NK/T-cell Lymphoma With Orbital Involvement: A Case Report and Systematic Review of the Literature.

PURPOSE: To present the clinical course of a patient with recurrent NK/T-cell lymphoma (NKTL) involving the orbit and to review the literature on patients with NKTL involving the orbit. METHODS: The PubMed database was searched for all cases of NKTL involving orbital, intraocular, or adnexal ocular structures. RESULTS: Ninety-six patients were included in the final analysis. The mean age of diagnosis was 48.1 ± 16.8 years. The patients were 53/96 (55.2%) male and 43/96 (44.8%) female. Tumor location varied and included the orbit in 80/96 (83.3%), nasosinus in 56/96 (58.3%), uvea in 11/96 (11.5%), lacrimal gland in 9/96 (9.4%), lacrimal drainage system in 11/96 (11.5%), and conjunctiva in 7/96 (7.3%) cases. Management included surgical debulking in 29/96 (30.2%) cases, radiotherapy in 52/96 (54.2%) cases, and chemotherapy in 82/96 (85.4%) cases. Median survival was 6 months (95% CI: 5-9). Chemotherapy (hazard ratio = 0.80, 95% CI: 0.67-0.95, p = 0.013), radiotherapy (hazard ratio = 0.75, 95% CI: 0.64-0.87, p < 0.001), and orbital involvement being a recurrence of disease (hazard ratio = 0.79, 95% CI: 0.67-0.95, p = 0.009) were associated with improved survival. Advanced Ann Arbor stage (III-IV) at diagnosis (hazard ratio = 1.22, 95% CI: 1.08-1.38, p = 0.001), vision loss (hazard ratio = 1.18, 95% CI: 1.04-1.34, p = 0.009), proptosis (hazard ratio = 1.15, 95% CI: 1.01-1.30, p = 0.035) and periorbital swelling (hazard ratio = 1.15, 95% CI: 1.00-1.33, p = 0.048) were associated with poor survival. CONCLUSIONS: NK/T-cell lymphoma involving the orbit, globe, or ocular adnexa heralds a poor prognosis where early diagnosis and therapy are critical. The use of radiotherapy and chemotherapy is associated with improved survival.

Resident Burnout and Well-being in Otolaryngology and Other Surgical Specialties: Strategies for Change.

OBJECTIVE: To perform a literature review on burnout prevalence, factors that affect burnout and well-being, and solutions to address burnout in otolaryngology-head and neck surgery (OTO-HNS) residents and residents in other surgical specialties. DATA SOURCES: Ovid Medline, Embase, and article reference lists. REVIEW METHODS: A literature search was performed to identify articles on resident burnout, distress, wellness, well-being, and quality of life. Articles deemed outside the scope of the current work were excluded. Search was limited to the past 5 years. CONCLUSIONS: Moderate to high burnout has been reported in 35% to 86% of OTO-HNS residents. Among other surgical specialties, resident burnout ranges between 58% and 66% in plastics, 11% and 67% in neurosurgery, 38% and 68% in urology, and 31% and 56% in orthopedics. Highest burnout rates were seen in postgraduate year 2 residents. Factors significantly associated with burnout included hours worked (>80 h/wk), level of autonomy, exercise, and program support. Reported resident work hours have steadily increased: 8% of OTO-HNS residents in 2005 vs 26% in 2019 reported averaging >80 h/wk. Practical implications of resident burnout include decreased empathy, moral distress and injury, poor health, decreased quality of life, increased attrition, decreased desire to pursue fellowship, and increased likelihood of medical errors. Structured mentorship programs, wellness initiatives, and increased ancillary support have been associated with lower burnout rates and improvements in resident well-being across specialties. IMPLICATIONS FOR PRACTICE: Addressing burnout, which is prevalent in OTO-HNS residents, is critical to improving patient care and physician well-being. Surgical specialties can share strategies to effectively address resident burnout through institutional interventions, which can be essential quality improvement initiatives, to promote well-being.

Trends in Residency Applicant Volume in Otolaryngology-Head and Neck Surgery and Peer Specialties.

