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There is concern that current otolaryngology residents may not receive adequate surgical training. We aimed to characterize residents' surgical experiences at 5 academic centers performing the 14 key indicator procedures (KIPs) outlined by the Accreditation Council for Graduate Medical Education.Prospective study.Five otolaryngology training programs.Data were gathered from December 2019 to December 2020 with a smartphone application from the Society for Improving Medical Professional Learning. After each operation, residents and faculty rated trainee autonomy on a 4-level Zwisch scale and performance on a 5-level modified Dreyfus scale.Residents and attendings (n = 92 and 78, respectively) logged 2984 evaluations. Attending ratings of resident autonomy and performance increased with training level (In this multicenter study, resident surgical autonomy and performance varied across otolaryngology KIPs. The development of nationwide benchmarks will help programs and residents set educational goals.2.

Background Gender disparities are prevalent in medicine, but their impact on surgical training is not well studied. Objective To quantify gender disparities in trainee intraoperative experiences and explore the variables associated with ratings of surgical autonomy and performance. Methods 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. Results 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). Conclusions 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.

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.

I. Executive summary BACKGROUND: The 5 years since the publication of the first International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICAR-RS) has witnessed foundational progress in our understanding and treatment of rhinologic disease. These advances are reflected within the more than 40 new topics covered within the ICAR-RS-2021 as well as updates to the original 140 topics. This executive summary consolidates the evidence-based findings of the document. Methods ICAR-RS presents over 180 topics in the forms of evidence-based reviews with recommendations (EBRRs), evidence-based reviews, and literature reviews. The highest grade structured recommendations of the EBRR sections are summarized in this executive summary. Results ICAR-RS-2021 covers 22 topics regarding the medical management of RS, which are grade A/B and are presented in the executive summary. Additionally, 4 topics regarding the surgical management of RS are grade A/B and are presented in the executive summary. Finally, a comprehensive evidence-based management algorithm is provided. Conclusion This ICAR-RS-2021 executive summary provides a compilation of the evidence-based recommendations for medical and surgical treatment of the most common forms of RS.

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.

Multimodality nonopioid analgesia can be effective for pain control. Balancing risks and benefits of treatment should guide the appropriateness of opioid versus nonopioid pain control.

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

Background Odontogenic sinusitis (ODS) can present a therapeutic dilemma because multiple treatment strategies have been reported. ODS review articles have been published, but they have lacked multidisciplinary collaboration and an evidence-based methodology. The purpose of this article was to perform an evidence-based review of ODS management options, and develop a multidisciplinary consensus statement on ODS management options. Methods An evidence-based review of dental and medical literature on ODS management was performed using PubMed, EMBASE, and Cochrane Review Databases up to December 2019. Exclusion criteria included non-English-language articles, case series with fewer than 10 patients, fungal sinusitis, and studies that did not report treatment success rates. Because aggregate levels of evidence for recommendations were no higher than level C, a clinical consensus statement was conducted using a modified Delphi method. Results Sixteen articles met inclusion criteria for the evidence-based review on the following ODS management options: dental treatment alone or combined with ESS for various dental pathologies, and endoscopic sinus surgery (ESS) alone for dental implant-related ODS. Strong consensus was achieved for 9 of the 10 clinical statements, the strongest being the use of shared decision-making for selecting management strategies. No consensus was reached for determining the extent of ESS necessary for uncomplicated ODS. Conclusion Strong consensus was reached that ODS management should involve shared decision-making between the otolaryngologist, dental provider, and patient, where the benefits and risks of dental treatment and ESS are discussed. Higher-quality studies are necessary to develop evidence-based treatment recommendations for ODS.

Background Drug-eluting implants are becoming increasingly popular in the treatment of chronic rhinosinusitis (CRS). A previous attempt to make an evidence-based recommendation was hindered by limited evidence and experience with these implants. Since that time, the body of literature discussing drug-eluting implants has grown rapidly. The objective of this study was to review drug-eluting implants designed for use in the sinonasal cavity through an evidence-based review with recommendations. Methods A systematic review of the literature was performed using PubMed, EMBASE, Cochrane Review, and gray literature databases from January 1990 through February 2019 to examine drug-eluting implants used in CRS. Benefit-harm assessments, value judgments, and recommendations were made based on the available evidence. Study exclusion criteria included studies unavailable in English and non-endoscopic sinus surgeries. All authors agreed on recommendations through an iterative process. Results Thirty-one studies were included in the final analysis. Absorbable drug-eluting implants achieved a high aggregate grade of evidence (A), with a recommendation for their use to be considered in carefully selected patients. Nonabsorbable drug-eluting implants were recommended against due to minimal evidence supporting clinical efficacy. Antibiotic and alternative drug-eluting implants lack sufficient evidence for recommendations. Conclusion Absorbable steroid-eluting implants are recommended for carefully selected patients with CRS. Additional research to define appropriate patient selection is needed.

