A Comparison of In-Person and Telemedicine Triage in Otolaryngology.

INTRODUCTION: The integration of virtual visits has been met with skepticism by many surgical specialties, including otolaryngology, due to the lack of a complete physical exam. Analysis of differences in the workup between patients triaged virtually or in-person is warranted. METHODS: A chart review was performed for a cohort of adults undergoing septoplasty (January 2021-May 2022). Groups (telemedicine, in-person) were compared by 2-sample t-test and chi-square test to determine the difference in the number of preoperative visits and to assess the variation in patients with preoperative laboratory testing, imaging, or referrals. RESULTS: Of 338 patients, initial evaluation was in-person for 225 (66.5%) and via telemedicine for 113 (33.5%). The groups were similar in demographics (mean age 39.1 years for telemedicine vs 38.8 years for in-person, female 28.9% vs male 37.7%, P = 0.088). The telemedicine group had a significantly higher number of preoperative visits (3.03) compared to the in-person group (2.38, P = 0.001). There was no significant difference in patients who underwent preoperative laboratory testing, imaging, or referrals. Patients triaged via telemedicine experienced a shorter time to surgery compared to those triaged in person (434 vs 208, P = 0.003). DISCUSSION: In this cohort, triage by telemedicine allowed otolaryngology patients to have an expedited path to surgery despite having more visits. There is no evidence to suggest that otolaryngologists had an overreliance on diagnostic modalities when triaging by telemedicine. CONCLUSION: Among patients undergoing septoplasty, those initially evaluated by telemedicine were more likely to have more preoperative visits and shorter time to surgery than those evaluated in person. Telemedicine can serve as an effective method for triaging surgical patients without excess diagnostics.

Differences in Patient Secure Message Volume Among Otolaryngologists: A Retrospective Cohort Study.

OBJECTIVE: To identify differences in inbox and secure message burden among otolaryngologists based on demographics and subspecialty over 4 years. METHODS: Inbox data were queried from January 2019 until December 2022. Otolaryngologists were categorized into cohorts by area of practice and gender. All inbox tasks, secure messages, and clinical encounters were collected and compared by gender, practice type, and years in practice. Means were compared using t-tests and chi-squared tests. RESULTS: Of the 128 physicians, 45.7% were comprehensive otolaryngologists and 61.3% were male. The most common subspecialties were facial plastics (15.6%), oncology (8.6%), and otology (7.8%). Otolaryngologists had an average of 143.5 inbox tasks per month, with 97.2 (67.7%) of them being secure messages, resulting in an average of 1.14 inbox tasks and 0.80 secure messages per clinical encounter. The ratio of secure messages per clinical encounter was consistent across all specialties except oncology (1.10, P = .003). Otology (0.86, P = .032) and facial plastics (0.95, P = .028) had significantly lower ratios of inbox tasks to clinical encounters when compared to their colleagues, while oncology had a higher ratio (1.70, P < .001). No significant differences in inbox burden were observed between genders, years in practice, or languages spoken. Secure messages steadily increased over the study period. CONCLUSION: Inbox burden for otolaryngologists primarily stems from patient secure messages and varies across subspecialties. Considerations should be made to the inbox burden of head and neck oncologists. The implementation of support systems for inbox management could improve the imbalance between clinical and non-clinical responsibilities in otolaryngology. LEVEL OF EVIDENCE: Level III, Retrospective Cohort Study.

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.

Complication Rates in Osteotome and Drill Techniques in External Auditory Canal Exostoses: A Systematic Review and Meta-Analysis.

OBJECTIVES: To assess and compare complication rates of symptomatic external auditory canal (EAC) exostoses treated with drill versus osteotome canalplasty. DATABASES REVIEWED: PubMed/Medline, OVID, EMBASE, Web of Science, Google Scholar. METHODS: A systematic review and meta-analysis in accordance with PRISMA guidelines and standardized bias assessment using the JBI critical appraisal checklist was performed. Studies containing original outcome data on drill and osteotome canalplasty were included. The primary study outcome was complication rates. RESULTS: Fifteen studies were included, encompassing 1399 total patients (1788 ears) with 530 and 1258 ears in the osteotome and drill groups, respectively. Ten studies used a drill, 2 used an osteotome, and 3 used both. The most frequently reported complications were tympanic membrane (TM) perforation (osteotome group: 5.3% [95% CI: 1.7%-10.9%]; drill group: 3.8% [1.5%-7.1%]), sensorineural hearing loss (SNHL) (0.69% [0.07%-1.9%]; 4.3% [2.2%-7.0%]), and postoperative stenosis (1.1% [0.0005%-4.3%]; 4.1% [1.9%-7.0%]). Use of the osteotome was associated with a lower rate of SNHL (P < .05) and stenosis (P < .05), and a higher rate of TM perforation (P < .05). Heterogeneity of the studies included in the analyzed complications ranged from moderate to high. Level of evidence in the included studies ranged from 2b to 4 and all studies had an overall low risk of bias. CONCLUSION: While an osteotome technique may increase the risk of TM perforation, drill canaloplasty may increase the risk of SNHL and postoperative stenosis in EAC exostectomy. The exact quantity of hearing loss could not be definitively evaluated. Additional research with participant randomization is needed to assess clinical efficacy. LEVEL OF EVIDENCE: Level 8.

