Resources Utilized by Otolaryngology Fellowship Directors When Determining Reputations of Residency Programs.

OBJECTIVE: Residency program reputation is consistently reported as an important factor by fellowship directors when considering applicants. This study sets out to determine resources fellowship directors rely on when determining residency program reputation. STUDY DESIGN: Cross-sectional study. SETTING: Using an anonymous online survey of all 2022 Otolaryngology (OHNS) fellowship program directors. METHODS: The 13-question survey sought to assess fellowship director's perspectives and resource utilization when determining residency program reputation. RESULTS: Representing all OHNS fellowship program directors and co-directors (N = 287), 103 responded to our survey, response rate 35.9%. Most participants reported that residency reputation was important for fellowship candidacy. On a Likert scale of 1 to 5, 1 being most important and 5 being not important, personal knowledge of the residency program (2.03 out of 5) and program faculty/mentor reputation (2.09 out of 5) were the most important factors cited. 63% were unfamiliar with the survey methodology of Doximity Residency Navigator (DRN), while 53% contributed to DRN by filling out surveys. Nearly all fellowship directors (N = 100, 97%) reported their rank list was not influenced by DRN. Most fellowship directors reported that US News and World Report (USNWR) and DRN were neither consistent nor inconsistent with their perceptions of residency reputations (38% and 56%, respectively), suggesting ambivalence toward these resources. CONCLUSION: Residency reputation is important for fellowship directors when evaluating fellowship candidates. Directors do not rely on USNWR, National Institute of Health (NIH) ranking, or DRN when gauging residency reputation, but rather personal knowledge of the applicant's residency program or reputation of the otolaryngology faculty.

The submental island flap in head and neck reconstruction: A 10-year experience examining application, oncologic safety, and role of comorbidity.

Background: We present our experience on reconstructive versatility and risk of nodal transfer with the submental island flap (SIF). We also examine the role of comorbidity as a predictor of complications. Methods: Retrospective cohort study of patients undergoing SIF over 10-year period. Comorbidity determined using Adult Comorbidity Evaluation 27 index (ACE-27). Univariable/multivariable logistic regressions performed to determine association of these characteristics and rates of major complications. Results: Fifty-eight patients underwent SIF reconstruction, 27 (45%) patients had moderate/severe comorbidity, and 24 (41%) experienced major complication. Multivariable analysis identified ACE-27 scores >2 predictive of major flap complications (OR: 17.38, 95% CI: 1.96-153.74, p = .01) and medical complications (OR: 5.8, 95% CI: 1.11-30.23, p = .037). There were no cases of pathologic nodal transfer. Conclusion: The SIF is a versatile flap and oncologically safe in carefully selected patients. The ACE-27 index is strongly predictive of major postoperative complications. Level of Evidence: 4.

Current Trainee and Workforce Patterns for Thyroid and Parathyroid Surgery in the United States.

OBJECTIVE: Thyroid and parathyroid surgery is performed by both general surgeons and otolaryngologists. We describe the proportion of surgeries performed by specialty, providing data to support decisions about when and to whom to direct research, education, and quality improvement interventions. METHODS: We tabulated case numbers for privately insured patients undergoing thyroid and parathyroid surgery in Marketscan: 2010-2016 and trainee case logs for residents and fellows in general surgery and otolaryngology. Summary statistics and tests for trends and differences were calculated. RESULTS: Marketscan data captured 114 500 thyroid surgeries. The proportion performed by each specialty was not significantly different. Otolaryngologists performed 58 098 and general surgeons performed 56 402. Otolaryngologists more commonly performed hemithyroidectomy (n = 25 148, 43.29% of all thyroid surgeries performed by otolaryngologists) compared to general surgeons (n = 20 353, 36.09% of all thyroid surgeries performed by general surgeons). Marketscan data captured 21 062 parathyroid surgeries: 6582 (31.25%) were performed by otolaryngologists, and 14 480 (68.75%) were performed by general surgeons. The case numbers of otolaryngology and general surgery trainees completing residency and fellowship varied 6- to 9-fold across different sites. The wide variation may reflect both the level of exposure a particular training program offers and trainee level of interest. CONCLUSION: Thyroid surgical care is equally provided by general surgeons and otolaryngologists. Both specialties contribute significantly to parathyroid surgical care. Both specialties should provide input into and be targets of research, quality, and education interventions.

A Double-Blind, Randomized Clinical Trial to Determine Effects of Increasing Doses and Dose-Response Relationship of IncobotulinumtoxinA in the Treatment of Glabellar Rhytids.

