Prediction of plan adaptation in head and neck cancer proton therapy using clinical, radiographic, and dosimetric features.

PURPOSE: Because proton head and neck (HN) treatments are sensitive to anatomical changes, plan adaptation (re-plan) during the treatment course is needed for a significant portion of patients. We aim to predict re-plan at plan review stage for HN proton therapy with a neural network (NN) model trained with patients' dosimetric and clinical features. The model can serve as a valuable tool for planners to assess the probability of needing to revise the current plan. METHODS AND MATERIALS: Mean beam dose heterogeneity index (BHI), defined as the ratio of the maximum beam dose to the prescription dose, plan robustness features (clinical target volume (CTV), V100 changes, and V100 > 95% passing rates in 21 robust evaluation scenarios), as well as clinical features (e.g., age, tumor site, and surgery/chemotherapy status) were gathered from 171 patients treated at our proton center in 2020, with a median age of 64 and stages from I-IVc across 13 HN sites. Statistical analyses of dosimetric parameters and clinical features were conducted between re-plan and no-replan groups. A NN was trained and tested using these features. Receiver operating characteristic (ROC) analysis was conducted to evaluate the performance of the prediction model. A sensitivity analysis was done to determine feature importance. RESULTS: Mean BHI in the re-plan group was significantly higher than the no-replan group (p < .01). Tumor site (p < .01), chemotherapy status (p < .01), and surgery status (p < .01) were significantly correlated to re-plan. The model had sensitivities/specificities of 75.0%/77.4%, respectively, and an area under the ROC curve of .855. CONCLUSION: There are several dosimetric and clinical features that correlate to re-plans, and NNs trained with these features can be used to predict HN re-plans, which can be used to reduce re-plan rate by improving plan quality.

Impact of the Standardized Interview Offer Date Initiatives: A Survey of Otolaryngology Applicants and Programs.

OBJECTIVE: To investigate residency applicant and program compliance with and attitudes toward a newly implemented standardized interview offer date program. STUDY DESIGN: Cross-sectional survey. SETTING: US Otolaryngology-Head and Neck Surgery training programs. METHODS: An electronic survey was distributed to applicants during match week in March 2022, and to program directors and program managers shortly after. The surveys included questions assessing program compliance with the standardized interview offer date as well as both applicant and program attitudes toward this newly implemented initiative. RESULTS: This study achieved a 47% (263/559) response rate from applicants and 57% (68/120) from programs. Both applicants and program directors reported high program compliance with this initiative. Ninety-six percent of program directors reported complying with releasing interview offers on 1 standardized day. Applicants endorsed a reduction in their anxiety surrounding the residency application process as well as an increased ability to engage in the fourth year of medical school as benefits of the initiative. Providing clarity surrounding the applicant's final application status and further standardization of the interview scheduling process were identified as areas for improvement. CONCLUSION: Standardization of residency interview offer and acceptance practices is both feasible and impactful. Providing applicants with a final applicant status and further efforts to improve the interview scheduling process may continue to bolster this initiative in future years.

Impact of Preference Signaling on Residency Interview Distribution Among Otolaryngology-Head and Neck Surgery Applicants.

OBJECTIVE: This study investigates interview offer distribution among applicants of varying levels of competitiveness in a residency application cycle with and without preference signaling. DESIGN AND SETTING: Self-reported applicant survey data evaluating the 2021-2022 Otolaryngology-Head and Neck Surgery residency signal experience was used to investigate the current distribution of interview offers among applicants. These data then informed a model to assess the distribution of interview offers without signaling in place. PARTICIPANTS: 260 (47% response rate) Otolaryngology-Head and Neck Surgery residency applicants who responded to the survey. RESULTS: Applicants were divided into four quartiles based on their overall interview offer rate (self-reported number of interviews/self-reported number of applications submitted). Applicants in the top quartile received fewer interview offers while applicants in all other quartiles received more interview offers when signaling was introduced. CONCLUSIONS: Our data demonstrate that when signaling is introduced, interviews are more evenly distributed among applicants.

Two-Year Interview and Match Outcomes of Otolaryngology Preference Signaling.

