Otolaryngology–Head and Neck Surgery

To develop a composite measure of thyroid cancer–specific hospital quality and to evaluate the association between hospital quality and survival in patients with well-differentiated thyroid cancer.

Retrospective cohort study.

Population-based cancer database.

Data were extracted from the California Cancer Registry data set linked with discharge records and hospital characteristics from the California Office of Statewide Health Planning and Development. The study cohort comprised adult patients with well-differentiated thyroid cancer diagnosed between January 1, 2004, and December 31, 2015. Principal component analysis, incorporating hospital volume, adherence to national guidelines, and accreditation/certification status, was used to generate a composite thyroid cancer–specific hospital quality score.

Treatment in hospitals ranked in the highest quartile of quality was associated with improved overall survival (OS) (hazard ratio [HR], 0.81; 95% confidence interval [CI], 0.67-0.98) and disease-specific survival (DSS) (HR, 0.72; 95% CI, 0.54-0.98). Treatment in hospitals meeting the combined metric of 10 or more thyroid cancer cases/year and 80% of patients with high-risk tumors treated with total/near-total thyroidectomy was associated with improved OS (HR, 0.80; 95% CI, 0.70-0.90) and DSS (HR, 0.77; 95% CI, 0.64-0.94).

Treatment in high-quality hospitals is associated with improved survival outcomes in patients with thyroid cancer. These findings are important because they help identify hospitals that are better suited to treat patients with thyroid cancer and provide actionable targets for quality improvement.

To compare morbidity and aesthetic outcomes of full-thickness skin grafts (FTSGs) and split-thickness skin grafts (STSGs) in the reconstruction of the forearm free flap donor site.

Case series, retrospective chart review.

Institutional microvascular database.

Subjects who underwent forearm free flaps and FTSGs for donor site reconstruction from April 2016 to November 2017 were included. FTSGs were obtained from the donor forearm with a proximal S-shaped incision, thereby avoiding additional wound creation. Morbidity outcomes were compared to 68 consecutive patients with STSG reconstruction from January 2009 to May 2010. Complications, including tendon exposure, subjective functional impairment, complete graft loss, partial graft loss, infection, paresthesias, and hematoma/seroma, were evaluated, as were aesthetic outcomes.

Sixty-eight patients underwent FTSG reconstruction. No significant differences between FTSGs and STSGs were demonstrated in terms of graft loss ≥40% (4% vs 4%, P = 1.000), partial graft loss (<40%) (29% vs 40%, P = .207), tendon exposure (9% vs 12%, P = .573), infection (15% vs 13%, P = .805), paresthesias (12% vs 7%, P = .382), subjective functional impairment (0% vs 2%, P = .316), or hematoma/seroma (2% vs 0%, P = .316). Aesthetic outcomes were better in the FTSG group compared to the STSG group, as determined by both patients (P = .004) and surgeon (P < .001).

Our results advocate for the consideration of FTSGs in the reconstruction of the forearm free flap donor site given superior aesthetic results without additional donor site morbidity or additional wound creation when compared to STSGs.

Cardiovascular risk factors have been associated with benign paroxysmal positional vertigo (BPPV), possibly causing degeneration of the utricular epithelium and subepithelium, but supportive evidence is mixed. This is the first study to examine the association between cardiovascular risk factors and BPPV as they present in the community practice of comprehensive otolaryngology–head and neck surgery.

Cross-sectional case-matched case-control series.

A community practice of otolaryngology–head and neck surgery with 3 clinical offices and a socioeconomically diverse patient population.

Clinical data were collected retrospectively from the electronic health records of a continuous 4-year series of 628 patients with BPPV and age- and sex-matched controls.

There were no statistically significant associations found between BPPV and diabetes, hypertension, dyslipidemia, or body mass index in the study population in pairwise comparisons or multivariable modeling.

This study suggests that BPPV as encountered in a community ear, nose, and throat practice is not generally associated with cardiovascular risk factors. The possibility that these or other cardiovascular risk factors may be causative in some cases cannot be excluded, though most cases of BPPV appear to be caused primarily by shedding of otoconia from the utricle that is idiopathic or at least in part by unconfirmed noncardiovascular factors.

