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Objective: To compare fiber-optic nasal endoscopy with Müller's maneuver (FNMM) against drug-induced sleep endoscopy (DISE) in diagnosing the presence of severe level-specific upper airway collapse in patients with obstructive sleep apnea/hypopnea syndrome (OSAHS).Study Design: Case series with chart review.Setting: Tertiary care academic center.Subjects and Methods: Medical records of all adult patients undergoing diagnostic DISE as part of their surgical evaluation were reviewed. Patients were included if they had undergone FNMM and had documented Friedman tongue position and tonsillar grade prior to DISE. Airway obstruction on both endoscopic procedures was described according to airway level and severity. Severe airway obstruction was defined as >75% collapse on endoscopy.Results: Fifty-three patients were included in this study. Fiber-optic nasal endoscopy with Müller's maneuver and DISE did not differ significantly regarding the presence of severe retropalatal airway collapse. There was a statistically significant difference in the incidence of severe retrolingual collapse identified via DISE (84.9% [45/53]) compared with FNMM (35.8% [19/53]; P < .0001). This discrepancy between FNMM and DISE findings was statistically significant in individuals with Friedman I and II tongue positions (FNMM = 16.7%, DISE = 88.9%, P < .0001) and individuals with Friedman III tongue position (FNMM = 31.8%, DISE = 81.8%, P = .002). Patients with Friedman IV showed no significant difference (P = .65) between FNMM (69.2%) and DISE (84.6%).Conclusion: This study shows a significant difference between FNMM and DISE in the identification of severe retrolingual collapse. Since the effectiveness of surgical interventions depends largely on the accurate preoperative identification of the site of obstruction, further scrutiny of each diagnostic endoscopic technique is warranted. [ABSTRACT FROM AUTHOR]

Fibrosarcomas are rare, malignant neoplasms of mesenchymal origin. Fibrosarcomas appear to be sporadic, but cases of fibrosarcomas secondary to radiation of nasopharyngeal carcinomas have been reported. Paranasal sinus fibrosarcomas (PNFS) are even rarer with few cases being reported since the 1950s. There have been several retrospective cohort studies examining PNFS; however, to our knowledge, no comprehensive review exists. This review aims to summarize the findings of all published cases of PNFS from the 1950s to the 2020s. We hope that a comprehensive review will assist in accurate and early diagnoses of PNFS, and help guide treatment as early treatment is associated with a favorable prognosis.This systematic review reports results following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A search was conducted on PubMed, Embase, and Cochrane Library. Studies were screened using established inclusion/exclusion criteria. A total of 26 studies were included for data extraction, and relevant data were collected and analyzed.In our study, the most common study type was case reports (n = 19). The most common presentation for PNFS included male gender (n = 17) with maxillary sinus (n = 57) involvement. Patients commonly presented with complaints of nasal obstruction (n = 15), epistaxis (n = 11), and facial fullness/pain (n = 9). Surgical resection was the mainstay treatment, with the use of chemotherapy or radiation depending on surgical margins and resectability. The diagnosis was commonly made with histological analysis. This review of the literature provides a summary and reference of important presenting factors, elements of diagnosis, and treatment options regarding PNFS to help bring awareness and guide the treatment of such a rare disease. Moving forward, there is a greater need for larger standardized studies that can further complement our findings, as well as more consistent reporting of cases., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2022, Bughrara et al.)

Objectives: To conduct a systematic review on the demographics, characteristics, management, treatment, complications, and outcomes of Ewing sarcomas in the craniofacial bones., Data Sources: Using Cochrane Library, EmBase, and PubMed, the authors identified 71 studies to be included., Review Methods: The Cochrane Library, EmBase, and PubMed databases were used to identify literature relating to Ewing sarcomas in the craniofacial bone to conduct a systematic review. Patient demographics, clinical characteristics, and treatment strategies were extracted., Results: Seventy-one studies encompassing 102 patients were identified. The most common craniofacial locations involved were the frontal bone (16.7%, n = 17), nasal cavity (16.7%, n = 17), and temporal bone (14.7%, n = 15). Stratified by location, the most common presenting symptoms were frontal bone (palpable mass, n = 8, 47.1%), nasal cavities (epistaxis, n = 9, 52.9%), and temporal bones (headache, n = 5, 33.3%). The 3 most commonly used treatment strategies were a combination of surgical intervention/radiotherapy/chemotherapy (n = 43, 43%), a combination of radiotherapy/chemotherapy (n = 18, 18%), and a combination of surgical intervention/chemotherapy (n = 15, 15%). Patients who received a combination of surgical intervention/radiotherapy/chemotherapy experienced local recurrence rate of 16.6%. However, other combinations of therapies such as surgical intervention/chemotherapy and radiotherapy/chemotherapy had a lower local recurrence rate but were limited by small sample size. Most patients (79.0%) were disease free without evidence of recurrence., Conclusion: Ewing Sarcoma of the craniofacial bones has a good prognosis when treated appropriately. Given that our study was limited by retrospective data, we advise clinicians to use the findings of this article with their own clinical judgment to determine which treatment strategy they should pursue.

Objective  The study aimed to evaluate the cost-effectiveness of obtaining preoperative type and screens (T/S) for common endonasal skull base procedures, and determine patient and hospital factors associated with receiving blood transfusions. Study Design  Retrospective database analysis of the 2006 to 2015 National (nationwide) Inpatient Sample and cost-effectiveness analysis. Main Outcome Measures  Multivariate regression analysis was used to identify factors associated with transfusions. A cost-effectiveness analysis was then performed to determine the incremental cost-effectiveness ratio (ICER) of obtaining preoperative T/S to prevent an emergency-release transfusion (ERT), with a willingness-to-pay threshold of $1,500. Results  A total of 93,105 cases were identified with an overall transfusion rate of 1.89%. On multivariate modeling, statistically significant factors associated with transfusion included nonelective admission (odds ratio [OR]: 2.32; 95% confidence interval [CI]: 1.78-3.02), anemia (OR: 4.42; 95% CI: 3.35-5.83), coagulopathy (OR: 4.72; 95% CI: 2.94-7.57), diabetes (OR: 1.45; 95% CI: 1.14-1.84), liver disease (OR: 2.37; 95% CI: 1.27-4.43), pulmonary circulation disorders (OR: 3.28; 95% CI: 1.71-6.29), and metastatic cancer (OR: 5.85; 95% CI: 2.63-13.0; p  < 0.01 for all). The ICER of preoperative T/S was $3,576 per ERT prevented. One-way sensitivity analysis demonstrated that the risk of transfusion should exceed 4.12% to justify preoperative T/S. Conclusion  Routine preoperative T/S does not represent a cost-effective practice for these surgeries using nationally representative data. A selective T/S policy for high-risk patients may reduce costs., Competing Interests: Conflict of Interest None declared., (Thieme. All rights reserved.)

Objective: Opioid use disorder (OUD), which includes the morbidity of dependence and mortality of overdose, has reached epidemic proportions in the United States. Overprescription of opioids can lead to chronic use and misuse, and unused narcotics after surgery can lead to their diversion. Research supports that most patients do not take all the prescribed opioids after surgery and that surgeons are the second largest prescribers of opioids in the United States. The introduction of opioids in those with OUD often begins with prescription opioids. Reducing the number of extra opioids available after surgery through smaller prescriptions, safe storage, and disposal should reduce the risk of opioid use disorder in otolaryngology patients and their families., Purpose: The purpose of this specialty-specific guideline is to identify quality improvement opportunities in postoperative pain management of common otolaryngologic surgical procedures. These opportunities are communicated through clear actionable statements with explanation of the support in the literature, evaluation of the quality of the evidence, and recommendations on implementation. Employing these action statements should reduce the variation in care across the specialty and improve postoperative pain control while reducing risk of OUD. The target patients for the guideline are any patients treated for anticipated or reported pain within the first 30 days after undergoing common otolaryngologic procedures. The target audience of the guideline is otolaryngologists who perform surgery and clinicians who manage pain after surgical procedures. Outcomes to be considered include whether the patient has stopped using opioids, has disposed of unused opioids, and was satisfied with the pain management plan.The guideline addresses assessment of the patient for OUD risk factors, counseling on pain expectations, and identifying factors that can affect pain duration and/or severity. It also discusses the use of multimodal analgesia as first-line treatment and the responsible use of opioids. Last, safe disposal of unused opioids is discussed.This guideline is intended to focus on evidence-based quality improvement opportunities judged most important by the guideline development group. It is not a comprehensive guide on pain management in otolaryngologic procedures. The statements in this guideline are not intended to limit or restrict care provided by clinicians based on their experiences and assessments of individual patients., Action Statements: The guideline development group made strong recommendations for the following key action statements: (3A) prior to surgery, clinicians should identify risk factors for opioid use disorder when analgesia using opioids is anticipated; (6) clinicians should advocate for nonopioid medications as first-line management of pain after otolaryngologic surgery; (9) clinicians should recommend that patients (or their caregivers) store prescribed opioids securely and dispose of unused opioids through take-back programs or another accepted method.The guideline development group made recommendations for the following key action statements: (1) prior to surgery, clinicians should advise patients and others involved in the postoperative care about the expected duration and severity of pain; (2) prior to surgery, clinicians should gather information specific to the patient that modifies severity and/or duration of pain; (3B) in patients at risk for OUD, clinicians should evaluate the need to modify the analgesia plan; (4) clinicians should promote shared decision making by informing patients of the benefits and risks of postoperative pain treatments that include nonopioid analgesics, opioid analgesics, and nonpharmacologic interventions; (5) clinicians should develop a multimodal treatment plan for managing postoperative pain; (7) when treating postoperative pain with opioids, clinicians should limit therapy to the lowest effective dose and the shortest duration; (8A) clinicians should instruct patients and caregivers how to communicate if pain is not controlled or if medication side effects occur; (8B) clinicians should educate patients to stop opioids when pain is controlled with nonopioids and stop all analgesics when pain has resolved; (10) clinicians should inquire, within 30 days of surgery, whether the patient has stopped using opioids, has disposed of unused opioids, and was satisfied with the pain management plan.

