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Objectives: Evaluate and compare the ability of large language models (LLMs) to diagnose various ailments in otolaryngology., Methods: We collected all 100 clinical vignettes from the second edition of Otolaryngology Cases-The University of Cincinnati Clinical Portfolio by Pensak et al. With the addition of the prompt "Provide a diagnosis given the following history," we prompted ChatGPT-3.5, Google Bard, and Bing-GPT4 to provide a diagnosis for each vignette. These diagnoses were compared to the portfolio for accuracy and recorded. All queries were run in June 2023., Results: ChatGPT-3.5 was the most accurate model (89% success rate), followed by Google Bard (82%) and Bing GPT (74%). A chi-squared test revealed a significant difference between the three LLMs in providing correct diagnoses (p = 0.023). Of the 100 vignettes, seven require additional testing results (i.e., biopsy, non-contrast CT) for accurate clinical diagnosis. When omitting these vignettes, the revised success rates were 95.7% for ChatGPT-3.5, 88.17% for Google Bard, and 78.72% for Bing-GPT4 (p = 0.002)., Conclusions: ChatGPT-3.5 offers the most accurate diagnoses when given established clinical vignettes as compared to Google Bard and Bing-GPT4. LLMs may accurately offer assessments for common otolaryngology conditions but currently require detailed prompt information and critical supervision from clinicians. There is vast potential in the clinical applicability of LLMs; however, practitioners should be wary of possible "hallucinations" and misinformation in responses., Level of Evidence: 3 Laryngoscope, 134:3997-4002, 2024., (© 2024 The Authors. The Laryngoscope published by Wiley Periodicals LLC on behalf of The American Laryngological, Rhinological and Otological Society, Inc.)

Objective/hypothesis: The COVID-19 pandemic has resulted in telehealth becoming commonplace in many health care fields. Telehealth benefits include improving access, decreasing costs, and elevating patient's experience. A review of cost minimization (CM) analyses was performed in order to explore scientific studies associated with integrating tele-otolaryngology in clinical practice. Our primary objective was to evaluate published literature for cost related to the implementation of telemedicine across otolaryngology, and to determine CM when compared to in-person visits., Study Design: Systematic Literature Review., Methods: We performed a systematic review using PubMed, EMBASE, and Cochrane in May 2020, to identify studies with a cost analysis of tele-otolaryngology care. Inclusion criteria focused on articles citing CM data from telehealth services. Literature quality was assessed using the MINORS scoring system., Results: From 380 original articles screened only nine evaluated cost in otolaryngology. CM in the US ranged from $68 to $900 per visit. Cost was evaluated in general otolaryngology, sleep medicine, otology, and head and neck cancer surgery, the latter had the most benefit. The most common types of telehealth visits were routine follow-up and screening. Data were insufficient for meta-analysis., Conclusions: Telemedicine has been trialed across various otolaryngology subspecialties; its incorporation is projected to have a meaningful impact on access to specialty care. This research suggests that the delivery of virtual care reduces cost with the potential of increasing net revenue across multiple otolaryngology subspecialties. Further studies are needed to better discern the entirety of cost savings and the best settings for integration., Level of Evidence: 3 Laryngoscope, 131:1741-1748, 2021., (© 2020 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives: Outcomes in laryngology focus primarily on patient reported outcome measures (PROMs). The increasing number of questionnaires may lead to survey fatigue. We sought to determine the relationship between the newest questionnaire, Laryngopharyngeal Universal Measure of Perceived Sensation (LUMP), and other laryngology PROMs., Study Design: Cross-sectional study., Methods: Patients undergoing laryngology multidisciplinary evaluation prospectively completed laryngology questionnaires. Average summed scores between standard laryngology PROMs (ie, VHI-10, RSI, DI, CSI, EAT-10) and LUMP were compared. Expert consensus panel identified the most clinically relevant statements which were then compared to LUMP summed scores, in increasingly additive fashion., Results: Four hundred eighty patients (259 female) were assessed. Average age was 57.1 ± 17.7 years. Intraclass correlation coefficient (ICC) for each PROM in comparison to LUMP ranged from moderate to poor correlation: 0.64 (RSI), 0.55 (EAT-10), 0.50 (DI), 0.48 (CSI), and 0.34 (VHI-10). ICC for combinations of the five most clinically relevant individual items ranged from 0.29-0.53., Conclusions: Patients with self-reported globus had statistically significantly higher scores across all PROMs. RSI had moderate correlation with LUMP, and the five selected expert consensus items demonstrated weaker correlation. While RSI may serve as a moderately selective clinical proxy for the LUMP questionnaire, LUMP remains a validated tool with increased specificity for quantification of globus which may be especially important in the research setting. There is continued question about the need for multiple laryngologic PROMs to evaluate patient complaints, and survey reduction remains an area of interest to decrease respondent fatigue, optimize patient care, and quantify interventional success., Level of Evidence: 4 Laryngoscope, 131:1561-1565, 2021., (© 2020 American Laryngological, Rhinological and Otological Society Inc, "The Triological Society" and American Laryngological Association (ALA).)

Objectives/hypothesis: With the increasing emphasis on developing effective telemedicine approaches in Otolaryngology, this study explored whether a single composite image stitched from a digital otoscopy video provides acceptable diagnostic information to make an accurate diagnosis, as compared with that provided by the full video., Study Design: Diagnostic survey analysis., Methods: Five Ear, Nose, and Throat (ENT) physicians reviewed the same set of 78 digital otoscope eardrum videos from four eardrum conditions: normal, effusion, retraction, and tympanosclerosis, along with the composite images generated by a SelectStitch method that selectively uses video frames with computer-assisted selection, as well as a Stitch method that incorporates all the video frames. Participants provided a diagnosis for each item along with a rating of diagnostic confidence. Diagnostic accuracy for each pathology of SelectStitch was compared with accuracy when reviewing the entire video clip and when reviewing the Stitch image., Results: There were no significant differences in diagnostic accuracy for physicians reviewing SelectStitch images and full video clips, but both provided better diagnostic accuracy than Stitch images. The inter-reader agreement was moderate., Conclusions: Equal to using full video clips, composite images of eardrums generated by SelectStitch provided sufficient information for ENTs to make the correct diagnoses for most pathologies. These findings suggest that use of a composite eardrum image may be sufficient for telemedicine approaches to ear diagnosis, eliminating the need for storage and transmission of large video files, along with future applications for improved documentation in electronic medical record systems, patient/family counseling, and clinical training., Level of Evidence: 3 Laryngoscope, 131:E1668-E1676, 2021., (© 2020 American Laryngological, Rhinological and Otological Society Inc, "The Triological Society" and American Laryngological Association (ALA).)

