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A paucity of literature exists about childbearing during otolaryngology residency. Pregnancy is a common part of many physician life cycles, but the timing of residency and the rigors of surgical training amplify the challenges. This study was designed to understand the experiences of childbearing otolaryngology residents and support them during this major life event. Unique challenges include long training, shortage of role models, combination surgical and clinical work, and higher rates of infertility.Qualitative research. IRB exempt.United States.To capture modern perspectives, 16 current and former otolaryngology residents that experienced pregnancy and childbirth during residency in all four geographic regions of the United States in the past 10 years were recruited to participate in individual structured qualitative interviews.Although there was significant training program and personal anxiety reported by childbearing otolaryngology residents, many surgeons experienced healthy pregnancies and postpartum recoveries with minimal disruption to clinical productivity and minimal disruption to their training programs. Multiple recurring themes were identified among the participants spanning the entire childbearing process: increased incidence of pregnancy complications and preterm labor, pregnancy stigma from leadership and coresidents, scheduling logistics regarding call and parental leave, and challenging transitions back to clinical work while navigating breastfeeding and childcare.There are actional recommendations that programs can address to make childbearing during residency accessible and acceptable. Understanding these challenges is an important step to encouraging childbearing residents to prosper in academic otolaryngology, increasing the diversity at the highest levels of the field.4.

To evaluate strategies to increase racial and ethnic diversity in the surgical workforce among trainees and faculty across surgical specialties.Embase, OVID/Medline, and Web of Science Core Collection.A review of US-based, peer-reviewed articles examining the effect of targeted strategies on racial and ethnic diversity in the surgical workforce was conducted from 2000 to 2020 with the PRISMA checklist and STROBE tool. Studies without an outlined strategy and associated outcomes were excluded. Eleven studies met inclusion criteria and were completed in general surgery, orthopaedic surgery, and otolaryngology-head and neck surgery.Efforts to increase exposure to surgery through internship programs and required clerkships with efforts to improve mentorship were common (6 of 11 [54.5%] and 3 of 11 [27.3%] studies, respectively). Three (27.3%) studies aimed to diversify the recruitment and selection process for the residency match and faculty hiring, and 2 (18.2%) aimed to increase representation among trainees, faculty, and leadership through holistic review processes paired with departmental commitment. Outcome metrics included surgical residency applications for individuals underrepresented in medicine, interview and match rates, faculty hiring, measures of a successful academic surgical career, and leadership representation. All strategies were successful in increasing diversity in the surgical workforce.A convincing yet limited body of literature exists to describe strategies and outcomes that address racial and ethnic diversity in the surgical workforce. While future inquiry is needed to move this field of interest forward, the evidence presented provides a framework for surgical residency programs/departments to develop approaches to increase racial and ethnic diversity.

Advances in endoscopic surgical technique have ushered in a new era of pituitary surgery with improved rates of resection and minimized operative morbidity and burden. Anatomically, endoscopic transnasal transsphenoidal pituitary surgery is split into nasal, sphenoidal, and sellar stages, each with unique considerations. Recent developments in knowledge and technology seek to build on the success of the endoscope in pituitary surgery, while expanding its capabilities.

This Viewpoint summarizes the research behind psychological mindsets and their possible applications to surgical training and introduces some practical recommendations to harness growth mindsets for optimizing the learning of otolaryngology residents.

Despite the significant morbidity associated with chronic rhinosinusitis in individuals with asthma (CRSwA) there is a paucity of codified, evidence-based management strategies for CRS in this population.Using PubMed, EMBASE, and Cochrane Review Databases, a systematic review was performed covering management strategies for CRSwA. 5,903 articles were screened; 70 were included for full-text analysis. After application of exclusion criteria, 53 articles comprised the qualitative synthesis. The level of evidence was graded, and benefit-harm assessments, as well as value judgment and recommendations were provided RESULTS: : Strong evidence confirms the benefit of oral and topical medications on sinonasal-specific outcomes in individuals with CRSwA; there is low-grade evidence demonstrating that these agents improve lung function and/or asthma control. Moderate-to-strong evidence suggests that endoscopic sinus surgery (ESS) improves both sinonasal- and asthma-specific quality of life. Although there is insufficient-to-low evidence to indicate that ESS improves pulmonary function in this population, data indicate a positive impact of this intervention on asthma control. Biologic medications strongly improve both subjective and objective sinonasal- and asthma-specific outcomes.Evidence supports managing CRS in individuals with CRSwA in a stepwise fashion, starting with traditional non-biologic oral and topical medication, and escalating to second-line treatments, such as ESS and biologics. Optimal treatment of individuals who suffer from CRSwA often requires concurrent, directed management of asthma, as not all CRS interventions impact asthma status. This article is protected by copyright. All rights reserved.

