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.

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.

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.

Cervical sympathetic chain schwannoma masquerading as a carotid body tumour with a postoperative complication of first-bite syndrome.

Carotid body tumours (CBT) are the most common tumours at the carotid bifurcation. Widening of the bifurcation is usually demonstrated on conventional angiography. This sign may also be produced by a schwannoma of the cervical sympathetic plexus. A 45-year-old patient presented with a neck mass. Investigations included contrast-enhanced CT, MRI and magnetic resonance arteriography with contrast enhancement. Radiologically, the mass was considered to be a CBT due to vascular enhancement and splaying of the internal and external carotid arteries. Intraoperatively, it was determined to be a cervical sympathetic chain schwannoma (CSCS). The patient had a postoperative complication of first-bite syndrome (FBS).Although rare, CSCS should be considered in the differential diagnosis for tumours at the carotid bifurcation. Damage to the sympathetic innervation to the parotid gland can result in severe postoperative pain characterised by FBS and should be considered in all patients undergoing surgery involving the parapharyngeal space.

Management of Jehovah's Witnesses in otolaryngology, head and neck surgery.

It is imperative that surgeons should have some knowledge and understanding of the beliefs of Jehovah's Witnesses to respect the patient's wishes and effectively minimize and manage blood loss. The objective of this review was to provide a management strategy for Jehovah's Witness patients undergoing otolaryngology, head and neck surgery, because there is paucity of information regarding this within our literature. A systematic review of medical literature was conducted. Articles were identified using MEDLINE (1966-2007). The search strategy used Medical Subject Heading terms Jehovah's Witnesses, Beliefs, Ethical and Legal issues, Blood transfusion alternatives, ENT, Head and Neck surgery in Jehovah' witnesses. There is a broad range of nonblood surgical management strategies available in other specialities, making major surgery possible within this population. This review suggests recommendations in elective surgery, trauma, and emergencies.

Treatment of squamous cell carcinoma of the tongue base: irradiation, surgery, or palliation?

OBJECTIVES: Squamous cell carcinoma of the tongue base has a poor prognosis, and treatment is accompanied by a number of major problems. In view of this, it is important to recognize which patients will benefit from treatment with curative intent and which treatment method to use. METHODS: One hundred sixty-five patients with squamous cell carcinoma of the tongue base were identified on our database. Eighty-two patients were treated by radical irradiation, and 41 by surgery. A further 42 patients were considered unsuitable for curative treatment. RESULTS: The 5-year cause-specific survival rate was 41% for those treated by irradiation, 58% for those treated by surgery, and 9% for untreated patients. There was no difference in the efficacy of treatment methods (p = .5362), but a highly significant difference was seen in survival rate between treated and untreated patients (p = .0028). The decision regarding administration of curative treatment was based on the extent of locoregional involvement at the primary site (p = .0139; odds ratio, 0.43) and in the neck (p = .0078; odds ratio, 0.23). No factors affected the decision to treat by irradiation or surgery. When the observed survival rate was calculated, there was no significant difference in 5-year survival rate between treated and untreated patients (p = .2762). Those with early (T1-2) disease at the primary site had an improved survival rate from 0.5 to 4 years compared with those who were untreated (T3-4; p = .0081; odds ratio, 2.2). In addition, those with early (T1-2) disease had a better survival rate than those with advanced cancers (p = .0139; odds ratio, 2.09). There was, however, no difference in survival rate at 5 years. Those with early disease compared with those with advanced disease were twice as likely to be alive at 2 years; however, all survival advantages had disappeared by 5 years. CONCLUSIONS: In terms of observed survival, treating tongue base squamous cell carcinoma that is locally advanced (T3-4) at presentation offers no survival advantage over palliation alone. Treating early disease (T1-2) doubles the survival rate for up to 4 years, but by 5 years this survival advantage is lost. The present study finds radiotherapy and surgery to be equivalent at controlling this disease.

An artificial neural network improves prediction of observed survival in patients with laryngeal squamous carcinoma.

The accepted method of modelling and predicting failure/survival, Cox's proportional hazards model, is theoretically inferior to neural network derived models for analysing highly complex systems with large datasets. A blinded comparison of the neural network versus the Cox's model in predicting survival utilising data from 873 treated patients with laryngeal cancer. These were divided randomly and equally into a training set and a study set and Cox's and neural network models applied in turn. Data were then divided into seven sets of binary covariates and the analysis repeated. Overall survival was not significantly different on Kaplan-Meier plot, or with either test model. Although the network produced qualitatively similar results to Cox's model it was significantly more sensitive to differences in survival curves for age and N stage. We propose that neural networks are capable of prediction in systems involving complex interactions between variables and non-linearity.

Predictive factors of long-term facial nerve function after vestibular schwannoma surgery.

OBJECTIVE: To assess predictive factors of long-term facial nerve function in a series of patients undergoing vestibular schwannoma surgery and to evaluate the reproducibility of the relevant parameters. STUDY DESIGN: Prospective. SETTING: Three tertiary referral neurotology units in two separate countries. PATIENTS: A total of 67 patients, with normal preoperative facial function and an anatomically intact facial nerve postoperatively, undergoing vestibular schwannoma surgery during a sequential 18-month period. INTERVENTIONS: Recording of intraoperative stimulus amplitudes (minimum intensity medial to the tumor after excision) and postoperative facial nerve function up to 2 years after surgery. MAIN OUTCOME MEASURES: Long-term facial nerve function related to tumor size, early postoperative facial nerve function, and intraoperative electrophysiologic intensities. RESULTS: Multivariate logistic regression model identified tumor size and the minimum intensity required to provoke a stimulus threshold event medial to the tumor after excision as independent predictors of a favorable initial outcome. Immediate facial nerve function was the only independent predictor of long-term normal function. The sensitivity of this predictor was 95% (95% confidence interval [CI], 89-100%); specificity, 83% (95% CI, 62-100%); positive predictive accuracy, 96% (95% CI, 91-100%); and negative predictive accuracy, 77% (95% CI, 54-100%). CONCLUSION: The combination of electrophysiologic intensities and tumor size are reproducible and better predictors of initial facial nerve function than any individual parameter, but long-term facial nerve function is more likely to have a better outcome if the nerve is left intact and a per-operative graft repair is not performed. The study suggests that although the best available predictor of overall long-term facial nerve outcome is the level of early postoperative function, this factor is not useful in surgical rehabilitation decision making.