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Postoperative salivary fistula is an especially undesirable complication because it can be difficult to address, may delay postoperative radiation, and always delays enteral nutrition. Patients who are malnourished, have already undergone radiotherapy, or are hypothyroid are at higher risk of developing this problem. Conservative measures work in most patients, but a significant percentage of patients require intervention beyond pressure dressings and tincture of time. Medications, hyperbaric oxygen therapy, and surgical intervention may be required when fistulas do not heal in a timely manner. Decisions about the approach and timing of more aggressive interventions are part of the art of medicine since definitive scientific protocols are lacking.

To determine whether annual surgeon volume of lateral neck dissections for squamous cell carcinoma is associated with complication rates.Retrospective review.Two US databases spanning 2000 to 2014.Neck dissections for squamous cell carcinoma from the National Inpatient Sample and State Inpatient Databases were analyzed. The primary outcome was any in-hospital complication common to neck dissection. The principal independent variable was surgeon volume. A multivariable logistic generalized estimating equation with a piecewise linear spline for surgeon volume was fit to assess its association with complication.The National Inpatient Sample had 3517 discharges fitting criteria, a median surgeon volume of 12, and an 11.1% complication rate. A 1-unit increase in surgeon volume was associated with a 7% increase in the odds of complication when volume ranged between 4 and 19 (adjusted odds ratio [AOR], 1.07; 95% CI, 1.04-1.11) and with a 3% decrease in the odds of complication when volume ranged between 19 and 51 (AOR, 0.97; 95% CI, 0.96-0.99). The State Inpatient Databases had 2876 discharges fitting criteria, a median surgeon volume of 30, and a 13.5% complication rate. Surgeon volume was not associated with complication when27 (AOR, 1.01; 95% CI, 0.99-1.02), but a 5-unit increase in volume was associated with a 7% decrease in the odds of complication with volume ≥27 (AOR, 0.93; 95% CI, 0.88-0.98).Surgeon volume was associated with complications for most volume ranges and with lower odds of complication for high-volume surgeons.

The Accreditation Council for Graduate Medical Education and the American Board of Otolaryngology-Head and Neck Surgery Milestones Project grew out of a continued need to document objective outcomes within resident education. Milestones 2.0 began its work in 2016, with an intent to resolve inconsistencies in the original milestones based on an iterative process. Milestones 2.0 retains the original 5 levels of achievement but includes a "not yet assessable" option as well. In addition, Milestones 2.0 has added harmonized milestones across all specialties. Each specialty has incorporated a supplemental guide with examples and resources to improve facility with the tool. There will be further refinement of the Milestones as new research emerges with the ultimate goal of providing programs and trainees with a reliable roadmap that can be used to direct and assess learning.

This cohort study examines the association of the lymph node ratio with overall survival in patients with papillary thyroid cancer.

Objective To create a high-quality annotated online surgical video atlas of key indicator otolaryngology cases and assess its use and overall journal trends over time. Methods Videos are recorded from multiple viewpoints within the operating room and compiled into a single stream. Postediting includes chaptering videos and overlaying relevant text annotations. Videos are published online and viewership trends analyzed. Results Over 3 years, 29 otolaryngology videos were published out of 161 journal publications (18%). Eight of the 14 key indicator procedures are included (57%). From the beginning of 2017 to the end of 2019, viewership of otolaryngology pages increased from 548 to 11,139 views per month, totaling >150,000 views. These now represent 10% of the total journal monthly views and 10% of the overall views. Users originate from the United States and from >10 other countries. Discussion Residents and faculty face challenges of providing the highest standard of clinical care, teaching, and learning in and out of the operating room. Inherent difficulties of surgical training, high-fidelity surgical simulation, and imposed work hour restrictions necessitate additional, more efficient and effective means of teaching and learning. Surgical videos demonstrating key anatomy, procedural steps, and surgical dexterity with hand positioning are increasing in their popularity among learners. Implications for Practice Surgical video atlases provide a unique adjunct for resident education. They are enduring and easily accessible. In a climate of work hour restrictions or elective case reduction, they may supplement how residents learn to operate outside the operating theater.