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

Objective We surveyed otolaryngology program directors (PDs) and recent otolaryngology residency graduates on the operative autonomy of graduating residents and their comfort with independent practice. Methods An anonymous survey was sent to otolaryngology PDs and recent graduates of training programs (members of the Young Physicians Section [YPS] of the American Academy of Otolaryngology‐Head and Neck Surgery Foundation). Questions were developed around the 14 key indicator procedures (KIPs) defined by the Accreditation Council for Graduate Medical Education. Results Fifty PDs (43% of PDs) and 152 recent graduates (6% of YPS members) responded. Over 90% of participating PDs felt their graduating residents were either somewhat or extremely comfortable performing 12 out of 14 KIPs. Among the 12 procedures PDs felt their graduating residents were comfortable performing, 57% to 95% of recent graduates also felt either somewhat or extremely comfortable performing them by graduation. Similarly, at least 90% of responding PDs felt their residents achieved meaningful autonomy in the last 2 months of residency prior to graduation for 11 of 14 KIPs. For these same 11 procedures, 74% to 95% of recent graduates indicated they achieved meaningful autonomy. The procedures that PDs and recent graduates felt required the most surgical assistance were ossiculoplasty/stapedectomy, rhinoplasty, and mastoidectomy. All PDs agreed or strongly agreed that graduating residents are comfortable operating and taking call as general otolaryngologists, compared to 86% and 93% of recent graduates. Conclusion Most PDs and recent graduates agree that residents are well‐prepared for general otolaryngology practice with the exception of select KIPs. Level of evidence: 4.

Background Gender disparities are prevalent in medicine, but their impact on surgical training is not well studied. Objective To quantify gender disparities in trainee intraoperative experiences and explore the variables associated with ratings of surgical autonomy and performance. Methods From September 2015 to May 2019, attending surgeons and trainees from 71 programs assessed trainee autonomy on a 4-level Zwisch scale and performance on a 5-level modified Dreyfus scale after surgical procedures. Multivariable regression models were used to examine the association of trainee gender with autonomy and performance evaluations. Results A total of 3255 trainees and attending surgeons completed 94 619 evaluations. Attendings gave lower ratings of operative autonomy to female trainees than male trainees when controlling for training level, attending, and surgical procedure (effect size B = −0.0199, P = .008). There was no difference in ratings of autonomy at the beginning of training (P = .32); the gap emerged as trainees advanced in years (B = −0.0163, P = .020). The gender difference in autonomy was largest for the most complex cases (B = −0.0502, P = .002). However, there was no difference in attending ratings of surgical performance for female trainees compared to male trainees (B = −0.0124, P = .066). Female trainees rated themselves as having less autonomy and worse performance than males when controlling for training level, attending, procedure, case complexity, and attending ratings (autonomy B = −0.0669, P < .001; performance B = −0.0704, P < .001). Conclusions While there was no significant difference in ratings of operative performance, a small difference between ratings of operative autonomy for female and male surgical trainees was identified.

Telemedicine utilization among otolaryngologists was rare prior to the COVID-19 pandemic. We sought to understand rates of telemedicine utilization by otolaryngologists amid unprecedented changes in care delivery during the pandemic. Using Medicare Physician/Supplier Procedure Summary data, we performed a retrospective cross-sectional analysis of telemedicine services provided to Medicare beneficiaries by otolaryngologists in 2020. The total number of services and amount of reimbursement received by otolaryngologists for telemedical care increased by 52,989% and 73,147% in 2020 relative to 2019: 139,094 vs 262 services and $9.9 million vs $13,536, respectively. The mean telemedicine revenue per otolaryngologist offset only 8.8% ($9304.69) of losses from the reduction in mean in-person revenue between 2019 and 2020. Further research will be necessary to inform successful adoption of telemedicine within our field amid the ongoing COVID-19 pandemic.