OBJECTIVE: To evaluate the 2020 to 2021 Otolaryngology residency application cycle in the context of recent trends. STUDY DESIGN: Retrospective data analysis. SETTING: Disruptions caused by the COVID-19 pandemic may significantly alter trends among residency applicants, especially in highly competitive and/or smaller specialties. METHODS: Applicant and residency statistics from Electronic Residency Application Service (ERAS) and National Residency Matching Program (NRMP) were extracted from the 2016 to 2021 and 2011 to 2021, respectively. Trends in Otolaryngology-Head and Neck Surgery (OHNS) were compared to peer specialties (PS) including Dermatology, Neurological Surgery, Orthopedic Surgery, and Integrated Pathway for Plastic and Reconstructive Surgery (PRS). The ratio of the number of applicants per positions (APP) was used to reflect the degree of competition. RESULTS: Between 2011 and 2021, the number of OHNS programs and positions expanded less than those of PS and General Surgery. The increase in the APP ratio was significantly greater for OHNS compared to those Dermatology, Orthopedic Surgery, General Surgery and all PGY1 residency positions for both US MD and all applicants (P < .01 for each). OHNS expansion of US MD (P = .046), but not all applicants (P = .169), outgrew that of Neurosurgery. CONCLUSION: The 2020 to 2021 cycle affected by the COVID-19 pandemic saw a continuation of the recent trend in the expanding OHNS applicant pool. OHNS remains one of the specialties with the highest APP ratio and has observed a significant growth compared to PS since 2018. Understanding and anticipating trends in residency application cycles is critical for designing processes to optimize the best fit between applicants and programs.

Facial Trauma Call Reimbursement Patterns Among American Society of Maxillofacial Surgery Members.

Facial trauma accounts for over 3 million emergency room encounters each year in the United States and places significant financial burden on the health care system and surgeons. However, data on facial trauma call practices among plastic surgeons are lacking. We surveyed members of the American Society of Maxillofacial Surgeons (ASMS) regarding their experience with facial trauma call. A 27-question online survey was distributed through e-mail to ASMS members. Forty-five ASMS members completed the survey, of whom 64% were required to take facial trauma call and 44% were compensated for call. Respondents in the North-East were less likely [odds ratio (OR): 0.234, confidence interval (CI), 0.054-1.015; P =0.052] to be compensated for taking call, whereas those who worked at level 1 trauma centers were more likely odds ratio: 5.42, CI, 0.892-32.89; P =0.066) to be compensated. Surgeons required to take facial trauma call were 4.646 (CI, 1.203-17.944; P =0.026) times more likely to take call ≥5 days per month. These results highlight a relatively low proportion of plastic surgeons receiving additional compensation for facial trauma call while work at a level 1 trauma center was associated with higher likelihood of compensation. Surgeons in the Northeast may be compensated less frequently than other regions. Plastic surgeons should be aware of these trends, as they decide how to incorporate facial trauma call into their practice.

Effects of COVID-19 on Facial Plastic and Reconstructive Surgery Fellowship Training and Director Practices.

OBJECTIVES: The objectives of this study include characterizing the practice patterns and testing strategies of facial plastic and reconstructive surgery (FPRS) fellowship directors (FDs) secondary to COVID-19 and to quantify the impact of COVID-19 on FPRS fellowship training. STUDY DESIGN: Cross-sectional survey. SETTING: Online. METHODS: A survey was sent to all American Academy of Facial Plastic and Reconstructive Surgery FDs and co-FDs in September 2020. Descriptive analyses were performed. RESULTS: Of 77 eligible FDs, 45 responded (58.4%) representing a diverse group across the United States. All but 1 FD routinely screened patients for COVID-19 in the preoperative setting. FDs largely believed that universal preoperative testing was cost-effective (66.7%), improved patient safety (80.0%) and health care worker safety (95.6%), and was not burdensome for patients (53.3%). With regard to volume of cosmetic/aesthetic, reconstructive, facial nerve, and trauma surgery, FDs indicated largely no change in volume (34.9%, 71.0%, 68.4%, and 80.0%, respectively) or fellow experience (67.4%, 80.6%, 84.2%, and 80.0%). Half (50.0%) of the FDs reported decreased volume of congenital/craniofacial surgery, but 75.0% did not believe that there was a change in fellow experience. Overall, of the 15 responses indicating "worsened training" across all domains of FPRS, 14 were located in the Northeast (93.33%). CONCLUSIONS: The COVID-19 pandemic has had the least impact on the volume of reconstructive procedures, facial nerve operations, and trauma surgery and a negative impact on congenital/craniofacial surgery volume, and it has accelerated the demand for cosmetic/aesthetic operations. Overall, the majority of FDs did not feel as though their fellows' trainings would be adversely affected by the ongoing pandemic.

The Utility of the Subalar Graft in Nostril Symmetry in Rhinoplasty.

