The Global Otolaryngology-Head and Neck Surgery Workforce.

Importance: A core component of delivering care of head and neck diseases is an adequate workforce. The World Health Organization report, Multi-Country Assessment of National Capacity to Provide Hearing Care, captured primary workforce estimates from 68 member states in 2012, noting that response rates were a limitation and that updated more comprehensive data are needed. Objective: To establish comprehensive workforce metrics for global otolaryngology-head and neck surgery (OHNS) with updated data from more countries/territories. Design, Setting, and Participants: A cross-sectional electronic survey characterizing the OHNS workforce was disseminated from February 10 to June 22, 2022, to professional society leaders, medical licensing boards, public health officials, and practicing OHNS clinicians. Main Outcome: The OHNS workforce per capita, stratified by income and region. Results: Responses were collected from 121 of 195 countries/territories (62%). Survey responses specifically reported on OHNS workforce from 114 countries/territories representing 84% of the world's population. The global OHNS clinician density was 2.19 (range, 0-61.7) OHNS clinicians per 100 000 population. The OHNS clinician density varied by World Bank income group with higher-income countries associated with a higher density of clinicians. Regionally, Europe had the highest clinician density (5.70 clinicians per 100 000 population) whereas Africa (0.18 clinicians per 100 000 population) and Southeast Asia (1.12 clinicians per 100 000 population) had the lowest. The OHNS clinicians deliver most of the surgical management of ear diseases and hearing care, rhinologic and sinus diseases, laryngeal disorders, and upper aerodigestive mucosal cancer globally. Conclusion and Relevance: This cross-sectional survey study provides a comprehensive assessment of the global OHNS workforce. These results can guide focused investment in training and policy development to address disparities in the availability of OHNS clinicians.

Presentation and management of delayed aortic endograft infection.

A man in his 60s who underwent endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm 4 years ago presents with 1 week of abdominal pain, fever and leucocytosis. CT angiogram demonstrated an enlarged aneurysm sac with intraluminal gas and periaortic stranding consistent with infected EVAR. He was clinically unfit for an open surgical intervention due to his significant cardiac comorbidities, including hypertension, dyslipidaemia, type 2 diabetes, recent coronary artery bypass grafting and congestive heart failure secondary to ischaemic cardiomyopathy with an ejection fraction of 30%. Therefore, due to this significant surgical risk, he was treated with percutaneous drainage for the aortic collection and lifelong antibiotics. The patient is well 8 months following presentation with no signs of ongoing endograft infection, residual aneurysm sac enlargement, endoleak or haemodynamic instability.

Laryngopharyngeal reflux induced sleep-related laryngospasm.

BACKGROUND: Sleep-related laryngospasm (SRL) has been defined as the sustained closure of the vocal cords during sleep. Studies have suggested that it is a rare manifestation of laryngopharyngeal reflux (LPR). Difficulties in diagnosing SRL and LPR have led to the condition being under-recognised in the clinical setting. AIMS: The aim of this study was to determine if LPR was the cause of the SRL symptoms seen in our patients. METHODS: A retrospective chart assessment of patients with SRL. Patients with risk factors for LPR were identified. These included smoking status, alcohol intake, a history of dyspepsia or history of gastroesophageal reflux disease, a history of late-night eating and a history of eating spicy or fatty foods before bed. A clinical diagnosis based on the history and response to management was made for the diagnosis of LPR. All were advised to refrain from late meals and those with signs of nasopharyngitis were commenced on proton pump inhibitor therapy. RESULTS: Nineteen patients (mean age ± SD: 57.21 ± 15.18) were included in the study. All had at least one risk factor for LPR. Ten (52.6%) had signs of nasopharyngitis on nasendoscopy. Following treatment, 17 (89.5%) reported no further SRL symptoms at 1-year follow-up. CONCLUSION: SRL is a largely unknown and under-diagnosed condition. We believe this study provides supportive evidence for the causal relationship between LPR and SRL.

