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The treatment of anaplastic thyroid cancer (ATC) has continued to rapidly evolve over time. Increased utilization of novel, personalized therapies based upon the tumour's somatic mutation status has recently been integrated. The aim of this case series is to describe a series of patients that underwent rapid genomic testing upon their diagnosis of ATC, allowing for the early integration of novel therapies.A fast track pathway for genomic tumour analysis of patients with ATC was implemented at a single academic cancer hospital in January of 2020.All patients were evaluated by head and neck surgery, endocrinology, and medical oncology upon diagnosis of ATC.Genetic work-up was completed, which prompted a recommendation for dual BRAF/MEK inhibition with dabrafenib and trametinib for tumours with BRAF V600E mutation. For patients whose tumours were BRAF V600E wild-type, pembrolizumab with lenvatinib was offered.A total of four patients were included in this series. Two patients (50%) had tumours that were BRAF V600E positive. Among patients that were BRAF V600E positive, both patients initiated urgent dabrafenib and trametinib dual tyrosine kinase inhibitor (TKI) therapy; with one patient demonstrating near-complete clinical response allowing for posttreatment surgery, while the other demonstrated decreased tumour burden. Among patients who were BRAF V600E wild-type, lenvatinib and pembrolizumab were recommended off-label; one patient demonstrated decreased tumour burden, but developed severe pure red cell aplasia, while the other patient is demonstrating an early clinical response.The integration of early genomic analysis and personalized neoadjuvant TKI therapy into the treatment of ATC can greatly benefit patient care outcomes and optimize tumour control.

Prior literature has indicated that the number of trained otolaryngologists required to meet the need of our growing population may be insufficient. Therefore, identifying trends in the subspecialty composition of future otolaryngology practices will elucidate workforce needs.One-page anonymous questionnaire.The survey was completed by examinees at the conclusion of their American Board of Otolaryngology-Head and Neck Surgery oral examination from 2011 to 2019.Data included age, gender, fellowship, practice type, and ideal future practice components.A total of 2286 examinees were included: 58.1% were male and 57.2% completed a fellowship. Ideal practice specialties included general otolaryngology (19%), rhinology (15%), head and neck (13%), and pediatrics (11%). General and pediatric otolaryngology had a negative correlation over time (There is a growing trend for more specialized otolaryngology practices. The data demonstrate a decline in considering general and pediatrics otolaryngology as part of practices, which portends a gap in access to comprehensive otolaryngology in the future.

Objectives: Self-inflicted facial gunshot wounds (GSWs) result in complex but consistent injuries that are often survivable. We suggest a novel method for rapid stratification into groups that may ...

Objective:The aim of this study is to describe the current state of robotic surgery training among Otolaryngology—Head and Neck Surgery (OHNS) residency programs in the United States.Methods:This is a national survey study among OHNS residents. All OHNS residency programs were identified via the Accreditation Council for Graduate Medical Education website. A total of 64/127 (50.3%) of OHNS programs were selected based on a random number generator. The main outcome measure was the number of OHNS residents with access to robotic surgery training and assessment of operative experience in robotic surgery among those residents.Results:A total of 140 OHNS residents participated in the survey, of which 59.3% (n = 83) were male. Response rate was 40.2%. Respondents came from middle 50.0% (n = 70), southern 17.8% (n = 25), western 17.8% (n = 25), and eastern sections 14.3% (n = 20). Most respondents (94.3%, n = 132) reported that their institution utilized a robot for head and neck surgery. Resident experience at the bedside increased in the junior years of training and console experience increased across the years particularly for more senior residents. However, 63.4% of residents reported no operative experience at the console. Only 11.4% of programs have a structured robotics training program.Conclusion:This survey indicated that nearly all OHNS residencies utilize robotic surgery in their clinical practice with residents receiving little formal education in robotics or experience at the console. OHNS residencies should aim to increase access to training opportunities in order to increase resident competency.Level of Evidence:IV

Background In-training examinations (ITEs) are intended for low-stakes, formative assessment of residents' knowledge, but are increasingly used for high-stake purposes, such as to predict board examination failures. Objective The aim of this review was to investigate the relationship between performance on ITEs and board examination performance across medical specialties. Methods A search of the literature for studies assessing the strength of the relationship between ITE and board examination performance from January 2000 to March 2019 was completed. Results were categorized based on the type of statistical analysis used to determine the relationship between ITE performance and board examination performance. Results Of 1407 articles initially identified, 89 articles underwent full-text review, and 32 articles were included in this review. There was a moderate-strong relationship between ITE and board examination performance, and ITE scores significantly predict board examination scores for the majority of studies. Performing well on an ITE predicts a passing outcome for the board examination, but there is less evidence that performing poorly on an ITE will result in failing the associated specialty board examination. Conclusions There is a moderate to strong correlation between ITE performance and subsequent performance on board examinations. That the predictive value for passing the board examination is stronger than the predictive value for failing calls into question the “common wisdom” that ITE scores can be used to identify “at risk” residents. The graduate medical education community should continue to exercise caution and restraint in using ITE scores for moderate to high-stakes decisions.

BACKGROUND There is variability in opioid prescription patterns among surgeons performing thyroidectomy. Thus, the aim of this study is to evaluate opioid prescription rates and opioid use among hemithyroidectomy (HT) and total thyroidectomy (TT) patients. DESIGN/METHOD An electronic postoperative survey was distributed to assess opiate use among patients undergoing HT/TT. Groups were compared using t-tests, chi-square tests, and analysis of variance. RESULTS A total of 142 opiate naive patients were included, of which 75 (52.8%) underwent HT and 67 (47.1%) underwent TT. The mean number of tablets prescribed was 21.3 (HT = 22.1, TT = 20.4; P = 0.3), with a mean of 14.1 tablets unused after surgery (HT = 13.2 tablets, TT = 15.0 tablets; P = 0.44). The mean morphine milligram equivalent (MME) prescribed was 150.1 mg (HT = 159.0 mg, TT = 140.2 mg; P = 0.3), with a mean of 98.2 MME unused after surgery (HT = 93.7 mg, TT = 103.2 mg; P = 0.6). CONCLUSIONS Opioids are overprescribed after thyroid surgery. Avoidance of overprescribing is vital in mitigating the current opioid crisis.

