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Objectives: To understand attentional preferences for normal and microtia ears., Methods: Eye-tracking technology was used to characterize gaze preferences. A total of 71 participants viewed images of 5 patients with unilateral microtia. Profile images of patient faces and isolated ears including normal, microtia, and post-reconstruction microtia ears were shown. Total time of fixation in predefined areas of interest (AOI) was measured. Inferential statistics were used to assess significance of fixation differences between AOIs within and between facial or auricular features., Results: The ear received most visual attention in lateral view of the face (1.91 s, 1.66-2.16 s) [mean, 95% CI], followed by features of the "central triangle"-the eyes (1.26 s, 1.06-1.46), nose (0.48 s, 0.38-0.58), and mouth (0.15 s, 0.15-0.20). In frontal view, microtia ears received less attention following surgical reconstruction (0.74 s vs. 0.4 s, p < 0.001). The concha was the most attended feature for both normal (2.97 s, 2.7-3.23) and reconstructed microtia ears (1.87 s, 1.61-2.13). Scars on reconstructed ears altered the typical visual scanpath., Conclusion: The ear is an attentional gaze landmark of the face. Attention to microtia ears, both pre- and post-reconstruction, differs from gaze patterns of normal ears. The concha was the most attended to subunit of the ear. Attentional gaze may provide an unbiased method to determine what is important in reconstructive surgery., Level of Evidence: NA Laryngoscope, 134:3136-3142, 2024., (© 2024 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives: The objective of this study is to determine whether machine learning may be used for objective assessment of aesthetic outcomes of auricular reconstructive surgery., Methods: Images of normal and reconstructed auricles were obtained from internet image search engines. Convolutional neural networks were constructed to identify auricles in 2D images in an auto-segmentation task and to evaluate whether an ear was normal versus reconstructed in a binary classification task. Images were then assigned a percent score for "normal" ear appearance based on confidence of the classification., Results: Images of 1115 ears (600 normal and 515 reconstructed) were obtained. The auto-segmentation task identified auricles with 95.30% accuracy compared to manually segmented auricles. The binary classification task achieved 89.22% accuracy in identifying reconstructed ears. When the confidence of the classification was used to assign percent scores to "normal" appearance, the reconstructed ears were classified to a range of 2% (least like normal ears) to 98% (most like normal ears)., Conclusion: Image-based analysis using machine learning can offer objective assessment without the bias of the patient or the surgeon. This methodology could be adapted to be used by surgeons to assess quality of operative outcome in clinical and research settings., Level of Evidence: 4 Laryngoscope, 133:2413-2416, 2023., (© 2022 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: Post-tonsillectomy hemorrhage (PTH) is a potentially life-threatening complication. A recent meta-analysis suggests that ibuprofen may increase the risk of PTH. The aims of this study were to 1) re-evaluate the effect of ibuprofen on PTH given additional recent evidence and 2) to evaluate a potential dose effect of ibuprofen., Study Design: Meta-analysis and meta-regression; single-institution retrospective review., Methods: We conducted a systematic review of the literature and a meta-analysis of 12 studies comparing postoperative ibuprofen analgesia to non-nonsteroidal anti-inflammatory drug (NSAID) controls. Next, we performed a meta-regression analysis to assess for an effect of dose, if any, on rates of PTH. Five studies specifying a dose of 5 mg/kg (828 patients, 1,411 controls) and 7 studies using 10 mg/kg (5,633 patients, 7,656 controls) were included. We then conducted a novel single-institution, retrospective review of data for 1,046 patients prescribed intermediate-dose 7.5 mg/kg ibuprofen., Results: Ibuprofen was not associated with an increased rate of PTH (log odds ratio [OR], 0.21; 95% confidence interval [CI] -0.15, 0.57). Meta-regression showed that ibuprofen dose (5 and 10 mg/kg) did not have a statistically significant effect on PTH (OR, 1.32; 95% CI 0.30, 5.84). Uncontrolled, aggregate rates of PTH across all studies were 2.29% (N = 828) for 5 mg/kg and 4.65% (N = 5,633) for 10 mg/kg dosing. The