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Telemedicine utilization among otolaryngologists was rare prior to the COVID‐19 pandemic. We sought to understand rates of telemedicine utilization by otolaryngologists amid unprecedented changes in care delivery during the pandemic. Using Medicare Physician/Supplier Procedure Summary data, we performed a retrospective cross‐sectional analysis of telemedicine services provided to Medicare beneficiaries by otolaryngologists in 2020. The total number of services and amount of reimbursement received by otolaryngologists for telemedical care increased by 52,989% and 73,147% in 2020 relative to 2019: 139,094 vs 262 services and $9.9 million vs $13,536, respectively. The mean telemedicine revenue per otolaryngologist offset only 8.8% ($9304.69) of losses from the reduction in mean in‐person revenue between 2019 and 2020. Further research will be necessary to inform successful adoption of telemedicine within our field amid the ongoing COVID‐19 pandemic. [ABSTRACT FROM AUTHOR]

Objective: We surveyed otolaryngology program directors (PDs) and recent otolaryngology residency graduates on the operative autonomy of graduating residents and their comfort with independent practice. Methods: An anonymous survey was sent to otolaryngology PDs and recent graduates of training programs (members of the Young Physicians Section [YPS] of the American Academy of Otolaryngology‐Head and Neck Surgery Foundation). Questions were developed around the 14 key indicator procedures (KIPs) defined by the Accreditation Council for Graduate Medical Education. Results: Fifty PDs (43% of PDs) and 152 recent graduates (6% of YPS members) responded. Over 90% of participating PDs felt their graduating residents were either somewhat or extremely comfortable performing 12 out of 14 KIPs. Among the 12 procedures PDs felt their graduating residents were comfortable performing, 57% to 95% of recent graduates also felt either somewhat or extremely comfortable performing them by graduation. Similarly, at least 90% of responding PDs felt their residents achieved meaningful autonomy in the last 2 months of residency prior to graduation for 11 of 14 KIPs. For these same 11 procedures, 74% to 95% of recent graduates indicated they achieved meaningful autonomy. The procedures that PDs and recent graduates felt required the most surgical assistance were ossiculoplasty/stapedectomy, rhinoplasty, and mastoidectomy. All PDs agreed or strongly agreed that graduating residents are comfortable operating and taking call as general otolaryngologists, compared to 86% and 93% of recent graduates. Conclusion: Most PDs and recent graduates agree that residents are well‐prepared for general otolaryngology practice with the exception of select KIPs. Level of evidence: 4. [ABSTRACT FROM AUTHOR]

Objectives: Socioeconomic factors affect oncologic outcome in sinonasal squamous cell carcinoma (SNSCC). However, the relationship between these factors and stage at presentation (SAP)—a critical, early point in the care cycle—is not known. This study sought to determine the role of race/ethnicity, treatment facility type, insurance status/carrier, and other socioeconomic factors in SAP and survival among patients with advanced SNSCC. Study Design: Retrospective cohort study. Methods: Using the National Cancer Database, 6,155 patients with SNSCC were identified and divided into those with "early" (Stage I or II; 2,212 (35.9%)) versus "advanced" (Stage III or IV; 3,943 (64.1%)) disease. Associations between sociodemographic and socioeconomic factors on SAP and survival were analyzed using multivariable logistic regression and Cox proportional hazard models. Results: Black (odds ratio [OR]: 2.18, CI: 1.74–2.76), Asian and Pacific Islander (API) (OR: 2.37, CI: 1.43–4.14), and Medicaid or uninsured (OR: 2.04, CI: 1.66–2.53) patients were more likely to present with advanced disease. Among patients with advanced disease, API patients demonstrated the highest 10‐year survival rate (30.2%), and Black patients had the lowest 2‐, 5‐, and 10‐year survival rates (47.7%, 31.9% and 19.2%, respectively). Older age (HR:1.03, CI:1.03–1.04), Black race (HR:1.39, CI:1.21–1.59), Medicaid or uninsured status (HR:1.48, CI:1.27–1.71), and treatment at a community hospital (HR:1.25, CI:1.14–1.37) were associated with poorer overall survival among patients with advanced disease. Conclusions: Factors including race/ethnicity, treatment facility type, insurance status/carrier, and other socioeconomic factors influence SAP and survival in SNSCC. An improved understanding of how these factors relate to outcomes may elucidate opportunities to address gaps in education and access to care in vulnerable populations. Level of Evidence: 4 Laryngoscope, 131:2421–2428, 2021 [ABSTRACT FROM AUTHOR]

The degree of markup between provider charges and Medicare prices reflects the potential balance bill for out-of-network commercially insured patients. Using publicly available Medicare data, we performed a retrospective cross-sectional analysis of markup ratios (MRs; ie, the ratio of submitted charges to Medicare-allowed prices) for services commonly performed by otolaryngologists in 2017. Median MRs were as follows: 2.9 (interquartile range, 2.0-4.3) in facility settings (eg, hospital) and 2.1 (interquartile range, 1.7-2.9) in nonfacility settings (eg, physician office). Among the 10 highest-markup procedures performed by otolaryngologists in facility and nonfacility settings, there was no consistent increase in median MRs between 2012 and 2017 (compound annual growth rates, –4.6% for labyrinthotomy to 24.6% for ultrasound-guided biopsy). Median MRs for these procedures were not consistently lower in states with surprise billing protection laws. These findings may reflect the comparatively low potential to "balance bill" patients for elective otolaryngologic services and the limitations of state-level protections against surprise billing. [ABSTRACT FROM AUTHOR]