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., The endoscopic endonasal surgical approach is the gold standard in these repairs, however, the LRS sinus is particularly challenging due to anatomical constraints. Another method, known as the endoscopic endonasal transpterygoid (ETTP) approach has been used, but requires a more invasive process. Depending on the location of the CSF leak, maneuverability limitations and risks are important to consider. Our goal is to define a quantifiable parameter that will be useful in preoperative surgical planning to determine the safest, most effective approach on a case‐by‐case basis.

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.

Background International experience with coronavirus 2019 (COVID-19) suggests it poses a significant risk of infectious transmission to skull base surgeons, due to high nasal viral titers and the unknown potential for aerosol generation during endonasal instrumentation. The purpose of this study was to simulate aerosolization events over a range of endoscopic procedures to obtain an evidence-based aerosol risk assessment. Methods Aerosolization was simulated in a cadaver using fluorescein solution (0.2 mg per 10 mL) and quantified using a blue-light filter and digital image processing. Outpatient sneezing during endoscopy was simulated using an intranasal atomizer in the presence or absence of intact and modified surgical mask barriers. Surgical aerosolization was simulated during nonpowered instrumentation, suction microdebrider, and high-speed drilling after nasal fluorescein application. Results Among the outpatient conditions, a simulated sneeze event generated maximal aerosol distribution at 30 cm, extending to 66 cm. Both an intact surgical mask and a modified VENT mask (which enables endoscopy) eliminated all detectable aerosol spread. Among the surgical conditions, cold instrumentation and microdebrider use did not generate detectable aerosols. Conversely, use of a high-speed drill produced significant aerosol contamination in all conditions tested. Conclusion We confirm that aerosolization presents a risk to the endonasal skull base surgeon. In the outpatient setting, use of a barrier significantly reduces aerosol spread. Cold surgical instrumentation and microdebrider use pose significantly less aerosolization risk than a high-speed drill. Procedures requiring drill use should carry a special designation as an "aerosol-generating surgery" to convey this unique risk, and this supports the need for protective personal protective equipment.

ObjectiveWe 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.MethodsA 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.ResultsSNOT-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 ConclusionCRSwNP 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.

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.

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).Retrospective cross-sectional analysis.ASCs, HOPDs.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.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.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.

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.

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.

Background: Pathophysiology-targeting treatments exist for aspirin-exacerbated respiratory disease (AERD) through aspirin desensitization and biologics, such as dupilumab. With increasing attention paid to these treatments, which may be associated with significant side effects and/or cost, there is little description of chronic rhinosinusitis with nasal polyps (CRSwNP) response to treatment with intranasal corticosteroids and saline irrigations in AERD. Objective: To determine the effect of intranasal budesonide irrigations for the treatment of CRSwNP in AERD. Methods: This is an observational study of 14 AERD patients presenting to a rhinology clinic for CRS who were treated with twice daily high volume, low pressure irrigations with 240 mL of saline to which a 0.5 mg/2 mL respule of budesonide was added. All participants completed a 22-item Sinonasal Outcome Test (SNOT-22) at enrollment and at follow up 1 to 6 months later. Polyp scores were also calculated at each time point. Results: SNOT-22 scores ranged from 26 to 98 (median: 40.5) at enrollment and 3 to 85 (median: 38.5) at follow-up. Polyp scores ranged from 2 to 6 (median: 4) at enrollment at 0 to 6 (median: 2) at follow-up. Over the treatment period, change in SNOT-22 score ranged from −38 to 16 (median: −18) and change in polyp score ranged from −2 to 0 (median: −0.5). Approximately 57% of participants experienced at least 1 minimal clinically important difference in SNOT-22 score and 21% of participants had a SNOT-22 score Conclusion: Medical management with intranasal corticosteroids and saline irrigations alone leads to significant improvement in sinonasal symptomatology in a subset of AERD.