rate of secondary hemorrhage in patients prescribed 7.5 mg/kg ibuprofen was 3.10% (N = 1,046)., Conclusion: We found no statistically significant increased risk of PTH when ibuprofen is prescribed at the low or high range of commonly used clinical dosages, compared to a non-ibuprofen regimen. Further studies with less heterogeneity are needed to determine if there is a clinically relevant dose-dependent difference in PTH with ibuprofen., Level of Evidence: 3 Laryngoscope, 132:1473-1481, 2022., (© 2021 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives: To determine whether hearing aid (HA) use affects social perceptions of general public adults and age-matched peers and if so, determine if effects are modulated by lack of societal representation of pediatric HAs., Methods: A 10-year-old boy was presented in six photographic conditions with and without HAs and eyeglasses (a worn sensory aid with wider societal representation). HAs were presented in neutral skin tone and bright blue colors. Photographic conditions were embedded into web-based surveys with visual analog scales to capture social perceptions data and sourced to 206 adults (age 18-65) and 202 peers (age 10) with demographic characteristics representative of the general US population. Mean differences in scores for each condition compared to control images were computed using two-tailed t-tests., Results: In both adult and child respondents, HAs were associated with decreased athleticism, confidence, health, leadership, and popularity. Glasses were associated with decreased athleticism and popularity but increased intelligence, overall success, and in the child respondents, friendliness. When worn in combination, the beneficial effects of glasses were mitigated by brightly colored but not neutrally colored HAs., Conclusion: Negative effects of pediatric HAs on social perceptions may be influenced by poor societal representation of HAs. These results suggest that greater representation of pediatric HAs is necessary to make society more inclusive for children with hearing loss., Level of Evidence: 4 Laryngoscope, 131:E2387-E2392, 2021., (© 2021 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: To analyze the impact of hospital safety-net burden on survival outcomes for laryngeal squamous cell carcinoma (LSCC) patients., Study Design: Retrospective cohort study., Methods: From 2004 to 2015, 59,733 LSCC patients treated with curative intent were identified using the National Cancer Database. Low (LBH) <25th, medium (MBH) 25th-75th, and high (HBH) >75th safety-net burden hospitals were defined by the percentage quartiles (%) of uninsured/Medicaid-insured patients treated. Social and clinicopathologic characteristics and overall survival (using Kaplan-Meier survival analysis) were evaluated. Crude and adjusted hazard ratios (HR) with 95% confidence intervals (CI) were computed using Cox regression modeling., Results: There were 324, 647, and 323 hospitals that met the criteria as LBH, MBH, and HBH, respectively. The median follow-up was 38.6 months. A total of 27,629 deaths were reported, with a median survival of 75.8 months (a 5-year survival rate of 56.6%). Median survival was 83.2, 77.8, and 69.3 months for patients from LBH, MBH, and HBH, respectively (P < .0001). The median % of uninsured/Medicaid-insured patients treated among LBH, MBH, and HBH were 3.6%, 14.0%, and 27.0%, respectively. Patients treated at HBH were significantly more likely to be young, Black, Hispanic, of low income, and present with more advanced disease compared to LBH and MBH. Survival was comparable for LBH and MBH (HR = 1.02; 95% CI = 0.97-1.07, P = .408) on multivariate analysis. HBH, compared to LBH patients, had inferior survival (HR = 1.07; 95% CI = 1.01-1.13, P = .023)., Conclusions: High burden safety-net hospitals receive disproportionately more patients with advanced-stage and low socioeconomic status, yielding inferior survival compared to low burden hospitals., Level of Evidence: 3 (individual cohort study) Laryngoscope, 131:E1987-E1997, 2021., (© 2021 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives: To examine the social perception of microtia and quantify the effect of reconstruction on socially perceived attributes., Methods: Parental consent was obtained for peri-reconstruction photographs in a patient with unilateral grade 3 microtia without an underlying craniofacial syndrome. With computer simulation, the normal, preoperative microtia, and postoperative reconstruction ear were isolated and blended into the