Objective: To investigate worldwide practices of otolaryngologists in the management of laryngopharyngeal reflux (LPR)., Methods: An online survey was sent on the management of LPR to members of many otolaryngological societies. The following aspects were evaluated: LPR definition, prevalence, clinical presentation, diagnosis, and treatment., Results: A total of 824 otolaryngologists participated, spread over 65 countries. The symptoms most usually attributed to LPR are cough after lying down/meal, throat clearing and globus sensation while LPR-related findings are arytenoid erythema and posterior commissure hypertrophy. Irrespective to geography, otolaryngologists indicate lack of familiarity with impedance pH monitoring, which they attribute to lack of knowledge in result interpretation. The most common therapeutic regimens significantly vary between world regions, with a higher use of H2 blocker in North America and a lower use of alginate in South America. The duration of treatment also significantly varies between different regions, with West Asia/Africa and East Asia/Oceania otolaryngologists prescribing medication for a shorter period than the others. Only 21.1% of respondents are aware about the existence of nonacid LPR. Overall, only 43.2% of otolaryngologists believe themselves sufficiently knowledgeable about LPR., Conclusions: LPR knowledge and management significantly vary across the world. International guidelines on LPR definition, diagnosis, and treatment are needed to improve knowledge and management around the world., Level of Evidence: N.A. Laryngoscope, 131:E1589-E1597, 2021., (© 2020 American Laryngological, Rhinological and Otological Society Inc, "The Triological Society" and American Laryngological Association (ALA).)

Objectives/hypothesis: During the current COVID-19 pandemic, the demand for direct-to-home telemedicine services has risen to an unprecedented level. Equal access to specialty care was assessed to identify potential barriers that may negatively impact telemedicine utilization., Study Design: Retrospective case series., Methods: We examined the 6-week period between March and May 2020 when the only access to nonurgent pediatric otolaryngology service was through telemedicine and compared it to in-person visits during the same period in 2019. We compared patient demographics, including age, gender, preferred language, zip code of residence, and primary insurance plan., Results: A total of 1,495 visits were conducted through telemedicine from March 23, 2020 to May 1, 2020, and 1983 in-person visits were completed in 2019. There was no difference in patient age and gender. The proportions of Spanish-speaking families were similar (15.8% in 2019 vs. 14.4% in 2020, P = .96). The percentage of Medi-Cal-insured patients (51.4% in 2019 vs. 49.8% in 2020, P = .73) and the mean poverty level (12.6% in 2019 vs. 12.2% in 2020, P = .38) also remained the same. Spanish-speaking families were statistically more likely to require rescheduling of their telemedicine visits (17.2%) when compared to the overall rescheduling rate of 11.9% (P = .0083)., Conclusions: We were able to successfully provide access to telemedicine services to our vulnerable populations during the current COVID-19 pandemic. Telemedicine is likely to remain an essential mode of delivering patient care going forward. It is important to evaluate and identify potential disparities to telemedicine access and proactively implement changes to address these barriers., Level of Evidence: 4. Laryngoscope, 131:1175-1179, 2021., (© 2020 American Laryngological, Rhinological and Otological Society Inc, "The Triological Society" and American Laryngological Association (ALA).)

This case series examines interactive AR during minor otolaryngologic procedures. Although VR has been successfully used for pediatric vascular access, removing children from comforting people in the real world has resulted in patient anxiety. AR offers a potential advantage, utilizing distracting holographic images when patients maintain eye contact with parents. The primary objective was to determine the effect of AR on fear during pediatric otolaryngologic procedures. Secondary objectives included evaluating pain; procedure compliance; and patient, parent and physician attitudes toward AR, as well as assessing the feasibility of adding AR to a busy outpatient otolaryngologic clinic. Laryngoscope, 131:E1342-E1344, 2021., (© 2020 American Laryngological, Rhinological and Otological Society Inc, "The Triological Society" and American Laryngological Association (ALA).)

Objectives/hypothesis: The aim of the study was to develop a test for the assessment of retronasal olfaction in healthy participants and patients with olfactory disorders using "tasteless" powders., Study Design: Prospective case-control series., Methods: A total of 150 participants (110 women, 40 men, mean age = 40 ± 16 years) were recruited for this study; 100 were healthy controls and 50 were patients with olfactory loss due to infections of the upper respiratory tract (n = 25), idiopathic causes (n = 12), sinonasal disease (n = 7), and head trauma (n = 6). Orthonasal olfactory function was evaluated using the Sniffin' Sticks test battery, and retronasal olfaction was evaluated using powders lacking distinctive tastes administered to the oral cavity. To establish test-retest reliability, healthy participants had their orthonasal and retronasal function tested twice., Results: The validity analyses revealed that the selected 16 stimuli differentiated between normosmic participants and patients with olfactory loss, and that retronasal and orthonasal olfaction were highly correlated., Conclusions: The results of the present study indicate that patients with olfactory loss and controls can be clearly separated using a reliable test of retronasal olfaction based on 16 retronasal stimuli., Level of Evidence: 2b Laryngoscope, 131:E324-E330, 2021., (© 2020 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: The COVID-19 pandemic has led to unprecedented global changes in the delivery of healthcare over a short period of time. With the implementation of shelter-in-place orders, otolaryngology clinic visits at our institution were transitioned to telemedicine. This change enabled the rapid characterization of the patients who accepted and declined telemedicine., Study Design: Cross-sectional analysis., Methods: A review was conducted of 525 otolaryngology patients at a tertiary-care referral center with scheduled visits requiring rescheduling to a future date or a telemedicine visit. Visit, demographic information, and reason for deferring telemedicine were collected for analysis., Results: Seventy-two percent of patients declined a telemedicine visit, with the most common reason being the lack of a physical exam (97%). There was an even distribution of demographics between those who accepted and declined visits. There was an association between declining telemedicine with older age (P = .0004) and otology visits (P = .0003), whereas facial plastics patients were more likely to accept (P < .0001). Patients scheduled earlier during the pandemic were more likely to accept a visit with a median of 28 days from onset of shelter-in-place orders versus 35 for those who declined (P < .0001)., Conclusions: We describe our initial experience with a transition to telemedicine, where the majority of patients would decline a virtual visit due to the lack of a physical exam. Although the future remains uncertain, telemedicine will continue to play a vital role in healthcare delivery. We believe that understanding our patient base gives critical insights that will help guide and improve virtual care to meet patients' needs., Level of Evidence: 4 Laryngoscope, 130:2568-2573, 2020., (© 2020 American Laryngological, Rhinological and Otological Society Inc, "The Triological Society" and American Laryngological Association (ALA).)