BACKGROUND: A deviated nose can be attributable to multiple anatomical factors, including asymmetric maxilla. A subalar graft helps to correct maxillary hypoplasia and may be a useful tool for correcting a deviated nose. The authors' objective is to show the effects of the subalar graft in improving nostril symmetry and to propose an algorithm for using this graft in open and endonasal rhinoplasty. METHODS: A retrospective case series was performed on patients who had undergone rhinoplasty performed by the senior author (R.W.) from September of 2008 to July of 2015. Patients with at least 3 months of follow-up and adequate photographs were included. The mean follow-up period was 11.0 months (range, 3 to 72 months). A total of 68 patients were included. Preoperative and postoperative photographs were analyzed to measure changes in nasal axis deviation, alar facial angle on base view, alar facial angle on frontal view, and nostril show bilaterally. RESULTS: Of the 68 patients, statistically significant improvement of nasal axis deviation of 4.32 degrees toward the midline was observed. Alar facial angle on base view was improved 1.01 degrees toward the horizontal. Nostril symmetry also improved based on the ratio between the shorter side and the longer side. The mean change in nostril show ratio was 0.19 toward a 1:1 ratio. CONCLUSIONS: Previous studies have shown that the subalar grafting technique is an important adjunctive technique in rhinoplasty for patients with midfacial asymmetries. This case series demonstrates that this technique can provide sustained results in the correction of the nasal foundation. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Characterizing Epidemiology and Associated-Factors of Adolescent Sports-Related Traumas Using Trauma Quality Improvement Program.

ABSTRACT: Sports-related injuries contribute to a considerable proportion of pediatric and adolescent craniofacial trauma, which can have severe and longstanding consequences on physical and mental health. The growing popularity of sports within this at-risk group warrants further characterization of such injuries in order to enhance management and prevention strategies. In this study, the authors summarized key trends in 1452 sports-related injuries among individuals aged 16 to 19 using the American College of Surgeon's Trauma Quality Improvement Program database from 2014 to 2016. The authors observed a preponderance of injuries associated with skateboarding, snowboarding, and skiing, with significantly higher percentages of traumatic brain injuries among skateboarding-related traumas. Notably, we observed that traumatic brain injurie rates were slightly higher among subjects who wore helmets. Intensive care unit durations and hospital stays appeared to vary by sport and craniofacial fracture. Altogether, this study contributes to the adolescent sports-related injuries and craniofacial trauma literature.

Pass/Fail Scoring of USMLE Step 1 and the Need for Residency Selection Reform.

The Federation of State Medical Boards and the National Board of Medical Examiners recently announced a change in the United States Medical Licensing Examination Step 1 scoring convention to take effect, at the earliest, on January 1, 2022. There are many reasons for this change, including decreasing medical student stress and incentivizing students to learn freely without solely focusing on Step 1 performance. The question remains how this will affect the future of the otolaryngology-head and neck surgery match. By eradicating Step 1 grades, other factors, such as research, may garner increased importance in the application process. Such a shift may discriminate against students from less well-known medical schools, international medical graduates, and students from low socioeconomic backgrounds, who have fewer academic resources and access to research. Residency programs should try to anticipate such unintended consequences of the change and work on solutions heading into 2022.

Ideas and Innovations to Improve the Otolaryngology-Head and Neck Surgery Residency Application and Selection Process.

OBJECTIVE: To (1) summarize strategies proposed in the recent otolaryngology-head and neck surgery (OTO-HNS) literature for improving the residency application and selection process, (2) evaluate the effects of recently implemented changes to the OTO-HNS match, and (3) discuss recommendations for future changes to the OTO-HNS residency application and selection process. DATA SOURCES: PubMed, Medline Ovid database, and article reference lists. REVIEW METHODS: A structured literature search was performed to identify current English language articles relating to the objectives of this study using the aforementioned data sources, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) guidelines. The search was limited to submissions published between January 1, 2015, and January 1, 2020. CONCLUSIONS: Numerous proposals have been made for improving the otolaryngology residency application and selection process and addressing the competitive nature of the Match. These proposals include but are not limited to mandating a secondary essay, implementing consortia and early match processes, using a signaling system, conducting regional and web-based interviews, offering early engagement with interest groups, instituting a hard cap on applications, increasing costs of applying, counseling self-restraint to prospective applicants, and creating application filters. IMPLICATIONS FOR PRACTICE: As the volume of literature surrounding the OTO-HNS Match continues to increase, this review aims to provide a summary of past proposals and serve as a guide for possible future innovations. We propose 3 initiatives that may improve the residency application and selection process for both program and resident, with minimal impact to the current National Resident Matching Program (NRMP) Match structure.

Indications and Outcomes of the Osteoplastic Flap Procedure With or Without Obliteration.

