Nasal Airway Evaluation.

The nose has several important functions including inspiration, humidification of air, and filtering of allergens. The nose also has a major role in facial harmony as the central focal point. Patients will present to the rhinoplasty surgeon in an effort to fix the inability to breathe through the nose or correct a perceived nasal deformity in the shape of the nose. Choosing the optimal techniques to effectively change the nose requires a thorough understanding of nasal anatomy and nasal mechanics. Ultimately, a complete nasal evaluation is essential in identifying what corresponds to a patient's complaints and how those issues can be addressed surgically or perhaps nonsurgically. When the nose is divided into subunits, and a systematic nasal analysis is performed, one can be confident that all components of the nasal skeleton have been assessed.

Patient-Reported Outcomes Measures in Rhinoplasty: Need for Use and Implementation.

Patient-reported outcome metrics (PROMs) are increasingly utilized to capture data about patients' quality of life. PROMs play an important role in the value-based health care movement by providing a patient-centered metric of quality. There are many barriers to the implementation of PROMs, and widespread adoption requires buy-in from numerous stakeholders including patients, clinicians, institutions, and payers. Several validated PROMs have been utilized by facial plastic surgeons to measure both functional and aesthetic outcomes among rhinoplasty patients. These PROMs can help clinicians and rhinoplasty patients participate in shared decision making (SDM), a process via which clinicians and patients arrive at treatment decisions together through a patient-centered approach. However, widespread adoption of PROMs and SDM has not yet been achieved. Further work should focus on overcoming barriers to implementation and engaging key stakeholders to increase the utilization of PROMs in rhinoplasty.

Variations in Payer-Negotiated Prices for Head and Neck Reconstructive Surgery.

OBJECTIVE: Little is known about pricing for reconstructive procedures of the head and neck. As of January 2021, the Centers for Medicare and Medicaid Services requires hospitals to disclose payer-negotiated prices for services, offering new insight into prices for privately insured patients. STUDY DESIGN: Cross-sectional analysis. SETTING: Turquoise database. METHODS: Payer-negotiated facility fees for 41 reconstructive surgeries were grouped by procedure type: primary closure, skin grafts, tissue rearrangement, locoregional flaps, or free flaps. Prices were normalized to account for local labor costs, then calculated as percent markup in excess of Medicare reimbursement. The mean percent markup between procedure groups was compared by the Kruskal-Wallis test. Subset analyses were performed to compare mean percent markup using a Student's t test. We also assessed price variation by calculating the ratio of 90th/10th percentile mean prices both across and within hospitals. RESULTS: In total, 1324 hospitals (85% urban, 81% nonprofit, 49% teaching) were included. Median payer-negotiated fees showed an increasing trend with more complex procedures, ranging from $379.54 (interquartile range [IQR], $230.87-$656.96) for Current Procedural Terminology (CPT) code 12001 ("simple repair of superficial wounds ≤2.5 cm") to $5422.60 ($3983.55-$8169.41) for CPT code 20969 ("free osteocutaneous flap with microvascular anastomosis"). Median percent markup was highest for primary closure procedures (576.17% [IQR, 326.28%-1089.34%]) and lowest for free flaps (99.56% [37.86%-194.02%]). Higher mean percent markups were observed for rural, for-profit, non-Northeast, nonteaching, and smaller hospitals. CONCLUSION: Wide variation in private payer-negotiated facility fees exists for head/neck reconstruction surgeries. Further research is necessary to better understand how pricing variation may correlate with out-of-pocket costs and quality of care.

Considerations for Optimal Grafting in Rhinoplasty.

A wide variety of grafting materials and techniques can be used to create functional and aesthetic changes in rhinoplasty. Choosing the optimal grafting approach is critical to achieving an optimal patient outcome. We present a review of autografts, allografts, and alloplasts used in primary and revision rhinoplasty and discuss factors that impact graft choice. Autologous grafts serve as the pillar for grafting material in rhinoplasty given their reliable long-term outcomes, low rates of infection, resorption, and extrusion, and ability to provide structural scaffolding as well as contour. Cadaveric allografts can be utilized as a source of grafting material in certain clinical scenarios including revision rhinoplasty and have been shown to be equally safe and effective as autologous grafts while avoiding donor-site morbidity. Alloplasts can prove useful in rhinoplasty in cases of iatrogenic nasal deformities or revision cases. Careful consideration of clinical scenario, patient factors, and outcome goals is necessary to choose the appropriate grafting approach to address functional and cosmetic outcomes.

NK cells reduce anergic T cell development in early-stage tumors by promoting myeloid cell maturation.