Gender disparities are prevalent in medicine, but their impact on surgical training is not well studied. To quantify gender disparities in trainee intraoperative experiences and explore the variables associated with ratings of surgical autonomy and performance. From September 2015 to May 2019, attending surgeons and trainees from 71 programs assessed trainee autonomy on a 4-level Zwisch scale and performance on a 5-level modified Dreyfus scale after surgical procedures. Multivariable regression models were used to examine the association of trainee gender with autonomy and performance evaluations. A total of 3255 trainees and attending surgeons completed 94 619 evaluations. Attendings gave lower ratings of operative autonomy to female trainees than male trainees when controlling for training level, attending, and surgical procedure (effect size B = −0.0199, P =.008). There was no difference in ratings of autonomy at the beginning of training (P =.32); the gap emerged as trainees advanced in years (B = −0.0163, P =.020). The gender difference in autonomy was largest for the most complex cases (B = −0.0502, P =.002). However, there was no difference in attending ratings of surgical performance for female trainees compared to male trainees (B = −0.0124, P =.066). Female trainees rated themselves as having less autonomy and worse performance than males when controlling for training level, attending, procedure, case complexity, and attending ratings (autonomy B = −0.0669, P <.001; performance B = −0.0704, P <.001). While there was no significant difference in ratings of operative performance, a small difference between ratings of operative autonomy for female and male surgical trainees was identified. [ABSTRACT FROM AUTHOR]

Objectives: To determine preference patterns for topical anesthesia in patients undergoing endoscopy pre‐coronavirus (2019 coronavirus disease [COVID‐19]) pandemic and analyze outcomes based on preference, using a decision aid format. Methods: A decision aid was developed with expert and patient input. New patients presenting to subspecialty clinics over a 2‐month pre‐COVID‐19 period completed a pre‐procedure survey about their priorities, then were asked to choose between topical oxymetazoline/lidocaine spray or none. A post‐procedure outcome survey followed. Results: Of 151 patients, 90.1% patients elected to have topical anesthesia. Top patient priorities were "I want the scope to be easy for the doctor" and "I want to be as comfortable as possible." Patients who strongly wanted to avoid medication (P =.002) and bad taste (P =.003) were more likely to select no spray, whereas those who wanted to avoid pain received anesthetic (P =.011). According to the post‐procedure assessment, 95.4% of patients were satisfied or strongly satisfied their choice, and this did not correlate with anesthetic vs none. Conclusions: Patient preferences are easily elicited and correlate with treatment choices. Most patients chose to have topical anesthetic and were willing to tolerate side effects; however, both patients with and without topical anesthetic were satisfied with their choices. This decision aid can be used to optimize shared decision making in the otolaryngology clinic. Given the aerosolizing potential of both spray and no spray conditions, this insight may be consequential when devising office protocols for post‐COVID‐19 practice. Level of evidence: II. [ABSTRACT FROM AUTHOR]

Introduction: Chronic rhinosinusitis (CRS) is associated with a significant decrease in general health‐related quality of life (QOL). The EuroQol 5‐dimensional questionnaire measures general health‐related quality of life through a health utility value (EQ‐5D HUV)—based on five domains reflecting mobility, self‐care, activities of daily life, pain/discomfort, and anxiety/depression—and an unbiased visual analog scale (EQ‐5D VAS). We sought to identify characteristics of CRS patients with a high EQ‐5D HUV but low EQ‐5D VAS score. Materials and Methods: Retrospective cross‐sectional study of 300 CRS patients with EQ‐5D HUV equal to 1.0 (reflecting perfect health). All patients completed a 22‐item Sinonasal Outcome Test (SNOT‐22)—from which nasal, sleep, ear/facial discomfort, and emotional subdomain scores were calculated, as well as the EQ‐5D. Low EQ‐5D VAS was defined as a score less than 80. Results: On multivariate analysis, low EQ‐5D VAS was associated with only the SNOT‐22 sleep subdomain score (odds ratio [OR] = 1.07, 95%CI: 1.02–1.12, P =.003). Comorbid asthma was also associated with lower EQ‐5D VAS (OR = 2.16, 95%CI: 1.02–4.59, P =.045). In contrast, polyps were negatively associated with having a lower EQ‐5D VAS (OR = 0.34, 95%CI: 0.17–0.69, P =.003). Conclusion: There are patients with perfect general health‐related QOL according to a health utility value‐based methodology (like the EQ‐5D HUV) who report low general health‐related QOL on an unbiased measure like the EQ‐5D VAS. In CRS patients with perfect EQ‐5D HUV, poor sleep and asthma were associated with low QOL on the EQ‐5D VAS, while polyps were negatively associated with low QOL. Level of Evidence: 3 Laryngoscope, 131:1206–1211, 2021 [ABSTRACT FROM AUTHOR]

Objectives: Chronic rhinosinusitis (CRS), like other sinonasal diseases, may be associated with avoidance of daily activities. Our goal was to identify characteristics associated with avoidance of activities due to CRS. Materials and Methods: A total of 194 CRS patients were recruited. CRS symptom burden was assessed with the 22‐item Sinonasal Outcome Test (SNOT‐22). SNOT‐22 nasal, sleep, ear/facial discomfort and emotional/psychological subdomain scores were calculated. Depressed mood was assessed using the two‐item Patient Health Questionnaire (PHQ‐2). Personality traits including conscientiousness, neuroticism, agreeableness, openness, and extraversion were assessed using the Big Five Inventory‐10 (BFI‐10) questionnaire. As the primary outcome, participants rated how often in the prior week that they had avoided any activities in day‐to‐day life due to their nasal or sinus symptoms on a scale of "never," "rarely," "sometimes," "often," or "extremely often." Ordinal regression models, with bootstrap validation, were used to identify associations between activity avoidance and participants' characteristics. Results: On multivariable analysis, SNOT‐22 score (odds ratio [OR] = 1.03, 95% CI, 1.01–1.04, P =.026), and conscientiousness personality trait (OR = 1.38, 95% CI, 1.05–1.81, P =.019) were positively associated with activity avoidance while age (OR = 0.98, 95% CI, 0.96–0.99, P =.049) was negatively associated with activity avoidance. Of CRS symptom burden/SNOT‐22 subdomains, only the emotional/psychological subdomain score (OR = 1.28, 95% CI, 1.12–1.46, P <.001) was associated with activity avoidance. Conclusion: Younger age and the conscientiousness personality trait were associated with activity avoidance in CRS patients. Of CRS‐associated symptomatology, sadness and embarrassment were associated with activity avoidance. Emotional traits and personality most strongly predict avoidance of activities in CRS patients. Level of Evidence: 2c. Laryngoscope, 131:707–712, 2021 [ABSTRACT FROM AUTHOR]

