Pain management and prescribing practices in otolaryngology residency programs.

PURPOSE: To understand the knowledge, competency and influencing factors regarding postoperative opioid prescribing practices among Otolaryngology Residents. To understand the educational background and resources regarding pain management and opioid prescribing among Otolaryngology Residency Programs. MATERIALS AND METHODS: An anonymous electronic survey was distributed to Otolaryngology residents in the greater New York City area. Subjects reported their preferred pain management prescription for eight common otolaryngology surgeries. Questions addressed opioid and non-opioid prescribing influences, use/knowledge of pain management resources, and prior opioid prescribing education (OPE). An anonymous survey was distributed to US Otolaryngology Program Directors addressing resident prescribing influences and OPE in residency training programs. RESULTS: Thirty-Five residents and fifteen PDs participated. Resident opioid prescribing was widely variable with averages ranging from 3.8 to 21.1 narcotic pills among eight standard otolaryngology surgeries. Attending/senior preference was believed to largely influence resident prescribing habits among residents (3.66, ±6.68), and PDs (4.73, ±0.46). Only 20% of programs had formal OPE in place, consistent with the 65.71% of residents who reported no prior OPE. CONCLUSIONS AND RELEVANCE: A large inconsistency in Otolaryngology resident postoperative pain management exists, despite their responsibility to provide analgesic therapy. The lack of formal OPE programs in US Otolaryngology residency programs may lead to outside factors unrelated to surgery influencing these prescribing practices. This brings light to the need of Otolaryngology Resident OPE to assist in standardizing prescribing practices, provide meaningful patient education on opioid use and disposal and educate residents on the risk assessment tools offered to provide the most appropriate and safe analgesic therapy to patients.

Surgical Techniques for Head and Neck Reconstruction in the Vessel-Depleted Neck.

The vessel-depleted neck presents a unique and challenging scenario for reconstructive surgery of the head and neck. Prior surgery and radiation often result in significant scarring and damage to the neck vasculature, making identification of suitable recipient vessels for microvascular free tissue transfer exceedingly difficult. Therefore, alternative reconstructive techniques and/or vessel options must be considered to obtain a successful reconstructive outcome for a patient. In this article, we discuss our experience and approach to the management of the vessel-depleted neck, emphasizing the importance of preoperative planning and having multiple backup options prior to surgery. The various preoperative imaging modalities and available options for recipient arteries and veins are presented in detail. Additionally, we discuss modifications of select free flaps to maximize their utility in successful reconstruction. Together with thoughtful preoperative planning, these techniques can help aid the reconstructive surgeon in addressing the complex decisions associated with the vessel-depleted neck.

Syphilis of the oropharynx: Case series of "The Great Masquerader".

OBJECTIVE: Syphilis is a sexually transmitted infection with various presentations. Although, oropharyngeal manifestations are known to occur, the purpose of this study is to present the first case series in which the lesions were initially mistaken for human-papillomavirus (HPV)-related oropharyngeal squamous cell carcinoma (OPSCC). METHODS: A multi-institutional retrospective review. RESULTS: Six cases of oropharyngeal syphilis were initially thought to be secondary to OPSCC due to presentation. Symptoms were vague and exam findings consisted of either a tonsillar or base of tongue mass, or lymphadenopathy. Biopsies were negative for OPSCC. Further workup diagnosed syphilis, with resolution of symptoms and lesions after antibiotic treatment. CONCLUSIONS: Head and neck manifestations of syphilis have been reported in the literature. However, this is the first series reporting on oropharyngeal syphilis masquerading as HPV-related OPSCC. Ultimately, otolaryngologists must maintain a high suspicion for syphilis in order to ensure prompt diagnosis and treatment.

Total mandibulectomy defect in the setting of chronic bisphosphonate use.

Bisphosphonates are among several drugs known in modern medicine to have a potentially deleterious effect on the mandible with chronic use. While purportedly causing a necrotic reaction in the bone, the complete mechanism is not fully elucidated yet as cases are quite rare in the general public. Despite the esoteric nature of this entity, patients suffering from bisphosphonate induced necrosis have a complicated and prolonged course often involving varying degrees of mandibular debridement with severe cases requiring reconstruction. In this report, we present the unique case of a patient with a progressive mandibular osteonecrosis requiring complete mandibulectomy and fibula flap reconstruction.

Surgical management of temporal bone osteoradionecrosis: Single surgeon experience of 47 cases.

