had converged; those under 40 years were less positive about the efficiency and quality of documentation in the new system and those over 40 years had become more enthusiastic about these aspects of EMR documentation.

Younger faculty members appear to be more comfortable with the use of computers. This possibly led them to be more optimistic about the potential benefits of the EMR system. However, implementation appeared to alter both age cohorts’ perspectives, with younger faculty becoming less positive and older faculty becoming more enthusiastic about the EMR’s impact.

(1) Describe the various basic recommended guidelines to safely perform office-based procedures in otolaryngology (levels of anesthesia, staff training, pre/post procedure care, critical equipment and supplies, and hospital transfer). (2) Discuss state-specific guidelines for office-based procedures. (3) Describe the basic equipment and room setup to ensure safe, efficient, and successful office-based procedures for anesthesia without sedation. (4) Develop a national standard for office-based procedures in otolaryngology that will act as a guideline for the office-based surgeon.

Office-based procedures will continue to gain significant popularity in otolaryngology as more surgeons take advantage of this safe and effective alternative to procedures based in the operating room. This paper involved examining the various existing guidelines for office-based procedures, including necessary equipment, staff training, anesthesia protocols, and documentation. The various state guidelines on office-based procedures were reviewed on an individual basis to produce a set of guidelines that any otolaryngologist can use to develop an office-based procedure practice.

A guideline has been developed covering all critical aspects necessary to perform safe, effective, and successful office-based procedures, focusing on anesthesia without sedation, for the otolaryngology surgeon. This guideline will help outline the necessary steps for the creation of an office-based procedure practice for otolaryngologists across the country.

Office-based otolaryngology procedures are quickly increasing in popularity and frequency. National guidelines are necessary to ensure these procedures continue to be successful, safe, and patient focused.

Determine the current cost impact and financial outcomes of robot-assisted surgery in otolaryngology.

A systematic review of the literature with a defined search strategy. Using keywords robotic or robot, ENT or otolaryngology, cost or economic, transoral robotic surgery or TORS, and thyroidectomy or parathyroidectomy, searches were performed on PubMed, MEDLINE, EMBASE, CINAHL, and Google Scholar, and reviewed by the authors for inclusion in the study.

A total of 4 papers were identified as being appropriate for analysis. Two addressed cost impact and financial outcome of robotic thyroidectomy, 1 the cost impact and financial outcome of transoral robotic surgery, and a fourth included otolaryngology robotic surgeries in the profitability analysis of robotic surgery but did not specify case or procedure types. Analyses found robotic thyroidectomy cost prohibitive, though transoral robotic surgery was financially sustainable, as overall costs of care are decreased from reduced length of stay.

There are diverging cost impact and economic outcomes being reported in robot-assisted surgery in otolaryngology. These trends should inform our decisions as to where robotic surgery should be focused to garner greatest cost and economic benefit.

(1) Describe the implementation of Lean Six Sigma (LSS) training within an otolaryngology residency program. (2) Illustrate the challenges and opportunities of project execution. (3) Address the institutional considerations for a successful LSS program.

(1) From July 2013, LSS training and Lean Belt Certification were offered through the IUSM Department of Otolaryngology in collaboration with VA Systems Redesign. (2) The curriculum and training were designed to maximize participant learning and engagement. (3) Resident and faculty initiated LSS projects were reviewed. (4) Participant feedback survey results were collected.

(1) The Lean Belt curriculum and training were completed by some of the residents and faculty to date. (2) Two medical students completed Yellow Belt Certification. (3) Salivary and thyroid gland ultrasound projects and a sterile supply project translate quality improvement and cost savings to patients and the organization. (4) Participant survey results have been overwhelmingly positive. The medical students identified the added value of LSS certification in their residency application process.

(1) Lean Belt Certification can be successfully incorporated into residency training. (2) Projects serve to improve patient care, increase value, and justify equipment and personnel retention and expansion. (3) Most academic centers have the necessary training available either internally or often from affiliated VAMC or Business Schools. (4) The Lean Belt curriculum and training program has since been used by other subspecialty departments. (5) The additional skill sets acquired by LSS trainees increase their confidence in identifying opportunities for improvement in their immediate health care environment.

(1) Understand difficulties associated with free flap monitoring and duty hour restrictions. (2) Describe techniques used to train intensive care unit (ICU) nurses to conduct free flap monitoring. The implementation of resident duty hour restrictions has resulted in a variety of modifications to residency training programs in otolaryngology–head and neck surgery. In those programs using a home call system, monitoring of free flaps in the postoperative period can be associated with difficulties in resident duty hour compliance. We sought to use a carefully constructed training program to transition a portion of free flap monitoring to a skilled group of ICU nurses.

A written reference manual describing the basic concepts behind free tissue transfer and normal free flap physiology was distributed. Nurses received a PowerPoint presentation and completed an online module designed to consolidate the didactic training. Finally, the responsibility of on-the-job training of the nurses was given to the otolaryngology house staff such that each nurse logged and documented 10 flap checks in the presence of a resident.

Thirty patients receiving free flaps were monitored by the ICU nursing team resulting in 100% flap survival.

Transitioning the monitoring of free flaps in the perioperative period to ICU nurses can be accomplished through the following principles: (1) Leadership and participation by the microvascular surgeons at a given institution. (2) Faculty-led didactic and web-based training modules prior to actual training. (3) Significant involvement of the otolaryngology house staff, allowing the ICU nurses to gain proficiency.

(1) Determine patient and provider factors associated with patient dissatisfaction in an otolaryngology clinic. (2) Identify strategies to improve the patient experience.

Patient satisfaction surveys were prospectively collected in an academic otolaryngology clinic from January 2011 through March 2013. Patient variables (age, insurance type, established vs new patient, diagnosis, and treatability of condition) and provider variables (years in practice, subspecialty, and clinic wait time) were retrospectively analyzed to determine factors associated with patient dissatisfaction. “Treatability” was graded on a scale of 1 to 5, with diagnoses having a clear treatment option (ie, tonsillectomy for chronic tonsillitis) = 1, and diagnoses with no therapeutic options available (ie, tinnitus) = 5.

The cohort included 820 patient satisfaction surveys and charts. Stepwise linear regression analysis identified no single patient or provider variable associated with poor satisfaction scores. Cluster analysis evaluating the interplay between variables identified 5 unique clusters of patients. Satisfaction scores in 4 of the clusters were in the 99th percentile, while the remaining cluster ranked in the 10th percentile. This cluster consisted of a higher proportion of new patients with difficult-to-treat otologic conditions who described their wait time as excessive and were more likely to be self-pay.

Several factors influence patient satisfaction in an otolaryngology clinic. In this study, variables associated with lower patient satisfaction scores included patients with longer clinic wait times, “difficult to treat” otologic diagnoses, and new patients. Addressing the issues common in this population to better meet their needs and expectations may improve overall patient satisfaction.

Demonstrate increasing demand of medical students applying to otolaryngology and decreasing supply of available residency training positions after the shift from an early match to conventional matching process. Demonstrate increasing United States Medical Licensing Examination (USMLE) Step I scores among matched otolaryngology applicants over time.

Matching statistics were obtained for first year residency positions through the National Residency Matching Program from 1998 to 2013. Matching statistics were obtained for otolaryngology residency positions through the San Francisco Match from 1998 to 2005. Univariate cross-sectional analysis was performed with a P value of .05 determined as significant.