Objective  This study aimed to describe the impact of adverse clinical and pathologic features in sinonasal squamous cell carcinoma (SCC). Design  This study is designed with retrospective chart review. Setting  The present study is conducted at a tertiary care institution. Participants  All patients treated surgically for sinonasal SCC at our tertiary care institution between January 2006 and December 2013. Main Outcome Measures  Overall survival (OS) and disease free survival (DFS) are the final measurement of this study. Results  Forty-eight patients were identified. Mean age at surgery was 65.8 years, and mean follow-up time was 40.7 months. Eighteen patients (38%) had T1–T3 disease, while 30 patients (63%) had T4 disease. Seven patients (8.3%) had nodal disease at presentation. At 2, 5, and 10 years, OS was 71, 54, and 48%, respectively, while DFS was 64, 51, and 45%, respectively. Twelve patients (25%) experienced local recurrences with mean time to recurrence of 15.3 months. Twenty-five patients (52%) had positive margins, 24 (50%) had high-grade tumors, 18 (38%) had perineural invasion (PNI), and 15 (31%) had lymphovascular invasion (LVI). In the univariate analysis, T4 disease (risk ratio [RR] = 2.7) and high grade (RR = 2.4) had a significant association with DFS. In the multivariate analysis, high grade (RR = 4.0 and 4.5) and LVI (RR = 4.1 and 4.7) had a significant association with OS and DFS. Conclusion  Our single-institution experience of 48 patients suggests that high grade and LVI are independently associated with survival outcomes in sinonasal SCC, while PNI and microscopically positive margins do not have a significant impact. [ABSTRACT FROM AUTHOR]

Objective: Women represent approximately 28.0% of academic otolaryngologists. Previous studies have shown that women in academic medicine, including surgical subspecialties, have disparate career advancement opportunities and grant funding compared to male counterparts. Representation at major academic meetings is an important career advancement opportunity. In this study, we assess the representation of women at otolaryngology conferences.Study Design: Cross-sectional analysis of otolaryngology conference programs.Methods: All publicly available scientific programs from The American Academy of Otolaryngology-Head and Neck Surgery Foundation Annual Meeting (AAO-HNSF), the Triological Society Annual Combined Sections Meeting (TS), and the Triological Society Annual Meeting at Combined Otolaryngology Spring Meetings (TS-COSM) were obtained and analyzed. Name and gender were collected, along with the type of role: speaker, panelist, oral session moderator, and other leadership positions. Yearly trends were analyzed and compared between the conferences and in aggregate.Results: AAO-HNSF had available scientific programs from 2012-2017, while TS and TS-COSM had programs available from 2003-2018. Across all conferences and years, 16.9% of recorded opportunities were occupied by women, with an upward trend from 2005 to 2018. Program committees had the highest proportion of women (21.4%) and presidential citation and guest of honor recipients had the lowest (9.1%). Of all panels, 87.5% did not have any women panelists in 2003, but by 2018 only 24.0% panels were male-only. There was marked repetition among women occupying roles, with only 423 unique women occupying a total of 1,733 filled spots.Conclusion: Measured representation of women in academic otolaryngology conferences has improved from 2003-2018. Despite this improvement, gender disparity still exists.Level Of Evidence: 5 Laryngoscope, 131:E373-E379, 2021. [ABSTRACT FROM AUTHOR]

Objectives/Hypothesis: Antibiotics and oral corticosteroids are used in the treatment of acute exacerbations of chronic rhinosinusitis (AECRS) and reflect poor disease control. We sought to characterize utilization of these systemic medications after appropriate medical management of chronic rhinosinusitis (CRS). Study Design: Prospective observational study. Methods: One hundred fifty patients undergoing medical management for CRS were studied. Data were collected at enrollment and follow‐up 3 to 12 months later. All patients were asked to report the number of CRS‐related antibiotics and oral corticosteroids used in the last 3 months. CRS symptom burden was measured using the 22‐item Sino‐Nasal Outcome Test (SNOT‐22). Associations were sought between CRS‐related antibiotics and oral corticosteroids use at follow‐up compared to enrollment. Results: From enrollment to follow‐up, the mean number of CRS‐related antibiotics courses used decreased by 0.2 courses (95% confidence interval [CI]: 0.1–0.4, P =.012), and the mean number of CRS‐related oral corticosteroid courses used also decreased by 0.2 courses (95% CI: 0.1–0.3, P =.029). The number of CRS‐related antibiotics used at follow‐up was associated with CRS‐related antibiotic use at enrollment (adjusted rate ratio [RR] = 1.58, 95% CI: 1.17–2.13, P =.003). The number of CRS‐related oral corticosteroids used at follow‐up was associated with reported CRS‐related oral corticosteroid use at enrollment (adjusted RR = 3.20, 95% CI: 1.69–6.07, P <.001). SNOT‐22 results at enrollment were also not predictive of future systemic medication use. Conclusions: Appropriate medical management of CRS is associated with decreased use of oral antibiotics and corticosteroids. Previous utilization of antibiotics and oral corticosteroids for CRS is associated with future use of these medications. Level of Evidence: 2c Laryngoscope, 2019 [ABSTRACT FROM AUTHOR]