(1) Understand attitudes of otolaryngology residency applicants regarding gender and racial diversity within programs. (2) Examine how program diversity affects applicant decisions during the residency match. (3) Compare the importance of racial and ethnic program diversity among applicants.

Web-based survey distributed in February and March 2019.

Tertiary care university setting.

An anonymous web-based survey was distributed to 418 applicants in the 2019 otolaryngology match. Respondents were queried about the importance of program diversity and its effects on the match process. Ratings were based on a scale of 1 to 5 (with 5 being extremely important or significant effect).

The response rate was 35%; 53% of responders were male; and 59% were white, 25% Asian, 6% black, and 6% Hispanic/Latino. Applicants rated the importance of having female faculty and residents as 4.1 (SD = 1.1) and 4.2 (SD = 1.1), respectively. Applicants rated the importance of having diverse faculty and residents as 3.9 (SD = 1.1) and 4 (SD = 1.2). Overall, 7.6% of applicants canceled interviews due to a lack of female residents and 5.5% due to a lack of female faculty; furthermore, 5.5% of applicants canceled interviews due to a lack of diverse residents and 4.9% due to a lack of diverse faculty. Female and nonwhite applicants prioritized females and diversity within programs more so than male and white applicants.

Although residency applicants felt that program diversity was important, this did not significantly affect decision making during the match process, likely due to the competitive nature of the match. Women and nonwhite applicants prioritized program diversity more than white male applicants.

We aimed to describe the mortality burden and macroeconomic effects of head and neck cancer as well as delineate the role of surgical workforce in improving head and neck cancer outcomes.

Statistical and economic analysis.

Research group.

We conducted a statistical analysis on data from the World Development Indicators and the 2016 Global Burden of Disease study to describe the relationship between surgical workforce and global head and neck cancer mortality-to-incidence ratios. A value of lost output model was used to project the global macroeconomic effects of head and neck cancer.

Significant differences in mortality-to-incidence ratios existed between Global Burden of Disease study superregions. An increase of surgical, anesthetic, and obstetric provider density by 10% significantly correlated with a reduction of 0.76% in mortality-to-incidence ratio (P < .0001; adjusted R² = 0.84). There will be a projected global cumulative loss of $535 billion US dollars (USD) in economic output due to head and neck cancer between 2018 and 2030. Southeast Asia, East Asia, and Oceania will suffer the greatest gross domestic product (GDP) losses at $180 billion USD, and South Asia will lose $133 billion USD.

The mortality burden of head and neck cancer is increasing and disproportionately affects those in low- and middle-income countries and regions with limited surgical workforces. This imbalance results in large and growing economic losses in countries that already face significant resource constraints. Urgent investment in the surgical workforce is necessary to ensure access to timely surgical services and reverse these negative trends.

To characterize the temporal trajectory of body image disturbance (BID) in patients with surgically treated head and neck cancer (HNC).

Prospective cohort study.

Academic medical center.

Patients with HNC who were undergoing surgery completed the Body Image Scale (BIS), a validated patient-reported outcome measure of BID, pretreatment and 1, 3, 6, 9, and 12 months posttreatment. Changes in BIS scores (ΔBIS) relative to pretreatment (primary endpoint) were analyzed with a linear mixed model. Associations between demographics, clinical characteristics, psychosocial attributes, and persistently elevated BIS scores and increases in BIS scores ≥5 points relative to pretreatment (secondary endpoints) were analyzed through logistic regression.

Of the 68 patients, most were male (n = 43), had oral cavity cancer (n = 37), and underwent microvascular reconstruction (n = 45). Relative to baseline, mean ΔBIS scores were elevated at 1 month postoperatively (2.9; 95% CI, 1.3-4.4) and 3 (3.2; 95% CI, 1.5-4.9) and 6 (1.8; 95% CI, 0.02-3.6) months posttreatment before returning to baseline at 9 months posttreatment (0.9; 95% CI, –0.8 to 2.5). Forty-three percent of patients (19 of 44) had persistently elevated BIS scores at 9 months posttreatment relative to baseline, and 51% (31 of 61) experienced an increase in BIS scores ≥5 relative to baseline.

In this cohort of patients surgically treated for HNC, BID worsens posttreatment before returning to pretreatment (baseline) levels at 9 months posttreatment. However, 4 in 10 patients will experience a protracted course with persistent posttreatment body image concerns, and half will experience a significant increase in BIS scores relative to pretreatment levels.

