Opportunities for Gender-Affirming Surgery Training in Residency and Fellowship.

The national otolaryngology-head and neck surgery (OHNS) landscape of transgender and nonbinary/gender-nonconforming (TNG) care education and gender-affirming surgical training is variable with limited availability. However, specialized and innovative training with breadth and depth is available at select training sites focusing on facial and/or vocal gender affirmation throughout the United States. With growing trainee interest, program and fellowship director-related efforts to expand training, and progressive arcs of social change focusing on protections and promotion of TNG health, the future of OHNS training opportunities to serve TNG patients is promising.

Feminization Laryngoplasty: 17-Year Review on Long-Term Outcomes, Safety, and Technique.

OBJECTIVES: Transfeminine patients can experience significant gender dysphoria in vocal communication. Feminization laryngoplasty (FL) is a gender-affirming surgery developed to elevate speaking vocal range, as well as alter vocal resonance and laryngeal cosmesis. The purpose here was to appraise FL's long-term voice outcomes across a 17-year review period. STUDY DESIGN: Level III, retrospective study and description of technique. SETTING: A single-institution transfeminine voice clinic. METHODS: Voice data (speaking fundamental frequency [F0], lowest F0, highest F0, F0 range in both Hertz and semitones, and maximum phonation time [MPT]) were collected and assessed. Self-assessment of voice femininity and complications were documented. RESULTS: The 162 patients, all transfeminine women, had a mean age of 40 years with 36-month mean follow-up. There were significant increases in mean speaking F0 (Δ = 50 ± 30 Hz, Δ = 6 ± 3 semitones; P < .001) and mean change in lowest F0 (Δ = 58 ± 31 Hz, Δ = 8 ± 4 semitones; P < .001). There was no significant difference in mean change in highest F0 or MPT. There was significant improvement (Δ = 60% ± 39%; P < .001) in perceptual self-assessment of vocal femininity. There was a 1.2% rate of major postoperative complications requiring inpatient admission or operative intervention. There were no differences in vocal outcomes between those patients who had less than 1-year follow-up and those who had 5-year follow-up. CONCLUSION: FL in this cohort was a safe and effective technique for increasing mean speaking F0, mean lowest F0, and voice gender perception over a prolonged follow-up period. These findings add to the possible treatments aimed at addressing the morbid dysphoria related to voice and communication for our transfeminine patients.

Effects of surgeon sociodemographics on patient-reported satisfaction.

BACKGROUND: Patient-reported satisfaction scores, including the Press Ganey surveys, are increasingly used as measures for quality healthcare among surgical subspecialties. However, the influence of surgeon sociodemographics is not clear. METHODS: This cross-sectional study analyzed Press Ganey surveys linked to outpatient surgical visits at a single academic institution from January 2015 to December 2018 as they related to surgeon age, gender, and race. The primary outcome variable was achievement of a top-box score (5/5) on likelihood to recommend surgeon queries. Secondary analysis examined the relationship of likelihood to recommend surgeon to other survey questions, such as those regarding surgeon courtesy, concern, understandability, patient inclusion in medical decision making, and patient confidence in surgeon. χ2 tests and generalized estimating equation regression models were run to assess correlation. RESULTS: In bivariate analysis of 36,840 surveys, non-Hispanic white surgeons were more likely to receive likelihood to recommend surgeon top-box ratings than Asian (P < .001) or underrepresented minority surgeons (P < .001). Additionally, male gender (P < .01) and older surgeon age (P < .001) were associated with higher top-box scores. However, in multivariate generalized estimating equation analysis, the effect of age was no longer significant, but female gender continued to be associated with lower odds of top-box likelihood to recommend surgeon ratings (odds ratio 0.83; 95% confidence interval, 0.70%-0.99%), as did Asian compared with white race (odds ratio 0.78; 95% confidence interval, 0.65%-0.95%). Likelihood to recommend surgeon scores correlated most closely with patients' "confidence" in the surgeon rather than measures of courtesy, concern, understandability, or inclusion in medical decision making. CONCLUSION: Top-box scores varied by surgeon race and gender in correlation with patients' perceived confidence in the provider. Interpretation of Press Ganey scores should account for potential bias in patient satisfaction surveys based on surgeon demographics.

The Social Perception of Microtia and Auricular Reconstruction.