BACKGROUND: The COVID-19 pandemic has significantly impacted medical training. Here we assess its effect on head and neck surgical education. METHODS: Surveys were sent to current accredited program directors and trainees to assess the impact of COVID-19 on the fellow's experience and employment search. Current fellows' operative logs were compared with those of the 2018 to 2019 graduates. RESULTS: Despite reduction in operative volume, 82% of current American Head and Neck Society fellows have reached the number of major surgical operations to support certification. When surveyed, 86% of program directors deemed their fellow ready to enter practice. The majority of fellows felt prepared to practice ablative (96%), and microvascular surgery (73%), and 57% have secured employment to follow graduation. Five (10%) had a pending job position put on hold due to the pandemic. CONCLUSIONS: Despite the impact of the COVID-19 pandemic, current accredited trainees remain well-positioned to obtain proficiency and enter the work-force.

Purpose To determine the complication profile for total thyroidectomy with and without concomitant lateral neck dissection using a large administrative database. Materials and methods The IBM MarketScan® Commercial Database (2010–2014) analytic cohort was queried for patients ≥18 years or older undergoing total thyroidectomy (or equivalent procedures) from January 1, 2010 to June 30, 2014. Subgroup analysis was performed for patients undergoing concomitant unilateral and bilateral lateral neck dissection. The complication profiles were described. Results 55,204 patients underwent total thyroidectomy or equivalent procedures. Hypoparathyroidism or hypocalcemia was coded in 20.3% overall, with 4.7% having permanent hypoparathyroidism. Vocal cord paralysis was coded in 3.3% overall with permanent rate of 0.7%. Tracheotomy was performed in 0.3% of patients. 2743 underwent total thyroidectomy with concomitant unilateral lateral neck dissection, and 560 of these patients underwent bilateral lateral neck dissection. In patients undergoing unilateral lateral neck dissection, 30.5% of patients have hypoparathyroidism/hypocalcemia coded, with a permanent rate of 8.8%. Vocal cord paralysis was coded in 8.3% of patients, with a permanent rate of 1.9%. Tracheotomy was performed in 1.2% of patients. In patients undergoing bilateral lateral neck dissection, 39.6% had hypoparathyroidism/hypocalcemia coded, with a permanent rate of 10.9%. These patients had vocal cord paralysis coded in 10.2% of cases, with a permanent rate of 2.1%. Tracheotomy was performed in 2.5% of patients. Conclusion The addition of unilateral and especially bilateral lateral neck dissection increases both overall and permanent complication rates for total thyroidectomy. These data may help to inform preoperative discussions with patients.

OBJECTIVE The purpose of this study was to assess the association between the Otolaryngology Training Examination (OTE) taken during residency and the passage rate of first-time examinees on the American Board of Otolaryngology-Head and Neck Surgery Written Qualifying Examination (WQE). METHODS Retrospective cohort study using a de-identified database containing information on examinees who took the WQE in 2007 through 2014, and examinees who took the OTE exam 2005 through 2014. A total of 2,214 otolaryngology residents took the WQE for the first time in 2007 through 2014 after taking the OTE during residency training. Data were analyzed using one-way frequencies and table analyses. Logistic regression was used to model the relationship between the pass/fail WQE result and the OTE stanine. Data transformations were used to analyze WQE passage as a function of OTE scores. RESULTS There is a significant relationship between OTE score and passage of the WQE on the first attempt, evident even for junior residents. The probability of passing the WQE on the first attempt is 97% if the resident scores in the top six stanines of the OTE during residency training compared to 71% to 79% if the examinee scores in the bottom three stanines. CONCLUSION There is a significant relationship between performance on the OTE and passing the WQE on the first attempt. Because this relationship is evident even in the first years of residency, it allows early identification of those with a higher chance of failing the WQE so that extra efforts can be undertaken to prepare for the WQE. LEVEL OF EVIDENCE 3 Laryngoscope, 129:124-128, 2019.

Background In February 2015, the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNSF) published the Allergic Rhinitis Clinical Practice Guideline (AR-CPG). The objective of this study was to assess otolaryngologists' perception of the accuracy and adherence to the AR-CPG. Methods A survey was distributed to fellows of the American Academy of Otolaryngic Allergy and members of the American Academy of Otolaryngology-Head and Neck Surgery Foundation. A total of 601 otolaryngologists responded. The survey evaluated otolaryngologists' demographic data, perception of the accuracy of the guideline, and adherence to the guideline action statements. Results The majority of respondents were actively practicing (544 [90.5%]), for a duration of 11-30 years (308 [51.2%]), in a private practice setting (387 [64.4%]). The cohort was largely fellowship trained (348 [57.9%]) and had reviewed the guideline (428 [71.2%]). Most respondents perceived the guideline as being correct "a great deal" (295 [69.7%]) and deviated from the guideline "only a little" (302 [71.6%]). High rates of adherence to the strong guideline recommendations were observed. Respondents "always/most of the time" recommended intranasal steroids (581 [97.6%]), and oral antihistamines (439 [74%]) as primary therapy. Otolaryngologists in practice for longer were more likely to deviate from the guideline recommendations by obtaining sinonasal imaging (p = 0.007) and recommending oral leukotriene receptor antagonists as primary therapy (p = 0.0001). Conclusion Overall perception of the correctness of and adherence to the AR-CPG was high in this cohort. Targeted education resources should be provided to otolaryngologists in practice for longer in efforts to reduce harmful or unnecessary variations in care.