oblique and lateral views of that volunteer's face to isolate ear morphology as a variable against a constant facial baseline. These photographs were embedded into Web-based surveys with visual analogue scales to capture social perception data and then were sourced to general population adults., Results: Survey respondents totaled 631. On average, the face with the microtia ear was perceived to be less friendly (P = .015), less healthy (P = .022), and less successful (P = .005) than the same face with the "normal" ear. There were no statistically significant differences in socially perceived attributes between the face with the normal ear and the face with the reconstructed ear., Conclusion: This is the first study to examine the social perception consequences of microtia and microtia reconstruction in children. These findings may explain the significant psychosocial distress experienced by these patients by exploring the social perception of specific attributes perceived. Lastly, this study may better inform microtia patients and their physicians on the impact of auricular reconstruction on third party's perception of social attributes., Level of Evidence: N/A Laryngoscope, 131:195-200, 2021., (© 2020 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: To determine the optimal sequencing of chemoradiotherapy for locally advanced laryngeal cancer. The hypothesis was that concurrent chemoradiotherapy (CCRT) would be associated with improved overall survival (OS) compared to induction chemotherapy followed by radiotherapy (RT)/surgery (IC)., Methods: The National Cancer Database identified 8,154 patients with American Joint Commission on Cancer stage III/IV (excluding T1) laryngeal cancer between 2004 and 2013 treated with one of the established organ preservation techniques: CCRT or IC. The association between OS and total radiation dose (< 66 gray [Gy] or ≥ 66 Gy) was analyzed using the Kaplan-Meier method, as was the association between OS and timing of IC (21-42, 43-100, or 101-120 days before RT). Hazard ratios (HR) adjusted for patient and clinical characteristics were computed using Cox regression modeling., Results: The median follow-up was 32.7 months. The estimated 5-year OS for CCRT and IC was 49.9% and 50.6%, respectively (P = 0.653). On multivariate analysis, no difference was observed between the two regimens (IC, adjusted HR 0.96, 95% confidence interval [CI] 0.88-1.04, P = 0.268). Radiation dose ≥66 Gy had improved OS overall in CCRT group but not in IC patients. When comparing CCRT and IC in patients receiving ≥66 Gy, there was no difference in OS (adjusted HR 0.97, 95% CI 0.89-1.06, P = 0.552). Patients starting chemotherapy 21 to 42 or 101 to 120 days prior to RT had inferior OS compared to patients starting between 43 to 100 days., Conclusion: For locally advanced laryngeal cancer, there is no difference in OS between CCRT and IC. Factors associated with survival included radiation dose and timing of induction chemotherapy before RT., Level of Evidence: 3b Laryngoscope, 129:2313-2320, 2019., (© 2019 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: Randomized data comparing surgery to radiation for locally advanced oropharyngeal cancer (OPC) are lacking. This study evaluated practice patterns and overall survival outcomes from the National Cancer Database., Methods: A total of 22,676 patients with stage III to IV, locally advanced OPC were treated between 2004 to 2013 with primary chemoradiation (CRT) or surgery with adjuvant radiotherapy with or without chemotherapy (aRT ± CT). Survival rates were estimated using the Kaplan-Meier method. Crude and adjusted hazard ratios (HR) were computed using Cox regression modeling., Results: Median follow-up was 40.7 months; 8,555 and 14,121 patients received surgery with aRT ± CT and CRT, respectively. Corresponding 3-year survival was 85.4% and 72.6% (P < 0.0001). On multivariate analysis, adjusting for age, gender, race insurance status, median income, percentage with no high-school degree, Charlson-Deyo score, clinical tumor and node stage, tumor grade, facility type, treatment at > 1 facility, and human papillomavirus (HPV) status, surgery with aRT ± CT had a reduced hazard of death, HR, 0.79 (95% confidence interval 0.69-0.91), P = 0.001., Conclusion: Primary surgery with aRT ± CT for locally advanced OPC has an improved survival compared to primary radiation-based treatment even when stratified by HPV status., Level of Evidence: 2c. Laryngoscope, 128:1353-1364, 2018., (© 2017 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: Randomized trials have demonstrated that adjuvant chemoradiotherapy (CRT) confers an overall survival (OS) benefit over adjuvant radiation therapy (RT) alone in patients with resected head and neck squamous cell carcinoma (HNSCC) with adverse pathologic features (positive surgical margins [SM+] and/or extracapsular extension [ECE]). Whether this OS benefit exists in an elderly population remains unknown., Study Design: Retrospective database study., Methods: Using the National Cancer Database, we identified 1,686 elderly patients (age ≥70 years) with resected HNSCC with SM+ and/or ECE, who received adjuvant CRT (491 patients, 29%) or adjuvant RT alone (1,195 patients, 71%) between 1998 and 2011. Three-year survival rates were estimated using the Kaplan-Meier method both before and after propensity score matching (PSM). Crude and adjusted hazard ratios (HR) with 95% confidence intervals (CI) were computed using Cox regression modeling., Results: Median follow-up was 23.5 and 42.8 months for all and surviving patients, respectively. Three-year OS was 50.7% and 44.4% among patients receiving adjuvant CRT and RT alone, respectively (P = .002). On multivariate analysis, there was no significant improvement in OS with adjuvant CRT relative to adjuvant RT alone (HR: 0.88, 95% CI: 0.73-1.06). Similarly, a PSM cohort showed no significant difference in the 3-year OS for patients receiving adjuvant CRT versus adjuvant RT alone (48.8% and 50.9%, respectively; P = .839)., Conclusions: Although the addition of chemotherapy to adjuvant RT has been proven effective in randomized trials of patients with resected HNSCC with SM+ or ECE, it may be less efficacious in an elderly patient population treated outside of a controlled trial setting., Level of Evidence: 2c. Laryngoscope, 128:831-840, 2018., (© 2017 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: Determine whether facility type effects overall survival in patients with oral cavity cancer., Study Design: Retrospective cohort study., Methods: Patients included in the National Cancer Database who were diagnosed with oral cavity cancer between 1998 and 2011 were included in the study. Data was stratified by facility where care was provided, including community cancer programs (CCP), comprehensive community cancer programs (CCCP), and academic centers (AC). Univariate analysis was performed using analysis of variance, chi squared, and log-rank test, whereas multivariate analysis was performed using Cox regression., Results: A total of 32,510 patients were included in the study, with 7.58% of patients receiving care at CCPs (n = 2,553), 39.53% at CCCPs (n = 12,852), and 52.61% at ACs (n = 17,105). Between 1998 and 2011, there was a greater percentage of patients receiving care at ACs, and a greater percentage of patients receiving surgical therapy versus nonsurgical therapy. Patients treated at ACs had the best 5-year overall survival of 51.26%, with a significant difference across facility types (P < 0.01). After adjusting for confounders, receiving care at ACs was a positive predictor of survival (hazard ratio: 0.95 95% confidence interval [0.91,0.98]))., Conclusion: Patients treated at ACs are more likely to receive surgical treatment, and have a greater 5-year overall survival compared to those patients treated at CCPs and CCCPs. Therefore, we advocate referring patients with advanced oral cavity cancers to ACs., Level of Evidence: 4. Laryngoscope, 127:2551-2557, 2017., (© 2017 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: Although several imaging characteristics of human papillomavirus (HPV)-related head and neck squamous cell carcinoma (HNSCC) have been reported, imaging features of nodal metastasis and influence to outcomes have not been well studied thus far. The purpose of the study was to investigate the imaging characteristics of nodal metastasis by HPV status in HNSCC and to clarify whether those findings influence the outcomes., Study Design: Retrospective review., Methods: Computed tomography and magnetic resonance imaging for initial staging on 139 patients of HNSCC with known HPV status were retrospectively reviewed. We investigated imaging characteristics of the nodal metastasis including the presence of extracapsular spread (ECS), and also investigated the influence of nodal metastasis characteristics to outcomes by HPV status. Two-year actuarial control and survival rates were estimated using the Kaplan-Meier product-limit method (P < 0.05)., Results: Eighty-eight patients with nodal metastasis were