Objective: We sought to determine if chronic rhinosinusitis (CRS) patients with nasal polyps (CRSwNP) differentially perceived CRS symptom burden compared to patients without nasal polyps (CRSsNP) and to what extent CRS symptom severity was associated with quality of life (QOL) and patient-reported symptom control in the 2 groups. Methods: A total of 600 patients (266 CRSwNP and 334 CRSsNP) presenting with CRS were recruited. CRS symptom burden was assessed with the 22-item Sinonasal Outcome Test (SNOT-22). SNOT-22 nasal, sleep, ear/facial discomfort, and emotional subdomain scores were calculated. General health-related QOL was assessed with the visual analog scale of the 5-dimensional EuroQol questionnaire (EQ-5D VAS). Patients rated their CRS symptom control on a 5-point scale. Results: SNOT-22 scores did not differ between CRSwNP (mean: 35.6) and CRSsNP (mean: 36.3). There were no differences in nasal, sleep, and emotional subdomains of the SNOT-22. CRSsNP had higher (P =.003) ear/facial subdomain scores than CRSwNP, while CRSwNP reported greater hyposmia (P <.001). EQ-5D VAS was significantly lower (P =.011) in CRSsNP (mean: 68.9) compared to CRSwNP (mean: 73.2). However, CRSwNP patients reported significantly less symptom control, compared to CRSsNP, in association with nasal and emotional symptoms. Conclusion: CRSwNP and CRSsNP have differences in symptom profile, effect on health-related QOL, and patient-perceived symptom control. CRSsNP experience significantly greater burden of ear/facial discomfort, while CRSwNP report greater hyposmia. Although CRSsNP reports lower general health-related QOL overall, CRSwNP patients had lower levels of CRS symptom control for every incremental increase in symptom burden suggesting greater sensitivity/intolerance to CRS symptoms. [ABSTRACT FROM AUTHOR]

The field of otolaryngology–head and neck surgery is rapidly changing, and surgical education must keep pace. In the face of recent advances in medical knowledge, surgical technique, and novel technology, educators may find it increasingly difficult to identify the evolving educational needs of otolaryngology residents. To better align training activities with modern practice patterns, we propose conducting a longitudinal needs assessment by designing a standardized specialty‐specific survey for practicing otolaryngologists. This recurring survey could be implemented alongside accreditation or other continuing medical education activities. The outcomes would report what contemporary otolaryngologists see and do in everyday practice to guide educational reforms to better prepare trainees for future practice. [ABSTRACT FROM AUTHOR]

Graduate medical education (GME) is funded by the Centers for Medicare and Medicaid Services through both direct and indirect payments. In recent years, stakeholders have raised concerns about the growth of spending on GME and distribution of payment among hospitals. Key stakeholders have proposed reforms to reduce GME funding such as adjustments to statutory payment formulas and absolute caps on annual payments per resident. Otolaryngology departmental leadership should understand the potential effects of proposed reforms, which could have significant implications for the short-term financial performance and the long-term specialty workforce. Although some hospitals and departments may elect to reduce resident salaries or eliminate positions in the face of GME funding cuts, this approach overlooks the substantial Medicare revenue contributed by resident care and high cost of alternative labor sources. Commitment to resident training is necessary to align both the margin and mission of otolaryngology departments and their sponsoring hospitals. [ABSTRACT FROM AUTHOR]

Objective: In the era of SARS-CoV-2, the risk of infectious airborne aerosol generation during otolaryngologic procedures has been an area of increasing concern. The objective of this investigation was to quantify airborne aerosol production under clinical and surgical conditions and examine efficacy of mask mitigation strategies.Study Design: Prospective quantification of airborne aerosol generation during surgical and clinical simulation.Setting: Cadaver laboratory and clinical examination room.Subjects and Methods: Airborne aerosol quantification with an optical particle sizer was performed in real time during cadaveric simulated endoscopic surgical conditions, including hand instrumentation, microdebrider use, high-speed drilling, and cautery. Aerosol sampling was additionally performed in simulated clinical and diagnostic settings. All clinical and surgical procedures were evaluated for propensity for significant airborne aerosol generation.Results: Hand instrumentation and microdebridement did not produce detectable airborne aerosols in the range of 1 to 10 μm. Suction drilling at 12,000 rpm, high-speed drilling (4-mm diamond or cutting burs) at 70,000 rpm, and transnasal cautery generated significant airborne aerosols (P < .001). In clinical simulations, nasal endoscopy (P < .05), speech (P < .01), and sneezing (P < .01) generated 1- to 10-μm airborne aerosols. Significant aerosol escape was seen even with utilization of a standard surgical mask (P < .05). Intact and VENT-modified (valved endoscopy of the nose and throat) N95 respirator use prevented significant airborne aerosol spread.Conclusion: Transnasal drill and cautery use is associated with significant airborne particulate matter production in the range of 1 to 10 μm under surgical conditions. During simulated clinical activity, airborne aerosol generation was seen during nasal endoscopy, speech, and sneezing. Intact or VENT-modified N95 respirators mitigated airborne aerosol transmission, while standard surgical masks did not. [ABSTRACT FROM AUTHOR]