Objective Understand the frailty of vestibular schwannoma surgical patients and how frailty impacts clinical course. Study design Retrospective Cohort. Setting Single-tertiary academic hospital. Patients All patients undergoing vestibular schwannoma surgery. Intervention The modified frailty index (mFI) was calculated for all patients undergoing surgery for vestibular schwannoma between 2011 and 2018. Patient demographics and medical history, perioperative course, and postoperative complications were obtained from the medical record. Main outcome measures The primary endpoint was hospital length of stay (LOS). Secondary endpoint was postoperative complications. Basic statistical analysis was performed including multivariate linear regressions to determine independent predictors of LOS. Results There were 218 patients included and the mean age was 48.1 ± 0.9 (range 12-77). One-hundred ten patients were male (50.5%). The mean ICU LOS was 1.6 ± 0.1 days while mean total hospital LOS was 4.3 ± 0.2. There were 145 patients (66.5%) who were robust (nonfrail) with an mFI of 0, while 73 (33.5%) had an mFI of ≥1. Frailty (mFI≥2) was associated with longer hospital LOS compared with the prefrail (p = 0.0014) and robust (p = 0.0004) groups, but was not associated with increased complications (OR = 1.3; 95% CI: 0.5-3.7; p = 0.5925) or ICU LOS (p > 0.05). In multivariate analysis, increased mFI, and NOT increased age, was an independent risk factor for increased hospital LOS (p = 0.027). Conclusion Increasing frailty, and not increasing age, is an independent risk factor for longer hospital LOS, but not for increased postoperative complications. Patients' frailty status may be useful preoperatively in counselling patients about postoperative expectations and frail vestibular schwannoma patients may require increased health spending costs given their increased hospital LOS.

Objective This study aimed to determine the outcomes from an expanded targeted early congenital cytomegalovirus (cCMV) testing program. Study Design A retrospective analysis of data was collected from June 2016 to April 2018 of patients who underwent expanded targeted early cCMV testing during the peri-implementation phase. Information regarding patient presentation, test type/result, and audiologic outcomes were collected. Chi-square and two-sample t-tests were performed. Results A total of 754 patients underwent cCMV testing; during that period there were 56,947 births at 20 different hospitals. Reasons for completing cCMV testing included the following: (1) failed hearing screening (35.8%), (2) intrauterine growth restriction (IUGR) or small for gestational age (SGA) (29.1%), (3) sepsis (10.7%), (4) other/unknown (8.7%), (5) elevated liver enzymes or bilirubin (5.1%), (6) thrombocytopenia (5.1%), (7) central nervous system abnormalities (3.3%), and (8) mother with suspected cCMV infection (2.2%). The most frequent type of cCMV test performed was urine polymerase chain reaction (75.8%). A total of 21 (2.8%) patients tested positive for cCMV, of which 12 (57%) were symptomatic. This value represents a prevalence of 36.9 cCMV cases and 21.1 symptomatic cCMV cases diagnosed per 100,000 live births. Criteria most commonly associated with a positive testing were failed hearing screening (33.3%), IUGR/SGA (28.6%), and a mother with suspected cCMV infection (19.0%). Conclusion Implementation of an expanded targeted early CMV testing program has the potential to identify symptomatic cCMV infants who would not be identified otherwise.

Objectives: To discuss the presentation and management of infants with arhinia or congenital absence of the nose. Methods: This case report describes an infant with arhinia that was diagnosed prenatally. In addition to a discussion of the case, a review of the literature was completed to define appropriate postnatal work-up and management. Results: The patient is a term male infant, diagnosed with arhinia on ultrasound and magnetic resonance imaging (MRI) performed at 21-weeks gestational age. Upon birth, the patient was subsequently intubated, followed by tracheostomy due to complete nasal obstruction. Through a genetics evaluation, the patient was found to be heterozygous for the SMCHD1 gene, with hypomethylation at the D4Z4 locus. Plans for reconstruction will be based on future imaging and the development of any nasal patency, however, the patient’s family plans to utilize a prosthetic nose until the patient is older. Conclusion: Arhinia is a rare condition causing respiratory distress in the neonatal period. While stabilization of the airway is the first priority, further management is not clearly defined given the rarity of the malformation. This case discusses stabilization of the airway with a review of treatment and reconstructive options.

OBJECTIVE To describe the clinical course and treatment outcomes for patients with petrous apex epidermoid with skull base erosion. STUDY DESIGN Retrospective case series. SETTING Tertiary-care academic center. PATIENTS Patients surgically managed for petrous apex epidermoids at a single-tertiary care institution from 2001 to 2017. INTERVENTIONS Surgical management of primary petrous apex epidermoids. MAIN OUTCOME MEASURES The presenting symptoms, imaging, pre- and postoperative clinical course, and complications were reviewed. RESULTS Seven patients were identified. The most common presenting symptoms included: sudden sensorineural hearing loss (n = 3), headaches (n = 1), vertigo (n = 2), and facial paralysis/paresis (n = 2). An epidermoid was discovered in two patients as an incidental finding after a head trauma and one patient after admission for altered mental status and meningitis. Two patients presented with complete facial paralysis (House-Brackmann 6/6). Preoperative normal hearing (pure-tone average < 25 db) was identified in three patients and serviceable hearing (pure-tone average 25-60 dB) in one patient. Three patients with nonserviceable hearing underwent a transcochlear or transotic approach. The remaining four patients underwent an attempted hearing preservation approach. Postoperatively, one patient developed delayed facial paralysis, improving within 3 months. Hearing was preserved in three patients. Two patients developed recurrence of disease within 4 and 7 years respectively. CONCLUSIONS Surgical management of aggressive petrous apex epidermoid is effective to preserve facial function and prevent recurrence. In our series different surgical approaches were used with variable outcomes.

