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Sinus infections are a common reason patients seek medical care. However, the intended meaning of the term sinus infection among patients and otolaryngologists is incompletely understood.In this multi-institutional cross-sectional study, a semantics-based questionnaire was provided to consecutive patients presenting to otolaryngology clinics at six academic centers from June 2020 until May 2021. The primary outcome was respondent definitions for sinus infection from a list of 28 proposed terms covering six general categories. Secondary outcome measures included differences between geographic regions.Responses were obtained from 560 patients (54% female, mean age 48.9 years) and 29 otolaryngologists (42% female, mean age 37.4 years). Patients and otolaryngologists selected a median of 10 and 11 terms, respectively, to define a sinus infection. Among patients the most frequently selected symptom categories were mucus (500, 89.3%), pressure/pain (480, 85.7%), and airflow (468, 83.6%). Compared to patients, clinicians selected with greater frequency the symptom categories of pressure/pain (14.3% difference; 95% CI, 7.6% to 22.5%), mucus (10.7% difference; 95% CI, 4.7% to 18.3%) and airflow (13.0% difference; 95% CI, 4.8% to 21.7%). Multiple categories were selected by 96% of patients and 100% of providers.The definition of sinus infection appears variable for both patients and otolaryngologists, though patients appear to apply a broader range of symptoms to the term sinus infection. There were no pronounced geographic differences in the description of a sinus infection in this US sample population. Patients commonly described sinus infection in the context of pain-related symptoms. Appreciation of these semantic differences may enable more effective patient-clinician communication.

To offer pragmatic, evidence-informed guidance on the use of systemic corticosteroids (SCS) for common otolaryngologic disorders.PubMed, Cochrane Library, and American Academy of Otolaryngology-Head and Neck Surgery Foundation clinical practice guidelines.A comprehensive search of published literature through November 2021 was conducted on the efficacy of SCS, alone or in combination with other treatments, for managing disorders in otolaryngology and the subdisciplines. Clinical practice guidelines, systematic reviews, and randomized controlled trials, when available, were preferentially retrieved. Interventions and outcomes of SCS use were compiled to generate summary tables and narrative synthesis of findings.Evidence on the effectiveness of SCS varies widely across otolaryngology disorders. High-level evidence supports SCS use for Bell's palsy, sinonasal polyposis, and lower airway disease. Conversely, evidence is weak or absent for upper respiratory tract infection, eustachian tube dysfunction, benign paroxysmal positional vertigo, adenotonsillar hypertrophy, or nonallergic rhinitis. Evidence is indeterminate for acute laryngitis, acute pharyngitis, acute sinusitis, angioedema, chronic rhinosinusitis without polyps, Ménière's disease, postviral olfactory loss, postoperative nerve paresis/paralysis, facial pain, and sudden sensorineural hearing loss.Clinicians should bring an evidence-informed lens to SCS prescribing to best counsel patients regarding the risks, anticipated benefits, and limited data on long-term effects. Alternate routes of corticosteroid administration-such as sprays, drops, inhalers, and intralesional injections-may be preferable for many disorders, particularly those that are self-limited or require a prolonged duration of therapy. Prudent use of SCS reduces the risk of medication-related adverse effects. Clinicians who are conversant with high-level evidence can achieve optimal outcomes and stewardship when prescribing SCS.

Enhanced recovery after surgery (ERAS) protocols aim to optimize the pre-, intra-, and postoperative care of patients to improve surgery outcomes, reduce complications, decrease length of stay, and more. We aim to perform a systematic review and meta-analysis of ERAS protocols for head and neck cancer surgery with or without microvascular reconstruction.PubMed, Embase, and Web of Science databases were queried, and abstracts were screened independently by 2 investigators.This review was conducted in accordance with the PRISMA guidelines. We included comparative observational studies but excluded animal studies, case reports, and case series.Of 557 articles initially reviewed by title and/or abstract, we identified 30 for full-text screening, and 9 met the criteria for qualitative synthesis. Meta-analysis of length of stay revealed a mean decrease of 1.37 days (95% CI, 0.77-1.96;Implementation of ERAS protocols can lead to decreases in length of stay and opioid drug utilization. However, further high-quality prospective studies of ERAS protocols are needed, especially with stratified analysis of outcomes based on the type of head and neck cancer surgery.

Artificial intelligence (AI) is ubiquitous and expanding, and the healthcare industry has rapidly adopted AI and machine learning for numerous applications. It is essential to understand that AI is not immune to the biases that impact our clinical and academic work, and in fact may inadvertently amplify rather than reduce them. As we harness the power of AI, it is our obligation to our patients to ensure that we address these concerns. We must take responsibility for proactive stewardship to protect against bias, not only for new AI algorithms, but also for our research studies that may one day provide data for those algorithms. This article is protected by copyright. All rights reserved.

To evaluate the predictive ability of symptom self-localization to distinguish obstructive eustachian tube dysfunction from non-obstructive salpingitis.Adult (age ≥18 years) patients with a primary complaint of aural discomfort who underwent diagnostic nasal endoscopy and tympanometry at a tertiary academic center were enrolled. Symptoms were self-localized by using a single finger on the affected side. All patients completed the 7-item Eustachian Tube Dysfunction Questionnaire (ETDQ-7) and underwent scoring of eustachian tube inflammation using the Endoscopic Evaluation of the Eustachian Tube (3ET) system.Seventy-three patients were included in the study. Symptoms were localized to the external auditory canal (EAC) in 28 (38.4%), to the infratemporal fossa (ITF) below the lobule in 37 (50.7%), and to the preauricular region in 8 (11.0%). Demographics and medical history were similar between groups. The EAC group had significantly more negative tympanometric peak pressure (TPP) (median, -92.0 daPa; IQR, 95.5) and higher 3ET scores. In contrast, the ITF group had normal TPP (median, -2.0 daPa; IQR, 7.0) and higher 3ET scores. The preauricular group was more likely to have temporomandibular joint or pterygoid muscle pain. ETDQ-7 scores did not differ significantly between groups.Symptom localization is associated with specific objective findings in the evaluation of aural discomfort. Patients with pain localizing to the ITF are more likely to have findings of eustachian tube salpingitis without obstruction whereas patients with symptoms deep in the EAC are more likely to have findings consistent with obstructive eustachian tube dysfunction.3 Laryngoscope, 2022.