Introduction: Otolaryngology (ORL) applicants face challenges finding information about residency programs. Due to COVID-19, the Society of University Otolaryngologists released suggestions for students to avoid away rotations and look for programs to expand and update their web presence. However, information on program websites is not always standardized or easily accessible. Many applicants use the American Medical Association's Fellowship and Residency Electronic Interactive Database (FREIDA), a designated, standardized resource of basic and detailed information on residency programs. However, the availability of information within FREIDA is unclear. Herein, we analyze available data within FREIDA on all 124 ORL residency programs to understand the completeness of the FREIDA database. Method: Data from all 124 otolaryngology-head and neck surgery residency programs within FREIDA was abstracted in early December 2020 and organized into 2 sections: basic information and detailed information (program details, educational features, and occupational benefits). The number of contributing programs in both sections was evaluated. Results: More than half of the programs (n = 65, 52.4%) did not provide any detailed information within FREIDA. While all 124 programs had their address, contact email, and the names of program directors available, slightly fewer had direct links to their website available (n = 113, 91.1%). Most programs (70.2%) did not include a brief 1-paragraph program description. Conclusion: Our findings suggest that FREIDA provides basic information for nearly all ORL programs, but it does not offer detailed information for most programs. As COVID-19 has negatively impacted the ability of ORL applicants to learn about programs, FREIDA is a helpful, centralized resource but is currently incomplete.

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 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.

BACKGROUND A short-course oral corticosteroid taper and topical intranasal corticosteroids may be used to maximize the success of medical management for chronic rhinosinusitis with nasal polyps (CRSwNP). In this study, we sought to identify characteristics that would be predictive of efficacy for this combination regimen. METHODS Sixty-four patients with CRS, bilateral polyps, a polyp score of at least 3, and a 22-item Sino-Nasal Outcome Test (SNOT-22) score ≥20 were prospectively enrolled and uniformly treated with a 15-day prednisone taper and twice daily dilute budesonide irrigations. Participants were assessed at enrollment and at follow up, 2 to 5 months later. Clinical and demographic characteristics were assessed at enrollment. At both time points, CRS symptoms were assessed with SNOT-22, and polyp score (range, 0 to 6) was assessed endoscopically. Associations were determined with regression. RESULTS Pretreatment SNOT-22 score (adjusted β = -0.83; 95% CI, -1.08 to -0.58; p < 0.001) and comorbid asthma (adjusted β = 15.75; 95% CI, 4.74 to 26.75; p = 0.007) were associated with a change in SNOT-22 experienced over the study period. Achieving a greater-than-1 minimal clinically important difference (MCID) improvement in SNOT-22 score was also associated with pretreatment SNOT-22 score (adjusted OR = 1.09; 95% CI, 1.04 to 1.14; p < 0.001) and comorbid asthma (adjusted OR = 0.13; 95% CI, 0.03 to 0.72; p = 0.019). SNOT-22 score ≥47 had 81.5% sensitivity and 78.4% specificity to detect patients experiencing 1 MCID improvement. Pretreatment polyp score was not associated with any outcome metric. CONCLUSION In treatment of CRSwNP with prednisone and budesonide irrigations, pretreatment endoscopy was not informative of treatment response. Pretreatment SNOT-22 and comorbid asthma may be more predictive.

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 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.

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

To investigate the demographics of CORE grant recipients (Centralized Otolaryngology Research Efforts) over the last decade and evaluate disparity among recipients as compared with otolaryngology overall. To assess whether procurement of a grant predicts pursuit of an academic career.Analysis of grant recipients' bibliometrics.Academic medical center.The list of recipients of grants from 2010 to 2019 was obtained from the website of the American Academy of Otolaryngology-Head and Neck Surgery. Demographics of recipients were collected through an internet search, including gender, race, residency program, andThe distribution of gender among recipients over the last decade remained nearly constant, with no significant difference versus residents in otolaryngology (CORE grants are favorably distributed as related to gender and racial disparities, and recipients frequently go on to achieve high levels of academic success.

Research productivity is a key metric used in evaluation for advancement and promotion in academic medicine. There are known gender, race, and ethnicity disparities in otolaryngology research and funding. Female academic otolaryngologists have been shown to lag in scholarly productivity, representation at national meetings, leadership positions on journal editorial boards, and National Institutes of Health and industry funding. Underrepresented minorities have been shown to be less successful at obtaining Centralized Otolaryngology Research Efforts grant funding. Directed approaches, such as research funding for women and minorities or targeted recruitment and retention of underrepresented faculty, may move the field toward parity.

