Will nasal airway surgery improve my sense of smell? A prospective observational study.

BACKGROUND: The effect of nasal airway surgery on olfaction has not been well established. The goal of this study is to assess changes in olfaction after septoplasty with inferior turbinate reduction through both objective and patient-reported measures. METHODS: Prospective, observational study was conducted of patients with nasal airway obstruction presenting between July 2017 and October 2019 who underwent septoplasty with inferior turbinate reduction. Nasal airflow was characterized with the Nasal Obstruction Symptom Evaluation (NOSE) scale and an 11-point ease-of-breathing (EOB) Likert scale, and olfaction with an 11-point olfactory Likert scale and the 40-item University of Pennsylvania Smell Identification Test (UPSIT), pre- and postoperatively. Pearson correlations were used to assess the relationship between measures of nasal obstruction and olfaction. RESULTS: Among 80 patients, mean NOSE scores improved from 67.4 preoperatively to 19.6 postoperatively (p < 0.001). EOB Likert scores improved from a mean of 3.9/10 to 8.1/10 after surgery (p < 0.001). Olfactory Likert scores improved from a baseline of 6.1/10 preoperatively to 7.9/10 after surgery (p < 0.001). No statistically significant difference was noted in UPSIT testing pre- versus postoperatively. A moderate correlation was noted between the degree of change in NOSE scores and improved olfactory Likert scores (r = 0.51, p < 0.001), and similarly between the degree of change in EOB Likert scores and improved olfactory Likert scores (r = 0.55, p < 0.0001). CONCLUSIONS: Based on our data, subjective tests of olfaction may improve with nasal airway surgery in some patients. Changes in olfaction best correlate with the extent to which surgery can improve subjective nasal obstructive symptoms.

An Updated Patient-Centered Sialadenitis Instrument: The Obstructive Salivary Problem Impact Test (SPIT).

OBJECTIVE: The Chronic Obstructive Sialadenitis Symptoms questionnaire (COSS) was created to assess chronic sialadenitis symptoms and treatment response, but its development lacked patient input and validation. We analyzed COSS responses and feedback from sialadenitis patients and physician experts to create the novel obstructive Salivary Problem Impact Test (SPIT), a new standardized measure of sialadenitis-associated symptoms. METHODS: We analyzed COSS responses via exploratory factor analysis (EFA) to identify essential symptom domains and reduce overlap in questions. Sialadenitis patients evaluated the significance of index symptoms identified from the literature review. Expert physicians rated symptom relevance in clinical assessment. An updated questionnaire (SPIT) was piloted with both patient and expert interviews to optimize structure and readability. The SPIT was assessed for internal consistency, construct validity, and test-retest stability. RESULTS: EFA of 310 COSS responses demonstrated 3 main symptom domains (functional impact, pain, swelling) that explained 58.4% of response variance. Results were not statistically different when collapsing from 11 to 5 question response options. Experts (n = 5) ranked gland swelling, mealtime pain, and foul taste as most clinically important, while patients (n = 12) ranked swelling, non-mealtime pain, and difficulty eating as most bothersome. Most patients experienced sialadenitis-related functional or psychosocial impairment. Following interviews for question refinement, a 25-question survey was finalized. SPIT responses from 50 sialadenitis patients demonstrated internal consistency (Cronbach's alpha = 0.96), 14-day stability (p < 0.001), and agreement with Oral Health Impact Profile-14 scores (p < 0.0001). CONCLUSIONS: We developed the SPIT instrument to improve usability and content validity in chronic sialadenitis evaluation. The psychometric assessment demonstrated high construct validity and test-retest reliability. Further work will assess longitudinal changes with treatment. LEVEL OF EVIDENCE: 4 Laryngoscope, 133:539-546, 2023.

Changes in otolaryngology application requirements and match outcomes: Are we doing any better?