The Safety of Early Discharge Following Transcatheter Aortic Valve Implantation Among Patients in Northern Ontario and Rural Areas Utilizing the Vancouver 3M TAVI Study Clinical Pathway.

Background: Early hospital ( < 48 hours) discharge following transcatheter aortic valve implantation (TAVI) is an increasingly adopted practice; however, data on the safety of such an approach among patients residing in North Ontario, including remote and medically underserved areas, are lacking. Methods: This retrospective study included patients who underwent TAVI in Sudbury, Ontario. The safety of early discharge after implementation of the Vancouver 3M (multidisciplinary, multimodality, but minimalist) clinical pathway was assessed. The primary endpoint was 30-day mortality. Resource utilization before vs after 3M clinical pathway implementation was also compared. Results: A total of 291 patients who underwent TAVI between 2012 and 2021 were included in the study. One in-hospital death (0.6%) occurred after the 3M clinical pathway implementation, with no mortality observed beyond hospital discharge. Eleven patients (6.7%) required rehospitalization within 30 days. The need for mechanical ventilation and surgical vascular cut-down declined from 100% and 97%, respectively, at baseline, to 6% and 2%. The number of patients receiving TAVI on a given procedural day increased from 2 to 3 patients. The median post-TAVI hospital length of stay decreased from 5 days (2-6 days) to 1 day (1-3 days) after 3M clinical pathway implementation. Conclusions: Following TAVI, early discharge of selected patients residing in Northern Ontario, including rural areas, using the Vancouver 3M clinical pathway was associated with favourable outcomes, short length of stay, and more-efficient resource utilization. These data can help improve healthcare efficiency and bridge variations in TAVI funding and accessibility in underserved locations.

Contexte: Il est de plus en plus admis d'accorder un congé rapide de l'hôpital (< 48 heures) après une implantation valvulaire aortique par cathéter (IVAC); toutefois, on ne dispose pas de données sur l'innocuité de cette pratique pour les patients du nord de l'Ontario, y compris ceux qui résident en régions éloignées moins bien desservies par les services médicaux. Méthodologie: Cette étude rétrospective a porté sur des patients ayant subi une IVAC à Sudbury (Ontario). L'innocuité d'un congé rapide après l'implantation selon le parcours de soins Vancouver 3M (multidisciplinaire, multimodal, mais minimaliste) a été évaluée. Le principal paramètre d'évaluation était la mortalité à 30 jours. Une comparaison de l'utilisation des ressources avant et après la mise en œuvre du parcours de soins 3M a également été effectuée. Résultats: Au total, 291 patients ayant subi une IVAC entre 2012 et 2021 ont été inclus dans l'étude. Un décès à l'hôpital (0,6 %) est survenu après la mise en œuvre du parcours de soins 3M, et aucune mortalité n'a été relevée après le congé de l'hôpital. Onze patients (6,7 %) ont dû être réhospitalisés dans les 30 jours suivants. Le recours à la ventilation mécanique et à la dénudation vasculaire a chuté, passant de 100 % et 97 % au départ, respectivement, à 6 % et 2 %. Le nombre de patients par jour d'intervention subissant une IVAC est passé de deux à trois patients. À la suite de la mise en œuvre du parcours de soins 3M, la durée médiane du séjour à l'hôpital après une IVAC est passée de cinq jours (deux à six jours) à un jour (un à trois jours). Conclusions: Après une IVAC, le congé rapide de patients sélectionnés habitant dans le nord de l'Ontario, y compris ceux habitant en région rurale, selon le parcours de soins Vancouver 3M a été associé à des résultats de santé favorables, à une durée courte d'hospitalisation et à une utilisation plus efficace des ressources. Ces données peuvent contribuer à améliorer l'efficacité des soins de santé et à combler des écarts liés aux variations du financement et de l'accessibilité des IVAC dans les régions moins bien desservies.

