bluuebunny/crossref_metadata_2025 huggingface dataset:
Inclusion of Otolaryngology in Medical Student Education: A National Survey
Authors: Ryan Timothy P. , Ishman Stacey L. , Stewart C. Matthew , Stewart Rosalyn W. , Stanley James , Stierer Kevin D. , Benke James R. , Kern David E.
Published: September 2014

Objectives:

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.

Methods:

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.

Results:

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.

Conclusions:

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.
An Innovative Smartphone‐Based Rhinoendoscope
Authors: Wu Cheng Jung , Wu Sheng Yu , Lin Yaoh Shiang
Published: September 2014

Objectives:

Traditional rhinoendoscope is widely used in the diagnosis of a variety of nose diseases, but they can only be used by one doctor at a time. With the advances of electronic health technology, the extended potential application of smartphones to support medical practice is evolving. The first phase of the study discussed how smartphones can be used for rhinoscopic photography and image management via an innovative adaptor. The second phase of the study is to evaluate the diagnostic capability of the smartphone‐based rhinoendcoscope compared with traditional video rhinoendoscope and its application in tele‐otolaryngology.

Methods:

We designed a unique adaptor to connect the rhinoendoscope and smartphone. The main idea is to transform the smartphone into a rhinoendoscope. The device uses the smartphone's camera to capture rhinoscopic images. With an available free web real‐time communication application platform and 3G (or WiFi) network, the smartphone‐based rhinoendoscope could also synchronize your smartphone‐based rhinoscopic image to other mobile devices.

Results:

Ten clinical rhinoscopic images acquired via the smartphone‐based rhinoendoscope were tested in this study. Four teleconsultants reviewed the 10 clinical rhinoscopic images and made a telediagnosis. Compared with the face‐to‐ face diagnosis, for which the diagnosis was made in person via traditional video rhinoendoscope, 4 teleconsultants obtained scores of correct primary telediagnosis of 90%, 90%, 100%, and 100%, respectively.

Conclusions:

The use of already available technologies, without any additional expensive devices, could significantly increase quality diagnostics while lowering extra costs. It also increases connectivity between most isolated family doctors and remote referral centers.
Maxillary Artery Embolization for the Treatment of Intractable Epistaxis
Authors: Partington Erin J. , Harrigan Mark
Published: September 2014

Objectives:

Arterial embolization has become a common treatment for intractable epistaxis. The objectives of this study are to evaluate the outcomes and optimal endovascular treatment strategy for patients undergoing embolization for intractable epistaxis.

Methods:

Retrospective review of patients undergoing endovascular embolization for intractable epistaxis from 2004 to 2013. Patients having tumor embolization were excluded. Vessels were embolized with polyvinyl alcohol (PVA). Data were collected concerning demographics, risk factors, management prior to embolization, vessels embolized, outcomes, and complications.

Results:

Forty‐three patients underwent embolization for intractable epistaxis. Risk factors included uncontrolled hypertension (n = 20), anticoagulation therapy (n = 17), facial trauma (n = 4), and recent nasal or palate surgery (n = 5). Therapy attempted prior to embolization included anterior nasal packing (86%), nasopharyngeal balloon packing (42%), chemical cauterization (9%), surgical intervention (19%), prior embolization (7%), and oropharyngeal packing (2%). Vessels embolized were bilateral maxillary arteries (MA) (81%), bilateral MA with bilateral facial arteries (5%), and unilateral MA when bilateral embolization was not possible due to vessel anatomy (14%). Successful embolization, defined as resolution of bleeding prior to discharge, occurred in 35 patients. Of the 8 cases with postembolization bleeding, 6 stopped spontaneously or with minimal intervention. The rate of successful embolization was 83% for both unilateral and bilateral MA embolization. The only major complication was nasal tip and alar necrosis that occurred in 1 patient after facial artery embolization. No neurologic complications were identified.

Conclusions:

Maxillary artery embolization had favorable outcomes and no significant complications in the current study.
National Trends and Associated Factors of Retropharyngeal Abscess among Adult Inpatients with Peritonsillar Abscess
Authors: Qureshi Hannan A. , Tan Bruce K. , Chandra Rakesh K. , Kern Robert C. , Smith Stephanie S.
Published: September 2014

Objectives:

(1) Describe national trends in retropharyngeal abscess (RPA) complicating peritonsillar abscess (PTA). (2) Determine factors associated with RPA in patients with PTA.

Methods:

Years 2003 to 2010 of the Nationwide Inpatient Sample (Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality) were queried for PTA (ICD‐9 code: 475) and RPA (ICD‐9 code: 478.24) in adult patients (age ≥18 years old). The cohort was analyzed using descriptive statistics and multivariate regression modeling to identify factors associated with RPA.