BACKGROUND: IncobotulinumtoxinA is an effective neuromodulator for treating glabellar rhytids. The relationship between dose and reduction in rhytid severity is well established. However, the effects of escalating doses on the treatment duration response are less understood. OBJECTIVES: The aim of this study was to assess the effects of increasing doses of incobotulinumtoxinA on the treatment duration for glabellar rhytids. METHODS: A randomized, double-blind, Phase IV study was conducted at a fully accredited, outpatient surgical facility. Subjects (31 female, 7 male) with moderate to severe glabellar rhytids were randomized to 1 of 3 incobotulinumtoxinA dose groups: 20, 60, or 100 U. Effect duration was determined by calculating the time to return to baseline for dynamic glabellar lines during maximal contraction. Follow-up was completed through 1 year, and adverse events were monitored. RESULTS: The median duration of effect was 120 days (95% confidence interval [CI] [90, 180 days]), 180 days (95% CI [180, 210 days]), and 270 days (95% CI [240, 330 days]) for the 20-, 60-, and 100-U groups, respectively. A Wald chi-square test from the Cox regression on the primary efficacy variable indicated a statistically significant effect of dose group on time to baseline (chi square = 54.63; df = 2; P < 0.001). Hazard ratios were HR = 0.21 (95% CI [0.10; 0.43] for the 60-U vs the 20-U group, and HR = 0.06 (95% CI [0.10; 0.43]) for the 100-U vs the 20-U group, indicating a statistically longer return to baseline for both the 60- and 100-U cohorts. CONCLUSIONS: There is a dose-dependent relationship between incobotulinumtoxinA and duration of effect in the glabella.

A Randomized, Blinded, Prospective Clinical Study Comparing Small-Particle Versus Cohesive Polydensified Matrix Hyaluronic Acid Fillers for the Treatment of Perioral Rhytids.

BACKGROUND: Perioral rhytids are a bothersome sign of aging for many patients. Although multiple treatments exist, choosing an optimal modality may be difficult considering that rhytids in this region are fine and the anatomy dynamic. OBJECTIVES: The authors sought to compare the efficacy and safety as well as patient satisfaction of a small-particle hyaluronic acid filler with 0.3% lidocaine (SP-HAL, Restylane Silk) and cohesive polydensified matrix hyaluronic acid filler (CPM-HA, Belotero Balance) in reducing superficial perioral rhytids. METHODS: The study was double-blinded, and 48 patients with moderate to severe superficial perioral rhytids were enrolled. Patients were randomized to receive either CPM-HA in the left perioral region and SPHAL in the right or vice versa. Rhytid severity was measured by patients utilizing a linear analog scale, and by investigators utilizing a validated 5-point scale, for 180 days following treatment. RESULTS: Both SP-HAL and CPM-HA achieved a reduction in rhytid severity, and neither treatment group returned to baseline after 180 days. Investigator-reported scores for rhytid severity were significantly better for SP-HAL than CPM-HA and remained so at 180 days (P < .05). SP-HAL also proved significantly better for reducing rhytids according to patient scores, although this difference occurred between 120 and 180 days only. Adverse events included rash and mild acne for CPM-HA, and SP-HAL was associated with 1 postinflammatory nodule and 2 occurrences of Tyndall effect. CONCLUSIONS: Although both SP-HAL and CPM-HA are effective at reducing perioral rhytid severity and have similar safety profiles, SP-HAL possesses a longer duration of effect.

Spontaneous regression of squamous cell carcinoma in the setting of dental infection and needle biopsy.

To our knowledge, this is the first reported case of spontaneous regression of squamous cell carcinoma within a lymph node. We speculate that prior dental infection, fever, and biopsy incited an antitumor immune reaction.

Nerve Blocks Prior to Microfocused Ultrasound Treatment are Safe and Reduce Patient Discomfort.