Objective: Determine the effect of patient demographics and surgical approach on patient outcomes after tracheal resection in the management of thyroid cancer., Study Design: Systematic review and meta-analysis., Methods: Systematic review of literature was performed using PubMed, Embase, and Cochrane Library to identify patients with thyroid carcinoma who underwent tracheal resection. Pooled estimates for patient demographics, presenting findings, complications, and outcomes are determined using random-effects meta-analyses., Results: Ninety-six relevant studies encompassing 1,179 patients met inclusion criteria. Meta-analysis pooled rates of complications: 1.7% (confidence interval [CI] 0.8-2.5; P < .001; I 2 = 1.85%) airway complications, 2.8% (CI 1.6-3.9; P < .001; I 2 = 13.34%) bilateral recurrent laryngeal nerve paralysis, 2.2% (CI 1.2-3.1; P < .001; I 2 = 6.72%) anastomotic dehiscence. Circumferential resection pooled estimates major complications, locoregional recurrence, distal recurrence, overall survival: 14.1% (CI 8.3-19.9; P < .001; I 2 = 35.26%), 15% (CI 9.6-20.3; P < .001; I 2 = 38.2%), 19.7% (CI 13.7-25.8; P < .001; I 2 = 28.83%), 74.5% (CI 64.4-84.6; P < .001; I 2 = 85.07%). Window resection estimates: 19.8% (CI 6.9-32.8; P < .001; I 2 = 18.83%) major complications, 25.6% (CI 5.1-46.1; P < .014; I 2 = 84.68%) locoregional recurrence, 15.6% (CI 9.7-21.5; P < .001; I 2 = 0%) distal recurrence, 77.1% (CI 58-96.2; P < .001; I 2 = 78.77%) overall survival., Conclusion: Management of invasive thyroid carcinoma may require tracheal resection to achieve locoregional control. Nevertheless, postoperative complications are not insignificant, and therefore this risk cannot be overlooked when counseling patients perioperatively. Laryngoscope, 131:932-946, 2021., (© 2020 American Laryngological, Rhinological and Otological Society Inc, "The Triological Society" and American Laryngological Association (ALA).)

Purpose: Evaluate trends in mortality due to acute epiglottitis before and after adoption of Haemophilus influenza Type b vaccination (Hib) in pediatric and adult populations., Materials and Methods: Patients who died from acute epiglottis from 1979 to 2017 identified using National Vital Statistics System. Mortality rates calculated using age-adjusted US census data expressed in rate per 100,000 individuals. Trends analyzed using the National Cancer Institute Joinpoint Regression Program (version 4.7.0; Bethesda, Maryland)., Results: 1187 epiglottitis-related deaths were identified over thirty-nine years. Total deaths decreased from 65 in 1979 to 15 in 2017. Adult deaths accounted for 63.5% and decreased from 0.015 per 100,000 individuals (24 deaths) in 1979 to 0.006 per 100,000 individuals (14 deaths) in 2017. Best fitting log-liner regression model showed APC of -3.5% (95% CI, -4.2 to -2.7%) from 1979 to 2017. Pediatric and adolescent deaths accounted for 443 (37.3%) deaths, decreasing from 0.064 per 100,000 individuals (41 deaths) in 1979 to 0.001 per 100,000 individuals (1 death) in 2017. APC was -11.1% (95% CI, -13.8% to -8.3%) in 1979 to 1990; 46.5% (95% CI, -16.6% to 157.3%) in 1990 to 1993; -61.6% (95% CI, -88% to 23%) in 1993 to 1996; and 1.1% (95% CI, -2.4% to 4.7%) in 1996 to 2017., Conclusions: Mortality from acute epiglottitis decreased after widespread adoption of Hib vaccination in the US. Adults are now more likely than children to die of acute epiglottitis. Further research including multi-institutional cohort studies must be done to elucidate causative factors contributing to remaining cases of mortality., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objectives: The current analysis queries rhinologists' attitudes about the use of telemedicine, including the degree to which it has impacted practice patterns during the COVID-19 pandemic. Our objective was to survey rhinologists and understand the extent to which telemedicine serves as a rejoinder to in-person consultation: appreciation of relevant factors may be important in planning for present and future considerations., Methods: A 14-question anonymous survey sent out to the American Rhinologic Society (ARS) membership in April 2020. It included demographic factors and detailed questions examining the extent of telemedicine use. Numerous topics including the degree of use, satisfaction with services, and utility of services were evaluated., Results: There were 134 respondents. Most reported seeing ≤30% of typical in-person volume, with 14.8% not seeing any patients at all. 88.1% used telemedicine; 82.0% reported some level of satisfaction with telemedicine. The vast majority utilized platforms employing audio and video (83.3%), and a plurality reported spending 5-15 min on calls. Numerous reasons were cited for the use of telemedicine, including significant public health benefits amid the crisis (89.7%). Only 12.0% of respondents reported using telemedicine for hospital consultation., Conclusion: Rhinologists have embraced telemedicine during the COVID-19 pandemic in an attempt to improve accessibility, patient satisfaction, and revenue stream. When utilized appropriately, this technology obviates the need for seeing at-risk patients and performing procedures such as nasal endoscopy. Only a minority of rhinologists was dissatisfied, viewing this as a temporary fix during the pandemic., (Copyright © 2020. Published by Elsevier Inc.)

Importance: There is controversy surrounding the management of orbital roof fractures. Guidelines with regard to when to operate and type of reconstruction are lacking. Categorizing these data will help clinicians make informed decisions about the management of orbital roof fractures and avoid preventable complications. Objective: To perform a systematic review evaluating underlying causes, associated complications, and management of orbital roof fractures including reconstructive options in the general population of children and adults. Evidence Review: A systematic review using the PubMed, EmBase, Cochrane, and MEDLINE databases identified relevant studies for inclusion. Studies were included from 1987 to 2017. Demographics, symptoms, management, reconstruction, and outcomes were reported following preferred reporting items for systematic reviews and meta-analyses guidelines. Inclusion criteria included articles discussing management of traumatic orbital roof fractures across all ages. Included studies were assessed for level of evidence. Findings: Forty-seven studies encompassing 526 patients met inclusion criteria. There were 28 case reports, 15 retrospective case series and 4 retrospective cohort studies. The most common etiologies were motor vehicle accidents (39.5%), falls (30.3%), and assault (11.8%). Periorbital ecchymosis, exophthalmos, and dystopia were the most common initial symptoms. In total, 60.0% of patients underwent surgical repair and 40% of patients were managed conservatively. The most common surgical approach was bicoronal (94.8%), followed by a superolateral orbital rim approach and transpalpebral (5.1%). A variety of grafting materials were utilized, including titanium miniplates (46.2%), bone graft (37.7%), porous polyethylene (2.8%), and silastic implants (2.8%). Overall patients undergoing surgery were adults with clinical symptoms including exophthalmos, diplopia, and gaze restriction as well as patients with dura exposure. Most patients undergoing surgery were those with concomitant fractures. The most common fractures among the surgical patients were frontal bone (32.2%), ethmoid (25.2%), and zygomaticomaxillary complex/zygoma (12.2%). Conclusions and Relevance: Management of orbital roof fractures varies based on individual clinical features including the presence of exophthalmos, gaze restriction, and concomitant injuries such as dural tears. Surgically, bicoronal approaches were performed most commonly along with reconstruction utilizing titanium miniplates. Conservative management was more common among the pediatric population. This systematic review demonstrates both conservative and surgical measures can lead to positive outcomes in appropriately selected patients.