OBJECTIVES: To examine the social perception of microtia and quantify the effect of reconstruction on socially perceived attributes. METHODS: Parental consent was obtained for peri-reconstruction photographs in a patient with unilateral grade 3 microtia without an underlying craniofacial syndrome. With computer simulation, the normal, preoperative microtia, and postoperative reconstruction ear were isolated and blended into the oblique and lateral views of that volunteer's face to isolate ear morphology as a variable against a constant facial baseline. These photographs were embedded into Web-based surveys with visual analogue scales to capture social perception data and then were sourced to general population adults. RESULTS: Survey respondents totaled 631. On average, the face with the microtia ear was perceived to be less friendly (P = .015), less healthy (P = .022), and less successful (P = .005) than the same face with the "normal" ear. There were no statistically significant differences in socially perceived attributes between the face with the normal ear and the face with the reconstructed ear. CONCLUSION: This is the first study to examine the social perception consequences of microtia and microtia reconstruction in children. These findings may explain the significant psychosocial distress experienced by these patients by exploring the social perception of specific attributes perceived. Lastly, this study may better inform microtia patients and their physicians on the impact of auricular reconstruction on third party's perception of social attributes. LEVEL OF EVIDENCE: N/A Laryngoscope, 131:195-200, 2021.

The Health Burden of Transfeminine Facial Gender Dysphoria: An Analysis of Public Perception.

Objectives/Hypothesis: The face is a major communicator of gender identity. Transfeminine individuals report debilitating quality-of-life deficits as a result of their gender dysphoria, which may be addressed with feminizing therapies. We aimed to quantify the potential impact of facial gender dysphoria experienced by transfeminine patients, as well as associated treatments, including feminizing facial gender surgery, through validated health state utility measures. Methods: A transfeminine patient volunteer who underwent head and neck gender-affirming treatments was consented for research use of perioperative photographs. These media aided in the description of two transfeminine health states, pre- and postfacial feminization facial gender dysphoria. Monocular blindness and binocular blindness were two health state controls. General population adults rated these four health states through visual analog scale (VAS), standard gamble (SG), and time trade-off (TTO), which were used to calculate the quality-adjusted life years (QALYs). Results: Survey respondents totaled 206 with a mean (standard deviation [SD]) age of 35.8 (11.9) years. Mean (SD) health utility measures included 0.75 (0.22) QALYs for VAS, 0.82 (0.19) QALYS for SG, 0.79 (0.21) QALYS for TTO for pretreatment facial gender dysphoria, and 0.81 (0.21), 0.86 (0.19), 0.83 (0.20) QALYS for postgender-affirming treatments for facial gender dysphoria. The health utility scores for the postgender-affirming treatments for facial gender dysphoria (+0.06 VAS, p = 0.005) were significantly improved compared with the pretreatment state. Conclusions: To our knowledge, this study is the first to examine how the general population perceives the health burden of facial gender dysphoria experienced by transfeminine patients. Facial gender dysphoria is perceived to have a negative impact on health states, not dissimilar to monocular blindness in our sample. Feminizing facial gender surgery appears to significantly increase health utility measures.

Social Perception of the Nasal Dorsal Contour in Male Rhinoplasty.