Objectives: Otolaryngology-specific requirements were piloted to minimize applicant and program burdens. We investigated the impact of introducing and then removing these requirements on Match outcomes. Methods: 2014-2021 National Resident Matching Program® data were examined. The primary outcome was the impact of Otolaryngology Resident Talent Assessment (ORTA; prematch 2017, postmatch 2019) and Program-Specific Paragraph (PSP; implemented 2016, optional 2018) on applicant numbers and match rates. Secondary survey analysis assessed candidate perceptions of PSP/ORTA. Results: Applicant numbers declined significantly during PSP/ORTA (18.9%; p = 0.001). With the optional PSP and postmatch ORTA, applicant numbers increased significantly (39.0%; p = 0.002). Examined individually, mandatory PSP was associated with a significant decline in applicants (p = 0.007), whereas postmatch ORTA was associated with significant increases in applicants (p = 0.010). ORTA and PSP negatively impacted the decision to apply to otolaryngology in 59.8% and 51.3% of applicants, respectively. Conversely, match rate success improved significantly from 74.8% to 91.2% during PSP/ORTA (p = 0.014), followed by a significant decline to 73.1% after PSP was made optional and ORTA moved to postmatch (p = 0.002). Conclusions: ORTA and PSP correlated with decreased applicant numbers and increased match rate success. As programs seek ways to remove barriers to applying to otolaryngology, the potential consequences of an increasing pool of unmatched candidates must also be considered.

Association of comprehensive thyroid cancer molecular profiling with tumor phenotype and cancer-specific outcomes.

BACKGROUND: Molecular testing improves the diagnostic accuracy of thyroid cancer. Whether specific molecular testing results are associated with tumor phenotype or provide prognostic information needs further delineation. METHODS: Consecutive thyroid cancer patients after index thyroidectomy with ThyroSeq version 3 (Rye Brook, NY) molecular testing obtained on preoperative fine-needle aspiration or thyroidectomy specimens from patients with thyroid cancer were categorized into 3 molecular risk groups based on detected mutations, fusions, copy number alterations, and/or gene expression alterations and correlated with histopathology and recurrence, defined as biochemical or structural. RESULTS: Of 578 patients, 49.9%, 37.5%, and 12.6% had molecular risk group-low, molecular risk group-intermediate, and molecular risk group-high cancers, respectively. With a median 19-month follow-up, 9.1% patients recurred. Compared with molecular risk group-low, molecular risk group-intermediate cancers were diagnosed in younger patients and more often had microscopic extrathyroidal extension, involved margins, and nodal disease. Compared with molecular risk group-intermediate, molecular risk group-high cancers were diagnosed in older patients and more often had gross extrathyroidal extension and vascular invasion. In multivariable analysis, recurrence was more likely in molecular risk group-high cancers than in molecular risk group-intermediate (hazard ratio = 4.0; 95% confidence interval, 1.9-8.6; P < .001) and more likely in molecular risk group-intermediate than in molecular risk group-low (hazard ratio = 5.0; 95% confidence interval, 2.0-12.5; P < .001). CONCLUSION: Using modern comprehensive genotyping, the genetic profile of thyroid cancers can be categorized into 3 novel molecular risk groups that were associated with histopathologic phenotype and recurrence in short-term follow-up.

Applicant Perspectives on Virtual Otolaryngology Residency Interviews.

OBJECTIVE: Residency interviews serve as an opportunity for prospective applicants to evaluate programs and to determine their potential fit within them. The 2019 SARS-CoV2 pandemic mandated programs conduct interviews virtually for the first time. The purpose of this study was to assess applicant perspectives on the virtual interview. METHODS: A Qualtrics survey assessing applicant characteristics and attitudes toward the virtual interview was designed and disseminated to otorhinolaryngology applicants from 3 large academic institutions in the 2020 to 2021 application cycle. RESULTS: A total of 33% of survey applicants responded. Most applicants were satisfied with the virtual interview process. Applicants reported relatively poor quality of interactions with residents and an inability to assess the "feel" of a geographic area. Most applicants received at least 11 interviews with over a third of applicants receiving >16 interviews. Only 5% of applicants completed >20 interviews. Most applicants believed interviews should be capped between 15 and 20 interviews. Most applicants reported saving >$5000, with over a quarter of applicants saving >$8000, and roughly one-third of applicants saving at least 2 weeks of time with virtual versus in-person interviews. CONCLUSIONS: While virtual interviews have limitations, applicants are generally satisfied with the experience. Advantages include cost and time savings for both applicants and programs, as well as easy use of technology. Continuation of the virtual interview format could be considered in future application cycles; geographical limitations may be overcome with in-person second looks, and increased emphasis should be placed on resident interactions during and prior to interview day.