Perioperative analgesic management is multifaceted, and an individualized approach should be taken with each patient. Preoperative discussion of the plan for pain control and the patient's postoperative expectations is a necessary facet for optimal outcomes of analgesia. There is the potential for significant abuse and development of dependence on opioids. Nonopioids, such as nonsteroidal anti-inflammatory drugs, acetaminophen, and gabapentinoids, provide reliable alternatives for analgesic management following sinus and skull-base surgery. There is a paucity of literature regarding perioperative pain regimens for sinus and skull-base surgery, and the authors hope that this review serves as a valuable tool for otolaryngologists., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objectives: Nasopharyngeal carcinoma has a unique worldwide racial and geographic distribution. Our objective was to evaluate socioeconomic disparities in the burden of nasopharyngeal cancer (NPC) between endemic and nonendemic regions., Methods: To demonstrate trends regarding societal burden of NPC and socioeconomic development, national disability-adjusted life year (DALY) rates and human development indices (HDI) between 1990 and 2015 were evaluated. Countries were divided based on the endemic versus nonendemic presence of NPC and further analyzed by HDI status as specified by the United Nations Development Program. Gini coefficients and concentration index were used to evaluate global equality in NPC burden over this period., Results: Age-standardized DALYs dropped from 36.1 in 1990 to 26.5 in 2015 (26.6% decline) (r = -0.991, P < 0.001). Lower socioeconomic countries harbored greater NPC burden upon controlling by endemic and nonendemic regions, as demonstrated by progressively negative concentration indexes. Health inequality was greater in nonendemic countries than in endemic countries (P < 0.01)., Conclusion: To our knowledge, this is the first study to investigate socioeconomic-related changes in NPC burden using statistical tools such as the Gini coefficient and concentration index. Although the burden of NPC has steadily decreased, there remain persistent inequalities associated with socioeconomic disparities. Nasopharyngeal cancer burden is more pronounced in countries with lower HDI. Our results reinforce the importance of increasing resources for developing countries and continuing inquiry into the screening, diagnosis, and management of NPC., Level of Evidence: NA Laryngoscope, 129:2482-2486, 2019., (© 2019 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives  To perform a systematic review examining experiences with endoscopic resection of skull base lesions in the pediatric population, with a focus on outcomes, recurrence, and surgical morbidities. Methods  PubMed/MEDLINE, Cochrane Library, Embase, and Web of Science databases were evaluated. Studies were assessed for level of evidence. Bias risk was evaluated using the Cochrane Bias tool, Grades of Recommendation, Assessment, Development and Evaluation (GRADE), and Methodological Index for Non-Randomized Studies (MINORS) criteria. Patient characteristics, pathology, site of primary disease, presenting symptoms, stage, procedure specific details, and complications were evaluated. Results were reported using the Preferred Reporting Systems for Systematic Reviews and Meta-Analysis guidelines. Results  Ninety-three studies met criteria for inclusion, encompassing 574 patients with skull base tumors. The GRADE and MINORS criteria determined the overall evidence to be moderate quality. The most common benign and malignant pathologies included juvenile nasopharyngeal angiofibromas ( n  = 239) and chondrosarcomas ( n  = 11) at 41.6 and 1.9%, respectively. Of all juvenile nasopharyngeal angiofibroma tumors, most presented at stage IIIa and IIIb (25.8 and 27.3%, respectively). Nasal obstruction (16.5%) and headache (16.0%) were common symptoms at initial presentation. Surgical approaches included endoscopic endonasal ( n  = 193, 41.2%) and endoscopic extended transsphenoidal ( n  = 155, 33.1%). Early (< 6 weeks) and late (>6 weeks) complications included cerebrospinal fluid leak ( n  = 36, 17.3%) and endocrinopathy ( n  = 43, 20.7%). Mean follow-up time was 37 months (0.5-180 months), with 86.5% showing no evidence of disease and 2.1% having died from disease at last follow-up. Conclusion  Endoscopic skull base surgery has been shown to be a safe and effective method of treating a variety of pediatric skull base tumors. If appropriately employed, the minimally invasive approach can provide optimal results in the pediatric population.

Background: Endoscopic skull-base surgery (ESBS) is employed in the management of diverse skull-base pathologies. Paralleling the increased utilization of ESBS, the literature in this field has expanded rapidly. However, the rarity of these diseases, the inherent challenges of surgical studies, and the continued learning curve in ESBS have resulted in significant variability in the quality of the literature. To consolidate and critically appraise the available literature, experts in skull-base surgery have produced the International Consensus Statement on Endoscopic Skull-Base Surgery (ICAR:ESBS)., Methods: Using previously described methodology, topics spanning the breadth of ESBS were identified and assigned a literature review, evidence-based review or evidence-based review with recommendations format. Subsequently, each topic was written and then reviewed by skull-base surgeons in both neurosurgery and otolaryngology. Following this iterative review process, the ICAR:ESBS document was synthesized and reviewed by all authors for consensus., Results: The ICAR:ESBS document addresses the role of ESBS in primary cerebrospinal fluid (CSF) rhinorrhea, intradural tumors, benign skull-base and orbital pathology, sinonasal malignancies, and clival lesions. Additionally, specific challenges in ESBS including endoscopic reconstruction and complication management were evaluated., Conclusion: A critical review of the literature in ESBS demonstrates at least the equivalency of ESBS with alternative approaches in pathologies such as CSF rhinorrhea and pituitary adenoma as well as improved reconstructive techniques in reducing CSF leaks. Evidence-based recommendations are limited in other pathologies and these significant knowledge gaps call upon the skull-base community to embrace these opportunities and collaboratively address these shortcomings., (© 2019 ARS-AAOA, LLC.)

Objective: Desmopressin (DDAVP) is a hemostatic agent used to manage bleeding in patients with hemostatic disorders, and there is a lack of published data to guide its use during otolaryngology procedures. The objective of this study was to conduct an evidence-based systematic review of the reported uses, efficacy, and adverse effects of DDAVP in the otolaryngology surgical setting., Data Sources: PubMed, MEDLINE, and EmBase were searched for articles on the use of DDAVP in otolaryngology., Review Methods: The Methodological Index for Non-Randomized Studies criteria and Cochrane bias tool were used to assess study quality. Patient demographics, DDAVP dosing and route, and outcomes such as bleeding and adverse events were collected. A summary of evidence table was created specifying levels of evidence, benefits, and harm., Results: Nineteen studies encompassing 440 patients were included. Sixteen studies discussed DDAVP for prophylaxis, and 3 discussed postoperative use. DDAVP effectively prevented bleeding in high-risk patients and successfully facilitated a dry surgical field when necessary. DDAVP had a 100% success rate when used symptomatically. Five studies described adverse effects, including hyponatremia (12.3%), nausea (2.0%), emesis (0.9%), and seizure (0.2%). The aggregate level of evidence for its use was Level B for adenotonsillectomy, septoplasty, and turbinate procedures and Level C for rhinoplasty., Conclusion: Current literature supports the use of DDAVP in otolaryngology surgical procedures as both a perioperative prophylactic agent and a postoperative symptomatic intervention for bleeding. Both modalities are effective with minimal adverse events. Further well-designed randomized trials are necessary to conclusively formulate guidelines for DDAVP use in otolaryngology.

Objectives/hypothesis: Opioid misuse and diversion is a pressing topic in today's healthcare environment. The objective of this study was to conduct a review of non-opioid perioperative analgesic regimens following septoplasty, rhinoplasty, and septorhinoplasty., Study Design: Evidence-based systematic review., Methods: PubMed, MEDLINE, Cochrane Library, and Embase databases were reviewed for articles related to perioperative analgesic use in septoplasty, rhinoplasty, and septorhinoplasty. Quality of studies were assessed via the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) criteria, Jadad scores, and the Cochrane bias tool. Patient demographic data and clinical outcomes, including medication type, dose, administration time, pain scores, and adverse events, were obtained from included studies. Summary tables detailing the benefits and harms of each investigated regimen are included., Results: Thirty-seven studies met inclusion criteria for this evidence-based review. The quality of the studies was determined to be of moderate quality based off of GRADE standardized criteria with a mean Jadad score of 3.1. A preponderance of evidence showed reduced perioperative pain scores and rescue analgesic requirements, supporting the use of local anesthetics for analgesic control. Nonsteroidal anti-inflammatory drugs (NSAIDs) demonstrated similar decreased visual analog scores and postoperative analgesic demand; however, increased adverse events in this class warrant caution., Conclusions: Contemporary literature supports the use of NSAIDs, gabapentin, local anesthetics, and α-agonists as effective perioperative analgesic opioid alternatives for septoplasty and septorhinoplasty. Local anesthetic use is a cost-effective option resulting in decreased postoperative pain scores and rescue analgesic requirements. Further large-scale, multi-institutional, controlled studies are needed to provide definitive recommendations., Level of Evidence: NA Laryngoscope, 129:E200-E212, 2019., (© 2018 The American Laryngological, Rhinological and Otological Society, Inc.)

Background: Although some causes of rhinogenic headache, such as acute sinusitis, have clear diagnostic criteria, others, such as "sinus headache" and mucosal contact points, are more nebulous. Misdiagnosis of these entities and primary headaches may result in unnecessary medical or surgical treatment. The purpose of this systematic review is to delineate current understanding of diagnosis and treatment of rhinogenic headaches, including sinus and mucosal contact point headaches, in children., Methods: PubMed, SCOPUS, and the Cochrane databases were searched for studies on sinus headache and mucosal contact point headaches in children. Studies were assessed for level of evidence, and risk of bias was assessed by Methodological Index for Non-Randomized Studies (MINORS) scoring. Diagnostic criteria, management strategies, and other clinical data were analyzed., Results: Eight studies met the inclusion criteria. Level of evidence was predominantly 4. Forty percent of pediatric patients with migraine had been previously misdiagnosed with sinus headache. Of 327 pediatric patients in two studies, between 55% and 73% had at least 1 cranial autonomic symptom associated with their migraine. For children with mucosal contact point headaches, surgical management in select patients improved headache intensity or severity in 17 (89%) cases., Conclusion: The majority of pediatric patients with sinus headache harbor a primary headache disorder, with migraine being most common. Physicians should suspect primary headache disorders in pediatric patients with chronic headaches and a normal exam. Although some case series are supportive of surgical management for mucosal contact point headaches in children, the level of evidence supporting these recommendations is insufficient. High-quality clinical trials are necessary for continuing to improve outcomes in patients with these clinical entities., (© 2019 ARS-AAOA, LLC.)