IMPORTANCE: The social perception of nasal dorsal modification for male rhinoplasty is poorly understood. OBJECTIVE: To investigate the association of modifying the male nasal dorsum with the perception of such social attributes as youth, approachability, healthiness, masculinity/femininity, intelligence, successfulness, and leadership. DESIGN, SETTING, AND PARTICIPANTS: Using computer simulation software, 12 images with varied combinations of the nasal dorsal shape, nasofrontal angle (NFA), and nasolabial angle (NLA) were generated from a photograph of a male volunteer's face in profile. These photographs were then sent to participants at a university clinic who were English-speaking adult internet users who were masked to the purpose of the study, which asked them to value different social attributes regarding the face in the photograph in a 16-question survey. The study was conducted in September 2018 and the data were analyzed thereafter until March 2019. EXPOSURES: Twelve photographs embedded in a 16-question survey. MAIN OUTCOMES AND MEASURES: Population proportions of responses and χ2 test and graphical analysis based on 95% confidence intervals. RESULTS: Of 503 respondents (survey provision rate, 100%), 412 (81.9%) were women, 386 (76.7%) were white, 32 (6.4%) were Hispanic or Latinx, 63 (12.5%) were black/African American, 10 (2.0%) were Asian/Pacific Islander, and the median age was 46 years (interquartile range, 32-61 years). The man with ski slope-shaped nose with an NFA of 130° and NLA of 97° was often associated with frequently perceived positive characteristics; specifically, he was judged to be the most attractive (95% CI, 18%-26%; P < .001). Participants also often associated superlative youth (95% CI, 15%-24%; P < .001), approachability (95% CI, 13%-20%; P = .002), and femininity (95% CI, 14%-22%; P < .001) with dorsal contours that did not feature a dorsal hump. The man with a dorsal hump-shaped nose with an NFA of 140° and NLA of 105° was associated by the highest proportion of participants with being the oldest (95% CI, 35%-44%; P < .001), least approachable (95% CI, 27%-35%; P < .001), least attractive (95% CI, 37%-42%; P < .001), and least healthy (95% CI, 26%-34%; P < .001). Subset analyses also revealed statistically significant dorsal contour preferences by observers' age, gender, and race/ethnicity. CONCLUSIONS AND RELEVANCE: A reduced dorsal slope combined with more acute NFAs and NLAs was associated with positively perceived social attributes. The results may be of interest to rhinoplasty surgeons and their male patients when planning changes to the nasal dorsal contour. LEVEL OF EVIDENCE: NA.

Relationship of Sociodemographic Factors and Outcomes in Functional Rhinoplasty.

The objective of this article was to compare the effect of such sociodemographic factors as gender, age, marital status, employment status, race, and income on short- and long-term rhinoplasty outcomes using a validated disease-specific instrument-Nasal Obstruction Symptom Evaluation (NOSE) scale, as well as complication and revision rates. Patients who underwent a functional (+/- cosmetic) rhinoplasty with the senior author between January, 1 2012, and September 9, 2017, and had both a preoperative and at least one postoperative NOSE score, were included in the study. Sociodemographic variables of binary gender, age, marital status, employment status, race, and income based on zip code were collected. The primary outcomes were the differences between the preoperative and postoperative NOSE scores with short-term (less than 3 months) and longer-term (greater than 3 months) follow-up. Secondary outcomes were general complications and specifically revision surgery. Standard descriptive statistics, as well as univariable linear and logistic regressions, were conducted with each outcome measure. A total of 341 patients were included in this study. No individual patient-level variables were found to significantly affect the short- or longer-term average change in NOSE scores, although older age trended toward significance in longer-term average change in NOSE scores (p = 0.07). No factors significantly affected the rate of complications or revision surgery in this cohort. The authors found improvement in NOSE scores after rhinoplasty was not related to factors of age, gender, race, employment status, income, and marital status. This cohort also did not demonstrate differential rates in complications or revision surgery based on sociodemographic variables.

Evaluation of Antibiotic Prophylaxis in Rhinoplasty: A Systematic Review and Meta-analysis.

IMPORTANCE: Although antibiotic prophylaxis following rhinoplasty is widespread, the evidence on antibiotic prophylaxis effectiveness and the superiority of particular administration regimens is controversial. To date, a meta-analysis on the topic has not been performed. OBJECTIVE: To systematically review the association between use of preventive antibiotics and postoperative complications in patients undergoing rhinoplasty and quantify the review through meta-analysis. DATA SOURCES: MEDLINE, Embase, CINAHL, Central (Cochrane Controlled Register of Trials), Scopus, and Web of Science were searched with prospectively designed search phrases on February 16, 2018. All databases were searched from database inception. Key search terms included rhinoplasty, nasal valve repair, and antibacterial agent. STUDY SELECTION: Randomized clinical trials (RCTs) with adults (≥18 years) undergoing rhinoplasty and including systemic antibiotic medications administered in the absence of other reasons for use of an antibiotic (eg, localized or systemic infection), without restrictions on language or the time of publication, were included in the study. Interventions of interest were classified into 3 types: (1) single-dose systemic antibiotic administered within 24 hours before the first incision, (2) multidose systemic antibiotic treatment started within 24 hours before the first incision and continuing after the operation, and (3) systemic antibiotic therapy (single dose or multidose) started within 24 hours after the first incision. The following comparisons were made: for the interventions of type 1, no antibiotic; for the interventions of types 2 or 3, no antibiotic or an intervention of type 1. DATA EXTRACTION AND SYNTHESIS: Data extraction was compliant with PRISMA guidelines and Cochrane Handbook for Systematic Reviews of Interventions. Two independent reviewers assessed the relevance of the remaining records at abstract and full-text stages. Meta-analysis pooled with random-effects model. MAIN OUTCOMES AND MEASURES: Difference in infectious complication rate between groups. RESULTS: A total of 262 records were identified; of these, only 5 RCTs fulfilled predetermined population, intervention, comparison, and outcome criteria. The pooled study sample consisted of 589 participants. No significant differences in outcome of preventive antibiotic therapy given either preoperatively or postoperatively were found, with a pooled risk ratio of 0.92 (95% CI, 0.35-2.43; P = .86). CONCLUSIONS AND RELEVANCE: This study appears to be the first Cochrane-protocol systematic review and meta-analysis investigating preventive antibiotics in rhinoplasty. This study's results suggest that pooled evidence from the 5 RCTs does not support the use of preventive antibiotic therapy in rhinoplasty. LEVEL OF EVIDENCE: 1.