Objective: Anchor‐based methods to calculate the minimal clinically important difference (MCID) of a patient‐reported outcome measure (PROM) may suffer from recall bias. This has never been investigated for otolaryngic PROMs. We sought to identify evidence of recall bias in calculation of MCIDs of PROMs for patients with chronic rhinosinusitis (CRS). Design: Retrospective analysis of data from two previous studies calculating the MCID of the 22‐item Sinonasal Outcome Test (SNOT‐22) and 5‐dimensonal EuroQol questionnaire (EQ‐5D) in CRS patients. Setting: Tertiary rhinology clinic. Participants: Adults with CRS. Main outcome measures: SNOT‐22 score, and EQ‐5D visual analog scale scores (EQ‐5D VAS) and health utility values (EQ‐5D HUV) before and after medical treatment for CRS. After treatment, participants were asked to rate the change in sinonasal symptoms and general health (the anchor question) as "Much worse," "A little worse," "About the same," "A little better" or "Much better." Participants' responses to the anchor question were checked for association with post‐treatment and pre‐treatment scores using ordinal regression. Results: On univariate association, post‐treatment SNOT‐22 and EQ‐5D scores were associated with respective participants' anchor question responses (P <.001 in all cases). Only pre‐treatment SNOT‐22 score was associated with anchor question responses (P =.017) on univariate association, in contrast to pre‐treatment EQ‐5D scores. Pre‐treatment EQ‐5D scores only associated with anchor question responses when controlling for post‐treatment scores. Conclusion: The anchor‐based MCIDs of the SNOT‐22, which reflects disease‐specific QOL, and the EQ‐5D, which reflects general health‐related QOL, appear to be largely free of recall bias. [ABSTRACT FROM AUTHOR]

Objectives  The main purpose of this article is to examine a single-center cohort of patients with nasopharyngeal adenoid cystic carcinoma (ACC) for pathologic features, skull base invasion, overall survival, and disease-free survival, with a focus on response to proton beam radiation therapy. Design, Setting, and Participants  Single-center institutional cancer registry was used to retrospectively identify and analyze outcomes for 12 patients treated for ACC of the nasopharynx from 2000 to 2016. Main Outcomes and Measures  Primary outcomes included 5-year overall survival and locoregional control. Statistical analysis was performed using STATA 12.0 (STATACorp, College Station, Texas, United States). Spearman's rank order correlation was used for ordinal, monotonic variables with p -values <0.05 considered statistically significant. Survival analysis was performed by Kaplan–Meier method; comparison between groups was performed using log-rank test. Results  Twelve patients with ACC of the nasopharynx were included. All patients presented with advanced disease and were treated with primary radiation therapy, typically proton beam therapy. Only two underwent a surgical attempt at resection. A majority of cases had a cribriform growth pattern. The 5-year survival was 75% and rate of locoregional control rate at 5 years was 50%, comparable to other ACC cohort studies that included earlier stage tumors in various subsites that were surgically resected. Conclusions  Although ACC is traditionally noted to be radioresistant, ACC of the nasopharynx was responsive to radiotherapy in our cohort, despite advanced stage and skull base invasion. Reasons for this improved survival are unclear and suggest the need for further pathologic and genetic characterization of nasopharyngeal ACC. [ABSTRACT FROM AUTHOR]

Objective: Surgical care is increasingly shifting to freestanding ambulatory surgical centers (ASCs). The extent to which otolaryngologists use ASCs has implications for patient safety and health care spending. This study characterizes trends in utilization and resultant financial implications for common otolaryngologic procedures performed at ASC and hospital outpatient departments (HOPDs).Study Design: Retrospective cross-sectional analysis.Setting: ASCs, HOPDs.Subjects and Methods: Subjects included Medicare beneficiaries undergoing outpatient otolaryngologic procedures between 2010 and 2017. Procedures included the 20 highest-volume procedures performed by otolaryngologists at ASCs in 2017. Main outcomes included absolute and relative percentage difference in the proportion of procedures furnished at ASCs and HOPDs and estimated Medicare cost savings resulting from increased ASC utilization between 2011 and 2017.Results: The proportion of outpatient otolaryngologic procedures performed at ASCs increased by 1.8% (relative difference: 10.0%; mean annual relative increase: 1.60%), and the proportion located at HOPDs decreased by 6.0% (relative difference: -11.8%; mean annual relative decrease: -1.6%) between 2010 and 2017. Rhinoplasty accounted for the largest absolute increase in ASC utilization over the study period (absolute [relative] 8.9% [33.5%]). Increased ASC utilization resulted in an estimated $7.1 million in cost savings to Medicare between 2011 and 2017.Conclusion: Otolaryngologists shifted outpatient surgical care from HOPDs to ASCs between 2010 and 2017, with resultant reductions in Medicare expenditures. Further research is necessary to examine the impact of this shift on patient safety. [ABSTRACT FROM AUTHOR]

Objective: Repair of cerebrospinal fluid (CSF) leaks of the lateral recess of the sphenoid (LRS) sinus can be challenging to accomplish via an endoscopic transphenoidal approach. The endoscopic transpterygoid approach can improve surgical access to the lateral recess but requires more extensive surgical dissection. We review our experience with LRS CSF leak repair via both techniques to determine whether preoperative radiologic data can help predict the most appropriate surgical approach. Methods: Electronic medical records of patients with LRS CSF leaks were retrospectively reviewed at a single tertiary referral center. Radiographic measurements from preoperative computed tomography images were reviewed. Results: Twenty‐two LRS CSF leaks were identified. The transphenoidal and transpterygoid approach were used in 6 (27.3%) and 16 (72.7%) cases, respectively. The mean vidian canal to foramen rotundum angle of the repairs accessed transphenoidally as compared to the transptyergoid approach were not significantly different (41.93° ±10.91, 40.72° ±19.49, respectively; P =.63). However, the mean volume of the LRS accessed by the transpterygoid approach was significantly greater compared to those accessed through the transphenoidal approach (0.97 cm3 ± 0.48, 0.39 cm3 ± 0.40, respectively; P =.04). A LRS volume of 0.400 cm3 or greater predicted the use of the transpterygoid approach with 93.3% sensitivity and 60.0% specificity. Conclusion: This study demonstrated that LRS CSF leaks that necessitated repair by the transpterygoid approach, rather than transphenoidal approach, were in the context of significantly larger lateral recess. Assessment of the LRS volume is a quantifiable parameter to aid in preoperative surgical planning. Level of Evidence: Level 4. [ABSTRACT FROM AUTHOR]