OBJECTIVE To evaluate patients who become symptomatic from superior semicircular canal dehiscence (SSCD) following head trauma. STUDY DESIGN Case series assessing patients presenting with SSCD after a trauma. METHODS A case series was completed assessing patients presenting with SSCD after trauma. Data from three academic medical centers were evaluated, including the following: imaging, videonystagmography (VNG)/vestibular evoked myogenic potential (VEMP) testing, audiometric assessment, and surgical repair. Outcome measures included the following: 1) Description of audio-vestibular symptoms, 2) mean pre- and post-operative pure tone average (PTA), word recognition score (WRS), and air bone gap (ABG). RESULTS A total of 14 patients were included; 86% were male. Approximately 43% were found to have bilateral SSCD on imaging, with 57% of patients pursuing surgical management. The most common presenting symptoms included pulsatile tinnitus (93%), autophony (79%), and hearing loss (64%). Approximately 36% of patients underwent VNG/VEMP testing, with 83.3% of those demonstrating abnormal results. The mean audiometric findings on the symptomatic side included an air-conduction PTA of 38.0 dB, bone-conduction PTA of 24.3 dB, WRS of 81%, and ABG of 17.9 dB. Among patients who underwent surgery (57%), there was no significant change in the air-conduction PTA, bone-conduction PTA, or WRS (P > .05). However, there was an improvement in the ABG (preoperative = 22.8 dB versus postoperative = 9.7 dB; P = .005). CONCLUSION Head trauma may be a potentiating event for SSCD syndrome. This study advances the hypothesis that these patients likely have underlying radiographic SSCD prior to their trauma, and a traumatic event increases in intra-vestibular or intracranial pressures, unmasking SSCD syndrome. LEVEL OF EVIDENCE 4 Laryngoscope, 131:E2810-E2818, 2021.

The goals of alveolar cleft repair include (1) stabilization of the maxilla, (2) permitting tooth eruption, (3) eliminating the oronasal fistula, (4) improving aesthetics, and (5) improving speech. Alveolar cleft repair should be considered one of the steps of a larger comprehensive orthodontic management plan. In conjunction with closure of the oronasal fistula, a variety of grafting materials can be used in the alveolar cleft. Autogenous grafts have been found to have greater efficacy compared with allogenic or xenogeneic bone, substitute bone, and alloplasts but with more donor site morbidity.

To summarize trends in otolaryngology fellowship applications, fellowships selected, and reasons for pursuing a fellowship.One-page anonymous questionnaire.A survey was completed by examinees at the conclusion of their American Board of Otolaryngology-Head and Neck Surgery oral examination from 2011 to 2019.Data included age, gender, fellowship type, reasons for doing a fellowship, and type of practice that examinees will enter. Spearman correlation and Pearson chi-square tests were completed.Over the 8-year study, 58% of the 2243 responding examinees did fellowships. The most frequently chosen fellowship was facial plastic surgery (25%), followed by pediatric otolaryngology (21%), head and neck surgery (19%), rhinology (13%), laryngology (9%), and neurotology (8%). The 2 most common reasons for doing a fellowship were desire for additional expertise beyond residency training (35%) and intellectual appeal (30%). Over the study period, the number of residents choosing to do a fellowship increased from 45.6% in 2011 to 61.5% in 2019, with a positive correlation between year and number of residents (There is a statistically significant increasing trend of otolaryngology residents who choose to undergo further training in fellowship. These data from a large, long-term study will be valuable in planning for training and workforce needs in the future.

OBJECTIVE Understand opioid-prescribing patterns in otologic surgery and the difference in opioid use between transcanal and postauricular surgery. STUDY DESIGN Prospective survey. SETTING Multihospital network. PATIENTS All patients undergoing otologic surgery from March 2017 to January 2019. INTERVENTION Patients undergoing otologic surgery were surveyed regarding postoperative opioid use and their level of pain control. Patients were divided by surgical approach (transcanal vs. postauricular). Those who underwent mastoid drilling were excluded. Narcotic amounts were converted to milligram morphine equivalents (MME) for analysis. MAIN OUTCOME MEASURES Amount of opioid was calculated and compared between the two groups. Mann-Whitney U test and Chi-square testing were used for analysis. RESULTS Fifty-five patients were included in the analysis; of these 18 (33%) had a postauricular incision. There was no difference in age (p = 0.85) or gender (p = 0.5) between the two groups. The mean amount of opioid prescribed (MME) in the postauricular and transcanal groups was 206.4 and 143 (p = 0.038) while the mean amount used was 37.7 and 37.5 (p = 0.29) respectively. There was no difference in percentage of opioid used (p = 0.44) or in patient-reported level of pain control (p = 0.49) between the two groups. CONCLUSION Patients in both the transcanal and postauricular groups used only a small portion of their prescribed opioid. There was no difference in the amount of opioid used or the patient's reported level of pain control based on the approach. Otologic surgeons should be aware of these factors to reduce narcotic diversion after ear surgery.