Background: Paragangliomas of the nasal cavity and paranasal sinuses, although exceedingly rare, can exhibit frequent and aggressive recurrences. Our objective was to evaluate tumor characteristics, clinical course, management, and associated complications of sinonasal paragangliomas METHODS: A systematic review of the literature was performed utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, searching for sinonasal paraganglioma. Studies meeting inclusion criteria were assessed for level of evidence. Patient demographics, tumor characteristics, primary intervention, and other clinical characteristics were evaluated., Results: Forty-five relevant studies encompassing 54 patients with sinonasal paraganglioma were identified. The most common tumor locations were the nasal cavity (66.7%), ethmoid sinuses (22.2%), maxillary sinuses (7.4%), and sphenoid sinuses (3.7%). Common presenting symptoms included recurrent epistaxis (68.5%), nasal obstruction (53.7%), and headache (13.0%). Tumors were malignant in 28.6% of patients. Only 4 cases (7.4%) involved functional tumors. Initial management was always surgical, via either an open (63.0%) or endoscopic (33.3%) approach. Radiotherapy was used as adjunctive treatment in 10 cases (18.5%). Recurrence rate was 21.7% and occurred between 12 to 156 months after initial resection. The overall survival was 87.0% with a metastatic rate of 8.7%., Conclusion: Sinonasal paragangliomas are vascular neoplasms manifesting clinically with recurrent epistaxis and nasal obstruction. Management goals are total resection with clear margins and long-term follow-up due to tendency for local recurrence. Radiotherapy has been utilized as adjuvant therapy with variable results. Further randomized controlled studies may be invaluable in elucidating these findings., (© 2018 ARS-AAOA, LLC.)

Objective: To evaluate ventral skull base lesion recurrences along surgical access pathways attributed to iatrogenic seeding., Methods: A systematic review of the literature was performed searching for recurrence of ventral skull base lesions attributed to iatrogenic implantation. Studies were assessed for level of evidence. Primary intervention, pathology, and other clinical factors were reported following Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines., Results: Among 69 patients with recurrent skull base lesions attributed to seeding, the most common pathologies were craniopharyngioma (52.2%), chordoma (33.3%), adenocarcinoma (4.3%), adenoid cystic carcinoma (2.9%), and squamous cell carcinoma (2.9%). Median time to recurrence was 36 months. Time to recurrence was significantly longer for craniopharyngiomas than for chordomas (42 months vs. 24 months, P ≤ 0.05). Surgical approaches included craniotomy (62.0%), transseptal (11.3%), transfacial (12.7%), and transpalatal (4.2%). Mean time to recurrence after craniotomy was 69 months. Endoscopic/endoscopic-assisted approaches were used in 5 cases (7.0%). Commonly reported recurrence sites included subarachnoid (29.6%), dura (21.1%), incision (12.7%), septum (7.0%), and ethmoid sinuses (4.2%)., Conclusions: The potential for iatrogenic tumor seeding exists for numerous skull base lesions, most notably craniopharyngioma and chordomas. Routine surveillance may be necessary owing to significant latency intervals to ectopic recurrence. Although transnasal endoscopic techniques have been extensively employed in recent decades, only a handful of reported cases involve lesions originally treated with this approach. Further direct comparison of traditional approaches with endoscopic approaches may be invaluable in further elucidating the role of surgical technique in tumor implantation and recurrence., (Copyright © 2018. Published by Elsevier Inc.)

Background: The objective of this work was to evaluate factors associated with antibiotic and oral corticosteroid (OCS) prescription among otolaryngologists regularly performing sinus surgery., Methods: Fellowship-trained rhinologists, including fellowship directors, were identified via the American Rhinologic Society (ARS) website. Non-fellowship-trained otolaryngologists performing ≥25 balloons (frontal/maxillary) or ≥25 functional endoscopic sinus surgeries (FESSs) (frontal/maxillary/ethmoids) were also included in "balloon surgeons" and "sinus surgeon" cohorts, respectively. Prescribing data for Medicare Part D beneficiaries was obtained for 2015., Results: Otolaryngologists included in this analysis wrote a median of 54 scripts for antibiotics, with a 15.1% antibiotic prescription rate. The overall script length per antibiotic was 11.1 days. Of fellowship-trained rhinologists, 90.2% wrote fewer than 100 scripts, compared to 25.6% and 32.5% of sinus surgeons and balloon surgeons, respectively. Fellowship-trained rhinologists wrote lengthier antibiotic scripts (14.1 vs 10.3 days, p < 0.05). Clinicians who have been in practice longer prescribed antibiotics significantly more frequently. Fellowship-trained rhinologists had a greater OCS rate (8.9%) than balloon and sinus surgeons (7.1%), also writing lengthier courses (15.0 vs 8.1 days). Early-career otolaryngologists wrote lengthier steroid prescriptions than those with 11 to 20 years and >20 years in practice., Conclusion: Antibiotic and OCS utilization varies by type of training, as non-fellowship-trained sinus surgeons and balloon surgeons tend to utilize antibiotics more aggressively, and fellowship-trained rhinologists utilize OCS more frequently. Otolaryngologists with more years in practice are more likely to incorporate antibiotics in the management of sinus disorders, although these conclusions must be considered in the context of this resource's limitations. Further clarification of guidelines may be helpful for minimizing divergent practices and maintaining a consensus., (© 2018 ARS-AAOA, LLC.)

Background: Misuse and diversion of prescription opioids have been critical in facilitating the opioid epidemic. Our objective was to perform a systematic evidence-based review delineating perioperative regimens (including opioid alternatives) evaluated for endoscopic sinus surgery., Methods: PubMed/MEDLINE, Cochrane Library, and EmBase databases were evaluated for studies detailing analgesics employed after endoscopic sinus surgery. Studies were assessed for level of evidence. Bias risk was evaluated using the Cochrane Bias tool and GRADE criteria. Medication, administration, adverse effects, pain scores, and rescue analgesic consumption were evaluated. A summary of evidence detailing benefits, harm, and cost was prepared., Results: Thirty-two studies encompassing 1812 patients were included. The GRADE criteria determined the overall evidence to be of moderate quality. Perioperative acetaminophen had few adverse events and reduced immediate need for opioid rescue after sinus surgery; studies evaluating acetaminophen demonstrate a preponderance of benefit over harm. Nonsteroidal anti-inflammatory drugs (NSAIDs) also reduce postoperative opioid consumption, although a small portion of patients undergoing sinus surgery harbor the potential for NSAID intolerance. The aggregate level of evidence for studies evaluating NSAIDs was grade A, whereas the aggregate grade of evidence for several other agents was grade B., Conclusion: There is evidence supporting the use of NSAIDs and gabapentin for the control of pain after endoscopic sinus surgery. Acetaminophen, α-agonists, and local anesthetics are also viable options for postoperative analgesia. Familiarity with these data is essential to facilitate the use of opioid alternatives. Further large-scale, multi-institutional, randomized trials are needed to provide conclusive recommendations for these perioperative analgesics., (© 2018 ARS-AAOA, LLC.)

Objectives/hypothesis: There has been growing recognition of the roles prescription drug misuse and diversion play in facilitating the ongoing opioid epidemic. Our objective was to evaluate opioid prescription patterns among practicing otolaryngologists., Study Design: Retrospective review of a CMS database., Methods: Medicare Part D beneficiary data (2015) were accessed for a list of otolaryngologists. Opioid prescription rates, amount, and supply were calculated. Factors including board certification, experience, gender, and location were obtained for the 9,068 unique otolaryngologists represented in this dataset., Results: In 2015, otolaryngologists wrote 133,779 opioid prescriptions for 922,806 days (6.9 days/per prescription). The majority was for hydrocodone-acetaminophen (64.0%). Most otolaryngologists (51.2%) prescribed ≤ 10 opioids; 6.1% offered > 50 opioid prescriptions. Men wrote more prescriptions on average. Opioid prescription rates were greatest in the Midwest (4.6%) and least in the Northeast (1.8%), and the highest/lowest rates were in Delaware (8.6%) and New York (1.3%). Midcareer (11 -20 years) otolaryngologists were most likely to write >50 prescriptions. The opioid prescription rate declined with greater experience., Conclusions: Opioid prescriptions written by otolaryngologists may play a significant role in the availability of these agents, as otolaryngologists wrote nearly 1 million days worth of opioids to Medicare beneficiaries in 2015. Although the majority of otolaryngologists write fewer than 11 prescriptions annually, those writing more prescriptions also write lengthier courses. There is significant geographic variation in prescribing patterns, highlighting a lack of consensus, and midcareer otolaryngologists are more aggressive in offering opioids. These findings highlight an urgent need for strengthening educational resources aimed at minimizing unnecessary prescriptions., Level of Evidence: NA. Laryngoscope, 128:1576-1581, 2018., (© 2018 The American Laryngological, Rhinological and Otological Society, Inc.)