Surgical management of the unknown primary head and neck squamous cell carcinoma (UP HNSCC) remains controversial due to challenging clinical diagnosis. This study compares positron emission tomography–computed tomography (PET-CT) findings with intraoperative identification of primary tumors and compares intraoperative frozen-section margins to final histopathology. In addition, adjuvant therapy indications are provided.

Prospective cohort study.

Academic university hospital.

Sixty-one patients with UP HNSCC were included. Patients received PET-CT, followed by oropharyngeal transoral laser microsurgery (TLM). Margins were assessed intraoperatively using frozen sections and afterward by final histopathology. Adjuvant treatment was based on final histopathology.

The sensitivity of localizing the primary tumor with PET-CT was 50.9% with a specificity of 82.5%. The primary tumor was found intraoperatively on frozen sections in 82% (n = 50) of patients. Five more tumors were identified on final histopathology, leading to a total of 90% (n = 55). Of the 50 intraoperatively found tumors, 98% (n = 49) had negative margins on frozen sections, and 90% (n = 45) were truly negative on final histopathology. Eighteen patients (29.5%) avoided adjuvant treatment.

PET-CT localized the primary tumor in fewer than half the cases. This protocol identified 90% of primary tumors. Intraoperative frozen-section margin assessment has shown potential with a specificity of 92% compared to final histopathology. As a result, adjuvant therapy was avoided in almost one-third of our patients.

The objective of this study was to determine the prevalence of benign vocal fold lesions (BVFLs) in patients with chronic cough over a 1-year period.

Case series with chart review.

Tertiary academic medical center.

A retrospective cohort study of patients with chronic cough seen in our tertiary multidisciplinary cough clinic from 2016 to 2017 was conducted. Patient characteristics, presence of BVFLs by laryngoscopy, and Leicester Cough Questionnaire (LCQ) were recorded.

A total of 419 patients were included (average age: 61 years), and 67% of patients were female. Ten percent of patients had BVFLs: granuloma (5%), leukoplakia (3%), nodules (2%), and polyps (1%). Median cough duration was 2.9 years (interquartile range [IQR], 0.7-8.5); no significant difference in median cough duration was observed between patients with BVFLs and those with no lesions (2.6 vs 3.0 years, P = .86). In total, 178 patients (42%) had available LCQ data: median score of 10.2 (IQR, 7.9-13.9); no significant difference in median LCQ was observed between patients with BVFLs and those with no lesions (10.5 vs 10.1, P = .54).

Prevalence of BVFLs in our cohort of patients with chronic cough was 10%, with posterior glottic lesions—granuloma—being the most common (5%). Prevalence of midmembranous lesions was as follows: vocal fold nodules (2%) and vocal fold polyps (1%). BVFLs were not associated with longer cough duration or more severe cough. We cannot determine a causative or noncausative relationship between BVFLs and chronic cough at this time due to lack of a control group.

Patients increasingly rely on online resources for medical information; however, the Internet is unregulated and prone to misinformation. This study analyzes the reliability, quality, and readability of websites for Ménière’s disease.

A Google search was performed using keywords Ménière’s disease. The first 5 pages (50 results) were reviewed. Websites were sorted into 5 categories: academic institutions, government agencies, professional organizations, medical information websites, and miscellaneous. The reliability, quality, and readability of each website were evaluated using the DISCERN instrument and Flesch-Kincaid Grade Level (FKGL). DISCERN assesses reliability and quality by scoring 15 questions on a scale from 1 (low) to 3 (high). The reliability score emphasizes clear objectives and sources, as well as lack of bias, whereas the quality score emphasizes information on treatment options. The FKGL of each website was calculated using a formula to determine the equivalent US grade reading level.

Ambulatory.

None.

Forty-two websites were analyzed. Academic institutions were the most common (n = 13, 31%) but scored the lowest using DISCERN at 1.75 ± 0.13. Medical information websites scored highest at 2.24 ± 0.09 (P = .024 compared to academic institutions). The average FKGL of all websites was 10.12 ± 0.57 with medical information websites being the easiest to read at 8.84 ± 0.83. Only 5 (13%) of websites scored below the eighth-grade reading level.