Objectives: Aspirin‐exacerbated respiratory disease (AERD) is a chronic respiratory condition characterized by a triad of symptoms: asthma, chronic rhinosinusitis with nasal polyposis, and a respiratory reaction to aspirin and other cyclooxygenase‐1 inhibitors, also known as nonsteroidal anti‐inflammatory drugs. The objective of this review is to provide otolaryngologists with an overview of the pathophysiology, diagnosis, and treatment of this under‐recognized condition. Data sources and methods: Foundational papers on AERD were reviewed, focusing on the clinical otolaryngology and allergy/immunology literature and other high impact journals or trials. Results: AERD results from increased production of pro‐inflammatory leukotrienes and a decrease in production of anti‐inflammatory prostaglandins associated with the dysregulation of multiple enzymes influencing eicosanoid metabolism. Diagnosis hinges on a high index of suspicion, careful history, and confirmatory testing for all three elements. Treatments include endoscopic sinus surgery; topical, inhaled, or oral corticosteroids; aspirin desensitization; leukotriene modifying drugs; and the new class of biologics such as dupilumab. Conclusion: AERD is an under‐recognized disease associated with substantial patient‐reported morbidity. We expect rapid progress in the pathophysiological understanding of this disease and available treatments in the coming decades. Level of evidence: 5 [ABSTRACT FROM AUTHOR]

Objective: Intranasal saline irrigations and intranasal corticosteroids are supported by level-1 evidence for medical management of chronic rhinosinusitis (CRS). We sought to study adherence with these medications.Methods: Prospective study of 174 patients with CRS. Patients reported their usage of intranasal saline irrigation and intranasal corticosteroid over the preceding 3 months, at presentation, and a subsequent follow-up visit 3 to 12 months later. Adherence was defined as reported medication usage for ≥6 days per week.Results: At the time of presentation, 44.3% of patients were using an intranasal corticosteroid spray or irrigation ≥6 days/week, whereas only 24.1% were using saline irrigation ≥6 days per week. At follow-up, 60.3% of patients were using either an intranasal corticosteroid spray or irrigation ≥6 days per week, whereas 35.6% were using saline irrigation ≥6 days per week. Adherence with intranasal corticosteroids was associated with comorbid asthma (adjusted odds ratio [OR] = 2.68, 95% confidence interval [CI]: 1.10-6.50, P = 0.029), allergy (OR = 2.22, 95% CI: 1.05-4.71, P = 0.037), and change in 22-item Sinonasal Outcome Test score (OR = 0.98, 95% CI: 0.96-0.99, P = 0.027). Use of intranasal corticosteroid sprays versus irrigations (OR = 2.56, 95% CI: 0.84-7.83, P = 0.099) was suggestive of association with improved adherence. Adherence with intranasal saline irrigation was associated with age (OR = 1.02, 95% CI: 1.01-1.05, P = 0.034).Conclusion: Usage and adherence with intranasal steroids and saline may be low in CRS patients even with management in a tertiary level, subspecialty rhinology clinic. Adherence with medications represents a major opportunity for improving patient care and outcomes, specifically by targeting patients with lower disease burden and improving convenience of medications.Level Of Evidence: 2C Laryngoscope, 130:852-856, 2020. [ABSTRACT FROM AUTHOR]

Background: The 22-item Sinonasal Outcome Test (SNOT-22) is a validated patient-reported outcome measure for chronic rhinosinusitis and in many circumstances is used in rhinology/otolaryngology clinics to assess sinonasal symptoms in general when a formal diagnosis is not established, although with little support for such usage. Objective: To assess the utility of the SNOT-22 as a reflection of quality of life (QOL) and symptom control for patients with allergic rhinitis (AR). Methods: Retrospective review of 353 patients with persistent AR. Each patient completed a SNOT-22, 5-item EuroQol general health-related QOL (EQ-5D) questionnaire (from which the visual analog scale [VAS] was used), and Rhinitis Control Assessment Test (RCAT). In addition, 95 patients also completed these questionnaires 1 to 12 months later. Results: The SNOT-22 was negatively correlated with the EuroQol 5-dimensional visual analog scale (EQ-5D VAS; r = −.45, 95% confidence interval [CI]: −0.53 to −0.36, P <.001) and RCAT (r = −.62, 95% CI: −0.68 to −0.55, P <.001), with excellent internal consistency. The SNOT-22 demonstrated responsiveness, with mean change of −5.8 (95% CI: −8.9 to −2.6, P <.001) from pre- to posttreatment. The change in SNOT-22 over the treatment period was correlated with change in EQ-5D VAS (r = −.28, 95% CI: −0.46 to −0.07, P =.008) and RCAT (r = −.56, 95% CI: −0.69 to −0.41, P <.001). The minimal clinically important difference was calculated to be between 6 and 11. Conclusion: The SNOT-22 has utility to assess QOL and symptom control in AR, and it is both reliable and responsive in its application to patients with AR. The SNOT-22 may therefore be a convenient and versatile tool in the clinical assessment of patients with AR. [ABSTRACT FROM AUTHOR]