To determine how augmented reality (AR) has been applied to the field of otology/neurotology, examine trends and gaps in research, and provide an assessment of the future potential of this technology within surgical practice and education.PubMed, EMBASE, and Cochrane Library were assessed from their inceptions through November 2021. A manual bibliography search was also conducted.A scoping review was conducted and reported according to PRISMA-ScR guidelines. Data from studies describing the application of AR to the field of otology/neurotology were evaluated, according to a priori inclusion/exclusion criteria. Exclusion criteria included non-English language articles, abstracts, letters/commentaries, conference papers, and review articles.Eighteen articles covering a diverse range of AR platforms were included. Publication dates spanned from 2007 to 2022 and the rate of publication increased over this time. Six of 18 studies were case series in human patients although the remaining were proof of concepts in cadaveric/artificial/animal models. The most common application of AR was for surgical navigation (14 of 18 studies). Computed tomography was the most common source of input data. Few studies noted potential applications to surgical training.Interest in the application of AR to otology/neurotology is growing based on the number of recent publications that use a broad range of hardware, software, and AR platforms. Large gaps in research such as the need for submillimeter registration error must be addressed prior to adoption in the operating room and for educational purposes.N/A Laryngoscope, 2022.

Otolaryngology residency applicants face challenges finding accurate information about training programs. Social media platforms are not verified, and official training program websites are not standardized. Currently, the American Medical Association's Fellowship and Residency Electronic Interactive Database (FREIDA) is the most comprehensive sanctioned and verified otolaryngology residency program database. However, the exact amount of information shared by individual programs included is not presently known.Herein, we analyzed the available data on all 124 otolaryngology residency programs in FREIDA to assess the completeness of the database.While every program listed an address, contact email, and the name of the program director, more than half of programs (Our findings suggest that while FREIDA is the only sanctioned online database for residency programs, it is inadequately populated with detailed program information.N/A.

OBJECTIVES Socioeconomic factors affect oncologic outcome in sinonasal squamous cell carcinoma (SNSCC). However, the relationship between these factors and stage at presentation (SAP)-a critical, early point in the care cycle-is not known. This study sought to determine the role of race/ethnicity, treatment facility type, insurance status/carrier, and other socioeconomic factors in SAP and survival among patients with advanced SNSCC. STUDY DESIGN Retrospective cohort study. METHODS Using the National Cancer Database, 6,155 patients with SNSCC were identified and divided into those with "early" (Stage I or II; 2,212 (35.9%)) versus "advanced" (Stage III or IV; 3,943 (64.1%)) disease. Associations between sociodemographic and socioeconomic factors on SAP and survival were analyzed using multivariable logistic regression and Cox proportional hazard models. RESULTS Black (odds ratio [OR]: 2.18, CI: 1.74-2.76), Asian and Pacific Islander (API) (OR: 2.37, CI: 1.43-4.14), and Medicaid or uninsured (OR: 2.04, CI: 1.66-2.53) patients were more likely to present with advanced disease. Among patients with advanced disease, API patients demonstrated the highest 10-year survival rate (30.2%), and Black patients had the lowest 2-, 5-, and 10-year survival rates (47.7%, 31.9% and 19.2%, respectively). Older age (HR:1.03, CI:1.03-1.04), Black race (HR:1.39, CI:1.21-1.59), Medicaid or uninsured status (HR:1.48, CI:1.27-1.71), and treatment at a community hospital (HR:1.25, CI:1.14-1.37) were associated with poorer overall survival among patients with advanced disease. CONCLUSIONS Factors including race/ethnicity, treatment facility type, insurance status/carrier, and other socioeconomic factors influence SAP and survival in SNSCC. An improved understanding of how these factors relate to outcomes may elucidate opportunities to address gaps in education and access to care in vulnerable populations. LEVEL OF EVIDENCE 4 Laryngoscope, 131:2421-2428, 2021.

The field of otolaryngology-head and neck surgery is rapidly changing, and surgical education must keep pace. In the face of recent advances in medical knowledge, surgical technique, and novel technology, educators may find it increasingly difficult to identify the evolving educational needs of otolaryngology residents. To better align training activities with modern practice patterns, we propose conducting a longitudinal needs assessment by designing a standardized specialty-specific survey for practicing otolaryngologists. This recurring survey could be implemented alongside accreditation or other continuing medical education activities. The outcomes would report what contemporary otolaryngologists see and do in everyday practice to guide educational reforms to better prepare trainees for future practice.