Patients mislabeled with a penicillin allergy are often unnecessarily given prophylactic clindamycin. Thus, otolaryngologists may cause harm due to clindamycin's associated risk of Clostridioides difficile infections (CDI) and surgical site infections (SSI). The objective of this study was to determine the economic feasibility of penicillin allergy testing in preventing unnecessary clindamycin use among patients with an unconfirmed penicillin allergy prior to otolaryngologic surgery.A break-even analysis was performed using the average cost of penicillin allergy testing and a CDI/SSI to calculate the absolute risk reduction (ARR) in baseline CDI/SSI rate due to clindamycin required for penicillin testing to be economically sustainable. The binomial distribution was used to calculate the probability that current penicillin testing can achieve this study's ARR.Preoperative penicillin testing was found to be economically sustainable if it could decrease the baseline CDI rate by an ARR of 1.06% or decrease the baseline SSI rate by an ARR of 1.34%. The probability of penicillin testing achieving these ARRs depended on the baseline CDI and SSI rates. When the CDI rate was at least 5% or the SSI rate was at least 7%, penicillin allergy testing was guaranteed to achieve economic sustainability.In patients mislabeled with a penicillin allergy, preoperative penicillin allergy testing may be an economically sustainable option to prevent the unnecessary use of prophylactic clindamycin during otolaryngologic surgery. Current practice guidelines should be modified to recommend penicillin allergy testing in patients with an unconfirmed allergy prior to surgery.N/A Laryngoscope, 2022.

Background: Complications following total laryngectomy can lead to increased hospital length of stay (LOS) and increased health care costs. Our objective was to determine the efficacy of a clinical care pathway for improving outcomes for patients following total laryngectomy. Methods: This quality improvement study included all adult patients undergoing total laryngectomy-either primary or salvage-at a tertiary referral center between January 2013 and December 2018. The primary outcome was hospital LOS measured in postoperative days. The total and specific postoperative complication frequencies were evaluated, as well as 30-day readmission rates and intensive care unit (ICU) LOS. Results: Sixty-three patients were included in the study: 29 (46.0%) patients before the pathway implementation and 34 (54.0%) patients after pathway implementation. Demographic characteristics between the groups were similar. The prepathway cohort had a higher rate of total complications compared to the postpathway group (relative risk=0.5; 95% CI 0.3-1.0), although the differences in individual complications were similar. The median LOS of 10 days was the same for the 2 cohorts. The median ICU LOS was 1 day greater in the postpathway cohort, but no difference was seen in rates of ICU readmission in the 2 groups. The 30-day readmission rate also was not significant between the 2 groups. Conclusion: Implementation of a postoperative order set pathway for patients undergoing laryngectomy is associated with decreased overall complication rates. Use of a clinical care pathway may improve outcomes in patients undergoing total laryngectomy.

Numerous pharmaceutical options are available over-the-counter (OTC) for the relief of sinonasal symptoms. Patients typically utilize these drugs in an unsupervised manner, without appreciation of their relative efficacy or potential for adverse effects. This review covers the scope and regulation of the OTC drug market, the pros and cons of OTC availability, and specific concerns that surround the most common classes of OTC sinonasal drugs. Suggestions are provided for the improvement of patient care and public health.MEDLINE publications and market reports.Literature review.Some of the most commonly used OTC sinonasal remedies, including decongestants and first-generation antihistamines, are less effective than alternative drugs and pose potential safety concerns.Clinicians should advocate to their patients for the appropriate use of alternative agents, such as intranasal corticosteroids and newer-generation antihistamines, and discourage the unsupervised use of oral and topical decongestants. Furthermore, health care practitioners should encourage dialogue with their patients about the use of OTC sinonasal remedies, with the goals of optimizing individual health and health care delivery.

To characterize the relationship between objective tympanogram values and patient-reported symptoms and associations with common comorbid conditions.Cross-sectional study with prospective data collection.Tertiary medical center.Patients undergoing routine audiometric evaluation between October 2018 and June 2019 were included. Participants with temporomandibular joint dysfunction, inner ear hydrops, and similar conditions were excluded. Symptoms were assessed with the 7-item Eustachian Tube Dysfunction Questionnaire. Demographics and medical comorbidities were recorded from the medical record. Analysis of tympanometric peak pressure (TPP), demographics, and comorbidities was performed to determine associations with clinically significant eustachian tube dysfunction (ETD) symptoms.A total of 250 patients were included with similar demographics: 101 (40.4%) in the asymptomatic group and 149 (59.6%) in the symptomatic group. The median (interquartile range) TPP was -10 (20) daPa and -25 (100) daPa in the asymptomatic and symptomatic groups, respectively. A diagnosis of rhinitis was more likely to be associated with significant ETD symptoms (adjusted odds ratio, 2.61; 95% CI, 1.23-5.63). A subgroup analysis revealed that symptomatic patients with normal TPP values were negatively skewed as compared with asymptomatic patients. This symptomatic group had a higher prevalence of rhinitis and chronic rhinosinusitis than the asymptomatic group.Patients with symptoms of ETD may have a TPP within a range typically considered normal per conventional standards. This suggests that the currently accepted interpretation of tympanometry findings may be insensitive for the diagnosis of less severe cases of ETD.

