Occupational and Environmental Medicine

A financial perspective on tuberculosis treatment adherence Rupal Kulkarni Indian Journal of Occupational and Environmental Medicine 2019 23(1):1-2

Stress among workers in diamond cutting and polishing occupations Girijesh Kumar Yadav, Sunil Kumar, Mahatam Mishra Indian Journal of Occupational and Environmental Medicine 2019 23(1):3-6 This study was conducted to assess the level of stress among diamond workers with respect to their job task. Three hundred and forty-two diamond workers were enrolled from Ahmedabad, Gujarat, with age ranging between 18 and 60 years, belonging to five different job tasks – ghat tarasi (N = 37), table cutting (N = 35), talia bottom (N = 123), athpel (N = 78), and mathala (N = 69). Depression anxiety stress scale (DASS) was used to assess the level of stress among diamond workers. Results showed a mild level of stress (M = 15.41, SD = 8.7) among diamond workers. One-way analysis of variance (ANOVA) revealed no significant difference in stress scores across different job tasks except ghat tarasi workers. Ghat tarasi workers did not exhibit stress. Hence, the level of stress among diamond workers have not been significantly influenced by their job task apart from ghat tarasi workers.

Perceived and manifested health problems among informal e-waste handlers: A scoping review Sapna Mishra Indian Journal of Occupational and Environmental Medicine 2019 23(1):7-14 E-waste being hazardous in nature demands scientific management thereby protecting and safeguarding the health of the workers. A major chunk of e-waste ends up in informal sectors where crude methods are employed thereby risking the health of workers. The current scoping review, Based on Arksey and O'Malley's framework was done to explore the available literature to summarize the perceived and manifested health problems among informal e-waste workers. A literature search was done in three databases namely PubMed, Web of Science and ScienceDirect between 1/01/2010 and 1/01/2018. All the titles and abstracts were scrutinized to include only those studies on the basis of health symptoms/problems among workers. Health problems, thus explored, were categorized into five broad categories- physical injuries, respiratory, skin, musculoskeletal, and other general health problems. Major factors which could be related to health problems were job designation, age, non-usage of personal protective equipment, exposure to dust, and hazardous chemicals.

How safe are industries in India? Ascertaining industrial injuries in Dadra and Nagar Haveli, India by capture-recapture method Sajjan S Yadav Indian Journal of Occupational and Environmental Medicine 2019 23(1):15-20 Context: Every year, more than 4 million people die from injuries worldwide. India reported 413,457 deaths due to unintentional injuries in 2015. Manufacturing industry is a major contributor to injury morbidity and mortality. Aims: This study aims to estimate the burden of industrial injuries in Dadra and Nagar Haveli, India. Settings and Design: Dadra and Nagar Haveli is a small territory spread over 491 sq. km, having a population of 343,709 as per 2011 population census. Methods and Materials: The two-sample capture-recapture method was used for ascertainment of fatal and non-fatal injuries reported from 1st January to 31st December 2017. The first capture was data of injuries extracted from First Information Reports registered by the police. The recapture was data of injuries reported by the government health facilities. Statistical Analysis Used: Chapman estimator was used to derive total fatal and non-fatal injuries. An analysis was done using Microsoft Excel software. Results: According to police records, there were nine fatal and eight non-fatal injuries during the study period. Health facilities reported 21 fatal and 113 non-fatal injuries. Six cases of fatal and 3 cases of non-fatal injuries were found in both the data sources. The capture-recapture analysis estimated 30 fatal (95% CI: 20 to 40) and 225 non-fatal injuries (95% CI: 90 to 420). Conclusions: Both records of police and government health facilities underestimate fatal and non-fatal injuries with under-reporting more pronounced in police records.

Risk assessment in mining-based industrial workers by immunological parameters as copper toxicity markers Rajani Ganpatrao Tumane, Nirmalendu Nath, Aqueel Khan Indian Journal of Occupational and Environmental Medicine 2019 23(1):21-27 Background: Manifestation of certain health morbidity in copper dust–exposed subjects impels us to obtain a cogent view regarding the implicate relationship of immunoglobulin on health risk assessment in them. We present here immunological profile of copper pit worker and office employees residing in the vicinity. Rationale of this study is to delineate the risk factors involved for copper toxicity. Materials and Methods: Copper mine workers (n = 87) were selected from a copper mine at Malanjkhand. Blood metal concentration and immunological profile such as IgG, IgM, IgA, and IgE were analyzed from these subjects. Data analysis was carried out using proper statistical tools. Results: Chronically copper dust–exposed miners (N = 71) and office employees (N = 47) exhibited significantly higher contents of copper (P < 0.0001) when compared with normal control. Serum IgG and IgA were found to be elevated significantly (P < 0.0001) in them when compared with both office employees and normal control. Contrarily, significant decrease in serum IgM was observed in both the groups when compared with normal control (P < 0.0001). Serum IgE was found to be elevated more significantly only in miner when compared with normal control. Copper exhibited significant positive Pearson's correlation coefficient with IgE, IgG, and IgA (r = 0.39; r = 0.28; r = 0.21) but negative correlation (r = −0.39) with IgM. Odds ratio analysis validated that elevated levels of IgE in miner and decrease in levels of IgM in both groups were truly affected by increase in copper levels from normal to abnormal. Conclusion: Miners are prone to morbidity such as type 2 diabetes and respiratory discomfort (asthma and hypersensitivity) since imbalance in both IgM and IgE is known to be associated with such morbidity. Immunopathy observed in chronically exposed miners could be attributed to copper toxicity in them.

Blood pressure and lipid profile in automechanics in relation to lead exposure Chikaodili Nwando Obi-Ezeani, Chudi Emmanuel Dioka, Samuel Chukwuemeka Meludu, Ifeoma Joy Onuora, Saheed Opeyemi Usman, Obiageli Bridget Onyema-Iloh Indian Journal of Occupational and Environmental Medicine 2019 23(1):28-31 Context: Elevated blood pressure and alterations in lipid and lipoproteins play a major role in the development and progression of cardiovascular diseases. Aim: This study is aimed at determining the blood pressure and lipid profile in automechanics. Settings and Design: A total of 120 male subjects between 18 and 55 years of age comprised 60 automechanics and 60 age-matched occupationally unexposed control subjects in Emene, Enugu State, Nigeria. Subjects and Methods: Four milliliters of fasting blood samples was collected from all subjects, 2 mL of blood was dispensed into K2-EDTA vacutainer tube for blood lead analysis, while the other 2 mL was dispensed into plain vacutainer tube, allowed to retract, centrifuged, and the serum used for serum lipid profile analysis. Blood pressure was measured using aneroid sphygmomanometer. Statistical Analysis: Statistical Package for Social Sciences (SPSS) version 21.0 was used for data analysis. Results: Automechanics had significantly higher values of systolic and diastolic blood pressures compared with the controls. Serum levels of total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), very low-density lipoprotein cholesterol (VLDL-C), and triglyceride (TG) were also significantly higher in the automechanics compared with the controls (P < 0.05); serum high-density lipoprotein cholesterol (HDL-C) level, however, did not differ significantly between the two groups (P > 0.05). Blood lead level showed a significant positive correlation (P < 0.05) with systolic and diastolic blood pressures, serum TC, LDL-C, VLDL-C, and TG, with no significant correlation with serum HDL-C (P > 0.05) in the automechanics and no correlation in the controls. Conclusion: The result of this study indicates that blood pressure is elevated and lipid profile altered in automechanics which suggests that these groups of workers are prone to increased risk of developing hypertension and cardiovascular disorders due to occupational exposure to lead.

Knowledge and perception of farmers regarding pesticide usage in a rural farming village, Southern India Minnikanti Venkata Satya Sai, G Devi Revati, R Ramya, Ann Mary Swaroop, Eswaran Maheswari, Mudigubba Manoj Kumar Indian Journal of Occupational and Environmental Medicine 2019 23(1):32-36 Background: Farmers are extensively using pesticides for pest control in agriculture. Their precarious handling practices may lead to higher exposure resulting in adverse health effects. Aim: Current study was aimed to evaluate the knowledge, attitude and practices regarding pesticide usage and its toxic effects by farmers. Settings and Design: Cross sectional, Study Setting: Rural village in south Karnataka. Materials and Methods: Sample size: 171 farmers, Data collection: face to face standardized validated questionnaire. Statistical Analysis: Chi-square test. Results: A total of 118 males and 53 females participated in this study with median age of 40 years. About 61% of the farmers knew the harmful effects of pesticides. However, 22% of them were mixing the pesticides using their bare hands and 26% were not wearing any protective clothing during spraying pesticides. Around 67% were carelessly disposing the leftover pesticides in the open fields. Skin problems and neurological system disturbances were the most common pesticide related health symptoms. Equipment washing practices (P < 0.05) and protective clothing (P < 0.03) were significant predictors of health related problems. Significant associations were found between the occurrence of headache and equipment washing practices (P < 0.03), storage of pesticide remains (P < 0.02) and protective clothing (P < 0.01). Conclusion: These findings showed that knowledge level is adequate among farmers but this did not reflect in their practice. There is a need for continuous pesticide safety education along with training to the farmers regarding use of personal protective devices, personal hygiene and sanitation practices during and after application of pesticides.

Contact sensitization to formaldehyde in veterinary medicine – An unexplored field in occupational health Maya G Lyapina, Vasil K Manov, Mariana P Cekova Indian Journal of Occupational and Environmental Medicine 2019 23(1):37-41 Background: Veterinary staff and students could be exposed to formaldehyde – a ubiquitous agent, common cause of contact allergy. Aim: To evaluate the incidence of contact sensitization to formaldehyde in exposures in veterinary medicine. Settings and Design: A cross-sectional study was conducted during July–December 2017. Materials and Methods: A total of 206 individuals were included, patch tested with formaldehyde 1.0%/aq – 36 veterinary medicine students, 20 veterinarians, 47 students and 28 trainees of dental medicine, 41 dental professionals, and 35 non-occupationally exposed individuals. Results: The incidence of contact sensitization to formaldehyde among the whole studied population was 48.1%, highest being among the students of veterinary medicine (94.4%) and the veterinarians (85%). With very high significance, the sensitization incidence was higher in the groups of students of veterinary medicine and veterinarians, if compared to the control group (P < 0.001); (P = 0.004), dental professionals (P < 0.001); (P = 0.001), trainees of dental medicine (P < 0.001); (P = 0.005), and students of dental medicine three-fourth year of education (P < 0.001); (P = 0.001). Significantly, higher was the incidence of contact allergy in the control group if compared to those of dental professionals (P = 0.033) and dental students three-fourth year of education (P = 0.028). Conclusions: The exposure to formaldehyde during the education in veterinary medicine and practice could be an important risk factor for the onset of contact sensitization. Stricter preventive measures are needed to reduce veterinary student's and lecturer's exposures. Equipment of dissection tables with local exhaust ventilation system could reduce the concentration of formaldehyde in the gross anatomy laboratory.

Knowledge, attitude, and practice of pesticides use among agricultural workers Fatemeh Rostami, Maryam Afshari, Masomeh Rostami-Moez, Mohammad Javad Assari, Ali Reza Soltanian Indian Journal of Occupational and Environmental Medicine 2019 23(1):42-47 Background: Pesticides have critical effects on human health. Because of the high amount of pesticides used, individual exposure is almost inevitable. According to the above-mentioned issues, few studies have been done in this area in Iran. Therefore, this study was conducted to evaluate the knowledge, attitude, and practice of pesticides use among farmers in Kabudrahang County, Hamadan Province, Iran. Materials and Methods: This cross-sectional study was conducted in Kabudrahang County. Data were collected from 262 farmer's sprayer, during April to July 2016. Data were collected, using convenience sampling through interviews with the farmers who had spryer during period spraying. Data collection instrument was a questionnaire that included three sections. Content validity ratio and content validity index indicators were used to measure the validity of questionnaire used from. Data were recorded in SPSS version 21.0 (SPSS Inc., Chicago, Illinois) and were analyzed using frequency analysis and Pearson correlation test. Results: Burning eyes and dizziness were the greater symptoms of poisoning with pesticides. Overall, most of them did not have proper knowledge. Many farmers had proper attitudes toward the use of personal protective equipment. However, 37.4% of them reported that the use of personal protective equipment is not easy. The farmers' practice toward the use of the personal protective equipment correlated with their knowledge and attitude (P < 0.001). Conclusion: It is proposed that educational sets consisted of acquaintance with poisons and their applications, storage, and carrying the pesticides, the methods for effective of different individual protection facilities, and utilizing the behavior to reduce the exposure to poisons should be developed and be available to farmers.

A cross-sectional study of prevalence of depression, anxiety and stress among professional cab drivers in New Delhi Akanksha Rathi, Vikas Kumar, Amrita Singh, Panna Lal Indian Journal of Occupational and Environmental Medicine 2019 23(1):48-53 Background: The profession of drivers is one of the occupational groups exposed to very poor working conditions. This study aimed to establish the prevalence of depression, anxiety and stress among cab drivers. Materials and Methods: This cross-sectional study included 134 cab drivers. Their mental health status was assessed with the help of a screening tool – Depression Anxiety Stress Scale (DASS-21). Their demographic details, working conditions, lifestyle factors and use of habit-forming substances were also assessed with the help of a semi-structured questionnaire. Results: It was revealed that all cab drivers were male and between 20 to 64 years of age. Eighty two (62%) drivers said they are sometimes irritated at work, 29 (21.5%) said they feel irritated daily and rest 23 (17.2%) said that they were never irritated at work. When screened for depression, anxiety and stress, it was found out that 81 (60.5%) were suffering from depression, 63 (47%) from anxiety and 49 (36.5%) had variable degree of stress. Conclusion: Cab drivers are at high risk of acquiring mental health diseases, yet the mental health of this large workforce is ignored.

Cliometrica

From boom to bust: a typology of real commodity prices in the long run Abstract This paper considers the evidence on real commodity prices from 1900 to 2015 for 40 commodities, representing 8.72 trillion US dollars of production in 2011. In doing so, it suggests and documents a comprehensive typology of real commodity prices, comprising long-run trends, medium-run cycles, and short-run boom/bust episodes. The main findings can be summarized as follows: (1) real commodity prices have been on the rise—albeit modestly—from 1950; (2) there is a pattern—in both past and present—of commodity price cycles, entailing large and long-lived deviations from underlying trends; (3) these commodity price cycles are themselves punctuated by boom/bust episodes which are historically pervasive.

The impact of labour policies on Canadian gold mines in World War II Abstract This paper uses a financial and operational data set of Canadian gold mines between 1939 and 1945 to analyse the efficacy of two government labour market policies implemented in World War II. An early war policy designated the gold mining industry as vital for the war effort to boost gold output in order to purchase foreign reserves. The late war policy resulted in restrictions that prevented labour movement into and between the mines. We find that the first policy is largely ineffective in its goal. Although the market allocated labour to the lowest cost producers, the policy caused only a modest increase in gold output. To evaluate the second policy, we estimate the cost curves of the individual mines. The results indicate an inefficient allocation of labour across mines. The gold mining industry experiences operating costs 22% higher than with efficient labour allocation during this late war period. The estimated efficiency loss to the industry is nearly $58.4 million 1940 Canadian dollars.

Welfare reform, 1834: Did the New Poor Law in England produce significant economic gains? Abstract The English Old Poor Law, which before 1834 provided welfare to the elderly, children, the improvident, and the unfortunate, was a bête noire of the new discipline of Political Economy. Smith, Bentham, Malthus, and Ricardo all claimed it created significant social costs and increased rather than reduced poverty. The Poor Law Amendment Act of 1834, drafted by Political Economists, cuts payments sharply. Because local rules on eligibility and provision varied greatly before the 1834 reform, we can estimate the social costs of the extensive welfare provision of the Old Poor Law. Surprisingly there is no evidence of any of the alleged social costs that prompted the harsh treatment of the poor after 1834. Political economy, it seems, was born in sin.

Distinct within North America: living standards in French Canada, 1688–1775 Abstract I use a novel dataset of prices and wages from the French colony of Quebec (Canada's second largest province today) to measure colonial-era living standards. Following Allen's (Explor Econ Hist 38(4):411–447, 2001; The British industrial revolution in global perspective, Cambridge University, Cambridge, 2009; Econ Hist Rev 68(1):1–22, 2015) welfare-ratios approach, I find that Quebec was poorer than the American colonies and London, but somewhat richer than Paris and Southern England. The Quebec–Paris comparison is sensitive to changes in the basket used to compare wages. Shifting from a bare bones basket to a respectable basket, Quebec loses its advantage over Paris, but remains poorer than the American colonies and London.

Regional prices in early twentieth-century Spain: a country-product-dummy approach Abstract This paper explores regional price variation in early twentieth-century Spain. Using consumer price information from the bulletins published by the Instituto de Reformas Sociales between 1910 and 1920, we build a dataset with a total of 40,581 quotes covering 22 items for each of the 49 provinces. We then estimate provincial price levels following a country-product-dummy (CPD) approach. Our findings suggest that spatial price variation existed across Spanish provinces. In line with the Balassa–Samuelson conjecture, consumer prices and productivity levels were somewhat related. Additionally, it is shown that prices rose in all provinces after the outbreak of World War I. Even more, it appears that this demand-shock brought about spatial asymmetries in price growth.

Human lifetime entropy in a historical perspective (1750–2014) Abstract This paper uses Shannon's entropy index to the base 2 to quantify the risk relative to the age at death in terms of bits (i.e. the amount of information revealed by tossing a fair coin). We first provide a simple decomposition of Shannon's lifetime entropy index that allows us to analyse the determinants of lifetime entropy (in particular its relation with Wiener's entropy of the event "death at a particular age conditional on survival to that age") and to study how the risk about the duration of life is resolved as the individual becomes older. Then, using data on 37 countries from the Human Mortality Database, we show that, over the last two centuries, (period) lifetime entropy at birth has exhibited, in all countries, an inverted-U shape pattern with a maximum in the first half of the twentieth century (at 6 bits), and reaches, in the early twenty-first century, 5.6 bits for men and 5.5 bits for women. It is also shown that the entropy age profile shifted from a non-monotonic profile (in the eighteenth and nineteenth centuries) to a strictly decreasing profile (in the twentieth and twenty-first centuries).

The impact of the 1932 General Tariff: a difference-in-difference approach Abstract We evaluate the effect of the 1932 British General Tariff on the output, labour productivity and employment growth of British industries. We provide a new disaggregated data set that matches industry-level Census of Production data with industry-specific tariff rates to accurately isolate treatment and control groups and estimate the effect of the General Tariff using difference-in-difference regressions. We evaluate a two-group comparison, between newly and non-newly protected industries, and a three-group comparison, between non-newly protected industries and newly protected industries further divided into those given a baseline 10% tariff rate and those given additional tariffs. In the two-group comparison, we identify a tariff effect that is large and statistically significant on output and productivity. In the three-group comparison, we show that the positive output and productivity effects of the tariff arise from the additional tariff protection, over and above the 10% level. These effects are observed over the periods 1930–1935 and 1930–1948, suggesting both short-run and medium-term effects on output and productivity of UK industries protected by the 1932 General Tariff.

The introduction of the reserve clause in Major League Baseball: evidence of its impact on select player salaries during the 1880s Abstract This paper investigates the impact of baseball's reserve clause as it evolved from a "gentleman's agreement" to a formal contract stipulation. Using data describing the salaries of 34 Major League Baseball players during the 1880s, we test whether average salaries, remuneration to marginal product, and the premium paid to a player for changing teams were materially impacted when the reserve clause became binding in 1887. The empirical results suggest that, controlling for player attributes and the overall macroeconomy, average real salaries in the sample fell by 6–9% after the binding reserve clause. We also find that the premium for moving to a new team was reduced by 70% after the binding reserve clause was implemented, supporting Rottenberg's invariance principle.

Monetary and fiscal interactions in the USA during the 1940s Abstract It is generally assumed that the buildup of liquid assets in the USA during WWII played a large role in generating postwar economic activity. Contrary to this assumption, I establish that military contract spending during the war slowed down the growth of bank balance sheets at the state level during the period 1940–1955. State-level bank balance sheets are 10.8 cents smaller per $1 of total military spending by 1949 and 5.8 cents smaller by 1955. This is primarily driven by slower growth of demand deposits. The adjustment on the asset side is largely through reserves and Treasury holdings. Local lending also grows more slowly after the war, but this decrease is relatively small and temporary. This suggests that the local real economy was largely insulated from the slower growth in deposits by the wartime buildup of paper assets. Historical evidence points to the fact that slower growth of deposits is likely driven by a relative decline in demand for deposits by large corporations in war industries.

Key forces behind the decline of fertility: lessons from childlessness in Rouen before the industrial revolution Abstract To better understand the forces underlying fertility decisions, we look at the forerunners of fertility decline. In Rouen, France, completed fertility dropped between 1640 and 1792 from 7.4 to 4.2 children. We review possible explanations and keep only three: increases in materialism, in women's empowerment, and in returns to education. The methodology is one of analytic narrative, bringing together descriptive evidence with a theoretical model. We accordingly propose a theory showing that we can discriminate between these explanations by looking at childlessness and its social gradient. An increase in materialism or, under certain conditions, in women's empowerment, leads to an increase in childlessness, while an increase in the return to education leads to a decrease in childlessness. Looking at the Rouen data, childlessness was clearly on the rise, from 4% in 1640 to 10% at the end of the eighteenth century, which appears to discredit the explanation based on increasing returns to education, at least for this period.