Comparing the early match time period to the conventional match time period, there was an increase in otolaryngology resident applicants overall (P = .002) and US senior otolaryngology applicants (.0006). There was also an increase in unmatched otolaryngology applicants (.0497). USMLE Step I scores increased between match time periods both among matched (P = .025) and unmatched applicants (P = .036). When comparing 5-year core otolaryngology residency positions to 6-year or 7-year research positions, the probability of having an unfilled research position was 24.8 times higher than having an unfilled core position.

Eight years ago, otolaryngology changed from an early to conventional time frame matching process. The match is now more competitive, as evidenced by an increase in the overall number of otolaryngology residency applications, an increased number of unmatched applicants, and an increase of 17 points on average among matched applicants on the USMLE Step I Score. Meanwhile, otolaryngology research positions remain more unlikely to fill compared with core positions.

Determine the variables that contribute to non-compliance with showing up to clinic appointments. Patients no-showing to their appointments represent a significant burden to the health care system by decreasing access to care and lost potential revenue. Identifying patient factors correlated with missed appointments may help characterize why these appointments are missed and identify opportunities to help patients get the care they need.

Retrospective chart review. Patients who did not show up to 3 or more clinic appointments in the otolaryngology department in the Henry Ford system in metro Detroit, Michigan, between July 1, 2011, and June 30, 2012, were analyzed. Controls were patients who had appointments on the same day with the same provider as the no-show patients.

A total of 106 patients were identified who no-showed to 3 or more clinic appointments. Younger age, black race, and lower income were found to be significant factors for patients not showing up to appointments on multiple variate model. On logistic regression, Medicaid insurance, closer distance from home to appointment, less bus transfers, and less time by bus travel were also found to be significant for no-showing.

Age, race, and income are significant contributors to patient noncompliance with clinic appointments. Paradoxically, proximity to the clinical appointment location is also a significant factor; we hypothesize this may be the result of relative income inequality in the metro Detroit population. Follow-up studies include analyzing severity of patient complaints and weather as a factor of noncompliance.

(1) Determine whether Accreditation Council for Graduate Medical Education fellowship-trained pediatric anesthesiologists improve the efficiency of pediatric operations at hospitals that do not have dedicated pediatric operating rooms (ORs). (2) Determine what anesthesia practices may account for a difference in efficiency between general and pediatric anesthesiologists.

This retrospective chart review study compared the anesthesia-controlled time (ACT) between pediatric and general anesthesiologists for pediatric adenotonsillectomies performed at an academic county hospital without dedicated pediatric operating rooms (ORs). All patients age 12 years and under who underwent tonsillectomy or adenotonsillectomy from January 2008 to July 2013 at San Francisco General Hospital were included. Patient demographics, surgical time, ACT, and anesthesia techniques were compared between pediatric and general anesthesiologists.

Pediatric anesthesiologists had significantly shorter ACT than general anesthesiologists (33 ± 12 vs 47 ± 15 minutes; P < .0001). Surgical time was also shorter for cases staffed by pediatric anesthesiologists (44 ± 14 vs 54 ± 23 minutes; P < .05).

These findings suggest that, at hospitals without dedicated pediatric ORs, staffing pediatric operations with fellowship-trained pediatric anesthesiologists may be an effective strategy for increasing OR efficiency and reducing costs without compromising patient care.

Infantile hemangiomas are the most common benign tumor of infancy and are well known for their rapid growth during the first 6 to 9 months of life, followed by a spontaneous but slow involution. The standard of care is to treat these lesions at an early age with propranolol to expedite the involution process. Residual telangiectasias often result following involution. We evaluated the efficacy of using a diode laser as an adjunct treatment for cervicofacial infantile hemangiomas.

Twenty patients, aged 4 months to 11 years, underwent treatment with a 532-nm diode laser as part of the management for their hemangiomas. The fluence was 10.2 to 25 J/cm², pulse durations of 36 to 44 ms, spot sizes of 0.7 to 2 mm, and pulse frequency of 3 to 5 Hz. All procedures were performed in the operating room. In order to assess the efficacy, pre- and posttreatment digital photography were evaluated independently by the authors and ranked on a 0 to 4 point scale (0 = no change and 4 = complete response). Adverse reactions were also recorded.

The telangiectasias showed significant improvement following treatment. In more than half of the patients treated, the affected area demonstrated a complete response. No adverse reactions were noted.

A 532-nm diode laser effectively treats the remaining telangiectasias following hemangioma involution. The treatment is well tolerated and demonstrates excellent results. Whether used independently or in conjunction with other treatment modalities, the diode laser should be part of the surgical armamentarium when treating infantile hemangiomas.

Measure the impact of facial lesion reconstruction on observer-graded attractiveness and measures of negative facial perception.

One hundred twenty casual observers viewed images of faces with lesions of varying sizes and locations before and after reconstruction as well as normal comparison faces. Observers rated attractiveness, lesion severity, and how disfiguring, bothersome, and important to repair they considered each face.

Facial lesions decreased attractiveness –2.26 [–2.45, –2.08] on a 10-point scale. Mixed effects linear regression modeling showed this attractiveness penalty varied with lesion size and location, with large and central lesions generating the greatest penalty. Reconstructive surgery increased attractiveness 1.33 [1.18, 1.47], an improvement that also varied with size and location, restoring some lesion categories to near normal ranges of attractiveness. Iterated principal factor analysis indicated the disfiguring, important to repair, bothersome, and severity variables were highly correlated and measured a common domain; thus they were combined to create the DIBS factor score, representing negative facial perception. The DIBS regression showed lesion faces have a 1.5 standard deviation increase in negative perception [DIBS: 1.69 (1.61,1.77)], which decreased by a similar magnitude after surgery [DIBS: –1.44 (–1.49, –1.38)]. These findings also varied with lesion size and location.

Surgical reconstruction of facial lesions increased attractiveness and decreased negative social facial perception, an impact that varied with lesion size and location. This new social perception evidence, when combined with patient and expert perception data, will inform our evidence-based soft tissue reconstructive algorithm.

Analyze outcomes after static sling suspension and orthodromic temporalis tendon transfer reanimation for facial nerve paralysis after definitive cancer resection with flap reconstruction.

Prospectively collected case series in which patient data were collected prospectively from 2004 to 2013 for patients undergoing reconstruction and facial reanimation after resection of malignancy which involved facial nerve sacrifice. Thirty patients were selected for 2 cohorts: static sling suspension (n = 18) and orthodromic temporalis tendon transfer (n = 12). Revision rates, length of stay, complications, time to follow-up, and postoperative symmetry were compared between the 2 groups.

Of the 30 patients, 18 underwent static suspension and 12 underwent temporalis tendon transfer. In the static sling group, 6 patients (33%) were advised to undergo revision compared with 2 in the temporalis tendon group (17%; P = .31). Only 4 patients underwent revision, 3 from the static group and 1 from the temporalis transfer group. Suture size, average number of sutures used to suspend the face, timing of procedure, radiation history, and flap reconstruction played no significant role between patients requiring revision surgery and those that did not. Of the patients requiring revision in the static sling group, 33% had undergone preoperative radiotherapy compared with 0% in the temporalis tendon transfer group (P = .35). The remaining patients either underwent adjuvant therapy or were observed.

There was no significant difference between the reconstruction methods. Static sling was performed more commonly at time of flap reconstruction.

(1) Recognize the potential efficacy of free flap reconstruction performed at a low volume program. (2) Understand how reconstructive microvascular outcomes and success change over 20 years.