OBJECTIVE To evaluate the effectiveness of neuromodulating agents for the management of atypical facial pain and primary facial neuralgias. METHODS We searched MEDLINE, Embase, CINAHL, and ClinicalTrials.gov databases for original research articles that examine the effectiveness and adverse reactions of pharmacologic therapy for the treatment of trigeminal neuralgia and atypical facial pain. Studies that included surgical interventions for atypical facial pain or facial pain secondary to other causes were excluded. Meta-analysis was conducted for reductions in symptom scores and adverse effects. RESULTS Of 3,409 articles screened, 73 full-text articles were included, consisting of 45 observational studies and 29 randomized controlled trials. Twenty-four different pharmacological agents were assessed; carbamazepine was the most frequently studied while botulinum toxin A demonstrated the highest consistency in reduction of symptom scores. Pooled estimate of three randomized controlled trials revealed that patients with trigeminal neuralgia who received botulinum toxin A had higher odds (odds ratio 7.46; 95% CI 3.53-15.78) of achieving a ≥50% reduction in visual analogue scale scores compared to controls. Pooled estimate of 15 observational studies showed that three-fourths of patients with trigeminal neuralgia who received carbamazepine experienced clinically significant pain reduction (prevalence proportion 0.75; 95% CI 0.66-0.83). CONCLUSIONS Patients receiving botulinum toxin A for trigeminal neuralgia had higher odds of achieving ≥50% reduction in pain scores. A significant proportion of patients with trigeminal neuralgia experienced positive response to carbamazepine. There was moderate evidence for amitriptyline in patients with atypical facial pain. Standardization of outcome reporting would facilitate future quantitative comparisons of therapeutic effectiveness. Laryngoscope, 131:1235-1253, 2021.

Background Common rhinologic diagnoses have similar presentations with a varying degree of overlap. Patterns may exist within clinical data that can be useful for early diagnosis and predicting outcomes. Objective To explore the feasibility of artificial intelligence to differentiate patterns in patient data in order to develop clinically-meaningful diagnostic groups. Methods A cross-sectional study of prospectively-acquired patient data at a tertiary rhinology clinic was performed. Data extracted included objective findings on nasal endoscopy, patient reported quality of life (PRQOL) instrument ratings, peripheral eosinophil fraction, and past medical history. Unsupervised non-hierarchical cluster analysis was performed to discover patterns in the data using 22 input variables. Results A total of 545 patients were analyzed after application of inclusion and exclusion criteria yielding 7 unique patient clusters, highly dependent on PRQOL scores and demographics. The clusters were clinically-relevant with distinct characteristics. Chronic rhinosinusitis without nasal polyposis (CRSsNP) was associated with two clusters having low frequencies of asthma and low eosinophil fractions. Chronic rhinosinusitis with nasal polyposis (CRSwNP) was associated with high frequency of asthma, mean (standard deviation [SD]) NOSE scores of 66 (19) and SNOT-22 scores of 41 (15), and high eosinophil fractions. AR was present in multiple clusters. RARS was associated with the youngest population with mean (SD) NOSE score of 54 (23) and SNOT-22 score of 41 (19). Conclusion Broader consideration of initially available clinical data may improve diagnostic efficiency for rhinologic conditions without ancillary studies, using computer-driven algorithms. PRQOL scores and demographic information appeared to be useful adjuncts, with associations to diagnoses in this pilot study.

To investigate the prevalence of eustachian tube dysfunction (ETD) in elderly adults in the United States and its association with other upper aerodigestive inflammatory processes.Cross-sectional study.Population based.In total, 147,805 patients without malignancy were compared to 13,804 demographically matched patients with malignancy of the upper aerodigestive tract (UADT) by querying the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database for patients aged 66 to 99 years between 2003 and 2011. The prevalence of ETD and inflammatory diseases among these patients was compared. Association between ETD, other upper aerodigestive inflammatory processes, and UADT malignancies was evaluated.The prevalence of ETD was 5.44% among patients without malignancy and 9.08% in those with cancer (odds ratio [OR], 1.73; 95% CI, 1.63-1.84). Patients with ETD in the control population were more likely (OR, 95% CI) to be diagnosed with chronic rhinitis (5.00, 4.70-5.33), chronic sinusitis (4.20, 3.98-4.43), allergic rhinitis (4.27, 4.08-4.47), and gastroesophageal reflux disease (GERD) (2.42, 2.31-2.53). Patients with ETD and chronic rhinitis (1.43, 1.24-1.65), chronic sinusitis (1.57, 1.38-1.78), and acute otitis media (1.33, 1.08-1.65) were associated with higher rates of UADT malignancy.Over 5% of patients older than 65 in the United States are diagnosed with ETD in the absence of UADT malignancy. Associations between ETD and chronic rhinitis, chronic sinusitis, allergic rhinitis, and GERD in the absence of UADT malignancy suggest that some patients may benefit from treatment of inflammatory disease as a cause of ETD.

Objective: To examine the use of intramuscular corticosteroid (IMCS) injections for treatment of acute upper respiratory infections (URI) and the influence on healthcare utilization. Methods: This retrospective cohort study used patient encounter data from a large multicenter regional health care system between 2013 and 2017. Adult patients diagnosed with acute URI (acute pharyngitis, acute sinusitis, acute otitis media, and URI not otherwise specified) during ambulatory encounters were included. Follow-up encounters for a diagnosis of acute URI within 60 days were identified and patient characteristics, encounter details, and procedure codes were retrieved. Frequency data was used to calculate IMCS injection administration prevalence, utilization trends, and associations with covariates. Follow-up data for return encounters within 60 days for the same diagnosis was examined. Results: Of the 153 848 initial encounters, 34 600 (22.5%) patients received IMCS injection for acute URI. Injection rates varied from 0.85% to 49.1% depending on specialty and practitioner type. Internal medicine, family medicine, urgent care, and otorhinolaryngology clinics most commonly administered IMCS. 3788 patients returned for a second encounter of which 751 (19.8%) received an injection. IMCS injection during the first encounter was associated with increased odds of repeat visit within 60 days (OR: 1.74; 95% CI: 1.61–1.88). Conclusion: IMCS use in the treatment of acute URI is highly prevalent despite lack of evidence for impact and safety. Prevalence is variable across multiple medical and surgical specialties including otorhinolaryngology. Administration of IMCS injection may contribute to the likelihood of a subsequent healthcare visit for the same indication.