OtoLaryngology

OnlineFirst

Last updated April 9, 2019

Original Research

Parathyroid Computed Tomography Angiography: Early Experience with a Novel Imaging Technique in Primary Hyperparathyroidism Isaac E. Schwartz, MD, Gregory G. Capra, MD, David P. Mullin, MD, Terence E. Johnson, MD,Gilbert E. Boswell, MD https://doi.org/10.1177/0194599819842106 |First Published April 9, 2019 Abstract Hide Preview Objectives To describe parathyroid computed tomography angiography (PCTA), determine its accuracy, and, as a secondary objective, calculate its mean radiation dosimetry. Study Design Retrospective chart review of patients who underwent parathyroidectomy for primary hyperparathyroidism from 2007 to 2015. Setting Single-center tertiary care academic military hospital. Subjects and Methods PCTA is a 2-phase computed tomography imaging technique that uses individualized timing of contrast infusion and novel patient positioning to accurately identify parathyroid adenomas. Consecutive patients who underwent parathyroidectomy for primary hyperparathyroidism from 2007 to 2015 were reviewed; 55% of patients were women. The mean age was 50.9 years (range, 26-68 years). Sensitivity and specificity were calculated as well as mean radiation dosimetry and timing of contrast. Results A total of 108 procedures were performed during the study period. Twenty-one patients undergoing 22 PCTAs after prior sestamibi scans were nonlocalizing or equivocal. In this group, there were 15 true-positive, 3 false-positive, 4 true-negative, and 0 false-negative PCTAs. This represents a sensitivity of 100% (95% CI, 74.7%-100%) and a specificity of 57% (95% CI, 20%-88%). The mean calculated radiation dose was 5.15 mSv. In the most recent studies, a mean dose of 4.1 mSv was calculated. The ideal time of image acquisition contrast administration varied from 20 to 30 seconds after contrast infusion. Conclusions PCTA is a new technique in anatomic imaging for hyperparathyroidism. In a single-center, single-radiologist retrospective study, it demonstrates excellent accuracy for patients with parathyroid adenomas that are otherwise difficult to localize preoperatively. Preliminary experience suggests that its use may be indicated as a primary imaging modality in the future. |

Original Research

Body Image Disturbance in Surgically Treated Head and Neck Cancer Patients: A Patient-Centered Approach Mark A. Ellis, MD, Katherine R. Sterba, PhD, MPH, Terry A. Day, MD, Courtney H. Marsh, Stacy Maurer, PhD, Elizabeth G. Hill, PhD, Evan M. Graboyes, MD https://doi.org/10.1177/0194599819837621 |First Published April 9, 2019 Abstract Hide Preview Objective To promote patient-centered oncology care through an in-depth analysis of the patient experience of body image disturbance (BID) following surgery for head and neck cancer (HNC). Study Design Qualitative methods approach using semistructured key informant interviews. Setting Academic medical center. Subjects and Methods Participants with surgically treated HNC underwent semistructured key informant interviews and completed a sociodemographic survey. Recorded interviews were transcribed, coded, and analyzed using template analysis to inform creation of a conceptual model. Results Twenty-two participants with surgically treated HNC were included, of whom 16 had advanced stage disease and 15 underwent free tissue transfer. Five key themes emerged characterizing the participants' lived experiences with BID following HNC treatment: personal dissatisfaction with appearance, other-oriented appearance concerns, appearance concealment, distress with functional impairments, and social avoidance. The participant's perceived BID severity was modified by preoperative patient expectations, social support, and positive rational acceptance. These 5 key themes and 3 experiential modifiers form the basis of a novel, patient-centered conceptual model for understanding BID in HNC survivors. Conclusion A patient-centered approach to HNC care reveals that dissatisfaction with appearance, other-oriented appearance concerns, appearance concealment, distress with functional impairments, and social avoidance are key conceptual domains characterizing HNC-related BID. Recognition of these psychosocial dimensions of BID in HNC patients can inform development of HNC-specific BID patient-reported outcome measures to facilitate quantitative assessment of BID as well as the development of novel preventative and therapeutic strategies for those at risk for, or suffering from, BID. |

Original Research

Growth and Management of Repaired Complete Tracheal Rings after Slide Tracheoplasty Lyndy J. Wilcox, MD, Claudia Schweiger, MD, PhD, Catherine K. Hart, MD, MS, Alessandro de Alarcon, MD, MPH, Nithin S. Peddireddy, Michael J. Rutter, MD, FRACS https://doi.org/10.1177/0194599819841893 |First Published April 9, 2019 Abstract Hide Preview Objective This study documents the growth and course of repaired complete tracheal rings over time after slide tracheoplasty. Study Design Case series with review. Setting Tertiary pediatric academic medical center. Subjects/Methods Medical records of pediatric patients with confirmed tracheal rings on bronchoscopy who underwent slide tracheoplasty between January 2001 and December 2015 were reviewed. Patients who had operative notes documenting tracheal sizing over time were included. Exclusion criteria included tracheal stenosis not caused by complete tracheal rings, surgical repair prior to presentation at our institution, or lack of adequate sizing information. The postoperative follow-up was examined and airway growth over time documented. Results Of 197 slide tracheoplasties performed during the study time period, 139 were for complete tracheal rings, and 40 of those children met inclusion criteria. The median age at time of surgery was 7 months, and the median initial airway size was 3.9 mm (n = 34). The median growth postoperatively was 1.9 mm over a median follow-up period of 57 months (0.42 mm/year), which is similar to growth rates of unrepaired complete tracheal rings (P = .53). Children underwent a median of 10 postoperative endoscopies, with time between endoscopies increasing further out from surgery. The most commonly performed adjunctive procedure was balloon dilation. Conclusions This is the first study documenting continued growth of repaired complete tracheal rings after slide tracheoplasty. Postoperative endoscopic surveillance ensures adequate growth. Intervals between airway endoscopies can be increased as the child gets older, as the airway increases in size, and as long as symptoms are minimal. |

Original Research

Thyroidectomy Complications in Patients with Diabetes Mellitus Sei Y. Chung, MD, Aparna Govindan, Archana Babu, MS, Andrew Tassler, MD https://doi.org/10.1177/0194599819835793 |First Published April 9, 2019 Abstract Hide Preview Objective To (1) analyze postoperative thyroidectomy outcomes in patients with diabetes mellitus (DM), who are prone to deleterious effects of glucose dysmetabolism, and (2) apply findings to optimize perioperative management of diabetics requiring thyroid surgery. Study Design Retrospective database analysis. Setting University hospital. Subjects and Methods The National Inpatient Sample was queried using International Classification of Diseases, Ninth Revision, Clinical Modification and Procedure Coding System (PCS) codes for patients with benign or malignant thyroid disease who underwent thyroid surgery between 2002 and 2013. An analysis of demographics, comorbidities, and postoperative outcomes was conducted between a DM vs non-DM cohort using bivariate and multivariate techniques. Results In total, 103,842 cases met inclusion criteria; 14.2% were diabetics. Diabetics had significantly higher rates of baseline comorbid chronic pulmonary disease, hypertension, obesity, and anemia. Following thyroidectomy, patients with DM were more likely to have vocal cord paresis or paralysis compared to non-DM patients (2.0% vs 1.3%; P < .001). However, when adjusting for demographics and comorbidities, there was no significant difference in this complication between the 2 groups. Diabetics had independently higher rates of cardiac, pulmonary, and urinary complications, as well as transfusion, reintubation, and in-hospital mortality. Diabetics had longer hospital stays (2.76 vs 1.97; P < .001) with higher incurred hospital charges (32,921 vs 25,198; P < .001). Conclusion Although DM often confers metabolic and ischemic derangements secondary to hyperglycemia such as neuropathy, this comorbidity was not independently associated with higher rates of vocal cord paresis or paralysis following thyroid surgery. However, DM predicted other adverse outcomes, including greater cardiac, pulmonary, and urinary complications, as well as transfusion, reintubation, and in-hospital mortality. |

Original Research

Multimodal Analgesia Protocol after Head and Neck Surgery: Effect on Opioid Use and Pain Control Eugenie Du, MD, MPH, Zainab Farzal, MD, Elizabeth Stephenson, MD, April Tanner, MD,Katherine Adams, MD, Douglas Farquhar, MD, MPH, Mark Weissler, MD, Samip Patel, MD,Jeffrey Blumberg, MD, Maryam Jowza, MD, Trevor Hackman, MD, Adam Zanation, MD https://doi.org/10.1177/0194599819841885 |First Published April 9, 2019 Abstract Hide Preview Objective To assess the effect that implementation of a multimodal analgesic plan has on opioid requirements and pain control in head and neck (H&N) surgery patients. Study Design Prospective cohort. Setting Tertiary academic hospital. Subjects and Methods An institutional review board (IRB)–approved quality improvement initiative was undertaken to implement a multimodal analgesic protocol for all admitted H&N surgery patients starting November 2017. Postprotocol data from January to May 2018 were compared to preprotocol data from May to October 2017. Data were obtained from the electronic health records as well as through preoperative and postoperative surveys. Average pain scores and opioid use in morphine milligram equivalents (MMEs) before and after protocol implementation were compared. Results In total, 139 postprotocol patients were compared to 89 preprotocol patients. The adjusted MMEs in the first 24 hours after surgery decreased significantly from 93.7 mg to 58.6 mg (P = .026) with protocol implementation. When averaged over the length of stay (MME/hospital day), the change was no longer statistically significant (57.9 vs 46.8 mg, P = .211). The average pain score immediately after surgery and on day of discharge did not change with protocol implementation. Conclusion Implementation of a multimodal analgesia plan reduced opioid use immediately after surgery but not over the course of hospitalization without any change in reported pain scores. This study shows that multimodal opioid-sparing analgesia after H&N surgery is feasible. Future studies are needed further refine the optimal analgesic strategy for H&N patients and assess the long-term efficacy, safety, and cost of such regimens. |

Systematic Review

Intranasal Azelastine and Fluticasone as Combination Therapy for Allergic Rhinitis: Systematic Review and Meta-Analysis Peter M. Debbaneh, Anna K. Bareiss, MD, Sarah K. Wise, MD, Edward D. McCoul, MD, MPH https://doi.org/10.1177/0194599819841883 |First Published April 9, 2019 Abstract Hide Preview Objective Combination therapy with intranasal azelastine and fluticasone propionate is an option for treatment of allergic rhinitis. This systematic review and meta-analysis examines existing literature to determine efficacy in treating allergic rhinitis compared to monotherapy. Data Sources The PubMed, EMBASE, Cochrane, and MEDLINE databases were systematically searched for randomized controlled trials using AzeFlu nasal spray. Review Methods Randomized, controlled trials that reported symptom relief of allergic rhinitis in males and females of all ages were included. Results were reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standard. Results Systematic review identified 8 articles suitable for review. The risk of bias was generally low. All studies exhibited a greater decrease in patient-reported symptom scores in patients treated with combination therapy compared to monotherapy or placebo. Meta-analysis revealed superiority of combination therapy in reducing Total Nasal Symptom Score compared to placebo (mean change from baseline: −2.41; 95% confidence interval [CI], −2.82 to −1.99; P < .001; I2 = 60%), azelastine (mean change from baseline: −1.40; 95% CI, −1.82 to −0.98; P < .001; I2 = 0%), and fluticasone (mean change from baseline: −0.74; 95% CI, −1.17 to −0.31; P < .001; I2= 12%). Conclusion Current evidence supports both efficacy and superiority of combination intranasal azelastine and fluticasone in reducing patient-reported symptom scores in patients with allergic rhinitis. Combination nasal spray should be considered as second-line therapy in patients with allergic rhinitis that is not controlled with monotherapy. |

State of the Art Review

Common Pitfalls of Head and Neck Research Using Cancer Registries Evan A. Jones, Andrew G. Shuman, MD, Brian L. Egleston, MPP, PhD, Jeffrey C. Liu, MD https://doi.org/10.1177/0194599819838823 |First Published April 2, 2019 Abstract Hide Preview Objective To highlight common pitfalls observed in scientific research derived from national cancer registries, predominantly the Survival, Epidemiology, and End Results Program and the National Cancer Database. Data Sources Literature review and expert opinion. Review Methods This state-of-the-art review consolidates the literature with editorial experiences describing how and why statistically flawed studies are usually rejected for publication, highlighting common errors in submitted articles employing national cancer registries. Conclusions Pitfalls were identified in 2 major areas—design and data analysis. Design pitfalls included unbalanced cohorts, uncontrolled covariates, and flawed oncologic variables. Analytical pitfalls included incorrect application of univariate analyses, inclusion of inaccurate data, and inclusion of stage IVc disease in curative survival analysis. Additional limitations of database studies were identified, including absence of patient-related outcomes, hypothesis-generating vs practice-changing implications, and inability to differentiate between overall survival and disease-specific survival. |

Patient Safety/Quality Improvement

Risk Factors for Blood Transfusion with Neck Dissection Monica C. Azmy, Juanita Pinto, Nirali M. Patel, Aparna Govindan, Evelyne Kalyoussef, MD https://doi.org/10.1177/0194599819839946 |First Published April 2, 2019 Abstract Hide Preview Objectives To identify risk factors of perioperative blood transfusions (PBTs) for neck dissection and identify the association of PBTs with other postoperative outcomes. Methods This is a retrospective study of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. The database was queried for neck dissection procedures performed by otolaryngologists from 2006 to 2014. Multivariable logistic regression was used to determine associations between demographic and preoperative factors, mortality, unplanned reoperation, and unplanned readmission with PBTs. Results Of the 3090 patients included in our study, 346 (11.2%) received a PBT, 249 patients (72.0%) received blood intraoperatively or on postoperative day (POD) 0, and 97 patients (28.0%) received blood within 5 PODs. American Society of Anesthesiologists (ASA) class ≥3 (odds ratio [OR], 2.1; 95% confidence interval [CI], 1.4-3.2), preoperative weight loss (OR, 2.2; 95% CI, 1.5-3.2), and anemia (OR, 5.5; 95% CI, 4.1-7.6) were independently associated with PBTs. Free flaps were also significantly associated with PBTs. PBTs were significantly associated with unplanned return to the operating room within 30 days (OR, 4.31; 95% CI, 3.01-6.18) but not with 30-day unplanned readmission or 30-day mortality. Discussion Eleven percent of patients undergoing neck dissection receive a PBT. Identifying associated risk factors may reduce PBT among patients with cancer. Comorbid data, such as weight loss, anemia, and ASA class, may be useful in determining risk for transfusion during these procedures. Implications for Practice Awareness of preoperative risk factors for PBT may lead surgeons to reduce the risk of PBT, anticipate the need for transfusion, and manage these patients carefully to prevent unplanned reoperation. |

Original Research

Clinical Prediction Model for Obstructive Sleep Apnea among Adult Patients with Habitual Snoring Hsin-Ching Lin, MD, Chi-Chih Lai, MD, Pei-Wen Lin, MD, Michael Friedman, MD, Anna M. Salapatas, MS, Hsueh-Wen Chang, PhD, Meng-Chih Lin, MD, Chien-Hung Chin, MD https://doi.org/10.1177/0194599819839999 |First Published April 2, 2019 Abstract Hide Preview Objective To identify standard clinical parameters that may predict the presence and severity of obstructive sleep apnea/hypopnea syndrome (OSA). Design Case series with chart review. Setting Tertiary academic medical center. Subjects and Methods A total of 325 adult patients (274 men and 51 women; mean age, 44.2 years) with habitual snoring completed comprehensive polysomnography and anthropometric measurements, including modified Mallampati grade (also known as updated Friedman's tongue position [uFTP]), tonsil size grading, uvular length, neck circumference, waist circumference, hip circumference, and body mass index (BMI). Results When the aforementioned physical parameters were correlated singly with the apnea/hypopnea index (AHI), we found that sex, uFTP, tonsil size grading, neck circumference, waist circumference, hip circumference, thyroid-mental distance, and BMI grade were reliable predictors of OSA. When all important factors were considered in a multiple stepwise regression analysis, an estimated AHI can be formulated by factoring sex, uFTP, tonsil size grading, and BMI grade as follows: –43.0 + 14.1 × sex + 12.8 × uFTP + 5.0 × tonsil size + 8.9 × BMI grade. Severity of OSA can be predicted with a receiver operating characteristic curve. Predictors of OSA can be further obtained by the "OSA score." Conclusion This study has distinguished the correlations between sex, uFTP, tonsil size, and BMI grade and the presence and severity of OSA. An OSA score might be beneficial in identifying patients who should have a full sleep evaluation. |

State of the Art Review

Periostin and Inflammatory Disease: Implications for Chronic Rhinosinusitis Ashton E. Lehmann, MD, George A. Scangas, MD, Regan W. Bergmark, MD, Edward El Rassi,MD, Konstantina M. Stankovic, MD, PhD, Ralph Metson, MD https://doi.org/10.1177/0194599819838782 |First Published April 2, 2019 Abstract Hide Preview Objective To provide a comprehensive overview of the emerging role of periostin, an extracellular matrix protein, as a key component in the development, diagnosis, and treatment of patients with chronic rhinosinusitis. Data Sources Medline database. Review Methods A state of the art review was performed targeting English-language studies investigating the role of periostin in cardiopulmonary, neoplastic, and inflammatory diseases, with emphasis on recent advances in the study of periostin in chronic rhinosinusitis. Conclusions Periostin has emerged as a novel biomarker and therapeutic target for numerous human pathologies, including cardiac, pulmonary, and neoplastic disease. The upregulation of periostin in chronic rhinosinusitis suggests the potential for similar roles among patients with sinonasal disease. Implications for Practice Chronic rhinosinusitis is a widespread disease with major clinical and societal impact. A critical limitation in the current treatment of patients with chronic rhinosinusitis is the absence of clinically relevant biomarkers to guide diagnosis and treatment selection. A review of the literature supports a likely role of periostin as a biomarker of chronic rhinosinusitis, as well as a novel therapeutic target in the future treatment of patients with sinonasal disease. |

Original Research

Surgical Site Infection in Head and Neck Surgery: A National Perspective Zaid Al-Qurayshi, MD, MPH, Jarrett Walsh, MD, PhD, Scott Owen, MD, Emad Kandil, MD, MBA https://doi.org/10.1177/0194599819832858 |First Published April 2, 2019 Abstract Hide Preview Objectives To examine trend, prevalence, and outcomes of surgical site infection (SSI) in head and neck surgery. Study Design Retrospective cross-sectional analysis. Setting The Nationwide Readmissions Database (2010-2014), which represents 56.6% of all US hospitalization. Subjects Adult patients (≥18 years) who underwent head and neck surgery. Patients with SSI were compared with controls. Methods Analysis included chi-square test and multivariate logistic and linear regression models. Results A total of 427 cases and 116,921 controls were identified. SSI prevalence among patients who underwent head and neck surgery was 0.37%, of which 41.0% was reported within the initial admission while the remaining 59.0% was reported on readmission within 30 days of first surgery. SSI was associated with a higher mortality risk (odds ratio, 3.95; 95% CI, 1.25-12.50; P = .019). Multivariate analysis demonstrated that a higher risk of SSI was associated with major surgery of the ear, nose and paranasal sinuses, mouth and tonsil, salivary glands and ducts, maxillofacial bones and mandible, and pharynx and larynx (P < .05 each). However, a lower risk of SSI was reported in thyroid and parathyroid and nonmajor procedures (P < .05 each). Other factors associated with a higher risk of SSI included multiple comorbidities, smoking, cancer diagnosis, concomitant neck dissection, and tracheostomy (P < .05 each). SSI was associated with a mean ± SE additional hospital stay of 8.1 ± 0.8 days per case (P < .001) and an additional cost on the health system of $20,953.00 ± $186.3 per case (P < .001). Conclusions SSI is associated with a significant mortality risk and burden on the health system. More than half of SSI cases were identified on readmission. |

Short Scientific Communication

Surgical Outcomes for the Treatment of Velopharyngeal Insufficiency in 22q11.2 Deletion Syndrome Lauren A. Bohm, MD, Jessa E. Miller, Noëlle Morrell, MA, CCC-SLP, James D. Sidman, MD,Brianne B. Roby, MD https://doi.org/10.1177/0194599819839958 |First Published April 2, 2019 Abstract Hide Preview This study aimed to compare outcomes of concomitant palatoplasty and sphincter pharyngoplasty with pharyngeal flap and sphincter pharyngoplasty alone for the treatment of velopharyngeal insufficiency in patients with 22q11.2 deletion syndrome. Thirty-one cases were identified for inclusion in the study. Patients were separated into 3 surgical groups: combined palatoplasty and sphincter pharyngoplasty (n = 11), pharyngeal flap (n = 7), and sphincter pharyngoplasty (n = 13). Outcome measures included perceptual speech analyses, surgical complications, and revision rates. There were no differences in preoperative speech analysis scores (P = .31). The combined palatoplasty and sphincter pharyngoplasty procedure had similar speech outcomes compared to pharyngeal flap, and both were significantly better than sphincter pharyngoplasty alone. Complication rates (P = .61) and the need for revision surgery (P = .25) were similar among all 3 groups. Concomitant palatoplasty and sphincter pharyngoplasty may be an alternative treatment for velopharyngeal insufficiency in children with 22q11.2 deletion syndrome. |

Systematic Review/Meta-analysis

Does Clearance of Positive Margins Improve Local Control in Oral Cavity Cancer? A Meta-analysis Mustafa G. Bulbul, MD, Osama Tarabichi, MD, Rosh K. Sethi, MD, MPH, Anuraag S. Parikh, MD,Mark A. Varvares, MD https://doi.org/10.1177/0194599819839006 |First Published March 26, 2019 Abstract Hide Preview Objectives To compare local recurrence-free survival (LRFS) in early oral cavity cancer (OCC) patients with positive/close frozen section (FS) cleared with further resection (R1 to R0) or positive FS not cleared (R1) to those with negative margins on initial FS analysis (R0). Data Sources PubMed, EMBASE, and Cochrane. Review Methods We followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) for reporting in our study. Only English-language articles that included patients with OCC and local recurrence (LR) comparisons between R0 and initially R1 to final R0 or final R1 groups were included. We requested the raw data from the corresponding authors of eligible studies and performed an individual participant data (IPD) meta-analysis of LRFS outcomes across groups. Results Pooled LRFS data from 8 studies showed that patients in the R1 to R0 group had worse LRFS compared to the R0 group (hazard ratio [HR] = 2.897, P < .001). Patients in the R1 group were also found to have worse LRFS compared to the R0 group (HR = 3.795, P < .001). When compared to final R1 group, the initially R1 to final R0 only showed a trend toward better LRFS. Conclusion Margin revision of initially positive margins to "clear" based on FS guidance does not equate to an initially negative margin and does not significantly improve local control. These findings call into question the effectiveness of the current methodology of intraoperative FS in OCC resections and call for a prospective study to determine what system of resected specimen analysis best predicts completeness of resection. |