A retrospective chart review was performed at a tertiary care academic program on all free tissue flaps from the primary reconstructive surgeon over 20 years (1993-2013). A total of 135 procedures were obtained from operative notes, billing codes, and chart databases. Outcome variables included overall procedure success, need for surgical revision, and complications. Patients stayed in general surgical intensive care and hospital floor units.

Free tissue flaps were successful in 91% of all cases. In the past 13 years, 70 flaps were performed with 3 failures (96% success rate). Take-back rate was 14% of total cases with a flap recovery rate of 50%. Postoperative failure occurred after 72 hours in 70% of cases. Nearly 60% of patients experienced a complication of any type or severity. Twenty percent of successful flaps had a complication, with half due to partial dehiscence. Systemic complications affected 20% of all cases. The average hospital stay for noncomplicated patients was 13 days. There was 1 postoperative mortality. Fibula and radial forearm were the most common flaps, at 44% and 26%, respectively.

Free flap reconstruction of the head and neck can be performed with acceptable outcomes even in low volume settings.

Report a method using a combination of the Furnas and the Mustardé techniques for the treatment of prominent pinna.

All the patients who underwent otoplasty under the supervision of a single surgeon between 1996 to 2013 were included. Surgical technique and complications were analyzed. Major complications were defined as those requiring revision surgery. Mustardé sutures were used to recreate the antihelix and correct upper/middle thirds of the pinna. In the conchal region, both conchal resection and the Furnas conchal-mastoid sutures were frequently used. Prospective outcome measures included overall benefit and patient satisfaction.

A total of 130 patients with protruding ears were operated upon (126 bilateral, 4 unilateral). Therefore, there were 256 primary interventions. Fifteen required a pure Mustardé technique and 4 underwent a pure Furnas technique. Hence, the combined technique was applied to 237 ears. Mean follow-up was 5 years (6 months-17 years). Only 9 (3.5%) required revision surgery owing to unsatisfactory results and 1 (0.04%) due to bleeding. Minor complications included suture extrusion in 35 ears (13.6%), some up to 5 years postop, and 2 patients (0.07%) developed a retroauricular keloid (treated successfully with intralesional triamcinolone). Overall benefit perceived by the patients was reported as good in 77% and satisfactory in 18%.

We present a technique that combines 2 previously well described techniques, using both cartilage resection in addition to permanent sutures. We believe that the good aesthetic results and acceptable number of complications make this technique an appropriate treatment option for patients with prominent ears.

Review a single institution’s experience with free flap reconstruction of the head and neck in patients 80 years of age and older.

A retrospective chart review was conducted of patients undergoing free tissue transfer for head and neck reconstruction in patients 80 years of age and older between 2008 and 2013 at a single academic tertiary care hospital. Main outcomes studied were free flap success rate, postoperative complications, discharge disposition, and length of hospital stay. Independent variables included age, type of reconstruction, and comorbid disease. Patients were stratified into high and low comorbidity groups using the Charlson Comorbidity Index, and associations with outcomes were analyzed.

A total of 65 patients 80 years of age or older were included in the review. There were 2 free flap failures with a success rate of 97%. Nine patients were 90 years of age or older. The average length of stay was 11 days. There were 11 (17%) flap-related complications and 18 (28%) medical complications. There was no difference in medical or flap-related complications between high and low comorbidity groups (P = .97 and P = .18, respectively). Patients who experienced flap- related complications were more likely to also experience medical complications (P = .002).

Free flap reconstruction in the head and neck remains a viable option in patients of advanced age. In our experience a comparable success rate with those reported in the literature among all patients has been achieved and the level of comorbid disease has not appeared to adversely affect outcomes.

(1) Discuss relevant tip projection ratios involved in surgical planning of rhinoplasty. (2) Implement findings of meta-analysis in cosmetic surgery planning.

Meta-analysis of journal articles through June 2013. Intervention: Cosmetic rhinoplasty for underprojected tip. Outcome Measurements: Pre- and postoperative Goode Ratio in cosmetic rhinoplasty patients. Null hypothesis: None of 3 techniques provides superior tip projection among: suture, internal graft, and external graft.

External graft techniques, such as Sheen shield grafting, were found to significantly increase tip projection over suture only techniques. External vs suture: P = .017. (2) Internal graft techniques, such as columellar strut grafting, approached significance in increased tip projection over suture only technique. Internal vs suture: P = .053. (3) Internal and external graft techniques did not differ significantly, but external graft techniques displayed a tendency to increase tip projection more. External vs internal: P = .360.

(1) Meta-analysis of the Goode Ratio has never been reported in the literature. (2) No technique has been proven to have significance in the past. (3) External grafts produce a significant change in nasal tip projection over suturing, and internal grafts approach significance. (4) This research allows the surgeon to rank techniques in order of magnitude of change desired.

(1) Recognize reconstructive options for lateral skull base defects. (2) Compare reconstructive techniques, operative times, duration of hospitalization, and need for subsequent flap revisions.

Retrospective review of surgical techniques used at a tertiary academic referral center between 2002 and 2014 to reconstruct lateral skull base composite defects involving facial skin, ear, and temporal bone. Data were analyzed for demographics, tumor characteristics, reconstructive technique, operative time, duration of hospitalization, complications, and outcomes.

Thirty-one patients were identified for inclusion. Lateral temporal bone defects resulted from resection of malignant lesions including squamous cell carcinoma (n = 22), basal cell carcinoma (n = 2), melanoma (n = 4), and sarcoma (n = 3). Defects were reconstructed with musculocutaneous free flaps (n = 9), pedicled latissimus dorsi flaps (n = 6), and pedicled submental flaps (n = 16). All cases involved neurosurgery, neurotology, and head and neck surgery services. Although time required for surgical resection was similar, time savings was noticed with submental reconstruction. Compared with free flaps, submental flap reconstruction was associated with significantly reduced total operative time (mean 578 vs 455 minutes; P = .0170) and duration of hospitalization (9 vs 4.9 days; P = .0207). Submental flaps were significantly less likely to require revision debulking procedures (median = 0) compared to free flaps (median = 1.8; P = .00002) and latissimus dorsi flaps (median = 1; P = .0093). There was 100% flap survival.

The musculocutaneous submental flap provides an excellent option for reconstruction of lateral skull base defects given its proximity, reliability, ease of harvest, and exceptional color match. Submental flap reconstruction was associated with reduced operative times, duration of hospitalization, and flap revisions.

Chimeric anterolateral thigh (ALT) free flaps are comprised of multiple skin paddles or muscular components, which allow for the reconstruction of complex 3-dimensional defects. There is a paucity of data in the literature regarding the outcomes with this reconstructive option. We sought to describe our results with this technique and identify outcome predictors.

Retrospective review of 24 patients undergoing reconstruction with a chimeric ALT free flap at an academic tertiary institution between 2009 and 2013. Demographics, indications, comorbidities, flap and functional outcomes were retrieved from the medical records and review of intraoperative photography. SPSS was used for data analysis.

The mean age was 57 years and the cohort primarily consisted of males (87.5%). The most frequent defects were: through-and-through pharyngoesophageal, n = 12 (50%) and skull base, n = 6 (25%). The flap consisted of double skin paddles in 11 cases (45.3%) and a skin paddle with an independent muscular component in 13 (54.7%). The mean skin paddle area was 62 cm². There were no total flap losses; partial loss (secondary skin paddle) was observed in 3 cases and was related to severe congestive heart failure (P = .005) and malnutrition (P = .002). Postoperative fistula was associated to immunodeficiency (P = .02) and malnutrition (P = .004). All except one patient who underwent pharyngeal reconstruction resumed oral diet. The mean time to resume diet was 27 days.