Objective: Access to otolaryngology is limited by lengthy wait lists and lack of specialists, especially in rural and remote areas. The objective of this study was to use an automated machine learning approach to build a computer vision algorithm for otoscopic diagnosis capable of greater accuracy than trained physicians. This algorithm could be used by primary care providers to facilitate timely referral, triage, and effective treatment., Methods: Otoscopic images were obtained from Google Images (Google Inc., Mountain View, CA), from open access repositories, and within otolaryngology clinics associated with our institution. After preprocessing, 1,366 unique images were uploaded to the Google Cloud Vision AutoML platform (Google Inc.) and annotated with one or more of 14 otologic diagnoses. A consensus set of labels for each otoscopic image was attained, and a multilabel classifier architecture algorithm was trained. The performance of the algorithm on an 89-image test set was compared to the performance of physicians from pediatrics, emergency medicine, otolaryngology, and family medicine., Results: For all diagnoses combined, the average precision (positive predictive value) of the algorithm was 90.9%, and the average recall (sensitivity) was 86.1%. The algorithm made 79 correct diagnoses with an accuracy of 88.7%. The average physician accuracy was 58.9%., Conclusion: We have created a computer vision algorithm using automated machine learning that on average rivals the accuracy of the physicians we tested. Fourteen different otologic diagnoses were analyzed. The field of medicine will be changed dramatically by artificial intelligence within the next few decades, and physicians of all specialties must be prepared to guide that process., Level of Evidence: NA Laryngoscope, 130:1408-1413, 2020., (© 2019 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: Institutional and national programs have endorsed the use of validated instruments in daily practice, but their utility for frontline clinicians is unknown. Our first objective was thus to determine if routinely obtained patient descriptions accurately predict disease-specific validated instrument results. Our second objective was to assess the feasibility of deploying an electronic system to obtain and document patient-reported descriptions of health status., Study Design: Prospective assessment of consecutive eligible ambulatory care patients., Methods: For the first objective, patients presenting with the same chief complaint at consecutive visits provided concurrent routine symptom descriptions and validated instrument responses. To determine whether patients' routine descriptions predicted scores from disease-specific instruments, receiver operator characteristic (ROC) curves, sensitivity/specificity, Spearman ρ correlation, and regression models were utilized. For the second objective, feasibility assessment focused on percent with successful response capture, time to questionnaire completion, and impact on physician time needed to obtain and document patient histories., Results: For the first objective, among patients with hearing loss, eustachian tube dysfunction, nasal obstruction, and chronic rhinosinusitis, the areas under the ROC curves were 0.38 to 0.83. Spearman ρ coefficients were 0.25 to 0.46. Sensitivity and specificity ranged from 15.9% to 87.8%, with correct classification in 42.3% to 55.2% of cases. For the second objective, there was a 91% completion rate. Completion times were 7:18 to 12:37 for new patients and 3:23 to 6:41 for established patients. Physician time savings were estimated at 11 minutes per patient., Conclusions: Using validated instruments and electronic data collection systems in daily practice has practical and clinical implications. These topics warrant further study., Level of Evidence: 2c Laryngoscope, 130:S1-S13, 2020., (© 2019 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: On the Press Ganey (PG) survey, the item "likelihood of recommending practice" is a proxy for patient satisfaction because only the most satisfied patients will recommend a practice to friends and family. The objective of this study is to determine which other items on the PG survey best correlate with "likelihood of recommending practice" as a measure of patient satisfaction in pediatric otolaryngology., Study Design: Retrospective analysis of a survey database., Methods: The PG survey, consisting of 24 questions scaled from 1 to 5 representing (1) very poor, (2) poor, (3) fair, (4) good, and (5) very good, was sent to 28 different pediatric otolaryngology practices. Using the Pearson correlation coefficient, the statistical relationship of each PG survey question was analyzed in its association to the PG question "likelihood of recommending practice." Factors with a correlation coefficient greater than 0.65 were considered significant., Results: Ten of 24 questions on the PG survey correlated with a top "likelihood of recommending practice" score. Eight of these 10 items were from the Care Provider category and were related to the physician-patient/family interaction., Conclusion: Patient satisfaction surveys are utilized as a quality metric of the patient and family experience. These scores serve as one of several measures that affect reimbursement. The results demonstrate that most of the factors correlated with "likelihood of recommending practice" are provider-based. In conclusion, the physician-patient interaction strongly influences the potential for a practice to earn top box scores on the PG item "likelihood of recommending practice" and thereby achieve the highest patient satisfaction., Level of Evidence: NA. Laryngoscope, 129:2610-2613, 2019., (© 2018 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: Augmented reality (AR) allows for the addition of transparent virtual images and video to one's view of a physical environment. Our objective was to develop a head-worn, AR system for accurate, intraoperative localization of pathology and normal anatomic landmarks during open head and neck surgery., Study Design: Face validity and case study., Methods: A protocol was developed for the creation of three-dimensional (3D) virtual models based on computed tomography scans. Using the HoloLens AR platform, a novel system of registration and tracking was developed. Accuracy was determined in relation to actual physical landmarks. A face validity study was then performed in which otolaryngologists were asked to evaluate the technology and perform a simulated surgical task using AR image guidance. A case study highlighting the potential usefulness of the technology is also presented., Results: An AR system was developed for intraoperative 3D visualization and localization. The average error in measurement of accuracy was 2.47 ± 0.46 millimeters (1.99, 3.30). The face validity study supports the potential of this system to improve safety and efficiency in open head and neck surgical procedures., Conclusions: An AR system for accurate localization of pathology and normal anatomic landmarks of the head and neck is feasible with current technology. A face validity study reveals the potential value of the system in intraoperative image guidance. This application of AR, among others in the field of otolaryngology-head and neck surgery, promises to improve surgical efficiency and patient safety in the operating room., Level of Evidence: 2b Laryngoscope, 129:S1-S11, 2019., (© 2019 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: Phonation threshold pressure (PTP), the minimum subglottal pressure (P s ) required for phonation, is sensitive to changes in laryngeal biomechanics and is often elevated with pathology. Little is reported on PTP in children; challenges with task performance and measurement reliability represent barriers to routine clinical assessment., Study Design: Pilot study evaluating PTP and P s measurement reliability in children using labial and mechanical interruption., Methods: Twenty-two subjects aged 4 to 17 years (10.7 ± 3.9 years) participated. Ten trials were performed for each method; task order was randomized. For labial interruption, subjects produced /pα/ five times at softest (onset PTP) and comfortable amplitude. For mechanical interruption, subjects produced a sustained /α/ while a balloon valve interrupted phonation five times for 250 ms each; mechanical interruption was performed with a mouthpiece and mask. PTP was recorded as the difference between P s and supraglottal pressure at phonation cessation (offset PTP). Mean PTP and P s and intrasubject coefficients of variation were compared. Correlations with age were evaluated., Results: Mean PTP (P < .001) and P s (P = .005) were higher for labial interruption. Intrasubject coefficients of variation for PTP (P = .554) and P s (P = .305) were similar across methods. Coefficient of variation was related to age for mechanical-mask trials only (r = -0.628, P = .00175)., Conclusions: Differences in means are likely related to differences in task and PTP hysteresis effect. Reliability is comparable with all methods; using a mouthpiece may be preferable to a mask for mechanical interruption. Measurement of PTP is noninvasive, reliable, and may be a useful adjunct in pediatric voice assessment., Level of Evidence: 3b Laryngoscope, 129:1520-1526, 2019., (© 2018 The American Laryngological, Rhinological and Otological Society, Inc.)

The purpose of the present study was to define the applicability of tissue clearing to the field of otology. We combined tissue clearing with vital staining perfusion via a pumping system to examine the vascular anatomy of temporal bones in laboratory animals. We used six different types of species including Korean wild mouse, mouse, Mongolian gerbil, hamsters and Guinea pigs. A mixture of Alcian blue reagent and 4% paraformaldehyde was circulated throughout the entire circulatory system of the animal via a perfusion pump system. Transparency images were obtained from the temporal bones according to the protocol of the SunHyun 3D Imaging Kit. In examining the inner surface of the tympanic membrane, flaccid part (pars flaccida) was positioned along the entire marginal area in Guinea pig. In the Guinea pig, unlike the other species, the cortical bone of the mastoid (bullae) was easily removed using cold instruments, allowing a direct approach to the enclosed structures. The distribution and pattern of cochlea melanocytes were compared among the species. "Mobius strip"-like accumulated melanocytes in vestibules were shown in both the Korean wild mouse and mouse. The collateral blood supply to the cochlea in six different species was checked in various pattern. Combining dye infusion with tissue-clearing techniques, we documented the middle ear and transparent inner ear structures in six different species. The information and associated images will help other researchers to develop hypotheses and design experimental investigations., (© 2019 Blackwell Verlag GmbH.)