Objectives:(1) To determine how pregnancy affects idiopathic subglottic stenosis (iSGS) symptoms. (2) To determine treatments utilized (including operating room (OR) and in-office procedures) for iSGS before, during, and after pregnancy.Methods:A 24-question survey was distributed to an international iSGS support group to assess the patient experience among individuals who have been pregnant with diagnosis of iSGS. Descriptive statistics and chi2analyses were completed.Results:A total of 413 iSGS patients participated; 84.7% (n = 350) of patients were diagnosed prior to menopause. A total of 25.5% patients reported being pregnant when they had airway stenosis; 71.1% of those reported more severe airway symptoms during pregnancy. The proportion of patients that reported requiring ≥1 OR interventions (microlaryngoscopy and bronchoscopy, laser, balloon dilation, or steroid injection) before, during and after pregnancy was the following, respectively: 37.3%, 35.6%, 51.3%. Whereas the proportion of patients that reported requiring ≥1 in-office interventions (awake balloon dilation or steroid injection) before, during and after pregnancy was the following, respectively: 13.6%, 11.8%, 15.8%. Number of pregnancies and age of diagnosis was not related to severity of symptoms or requiring more airway interventions ( P > .05).Conclusions:This survey reveals worsening of symptoms during pregnancy, however, this did not lead to increase in operative or clinic interventions to improve airway symptoms during pregnancy. Future avenues for research include optimizing management of airway symptoms during pregnancy to limit OR-based interventions.Level of evidence:Level IV

Type one laryngeal cleft (T1LC) has been implicated as a major contributor to aspiration in non-syndromic pediatric dysphagia. Despite an increasing incidence, there remains controversy in diagnosis and treatment algorithms.The primary objective of this study was to evaluate the inter-rater reliability (IRR) for the diagnosis and treatment of T1LC.A retrospective analysis was conducted to identify children evaluated for a T1LC from 2016 to 2017 at a single tertiary care center. The microlaryngoscopy video recordings depicting palpation of the interarytenoid region with a right-angle probe were reviewed. These recordings were shown to blinded pediatric otolaryngologists and each surgeon's determination of the presence or absence of a T1LC as well as recommended treatment (observation, injection laryngoplasty, or endoscopic cleft repair) was recorded and compared against the other blinded surgeons. Fleiss's kappa was calculated to evaluate IRR in both diagnosis and treatment.Eight pediatric otolaryngologists were included in the study with a mean post-training experience of 15 years (range 1-35 years). The inter-rater percent agreement in diagnosis of our patient population was 28.6% (range 3.7-71%) with a kappa value of 0.31 (p 0.0001). In regard to management, the inter-rater percent agreement in treatment was 11.4% (range 0-35%) with a kappa value of 0.14 (p = 0.01).This study highlights the challenges and variation that exists among surgeons in diagnosing and managing potential T1LC. Further standardizing the endoscopic examination and treatment algorithm may reduce diagnostic and treatment discordance.

OBJECTIVES: Congenital human cytomegalovirus (cCMV) is a leading cause of pediatric hearing loss. Recent literature has suggested that valganciclovir (VGCV) therapy can improve hearing outcomes. The objective of this study was to evaluate the long-term hearing outcomes among symptomatic CMV patients treated with VGCV. METHODS: A retrospective chart review of symptomatic CMV patients treated with VGCV was completed. The primary endpoint was the change in best ear hearing scores prior to treatment and after follow-up audiograms. A paired-sample t-test was used to evaluate the data. RESULTS: A total of 16 children were included in the study and participants were followed for an average of 3.2 years. There was a measurable worsening, but not a statistically significant change in the best ear hearing scores, where the mean change was 11.9dB (p-value=0.070). However, 14/16 patients (87.5%, p-value

Introduction Surgical faculty and residents are responsible for the clinical education of medical students during their core surgical clerkship, sub-internships, and clinical electives. Much attention has been paid to faculty development in teaching, as well as residents-as-teachers programs, to enhance student learning in the surgical environment. This focus to “train the trainers” has not addressed what medical students can do to take ownership of and improve their own learning, as partners in educational interactions. The purpose of this exploratory study was to investigate how medical students’ attitudes and actions can enhance clinical teaching interactions during surgical rotations. Methods Previously collected data from a multiple case study that explored the learning environment at a single academic medical center was analyzed to understand the roles that students play in their learning. The data includes transcriptions from semi-structured interviews with four 4th year mediacl students, three general surgery residents, and four surgery attendings, and focus groups with two sets of 3rd year medical students. Two authors employed thematic analysis to code the data. Results Findings were organized into five themes: eagerness, humility, confidence, team player, and adaptability. Each attitudinal theme was associated with specific actions that students adopted to encourage teaching behaviors from resident and faculty surgeons during their surgery rotations. Participants discussed the importance of students “seek[ing] out opportunities” for learning (eagerness) and being “willing to be wrong” (humility). Student expressions of confidence in their knowledge and skills were marked by following “steps that I know,” which signaled to teachers that they could be entrusted to participate in patient care. Students categorized as team players “follow[ed] up on information without specifically being told.” Finally, students categorized as adaptable responded to “immediate feedback” by making “adjustments.” Conclusions Medical students are important stakeholders and contributors to teaching interactions and are likely to impact their own learning experience through the adoption of key attitudes and associated actions.

BACKGROUND Clear patient-physician communication is critical in improving patient compliance, outcomes, and satisfaction. However, constraints of shortened clinic visits, patient anxiety, and poor recall can cause significant barriers to effective communication. We hypothesized that the ability to view patient-physician counseling videos at home would improve health outcomes. METHODS Patients in a tertiary rhinology clinic were enrolled into a single-blinded prospective study after obtaining institutional review board (IRB) approval and informed consent. All enrollees had a short summary of their clinical encounter video-recorded with a tablet using Medical Memory, a Health Insurance Portability and Accountability Act (HIPAA)-compliant software system. Patients were randomized to receive access to their videos by our research coordinator, and outcomes included questionnaires at the first postoperative visit to assess patient recall and satisfaction. RESULTS A total of 101 patients were enrolled. Half of those with video access watched the video at least once, on average 3.44 times. Of those without access, 90% would have liked the option. Those with video access had a higher percentage of correct answers to questions regarding surgical risk and extent of surgery; however, there was no significant difference between the 2 groups. CONCLUSION Our results show that patients in both groups were enthusiastic about this technology and often shared their videos with family and friends. Video-recordings of physician-patient encounters may be a possible solution to improve physician-patient communication.