Introduction: Studies of NK cells in tumors have primarily focused on their direct actions towards tumor cells. We evaluated the impact of NK cells on expression of homing receptor ligands on tumor vasculature, intratumoral T cell number and function, and T cell activation in tumor draining lymph node. Methods: Using an implantable mouse model of melanoma, T cell responses and homing receptor ligand expression on the vasculature were evaluated with and without NK cells present during the early stages of the tumor response by flow cytometry. Results: NK cells in early-stage tumors are one source of IFNγ that augments homing receptor ligand expression. More significantly, NK cell depletion resulted in increased numbers of intratumoral T cells with an anergic phenotype. Anergic T cell development in tumor draining lymph node was associated with increased T-cell receptor signaling but decreased proliferation and effector cell activity, and an incomplete maturation phenotype of antigen presenting cells. These effects of NK depletion were similar to those of blocking CD40L stimulation. Discussion: We conclude that an important function of NK cells is to drive proper APC maturation via CD40L during responses to early-stage tumors, reducing development of anergic T cells. The reduced development of anergic T cells resulting in improved tumor control and T cell responses when NK cells were present.

Long-term SARS-CoV-2-specific and cross-reactive cellular immune responses correlate with humoral responses, disease severity, and symptomatology.

BACKGROUND: Cellular immune memory responses post coronavirus disease 2019 (COVID-19) have been difficult to assess due to the risks of contaminating the immune response readout with memory responses stemming from previous exposure to endemic coronaviruses. The work herein presents a large-scale long-term follow-up study investigating the correlation between symptomology and cellular immune responses four to five months post seroconversion based on a unique severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-specific peptide pool that contains no overlapping peptides with endemic human coronaviruses. METHODS: Peptide stimulated memory T cell responses were assessed with dual interferon-gamma (IFNγ) and interleukin (IL)-2 Fluorospot. Serological analyses were performed using a multiplex antigen bead array. RESULTS: Our work demonstrates that long-term SARS-CoV-2-specific memory T cell responses feature dual IFNγ and IL-2 responses, whereas cross-reactive memory T cell responses primarily generate IFNγ in response to SARS-CoV-2 peptide stimulation. T cell responses correlated to long-term humoral immune responses. Disease severity as well as specific COVID-19 symptoms correlated with the magnitude of the SARS-CoV-2-specific memory T cell response four to five months post seroconversion. CONCLUSION: Using a large cohort and a SARS-CoV-2-specific peptide pool we were able to substantiate that initial disease severity and symptoms correlate with the magnitude of the SARS-CoV-2-specific memory T cell responses.

Disparities in Index of Care for Otolaryngologic Procedures Performed in Ambulatory and Inpatient Settings.

OBJECTIVE: To compare the same surgical procedure performed in ambulatory and inpatient settings to determine the demographics associated with this selection, the differences in 30-day revisit rates, and the total 30-day cost of care. STUDY DESIGN: Retrospective cohort analysis. SETTING: Ambulatory and inpatient centers in Florida, New York, and Maryland. METHODS: The Healthcare Cost and Utilization Project, the State Ambulatory Surgery and Services Database, and the State Inpatient Database were used to identify patients undergoing commonly performed otolaryngologic procedures in 2016. The State Emergency Department Database and State Inpatient Database were used to identify 30-day revisits. RESULTS: A total of 55,311 patients underwent an otolaryngologic procedure: 51,136 (92.4%) ambulatory and 4175 (7.6%) inpatient. Adjusted odds of receiving care in the ambulatory setting was significantly lower for Black patients (odds ratio, 0.69 [95% CI, 0.55-0.85]; P = .001) and nonspecified other races (odds ratio, 0.71 [95% CI, 0.52-0.95]; P = .001) as compared with White patients. Women had 1.16-higher adjusted odds of undergoing a procedure in the ambulatory setting (95% CI, 1.05-1.29; P = .005). Insurance status and income were associated with location of care in the subcategorization of head and neck surgery. Adjusted inpatient procedure costs were significantly more than ambulatory (median, $59,112 vs $14,899); 30-day adjusted costs were $71,333.07 (95% CI, $56,223.99-$86,42.15; P < .001) more expensive for inpatient procedures vs ambulatory; and the adjusted 30-day odds of revisit were 2.23 times greater (95% CI, 1.44-3.44; P < .001) for ambulatory surgery across all procedures. CONCLUSIONS: Disparities exist in the use of ambulatory settings to provide otolaryngologic surgery. Additional research is required to ensure equitable triaging of surgical care setting.

The Impact of Component Dorsal Hump Reduction on Patient-Perceived Nasal Aesthetics and Obstruction in Rhinoplasty.