Objectives Methods Results Conclusions Level of evidence 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.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.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.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.II. [ABSTRACT FROM AUTHOR] Copyright of Laryngoscope Investigative Otolaryngology is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

BACKGROUND A recent analysis suggested potential narrowing of the gender gap in research productivity in the field of rhinology. This analysis did not, however, provide insight into how the genders are represented in the rhinologic literature. This study aimed to evaluate 11 years of literature to evaluate for gender differences in authorship position, collaborations, category and content of research, citations, and funding to gain perspective on how gender and authorship has changed over time. METHODS Authorship data for all articles on rhinologic subject matter published between January 1, 2008 and December 31, 2018 in four otolaryngology journals was collected. The gender of authors was determined by protocol. Category and content of research and funding status/source were additionally obtained. RESULTS Data were collected from 2666 articles. Gender of 14,510 authors was determined. Female authors accounted for 23% of the overall authors and male authors accounted for 77%. Female first authorship increased significantly over time, but there was no change in female senior authorship. The percentage of female authors steadily increased over time, whereas male authorship decreased slightly. Mixed gender teams were shown to be increasing in frequency. Women published more than expected in basic science and allergy and less than expected in skull base. On funded studies, women were significantly underrepresented as senior authors. CONCLUSION This study represents the first assessment of gender differences in the rhinology literature. Areas where female representation can improve include senior authorship, increased involvement in skull base publications, and increased funding.

Objectives This article examines a national cohort of patients with nasopharyngeal adenoid cystic carcinoma (ACC) for incidence, skull base invasion, overall survival, and treatment paradigms. Design, Setting, and Participants Retrospective national population-based study using Surveillance, Epidemiology, and End Results program data of patients with ACC of the nasopharynx (NACC) and skull base between 2004 and 2016. Main Outcomes and Measures Primary outcomes included 5-year overall survival and odds of radiation treatment. Statistical analysis was performed using STATA 15.0 (STATACorp). p-Values Results Of the 2,385 cases of ACC, 70 cases were classified as NACC. Twenty-one percent (15) involved invasion of the skull base or posterior pharyngeal wall, and 42% (30) were either stage 3 or stage 4. The 5-year overall survival for patients with NACC without skull base invasion was 67% which dropped to 40% with invasion into the skull base. Radiation was used as the primary form of therapy for 62% of NACC and 73% of NACC invading into skull base. Odds of receiving radiation therapy and 5-year survival were not affected by socioeconomic status or density of providers. Conclusion NACC is rare in incidence and was most commonly treated with radiation therapy when advanced in stage. Prognosis was dependent on invasion through posterior pharyngeal wall and skull base. Provider density and socioeconomic status did not affect odds of radiation or overall survival for NACC.

BACKGROUND Surgeons commonly prescribe prophylactic antibiotics after endoscopic sinus surgery (ESS), yet minimal data exist to support this practice. In this study we aimed to assess the impact of post-ESS antibiotics on infection, quality of life (QOL), and endoscopic scores. METHODS This was a randomized, double-blind, placebo-controlled, noninferiority trial comparing amoxicillin-clavulanate vs placebo after ESS (NCT01919411, ClinicalTrials.gov). Adults (N = 77) with chronic rhinosinusitis (CRS) refractory to appropriate medical therapy who underwent ESS were randomized to antibiotics (N = 37) or placebo (N = 40) and followed clinically (mean ± standard deviation: 1.3 ± 0.3 and 8.8 ± 3.9 weeks postoperatively). At baseline and follow-up, QOL was measured with 22-item Sino-Nasal Outcome Test questionnaires and Lund-Kennedy endoscopic scores were evaluated. Outcomes were analyzed with repeated-measures analysis of variance and analysis of covariance and z tests for proportions. RESULTS Placebo was noninferior to antibiotic prophylaxis with regard to postoperative SNOT-22 scores (β = 0.18, 2-tailed p < 0.05). There were no significant differences between the antibiotic and placebo groups in LK score trajectories over time (p = 0.63) or in postoperative infection rates (2.6% vs 2.4%, respectively; p = 0.96). The rate of diarrhea was significantly higher in the antibiotic group (24.3% vs 2.5%; relative risk = 10.8; p = 0.02). CONCLUSION Although statistically underpowered, the results suggest placebo was noninferior to prophylactic antibiotics after ESS for CRS regarding postoperative sinonasal-specific QOL. There were no significant differences in postoperative endoscopic scores or rates of infection, but the rate of diarrhea was significantly higher in the antibiotic group. These findings add to the growing evidence that routine use of prophylactic postoperative antibiotics does not improve outcomes post-ESS and significantly increases the rate of diarrhea.

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.