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

The degree of markup between provider charges and Medicare prices reflects the potential balance bill for out-of-network commercially insured patients. Using publicly available Medicare data, we performed a retrospective cross-sectional analysis of markup ratios (MRs; ie, the ratio of submitted charges to Medicare-allowed prices) for services commonly performed by otolaryngologists in 2017. Median MRs were as follows: 2.9 (interquartile range, 2.0-4.3) in facility settings (eg, hospital) and 2.1 (interquartile range, 1.7-2.9) in nonfacility settings (eg, physician office). Among the 10 highest-markup procedures performed by otolaryngologists in facility and nonfacility settings, there was no consistent increase in median MRs between 2012 and 2017 (compound annual growth rates, -4.6% for labyrinthotomy to 24.6% for ultrasound-guided biopsy). Median MRs for these procedures were not consistently lower in states with surprise billing protection laws. These findings may reflect the comparatively low potential to "balance bill" patients for elective otolaryngologic services and the limitations of state-level protections against surprise billing.

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

OBJECTIVE Anchor-based methods to calculate the minimal clinically important difference (MCID) of a patient-reported outcome measure (PROM) may suffer from recall bias. This has never been investigated for otolaryngic PROMs. We sought to identify evidence of recall bias in calculation of MCIDs of PROMs for patients with chronic rhinosinusitis (CRS). DESIGN Retrospective analysis of data from two previous studies calculating the MCID of the 22-item Sinonasal Outcome Test (SNOT-22) and 5-dimensonal EuroQol questionnaire (EQ-5D) in CRS patients. SETTING Tertiary rhinology clinic. PARTICIPANTS Adults with CRS. MAIN OUTCOME MEASURES SNOT-22 score, and EQ-5D visual analog scale scores (EQ-5D VAS) and health utility values (EQ-5D HUV) before and after medical treatment for CRS. After treatment, participants were asked to rate the change in sinonasal symptoms and general health (the anchor question) as "Much worse," "A little worse," "About the same," "A little better" or "Much better." Participants' responses to the anchor question were checked for association with post-treatment and pre-treatment scores using ordinal regression. RESULTS On univariate association, post-treatment SNOT-22 and EQ-5D scores were associated with respective participants' anchor question responses (P

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

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

Objective Repair of cerebrospinal fluid (CSF) leaks of the lateral recess of the sphenoid (LRS) sinus can be challenging to accomplish via an endoscopic transphenoidal approach. The endoscopic transpterygoid approach can improve surgical access to the lateral recess but requires more extensive surgical dissection. We review our experience with LRS CSF leak repair via both techniques to determine whether preoperative radiologic data can help predict the most appropriate surgical approach. Methods Electronic medical records of patients with LRS CSF leaks were retrospectively reviewed at a single tertiary referral center. Radiographic measurements from preoperative computed tomography images were reviewed. Results Twenty‐two LRS CSF leaks were identified. The transphenoidal and transpterygoid approach were used in 6 (27.3%) and 16 (72.7%) cases, respectively. The mean vidian canal to foramen rotundum angle of the repairs accessed transphenoidally as compared to the transptyergoid approach were not significantly different (41.93° ±10.91, 40.72° ±19.49, respectively; P = .63). However, the mean volume of the LRS accessed by the transpterygoid approach was significantly greater compared to those accessed through the transphenoidal approach (0.97 cm3 ± 0.48, 0.39 cm3 ± 0.40, respectively; P = .04). A LRS volume of 0.400 cm3 or greater predicted the use of the transpterygoid approach with 93.3% sensitivity and 60.0% specificity. Conclusion This study demonstrated that LRS CSF leaks that necessitated repair by the transpterygoid approach, rather than transphenoidal approach, were in the context of significantly larger lateral recess. Assessment of the LRS volume is a quantifiable parameter to aid in preoperative surgical planning. Level of Evidence Level 4., The endoscopic endonasal surgical approach is the gold standard in these repairs, however, the LRS sinus is particularly challenging due to anatomical constraints. Another method, known as the endoscopic endonasal transpterygoid (ETTP) approach has been used, but requires a more invasive process. Depending on the location of the CSF leak, maneuverability limitations and risks are important to consider. Our goal is to define a quantifiable parameter that will be useful in preoperative surgical planning to determine the safest, most effective approach on a case‐by‐case basis.