OBJECTIVE: To present the first year-over-year data comparison of preference signaling for residency interviews in the otolaryngology application marketplace. STUDY DESIGN: Cross-sectional study conducted over 2 application cycles. SETTING: Otolaryngology training programs in the United States. METHODS: Otolaryngology residency applicants were invited to participate in preference signaling during the 2021 and 2022 application cycles. Submissions were collected using a web-based interface. The distribution of signals among programs was evaluated descriptively and in relationship to Doximity program reputation rankings. Surveys were sent to applicants to assess general attitudes and the number of interview invitations received from signaled and nonsignaled programs. Surveys were sent to programs to evaluate use of signals and the impact on match results. RESULTS: Programs received a range of signals, from 0 to 66, with 50% of signals going to 24% of programs in 2022, which was similarly found in 2021. Programs of higher rank tended to receive more signals. Overall, >87% of surveyed applicants received an interview offer from at least 1 program that they signaled. In 2021 and 2022, applicants were 2.6 times more likely to get an interview from a signaled program than a comparator nonsignaled program. A greater positive impact on interview offer rate was seen for less competitive applicants. Signaling was viewed favorably by the majority of surveyed applicants and programs. CONCLUSIONS: Preference signaling for otolaryngology residency interviews demonstrates a promising mechanism to improve applicant visibility to programs during the application cycle. This impact is consistent over 2 application cycles.

Impact of COVID-19 on nationwide pediatric otolaryngology practice: Adenotonsillectomies (TA) and tonsil-related diagnoses trends.

OBJECTIVES/HYPOTHESIS: To determine the effects of the COVID-19 pandemic on Adenotonsillectomies (TA), Tonsil Related Cases (TC), and Peritonsillar Abscess (PTA) Trends. STUDY DESIGN: Retrospective Cohort Study. METHODS: This is a retrospective cohort study using the Pediatric Health Information System® (PHIS) database, which consists of 51 children's hospitals. Regions were defined according to PHIS rules with at least five children's hospitals per region. We compared monthly total TA, TC, TC as a proportion of all hospital visits, and PTA from all encounters at each hospital from January 1, 2019, through December 31, 2021. RESULTS: Compared to 2019, April 2020 saw mean TC drop significantly from 371.62 to 68.37 (p < 0.001). Interestingly, June, September, and December 2020 had significantly higher mean TC compared to 2019. TC as a proportion of all hospital visits decreased significantly throughout the majority of 2021. Similarly, TA significantly decreased during 2020 and 2021 across all regions in the US, starting in March 2020 and this reduction in TA extended through the end of 2021 without any signs of recovery. PTA rates did not change significantly over the three years. CONCLUSIONS: The pandemic-plagued 2020 saw a noticeable decrease in overall TC and TA but then rebounded quickly to even higher than pre-pandemic levels. However, this rebound halted for the majority of 2021 and subsequently decreased to lower than pre-pandemic levels, which differs from other communicable pathologies such as otitis media which decreased initially then recovered to pre-pandemic levels by Summer of 2021.

Corticosteroid Use in Otolaryngology: Current Considerations During the COVID-19 Era.

OBJECTIVE: To offer pragmatic, evidence-informed advice on administering corticosteroids in otolaryngology during the coronavirus disease 2019 (COVID-19) pandemic, considering therapeutic efficacy, potential adverse effects, susceptibility to COVID-19, and potential effects on efficacy of vaccination against SARS-CoV-2, which causes COVID-19. DATA SOURCES: PubMed, Cochrane Library, EMBASE, CINAHL, and guideline databases. REVIEW METHODS: Guideline search strategies, supplemented by database searches on sudden sensorineural hearing loss (SSNHL), idiopathic facial nerve paralysis (Bell's palsy), sinonasal polyposis, laryngotracheal disorders, head and neck oncology, and pediatric otolaryngology, prioritizing systematic reviews, randomized controlled trials, and COVID-19-specific findings. CONCLUSIONS: Systemic corticosteroids (SCSs) reduce long-term morbidity in individuals with SSNHL and Bell's palsy, reduce acute laryngotracheal edema, and have benefit in perioperative management for some procedures. Topical or locally injected corticosteroids are preferable for most other otolaryngologic indications. SCSs have not shown long-term benefit for sinonasal disorders. SCSs are not a contraindication to vaccination with COVID-19 vaccines approved by the US Food and Drug Administration. The Centers for Disease Control and Prevention noted that these vaccines are safe for immunocompromised patients. IMPLICATIONS FOR PRACTICE: SCS use for SSNHL, Bell's palsy, laryngotracheal edema, and perioperative care should follow prepandemic standards. Local or topical corticosteroids are preferable for most other otolaryngologic indications. Whether SCSs attenuate response to vaccination against COVID-19 or increase susceptibility to SARS-CoV-2 infection is unknown. Immunosuppression may lower vaccine efficacy, so immunocompromised patients should adhere to recommended infection control practices. COVID-19 vaccination with Pfizer-BioNTech, Moderna, or Johnson & Johnson vaccines is safe for immunocompromised patients.

Scalp and Forehead Injury: Management of Acute and Secondary Defects.