Original Research

Endoscopic Type 1 Tympanoplasty in Chronic Otitis Media: Comparative Study with a Postauricular Microscopic Approach Masafumi Ohki, MD, Shigeru Kikuchi, MD, PhD, Sunao Tanaka, MD, PhD https://doi.org/10.1177/0194599819838778 |First Published March 26, 2019 Abstract Hide Preview Objective To compare surgical outcomes after tympanoplasty without ossiculoplasty for chronic otitis media between transcanal endoscopic ear surgery (TEES) and postauricular microscopic ear surgery (PAMES). Study Design Case-control study. Setting Tertiary care university hospital. Subjects and Methods Consecutive patients (N = 122) who had undergone tympanoplasty without ossiculoplasty for chronic otitis media were enrolled in this retrospective study and divided into 2 groups: TEES (n = 47) and PAMES (n = 75). Middle ear condition was graded with the middle ear risk index. Hearing, repair of tympanic membrane perforation, and surgical time were assessed. Results The surgical success rate for hearing (air-bone gap ≤20 dB) was 95.7% in the TEES group and 84.0% in the PAMES group. Lower middle ear risk resulted in similar mean (95% CI) closure of air-bone gaps (TEES: 9.6, 6.5-12.6; PAMES: 8.0, 6.4-9.7; P = .333), whereas higher middle ear risk demonstrated significantly larger closure of air-bone gaps for the TEES group (10.1, 3.3-16.9) than the PAMES group (–0.2, –4.5 to 4.2; P = .009). The surgical success rate for repair of tympanic membrane perforation and surgical time were equivalent between TEES and PAMES. Conclusion Under favorable conditions of the middle ear, TEES and PAMES resulted in similar hearing improvement by tympanoplasty without ossiculoplasty. However, under adverse conditions of the middle ear, TEES was a more beneficial approach for hearing improvement than PAMES. |

Systematic Review Meta-analysis

Submandibular Gland Invasion by Oral Cavity Cancers: A Systematic Review Yusuf Dundar, MD, Quinton Mandle, Syed N. Raza, MD, Ho-Sheng Lin, MD, John Cramer, MD,Jeffrey M. Hotaling, MD https://doi.org/10.1177/0194599819838475 |First Published March 26, 2019 Abstract Hide Preview Objective The submandibular gland (SMG) is typically included in level I neck dissection specimens despite limited data demonstrating SMG invasion. The main objective of this article is to determine the rate and pathways of SMG invasion by squamous cell carcinoma of the oral cavity and oropharynx. Data Sources A systematic review of relevant studies was performed, evaluating articles identified via the PubMed, Cochrane, and Medline databases. Review Methods Descriptive features of primary tumors, primary treatment modalities, the rate and pathway of SMG invasion, and survival outcomes, if present, were reported following the PRISMA guidelines. Results The initial literature search yielded 273 articles, of which 17 met inclusion criteria. A total of 2306 patients with 2792 SMG resections were analyzed. Fifty-eight resections (2.0%) were revealed to have tumor involvement. Among patients with SMG tumor involvement, the most common invasion pathway was direct SMG invasion by primary tumor (43 of 58, 74.1%). The second-most common mode of SMG invasion was from involved adjacent lymph nodes (10 of 58, 17.2%). Only 3 SMG resections out of 2792 (0.1%) had isolated metastatic parenchyma without evidence of direct tumor invasion or invasion by involved lymph nodes. Conclusion Given this rarity of SMG involvement, preservation of SMG might be feasible in selected patient population. However, additional studies need to examine the functionality of preserved SMGs among patients who receive postoperative adjuvant radiation therapy. |

Original Research

American Society of Anesthesiologists Class as Predictor for Perioperative Morbidity in Head and Neck Free Flaps Luke T. Small, MD, Madison Lampkin, MD, Emre Vural, MD, Mauricio A. Moreno, MD https://doi.org/10.1177/0194599819832812 |First Published March 26, 2019 Abstract Hide Preview Objective To evaluate outcomes of free flaps in low- versus high-risk American Society of Anesthesiologists (ASA) classes utilizing a standardized perioperative clinical pathway. Study Design Case series with chart review. Setting Single tertiary care academic institution. Subjects and Methods Data were collected from 301 patients who underwent 305 free flap reconstructions for head and neck defects from January 2012 to March 2016 by a single surgeon (M.M.). A standardized perioperative clinical pathway was utilized for all patients, aimed at abbreviating hospital stay and minimizing intensive care unit stay. Data included ASA classification, comorbidities, length of hospitalization, intensive care unit stay, 30-day mortality/readmission, discharge disposition, flap survival, and postoperative complications. Low-risk ASA classes were defined as 1 and 2 (n = 53) and high risk as 3 and 4 (n = 248). Results Total medical complication rates (P = .012) were mildly increased in the high-risk group, as a result of increased minor—not major—medical complication rates (P = .007). Discharge to a nursing or rehabilitation facility was found to be more common in the high-risk group (P = .024). All other outcomes were not statistically different between the cohorts. Conclusion The ASA classification system is a validated tool in determining perioperative risk. We found that minor medical complications and discharge to a rehabilitation/nursing facility were increased in the high-risk ASA classes; otherwise, there were no statistical differences between the groups. These findings suggest that the ASA classification may be helpful for preoperative discharge planning and counseling but should not be used for patient selection or to assess candidacy for the procedure. |

Original Research

Associations of Video Head Impulse Test and Caloric Testing among Patients with Vestibular Schwannoma C. Scott Brown, MD, Sarah B. Peskoe, PhD, Thomas Risoli, Jr, MS, Douglas B. Garrison, AuD,David M. Kaylie, MD https://doi.org/10.1177/0194599819837244 |First Published March 26, 2019 Abstract Hide Preview Objective To determine relationships between caloric testing (CT) and video head impulse testing (vHIT) among patients with unilateral vestibular schwannoma (VS). To describe the distribution of CT and vHIT measurements and assess associations with tumor size and self-perceived handicapping effects. Study Design Retrospective review. Setting Tertiary referral hospital. Subjects and Methods Subjects were adults with presumed unilateral VS between 2014 and 2017. Interventions were CT and vHIT. Primary outcomes were vHIT value (abnormal <0.8) and CT value (abnormal >25%). Secondary outcomes were tumor size and Dizziness Handicap Inventory scores. Results Fifty-one individuals had complete data for CT and vHIT. The odds of abnormal gain increases by 2.18 for every 10% increase in unilateral weakness on CT (range, 1.44-3.34; P < .001). A significant negative correlation between CT and gain exists (rs = −0.64, P < .001). Odds of observing saccades increased by 2.68 for every 10% increase in unilateral weakness (range, 1.48-4.85; P = .001). This association was larger in magnitude for overt than covert saccades (odds ratios, 2.48 and 1.59, respectively). Tumor size was significantly associated with an increase in caloric weakness (β = 0.135, P < .001). With every 10-mm increase of tumor size, odds of abnormal gain on vHIT increased 4.13 (range, 1.46-11.66; P = .007). Mean Dizziness Handicap Inventory score was 19.7 (σ = 22), without association to caloric weakness, gain, or tumor size. Conclusion CT and vHIT both effectively assess vestibular function for patients with VS and correlate to tumor size. These findings are important as vHIT has a lower overall cost, improved patient tolerance, and demonstrated reliability. |

Original Research

Predictors of High Costs of Care among Otolaryngology Patients Karthik Balakrishnan, MD, MPH, James P. Moriarty, MSc, Jordan Rosedahl, Colin L. Driscoll,MD, Bijan J. Borah, PhD https://doi.org/10.1177/0194599819838843 |First Published March 26, 2019 Abstract Hide Preview Objectives Identify predictors of high-cost otolaryngology care. Study Design Cross-sectional. Setting Tertiary academic multispecialty hospital. Subjects/Methods All patients undergoing ≥1 otolaryngologic procedures from 2011 to 2015. Encounter costs were standardized using previously described methods approximating Medicare reimbursement. Patients were stratified by adult/pediatric and inpatient/outpatient. "Outliers" were defined as total encounter costs ≥95th percentile. Logistic regression measured predictors of outlier status. Results In total, 2433 adult inpatient encounters (95th percentile $57,611), 10,031 adult outpatient encounters ($10,772), 346 pediatric inpatient encounters ($84,639), and 3027 pediatric outpatient encounters ($8978) were included. For adult inpatient and outpatient, isolated head and neck oncologic procedures were the reference group. Among adult inpatients, laryngology and facial plastics procedures predicted higher odds of outlier status (odds ratio [OR] = 4.1 and 7.2). Involvement of multiple otolaryngology subspecialties increased the odds (OR = 4.7). Neck dissection and reconstructive procedures were the most common primary operations for adult inpatient outliers. For adult outpatients, several subspecialties had lower odds than head and neck (OR ≤0.44). Increased comorbidities predicted outliers for adult inpatient care (OR = 1.5); sex, age, race, and ethnicity did not. Cochlear implant was the most common primary operation among adult and pediatric outpatient outliers. Greater subspecialty involvement and increasing age predicted pediatric outpatient outliers (OR = 8.0 and 1.1); younger age and female sex predicted pediatric inpatient outliers (OR = 0.8 and 3.5). Airway procedures dominated pediatric inpatient outliers. Conclusion This is the first large-scale study of high-cost otolaryngology care across multiple subspecialties. Specific procedures and subspecialties and increased comorbidities predicted high-cost care. Contrary to previous studies, patient sex, race, and ethnicity did not. |

Systematic Review/Meta-analysis

Depression in Patients with Tinnitus: A Systematic Review James W. Salazar, MD, MAS, Karl Meisel, MD, MA, Eric R. Smith, MD, Aaron Quiggle, MD, MS,David B. McCoy, MSc, Matthew R. Amans, MD, MSc https://doi.org/10.1177/0194599819835178 |First Published March 26, 2019 Abstract Hide Preview Objective Tinnitus is a condition that causes distress and impairment across cognitive, functional, and psychiatric spectra. In the psychiatric realm, tinnitus has long been associated with depression. To better characterize the co-occurrence of depression and tinnitus, we performed a systematic review of the prevalence of depression among patients with tinnitus. Data Sources We comprehensively examined original studies reporting the prevalence of depression in adult populations with tinnitus, as indexed in the PubMed and Web of Science databases and published from January 2006 to August 2016. Review Methods All identified articles were reviewed independently by 2 researchers, with a third reviewer for adjudication. Included studies were evaluated for threats to validity across 3 domains—representativeness, response rate, and ascertainment of outcome—on a 4-point modified Newcastle-Ottawa Quality Assessment Scale. Results Twenty-eight studies were included, representing 15 countries and 9979 patients with tinnitus. Among the included studies, the median prevalence of depression was 33%, with an interquartile range of 19% to 49% and an overall range of 6% to 84%. Studies were high quality overall, with a mean score of 3.3 (SD = 0.76), and 89% utilized a validated tool to ascertain depression. Conclusions We conducted one of the largest contemporary comprehensive reviews, which suggests a 33% prevalence of depression among patients with tinnitus. Our review reaffirms that a substantial proportion of patients with tinnitus have depression, and we recommend that all who treat tinnitus should screen and treat their patients for depression, if present. |

Original Research

The Upper Airway Nasal Complex: Structural Contribution to Persistent Nasal Obstruction Ryan Williams, MD, Vishal Patel, MD, Yu-Feng Chen, DDS, Navarat Tangbumrungtham, MD,Andrew Thamboo, MD, MSc, Sam P. Most, MD, Jayakar V. Nayak, MD, PhD, Stanley Y. C. Liu,MD, DDS https://doi.org/10.1177/0194599819838262 |First Published March 26, 2019 Abstract Hide Preview Objective To determine the contribution of the nasal floor and hard palate morphology to nasal obstruction for nonresponders to prior intranasal surgery. Study Design Retrospective case-control study. Setting Tertiary academic center. Methods Institutional review board–approved, retrospective institutional database analysis was obtained of a cohort of 575 patients who presented with nasal obstruction over a 21-year period. Of the patients, 89 met inclusion criteria: 52 were placed into the experimental group, defined as having persistent nasal obstruction following endoscopic sinus surgery (ESS), septoplasty, nasal valve repair, and/or turbinoplasty using validated subjective questionnaires, and 37 were placed into the control group, defined as having resolution of subjective nasal obstruction. Computed tomography imaging was presented to 3 blinded experts, who measured numerous nasal airway and hard palate morphology parameters, including anterior nasal floor width, anterior maxillary angle, maxilla width, anterior nasal floor width, and palatal vault height. Standard demographic information, comorbidities, perioperative 22-item Sinonasal Outcome Test (SNOT-22), and follow-up time were also assessed. Wilcox rank sum analysis or t test was performed where appropriate. Results Follow-up ranged from 2 to 36 months following surgical intervention. Several skeletal characteristics within the upper airway were significantly associated with persistent nasal obstruction, including acute maxillary angle (P = .035), narrow maxillary width (P = .006), and high arched palate (P = .004). Conclusion Persistent nasal obstruction may be seen in patients with narrow, high arched hard palate despite prior nasal surgical intervention and may benefit from additional skeletal remodeling procedures such as maxillary expansion. |

Clinical Techniques and Technology

The Sternocleidomastoid Myocutaneous Flap: A Laryngeal Preservation Option for Total Hyopharyngoesophageal Stenosis Hassan Paknezhad, MD, Nicole A. Borchard, Gordon K. Lee, MD, Edward J. Damrose, MD https://doi.org/10.1177/0194599819835784 |First Published March 26, 2019 Abstract Hide Preview Complete hypopharyngoesophageal (HPE) stenosis is rare and a challenging condition to treat. When endoscopic therapy fails, total laryngectomy with or without pharyngeal reconstruction is usually performed. We present a retrospective case series involving 3 patients with complete HPE stenosis who failed endoscopic repair and were gastrostomy dependent. All were managed successfully with the sternocleidomastoid myocutaneous (SCM) flap. A temporary fistula occurred in 1 patient. Hospitalization ranged from 5 to 15 days, patients resumed oral intake from 21 to 82 days postoperatively, and their gastrostomy tubes were removed from 28 to 165 days postoperatively. We suggest that the SCM flap is a laryngeal preservation option for reconstruction of complete HPE stenosis when endoscopic techniques fail. This flap allows HPE repair and reconstruction within the same surgical field, imposes no significant donor site morbidity, and affords good functional and cosmetic outcomes. |

Original Research

A Prospective Study of Outcomes of Septoplasty with Turbinate Reductions in Patients with Allergic Rhinitis Grant S. Gillman, MD, FRCS, Giuseppe V. Staltari, MD, Yue-Fang Chang, PhD, Jose L. Mattos,MD, MPH https://doi.org/10.1177/0194599819838761 |First Published March 26, 2019 Abstract Hide Preview Objective Examine outcomes of septoplasty with turbinate reductions in patients with allergic rhinitis as compared to patients without allergic rhinitis using validated outcome and quality-of-life (QOL) instruments. Study Design Prospective observational cohort study. Setting Single surgeon, university hospital. Subjects and Methods Consecutive study-eligible patients with a symptomatic nasal septal deviation, with (n = 30) or without (n = 30) documented allergic rhinitis, were enrolled from March 2014 to February 2017. All patients subsequently underwent nasal septoplasty and inferior turbinate reductions. Outcomes were studied using the Nasal Obstruction Symptom Evaluation (NOSE) scale, mini–Rhinoconjunctivitis Quality of Life Questionnaire (mini-RQLQ), and Ease-of-Breathing (EOB) Likert scores completed preoperatively and, together with a patient satisfaction Likert, at 3 and 6 months postoperatively. Results NOSE scores, EOB scores, and mini-RQLQ scores improved significantly in both groups at 3 and 6 months postoperatively. Results were sustained from 3 to 6 months. Although mini-RQLQ scores in allergic patients were higher at all intervals, the magnitude of change in scores in both groups was comparable. Conclusion Although patients with allergic rhinitis report greater allergy-related QOL impairment (mini-RQLQ) on a day-to-day basis than nonallergic patients, this does not appear to attenuate the benefit they might experience from septoplasty and turbinate reductions when indicated for nasal obstruction. Furthermore, the symptomatic relief of their structural nasal obstruction appears to significantly improve their overall allergy-related quality of life. If appropriate expectations are set pre-operatively, allergic rhinitis is neither a contraindication nor a deterrent to septoplasty and turbinate reductions and these patients can reasonably expect a high degree of satisfaction post-operatively. |

Original Research

Industry Involvement in Otolaryngology: Updates from the 2017 Open Payments Database Elliot Morse, Elisa Berson, Saral Mehra, MD, MBA https://doi.org/10.1177/0194599819838268 |First Published March 26, 2019 Abstract Hide Preview Objective To characterize drug and device industry payments to otolaryngologists in 2017 and compare them with payments from 2014 to 2016. Study Design Retrospective cross-sectional analysis. Setting 2017 Open Payments Database. Subjects and Methods We identified otolaryngologists in the Open Payments Database receiving nonresearch industry payments in 2017. We determined the total number and value of payments and the mean and median payments per compensated otolaryngologist. We characterized payments by census region, nature of payment, and sponsor subspecialty. Results A total of 8131 otolaryngologists received 66,414 payments totaling to $11.2 million in industry compensation in 2017. This is decreased from $14.5 million in 2016. The mean and median payment per compensated otolaryngologist was $1383 ($10,459) and $159 ($64-$420), respectively. Of the total compensation, 85% was received by the top 10th percentile of otolaryngologists. Speaking fees accounted for $3.1 million (28% of total payments), and food and beverage was the most common payment type (57,691 payments; 87%). Consulting fees decreased by $1 million from 2016 to 2017, and ownership interests decreased by $1.2 million from 2016 to 2017. The south had the highest total compensation value ($4.2 million), while the west had the highest mean payment value ($1561). Rhinology accounted for the highest proportion of payments of all otolaryngology subspecialties at $3.9 million (34%). Conclusion Industry payments to otolaryngologists decreased to $11.2 million in 2017 from $14.5 million in 2016. Much of the decrease can be attributed to decreases in consulting fees and ownership payments. It is important that otolaryngologists remain aware of changes in industry funding with each release of the Open Payments Database. |

Original Research

Adherence to Guidelines for Screening Polysomnography in Children with Down Syndrome Philip D. Knollman, MD, Christine H. Heubi, MD, Jareen Meinzen-Derr, PhD, David F. Smith,MD, PhD, Sally R. Shott, MD, Susan Wiley, MD, Stacey L. Ishman, MD, MPH https://doi.org/10.1177/0194599819837243 |First Published March 26, 2019 Abstract Hide Preview Objectives To compare the percentage and mean age of children with Down syndrome (DS) who underwent polysomnography (PSG) to evaluate for obstructive sleep apnea (OSA) before and after the introduction of the American Academy of Pediatrics guidelines recommending universal screening by age 4 years. Study Design Retrospective cohort study. Setting Single tertiary pediatric hospital. Methods This study is a review of patients with DS seen in a subspecialty clinic. Children born preguidelines (2000-2006) were compared with children born postguidelines (2007-2012) regarding percentage receiving PSG, age at first PSG, and rate of OSA. Results We included 766 children with DS; 306 (40%) were born preguidelines. Overall, 61% (n = 467) underwent PSG, with a mean ± SD age of 4.2 ± 2.9 years at first PSG; 341 (44.5%) underwent first PSG by age 4 years. The rate of OSA (obstructive index ≥1 event/hour) among children undergoing first PSG was 78.2%. No difference was seen in the percentage receiving PSG preguidelines (63.4%) versus postguidelines (59.4%, P = .26). The mean age at the time of first PSG was 5.3 ± 3.5 years preguidelines versus 3.4 ± 2.0 years postguidelines (P < .0001). Children in the postguidelines cohort were more likely to undergo first PSG during the ages of 1 through 4 years (67.4% vs 52.1%, P < .0001). There was no difference in rates of OSA between the pre- and postguidelines cohorts (79.8% vs 75.9%, P = .32). Conclusions Nearly two-thirds of children with DS (61%) underwent PSG overall, with a significant shift toward completion of PSG at an earlier age after the introduction of the American Academy of Pediatrics guidelines for universal screening for OSA. |

Systematic Review/Meta-analysis

Assessment and Treatment of Pain during In-Office Otolaryngology Procedures: A Systematic Review Ethan Frank, MD, Bradley Carlson, Amanda Hu, MD, FRCSC, Derrick Randall, MD, MSc,Shanalee Tamares, MLIS, Jared C. Inman, MD, Brianna K. Crawley, MD https://doi.org/10.1177/0194599819835503 |First Published March 19, 2019 Abstract Hide Preview Objective To qualitatively assess practices of periprocedural pain assessment and control and to evaluate the effectiveness of interventions for pain during in-office procedures reported in the otolaryngology literature through a systematic review. Data Sources PubMed, CINAHL, and Web of Science searches from inception to 2018. Review Methods English-language studies reporting qualitative or quantitative data for periprocedural pain assessment in adult patients undergoing in-office otolaryngology procedures were included. Risk of bias was assessed via the Cochrane Risk of Bias or Cochrane Risk of Bias in Non-Randomized Studies of Interventions tools as appropriate. Two reviewers screened all articles. Bias was assessed by 3 reviewers. Results Eighty-six studies describing 32 types of procedures met inclusion criteria. Study quality and risk of bias ranged from good to serious but did not affect assessed outcomes. Validated methods of pain assessment were used by only 45% of studies. The most commonly used pain assessment was patient tolerance, or ability to simply complete a procedure. Only 5.8% of studies elicited patients' baseline pain levels prior to procedures, and a qualitative assessment of pain was done in merely 3.5%. Eleven unique pain control regimens were described in the literature, with 8% of studies failing to report method of pain control. Conclusion Many reports of measures and management of pain for in-office procedures exist but few employ validated measures, few are standardized, and current data do not support any specific pain control measures over others. Significant opportunity remains to investigate methods for improving patient pain and tolerance of in-office procedures. |

Original Research

Risk Recall of Complications Associated with Vestibular Schwannoma Treatment Khodayar Goshtasbi, Mehdi Abouzari, MD, PhD, Omid Moshtaghi, MD, MS, Marlon Maducdoc,MD, MBA, Brandon M. Lehrich, Harrison W. Lin, MD, Hamid R. Djalilian, MD https://doi.org/10.1177/0194599819837257 |First Published March 19, 2019 Abstract Hide Preview Objective To assess the risk recall of complications among patients who underwent different vestibular schwannoma (VS) treatments. Study Design Patients with VS completed a voluntary and anonymous survey. Setting Survey links were distributed via the Acoustic Neuroma Association (ANA) website, Facebook, and email list. Subjects and Methods Surveys were distributed to ANA members from January to March 2017. Of the 3200 ANA members with a VS diagnosis at the time of survey distribution, 789 (25%) completed the survey. Results Subjects reported the following incidence of posttreatment complications: imbalance (60%), hearing issues (51%), dry eyes (30%), headache (29%), and facial weakness (27%). Overall, 188 (25%) recalled remembering all the risks associated with their treatment. Among those in the surgical cohort (52%) who experienced balance issues, facial weakness, cerebrospinal fluid leak, meningitis, and stroke, 73%, 91%, 77%, 67%, and 33% claimed recall of these associated risks. Among those in the radiosurgery cohort (28%) who experienced balance issues, facial weakness, and hydrocephalus, 56%, 52%, and 60% recalled discussions of those risks. Patients with higher-level education (P = .026) and those who underwent surgery (P = .001) had a significantly higher risk recall ratio, while sex, age, and tumor size were not significant contributing factors. Conclusion Not all patients with VS who experienced treatment complications recalled remembering those risks being discussed with them. Patients with higher education and those who underwent surgery had a better recall of risks associated with different treatment modalities. The risk recall ratio of patients experiencing complications ranged 33% to 91%, suggesting an opportunity for decision-making and discussion improvement. |