Objective In the era of SARS-CoV-2, the risk of infectious airborne aerosol generation during otolaryngologic procedures has been an area of increasing concern. The objective of this investigation was to quantify airborne aerosol production under clinical and surgical conditions and examine efficacy of mask mitigation strategies. Study Design Prospective quantification of airborne aerosol generation during surgical and clinical simulation. Setting Cadaver laboratory and clinical examination room. Subjects and Methods Airborne aerosol quantification with an optical particle sizer was performed in real time during cadaveric simulated endoscopic surgical conditions, including hand instrumentation, microdebrider use, high-speed drilling, and cautery. Aerosol sampling was additionally performed in simulated clinical and diagnostic settings. All clinical and surgical procedures were evaluated for propensity for significant airborne aerosol generation. Results Hand instrumentation and microdebridement did not produce detectable airborne aerosols in the range of 1 to 10 μm. Suction drilling at 12,000 rpm, high-speed drilling (4-mm diamond or cutting burs) at 70,000 rpm, and transnasal cautery generated significant airborne aerosols (P < .001). In clinical simulations, nasal endoscopy (P < .05), speech (P < .01), and sneezing (P < .01) generated 1- to 10-μm airborne aerosols. Significant aerosol escape was seen even with utilization of a standard surgical mask (P < .05). Intact and VENT-modified (valved endoscopy of the nose and throat) N95 respirator use prevented significant airborne aerosol spread. Conclusion Transnasal drill and cautery use is associated with significant airborne particulate matter production in the range of 1 to 10 μm under surgical conditions. During simulated clinical activity, airborne aerosol generation was seen during nasal endoscopy, speech, and sneezing. Intact or VENT-modified N95 respirators mitigated airborne aerosol transmission, while standard surgical masks did not.

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

ObjectiveWe sought to determine if chronic rhinosinusitis (CRS) patients with nasal polyps (CRSwNP) differentially perceived CRS symptom burden compared to patients without nasal polyps (CRSsNP) and to what extent CRS symptom severity was associated with quality of life (QOL) and patient-reported symptom control in the 2 groups.MethodsA total of 600 patients (266 CRSwNP and 334 CRSsNP) presenting with CRS were recruited. CRS symptom burden was assessed with the 22-item Sinonasal Outcome Test (SNOT-22). SNOT-22 nasal, sleep, ear/facial discomfort, and emotional subdomain scores were calculated. General health-related QOL was assessed with the visual analog scale of the 5-dimensional EuroQol questionnaire (EQ-5D VAS). Patients rated their CRS symptom control on a 5-point scale.ResultsSNOT-22 scores did not differ between CRSwNP (mean: 35.6) and CRSsNP (mean: 36.3). There were no differences in nasal, sleep, and emotional subdomains of the SNOT-22. CRSsNP had higher ( P = .003) ear/facial subdomain scores than CRSwNP, while CRSwNP reported greater hyposmia ( P ConclusionCRSwNP and CRSsNP have differences in symptom profile, effect on health-related QOL, and patient-perceived symptom control. CRSsNP experience significantly greater burden of ear/facial discomfort, while CRSwNP report greater hyposmia. Although CRSsNP reports lower general health-related QOL overall, CRSwNP patients had lower levels of CRS symptom control for every incremental increase in symptom burden suggesting greater sensitivity/intolerance to CRS symptoms.