The primary challenges in scalp reconstruction are the relative inelasticity of native scalp tissue and the convex shape of the calvarium. All rungs of the reconstructive ladder can be applied to scalp reconstruction, albeit in a nuanced fashion due to the unique anatomy and vascular supply to the scalp. Important defect variables to incorporate into the reconstructive decision include site, potential hairline distortion, size, depth, concomitant infection, prior radiation therapy, planned adjuvant therapy, medical comorbidities, patient desires, and potential calvarium and dura defects.

Intraoperative Sentinel Events in the Era of Surgical Safety Checklists: Results of a National Survey.

OBJECTIVE: Despite the implementation of advanced health care safety systems including checklists, preventable perioperative sentinel events continue to occur and cause patient harm, disability, and death. We report on findings relating to otolaryngology practices with surgical safety checklists, the scope of intraoperative sentinel events, and institutional and personal response to these events. STUDY DESIGN: Survey study. SETTING: Anonymous online survey of otolaryngologists. METHODS: Members of the American Academy of Otolaryngology-Head and Neck Surgery were asked about intraoperative sentinel events, surgical safety checklist practices, fire safety, and the response to patient safety events. RESULTS: In total, 543 otolaryngologists responded to the survey (response rate 4.9% = 543/11,188). The use of surgical safety checklists was reported by 511 (98.6%) respondents. At least 1 patient safety event in the past 10 years was reported by 131 (25.2%) respondents; medication errors were the most commonly reported (66 [12.7%] respondents). Wrong site/patient/procedure events were reported by 38 (7.3%) respondents, retained surgical items by 33 (6.4%), and operating room fire by 18 (3.5%). Although 414 (79.9%) respondents felt that time-outs before the case have been the single most impactful checklist component to prevent serious patient safety events, several respondents also voiced frustrations with the administrative burden. CONCLUSION: Surgical safety checklists are widely used in otolaryngology and are generally acknowledged as the most effective intervention to reduce patient safety events; nonetheless, intraoperative sentinel events do continue to occur. Understanding the scope, causes, and response to these events may help to prioritize resources to guide quality improvement initiatives in surgical safety practices.

Otolaryngology Match Trends: Considerations for Proper Data Interpretation.

There is an extensive amount of data available from the leading organizations involved in the residency selection process. Tracking trends in otolaryngology residency applications and match outcomes is vital to understand the pipeline of individuals joining our profession. As we make changes to the application or match process, proper interpretation of available data is vital to prevent erroneous analyses and inappropriate conclusions. In the commentary, we explore the nuances of data from the Electronic Residency Application Service and National Residency Matching Program to help our specialty direct research endeavors and policy changes that will ultimately affect the makeup of our future workforce.

COVID-19 Anosmia Reporting Tool: Initial Findings.

There is accumulating anecdotal evidence that anosmia and dysgeusia are associated with the COVID-19 pandemic. To investigate their relationship to SARS-CoV2 infection, the American Academy of Otolaryngology-Head and Neck Surgery developed the COVID-19 Anosmia Reporting Tool for Clinicians for the basis of this pilot study. This tool allows health care providers to confidentially submit cases of anosmia and dysgeusia related to COVID-19. We analyzed the first 237 entries, which revealed that anosmia was noted in 73% of patients prior to COVID-19 diagnosis and was the initial symptom in 26.6%. Some improvement was noted in 27% of patients, with a mean time to improvement of 7.2 days in this group (85% of this group improved within 10 days). Our findings suggest that anomia can be a presenting symptom of COVID-19, consistent with other emerging international reports. Anosmia may be critical in timely identification of individuals infected with SARS-CoV2 who may be unwittingly transmitting the virus.

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.

Patient Safety/Quality Improvement Primer, Part I: What PS/QI Means to Your Otolaryngology Practice.

Patient safety/quality improvement (PS/QI) is the cornerstone of 21st-century health care. Otolaryngology-Head and Neck Surgery is excited to provide a dedicated PS/QI primer. The overarching goal for this PS/QI series is to provide a comprehensive and practical resource that assists readers, authors, and peer reviewers in understanding PS/QI research, its unique methodology, and the associated reporting standards for trustworthy performance measures. The target audience includes resident and fellows, faculty from the private sector and academia, and allied health professionals. This inaugural primer reviews PS/QI background as it relates to otolaryngology practice. It explores the history, goals, and development of performance measurement. In addition, it highlights opportunities for integrating PS/QI into otolaryngology practice. Payers will drive patients to quality care based on outcomes. Otolaryngologists have a responsibility to embrace a culture of PS/QI. In doing so, we will define optimal, quality otolaryngology care through objective data and metrics.

Epidemiology and Management of Pediatric Epistaxis.