This study is meant to illustrate and describe the features of the auditory ossicles of the chinchilla (Chinchilla lanigera), one of the species used more and more frequently in otology and ear surgery as animal model. Cephalic extremities of 12 C. lanigera individuals obtained from a private farm, where this species was bred for fur, were used in this study. The ossicles were obtained either by direct surgical harvesting by mastoid approach or after a dermestid beetle exposure followed by anatomical dissection. The three ossicles that form the assembly are the malleus, incus and stapes. After the removal of these ossicles, a series of anatomical descriptions were made, followed by seriate sets of measurements. The malleus and incus form a joined-single unit called the maleo-incal complex, with an elongated straight appearance, also due to the development of the anterior process. The handle of the malleus and the long process of incus are almost perpendicular to the main axis of the maleo-incal complex. The presence of the muscular process on the handle of the malleus is recorded. The overall shape of the incus is given by the uneven development of the two processes and the reduced neck part. The stapes is the smallest of the components that maintains the well-known architecture in accordance with the general model. The morphology of all three ossicles is backed by a series of measurements, some standard, some adapted to the morphology of the ossicles. From the very reduced comparative metrical data at our disposal, our study presents an average of 10% lower values for the ones presented earlier by other researchers in the same species., (© 2019 Blackwell Verlag GmbH.)

Objectives/hypothesis: The European Position Paper on Rhinosinusitis and Nasal Polyps proposes an assessment of clinical control of chronic rhinosinusitis (CRS). However, there are limited data about the percentage of postoperative control, and no prediction models for uncontrolled CRS have been reported. The aim of the study was to develop prediction models for postoperative uncontrolled CRS., Study Design: Retrospective case series., Methods: Patients (n = 136) who had undergone endoscopic sinus surgery at least 1 year prior to the study were recruited to assess the clinical control. Risk factors were determined by logistic models and presented as odds ratio (OR) with a 95% confidence interval. Receiver operating characteristics curves were constructed to set the cutoff points and create predictive models., Results: Approximately 47.8% of patients had controlled, 22.1% partially controlled, and 30.1% uncontrolled CRS. Univariate regression models revealed the risk factors for uncontrolled CRS: tissue eosinophilia, blood eosinophilia, high computed tomography (CT) score, bilateral disease, asthma, and allergic rhinitis. Multiple regression models found tissue eosinophil ratio >0.206 (OR: 12.96, P = .001) or blood eosinophil ratio >0.025 (OR: 4.56, P = .003), Lund-Mackay (LM) score ≥ 15 (OR: 15.50, P < .001) and CT ethmoid (E) score ≥ maxillary (M) score (OR: 3.51, P = .037) were independent risk factors. We generated a pathological model (tissue eosinophil ratio and LM score) and a clinical model (blood eosinophil ratio, LM score and E ≥ M score) to categorize CRS into mild, moderate, and severe., Conclusions: This research provides simplified and efficient prediction models for uncontrolled CRS. It may help otolaryngologists to predict the prognosis before surgery in daily practice., Level of Evidence: 2b Laryngoscope, 128:2673-2680, 2018., (© 2018 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: This study investigated the perceived impact of electronic health records (EHR) on otolaryngology residents with regard to education, patient care, and workflow, and then compared the trends with those of practicing otolaryngologists., Methods: A descriptive, cross-sectional survey was developed for each core study group: the otolaryngology resident group (ORG) and the practicing otolaryngologist group (POG). In total, 536 surveys were submitted: 33 from the ORG survey and 510 from the POG survey. Response rates were 51.5% and 21.3%, respectively., Results: Within the two study groups, ORG reported a predominately neutral response relating to the impact of EHR on experience compared with the POG, which reported far more negative responses. The most negative reported change in the ORG related to feeling more like a passive observer and scribe in terms of how EHR negatively impacted the role of resident. Within the POG group, the majority of negative responses were recorded on the impact of EHR on practice efficiency, practice overhead, and number of employees required to maintain practice function., Conclusion: With otolaryngologists making up 1.1% of the U.S. physician workforce in 2015, it is likely that software programing of EHR underrepresents the workflow needs of otolaryngologists at this time. Future studies investigating the impact of EHR on otolaryngology patient care and resident education are needed in the future. Laryngoscope, 128:2726-2731, 2018., (© 2018 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/objectives: We aimed to provide an otolaryngologist-targeted summary regarding the epidemiology, carcinogenesis, and cessation strategies for smokeless tobacco usage., Study Design: Evidence-based literature review., Methods: We reviewed the current evidence-based literature concerning trends in smokeless tobacco use, associations with neoplastic change, and therapeutic interventions to assist with sustained abstinence. In complement, we present an actual case of laryngeal squamous cell carcinoma in the setting of chronic tobacco-dentifrice usage in a lifelong nonsmoker., Results: This report provides a synopsis of epidemiological data and evidence-based recommendations for general, pharmaceutical, and behavioral cessation strategies., Conclusions: Smokeless tobacco use continues to be prevalent among patients seen by otolaryngologists, particularly of various Indian and Southeast Asian descent. The data presented in this article will aid in the identification of at risk patients. The provided recommended cessation strategies will tool otolaryngologists for patient counseling and management, ultimately aimed at improving health outcomes. Laryngoscope, 128:2067-2071, 2018., (© 2018 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: We present our experience with telemedicine visits in an otolaryngology outpatient setting within our institution's Center for Head and Neck Surgery., Study Design: Retrospective chart review., Methods: A review of telemedicine outpatient encounters examining patient demographics, visit type, and wait times was conducted. Internet-based navigation applications were used to calculate travel distance and estimate commute time to our clinic. Patient survey responses were reviewed., Results: Two hundred fifty telemedicine encounters were reviewed between December 2015 and June 2017. The average age of patients was 50 years (range, 4-87 years). Patients waited an average of 10 minutes for their telemedicine appointments and avoided an average estimated commute time of 78 minutes (64 miles). The majority of visits were postoperative encounters (70%). Clinical follow-up of recent results or nonpostoperative complaints accounted for the remaining 30% of visits. All patients were offered a post-telemedicine survey, and 78 (31%) completed the survey. Of the respondents, 95% of patients reported that they were satisfied with their visit. Among patients who were dissatisfied, wait time and technical issues were cited as reasons., Conclusions: With appropriate patient selection, telemedicine is an effective way to safely conduct outpatient clinic visits while maintaining high patient satisfaction. It can be particularly useful for institutions with large catchment areas to minimize travel times and increase ease of communication., Level of Evidence: 4. Laryngoscope, 128:2072-2075, 2018., (© 2018 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: To evaluate diagnostic concordance of a synchronous telemedicine otolaryngology clinic with use of currently available technology., Study Design: Prospective., Methods: Patients in a rural otolaryngology clinic were enrolled in a pilot telemedicine clinic. To assess system fidelity, an on-site and remote (consulting) otolaryngologist conducted simultaneous patient evaluations using streaming telecommunication technology for all aspects of the clinical encounter, including high-definition examination and endoscopic images. Both physicians and patients were blinded and diagnoses recorded. Post-encounter physician surveys