Drug-induced olfactory and gustatory dysfunction: Analysis of FDA adverse events reporting system.

OBJECTIVES: With the COVID-19 pandemic, there is growing interest and research in olfactory and gustatory dysfunction (OGD). Drug-induced dysfunction is an often overlooked etiology. While several medications include smell or taste disturbance as a side effect, there are no publications describing which medications are most frequently implicated. We aim to describe the patterns of these adverse drug reactions (ADRs) using the FDA Adverse Events Reporting System (FAERS). METHODS: The FAERS database was queried from 2011 to 2021 for terms describing ADRs related to OGD. Terms included anosmia, hyposmia, olfactory test abnormal, olfactory nerve disorder, hallucination olfactory, parosmia, ageusia, hypogeusia, dysgeusia, and taste disorder. We identified the top reported medications associated with general smell dysfunction, general taste dysfunction, reduced smell, and altered smell. RESULTS: From 2011 to 2021, 16,091 ADRs were reported with OGD, of which13,641 (84.8%) and 2,450 (15.2%) were associated with gustatory and olfactory reactions, respectively. Zinc products (370 reports) and fluticasone propionate (214) were most commonly associated with olfactory dysfunction, specifically reduced olfaction. Varenicline (24) and fluticasone propionate (23) were most commonly associated with altered smell. Lenalidomide (490) and sunitinib (468) were most commonly associated with gustatory dysfunction. Antineoplastic and immunomodulating medications accounted for 21.6% and 36.3% of olfactory and gustatory ADRs, respectively. Among this category, immunoglobulin drugs were the most commonly associated with OGD ADRs. CONCLUSION: Gustatory dysfunction is more commonly reported ADR compared with olfactory dysfunction. Immunologic/rheumatologic medications are the leading culprit of reported OGD. With increasing numbers of patients presenting to otolaryngologists for OGD, it is important to consider drug-induced etiology. LEVEL OF EVIDENCE: III.

Racial Disparities in Tympanoplasty Surgery: A 30-Day Morbidity and Mortality National Cohort Study.

OBJECTIVES: To assess the impact of race and ethnicity on 30-day complications after tympanoplasty surgery. METHODS: The National Surgical Quality Improvement Program database was queried for tympanoplasty procedures from 2005 to 2019. Demographic, comorbidity, and postoperative complication data were compared according to race using univariate and binary logistic regression analyses. RESULTS: A total of 11,701 patients were included, consisting of 80.3% White, 3.0% Black, 7.7% Asian, 5.7% Hispanic, 2.5% American Indian/Alaska Native, and 0.8% other. Binary logistic regression model indicated that Black patients had increased odds of unplanned readmittance (p = 0.033; odds ratio [OR], 3.110) and deep surgical site infections (p = 0.008; OR, 6.292). American Indian/Alaska Native patients had increased odds of reoperation (p = 0.022; OR, 6.343), superficial surgical site infections (p < 0.001; OR, 5.503), urinary tract infections (p < 0.001; OR, 18.559), surgical complications (p < 0.001; OR, 3.820), medical complications (p = 0.001; OR, 10.126), and overall complications (p < 0.001; OR, 4.545). CONCLUSION: Although Black and American Indian/Alaskan Native patients were more likely to have complications after tympanoplasty surgery after adjusting for comorbidities, age, and sex, these results are tempered by an overall low rate of complications. Future studies should be devoted to understanding the drivers of these health inequities in access to otologic care and surgical treatment to improve outcomes and achieve equitable care.

Electronic Cigarettes: A Narrative Review and Cohort Study of Electronic Cigarette Users in the Otolaryngology Clinic.

