Climate change and environmental sustainability in otolaryngology: A state-of-the-art review.

BACKGROUND: Climate change has been identified by the World Health Organization (WHO) as the greatest existing threat to human health. Given the direct exposure of the upper aerodigestive system to pollutants, patients in otolaryngology are at high risk for increased disease burden in the setting of climate change and worsening air quality. Given this and the environmental impact of surgical care, it is essential for surgeons to understand their role in addressing climate health through quality-driven clinical initiatives, education, advocacy, and research. METHODS: A state-of-the-art review was performed of the existing literature on the otolaryngologic health impacts of climate change and environmental sustainability efforts in surgery with specific attention to studies in otolaryngology - head and neck surgery. FINDINGS: Climate variables including heat and air pollution are associated with increased incidence of allergic rhinitis, chronic rhinosinusitis and head and neck cancer. A number of studies have shown that sustainability initiatives in otolaryngology are safe and provide direct cost benefit. CONCLUSION: Surgeons have the opportunity to lead on climate health and sustainability to address the public health burden of climate change.

Temporomandibular disorder treatment algorithm for otolaryngologists.

OBJECTIVE: To review current literature describing the management of temporomandibular disorder (TMD) and to propose an evidence-based algorithm for otolaryngologists. DATA SOURCES: A literature review using PubMed and Scopus was conducted to identify manuscripts that describe TMJ disorder etiology, diagnostic methods, and management across the fields of otolaryngology, general practice medicine, physical therapy, dentistry, and maxillofacial surgery. REVIEW METHODS: Two reviewers subjectively evaluated the studies based on the inclusion criteria, incorporating them into a comprehensive algorithm. CONCLUSIONS: TMD is one of the most common conditions presenting to otolaryngology outpatient clinics. Etiologies of TMD vary widely, including myofascial, intraarticular, neurologic, traumatic, or psychiatric in origin. When conservative measures fail to produce symptom relief, alternative treatments and referral to outside specialists including psychiatry, physical therapy, dentistry, and maxillofacial surgery may be indicated. Premature or inappropriate referrals may lead to patients suffering TMD for extended periods of time, with alternating referrals between various specialists. Thus, we present a TMD treatment algorithm for otolaryngologists to aid in the decision-making process in managing TMD. IMPLICATIONS FOR PRACTICE: Patients frequently present to otolaryngology outpatient clinics for symptoms of TMD. Multidisciplinary practice may be necessary to effectively treat TMD of varying etiology and severity. Following conservative treatment, appropriate referrals and treatment plans will reduce ineffective use of resources, deferral of treatment, and patient suffering. For this reason, a comprehensive algorithm for otolaryngologists will improve resource utilization and efficiency of treatment to ultimately provide improved treatment outcomes for patients.

Oropharyngeal hemorrhage in patients with COVID-19: A multi-institutional case series.

BACKGROUND: Patients with COVID-19 who are intubated and require mechanical ventilation have been observed to have oropharyngeal bleeding necessitating otolaryngology intervention. METHODS: We report five cases of oropharyngeal hemorrhage in COVID-19 patients on mechanical ventilation requiring evaluation by otolaryngologists at George Washington University Hospital (GWUH) and Boston Medical Center (BMC) from March to April 2020. Institutional Review Board at both institutions exempted this study from informed consent because there were no identifiable patient characteristics, photographs, or imaging studies included. RESULTS: All five patients were managed conservatively; four required packing with Kerlix gauze by an otolaryngologist. Two patients had the additional requirement of extracorporeal membrane oxygenation (ECMO) and associated anticoagulation. Three patients improved with oropharyngeal packing; two had persistent bleeding. Three patients expired. Endotracheal tubes were repositioned less frequently due to the COVID-19 pandemic. CONCLUSIONS: Intubated patients with COVID-19 may have an increased risk of oropharyngeal hemorrhage. This may be due to anticoagulation, prolonged intubation, or decreased frequency of endotracheal tube repositioning. Otolaryngologists should wear appropriate PPE when managing this hemorrhagic complication.

Factors Influencing Underrepresented Medical Students' Career Choice in Surgical Subspecialties.