Most top online search results for Ménière’s disease are deficient in quality and readability. Medical information websites are generally the most reliable and easy to read.

Idiopathic sudden sensorineural hearing loss (ISSNHL) is a distressing condition that can significantly affect quality of life. Unilateral ISSNHL, occurring first in 1 ear and then the contralateral ear at a separate and discrete time, is a rare presentation that we refer to as metachronous ISSNHL. Our objective was to characterize the presentation of metachronous ISSNHL and report on management and hearing outcomes.

Retrospective case series.

Otology clinic at an academic tertiary referral center.

Patients ≥18 years old presenting with metachronous ISSNHL between April 2008 to November 2017 were identified through review of the clinic electronic medical record. Metachronous ISSNHL was defined as unilateral ISSNHL occurring in temporally discrete episodes (>6 months apart) affecting both ears. Patients with identifiable causes for sudden hearing loss were excluded. Patient demographics, comorbidities, management, and audiologic outcomes were recorded.

Eleven patients with metachronous ISSNHL were identified out of 558 patients with ISSNHL. In patients with metachronous ISSNHL, the mean ± standard deviation age at the time of ISSNHL in the second ear was 58.6 ± 15.2 years (range, 31-77 years). The mean interval between episodes was 9.6 ± 7.5 years (range, 1-22 years). Patients were treated with systemic and intratympanic steroids with variable hearing recovery; 5 patients with resultant bilateral severe to profound hearing loss underwent successful cochlear implantation.

Metachronous ISSNHL is uncommon. Treatment is similar to ISSNHL, and cochlear implantation can successfully restore hearing in individuals who do not experience recovery.

The aim of this study was to investigate the clinical implications of diabetes for the management of idiopathic sudden sensorineural hearing loss (ISSNHL).

Retrospective study.

Tertiary referral center.

ISSNHL patients (N = 403) who received inpatient management between January 2015 and December 2018 were analyzed. All were managed by a uniform treatment protocol of high-dose steroid therapy and salvage intratympanic steroid injections. Treatment results were evaluated according to the American Academy of Otolaryngology—Head and Neck Surgery’s criteria 3 months after the start of treatment. We compared the clinical parameters and treatment outcomes of ISSNHL with and without diabetes. We also evaluated the influence of diabetes on the prognosis of ISSNHL by propensity score matching.

Overall, of the 403 ISSNHL patients, 94 (23.3%) had diabetes, and 11 were newly diagnosed with diabetes. The patients with diabetes were older than those without diabetes (P < .001), and their initial hearing threshold was significantly higher (P < .001). The diabetic patients were hospitalized for a longer period, and their hearing recovery rate was lower. However, when age, sex, and initial hearing level were adjusted by propensity score matching, the diabetic patients and matched controls yielded similar treatment results.

ISSNHL with diabetes usually presents with severe hearing loss and requires longer hospitalization. However, diabetes itself may not influence the prognosis of ISSNHL. Proper management must be provided in ISSNHL with diabetes.

To determine the relationship, if any, between body mass index (BMI) and attenuation of the arcuate eminence (AE).

Case series with chart review.

Tertiary neurotologic referral center.

Submillimeter distances were recorded from high-resolution temporal bone computed tomography (CT) scans of 50 patients (100 sides). The AE (defined as the superiormost location of the petrous bone over the otic capsule), the bony apex of the superior semicircular canal (SSC), and the geniculate ganglion (GG) were identified and 3-dimensional distances measured. The height of the AE relative to the bony apex of the superior semicircular canal was determined using Euclidean geometry using the fixed anatomical landmark of the GG as the origin. Correlations between AE and BMI were calculated using Pearson’s, linear mixed effects, and sensitivity analysis models.

The mean (SD) BMI was 30 (8.1) kg/m², with 16 (30%) patients falling in the underweight/normal category (BMI <25 kg/m²), 10 (20%) overweight patients (25 kg/m²≤ BMI ≤ 30 kg/m²), and 24 (48%) patients considered obese (BMI >30 kg/m²). The mean (SD) AE heights for the left and right ears were 2.5 (1.11) and 2.6 (1.09), respectively. The results of the linear mixed-effects models indicated little evidence that BMI is associated with AE height when including all patients (partial R² = 0.040) and when using BMI categories (partial R² = 0.025).