IMPORTANCE: Women comprise an increasing proportion of the otolaryngology workforce. Prior studies have demonstrated gender-based disparity in physician practice and income in other clinical specialties; however, research has not comprehensively examined whether gender-based income disparities exist within the field of otolaryngology. OBJECTIVE: To determine whether diversity of practice, clinical productivity, and Medicare payment differ between male and female otolaryngologists and whether any identified variation is associated with practice setting. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cross-sectional analysis of publicly available Medicare data summarizing payments to otolaryngologists from January 1 through December 31, 2017. Male and female otolaryngologists participating in Medicare in facility-based (FB; hospital-based) and non–facility-based settings (NFB; eg, physician office) for outpatient otolaryngologic care were included. MAIN OUTCOMES AND MEASURES: Number of unique billing codes (diversity of practice) per physician, number of services provided per physician (physician productivity), and Medicare payment per physician. Outcomes were stratified by practice setting (FB vs NFB). RESULTS: A total of 8456 otolaryngologists (1289 [15.2%] women; 7167 [84.8%] men) received Medicare payments in 2017. Per physician, women billed fewer unique codes (mean difference, −2.10; 95% CI, −2.46 to −1.75; P

Importance Clinicians are increasingly adopting telemedicine in an effort to expand patient access and efficiently deliver care. However, the extent to which otolaryngologists provide telemedicine services is unclear. Objective To characterize recent trends in the use of telemedicine by otolaryngologists to deliver care to Medicare beneficiaries. Design, Setting, and Participants A retrospective cross-sectional analysis was conducted between January 1, 2010, and December 31, 2018, using publicly available Medicare Physician/Supplier Procedure Summary data on physicians practicing in the field of otolaryngology and benchmark specialties (dermatology and psychiatry) that provided telemedicine services to Medicare beneficiaries. Main Outcomes and Measures Primary outcomes were the mean annual number of telemedicine services delivered per active physician and mean annual payment per active physician for these services. Secondary outcomes included the number, setting, and complexity of telemedicine services. Results Between 2010 and 2018, otolaryngologists provided 2127 total telemedicine services (7 unique service types) to Medicare beneficiaries and received $88 574 in total payment for these services. During this period, the mean number of telemedicine services increased at a compound annual growth rate (CAGR) of 11.0%, and the mean Medicare payment per otolaryngologist increased at a CAGR of 21.8%. In comparison, telemedicine use during this period generally increased at a higher rate in the fields of dermatology (mean number of services per active physician at CAGR of 13.0%; mean Medicare payment per active physician at CAGR of 12.5%) and psychiatry (mean number of services per active physician at CAGR of 25.8%; mean Medicare payment per active physician at CAGR of 26.6%). In 2018, outpatient evaluation and management visits accounted for most telemedicine services provided (337 of 353 [95.5%]) and the payments received ($17 542.13 of $18 470.47 [95.0%]) by otolaryngologists. In contrast, physicians in other specialties also provided substantial portions of telemedicine services in the inpatient (psychiatry, 18 403 of 198 478 [9.3%]; dermatology, 231 of 1034 [22.3%]) and skilled nursing facility settings (psychiatry, 14 690 of 198 478 [7.4%]; dermatology, 46 of 1034 [4.4%]). Conclusions and Relevance This study suggests that the extent to which otolaryngologists used telemedicine to deliver care to Medicare beneficiaries between 2010 and 2018 was rare. Although there was relative growth in the use of telemedicine by otolaryngologists during this period, absolute growth remained low. Policy makers and provider organizations should support otolaryngologists in the adoption of telemedicine technologies, especially while coronavirus disease 2019 (COVID-19) viral suppression efforts necessitate prolonged restriction of physical clinic throughput.

Chronic rhinosinusitis (CRS) disease burden is associated with pulmonary status in asthmatic CRS patients. Asthma-related emergency department (ED) usage is a predictor of asthma-related mortality. We sought to determine whether measures of CRS disease burden are associated with asthma-related ED usage. We prospectively recruited 263 asthmatic CRS patients for this cross-sectional study. CRS burden was measured using the 22-item Sinonasal Outcome Test (SNOT-22), and patient-reported CRS-related antibiotic usage and CRS-related oral corticosteroids usage over the preceding year. Asthma-related ED visits over the prior year were also assessed. Of all participants, 18.6% had at least 1 asthma-related ED visit (mean 0.3 ED visits for the whole cohort). Asthma-related ED usage was associated with SNOT-22 score [adjusted rate ratio (RR) = 1.02, 95% CI 1.01–1.03, p = 0.040] and CRS-related oral corticosteroids usage in the past year (RR = 1.52, 95% CI 1.26–1.83, p

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.

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.