OBJECTIVES: Surgical subspecialties rank among the least racially and gender diverse of the medical specialties. The purpose of this systematic review is to evaluate the current factors that influence female, gender and sexual minority (GSM), and underrepresented in medicine (URiM)-identifying medical students' decision to pursue a career in a surgical subspecialty. DATA SOURCES: A structured literature search of PubMed, Scopus, Web of Science, and Medline was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Criteria for eligibility included surveys and interviews assessing factors and barriers influencing underrepresented medical students' career choices. REVIEW METHODS: Two independent researchers screened the articles' titles and abstracts for relevance; three performed full-text reviews. RESULTS: Of 343 studies identified, 17 met the inclusion criteria. Fourteen (82%) were survey-based studies; three (18%) were qualitative interviews. Represented minorities included females (14), URiM (13), and GSM (4). Female medical students were most influenced by (1) exposure to surgery, (2) mentorship, and (3) surgical lifestyle. URiM medical students were most influenced by (1) mentorship, (2) culture and diversity, (3) research opportunities, and (4) personality fit. GSM medical students were most influenced by identity acceptance and instances of discrimination and bias. CONCLUSIONS: Our review provides granular data on positive and negative factors influencing career choice among underrepresented medical students to facilitate the development of a more diverse surgical workforce. Female medical students were more positively influenced by increased exposure to surgical subspecialties, whereas URiM medical students were more positively influenced by race-concordant mentorship. Laryngoscope, 134:1498-1506, 2024.

Race and Ethnicity Independently Predict Adverse Outcomes Following Head and Neck Autograft Surgery.

OBJECTIVE: There is growing attention toward the implications of race and ethnicity on health disparities within otolaryngology. While race is an established predictor of adverse head and neck oncologic outcomes, there is paucity in the literature on studies employing national, multi-institutional data to assess the impact of race and ethnicity on head and neck autograft surgery. METHODS: Using the National Surgical Quality Improvement Program (NSQIP) database, trends in 30 days outcomes were assessed. Patients with ICD-10 codes for malignant head and neck neoplasms were isolated. Autograft surgeries were selected using Current Procedural Terminology (CPT) codes for free flap and pedicled flap reconstruction. Primary outcomes included surgical complications, reoperation, readmission, extended length of stay and operation time. Each binary categorical variable was compared to racial/ethnic identity via binary logistic regression. RESULTS: The study cohort consisted of 2447 patients who underwent head and neck autograft surgery (80.71% free flap reconstruction and 19.39% pedicled flap reconstruction). Black patients had significantly higher odds of overall surgical complications (odds ratio [OR] 1.583, 95% confidence interval [CI] 1.091, 2.298, p = 0.016) with much higher odds of perioperative blood transfusions (OR 2.291, 95% CI 1.532, 3.426, p = <.001). Hispanic patients were more likely to undergo reoperation within 30 days after surgery and were more likely to be hospitalized for more than 30 days post-operatively (OR 1.566, 95% CI 1.015, 2.418, p = 0.043 and OR 12.224, 95% CI 2.698, 55.377, p = 0.001, respectively). CONCLUSIONS: Race and ethnicity serve as independent predictors of complications in the post-operative period following head and neck autograft surgery. LEVEL OF EVIDENCE: 3 Laryngoscope, 134:3595-3603, 2024.

Trends of female authorship in head and neck surgery publications over the last decade.

BACKGROUND: While other otolaryngology subspecialties have established female authorship trends, there is no comprehensive study within head and neck surgery (HNS). METHODS: Five researchers recorded the gender identity of first and senior authors from HNS subspecialty papers (head and neck oncology, endocrine surgery, salivary gland pathology, and microsurgery) derived from 10 journals in otolaryngology and oncology in the years 2013, 2016, 2019, and 2022. RESULTS: From 3457 articles, 6901 unique author identities were analyzed. Female authors represented 32% (N = 1103) of first authors and 20% (N = 690) of senior authors. Female authors were less likely to publish in microvascular and reconstructive surgery. Senior female authors were more likely to publish in higher impact journals than male senior authors, and first female authors had an increased likelihood of funding compared to their male counterparts. CONCLUSIONS: While female authors remain underrepresented in certain literature, we illustrate promising trends in productivity, funding allocation, and impact.

Cochlear implantation outcomes in patients with far advanced otosclerosis.