BACKGROUND: Microfocused ultrasound with visualization has become one of the more popular nonsurgical facial rejuvenation therapies available. Although the treatment has gained wide acceptance, providing adequate pain relief during the procedure can be challenging. OBJECTIVES: The aim of this study was to test our hypothesis that nerve blocks prior to treatment would be well tolerated and significantly reduce patient discomfort. METHODS: Subjects undergoing microfocused ultrasound were offered the choice of participating in a split face nerve block, bilateral block, or a control group. Nerves targeted included infraorbital, supratrochlear, supraorbital, zygomaticofrontal, mental, great auricular, and cervical plexus. Pain assessment was based on a 10-point Wong-Backer FACES Pain score. RESULTS: A total of 65 patients were included in the study: 28 in the split face group, 19 in the bilateral block group, and 18 without a block. The mean [standard deviation] pain score of the bilateral block cohort was 3.9 [1.2], and that of the control group was 5.1 [1.7] (P = 0.001). Patients in the split face cohort reported a higher pain score on the unblocked side of the face (7.5 [1.3]) than on the blocked side (2.9 [1.0]) (P < 0.001). The mean pain score for local anesthetic injection was 2.7 and 1.4 for the split face and the bilateral groups, respectively. There were no adverse events. CONCLUSIONS: Nerve blocks are well tolerated and significantly improve patient comfort during microfocused ultrasound treatment without compromising outcomes or increasing adverse events.

A Rare Case of Odontogenic Chronic Suppurative Otitis Media.

Common causes of chronic suppurative otitis media (CSOM) include persistence of acute otitis media, cholesteatoma, and eustachian tube dysfunction. We describe a patient who presented with CSOM of several years duration refractory to medical management. Ultimately, a dental abscess was found on computed tomography (CT) to be the source of concurrent ipsilateral maxillary sinusitis and mastoiditis. Extraction of the molar abscess resulted in complete resolution of her CSOM and need to be on antibiotics. To our knowledge, this is the first report of an odontogenic cause of chronic suppurative otitis media.

Diagnostic Value of Lingual Tonsillectomy in Unknown Primary Head and Neck Carcinoma Identification After a Negative Clinical Workup and Positron Emission Tomography-Computed Tomography.

OBJECTIVE: Diagnostic rates of unknown primary head and neck carcinoma (UPHNC) using lingual tonsillectomy (LT) are highly variable. This study sought to determine the diagnostic value of LT in UPHNC identification using strict inclusion criteria and definitions to produce a more accurate estimate of diagnosis rate. METHODS: In this retrospective chart review, records of patients who underwent LT for UPHNC were reviewed. Inclusion criteria included absence of suspicious findings on physical exam and positron emission tomography-computed tomography as well as negative biopsies after panendoscopy and palatine tonsillectomy. Following inclusion criteria, 16 patients were reviewed. A systematic literature review on LT for the workup of CUP was also performed. RESULTS: LT was performed using transoral robotic surgery (TORS), transoral laser microsurgery (TLM), or transoral microsurgery with cautery (TMC). Following LT, primary tumor was identified in 4 patients out of 16. Detection rate by technique was 1/6, 2/7, and 1/3 for TORS, TLM, and TMC respectively. Postoperative bleeding occurred in three patients (19%); however, this was not related to the LT. Following literature review, 12 studies were identified; however, only 3 had enough data to compare against. All three studies had a cohort with suspicious findings on clinical exam. A total of 34 patients had a negative workup, with no suspicious findings on clinical exam and subsequently received an LT. CONCLUSION: This study suggests that LT should be considered initially in the diagnostic algorithm for UPHNC. This study can increase the patient size in this cohort by approximately 47%.

Parotidectomy using the Harmonic scalpel: ten years of experience at a rural academic health center.

BACKGROUND: Parotidectomy is one of the most commonly performed procedures by otorhinolaryngologists. Traditionally dissection is performed with a combination of a steel scalpel and bipolar cautery; however, starting in the early 2000s, the Harmonic scalpel has provided an alternative method for dissection and hemostasis. The purpose of this study is to compare operative time, blood loss, complications, and cost between the Harmonic scalpel and steel scalpel plus bipolar cautery for superficial and total parotidectomy. METHODS: Retrospective cohort of patients who underwent superficial or total parotidectomy with the Harmonic or cold steel between 2000 and 2015. Across 255 patients, comparison between operative time, blood loss, complications, and cost was performed. RESULTS: Superficial parotidectomy was performed on 120 patients with the Harmonic and 54 with steel scalpel. Total parotidectomy was performed on 59 patients using the Harmonic and 22 patients with cold steel. For superficial parotidectomy, the Harmonic reduced operative time (216 ± 42 vs. 234 ± 54 min, p = 0.03) and decreased blood loss (28 ± 19 vs. 76 ± 52 mls, p < 0.05). With total parotidectomy the Harmonic decreased operative time (240 ± 42 vs. 288 ± 78 min, p = 0.01) and reduced blood loss (38 ± 21 mls vs. 85 ± 55 mls, p < 0.05). There were no differences in complication rates between groups. Harmonic use was associated with surgical cost reduction secondary to reduced operative times. CONCLUSIONS: The Harmonic scalpel decreases blood loss and operating time for superficial and total parotidectomy. Shorter operative times may decrease the overall cost of parotidectomy.