OBJECTIVE: This study aimed to evaluate functional and aesthetic patient-reported outcomes using validated metrics after component dorsal hump reduction (DHR) with spreader graft placement, which have not been previously reported. STUDY DESIGN: Prospective cohort study. METHODS: This prospective cohort study was conducted in a tertiary care medical center. Participants underwent septorhinoplasty (SRP) with spreader graft placement with cosmetic, component DHR (cosmetic DHR), or SRP with spreader graft placement without dorsal hump reduction (noncosmetic, non-DHR). The Nasal Obstruction Symptom Evaluation (NOSE) scale and the FACE-Q Satisfaction with Nose, Nostrils, and Social Functioning scales were administered to patients preoperatively and postoperatively (at 2, 4, 6, and/or 12 months). Pre- and postoperative NOSE and FACE-Q scores were compared. RESULTS: A total of 226 patients underwent SRP with spreader graft placement; 113 (50.0%) with cosmetic DHR and 113 (50.0%) noncosmetic, non-DHR (control). Patients who completed the NOSE and FACE-Q surveys preoperatively and at least at one postoperative time point were included. Both cohorts had a statistically and clinically significant improvement in NOSE and FACE-Q scores. There were similar improvements in NOSE scores in both cohorts. Postoperative FACE-Q scores were higher in the cosmetic DHR cohort despite lower preoperative FACE-Q scores when compared to the control cohort. CONCLUSIONS: Although there are multiple techniques for DHR, component DHR with spreader graft placement has long been considered the standard. Therefore, it is important to note the significant postoperative cosmetic and functional improvements reported by patients who have undergone this procedure to compare to newer techniques as they evolve. LEVEL OF EVIDENCE: 3 Laryngoscope, 132:2157-2161, 2022.

Islet Lymphocytes Maintain a Stable Regulatory Phenotype Under Homeostatic Conditions and Metabolic Stress.

T cells and B cells have been identified in human and murine islets, but the phenotype and role of islet lymphocytes is unknown. Resident immune populations set the stage for responses to inflammation in the islets during homeostasis and diabetes. Thus, we sought to identify the phenotype and effector function of islet lymphocytes to better understand their role in normal islets and in islets under metabolic stress. Lymphocytes were located in the islet parenchyma, and were comprised of a mix of naïve, activated, and memory T cell and B cell subsets, with an enrichment for regulatory B cell subsets. Use of a Nur77 reporter indicated that CD8 T cells and B cells both received local antigen stimulus, indicating that they responded to antigens present in the islets. Analysis of effector function showed that islet T cells and B cells produced the regulatory cytokine IL-10. The regulatory phenotype of islet T cells and B cells and their response to local antigenic stimuli remained stable under conditions of metabolic stress in the diet induced obesity (DIO) model. T cells present in human islets retained a similar activated and memory phenotype in non-diabetic and T2D donors. Under steady-state conditions, islet T cells and B cells have a regulatory phenotype, and thus may play a protective role in maintaining tissue homeostasis.

The Impact of Upper Lateral Cartilage Release on Patient-Perceived Nasal Appearance and Obstruction.

OBJECTIVES/HYPOTHESIS: Although upper lateral cartilages are commonly released from the dorsum of the septum during spreader graft placement in septorhinoplasty (SRP), there has been a focus on maintaining integrity of connections in the middle vault. Avoiding release of upper lateral cartilages in certain patient groups may represent an early step in this paradigm shift. We aim to assess satisfaction with nasal appearance and correction of nasal obstruction in patients who underwent SRP with spreader graft placement without upper lateral cartilage release and compared it to the traditional upper lateral cartilage release cohort. STUDY DESIGN: Prospective cohort study. METHODS: A total of 559 patients who underwent SRP with spreader graft placement with upper lateral cartilage release and 30 patients who underwent SRP with spreader graft placement without release between 2012 and 2020 were administered the Nasal Obstruction Symptom Evaluation (NOSE), FACE-Q Satisfaction with Nose, and FACE-Q Social Functioning scales pre- and postoperatively. Pre- and postoperative NOSE FACE-Q, and negative inspiratory force (NIF) scores and changes were compared between groups. RESULTS: Results demonstrated clinically and statistically significant improvement at follow-up for both groups. There was no significant difference between groups in mean improvement of NOSE, FACE-Q, and NIF scores at time of last follow-up. CONCLUSION: SRP with spreader graft placement with and without upper lateral cartilage release provide clinically and statistically significant improvement, and no significant difference in functional outcome. This suggests that upper lateral cartilages do not need to be released to achieve functional improvement and that surgeons should consider whether release is necessary to achieve goals of surgery. LEVEL OF EVIDENCE: 3 Laryngoscope, 132:1189-1195, 2022.