Chimeric ALT flaps represent an excellent alternative for reconstruction of complex defects. Patients with congestive heart failure, with immunodeficiency, and who are malnourished are at higher risk of partial flap loss. A second muscle paddle might be indicated in these cases.

The aim of our study was to look at patient related outcome measures and complications post–open structure septorhinoplasty performed by the same experienced rhinologist and to look at any factors associated with increased risk for requirement of revision surgery.

Retrospective review of case notes of all patients who underwent septorhinoplasty at the same institute, performed by the same rhinologist, between January 2009 and February 2013. Assessment of patient satisfaction was made using the Rhinoplasty Outcomes Evaluation (ROE) tool.

One hundred seventy patients were included in the study, with mean follow-up of 28.2 months. The most common complication was residual deformity (10/170, 5.9%). Eleven patients required further revision nasal surgery (11/170, 6.5%). There was a statistically significant increase in the ROE scores pre- and postoperatively in all patients undergoing surgery (19.5 ± 9.41 vs 68.4 ± 23.7, P < .001). There was a statistically significantly higher rate of revision surgery in patients who had complex surgery (4/16 vs 7/154, P = .01), a higher rate of nasal tip deformity in the revision surgery group compared with the primary surgery group (10/24 vs 29/146, P = .03), and a higher rate of augmentation surgery in the revision surgery group compared with the primary surgery group (13/24 vs 40/146, P =.02).

Open structure septorhinoplasty results in a significant increase in patient satisfaction. Our rate of revision surgery is lower than the average reported in the literature. The rate of revision surgery is higher in cases judged to be more complex preoperatively.

(1) Ascertain the safety of topical mitomycin C in the prevention of recurrent keloid scars after surgical excision. (2) Determine the efficacy of mitomycin C in keloid prevention.

This was a prospective pilot study of 10 patients. Between August 2009 and September 2011, subjects underwent surgical excision of keloids located in the head and neck region with a one-time, intraoperative, topical application of mitomycin C. Patients were followed for 12 months postoperatively. During this period, laboratory values reflecting complete metabolic profile and coagulation studies were drawn preoperatively and postoperatively (at 2 weeks and the first, second, and third months). Additionally, photo-documentation was obtained at regular intervals to ascertain the efficacy in prevention of keloid recurrence.

Twelve patients enrolled in the study. Nine patients completed the protocol. Three patients dis-enrolled prior to surgical excision. No patients were lost to follow-up. Analysis of variance performed demonstrating no statistical significance in the variance of the laboratory values. Additionally, no patient demonstrated abnormality of any laboratory value beyond the reference range. Next, clinical examination of the wounds demonstrated no evidence of necrosis or dehiscence. Finally, no wound demonstrated recurrence at the one-year follow-up visit.

Mitomycin C appears safe for topical use after excision of keloids in the head and neck region. This study demonstrates no evidence of recurrence in all patients enrolled and followed for one year.

Describe common cosmetic deformities and options for reconstruction following parotidectomy.

The authors reconstructed parotid defects in 50 patients and will present an algorithm for reconstruction based on volume, location, and coexisting defects.

The parotid gland is the largest salivary gland in the head and neck, occupying a significant tissue volume. While not every parotidectomy requires reconstruction, excision of large parotid lesions, especially those involving the preauricular area, produce sizeable concavity and skeletonization of the mandible. The resulting cosmetic deformity can significantly affect patients’ self-image and negatively impact their quality of life. Free fat, alloderm, superficial musculoaponeurotic system, rotational sternocleidomastoid flap, and free tissue transfer are possible reconstructive options. Choosing an appropriate donor site requires consideration of the volume, location, and coexisting defects. Free fat grafts are best suited for small lateral parotid defects. In larger volume defects the amount of fat reabsorption is variable, making long-term results less reliable. Similarly, the muscle atrophy of rotational sternocleidomastoid flaps limits their use to filling medium- sized defects, and the arch of rotation allows for only middle and inferior filling of the gland. Finally, large volume reconstruction of total parotidectomy defects, with or without skin, is best accomplished with free tissue transfer.

Reconstructing parotid defects slightly increases operative time and blood loss, but patient satisfaction with the cosmetic outcome is high. Regardless of method used, same-stage reconstruction of parotidectomy defects is advocated and of benefit to the patient. An algorithm for choosing one of several reconstructive options is presented.

(1) Describe the usefulness of osteocutaneous forearm flaps in reconstruction of the naso-ethmoid-orbital (NOE) defect. (2) Describe a case series outlining the authors’ experiences with this reconstruction.

A retrospective review and case series was conducted on patients between 2000 and 2014 who underwent NOE involving resections with reconstruction using radial forearm flap. All disease causes were included and all consecutive patients at 2 institutions were analyzed. Aesthetic results, nasal airway, diplopia, and enophthalmus were assessed in recent patients available. Technical feasibility and methods of reconstruction were assessed, including where bone was plated and which portions of the NOE structure were reconstructed. Patient disease outcomes were included to assess the durability of reconstruction for remaining survival period.

Fifteen patients underwent NOE reconstruction in the timeframe studied. Four recent patients reported poor nasal airway, but no diplopia, and no immediate enopthalmus after NOE reconstruction. Patients felt their appearance had been positively impacted by reconstruction. One-third of patients succumbed to disease in the study period within 3 years of reconstruction, but without need for additional reconstructions.

Ostteocutaneous radial forearm flap (OCRFF) is a cosmetically acceptable and functional method of reconstructing a variety of NOE defects. In NOE cancer patients with limited survival, a one-step reconstruction can be serviceable and not require multiple additional procedures, while ensuring aesthetic results and prevention of ocular comorbidity.

Natural sculpturing of the nose during secondary rhinoplasty is the common goal of every rhinoplastic surgeon. Even for the most experienced surgeons, rhinoplasty remains the most challenging of all aesthetic surgeries. The aim of this study is to assess secondary rhinoplasty surgery on patients by presenting the functional and aesthetic techniques, and evaluating the results of the surgical interventions.

Between January 2000 and January 2014, 1242 secondary rhinoplasty surgeries were performed on 162 males and 1080 females with a mean age of 26 years. Open rhinoplasty surgery was performed on 1170 patients, and closed rhinoplasty surgery was performed on 252 patients. A total of 108 surgeries were performed with local anesthesia and 1134 surgeries under general anesthesia, with or without submucosal reduction of septal deviation and inferior turbinectomy. Septal, auricular, or costal cartilage graft reconstruction was also performed. The reconstructive and aesthetic techniques were performed on 9 different categories. The patients’ functional and aesthetic results were then evaluated.

All patients reported significant aesthetic, olfactory, and respiratory improvement: 990 excellent results, 216 good results, 36 average results, 0 mediocre results.

Advances in rhinoplasty techniques allow satisfactory results in secondary rhinoplasty that were not possible in the past. Furthermore, the choice of a qualified surgeon is of paramount importance. Only the surgeon that has great skills, and who is experienced, careful, and artistic, will make all the difference in achieving great results in the surgical procedure.

(1) Rhinoplasty is the treatment of choice for patients with crooked nose deformity. (2) Objective assessment of nasal and facial profile using digital photographs and computer software is an integral part of management. (3) Recognize that subjective evaluation of patient satisfaction regarding aesthetic improvement is an important aspect of rhinoplasty.