Bilateral giant submandibular sialoliths and the role for salivary endoscopy.

Salivary stones larger than 15 mm are classified as giant sialoliths. They are uncommon in the practice of otolaryngology, and their management has always been a therapeutic challenge. Traditionally, when they cannot be retrieved by marsupialization, removal of the salivary gland has been advocated. Sialendoscopy and the recent development of combined endoscopic and external approaches for extraction of large stones with preservation of the major salivary glands are promising. We present the first case of simultaneous bilateral giant sialoliths, and the first report that associates giant sialoliths and the use of salivary endoscopy. In this case, both giant stones were removed with the assistance of a salivary endoscope and without removing the submandibular glands.

Management of Mucoceles, Sialoceles, and Ranulas.

Mucoceles are common salivary gland disorders. Mucoceles are benign, mucus-filled extravasation pseudocysts that commonly arise on the lower lip of children and young adults. Although surgical excision is commonly performed to remove these lesions, other treatments include marsupialization, micromarsupialization laser ablation, cryotherapy, intralesional steroid injection, and sclerosing agents. Traumatic sialoceles commonly arise from injury to the parotid duct. Treatment of sialoceles from acute parotid duct injury and for delayed presentations after injury are discussed. Ranulas are a subtype of mucocele from the sublingual gland classified as superficial or plunging. Treatment of ranulas must address the sublingual gland.

An Update on Nontumorous Disorders of the Salivary Glands and Their Management for Internists.

Salivary disease may present as pain or swelling in unilateral or bilateral salivary glands. Symptoms may be periprandial or recurrent and inflammatory. If a patient fails conservative treatment, they should be referred to an otolaryngologist. If there is no clear cause based on history and physical examination, sialendoscopy can be performed to directly visualize tissues, provide a diagnosis, drive treatment plans, and sometimes concurrently provide therapeutic intervention. Based on the pathology visualized on sialendoscopy, treatment options include endoscopic intervention, Botox, and gland-preserving surgical techniques, which promote healing of glandular tissue, ultimately preserving function.

Salivary and lacrimal dysfunction after radioactive iodine for differentiated thyroid cancer: American Head and Neck Society Endocrine Surgery Section and Salivary Gland Section joint multidisciplinary clinical consensus statement of otolaryngology, ophthalmology, nuclear medicine and endocrinology.

BACKGROUND: Postoperative radioactive iodine (RAI) administration is widely utilized in patients with differentiated thyroid cancer. While beneficial in select patients, it is critical to recognize the potential negative sequelae of this treatment. The prevention, diagnosis, and management of the salivary and lacrimal complications of RAI exposure are addressed in this consensus statement. METHODS: A multidisciplinary panel of experts was convened under the auspices of the American Head and Neck Society Endocrine Surgery and Salivary Gland Sections. Following a comprehensive literature review to assess the current best evidence, this group developed six relevant consensus recommendations. RESULTS: Consensus recommendations on RAI were made in the areas of patient assessment, optimal utilization, complication prevention, and complication management. CONCLUSION: Salivary and lacrimal complications secondary to RAI exposure are common and need to be weighed when considering its use. The recommendations included in this statement provide direction for approaches to minimize and manage these complications.

Facial Nerve Grading System 2.0.