Results:

Of the 90,941 (95% confidence interval [CI]: 86,433‐95,449) patients identified with PTA, 885 (1.0%) also had a concurrently coded RPA. The annual rate of concomitant RPA doubled (P <. 001) from 0.5% (95% CI: 0.3%‐0.8%) to 1.4% (95% CI: 1.0%‐2.0%) between 2003 and 2010. Patients with RPA were more likely to undergo tonsillectomy (23.5% vs 11.1%) and mechanical ventilation (13.2% vs 2.0%) than those without RPA (all P <. 001). RPA patients were significantly (all P <. 001) older (41 vs 34 years old), had a longer hospital stay (6.4 vs 2.5 days), and had more procedures (2.5 vs 0.9) compared with patients without RPA. Upon multivariate regression analysis, factors associated with RPA included age groups 40 to 64 years (odds ratio [OR] = 2.073, P <. 001), 65 years and older (OR = 2.148, P =. 021), and teaching hospital (OR = 1.838, P <. 001). When controlling for age, sex, and hospital characteristics, general linear modeling demonstrated that RPA accounted for $27,240 (P <. 001) in excess total charges per patient.

Conclusions:

The incidence of RPA among adult inpatients with PTA is increasing, and patients with RPA have higher in‐hospital resource utilization. Further studies may help validate factors predictive of RPA to enable earlier identification.
A New Trend in the Management of Esophageal Foreign Bodies: Transnasal Esophagoscopy
Authors: Shih Chun Wen , Hao Sheng‐Po
Published: September 2014

Objectives:

(1) Retrospectively review esophageal foreign body (EFB) management. (2) Analyze the outcome of patients with EFB managed by either transnasal esophagoscopy (TNE) or rigid esophagoscopy. (3) Review the value of neck lateral view x‐ray.

Methods:

We retrospectively reviewed the cases suspicious for EFB managed between January 2007 and December 2013. In each case, neck lateral view was used for initial screening and the cases suspected to have EFB underwent esophagoscopy, which was rigid before July 2010, and TNE after July 2010.

Results:

From January 2007 to June 2010, 43 patients received rigid esophagoscopy and 31(72.1%) of them were positive for EFB. From July 2010 to December 2013, 302 patients underwent TNE. EFB was noted in only 52 patients and in 36 (69.2%) patients, the EFB could be removed by TNE, while in the other 16 patients with large, or sharp EFB, or possibly perforated esophagus, the EFB could only be removed by rigid esophagoscopy. In the 302 patients that underwent TNE, the sensitivity and specificity of true EFB by neck lateral view x‐ray was 59% and 83%, respectively. There is no major complication of mediastinitis or esophageal perforation in both groups.

Conclusions:

The introduction of TNE changes the diagnosis and management for EFB. TNE is a quick and safe office procedure under local anesthesia. Neck lateral view X‐ray should not be a routine examination any more. TNE could replace neck lateral view X‐ray to be the first screening procedure and also a useful treatment for patients with EFB.
Incorporating Lean Six Sigma Training within an Otolaryngology Residency Program
Authors: Lobo Brian C. , Johnson Kim , Wannemuehler Todd J. , Matt Bruce H. , Woodward‐Hagg Heather K. , Shipchandler Taha Z. , Kokoska Mimi S.
Published: September 2014

Objectives:

(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.

Methods:

(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.

Results:

(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.

Conclusions:

(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.
Nonrandomized Prospective Study of an Upper Esophageal Sphincter (UES) Assist Device for Treating Laryngopharyngeal Reflux
Authors: Silvers Stacey L.
Published: September 2014

Objectives:

(1) Describe treatment of the heterogeneous disorder of laryngopharyngeal reflux (LPR) with a new upper esophageal sphincter (UES) assist medical device designed to eliminate the reflux of gastric contents into the laryngopharynx. (2) Analyze the reduction of symptoms pre‐therapy compared to posttherapy.

Methods:

Patients presenting with a reflux symptoms index (RSI) >13 and diagnosed with chronic cough, postnasal drip, globus, or throat clearing were included in the study. The UES assist device was fitted individually to apply external pressure above 20 mm Hg at the cricoid and worn when sleeping. The primary effectiveness endpoint was reduction of the RSI at 4 weeks. SF‐36 Health Survey, Functional Outcomes of Sleep Questionnaire (FOSQ), and patient and physician satisfaction scores were secondary end points. Intent to treat (ITT) analysis was performed. Safety was based on reported adverse reactions.

Results:

Forty‐four patients consented, with 42 (ITT) completing the study (age, 47 ± 13.1 years; body mass index, 24.8 ± 3.5; 66% female; 75% Caucasian). Most troublesome symptoms were post nasal drip, throat clearing, and annoying cough. Adverse events were mild and short in duration with no study withdrawals due to an adverse event. There was a significant (P <. 0001) reduction of the RSI at 2 weeks (13.2 ± 8.8) and 4 weeks (10.2 ± 7.6) posttherapy compared with pretherapy (24.5 ± 5.9). Ninety‐one percent of patients improved at least 25% with 33% improving at least 75%.