Comparison of Primary and Secondary Anterior Septal Reconstruction: A Cohort Study.

This article compares outcomes in patients presenting for either primary or secondary (revision) anterior septal reconstruction (ASR) to treat caudal septal deviation. Patients undergoing ASR by senior author (S. P. M.) between January 1, 2012 and September 1, 2017, with both preoperative and postoperative Nasal Obstruction Symptom Evaluation (NOSE) scores documented in the chart were included. Data were compared between patients undergoing primary and secondary ASR by univariable and multivariable logistic regression. A total of 199 patients were included in this study; 128 (64%) underwent primary ASR and 71 (36%) underwent secondary ASR. After multivariable analysis, a greater ratio of females and autologous rib graft harvest in the secondary compared with primary ASR, and decreased odds of inferior turbinate reduction in the secondary group was found. There was no significant difference in NOSE scores between the primary and secondary group, and there were very few complications or revision surgeries. While outcomes are similar between primary and secondary (revision) ASR to treat caudal septal deviation, there was a significantly higher rate of autologous rib harvest, highlighting the importance of addressing deviations of the caudal septum at the primary procedure to reduce morbidity related to rib graft harvest and revision surgery.

Outcomes in Head and Neck Resections That Require Multiple-Flap Reconstructions: A Systematic Review.

Importance: Complex head and neck cancer defects that require multiflap reconstructions are technically feasible, but the morbidity and patient outcomes of such large-scale head and neck operations have yet to be systematically reviewed. Objective: To systematically review existing literature to characterize the outcomes of large-scale head and neck resections that require multiple-flap reconstructions (defined as defects that require >1 flap [free, pedicled, or combinations thereof]). Evidence Review: Two authors independently searched PubMed, Embase, and the Cochrane Review databases for English-only texts published on any date. Included studies examined patients who underwent complex head and neck surgical resections that required multiple simultaneous flaps for reconstruction. Included studies reported results on at least one of the following outcomes: functional and aesthetic, patient survival, or cost (estimated by operating room time, length of stay, and/or complications). Methodological Index for Non-Randomized Studies (MINORS) criteria for bias and modified Oxford Centre for Evidence-Based Medicine recommendations were used to assess study quality. Findings: Twenty-four studies published from November 1, 1992, through September 1, 2016, met the final inclusion criteria, with a total of 487 patients (370 male [79.4%]; mean [SD] weighted age, 55.1 [4.1] years). Sixty-two of 250 patients (24.8%) were partially or fully dependent on feeding tubes at follow-up. Twenty-two of 75 patients (29.3%) had poor postoperative oral competence, causing moderate to severe drooling. Nineteen of 108 patients (17.6%) had unintelligible speech. Nine of 64 patients (14.1%) were unsatisfied with their aesthetic outcome. The mean (SD) reported survival was 2.36 (1.39) years. The mean (SD) length of stay was 24.5 (12.2) days in 219 patients. Eighty-eight minor complications (eg, partial flap necrosis, donor site complications) and 185 major complications (eg, surgical reexplorations, flap loss, or cardiopulmonary complications) were reported in 380 patients. Mean (SD) MINORS scores were 16.0 (3.2) for comparison studies and 11.4 (1.8) for noncomparison studies. Conclusions and Relevance: Because of limited patient life expectancies, modest functional and aesthetic outcomes, and significant associated costs, surgeons should weigh the curative potential and palliative benefits for individual patients with a comprehensive view of the overall outcomes of extensive head and neck resections and reconstructions. Realistic expectations should be emphasized during preoperative discussions with patients.