Objectives Aspirin-exacerbated respiratory disease (AERD) is a chronic respiratory condition characterized by a triad of symptoms: asthma, chronic rhinosinusitis with nasal polyposis, and a respiratory reaction to aspirin and other cyclooxygenase-1 inhibitors, also known as nonsteroidal anti-inflammatory drugs. The objective of this review is to provide otolaryngologists with an overview of the pathophysiology, diagnosis, and treatment of this under-recognized condition. Data sources and methods Foundational papers on AERD were reviewed, focusing on the clinical otolaryngology and allergy/immunology literature and other high impact journals or trials. Results AERD results from increased production of pro-inflammatory leukotrienes and a decrease in production of anti-inflammatory prostaglandins associated with the dysregulation of multiple enzymes influencing eicosanoid metabolism. Diagnosis hinges on a high index of suspicion, careful history, and confirmatory testing for all three elements. Treatments include endoscopic sinus surgery; topical, inhaled, or oral corticosteroids; aspirin desensitization; leukotriene modifying drugs; and the new class of biologics such as dupilumab. Conclusion AERD is an under-recognized disease associated with substantial patient-reported morbidity. We expect rapid progress in the pathophysiological understanding of this disease and available treatments in the coming decades. Level of evidence 5.

Surgical care is increasingly shifting to freestanding ambulatory surgical centers (ASCs). The extent to which otolaryngologists use ASCs has implications for patient safety and health care spending. This study characterizes trends in utilization and resultant financial implications for common otolaryngologic procedures performed at ASC and hospital outpatient departments (HOPDs).Retrospective cross-sectional analysis.ASCs, HOPDs.Subjects included Medicare beneficiaries undergoing outpatient otolaryngologic procedures between 2010 and 2017. Procedures included the 20 highest-volume procedures performed by otolaryngologists at ASCs in 2017. Main outcomes included absolute and relative percentage difference in the proportion of procedures furnished at ASCs and HOPDs and estimated Medicare cost savings resulting from increased ASC utilization between 2011 and 2017.The proportion of outpatient otolaryngologic procedures performed at ASCs increased by 1.8% (relative difference: 10.0%; mean annual relative increase: 1.60%), and the proportion located at HOPDs decreased by 6.0% (relative difference: -11.8%; mean annual relative decrease: -1.6%) between 2010 and 2017. Rhinoplasty accounted for the largest absolute increase in ASC utilization over the study period (absolute [relative] 8.9% [33.5%]). Increased ASC utilization resulted in an estimated $7.1 million in cost savings to Medicare between 2011 and 2017.Otolaryngologists shifted outpatient surgical care from HOPDs to ASCs between 2010 and 2017, with resultant reductions in Medicare expenditures. Further research is necessary to examine the impact of this shift on patient safety.

Objective Intranasal saline irrigations and intranasal corticosteroids are supported by level-1 evidence for medical management of chronic rhinosinusitis (CRS). We sought to study adherence with these medications. Methods Prospective study of 174 patients with CRS. Patients reported their usage of intranasal saline irrigation and intranasal corticosteroid over the preceding 3 months, at presentation, and a subsequent follow-up visit 3 to 12 months later. Adherence was defined as reported medication usage for ≥6 days per week. Results At the time of presentation, 44.3% of patients were using an intranasal corticosteroid spray or irrigation ≥6 days/week, whereas only 24.1% were using saline irrigation ≥6 days per week. At follow-up, 60.3% of patients were using either an intranasal corticosteroid spray or irrigation ≥6 days per week, whereas 35.6% were using saline irrigation ≥6 days per week. Adherence with intranasal corticosteroids was associated with comorbid asthma (adjusted odds ratio [OR] = 2.68, 95% confidence interval [CI]: 1.10-6.50, P = 0.029), allergy (OR = 2.22, 95% CI: 1.05-4.71, P = 0.037), and change in 22-item Sinonasal Outcome Test score (OR = 0.98, 95% CI: 0.96-0.99, P = 0.027). Use of intranasal corticosteroid sprays versus irrigations (OR = 2.56, 95% CI: 0.84-7.83, P = 0.099) was suggestive of association with improved adherence. Adherence with intranasal saline irrigation was associated with age (OR = 1.02, 95% CI: 1.01-1.05, P = 0.034). Conclusion Usage and adherence with intranasal steroids and saline may be low in CRS patients even with management in a tertiary level, subspecialty rhinology clinic. Adherence with medications represents a major opportunity for improving patient care and outcomes, specifically by targeting patients with lower disease burden and improving convenience of medications. Level of evidence 2C Laryngoscope, 130:852-856, 2020.