Importance Pharyngocutaneous fistula (PCF) is a serious complication after total laryngectomy. Despite the well-described clinical risk factors for PCF and its association with poor quality of life, there is a paucity of data on the nonclinical factors that may be associated with this complication. Objective To determine whether nonclinical risk factors (eg, age, sex, race and ethnicity) are associated with an increased risk of developing a PCF after total laryngectomy, and whether or not the method of reconstruction explains any differences found. Design, setting, and participants This retrospective multicenter cohort study used data from a nationally validated, risk-adjusted, outcomes-based, surgical quality improvement database (the National Surgical Quality Improvement Program) to examine outcomes in patients who underwent a total laryngectomy from 2005 to 2018. The database was queried from January 1, 2005, to December 31, 2018; data analyses were performed from September 1, 2020, to March 31, 2021. Main outcomes and measures The primary outcome was development of a PCF within 30 days of a total laryngectomy. Patient characteristics, including age, sex, race and ethnicity, comorbidities, and mode of reconstruction, were analyzed. Results A cohort of 1573 adult patients (median age [IQR], 63 [56-71] years; 1280 [81.4%] men; 293 [18.6%] women; 1001 [63.6%] non-Hispanic White individuals) had undergone a total laryngectomy during the study period and were included in the analyses. The overall rate of PCF formation was 4.3% (68 of 1573 patients). Hispanic patients had the highest rate (9.5%; 9 of 95 patients) of PCF formation, which was more than twice the rate among non-Hispanic White patients (3.8%; 38 of 1001) and non-Hispanic Black patients (4.7%; 11 of 236). After adjusting for clinical and other covariates, women were 1.9 times more likely to develop a PCF compared with men (adjusted odds ratio, 1.90; 95% CI, 1.08-3.35). We also found that the odds of developing a PCF were 3-fold higher among Hispanic patients compared with non-Hispanic White patients (adjusted odds ratio, 2.96; 95% CI, 1.36-6.47). The type of reconstruction did not differ across age or race and ethnicity after controlling for clinical risk factors. Conclusions and relevance This multicenter cohort study found that 2 nonclinical risk factors-Hispanic ethnicity and female sex-were associated with an increased risk of PCF formation. Knowledge of these risk factors should be included in patient-physician decision-making as well as future interventions to decrease the rate of PCF formation after laryngectomy.

Successful simulation requires effective facilitation and debriefing to achieve educational goals. Simulation educational methods are diverse, ranging from partial task training to complicated, interdisciplinary team training. Various debriefing models have emerged based on method of instruction, learner experience, time and equipment capability, and physical facilities. The general structure of most debriefing sessions focuses on participant reactions, followed by analysis, and ending with a discussion of lessons learned. Two leading debriefing models, the Structured and Supported Debriefing Model and the Debriefing with Good Judgment Model, are described in further detail.

The management of frontal sinus fractures has evolved in the endoscopic era. The development of functional endoscopic sinus surgery (FESS) has been incorporated into management algorithms proposed by otolaryngologists, but the extent of its influence on plastic surgeons and oral and maxillofacial surgeons is heretofore unknown. A cross-sectional survey was performed to assess the practice pattern variations in frontal sinus fracture management across multiple surgical disciplines. A total of 298 surveys were reviewed. 33.5% were facial plastic surgeons with otolaryngology training, 25.8% general otolaryngologists, 25.5% plastic surgeons, and 15.1% oral and maxillofacial surgeons. 74.8% of respondents practiced in an academic setting. 61.7% felt endoscopic sinus surgery changed their management of frontal sinus fractures. 91.8% of respondents favored observation for uncomplicated, nondisplaced frontal sinus outflow tract fractures. 36.4% favored observation and 35.9% favored endoscopic sinus surgery for uncomplicated, displaced frontal sinus outflow tract fractures. For complicated, displaced frontal sinus outflow tract fractures, obliteration was more frequently favored by plastic surgeons and oral and maxillofacial surgeons than those with otolaryngology training. The utility of FESS in managing frontal sinus fractures appears to be recognized across multiple surgical disciplines.