Objective The Accreditation Council for Graduate Medical Education (ACGME) requires competency-based education for residents and recommends 5 basic features of high-quality feedback. Our aim was to examine the incorporation of feedback in articles regarding professionalism and interpersonal/communication skills for otolaryngology residency training curriculum. Data Sources PubMed, Embase, ERIC, Cochrane Library, Web of Science, Scopus, and ClinicalTrials.gov . Methods We used studies identified during a systematic review of all indexed years through October 4, 2016. Results Eighteen studies were included in this review. Professionalism was discussed in 16, of which 15 (94%) examined aspects of feedback. Interpersonal/communication skills were the focus of 16 articles, of which 14 16 (88%) discussed aspects of feedback. Our assessment demonstrated that timeliness was addressed in 8 (44%) articles, specificity in 4 (22%), learner reaction and reflection in 4 (22%), action plans in 3 (20%), and balancing reinforcing/corrective feedback in 2 (13%). Two articles did not address feedback, and 6 did not address aspects of high-quality feedback. The ACGME-recommended feedback systems of ADAPT (ask, discuss, ask, plan together) and R2C2 (relationship, reactions, content, and coach) were not reported in any of the studies. Conclusion Feedback is an essential component of graduate medical education and is required by the ACGME milestones assessment system. However, the core feedback components recommended by the ACGME are rarely included in the otolaryngology resident education literature.

While women represent approximately half of all medical students, only 38% of general surgery residents are women. The objective of this study is to explore how access to mentors and organizational support affects career choices.In June of 2016, a survey was sent to medical students at a single institution (n = 472). Questions utilized a 5-point Likert scale. A two-sample t-test was used to evaluate data.A total of 160 students participated in the survey. Among MS1/MS2 students, women were more likely to rank same-sex role models as a positive influence (mean 3.1 vs. 2.4; p 0.05). Similar results were seen among MS3/MS4 students (mean 3.6 vs. 2.5; p 0.05). More women ranked the presence of organizations that support women in surgery as being important (mean 4.6 vs. 4.1; p 0.05).Exposure to same-sex mentors was highly rated among female participants. These findings encourage the creation of national mentorship programs. Early involvement in organizations can positively influence career choice. Addressing gaps in mentorship opportunities and widening accessibility to national organizations are important in reducing barriers.

BACKGROUND A realistic model for the instruction of basic dermatologic procedural skills was developed, while simultaneously increasing medical student exposure to the field of dermatology. OBJECTIVE The primary purpose of the authors' study was to evaluate the utilization of a fresh-tissue cadaver model (FTCM) as a method for the instruction of common dermatologic procedures. The authors' secondary aim was to assess students' perceived clinical skills and overall perception of the field of dermatology after the lab. METHODS Nineteen first- and second-year medical students were pre- and post-tested on their ability to perform punch and excisional biopsies on a fresh-tissue cadaver. Students were then surveyed on their experience. RESULTS Assessment of the cognitive knowledge gain and technical skills revealed a statistically significant improvement in all categories (p < .001). An analysis of the survey demonstrated that 78.9% were more interested in selecting dermatology as a career and 63.2% of participants were more likely to refer their future patients to a Mohs surgeon. CONCLUSION An FTCM is a viable method for the instruction and training of dermatologic procedures. In addition, the authors conclude that an FTCM provides realistic instruction for common dermatologic procedures and enhances medical students' early exposure and interest in the field of dermatology.

Objective: To evaluate the association of 2-stage cleft palate (CP) surgery on velopharyngeal insufficiency (VPI) incidence, speech surgeries, and cleft-related surgical burden. Design: Retrospective cohort with follow-up of 4 to 19 years. Setting: Academic, tertiary children’s hospital. Patients: Patients who underwent CP surgery between 2000 and 2017. Exclusions included submucous CP or age at last contact under 3.9. Interventions: Cleft palate surgery, completed in either a single-stage or 2-stage repair. Main Outcome Measure(s): Rates of VPI diagnosis and speech surgery and total cleft surgeries; t tests, tests of proportion, and linear and logistic regression were performed. Total cleft-related surgeries were examined in a subset (n = 418) of patients with chart reviews. Results: A total of 1047 patients were included; 59.6% had 2-stage CP repair, 40.4% had single-stage repair. Approximately 32% of children with 2-stage CP repair were diagnosed with VPI, as opposed to 22% of single-stage patients ( P < .001). Children with 2-stage CP repair were 1.8 times as likely to be diagnosed with VPI ( P < .001). Speech surgery rates were similar across groups. Patients who had 2-stage repair received an average of 2.3 more cleft-related procedures, when excluding prosthesis management procedures. Conclusion: Our data show an increased risk of VPI diagnosis and increased surgical burden among patients receiving 2-stage CP repair.

Importance Malignant head and neck paragangliomas (HNPGLs) are rare entities, and there are limited data regarding optimal treatment recommendations to improve clinical outcomes. Objective To classify succinate dehydrogenase ( SDH ) germline mutations associated with malignant HNPGLs, evaluate time from diagnosis to identification of malignant tumor, describe locations of metastases and the functional status of malignant HNPGLs, and determine the role of selective neck dissection at the time of initial surgical resection. Design, Setting, and Participants A retrospective cohort study was completed of patients diagnosed with paragangliomas on various sites on the body at an academic tertiary cancer hospital between the years 1963 and 2018. A subanalysis of HNPGLs was also completed. Data regarding diagnosis, gene and mutation, tumor characteristics and location, and treatments used were reviewed between February 2017 and March 2018. Main Outcomes and Measures Mutations of SDH genes associated with benign and malignant HNPGLs, treatments used, time to the discovery of malignancy, and location of metastasis. Results Of the 70 patients included in the study, 40 (57%) were male, and the mean (SD) age was 47 (21.1) years. Of patients with tumors isolated to the head and neck, 38 (54%) had benign HNPGLs, which were associated with mutations in the genes SDH subunit B ( SDHB ) (n = 18; 47%), SDH subunit C (n = 2; 5%), and SDH subunit D (n = 18; 47%). Among those with malignant HNPGLs, all but 1 patient had mutations in SDHB (n = 5; 83%); 1 patient had no mutation associated with their disease. The average age at diagnosis for malignant HNPGLs was 35 years, while benign tumors were diagnosed at an average age at 36 years. All patients with malignant disease underwent surgery. Four patients were found to have metastasis at the time of selective neck dissection. Among patients with malignant HNPGLs, 5 (83%) were treated with adjuvant radiation, and 1 (17%) was treated with adjuvant chemotherapy. Conclusions and Relevance Malignant HNPGLs are rare entities that are difficult to diagnose and are typically identified by the presence of regional or distant metastasis. The results of this study found the prevalence of malignant HNPGLs to be 9%. These data suggest that it is beneficial to perform a selective neck dissection at the time of tumor excision. All patients with malignant HNPGLs but 1 had SDHB mutations.