OBJECTIVES: To compare hearing outcomes in patients with far advanced otosclerosis (FAO) undergoing cochlear implantation to an age-matched group of controls, to describe the effects of cochlear ossification on hearing, and to review the adverse effects of implantation in patients with FAO. HYPOTHESIS: Hearing performance in patients with FAO after cochlear implantation is comparable to similarly treated postlingually deafened adults without FAO. Ossification or retrofenestral otosclerosis does not predict poor hearing outcomes. Modiolar-hugging technology reduces postoperative facial nerve stimulation. STUDY DESIGN: Retrospective chart review. SETTING: Academic neurotologic tertiary referral center. PATIENTS: Thirty patients with FAO, who metaudiological criteria for cochlear implantation, were compared to 30 age-matched controls, postlingually deafened by non-otosclerotic causes. MAIN OUTCOME MEASURES: Audiometric pre- and postoperative speech reception threshold, word, and sentence scores were analyzed. The presence of retrofenestral findings on computed tomography or intraoperative cochlear ossification were noted. RESULTS: In the FAO group, radiographic abnormalities were noted in 26.4% of patients. Intraoperative ossification requiring drillout was seen in 29.4% of patients. None developed postoperative facial nerve stimulation. There was no difference between the FAO and control groups in the mean short-term and long-term postoperative speech reception threshold, word, and sentence scores (P = .77). The presence of radiographic abnormalities did not predict hearing outcome. Intraoperative cochlear ossification was not associated with worse short-term word and sentence scores (P = .58 and 0.79, respectively), and for the long-term hearing outcome (P = .24). CONCLUSIONS: In patients with FAO, effective and safe hearing rehabilitation can be accomplished with cochlear implantation.

How Should We Respond to Health Sector Emissions That Exacerbate Climate Change and Inequity?

A warming climate poses substantial risk to public health and worsens existing health inequity. As a contributor to greenhouse gas emissions and air pollution, the health sector has obligations and ample opportunities to protect health by decreasing waste and motivating more system-wide sustainable clinical practices. Such efforts will have important ethical implications for health equity.

Comparison of W-Plasty vs Traditional Straight-Line Techniques for Primary Paramedian Forehead Flap Donor Site Closure.

IMPORTANCE: The paramedian forehead flap (PMFF) donor site scar is hard to disguise and may be a source of patient dissatisfaction. OBJECTIVE: To evaluate the aesthetic outcome of W-plasty vs traditional straight-line (SL) closure techniques of the PMFF donor site. DESIGN, SETTING, AND PARTICIPANTS: A retrospective cohort study was conducted at the University of California, San Francisco Medical Center. Clinical history and operative reports were reviewed for 31 patients who underwent a PMFF procedure performed between November 1, 2011, and May 29, 2014. Blinded photographic analysis of postoperative photographs was performed. INTERVENTIONS: The pedicled component of the PMFF was raised primarily with either a W-plasty or traditional SL design. MAIN OUTCOMES AND MEASURES: Standard photographs of the donor site, obtained at least 90 days after surgery, were reviewed and scored in a blinded fashion by 4 dermatologic surgeons using a 100-point visual analog scale (from 0 [worst possible outcome] to 100 [best possible outcome]) and a 5-point Likert scale (from very poor to excellent). Interrater reliability was assessed via Cronbach α testing. RESULTS: All 31 forehead flaps survived during this study period; 16 PMFFs were raised with the W-plasty technique and 15 were raised with the SL technique. The W-plasty and SL groups were similar in terms of age, sex, and race/ethnicity (mean [SD] age, 68.4 [12.4] vs 61.8 [11.6] years; 13 [84%] vs 9 [60%] men; and 15 [94%] vs 13 [87%] white). Patients undergoing W-plasty closure had significantly higher mean visual analog scale scores compared with those undergoing SL closure (72.8 [18.3] vs 65.6 [18.1]; P = .03). Mean Likert scale scores for W-plasty were higher than those for SL closure, but the difference was not significant (3.77 [1.02] vs 3.43 [0.98]; P = .08). Overall interrater reliability for the visual analog scale and Likert scale scores were 0.67 and 0.58, respectively. CONCLUSIONS AND RELEVANCE: Patients undergoing PMFF donor site closure using a primary W-plasty technique demonstrated better mean scar appearance of the forehead donor site compared with SL closure. The primary W-plasty technique did not result in any PMFF losses and should be considered for appropriate patients. LEVEL OF EVIDENCE: 3.