Leveraging the virtual landscape to promote diversity, equity, and inclusion in Otolaryngology-Head & Neck Surgery.

The pandemic era has wrought disruptive changes across all aspects of academic medicine, transforming clinical care systems, research enterprises, and educational practices. Among these sweeping changes, some of the most significant for Otolaryngology-Head & Neck Surgery (OHNS) relate to innovative use of virtual communication. The virtual landscape has not only redefined the delivery of patient care but also expanded educational interactions across the career continuum. As the architecture of relationships has been reimagined, the traditional Halstedian teaching paradigm has evolved, now integrating in-person, virtual, and hybrid learning. Once formidable barriers to distance learning have diminished, giving way to social networks that support mentorship, coaching, and sponsorship. Creative use of technology supports collaboration, feedback, spaced learning, scaffolding, and interleaving. These advances have immediate significance for OHNS, a highly collaborative specialty that leads in technological innovation and aspires to improve diversity. Whereas traditional efforts to grow the ranks of underrepresented in medicine (URiM) individuals in OHNS yielded only incremental progress, the virtual landscape is unveiling new strategies for reengineering narrow or leaky pipelines. Strategies that can help attract URiM applicants include inclusive departmental web presence, interactive online clinical experiences, virtual interviews, and remote research opportunities. As students, surgeons, and scientists collectively embrace technology, accelerated progress toward diversity, equity, and inclusion (DEI) becomes possible. Maximizing these opportunities requires aligning national and institutional imperatives for diversity with departmental priorities and mission. Finally, intentional outreach and holistic assessment support growth of structured virtual communities that foster equitable access for those who need it most.

Pediatric tracheostomies in patients less than 2 years of age: Analysis of complications and long-term follow-up.

PURPOSE: Identify variables that are predictive of morbidity and mortality in children under the age of two undergoing tracheostomy and to provide longitudinal data on this patient population. METHODS: Patients were retrospectively identified using Current Procedural Terminology codes 31600, 31601, 31610 from 2009 to 2016. RESULTS: Median age at time of tracheostomy was 0.43 years (interquartile range, 0.27-0.61). Patients were followed for a median of 1.39 years (range 0.03-4.25). Overall mortality rate in this cohort was 23.5% with the majority (81.3%) of deaths occurring >30 days following tracheostomy. The most frequently encountered major complication was cardiopulmonary arrest (10.29%) in the short-term follow up period (<30 days) and accidental decannulation (32.81%) during long-term follow up (>30 days). Peristomal skin breakdown was less likely to develop in patients who did not receive paralytics following tracheostomy. Most patients (54.4%) were discharged to home following initial admission and experienced a mean of 2.10 readmissions for any reason during the follow-up period. 64.4% of patients underwent surveillance direct laryngoscopy and bronchoscopy during the follow-up period and suprastomal granuloma formation was detected in 31.2% of these patients. 9 patients underwent decannulation at a median of 2 years from original tracheostomy placement. CONCLUSION: Pediatric patients under the age of 2 undergoing tracheostomy exhibit high morbidity during both the initial hospital admission and the subsequent months following discharge. However, major complications were low and mortality was not directly related to tracheostomy status in any case.

Allyship to Advance Diversity, Equity, and Inclusion in Otolaryngology: What We Can All Do.

Purpose of review: To summarize the current literature on allyship, providing a historical perspective, concept analysis, and practical steps to advance equity, diversity, and inclusion. This review also provides evidence-based tools to foster allyship and identifies potential pitfalls. Recent findings: Allies in healthcare advocate for inclusive and equitable practices that benefit patients, coworkers, and learners. Allyship requires working in solidarity with individuals from underrepresented or historically marginalized groups to promote a sense of belonging and opportunity. New technologies present possibilities and perils in paving the pathway to diversity. Summary: Unlocking the power of allyship requires that allies confront unconscious biases, engage in self-reflection, and act as effective partners. Using an allyship toolbox, allies can foster psychological safety in personal and professional spaces while avoiding missteps. Allyship incorporates goals, metrics, and transparent data reporting to promote accountability and to sustain improvements. Implementing these allyship strategies in solidarity holds promise for increasing diversity and inclusion in the specialty.

Racial, ethnic, and socioeconomic disparities in the presentation and management of pediatric thyroid cancer.