This case series aims to determine the optimal surgical approach for pediatric laryngeal saccular cysts. A retrospective chart review of patients who underwent surgical treatment for laryngeal saccular cysts was completed; 5 patients were diagnosed and surgically treated. Treatment approaches included aspiration, supraglottoplasty, injection of bleomycin, endoscopic subtotal resection (marsupialization with the laser or endoscopic instrumentation of the cyst), endoscopic extended subtotal excision (subtotal resection plus removal of false vocal fold with lasering or coblation of the inner cyst wall), and transcervical approaches for resection. Based on our outcomes, an endoscopic extended subtotal resection of the cyst will achieve the best outcomes for cysts confined to the larynx or for Type 1 cysts. A transcervical approach for resection of the cyst will achieve the best outcomes for Type 2 cysts that extend into the neck or are extralaryngeal.

Objective Antioxidants have been used as a therapeutic measure for several causes of hearing loss, and this study aims to examine the use of antioxidants in children with congenital cytomegalovirus (cCMV)–related hearing loss. Study Design Case-control study. Setting Academic pediatric hospital. Subjects and Methods A retrospective chart review of pediatric patients with cCMV-related hearing loss treated with and without antioxidants (vitamins A, C, and E and magnesium, known as ACE-Mg) was completed. The primary end point was the mean change in hearing thresholds for the right and left ears after therapy. An evaluation of the mean change in thresholds was evaluated at the following frequencies: 500 Hz, 1000 Hz, 2000 Hz, and 4000 Hz. A 2-sample t test and multiple linear regression were used to evaluate the data. Results A total of 78 children with cCMV-related hearing loss were included in the study, of whom 10 were treated with antioxidants. The average amount of time in which antioxidants were taken was 387 days. When comparing cases and controls, there was no differences in the mean change of hearing thresholds at each frequency for both the right and left ears ( P > .05). Length of antioxidant therapy and age at which therapy was initiated had no effect on hearing scores ( P > .05). Conclusions Oxidative stress plays a role in the pathogenesis of cCMV-related hearing loss. ACE-Mg is a safe adjuvant therapy for the treatment of hearing loss in children; however, this study demonstrates no hearing-related benefit from ACE-Mg antioxidant therapy.

To investigate postoperative hearing outcomes in older patients who qualified for cochlear implant (CI) by Medicare criteria using AZBio sentence tests performed in noise but not in quiet.Review of patient records.University-based otology/neurotology practice.The senior author performed 136 CI between January 2013 and September 2015. Starting in 2013, CI candidacy evaluation included AZBio sentence tests performed in quiet and noise. For the current study, older patients with preoperative AZBio scores greater than 40% in quiet but less than 40% in noise (+10 or +5 dB signal to noise ratio [SNR]) and follow up/=6 months were included.Cochlear implantation in one ear.Pre- versus postoperative AZBio sentence test scores.Fifteen patients with an average age of 73 years (range, 59-91) met inclusion criteria. Preoperative AZBio scores for the implanted ear averaged 47% points in quiet and 9% points in noise (+10 or +5 dB SNR). Preoperative bilateral AZBio scores averaged 70% points in quiet and 24% points in noise (+10 or +5 dB SNR). Postoperative AZBio scores for the implanted ear improved an average of 71% points in quiet and 51% points in noise. Postoperative bilateral hearing improved 23% points in quiet and 27% points in noise.All patients undergoing CI candidacy testing should be tested in both quiet and noise conditions. For those who qualify only in noise, our results demonstrate that cochlear implantation typically improves hearing both in quiet and noise.

Background The aim of our study was to determine if a fresh cadaver model is a viable method for teaching ultrasound (US)-guided breast biopsy of palpable breast lesions. Methods Third-year medical students were assessed both preinstruction and postinstruction on their ability to perform US-guided needle aspiration or biopsy of artificially created masses using a 10-item checklist. Results Forty-one third-year medical students completed the cadaver laboratory as part of the surgery clerkship. Eight items on the checklist were found to be significantly different between pre-testing and post-testing. The mean preinstruction score was 2.4, whereas the mean postinstruction score was 7.10 ( P Conclusions Fresh cadaver models have been widely used in medical education. However, there are few fresh cadaver models that provide instruction on procedures done in the outpatient setting. Our model was found to be an effective method for the instruction of US-guided breast biopsy among medical students.

Immunoglobulin G4-related sclerosing disease (IgG4-RSD) is a fibroinflammatory condition that has the potential to affect nearly every organ system. Classic histological findings include storiform fibrosis and lymphoplasmacytic infiltrates of immunoglobulin G4 (IgG4)-positive plasma cells. The clinical features of IgG4-RSD may be an under-recognized disease process that can mimic other autoimmune disorders, including Sjogren's syndrome. We describe a rare case of IgG4-RSD involving the salivary glands, initially misdiagnosed as Sjogren's syndrome. Clinical features of IgG4-RSD can mimic those of other autoimmune disorders affecting the head and neck. Therefore, otolaryngologists should have IgG4-RSD on their differential when evaluating patients with diffuse salivary gland swelling. Laryngoscope, 126:2242-2245, 2016.