The Quality of Otology and Neurotology Research in Otology Journals.

OBJECTIVE: To establish the level of evidence and publishing trends in otology-specific journals over a 20-year period. DESIGN: Retrospective analysis. METHODS: The three O/N specific journals with the highest Eigenfactor scores were identified. All articles published in the years 1998, 2008, and 2018 were reviewed and level of evidence (LoE) based on standards set by the Oxford Centres for Evidence Based Medicine was assigned by two independent reviewers. One way analysis of variance and 95% bootstrap sensitivity analysis were performed. RESULTS: A total of 1,062 studies were published over 20 years, of these 809 (76.2%) were eligible for inclusion in the present study. The average number of publications per year increased over time. The average LoE improved significantly over the total interval (-0.235, p = 0.027, [CI -0.45, -0.019]), however did not between 1998 and 2008 (p = 0.111) or between 2008 and 2018 (p = 1). When looking at just LoE 1 or 2, the number and percentage of higher quality papers improves over time-48/158 (30.4%) in 1998, rising to 94/250 (37.6%) in 2008, and 158/401 (39.4%) in 2008. CONCLUSIONS: Over the past two decades there has been an overall increase in the quantity and quality (as measured by LoE) of publications in O/N-specific journals. In general, quality of O/N studies is slightly better in O/N-specific journals compared with general OHNS journals. However, there are still improvements to be had in the proportion of high-evidence publications, as they still number less than half of all total publications in the subspecialty.

Appropriateness for SARS-CoV-2 vaccination for otolaryngologist and head and neck surgeons in case of pregnancy, breastfeeding, or childbearing potential: Yo-IFOS and CEORL-HNS joint clinical consensus statement.

PURPOSE: SARS-CoV-2 vaccines are a key step in fighting the pandemic. Nevertheless, their rapid development did not allow for testing among specific population subgroups such as pregnant and breastfeeding women, or elaborating specific guidelines for healthcare personnel working in high infection risk specialties, such as otolaryngology (ORL). This clinical consensus statement (CCS) aims to offer guidance for SARS-CoV-2 vaccination to this high-risk population based on the best evidence available. METHODS: A multidisciplinary international panel of 33 specialists judged statements through a two-round modified Delphi method survey. Statements were designed to encompass the following topics: risk of SARS-Cov-2 infection and use of protective equipment in ORL; SARS-Cov-2 infection and vaccines and respective risks for the mother/child dyad; and counseling for SARS-CoV-2 vaccination in pregnant, breastfeeding, or fertile healthcare workers (PBFHW). All ORL PBFHW were considered as the target audience. RESULTS: Of the 13 statements, 7 reached consensus or strong consensus, 2 reached no consensus, and 2 reached near-consensus. According to the statements with strong consensus otorhinolaryngologists-head and neck surgeons who are pregnant, breastfeeding, or with childbearing potential should have the opportunity to receive SARS-Cov-2 vaccination. Moreover, personal protective equipment (PPE) should still be used even after the vaccination. CONCLUSION: Until prospective evaluations on these topics are available, ORL-HNS must be considered a high infection risk specialty. While the use of PPE remains pivotal, ORL PBFHW should be allowed access to SARS-CoV-2 vaccination provided they receive up-to-date information.

Sleeping beauties in the otolaryngology-head & neck surgery literature.