Conclusions:

The UES assist device is a safe and effective noninvasive method for the treatment of LPR and provides clinical utility within 2 weeks. This could be a potential alternative for LPR before considering medications or surgery.
The Pacific Island Health Care Project: Utilization of Otolaryngology and Impact on Graduate Medical Education
Authors: Groom Kelly , Ramsey Mitchell J.
Published: September 2014

Objectives:

(1) Assess otolaryngology–head and neck subspecialist utilization within a large telemedicine program. (2) Examine the impact of that program on graduate medical education.

Methods:

A retrospective review of the Pacific Island Health Care Project records from 1998 to 2012 was performed to identify the number and type of telehealth consultations for patients with disorders of the head and neck. Consultations were categorized into diagnostic groups to evaluate referral patterns. Medical records from patients referred through the program were reviewed to determine the number and types of surgical procedures performed.

Results:

Four thousand telehealth consultations were sent to a single medical center with consultants representing all major medical and surgical subspecialties. A total of 730 teleconsultations were submitted for primary disorders of the head/neck, representing 18.3% of all consultations. The 3 most common reasons for teleconsultation included: benign or malignant head/neck mass (nonthyroid); thyroid mass; and cleft lip/palate. A total of 242 patients were referred for definitive surgical management. Seven hundred fifty‐eight coded procedures were performed on those patients resulting in 383 key index procedures.

Conclusions:

Otolaryngology as a specialty is well suited for telemedicine applications. This study demonstrates a high utilization of otolaryngology indicating a high degree of referral feasibility and a high requirement for head and neck specialist consultation. This program had a large impact on graduate medical education, not only in terms of increased experience with complex patient care and operative case numbers, but also less tangible benefits relating to opportunities for residents to develop key competencies required for successful graduate medical training.
Pediatric Head and Neck Gunshot Wounds in the United States: A Cohort Study
Authors: Johnson Romaine F. , Shah Gopi
Published: September 2014

Objectives:

Study head and neck gunshot wounds (GSW) involving pediatric patients in the United States.

Methods:

Study Design: Retrospective cohort study. Setting: The KIDS Inpatient Database (KID) years 2003, 2006, and 2009. The subpopulation of pediatric patients 21 years and younger admitted with head and neck trauma due to gunshot wounds were compared with all patients admitted with head and neck traumatic injuries. Univariate and multivariate analysis was completed to evaluate demographics, morbidity, and mortality associated with gunshot wounds to the head and neck. Age, sex, and ethnic disparities were also examined.

Results:

An estimated 1342 (SE, 100.7) pediatric patients suffered gun shot wounds to the head and neck, 3.2% (SE, 0.19) of all head and neck traumatic wounds. The mean age was 17.1 years (SE 0.12). The population was 88.1 % male (SE, 1.1), 48.2% (SE, 2.9) black, and 10.2% (SE, 1.1) died during their hospitalization. Mean total charges were $70,312 (SE, $4216). When compared with the larger population of pediatric head and neck trauma patients, GSW patients were statistically significantly older, male, black, and living in the lowest income quartile (all P <. 01). Additionally, GSW patients had longer hospital stays, higher total charges, and higher mortality rates. These findings held constant when controlling for age, sex, and injury severity/mortality risk.

Conclusions:

Gunshot wounds to the head and neck are an uncommon but serious injury in pediatric patients. Continued research regarding treatment and prevention is warranted.
Postoperative Pain Scores in Thermal Welding and Conventional Tonsillectomy Techniques: A Randomized Controlled Study
Authors: Fida Abdulkareem R. , Sendi Khalil S.
Published: September 2014

Objectives:

Assess postoperative pain of the thermal welding system tonsillectomy compared to conventional tonsillectomy.

Methods:

A total of 342 patients aged from 8 through 39 years were enrolled in a randomized prospective controlled study. Extracapsular tonsillectomy with thermal welding and conventional system was performed randomly in each patient. Patients with chronic tonsillitis were included. Patients undergoing adenoidectomy, with suspected or confirmed tonsillar malignancy, or undergoing another procedure together with tonsillectomy were excluded from the study. Postoperative pain was measured by means of Face Pain Scale and Numerical Pain Score for each patient on 3 occasions (6‐8 hours postoperative, 24 hours postoperative, and 6 days later during the first postoperative visit) for each side.

Results:

There was a statistically significant difference between the pain scores of both procedures on all 3 occasions (P >. 001). Patients treated with thermal welding had the lowest postoperative pain score regardless of the occasion. Patients treated with the conventional technique had a significantly higher postoperative pain score on all 3 occasions.