Short Scientific Communication

Body Image Disturbance in Surgically Treated Head and Neck Cancer Patients: A Prospective Cohort Pilot Study Evan M. Graboyes, MD, Elizabeth G. Hill, PhD, Courtney H. Marsh, Stacey Maurer, PhD, Terry A. Day, MD, Katherine R. Sterba, PhD, MPH https://doi.org/10.1177/0194599819835534 |First Published March 12, 2019 Abstract Hide Preview This prospective cohort pilot study sought to characterize the short-term temporal trajectory of, and risk factors for, body image disturbance (BID) in patients with head and neck cancer (HNC). Most patients were male (35/56), had oral cavity cancer (33/56), and underwent microvascular reconstruction (37/56). Using the Body Image Scale (BIS), a validated patient-reported outcome measure of BID, the prevalence of BID (BIS ≥10) increased from 11% preoperatively to 25% at 1 month postoperatively and 27% at 3 months posttreatment (P < .001 and P = .0014 relative to baseline, respectively). Risk factors for BID included female sex (odds ratio [OR], 4.8; 95% confidence interval [CI], 1.3-19.8), pT 3 to 4 tumors (OR, 8.9; 95% CI, 2.0-63.7), and more severe baseline shame and stigma (OR, 1.06; 95% CI, 1.01-1.13), depression (OR, 1.25; 95% CI, 1.06-1.51), and social isolation (OR, 1.21; 95% CI, 1.01-1.49). The prevalence and severity of BID increase immediately posttreatment. Demographic, oncologic, and psychosocial characteristics identify high-risk patients for targeted interventions. |

Original Research

Outcomes of Hypoglossal Nerve Upper Airway Stimulation among Patients with Isolated Retropalatal Collapse Ahmad F. Mahmoud, MD, Erica R. Thaler, MD https://doi.org/10.1177/0194599819835186 |First Published March 12, 2019 Abstract Hide Preview Objective To examine whether patients with isolated retropalatal collapse perform as well as others following implantation with an upper airway stimulation (UAS) device. Study Design Retrospective review. Setting Single-institution tertiary academic care medical center. Subjects and Methods Following drug-induced sleep endoscopy, subjects who met inclusion criteria for implantation with a UAS device received an implant per industry standard. Subjects with isolated retropalatal collapse were compared with those having other patterns of collapse. Outcome measures included apnea-hypopnea index (AHI) and nadir oxyhemoglobin saturation (NOS). Results Ninety-one patients were implanted during the duration of the study, and 82 met inclusion criteria for analysis. Twenty-five had isolated retropalatal collapse, while the remaining 57 had other patterns of collapse on drug-induced sleep endoscopy. For all patients, mean preoperative AHI and NOS were 38.7 (95% CI, 35.0-42.4) and 78% (95% CI, 75%-80%), respectively; these improved postoperatively to 4.5 (95% CI, 2.3-6.6) and 91% (95% CI, 91%-92%). There was no significant preoperative difference between groups with regard to demographics, AHI, or NOS. Group comparison showed postoperative AHI to be 5.7 (95% CI, 0.57-10.8) for patients with isolated retropalatal collapse and 3.9 (95% CI, 1.7-6.1) for other patients (P = .888). Postoperative NOS was 92% (95% CI, 90%-94%) among patients with isolated retropalatal collapse and 91% (95% CI, 90%-92%) for others (P = .402). Conclusions All patients showed significant improvement following implantation with UAS. Patients with isolated retropalatal collapse showed similar improvement to other types of collapse with regard to AHI and NOS. |

Original Research

Patterns of Care and Outcome of Clear Cell Carcinoma of the Head and Neck Jamie Oliver, Peter Wu, MD, Clifford Chang, Dylan Roden, MD, Binhuan Wang, PhD, Cheng Liu, MD, PhD, Kenneth Hu, MD, David Schreiber, MD, Babak Givi, MD https://doi.org/10.1177/0194599819835779 |First Published March 12, 2019 Abstract Hide Preview Objective Clear cell carcinoma (CCC) is a rare salivary gland malignancy, believed to be generally low grade. We investigated CCC epidemiology and clinical behavior, using the National Cancer Database (NCDB). Study Design Retrospective cohort study. Setting NCDB. Subjects and Methods All CCCs of the salivary glands were selected between 2004 and 2015. Patient demographics, tumor characteristics, treatments, and survival were analyzed. Cox regression analyses were performed in treated patients. Results We identified 268 patients with CCC. Median age was 61 (21-90) years. Most were female (145, 54%). The most common site was oral cavity (119, 44%), followed by major salivary glands (68, 25%) and oropharynx (41, 15%). Most tumors were low grade (81, 68%) and stages I to II (117, 60.6%). Nodal (36, 17.5%) and distant metastases (6, 2.4%) were rare. Most were treated by surgery alone (134, 50.0%), followed by surgery and radiotherapy (69, 25.7%). Five-year overall survival (OS) was 77.6% (95% CI, 71.4%-84.2%). In univariate analysis, older age, major salivary gland and sinonasal site, stages III to IV, high grade, and positive margins were associated with worse OS. In multivariate analysis, only high tumor grade (hazard ratio [HR], 5.76; 95% CI, 1.39-23.85; P = .02), positive margins (HR, 4.01; 95% CI, 1.20-13.43; P = .02), and age ≥60 years (HR, 3.45; 95% CI, 1.39-8.55; P = .01) were significantly associated with OS. Conclusion We report the largest series of clear cell carcinomas of the head and neck. Outcomes are generally favorable following surgical-based treatments. In this series, pathologic tumor grade is associated with worse survival. Routine evaluation and reporting of tumor grade might better guide physicians in recommending appropriate treatments in this rare malignancy. |

Original Research

Postoperative Venous Thromboembolism after Extracranial Otologic Surgery Yohan Song, MD, Jennifer C. Alyono, MD, Noor-E-Seher Ali, MD, Nikolas H. Blevins, MD https://doi.org/10.1177/0194599819835743 |First Published March 12, 2019 Abstract Hide Preview Objective To determine the incidence of postoperative venous thromboembolism (VTE) in adults undergoing otologic surgery. Study Design Cross-sectional retrospective study. Setting Single tertiary academic center. Subjects and Methods Adults undergoing nononcologic, extracranial otologic surgery from August 2009 to December 2016. Patients with postoperative diagnosis VTE codes were identified. Imaging and clinical documents were searched for VTE evidence within the first 30 postoperative days. Methods of thromboprophylaxis were documented, and Caprini risk scores were calculated. Results In total, 1213 otologic surgeries were evaluated. No postoperative VTE events were identified (0/1268). Mean age was 51.0 ± 17.3 years (range, 18.1-93.4 years). Average length of surgery was 136.0 ± 79.0 minutes (range, 5-768 minutes). The average Caprini score in all patients was 4.0 ± 1.7 (range, 1-15). Eighty-five percent of patients had a Caprini score ≥3, the threshold at which chemoprophylaxis has been recommended in general surgery patients by the American College of Chest Physicians 2012 guidelines. Six patients had documented preoperative chemoprophylaxis and a Caprini score of 4.8 ± 1.7. This was not significantly different from that of patients who did not receive preoperative chemoprophylaxis (ttest, P = .3). The literature would estimate a rate of 3.7% VTE in adults with similar Caprini scores undergoing general surgery procedures with no VTE prophylaxis. Conclusion The Caprini risk assessment model may overestimate VTE risk in patients undergoing extracranial otologic surgery. Postoperative VTE following otologic surgery is rare, even in patients traditionally considered moderate or high risk. Chemoprophylaxis guidelines in this group should be balanced against the potential risk of increased intraoperative bleeding and its associated effects on surgical visualization and morbidity. |

Original Research

Recent Trends in Vestibular Schwannoma Management: An 11-Year Analysis of the National Cancer Database Solymar Torres Maldonado, James G. Naples, MD, Ramie Fathy, AB, Steven J. Eliades, MD, PhD, John Y. K. Lee, MD, Jason A. Brant, MD, Michael J. Ruckenstein, MD, MSc https://doi.org/10.1177/0194599819835495 |First Published March 12, 2019 Abstract Hide Preview Objective A better understanding of the natural history of vestibular schwannoma (VS) has resulted in a change in treatment paradigms. It has also been proposed that increased use of high-resolution magnetic resonance imaging has allowed for an increased identification of small tumors. The aim of this study was to evaluate recent trends in the presentation and primary management of VS in the United States. Study Design Retrospective analysis of the National Cancer Database (NCDB). Setting NCDB database. Subjects and Methods All patients with a diagnosis of VS between 2004 and 2014 were included. Data were analyzed with univariable and multivariable logistic regression. Results In total, 28,190 patients (mean age 55 years, 52.9% female) with VS were analyzed. Linear regression showed a small decrease in average tumor size over time (–0.06 mm/year, P = .03). Overall, 11,121 patients (40%) received surgery, 8512 (30%) radiation, and 7686 (27%) observation. Controlling for patient, tumor, and treatment center factors, the odds ratio (OR) for receiving surgery in 2014 was 0.60 (confidence interval [CI], 0.50-0.71) while the OR for receiving radiation was 0.75 (CI, 0.64-0.87) as compared to those diagnosed in 2004. The largest increases in observation rates occurred among tumors ≤2 cm (P < .001). Conclusion There was not a clinically significant change in the average tumor size at diagnosis. Although surgery remained the most common treatment modality in the United States, there was a strong shift in the management of VS away from primary surgery and radiation and toward a "wait-and-scan" approach. |

Systematic Review

Perioperative Desmopressin for Patients Undergoing Otolaryngologic Procedures: A Systematic Review Gregory L. Barinsky, PharmD, David Buziashvili, MBS, Peter F. Svider, MD, Michael A. Carron,MD, Adam J. Folbe, MD, Wayne D. Hsueh, MD, Jean Anderson Eloy, MD, Andrew P. Johnson,MD https://doi.org/10.1177/0194599819831288 |First Published March 12, 2019 Abstract Hide Preview Objective Desmopressin (DDAVP) is a hemostatic agent used to manage bleeding in patients with hemostatic disorders, and there is a lack of published data to guide its use during otolaryngology procedures. The objective of this study was to conduct an evidence-based systematic review of the reported uses, efficacy, and adverse effects of DDAVP in the otolaryngology surgical setting. Data Sources PubMed, MEDLINE, and EmBase were searched for articles on the use of DDAVP in otolaryngology. Review Methods The Methodological Index for Non-Randomized Studies criteria and Cochrane bias tool were used to assess study quality. Patient demographics, DDAVP dosing and route, and outcomes such as bleeding and adverse events were collected. A summary of evidence table was created specifying levels of evidence, benefits, and harm. Results Nineteen studies encompassing 440 patients were included. Sixteen studies discussed DDAVP for prophylaxis, and 3 discussed postoperative use. DDAVP effectively prevented bleeding in high-risk patients and successfully facilitated a dry surgical field when necessary. DDAVP had a 100% success rate when used symptomatically. Five studies described adverse effects, including hyponatremia (12.3%), nausea (2.0%), emesis (0.9%), and seizure (0.2%). The aggregate level of evidence for its use was Level B for adenotonsillectomy, septoplasty, and turbinate procedures and Level C for rhinoplasty. Conclusion Current literature supports the use of DDAVP in otolaryngology surgical procedures as both a perioperative prophylactic agent and a postoperative symptomatic intervention for bleeding. Both modalities are effective with minimal adverse events. Further well-designed randomized trials are necessary to conclusively formulate guidelines for DDAVP use in otolaryngology. |

Original Research

Pediatric Stapes Surgery: Hearing and Surgical Outcomes in Endoscopic vs Microscopic Approaches Anthony M. Tolisano, MD, Miles R. Fontenot, Ashley M. Nassiri, MD, MBA, Jacob B. Hunter,MD, Joe Walter Kutz, Jr., MD, Alejandro Rivas, MD, Brandon Isaacson, MD https://doi.org/10.1177/0194599819836679 |First Published March 12, 2019 Abstract Hide Preview Objective To compare endoscopic and microscopic pediatric stapes surgery. Study Design Case series with chart review. Setting Two academic otology practices. Subjects and Methods Surgical and hearing outcomes were compared for consecutive children (<18 years) undergoing microscopic and endoscopic stapes surgery. The main outcome measure was closure of the air-bone gap (ABG) to ≤20 dB. Results Twenty-two endoscopic surgeries (17 stapedectomies, 4 stapedotomies, and 1 stapes mobilization) and 52 microscopic surgeries (30 stapedectomies, 19 stapedotomies, and 3 stapes mobilizations) were performed. Patient demographics, history of ipsilateral middle ear surgery, and revision stapes surgery status were similar. The most common diagnosis for the endoscopic group and microscopic group were congenital stapes footplate fixation (45.5%) and juvenile otosclerosis (46.2%), respectively. Preoperative ABGs in the endoscopic (37.7 dB) and microscopic (32.8 dB) groups (P = .170) were similar. There were no major complications, including facial nerve injury or anacusis, in the endoscopic group. Postoperative sensorineural hearing loss (>15 dB) did not occur in any patients in the endoscopic group but was present in 2 patients in the microscopic group (P = .546). Improvement in pure-tone average (25.9 dB vs 18.5 dB, P = .382) and ABG (21.7 dB vs 14.7 dB, P = .181) was similar, and postoperatively, the median ABG was 11.3 dB and 15.0 dB for endoscopic and microscopic cases (P = .703), respectively. ABG closure to ≤20 dB (72.7% vs 65.2%, P = .591) was also similar. Conclusion Pediatric endoscopic stapes surgery is safe and hearing outcomes are similar to the microscopic approach when performed by experienced endoscopic ear surgeons. |

Original Research

Continuous Vagal Neuromonitoring Using the Laryngeal Adductor Reflex: Can Preincision Dyssynchrony Predict Intraoperative Nerve Behavior? Maria De Los Angeles Sanchez Roldan, MD, Maria J. Téllez, MD, Sedat Ulkatan, MD, Catherine F. Sinclair, MD https://doi.org/10.1177/0194599819835781 |First Published March 12, 2019 Abstract Hide Preview Objective The laryngeal adductor reflex (LAR) is an airway-protective response triggered by sensory laryngeal receptors and resulting in bilateral vocal fold adduction. The normal morphology of the early R1 response resembles that of the compound muscle action potential (CMAP). However, in a small subset of patients, the morphology is dyssynchronous with multiple peaks. This study investigates whether preoperative LAR dyssynchrony predicts intraoperative nerve behavior during thyroid surgeries. Study Design Retrospective case-control study. Setting US academic health center. Subjects and Methods Opening and closing LAR waveforms from 200 patients with normal preoperative laryngeal examinations monitored continuously during thyroid surgeries using the LAR were analyzed. Area under the curve (AUC) and number of "events" during surgery (defined as any transient decline in AUC >50% baseline) were determined for patients who demonstrated opening dyssynchronous LAR traces compared to demographically matched controls. Results Six patients had opening dyssynchronous LAR traces. These patients had significantly greater declines in R1 AUC than demographically matched patients with opening synchronized R1 traces (P = .007). Upon thyroid removal, 1 patient converted from a dyssynchronous to synchronous trace. Conclusions Preincision dyssynchronous LAR waveforms may indicate subclinical, potentially reversible, neuropathy of the recurrent laryngeal nerve (RLN) and predict intraoperative RLN behavior. Preincision knowledge of R1 dyssynchrony can facilitate surgical planning as such patients may glean particular benefit from continuous intraoperative nerve monitoring, frequent tissue relaxation, and saline irrigation as means to minimize nerve stress intraoperatively. |

Patient Safety/Quality Improvement

Discharge Delay in Head and Neck Free Flap Surgery: Risk Factors and Strategies to Minimize Hospital Days Dustin M. Lang, MD, MS, Deepa Danan, MD, MBA, Raja Sawhney, MD, MFA, Natalie L. Silver,MD, MS, Varun V. Varadarajan, MD, Sanjeev Balamohan, MD, Stewart H. Bernard, MD, Brian J. Boyce, MD, Peter T. Dziegielewski, MD, FRCS(C) https://doi.org/10.1177/0194599819835545 |First Published March 12, 2019 Abstract Hide Preview Objective Length of stay (LOS) includes time medically necessary in the hospital and time waiting for discharge (DC) afterward. This DC delay is determined in head and neck free flap patients. Reasons for and factors leading to DC delay, as well as associated adverse outcomes, are elucidated. Methods Retrospective chart review was performed for all head and neck free flap surgeries from 2012 to 2017. Data including demographics, comorbidities, and perioperative factors were collected. Regression analyses were performed to identify factors associated with DC delay. Results In total, 264 patients were included. Mean total LOS was 13.1 days. DC delay occurred in 65% of patients with a mean of 4.8 days. Factors associated with DC delay on univariate analysis included Medicaid/self-pay insurance, DC to a facility, and not having children (P < .05). Multivariate analysis showed prolonged medically necessary LOS and surgery on a Monday/Friday (P < .05) were associated with DC delay. Top reasons for DC delay included case management shortages, rejection by facility, and awaiting supplies. Eleven percent experienced complications during the DC delay. Discussion DC delay can add days and complications to the LOS. Prevention begins preoperatively with DC planning involving the patient's closest family. Understanding limitations of the patient's insurance may help plan DC destination. Optimizing hospital resources when available should be a focus. Implications for Practice Head and neck free flap patients require a team of teams unified in optimizing quality of care. DC delay is a novel quality metric reflecting the team's overall performance. Through strategic DC planning and capitalizing on available resources, DC delay can be minimized. |

Original Research

Long-term Swallowing Function, Pulmonary Complications, and Quality of Life after Supracricoid Laryngectomy Davide Di Santo, MD, Stefano Bondi, MD, Leone Giordano, MD, Andrea Galli, MD, Michele Tulli, MD, Barbara Ramella, CCC-SLP, Mario Bussi, MD https://doi.org/10.1177/0194599819835189 |First Published March 12, 2019 Abstract Hide Preview Objectives Long-term effects of supracricoid laryngectomies are nowadays under discussion. The purpose of this study was to detect the prevalence of chronic aspiration and incidence of pulmonary complications, to investigate possible influencing factors, and to analyze dysphagia-related quality of life in a cohort of patients who recovered swallowing function after undergoing supracricoid laryngectomies. Study Design Retrospective observational study. Setting San Raffaele Hospital, Vita-Salute University, Milan, Italy. Methods A cohort of 39 patients who recovered swallowing function free of disease after a minimum 3-year follow-up period was retrospectively investigated between October and December 2017—clinically with the Pearson's Scale and M. D. Anderson Dysphagia Inventory and instrumentally with fiberoptic endoscopic evaluation of swallowing. Results Chronic aspiration was demonstrated in a significant portion of patients (clinically in 33.3% and instrumentally in 35.9%). Aspiration was influenced by advanced age at surgery (P = .020). Type of surgical procedure, resection of 1 arytenoid cartilage, postoperative rehabilitation with a speech-language therapist, radiotherapy, age at consultation, and length of follow-up did not influence the prevalence of aspiration. Pulmonary complications affected 5 patients; incidence of pulmonary complications was related to aspiration and was favored by poor laryngeal sensation/cough reflex. Aspiration significantly affected quality of life. Conclusions Chronic aspiration is frequent and affects patients' quality of life. However, incidence of pulmonary complications is low; therefore, oral feeding should not be contraindicated for aspirating patients. Preservation of laryngeal sensation and cough reflex is mandatory to prevent pulmonary complications. |

Short Scientific Communication

Audiology Telemedicine Evaluations: Potential Expanded Applications Kyle T. Fletcher, MD, PharmD, Frank W. Dicken, Margaret M. Adkins, AuD, Trey A. Cline, AuD,Beth N. McNulty, MD, Jennifer B. Shinn, PhD, CCC-A, Matthew L. Bush, MD, PhD https://doi.org/10.1177/0194599819835541 |First Published March 5, 2019 Abstract Hide Preview There is underutilization of cochlear implants with delays in implantation linked to distance from implant centers. Telemedicine could connect cochlear implant specialists with patients in rural locations. We piloted telemedicine cochlear implant testing in a small study, largely composed of normal-hearing volunteers to trial this new application of teleaudiology technology. Thirteen subjects (8 with normal hearing and 5 with hearing loss ranging from mild to profound) underwent a traditional cochlear implant evaluation in person and then via telemedicine technology. Routine audiometry, word recognition testing, and Arizona Biological Test (AzBio) and consonant-nucleus-consonant (CNC) testing were performed. Mean (SD) percent difference in AzBio between in-person and remote testing was 1.7% (2.06%). Pure tone average (PTA), speech reception threshold (SRT), and word recognition were similar between methods. CNC testing showed a mean (SD) difference of 6.8% (10.2%) between methods. Testing conditions were acceptable to audiologists and subjects. Further study to validate this method in cochlear implant candidates and a larger population is warranted. |

Original Research

Comparison of Transmastoid and Middle Fossa Approaches for Superior Canal Dehiscence Repair: A Multi-institutional Study Seth R. Schwartz, MD, MPH, Galit Almosnino, MD, Kathryn Y. Noonan, MD, Renee M. Banakis Hartl, MD, AuD, Daniel M. Zeitler, MD, James E. Saunders, MD, MS, Stephen P. Cass, MD, MPH https://doi.org/10.1177/0194599819835173 |First Published March 5, 2019 Abstract Hide Preview Objective To compare outcomes for patients undergoing a transmastoid approach versus a middle fossa craniotomy approach with plugging and/or resurfacing for repair of superior semicircular canal dehiscence. Outcome measures include symptom resolution, hearing, operative time, hospital stay, complications, and revision rates. Study Design Multicenter retrospective comparative cohort study. Settings Three tertiary neurotology centers. Subjects and Methods All adult patients undergoing repair for superior canal dehiscence between 2006 and 2017 at 3 neurotology centers were included. Demographics and otologic history collected by chart review. Imaging, audiometric data, and vestibular evoked myogenic potential measurements were also collected for analysis. Results A total of 68 patients (74 ears) were included in the study. Twenty-one patients underwent middle fossa craniotomy repair (mean age, 47.9 years), and 47 underwent transmastoid repair (mean age, 48.0 years). There were no significant differences in age or sex distribution between the groups. The transmastoid group experienced a significantly shorter duration of hospitalization and lower recurrence rate as compared with the middle fossa craniotomy group (3.8% vs 33%). Both groups experienced improvement in noise-induced vertigo, autophony, pulsatile tinnitus, and nonspecific vertigo. There was no significant difference among symptom resolution between groups. Additionally, there was no significant difference in audiometric outcomes between the groups. Conclusion Both the transmastoid approach and the middle fossa craniotomy approach for repair of superior canal dehiscence offer symptom resolution with minimal risk. The transmastoid approach was associated with shorter hospital stays and lower recurrence rate as compared with the middle fossa craniotomy approach. |