INTRODUCTION: "Sleeping Beauties" (SBs) are articles that receive little attention in the literature for many years after publication but suddenly "awaken" at a later date to greatly increased relevance. This effort represents the first attempt at identifying SBs within the otolaryngology literature. METHODS: The Web of Science Database was queried for all papers under the section "Otolaryngology" between 1945 and 2007. All papers were assigned a "Beauty Coefficient" (B), based on an a priori formula. Three groups were analyzed: 1) highest overall SBs, 2) clinically significant SBs (papers with greater than 100 total citations), and 3) modern SBs (published 1988 and later). RESULTS: 80,532 papers were identified, with SB able to be calculated in 79,523. Papers spanned a wide array of topics within the Otolaryngology literature. Unlike analysis of SBs in other disciplines, no obvious patterns or themes appeared consistently within or between any of the three groups. CONCLUSIONS: This study represents the first known analysis of SBs in our field. While no obvious patterns or unifying themes were observed, this analysis highlights the clinical impact of SBs and underscores the idea that in this surgical field, important ideas may be proposed "ahead of their time." LEVEL OF EVIDENCE: NA Laryngoscope, 130:609-614, 2020.

Reference Errors in Otolaryngology-Head and Neck Surgery Literature.

Objective Proper use of citation and quotation is crucial to the integrity of the medical literature. The purpose of this study was to determine the prevalence of quotation and citation errors in otolaryngology-head and neck surgery (OHNS) journals and how they have changed over time. Study Design Literature review. Methods Fifty references were randomly selected from the first published issue of 2017 for 8 leading OHNS journals. These were analyzed for errors in citation (data elements by which the article is referenced) and quotation (factual inaccuracies of the reference). Citation errors were categorized as major, intermediate, or minor. Quotation errors were categorized as major or minor. Results were compared with data from 1997 articles. Results Citation errors occurred in 17% of all references studied, with 34% classified as major. Quotation errors occurred in 9%, with 69% classified as major. There was no association between journal impact factor and total number of errors ( r = -0.33, P = .42). This compares with a 37% citation error rate (32% major) and 17% quotation error rate (65% major) from 1997. Conclusion Citation and quotation errors are still prevalent in the OHNS literature albeit decreased from previously reported data. Improvement in citation errors may be due to technological improvements in reference management. However, it is the continued responsibility of the authors, reviewers, and editors to further reduce error rates to maintain the integrity of our publications.

Functional and psychological impact of nasal bone fractures sustained during sports activities: A survey of 87 patients.

Nasal bone fractures that require reduction are a common sequela of sports injuries. We conducted a survey to ascertain the outcomes of patients who had experienced a nasal bone fracture and who subsequently underwent manipulation under anesthesia. We reviewed data on 217 nasal bone fractures that had been seen at our institution over a 3-year period. Of these, 133 (61.3%) had occurred as a result of a sports activity. Thirty of the 133 patients (22.6%) had been managed conservatively, while the other 103 (77.4%) had undergone manipulation under anesthesia. We were able to contact 87 of the 103 patients (84.5%) by telephone, who served as the study population. The most common sports associated with these 87 injuries were hurling (n = 26; 29.9%), rugby (n = 22; 25.3%), Gaelic football (n = 20; 23.0%), and soccer (n = 13; 14.9%). Patients who had undergone treatment within 2 weeks were significantly more satisfied with their outcome than were those who had been treated later (p < 0.01). Twenty-six patients (29.9%) reported that their injury had had a detrimental impact on their subsequent performance in their sport; 12 (13.8%) described a fear of reinjury when they returned to play, 7 (8.0%) experienced functional problems, 3 (3.4%) complained of diminished performance, and 4 others (4.6%) quit playing contact sports altogether. To the best of our knowledge, our study is the first to demonstrate that a fracture of the nasal bones may have a notable psychological impact on an athlete and that it can lead to diminished performance or a complete withdrawal from contact sports.

A case of failed eradication of cystic fibrosis-related sinus colonisation by Pseudomonas aeruginosa.