identified and outcome information was available for 78 patients. Nodal metastasis was significantly more common in HPV-positive patients compared to HPV-negative patients (75% vs. 54%, P = 0.009). HPV-positive patients showed a higher prevalence of ECS compared to HPV-negative patients (77% vs. 56%, P = 0.041). The prevalence of disease recurrence was more common in HPV-negative patients (67% vs. 13%, P < 0.0001), and it was independent of the presence of ECS in nodal metastasis., Conclusions: Nodal metastases were significantly more common in HPV-positive HNSCC, whereas the prevalence of disease recurrence was greater in HPV-negative HNSCC. Although ECS was noted in the majority of the HPV-positive patients with nodal metastasis, rates of recurrence were lower compared to HPV-negative patients., Level of Evidence: 4., (© 2015 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives: To determine the impact of race on laryngeal preservation strategies and overall survival (OS) for laryngeal squamous cell carcinoma (SCC)., Study Design: Retrospective, national cancer database analysis., Methods: Data were extracted from the Surveillance, Epidemiology, and End Results database. Chi-square test, Kaplan-Meier method, and Cox regression models were employed in SPSS 20.0 (Armonk, NY: IBM Corp.) for data analyses., Results: A total of 24,069 patients with laryngeal SCC were identified. Of these, 18,166 (75.5%) patients were white, 3,475 (14.4%) were black, 1,608 (6.7%) were Hispanic, and 820 (3.4%) were Asian. Compared with other races, black patients were more likely to be diagnosed at a younger age (P < 0.001), undergo lymph node dissection (P < 0.001), have nodal metastasis (P < 0.001), be with advanced stage disease (P < 0.001), and be unmarried (P < 0.001). Black patients with T1 to T2 and T3 disease were more likely to undergo total laryngectomy as compared with white patients (T1-2: 8.2% vs. 4.3%; P < 0.001; T3: 28.4% vs. 24.3%; P = 0.023). For patients with T4 disease, however, rates of primary radiotherapy among black patients were higher (40.5% vs. 35.7%; P = 0.015). The 5-year OS for white, black, Hispanic, and Asian patients were 60.6%, 52.7%, 59.5% and 65.7% (P < 0.001). This significant 5-year OS difference by race persisted regardless of age, gender, year of diagnosis, primary treatment, nodal status, or tumor grade. On multivariate analysis, race remained an independent prognostic factor for OS., Conclusions: Race is an independent prognostic factor for OS. Further studies are warranted to evaluate causes for racial disparities and discrepancies in OS and laryngeal preservation strategies., (© 2015 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: To evaluate the impact of case volume and other variables on outcomes after head and neck oncologic surgery was performed at academic medical centers in the United States., Study Design: Cross Sectional Ecological Study., Methods: The University HealthSystems Consortium (UHC) database was analyzed for discharge data on all patients who underwent surgery for head and neck cancers (excluding thyroid and skin cancer) at full- member academic medical centers between quarter 4 of 2006 and quarter 4 of 2009. Multivariate and linear regression analyses and chi-square tests were applied to evaluate significant associations between hospital surgical volume and other independent variables, and to evaluate the risk of mortality, mortality index, complications, length of stay (LOS), LOS index, cost, and cost index., Results: Of 22,357 surgical cases, 11,573 met our inclusion criteria. The only outcome that was statistically significant based on volume was a lower complication rate in high volume hospitals (P = 0.0486) as compared to low volume hospitals. All Payer Refined-Diagnosis Related Group defined major severity of illness was the only independent variable significantly associated with higher complication rates, observed LOS, and observed cost (P <0.0001, P = 0.0139, and P = 0.0092, respectively). Management of male patients and black patients resulted in a lower cost index (P = 0.0472) and a higher complication rate (P = 0.0297), respectively. Patients with private insurance had lower complication rates, observed LOS, and observed cost (P = 0.0401, P = 0.0001, and P = 0.0187, respectively)., Conclusions: After controlling for other factors, academic medical centers with a higher cumulative case volume have lower rates of complications., (Copyright © 2012 The American Laryngological, Rhinological, and Otological Society, Inc.)