PURPOSE: To report the outcomes of 47 patients with temporal bone osteoradionecrosis treated primarily with surgical resection in order to analyze whether flap type and hyperbaric oxygen use affect wound breakdown. MATERIALS AND METHODS: Between January 1998 and January 2016, 47 patients were treated for temporal bone osteoradionecrosis with surgery. Some patients were also treated with hyperbaric oxygen. Resection of grossly necrotic temporal bone was followed by immediate reconstruction with local, regional, or free flaps. Minimum follow-up was 6months. If patients had breakdown of their initial reconstructions, secondary reconstruction was performed with either a regional or free flap. During the post-operative period, wound breakdown, flap complications, and patient survival were noted. RESULTS: 30 patients developed ORN from primary radiotherapy while 17 had post-operative radiation. It was found that wound breakdown was significantly associated with type of flap reconstruction (p=0.02) with local flap reconstruction portending a poorer prognosis. Hyperbaric oxygen was not associated with decreased wound breakdown (p=0.5). CONCLUSIONS: Surgical treatment can be an effective treatment for temporal bone osteoradionecrosis, without hyperbaric oxygen providing any additional benefit. Reconstruction with regional or free flaps may be a more reliable method to resurface defects compared to local flaps.

The role of intraoperative nerve monitoring in tracheal surgery: 20-year experience with 110 cases.

PURPOSE: To determine the utility of intraoperative nerve monitoring (IONM) during tracheal resection or slide tracheoplasty to prevent recurrent laryngeal nerve injury. METHODS: 110 patients underwent tracheal resection or tracheoplasty between 1997 and 2016. During the first 10-year period, IONM was not used while during the second 10-year period, IONM was used. 49 patients had surgery without IONM while 61 had surgery with IONM. During the post-operative period, patients with nerve injury were compared to determine if significant difference existed between the two modalities. RESULTS: In patients who had surgery without IONM, 7 (14.2%) patients were found to have compromised nerve function whereas 8 (13.1%) patients in the group with IONM had nerve injury. 3 patients regained function in the first group while four regained function in the second. A Fisher's exact test was run on the entire cohort and the difference in vocal fold injury was not found to be statistically significant (p > 0.05). CONCLUSION: Based on this single surgeon experience, there may be no protective benefit with the use of IONM during tracheal surgery.

Multiflap closure of scalp defects: Revisiting the orticochea flap for scalp reconstruction.

Reconstruction of the scalp following oncologic resection is a challenging undertaking owing to the variable elasticity of the soft tissue overlying the calvarium and the limited amount of tissue available for recruitment. Defect size, location, and skin characteristics heavily influence the reconstructive options available to the surgeon. Reconstruction options for scalp defects range from simple direct closure, to skin grafting, to adjacent tissue transfer with local flaps, and ultimately to free tissue transfer. Dermal regeneration templates have also gained popularity in the recent past. Often times a primary closure with multiple local flaps can be a prime choice in these scenarios. One such modality of multi-flap closure, the Orticochea flap, is an excellent option for scalp reconstruction as it decreases operative time, may provide hair-bearing skin, and potentially avoids the risks of general anesthesia in debilitated patients. We present an interesting case of a patient with a large scalp defect following melanoma excision that was successfully reconstructed with an Orticochea flap. A review of scalp reconstruction and uses of the Orticochea flap will follow the case presentation.

National Survey of Otolaryngology Program Directors Regarding Recruitment Methods for Underrepresented in Medicine Residents.

OBJECTIVE: To characterize Otolaryngology residency program strategies for recruiting underrepresented minorities in medicine (URiM) residents and their perceived effectiveness, and explore perceived barriers to recruitment. DESIGN: We conducted a survey of Otolaryngology program directors (PDs) at the 122 accredited programs within the United States, utilizing a validated and previously published survey utilized within the OB-GYN literature. We solicited information regarding recruitment of underrepresented minorities in medicine (URiM) applicants, effectiveness of strategies, and perceived barriers in recruitment. SETTING: A national survey of U.S. accredited residency programs in Otolaryngology in 2022-2023. RESULTS: A total of 42 (34%) PDs responded. 55% of programs reported an increase in URiM residents, of which 18(43%) described an intentional change. Almost all PDs reported placing at least "some" significance in the recruitment of URiM residents (95%). Statistically significant differences were seen in recruitment methods between programs that saw an increase in URiM resident recruitment an those that did not. Additionally, Program Directors believed that increased face-face interaction with applicants were the most effective forms of recruitment. PDs found the biggest challenge to recruitment was a lack of diverse applicants (6.3/10) and faculty (5.8/10). This perception did not change when adjusted for programs that saw an increase in URiM trainee recruitment. CONCLUSIONS: This study demonstrates the URiM resident recruitment practices and perceived effectiveness of these strategies within otolaryngology programs nationally. The results and analysis may provide programs who are looking to diversify their workforce with some effective and meaningful strategies to start the process.