Background The frequencies of systemic antibiotics and oral corticosteroids taken for chronic rhinosinusitis (CRS) indicate poor CRS disease control. We sought to determine the validity and responsiveness of these metrics as reflections of CRS disease burden. Methodology One hundred and eighty-seven patients undergoing medical management for CRS were recruited. Participants were assessed at two time points: enrollment and a follow-up appointment three to nine months later. At each time point, CRS related antibiotic and oral corticosteroid usage in the previous three months was measured, while general and disease-specific quality of life (QOL) was measured using the visual analog scale of the 5-dimension EuroQol questionnaire (EQ-5D VAS) and the 22-item Sinonasal Outcome Test (SNOT-22), respectively. Results The frequency of CRS-related antibiotics and oral corticosteroids use was cross-sectionally correlated with EQ-5D VAS and SNOT-22 at the corresponding time points. For participants reporting usage of these medications at enrollment, there was a decrease of 1 course per 3 months for both CRS-related antibiotics and oral corticosteroids. Change in CRS-related antibiotics from enrollment to follow-up was correlated with change in both EQ-5D and SNOT-22 over the same timeframe. The change in CRSrelated oral corticosteroids was correlated with change in both EQ-5D VAS and SNOT-22). These correlations were stronger in the subset of patients who had a change in these metrics over the study period. Conclusions The frequencies of CRS-related antibiotic use and oral corticosteroid use are valid and responsive measures of CRS disease burden.

It is unknown how severity of depressed mood affects the well-recognized relationship between chronic rhinosinusitis (CRS) symptom burden and decreased general health-related quality of life (QOL).The objective of this study was to determine whether depressed mood would affect the relationship between CRS symptom burden and decreased general health-related QOL.For this cross-sectional study, 610 participants with CRS were prospectively recruited. CRS symptom burden was measured with the 22-item Sino-Nasal Outcome Test (SNOT-22). General health-related QOL was measured with the EuroQol 5-dimensional health utility value (EQ-5D HUV) and visual analog scale (EQ-5D VAS). Depressed mood was measured using the Patient Health Questionnaire-2 (PHQ-2). Participants were stratified as having well-controlled CRS symptoms (SNOT-2235) and poorly controlled CRS symptoms (SNOT-22 ≥ 35). Good general health-related QOL was determined as EQ-5D HUV ≥ 0.9 or EQ-5D VAS ≥ 80, in contrast to low general health-related QOL.In participants with well-controlled CRS symptoms, both SNOT-22 and PHQ-2 were significantly and negatively associated with good general health-related QOL (P.020 in all cases using multivariable regression). In participants with poorly controlled CRS symptoms, the PHQ-2 was significantly and negatively associated with good general health-related QOL using the EQ-5D HUV (adjusted odds ratio [OR] = 0.37, 95% confidence interval [CI]: 0.22-0.62, P.001) or the EQ-5D VAS (adjusted OR = 0.74, 95% CI: 0.57-0.96, P = .024). In contrast, SNOT-22 was not associated with general health-related QOL in these patients.Depressed mood modulates the association between CRS symptom burden and general health-related QOL. Our results suggest a threshold of CRS symptom burden or control, beyond which depressed mood-not CRS symptom burden-drives the association with general health-related QOL.

Objectives The concept of disease control incorporates independent disease characteristics that are longitudinally reflective of disease status and which can be used to make treatment decisions. Chronic rhinosinusitis (CRS) is a chronic condition for which the determination of disease control by both the patient and the treating physician is important. Our objectives were to determine CRS disease characteristics that are associated with patient-reported and physician-rated CRS disease control. Study Type Cross-sectional. Methods A total of 209 participants were prospectively recruited. Participants were asked to rate their global level of CRS control as "not at all," "a little," "somewhat," "very," and "completely." All participants completed a 22-item Sinonasal Outcome Test (SNOT-22) and also reported the number of sinus infections, CRS-related antibiotic courses taken, CRS-related oral corticosteroid courses taken, and missed days of work or school due to CRS, all in the last 3 months. Clinical and demographic characteristics were also collected from each participant. A Lund-Kennedy endoscopy score was calculated for each participant from nasal endoscopy. Two rhinologists were then given each participant's SNOT-22 score (as well as SNOT-22 nasal, sleep, otologic/facial pain, and emotional subdomain scores), endoscopy score, and the number of sinus infections, CRS-related antibiotics, CRS-related oral corticosteroid courses and missed days of work or school due to CRS in the preceding 3 months as reported by the patient. The two rhinologists were blinded to all other participant characteristics and each rhinologist independently rated every participant's global control level as "not at all," "a little," "somewhat," "very," and "completely." Associations were sought between CRS disease characteristics (SNOT-22 score, endoscopy score, sinus infections, CRS-related antibiotic usage, CRS-related oral corticosteroid usage, and lost productivity due to CRS) and patient-reported CRS control as well as mean physician-rated CRS control. Results Patient-reported global CRS control was associated only with SNOT-22 (adjusted relative risk [RR] = 0.99, 95% CI: 0.98-0.99, P