Otitis Media and Nasopharyngeal Colonization in ccl3-/- Mice.

We previously found CC chemokine ligand 3 (CCL3) to be a potent effector of inflammation during otitis media (OM): exogenous CCL3 rescues the OM phenotype of tumor necrosis factor-deficient mice and the function of macrophages deficient in several innate immune molecules. To further delineate the role of CCL3 in OM, we evaluated middle ear (ME) responses of ccl3-/-mice to nontypeable Haemophilus influenzae (NTHi). CCL chemokine gene expression was evaluated in wild-type (WT) mice during the complete course of acute OM. OM was induced in ccl3-/- and WT mice, and infection and inflammation were monitored for 21 days. Phagocytosis and killing of NTHi by macrophages were evaluated by an in vitro assay. The nasopharyngeal bacterial load was assessed in naive animals of both strains. Many CCL genes showed increased expression levels during acute OM, with CCL3 being the most upregulated, at levels 600-fold higher than the baseline. ccl3-/- deletion compromised ME bacterial clearance and prolonged mucosal hyperplasia. ME recruitment of leukocytes was delayed but persisted far longer than in WT mice. These events were linked to a decrease in the macrophage capacity for NTHi phagocytosis and increased nasopharyngeal bacterial loads in ccl3-/- mice. The generalized impairment in inflammatory cell recruitment was associated with compensatory changes in the expression profiles of CCL2, CCL7, and CCL12. CCL3 plays a significant role in the clearance of infection and resolution of inflammation and contributes to mucosal host defense of the nasopharyngeal niche, a reservoir for ME and upper respiratory infections. Therapies based on CCL3 could prove useful in treating or preventing persistent disease.

Refractory sleep-disordered breathing due to unilateral lingual tonsillar hypertrophy in a child with Proteus Syndrome.

Proteus Syndrome (PS) is a rare congenital overgrowth disease affecting bones, skin, adipose and the central nervous system. The result is asymmetric, disfiguring hypertrophy which can manifest as craniofacial dysmorphia and aerodigestive tract abnormalities. We report the case of obstructive lingual tonsillar hypertrophy resulting in residual sleep disordered breathing after adenotonsillectomy in a child with PS, a previously unrecognized manifestation of the disease. Endoscopic treatment with coblation effectively and safely treated the obstructive symptoms.

Gingival Metastasis: A Case Report and Literature Review.

Secondary oral cavity neoplasms are rare. We describe a case of an indurated, nonulcerating gingival lesion in a 59-year-old nonsmoking man with no family history of lung cancer. The lesion was the presenting symptom of metastatic lung adenocarcinoma. Reviewing the literature, we find that primary lung cancer among men is one of the most common cancers to metastasize to the oral cavity. Renal and cutaneous neoplasms are the next most common neoplasms to metastasize to the oral cavity. Furthermore, the gingiva, a tissue prone to inflammation, is noted to be a common site for secondary oral cavity neoplasms. This rare case highlights that metastases should influence the clinician's differential of oral mucosal lesions.

The coccidioidomycosis conundrum: a rare parotid mass.

A man, age 62 years, presented to the clinic with a 2-week history of increased nontender, nonerythematous, indurated right-sided parotid swelling. A 4 × 6-cm firm, well-circumscribed mass was palpated in the right parotid gland. A fine-needle aspiration biopsy was performed on the parotid mass with aspiration of 0.5 cc of purulent fluid with some blood. Cultures from the aspirate revealed Coccidioides immitis confirmed by DNA probe. Pathology slides revealed fungal spores. The patient was treated with 800 mg of fluconazole every day for 3 months with resolution of the parotid swelling. However, persistent cervical adenopathy remains.Although this is a rare case of acute parotid swelling, Coccidioides immitis should be considered in the differential diagnosis of parotid masses in a patient with previous coccidioidomycosis. There may be a potential for an increase in frequency and variety of atypical extrapulmonary manifestations of coccidioidomycosis that parallels the increase in coccidioidomycotic pulmonary infections. Long-term antifungal therapy appears essential for control.