Original Research

Cost-effectiveness of Screening for Nasopharyngeal Carcinoma among Asian American Men in the United States Jeremy P. Harris, MD, MPhil, Anirudh Saraswathula, Brian Kaplun, Yushen Qian, MD, K. C. Allen Chan, MD, Anthony T. C. Chan, MD, Quynh-Thu Le, MD, Douglas K. Owens, MD, MS,Jeremy D. Goldhaber-Fiebert, PhD, Erqi Pollom, MD, MS https://doi.org/10.1177/0194599819832593 |First Published March 5, 2019 Abstract Hide Preview Objective Most patients with nasopharyngeal carcinoma (NPC) in the United States are diagnosed with stage III-IV disease. Screening for NPC in endemic areas results in earlier detection and improved outcomes. We examined the cost-effectiveness of screening for NPC with plasma Epstein-Barr virus DNA among Asian American men in the United States. Study Design We used a Markov cohort model to estimate discounted life-years, quality-adjusted life-years (QALYs), costs, and incremental cost-effectiveness ratios for screening as compared with usual care without screening. Setting The base case analysis considered onetime screening for 50-year-old Asian American men. Subjects and Methods Confirmatory testing was magnetic resonance imaging and nasopharyngoscopy. Cancer-specific outcomes, health utility values, and costs were determined from cancer registries and the published literature. Results For Asian American men, usual care without screening resulted in the detection of NPC at stages I, II, III-IVB, and IVC among 6%, 29%, 54%, and 11% of those with cancer, respectively, whereas screening resulted in earlier detection with a stage distribution of 43%, 24%, 32%, and 1%. This corresponded to an additional 0.00055 QALYs gained at a cost of $63 per person: an incremental cost of $113,341 per QALY gained. In probabilistic sensitivity analysis, screening Asian American men was cost-effective at $100,000 per QALY gained in 35% of samples. Conclusion Although screening for NPC with plasma Epstein-Barr virus DNA for 50-year-old Asian American men may result in earlier detection, in this study it was unlikely to be cost-effective. Screening may be reasonable for certain subpopulations at higher risk for NPC, but clinical studies are necessary before implementation. |

Original Research

A Randomized Single-Blinded Trial of Ibuprofen- versus Opioid-Based Primary Analgesic Therapy in Outpatient Otolaryngology Surgery Khanh K. Nguyen, MD, Yuan F. Liu, MD, Crystal Chang, Jaimie J. Park, Cherine H. Kim, MD, PhD, Brian Hondorp, MD, Christopher Vuong, MD, Helen Xu, MD, Brianna K. Crawley, MD,Alfred A. Simental, MD, Christopher A. Church, MD, Jared C. Inman, MD https://doi.org/10.1177/0194599819832528 |First Published March 5, 2019 Abstract Hide Preview Objective To compare the efficacy of pain control and opioid consumption between patients who receive opioid as primary analgesic therapy and those who receive ibuprofen. Study Design Prospective randomized trial. Setting Tertiary care academic hospital. Subject and Methods Adult patients undergoing outpatient otolaryngology surgery were assigned to take hydrocodone/acetaminophen or ibuprofen for postoperative analgesia. Patient-recorded pain scores and analgesic consumption were analyzed. Results Out of 185 recruits, 108 (58%) completed responses. Fifty-six patients (52%) received opioid medication for primary analgesic treatment versus 52 (48%) who received ibuprofen. There was no difference in reported pain scores between the treatment groups. Those who received ibuprofen as primary therapy reported a significantly lower consumption of opioid medication at 2.04 tablets/pills (95% CI, 0.9-3.1) versus 4.86 (3.6-6.1; P = .001). Based on multivariate analysis, male sex and older age exhibited lower reported pain scores, while older age and use of ibuprofen as primary therapy exhibited lower opioid requirements. Conclusion For postoperative pain management in outpatient otolaryngology procedures, ibuprofen as primary therapy can provide equally effective pain control as compared with hydrocodone/acetaminophen while decreasing overall opioid requirement. Prescription pill counts are further described to help guide physician practices in the era of an opioid epidemic. |

Systematic Review

Epistaxis Risk Associated with Intranasal Corticosteroid Sprays: A Systematic Review and Meta-analysis Eric L. Wu, MD, William C. Harris, MD, Casey M. Babcock, Bailin H. Alexander, MS, Charles A. Riley, MD, Edward D. McCoul, MD, MPH https://doi.org/10.1177/0194599819832277 |First Published February 19, 2019 Abstract Hide Preview Objective Intranasal corticosteroids (INCSs) are widely utilized for the treatment of allergic rhinitis. Epistaxis is a known adverse effect of INCSs, but it is not known if the risk of epistaxis differs among INCSs. Data Sources Systematic review of primary studies identified through Medline, Embase, Web of Science, PubMed Central, and Cochrane databases. Review Methods Systematic review was conducted according to the PRISMA standard. English-language studies were queried through February 1, 2018. The search identified randomized controlled trials of INCSs for treatment of allergic rhinitis that reported incidence of epistaxis. An itemized assessment of the risk of bias was conducted for each included study, and meta-analysis was performed of the relative risk of epistaxis for each INCS. Results Of 949 identified studies, 72 met the criteria for analysis. Meta-analysis demonstrated an overall relative risk of epistaxis of 1.48 (95% CI, 1.32-1.67) for all INCSs. The INCSs associated with the highest risk of epistaxis were beclomethasone hydrofluoroalkane, fluticasone furoate, mometasone furoate, and fluticasone propionate. Beclomethasone aqueous, ciclesonide hydrofluoroalkane, and ciclesonide aqueous were associated with the lowest risk of epistaxis. Conclusions about epistaxis with use of budesonide, triamcinolone, and flunisolide are limited due to the low number of studies and high heterogeneity. Conclusions While a differential effect on epistaxis among INCS agents is not clearly demonstrated, this meta-analysis does confirm an increased risk of epistaxis for patients using INCSs as compared with placebo for treatment of allergic rhinitis. |

Systematic Review

Surgery for Obstructive Sleep Apnea in Obese Children: Literature Review and Meta-analysis Patrick Scheffler, MD, CM, Nikolaus E. Wolter, MD, MSc, FRCSC, Indra Narang, MBBCH, MD, FRCPCH, Reshma Amin, MD, MSc, FRCPC, Theresa Holler, MD, MSc, FRCSC, Stacey L. Ishman,MD, MPH, Evan J. Propst, MD, MSc, FRCSC https://doi.org/10.1177/0194599819829415 |First Published February 19, 2019 Abstract Hide Preview Objectives Surgical intervention for obstructive sleep apnea (OSA) in overweight and obese children may not be as effective as it is in normal-weight children. The purpose of this study was to systematically review the effects of various surgical interventions for OSA in obese children and to meta-analyze the current data. Data Sources PubMed, OVID, and Cochrane databases. Review Methods Databases were searched for studies examining adenotonsillectomy, uvulopalatopharyngoplasty, supraglottoplasty, or tongue base surgeries and combinations in obese children with OSA. Adenotonsillectomy was the only procedure with enough data for meta-analysis; polysomnographic data were extracted and analyzed using a random-effects model. Results For adenotonsillectomy, 11 studies were included in the meta-analysis. Despite significant improvement in the apnea-hypopnea index (22.9 to 8.1 events/h, P < .001), respiratory disturbance index (24.8 to 10.4 events/h, P < .001), and oxygen saturation nadir (78.4% to 87.0%, P < .001), rates of persistent OSA ranged from 51% to 66%, depending on the outcome criterion used. There was evidence of limited effectiveness for surgical interventions to treat OSA in obese children using uvulopalatoplasty (12.5%) and tongue base surgery (74%-88%). Conclusions Surgical interventions for OSA in overweight and obese children are effective at reducing OSA but with higher rates of persistent OSA than reported for normal-weight children. However, the amount of reduction appears to vary by surgical procedure. More attention should be paid toward preoperative weight loss and patient selection, and parents should be provided with realistic postoperative expectations in this difficult-to-treat population. |

Original Research

Recurrent Laryngeal Nerve Reinnervation in Rats Posttransection: Neurotrophic Factor Expression over Time Michael B. Montalbano, Ignacio Hernández-Morato, PhD, Likun Tian, Victoria X. Yu, Sonam Dodhia, MD, Jose Martinez, PhD, Michael J. Pitman, MD https://doi.org/10.1177/0194599819831289 |First Published February 19, 2019 Abstract Hide Preview Objective Recurrent laryngeal nerve (RLN) injury causes vocal fold paralysis from which functional recovery is typically absent due to nonselective reinnervation. This study investigates expression of axon guidance cues and their modulators relative to the chronology of reinnervation by examining the expression of glial-derived neurotrophic factor (GDNF), netrin 1, and laminin 111 (LAMA1) in nonpooled laryngeal muscles. This study is the first to describe the post-RLN injury expression pattern of LAMA1, a target of particular interest as it has been shown to switch netrin 1–mediated growth cone attraction to repulsion. Study Design Animal experiment (rat model). Setting Basic science laboratory. Methods The right RLNs of 64 female Sprague-Dawley rats were transected, with sacrifice at 1, 3, 7, 21, 28, and 56 days postinjury (DPI). Single-animal messenger RNA was isolated from the ipsilateral posterior cricoarytenoid (PCA), lateral thyroarytenoid (LTA), and medial thyroarytenoid (MTA) for quantitative reverse transcription polymerase chain reaction (qRT-PCR) analysis. Immunostaining for LAMA1 expression was performed in the same muscles. Results LAMA1 was elevated in the PCA at 3 to 56 DPI, LTA at 7 DPI, and MTA at 14 and 28 DPI. This correlates with the chronology of laryngeal reinnervation. Using a new protocol, single-animal muscle qRT-PCR possible and expression results for GDNF and netrin 1 were similar to previous pooled investigations. Conclusion Reliable qRT-PCR is possible with single rat laryngeal muscles. The expression of netrin 1 and LAMA1 is chronologically coordinated with muscle innervation in the LTA and MTA. This suggests that LAMA1 may influence netrin 1 to repel axons and delay LTA and MTA reinnervation. |

Original Research

Long-Term Hearing Outcomes following Total Ossicular Reconstruction with Titanium Prostheses C. Burton Wood, MD, Robert Yawn, MD, Anne Sun Lowery, Brendan P. O'Connell, MD, David Haynes, MD, George B. Wanna, MD https://doi.org/10.1177/0194599819831284 |First Published February 19, 2019 Abstract Hide Preview Objective (1) Characterize a large cohort of patients undergoing total ossicular chain reconstruction with titanium prosthesis. (2) Analyze long-term hearing outcomes of the same cohort. Study Design Case series with chart review. Setting Tertiary care center. Subject and Methods This study reviews patients who underwent total ossicular chain reconstruction (OCR) with titanium prostheses (TORPs) at a single tertiary care center from 2005 to 2015. Patient charts were reviewed for demographic data, diagnosis, and operative details. Patients were included in statistical analysis if length of follow-up was 2 years or more. Evaluation of hearing improvement was made by comparing preoperative air-bone gap (ABG) and ABG at follow-up at 2 years. Results In total, 153 patients were identified who met inclusion criteria. The mean age of included patients was 40 years (range, 6-89 years). Sixty patients (39%) had a history of OCR, and 120 patients (78%) had a diagnosis of cholesteatoma at the time of OCR. Preoperatively, the mean ABG was 36 ± 12, whereas the mean ABG at 2-year follow-up improved to 26 ± 13. This was statistically significant (P < .0001) using a Wilcoxon matched-pairs signed rank test. Twelve patients (8%) required revision OCR. Two revisions were performed due to prosthesis extrusion (<1%). Conclusion Titanium prostheses lead to significant improvement in hearing over long periods. The results are sustained as far out as 5 years following surgery. In addition, rates of revision surgery with titanium TORPs are low. Based on this series, there are no readily identifiable predictors for outcomes following total OCR. |

Original Research

The Role of Cognitive Evaluation in Predicting Successful Audiometric Testing among Children Taylor B. Teplitzky, MD, Kristen Angster, MD, Lauren E. Rosso, Anne R. Ferruggiaro, AuD,Amal Isaiah, MD, PhD, Kevin D. Pereira, MD, MS https://doi.org/10.1177/0194599819832510 |First Published February 19, 2019 Abstract Hide Preview Objective To determine the role of cognitive testing in predicting age-appropriate audiometric responses among children aged 30 to 42 months. Study Design Prospective. Setting Tertiary care audiology clinic. Subjects and Methods Subjects included primary English–speaking children aged 30 to 42 months. A certified pediatric audiologist performed the cognitive aspect of the Developmental Assessment of Young Children–Second Edition (DAYC-2). A second, blinded audiologist performed age-appropriate audiometry. The raw, age-equivalent, percentile, and standard DAYC-2 scores were compared by agreement between speech reception threshold (SRT) and pure tone average (PTA). Optimal DAYC-2 thresholds were also calculated for prediction of SRT-PTA agreement and assessed for sensitivity, specificity, and positive and negative predictive values. P < .05 was considered significant. Results Complete data were obtained from 37 children. The mean age was 34.9 months (95% CI, 33.5-36.2), and 15 (41%) were female. Among the 37 children, 24 (65%) and 13 (35%) underwent visual reinforcement audiometry and conditioned play audiometry, respectively. SRT-PTA agreement was seen in 32 (87%) tests. Mean DAYC-2 raw score grouped by SRT-PTA agreement was 39.4 versus 33.4 for nonagreement (2.8-9.3, P < .001). The mean age-equivalent score grouped by SRT-PTA agreement was 29.6 versus 23.0 for nonagreement (2.7-10.6, P = .002). Optimal cut points based on DAYC-2 scores achieved moderate overall prediction performance (area under the curve, 0.73-0.77) with a positive predictive value of 100%. Conclusion The DAYC-2 is a useful screen to identify children likely to complete an age-appropriate audiogram. |

Systematic Review

What Affects Postoperative Sinusitis and Implant Failure after Dental Implant: A Meta-analysis Jong Seung Kim, MD, PhD, Sang Moon Choi, DDS, Ji Hyun Yoon, DDS, Eun Jung Lee, MD, PhD,Jin Yoon, MD, Sam Hyun Kwon, MD, PhD, Cha Dong Yeo, MD, Ji Seob Ryu, MD, Jong Hwan Lee, MD, Yeon Seok You, MD, Su Geun Kim, MD, Min Hee Lee, MD, Baek Hwa Han, MD https://doi.org/10.1177/0194599819829747 |First Published February 19, 2019 Abstract Hide Preview Objective The dental implant is an innovative instrument that enables the edentulous patient to chew. Many factors have a bearing on the success of dental implantation. There are also many complications after dental implantation. In this meta-analysis, we investigated which factors increase the risk of postoperative sinusitis and implant failure after dental implant for the first time. Data Sources Included data were searched through the PubMed, EMBASE, and Cochrane library databases. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and 2 authors (J.S.K., S.H.K.) independently extracted data by multiple observers. Review Methods We used a random-effects model considering the variation between and within the included studies. Results Twenty-seven studies were included in our final meta-analysis. The proportion of postoperative sinusitis, perforation of the sinus membrane, and implant failure was 0.05 (95% confidence interval [CI], 0.04-0.07), 0.17 (95% CI, 0.13-0.22), and 0.05 (95% CI, 0.04-0.07), respectively, using the single proportion test. The only factors that affected postoperative sinusitis were preoperative sinusitis and intraoperative perforation of the Schneiderian membrane (P < .01 and P < .01, respectively). The only factors that affected dental implant failure were smoking and residual bone height of the maxilla (P < .05 and P < .01, respectively). Conclusions Two factors affect postoperative sinusitis after implant surgery: preoperative sinusitis and Schneiderian membrane rupture. It should also be noted that the factors affecting implant failure are residual bone height and smoking. These findings will have a significant impact on the counseling and treatment policy of patients who receive dental implants. |

Original Research

Salvage of Recurrence after Surgery and Adjuvant Therapy: A Multi-institutional Study Joseph Zenga, MD, Evan Graboyes, MD, Tyler Janz, Virgina Drake, MD, Eleni Rettig, MD,Shaun Desai, MD, Christopher Nickel, MD, Sepehr Shabani, MD, Tapan Padhya, MD, Mario Scarpinato, MHA, Michael Stadler, MD, Becky Massey, MD, Bruce Campbell, MD, Monica Shukla, MD, Musaddiq Awan, MD, Christopher J. Schultz, MD, Stuart Wong, MD, Ryan S. Jackson, MD, Patrick Pipkorn, MD https://doi.org/10.1177/0194599819830664 |First Published February 12, 2019 Abstract Hide Preview Objectives To determine the oncologic outcomes of patients undergoing salvage surgery for recurrent oral cavity squamous cell carcinoma (OCSCC) and oropharyngeal squamous cell carcinoma (OPSCC) after initial treatment with surgery and adjuvant therapy. Study Design Retrospective case series with chart review. Setting Five academic tertiary care centers. Subjects and Methods Patients included those with OCSCC and OPSCC who were initially treated with surgery and adjuvant therapy between 2000 and 2015 and underwent salvage surgery for local and/or regional recurrence. Results A total of 102 patients were included (76% OCSCC, 24% OPSCC). Five-year overall survival was 31% (95% CI, 21%-41%) and was significantly improved among patients with human papillomavirus–associated oropharyngeal tumors (hazard ratio [HR], 0.34; 95% CI, 0.11-0.98) and significantly worse for those with postoperative positive margins (HR, 2.65; 95% CI, 1.43-4.93). Adjuvant (chemo)reirradiation was not associated with disease control or survival regardless of margin status. Combined locoregional recurrence was significantly correlated with a positive margin resection (HR, 5.75; 95% CI, 1.94-17.01). Twenty-five patients (25%) underwent a second salvage surgical procedure, of whom 8 achieved long-term disease control. Conclusion Patients presenting with resectable recurrence after initial therapy with surgery and adjuvant therapy have a reasonable salvage rate when a negative margin resection can be attained. Patients with postoperative positive margins have poor survival outcomes that are not significantly improved with adjuvant (chemo)reirradiation. Those with combined locoregional recurrence are at particularly high risk for postoperative positive margins. The functional consequences of salvage surgery and its effect on quality of life are critical in decision making and require further investigation. |

Original Research

Outcomes of Children with Mild Obstructive Sleep Apnea Treated Nonsurgically: A Retrospective Review Jocelyn L. Kohn, MD, Prachi Patel, Jessica R. Levi, MD, Michael B. Cohen, MD https://doi.org/10.1177/0194599819829019 |First Published February 12, 2019 Abstract Hide Preview Objective Obstructive sleep apnea (OSA) is characterized by partial or complete obstruction of the upper airway and is commonly caused by adenotonsillar hypertrophy in children. Accordingly, adenotonsillectomy is considered first-line treatment. However, in cases of mild OSA, nonsurgical management has been proposed as an alternative. The purpose of this study was to determine the outcomes of pediatric patients with mild obstructive sleep apnea (OSA) treated without surgical intervention. Study Design Case series with chart review. Setting Tertiary care university medical center. Subjects and Methods The medical records of children ages 2 to 18 years with OSA at Boston Medical Center from January 2000 to April 2017 were reviewed. Children with mild OSA (apnea- hypopnea index [AHI] between 1 and 5), who were managed nonsurgically and had serial polysomnograms, were included. Serial sleep studies were compared to assess for patterns of change. Results Of the 201 patients with mild OSA who were identified, 104 (52%) opted for initial nonsurgical management. Of those, 91 had a follow-up sleep study to reassess their OSA. Forty-two (46 %) had a greater than 20% decrease in AHI and 38 (41%) had a greater than 20% increase on the second sleep study. The remaining 11 had changes less than 20% in either direction. There was not a significant difference in the proportion of patients with an increase vs decrease in AHI on follow-up sleep study (P > .05). Conclusions Mild pediatric OSA has approximately equal chances of worsening or improvement over time without surgical intervention, which is useful for counseling parents on treatment options. |

Systematic Review

A Systematic Review of Patient-Reported Outcome Measures Assessing Body Image Disturbance in Patients with Head and Neck Cancer Mark A. Ellis, MD, Katherine R. Sterba, PhD, MPH, Emily A. Brennan, MLIS, Stacey Maurer,PhD, Elizabeth G. Hill, PhD, Terry A. Day, MD, Evan M. Graboyes, MD https://doi.org/10.1177/0194599819829018 |First Published February 12, 2019 Abstract Hide Preview Objective To synthesize published literature describing the severity of body image disturbance (BID) in patients with head and neck cancer (HNC) over time, its psychosocial and functional associations, and treatment strategies as assessed by patient-reported outcome measures (PROMs). Data Source PubMed/MEDLINE, Scopus, PsycINFO, Web of Science, and Google Scholar. Review Methods A systematic review of the English-language literature was performed to identify studies of BID in patients with HNC using psychometrically validated PROMs to assess (1) severity of BID over time, (2) psychosocial and functional associations, and (3) management strategies. Results A total of 17 studies met inclusion criteria. BID was assessed via 10 different PROMs, none of which were HNC-specific measures of BID. Two of 2 longitudinal studies (100%) reported that BID improved from pretreatment to posttreatment, and 2 of 3 longitudinal studies (67%) showed that the severity of BID decreased over time as survivors got further out from treatment. Seven of 17 studies (41%) described negative functional and psychosocial associations with BID, although study methodology limited conclusions about cause and effect. None of the studies assessing interventions to manage BID (0/2, 0%) demonstrated an improvement in BID relative to control. Conclusion BID in patients with HNC has negative functional and psychosocial associations and lacks evidence-based treatment. Research is limited by the lack of an HNC-specific BID PROM. Further research should address knowledge gaps related to the lack of an HNC-specific BID PROM, longitudinal course of BID in patients with HNC, confusion with regards to risk factors and outcomes, and lack of prevention and treatment strategies. |