Objective To ascertain what relationship exists between the United States Medical Licensing Examination (USMLE) and the American Board of Otolaryngology Written Qualifying Examination (WQE). Study Design Retrospective, longitudinal study. Setting De-identified database. Subjects Residents entering otolaryngology-head and neck surgery (OHNS) residency between 2007 and 2009 and taking the WQE for the first time between 2012 and 2014. Methods Regression models were used to determine if the USMLE score predicts passage of the WQE on the first attempt, which step score was a better predictor, and whether an increase in the Step 2 score increased the chances of WQE passage. Results There were 611 Step 1 and 402 Step 2 scores. Mean (SD) Step 1 score was 238 (14.4), and the mean (SD) Step 2 score was 243 (16.8). The overall WQE first-time passage rate was 95.3%. Step 1 score was a better predictor than Step 2 for successful passage of the WQE on the first attempt ( P = .0026). An increase in the Step 2 score compared with the Step 1 score did not predict an improved first-time passage rate on the WQE. Conclusions There is an association between USMLE scores and successful first-time passage of the WQE, with Step 1 being a stronger predictor than Step 2. Residents with USMLE scores lower than the average successful OHNS applicant still have a high chance of passing the WQE. USMLE scores alone are of limited usefulness in identifying those applicants at risk of failing the WQE on the first attempt.

To analyze variation in tonsillectomy procedure rates between health care system types around the world.International database analysis.The 2015 Organization for Economic Co-operation and Development (OECD) Health Statistics surgical procedures database was used to ascertain tonsillectomy procedure volumes for 31 countries. Each country's health system type and structure were classified by overall system type, and by health care regulation, financing, and provision methods. Each system type and structure variable were compared using the rate of tonsillectomy procedures per 100,000 citizens.10.5 million tonsillectomy procedures completed between 1993 and 2014 were analyzed. Overall, social health insurance system types had higher total tonsillectomy rates versus other health care system types (p 0.05 for each comparison). Health systems with private care provision had a higher procedure rate versus state provided care (159.1 vs. 131.1 per 100,000 citizens; p = 0.002). Health care systems with societal regulation and financing had a higher procedure count versus state regulated or financed care (regulation 193.3 vs. 139.7 per 100,000 citizens, p 0.0001; financing 168.2 vs. 135.0 per 100,000 citizens, p = 0.0004).The volume of tonsillectomy procedures is associated with a health care system's overall structure, regulation, financing, and provision methods. International health care systems with state mediated provision, regulation, and financing had lower tonsillectomy rates versus systems with private provision, and societal regulation or financing. Further study is needed to determine differences in indications for tonsillectomy between countries, but these results underscore potential variation in health care delivery in different systems.

Objectives To identify how applicants to otolaryngology residency determine how to apply to, interview with, and rank programs on the interview trail and to determine the extent of the financial burden of the otolaryngology interview trail. Study Design Web-based survey distributed in March and April 2016. Setting Otolaryngology residency applicants throughout the United States. Subjects and Methods Applicants to otolaryngology residency during the 2016 match cycle and current otolaryngology residents were surveyed. Results Median number of applications, interview offers, interviews attended, and programs ranked was not different during the 2016 match and the previous 5 match years. The most important factor affecting the number of applications was the need to apply widely to ensure sufficient interview offers. The most common reason for declining an interview offer was scheduling conflict. Applicants during the 2016 match spent a median of $5400 applying and interviewing for otolaryngology residency. Conclusions Median number of applications, interview offers, interviews attended, and programs ranked has not changed. The most cited reason for applying to many programs was to increase the chances of matching, but this is not statistically likely to increase match success. We advocate for continued attempts to make the otolaryngology match process more transparent for both applicants and resident selection committees, but recognize that applicants are likely to continue to overapply for otolaryngology residency positions.

The increasing number of senior physicians and calls for increased accountability of the medical profession by the public have led regulators and policymakers to consider implementing age-based competency screening. Some hospitals and health systems have initiated age-based screening, but there is no agreed upon assessment process. Licensing and certifying organizations generally do not require that senior physicians pass additional assessments of health, competency, or quality performance. Studies suggest that physician performance, on average, declines with increasing years in medical practice, but the effect of age on an individual physician's competence is highly variable. Many senior physicians practice effectively and should be allowed to remain in practice as long as quality and safety are not endangered. Stakeholders in the medical profession should consider the need to develop guidelines and methods for monitoring and/or screening to ensure that senior physicians provide safe and effective care for patients. Any screening process needs to achieve a balance between protecting patients from harm due to substandard practice, while at the same time ensuring fairness to physicians and avoiding unnecessary reductions in workforce.