OBJECTIVE: To present an updated version of the original Facial Nerve Grading Scale (FNGS), commonly referred to as the House-Brackmann scale. STUDY DESIGN: Controlled trial of grading systems using a series of 21 videos of individuals with varying degrees of facial paralysis. RESULTS: The intraobserver and interobserver agreement was high among the original and revised scales. Nominal improvement is seen in percentage of exact agreement of grade and reduction of instances of examiners differing by more then one grade when using FNGS 2.0. FNGS 2.0 also offers improved agreement in differentiating between grades 3 and 4. CONCLUSION: FNGS 2.0 incorporates regional scoring of facial movement, providing additional information while maintaining agreement comparable to the original scale. Ambiguities regarding use of the grading scale are addressed.

Endoscopic sialolith removal: orientation and shape as predictors of success.

PURPOSE: To identify factors that may influence successful retrieval of salivary stones with interventional sialendoscopy. MATERIALS AND METHODS: A retrospective chart review of sialendoscopy procedures performed in the Department of Otolaryngology at the University of Pittsburgh from July 2005 to August 2007 was conducted. We identified thirty consecutive cases of sialolithiasis treated with sialendoscopy. RESULTS: The mean age at presentation was 45 years (range, 7-77 years) with a male-to-female sex ratio of 1:1.5. The most common presentation was recurrent or persistent salivary gland swelling (53%), followed by salivary gland swelling associated with meals (37%). All these procedures were performed under sedation or general anesthesia. Size of the stones ranged from 0.2 to 1.2 cm. Our success rate for their endoscopic removal was 74% (14/19). Four patients (4/30) required a planned combined technique for stone removal. CONCLUSIONS: Sialendoscopy is a reasonable minimally invasive option to treat sialolithiasis that avoids the need for salivary gland excision. Salivary stones larger than 4 mm for submandibular cases and 3 mm for parotid cases may be amenable to endoscopic removal provided their largest dimension is orientated favorably along the length of the duct.

Cultivating and Recruiting Future Otolaryngology Residents: Shaping the Tributary.

The future vibrancy, relevancy, and strength of our specialty depend on cultivating a pipeline of resident otolaryngologists who embody what our society wishes to become. In attracting, seeking, and nourishing physicians of all stripes, we offer several considerations regarding medical student education and the residency selection process.

Sialendoscopy and associated complications: a preliminary experience.

OBJECTIVES/HYPOTHESIS: To review our experience with diagnostic and therapeutic sialendoscopy for the management of major salivary gland disorders with respect to complications and also to validate its use in our patient population. STUDY DESIGN: Retrospective chart review. METHODS: We identified 56 consecutive cases of sialendoscopy procedures performed over 2 years in the Department of Otolaryngology at the University of Pittsburgh from July 2005 to August 2007. RESULTS: The mean age of presentation was 43 (range, 7-77) years, with a male to female sex ratio of 1:2. The most common indications included sialolithiasis (52%) followed by salivary gland swelling (16%). The average size of the stones ranged from 2 to 12 mm. The overall success rate for endoscopic stone removal was 74% (14 of 19). Three (3 of 29) patients required a planned combined technique for stone removal. The overall complication rate was 25% (14 of 56). The major and minor complication rates were 2% (1 of 56) and 23% (13 of 56), respectively. CONCLUSIONS: Sialendoscopy is a safe and effective technology for treating major salivary gland disorders. In the early phases of sequential learning, complications rates are significant. However, major complications are infrequent and in general can be salvaged by standard salivary gland surgery.

Aggressive fibromatosis of the parotid gland.

Extra-abdominal fibromatosis (EAF) is a rare, locally aggressive tumor that originates in fascial structures. It accounts for less than 0.3% of all tumors diagnosed. Head and neck tumors account for only 7% of those, and only a few cases occurring in the parotid gland have been previously reported. We describe the case of a 34-year-old woman who presented with a painful parotid mass. She was found to have an EAF of her right parotid gland. Medical management with antibiotics and immunosuppression therapy was unsuccessful. Surgical resection was required for both a definitive diagnosis and management. Preoperative findings on computed tomography, magnetic resonance imaging, and both fine-needle aspiration biopsy and surgical biopsy were nonspecific, as is typical in EAF cases.