Patient Safety/Quality Improvement

Endovascular Embolization in the Treatment of Epistaxis Phillip Huyett, MD, Brian T. Jankowitz, MD, Eric W. Wang, MD, Carl H. Snyderman, MD, MBA https://doi.org/10.1177/0194599819829743 |First Published February 12, 2019 Abstract Hide Preview Objective The cost-effectiveness of endovascular embolization (EE) for intractable epistaxis has been questioned, especially as endoscopic surgical techniques have become standard of care at many institutions. Our objectives were to review the safety profile and effectiveness of EE for epistaxis. Study Design Retrospective case series. Setting Tertiary care hospital. Subjects There were 54 patients and 64 unique encounters. Patients were 66.7% male, with a mean age of 64.5 years. Bleeding disorders were present in 18.8%, hypertension was present in 71.7%, and 61.1% were on anticoagulant/platelet drugs. Methods Charts of patients undergoing EE for epistaxis between 2005 and 2015 were retrospectively reviewed. Results The immediate bleeding control rate was 92.6%. Three patients died within 1 week of EE and were excluded from further analysis. Overall, 64.7% of the remaining patients had no further episodes of epistaxis. Thirteen patients (25.4%) rebled within 1 week, 11 of whom required repeat EE or operative control. Five patients (9.8%) rebled more than 1 week following the procedure with 4 requiring repeat EE or operative control. The major complication rate was 7.4% and included transient stroke, diplopia, facial skin necrosis, and extraperitoneal hemorrhage. Conclusion While the immediate success rate of EE for epistaxis was comparable to the literature, the overall short- and long-term rebleed rate was high in this selected population. The results suggest that patients who are referred for EE represent a high-risk group with increased risk of repeat hemorrhage and morbidity. Patients who undergo EE for epistaxis should be carefully monitored for complications, including repeat hemorrhage. |

Original Research

Loss of CD169+ Subcapsular Macrophages during Metastatic Spread of Head and Neck Squamous Cell Carcinoma Michael C. Topf, MD, Larry Harshyne, PhD, Madalina Tuluc, MD, Stacey Mardekian, MD, Swar Vimawala, David M. Cognetti, MD, Joseph M. Curry, MD, Ulrich Rodeck, MD, PhD, Adam Luginbuhl, MD https://doi.org/10.1177/0194599819829741 |First Published February 12, 2019 Abstract Hide Preview Objective The purpose of this study is to assess CD169 expression in metastatic and nearby tumor-free lymph nodes of patients with head and neck squamous cell carcinoma (SCC). Study Design Retrospective analysis based on immunohistochemistry. Setting Tertiary care center. Subjects and Methods The abundance of CD169+ cells in the subcapsular sinuses (SCSs) of lymph nodes was assessed immunohistochemically in paraffin-embedded tissue samples derived from 22 patients with oral cavity and oropharyngeal SCC. Results SCSs of lymph nodes harboring metastatic SCC contained significantly fewer CD169+ macrophages (106.5 ± 113.6 cells/mm2) compared to nearby tumor-free lymph nodes (321.3 ± 173.4 cells/mm2, P < .001). This observation extended to 21 of the 22 cases investigated. In addition, 6 patients who later developed recurrent disease contained lower numbers of CD169+ cells (268.6 ± 169.5 cells/mm2) in nearby tumor-free lymph nodes compared to 341.0 ± 176.1 cells/mm2 in those who remained disease free (P = .399). Human papillomavirus (HPV)–positive patients (n = 4) had a 6-fold lower number of CD169+ cells in metastatic nodes (61.2 ± 85.5 cells/mm2) compared to nearby tumor-free lymph nodes (369.5 ± 175.5 cells/mm2, P= .028). In comparison, HPV-negative patients had only a 3-fold reduction (116.6 ± 118.5 cells/mm2 vs 310.6 ± 176.2 cells/mm2, P < .001). Conclusion Metastatic spread of SCC to regional lymph nodes is associated with lower abundance of CD169+ macrophages in the SCSs of draining lymph nodes. These results set the stage for an in-depth investigation into the mechanism(s) by which metastatic SCC controls CD169+ macrophage abundance and its significance as it relates to prognosis and treatment response. |

State of the Art Review

Evaluation and Management of Laryngopharyngeal Reflux Disease: State of the Art Review Jerome R. Lechien, MD, PhD, MS, Lee M. Akst, MD, Abdul Latif Hamdan, MD, MPH, Antonio Schindler, MD, PhD, Petros D. Karkos, MD, PhD, AFRCS, Maria Rosaria Barillari, MD, PhD,Christian Calvo-Henriquez, MD, Lise Crevier-Buchman, MD, PhD, Camille Finck, MD, PhD,Young-Gyu Eun, MD, PhD, Sven Saussez, MD, PhD, Michael F. Vaezi, MD, PhD, MS https://doi.org/10.1177/0194599819827488 |First Published February 12, 2019 Abstract Hide Preview Objective To review the current literature about the epidemiology, clinical presentation, diagnosis, and treatment of laryngopharyngeal reflux (LPR). Data Sources PubMed, Cochrane Library, and Scopus. Methods A comprehensive review of the literature on LPR epidemiology, clinical presentation, diagnosis, and treatment was conducted. Using the PRISMA statement, 3 authors selected relevant publications to provide a critical analysis of the literature. Conclusions The important heterogeneity across studies in LPR diagnosis continues to make it difficult to summarize a single body of thought. Controversies persist concerning epidemiology, clinical presentation, diagnosis, and treatment. No recent epidemiologic study exists regarding prevalence and incidence with the use of objective diagnostic tools. There is no survey that evaluates the prevalence of symptoms and signs on a large number of patients with confirmed LPR. Regarding diagnosis, an increasing number of authors used multichannel intraluminal impedance–pH monitoring, although there is no consensus regarding standardization of the diagnostic criteria. The efficiency of proton pump inhibitor (PPI) therapy remains poorly demonstrated and misevaluated by incomplete clinical tools that do not take into consideration many symptoms and extralaryngeal findings. Despite the recent advances in knowledge about nonacid LPR, treatment protocols based on PPIs do not seem to have evolved. Implications for Practice The development of multichannel intraluminal impedance–pH monitoring and pepsin and bile salt detection should be considered for the establishment of a multiparameter diagnostic approach. LPR treatment should evolve to a more personalized regimen, including diet, PPIs, alginate, and magaldrate according to individual patient characteristics. Multicenter international studies with a standardized protocol could improve scientific knowledge about LPR. |

Systematic Review

Effects of Preoperative Iodine Administration on Thyroidectomy for Hyperthyroidism: A Systematic Review and Meta-analysis Chung-Hsin Tsai, MD, PhD, Po-Sheng Yang, MD, PhD, Jie-Jen Lee, MD, PhD, Tsang-Pai Liu, MD, PhD, Chi-Yu Kuo, MD, Shih-Ping Cheng, MD, PhD https://doi.org/10.1177/0194599819829052 |First Published February 5, 2019 Abstract Hide Preview Objective The current guidelines recommend that potassium iodide be given in the immediate preoperative period for patients with Graves' disease who are undergoing thyroidectomy. Nonetheless, the evidence behind this recommendation is tenuous. The purpose of this study is to clarify the benefits of preoperative iodine administration from published comparative studies. Data Sources We searched PubMed, Embase, Cochrane, and CINAHL from 1980 to June 2018. Review Methods Studies were included that compared preoperative iodine administration and no premedication before thyroidectomy. For the meta-analysis, studies were pooled with the random-effects model. Results A total of 510 patients were divided into the iodine (n = 223) and control (n = 287) groups from 9 selected studies. Preoperative iodine administration was significantly associated with decreased thyroid vascularity and intraoperative blood loss. Significant heterogeneity was present among studies. We found no significant difference in thyroid volume or operative time. Furthermore, the meta-analysis showed no difference in the risk of postoperative complications, including vocal cord palsy, hypoparathyroidism/hypocalcemia, and hemorrhage or hematoma after thyroidectomy. Conclusion Preoperative iodine administration decreases thyroid vascularity and intraoperative blood loss. Nonetheless, it does not translate to more clinically meaningful differences in terms of operative time and postoperative complications. |

Original Research

Survival Impact of Adjuvant Therapy in Salivary Gland Cancers following Resection and Neck Dissection Katri Aro, MD, PhD, Allen S. Ho, MD, Michael Luu, MPH, Sungjin Kim, MS, Mourad Tighiouart,PhD, Emi J. Yoshida, MD, Jon Mallen-St Clair, MD, Stephen L. Shiao, MD, PhD, Ilmo Leivo, MD, PhD, Zachary S. Zumsteg, MD https://doi.org/10.1177/0194599819827851 |First Published February 5, 2019 Abstract Hide Preview Objective To evaluate the impact of postoperative radiotherapy (PORT) and chemotherapy on survival in salivary gland cancer (SGC) treated with curative-intent local resection and neck dissection. Study Design Retrospective population-based cohort study. Setting National Cancer Database. Subjects and Methods Patients with SGC who were undergoing surgery were identified from the National Cancer Database between 2004 and 2013. Neck dissection removing a minimum of 10 lymph nodes was required. Because PORT violated the proportional hazards assumption, this variable was treated as a time-dependent covariate. Results Overall, 4145 cases met inclusion criteria (median follow-up, 54 months). PORT was associated with improved overall survival in multivariable analysis, both ≤9 months from diagnosis (hazard ratio [HR], 0.26; 95% CI, 0.20-0.34; P < .001) and >9 months (HR, 0.75; 95% CI, 0.66-0.86; P < .001). In propensity score–matched cohorts, 5-year overall survival was 67.1% and 60.6% with PORT and observation, respectively (P < .001). Similar results were observed in landmark analysis of patients surviving at least 6 months following diagnosis. Adjuvant chemotherapy was not associated with improved survival (HR, 1.15; 95% CI, 0.99-1.34; P = .06). Conclusion PORT, but not chemotherapy, is associated with improved survival among patients with SGC for whom neck dissection was deemed necessary. These results are not applicable to low-risk SGCs not requiring neck dissection. |

Original Research

Health Care Utilization and Prescribing Patterns for Adult Eustachian Tube Dysfunction Edward D. McCoul, MD, MPH, Heather M. Weinreich, MD, MPH, Hillary Mulder, MS, Li-Xing Man, MSc, MD, MPA, Kristine Schulz, DrPH, MPH, Jennifer J. Shin, MD, SM https://doi.org/10.1177/0194599819826959 |First Published February 5, 2019 Abstract Preview |

Original Research

Basaloid Squamous Cell Carcinoma of the Larynx: A National Cancer Database Analysis Mejd Jumaily, Farhoud Faraji, MD, PhD, Donald Zhang, MD, Ronald J. Walker, MD, Gregory M. Ward, MD, MEd https://doi.org/10.1177/0194599818816299 |First Published February 5, 2019 Abstract Hide Preview Objective Basaloid squamous cell histology is a rare variant that accounts for about 2% of all head and neck squamous cell laryngeal carcinomas. The purpose of this study was to examine overall survival rates of patients according to treatment, stage, and laryngeal subsite. Study Design Retrospective analysis. Setting National Cancer Database (NCDB). Subjects and Methods The NCDB was queried for patients with basaloid squamous cell carcinoma (BSCC) who were treated from 2004 to 2014. Five-year overall survival rates were determined by the Kaplan-Meier method. Univariate and multivariate analysis was used to identify factors correlated with 5-year overall survival. Results The NCDB identified 440 patients meeting inclusion criteria. Median follow-up time was 31.2 months. On univariate analysis, the treatment modalities assessed (surgery alone, surgery with radiotherapy, surgery with chemoradiotherapy, radiotherapy, chemoradiotherapy) did not differ in their survival benefit. On multivariate analysis, only chemoradiotherapy (hazard ratio, 0.587; 95% CI, 0.37-0.93; P = .022) was associated with improved survival. All treatment modalities performed similarly between stage I and II tumors (P = .340) and stage III and IV tumors (P = .154). Conclusion This study represents the largest laryngeal BSCC series to date. We found that chemoradiotherapy was associated with improved 5-year overall survival of laryngeal BSCC on multivariate analysis. |

Original Research

Diagnostic Accuracy of Midline Pediatric Neck Masses Hilary Pitner, MS, Charles Elmaraghy, MD, Beth Fischer, PhD, Amanda Onwuka, PhD, Andrew Rabe, DO, Patrick Walz, MD https://doi.org/10.1177/0194599819827845 |First Published February 5, 2019 Abstract Hide Preview Objective To assess clinical evaluation, ultrasound, and previously published predictive score at preoperatively diagnosing midline neck masses and demographic or clinical associations that aid in differentiation of thyroglossal duct and dermoid cysts. Study Design Retrospective chart review. Setting Tertiary care children's hospital. Subjects Patients <18 years undergoing primary midline neck mass surgery with histopathologic diagnosis of thyroglossal duct or dermoid cyst who had preoperative ultrasound performed were included. Methods An electronic medical record query generated 142 patients whose histopathologic diagnosis was thyroglossal duct cysts (TGDCs) or dermoid cysts (DCs). Charts were reviewed for demographic and clinical features. A radiologist blindly reviewed patients' ultrasounds for SIST (septae + irregular walls + solid components = thyroglossal) score components. Each patient received 3 preoperative diagnoses: clinical, ultrasound, and SIST. Statistical analyses were conducted to determine association of demographic, clinical, or radiographic variables with diagnoses. Specificity, sensitivity, and predictive values were evaluated for each candidate diagnosis. Results There were 83 TGDCs and 59 DCs. Tenderness, infection history, depth relative to strap muscles, and SIST components were more common among TGDCs. Sensitivity and positive and negative predictive values surpassed 63% for each diagnostic modality. SIST score outperformed other diagnostic modalities with sensitivity, positive predictive value, and negative predictive value of 84%, 91%, and 81%, respectively. Clinical and ultrasound assessments were largely inconclusive for dermoid cysts, but SIST correctly identified 89% of DCs. Conclusion SIST score was the most accurate predictor of pediatric midline neck masses. Clinical and radiographic findings may help guide preoperative diagnosis, although further evaluation is required to develop more efficacious diagnostic tools. |

Clinical Techniques and Technology

Submental Flap for Soft Tissue Reconstruction following Radical Parotidectomy Rodrigo Bayon, MD, Andrew B. Davis, MD https://doi.org/10.1177/0194599819827822 |First Published February 5, 2019 Abstract Hide Preview This study analyzed our institution's experience with a buried submental flap for soft tissue reconstruction following radical parotidectomy. A retrospective chart review was conducted of patients who had parotid malignancies requiring radical parotidectomy, who also underwent a buried submental flap reconstruction. Analysis included patient demographics and clinical, surgical, and outcome data. Three patients met criteria for this study who underwent a buried submental flap at a tertiary medical center between 2012 and 2016. All patients had oncologic surgery and reconstruction using a deepithelialized submental island flap, which was used to fill the radical parotidectomy surgical defect with no complications and good aesthetic results. Each patient received appropriate adjuvant therapy. This case series shows that the buried submental island flap is a versatile flap that is adequate bulk after radical parotidectomy. It also has no impact on hospital length of stay and provides excellent cosmetic outcomes with minimal donor site morbidity. |

Original Research

The Impact of RVU-Based Compensation on Patient Safety Outcomes in Outpatient Otolaryngology Procedures Luke Stanisce, Nadir Ahmad, MD, Nathan Deckard, MD, Donald Solomon, MD, Thomas C. Spalla, MD, John P. Gaughan, PhD, MBA, Yekaterina Koshkareva, MD https://doi.org/10.1177/0194599819827881 |First Published February 5, 2019 Abstract Hide Preview Objective To determine the effects an incentive-based physician compensation model has on safety outcomes related to outpatient otolaryngology surgical procedures. Study Design A retrospective analysis of a prospectively maintained database assessing the difference in outpatient surgical volume and postoperative adverse outcomes before and after the implementation of a relative value unit (RVU)–based payment structure. Setting Single-center academic otolaryngology practice operating at a hospital-owned ambulatory surgery center. Subjects and Methods Data prospectively collected from outpatient otolaryngology surgical cases performed at the surgery center from April 2013 to April 2018 were retrospectively reviewed. Equal pre-RVU and post-RVU study periods were calculated for 4 surgeons based on their chronological transition in payment structure (range, 46-56 months). Case volume and incidence rates of adverse outcomes, including postoperative infections, emergency department visits, unplanned hospital admissions, and returns to the operating room, were compared between the pre-RVU and post-RVU study periods at both the surgeon and group levels. Results At the group level, the post-RVU period was associated with a higher volume of surgical cases (P = .001). No significant differences were observed in the overall incidence of adverse outcomes (P = .21) or among the specific rates of postoperative hospitalizations (P = .39), infections (P = .45), unplanned returns to the operating room (P = 1.00), or emergency department visits (P = .39). Comparable results were observed at the individual surgeon level. Conclusion The implementation of an incentive-based salary was not associated with a change in the incidence of adverse safety outcomes in the setting of increased outpatient otolaryngology procedures. |

Original Research

Evaluating Perineural Spread to the Intratemporal Facial Nerve on Magnetic Resonance Imaging Marc-Elie Nader, MD, FRCSC, Lawrence E. Ginsberg, MD, Diana Bell, MD, Dianna B. Roberts,PhD, Paul W. Gidley, MD https://doi.org/10.1177/0194599819827848 |First Published February 5, 2019 Abstract Hide Preview Objectives To determine the sensitivity and specificity of magnetic resonance imaging (MRI) for the detection of perineural spread (PNS) along the intratemporal facial nerve (ITFN) in patients with head and neck cancers. Study Design Case series with chart review. Setting Tertiary care center. Subjects and Methods We included 58 patients with head and neck malignancies who underwent sacrifice of the ITFN between August 1, 2002, and November 30, 2015. Demographics, preoperative facial nerve function, prior oncologic treatment, and timing between MRI and surgery were recorded. Histopathology slides and preoperative MRI were reviewed retrospectively by a neuropathologist and a neuroradiologist, respectively, both blinded to clinical data. The mastoid segment of the facial nerve (referred to as the descending facial nerve [DFN]) and stylomastoid foramen (SMF) were evaluated separately. A grading system was devised when radiographically assessing PNS along the DFN. Results Histopathologic evidence of PNS was found in 21 patients (36.2%). The sensitivity and specificity of MRI in detecting PNS to the DFN were 72.7% and 87.8%, respectively. MRI showed higher sensitivity but slightly lower specificity when evaluating the SMF (80% and 82.8%, respectively). Prior oncologic treatment did not affect the false-positive rate (P = .7084). Sensitivity was 100% when MRI was performed within 2 weeks of surgery and was 62.5% to 73.3% when the interval was greater than 2 weeks. This finding was not statistically significant (SMF, P = .7076; DFN, P = .4143). Conclusion MRI shows fair to good sensitivity and good specificity when evaluating PNS to the ITFN. |

Original Research

Postoperative Tachycardia in Head and Neck Microvascular Free Flap Patients Andrea Ziegler, MD, Alexander Schneider, MD, Amy Pittman, MD, Eric Thorpe, MD https://doi.org/10.1177/0194599819827816 |First Published February 5, 2019 Abstract Hide Preview Objective The goal of this study was to determine the incidence of postoperative tachycardia and its predictive value of complications in patients following microvascular free flap surgery in the head and neck. Study Design Retrospective chart review. Setting Single tertiary care academic medical center. Subjects and Methods All patients who underwent a microvascular free flap of the head and neck by surgeons in the department of otolaryngology from 2013 to 2017 were included in this study. Results Of the 344 who patients met inclusion criteria, 40.4% had a maximum heart rate (HR) of the hospitalization over 110 beats per minute (bpm). Patients with a maximum HR greater than 110 bpm were 19 times more likely to experience a composite vascular complication (myocardial infarction, myocardial necrosis, or pulmonary embolism) than patients with a maximum HR <110 bpm (P = .0063). Patients with a history of chronic kidney disease were also noted to have an increased risk of experiencing a postoperative composite vascular event. Conclusion Postoperative tachycardia is significantly associated with adverse outcomes and should not be dismissed as a normal variant. Identifying patients at an increased risk of having an underlying complication can help guide interpretation, workup, and management of postoperative patients in the head and neck population. |

Original Research

Laryngotracheal Reconstruction in Adults Aged 60 Years and Older Saad C. Rehman, MD, MBA, Deborah X. Xie, James R. Bekeny, MD, Alexander Gelbard, MD,Christopher T. Wootten, MD https://doi.org/10.1177/0194599818825471 |First Published February 5, 2019 Abstract Hide Preview Objective The primary aim of this study is to evaluate the safety, efficacy, and execution of major open laryngotracheal operations for patients in the advanced decades. Study Design Case series with chart review. Setting Multidisciplinary clinic at a tertiary care academic hospital. Subjects and Methods Patient characteristics, operative course, and postoperative outcomes were retrospectively recorded for all airway reconstruction operations performed between 1999 and 2016 on patients aged ≥60 years Long-term success was defined as prosthesis-free survival at last follow-up. Descriptive statistics were performed. Results Twenty-nine patients met inclusion criteria, and the median age was 71 years (interquartile range, 63-74). Tracheal resection was the most common procedure (13 patients), followed by laryngotracheal reconstruction (7 patients). Fifteen patients began their operation with a tracheostomy, 6 of whom underwent decannulation prior to leaving the operating room. Three additional patients underwent decannulation at follow-up appointments and were prosthesis-free at most recent follow-up. The mean time to decannulation among these patients was 3 months. Of the 14 patients beginning their procedure without a tracheostomy, only 2 required permanent airway prosthesis. The overall long-term rate of prosthesis-free survival was 72.4% (21 of 29 patients). Factors suggestive of long-term success include lower McCaffrey grade and lack of pulmonary disease, hypertension, or diabetes, as well as decreased red blood cell distribution width on preoperative complete blood count. Conclusion Through careful patient selection, preoperative workup, and meticulous postoperative care, airway reconstruction procedures in patients aged ≥60 years are reasonably successful. Of 29 patients, 21 (72.4%) were successfully breathing long-term without airway prosthesis. |