Penetrating neck trauma (PNT), generally a result of a gunshot or stab wound to the neck, makes up 5–10% of traumatic injuries in adults. Key structures located in the neck, such as the carotid arteries, jugular veins, and aerodigestive tract, make this a high-risk injury. Patients with PNT require immediate transport to a trauma center due to the risk for airway compromise and/or significant vascular damage. It is important to note that impaling objects should not be removed in the field, due to potential for hemorrhage or further structural damage. Upon arrival to a trauma center, surgery should be consulted for all patients with PNT.

Importance Patients with head and neck squamous cell cancer (HNSCC) are often uninsured or underinsured at the time of their diagnosis. This access to care has been shown to influence treatment decisions and survival outcomes. Objective To examine the association of the Patient Protection and Affordable Care Act (ACA) health care legislation with rates of insurance coverage and access to care among patients with HNSCC. Design, Setting, and Participants Prospectively gathered data from the Surveillance, Epidemiology, and End Results (SEER) database were used to examine rates of insurance coverage and access to care among 89 038 patients with newly diagnosed HNSCC from January 2007 to December 2014. Rates of insurance were compared between states that elected to expand Medicaid coverage in 2014 and states that opted out of the expansion. Statistical analysis was performed from January 1, 2007, to December 31, 2014. Main Outcomes and Measures Rates of insurance coverage and disease-specific and overall survival. Results Among 89 038 patients newly diagnosed with HNSCC (29 384 women and 59 654 men; mean [SD] age, 59.8 [7.6] years), there was an increase after implementation of the ACA in the percentage of patients enrolled in Medicaid (16.2% after vs 14.8% before; difference, 1.4%; 95% CI, 1.1%-1.7%) and private insurance (80.7% after vs 78.9% before; difference, 1.8%; 95% CI, 1.2%-2.4%). In addition, there was a large decrease in the rate of uninsured patients after implementation of the ACA (3.0% after vs 6.2% before; difference, 3.2%; 95% CI, 2.9%-3.5%). This decrease in the rate of uninsured patients and the associated increases in Medicaid and private insurance coverage were only different in the states that adopted the Medicaid expansion in 2014. No survival data are available after implementation of the ACA, but prior to that point, from 2007 to 2013, uninsured patients had reduced 5-year overall survival (48.5% vs 62.5%; difference, 14.0%; 95% CI, 12.8%-15.2%) and 5-year disease-specific survival compared with insured patients (56.6% vs 72.2%; difference, 15.6%; 95% CI, 14.0%-17.2%). Conclusions and Relevance Access to health care for patients with HNSCC was improved after implementation of the ACA, with an increase in rates of both Medicaid and private insurance and a 2-fold decrease in the rate of uninsured patients. These outcomes were demonstrated only in states that adopted the Medicaid expansion in 2014. Uninsured patients had poorer survival outcomes.

Objectives Cigarette smoking and passive smoke exposure have been associated with chronic rhinosinusitis (CRS). Our goal in this systematic review was to (1) determine if there was a strong correlative effect in large population studies between cigarette smoke exposure and the prevalence of CRS, (2) investigate pathogenic mechanisms of cigarette smoke in the upper airway, and (3) determine if a history of cigarette smoking affects the medical and surgical outcomes of CRS. Data Sources MEDLINE, Embase, Cochrane CENTRAL, Web of Science SCI and CPCI-S, and websites. Methods A comprehensive literature review and quantitative meta-analysis of studies based on the PRISMA protocol and examining the relationship between cigarette smoke exposure and CRS was performed. A search strategy was developed using various terms such as sinusitis, rhinitis, rhinosinusitis, and smoking. The articles were categorized by (1) epidemiology, (2) pathophysiology, and (3) outcomes. Data regarding study design, population/setting, methods, and bias were collected. Results The initial search generated 2621 titles/abstracts with 309 articles undergoing secondary review and 112 articles for final review. We determined that there is a strong correlation between active and passive cigarette smoke with the prevalence of CRS. Cigarette smoke challenge to sinonasal epithelia results in the release of inflammatory mediators and altered ciliary beat frequency. Pediatric patients exposed to secondhand smoke appear to have particularly poor outcomes. Conclusion There is clear evidence that cigarette smoke is related to CRS, but longitudinal and mechanistic studies are required to determine a causative effect. This information is critical for greater understanding of CRS health outcomes.

Objective The aim of our study is to determine if a fresh cadaver model (FCM) for the instruction of ultrasound (US)-guided fine-needle aspiration (FNA) of thyroid nodules is a practical method for instruction. Study Design Pre- and postinstruction assessment of medical students' ability to perform US-guided FNA of artificially created thyroid nodules placed adjacent to the thyroid gland of a fresh cadaver. Setting University-based fresh cadaver laboratory. Subjects and Methods Study participants included a total of 17 first- and second-year medical students with minimal US training. Technical skills were assessed using a 10-item checklist. In addition, a cognitive assessment regarding the indications, contraindications, and complications of the procedure was completed. A postinstruction assessment was provided for participants 5 weeks after their initial assessment. Differences between pre- and postinstruction assessment scores of technical skills were analyzed using McNemar's test. The mean cognitive knowledge gain was analyzed using a paired 2-sample t test. Results Eight of 10 items on the skills checklist were statistically significant between pre- and postinstruction skills assessment ( P < .05). There was a statistically significant change in cognitive knowledge gain regarding the contraindications of the procedure ( P = .001), but not for indications or complications ( P = .104 and P = .111, respectively). Conclusion US-guided FNA continues to be an important diagnostic procedure in the workup of thyroid nodules, making it an essential skill to integrate into surgical skills lab. Our FCM for the instruction of US-guided FNA is the first of its kind, and this pilot study shows this is a viable method for instruction.