BACKGROUND: Pseudomonas aeruginosa is a pathogen associated with cystic fibrosis that has potential to decrease lung function and cause respiratory failure. Paranasal sinuses are increasingly recognised as potential reservoirs for intermittent colonisation by P. aeruginosa. This case documents investigation and outcome of P. aeruginosa recurrence in a male paediatric patient over an eight year period. CASE PRESENTATION: A 12 year old Irish male paediatric cystic fibrosis patient experienced intermittent culturing of P. aeruginosa from the oropharyngeal region, indicating chronic infection of the sinuses despite absence of symptoms, retaining good lung function, and normal bronchoscopy and bronchoalveolar lavage. However, P. aeruginosa was isolated from a sinus wash-out and was identified as a unique strain of P. aeruginosa that was also cultured from cough swabs. Despite treatment, successful eradication from the paranasal sinuses was not achieved. CONCLUSIONS: Few reports have addressed the paranasal sinuses as a reservoir for lung infection in cystic fibrosis patients despite increased recognition of the need to investigate this niche. In this case, attempts at eradication of P. aeruginosa present in paranasal sinuses including oral and nebulised antimicrobials proved unsuccessful. However, detection of P. aeruginosa in the paranasal sinuses instigated antimicrobial treatment which may have contributed to prevention of migration to the lower airways. Our outcome provides additional insight and may indicate utility of nasal lavage or nasal endoscopy in paediatric cystic fibrosis patients' annual review clinic visits.

Lipomas of the submandibular space: case report of a sialolipoma and review of diagnostic investigations available.

This report describes and discusses the radiologic investigations available for the investigation of fatty tumors of the submandibular triangle, with a focus on sialolipomas. A 33-year-old woman presented with a 3-year history of a slowly growing, painless mass in her right submandibular region. She underwent multiple imaging modalities before having a histologic diagnosis of a sialolipoma. To the best of the authors' knowledge, this is the first reported case using ultrasound, computed tomography (CT), and magnetic resonance imaging (MRI) for investigation of a sialolipoma of the submandibular gland region. Ultrasound and fine-needle aspiration offer a tentative diagnosis of a lipoma without the associated radiation and cost associated with CT and MRI, respectively. CT and MRI offer the definite diagnosis of a lipoma, with MRI depicting better delineation and the ability to identify glandular elements of the tumor. Importantly, the development of sarcomatous change within the lipoma cannot be out ruled at imaging and requires a histologic specimen.

Hyoid bone tenderness as a clinical indicator of laryngeal pathology.

OBJECTIVES: Hyoid bone tenderness is an underemphasized clinical abnormality and is described as discomfort or pain on gentle palpation of the greater cornu. The primary outcome of this study is to assess if there is any association between hyoid tenderness and laryngeal pathology. STUDY DESIGN: This is a retrospective case-control study. METHODS: Ninety-four subjects were identified. These were divided into two groups, those with hyoid tenderness and those without hyoid tenderness. Presenting complaints and findings on nasal laryngoscopy were compared to identify any association between hyoid tenderness and laryngeal pathology. RESULTS: There were a total of 76 (80.9%) female and 18 (19.1%) male patients in the study. Analysis of presenting complaints showed that dysphonia (P < 0.001, odds ratio = 4.82) and neck pain (P = 0.015, odds ratio = 10.9) were significantly associated with hyoid tenderness, more with these symptoms had hyoid tenderness than expected by chance. Findings on nasal laryngoscopy showed a significant association between hyoid tenderness and vocal fold nodules (P < 0.001). Nasopharyngitis (P = 0.065) and tense anterior neck muscles (P = 0.056) were almost significantly associated with hyoid tenderness. CONCLUSION: Hyoid tenderness has previously been reported as an early sign in acute epiglottitis. These results indicate that hyoid bone tenderness may be a useful clinical indicator of various other laryngeal pathologies or dysfunctions.

A century of citation classics in otolaryngology-head and neck surgery journals revisited.