Original Research

Impact of Aspirin and Other NSAID Use on Volumetric and Linear Growth in Vestibular Schwannoma John P. Marinelli, Katherine A. Lees, MD, Nicole M. Tombers, RN, Christine M. Lohse, MS,Matthew L. Carlson, MD https://doi.org/10.1177/0194599819827812 |First Published February 5, 2019 Abstract Hide Preview Objectives Conflicting research exists surrounding the utility of aspirin to prevent tumor growth in the medical management of vestibular schwannoma (VS). Recent studies demonstrated no association between aspirin and VS growth using linear tumor measurements. Given the heightened sensitivity of volumetric analyses to monitor tumor growth, the current study was conceived with the chief objective of assessing the association between aspirin or other nonsteroidal anti-inflammatory drug (NSAID) use and VS growth using volumetric analyses. Study Design Retrospective review. Setting Tertiary referral center. Subjects and Methods A total of 361 patients totaling 1601 volumetrically analyzed magnetic resonance imaging studies who underwent initial observation since January 1, 2003. Results In total, 123 (35%) patients took 81 mg aspirin daily, 23 (7%) took 325 mg aspirin daily, and 41 (11%) reported other NSAID use. Among those taking aspirin, 112 (72%) exhibited volumetric tumor growth during observation compared to 33 (80%) among other NSAID users and 137 (67%) among nonaspirin users. Patients taking aspirin or other NSAIDs were significantly older at time of diagnosis (median, 66 vs 56 years; P < .001). Neither aspirin use (hazard ratio [HR], 0.96; P = .73) nor other NSAID use (HR, 1.39; P = .081) was significantly associated with a reduced risk of volumetric tumor growth. These results were similar following age adjustment (P = .81 and .087, respectively). When separating aspirin users by 81-mg or 325-mg dosing, neither group exhibited a reduced risk of growth (P = .95 and .73, respectively). Conclusion Despite promising initial results, the preponderance of existing literature suggests that aspirin and other NSAID use does not prevent tumor growth in VS. |

Original Research

Machine Learning to Predict Delays in Adjuvant Radiation following Surgery for Head and Neck Cancer Matthew Shew, MD, Jacob New, PhD, Andrés M. Bur, MD https://doi.org/10.1177/0194599818823200 |First Published January 29, 2019 Abstract Hide Preview Objective To apply a novel methodology with machine learning (ML) to a large national cancer registry to help identify patients who are high risk for delayed adjuvant radiation. Study Design Observational cohort study. Setting National Cancer Database (NCDB). Subjects and Methods A total of 76,573 patients were identified from the NCDB who had invasive head and neck cancer and underwent surgery, followed by radiation. The model was constructed from 80% of the patient data and subsequently evaluated and scored with the remaining 20%. Permutation feature importance analysis was used to understand the weighted model construction. Results A total of 76,573 patients met inclusion and exclusion criteria. Our ML model was able to predict whether patients would start adjuvant therapy beyond 50 days after surgery with an overall accuracy of 64.41% and a precision of 58.5%. The 2 most important variables used to build the model were treating facility and urban versus rural demographics. Conclusion Statistics can provide inferences within an overall system, while ML is a novel methodology that can make predictions. We can identify patients who are "high risk" for delayed radiation using information from >75,000 patient experiences, which has the potential for a direct impact on clinical care. Our inability to achieve greater accuracy is due to limitations of the data captured by the NCDB, and we need to continue to identify new variables that are correlated with delayed radiation therapy. ML will prove to be a valuable clinical tool in years to come, but its utility is limited by available data. |

Patient Safety/Quality Improvement

Increased Accuracy, Confidence, and Efficiency in Anterior Ethmoidal Artery Identification with Segmented Image Guidance Deeyar A. Itayem, C. Lane Anzalone, MD, James R. White, MD, John F. Pallanch, MD, Erin K. O'Brien, MD https://doi.org/10.1177/0194599818825454 |First Published January 29, 2019 Abstract Hide Preview Objective To determine whether using image guidance technology with 3-dimensional image segmentation increases the endoscopic surgeon's accuracy, efficiency, and confidence in identifying the anterior ethmoidal artery. Methods This is a cross-sectional study of attending physicians and residents at an academic medical center. Because identification of the anterior ethmoidal artery during image-guided surgery can be challenging, we studied the effect of anterior ethmoidal artery image segmentation (ie, partitioning and coloring) on surgeon test performance. A computerized test was administered to 16 surgeons who were asked to identify the anterior ethmoidal artery on multiplanar computed tomographic images and to answer multiple-choice questions. Half the questions showed segmented images of the anterior ethmoidal artery, and half showed images without segmentation. Efficiency and accuracy of identification and subjective surgeon confidence were determined for each question. Descriptive statistics were used to compare test performance for identification of the anterior ethmoidal artery on images with or without segmentation. Results Percentage of correct answers (P < .001), efficiency (P < .001), and confidence (P < .001) in identification of the anterior ethmoidal artery were significantly better with segmented computed tomographic images. Discussion We demonstrated that use of segmented images improves surgeons' accuracy, confidence, and efficiency for identification of the anterior ethmoidal artery. Implications for Practice We describe how segmentation can allow surgeons to improve the surgical course by increasing their accuracy, confidence, and efficiency in identifying the anterior ethmoidal artery. |

Original Research

Association of Respiratory Mechanic Instability and Respiratory Parameters among Adults with Obstructive Sleep Apnea Ji Ho Choi, MD, Bora Lee, Se-Hwan Hwang, MD https://doi.org/10.1177/0194599818825468 |First Published January 22, 2019 Abstract Hide Preview Objectives Respiratory mechanic instability (RMI) is derived from analysis of paradoxical thoracoabdominal movements during airway obstruction. This study aimed to evaluate RMI parameters in obstructive sleep apnea (OSA) and the correlation between RMI parameters and other parameters in polysomnography. Study Design Retrospective review. Setting A university hospital. Methods A retrospective chart review was performed, and data from 189 adult patients who underwent an in-laboratory sleep study and were seen in our clinic during the past 8 months. The RMI parameters were measured from thoracoabdominal bands during polysomnography. Results Subjects were divided into 2 groups: control (n = 67, apnea-hypopnea index [AHI] <5) and OSA (n = 122, AHI ≥5). The OSA group was divided into 2 subgroups according to AHI: mild, 5 ≤ AHI < 15; moderate, 15 ≤ AHI < 30; severe, AHI ≥30. As AHI increased, all RMI parameters showed a significant rising pattern and difference between control and subgroups. Arousal index, lowest oxygen saturation, and oxygen desaturation index ≥3% were significantly correlated with all RMI parameters. Based on cutoff values, areas under the curves of the RMI index for predicting mild, moderate, and severe OSA were >0.85. Conclusion All RMI parameters were well related to respiratory parameters of polysomnography, such as arousal index, lowest oxygen saturation, and oxygen desaturation index ≥3%. The areas under the curves of all RMI parameters for predicting OSA and subgroups showed significant diagnostic performance. These parameters may be useful to identify OSA cases from control. |

Original Research

Effect of Adenotonsillectomy on Ambulatory Blood Pressure in Pediatric Obstructive Sleep Apnea: 6-Month Follow-up Study Kun-Tai Kang, MD, MPH, Shuenn-Nan Chiu, MD, PhD, Che-Yi Lin, MD, Wen-Chin Weng, MD, Pei-Lin Lee, MD, PhD, Wei-Chung Hsu, MD, PhD https://doi.org/10.1177/0194599818825462 |First Published January 22, 2019 Abstract Hide Preview Objective To investigate 24-hour ambulatory blood pressure changes 6 months after surgery among children with obstructive sleep apnea. Study Design Prospective interventional study. Setting Tertiary medical hospital. Subjects and Methods Children aged 4 to 16 years with symptoms of obstructive sleep apnea (apnea-hypopnea index >1) were recruited. All children underwent adenotonsillectomy and postoperative polysomnography overnight. The 24-hour ambulatory blood pressure was measured before and 6 months after surgery. Results The study cohort enrolled 124 children: mean (SD) age, 7.3 (3.1) years; 73% boys. After surgery, the apnea-hypopnea index significantly decreased from 13.3 (18.1) to 3.3 (7.2) events per hour (P < .001). Overall systolic blood pressure and diastolic blood pressure were not significantly different following surgery, while daytime systolic blood pressure was slightly increased (114.3 to 117.3 mm Hg, P < .01) postoperatively. The hypertensive group (n = 43) exhibited significantly decreased levels of overall diastolic, nighttime systolic, and nighttime diastolic blood pressure (P< .05), and 54% of hypertensive children became nonhypertensive after surgery. The nonhypertensive group (n = 81) showed slightly increased levels of nocturnal overall systolic, daytime systolic, and nighttime systolic blood pressure. A generalized linear mixed model revealed that children with hypertension had a greater decrease in systolic and diastolic ambulatory blood pressure during the daytime and nighttime (all P < .05) than those without hypertension. Conclusions Ambulatory blood pressure changes after adenotonsillectomy among children with obstructive sleep apnea are minimal. The decrease in ambulatory blood pressure after surgery is more prominent for hypertensive children than nonhypertensive children. |

Original Research

Children with Cleft Palate: Predictors of Otologic Issues in the First 10 Years Jamie L. Funamura, MD, MPH, Janet W. Lee, MD, Samantha McKinney, AuD, Ahmed G. Bayoumi, MB BCh, Craig W. Senders, MD, Travis T. Tollefson, MD, MPH https://doi.org/10.1177/0194599818825461 |First Published January 22, 2019 Abstract Hide Preview Objective To evaluate the characteristics of children with cleft palate associated with persistent otologic issues in the first 10 years of life. Study Design Case series with chart review. Setting Single academic center. Subjects and Methods Children born with cleft palate from 2003 to 2007 and treated by the UC Davis Cleft and Craniofacial Team between January 2003 and December 2017 were included in the study. Data from 143 patients were analyzed via Wilcoxon rank sum and Fisher exact tests for univariate analysis and logistic regression to determine adjusted odds ratios. Results The median length of follow-up was 9.9 years, and the age at last ear examination was 10.7 years. At the last evaluation, unresolved otologic issues were common, with at least 1 ear having a tympanic membrane (TM) perforation (16.1%), a tympanostomy tube (36.2%), or conductive hearing loss (23.1%). After adjusting for demographic and clinical characteristics, history of palate revision or speech surgery was associated with having a TM perforation (P = .02). The only clinical variables associated with conductive hearing loss was the presence of a TM perforation (P < .01) or a genetic abnormality (P = .02). Severity of palatal clefting was not associated with specific otologic or audiologic outcomes after adjusting for other characteristics. Conclusion A large proportion of children with cleft palate have persistent otologic issues at age 10 years and would benefit from continued close monitoring well after the age when most children have normalized eustachian tube function. Prolonged otologic issues were not found to be associated with cleft type. |

Original Research

Relative Preservation of Superior Semicircular Canal Architecture in CHARGE Syndrome Kareem O. Tawfik, MD, Brittany A. Leader, MD, Zoe A. Walters, Daniel I. Choo, MD https://doi.org/10.1177/0194599818824306 |First Published January 22, 2019 Abstract Hide Preview Objectives (1) Describe common patterns of semicircular canal (SCC) anomalies in CHARGE syndrome (CS) and (2) recognize that in CS, the architecture of the superior SCC may be relatively preserved. Study Design This is a retrospective review of temporal bone imaging studies. Setting Quaternary care center. Subjects and Methods A sample of 37 patients with CS. All subjects met clinical diagnostic criteria for CS. The presence/absence of anomalies of the middle ear, mastoid, temporal bone venous anatomy, inner ear, and internal auditory canal was recorded. Anomalies of each SCC were considered separately and by severity (normal, dysplasia, aplasia). Results Thirty-seven subjects (74 temporal bones) were reviewed. Thirty-four (92.0%) patients demonstrated bilateral SCC anomalies. Three (8.0%) had normal SCCs. In patients with SCC anomalies, all canals demonstrated bilateral abnormalities. Thirty-two (86.5%) patients had bilateral horizontal SCC aplasia. These 32 patients also demonstrated posterior SCC aplasia in at least 1 ear. Of 74 temporal bones, 37 (50.0%) had superior SCC dysplasia. All dysplastic superior SCCs showed preservation of the anterior limb. Complete superior SCC aplasia was found in 28 (37.8%) temporal bones. Conclusion SCC anomalies occur with high frequency in CS. Complete absence of the horizontal and posterior canals is typical and usually bilateral. By contrast, the superior SCC often demonstrates relative preservation of the anterior limb. |

Systematic Review

Systematic Review of Temporal Bone–Resurfacing Techniques for Pulsatile Tinnitus Associated with Vascular Wall Anomalies George S. Liu, Brian C. Boursiquot, Nikolas H. Blevins, MD, Yona Vaisbuch, MD https://doi.org/10.1177/0194599818823205 |First Published January 22, 2019 Abstract Hide Preview Objective To systematically review literature evidence on temporal bone–resurfacing techniques for pulsatile tinnitus (PT) associated with vascular wall anomalies. Data Sources We searched PubMed, Embase, and the Cochrane Database. The period covered was from 1962 to 2018. Review Methods We included studies in all languages that reported resurfacing outcomes for patients with PT and radiographic evidence or direct visualization of sigmoid sinus wall anomaly, jugular bulb wall anomaly, or dehiscent or aberrant internal carotid artery. Results Of 954 citations retrieved in database searches and 5 citations retrieved from reference lists, 20 studies with a total of 141 resurfacing cases involving 138 patients were included. Resurfacing outcomes for arterial sources of PT showed 3 of 5 cases (60%) with complete resolution and 2 (40%) with partial resolution. Jugular bulb sources of PT showed 11 of 14 cases (79%) with complete resolution and 1 (7%) with partial resolution. Sigmoid sinus sources of PT showed 91 of 121 cases (75%) with complete resolution and 12 (10%) with partial resolution. Symptoms occurred more in females and on the right side. Most cases (94%) used hard-density materials for resurfacing. Material density did not appear to be associated with resurfacing outcomes. Use of autologous materials was associated with improved outcomes for arterial sources resurfacing. Major complications involving sigmoid sinus thrombosis or compression were reported in 4% of cases without long-term morbidity or mortality. Conclusions Resurfacing surgery is likely effective and well tolerated for select patients with PT associated with various vascular wall anomalies. |

Original Research

Peripheral Vestibulopathy Presenting as Acute Vertigo and Spontaneous Nystagmus with Negative Video Head Impulse Test Jung-Yup Lee, MD, Chang-Hee Kim, MD, PhD, Jin Su Park, MD, Min-Beom Kim, MD, PhD https://doi.org/10.1177/0194599818825458 |First Published January 22, 2019 Abstract Hide Preview Objective To analyze acute vertigo showing spontaneous nystagmus with negative video head impulse test (vHIT). Study Design Retrospective chart analysis. Setting Tertiary referral hospital. Subjects and Methods Over 16 months, 155 patients were identified with acute vertigo with spontaneous nystagmus. Of these 155, 30 (19.4%) were enrolled in this study because they did not show gain loss or catch-up saccades in both sides of the horizontal vHIT. Results of vestibular function tests (videonystagmography, horizontal vHIT, caloric test, and cervical vestibular-evoked myogenic potential [cVEMP]) and pure tone audiometry were analyzed. For all cases, magnetic resonance imaging with diffusion-weighted imaging was checked. Results Patients consisted of 17 with Ménière's disease and 7 with sudden sensorineural hearing loss with vertigo (SSNHL_V), and only 3 patients were finally diagnosed as having acute vascular stroke. Except for the loss of hearing on the lesion side, the direction of nystagmus or cVEMP asymmetry showed very different results. All 7 patients with SSNHL_V did not have canal paresis in the caloric test, but cVEMP amplitude was smaller on the lesion side for 6 patients. Conclusions For patients with acute vertigo presenting spontaneous nystagmus with negative horizontal vHIT, it is important not only to focus on the diagnosis of acute vascular stroke but also to evaluate hearing because of the high possibility of Ménière's disease or SSNHL_V. |

Original Research

Airway Closure Delay: The Predominant Pathophysiology in Reflux-Associated Dysphagia Katherine A. Kendall, MD https://doi.org/10.1177/0194599818824302 |First Published January 22, 2019 Abstract Hide Preview Objective Reflux disease is common in patients with oropharyngeal dysphagia, but the impact of reflux on oropharyngeal swallowing physiology is not known. This study uses objective measures of swallowing function from modified barium swallow studies to describe the pathophysiology of dysphagia in a group of patients whose only associated condition is reflux. Study Design Retrospective chart review. Setting Tertiary care voice and swallowing clinic. Subjects and Methods The Swallowing Database at the University of Utah was queried for patients with a diagnosis of reflux without additional conditions known to affect swallowing function. Pharyngeal transit time (TPT), distance of hyoid elevation (Hmax), maximum opening size of the upper esophageal sphincter (UESmax), area of pharynx at maximum constriction (PAmax), airway closure timing relative to the arrival of the bolus at the UES, and penetration/aspiration (Pen/Asp) score were assessed. Results Of the 122 patients who met inclusion criteria for the study, 42% had normal pharyngeal swallowing function, 57% had at least 1 abnormal swallowing measure, and 47.5% demonstrated a delay in airway closure relative to arrival of the bolus at the UES on at least 1 swallow. The incidence of prolonged TPT, diminished Hmax, poor UESmax, and enlarged PAmax were 2.5%, 8%, 4%, and 11.5%, respectively. Sixty percent with a delay in airway closure had a normal Pen/Asp score. Conclusion A delay in airway closure relative to the arrival of the bolus at the UES is the most common abnormality of swallowing function found in patients with reflux-associated dysphagia but may not be identified using the Pen/Asp score. |

Original Research

Neck and Shoulder Motor Function following Neck Dissection: A Comparison with Healthy Control Subjects Elise M. Gane, PhD, Steven M. McPhail, PhD, Anna L. Hatton, PhD, Benedict J. Panizza, MBBS, MBS, FRACS, Shaun P. O'Leary, PhD, MPhty https://doi.org/10.1177/0194599818821885 |First Published January 22, 2019 Abstract Hide Preview Objective To compare the neck and shoulder motor function of patients following neck dissection, including comparison with a group of healthy volunteers. Study Design Cross-sectional study. Setting Two tertiary hospitals in Brisbane, Australia. Subjects and Methods Participants included patients 0.5 to 5 years after unilateral nerve-sparing neck dissection and healthy control subjects. Demographic and clinical information was collected with cervical and shoulder motor function measures (scapular resting position, active range of motion, and isometric muscle strength). Differences between groups were examined via regression analyses that included statistical adjustment for the potential effect of age, sex, body mass index, and other disease-related variables. Results The 57 patients (68%, men; median age, 62 years) were typically older than the 34 healthy controls (47%, men; median age, 46 years). There were no differences between types of nerve-preserving neck dissection for any of the motor function measures. When adjusted for age, sex, and body mass index, healthy volunteers (vs patients) had significantly greater cervical range (eg, extension coefficient [95% CI]: 11.04° [4.41°-17.67°]), greater affected shoulder range (eg, abduction: 16.64° [1.19°-31.36°]), and greater isometric strength of the cervical flexors (eg, men: 4.24 kgf [1.56-6.93]) and shoulder flexors (eg, men: 8.00 kgf [1.62-14.38]). Conclusions Strength and flexibility of the neck and shoulder are impaired following neck dissection in comparison with healthy controls. Clinicians and researchers are encouraged to consider the neck—and the neck dissection as a whole—as a source of motor impairment for these patients and not just the status of the accessory nerve. |

Clinical Photograph

Complete Glottic Obstruction by an Unusual Foreign Body Ruth J. Davis, MD, C. Matthew Stewart, MD, PhD https://doi.org/10.1177/0194599818824298 |First Published January 15, 2019 Abstract |

Patient Safety/Quality Improvement

Unsolicited Patient Complaints among Otolaryngologists Ashley M. Nassiri, MD, MBA, James W. Pichert, PhD, Henry J. Domenico, MS, Mitchell B. Galloway, MS, William O. Cooper, MD, MPH, Marc L. Bennett, MD, MMHC https://doi.org/10.1177/0194599818823706 |First Published January 15, 2019 Abstract Hide Preview Objectives To analyze unsolicited patient complaints (UPCs) among otolaryngologists, identify risk factors for UPCs, and determine the impact of physician feedback on subsequent UPCs. Methods This retrospective study reviewed UPCs associated with US otolaryngologists from 140 medical practices from 2014 to 2017. A subset of otolaryngologists with high UPCs received peer-comparative feedback and was monitored for changes. Results The study included 29,778 physicians, of whom 548 were otolaryngologists. UPCs described concerns with treatment (45%), communication (19%), accessibility (18%), concern for patients and families (10%), and billing (8%). Twenty-nine (5.3%) otolaryngologists were associated with 848 of 3659 (23.2%) total UPCs. Male sex and graduation from a US medical school were statistically significantly associated with an increased number of UPCs (P = .0070 and P = .0036, respectively). Twenty-nine otolaryngologists with UPCs at or above the 95th percentile received peer-comparative feedback. The intervention led to an overall decrease in the number of UPCs following intervention (P = .049). Twenty otolaryngologists (69%) categorized as "responders" reduced the number of complaints an average of 45% in the first 2 years following intervention. Discussion Physician demographic data can be used to identify otolaryngologists with a greater number of UPCs. Most commonly, UPCs expressed concern regarding treatment. Peer-delivered, comparative feedback can be effective in reducing UPCs in high-risk otolaryngologists. Implications for Practice Systematic monitoring and respectful sharing of peer-comparative patient complaint data offers an intervention associated with UPCs and concomitant malpractice risk reduction. Collegial feedback over time increases the response rate, but a small proportion of physicians will require directive interventions. |

Original Research

p16 Influence on Laryngeal Squamous Cell Carcinoma Relapse and Survival Alvaro Sánchez Barrueco, MD, PhD, Fernando González Galán, MD, José Miguel Villacampa Aubá, MD, PhD, Gonzalo Díaz Tapia, MD, Sofía Fernández Hernández, MD, Cristina Martín-Arriscado Arroba, Carlos Cenjor Español, MD, PhD, Carlos Almodóvar Álvarez, MD, PhD https://doi.org/10.1177/0194599818821910 |First Published January 15, 2019 Abstract Hide Preview Objective (1) To identify p16 protein in laryngeal squamous cell carcinoma (LSCC) specimens and to correlate it with the presence of human papillomavirus (HPV) found in these specimens from a previous study. (2) To analyze p16 impact on 10-year overall and disease-free survival. Study Design Retrospective case series with oncologic database chart review. Setting Academic tertiary care hospital. Subjects A total of 123 samples of LSCC (taken from the glottis only) from patients treated with primary surgical resection between 1977 and 2005. Methods p16 protein expression was analyzed through immunohistochemistry and compared with the presence of HPV established in our previous studies. Results were compared with histologic, clinicopathologic, and survival parameters, with a 10-year follow-up. Results Of the samples, 39.02% were positive for p16, but only 11.38% were positive for both p16 and HPV. The p16+ cohort showed a significant improvement in disease-free survival (P = .0022); statistical significance was not achieved for overall survival. p16+ cases had fewer relapses over time, with no relapses after a 2-year follow-up. Age at the time of diagnosis and tobacco consumption were the only epidemiologic factors that influenced overall survival. Conclusion The expression of p16 protein was a beneficial prognostic factor for disease-free survival among patients with LSCC of the glottis, with no relapses after a 2-year follow-up. |