Objective To determine whether instructional videos modeling examples of “good” and “bad” patient communication skills are useful as an educational tool for improving resident-patient communication. Design Retrospective study in which resident participants in the module gave survey responses indicating perceived utility of the exercise. Setting Tertiary academic medical center. Participants A total of 11 otolaryngology trainees from postgraduate year 1-5 who attended the course over 2 separate sessions and provided feedback on the benefits of the module. Results All 11 residents attended both sessions. Of 22 total survey responses, 21 found that the videos were “realistic and engaging” and were a true representation of commonly encountered clinical scenarios. Residents identified multiple themes and behaviors distinguishing “good” vs “bad” communication with patients and felt they could incorporate these into daily practice. A perceived weakness was the lack of opportunity for “role playing” with a video-based module as opposed to standardized patients. Conclusions Instructional videos, when realistic, are useful for modeling effective patient communication skills for residents. By watching the videos, residents are able to identify specific techniques they can incorporate into their daily practice.

In February 2015, the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNSF) published the Allergic Rhinitis Clinical Practice Guideline (AR-CPG). The objective of this study was to assess otolaryngologists' perception of the accuracy and adherence to the AR-CPG.A survey was distributed to fellows of the American Academy of Otolaryngic Allergy and members of the American Academy of Otolaryngology-Head and Neck Surgery Foundation. A total of 601 otolaryngologists responded. The survey evaluated otolaryngologists' demographic data, perception of the accuracy of the guideline, and adherence to the guideline action statements.The majority of respondents were actively practicing (544 [90.5%]), for a duration of 11-30 years (308 [51.2%]), in a private practice setting (387 [64.4%]). The cohort was largely fellowship trained (348 [57.9%]) and had reviewed the guideline (428 [71.2%]). Most respondents perceived the guideline as being correct "a great deal" (295 [69.7%]) and deviated from the guideline "only a little" (302 [71.6%]). High rates of adherence to the strong guideline recommendations were observed. Respondents "always/most of the time" recommended intranasal steroids (581 [97.6%]), and oral antihistamines (439 [74%]) as primary therapy. Otolaryngologists in practice for longer were more likely to deviate from the guideline recommendations by obtaining sinonasal imaging (p = 0.007) and recommending oral leukotriene receptor antagonists as primary therapy (p = 0.0001).Overall perception of the correctness of and adherence to the AR-CPG was high in this cohort. Targeted education resources should be provided to otolaryngologists in practice for longer in efforts to reduce harmful or unnecessary variations in care.

Acute macroglossia, while rare and often limited in duration, can present significant management challenges. The anatomic position of the tongue, which can result in airway compromise in cases of enlargement, contributes significantly to difficulty with management. We review several management options for persistent acute onset lingual macroglossia and present a novel noninvasive management technique in a case which was refractory to several strategies.

Little is known about what patients and physicians value in end-of-life care, or how these groups would craft a health plan for those with advanced cancer.The study objective was to assess how otolaryngology, head and neck surgery (OHNS) physicians would structure a Medicare benefit plan for patients with advanced cancer, and to compare this with cancer patient and cancer patient caregiver preferences.OHNS physicians used an online version of a validated tool for assessing preferences for health plans in the setting of limited resources. These data were compared to cancer patient and caregiver preferences.OHNS physicians nationwide were assessed with comparison to similar data obtained in a separate study of cancer patients and their caregivers treated at Duke University Medical Center.Otolaryngology physicians (n=767) completed the online assessment and this was compared with data from 146 patients and 114 caregivers. OHNS physician allocations differed significantly in 14 of the 15 benefit categories when compared with patients and caregivers. Physicians elected more coverage in the Advice, Emotional Care, Palliative Care, and Treatment for Cancer benefit categories. Patients and their caregivers elected more coverage in the Cash, Complementary Care, Cosmetic Care, Dental and Vision, Drug Coverage, Home Improvement, House Calls, Nursing Facility, Other Medical Care, and Primary Care benefit categories.Otolaryngology physicians have significantly different values in end-of-life care than cancer patients and their caregivers. This information is important for efficient allocation of scarce Medicare resources and for effective end-of-life discussions, both of which are key for developing appropriate health policy.