Conclusions:

Thermal welding tonsillectomy is superior to the conventional technique, with less postoperative pain.
Predictors of Initial Technical Skill Acquisition in Otorhinolaryngology Residency Applicants
Authors: Gomez Ernest D. , Bur Andres , Eliades Steven J. , Lee Jonathan M. , Kearney James J. , Ruckenstein Michael J.
Published: September 2014

Objectives:

(1) Investigate the utility of residency applicant characteristics as predictors of technical skill. (2) Demonstrate the feasibility of technical skill assessment in the residency interview setting.

Methods:

A cross‐sectional study was performed in December of 2013 to identify residency applicant characteristics that may predict technical skill. During 2 residency interview days, 39 medical students performed up to 5 trials each of 2 box trainer tasks: myringotomy and endoscopic grasping. Subject performance was assessed by an attending surgeon using a global rating scale (GRS). Completion time and error counts were recorded. Applicant factors studied were United States Medical Licensing Examination Step 1 score, Alpha Omega Alpha status, medical school grades, and extracurricular activities. Pearson coefficients and Wilcoxon rank‐sum tests were used to evaluate each applicant characteristic.

Results:

A total of 117 endoscopic grasping trials and 179 myringotomy trials were assessed. Thirty‐eight of 39 subjects completed both tasks at least 3 times. Participation in competitive sports was associated with more errors during the first endoscopic grasping trial (W = 110.5, P =. 0036) with no difference found in subsequent trials. Step 1 scores and honors grades in core clerkships did not correlate with performance metrics for either task during any trial. Participation in competitive sports did not correlate significantly with task performance for myringotomy.

Conclusions:

Common methods of residency applicant assessment do not predict performance on otolaryngology‐specific task trainers. It is feasible to measure initial technical skill acquisition in the residency interview setting. It is unknown whether initial technical skill acquisition will correlate with technical skill during residency.
Predictors of Outcome in Angiotensin Converting‐Enzyme Inhibitor‐Induced Angioedema
Authors: Kieu Monica C. Q. , Rajasakher Arun , Bangiyev John N. , Thottam Prasad J. , Wilburn John , Stern Noah , Levy Phillip
Published: September 2014

Objectives:

(1) Identify high‐risk symptoms and anatomical regions involved in Angiotensin Converting‐Enzyme Inhibitor‐Induced Angioedema (AIIA) that may affect admission and placement, hospital length of stay, need for airway intervention, and clinical improvement versus deterioration. (2) Describe a clinical algorithm for the management and treatment of AIIA that would dictate placement of patients (ICU, general medical floor, observation unit, or discharge home), medical therapy, and the need for airway intervention (intubation or tracheostomy).

Methods:

A retrospective chart review of adult patients presenting to the emergency department (ED) at Detroit Medical Center diagnosed with AIIA from July 2010 to July 2013. Patients were followed from initial presentation until discharge. Descriptive statistics (frequency, means, and standard deviations) were calculated for all predictor, outcome, and control variables.

Results:

A total of 302 patients who were diagnosed with AIIA in the ED were evaluated with flexible laryngoscopy by an otolaryngologist. A total of 94% of patients were African American, with a slight female predominance of 63%. The most frequent presenting sign was lip swelling (62%). Angioedema confined to the lips was a negative predictor for airway intervention (P <. 01). Also, patients with isolated lip swelling were less likely to have progression of symptoms (P <. 05), and were less likely to require ICU monitoring (P <. 05).

Conclusion:

This is the largest patient series to date of AIIA. Using the information from this study, a clinical algorithm was developed that details management of AIIA based on presenting signs and anatomic location, with otolaryngologists playing a vital role in the decision making process.
Pediatric Anesthesiologists Increase Operating Room Efficiency for Pediatric Adenotonsillectomies
Authors: Dewyer Nicholas A. , Russell Marika D.
Published: September 2014

Objectives:

(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.

Methods:

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.

Results:

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).

Conclusions:

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.
A Standardized Lingual Tonsil Grading System: Interexaminer Agreement
Authors: Friedman Michael , Yalamanchali Sreeya , Kaye Kathryn , Joseph Ninos J.
Published: September 2014

Objectives:

Comparisons between studies involving the tongue base are limited by the lack of a universal system for grading lingual tonsils. The authors propose a new standardized grading system for lingual tonsil hypertrophy (LTH). Validation was assessed via an interexaminer agreement study.

Methods:

Video assessment: The proposed grading system consists of a 0 to 4 scale with: 0 = complete absence of lymphoid tissue, 1 = lymphoid tissue scattered over tongue base, 2 = lymphoid tissue covering entirety of the tongue base with limited vertical thickness, 3 = lymphoid tissue 5 to 10 mm in thickness, 4 = lymphoid tissue >1 cm in thickness (above tip of the epiglottis). A teaching video was created to demonstrate identification of this grading system. After viewing the teaching video, 8 trained otolaryngologists graded 25 video clips of the tongue base, recorded during flexible laryngoscopy. Live assessment: A second study was performed by 2 examiners directly examining the tongue base of 23 patients using flexible laryngoscopy during a routine clinic visit. Each examiner viewed and recorded the grade of the lingual tonsils independently.