and an original patient-centered TeleENT Satisfaction Questionnaire (TESQ) were used to assess overall satisfaction., Results: Twenty-one patients were enrolled consecutively. Visual technology was found acceptable in all cases, and audio technology was acceptable in 20 of 21 encounters. Patient satisfaction was 96%, and patients felt comfortable using a telemedicine system in the future. Encounters were not significantly longer than traditional encounters. Physician diagnostic agreement was found in 95% of cases, and the consulting physician indicated that all encounters provided sufficient history, examination, and high-quality images to generate an accurate diagnosis, order additional workup, and/or make an appropriate referral., Conclusion: A synchronous otolaryngology telemedicine clinic is comparable to a standard clinic in terms of diagnostic concordance and patient satisfaction when using streaming technology and high-definition images. Using telemedical technology may be a viable way to increase otolaryngology access in remote or underserved areas. With system validity now established, future studies will assess the feasibility of using trained on-site physician extenders (nurse practitioners or physician assistants) to conduct in-person patient encounters with remote otolaryngologist support., Level of Evidence: 2c. Laryngoscope, 128:1068-1074, 2018., (© 2017 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: Fiberoptic laryngoscopy is dependent on accurate descriptions of examination findings. Traditional recording methods can be impractical for inpatient consults. Therefore, we aim to determine the utility of a smartphone-coupled portable recording system with flexible laryngoscopy for transmitting information between resident and attending physicians in a real-time setting., Study Design: Pilot prospective study in a tertiary academic hospital., Methods: This is a prospective study of inpatient consultations in a tertiary referral hospital over a 3-month period from April 2015 to June 2015. Flexible laryngoscopy was performed by a resident physician, and mobile recordings were relayed to an attending physician. Concordance of laryngoscopy interpretations between resident and attending physicians as well as changes in management were documented., Results: Seventy-nine fiberoptic examinations were recorded and compared. Each consult was categorized as follows: airway evaluation (AE) (43%, 34/79), voice evaluation (VE) (3.7%, 3/79), dysphagia (D) (24%, 19/79), and aerodigestive tract mass/pathology (ADM) (29.1%, 23/79). Nine examinations showed discordance between resident and attending interpretations. Inter-rater agreement was good, with a kappa value of 0.747 (95% confidence interval: 0.643-0.851). The frequency of discordant exams within each group was as follows: AE (15%, 5/34), VE (33%, 1/3), D (11%, 2/19), and ADM (4.3%, 1/23). In five patients, changes in laryngoscopy interpretation changed clinical management. Seven nondiscordant exams had a change in management after attending review. Of the 79 exams, only one required repeat flexible laryngoscopy by the attending physician., Conclusions: Portable recording of flexible laryngoscopy is an effective tool for timely management of inpatient consultations., Level of Evidence: 4. Laryngoscope, 128:818-822, 2018., (© 2017 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: Prolonged wait times have become common. Electronic consultations (eConsults) have been shown in previous studies to reduce unnecessary face-to-face consultations to specialists, but no prior study has investigated the feasibility or efficacy of eConsults in an otolaryngology-head and neck surgery (OTO-HNS) practice., Study Design: Prospective observational study., Methods: The Champlain BASE eConsult system is a secure web portal allowing primary care physicians (PCPs) to communicate asynchronously with specialists about a patient, without requiring a formal face-to-face consult. The data from all eConsults sent through this portal to OTO-HNS practices between July 2011 and January 2015 were collected and analyzed., Results: Response time was rapid; over 40% of eConsults received a response within 24 hours, and nearly all eConsults were answered within 7 calendar days. The median response time was nearly 29 times faster than traditional face-to-face consultation. Unnecessary face-to-face referrals were avoided in 33.4% of all eConsults, and in nearly 50% of cases where the PCP initially planned a formal referral. PCPs reported adopting a new or additional course of action over 50% of the time following an eConsult. Eighty-eight percent of PCPs reported the service to be valuable for their patients, and 92% found it valuable for themselves. eConsults require only a limited time commitment from specialists, with over 75% taking less than 10 minutes to complete., Conclusions: eConsultation is a cost-effective system that can lead to decreased wait times, improved communication between PCPs and otolaryngologists, and help guide the development of targeted continuing professional development modules for PCPs., Level of Evidence: 4. Laryngoscope, 128:350-355, 2018., (© 2017 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: To describe the clinical presentation and role of the otolaryngologist in the evaluation of eosinophilic esophagitis (EoE) at a tertiary pediatric hospital., Study Design: Retrospective review., Methods: Records from pediatric patients with a diagnosis of EoE from 2003 to 2015 were reviewed. Study variables were analyzed to compare patients presenting to different specialties., Results: Two hundred and fifty-one patients with EoE were evaluated. The median age at diagnosis was 9.0 years (range 0.8-19.0); 73% were male. Sixty-seven percent of patients initially presented to gastroenterology and 18% to otolaryngology. Time from initial presentation to diagnosis did not differ between the patients presenting to the two specialties (median 2.3 vs. 2.0 months, P = 0.510). Overall, 26% presented with airway symptoms (stridor, chronic cough, croup, or dysphonia). Patients diagnosed by the otolaryngology service were younger (3.4 vs. 10.4 years, P < 0.0001), had a higher incidence of airway symptoms (68% vs. 15%, P < 0.001), and demonstrated fewer gastrointestinal symptoms (86% vs. 100%, P < 0.001)., Conclusion: Patients with EoE frequently present to otolaryngology undiagnosed in the first 5 years of life, making esophagoscopy with biopsy an important adjunct to airway endoscopy in children with refractory aerodigestive symptoms. Otolaryngologists are uniquely poised to facilitate early diagnosis and initiation of therapy for these children, potentially reducing long-term sequelae., Level of Evidence: 4. Laryngoscope, 127:1459-1464, 2017., (© 2016 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: To assess the efficacy of a novel high-fidelity epistaxis simulator in teaching epistaxis management to junior otolaryngology head and neck surgery residents., Study Design: Prospective cohort study., Methods: A novel high-fidelity epistaxis task trainer was developed using a cadaver head, intravenous tubing, and a food coloring-filled saline bag to emulate blood. Learners were instructed on two techniques of nasal packing (formal nasal pack and nasal tampon) for the management of epistaxis using the task trainer. Learners were videotaped attempting to pack the nose of the task trainer pre- and postintervention (verbal instruction, and practice time with task trainer). Five board-certified otolaryngologists (blinded to pre- and postintervention status) evaluated the packing technique using standardized subjective outcome measures., Results: There were 13 junior otolaryngology residents enrolled in the study. This cohort showed a statistically significant increase in global rating scores (P < 0.05) in all items measured for both packing methods., Conclusion: This novel cadaveric epistaxis simulator has been successful in teaching and the practical application of various skills in epistaxis management. This task trainer appears to confer an educational benefit in technical skills acquisition in novice learners. Further studies are needed to determine long-term skill retention. Simulation is a promising educational adjunct that effectively enhances epistaxis management skills acquisition while maximizing patient safety., Level of Evidence: NA. Laryngoscope, 126:1501-1503, 2016., (© 2015 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: To determine the otolaryngology needs in a free clinic providing care to medically indigent patients, as perceived by the patients and health care providers., Study Design: Cross-sectional