OBJECTIVE: To describe the osteoplastic approach and to perform a systematic review of the indications and outcomes of the osteoplastic flap procedure for frontal sinus surgeries with or without obliteration. DATA SOURCES: PubMed, Medline, Google Scholar, and Cochrane databases. REVIEW METHODS: All published studies in the English language on the osteoplastic flap with or without obliteration were identified from 1905 to 2018. All studies with <20 patients were excluded. The number of patients, technique, indications, follow-up period, symptom relief, revision rates, and complications were recorded and analyzed. RESULTS: A systematic review yielded 25 series containing 1374 patients for analysis. Indications for surgery included chronic frontal sinusitis, mucoceles, fractures or traumas, osteomas, neoplasms, and cerebrospinal fluid leak. The mean follow-up period ranged from 12.8 to 144 months. The percentage of patients needing revisions for frontal sinus disease was 6.2%. There was a high rate of symptomatic improvement (85.0%) and a low rate of major complications (0.7%). However, minor complications occurred in 19.4% of patients. CONCLUSION: The osteoplastic flap with or without obliteration has many indications. In an era where endoscopic technique provides excellent access to the frontal sinuses, external approaches remain a useful adjunct, and/or salvage technique. In experienced hands, the osteoplastic flap can yield excellent long-term clinical results, with low rates of complications. Regardless of the surgical approach, long-term follow-up is necessary due to the recurrent nature of frontal sinus disease.

Telemedicine Practices of Facial Plastic and Reconstructive Surgeons in the United States: The Effect of Novel Coronavirus-19.

Introduction: The objectives of this study among facial plastic and reconstructive surgeons (FPRS), include (1) quantifying the use of telemedicine, (2) examining the impact of novel coronavirus-19 (COVID-19) on telemedicine practices, (3) highlighting the types of telemedicine employed, (4) anticipating how telemedicine will be utilized in the future, and (5) describing FPRS' attitudes and understanding of telemedicine technologies. Study Type: Cross-sectional survey. Methods: A 6-13 question survey was sent to the American Academy of Facial Plastic and Reconstructive Surgery membership. Descriptive analyses were performed, along with a Fisher's exact test. Results: We received 100 responses from a diverse group of surgeons across the United States. Overall, 91% of responders utilize telemedicine, of which 76.9% began during the COVID-19 pandemic. 33.3% of responders thought that their platforms were not Health Insurance Portability and Accountability Act compliant or were unsure. Of those that utilize telemedicine, the two biggest concerns were difficulties with physical examination (69.2%) and lack of human connection (44%). 75.8% of telemedicine utilizers plan to incorporate telemedicine into their practice moving forward. Of all responders, 71% believed that telemedicine will have a positive effect on the field of FPRS, although on univariate analysis those in practice >20 years were more likely to believe that there will be no effect or a negative effect (p = 0.014). Conclusions: The COVID-19 pandemic has accelerated the adoption of telemedicine among FPRS in the United States. The great majority of responders plan to incorporate telemedicine into their practice even after the pandemic subsides and believe that telemedicine will have a net positive effect on the field of FPRS.

Consequences of Medical Hierarchy on Medical Students, Residents, and Medical Education in Otolaryngology.

OBJECTIVE: To (1) review concepts of medical hierarchy; (2) examine the role of medical hierarchy in medical education and resident training; (3) discuss potential negative impacts of dysfunctional hierarchy in medical and surgical training programs, focusing on otolaryngology; and (4) investigate solutions to these issues. DATA SOURCES: Ovid Medline, Embase, GoogleScholar, JSTOR, Google, and article reference lists. REVIEW METHODS: A literature search was performed to identify articles relating to the objectives of the study using the aforementioned data sources, with subsequent exclusion of articles believed to be outside the scope of the current work. The search was limited to the past 5 years. CONCLUSIONS: Two types of hierarchies exist: "functional" and "dysfunctional." While functional medical hierarchies aim to optimize patient care through clinical instruction, dysfunctional hierarchies have been linked to negative impacts by creating learning environments that discourage the voicing of concerns, legitimize trainee mistreatment, and create moral distress through ethical dilemmas. Such an environment endangers patient safety, undermines physician empathy, hampers learning, lowers training satisfaction, and amplifies stress, fatigue, and burnout. On the other hand, functional hierarchies may improve resident education and well-being, as well as patient safety. IMPLICATIONS FOR PRACTICE: Otolaryngology-head and neck surgery programs ought to work toward creating healthy systems of hierarchy that emphasize collaboration and improvement of workplace climate for trainees and faculty. The goal should be to identify aspects of dysfunctional hierarchy in one's own environment with the ambition of rebuilding a functional hierarchy where learning, personal health, and patient safety are optimized.