Introduction To describe the current state of literature involving SMARCB1/INI-1 deficient sinonasal carcinoma (SDSC) and examine a case at our institution. Methods A systematic search was performed using the Population, Intervention, Comparator, Outcome, and Study Design approach. Search criteria included all occurrences in the title or abstract of the terms: “integrase interactor 1 deficient,” “INI1 deficient,” or “SMARCB1 deficient” and “sinonasal carcinoma.” The main outcomes were disease-free survival, all-cause mortality, rates of recurrence, or metastases. Results Systematic search yielded 13 studies for final review. All studies were either case series or case reports with 82 cases of SDSC published since 2014. Age on presentation ranged from 19 to 75 years, with the majority of patients being male. Surgical resection was the primary modality of treatment with adjuvant radiation or chemoradiation therapy. Overall, the prognosis was poor, with most tumors presenting at advanced stages with an overall median (range) survival of 22 (12–44) months with an average (standard deviation) of 45.3% (33.1%) of patients dying of the disease. An average (standard deviation) of 38.2% (34.0%) of patients had no evidence of disease at follow-up. Studies comparing sinonasal undifferentiated carcinoma to SDSC reported worse prognosis for SDSC and increased risk for locoregional recurrence in the latter cohort. Conclusions SDSC represents a highly aggressive tumor presenting at advanced stage with propensity of metastasis. More research is necessary to determine the optimal treatment modality and management.

Objective: To offer pragmatic, evidence-informed advice on administering corticosteroids in otolaryngology during the coronavirus disease 2019 (COVID-19) pandemic, considering therapeutic efficacy, potential adverse effects, susceptibility to COVID-19, and potential effects on efficacy of vaccination against SARS-CoV-2, which causes COVID-19. Data Sources: PubMed, Cochrane Library, EMBASE, CINAHL, and guideline databases. Review Methods: Guideline search strategies, supplemented by database searches on sudden sensorineural hearing loss (SSNHL), idiopathic facial nerve paralysis (Bell’s palsy), sinonasal polyposis, laryngotracheal disorders, head and neck oncology, and pediatric otolaryngology, prioritizing systematic reviews, randomized controlled trials, and COVID-19–specific findings. Conclusions: Systemic corticosteroids (SCSs) reduce long-term morbidity in individuals with SSNHL and Bell’s palsy, reduce acute laryngotracheal edema, and have benefit in perioperative management for some procedures. Topical or locally injected corticosteroids are preferable for most other otolaryngologic indications. SCSs have not shown long-term benefit for sinonasal disorders. SCSs are not a contraindication to vaccination with COVID-19 vaccines approved by the US Food and Drug Administration. The Centers for Disease Control and Prevention noted that these vaccines are safe for immunocompromised patients. Implications for Practice: SCS use for SSNHL, Bell’s palsy, laryngotracheal edema, and perioperative care should follow prepandemic standards. Local or topical corticosteroids are preferable for most other otolaryngologic indications. Whether SCSs attenuate response to vaccination against COVID-19 or increase susceptibility to SARS-CoV-2 infection is unknown. Immunosuppression may lower vaccine efficacy, so immunocompromised patients should adhere to recommended infection control practices. COVID-19 vaccination with Pfizer-BioNTech, Moderna, or Johnson & Johnson vaccines is safe for immunocompromised patients.

Aural discomfort may be the result of obstructive eustachian tube (ET) dysfunction, temporomandibular joint dysfunction, or other causes. The infratemporal fossa (ITF) sign, in which a patient points to a characteristic location below the auricle, is proposed as an indicator of nonobstructive eustachian salpingitis. A preliminary study included patients with a complaint of aural discomfort who were prompted to localize symptoms using a single finger. Group 1 localized by using the ITF sign; group 2 localized deep within the external ear canal (suggesting ET dysfunction); and group 3 localized to the preauricular region (suggesting temporomandibular joint dysfunction). Findings of ET inflammation recorded during nasal endoscopy were greater in groups 1 and 2. Tympanometry and otoscopy were uniformly abnormal for group 2 and uniformly normal for groups 1 and 3. The ITF sign may help to identify eustachian salpingitis as a phenotype of ET disease characterized by symptomatic inflammation without abnormal middle ear pressure.

Gastroesophageal reflux disease (GERD) has been hypothesized as a risk factor for development of laryngeal cancer. A case-control study was performed to assess the association of laryngeal neoplasia with GERD. Cases consisted of patients with a history of laryngeal cancer or carcinoma in situ. Controls were patients without neoplasia who matched cases 2:1 on age, sex, race, and smoking history. Univariate and multivariate analyses were performed to assess risk of laryngeal neoplasia and GERD. In total, 2094 patients were included. Cases had higher rates of GERD. Univariate analysis demonstrated a positive association between GERD and laryngeal neoplasia (odds ratio, 1.33; 95% CI, 1.07-1.64). Multivariate analysis controlling for alcohol use history also demonstrated a positive association between GERD and laryngeal neoplasia (adjusted odds ratio, 1.29; 95% CI, 1.04-1.59). These results suggest increased odds of laryngeal carcinoma and carcinoma in situ in patients with GERD when controlling for smoking and drinking history.

Background Endoscopic sinus surgery (ESS) is a variable combination of individual procedures. Cost estimates for ESS as a single entity have wide variation, likely influenced by variation in procedures performed. We sought to identify operative time, supply costs, and total procedure cost specific to the component procedure combinations comprising ESS.Methods Bilateral ESS cases at 13 Intermountain Healthcare facilities (2008 to 2016) were identified from a database with corresponding cost and time data. Procedure details were obtained by chart review. Least-squares (LS) means of cost (in 2016 US dollars) and time for specific procedures were obtained by multivariable gamma regression models.Results Among 1477 bilateral ESS cases with 19 different procedure combinations, operative time ranged from 59.5 (95% confidence interval [CI], 48.6-73.0) minutes for total ethmoid to 147.1 (95% CI, 126.4-171.2) minutes for full ESS with maxillary and sphenoid tissue removal. Sphenoidotomy had lowest total and supply costs (in US dollars) of $2112 (95% CI, $1672-$2667) and $636 (95% CI, $389-$1040), respectively. Total cost was highest for full ESS with maxillary tissue removal at $4640 (95% CI, $4115-$5232). Supply cost was highest for full ESS with maxillary and sphenoid tissue removal at $2191 (95% CI, $1649-$2909).Conclusion Operative time and costs for ESS vary depending on the procedures performed, demonstrating the importance of procedure specificity in assessment of ESS time, cost, and, ultimately, value. These procedure-specific estimates of cost enable nonbinary valuation of ESS, appropriate for the multitude of procedure options intended to optimize individual outcomes.