Electronic nicotine delivery systems (ENDSs) are growing in popularity, particularly in young adults. While in vitro and murine models have demonstrated potentially harmful health effects of ENDSs, long-term health effects and clinical outcomes are generally unknown. Use as a smoking cessation aid is propagated by studies of potential harm reduction compared to conventional cigarette smoking. We present a review of the current controversies of ENDS use and present a novel cohort of patients visiting the otolaryngology clinic with known ENDS use to understand their clinical and demographic characteristics and the prevalence of otolaryngologic inflammatory diagnoses. Eighty-eight patients had 105 diagnoses. Forty-three (48.9%) ENDS users had at least 1 inflammatory diagnosis. ENDS use was more common in White, male patients between the ages of 18 and 35 years. The most common inflammatory diagnoses were chronic otitis media (17.4%) and allergic rhinitis (13.0%). While the rate of inflammatory disease was significantly higher in male than in female patients (60.7% vs 28.1% p = 0.003), no significant association was seen between inflammatory disease and age, race/ethnicity, or length of ENDS use. The identification and description of patients with ENDS use will help clinicians' better risk-stratify otolaryngologic diagnoses associated with this novel health behavior. Additionally, further clinical research is necessary to elucidate long-term health outcomes of ENDS use.

Incidental paratracheal lymph node lung adenocarcinoma in a patient with goiter: a case report.

Background: Paratracheal lymph nodes can be sites of metastasis for a variety of malignancies, but these metastases are treated differently depending on the tissue of origin. We describe a patient who underwent combined thoracoscopic and cervical resection of a multinodular goiter who was found to have incidental lung adenocarcinoma in an adjacent paratracheal lymph node despite having no pulmonary nodules. Case Description: A 62-year-old male with longstanding substernal multinodular goiter presented to his primary care doctor with continued growth of his goiter. After repeatedly declining surgery, he became amenable to resection and underwent right video-assisted thoracoscopic and cervical approaches. An incidentally found separate large right paratracheal lymph node was also discovered and completely resected. Final pathology of the thyroid mass revealed hyperplastic thyroid nodules consistent with a benign goiter. However, the separate right paratracheal lymph node revealed a thyroid transcription factor 1-positive (TTF-1) specimen concerning for lung adenocarcinoma in the absence of pulmonary nodules on imaging. Conclusions: Noteworthy to this case is the minimally invasive thoracoscopic approach preventing the need for median sternotomy and preventing any increased morbidity for the patient's incidentally found TxN3M0 lung adenocarcinoma. The patient could have been spared resection of the lymph node given its pulmonary origin as the standard of care for stage IIIB non-small cell lung cancer is definitive chemoradiation and adjuvant immunotherapy.

Pediatric Subcutaneous Scalp Mass: A Case Report and Review.

Infantile myofibroma is a unique fibrous tumor encountered in the head and neck. Although the majority of cases are solitary nodules that require only conservative management, awareness of the possibility of multicentric disease is important considering its substantial morbidity. A 3-month-old girl presenting with an enlarging 2.5-cm firm, mobile, nontender subcutaneous scalp mass was evaluated with magnetic resonance imaging and biopsy, revealing a diagnosis of infantile myofibroma. The literature was reviewed for supporting evidence of recommended management in a disease with no official treatment guidelines. Histological, genetic, and imaging characteristics are reviewed. Although biopsy is mandatory, conservative management can be employed for cases without multicentric involvement. Although there are no official guidelines for the evaluation of visceral involvement, skeletal radiograph and abdominal ultrasound are recommended. Infantile myofibroma is a distinct clinical entity with predilection for the head and neck. Its unique immunohistopathology and clinical course should be well understood and should be included in the differential diagnosis of infantile skin and subcutaneous masses.

Chondrolaryngoplasty.

Chondrolaryngoplasty is a well-described surgical procedure most commonly performed as part of facial feminization surgery for transgender patients with a diagnosis of gender dysphoria. A complete understanding of relevant neck anatomy and laryngeal function is critical to optimizing surgical outcomes. The overall goal of the procedure is to maximally reduce the thyroid cartilage prominence while preserving laryngeal integrity and minimizing the risk of external scarring. Among available approaches, the bronchoscopic-assisted technique with intraoperative needle localization has been demonstrated to reliably lead to safe and effective surgical outcomes while minimizing the risk of postoperative complications.

Representation of Race and Sex in Sleep Surgery Studies.