Contrary to other structures within the lateral skull base, the relative prominence of the arcuate eminence does not correlate with BMI or any other demographic variables.

To determine the optimal timing of the first posttracheostomy microlaryngoscopy and bronchoscopy (MLB).

Case series with chart review.

Tertiary pediatric medical center.

Patients (<21 years of age) who underwent tracheostomy placement from January 1, 2011, to December 31, 2016. Patients were divided into early and late posttracheostomy surveillance groups (<6 weeks vs 6 to 14 weeks, respectively) based on the timing of their first posttracheostomy MLB. The primary outcome was to ascertain the clinical yield of the initial posttracheostomy MLB by documenting whether a medical or surgical treatment decision was made based on MLB findings.

In total, 202 patients were included; of these patients, 162 met criteria for placement in the early group and 40 met criteria for the late group. There was no significant difference between the early and late groups regarding whether a medical or surgical decision was made at the time of the first MLB (21.5% vs 19%, respectively; P = .49). Multiple logistic regression identified that the presence of tracheostomy-related symptoms prior to MLB (odds ratio, 6.75; 95% confidence interval, 2.78-16.39) was the sole predictor of a medical or surgical decision being made at the first posttracheostomy MLB.

The presence of tracheostomy-related symptoms was predictive of a medical or surgical decision being made using information obtained at the time of the first posttracheostomy MLB. We thus recommend that surveillance endoscopy be initiated when tracheotomized children start to develop tracheostomy-related symptoms.

To determine the feasibility of detecting and differentiating middle ear effusions (MEEs) using an optical coherence tomography (OCT) otoscope.

Cross-sectional study.

US tertiary care children’s hospital.

Seventy pediatric patients undergoing tympanostomy tube placement were preoperatively imaged using an OCT otoscope. A blinded reader quiz was conducted using 24 readers from 4 groups of tiered medical expertise. The primary outcome assessed was reader ability to detect presence/absence of MEE. A secondary outcome assessed was reader ability to differentiate serous vs nonserous MEE.

OCT image data sets were analyzed from 45 of 70 total subjects. Blinded reader analysis of an OCT data subset for detection of MEE resulted in 90.6% accuracy, 90.9% sensitivity, 90.2% specificity, and intra/interreader agreement of 92.9% and 87.1%, respectively. Differentiating MEE type, reader identification of nonserous MEE had 70.8% accuracy, 53.6% sensitivity, 80.1% specificity, and intra/interreader agreement of 82.9% and 75.1%, respectively. Multivariate analysis revealed that age was the strongest predictor of OCT quality. The mean age of subjects with quality OCT was 5.01 years (n = 45), compared to 2.54 years (n = 25) in the remaining subjects imaged (P = .0028). The ability to capture quality images improved over time, from 50% to 69.4% over the study period.

OCT otoscopy shows promise for facilitating accurate MEE detection. The imageability with the prototype device was affected by age, with older children being easier to image, similar to current ear diagnostic technologies.

To investigate the expression of B1 and B2 receptors in patients with nasal polyps (NPs) compared to controls.

Retrospective case series.

Single academic center.

Nasal biopsies of patients with NPs were compared to inferior turbinates of control patients. Comparisons included basic demographics and comorbidities, intensity of inflammation, and immunohistochemical staining of B1 and B2 receptors measured by immunohistochemistry staining scores (ISSs).

A total of 41 patients were enrolled, with 21 patients (51.2%) in the NP group and 20 patients as controls. No differences were found in the prevalence of allergic comorbidities and smoking between the groups. The NP group demonstrated significantly higher prevalence of moderate and severe mononuclear infiltrates compared to the control group (57.1% vs 5.3%, P < .001). The NP group had significantly lower B1 expression in smooth muscle compared to the control group (mean ISS 0.22 vs 1.56, P < .001, respectively) and significantly more B2 expression in epithelial cells (mean ISS 1.81 vs 0, P < .001, respectively).

Patients with NPs exhibit different expression patterns of B1 and B2 compared to control patients. This implies that bradykinin receptor regulation participates in the pathogenesis of NPs.