OBJECTIVES/HYPOTHESIS: Citation classics have traditionally been defined in the smaller medical specialties as any article published in a peer-reviewed journal that has received 100 or more citations from other articles also published in peer-reviewed journals. This study aimed to determine patterns of citation classics changes in the medical field otorhinolaryngology and head and neck surgery (OHNS) over the past decade and serves as a follow-up to an original study published in 2002, "A Century of Citation Classics in Otolaryngology-Head & Neck Surgery." STUDY DESIGN: Bibliometric analysis. METHODS: Using the Journal Citation Reports and Web of Science, OHNS journals were selected and assessed for the content of citation classics. RESULTS: Nine-hundred five citation classics were found, over 11-fold more than 1 decade prior. Other significant changes were seen in country of origin, decade of publication, number of authors per article, subspecialty of article, and most frequently discussed topics. CONCLUSIONS: The dramatic rise in quantity and nature of citation classics in the past decade may be due to unprecedented advancements in information technology and communication, allowing studies and experiments to be performed, written, reviewed, published, and cited at rapid rates. LEVEL OF EVIDENCE: NA.

The effect of passive smoking on the levels of matrix metalloproteinase 9 in nasal secretions of children.

BACKGROUND: Matrix metalloproteinase (MMP) 9 is a gelatinase associated with tissue remodeling. It is thought to play a part in the pathogenesis of allergy. Increased levels of MMP-9 have been shown to increase in the acute allergic response in the nose, lungs, and skin. Exposure to passive tobacco smoke is associated with an increase in sneezing, nasal blockage, and a decreased sense of smell. The aim of this study was to study the effect of passive smoking on the levels of MMP-9 in nasal secretions of children. METHODS: A prospective descriptive study was performed. Thirty-nine children aged between 7 and 16 years were enrolled in the study. They were selected based on attendance at the Otorhinolaryngology Outpatients Clinic with a primary complaint unrelated to the nose or paranasal sinuses. Children with allergic rhinitis, sinusitis, or a recent cold were excluded. The study was performed at a tertiary pediatric referral center. Exposure to passive smoking was determined by measuring the urinary cotinine to creatinine ratio. Nasal fluid was obtained by using a Rhino-Probe curette (Arlington Scientific, Inc., Springville, UT). The concentration of MMP-9 was determined by ELISA. MMP-9 activity was determined by gelatin zymography. Data were tabulated on Microsoft Excel (Microsoft Corp., Redmond, WA) and analyzed using SPSS (SPSS Inc., Chicago, IL). RESULTS: Using a cutoff urinary cotinine/creatinine ratio of 0.025 ng/mg, 15 children were found to be exposed to passive smoking. Both the MMP-9 concentration and the activity were significantly higher in nasal secretions of children exposed to passive smoking. There was a distinct difference between the two cohorts with regard to the level of enzyme activity per weight of protein. The lowest level of enzyme activity recorded in the "exposed" cohort was over twice that of the level in the "not exposed" cohort. CONCLUSION: MMP-9 activity and concentration is higher in nasal secretions of children exposed to passive smoking. This suggests that passive smoking might alter the inflammatory response within the nasal mucosa in a similar way to allergy.

Return to contact sports following infectious mononucleosis: the role of serial ultrasonography.

Splenic rupture is a rare but potentially fatal complication of infectious mononucleosis. Athletes returning to contact sports following infectious mononucleosis are at potential risk of splenic rupture secondary to abdominal trauma. No clear consensus exists as to when it is safe to allow these athletes to return to contact sports. Suggested periods of abstinence have ranged from 2 weeks to 6 months. We outline our experiences with the use of abdominal ultrasonography at 1 month after the diagnosis of infectious mononucleosis as a means of determining when athletes can safely return to contact sports. Our study group was made up of 19 such patients (mean age: 16.7 yr). We found that 16 of these patients (84%) had normal splenic dimensions on ultrasonography 1 month after diagnosis, and they were therefore allowed to return to contact sports. While the remaining 3 patients had an enlarged spleen at 1 month, their splenic dimensions had all returned to normal when ultrasonographic examination was repeated at 2 months postdiagnosis. We conclude that serial abdominal ultrasonography allows for informed decision making in determining when athletes can safely return to contact sports following infectious mononucleosis.