A prospective study from January 2011 to September 2012. Crooked nose deformity in 20 cases of either sex in the age group of 18 to 40 years. Setting: Pt. BDS Post graduate Institute Medical Sciences Rohtak, India, a tertiary care center. Rhinoplasty was performed through the external approach, and aesthetic improvement was evaluated through photographic analysis. Patient satisfaction was also assessed using a visual analog scale of 1 to 100. Independent Variables: Age, sex, external nasal deformity, and nasal septum deviation.

Statistical analysis was done using IBM SPSS v.20 software by paired “t” test. The preoperative nasal deviation alignment angle was 13.76° ± 5.21° while in the postoperative period it was 3.07° ± 2.08° (P < .001). Subjective assessment using visual analog scale showed an improvement from preoperative score of 47.6 ± 7.27 to 81.5 ± 10.69 postoperatively (P < .001).

Objective assessment and documentation of nasal deformities is an integral part of rhinoplasty. Subjective evaluation, on the other hand, is a useful tool to assess the degree of patient satisfaction.

Venous malformations (VMs) are the most commonly encountered vascular malformation of the cervico-facial region. Their clinical spectrum is extremely variable as they can present as single small lesions (often confined within muscle fasciae) or huge infiltrating ones. They can be part of a syndrome, as with Bean Syndrome, or in cutaneous mucosal venous malformation syndrome, among others. The aims of the study were: (1) Diagnose and stage a cervico-facial VM. (2) Describe the available treatment for head and neck VMs. (3) Propose the most appropriate treatment based on the staging of the VM.

A review of the pertinent literature was performed to provide the common indications and techniques to treat head and neck VMs. Thirty-four consecutive cases of VMs have been treated by the authors by means of endovascular sclerotherapy with sodium tetradecyl sulphate, surgery, or both. Only patients with intraosseous VMs (8 total) were treated by surgery alone. Three large, unresectable cervicofacial VMs were treated by means of the “strangling technique.”

Good to very good aesthetic and functional results were obtained in all 34 patients. All 26 patients who underwent sclerotherapy experienced significant swelling. Six cases of skin or mucosal ulcerations were noted. No damage to the facial nerve was observed. Five patients affected by larger VMs showed partial recanalization/recurrence of the malformation.

Cervicofacial VMs have to be managed by an experienced, multidisciplinary team. A protocol with increasing invasiveness is proposed to maximize results after their treatment.

Airway stabilization is critical in combat-related maxillofacial injury as normal anatomical landmarks can be obscured by blood and debris. The objective of this study was to characterize the epidemiology of airway management in maxillofacial trauma.

A total of 1345 military personnel with combat-related maxillofacial injuries were retrospectively identified from the Expeditionary Medical Encounter Database using ICD-9-CM diagnostic codes. Maxillofacial injury severity was quantified with the Abbreviated Injury Scale (AIS). Service members with maxillofacial injury and severe combat trauma were included in the analysis (n = 239). Study variables included the frequency and timing of intubation, presence and severity of burn injury, frequency of tracheostomy, and presence of inhalational injury.

A total of 239 severe maxillofacial injuries were identified. The most common mechanism of injury was Improvised Explosive Device (IED) (66%), followed by gunshot wounds (8%), mortar (5%), and landmines (4%). A total of 51.0% of the subjects required intubation on their initial presentation to triage facilities. Field surgical airways were rare, but demonstrated a 75% success rate. Of the patients who underwent bronchoscopy, 65.2% were found to have airway inhalational injury. There was a significant relationship between the severity of facial injury and the need for intubation on initial presentation (P = .0027). Of the subjects, 19.7% had tracheostomy performed. Furthermore, 12.3% of the study subjects required surgical neck explorations.

There is a high incidence of airway injury in combat-related maxillofacial trauma, which may be underestimated. Airway management in this population requires a high degree of suspicion and low threshold for airway stabilization.

(1) Describe 3-dimensional (3D) computed tomography (CT) anatomic features of the stylohyoid chain in Eagle’s syndrome patients (ES), glossopharyngeal neuralgia patients (GPN), and normal asymptomatic controls (NC). (2) Understand 3D-CT features findings associated with Eagle’s syndrome.

Retrospective chart review from November 2000 to November 2013. 3D shaded surface display CT reconstructions of the stylohyoid chain were generated for 10 ES patients, 16 GPN, and 15 NC patients. Demographic and clinical symptom data were recorded. Anatomic data collected from CT scans included: length of ossified styloid process, anterior-posterior (APA) and medial-lateral (MLA) styloid process angulation, ossification pattern of the stylohyoid chain, and minimum distances between the styloid process and the internal carotid artery, C1 transverse process, and tonsillar fossa.

The average distance from the styloid process tip to the tonsillar fossa was found to be significantly shorter in ES patients (12.7 mm) compared with GPN (21.4 mm; P < .05) or NC (24.8 mm; P < .001) patients. No other measured variables were found to be significantly different between groups, including average styloid process length (ES: 48.0 vs GPN: 40.3 vs NC: 40 mm; P > .05).

The styloid process was found to be significantly closer to the tonsillar fossa in ES patients as compared to GPN and NC patients by 3D-CT reconstructions. No significant differences were found in other measures, including styloid process length. Distance to the tonsillar fossa may be a more appropriate diagnostic criterion for ES than styloid process length, and may contribute to the pathophysiology of ES.

(1) Characterize opinions of applicants participating in simulation during an otolaryngology interview process. (2) Describe the effect of task simulation on applicant impression of the host program. (3) Evaluate correlation between objective simulation performance and traditional rank order methods.

Applicants completed pressure equalization tube (PET) insertion on a simulator following an instructional presentation. A published global rating scale (GRS) was completed by the resident proctor and time to completion was recorded. Applicants were informed that scores were not used in final rank order list. After the interview an online survey was sent to the applicants.

Forty-eight applicants completed PET simulation. Survey response rate was 81% (39/48). Inclusion of a simulation exercise during interviewing positively changed the opinion of 21% (8/38) of the applicants, with 1 negative response. The majority of respondents (88%) had no negative response to inclusion of simulation if GRS scores are not included in ranking process. If GRS results are used for ranking, respondents felt it was more fair if the task was non-novel versus novel (54% vs 23%). The inclusion of GRS results in ranking engendered negative opinions of the program (28% non-novel task, 46% novel task). Mean GRS score for applicants was 16 ± 0.98. Time to completion and GRS score were correlated (P < .01), but neither GRS score (P = .91) nor time to completion (P = .31) were correlated to rank order.

Simulated task performance may provide complementary information to that of traditional interviews. Inclusion in ranking may negatively affect resident perception of the program, notably if the task is novel.

Immunoglobulin G4-related disease (IgG4-RD) is a poorly understood chronic inflammatory disorder affecting the middle aged and elderly that can present to the otolaryngologist. We aim to summarize the current literature by performing a systematic review as well as describe our institutional experience with 8 patients.

Our search used Pubmed, Ovid, and Scopus using the keywords IgG4 related disease, head and neck, orbit, salivary glands, sialadenitis, Kuttner, angiocentric eosinophilic fibrosis, submandibular, lacrimal, thyroid, dacryoadenitis, nasal, sinus, paranasal, and Mikulicz’s. Original research and review articles published in English from 1964 to 2013 whose major topic was IgG4-RD affecting the head and neck were included. Data regarding the various presentations and management of IgG4-RD were summarized. Additionally, we present our own experience with a series of 8 patients diagnosed with this condition.