Original Research

Survival Outcomes in T4aN0M0 Mandibular Gingival Squamous Cell Carcinoma Treated with Surgery Alone Ashley M. Nassiri, MD, MBA, Benjamin R. Campbell, Kyle Mannion, MD, Robert J. Sinard, MD,James L. Netterville, MD, Sarah L. Rohde, MD https://doi.org/10.1177/0194599818821892 |First Published January 1, 2019 Abstract Hide Preview Objectives To measure disease-free, disease-specific, and overall survival among patients with T4aN0M0 mandibular gingival squamous cell carcinoma who were treated with surgery alone. Study Design Case series with chart review. Setting Tertiary care center. Subjects and Methods A retrospective chart review was performed of all adult patients treated surgically with an oral cavity composite resection between January 2005 and March 2017. Among other data, patient preoperative characteristics were recorded (eg, age, sex, smoking history, alcohol use, and clinical stage); operative notes were reviewed to determine tumor subsite involvement, reconstruction method, and intraoperative surgical complications; and pathology reports were evaluated for various pathologic findings. Survival outcomes were determined with Kaplan-Meier analysis. Results The mean follow-up was 18.5 months (range, 0.1-100). The 1- and 5-year disease-free survival rates were 90.5% and 84.5%, respectively, while the 1- and 5-year disease-specific survival rates were 87.8% and 81.9%. The 1- and 5-year overall survival rates were 86.4% and 80.6%. Conclusions Patients with T4aN0M0 squamous cell carcinoma of the mandibular gingiva treated with surgery alone have a 5-year overall survival of 80.6%. Treatment with surgery alone obviates morbidities associated with adjuvant therapy while upholding survival outcomes. |

Original Research

Mandibular Invasion by Oral Squamous Cell Carcinoma: Clinicopathologic Features of 74 Cases Jumah G. Ahmad, Arya W. Namin, MD, Jeffrey B. Jorgensen, MD, Robert P. Zitsch, III, MD,Lester J. Layfield, MD https://doi.org/10.1177/0194599818821859 |First Published January 1, 2019 Abstract Hide Preview Objectives (1) For patients with oral squamous cell carcinoma (OSCC) and mandibular invasion, to determine whether prior radiation to the head and neck region (PXRTHN) affects the density of osteoblasts, osteoclasts, or fibroblasts along the tumor interface invading the mandible and whether this is significantly associated with overall survival. (2) To identify clinicopathologic features that are associated with overall survival. Study Design Case series with chart review. Setting University of Missouri hospital. Subjects and Methods Retrospective review of 74 cases with pathologically confirmed mandible invasion by OSCC and surgical treatment between January 1, 2005, and December 31, 2015. A board-certified anatomic pathologist reviewed the slides from all mandibulectomy cases. Results The mean density of osteoclasts was 2.0 per linear mm among the patients with PXRTHN and 7.1 among those without PXRTHN (P < .001). Positive soft tissue frozen section margin was significantly associated with overall survival on univariate analysis (P < .001; hazard ratio [HR], 0.34; 95% CI, 0.19-0.62) and multivariate analysis (P = .026; HR, 0.41; 95% CI, 0.19-0.90). Maximum tumor dimension was significantly associated with overall survival on univariate analysis (P = .021; HR, 1.19; 95% CI, 1.03-1.38) and multivariate analysis (P = .002; HR, 1.49; 95% CI, 1.16-1.93). Osteoclast, osteoblast, and fibroblast density were not associated with overall survival. Conclusions (1) Osteoclast density along the tumor front is significantly lower among patients with PXRTHN. Stromal cell density was not associated with overall survival. (2) Positive soft tissue frozen section margin and maximum tumor dimension are significantly associated with overall survival among patients with mandibular invasion by OSCC. |

Short Scientific Communication

Evidence for Oncolytic Viral Eradication of Cholesteatoma In Vitro Ravi N. Samy, MD, Noga Lipschitz, MD, Brian R. Earl, PhD, Timothy P. Cripe, MD, PhD https://doi.org/10.1177/0194599818821863 |First Published January 1, 2019 Abstract Hide Preview Cholesteatomas (CHSTs) are congenital or acquired lesions of the temporal bone that are associated with significant morbidity. We hypothesized that an oncolytic herpes simplex virus (oHSV) could preferentially eradicate primary human CHST cells in vitro and that this virus will replicate selectively and efficiently in CHST cells when compared with control cells. In this work, primary human CHST cells were cultured from surgically collected tissue. Cholesteatomas and control cells were grown and infected by oncolytic oHSV. More than 80% CHST cells versus <5% control cells were killed by oHSV. The oHSV showed a significant enhanced cytotoxic effect against CHST cells in a time- and dose-dependent manner. Therefore, this novel therapy has promise as a future treatment to minimize the spread and recurrence of CHST. |

Original Research

Prognostic Impact of High-Risk Pathologic Features in HPV-Related Oropharyngeal Squamous Cell Carcinoma and Tobacco Use Anvesh R. Kompelli, Patrick Morgan, MD, Hong Li, PhD, William Harris, Terry A. Day, MD,David M. Neskey, MD, MSCR https://doi.org/10.1177/0194599818818446 |First Published December 11, 2018 Abstract Hide Preview Objectives To assess the impact of pathologic features and chronic tobacco use on human papillomavirus (HPV)–related oropharyngeal squamous cell carcinoma (OPSCC). Study Design Case series with chart review. Setting Single tertiary care referral center. Subject and Methods A total of 301 patients were treated for OPSCC from 2008 to 2016. Clinical and pathologic T and N stage, American Joint Committee on Cancer (AJCC) stage (seventh and eighth edition staging manuals), cigarette pack years, alcohol use, and presence of extranodal extension (ENE), perineural invasion (PNI), or lymphovascular invasion (LVI) were assessed. Patients were stratified into HPV negative, HPV-positive heavy smokers (≥20 pack years), and HPV-positive nonsmokers. Five-year survival by Kaplan-Meier method was assessed. Results Of the HPV-positive patients, 97 were nonsmokers and 73 were heavy smokers. HPV-positive heavy smokers had significantly decreased survival compared to their nonsmoking counterparts (P = .02). The presence of ENE was associated with a significantly decreased 5-year survival (P = .02) in heavy smokers relative to nonsmokers in HPV-positive patients. Furthermore, for the AJCC eighth edition, clinically stage 1 HPV-positive heavy smokers had significantly decreased survival relative to nonsmokers (P = .01). Conclusions This series highlights the potential need for more aggressive therapy for HPV-positive patients with extensive tobacco use under the new staging system. |

Original Research

Salvage Surgery for Recurrence after Radiotherapy for Squamous Cell Carcinoma of the Head and Neck Joris B. W. Elbers, MD, Abrahim Al-Mamgani, MD, PhD, Michiel W. M. van den Brekel, MD, PhD,Katarzyna Jóźwiak, PhD, J. P. de Boer, MD, PhD, Peter J. F. M. Lohuis, MD, PhD, Stefan M. Willems, MD, PhD, Marcel Verheij, MD, PhD, Charlotte L. Zuur, MD, PhD https://doi.org/10.1177/0194599818818443 |First Published December 11, 2018 Abstract Hide Preview Objective Most studies that report on salvage surgery after primary radiotherapy for head and neck squamous cell carcinoma (HNSCC) are small and heterogeneous. Subsequently, some relevant questions remain unanswered. We specifically focused on (1) difference in prognosis per tumor subsite, corrected for disease stage, and (2) differences in prognosis after salvage surgery for local, regional, and locoregional recurrences. Study Design Retrospective analysis. Setting Single-center study (2000-2016). Subjects and Methods Patients treated with salvage surgery for HNSCC recurrence after (chemo)radiotherapy. Results In total, 189 patients were included. Five-year overall survival (OS) was 33%, and median OS was 18 (95% confidence interval [CI], 11-26) months. Treatment-related mortality was 2%. Larynx carcinoma was associated with more favorable local (adjusted hazard ratio [HR] = 4.02; 95% CI, 1.46-11.10; P = .007) and locoregional control (adjusted HR = 5.34; 95% CI, 1.83-15.61; P = .002) than pharyngeal carcinoma. American Society of Anesthesiologists (ASA) score (≥3 vs 1-2: adjusted HR = 3.04; 95% CI, 1.17-7.91; P = .023), pT stage (3-4 vs 1-2: adjusted HR = 4.41; 95% CI, 1.65-11.82; P = .003), and salvage surgery for locoregional recurrences (locoregional vs local: adjusted HR = 3.81; 95% CI, 1.13-11.82; P = .021) were independent predictors for disease-free survival (DFS). Conclusion Salvage surgery for larynx carcinoma, regardless of disease stage and other prognostic factors, results in more favorable loco(regional) control but not favorable DFS than pharyngeal carcinoma. The observed difference in DFS between salvage surgery for local and regional recurrences was not significant after correction for confounders. However, survival following salvage surgery for locoregional disease is significantly worse. For this subgroup, we propose to consider T status and comorbidity for clinical decision making, as high pT stage and ASA score are independent predictors for worse DFS. |

Original Research

Multi-institutional Evaluation of Medialization Laryngoplasty in the Elderly Ramez Philips, MD, Kevin Chorath, Brad DeSilva, MD, L. Arick Forrest, MD, C. Blake Simpson,MD, Laura Matrka, MD https://doi.org/10.1177/0194599818817762 |First Published December 11, 2018 Abstract Hide Preview Objective To evaluate voice outcomes of medialization laryngoplasty in the elderly population (65 years and older) and to identify swallow outcomes, complication rates, and predictors of voice outcomes. Study Design Case series with chart review. Setting Two tertiary academic medical centers. Subjects and Methods We retrospectively reviewed charts of 136 patients age 65 years and older undergoing medialization laryngoplasty between January 2008 and May 2016 at 2 tertiary academic institutions. Primary outcome was assessed using Voice Handicap Index 10 (VHI-10) score and Grade, Roughness, Breathiness, Asthenia, and Strain (GRBAS) score. Secondary outcomes were assessed using the Eating Assessment Tool 10 (EAT-10) when dysphagia was present, stroboscopic analysis of glottic closure, and complication rates. A logistic regression analysis assessed predictors of voice improvement after medialization laryngoplasty. Results Total GRBAS and VHI-10 scores showed a significant improvement postoperatively (P < .05). A ≥20% improvement was seen in 81.6% of patients, and a ≥50% improvement was seen in 53.7%. No patient had major complications. Minor complications occurred in 5.9% of patients. Multivariable logistic regression identified preoperative injection augmentation as an independent predictor of less improvement in VHI-10 score (P = .015). Voice therapy prior to medialization did not affect voice outcomes (P = .640). Conclusion Patient- and provider-perceived voice quality are significantly improved after medialization laryngoplasty in the elderly, and the procedure is associated with a low complication rate even in an elderly cohort. Improvement in patient-perceived voice outcomes after medialization laryngoplasty was diminished in patients with preoperative injection augmentation. |

Systematic Review/Meta-analysis

Identifying the Prevalence of Dysphagia among Patients Diagnosed with Unilateral Vocal Fold Immobility Dimin Zhou, MS, MS-3, Mohsin Jafri, Inna Husain, MD https://doi.org/10.1177/0194599818815885 |First Published December 11, 2018 Abstract Hide Preview Objective To identify dysphagia prevalence and characteristics among patients with unilateral vocal fold immobility (UVFI) through a systematic review of current literature. Data Sources Embase, PubMed, ScienceDirect, Wiley Online Library. Review Methods Four electronic databases were reviewed according to the PRISMA criteria. Original English-language studies examining dysphagia among adult patients with UVFI met eligibility. Two researchers independently analyzed qualified articles. Results Of 227 studies discovered through the literature search, 17 satisfied eligibility criteria. The prevalence of symptomatic dysphagia ranged from 55.6% to 69.0%, and the aspiration rate was 20.0% to 50.0%. Self-reporting and clinical evaluation were used to identify symptomatic dysphagia, while videofluoroscopic swallowing study and functional endoscopic evaluation of swallowing evaluated aspiration. Left-sided UVFI predominated. The most common causes of UVFI were iatrogenic and idiopathic. Central lesions and acute-onset UVFI were each associated with more severe dysphagia. Patients were more likely to aspirate on liquids versus purées and pastes. Benefits of medialization thyroplasty and vocal cord injection were equivocal. Conclusion A significant portion of patients with UVFI present with dysphagia due to anatomic and physiologic disruptions during the swallow. Study population heterogeneity and small sample sizes in the reviewed studies may have compromised reliability, calling for large-scale studies with rigorous methodology. Future studies should not only strive to identify the mechanics of the disordered swallow but also explore patients' quality of life and the effectiveness of current treatments for dysphagia with underlying UVFI. |

Original Research

Long-term Outcome for Open and Endoscopically Resected Sinonasal Tumors Jan Hagemann, MD, Jana Roesner, Soenke Helling, MD, Christian Jacobi, MD, Johannes Doescher, MD, Matthias Engelbarts, MD, Julian Kuenzel, MD, Philipp Krauss, MD, Sven Becker, MD, Christian Stephan Betz, MD https://doi.org/10.1177/0194599818815881 |First Published December 4, 2018 Abstract Hide Preview Objective Endoscopic resection of sinonasal cancer has become an alternative to open craniofacial surgery and leads to safe and satisfying results in emerging numbers. Randomized study data comparing outcomes between approaches are missing. Hence, it remains unclear which subgroups of patients might profit most from each technique. We aimed to identify such patient and tumor characteristics and gather information for future prospective study design. Study Design Case series with chart review. Setting Tertiary academic center. Subjects and Methods This study is based on a retrospective chart review of 225 patients undergoing open craniofacial or endoscopic resection for sinonasal malignancy between 1993 and 2015 at Munich University Hospital. Statistical analyses include t test, chi-square, Kaplan-Meier charts, and univariate and multivariate analyses. Results The sample size was similar between the endoscopic and open surgery groups. Tumors were significantly larger in patients who underwent open craniofacial resection. The risk of notable bleeding (P = .041) was lower and hospital stay shorter (P = .001) for endoscopic interventions of all tumor stages. Rates of overall (P = .024) and disease-specific (P = .036) survival were significantly improved for endoscopic cases; improved recurrence-free survival rates did not achieve statistical significance (P = .357). For cases matched for tumor size, this improvement was confirmed for T3 tumors (P = .038). Regional and distant metastatic tumor spread generally worsened survival in both surgical subgroups. Multivariate Cox regression analysis revealed independent prognosticators for overall survival. Conclusion Endoscopic tumor resection remains a suitable option for distinct indications and showed improved outcome in intermediate-stage tumors in our collective. Further randomized studies acknowledging the here-identified factors are needed to improve future therapy guidelines and patient care. |

Original Research

Impact of Septal Deviation on Recurrent Chronic Rhinosinusitis after Primary Surgery: A Matched Case-Control Study Terence Fu, MD, MBA, Daniel Lee, MD, Jonathan Yip, MD, Alisha Jamal, MD, John M. Lee, MD, MSc https://doi.org/10.1177/0194599818815106 |First Published November 27, 2018 Abstract Hide Preview Objective To evaluate the impact of untreated deviated nasal septum (DNS) on recalcitrant chronic rhinosinusitis (CRS) among patients undergoing revision endoscopic sinus surgery (ESS). Study Design Case-control study. Setting Tertiary academic center. Subjects and Methods We performed a retrospective review of 489 patients undergoing revision ESS for CRS at a tertiary academic center. Patients undergoing septoplasty were matched to nonseptoplasty controls based on age and sex. Preoperative Lund-Mackay score (LMS) was compared between cohorts. Linear regression was used to identify predictors of LMS and ostiomeatal complex (OMC) obstruction. Results Thirty-six matched pairs (72 patients) were selected for analysis: 36 undergoing septoplasty and revision ESS and 36 undergoing revision ESS alone. Compared with nonseptoplasty controls, the septoplasty group had a significantly higher average LMS (17.8 vs 14.6, P = .02) and a greater rate of OMC obstruction (89% vs 61%, P < .01). The septoplasty group also had significantly higher opacification scores in the maxillary (1.5 vs 1.2, P = .03) and posterior ethmoid (1.8 vs 1.4, P = .02) sinuses. On multivariable analysis, DNS was an independent predictor of LMS (P = .02) and OMC obstruction (P < .01). Conclusion Untreated DNS is associated with radiographic markers of CRS severity among patients undergoing revision ESS and may contribute to the multifactorial pathogenesis of persistent CRS. |

Patient Safety/Quality Improvement

Effects of a Comprehensive Performance Improvement Strategy on Postoperative Adverse Events in Head and Neck Surgery Bharat Panuganti, MD, Yuqi Qiu, MS, Barbara Messing, MA, Gregory Lee, MS, Carole Fakhry,MD, MPH, Raymond Blanco, MD, Patrick Ha, MD, Karen Messer, PhD, Joseph A. Califano, MD https://doi.org/10.1177/0194599818793887 |First Published August 28, 2018 Abstract Hide Preview Objectives We aimed to demonstrate the efficacy of a multifaceted performance improvement regimen to reduce the incidence of adverse events following a spectrum of head and neck surgical procedures. Methods We conducted a chart review of patients who underwent a head and neck procedure between January 1, 2013, and October 30, 2015, at our institution, including 392 patients (450 procedures) before the quality improvement regimen was implemented (October 1, 2013) and 942 patients (1136 procedures) after implementation. Multivariate statistical models were used to investigate the association of clinical parameters and the intervention with postoperative adverse event rate. Results The incidence of adverse events decreased from 12.9% to 7.2% (95% CI, 2.46%-9.38%) after the intervention. Male sex (adjusted odds ratio [ORadj] = 1.57; 95% CI, 1.06-2.31) and the intervention (ORadj = 0.51; 95% CI, 0.35-0.74) were predictive of overall adverse event incidence by univariate and multivariate analyses. Although patient comorbid status, quantified with the Charlson Comorbidity Index, was not found to affect overall adverse event risk, each 1-point increase in index score was associated with a 17% relative increase (ORadj = 1.17; 95% CI, 1.03-1.33) in the odds of a high-grade adverse event. Discussion Comprehensive performance improvement programs can improve perioperative adverse event risk in head and neck surgery. Patient comorbid status and sex are considerations during assessment of the likelihood of high-grade and overall adverse event risk, respectively. Implications for Practice Given the cost of surgical complications, a comprehensive approach to perioperative risk mitigation is warranted. |

Patient Safety/Quality Improvement

Improving Communication Delay of Outpatient Sleep Study Results to Pediatric Otolaryngology Patients and Families James M. Ruda, MD, Linda Payne, MSN, Anne May, MD, Mark Splaingard, MD, Stephanie Lemle, MBA, Kris R. Jatana, MD https://doi.org/10.1177/0194599818789116 |First Published July 31, 2018 Abstract Hide Preview Objective We undertook this quality improvement project to improve communication of outpatient pediatric sleep study results to families in a consistent and timely manner. Methods Based on the Institute for Healthcare Improvement quality improvement methodology, multiple key drivers were identified, including standardizing documentation and communication for sleep study results among the otolaryngology department, sleep center, and families. Meaningful interventions included developing standard electronic medical record documentation and utilizing otolaryngology nurses and advanced practice nurses to assist with communication by sending the results from the sleep center to both the referring otolaryngology provider and the triage nurses. The primary outcome measure was the monthly proportion of sleep studies communicated by the otolaryngology department to families within 3 business days. Results Average monthly sleep study results communicated to families within 3 business days increased from 31% to 92.9% over the study period (P < .0001). Sleep study results were personally communicated via telephone and voicemail in 60.88% and 34.0% of cases, respectively. Approximately 50.0% of families receiving voicemails later contacted our department for their children's study results. Discussion Novel documentation strategies and involvement of our entire clinical team (physicians, nurses, and advanced practice nurses), allowed us to significantly improve the consistency and timeliness of our communication of outpatient sleep study results to families in a proactive manner. Implications for Practice With time-sensitive clinical test results, such as those from pediatric sleep studies, intra- and interdepartmental collaboration and standardization of the communication process and documentation may allow for more expedient care of children with suspected obstructive sleep apnea. |

Patient Safety/Quality Improvement

A Clinical Care Pathway to Reduce ICU Usage in Head and Neck Microvascular Reconstruction Elliot Morse, Cara Henderson, RN, Tracy Carafeno, RN, Jacqueline Dibble, APRN, Peter Longley, RN, Edwin Chan, Benjamin Judson, MD, Wendell G. Yarbrough, MD, MMHC, Clarence Sasaki, MD, Saral Mehra, MD, MBA https://doi.org/10.1177/0194599818782404 |First Published July 31, 2018 Abstract Hide Preview Objective To design and implement a postoperative clinical care pathway designed to reduce intensive care usage on length of stay, readmission rates, and surgical complications in head and neck free flap patients. Methods A postoperative clinical care pathway detailing timelines for patient care was developed by a multispecialty team. In total, 108 matched patients receiving free tissue transfer for reconstruction of head and neck defects in the year before (prepathway), year after (early pathway), and second year after (late pathway) pathway implementation were compared based on postoperative length of stay, 30-day readmission rate, intensive care unit (ICU) admission, and rates of medical/surgical complications. Results Median length of stay decreased from 10 to 7.5 and 7 days in the pre-, early, and late-pathway groups, respectively (P = .012). Readmission rate decreased from 16% in the prepathway group to 0% and 3% in the early and late-pathway groups. The number of patients admitted to the ICU postoperatively decreased from 100% to 36% and 6% in the pre-, early, and late-pathway groups, respectively (P = .025). The rates of surgical and medical complications were equivalent. Discussion This pathway effectively reduced ICU admission, length of stay, and readmission rates, without increasing postoperative complications. These outcomes were sustainable over 2 years. Implications for Practice Free flap patients may not require routine ICU admission and may be taken off ventilatory support in the operating room. This effectively reduces costly resource use in this patient population. Similar pathways could be introduced at other institutions. |