Sinus, cold, and allergy remedies comprise the most widely used sector of the over-the-counter (OTC) drug market. Direct-to-consumer advertising (DTCA) of pharmaceutical products has increased over the past 30 years, including the promotion of OTC drugs. The influence of DTCA on OTC sinonasal remedies comprises several positive and negative effects. Favorable aspects of this influence include empowerment and promotion of autonomy among patients, avoidance of low-value clinical encounters, self-directed education, and decreased healthcare expenditures. This is balanced by potential concerns, including the lack of rigorous regulation of OTC drugs, the burden of self-diagnosis, the risk of unsupervised use resulting in adverse effects or drug interactions, and redistribution of pharmacy costs to the consumer. Despite the proliferation of product options and consumer-directed information, healthcare utilization and cost of treating sinonasal disease remains high. Moreover, the availability of OTC sinonasal remedies and exposure to DTCA has had mixed effects without apparent overall benefit to patient and consumer health. Laryngoscope, 130:2114-2119, 2020.

To develop a clinical consensus statement on the use of balloon dilation of the eustachian tube (BDET).An expert panel of otolaryngologists was assembled with nominated representatives of general otolaryngology and relevant subspecialty societies. The target population was adults 18 years or older who are candidates for BDET because of obstructive eustachian tube dysfunction (OETD) in 1 or both ears for 3 months or longer that significantly affects quality of life or functional health status. A modified Delphi method was used to distill expert opinion into clinical statements that met a standardized definition of consensus.After 3 iterative Delphi method surveys, 28 statements met the predefined criteria for consensus, while 28 statements did not. The clinical statements were grouped into 3 categories for the purposes of presentation and discussion: (1) patient criteria, (2) perioperative considerations, and (3) outcomes.This panel reached consensus on several statements that clarify diagnosis and perioperative management of OETD. Lack of consensus on other statements likely reflects knowledge gaps regarding the role of BDET in managing OETD. Expert panel consensus may provide helpful information for the otolaryngologist considering the use of BDET for the management of patients with OETD.

Background Intranasal corticosteroid (INCS) sprays are indicated for use in the treatment of seasonal and perennial allergic rhinitis and include aqueous and nonaqueous formulations. Secondary symptoms of rhinitis include postnasal drip, facial pain/pressure, headache, cough, and ear fullness. The effectiveness of INCS on these specific symptoms, as well as the comparative effectiveness of aqueous and nonaqueous formulations, is poorly defined. Objective To evaluate the effectiveness of aqueous versus nonaqueous INCS formulations on less common sinonasal symptoms. Methods A systematic review was conducted of English-language, randomized controlled trials, with adherence to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) standard. Studies that did not provide quantitative data on relief of postnasal drip, facial pain/pressure, headache, cough, and ear fullness were excluded. An itemized assessment of the risk of bias was conducted for each included study. Results Of the 118 studies identified, 9 met the criteria for qualitative analysis. An effect on postnasal drip was reported in 5 studies, facial pain/pressure in 2 studies, and cough in 2 studies. A reduction in a specific symptom was reported in about half of these studies, with heterogenous outcome measures. Only 1 study reported the effect of a nonaqueous formulation on a specific symptom. No studies reported an effect on aural fullness. Conclusions Limited data are available regarding the effectiveness of aqueous or nonaqueous INCS on secondary symptoms in adult patients with rhinitis. Further study is needed using homogenous outcome measures and direct comparison of INCS formulations.

Introduction: The unpredictable nature of the COVID-19 pandemic portends further uncertainty in patient decisionmaking. This study explores decisional conflict and patientspecific concerns for people undergoing otolaryngologic surgery during the pandemic. Method: This was a prospective, single-institution, crosssectional study of English-speaking adults undergoing otolaryngologic surgery, conducted from April 22 to August 31, 2020. Individuals who were non-English speaking, lacked autonomous medical decision-making capacity, underwent emergent surgery, or had a communitive disability were excluded. The primary outcome of decisional conflict was measured using the validated “SURE” screening questionnaire. Relationships between decisional conflict and patient demographics were assessed via bivariate analyses, multivariable logistic regression, and conjunctive consolidation. The secondary outcome of patient-specific concerns was obtained through open-ended interview and qualitatively assessed using thematic analysis with open coding. Results: There was a 41% response rate (182 of 444 patients). The median age was 60.5 years (range 18-88);92 patients (51%) were women. Decisional conflict was more prevalent in non-White compared with White participants (difference 18%;95% CI, 0.6%-37.0% and adjusted odds ratio 3.0;95% CI, 1.2-7.4). Combining information from multiple variables through conjunctive consolidation, the group with the highest rate of decisional conflict was non- White patients with no college education, receiving urgent surgery. “Intraoperative” and “postoperative concerns” were the most common patient-specific concerns. Among those patients reporting concerns about COVID-19, the majority had decisional conflict. Conclusion: This study highlighted factors associated with decisional conflict and emphasized the need for physicians to engage in shared-decision making with patients. The COVID- 19 pandemic contributed to decisional conflict. Consistent discussion of risks and benefits is essential. The role of race and decisional conflict needs further study.