One hundred twenty-four articles met our inclusion criteria. IgG4-RD most often presents as a mass lesion in the head and neck region. Common diagnostic features include: (1) elevated serum IgG4 level, (2) marked infiltration of exocrine glands by IgG4-positive plasma cells with fibrosis, and (3) marked improvement with corticosteroid therapy. Early diagnosis and involvement of rheumatology is important in management.

IgG4-RD is a challenging nonsurgical disease that has multiple manifestations in the head and neck. It must be distinguished from various mimics including malignancy, systemic diseases, and infectious. Otolaryngologists should be aware of this condition and its management.

(1) Characterize contemporary utilization patterns of a stand-alone otolaryngology emergency room (ER). (2) Assess the range of otolaryngologic complaints. (3) Determine characteristics of patients that require inpatient admission. (4) Provide a practical discussion about the utility of a specialized ER in otolaryngologic care.

Retrospective review of demographic and diagnostic data for all patients with an otolaryngologic complaint evaluated at our institutions ER from January 2011 through September 2013. Descriptive analysis was performed to characterize utilization and diagnostic patterns. Multivariable regression modeling was used to identify predictors of inpatient admission. Geocoding analysis was performed to characterize the ER catchment area.

A total of 12,234 patient visits were evaluated. Mean patient age was 44.7 years with equal sex distribution. The majority of visits occurred during daytime hours (75%) with peak volume occurring mid-day. Auditory and vestibular problems constituted the most frequent presenting complaints (50.0%). The majority of patients were discharged home (92.3%). Significant predictors of inpatient admission were pediatric designation (odds ratio [OR] 1.9, P < .0001), male sex (OR 1.3, P < .0001), arrival overnight (OR 3.3, P < .0001), postoperative complaint (OR 7.3, P < .0001), and laryngeal complaint (OR 2.4, P < .0001). Median distance traveled was 9.6 miles. Patients traveled farther for evaluation of hearing loss (11 miles) and less far for common diagnoses including impacted cerumen (7.1 miles; P < .0001).

This study provides a contemporary analysis of patterns of specialized otolaryngology ER care in the United States. This study has broad implications for otolaryngology care and resource utilization in the emergency care setting.

(1) Understand evolving national trends in diagnosis and management of reflux disease. (2) Be able to analyze these by provider specialty.

National Ambulatory Medical Care Survey (NAMCS) data for time periods 1998-2001, 2002-2005, and 2006-2009 were reviewed for number of visits, provider type, and prescriptions provided.

Addition of 2 more 4-year periods to previously reported data demonstrates increasing ambulatory visits for reflux across all races, sexes, and age groups. In 2006-2009, there were 15,750,000 visits for reflux, representing 6.9 visits per 100 people on a population basis. Overall visits increased across each sequential time period for internal medicine, family, and gastroenterology physicians. Among otolaryngologists, reflux visits increased from 1998-2001 to 2002-2005 but then decreased in 2006-2009; percentage of reflux visits to otolaryngologists fell from 4.4% in 2002-2005 to 2.9% in 2006-2009. Approximately two-thirds of reflux visits were among internal medicine and family practice providers. Among the 3 study periods, number of reflux prescriptions increased 233% with continuing trends toward increased proton pump inhibitor and reduced H2 antagonist use.

Number of ambulatory visits for reflux continues to increase over time, across all demographic subgroups studied. Otolaryngologists are the only specialty who saw a decrease in overall reflux visits from 2002-2005 through 2006-2009; this may reflect real change in practice patterns, change in coding strategies or uncertainty in firmly establishing a reflux diagnosis. Understanding trends in this increasingly prevalent disease may focus attention on more precise diagnosis and improved treatment.

Evaluate the efficacy and safety of intranasal midazolam and syrup chloral hydrate for procedural sedation in children.

A prospective, randomized, double-blinded placebo controlled trial, in a tertiary care hospital over 18 months. A total of 82 children, ages 1 to 6 years, undergoing auditory brainstem response testing, were randomized to receive either midazolam nasal spray with oral placebo or syrup chloral hydrate with placebo nasal spray. Midazolam at 0.5 mg/kg delivered as 100 mcg per spray and oral syrup at a dose of 50 mg/kg. Children not sedated at 30 minutes had a second dose at half the initial dose. The primary outcomes measured were safety and efficacy. Secondary outcomes were time to onset of sedation, parental separation, nature of parental separation, parental satisfaction, audiologists satisfaction, time to recovery, and number of attempts.

There were 41 children in each group. No major adverse events noted. The chloral hydrate group showed earlier onset of sedation (66%) compared with midazolam group (33%). A significant difference in the time to recovery in the chloral hydrate (78 min) group compared with the midazolam group (108 min). Parental and audiologist satisfaction was higher for chloral hydrate (95 % and 75%) than for midazolam (49% and 29%). Overall, sedation with chloral hydrate was 95% compared with 51% with midazolam. Both the drugs maintained sedation.

Both intranasal midazolam and oral chloral hydrate are safe and efficacious for pediatric procedural sedation. Chloral hydrate was superior to intranasal midazolam with an earlier time to onset of sedation, a faster recovery, better parental and audiologist satisfaction, and successful sedation.

(1) Describe the treatment patterns for the management of severe epistaxis at a tertiary-care center. (2) Develop a clinical care pathway (CCP) for system-wide management of severe epistaxis.

A review of patients admitted for epistaxis from August 2012 to December 2013 was performed using: (1) CPT codes and (2) a digital archive of all medical records. Severe epistaxis was defined as persistent bleeding not controlled using local pressure, vasoconstrictive medication, and anterior packing. A root cause analysis identified factors contributing to the morbidity and mortality of patients with severe epistaxis.

Of 332 cases of epistaxis, 48 met criteria for severe epistaxis. Of these, 64.6% (31/48) presented via the Emergency Department and 35.4% (17/48) as an inpatient. All were packed initially. Average duration of packing was 3.02 ± 1.88 days. Nearly half (45.8%) failed packing and had either sphenopalatine artery ligation (37.5%) or embolization (8.3%). Intubation was required in 16.7% (8/48) for airway protection. Nearly half (48.9%) were inappropriately admitted to a location where key resources (operating room and interventional radiology) were unavailable after hours. A CCP was then devised in conjunction with emergency medicine that minimizes the duration of nasal packing and length of hospitalization and reduces the total cost of care. Implementation of the pathway required changes in the electronic medical record and educational programs.

Implementation of a CCP requires evaluation of current practices and the standard of care followed by input from institutional decision makers. Quantifying improvement requires retrospective normative data with ongoing review of compliance with the CCP.

Determine whether it is more cost beneficial to partake in a medical mission trip to developing countries to complete cleft repairs or to support medical professionals in providing local care.

Retrospective analysis of surgical costs per patient of different types of US-based charitable organizations. We compared financial information of 3 separate 501(c)(3)s for fiscal years 2011 and 2012. Cost per surgery was determined through expenses and total number of surgeries. Two organizations focus on service-based missions (typically US-trained surgeons and other clinicians traveling to developing countries to complete surgeries over a 1-2 week period). The third organization focuses on funding local surgeons (who are already trained and have proven expertise) to complete cleft repairs. This organization pays local clinicians to complete surgeries, and in return, surgeons upload results to an electronic medical record system so outcomes and progress can be tracked.