Background Misuse and diversion of opioids have contributed to the U.S. opioid crisis, making an understanding of specialty-specific and procedure-specific trends essential. Objective The objective of this analysis was to evaluate nationwide trends in opioid prescribing patterns among sinus surgeons performing functional endoscopic sinus surgery and maxillary sinus balloon dilation, specifically examining factors associated with variations. Methods High-volume sinus surgeons were identified through the Centers for Medicare and Medicaid Services database and cross-referenced against prescriptions to Medicare Part D beneficiaries during 2013 through 2015. Number of opioid prescriptions, prescription lengths, and demographic information were obtained. Results This cohort of 570 surgeons wrote 21,042 opioid prescriptions (5.4 days per prescription) in 2015, with 80.3% and 54.7% writing >10 and >25 prescriptions, respectively. Surgeons writing a greater amount of prescriptions wrote lengthier courses throughout all 3 years ( P = .01, P = .002, P = .003). Female otolaryngologists wrote lengthier prescriptions (6.2 vs 5.3 days, P = .01). Early career otolaryngologists (≤10 years) offered fewer prescriptions compared to those who had greater experience (31.1 vs 39.3, P = .02). Moreover, 73.6% of fellowship-trained otolaryngologists offered >10 prescriptions versus 82.7% of nonfellowship-trained otolaryngologists ( P = .02). Practitioners in the South on average prescribed the greatest amount of opioids ( P < .05). Conclusion A majority of sinus surgeons prescribe ≥25 opioid prescriptions annually, with otolaryngologists who write a greater amount of prescriptions writing lengthier courses. As the mean opioid prescription length is 5.4 days, recent legislation limiting opioid prescriptions to 5 days may only have a modest impact for preventing the diversion of perioperative opioid prescriptions. These data suggest further standardized guidelines may be beneficial in elucidating the appropriate indications for the prescription of opioids among sinus surgeons.

Objectives/hypothesis: Balloon dilation (BD) represents a minimally invasive alternative to endoscopic sinus surgery (ESS). Although BD was introduced in 2006, distinct Current Procedural Terminology (CPT) codes were not available until 2011, making prior analysis of population-based trends difficult. Our objectives were to evaluate these trends and compare any changes to the use of traditional ESS techniques. Geographic trends also were evaluated., Methods: Medicare Part B national datasets encompassing procedures from 2011 to 2015 were obtained. ESS CPT codes (frontal sinusotomy, maxillary antrostomy with/without tissue removal, sphenoidotomy) and BD codes were searched to determine temporal trends in their use. Additionally, state carriers were individually evaluated for geographic trends., Results: National use of BD increased greater than five-fold (39,193 from 7,496 among Medicare patients), whereas the use of ESS increased by only 5.9%. This increase in BD was observed across all sites, including the sphenoid (7.0x), maxillary (5.1x), and frontal (4.7x) sinuses. In the most recent year for which data was available (2015), a significantly greater portion of sinus procedures in these sites utilized BD in the South (42.1%) compared to the Northeast (30.6%), West (29.5%), and Midwest (25.3%) regions (P < 0.0001)., Conclusion: The performance of BD has increased markedly in recent years. Because the use of ESS codes remain stable, observed BD trends are unlikely to be due simply to greater familiarity with newer CPT coding. The reasons for the striking increase in BD popularity are speculative and beyond the scope of this analysis, but further study may be needed., Level of Evidence: NA. Laryngoscope, 128:1299-1303, 2018., (© 2017 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: To characterize trends in rhinosinusitis clinical trials to provide recommendations for therapeutic directions, highlight possible redundancy, and provide a framework for prioritization of future clinical trials., Study Design: Database analysis., Methods: Data were collected from ClinicalTrials.gov including all clinical trials that focused on rhinosinusitis with the exclusion of trials withdrawn prior to enrollment. Variables recorded included study design, study population, pharmaceutical involvement, publication, and whether a trial was a medical or surgical intervention. Associated publications were identified using the PubMed, Embase, and Cochrane databases., Results: There were 269 rhinosinusitis clinical trials, dating from 1993 to 2017, that met inclusion reauirements. Of the studies included in this analysis, 51.7% had at least one scientific publication, and of those with publications, 80.6% had positive results and 19.3% had negative results. Twenty-three clinical trials (8.5%) studied drugs already approved for rhinosinusitis, 113 (42.0%) trials studied drugs that were approved for other uses, 42 (15.6%) trials studied experimental drugs, and 102 (39.4%) studied surgical intervention. Of the trials studying drugs, the data showed many clinical trials that studied the same drug. The data demonstrate a steady decline in clinical trials with medical intervention and a rise in clinical trials with surgical intervention., Conclusions: This analysis is the first to characterize rhinosinusitis clinical trials, highlighting the over-representation of certain drugs and demonstrating an increased focus on clinical trials employing surgical intervention. We provide a framework to discuss prioritization of future studies to guide clinical and research practice., Level of Evidence: 4. Laryngoscope, 128:1281-1286, 2018., (© 2017 The American Laryngological, Rhinological and Otological Society, Inc.)

Background: This analysis explores the increasing heterogeneity of trends in allergy management under the premise that the practice of allergy has undergone significant changes in national economics, healthcare delivery, and treatment options from 2007 to 2016., Methods: Centers for Medicare and Medicaid Services (CMS) data were obtained for: (1) temporal trends in allergy immunotherapy injection (Current Procedural Terminology [CPT] codes 95115, 95117) and testing (CPT 95004, 95024) from 2007 to 2016; (2) geographic trends; and (3) practitioners administering immunotherapy. Although there are no sublingual immunotherapy (SLIT) CPT codes, billing for unlisted allergy/immunologic services (CPT 95199) were obtained., Results: Since 2007, there were 99.5 million allergy tests and 33.5 million immunotherapy injections billed to Medicare beneficiaries. Increases in testing have outpaced rising immunotherapy administration (49.7% vs 19.6% increase). Significant regional variation in testing rates was noted, with the greatest ratio of testing to immunotherapy in the South (0.35) and smallest ratio in the Northeast (0.18). The maximum unlisted allergy services billed was 594 (of which includes SLIT), compared to annual subcutaneous immunotherapy (SCIT) totals in the millions. The majority of immunotherapy in 2016 was administered by allergists/immunologists (51.6%) followed by otolaryngologists (31.2%), trends that have remained consistent since 2012., Conclusion: Physicians have been more aggressive in the workup of allergy-mediated disorders in recent years. Although differences in allergen load exist, there is tremendous geographic variation in the ratio of testing to immunotherapy. While the role otolaryngologists play in immunotherapy remains stable, allergists manage the majority of patients, reinforcing the importance of interdisciplinary cooperation and outreach. SLIT does not appear to play a significant role in this population., (© 2018 ARS-AAOA, LLC.)

Background: Although the endoscopic approach has been increasingly utilized for a variety of sinonasal and skull base pathologies, there has been little inquiry into its adoption in the surgical management of orbital disease. Our objective was to evaluate nationwide temporal and geographic trends in approaches for orbital decompression., Methods: Data available from the Centers for Medicare and Medicaid Services (CMS) were evaluated, focusing on the use of open and endoscopic approaches for orbital decompression (CPT codes 67414, 67445, 31292, and 31293) among Medicare beneficiaries over a 10-year period. Regional data were also analyzed., Results: There were 8047 orbital decompressions billed to Medicare from 2007 to 2016. The number of external and endoscopic approaches increased by 73.0% and 29.2%, respectively, while the number of Medicare beneficiaries increased by 29.1%. Endoscopic decompression represented 23.5% of Medicare-billed orbital decompressions in 2016 (221 of 939), down from 29.2% in 2007 (171 of 586). The South had the greatest proportion of decompressions utilizing an endoscopic approach (30.2%)., Conclusion: There has not been a clear movement toward the endoscopic approach for orbital decompression, with modest growth when compared with external approaches. Potential explanations include the specialty-exclusive nature of approaches, as well as a lack of consensus; the latter idea is further reinforced by geographic variation. High-quality prospective trials may clarify the role of endoscopic approaches in these patients., (© 2018 ARS-AAOA, LLC.)

Objectives/hypothesis: To characterize the disability-related health burden of hearing loss (HL) at a global level, with a focus on socioeconomic health disparities., Methods: The global burden of HL, as calculated by disability-adjusted life years (DALYs) per 100,000 individuals, was evaluated for 184 countries. Data from 5-year intervals encompassing 1990 to 2015 were organized by human development index (HDI) categorizations as specified by the U.N. Development Program (UNDP). Gini coefficients and concentration indices were used to evaluate global inequality in HL burden over this time period., Results: There was a global lack of improvement in hearing loss burden over 25 years. National HL burden, as measured by age-standardized DALYs, had an inverse relationship with successive level of development (p < 0.0001). Global inequalities in HL burden as measured by the concentration index decreased from 1990 to 2005, remained stable between 2005 and 2010, and slightly increased from 2010 to 2015. Central Sub-Saharan Africa, followed by Eastern Sub-Saharan Africa and South Asia, had the greatest rates of disease burden in 2015., Conclusions: To our knowledge, this analysis is the first to investigate socioeconomic-related inequalities in hearing loss burden using statistical tools such as the Gini coefficient and concentration index. Although inequalities have largely decreased in recent decades, the global burden of hearing loss remains high and there are recent signs of increased inequality. These data suggest that a greater distribution of hearing care resources may need to be directed towards developing countries to combat global hearing loss burden., Level of Evidence: III.

Background: Allergy-related illness impacts millions of individuals worldwide. Our objectives were to characterize current trends of clinical trials research relating to allergen immunotherapy and to describe the landscape of allergen immunotherapy in National Institutes of Health (NIH)-supported research inquiry., Methods: On ClinicalTrials.gov, the following terms were searched: allergen immunotherapy OR allergy immunotherapy. Variables, including completion status, dates, design, study population, funder, location, and allergen were recorded. The NIH Research Portfolio Online Reporting Tools (RePORTER) system was also used to gather relevant variables., Results: A total of 372 clinical trials met inclusion criteria. The proportion of industry-funded clinical trials has declined over 15 years. There has been a slow decline in pollen allergy immunotherapy research, with an increase in both food and animal allergy immunotherapy research. Otolaryngologists comprised only 6.4% of clinical trials principal investigators (PIs). There was a total adjusted NIH funding of $74,986,125 for the 118 total funding years., Conclusion: Despite an immense interest in allergen immunotherapy, this analysis demonstrates that otolaryngologists represented a small proportion of PIs leading associated clinical trials and basic science inquiry. The proportion of trials with industry sponsorship has declined considerably in recent decades. These trends could help direct future resource allocation for allergen immunotherapy., (© 2017 ARS-AAOA, LLC.)