Patient Recovery and Satisfaction with Perioperative Care After Rhinoplasty.

Background: Recovery after rhinoplasty is not well characterized in the literature. Objective: To quantify key aspects of patient recovery after rhinoplasty and characterize factors that may impact recovery and overall satisfaction with perioperative care. Methods: Prospective cohort study of rhinoplasty patients undergoing surgery at a tertiary referral center between January 2018 and January 2020, and completed a patient experience questionnaire at first postoperative visit. Results: Fifty-one patients underwent functional septorhinoplasty. Mean age was 37.8 years (standard error [SE] 2.4) with median 36.0 years (range 16-79). Fifty-three percent were female (n = 27). Patients resumed most daily activities within 4.1 days. Overall satisfaction with perioperative care was high (mean 9.6, SE 0.1), although 29% of patients (n = 15) wished they had more information regarding surgical care. Patients who did not desire additional information reported higher satisfaction and faster time to activity recovery compared with those who desired additional information. Conclusions: Rhinoplasty patients are able to resume most routine activities within 4.1 days after surgery, although patients desiring additional information about care demonstrate lower satisfaction with perioperative care and slower recovery compared to those who felt well informed.

Comparative Effectiveness of Cartilage Grafts in Functional Rhinoplasty for Nasal Sidewall Collapse.

Objective: To compare the patient-reported outcomes among patients with nasal obstruction undergoing two rhinoplasty techniques to a control group. Methods: Prospective longitudinal study in a university-based tertiary care medical center. All patients undergoing functional septorhinoplasty for correction of lateral wall insufficiency between October 2015 and March 2019 were included; n = 704, mean age (standard deviation) 39.0 (15.4) years, 52.7% females. Patients completed the Nasal Obstruction Symptom Evaluation (NOSE) and FACE-Q subscales pre- and postoperatively. Patients were divided into three cohorts: spreader and lateral crural strut (LCS) grafts (n = 141), spreader and alar rim (AR) grafts (n = 104), and the control spreader grafts alone (n = 218). Results: The median NOSE scores at last postoperative visit were improved from baseline (p < 0.001) for all cohorts. The FACE-Q nasal satisfaction median scores also improved postoperatively in all cohorts, AR, LCS, and spreader, respectively (p = 0.001, p < 0.001, and p < 0.0001). Conclusions: There was no detectable difference in the improved subjective nasal function, nor adverse aesthetic outcomes in the patients with lateral wall insufficiency treated with functional rhinoplasty techniques in this study.

Otolaryngologists Trail Other Specialties in Industry Payments From Dermal Filler Companies.

OBJECTIVES/HYPOTHESIS: Dermal filler (DF) is a widely used nonsurgical option for facial rejuvenation with a rapidly expanding market. Physician payments by DF industry leaders have yet to be characterized. We sought to investigate trends in physician-industry payments by DF companies over 6 years. Differences in payments based on physician specialty and time were characterized. STUDY DESIGN: Database review. METHODS: The Open Payments Database was queried from 2013 to 2018. Payments made by the three largest DF companies by market share to otolaryngologists, plastic surgeons, and dermatologists were analyzed. Total dollars paid, number of payments made, type of payments made, and total number of specialists paid were recorded. One-way ANOVA was used for statistical analysis. RESULTS: Otolaryngologists, plastic surgeons, and dermatologists received average annual payments of $0.36 million, $6.3 million, and $6.6 million respectively (P < .001). An average of 330 otolaryngologists, 2,128 plastic surgeons, and 5,980 dermatologists were paid annually (P < .001). Accredited speaking arrangements, consulting fees, and royalty/licensing fees comprised the majority of dollars paid to physicians. CONCLUSIONS: Average physician payment by DF companies exceeds $12 million annually, with otolaryngologists receiving significantly less compared to plastic surgeons and dermatologists. LEVEL OF EVIDENCE: NA Laryngoscope, 132:301-306, 2022.

Moving Toward Professional Equity in Otolaryngology.

Gender-based equity in compensation, access to opportunity and resources, and leadership roles are critical to the health and future of otolaryngology; however, significant gaps continue to persist. Professional equity in otolaryngology will be achieved by leadership prioritization of equity as mission critical, improving organizational culture and developing systems for advocacy, understanding what constitutes equal pay in otolaryngology, the development of transparent and reoccurring equity review processes and the promotion of women and underrepresented minorities into leadership positions.

An evaluation of a FluoroSpot assay as a diagnostic tool to determine SARS-CoV-2 specific T cell responses.