Results:

Video assessment: The overall Fleiss kappa statistic was found to be κ = 0.449 (P <. 0001). This value denotes moderate agreement. Live assessment: The overall kappa for nominal data were found to be κ = 0.8665 (P <. 0001). This value denotes perfect agreement.

Conclusions:

The moderate interexaminer correlation demonstrated during video‐assessment, and perfect interexaminer correlation demonstrated during live assessment, indicate that this proposed grading system may be a valuable and useful tool in creating a common language to describe lingual tonsils.
Substantial Delay in Discharge of Elderly with Tracheotomies: Our 10‐Year Experience
Authors: Bergeron Mathieu , Audet Nathalie
Published: September 2014

Objectives:

Comparing management of tracheotomies in older (>75 years old) versus younger patients ≤75 years old) for duration of hospitalization secondary to tracheotomy and finding associated risk factors.

Methods:

Retrospective chart review (2003‐2013) for all patients >75 years old who had tracheotomy compared to patients ≤75 years old.

Results:

Mean age is 79.3 versus 53.1 years, respectively (P <. 0001). Main reason for tracheotomy is prolonged endotracheal intubation (59/112‐52.7% vs 65/99‐65.7%, P =. 181). There is a statistically significant difference between time performing tracheotomy and its weaning for older versus younger patients: 33.14 (24.41‐41.87 confidence interval [CI] 95%) versus 22.90 days (19.22‐26.59 CI 95%, <. 0285). Older patients stayed 4.73 days longer at hospital specifically for tracheotomy management (1.97‐41.87, CI 95%) versus 0.58 days for younger patients (0.00‐1.42 CI 95%, P <. 0001). When leaving hospital with a tracheotomy, discharge is delayed by 14.39 days in older (5.80‐22.98 CI 95%) versus 3.17 days in younger patients (0.00‐8.02 CI 95%, P =. 0299). Elderly patients are discharged to a nursing home more frequently (36.5% vs 20.7%, P =. 0255). Spearman correlation revealed that time between tracheotomy and the first change of cannula, time to wean tracheotomy and postoperative Eastern Cooperative Oncology Group status were all predictive factors of prolonged hospitalization (all P <. 0001).

Conclusion:

Elderly patients need special management secondary to a tracheotomy to prevent prolonged hospitalization. Improving doctor awareness and knowledge of patient risk factors may improve tracheotomy management.
Tonsillotomy or Tonsillectomy: What Do Parents Prefer?
Authors: Stasio Sally D. , Brietzke Scott E. , Shah Rahul K.
Published: September 2014

Objectives:

Tonsillotomy has been presented as a less‐invasive alternative to the traditional tonsillectomy. The decreased pain and recovery time after tonsillotomy have been well established, but questions regarding tonsil regrowth remain. It has been assumed that parents would prefer tonsillotomy because of its recovery advantages. The objective of this study is to (1) directly sample the opinion of typical parents who would be considering tonsillotomy versus tonsillectomy. (2) Assess the role of age, educational level, and risk aversion in this parental choice.

Methods:

Parents in a busy pediatric otolaryngology waiting room were approached and asked to hypothetically choose either tonsillectomy or tonsillotomy for their child via a written survey. Each procedure was described in basic terms listing basic risks and benefits including pain, recovery, regrowth, and incidence of complications. Parents were also asked simple questions regarding age range, educational level, and risk tolerance. Data analysis included simple descriptive statistics and contingency table analysis.

Results:

Two hundred thirty parents completed the survey. Parents overwhelmingly (85.8%) preferred tonsillectomy over tonsillotomy. An increasing risk aversion score was associated with a preference for tonsillectomy (P =. 001, Fisher's exact test). Education and age range were not significantly related to procedural preference or risk tolerance. As might be expected, most parents (72%) were generally risk averse.

Conclusions:

Despite prevailing opinion that presumes parents generally prefer tonsillotomy over tonsillectomy because of its recovery advantages, an overwhelming majority of parents surveyed actually prefer tonsillectomy. The basis of this decision appears to be in part risk aversion of tonsil regrowth.
Triune Tube Outcomes
Authors: Schramm Jordan C. , Person Austin , Burt Alexandra J. , Yonkers Anthony J.
Published: September 2014

Objectives:

(1) Determine complication rates of Triune tubes. (2) Compare complication rates of the Triune tubes with rates cited previously in the literature. (3) Compare complication rates of Triune tubes with T‐tubes and grommet tubes.