Importance: As the US population ages, public health agencies have released guidelines encouraging aerobic activity and muscle-strengthening exercises among older individuals. Facial trauma from such activities among elderly individuals has long been underappreciated., Objectives: To evaluate the incidence of recreational activity-associated facial fractures among older adults and to further delineate injury characteristics including demographics, fracture location, and specific activities., Design, Setting, and Participants: The National Electronic Injury Surveillance System was used to collect data on emergency department visits from January 1, 2011, to December 31, 2015, for individuals 55 years of age or older who sustained facial fractures from recreational activities. Individual entries were evaluated for activity code, fracture site, and demographics. Weighting data were used to extrapolate national incidence., Main Outcomes and Measures: Incidence and location of facial fractures and associated recreational activity., Results: During the study period, there were 20 519 emergency department visits for recreational activity-associated facial fractures among adults 55 years of age or older (8107 women and 12 412 men; mean [SD] age, 66.5 [9.1] years). The annual incidence of facial fractures increased by 45.3% from 2011 (n = 3174) through 2015 (n = 4612). Bicycling (26.6%), team sports (15.4%), outdoor activities (10.1%), and gardening (9.5%) were the most common causes of facial fractures. Walking and jogging caused 5.5% of fractures. In cases specifying site of fracture, nasal (65.4%) and orbital (14.1%) fractures were the most common. A greater proportion of men than women sustained bicycle-associated fractures (35.7% vs 14.9%; P = 3.1056 × 10-170), while more women than men sustained fractures associated with gardening (15.5% vs 6.1%; P = 2.1029 × 10-97), outdoor activities (14.6% vs 7.7%; P = 4.3156 × 10-50), and gym exercise (7.7% vs 1.3%; P = 3.0281 × 10-114). Men harbored a greater likelihood than women of orbital (14.9% vs 12.8%; P = 6.1468 × 10-5) and mandible fractures (9.3% vs 2.0%; P = 9.3760 × 10-64). Walking and jogging and gardening comprised a greater proportion of injuries in older cohorts., Conclusions and Relevance: Facial fractures sustained from recreational activity increased by 45.3% during a 5-year period among older adults. Although bicycling was the most common activity facilitating these injuries, many other pursuits represent areas of concern. Nasal fractures predominated, although orbital fractures increased with age. These findings offer areas for targeted prevention and provide valuable information for patient counseling. Furthermore, initiatives encouraging greater activity among this population may need to be accompanied by guidelines for injury prevention., Level of Evidence: NA.

Objectives/hypothesis: Invasive fungal sinusitis is an uncommon entity among children. Early recognition is crucial for facilitating successful treatment with minimal morbidity. The goal of this analysis was to identify patient characteristics associated with high-risk surgical disease through a population-based examination into this rare and deadly disease process., Methods: A retrospective chart review of the 2009 and 2012 Kids' Inpatient Database (KID) was conducted. A series of queries (Fungal infection→immunocompromised diagnosis→sinus procedure) identified 102 patients with likely invasive fungal sinusitis. Outcomes included: species, invasive extension, death, and other clinical characteristics., Results: Patients with leukemia/lymphoma constituted 90.2% of individuals evaluated in this analysis. Nearly a quarter of pediatric patients receiving surgical treatment for invasive fungal sinusitis died during their hospital stay -24.9%. Aspergillus was the most commonly recorded mycotic species. Average hospital stay was 59.3 days, and associated hospital costs averaged $746,299 per stay. Patients 0-5 years old were more likely to have orbital involvement -56.3%. Brain extension was noted in 33.7% of this cohort as well. Mucormycosis was an independent predictor of death (p = 0.03), with an odds ratio of 3.835., Conclusion: To the best of our knowledge, this is the largest pediatric cohort with invasive fungal sinusitis in the literature. Patient demographics, cytology, and disease extension offer predictive information regarding patient outcomes for invasive fungal sinusitis. A high clinical suspicion and early treatment may decrease the lengthy and costly hospitalizations in this population., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Objectives: Salivary gland dysfunction as a consequence of radioiodide ablation is present in as many as two-thirds of patients, and unfortunately, many of these individuals do not respond to conservative measures. Sialendoscopy as a minimally invasive therapeutic modality may have utility in the treatment of radioiodide induced sialadenitis (RAIS). Our aim was to explore whether sialendoscopy resulted in clinical improvement in patients with RAIS., Methods: A systematic review of studies on sialendoscopy for RAIS was conducted using MEDLINE database, Embase, and Cochrane Library. The outcomes of interest included the proportion of patients demonstrating clinical improvement after intervention, patient demographics, radiation dose, specific procedural variations, specific salivary gland, failure rate, and recurrence., Results: Eight studies met inclusion criteria. Data reviewed showed an increased predilection of parotid sialadenitis relative to submandibular gland sialadenitis. All but 2 studies employed sialendoscopy only after failure of conservative measures. An overall rate of clinical improvement ranging from 75% to 100% was reported., Conclusion: This systematic review encompassing 122 patients represents the largest pooled sample to date of patients undergoing sialendoscopy for RAIS. Sialendoscopy represents an invaluable minimally invasive modality that may obviate the need for more invasive surgery as intervention was associated with a high success rate.

Objectives: Despite dramatic developments in drugs established for other malignancies, historically there have been few novel systemic agents available for the management of head and neck squamous cell carcinoma (HNSCC). However, the last decade has observed increased interest in targeted therapies for HNSCC. In 2006, cetuximab became the first major drug for HNSCC to gain Food and Drug Administration (FDA) approval in 3 decades. Recently, both pembrolizumab and nivolumab gained FDA approval for treatment of recurrent or metastatic HNSCC, and trials for other indications in HNSCC are actively underway. As older agents including cisplatin and 5-fluorouracil continue to play a significant role in the management of advanced HNSCC, an understanding of their legacy is paramount. This historical review is not meant to exhaustively catalog every finding relating to HNSCC systemic therapy, but rather is meant to highlight important advances., Data Sources: Case series and clinical trials available in the literature., Review Methods: Historically significant series and trials evaluating HNSCC systemic therapy were evaluated., Results: Standard regimens employed today are largely comprised of drugs discovered over 4 decades ago, although a number of recent phase III clinical trials have shown great promise, leading to the adoption of several new chemotherapeutic agents and treatment strategies., Conclusions: These findings reinforce the importance of supporting further HNSCC drug discovery as modern treatment strategies using systemic therapy have resulted in measurable improvements in oncologic outcomes. Laryngoscope, 127:2565-2569, 2017., (© 2017 The American Laryngological, Rhinological and Otological Society, Inc.)

Background: The objective of this research was to evaluate litigation relating to the diagnosis and management of pituitary and ventral skull base lesions and delineate allegations involved in the decision to pursue medicolegal proceedings., Methods: Publically available federal and court records were accessed via the Westlaw Next database. Jury verdict and settlement reports relevant to pituitary and anterior skull-base lesions were accessed, and litigation was reviewed for alleged injuries, defendant specialty, patient demographics, and other factors raised in proceedings., Results: Of 75 cases included, 50.7% were resolved in the defendant's favor. The most frequent physician specialties cited as defendants included primary care (20%), neurosurgery (17%), and radiology (16%), while otolaryngologists were defendants in only 5% of cases. Fifty-two (69%) did not involve surgical intervention; the most common allegations in these proceedings were misdiagnosis, permanent injury (19%), requiring additional procedures as a result of misdiagnosis (17%), permanent endocrine dysfunction (14%), and visual sequelae (12%). Among surgical cases, the most common allegations raised included permanent injury (17%), postoperative complications (14%), intraoperative complications (13%), and death (10%). Among cases resolved with payment, there was no statistical difference in payment between surgical cases ($5.7M) and nonsurgical cases ($4.8M)., Conclusion: Misdiagnosis of endocrinopathy, failure to appropriately workup patients presenting with neurologic complaints, and radiologic misdiagnosis play important roles in the pursuit of litigation in nonsurgical cases. Sustaining permanent sequelae including endocrine and visual injury play an important role in surgical cases. Postoperative management appears to play just as important a role in the decision to pursue litigation as intraoperative considerations., (© 2017 ARS-AAOA, LLC.)