Objectives The purpose of this study is to describe the demographics of children undergoing inpatient management of epistaxis and recognize the clinical circumstances that may necessitate embolization or ligation for epistaxis management. Study Design and Setting Cross-sectional analysis of a national database. Subjects and Methods A review of data reported by hospitals in the United States to the Healthcare Cost and Utilization Project Kids' Inpatient Database with a diagnosis of epistaxis was conducted ( International Classification of Diseases, Ninth Revision [ ICD-9] code 784.7). The database provides new data every 3 years. The most recent databases, 2006, 2009, and 2012, were reviewed. Results A total of 11,366 patients with a diagnosis of epistaxis were identified. The average age was 12 years, and most patients were male (60%). Of the patients who underwent intervention for epistaxis, 704 underwent packing, 119 underwent ligation, and 98 underwent embolization. Transfusion of blood or platelets was highest in the patients undergoing packing only (38%, P < .0001). The lowest average length of stay was for the ligation group with a mean (SD) of 6.95 (14.02) days. Embolization and ligation most frequently occurred in the setting of an urban teaching hospital (95.63% and 73.28%, respectively). For patients who underwent embolization with epistaxis as a secondary diagnosis, benign neoplasm of nasopharynx (58.3%) was the most common primary diagnosis. In those patients who underwent ligation, nasal bone fracture (28.5%) was the most common primary diagnosis. Conclusion This study highlights that 11,366 patients were treated for epistaxis during 2006, 2009, and 2012, and most patients were treated conservatively.

Match 2017: Blindsided or Fumbled?

The field of otolaryngology has historically enjoyed extreme interest among residency applicants. However, in the past few years, the number of applicants has precipitously dropped, so that there is no longer a significant excess of applications. It remains important for academic programs to promote student interest in otolaryngology, to break down barriers that may dissuade excellent candidates, and to widen the welcome.

Declining Otolaryngology Resident Training Experience in Tracheostomies: Case Log Trends from 2005 to 2015.

Objective To evaluate recent tracheostomy surgical experience among otolaryngology residents and general surgery residents. Study Design Retrospective database review. Setting Accreditation Council for Graduate Medical Education otolaryngology and general surgery programs. Subjects and Methods Accreditation Council for Graduate Medical Education case log data from 2005 to 2015 for resident graduates in otolaryngology and general surgery were used to obtain mean graduate tracheostomy numbers, mean graduate composite case numbers, and number of graduating residents. Market share for each specialty was estimated through the derived metric of nationwide total tracheostomy graduate experience, calculated by multiplying the number of graduating residents by the mean number of graduate tracheostomies. Linear regression analysis was used to calculate trends. Multiple linear regression analysis was used for pairwise comparison of trends. Results From 2005 to 2015, mean graduate tracheostomy numbers for otolaryngology residents declined 2.3% per year, while those for general surgery residents increased 1.8% per year. Accounting for changes in number of resident graduates, market share of tracheostomy decreased 1.0% per year for otolaryngology and increased 3.0% per year for general surgery. Mean graduate composite case numbers increased significantly by 1.8% and 1.0% per year for otolaryngology and general surgery residents, respectively. Conclusion Tracheostomy case volume in otolaryngology residency has decreased steadily in comparison with general surgery residency. However, current otolaryngology graduates have more experience in tracheostomy when compared with general surgery graduates. While otolaryngology residents have excellent exposure to tracheostomy, otolaryngology programs should be made aware of this declining trend as well as changing procedural trends, which may affect training needs.

USMLE and Otolaryngology: Predicting Board Performance.

Objective To ascertain what relationship exists between the United States Medical Licensing Examination (USMLE) and the American Board of Otolaryngology Written Qualifying Examination (WQE). Study Design Retrospective, longitudinal study. Setting De-identified database. Subjects Residents entering otolaryngology-head and neck surgery (OHNS) residency between 2007 and 2009 and taking the WQE for the first time between 2012 and 2014. Methods Regression models were used to determine if the USMLE score predicts passage of the WQE on the first attempt, which step score was a better predictor, and whether an increase in the Step 2 score increased the chances of WQE passage. Results There were 611 Step 1 and 402 Step 2 scores. Mean (SD) Step 1 score was 238 (14.4), and the mean (SD) Step 2 score was 243 (16.8). The overall WQE first-time passage rate was 95.3%. Step 1 score was a better predictor than Step 2 for successful passage of the WQE on the first attempt ( P = .0026). An increase in the Step 2 score compared with the Step 1 score did not predict an improved first-time passage rate on the WQE. Conclusions There is an association between USMLE scores and successful first-time passage of the WQE, with Step 1 being a stronger predictor than Step 2. Residents with USMLE scores lower than the average successful OHNS applicant still have a high chance of passing the WQE. USMLE scores alone are of limited usefulness in identifying those applicants at risk of failing the WQE on the first attempt.