Objectives/hypothesis In otolaryngology, γ-aminobutyric acid (GABA) analogues have been previously analyzed for their roles in neuropathic pain, chronic cough, tinnitus, and perioperative analgesia. The primary aim of this study is to comprehensively summarize and synthesize the existing evidence for lesser known uses of gabapentin and pregabalin in otolaryngology. Study design A scoping review conducted of the available English-language literature was performed by two authors through April 1, 2021. Methods The Preferred Reporting Items for Systematic Review and Meta-Analysis criteria were followed, and a quality assessment of included studies was performed using the Methodological Index for Non-Randomized Studies. Results Ten studies met inclusion criteria. Three studies found that gabapentin may reduce gastrostomy tube usage and improve swallowing function in head and neck cancer patients undergoing radiation therapy (RT). Three studies suggested that gabapentin may help reduce opiate use when used as a primary analgesic in patients with radiation-induced mucositis. One study demonstrated that pregabalin-reduced trismus severity in patients with radiotherapy-induced trismus. One study demonstrated gabapentin may be useful in patients with phonasthenia. Two studies demonstrated that GABA analogues may be a useful adjunct in patients with globus pharyngeus in the context of likely laryngeal sensory neuropathy. Conclusions The most promising potential uses for GABA analogues identified in this review are for improving swallowing, trismus, and narcotic overuse after RT. The benefit of GABA analogues for improving nonorganic voice disorders is also promising while the benefit for globus pharyngeus when possibly related to laryngeal sensory neuropathy is inconclusive. Laryngoscope, 2021.

IMPORTANCE: The opioid epidemic has generated interest in optimizing opioid prescribing after common surgeries. Recent studies have shown a broad range of analgesic prescription patterns following endoscopic sinus surgery (ESS). OBJECTIVE: To compare the efficacy of different analgesic regimens after ESS. DESIGN, SETTING, AND PARTICIPANTS: This multi-institutional, nonblinded randomized clinical trial was conducted at 6 tertiary centers across the US and Canada and included participants who underwent ESS for acute or chronic rhinosinusitis. The study was conducted from March 2019 to March 2020, and the data were analyzed in November to December 2020. INTERVENTIONS: All participants received acetaminophen, 650 mg, as the first-line analgesic. From there, patients were randomized to either oxycodone rescue (oxycodone, 5 mg, as second-line therapy) or ibuprofen rescue (ibuprofen, 600 mg, as second-line therapy, with oxycodone, 5 mg, reserved for breakthrough pain). MAIN OUTCOMES AND MEASURES: Baseline characteristics and disease severity were collected at enrollment. Medication logs, pain scores, and epistaxis measures were collected until postoperative day 7. The primary outcome was the postoperative visual analog scale score for pain. Brief Pain Inventory Pain Severity and Pain Interference Scores were also collected. RESULTS: A total of 118 patients were randomized (62 [52.5%] oxycodone rescue, 56 [47.5%] ibuprofen rescue; mean [SD] age, 46.7 [16.3] years; 44 women [44.0%]; 83 White [83.0%], 7 Black [7.0%], and 7 Asian individuals [7.0%]). After exclusions for loss to follow-up and noncompliance, 51 remained in the oxycodone rescue group and 49 in the ibuprofen rescue group. The groups had similar demographic characteristics and disease severity. Thirty-two (63%) in the oxycodone rescue group had adequate pain management with acetaminophen only, while 19 (37%) consumed at least 1 oxycodone dose. In the ibuprofen rescue group, 18 (16%) required only acetaminophen, 28 (57%) used only acetaminophen and ibuprofen, and the remaining 13 (26%) consumed 1 or more oxycodone doses. The groups had similar average acetaminophen (9.69 vs 7.96 doses; difference, 1.73; 95% CI, –1.37 to 4.83) and oxycodone (1.89 vs 0.77 doses; difference, 1.13; 95% CI, –0.11 to 2.36) use. Both groups had similar postoperative visual analog scale scores. A subanalysis that compared opioids users with nonusers showed clinically significant lower pain scores in nonusers at multiple postoperative points. CONCLUSIONS AND RELEVANCE: In this randomized clinical trial, most patients who underwent ESS could be treated postoperatively using a nonopioid regimen of either acetaminophen alone or acetaminophen and ibuprofen. Ibuprofen as a second-line therapy did not reduce overall narcotic consumption, but the overall narcotic use was low in both groups. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03783702

OBJECTIVES/HYPOTHESIS To evaluate survival for nasopharyngeal carcinoma in relation to socioeconomic status. STUDY DESIGN Retrospective cohort study using the Surveillance, Epidemiology, and End Results (SEER) Census Tract-level Socioeconomic Status Database (2000-2016). METHODS Patients with nasopharyngeal carcinoma diagnosed between 2000 and 2016 were identified. Data were stratified based on socioeconomic status, divided into three groups: group 1 being the poorest and group 3 the wealthiest. Univariate analysis as well as multivariate Cox regression analysis adjusted for individual variables was performed. RESULTS A total of 5,527 patients were included in the study, with 33% in group 1, 34% in group 2, and 33% in group 3. There was a significant difference between groups in regard to age at diagnosis, race, histologic subtype, overall stage, tumor stage, nodal stage, and whether or not they received radiation. Patients in group 1, the poorest socioeconomic status, were more likely to be young (P = .003), black (P

Objective To collect real‐world data on the safety and effectiveness of balloon dilation of the Eustachian tube using a seeker‐based device in patients with persistent/chronic symptoms of Eustachian tube dysfunction. Methods A multicenter, prospective, single‐arm registry was conducted from June 2018 through August 2020 at 10 US centers, including tertiary care and private practices. Primary endpoints included mean change from baseline in the 7‐item Eustachian Tube Dysfunction Questionnaire (ETDQ‐7) and the serious related adverse event rate. Secondary endpoints include changes in middle ear assessments, surgical intervention rate, and changes in Sino‐Nasal Outcome Test and Work and Activity Impairment (WPAI) questionnaires. Results A total of 169 participants were treated with balloon dilation of the Eustachian tube, with 166 and 154 participants completing the 6‐week and 6‐month follow‐ups, respectively. Repeated measures analysis of the change in ETDQ‐7 scores indicated statistically significant improvement (−2.1; 95% CI −2.40, −1.84; P, The purpose of this current study was to gather effectiveness and safety data for BDET using a seeker‐based device in real‐world settings. We conclude that balloon dilation of the Eustachian tube with a seeker‐based device is a safe and effective procedure to treat ETD symptoms.