survey., Methods: A survey was administered to patients and health care providers of a free clinic from September 2014 through January 2015 in an urban, inner-city location., Results: One hundred and thirty-seven patients (35.8% male, age 50.8 ± 13.0 years) completed the survey. Mean household income was $29,838 ± $10,425; 32.1% spoke English; 54.7% were employed; 10.2% had health insurance; and 37.2% had seen a primary care provider outside of the free clinic. The top three otolaryngology symptoms among patients were sleep apnea/snoring (39.4%), heartburn/reflux (30.7%), and dizziness (29.9%). Eleven health care providers (45% male, age 50.5 ± 15.3 years, 63.6% physician, 36% nurse) completed the survey. Providers perceived the following otolaryngology complaints as the most prevalent, in descending order: cough, nasal congestion, reflux/heartburn, sore throat, and ear infection/otalgia. Providers felt that sleep apnea and hearing loss were the less common otolaryngology complaints, whereas surveyed patients indicated these symptoms with high frequency. The most requested diagnostic tool among patients and providers was chest X-rays., Conclusion: There are unmet otolaryngology needs in a free clinic. Medically indigent patients have significant barriers to accessing health care. Patient and provider perceptions of top otolaryngology complaints differed, but both identified access to chest X-rays as a major unmet need. Knowledge of patient perceptions may help providers elicit the breadth of otolaryngology complaints., Level of Evidence: 4. Laryngoscope, 126:1321-1326, 2016., (© 2015 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: To examine the utilization of speech-language pathology (SLP) services by otolaryngology for outpatients with laryngeal/voice disorders., Study Design: Retrospective analysis of a large, national, administrative US claims database., Methods: The study population included patients with a laryngeal/voice disorder based on International Classification of Diseases, Ninth Revision, Clinical Modification codes from January 1, 2004 to December 31, 2008, seen by an otolaryngologist as an outpatient, and 12 months of follow-up. Data were collected on SLP evaluation and treatment and patient factors including age, gender, geographic region, employment status, initial laryngeal diagnosis, and laryngeal diagnosis change over 12 months. Multivariable logistic regression analysis was used to investigate factors associated with receipt of SLP evaluation and treatment., Results: There were 91,898 unique patients who met study criteria. A total of 4,485 (4.9%) patients had an SLP evaluation, of whom 2,216 (49.4%) had at least one voice therapy session. Patient age, gender, geographic region, and laryngeal diagnosis were associated with increased likelihood of receiving SLP services. Patients whose final laryngeal diagnosis changed from their initial diagnosis had greater odds of having an SLP evaluation (odds ratio = 1.18, 95% confidence interval = 1.06-1.31) compared to patients without laryngeal diagnosis change., Conclusions: SLP evaluation and treatment occurred in a minority of laryngeal/voice-disordered patients. Further study is needed to assess the impact of SLP services on the healthcare utilization of patients with laryngeal/voice disorders., Level of Evidence: 2C., (© 2015 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: Rhinologists are seeing an increasing number of immunosuppressed patients. Currently, no treatment paradigm exists for treating acute and chronic noninvasive rhinosinusitis (ARS, CRS) in this growing population. This study aims to identify patient and treatment factors that affect rhinosinusitis outcomes in this vulnerable population., Study Design: Prognostic retrospective cohort study., Methods: Immunocompromised patients treated by rhinologists for ARS or CRS 10/2007 to 10/2012 were identified by rhinosinusitis diagnostic codes, codes for transplant, cancer, HIV, diabetes, and codes indicating immunosuppression in the intensive care setting. Associations between patient factors and outcome were analyzed by logistic regression. Associations between treatment and outcome were analyzed by Firth logistic regression., Results: A total of 132 subjects were identified. Of those, 90.9% had CRS and 9.1% had ARS; 12.9% were transplant patients; 47% were diabetic; 37.9% were cancer patients; and 16.7% were in the intensive care unit. Patients with higher American Society of Anesthesiologists (ASA) scores had decreased disease resolution (odds ratio [OR] = 0.5, P = 0.021). Transplant patients (OR = 22.5, P = 0.001), diabetics patients (OR = 6.4, P = 0.017), cancer patients (OR = 5.4, P = 0.046), and patients with prior medical therapy for rhinosinusitis (OR = 5.84, P < 0.001) had increased disease resolution compared to immunosuppressed critical care patients. Patients treated with antibiotics alone had no statistically significant difference in disease resolution compared to those receiving no treatment. In contrast, treatment plans including surgery were associated with greater disease resolution., Conclusion: This data indicates that surgical treatment provides improved outcomes for patients presenting with acute exacerbations of rhinosinusitis related to their immunocompromised state. Given the limited study population, these findings may not apply to HIV-positive or ARS patients, and further study should be undertaken in these groups., Level of Evidence: 4., (© 2015 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: To describe the initial results of sialendoscopy as a diagnostic and therapeutic tool in pediatric inflammatory salivary gland disease., Study Design: Retrospective review of patient medical records from a private practice consisting of three fellowship-trained pediatric otolaryngologists., Methods: Consecutive pediatric patients with either recurrent or chronic sialadenitis underwent diagnostic and therapeutic sialendoscopy as an alternative to continued antibiotic therapy or surgical gland excision. Data collected included age, gender, indications for surgery, intraoperative findings, complications, recurrences, follow-up intervals, and need for additional procedures., Results: Twelve pediatric patients underwent sialendsocopy (9 cases of juvenile recurrent parotitis, 3 cases of chronic submandibular sialadenitis. Intraoperative findings included ductal stricture (n = 8), thick intraductal mucus (n = 6), and ductal calculus (n = 1). The only postoperative complication was one case of a submandibular gland, which remained enlarged for 1 month postoperatively before resolving. Average follow-up was 16.5 months (range: 1-49 months), during which time two patients had recurrence (17%). One patient had repeated recurrences that only resolved after salvage parotidectomy. Another patient had one isolated recurrence that resolved with antibiotics. To date, 92% of patients have not required any further surgical intervention after a sialendoscopy procedure., Conclusions: Sialendoscopy was successfully implemented as a safe and effective technique for management of recurrent and chronic parotid and submandibular sialadenitis in a pediatric otolaryngology practice., Level of Evidence: 4., (© 2014 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: To provide the otolaryngologist an evidence-based sound review of glucocorticoid use for laryngeal pathology., Study Design: Review of contemporary peer-reviewed literature as well as review articles., Methods: A review of the literature regarding glucocorticoids as a therapeutic intervention for the treatment of benign laryngeal pathology and laryngeal manifestations of systemic disease was performed. Review included both systemic administration as well as local injection., Results: Glucocorticoids, administered in the critical care setting for planned extubation, markedly reducing the risk of reintubation and remain a rudimentary pharmacologic adjunct in laryngeal manifestations of common autoimmune and inflammatory disorders. Intralesional injection has reduced the rate of surgical intervention for benign inflammatory primary laryngeal pathology., Conclusions: Glucocorticoids are effective in the treatment of a number of laryngeal pathologies, through both systemic and intralesional administration. However, a clear consensus for utilization of glucocorticoids in the treatment of specific laryngeal disorders has yet to be published., (© 2013 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: Previous studies showed that chronic rhinosinusitis (CRS) accounts for billions of dollars in healthcare resource utilization. However, all such study estimates of the economic