A retrospective, multi-center study of adults with and without chronic rhinosinusitis (CRS) identifies a significant association between rs6967330 in the viral receptor CDHR3 – known to be associated with wheezing and asthma in children – and the development of CRS.

Cutaneous neuroendocrine lesions of the external auditory canal (EAC) are exceptionally rare, with only five cases reported in the literature. In this case report, we present a patient with a recurrent carcinoid tumor in the EAC, which has yet to be described.A 38-year-old woman presenting with otalgia, aural fullness, and decreased hearing was found to have a recurrent EAC carcinoid tumor, 8-years after initial resection at an outside facility.The recurrent tumor involved much of the proximal, anterior bony ear canal and was trans-tympanic, extending to the middle ear and epitympanum; therefore, a lateral temporal bone resection was performed to ensure complete resection.Surgical pathology confirmed the presence a recurrent carcinoid tumor in the EAC, with immunohistochemistry positive for pancytokeratin (MAK6), CD56, and synaptophysin, with chromogranin showing rare cells positive for cytoplasmic granules. There was no evidence of metastasis.Lateral temporal bone resection was successful and the patient is being followed with annual imaging. The patient is considering future hearing rehabilitation with a bone anchored hearing device.This case report highlights the first known case of recurrent carcinoid tumor in the EAC, treated with lateral temporal bone resection. Clinical presentation, imaging, treatment, and pathology are reviewed along with a review of the literature.

Introduction Accountable care organizations (ACO) and alternative payment models are a sign of the change in reimbursement from fee-for-service to value-based reimbursement. The focus of health care under ACOs is represented by the Triple Aim: to improve the experience of health care, improve the health of populations, and reduce the per capita costs. Individuals with chronic rhinosinusitis (CRS) are heavy consumers of health care services. Results of recent studies have indicated that there is the potential for improved outcomes and cost savings from early surgical intervention. Adhering to the principles of the Triple Aim may signal a paradigm shift in regard to timing of intervention for CRS in certain patients. Methods A scoping review was performed to analyze the current literature related to management of CRS and the impact on cost, population health outcomes, and the patient's experience of health care. Results A growing body of literature indicates that, in appropriately selected patients, when compared with medical management, endoscopic sinus surgery has the potential to improve patient outcomes and reduce the long-term cost burden of CRS. Conclusion With the advent of ACOs, a paradigm shift in the treatment of CRS is inevitable to better conform to the goals of the Triple Aim. Future treatment algorithms will need to account for the heterogeneity within CRS and seek to identify appropriate timing and interventions for patients on an individual basis if the value of health care is to be improved.

Cystic fibrosis (CF) is an autosomal recessive genetic disorder caused by mutations in the CF transmembrane conductance regulator gene(CFTR) resulting in impaired ion transport. Nearly all people with CF will develop chronic rhino-sinusitis (CRS) and present with the characteristic viscous mucus, impaired mucociliary clearance and chronic inflammation/infection of the sinonasal cavity. While some individuals with CF can appear relatively asymptomatic in terms of their sinus disease, commonly reported symptoms include anosmia, headache, facial pain, nasal obstruction, chronic congestion and nasal discharge. Nasal endoscopy typically reveals mucosal edema, purulent discharge and nasal polyposis. Computed tomography (CT) imaging classically demonstrates the distinguishing findings of sinus hypoplasia or aplasia with generalized opacification, medial bulging of the lateral sinonasal sidewall and a demineralized uncinate process. Current treatment for CF sinusitis includes the use of hypertonic saline, topical and systemic steroids, antibiotics and endoscopic surgery. Research investigating novel therapies designed at targeting the primary defect of CF is showing promise for reversal of CF sinus disease, in addition to potential for disease prevention.

Objectives: The aim of this report is to describe a case of a retained projectile metal object to the neck that occurred after airbag deployment during a motor vehicle accident. Methods: Case report with literature review. Results: After a motor vehicle accident on the interstate, a 19-year-old man presents to the emergency department for several open extremity fractures, a neck laceration, and a C1 lateral mass fracture. The trauma surgery team repaired the neck laceration with no further evidence of injury. Several weeks later on follow-up, the patient presents with dysphagia and pain when turning his head to the right. A repeat computed tomography angiography (CTA) scan revealed a metallic foreign body in the left posterior pharyngeal, prevertebral soft tissues, which was subsequently removed during exploratory surgery 2 months after his initial accident. Conclusions: This is the first report, to our knowledge, of a projectile metal object to the neck that may be related to airbag deployment. The car involved in this accident was under recall for airbags that were associated with projectile objects, which warrants further investigation into the possible risks of such airbags.

Cystic fibrosis (CF) is an autosomal recessive genetic disorder caused by mutations in the CF transmembrane conductance regulator gene(CFTR) resulting in impaired ion transport. Nearly all people with CF will develop chronic rhino-sinusitis (CRS) and present with the characteristic viscous mucus, impaired mucociliary clearance and chronic inflammation/infection of the sinonasal cavity. While some individuals with CF can appear relatively asymptomatic in terms of their sinus disease, commonly reported symptoms include anosmia, headache, facial pain, nasal obstruction, chronic congestion and nasal discharge. Nasal endoscopy typically reveals mucosal edema, purulent discharge and nasal polyposis. Computed tomography (CT) imaging classically demonstrates the distinguishing findings of sinus hypoplasia or aplasia with generalized opacification, medial bulging of the lateral sinonasal sidewall and a demineralized uncinate process. Current treatment for CF sinusitis includes the use of hypertonic saline, topical and systemic steroids, antibiotics and endoscopic surgery. Research investigating novel therapies designed at targeting the primary defect of CF is showing promise for reversal of CF sinus disease, in addition to potential for disease prevention.