Methods:

A retrospective chart review was conducted on myringotomy tubes placed from 2002 to 2011 by a single surgeon in a university hospital setting. Medical records were reviewed for the following data: type of myringotomy tube placed, duration of time the tube remained situated in the tympanic membrane, complications related to the tube placement (persistent tympanic membrane perforation, tube obstruction, granuloma formation, or reoperation), and procedures performed to remediate any encountered complications.

Results:

A total of 1216 tubes were placed in 565 patients (250 female). Average patient age was 6.8 years (range, 3.7 months to 95.6 years). The primary indication for myringotomy with tube placement was chronic serous otitis media (n = 1062, 87.2%). Other indications included recurrent acute otitis media (n = 12, 1.0%), removal and replacement of nonfunctioning tubes (n = 132, 10.8%), and barotrauma (n = 11, 0.9%). The indication was not specified for 1 tube (0.1%). During the study period, 459 (37.7%) of the tubes placed were Triune, 650 (53.5%) were T‐tubes, 88 (7.2%) were grommets, and 19 (1.6%) were not specified. Overall, complications occurred in 96 (20.9%) Triune tubes, 134 (20.6%) T‐tubes, and 9 (10.2%) grommet tubes. However, these differences were not statistically significant (chi‐square 4.797; P =. 187).

Conclusions:

Triune tubes are safe when myringotomy tube placement is indicated. Complication rates with Triune tubes are comparable with both grommet tubes and T‐tubes.
Validation Study on Intraoperative Video Recording as an Objective Assessment Tool in ENT Surgery
Authors: Bowles Philippe F. , Das Prodip , Young John P. F. , Saunders Nicholas , Harries Meredydd L. , Fleming Jason
Published: September 2014

Objectives:

(1) Determine the construct validity and the reliability of video assessment scoring of myringotomy and grommet insertion. (2) Measure the performance (by rating) of participants compared to operative time.

Methods:

Study design was a single blinded (raters) video assessment, conducted in a tertiary care university hospital August to October 2013. Participants were consultant and trainee (Specialty Registrar [StR] and Core Trainee [CT]) ear, nose, and throat (ENT) surgeons performing a total of 30 consecutive index procedures. Two raters at ENT Consultant level with a subspecialty interest in otology who did not take part in the study were invited to score results.

Results:

A strong correlation between scores by the 2 blinded raters was demonstrated (rho = 0.748; P <. 001). Median scores (/45) for each group were: CT 25.5 (interquartile range [IQR] 21.13‐31.25), SpR 33 (IQR 24.88‐35), and consultant 40 (IQR 35.38‐42.63). Kruskal‐Wallis test analysis showed statistically significant mean rank scores between the 3 different levels of experience (H = 12.77, P =. 002). Multiple group comparisons indicated a significant difference between CT and consultant groups (P <. 001) and StR and consultant groups (P =. 007). Analysis of the time taken between the experience groups demonstrated a difference (H = 8.689, P =. 013), although individual intergroup comparisons indicated this was only significant between CT and consultant groups (P =. 004). There was a significant negative correlation (rho = –0.842; P <. 001) between time taken for procedure and score achieved.

Conclusions:

Video assessment of this procedure may represent a valid, feasible tool for use in summative and formative assessments of trainee ENT surgeons. Remote scoring of assessment procedures minimizes bias and enables blinding of raters.
Awareness of Human Papillomavirus and Its Association with Oropharyngeal Cancer
Authors: Goldenberg David , Williams Michael U. , Carr Michele M.
Published: September 2014

Objectives:

Assess public awareness of human papillomavirus (HPV) as a cause of oropharyngeal cancer.

Methods:

A total of 477 participants were randomly chosen to participate in a 23‐item survey at various shopping malls and Maxwell Air Force Base in 2012. The Chi‐square test was used in statistical analysis.

Results:

Three hundred nineteen participants were civilians and 158 were military officer trainees (MOT). All MOT had a bachelor's degree or higher, while 37% of civilian participants had a bachelor's degree or higher. Eighty‐two percent of MOT knew of oropharyngeal cancer, but 53% of civilians had not heard of oropharyngeal cancer (P <. 0001). Most participants (75% civilian and 94% military) were aware of the connection between HPV and cervical cancer. Conversely, 75% of civilian population and 49% of MOT had no knowledge of the association between HPV and oropharyngeal cancer (P <. 0001). The majority of participants (61% military and 81% civilian) did not know that both sexes were eligible for HPV vaccine (P <. 0001). A total of 75% of MOT and 63% of civilians would agree to be vaccinated for HPV if it were free and they were eligible.