OBJECTIVE: Obstructive sleep apnea (OSA) is a highly prevalent disorder with many treatment modalities, including surgical intervention. While OSA is known to be more prevalent in males and Black Americans, the representation of race and sex in sleep surgery studies is unknown. The aim of this systematic review is to assess the race and sex demographics represented in sleep surgery studies relative to known OSA demographics. DATA SOURCES: PubMed, MEDLINE, and OVID databases. REVIEW METHODS: A systematic review was conducted to identify studies published between 2016 and 2020 that investigated sleep outcomes following nonnasal surgical intervention for OSA in adults. Pooled racial, ethnic, and sex data of the enrolled subjects in selected studies were analyzed. RESULTS: The 148 included studies comprised 13,078 patients. Of the 137 studies that reported sex, 84.0% of participants were male, exceeding the population prevalence of OSA in males, which is estimated at 66%. Only 13 studies reported racial/ethnic demographic data. Of these, 87.8% of patients were White. Out of 30 studies of primarily American patients, only 4 reported race demographic data, with an average of 82.8% White participants. CONCLUSION: There is a racial/ethnic and sex inclusion bias among sleep surgery studies. Future studies should better document the demographics of enrolled participants as well as recruit participants who better represent the demographics of adults with OSA in the general population.

Differences in the Intended Meaning of Congestion Between Patients and Clinicians.

Importance: Disagreement in the presumed meaning of common medical terms may impair communication between patients and caregivers. Objective: To clarify the intended meaning of the term congestion among otolaryngology clinic patients and to identify discrepancies in definitions between patients and otolaryngologists. Design, Setting, and Participants: In this cross-sectional survey study from an otolaryngology clinic at an academic center, a semantics-based questionnaire was provided to consecutive new patients during intake for a clinical encounter from December 2016 through February 2017, and to 31 otolaryngologists and 28 nonotolaryngologist physicians in February 2018. Respondent definitions for congestion were selected from a list of 16 proposed terms covering 4 general categories. Main Outcome and Measures: Symptom categories for term used to describe congestion by patients and clinicians. Results: Among 226 patient respondents (133 female [58.8%]; mean [SD] age, 54 [15.6] years), the most commonly selected definitions for congestion were from the obstructive (199; 88.1%) and mucus-related (196; 86.7%) symptom categories. More than 1 general category was selected by 208 patients (92.0%), whereas 11 patients (4.9%) described congestion only in terms of mucus-related symptoms. Definitions were limited to upper respiratory tract symptoms by 83 (36.7%) patients and lower respiratory tract symptoms by 2 (0.9%) patients. Among 31 otolaryngologists, congestion was most frequently defined in terms of obstructive symptoms (difference, 11.9%; 95% CI, 7.4%-16.5%). In contrast, patients more often described congestion in terms of pressure-related (difference, 38.8%; 95% CI, 7.5%-70.1%) or mucus-related (difference, 51.2%; 95% CI, 22.6%-79.9%) symptoms. A total of 22 otolaryngologists (71.0%) defined congestion using 1 to 4 symptoms, compared with only 69 patients (30.5%). Conclusions and Relevance: The definition of congestion appears to be highly variable and ambiguous for many patients. Moreover, the findings suggest that patients and otolaryngologists generally do not describe congestion using the same terms.

Intranasal Azelastine and Fluticasone as Combination Therapy for Allergic Rhinitis: Systematic Review and Meta-analysis.

OBJECTIVE: Combination therapy with intranasal azelastine and fluticasone propionate is an option for treatment of allergic rhinitis. This systematic review and meta-analysis examines existing literature to determine efficacy in treating allergic rhinitis compared to monotherapy. DATA SOURCES: The PubMed, EMBASE, Cochrane, and MEDLINE databases were systematically searched for randomized controlled trials using AzeFlu nasal spray. REVIEW METHODS: Randomized, controlled trials that reported symptom relief of allergic rhinitis in males and females of all ages were included. Results were reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standard. RESULTS: Systematic review identified 8 articles suitable for review. The risk of bias was generally low. All studies exhibited a greater decrease in patient-reported symptom scores in patients treated with combination therapy compared to monotherapy or placebo. Meta-analysis revealed superiority of combination therapy in reducing Total Nasal Symptom Score compared to placebo (mean change from baseline: -2.41; 95% confidence interval [CI], -2.82 to -1.99; P < .001; I2 = 60%), azelastine (mean change from baseline: -1.40; 95% CI, -1.82 to -0.98; P < .001; I2 = 0%), and fluticasone (mean change from baseline: -0.74; 95% CI, -1.17 to -0.31; P < .001; I2 = 12%). CONCLUSION: Current evidence supports both efficacy and superiority of combination intranasal azelastine and fluticasone in reducing patient-reported symptom scores in patients with allergic rhinitis. Combination nasal spray should be considered as second-line therapy in patients with allergic rhinitis that is not controlled with monotherapy.