burden of CRS were based on subpopulations in Western societies. This study aimed to investigate differences in the utilization of healthcare services between subjects with CRS and comparison subjects using Taiwan's National Health Insurance database., Study Design: A cross-sectional study., Methods: In total, 5,849 CRS subjects and 17,547 selected comparison subjects were included in this study. We evaluated healthcare resource utilization in a 1-year period. Variables of healthcare resource utilization included the following: numbers of outpatient visits and inpatient days, and the mean costs of outpatient and inpatient treatment. We also divided healthcare resource utilization into ear, nose, and throat (ENT) and non-ENT services., Results: On the utilization of ENT services, CRS subjects had significantly more outpatient visits (3.9 vs. 1.4, P < .001) and significantly higher outpatient costs (US$77.7 vs. US$19.4, P < .001) than comparison subjects. As for the use and costs of all healthcare services, CRS subjects had significantly more outpatient visits (27.9 vs. 18.3, P < .001) and significantly higher outpatient (US$953 vs. US$665, P < .001) and total (US$1319 vs. US$946, P < .001) costs than comparison subjects. Namely, on average, CRS subjects had 152% more outpatient visits and 139% higher total costs than comparison subjects., Conclusions: This study found that subjects with CRS had significantly higher use of all healthcare services and costs than aged-matched controls., Level of Evidence: 2c., (© 2013 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: To describe and analyze the causes and outcomes of lawsuits pertaining to sleep surgery to mitigate future litigation and improve physician education., Study Design: A retrospective review of a publicly available database containing jury verdicts and settlements., Methods: The LexisNexis MEGA Jury Verdicts and Settlements database was reviewed for all lawsuits including settlements and trial verdicts related to sleep surgery. Data including type of surgery performed, plaintiff allegation, nature of injury, outcomes, and indemnities were collected and analyzed., Results: Fifty-one cases met the inclusion criteria. Of these, 30 were decided by a jury, nine were settled out of court, and 10 were resolved by other means. Overall, 57% of known outcomes favored the defendant. The most common surgery performed was tonsillectomy (57%), followed by uvulopalatopharyngoplasty (45%), adenoidectomy (31%), and septoplasty (31%). No difference was found between outcomes when comparing the most common injuries cited, including wrongful death (P = .572), airway compromise (P = .376), and drug reaction (P = .443). If failure to recognize a complication (P = .034) or delay in diagnosis (P = .026) was a component of the legal allegations, the outcome significantly favored the plaintiff. The median settlement ($545,000) and plaintiff award ($1.45 million) were not significantly different (P = .13)., Conclusions: The majority of outcomes favored the defendant. Type of injury did not predict outcome. Failure to recognize complications and delay in diagnosis strongly predicted a verdict in favor of the plaintiff., Level of Evidence: 2c., (© 2014 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: To evaluate the cost-effectiveness of preapproval requirements for computed tomography (CT) of the sinuses in the evaluation and management of chronic rhinosinusitis (CRS)., Study Design: Retrospective analysis of prospectively collected data., Methods: Over a 6-month period, all sinus CT scans ordered by an otolaryngology practice and requiring preapproval by a third-party payor were tabulated. Characteristics of the preapproval process that were recorded and analyzed included time spent by office administrative staff, need for peer-to-peer review, and time spent by the ordering physician., Results: All 111 sinus CT scans ordered during the 6-month time period required preapproval based on insurer requirements-38 performed by computer, 71 by telephone, and two required both-costing an average of 8.1 minutes per scan by administrative staff (range, 2.0-20.0 minutes). Thirteen preapprovals required peer-to-peer telephone interaction by the ordering physician, utilizing an average of 7.7 minutes (range, 5-12 minutes). In no case was the insurance company peer an otolaryngologist. Ultimately, no sinus CT scan request was rejected by a third-party payor., Conclusions: Preapprovals for sinus CTs ordered by otolaryngologists are unlikely to save costs for third-party payors, as sinus CT for the evaluation of CRS is well established and therefore unlikely to be rejected. Preapproval in this context comes at the expense of practice administrative and physicians' time. Based on our results, preapproval for sinus CT scans ordered by an otolaryngologist for evaluation of CRS appears to be an unnecessary and costly requirement., Level of Evidence: N/A., (© 2013 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: To determine trends in office visits and medical specialty seen for surgical diagnoses of the thyroid gland., Study Design: A cross-sectional analysis of a national healthcare database., Methods: From the National Ambulatory Medical Care Survey (NAMCS), all cases of surgical thyroid disorders (e.g., benign neoplasm of thyroid gland, malignant neoplasm of thyroid gland, multinodular goiter) were extracted for 2 calendar year cohorts: 1995 to 1999 and 2005 to 2009. In addition to demographic information, the medical specialty of the health care provider seen was extracted. Comparisons were conducted for the proportion of surgical thyroid cases seen between general surgeons and otolaryngologists for the respective cohorts., Results: In the 1995 to 1999 cohort, there were a total of 107 ± 13 thousand outpatient visits annually to either general surgery or otolaryngology for surgical thyroid conditions. Among these, 62.7 ± 8.4 thousand visits (58.3 ± 5.6%) were seen by general surgery versus 44.8 ± 9.1 thousand (41.7 ± 5.6%) seen by otolaryngology. In comparison, in the 2005 to 2009 cohort, there were 218 ± 29 thousand visits annually for surgical thyroid conditions. Among these, 88.4 ± 17 thousand (40.5 ± 5.4%) were seen by general surgery versus 130 ± 21 thousand (59.5 ± 5.4%) seen by otolaryngology. The increase in proportion of surgical thyroid patients seen by otolaryngology in the second 5 year cohort was statistically significant (P = 0.032, chi-square)., Conclusions: There is a national trend in the United States toward otolaryngologists seeing an increasing majority proportion of increasingly prevalent surgical thyroid conditions. These data objectively confirm the perceived increasing role of otolaryngologists in the management of surgical thyroid disorders on a national level., (Copyright © 2013 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: To evaluate the efficacy of image-guided surgical navigation (IGSN) in otologic surgery and establish practice guidelines., Study Design: Prospective study., Methods: Between January 2003 and January 2010, all patients requiring complicated surgery for chronic otitis media, glomus jugulare, atresia, cerebrospinal fluid leak with or without encephalocele, and cholesterol granuloma of the petrous apex were offered IGSN. The accuracy of IGSN relative to pertinent pathology and 11 anatomic landmarks was established. Additionally IGSN-related operative time, complications, and surgical outcome were recorded., Results: In the study period there were 820 otologic procedures, among 94 patients (96 ears) with disease meeting proposed criteria. Thirteen patients (15 procedures) consented to the use of IGSN. All patients had a minimum 6 months of follow-up. The average additional operative time required was 36.7 minutes. The mean accuracy error was 1.1 mm laterally at the tragus but decreased to 0.8 mm medially at the level of the oval window. The mean accuracy of IGSN was within 1 mm in 10 of the 11 targeted surgical anatomic landmarks., Conclusions: Interactive image-guided surgical navigation during complex otologic surgery may improve surgical outcome and decrease morbidity by providing an accurate real-time display of surgical instrumentation relative to patient anatomy and pathology. In select cases, the extra cost of imaging immediately prior to surgery and extra operating room time may be compensated by enhancing the ability to distinguish distorted anatomy relative to disease, potentially improving surgical outcome. IGSN, although useful, does not replace surgical expertise and experience., (Copyright © 2012 The American Laryngological, Rhinological, and Otological Society, Inc.)