Perineural Invasion in Parotid Gland Malignancies.

Objectives To investigate the clinical predictors and survival implications of perineural invasion (PNI) in parotid gland malignancies. Study Design Case series with chart review. Setting Tertiary care medical center. Subjects and Methods Patients with parotid gland malignancies treated surgically from 2000 to 2015 were retrospectively identified in the Head and Neck Cancer Registry at a single institution. Data points were extracted from the medical record and original pathology reports. Results In total, 186 patients with parotid gland malignancies were identified with a mean follow-up of 5.2 years. Salivary duct carcinoma (45), mucoepidermoid carcinoma (44), and acinic cell carcinoma (26) were the most common histologic types. A total of 46.2% of tumors were found to have PNI. At the time of presentation, facial nerve paresis (odds ratio [OR], 64.7; P < .001) and facial pain (OR, 3.7; P = .002) but not facial paresthesia or anesthesia (OR, 2.8, P = .085) were predictive of PNI. Malignancies with PNI were significantly more likely to be of advanced T and N classification, be high-risk pathologic types, and have positive margins and angiolymphatic invasion. PNI positivity was associated with worse overall (hazard ratio, 2.62; P = .001) and disease-free survival (4.18; P < .001) on univariate Cox regression analysis. However, when controlling for other negative prognosticators, age, and adjuvant therapy, PNI did not have a statistically significant effect on disease-free or overall survival. Conclusions PNI is strongly correlated with more aggressive parotid gland malignancies but is not an independent predictor of worse survival. Facial paresis and pain were predictive of PNI positivity, and facial paresis correlated with worse overall and disease-free survival.

Teach the teacher: Training otolaryngology fellows to become academic educators.

OBJECTIVES/HYPOTHESIS: Fellowship is the capstone of academic training and serves as preparation for an academic career. Fellows are expected to educate medical students and residents during and long after fellowship. However, little time is typically spent teaching fellows to become effective educators. We investigate a formal curriculum addressing teaching skills among fellows in otolaryngology-head and neck surgery (OHNS). STUDY DESIGN: E-mail survey. METHODS: We developed and implemented an educational program called Teach the Teacher to build skills as educators for fellows in OHNS. We conducted a survey of fellows from 2014 to 2017 in OHNS who participated in the course. The survey evaluated demographics, teaching experiences, and teaching limitations structured as yes/no and Likert-style questions (1 = strongly disagree, 5 = strongly agree). RESULTS: Thirty fellows were surveyed with a response rate was 80%. Fellowship was rated highly as an experience that will make fellows a better academic educator (mean ± standard deviation: 4.54 ± 0.64). The most important components of teaching during fellowship were role modeling (4.67 ± 0.62), followed by teaching psychomotor skills in the operating room (4.29 ± 0.89), diagnostic reasoning (4.25 ± 0.66), and evidence-based medicine (4.25 ± 0.83). The Teach the Teacher course specifically was rated as a helpful experience (4.00 ± 0.90). The primary limitations to developing teaching skills during fellowship identified were lack of time, patient safety, and inexperience with hospital culture. CONCLUSIONS: Fellowship is a key time to improve skills as academic educators. Fellows value formal efforts to teach academic skills. LEVEL OF EVIDENCE: NA. Laryngoscope, 128:2034-2048, 2018.

Palatal botulinum toxin as a novel therapy for objective tinnitus in forced eyelid closure syndrome.

Objective tinnitus associated with eyelid closure is a rare clinical entity with only a few reported cases. This association previously was identified as forced eyelid closure syndrome (FECS) and involves an aberrant neural reflex between cranial nerve VII (activating the orbicularis oculi muscle) and cranial nerve V (activating the tensor tympani muscle). We present a 52-year-old Caucasian female with a 2-month history of FECS who was successfully treated with intrapalatal botulinum toxin, with full resolution of her objective tinnitus symptoms. This is the first reported use of botulinum toxin in FECS. Laryngoscope, 127:1199-1201, 2017.