Purpose 1) Evaluate the effectiveness of a postoperative disposition protocol for upper airway surgery in patients with sleep apnea. 2) Compare the cost-effectiveness of outpatient and overnight observational sleep apnea surgery versus surgical intensive care admission determined by preoperative screening criteria. Materials and methods A new preoperative protocol for sleep apnea surgery was instituted at the Durham Veterans Affairs Medical Center in 2008 to triage patients undergoing sleep apnea surgery to one of three postoperative dispositions: intensive care, routine ward bed, or discharge home. An Institutional Review Board approved retrospective chart review of patients undergoing sleep apnea surgery between May 2008 and January 2012 was performed. Postoperative complications and cost comparisons were assessed between each of the three postoperative disposition groups. Results 115 patients underwent sleep apnea surgery between July 2008 and January 2012. 11 patients were excluded leaving 104 patients in the final analysis. Median follow-up was 1.25 months. Overall complication rate was 12.5%. Eight complications occurred in the group triaged to intensive care, and 5 occurred in those triaged to lesser levels of postoperative care. All serious complications occurred during the immediate postoperative period. Based on only room charges, $125,275 was saved over the 3.6 years of this study. Conclusion A post operative disposition protocol can be effectively used to triage patients to less than intensive postoperative care. In institutions like the Durham VA, where sleep apnea patients were routinely triaged to intensive care, postoperative resources will be more efficiently utilized.

As the U.S. population ages and life expectancy increases, the number of elderly patients seeking trauma care and treatment for facial fractures will increase. Understanding age-related differences in the pattern, cause, and management of these fractures is essential for improving care.A retrospective review of adults presenting to a Level I trauma center was performed to evaluate age-related differences in facial fractures. Descriptive statistics were used to compare fracture number, type, cause of injury, management, and adverse events between elderly (older than 64 years) and younger cohorts (aged 18 to 64 years). Logistic regression was used to evaluate the effect of age on fracture type while controlling for potential confounding variables.Two thousand twenty-three adult patients sustained a facial fracture from 2001 to 2011. Two hundred nine patients were elderly and 1814 were younger. Regarding cause of injury, older patients were more likely to fall and younger patients were more likely to be injured through assaults, motor vehicle collisions, or sports (p0.0001). Elderly patients sustained a higher incidence of maxillary (16.3 percent versus 11.4 percent; p = 0.0401), nasal (54.1 percent versus 45.3 percent; p = 0.0156), and orbital floor fractures (28.2 percent versus 18.1 percent; p = 0.004) and a lower incidence of mandible fractures (10.1 percent versus 21.3 percent; p = 0.0001). The elderly had significantly less operative intervention (24.9 percent versus 43 percent; p0.0001) and were less likely to experience complications (5.3 percent versus 10.5 percent; p = 0.0162).Elderly patients tend to suffer from less severe facial fractures, requiring less need for operative intervention, likely secondary to low-energy mechanisms of injury.Risk, II.

Background As multidisciplinary cancer treatment evolves, strategies to identify patients needing early resection/salvage are necessary. Some have suggested that vocal cord function after organ-preservation treatment may be an indicator. Methods A retrospective review was performed of patients presenting with fixed or impaired vocal cord function at a tertiary center. Local recurrence rates were examined in patients with and without improved/normal mobilization after treatment. Results Sixty-nine patients met the inclusion criteria, with 35 patients having vocal cord fixation and 34 patients with impaired mobility. After treatment, 44 patients had normalization of vocal cord function, while 25 patients did not, with 2-year local control rates of 70% and 77%, p = .23, respectively. No difference in local control was found between patients with normalized/improved cord function (n = 53) and those who remained the same/worsened (n = 16; p = .81). Conclusion Therapy-induced changes in vocal cord mobility did not correlate with local recurrence. Other criteria are needed to identify patients most likely to benefit from early surgical resection/salvage after organ preservation. © 2011 Wiley Periodicals, Inc. Head Neck, 2011

Investigate the use of optical reflectance spectroscopy to differentiate malignant and nonmalignant tissues in head and neck lesions and characterize corresponding oxygen tissue biomarkers that are associated with pathologic diagnosis.Cross-sectional study.Tertiary Veterans Administration Medical Center.All patients undergoing panendoscopy with biopsy for suspected head and neck cancer were eligible. Prior to taking tissue samples, the optical probe was placed at 3 locations to collect diffuse reflectance data. These locations were labeled "tumor," "immediately adjacent," and "distant normal tissue." Biopsies were taken of each of these respective sites. The diffuse reflectance spectra were analyzed, and biomarker-specific absorption data were extracted using an inverse Monte Carlo algorithm for malignant and nonmalignant tissues. Histopathological analysis was performed and used as the gold standard to analyze the optical biomarker data.Twenty-one patients with mucosal squamous cell carcinoma of the head and neck were identified and selected to participate in the study. Statistically significant differences in oxygen saturation (P = .001) and oxygenated hemoglobin (P = .019) were identified between malignant and nonmalignant tissues.This study established proof of principle that optical spectroscopy can be used in the head and neck areas to detect malignant tissue. Furthermore, tissue biomarkers were correlated with a diagnosis of malignancy.