Objectives: Surgical education has shifted from the Halstedian model of "see one, do one, teach one" to a competency-based model of training. Otolaryngology residency programs can benefit from a fast and simple system to assess residents' surgical skills. In this quality initiative, we hypothesize that a novel smartphone application called System for Improving and Measuring Procedural Learning (SIMPL) could be applied in an otolaryngology residency to facilitate the assessment of resident operative experiences.Methods: The Plan Do Study Act method of quality improvement was used. After researching tools of surgical assessment and trialing SIMPL in a resident-attending pair, we piloted SIMPL across an otolaryngology residency program. Faculty and residents were trained to use SIMPL to rate resident operative performance and autonomy with a previously validated Zwisch Scale.Results: Residents (n = 23) and faculty (n = 17) were trained to use SIMPL using a standardized curriculum. A total of 833 assessments were completed from December 1, 2017, to June 30, 2018. Attendings completed a median 20 assessments, and residents completed a median 14 self-assessments. All evaluations were resident initiated, and attendings had a 78% median response rate. Evaluations took residents a median 22 seconds to complete; 126 unique procedures were logged, representing all 14 key indicator cases for otolaryngology.Discussion: This is the first residency-wide application of a mobile platform to track the operative experiences of otolaryngology residents.Implications For Practice: We adapted and implemented a novel assessment tool in a large otolaryngology program. Future multicenter studies will benchmark resident operative experiences nationwide. [ABSTRACT FROM AUTHOR]

Background: In the era of duty hour restrictions, otolaryngology residents may not gain the operative experience necessary to function autonomously by the end of training. This study quantifies residents' autonomy during key indicator cases, defined by the Accreditation Council for Graduate Medical Education. Study Design: Prospective cohort study. Methods: Faculty and residents at a large academic institution were surveyed on the surgical autonomy trainees should achieve for otolaryngology key indicator surgeries at each training level. Residents and faculty used the mobile application "System for Improving and Measuring Procedural Learning" (SIMPL) between December 2017 and July 2018 to log trainees' operative autonomy during cases on a validated four‐level Zwisch scale, from "show and tell" to "supervision only." Results: The study included 40 participants (23 residents and 17 attendings). The survey response rate was 83%. In surveys, residents overestimated the autonomy PGY5 residents should achieve for parotidectomy, rhinoplasty, thyroid/parathyroidectomy, and airway procedures compared with faculty (P <.05). Using SIMPL, 833 evaluations were logged of which 253 were paired evaluations for key indicator cases. Comparing survey predictions with actual cases logged in SIMPL, residents and faculty overestimated the autonomy achieved by senior trainees performing mastoidectomy (PGY5, P <.05) and ethmoidectomy (PGY4/5, P <.05); both felt that senior residents should operate with between "passive help" and "supervision only" whereas residents actually had "passive help." Residents overestimated their autonomy during rhinoplasty (PGY5, P =.017) and parotidectomy (PGY5, P =.007) while attendings accurately expected chief residents to have "passive help." Conclusions: Resident surgical autonomy varies across otolaryngology procedures. Multicenter studies are needed to elucidate national trends. Level of Evidence: 2 [ABSTRACT FROM AUTHOR]

Objective: Acute exacerbation of chronic rhinosinusitis (AECRS) is associated with significant quality-of-life decreases. We sought to determine characteristics associated with an exacerbation-prone phenotype in chronic rhinosinusitis (CRS).Study Design: Cross-sectional.Setting: Tertiary care rhinology clinic.Subjects: Patients with CRS (N = 209).Methods: Patient-reported number of sinus infections, CRS-related antibiotics, and CRS-related oral corticosteroids taken in the last 12 months were used as metrics for AECRS frequency. Sinonasal symptom burden was assessed with the 22-item Sinonasal Outcome Test (SNOT-22). Ninety patients reporting 0 for all AECRS metrics were considered to have had no AECRS in the prior 12 months. A total of 119 patients reported >3 on at least 1 AECRS metric and were considered as having an exacerbation-prone phenotype. Characteristics associated with patients with an exacerbation-prone phenotype were identified with exploratory regression analysis.Results: An exacerbation-prone phenotype was positively associated with comorbid asthma (adjusted odds ratio [ORadj] = 3.68, 95% CI: 1.42-9.50, P = .007) and SNOT-22 (ORadj = 1.06, 95% CI: 1.04-1.09, P < .001). Polyps were negatively associated (ORadj = 0.27, 95% CI: 0.11-0.68, P = .005) with an exacerbation-prone phenotype. SNOT-22 score ≥24 identified patients with an exacerbation-prone phenotype with a sensitivity of 93.3% and a specificity of 57.8%. Having either a SNOT-22 score ≥24 with a nasal subdomain score ≥12 or a SNOT-22 score ≥24 with an ear/facial discomfort subdomain score ≥3 provided >80% sensitivity and specificity for detecting patients prone to exacerbation.Conclusions: In total, these results point to a CRS exacerbation-prone phenotype characterized by high sinonasal disease burden with comorbid asthma but interestingly without polyps. [ABSTRACT FROM AUTHOR]