Background: Industry outreach promotes awareness of novel technologies. However, concerns have been raised that such relationships may also unduly impact medical decision-making. Our objective in this study was to evaluate industry relationships among practitioners who frequently employ balloon dilation (BD), characterizing whether there is any association between financial relationships and BD utilization., Methods: Provider utilization data (FY-2014) was accessed for individuals billing BD procedures to Medicare, the largest healthcare payor in the United States. The names of individuals included in these data sets were cross-referenced with the Centers for Medicare and Medicaid Services Open Payment site to determine the extent of industry relationships during this same year. Individuals included in this analysis were organized by those with "significant" ($1,000 to $10,000) and "major" (> $10,000) industry relationships. Practice setting, training, and experience were also evaluated., Results: Of the 302 otolaryngologists who billed enough BDs for inclusion in this data set, 99.3% were in private practice, 89.7% were board-certified, 8.3% had facial plastic and reconstructive fellowship training, and 1.3% had rhinology fellowship training. There was a significant increase in BDs performed with increasing BD company financial contributions (analysis of variance, p = 0.0003). Individuals without "significant" relationships with BD companies billed fewer BDs than those with at least "significant" (>$1,000) relationships (57.0 ± 4.3 vs 87.7 ± 10.0, p = 0.001)., Conclusion: There is an association between receiving money from industry and the frequency with which otolaryngologists employ BD. Although our analysis demonstrates an association, these results in no way imply causation. Further analysis exploring the reasons for this association may be necessary., (© 2017 ARS-AAOA, LLC.)

Importance: Gender disparities continue to exist in the medical profession, including potential disparities in industry-supported financial contributions. Although there are potential drawbacks to industry relationships, such industry ties have the potential to promote scholarly discourse and increase understanding and accessibility of novel technologies and drugs., Objectives: To evaluate whether gender disparities exist in relationships between pharmaceutical and/or medical device industries and academic otolaryngologists., Design, Setting, and Participants: An analysis of bibliometric data and industry funding of academic otolaryngologists., Main Outcomes and Measures: Industry payments as reported within the CMS Open Payment Database., Methods: Online faculty listings were used to determine academic rank, fellowship training, and gender of full-time faculty otolaryngologists in the 100 civilian training programs in the United States. Industry contributions to these individuals were evaluated using the CMS Open Payment Database, which was created by the Physician Payments Sunshine Act in response to increasing public and regulatory interest in industry relationships and aimed to increase the transparency of such relationships. The Scopus database was used to determine bibliometric indices and publication experience (in years) for all academic otolaryngologists., Results: Of 1514 academic otolaryngologists included in this analysis, 1202 (79.4%) were men and 312 (20.6%) were women. In 2014, industry contributed a total of $4.9 million to academic otolaryngologists. $4.3 million (88.5%) of that went to men, in a population in which 79.4% are male. Male otolaryngologists received greater median contributions than did female otolaryngologists (median [interquartile range (IQR)], $211 [$86-$1245] vs $133 [$51-$316]). Median contributions were greater to men than women at assistant and associate professor academic ranks (median [IQR], $168 [$77-$492] vs $114 [$55-$290] and $240 [$87-$1314] vs $166 [$58-$328], respectively). Overall, a greater proportion of men received industry contributions than women (68.0% vs 56.1%,). By subspecialty, men had greater median contribution levels among otologists and rhinologists (median [IQR], $609 [$166-$6015] vs $153 [$56-$336] and $1134 [$286-$5276] vs $425 [$188-$721], respectively)., Conclusions and Relevance: A greater proportion of male vs female academic otolaryngologists receive contributions from industry. These differences persist after controlling for academic rank and experience. The gender disparities we have identified may be owing to men publishing earlier in their careers, with women often surpassing men later in their academic lives, or as a result of previously described gender disparities in scholarly impact and academic advancement.

Objectives/hypothesis: Despite the increasing role of mobile applications (apps) in patient education, there has been little inquiry evaluating the quality of these resources. Because poor health literacy has been associated with inferior health outcomes, evaluating the quality of patient education materials takes on great importance. Our objective was to employ validated readability tools for the evaluation of gastroesophageal reflux (GERD) mobile apps., Methods: GERD-specific apps found in the Apple App Store (Apple Inc., Cupertino CA) were evaluated using the Readability Studio Professional Version 2015 for Windows (Oleander Software, Ltd, Vandalia, OH). All text was evaluated using nine validated algorithms measuring readability including Flesch-Kincaid Grade Level, Simple Measure of Gobbledygook grading, Gunning Fog index, Coleman-Liau, New Fog Count formula, Raygor Readability Estimate, FORCAST, Fry graph, and Flesch Reading Ease score., Results: Average reading grade levels for individual GERD apps ranged from 9.6 to 12.9 (interquartile range 10.3-12). The average reading grade level for all apps analyzed was 11.1 ± 0.2 standard error of the mean (SEM), with an average Flesch Reading Ease score for all mobile apps analyzed of 51 ± 2.05 (SEM), falling into the "fairly difficult" category given by this measure. Raygor Readability estimates that most mobile apps have a reading grade level between 10 and 12, with the majority of this outcome due to long words., Conclusion: This analysis demonstrates the feasibility of assessing readability of mobile health apps. Our findings suggest significant gaps in potential comprehension between the apps analyzed and the average reader, diminishing the utility of these resources. We hope our findings influence future mobile health-related app development and thereby improve patient outcomes in GERD and other chronic diseases., Level of Evidence: NA. Laryngoscope, 127:1775-1779, 2017., (© 2016 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: To explore the relationship between lower airway disease and postoperative cerebrospinal fluid (CSF) rhinorrhea among patients undergoing pituitary surgery STUDY DESIGN: Retrospective review., Methods: A retrospective review of the Healthcare Cost and Utilization Project's 2013 National Inpatient Sample was conducted to characterize the hospital stay and surgical outcomes of patients undergoing pituitary surgery. Patients with lower airway disease (including chronic obstructive pulmonary disease and asthma) were compared to a disease-free population identifying demographics and complications over-represented in the lower airway group., Results: The majority of hypophysectomies (92.1%) were performed via a transsphenoidal approach. Among transsphenoidal patients, individuals with asthma (92.8% of the lower airway disease cohort) harbored a greater postoperative CSF leak rate (4.7% vs. 2.7%, P = .022), and were more likely to develop postoperative diabetes insipidus (6.2% vs. 4.1%, P = .024) and neurological complications (13.0% vs. 9.6%, P = .010) when compared to a lower airway disease-free cohort. Patients with CSF rhinorrhea had longer lengths of stay (7.8 days vs. 4.5 days, P < .001) and higher discharge costs ($148,309 vs. $76,246, P < .001). A binary logistic regression model identified having asthma (P = .042), being female (P = .011), and having gastroesophageal reflux disease (P = .006) as independent predictors of postoperative CSF rhinorrhea., Conclusions: Several patient comorbidities including asthma are associated with a greater risk of postoperative CSF rhinorrhea. Perioperative lower airway assessment and disease control may potentially decrease one's risk of this complication, although further inquiry is urgently needed to identify optimal preventive strategies., Level of Evidence: 2c. Laryngoscope, 127:1543-1550, 2017., (© 2016 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: To determine the relationship between industry payments and scholarly impact among academic neurosurgeons., Methods: Faculty names and academic rank data were obtained from department websites, bibliometric data were obtained from the Scopus database, and industry payment data were obtained from the Center for Medicare and Medicaid Services open payments database (openpayments.cms.gov). The h-index was used to estimate scholarly impact. Payments were classified as "general," "associated research," and "research payments." Subgroup analyses were done for academic rank, fellowship training, and sex., Results: Among 1008 academic neurosurgeons, scholarly impact was greater among individuals receiving associated research industry support compared with those not receiving it. Scholarly impact also was greater among individuals who received more than $10,000 of any type of industry support compared with individuals who received less than that or no payment. This association also was seen in fellowship-trained surgeons. Female neurosurgeons were less likely than male neurosurgeons to get industry funding and were likely to get less funding., Conclusions: There is a strong association between associated research funding from industry and scholarly impact among academic neurosurgeons. It's unclear whether this association is a result of funding facilitating more research projects that eventually lead to more high-impact publications, if industry is providing more funding to academic neurosurgeons with greater scholarly impact, or whether it represents intrinsic academic activity among a group of neurosurgeons who are more likely to be academically productive and procure funding from all potential sources to increase this activity., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Importance: As the nursing home population continues to increase, an understanding of preventable injuries becomes exceedingly important. Although other fall-related injuries have been characterized, little attention has been dedicated to facial trauma., Objectives: To estimate the incidence of facial trauma among nursing home residents and detail mechanisms of injury, injury characteristics, and patient demographic data., Design, Setting, and Participants: The National Electronic Injury Surveillance System was used to calculate a weighted national incidence of facial trauma among individuals older than 60 years from a nationally representative collection of emergency departments from January 1, 2011, through December 31, 2015. Entries were screened for nursing home residents, and diagnosis, anatomical site, demographic data, and mechanism of injury were analyzed., Results: There were 109 795 nursing home residents (median age, 84.1 years; interquartile range, 79-89 years; 71 466 women [65.1%]) who required emergency department care for facial trauma. Women sustained a greater proportion of injuries with increasing age. The most common injuries were lacerations (48 679 [44.3%]), other soft-tissue injuries (45 911 [41.8%]; avulsions, contusions, and hematomas), and fractures (13 814 [12.6%]). Nasal (9331 [67.5%]) and orbital (1144 [8.3%]) fractures were the most common sites. The most common injury causes were direct contact with structural housing elements or fixed items (62 604 [57.0%]) and transfer to and from bed (24 870 [22.6%])., Conclusions and Relevance: Despite falls being considered a Centers for Medicare & Medicaid Services preventable never event in hospitals, our analysis in the nursing home setting found more than 100 000 facial injuries during 5 years, suggesting these underappreciated injuries contribute substantially to health care expenditures. Although structural elements facilitated the greatest number of falls, transfer to and from bed remains a significant mechanism, suggesting an area for intervention.