Conclusions:

Most people were aware that HPV is a causative agent of cervical cancer. However, the majority were not aware of the association between oropharyngeal cancer and HPV. Furthermore, many participants were not aware that HPV equally affects men and women and that the vaccine is available for both sexes. This underscores the need to educate the public on the availability of HPV vaccine and the association between HPV and oropharyngeal cancer.
Development of a Translation‐Ready Combination Cancer Immunotherapy Regimen Based on Clinically Available Drugs
Authors: Kidwai Sarah M. , Jayaraman Padmini , Sikora Andrew G.
Published: September 2014

Objectives:

Immunosuppressive immunocytes induced by cancer‐associated inflammation, such as myeloid derived suppressor cells (MDSC) and T‐regulatory cells (Treg), mediate immune‐escape critical to development of solid tumors, including melanoma and oral squamous cell carcinoma (OSCC). Novel therapeutic approaches, which block tumor‐mediated immunosuppression, unmasking endogenous anti‐tumor immune responses, are thus a rational treatment approach. The aims of the study were: (1) Demonstrate that inhibition of inducible nitric oxide synthase (iNOS, critical for MDSC development) and Treg depletion in preclinical cancer models leads to potent anti‐tumor activity; (2) Design a regimen suitable for testing in clinical trials.

Methods:

Mouse bone marrow cells were co‐cultured with MT‐RET melanoma supernatants ex vivo to generate MDSC in the presence of doxycycline, an iNOS inhibitor. C57/BL6 wild‐type mice were injected with syngeneic MT‐RET‐1 melanoma. Tumor‐bearing mice were treated with injection(s) of cyclophosphamide and/or doxycycline. Tumor growth and survival times were measured, and tumors and spleens harvested for CD8+ T‐cell and other immunocyte levels.

Results:

In co‐cultures, induction of MDSC was significantly reduced in the presence of doxycycline. Treatment of MT‐RET melanoma‐bearing C57/B16 mice with doxycycline resulted in tumor‐infiltrating CD8+ T cells enhancement and tumor growth suppression. Treatment with cyclophosphamide suppressed intratumoral Treg accumulation. Dual treatment with cyclophosphamide and doxycycline suppressed tumor growth more efficiently than either alone.

Conclusions:

Treatment with the immunomodulators doxycycline and cyclophosphamide is a promising approach to reversing tumor‐mediated immunosuppression and suppressing cancer growth in solid tumors, like melanoma and OSCC. Thus, we have designed a window of opportunity clinical trial of doxycycline and cyclophosphamide before surgical resection of OSCC.
Early Oral Feeding versus Delayed Oral Feeding in Patients following Total Laryngectomy: A Systematic Review
Authors: Hay Ashley , Pitkin Lisa , Mathew Rajeev , Gurusamy Kurinchi
Published: September 2014

Objectives:

Assess the effects of early oral feeding in laryngectomy patients (before 7 days) versus delayed or late oral feeding (7 days or later).

Methods:

We considered randomized controlled trials (RCTs) irrespective of the use of blinding, language status, date of publication, setting, or sample sizes. The outcomes used were mortality, pharyngo‐cutaneous fistula rate, quality of life, hospital length of stay, and complications. To improve harmful effect estimates, trials with early oral feeding groups and a control group were also considered. We analyzed the data with fixed effect and random effect models and present the rate ratios, risk ratio, or mean difference.

Results:

We included 4 RCTs and 3 case controlled trials with 393 participants for assessment of harmful effects. The risk of bias in all trials was high. There was no statistically significant difference detected in mortality rates at 6 months, pharyngo‐cutaneous fistula rate, or complications between intervention and control groups. There was no data on quality of life. The length of hospital stay was shorter in the intervention early feeding group, mean difference effect estimate and confidence intervals using fixed effect model –2.72 [–5.34, –0.09] in favor of early oral feeding.

Conclusions:

The low quality of evidence does not support a change in practice. However, in an appropriate selected patient group early oral feeding has been used and there has been no detectable difference in mortality or complication rates. A shorter hospital stay was seen but was supported by limited evidence.
Factors Affecting Delays to Surgery for Oral Tongue Carcinoma in the National Cancer Data Base
Authors: Nocon Cheryl C. , Liederbach Erik , Sisco Mark , Yao Katherine , Gerber Mark E. , Lewis Carol M. , Bhayani Mihir K.
Published: September 2014

Objectives:

Surgery is the definitive treatment for oral tongue squamous cell carcinoma (OSCC). Studies have described correlates of delayed diagnosis. However, little is known about treatment delays after diagnosis. This study investigates time intervals from diagnosis to surgery for OSCC using the National Cancer Data Base (NCDB).

Methods:

The NCDB was queried for OSCC patients initially treated with surgery in 1998 through 2009. Patients were dichotomized based on time to surgery relative to the median. Chi‐square and multivariable logistic regression models were used for statistical analyses.