The extent to which medical management of chronic rhinosinusitis (CRS) may improve health utility value (HUV) remains unknown. We conducted a prospective pilot study to longitudinally assess HUV via the EQ-5D-5L questionnaire in patients with CRS who were receiving medical therapy but did not undergo sinus surgery. The primary study outcome was HUV at 12-month follow-up; secondary end points included HUV at baseline and 3- and 24-month follow-up. Our study enrolled 115 patients who received the following medical treatments: saline irrigations (n = 83, 72.2%), steroid sprays (n = 93, 80.9%), antihistamines (n = 64, 55.7%), steroid irrigations (n = 29, 25.2%), and oral antibiotics (n = 58, 50.4%). There was a statistically significant improvement (mean, +0.073

Surgical education is changing in an era of new regulations and evolving training cultures. We sought to understand the factors that affect operative experiences during otolaryngology residency.From December 2019 to December 2020, five otolaryngology training programs used the SIMPL OR smartphone application to evaluate residents after each operation. Residents and attendings rated the trainee's autonomy on a 4-level Zwisch scale, performance on a 5-level scale, and case complexity on a 3-level scale. We examined associations between ratings of autonomy and performance with variables including postgraduate year (PGY), case complexity, gender, week of the academic year (AY), and whether multiple procedures were logged.78 attendings and 92 residents logged 2984 evaluations. PGY level and week of the AY were positively associated with attending ratings of autonomy and performance (PGY3 vs. PGY2:Resident autonomy and performance were positively associated with PGY level and week of the academic year, and negatively associated with case complexity and multiple procedures. These findings highlight the need to align training level with case complexity to promote quality operative experiences.2.

Graduate medical education (GME) is funded by the Centers for Medicare and Medicaid Services through both direct and indirect payments. In recent years, stakeholders have raised concerns about the growth of spending on GME and distribution of payment among hospitals. Key stakeholders have proposed reforms to reduce GME funding such as adjustments to statutory payment formulas and absolute caps on annual payments per resident. Otolaryngology departmental leadership should understand the potential effects of proposed reforms, which could have significant implications for the short-term financial performance and the long-term specialty workforce. Although some hospitals and departments may elect to reduce resident salaries or eliminate positions in the face of GME funding cuts, this approach overlooks the substantial Medicare revenue contributed by resident care and high cost of alternative labor sources. Commitment to resident training is necessary to align both the margin and mission of otolaryngology departments and their sponsoring hospitals.

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

Background In the era of duty hour restrictions, otolaryngology residents may not gain the operative experience necessary to function autonomously by the end of training. This study quantifies residents' autonomy during key indicator cases, defined by the Accreditation Council for Graduate Medical Education. Study Design Prospective cohort study. Methods Faculty and residents at a large academic institution were surveyed on the surgical autonomy trainees should achieve for otolaryngology key indicator surgeries at each training level. Residents and faculty used the mobile application “System for Improving and Measuring Procedural Learning” (SIMPL) between December 2017 and July 2018 to log trainees' operative autonomy during cases on a validated four‐level Zwisch scale, from “show and tell” to “supervision only.” Results The study included 40 participants (23 residents and 17 attendings). The survey response rate was 83%. In surveys, residents overestimated the autonomy PGY5 residents should achieve for parotidectomy, rhinoplasty, thyroid/parathyroidectomy, and airway procedures compared with faculty (P

Background The 22-item Sinonasal Outcome Test (SNOT-22) is a validated patient-reported outcome measure for chronic rhinosinusitis and in many circumstances is used in rhinology/otolaryngology clinics to assess sinonasal symptoms in general when a formal diagnosis is not established, although with little support for such usage. Objective To assess the utility of the SNOT-22 as a reflection of quality of life (QOL) and symptom control for patients with allergic rhinitis (AR). Methods Retrospective review of 353 patients with persistent AR. Each patient completed a SNOT-22, 5-item EuroQol general health-related QOL (EQ-5D) questionnaire (from which the visual analog scale [VAS] was used), and Rhinitis Control Assessment Test (RCAT). In addition, 95 patients also completed these questionnaires 1 to 12 months later. Results The SNOT-22 was negatively correlated with the EuroQol 5-dimensional visual analog scale (EQ-5D VAS; r = −.45, 95% confidence interval [CI]: −0.53 to −0.36, P Conclusion The SNOT-22 has utility to assess QOL and symptom control in AR, and it is both reliable and responsive in its application to patients with AR. The SNOT-22 may therefore be a convenient and versatile tool in the clinical assessment of patients with AR.

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