Digging into Debt: The Financial Burden Associated with the Otolaryngology Match.

Objective To quantify the cost incurred during the match process for otolaryngology applicants, determine sources of expenditures, and highlight potential methods to alleviate financial burden of the match process. Study Design Cross-sectional. Study Setting Online survey. Subjects and Methods An electronic survey was sent via email to those who applied to the otolaryngology residency programs at Dartmouth-Hitchcock Medical Center and MedStar Georgetown University Hospital during the 2016 application cycle. Questions regarding demographics and experiences with the match were multiple choice, and questions regarding cost were open answer. Data were downloaded and analyzed on Excel and Minitab software. Results Twenty-eight percent of the total 370 applicants completed the survey. The mean cost of away rotations was $2500 (95% confidence interval [CI], $2224-$2776). With application fees and the cost of interviewing, the mean total cost of applying for the 2016 otolaryngology match was $6400 (95% CI, $5710-$7090), with a total range of $1200 to $20,000. Twenty-eight percent of students did not have sufficient funds for applying and interviewing despite seeking out additional monetary resources. Conclusion In 2016, otolaryngology applicants spent a mean of $8900 (95% CI, $7935-$9865) on away rotations, applications, and interviewing. Half of the applicants obtained additional funding to cover this cost, while 28% still did not have sufficient funding. Methods of decreasing cost may include instituting a cap on application number, videoconferencing interviews, regionalizing interviews, and adjusting the interview timeline.

Intracellular calcium and cyclic nucleotide levels modulate neurite guidance by microtopographical substrate features.

Micro- and nanoscale surface features have emerged as potential tools to direct neurite growth into close proximity with next generation neural prosthesis electrodes. However, the signaling events underlying the ability of growth cones to respond to topographical features remain largely unknown. Accordingly, this study probes the influence of [Ca(2+) ]i and cyclic nucleotide levels on the ability of neurites from spiral ganglion neurons (SGNs) to precisely track topographical micropatterns. Photopolymerization and photomasking were used to generate micropatterned methacrylate polymer substrates. Dissociated SGN cultures were plated on the micropatterned surfaces. Calcium influx and release from internal stores were manipulated by elevating extracellular K(+) , maintenance in calcium-free media, or bath application of various calcium channel blockers. Cyclic nucleotide activity was increased by application of cpt-cAMP or 8-Br-cGMP. Elevation of [Ca(2+) ]i by treatment of cultures with elevated potassium reduced neurite alignment to physical microfeatures. Maintenance of cultures in Ca(2+) -free medium or treatment with the non-selective voltage-gated calcium channel blocker cadmium or L-type Ca(2+) channel blocker nifedipine did not signficantly alter SGN neurite alignment. By contrast, ryanodine or xestospongin C, which block release of internal calcium stores via ryanodine-sensitive channels or inositol-1,4,5-trisphosphate receptors respectively, each significantly decreased neurite alignment. Cpt-cAMP significantly reduced neurite alignment while 8-Br-cGMP significantly enhanced neurite alignment. Manipulation of [Ca(2+) ]i or cAMP levels significantly disrupts neurite guidance while elevation of cGMP levels increases neurite alignment. The results suggest intracellular signaling pathways similar to those recruited by chemotactic cues are involved in neurite guidance by topographical features. © 2016 Wiley Periodicals, Inc. J Biomed Mater Res Part A: 104A: 2037-2048, 2016.

Vallecular Varix: A Perplexing Cause of Oral Cavity Bleeding.

Often discovered only after an extensive work up for hemoptysis and hematemesis, vallecular varices are a rare cause of oral bleeding that increase patient morbidity due to delay of diagnosis. We describe an 89-year-old male who presented with a week of intermittent oral blood production. A vallecular varix was identified on fiberoptic laryngoscopy after studies for hematemesis and hemoptysis had been performed, including negative esophagogastroduodenoscopy and bronchoscopy. Awareness of this pathology and key points in the patient history can direct the clinician toward the correct diagnosis, expediting treatment and limiting invasive diagnostic procedures for pulmonary or gastric etiologies of bleeding.