The cost per patient is significantly lower when local surgeons are paid to complete cleft repair cases than when entire teams of clinicians partake in service-based missions for cleft repairs. While different from country to country, the typical cost for locally provided care is as low as $250/patient. When relying on service-based missions, the average cost is above $500.

It is more cost beneficial to empower local surgeons in developing countries to complete cleft repairs.

The recurrent aphthous stomatitis (RAS) is a chronic oral inflammatory disease and it still poses as a clinical problem without satisfactory treatment. The aims of the study were: (1) Evaluate the clinical outcome of RAS patients towards the use of symbiotic Lactofos/Simbioflora, analyzing symptoms, seizure frequency, number, duration, and size of the lesions. (2) Compare the immune profile of RAS patients through cytokine levels with each other and controls before and after treatment.

We conducted double blind randomized clinical trial placebo controlled study with 60 patients with RAS and 30 controls in a period of 2 years (2011-2012).

The symbiotic group showed improvement in pain compared with placebo (P = .027), with no statistical difference for the other clinical variables assessed. The side effects observed were similar in both groups, but flatulence (P = .003) and diarrhea (P = .04) were significant for the symbiotic group. Significant differences were found in cytokine IFN-Y, IL-4, and IL-6 in serum of peripheral blood mononuclear cells (PBMCs) of patients when compared with control and RAS groups. Regarding treatment over time we observed that IFN-Y (P = .023), IL-4 (P = .045), IL-10 (P = .000), and IL-12p70 (P = .027) showed significant difference or between treatments or during the time line.

The symbiotic was effective in improving pain compared with placebo. Patients with RAS have a mixed profile of Th1/Th2 immune response when compared with the control group at baseline. The symbiotic induced Th1 and Th2 responses by increasing IL-12 and IFN-Y and IL-4 and IL-10, respectively.

(1) Describe the outcomes of early versus late tracheostomy in the critically ill patient population. (2) Apply these findings to the clinical setting when deciding on the timing of tracheostomy.

A systematic search was performed of the Medline, PubMed, and Embase databases, as well as the Cochrane Central Register of Controlled Trials. Randomized controlled studies investigating the outcomes of early versus late tracheostomies were included. The primary outcome of interest was the length of mechanical ventilation. Secondary outcomes include intensive care unit length of stay, incidence of pneumonia, and hospital mortality. The meta-analysis was completed using RevMan 5.2 (Cochrane Collaboration, Oxford).

The systematic search yielded 14 studies. There was no significant difference in the length of mechanical ventilation, with a weighted mean difference of –7.28 days (95% confidence interval [CI] –17.66 to 3.10). There was a significant decrease in the length of intensive care unit (ICU) stay with a weighted mean difference of –12.1 days (95% CI –21.7 to –2.52). The weighted risk ratio for pneumonia was 0.79 (95% CI 0.65 to 0.97) and for hospital mortality was 0.84 (95% CI 0.64 to 1.09).

Performing a tracheostomy within 8 days of intubation significantly decreased the length of ICU stay. It may also be associated with a modest decrease in the incidence of pneumonia. No difference was found in the length of mechanical ventilation or hospital mortality.

Identify factors that may be associated with lingual tonsil hypertrophy (LTH).

Retrospective chart review identified 380 patients from August 2013 to January 2014 with graded lingual tonsils, documented during routine flexible laryngoscopy. Lingual tonsils were graded using a 0 to 4 scale: 0 = complete absence of lymphoid tissue, 1 = lymphoid tissue scattered over tongue base, 2 = lymphoid tissue covers entirety of tongue base with limited thickness, 3 = lymphoid tissue 5 to 10 mm in thickness, 4 = lymphoid tissue >1 cm in thickness (above tip of epiglottis). Reflux symptom index (Reflux Symptom Index (RSI)–collected during patient intake), presence of obstructive sleep apnea (OSA; confirmed by polysomnogram), smoking habits, and basic demographics were gathered. Ï•2 and linear multi-variate regression analyses were used to identify significant correlating demographics with LTH.

Overall, 59.5% were male with a mean age of 50.2 ± 16.5 years and body mass index (BMI) of 30.1 ± 18.0. Ï•2 analysis revealed no significant relationship between OSA and LTH (P = .059). When RSI was stratified to ≥10 or <10, a Cochran-Armitage test supported the trend hypothesis that as RSI increases lingual tonsil grading increases. Significant univariate correlates included age (r = –0.307, P < .001) and smoking (r = 0.186, P = .002). Multivariate regression revealed the combination of age and smoking (r = –0.297, P < .001) to be a significant correlate.

LTH does not seem to be associated with OSA in this group of patients. Abnormal RSI may be a factor associated with increased lingual tonsil thickness. Younger patients who smoke are more likely to have LTH.

(1) Analyze the evolving technique for gland-preserving transfacial removal of parotid stones including ultrasound, needle localization, and the combination of endoscopy with transfacial removal. (2) Review the success rate for patients treated with gland-preserving transfacial removal of parotid stones in an updated cohort.

Case series with chart review at a tertiary care university hospital from 2010 to 2014. Disease: Parotid sialolithiasis. Subjects: Patients with parotid sialolithiasis unmanageable with endoscopy alone. Intervention: Transfacial removal. Outcome measurements: Symptom relief, gland preservation, use of ultrasound, use of needle localization, stone size, stone location, facial nerve visualization, complications, and endoscopic confirmation of stone location prior to stone removal.

A total of 25 patients underwent transfacial operation for symptomatic parotid sialolithiasis. Ultrasound was used in 88% of cases and needle localization was used in 64% of cases. Sixteen out of 25 patients (64%) had completely successful therapy defined by no symptoms postoperatively with a preserved, functional gland. Ten of the remaining eleven patients without complete symptom resolution did endorse significant symptom improvement, while the final patient eventually underwent parotidectomy. Fifteen out of 25 patients (60%) had a stone that was localized with the endoscope prior to transfacial resection.

Transfacial removal of certain parotid stones is a functional alternative to parotidectomy for patients in whom endoscopy or shock wave therapy for stone retrieval is ineffective, unavailable, or contraindicated. Ultrasound and needle localization are useful adjuncts in stone retrieval.

(1) Implement the use of Google Glass in the operating room and in the office for teaching purposes and intraoperative consultations. (2) Recognize the potential for wearable technologies to maximally leverage the electronic medical record (EMR) as a platform to optimize communication between physicians and care for patients.

Google Glass is a wearable camera with an optical head mounted display (OHMD) with voice control and internet connectivity via either wireless or Bluetooth-smartphone tethering. The OHMD was used for procedures including tonsillectomy, endoscopic nasal polypectomy, office-based vocal cord injection, and flexible transnasal laser laryngoscopy.

The smartphone technology was used to successfully broadcast the surgical procedures to consultant surgeons off-site as well as mentor resident physicians during procedures. Procedures were performed without complications on patients under general anesthesia as well as patients under local anesthesia without sedation.

We report, to our knowledge, the first uses of Google Glass in head and neck surgery. This feasibility study will review potentials for Google Glass, including resident teaching and intraoperative consultations. We will address lessons learned thus far in optimizing the view obtained from the OHMD. We will also discuss implications of wearable technology in the hospital environment from the standpoint of the future of telemedicine, the consent process, and the potential for novel user interfaces with the EMR.

(1) Evaluate cricopharyngeal myotomy (CPM) for cricopharyngeal dysfunction (CPD) including Zenkers diverticulum (ZD) and cricopharyngeal bar/hypertrophy (CPB). (2) Analyze functional outcomes and quality of life associated with CPD following CPM.