Interpretation of tympanometry commonly relies on the historical convention of classifying findings according to large and arbitrary threshold shifts of tympanometric peak pressure (TPP). This convention had value for prior generations of otolaryngologists in diagnosing severe, chronic middle ear disease requiring surgical intervention but may not be well suited for the present-day evaluation of less severe disease. The existing definition of a type C curve (less than -100 daPa) is likely insensitive to detect subtle abnormalities, including some presentations of obstructive eustachian tube dysfunction. The accuracy of clinical diagnosis may be improved by reporting the absolute values of TPP and moving beyond classification according to arbitrary thresholds.

BACKGROUND Standardized diagnostic criteria for Eustachian tube (ET) dysfunction (ETD) have not been established. The purpose of this study was to characterize the relationship between ET inflammation and ETD symptoms and to determine the diagnostic performance of a quantitative score. METHODS Patients were enrolled in a rhinology clinic between October 2018 and June 2019. Patients underwent nasal endoscopy and completed the 7-item Eustachian Tube Dysfunction Questionnaire (ETDQ-7). Nasopharyngeal inflammation identified on endoscopy was quantified using the Endoscopic Evaluation of the Eustachian Tube (3ET) score. Tympanometry was performed as indicated. Comorbid conditions were assigned during the patient encounter. RESULTS A total of 414 patients were included in the study. Patients with clinically significant ETD symptoms (ETDQ-7 ≥2.1) had higher 3ET scores than those without symptoms. A 1-point increase in 3ET score was associated with a 1.7-fold increase in odds of clinically significant ETD symptoms (adjusted OR [aOR], 1.72; 95% CI, 1.46 to 2.05). The 3ET scores were correlated with ETDQ-7 scores (ρ = 0.54) and 22-item Sino-Nasal Outcome Test (SNOT-22) scores (ρ = 0.52). 3ET scores were not associated with tympanometric peak pressures. Patients with ETD symptoms were more likely to have laryngopharyngeal reflux (aOR, 2.71; 95% CI, 1.24 to 6.18). A 3ET score of 4 predicted symptomatic state in 80% of cases with a specificity of 97.8% and positive predictive value of 96.6%. CONCLUSION Inflammatory findings at the nasopharyngeal ET orifice are associated with clinically significant ETD symptoms. The 3ET score is specific for a symptomatic state and has potential clinical utility in the evaluation of suspected ETD. ©2021 ARSAAOA, LLC.

OBJECTIVE/HYPOTHESIS To assess for semantic differences regarding the definition of dizziness among otolaryngology patients, otolaryngologists, and non-otolaryngologist providers. STUDY DESIGN Cross-sectional survey. METHODS Between March and May 2020, a survey consisting of 20 common descriptors for dizziness within five domains (lightheadedness, motion sensitivity, imbalance, vision complaints, and pain) was completed by patients at two outpatient otolaryngology clinics. Surveys were subsequently obtained from otolaryngology and non-otolaryngology providers attending a multidisciplinary dizziness lecture. The primary outcome measure was to assess for differences in definition of dizziness between patients and providers. Secondary outcome measures included assessing differences between otolaryngologists and non-otolaryngologists. RESULTS About 221 patients and 100 providers participated. Patients selected a median of 7 terms compared to 8 for providers (P = .375), although providers had a larger overall distribution of number of terms selected (P = .038). Patients were more likely than providers to define dizziness according to the following domains: lightheadedness (difference 15.0%; 95% confidence interval [CI] 5.5%-25.3%), vision complaints (difference 21.6%, 95% CI 12.0%-29.6%), and pain (difference 11.5%, 95% CI 4.7%-17.1%). Providers were more likely to define dizziness according to the motion sensitivity domain (difference 13.8%, 95% CI 6.8%-19.6%). Otolaryngology and non-otolaryngology providers defined dizziness similarly across symptom domains. CONCLUSION Although patients and providers both view dizziness as imbalance, patients more commonly describe dizziness in the context of lightheadedness, vision complaints, and pain, whereas providers more frequently define dizziness according to motion sensitivity. These semantic differences create an additional barrier to effective patient-provider communication. LEVEL OF EVIDENCE 4. Laryngoscope, 131:E1443-E1449, 2021.

Olfactory dysfunction is a common problem that is most frequently attributed to upper respiratory infection. Postviral olfactory dysfunction (PVOD) can be prolonged and clinically challenging to treat. Olfactory training (OT) has demonstrated potential benefit for patients with nonspecific olfactory dysfunction. We sought to evaluate the efficacy of OT specifically for PVOD by pooled analysis of the existing evidence.PubMed, Embase, and Web of Science.Following PRISMA guidelines, PubMed, Embase, and Web of Science databases were queried and abstracts screened independently by 2 investigators. We included studies evaluating the efficacy of OT for PVOD and excluded studies evaluating pharmacologic interventions or olfactory loss from other causes.Of the initial 1981 abstracts reviewed, 16 full-text articles were included. Sniffin' Sticks olfactory testing results were reported in 15 (93%) studies as threshold (T), discrimination (D), and identification (I) subscores and TDI total scores. All studies reported clinically significant results after OT, defined as a score improvement of TDI5.5. Four studies were included in the meta-analysis, in which pooled estimates revealed that patients with PVOD who received OT had a 2.77 (95% confidence interval, 1.67-4.58) higher odds of achieving a clinically important difference in TDI scores compared to controls.Meta-analysis of existing data demonstrates clinically significant improvements in PVOD associated with OT. Variability exists among OT protocols and may benefit from further optimization. Existing data supports the use of OT for the treatment of existing and newly emerging cases of PVOD.