To evaluate criteria used by residency applicants in ranking otolaryngology residency programs and to compare applicant criteria with program expectations of ranking otolaryngology residency programs.Cross-sectional survey.2009 and 2010 match cycles.Program applicants and otolaryngology program directors.Applicants were asked to rank the importance of 10 criteria in choosing a residency program (1 = criterion was of the utmost importance and 20 = not important at all). Program directors were asked to express expectations of how applicants should rank programs using those same criteria. The Mann-Whitney U test was used to analyze responses between groups.Comprehensiveness of subspecialties and resident satisfaction were the most important criteria for both groups; salary, call schedule, and likelihood to rank the resident highly were least valued. Four criteria were significantly different between groups. Applicants significantly valued location (4.36 vs 8.9, P.0001) and call schedule (9.85 vs 12.73, P = .002) more than program directors did. Program directors valued didactic schedule (6.1 vs 9.18, P.0001) and comprehensiveness of subspecialties (2.53 vs 3.02, P = .007) more than applicants did. Forty-one of 105 (39%) program directors completed the survey.While applicants and program directors agree on the most and least important criteria for ranking residency programs, there are several significant differences in these criteria. This study provides insight on ranking criteria that may improve the resident match process and subsequent training experience. However, the ability to generalize the results is limited by the low response rate.

The provision of trauma care is a financial burden, continually associated with low reimbursement, and shifts the economic burden to major trauma centers and providers. Meanwhile, the volume of craniomaxillofacial (CMF) trauma and the number of surgically managed facial fractures are unchanged. Past financial analyses of cost and reimbursement for facial trauma are limited to mandibular and midface injuries, consistently revealing low reimbursement. The incurred financial burden also coincides with the changing landscape of health insurance. The goal of this study is to determine the opportunity cost of operative management of facial trauma at our institution. From our CMF database of greater than 3,000 facial fractures, the physician charges, collections, and relative value units (RVUs) for CMF trauma per year from 2007 to 2013 were compared with a general plastic surgery and otolaryngology population undergoing operative management during this same period. Collection rates were analyzed to assess if a significant difference exists between reimbursement for CMF and non-CMF cases. Results revealed a significant difference between the professional collection rate for operative CMF trauma and that for other operative procedures (17.25 vs. 29.61%, respectively; p < 0.0001). The average number of RVUs billed per provider for CMF trauma declines significantly, from greater than 700 RVUs to 300 over the study period, despite a stable volume. Surgical management of CMF trauma generates an unfavorable financial environment. The large opportunity cost associated with offering this service is a potential threat to the sustainability of providing care for this population.

Importance The consultation patterns of an otolaryngology–head and neck surgery service have not previously been reported. The time, resources, and attention required to operate such a consultation service are unknown. Objective To assess trends in otolaryngology–head and neck surgery consultations conducted in emergency departments (EDs) and inpatient services. Design, Setting, and Participants A retrospective analysis was conducted of the medical records of patients at a quaternary care center receiving inpatient otolaryngology consultations from January 1 to December 31, 2014. Exposure Clinical evaluation and bedside and operative procedures performed by the otolaryngology–head and neck surgery service. Main Outcomes and Measures Demographics, reason for consultation, diagnosis, bedside procedures, operative interventions, and admission variables. Results A total of 1491 consultations were completed for adult (1091 [73.2%]; 854 men and 637 women; mean [SD] age 50.3 [19.3] years) and pediatric (400 [26.8%]; 232 boys and 168 girls; mean [SD] age, 4.0 [5.2] years) patients. Of the 1491 consultations, 766 (51.4%) originated from inpatient teams vs 725 (48.6%) from the ED. A total of 995 of all consultations (66.7%) resulted in a bedside procedure, and 243 (16.3%) required operative intervention. Consultations regarding airway evaluation (362 [47.3%] vs 143 [19.7%]), management of epistaxis (78 [10.2%] vs 33 [4.6%]), and rhinologic evaluation (79 [10.3%] vs 18 [2.5%]) were more frequent from inpatient teams than from the ED. Consultations regarding management of head and neck infections (162 [22.3%] vs 32 [4.2%]), facial trauma (235 [32.4%] vs 16 [2.1%]), and postoperative complications (73 [10.1%] vs 2 [0.3%]) were more frequent in the ED. Of the 725 consultations performed in the ED, 212 patients (29.2%) required hospitalization. Conclusions and Relevance The consultation volume of an otolaryngology–head and neck surgery service requires significant time and resources. Consultations are most often for rhinologic or laryngologic issues and are reflective of the clinical setting in which the patient is evaluated. Cost savings may be realized by increasing health care access points for nonurgent concerns that can be evaluated in an outpatient setting.