Objectives/hypothesis: As our population ages, injuries attributable to falls continue to increase, impacting healthcare delivery. Evaluation of craniofacial trauma with focus on elderly patients remains an underappreciated concern. Our objectives were to evaluate injury trends associated with elderly bathroom falls, as this information may be useful for counseling and preventive purposes., Study Design: Database review., Methods: The National Electronic Injury Surveillance System was evaluated for craniofacial trauma among patients 60 years and older presenting to the emergency department (ED) (2010-2014). Injury descriptions were reviewed for mechanism of injury, patient demographics, and other injury characteristics., Results: In total, 7.2% of the estimated 3.4 million ED visits for elderly craniofacial trauma were bathroom related. Females comprised the majority (60.9%) of patients, and a plurality of patients were in their 80s. A greater proportion of facial injuries resulted from syncope (16.6% vs. 10.9% compared to head injuries). Toilets facilitated a greater proportion of facial insults and were more likely to require admission; the most common mechanism was "falling off." Showers contributed a majority of head injuries and had a lower median age than toilet injuries. Fractures comprised 12.6% of facial injuries; of craniofacial fractures, common sites included the nose (54%), mandible (6%), and orbit (6%). Admitted patients were significantly older than those who were released., Conclusions: Bathroom falls result in a significant proportion of elderly traumatic injury. The trends we present offer the opportunity for targeted preventative measures to decrease the occurrence of these events. Additionally, this information may adjunct a detailed history and physical to ensure appropriate patient management., Level of Evidence: 4 Laryngoscope, 127:820-827, 2017., (© 2016 The American Laryngological, Rhinological and Otological Society, Inc.)

Surgical management of clival lesions presents numerous therapeutic challenges because of the close proximity of surrounding critical structures. With a detailed understanding of the endoscopic endonasal approach and relevant considerations, appropriate lesions can be removed in a safe and minimally invasive manner. Use of this technique as a primary approach represents the standard of care for many lesions at leading skull base centers, although adjunct techniques may be necessary in extensive lesions and those with significant lateral extension., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objectives/hypothesis: Our objectives included using a nationally representative resource to evaluate charges, demographics, and complication rates among diabetics undergoing surgical repair of facial fractures., Methods: We evaluated the Nationwide Inpatient Sample, a database encompassing nearly 8 million hospitalizations, for patients with a diagnosis of a facial fracture who underwent surgical intervention during their hospitalization. Patients were organized by whether they had a diagnosis of diabetes mellitus (DM)., Results: Of 45,509 inpatients included, diabetics had greater costs, longer length of stays, and were significantly more likely to have a host of baseline comorbidities. On multivariate logistic regression corrected for age, race, gender, and preexisting cardiac disease, DM patients had significantly greater odds for cardiac complications (3.3; P < 0.001) and hepatic failure (15.0; P = 0.007). There were no significant differences associated with DM in the rates of enophthalmos, epiphora, and diplopia among patients with orbital fractures. Diabetics did have a significantly greater risk of postoperative infection after mandible repair., Conclusion: In addition to a significant association with greater length of stay and increased hospital charges, DM patients undergoing surgical repair of facial fractures had a significantly greater risk of postoperative complications, including cardiac complications. Diabetics undergoing mandible repair had a greater risk of postoperative infection, even upon controlling for demographic factors, suggesting the need for further study evaluating the role of postoperative antibiotic prophylaxis in this patient population. These findings reveal the potential value of developing and using standardized postoperative care algorithms aimed at minimizing complications in this susceptible population., Level of Evidence: 2c. Laryngoscope, 127:809-814, 2017., (© 2016 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: Our objective was to perform an economic analysis evaluating whether ordering a magnetic resonance imaging (MRI) is a cost-effective practice in the workup of undifferentiated asymmetric sensorineural hearing loss (ASNHL). Use of T1 gadolinium-weighted MR (GdT1W) and T2 weighted MR without contrast (T2MR) was each examined., Methods: The incremental cost-effectiveness ratio (ICER) of MR imaging among ASNHL patients was evaluated using a decision tree. We calculated what the probability of having a cerebellopontine angle/internal auditory canal lesion would have to be to make MR more cost-effective than observation. The decision pathways included observation, GdT1W, and T2MR. The probability of detecting a lesion and associated costs were employed in constructing our tree. Missing a mass in the observation branch was considered to have an effectiveness of 0. The costs and probabilities were extracted from previously published studies., Results: The ICERs of pursuing GdT1W and T2MR were $27,660 and $15,943, respectively, both below the widely accepted willingness to pay (WTP) thresholds of $30,000 and $50,000. Probabilistic sensitivity analysis with Monte Carlo simulations for GdT1W showed that it is more cost-effective than no imaging, with 54.4% and 83.5% certainty at $30,000 and $50,000 WTP thresholds. Probabilistic sensitivity analysis with Monte Carlo simulations for T2MR showed that it is more cost-effective than no imaging, with 75.2% and 92.6% certainty at $30,000 and $50,000 WTP thresholds., Conclusion: This economic evaluation strongly supports pursuing MRI in patients with documented ASNHL as a cost-effective strategy. Both GdT1W and T2MR are more cost-effective than observation. Furthermore, noncontrast T2 imaging may be the more cost-effective modality of these two techniques., Level of Evidence: 2c. Laryngoscope, 127:939-944, 2017., (© 2016 The American Laryngological, Rhinological and Otological Society, Inc.)

Importance: The number of patients using the internet to obtain health information is growing. This material is unregulated and heterogeneous and can influence patient decisions., Objective: To compare the quality, readability, and technical aspects of online information about neck-lifts provided by private practice websites vs academic medical centers and reference sources., Design, Setting, and Participants: In this cross-sectional analysis conducted between November 2015 and January 2016, a Google search of the term neck-lift was performed, and the first 45 websites were evaluated. The websites were categorized as private practice vs other. Private websites (PWs) included sites created by private practice physicians. Other websites (OWs) were created by academic medical centers or reference sources., Main Outcomes and Measures: Quality, readability, and technical aspects of online websites related to neck-lifts. Quality was assessed using the DISCERN criteria and the Health on the Net principles (HONcode). Readability was assessed using 7 validated and widely used criteria. Consensus US reading grade level readability was provided by a website (readabilityformulas.com). Twelve technical aspects were evaluated based on criteria specified by medical website creators., Results: Forty-five websites (8 OWs [18%] and 37 PWs [82%]) were analyzed. There was a significant difference in quality between OWs and PWs based on the DISCERN criteria and HONcode principles. The DISCERN overall mean (SD) scores were 2.3 (0.5) for OWs and 1.3 (0.3) for PWs (P < .001). Of a total possible score of 14 using the HONcode analysis, the mean (SD) was 8.6 (1.8) (range, 5-11) for OW, and the mean (SD) was 5.8 (1.7) (range, 2-9) for PW. The mean (SD) readability consensus reading grade level scores were 11.7 (1.9) for OWs and 10.6 (1.9) for PWs. Of a total possible score of 12, the mean (SD) technical scores were 6.3 (1.8) (range, 4-9) for OWs and 6.4 (1.5) (range, 3-9) for PWs., Conclusions and Relevance: Compared with PWs, OWs had a significantly higher quality score based on both the DISCERN criteria and HONcode principles. The mean readability for OWs and PWs was grade 11 and grade 10, respectively, significantly higher than the grade 7 level recommended by the National Institutes of Health. Assessment of technical criteria demonstrated room for improvement in providing links to social media and blogs and reducing advertisements. Improving the quality and readability of online information may result in increased patient understanding, more active patient involvement, and ultimately better outcomes. Enhancing the technical aspects of websites may increase website traffic and patient volume., Level of Evidence: NA.

Objectives/hypothesis: To evaluate the cost-effectiveness of routine computed tomography (CT) in individuals with unilateral vocal fold paralysis (UVFP) STUDY DESIGN: Health Economics Decision Tree Analysis METHODS: A decision tree was constructed to determine the incremental cost-effectiveness ratio (ICER) of CT imaging in UVFP patients. Univariate sensitivity analysis was utilized to calculate what the probability of having an etiology of the paralysis discovered would have to be to make CT with contrast more cost-effective than no imaging. We used two studies examining findings in UVFP patients. The decision pathways were utilizing CT neck with intravenous contrast after diagnostic laryngoscopy versus laryngoscopy alone. The probability of detecting an etiology for UVFP and associated costs were extracted to construct the decision tree. The only incorrect diagnosis was missing a mass in the no-imaging decision branch, which rendered an effectiveness of 0., Results: The ICER of using CT was $3,306, below most acceptable willingness-to-pay (WTP) thresholds. Additionally, univariate sensitivity analysis indicated that at the WTP threshold of $30,000, obtaining CT imaging was the most cost-effective choice when the probability of having a lesion was above 1.7%. Multivariate probabilistic sensitivity analysis with Monte Carlo simulations also showed that at the WTP of $30,000, CT scanning is more cost-effective, with 99.5% certainty., Conclusions: Particularly in the current healthcare environment characterized by increasing consciousness of utilization defensive medicine, economic evaluations represent evidence-based findings that can be employed to facilitate appropriate decision making and enhance physician-patient communication. This economic evaluation strongly supports obtaining CT imaging in patients with newly diagnosed UVFP., Level of Evidence: 2c. Laryngoscope, 2016 127:440-444, 2017., (© 2016 The American Laryngological, Rhinological and Otological Society, Inc.)