Eustachian tube dysfunction (ETD) prompts2 million adult visits in the United States annually. While disease prevalence and health care utilization are established for children, practice patterns for adults remain unknown. Our objective was to determine national resource utilization for adult ETD.Cross-sectional study.National database sample.The Truven Health MarketScan Databases (2010-2014) analytic cohort included health care encounters of patients ≥18 years of age with a diagnosis of ETD, otitis media with effusion, or tympanic membrane retraction. Visits associated with recent diagnoses of acute upper respiratory infection, head and neck cancer, or radiation therapy were excluded. Acute ETD (3 months) and chronic ETD (≥3 months) were subgroups. Medication usage was quantified by class.ETD was diagnosed for 1,298,987 patients, 11% of which was chronic. Over 92% of patients were seen in outpatient clinics, most often by otolaryngology (57%) for chronic ETD and by general medicine (49%) for acute ETD. Medications were frequently utilized, as 530,146 (53.7%) patients received ≥1 prescription. Top prescriptions for chronic ETD included intranasal corticosteroids (22%), antibiotics (22%), oral corticosteroids (13%), and analgesics (6%). The overall annual cost of prescribed medications associated with visits in which either acute or chronic ETD was diagnosed exceeded $8.5 million for a mean of $80.78 per patient who filled a prescription.Adult ETD is frequently treated with several medication classes by a variety of provider types. Understanding the potential adverse effects and cost associated with these practices should be a priority.

Background: An association is suggested between gastroesophageal reflux disease (GERD) or laryngopharyngeal reflux (LPR) and malignancy of the larynx in elderly patients in the United States. Early detection with flexible fiberoptic laryngoscopy (FFL) or CT remains poorly defined. Methods: The Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database was queried from 2003 to 2011.A case-cohort design evaluated patients aged 66 and older with a diagnosis of GERD and/or LPR for the occurrence of FFL or CT within 6 months of the exposure diagnosis. Results: Of a total 156 426 Medicare beneficiaries, the relative risk of early cancer diagnosis with FFL was 14.61(95% confidence interval [CI], 13.59-15.70), corresponding to a number needed to detect (NND) a case of cancer of 13(95% CI, 13-14). The relative risk of an early cancer diagnosis with CT was 31.83 (95% CI, 29.57-34.26), with a NND of 5 (95% CI, 5-5). Conclusions: Early FFL and CT are associated with a higher likelihood of laryngeal cancer diagnosis in elderly individuals with a diagnosis of reflux. Screening trials are necessary to establish this relationship.

Background: Signs of inflammation are commonly encountered during endoscopic examination of the Eustachian tube (ET) region. The clinical applicability of these findings may be enhanced by use of a standardized assessment score. Methods: Digital video recordings were obtained of 50 nasal endoscopy examinations of the nasopharyngeal portion of the ET. Four fellowship-trained rhinologists independently reviewed the videos with regard to specific physical findings: edema of the ET torus, erythema of the ET torus, exudate at the ET orifice, and presence of tubal tonsil. Scoring of this Endoscopic Evaluation of the Eustachian Tube (3ET) was reported using both 2-point and 3-point scales. Each reviewer repeated the scoring at a 10-day interval. Interrater and intrarater agreement were calculated for each item and the total scores. Results: Interrater and intrarater agreement were greater for the 3-point scale than the 2-point scale. Interrater agreement for overall instrument using the 3-point scale was in the “acceptable” range for Krippendorff's alpha on both the first trial (0.6922) and second trial (0.7238). Intrarater agreement was generally “excellent” for individual items as well as the overall instrument. Conclusion: The 3ET comprising these 4 physical findings has acceptable interrater and intrarater reliability, and may be applied to future clinical studies of ET function and disease.

Total intravenous anesthesia (TIVA) has been proposed as a method to reduce blood loss during endoscopic sinus surgery (ESS). Impaired sinonasal visualization due to mucosal bleeding may be burdensome in cases of chronic rhinosinusitis (CRS) with high-grade inflammatory disease, suggesting a role for TIVA in that disease subgroup. A double-blind, randomized controlled trial was conducted of adults undergoing ESS at a tertiary medical center. Patients considered for inclusion had high-grade CRS defined as either sinonasal polyposis or a preoperative Lund-Mackay score of ≥12. Subjects were randomized to receive either TIVA or inhaled anesthesia (IA) during ESS. The primary outcome measure was intraoperative visibility as rated by 3 blinded reviewers utilizing the 10-point Wormald Surgical Field Grading Scale. Secondary outcomes included operative blood loss, complications, and change in quality of life evaluated by the 22-item Sino-Nasal Outcome Test (SNOT-22). A total of 72 patients were randomized into TIVA (n = 37) and IA (n = 35) study arms. Aggregate median (interquartile range) Wormald scores across all reviewers demonstrated a more favorable visual field with TIVA compared to IA (3.5 [2.4-3.9] vs IA 4.1[3.0-5.8], p = 0.0089). There was significantly less blood loss in the TIVA group compared to the IA group (200 mL [100-450] vs 300 mL [200-500], p = 0.046). Baseline patient characteristics were comparable between cohorts with no significant postoperative complications. No significant changes were detected between postoperative SNOT-22 scores at 3 months (p = 0.278) and at 6 months (p = 0.396) following ESS. TIVA contributes to improved intraoperative visualization and decreased blood loss in patients undergoing ESS for high-grade inflammatory sinus disease.

Objective:Summarize the effectiveness of intraoperative cryoanalgesia in the management of postoperative pain among patients undergoing palatine tonsillectomy.Methods:A systematic review of PubMED, MEDLINE, EMBASE, Google Scholar, and Cochrane trial registries was performed through January 2017 using the PRISMA standards. We included English-language randomized controlled trials evaluating patients of all age groups with benign pathology who underwent tonsillectomy with cryoanalgesia versus without.Results:Three limited quality randomized controlled trials involving 153 participants (age range, 1-60 years) were included. Cryoanalgesia was performed with a cryotherapy probe (−56°C) in 1 trial and ice-water cooling (4°C to 10°C) in 2. In the 3 trials reviewed, patients who received cryoanalgesia reported 21.38%, 28.33%, and 31.53% less average relative postoperative pain than controls on the visual analog scale. Review of secondary outcomes suggested no significant difference in time to resume normal diet (2 studies) or postoperative bleeding (2 studies) between the 2 groups. Cryoanalgesia allowed patients to return to work 4 days earlier than controls in 1 study. Two studies reported a trend toward less postoperative analgesia use among the treatment group; however, no statistical conclusions could be drawn.Conclusion:The available evidence suggests that patients undergoing tonsillectomy with cryoanalgesia experience less average postoperative pain without additional complications.