Background The number of rhinology fellowship programs has grown rapidly over the past decade. To date, no standardization or accreditation process exists, raising the potential for disparate programs. The attitudes of faculty regarding training are important to elucidate the educational experience of rhinology fellowship. Methods An anonymous, web-based survey of rhinology faculty assessed the subjective attitudes toward various domains of fellowship training including surgery, office-based procedures, research, and career development. A 5-point Likert-type scale assessing importance was used (1—not at all important, 5—extremely important). Results A total of 34 faculty (response rate 35.8%) completed the survey. The surgical procedures that received the highest mean importance scores were endoscopic surgery for advanced inflammatory disease (median = 5), cerebrospinal fluid leak closure (5), and extended endoscopic sinus surgery (5). The procedures with the lowest scores were nasal valve repair (2), inferior turbinate surgery (3), and open approaches to the sinuses (4). A wide range of responses was noted for the minimum target number of fellow cases for the surveyed procedures. Higher importance scores were noted for direct attending supervision (5) when compared to fellow autonomy (4, P Conclusion A range of faculty attitudes with respect to fellowship training was noted in this study. Continued assessment and refinement of the educational experience in rhinology fellowships is necessary.

Background Differentiating the non-sinogenic headache from chronic rhinosinusitis (CRS) remains a significant clinical challenge due to the extensive overlap in symptoms. The objective of this study was to evaluate the 22-item Sino-Nasal Outcome Test (SNOT-22) score patterns in patients with confirmed non-sinogenic headache in order to develop negative predictors of CRS. Methods Institutional Review Board (IRB)-approved, retrospective review of patients diagnosed with CRS or non-sinogenic headache defined as patients with a chief complaint of headache, facial pain, and facial pressure in the absence of both endoscopic and computed tomography (CT) evidence of inflammation. The optimal cutoff points of potential predictors of non-sinogenic headache by SNOT-22 score were quantified by receiver operating characteristic (ROC) curve. The negative predictive values (NPVs) for CRS were calculated in a discovery population and then validated in an independent population. Results A total of 724 (164 non-sinogenic headache and 560 CRS) and 412 (88 non-sinogenic headache and 324 CRS) patients were recruited in the discovery and validation populations, respectively. Domain 3 (Ear/facial) and domain 4 (Psychological dysfunction) were significantly higher in patients with non-sinogenic headache as compared with CRS while domain 1 (Rhinologic) and domain 2 (Extranasal rhinologic) were significantly lower. The top 4 predictors of non-sinogenic headache were the domain 3 (Ear/facial)/domain 1 (Rhinologic) ratio, item 12, domain 3 (Ear/facial), and (item 12 + item 10)/(item 4 + item 5) ratio, with areas under the ROC curve (AUCs) ranging from 0.637 to 0.720 by ROC curve. A domain 3 (Ear/facial)/domain 1 (Rhinologic) ratio over 0.66 performed as the best negative predictor of CRS with the highest NPVs of 0.880 and 0.889 in the discovery and validation populations, respectively. Conclusion Patients with non-sinogenic headache have distinct SNOT-22 score patterns compared with patients with CRS. A domain 3 (Ear/facial)/domain 1 (Rhinologic) ratio greater than 0.66 is a strong negative predictor of CRS, which can be used to aid in patient counseling and potentially limit the use of unnecessary sinonasal therapeutics.

OBJECTIVES/HYPOTHESIS Endoscopic sinus surgery (ESS) is frequently performed for recurrent acute rhinosinusitis (RARS). Appropriate indications for surgery among patients with RARS have not yet been rigorously determined. The objective of this study was to define appropriateness criteria for ESS in the management of adult RARS. STUDY DESIGN Application of RAND-UCLA appropriateness methodology. METHODS A panel of nine multidisciplinary experts in RARS was formed to evaluate RARS scenarios generated from current evidence. The panel completed two rounds of a modified Delphi-ranking process and a teleconference. RESULTS A total of 32 clinical scenarios were ranked in each round. For adult patients with RARS, ESS can appropriately be offered as a treatment option when patients experience ≥ four annual episodes, and there is confirmation of at least one episode via computed tomography or nasal endoscopy, and the patient and clinician jointly participate in shared decision making, and the patient has either failed a trial of topical nasal steroids or experienced RARS-related productivity loss. CONCLUSIONS This study has defined appropriateness criteria for ESS as a management option for adult patients with RARS. These criteria are intended to represent a minimum threshold for which ESS should be considered in the treatment of RARS and do not suggest that all patients who meet these criteria should undergo surgery. These criteria may serve as a baseline set of indications for ESS in patients with RARS. LEVEL OF EVIDENCE NA Laryngoscope, 129:37-44, 2019.