Intraoperative Use of Wide-Field Optical Coherence Tomography to Evaluate Tissue Microstructure in the Oral Cavity and Oropharynx.

Importance: Involvement of deep margins represents a significant challenge in the treatment of oropharyngeal cancer, and given practical limitations of frozen-section analysis, a need exists for real-time, nondestructive intraoperative margin analysis. Wide-field optical coherence tomography (WF-OCT) has been evaluated as a tool for high-resolution adjunct specimen imaging in breast surgery, but its clinical application in head and neck surgery has not been explored. Objective: To evaluate the utility of WF-OCT for visualizing microstructures at margins of excised oral and oropharyngeal tissue. Design, Setting, and Participants: This nonrandomized, investigator-initiated qualitative study evaluated the feasibility of the Perimeter Medical Imaging AI Otis WF-OCT device at a single academic center. Included participants were adults undergoing primary ablative surgery of the oral cavity or oropharynx for squamous cell carcinoma in 2018 and 2019. Data were analyzed in October 2019. Exposures: Patients were treated according to standard surgical care. Freshly resected specimens were imaged with high-resolution WF-OCT prior to routine pathology. Interdisciplinary interpretation was performed to interpret WF-OCT images and compare them with corresponding digitized pathology slides. No clinical decisions were made based on WF-OCT image data. Main Outcomes and Measures: Visual comparisons were performed between WF-OCT images and hematoxylin and eosin slides. Results: A total of 69 specimens were collected and scanned from 53 patients (mean [SD] age, 59.4 [15.2] years; 35 [72.9%] men among 48 patients with demographic data) undergoing oral cavity or oropharynx surgery for squamous cell carcinoma, including 42 tonsillar tissue, 17 base of the tongue, 4 buccal tissue, 3 mandibular, and 3 other specimens. There were 41 malignant specimens (59.4%) and 28 benign specimens (40.6%). In visual comparisons of WF-OCT images and hematoxylin and eosin slides, visual differentiation among mucosa, submucosa, muscle, dysplastic, and benign tissue was possible in real time using WF-OCT images. Microarchitectural features observed in WF-OCT images could be matched with corresponding features within the permanent histology with fidelity. Conclusions and Relevance: This qualitative study found that WF-OCT imaging was feasible for visualizing tissue microarchitecture at the surface of resected tissues and was not associated with changes in specimen integrity or surgical and pathology workflow. These findings suggest that formal clinical studies investigating use of WF-OCT for intraoperative analysis of deep margins in head and neck surgery may be warranted.

Descriptors in Letters of Recommendation for Otolaryngology Residency Across Gender, Race, and Time.

OBJECTIVE: To determine whether differences exist in the descriptors used in letters of recommendations for Otolaryngology - Head and Neck Surgery (OHNS) residency candidates, comparing race and gender as depicted in visual letters of recommendation (VLORs) from the 2014 and 2019 application cycles. DESIGN: Four hundred thirty-three LORS (284 narrative LORs and 149 standardized LORs) and 63 medical student performance evaluations for 104 candidates who interviewed at the University of Cincinnati OHNS residency program in 2014 and 2019 were analyzed. Descriptors from LORs and medical student performance evaluations were collected by two reviewers and QSR NVivo 12 was used to generate a word cloud that grouped words by synonym and weighted them by frequency. Reviewers coded these synonyms into one of eight descriptor categories. Race and gender were self-reported from residency applications. The average of each category frequency for each race and gender were compared using student t-tests. SETTING: University of Cincinnati OHNS Residency Program. PARTICIPANTS: 104 OHNS applicants that interviewed at the University of Cincinnati in 2014 and 2019. RESULTS: Of the 104 candidates reviewed, 39 were female (37.5%). 66/104 (63%) of applicants identified as white, 31/104 (30%) as non-white, and 7/104 (7%) preferred not to say. No significant differences were found between male vs female descriptors. However, white applicants had more "leadership" descriptors (1.3% vs 0.5%, p = 0.01) and fewer "intelligence" words (6.6% vs 4.8%, p = 0.02) than non-white applicants. Applicants in 2019 were described with more team player (14.2% vs 9.6%, p < 0.0001), leadership (1.6% vs 0.7%, p = 0.047), and reserved (1.7% vs 0.7%, p = 0.02) words, but fewer grindstone (25.2% vs 32.1%, p < 0.0001) and ability/agentic (27.9% vs 32.6%, p < 0.0001) words than applicants in 2014. CONCLUSIONS: In VLORs for OHNS residency, male and female applicants are described similarly, but white applicants are described as leaders more frequently and as intelligent less frequently than non-white counterparts. Regardless, it is encouraging to see applicants described with a more humanistic vocabulary in 2019.