Background: Timely postoperative radiation therapy (RT) within 50 days of surgery for head and neck cancers provides a survival advantage. Methods: Using the National Cancer Database, we performed a propensity score‐matched analysis comparing patients undergoing open or endoscopic surgery for squamous cell carcinoma (SCC) of the nasal cavity and paranasal sinuses from 2010 to 2015. Results: Among 168 pairs, patients undergoing endoscopic surgery had shorter time to surgery (24.2 vs 36.7 days, P < .001) and shorter postoperative time to RT (PTTR, 51.2 vs 58.4 days, P =.02). On multivariable linear regression, endoscopic surgery predicted shorter PTTR (β = −7.6, P =.01). Using the Kaplan‐Meier method, patients in the longest PTTR quartile had decreased overall survival (OS; Q1 vs Q4, 3‐year OS 76.5% vs 53.3%, P =.007), a durable finding when adjusted for covariates (Q1 vs Q4, HR 0.50, P =.008). Conclusions: Patients undergoing endoscopic surgery for sinonasal SCC experience shorter PTTR. Shorter PTTR is associated with extended OS. [ABSTRACT FROM AUTHOR]

Objectives/hypothesis: There are limited data on laryngeal fracture presentation and management in US emergency departments (EDs). We aimed to characterize patients who are diagnosed with laryngeal fractures in the ED and identify management patterns.Study Design: Retrospective review of the Nationwide Emergency Department Sample (NEDS) from 2009 to 2011.Methods: The NEDS was queried for patient visits with a primary diagnosis of open or closed laryngeal fracture (International Classification of Diseases, Ninth Revision codes 807.5 and 807.6). Patient demographics, comorbidities, ED management, and hospital characteristics were extracted.Results: There were 3,102 ED visits with a diagnosis of laryngeal fracture during the study period. Mean patient age was 40.9 years (range, 3-93 years). The majority of patients were male (85.5%) and sustained a closed (vs. open) fracture (91.4%), with an overall mortality rate of 3.8%. The majority of patients were treated for more than one injury during the same visit (76.2%). Most patients were evaluated at a trauma hospital (53.9%), and most patients were admitted to the hospital (71.9%). Emergent intubation or tracheostomy was rarely reported (2.6% and 0.1% of all cases), and a minority of patients underwent fiberoptic flexible laryngoscopy in the ED (1.9%). Laryngeal fractures occurred more frequently during summer months (28.2%). Mean charge for the entirety of the ED stay was $4,957.34.Conclusions: Laryngeal fracture is rare and frequently associated with other injuries. The frequency of emergent airway procedure, imaging, and flexible fiberoptic laryngoscopy is lower than expected, raising concerns about appropriate workup and management or recognition of injury in the ED setting.Level Of Evidence: NA Laryngoscope, 129:2341-2346, 2019. [ABSTRACT FROM AUTHOR]

Objectives: To evaluate the long-term impact of functional septorhinoplasty (SRP) with and without inferior turbinate reduction (ITR) on disease-specific symptom severity and general health-related quality of life (QOL).Study Design: Prospective cohort study at a tertiary referral center.Methods: Patients undergoing functional SRP with and without ITR were administered the Nasal Obstruction Symptom Evaluation (NOSE) scale to assess severity of nasal obstruction and the EuroQol-5 Dimension Questionnaire Visual Analog Scale (EQ-5D VAS) to assess general health-related QOL preoperatively and at 2, 4, 6, 12, 24, and 36 months postoperatively. Patient demographics, surgical technique, symptom severity, and QOL outcomes were analyzed.Results: A total of 567 patients were included, with 391 patients undergoing functional SRP alone (54.0% female; mean age 36.0 years [standard deviation (SD):16.2]) and 176 patients undergoing functional SRP with ITR (50.0% female; mean age 35.6 years [SD:13.6]). There was a significant decrease in NOSE and increase in EQ-5D VAS scores in both groups through at least 24 months postoperatively. Change in NOSE scores was negatively correlated with change in EQ-5D VAS (r = -0.38, P < 0.01). Compared to patients undergoing SRP, patients also undergoing ITR had a statistically but nonclinically significant improvement in NOSE, with similar trends for EQ-5D VAS that were not significant.Conclusion: SRP results in a sustained, long-term improvement in nasal obstruction based on disease-specific and general health-related QOL measures, with incremental improvement in outcomes with addition of ITR. This study provides the foundation for defining health outcomes and the health utility value of surgical interventions that address nasal obstruction.Level Of Evidence: 2c Laryngoscope, 129:1554-1560, 2019. [ABSTRACT FROM AUTHOR]

Objectives/hypothesis: Opioid-related deaths in the United States have increased 200% since 2000, in part due to prescription diversion from patients who had a surgical procedure. The purpose of this study was to characterize provider prescription patterns and assess patient-reported opioid use after endoscopic sinus surgery (ESS).Study Design: Retrospective chart review.Methods: Patients who underwent ESS between May 2017 and May 2018 were included. Opioid prescription, operative details, and postoperative opioid use data were extracted. The Massachusetts Prescription Awareness Tool (MassPAT) was queried to determine if patients filled their prescription.Results: One hundred fifty-five patients were included. Nearly all patients received an opioid prescription (94.8%). An average of 15.6 tablets was prescribed per patient. Among 116 patients with MassPAT data, 91.4% filled their prescription. Among 67 patients who reported the number of tablets they had used at the time of first follow-up appointment, 73.1% reported taking no opioids. Mean number of tablets prescribed was significantly greater among patients who underwent primary versus revision surgery (16.5 vs. 13.5, P = .0111) and those who had splints placed (21.5 vs. 15.1, P = .0037). Predictors of opioid use included concurrent turbinate reduction (58.3% vs. 14.3%, P < .0001) and concurrent septoplasty (45.5% vs. 21.6%, P = .039).Conclusions: Nearly all patients who underwent ESS were prescribed an opioid, and nearly all patients filled their prescription. However, the vast majority of patients did not require any opioid medication for postoperative pain control. As the opioid epidemic continues to persist, these findings have immediate relevance to current prescribing patterns and pain management practices.Level Of Evidence: 4 Laryngoscope, 129:1046-1052, 2019. [ABSTRACT FROM AUTHOR]