Numerous assays evaluating serological and cellular responses have been developed to characterize immune responses against SARS-CoV-2. Serological assays are both cost- and time-effective compared to cellular assays, but cellular immune responses may provide a diagnostic value to determine previous SARS-CoV-2 infection in seronegative individuals. However, potential cross-reactive T cell responses stemming from prior encounters with human coronaviruses (HCoVs) may affect assay specificity. In this study, we evaluated the specificity and sensitivity of a SARS-CoV-2 IFN-γ Release Assay (IGRA) based on the FluoroSpot method employing commercially available SARS-CoV-2-specific peptide pools, as well as an in-house designed SARS-CoV-2 peptide pool restricted to 5 amino acid stretches or less aligning with endemic HCoVs. Blood samples were obtained from healthcare workers (HCW) 5-6 months post SARS-CoV-2 spike (S) IgG and nucleocapsid (N) IgG dual seroconversion (n = 187) and HCW who had been S IgG and N IgG dual seronegative at repeated occasions, including the current sampling time point (n = 102). In addition, samples were obtained 4 to 5 months post infection from 55 polymerase chain reaction (PCR)-confirmed COVID-19 patients. Assay specificity and sensitivity were calculated with serology as a reference standard for HCW. The in-house generated peptide pool displayed a specificity of 96.1%, while the commercially available peptide pools displayed specificities of 80.4% and 85.3%, respectively. Sensitivity was higher in a cohort of previously hospitalized COVID-19 patients (96.4% and 84.0% for the commercially available peptide pools and 92.7% for the in-house generated peptide pool) compared to the HCW cohort (92.0% and 66.8% for the commercially available peptide pools and 76.0% for the in-house generated peptide pool). Based on these findings, the individual diagnostic value of T cell immune responses against SARS-CoV-2 currently appears to be limited but remain an important research tool ahead.

Computational Fluid Dynamics Modeling of Nasal Obstruction and Associations with Patient-Reported Outcomes.

BACKGROUND: Nasal obstruction is a common problem, with significant impact on quality of life. Accurate diagnosis may be challenging because of the complex and dynamic nature of the involved anatomy. Computational fluid dynamics modeling has the ability to identify specific anatomical defects, allowing for a targeted surgical approach. The goal of the current study is to better understand nasal obstruction as it pertains to disease-specific quality of life by way of a novel computational fluid dynamics model of nasal airflow. METHODS: Fifty-three patients with nasal obstruction underwent computational fluid dynamics modeling based on computed tomographic imaging. Nasal resistance was compared to demographic data and baseline subjective nasal patency based on Nasal Obstructive Symptom Evaluation scores. RESULTS: Mean Nasal Obstructive Symptom Evaluation score among all patients was 72.6. Nasal Obstructive Symptom Evaluation score demonstrated a significant association with nasal resistance in patients with static obstruction (p = 0.03). There was a positive correlation between Nasal Obstructive Symptom Evaluation score and nasal resistance in patients with static bilateral nasal obstruction (R2 = 0.32) and poor correlation in patients with dynamic bilateral obstruction caused by nasal valve collapse (R2 = 0.02). Patients with moderate and severe bilateral symptoms had significantly higher nasal resistance compared to those with unilateral symptoms (p = 0.048). CONCLUSIONS: Nasal obstruction is a multifactorial condition in most patients. This study shows correlation between simulated nasal resistance and Nasal Obstructive Symptom Evaluation score in a select group of patients. There is currently no standardized diagnostic algorithm or gold standard objective measure of nasal airflow; however, computational fluid dynamics may better inform treatment planning and surgical techniques on an individual basis. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, V.

MERTK on mononuclear phagocytes regulates T cell antigen recognition at autoimmune and tumor sites.

Understanding mechanisms of immune regulation is key to developing immunotherapies for autoimmunity and cancer. We examined the role of mononuclear phagocytes during peripheral T cell regulation in type 1 diabetes and melanoma. MERTK expression and activity in mononuclear phagocytes in the pancreatic islets promoted islet T cell regulation, resulting in reduced sensitivity of T cell scanning for cognate antigen in prediabetic islets. MERTK-dependent regulation led to reduced T cell activation and effector function at the disease site in islets and prevented rapid progression of type 1 diabetes. In human islets, MERTK-expressing cells were increased in remaining insulin-containing islets of type 1 diabetic patients, suggesting that MERTK protects islets from autoimmune destruction. MERTK also regulated T cell arrest in melanoma tumors. These data indicate that MERTK signaling in mononuclear phagocytes drives T cell regulation at inflammatory disease sites in peripheral tissues through a mechanism that reduces the sensitivity of scanning for antigen leading to reduced responsiveness to antigen.