A prospective multicenter study performed from January 1, 2012, to July 1, 2014, included patients presenting with CPD undergoing CPM. Standardized questionnaires including the 10-item Eating Assessment Tool (EAT-10), Functional Outcome of Swallowing Scale (FOSS), and the Reflux Symptom Index (RSI) were completed preoperatively, at 3 and 6 months postoperatively.

Thirty-two patients were included (18F; mean 71 years; range, 53-86 years). Primary CPD included ZD (17/32; 53.1%), CPB (6/32; 18.8%), and ZD+CPB (9/32; 28.1%). The most common comorbidities included GERD (11/32; 34.4%), hiatal hernia (6/32; 18.8%), and an underlying neurologic disease (5/32; 15.6%). Twenty-six patients (81.3%) underwent rigid-endoscopic, 3 (9.4%) underwent flexible-endoscopic, and 3 (9.4%) underwent open-transcervical CPM. One patient developed a leak on postoperative day 3. There were no deaths. Three patients experienced treatment failure at 7, 14, and 14 months postoperatively, requiring revision surgery. Mean preoperative RSI was 24.7 (range, 10-40), FOSS was 2.2 (range, 0-4), and EAT-10 was 20.7 (range, 2-34). The 3-month questionnaire (32/32, 100%) demonstrated an improved mean RSI of 7.2 (range, 0-30), FOSS of 0.6 (range, 0-3), and EAT-10 of 4.6 (range, 0-24). A total of 63% (20/32) completed the 6-month questionnaire, demonstrating a stable/improved mean RSI of 4.95 (range, 0-17), FOSS of 0.55 (range, 0-2), and EAT-10 of 3.1 (range, 0-15).

This represents one of the first prospective studies to demonstrate a significant improvement in functional outcome and quality of life in patients with CPD undergoing CPM.

Analyze the frequency of and techniques used in performing tracheostomies. Understand the prevailing contraindications used in the decision between open versus percutaneous method. Evaluate outcomes among the 2 modes of tracheostomy procedures.

Case-series review of all patients who underwent a tracheostomy spanning 4 years within a tertiary metropolitan hospital. Clinical and demographic data were used to compare the 2 groups of patients with respect to average age, hospital stay, related emergency department (ED) visits, and other complications.

A total of 1333 tracheostomies were performed on 1302 patients. This included 452 (34%) open versus 881 (66%) via the percutaneous dilatational technique (PDT). There was no difference in short-term complications between the 2 groups. The primary long-term complication, tracheal stenosis, occurred most commonly in the PDT group. The contraindications practiced in decision for open versus PDT are not uniform among the various services performing tracheostomies. Approximately 26% of all discharged patients presented to the ED with respiratory or tracheostomy-related complaint within 90 days of discharge.

We present the largest tracheostomy case-series containing a majority performed via the percutaneous technique. Tracheal stenosis is the most common long-term complication seen primarily among PDT group, indicating that factors such technique may lead to such outcomes. Institutional adoption of absolute contraindications may be necessary to avoid long-term complications. The development of an institutional common pathway for care and follow-up may help avoid related ED visits.

Different types of tympanostomy tubes (TT) are available to the otolaryngologist with relative advantages and disadvantages. The objectives of this study are: (1) Use a utility-based Markov Decision Analysis model to compare outcomes of short-term grommet tubes, “intermediate” type tubes (Triune, Grace Medical, USA), and “permanent” T-Tubes. (2) Use sensitivity analysis to determine the most important factors influencing outcomes with one type of TT versus another.

A Markov cohort decision analysis model was created using computer software (Treeage Software, Inc. USA) comparing the 3 types of TT. Published data were used to determine key baseline model parameters. The model featured potential complications including eardrum perforation, early TT extrusion, and the need for possible repeat TT placement after extrusion. Outcomes were quantified using a 0.95 (one procedure, full recovery) to 0.6 (failed myringoplasty) utility scale. Utility values were discounted over time to incorporate real life inconvenience. Statistical analysis included simple descriptive statistics and contingency tables.

The intermediate TT accumulated superior total utility in 2-, 4-, and 6-year models (2.48, 3.96, and 5.27 total utility) compared with grommets (2.32,3.82,5.18) and T-tubes (2.42, 3.86, 5.18). Examining a hypothetical 3000 child cohort, T-tubes resulted in an increased overall perforation rate (10.5% versus 2.0%, P < .001 chi-squared). Sensitivity analysis indicated that the rate of repeat TT placement and the inconvenience utility discount factor over time were the driving factors of the model.

The intermediate TT may produce favorable outcomes as it combines a balance of a lower perforation rate than T-tubes and a longer period of ventilation than grommet tubes.

(1) Determine incidence of HPV (human papillomavirus) infection in routine tonsillectomy swabs and specimens. (2) Determine if vaccination impacts tonsillar HPV infection.

This was a prospective study conducted from July 2012 to January 2014. Patients ages 1 to 100 years undergoing tonsillectomy for nonmalignant indications were enrolled. Demographic data and immunization status were collected. Specimens collected during surgery included a flocked swab and half of the left and right tonsil. All specimens were tested for HPV DNA using the polymerase chain reaction–based Roche Cobas Amplicor test and for the presence of E6/E7 mRNA using the Gen-Probe Aptima HPV test.

Patients were stratified into 2 groups, pediatric (ages 1-12 years) and adults (age 13 years and up) based on age of potential sexual maturity. In the pediatric group (n = 130) mean age was 5.2 years, 42% were female, 58% were male, and only 3 patients were fully vaccinated against HPV. In the adult group (n = 64) mean age was 24 years, 76% female, 24% male, and 47% were either fully or partially vaccinated. All specimens were negative for HPV infection via both testing methods. Internal controls confirmed the tests were functioning properly.

This is the first study to examine fresh tonsil swabs and tonsillectomy specimens for HPV infection using a Food and Drug Administration–approved method. Interestingly, both adult and pediatric specimens were negative for HPV infection. The role of vaccination in oropharyngeal HPV infection remains unclear.

Otolaryngology-related conditions make up 25% of primary care complaints; however, US medical schools do not routinely require otolaryngology instruction, potentially negatively impacting knowledge, attitudes, and medical student career choices. This survey was intended to (1) determine the extent of clinical and pre-clinical otolaryngology education at Accreditation Council for Graduate Medical Education institutions, and (2) focus future educational efforts.

A prospective online survey was sent from the Education Steering Committee of the American Academy of Otolaryngology—Head and Neck Surgery Foundation (AAO-HNSF) to all Accreditation Council for Graduate Medical Education (ACGME) otolaryngology training programs.

Forty percent (42/105) of program directors responded. They reported that medical students could graduate without any clinical instruction in otolaryngology in 85% (34/40) or any formal otolaryngology instruction in 59% (24/41). An otolaryngology rotation was required in only 5% (2/41) of programs. Increased exposure to otolaryngology was noted in 44% (18/41) while decreased exposure was seen in only 22% (9/41). Otolaryngologists provided formal teaching sessions for less than 8 hours over 4 years of medical school in 90% (26/29) of programs. When asked about instruction in specific topic areas, respondents did not know if topics were covered in 19-37% (8-15/42), regardless of topic.

Otolaryngology-provided education is extremely limited in ACGME medical student education despite its importance in patient care. We suggest that the lack of otolaryngology integration in the medical student curriculum should be the focus of future educational efforts, including a national medical student curriculum.