Objectives: Public reporting and transparency of patient experience is an emerging national healthcare priority. The objectives of this report are to describe patient satisfaction scores in ambulatory otolaryngology and examine the association of teaching status across multiple service domains., Study Design: Cross-sectional patient-level analysis of Press Ganey outpatient medical practice surveys completed by otolaryngology patients in fiscal year 2010., Methods: The survey contains 29 Likert-scaled items that comprise an overall score and scores in six service domains: access, visit, nursing, care provider, personal issues, and assessment. The item "likelihood-to-recommend practice" was measured as an indicator of patient loyalty. Surveys were grouped according to teaching or nonteaching setting. Mean scores were compared by Kruskal-Wallis rank test for nonparametric data with Bonferroni's correction for multiple comparisons. A dichotomous variable (ALL-5s) was created to measure percentages of surveys with highest scores in each domain. Multivariate logistic regression adjusting for sex, age, geographical region, urban-rural status, and first visit was performed to evaluate the association of teaching status with ALL-5s in each domain. Pearson correlation (r) was used to evaluate correlation of individual survey items to the "likelihood-to-recommend practice" question., Results: A total of 36,089 surveys were included, of which 16,057 (44%) were from a teaching setting. The mean age of respondents was 54.1 years (range, 0-90 years), and 52.7% were female. Patients seen in the teaching setting had lower mean scores overall and in domains of access, visit, and personal issues (P = .004) but had higher mean scores for likelihood-to-recommend practice (P = .007). No differences were identified between groups in domains of nursing, care provider, and assessment. Multivariate analysis of association of teaching setting with ALL-5s demonstrated that patients in a teaching setting were more likely to have the highest scores (ALL-5s) in the domain of nursing (OR, 1.09; 95% confidence interval [CI], 1.03-1.16; P = .002) and for the loyalty question of "likelihood-to-recommend practice" (OR, 1.12; 95% CI, 1.05-1.19; P = .001), and less likely to have highest scores for the overall survey (OR, 0.88; 95% CI, 0.83-0.93; P < .001) and domains of access (OR, 0.89; 95% CI, 0.84-0.94;P < .001) and visit (OR, 0.89; 95% CI, 0.85-0.94; P < .001). No association was identified between teaching status and domains of care provider, personal issues, and assessment. Survey items correlated with likelihood-to-recommend practice were similar between groups. Items most closely correlated with loyalty were all within the care provider domain consisting of "likelihood-to-recommend care provider" (r = 0.839), "confidence in care provider" (r = 0.785), and "concern care provider showed" (r = 0.733; P < .001). Items least closely correlated were within the visit domain related to waiting room comfort (r = 0.467), registration speed (r = 0.447), and wait time (r = 0.432; P < .001)., Conclusions: Otolaryngology patients evaluated in the teaching setting report lower patient satisfaction overall, primarily related to access to care and visit-specific processes; however, they are more likely to display loyalty and recommend their practice and care provider. The teaching setting does not influence care provider satisfaction scores. Because practice loyalty is most closely correlated to provider-specific behaviors, otolaryngologists may consider enhancement of provider-patient communication to improve patient satisfaction regardless of the practice setting. Academic otolaryngology practices should consider focusing on access systems and process improvement to enhance the overall patient experience., (Copyright © 2012 The American Laryngological, Rhinological, and Otological Society, Inc.)

Objectives/hypothesis: To measure the laryngeal resistance (R(L)), subglottal pressure (P(s)), and mean flow rate (MFR) of adductor (ADSD) and abductor (ABSD) spasmodic dysphonia patients using the airflow interrupter., Methods: The R(L) of six ABSD and seven ADSD patients was measured using the airflow interrupter, a noninvasive device designed to measure MFR and P(s) via mechanical balloon valve interruption. Subjects performed 10 trials at each of two intensity levels, with each trial consisting of a sustained /a/ during which phonation was interrupted for 500 ms. Laryngeal resistance was calculated as subglottal pressure divided by airflow., Results: Mean R(L) for the ADSD and ABSD subtypes at 65 dB were 24.78 cmH(2)O/L/s and 14.51 cmH(2)O/L/s, respectively (P = .04). Mean R(L) at 70 dB were 40.02 cmH(2)O/L/s and 15.84 cmH(2)O/L/s (P = .014). P(s) for the ADSD and ABSD subtypes at 65 dB were 10.23 cmH(2)O and 8.32 cmH(2)O, respectively (P = .582). At the 70 dB level, P(s) were 12.39 cmH(2)O and 11.78 cmH(2)O (P = .886). MFR for the ADSD and ABSD subtypes at 65 dB were 435 mL/s and 746 mL/s (P = .205). Mean MFR at 70 dB were 518 mL/s and 848 mL/s (P = .198)., Conclusions: Noninvasive measurements of R(L) may be useful for differentiating between ADSD and ABSD. This simple objective test, which produces a quantitative output, could be used to evaluate laryngeal function in patients with spasmodic dysphonia.

Objectives/hypothesis: Eosinophilic esophagitis is a rather new disease entity diagnosed with increasing frequency. The main symptoms in adults are dysphagia and food impaction. The aim of this review is to summarize the present knowledge about adult eosinophilic esophagitis, and in particular to cast light on certain issues of concern for the ear, nose, and throat (ENT) specialist., Study Design: Scientific review., Methods: The biomedical literature on adult eosinophilic esophagitis was reviewed regarding epidemiology, etiology, subjective symptoms and objective signs, diagnosis, treatment, and prognosis with an emphasis on matters of interest for the ENT specialist. PubMed was used as the search engine., Results: Among the 393 papers on eosinophilic esophagitis published in PubMed, only 162 deal with adults. During the last few decades, the annual number of papers has been exponentially increasing. A high prevalence of eosinophilic esophagitis in combination with a diagnostic delay suggests the existence of an unacceptable number of undiagnosed cases. This calls for increased attention. Endoscopic examination, including proper biopsies, verifies the diagnosis. Untreated, the disease will lead to substantial distress and in some cases even strictures. Keeping the diagnosis in mind will avoid improper treatment and the risk of accidental perforation., Conclusions: It is imperative that ENT specialists recognize patients with eosinophilic esophagitis.

Sleep medicine is an important component of current head and neck surgery practices. Furthermore, obstructive sleep apnea is an anatomic disease of the upper respiratory tract, a region of anatomy best known to head and neck surgeons. If head and neck surgeons choose to participate in the surgical treatment of sleep apnea, they must develop expertise in the evaluation and home sleep testing aspects of sleep apnea. Because positive airway pressure remains the front line treatment, they must also develop expertise in the prescription of positive airway pressure therapy.