OBJECTIVES/HYPOTHESIS The recent addition of mandatory program-specific paragraphs within the personal statement during the otolaryngology match process has been controversial. It is unclear whether applicants customize these paragraphs for programs, or if they are largely uniform across applications. The objective of our study was to assess the degree of variability among program-specific paragraphs. STUDY DESIGN Retrospective cohort analysis. METHODS An analysis of deidentified program-specific paragraphs of 2016 otolaryngology residency applicants at two institutions was performed. Applicants who applied to both and had program-specific paragraphs were included. Paragraphs were assessed for 24 parameters, including quantitative content analysis. Subjective and objective similarity scores were assigned to each pair, using a five-point scale and Levenshtein distance function respectively. Differences between institutions were calculated using χ2 and two-sided t tests. RESULTS Two hundred eight-five applications were reviewed, and 181 applied to both programs and had program-specific paragraphs. The median subjective similarity score among all paragraphs was "mildly similar" (2/5). The mean objective similarity score was 0.59. There were statistical differences between institutions in 13 parameters. One institution garnered more applicants who mentioned interest in research or global surgery (71.3% vs. 57.5%, P = .006; 17.7% vs. 4.4%, P

Previous work has shown that the symptoms of chronic rhinosinusitis (CRS) differentially associate with decreased general health-related quality of life (QOL).We sought to determine whether longitudinal changes in different types of CRS symptomatology lead to correspondingly different magnitude changes in general health-related QOL.Prospective observational study of 145 patients undergoing medical management for CRS. Chronic rhinosinusitis symptom severity was measured using the 22-item Sinonasal Outcome Test (SNOT-22) and associated nasal, sleep, ear/facial discomfort, and emotional subdomains of the SNOT-22. General health-related QOL was measured using the 5-dimensional EuroQoL questionnaire's visual analog scale (EQ-5D VAS). These data were collected at 2 time points: at enrollment and at a subsequent follow-up visit within the next 2 to 6 months. Associations were sought between the changes in SNOT-22 and EQ-5D VAS.The change in SNOT-22 was associated with change in EQ-5D VAS (adjusted linear regression coefficient [β] = -0.37, 95%CI: -0.51 to -0.24, P .001). The change in EQ-5D VAS was only associated with changes in the sleep (adjusted β = -0.42, 95% confidence interval [95%CI]: -0.81 to -0.04, P = .034) and ear/facial discomfort (adjusted β = -1.00, 95%CI: -1.89 to -0.10, P = .031) subdomains but not nasal (adjusted β = -0.12, 95%CI: -0.52 to 0.28, P = .564) or emotional (adjusted β = -0.17, 95%CI: -1.83 to 1.49, P = .840) subdomains.Changes in the severity of sleep and ear/facial discomfort symptoms associate most greatly with the change in general health-related QOL that CRS patients experience during routine medical management. Reduction of these extranasal symptoms of CRS may therefore lead to the greatest improvement in general health-related QOL.

The aim of this study was to evaluate sex differences in full professorship among a comprehensive, contemporary cohort of US academic surgeons.Previous work demonstrates that women are less likely than men to be full professors in academic medicine, and in certain surgical subspecialties. Whether sex differences in academic rank exist across all surgical fields, and after adjustment for confounders, is not known.A comprehensive list of surgeons with faculty appointments at US medical schools in 2014 was obtained from Association of American Medical Colleges (AAMC) faculty roster and linked to a comprehensive physician database from Doximity, an online physician networking website, which contained the following data for all physicians: sex, age, years since residency, publication number (total and first/last author), clinical trials participation, National Institutes of Health grants, and surgical subspecialty. A 20% sample of 2013 Medicare payments for care was added to this dataset. Multivariable regression models were used to estimate sex differences in full professorship, adjusting for these variables and medical school-specific fixed effects.Among 11,549 surgeon faculty at US medical schools in 2014, 1692 (14.7%) were women. Women comprised 19.4% of assistant professors (1072/5538), 13.8% of associate professors (404/2931), and 7.0% of full professors (216/3080). After multivariable analysis, women were less likely to be full professors than men (adjusted odds ratio: 0.76, 95% confidence interval: 0.6-0.9).Among surgical faculty at US medical schools in 2014, women were less likely than men to be full professors after adjustment for multiple factors known to impact faculty rank.