To analyze the resource utilization of performing drug-induced sleep endoscopy (DISE) procedures in an endoscopy suite (ES) setting as compared with the operating room (OR).

A retrospective review of DISE procedures performed by a single attending surgeon from 2016 to 2018.

Tertiary hospital.

All patients undergoing sleep endoscopy without concurrent surgical procedures were included. No exclusion criteria were incorporated. Analysis assessed for differences in procedure-related expenditures, patient characteristics, anesthesia and surgeon time, and access to care.

A total of 87 sleep endoscopies were included: 65 (74.7%) performed in the ES and 22 (25.3%) in the OR. Patient groups were similar in age and apnea-hypopnea index severity (P > .05). Patient body mass index was significantly higher for the ES group (P = .03). Total facility time, postoperative recovery time, anesthesia care time, and time in the surgical room were significantly decreased in the ES setting (P < .01). Surgical time was similar between the groups (P > .05). For ES procedures, total cost was reduced by 74% (P < .01). DISE in the ES resulted in a mean $5080 less in health system charges versus the OR group (P < .01). There were no treatment-related complications in either setting.

The resource utilization profile of performing DISE can be significantly improved by transferring these procedures from the OR to the ES setting.

To predict the apnea-hypopnea index (AHI) in patients with obstructive sleep apnea (OSA) using data from breathing sounds recorded using a noncontact device during sleep.

Prospective cohort study.

Tertiary referral hospital.

Audio recordings during sleep were performed using an air-conduction microphone during polysomnography. Breathing sounds recorded from all sleep stages were analyzed. After noise reduction preprocessing, the audio data were segmented into 5-second windows and sound features were extracted. Estimation of AHI by regression analysis was performed using a Gaussian process, support vector machine, random forest, and simple linear regression, along with 10-fold cross-validation.

In total, 116 patients who underwent attended, in-laboratory, full-night polysomnography were included. Overall, random forest resulted in the highest performance with the highest correlation coefficient (0.83) and least mean absolute error (9.64 events/h) and root mean squared error (13.72 events/h). Other models resulted in somewhat lower but similar performances, with correlation coefficients ranging from 0.74 to 0.79. The estimated AHI tended to be underestimated as the severity of OSA increased. Regarding bias and precision, estimation performances in the severe OSA subgroup were the lowest, regardless of the model used. Among sound features, derivative of the area methods of moments of overall standard deviation demonstrated the highest correlation with AHI.

AHI was fairly predictable by using data from breathing sounds generated during sleep. The prediction model may be useful not only for prescreening but also for follow-up after treatment in patients with OSA.

Hypoglossal nerve stimulation (HGNS) is an effective treatment for patients with obstructive sleep apnea (OSA) who fail continuous positive airway pressure (CPAP). We assessed the relationship between patient characteristics and response to HGNS.

Retrospective cohort study.

Single tertiary care institution.

This study included CPAP-intolerant patients with moderate to severe OSA after HGNS system implantation from November 2015 to December 2017. Patient measures, drug-induced sleep endoscopy (DISE) findings, and apnea-hypopnea indices (AHIs) were recorded.

Forty-eight patients underwent implantation with the following median measures: age, 66 years; body mass index, 28.6; and neck circumference, 41.0 cm. Patients were classified by Friedman tongue position (II, 27%; III, 56%; IV, 17%) and Mallampati grade (I, 25%; II, 50%; III, 23%; IV, 2%). By DISE, 71% had anterior-posterior palatal collapse. Additionally, 38% had lateral oropharynx collapse; 50%, tongue base collapse; and 27%, epiglottis collapse. Following implantation, median AHI improved from 38.5 to 2.7 (P < .001), and 92% of patients had no worse than mild OSA (8% moderate). Patients with Friedman tongue position grade II/III experienced greater change in AHI as compared with grade IV (94.2% vs 73.8%, P < .001). Patients with Mallampati score I/II experienced greater improvement versus score III/IV (94.7% vs 66.5%, P < .001). No DISE findings, including any obstruction or collapse, were associated with change in AHI.

This study further confirms HGNS as an effective treatment of CPAP-intolerant OSA. Office measures such as Friedman tongue position IV and Mallampati III/IV were associated with mildly decreased response. DISE findings were not associated with patient response.