Summary Objectives We propose the use of morphological optical biomarkers for rapid detection of human head and neck squamous cell carcinoma (HNSCC) by leveraging the underlying tissue characteristics in aerodigestive tracts. Materials and Methods Diffuse reflectance spectra were obtained from malignant and contra-lateral normal tissues of 57 patients undergoing panendoscopy and biopsy. Oxygen saturation, total hemoglobin concentration, and the reduced scattering coefficient were extracted. Differences in malignant and normal tissues were examined based on two different groupings: anatomical site and morphological tissue type. Results and Conclusions Measurements were acquired from 252 sites, of which 51 were pathologically classified as SCC. Optical biomarkers exhibited statistical differences between malignant and normal samples. Contrast was enhanced when parsing tissues by morphological classification rather than anatomical subtype for unpaired comparisons. Corresponding linear discriminant models using multiple optical biomarkers showed improved predictive ability when accounting for morphological classification, particularly in node-positive lesions. The false-positive rate was retrospectively found to decrease by 34.2% in morphologically- vs. anatomically-derived predictive models. In glottic tissue, the surgeon exhibited a false-positive rate of 45.7% while the device showed a lower false-positive rate of 12.4%. Additionally, comparisons of optical parameters were made to further understand the physiology of tumor staging and potential causes of high surgeon false-positive rates. Optical spectroscopy is a user-friendly, non-invasive tool capable of providing quantitative information to discriminate malignant from normal head and neck tissues. Predictive models demonstrated promising results for real-time diagnostics. Furthermore, the strategy described appears to be well suited to reduce the clinical false-positive rate.

To assess otolaryngology physician knowledge of and attitudes toward the Patient Protection and Affordable Care Act (PPACA) and compare the association of bias toward the PPACA with knowledge of the provisions of the PPACA.Cross-sectional survey.Nationwide assessment.Members of the American Academy of Otolaryngology-Head and Neck Surgery.Otolaryngology physicians answered 10 true/false questions about major provisions of the PPACA. They also indicated their level of agreement with 9 statements about health care and the PPACA. Basic demographic information was collected.Email solicitation was sent to 9972 otolaryngologists and 647 responses were obtained (6.5% response rate). Overall correct response rate was 74%. Fewer than 60% of physicians correctly answered questions on whether small businesses receive tax credits for providing health insurance, the effect of the PPACA on Medicare benefits, and whether a government-run health insurance plan was created. Academic center practice setting, bias toward the PPACA, and Democratic Party affiliation were associated with significantly more correct responses.Overall physician knowledge of the PPACA is assessed as fair, although better than the general public in 2010. There are several areas where knowledge of physicians regarding the PPACA is poor, and this knowledge deficit is more pronounced within certain subgroups. These knowledge issues should be addressed by individual physicians and medical societies.

Hyperbaric oxygen (HBO) therapy induces native tissue oxygenation. The hypothesis was patients with mandibular osteoradionecrosis (ORN) and a history of HBO therapy would have less free flap reconstruction complications than patients without HBO therapy.We conducted a multisite retrospective review involving radical debridement and free flap reconstruction for ORN between January 1, 1995 and June 30, 2011. Patients were stratified based on receiving prior HBO therapy or not.Thirty-nine of 89 patients (43.8%) had HBO therapy whereas 50 of 89 (56.2%) did not. The HBO therapy group had significantly less patients with diabetes. There was no statistical difference in overall complication in patients between groups (p = .5478). However, there was marginal significance of increased infections in the patients with a history of HBO therapy (p = .0545).Although no significant differences in free flap reconstruction complication rates were observed between these 2 patient cohorts, there was marginal significance of increased infections in the patients with a history of HBO therapy. A prospective multi-institutional randomized study examining issues of infection would address issues inherent in this retrospective study.