Sialendoscopy: Getting started, how long does it take?

OBJECTIVES/HYPOTHESIS: Dilation of the salivary gland papilla for access is well-recognized as one of the major rate-limiting steps to sialendoscopy and has been shown to be a major challenge for beginners. The purpose of this study was to demonstrate that an algorithm involving multiple techniques for salivary duct access in sialendoscopy results in excellent success rates and acceptable operative times. STUDY DESIGN: A retrospective, observational review of 61 patients who underwent sialendoscopy of the parotid or submandibular gland, for a total of 65 papillas accessed (31 parotid, 34 submandibular) with seven different trainees utilizing a standard protocol for duct access, was performed. The time interval from the case start to endoscopic visualization of the ductal lumen was measured. Average values for time to duct access were then calculated. RESULTS: The papilla was identified in all but one case without difficulty. Five submandibular gland cases required sialodochotomy for access. The average time to duct access was 4.2 ± 4.7 minutes (range: 0.67-25 minutes). Exclusion of four difficult cases with access times over 15 minutes yielded an average access time of 3.2 ± 2.2 minutes. CONCLUSION: This standardized protocol demonstrates high rates of success for salivary duct access via the papilla in a short time interval with infrequent need for sialodochotomy, even in the hands of novice surgeons. LEVEL OF EVIDENCE: 4. Laryngoscope, 126:1083-1085, 2016.

Perineural invasion of squamous cell carcinoma of the lip with occult involvement of the infra-orbital nerve detected by PET-CT and treated with MRI-based IMRT: a case report.

A 51 year old male with a history of right facial numbness developed progressive upper lip swelling for one year, but an MRI of the head was unremarkable. A wide local excision of the upper lip was performed and pathology revealed a 1.7 cm mass, poorly differentiated squamous cell carcinoma with perineural invasion. Surgical margins were free of tumor. Two months postoperatively, a hybrid PET-CT of the whole body was performed due to the persistent right facial numbness. The CT portion identified an equivocal lesion at the base of the right orbit correlating to the right infraorbital nerve. However, the PET-CT image revealed avid uptake in this location suggesting perineural invasion which was confirmed with biopsy of the right infraorbital nerve demonstrating carcinoma. Subsequently, the patient was treated with Intensity Modulation Radiation Therapy (IMRT) using MRI fusion for proper delineation of the right infraorbital nerve to its origin in the base of skull. This case exemplifies the superiority of hybrid PET-CT over CT or MRI alone in head and neck imaging which can lead to significant impact on management for patients with head and neck cancer.

Quantification of maxillary sinus accessibility via a middle meatal antrostomy.

OBJECTIVE: To quantify maxillary sinus volume and mucosal surface area (SA) that is accessible endoscopically via a middle meatal antrostomy and to explore the financial implications of using multiple disposable instruments for this procedure. METHODS: Eight cadaver maxillary sinuses configured with image guidance software were evaluated. In each sinus, a standard middle meatal antrostomy was created, through which curved microdebriders of 15, 40, 70, and 120° were placed. The SA and volume of the region accessible by each microdebrider tip was calculated. RESULTS: Mean maxillary sinus volume was 16.5 ± 2.5 cm(3) and mean SA was 31.0 ± 2.3 cm(2). The 15, 40, 70 and 120° microdebriders accessed an average of 10, 25, 41, and 66%, respectively, of the SA, and of 2, 9, 17, and 36%, respectively, of the volume. There was a trend toward improved accessibility of the superior half versus the inferior half of the maxillary sinus. When instruments of different degrees were combined to maximize accessibility, 81% of the SA of the sinus could be accessed. CONCLUSIONS: Microdebriders with increasing curvatures allowed for greater access of the maxillary sinus mucosa through an middle meatal antrostomy. No single microdebrider curvature or combination of curvatures reached the entirety of the maxillary sinus wall. Knowledge about the area of reach for these blades can lead to lower per procedure costs.