Results:

A total of 14,270 patients were identified. The median age was 60 years (range, 18‐90 years). For all stages, the median time from diagnosis to surgery was 27 days (SD = 42). Factors that predicted a longer interval to surgery included: advanced stage (28 days), Hispanic ethnicity (29 days), lack of health insurance (29 days), treatment at an academic/research facility (29 days), residence >75 miles from the hospital (31 days), treatment in the Middle (29 days) and South Atlantic (28 days) states, and having a referral to a different treating center (30 days). The strongest predictors of time delay were having a referral (odds ratio [OR] 1.97, 95% confidence interval [CI] 1.83‐2.13, P <. 001) and geographic location (Middle Atlantic: OR 1.83, 95% CI 1.57‐2.14, P <. 001).

Conclusions:

There is significant variation in the time from diagnosis to surgery for patients with OSCC. Several patient, geographic, and facility factors predict treatment delays. These findings can be used as a benchmark for quality of care and to guide further investigation into whether timing disparities affect outcomes.
Head and Neck Cancers: Why Is It Better to HPV than Not to HPV?
Authors: Baruah Paramita , Lee Michael S. W. , Wilson Phil , Kaski Juan Carlos , Dumitriu Ingrid E.
Published: September 2014

Objectives:

Dissect the impact of human papillomavirus (HPV) on angiogenesis in head and neck cancers (HNSCC).

Methods:

We analyzed 18 newly diagnosed HNSCC patients and controls. HPV tumor status was ascertained by p16 staining. Eleven pro‐ and anti‐angiogenic factors were quantified in sera using a multiplex assay. Angiogenic factors were analyzed in the tumor tissue using immunohistochemistry.

Results:

We found that circulating levels of anti‐angiogenic factor endostatin were higher in all HNSCC patients compared with healthy subjects irrespective of HPV status. Notably, we detected higher levels of the proangiogenic factors angiopoetin‐1 and vascular endothelial growth factor (VEGF) in the circulation of HPV‐negative patients compared with patients with HPV‐positive tumors. Interestingly, levels of thrombospondin‐2, an antiangiogenic factor, were lower in the circulation of patients with HPV‐positive compared with HPV‐negative tumors and healthy controls. We next analyzed these angiogenic factors in the tumor tissue. Interestingly, while HPV‐negative tumors exhibited VEGF expression both in tumor tissue and stromal cells, only a fraction of HPV‐positive tumors exhibited VEGF expression in tumor tissue. Angiopoietin‐1 was expressed in tumor cells as well as endothelial cells in the stroma. Another interesting finding was that macrophages in HNSCC had an M2 “alternatively activated” phenotype and appeared to be the major source of endostatin in the stroma.

Conclusions:

Our novel results indicate that angiogenic factors are differentially expressed in the circulation and tumor tissue in HPV‐positive and HPV‐negative HNSCC and could potentially confer a more aggressive phenotype to HPV‐negative tumors.
Diode Laser for the Treatment of Telangiectasias following Hemangioma Involution
Authors: Cerrati Eric W. , O Teresa M. , Waner Milton
Published: September 2014

Objectives:

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.

Methods:

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.

Results:

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.

Conclusions:

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.
Hospital Volume and Failure to Rescue in Head and Neck Cancer Surgery
Authors: Mulvey Carolyn L. , Gourin Christine G.
Published: September 2014

Objectives:

(1) Apply the concept of failure to rescue to outcomes research in head and neck cancer (HNCA) surgery. (2) Understand the relationship between hospital volume and failure to rescue.

Methods:

Discharge data from the Nationwide Inpatient Sample for 159,301 patients who underwent an ablative procedure for a malignant oral cavity, laryngeal, hypopharyngeal, or oropharyngeal neoplasm in 2001 to 2010 were analyzed using cross‐tabulations and multivariate regression modeling. Failure to rescue was defined as death after a major complication including acute myocardial infarction, acute renal failure, venous thromboembolism, pneumonia, gastrointestinal bleed, pulmonary failure, hemorrhage, or surgical site infection. We compared the incidence of mortality, complications, and failure to rescue across hospital volume tertiles.

Results:

The majority of hospitals performing HNCA surgery were low‐volume hospitals (N = 7635), which performed an average of 6 cases per year. Intermediate‐volume hospitals (N = 729) performed a mean of 37 cases per year, and high‐volume hospitals (N = 207) performed a mean of 131 cases per year. High‐volume hospitals were associated with significantly decreased odds of death (0.7% vs 1.0%, odds ratio [OR] 0.56 [0.46‐0.86]) compared with low‐volume hospitals. There was no significant difference in major complication rates at high‐volume hospitals compared with low‐volume hospitals (18.5% vs 15.6%, OR 0.96 [0.80‐1.15]); however, high‐volume hospitals were associated with significantly decreased failure to rescue rates (3.1% vs 4.4%, OR 0.56 [0.33‐0.97]) compared with low‐volume hospitals.

Conclusions:

Improved survival among patients undergoing HNCA surgery at high‐volume hospitals appears to be associated with differences in the response to and management of complications, rather than differences in complication rates.