OBJECTIVES: Disparities across race and socioeconomic status (SES) in cancer treatment exist for many malignancies. Disadvantaged groups have repeatedly been shown to receive sub-optimal treatment. This study intends to analyze racial and SES disparities in the presentation and management of pediatric thyroid cancer. METHODS: A retrospective national database study of children who underwent thyroidectomy for thyroid papillary, medullary, and follicular carcinoma between 2007 and 2016 was conducted using the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) database. Multivariable logistic regression was conducted to identify predictors of 1) tumor stage/size at diagnosis and 2) treatment modalities. RESULTS: 1942 children were analyzed. The average tumor size at presentation was 20 mm for White patients, 26 mm for Non-White patients, and 27 mm for Hispanic patients (p < 0.001). Stage of disease differed significantly by race/ethnicity (p < 0.001) with Non-White and Hispanic patients having more distant disease than White patients at presentation. On multivariable regression, Hispanic patients (OR 1.41, 95%CI 1.06-1.87, p = 0.017) were more likely to be diagnosed at later stages. Non-White (OR 2.03, 1.50-2.73, p < 0.001) and Hispanic patients (OR 1.57, 1.19-2.07, p = 0.002) had larger tumors at diagnosis than White patients after controlling for other SES factors. CONCLUSIONS: SES disparities exist in pediatric thyroid cancer. Non-White and Hispanic patients are more likely to present with larger tumors and distant disease as compared to White patients. Understanding and intervening on these SES disparities is essential to improve outcomes.

Endotracheal Tube Size in Critically Ill Patients.

Importance: Many patients who survive critical illness are left with laryngeal functional impairment from endotracheal intubation that permanently limits their recovery and quality of life. Although the risk for laryngeal injury increases with larger endotracheal tube sizes, there are no data delineating the association of smaller endotracheal tube sizes with survival or acute recovery from critical illness. Objective: To determine if smaller endotracheal tubes are noninferior to larger endotracheal tubes with respect to critical illness outcomes. Design, Setting, and Participants: This propensity score-matched retrospective cohort study included all adult patients who underwent endotracheal intubation in the emergency department or intensive care unit and received mechanical ventilation for at least 12 hours from June 2020 to November 2020 at a single tertiary referral academic medical center. Exposures: Endotracheal intubation. Main Outcomes and Measures: Propensity score-matched analyses were performed with respect to the primary end point of 30-day all-cause in-hospital survival as well as the secondary end points of duration of invasive mechanical ventilation, length of hospital stay, mean peak inspiratory pressure, 30-day readmission, need for reintubation, and need for tracheostomy or gastrostomy tube placement. Results: Overall, 523 participants (64%) were men and 291 (36%) were women. Of these, 814 patients were categorized into 3 endotracheal tube groups: small for height (n = 182), appropriate for height (n = 408), and large for height (n = 224). There was not a significant difference in 30-day all-cause in-hospital survival between groups ([HR, 1.1; 95% CI, 0.7-1.7] for small vs appropriate; [HR, 1.1; 95% CI, 0.7-1.6] for large vs appropriate). Patients with small-for-height endotracheal tubes had longer intubation durations (mean difference, 32.5 hrs [95% CI, 6.4-58.6 hrs]) compared with patients with appropriate-for-height tubes. Conclusions and Relevance: Despite differences in intubation duration, the results of this cohort study suggest that smaller endotracheal tube sizes are not associated with impaired survival or recovery from critical illness. They support future prospective exploration of the association of smaller endotracheal tube sizes with recovery from critical illness.

Disseminated Herpes Simplex Infection Presenting as Acute Supraglottitis in an Adult.

Supraglottitis is a life-threatening, predominantly bacterial disease that is rarely caused by viral etiologies. Herpes Simplex Virus (HSV) supraglottitis has been infrequently reported, but its presentation can mimic that of bacterial supraglottitis or pharyngitis which may lead to delayed diagnosis and increased morbidity. We present a case of supraglottitis in an immunocompetent man initially thought to have bacterial epiglottitis. After receiving a tracheostomy due to impending airway compromise and failing to improve on antibiotic therapy, biopsy of the upper airway tissue revealed infection with HSV type 2. The patient improved after multiple weeks of systemic antivirals. HSV supraglottitis remains an unusual but important diagnostic consideration in patients with dysphonia, dysphagia, ulcerative supraglottal lesions, and acute supraglottic inflammation unresponsive to antibiotics.

Critical Components of Diversity Initiatives.

The importance of diversity is well established and holds important implications for workplace and physician-patient relationships. Evaluation of diversity statistics within otolaryngology-head and neck surgery reveals areas of deficiency that may be improved with targeted proactive approaches. This article provides a general overview of diversity within otolaryngology, highlights key components of diversity initiatives, and provides strategies for implementation.

New Age Mentoring and Disruptive Innovation-Navigating the Uncharted With Vision, Purpose, and Equity.

For individuals aspiring to a career in otolaryngology-head and neck surgery, mentorship can shape destiny. Mentorship helps assure safe passage into the specialty, and it influences the arc of professional development across the career continuum. Even before the novel coronavirus disease 2019 (COVID-19) pandemic, technology and social networking were transforming mentorship in otolaryngology. Now, in an increasingly virtual world, where in-person interactions are the exception, mentorship plays an even more pivotal role. Mentors serve as trusted guides, helping learners navigate accelerating trends toward early specialization, competency-based assessments, and key milestones. However, several structural barriers render the playing field unlevel. For medical students, cancellation of visiting clerkships, in-person rotations, and other face-to-face interactions may limit access to mentors. The pandemic and virtual landscape particularly threaten the already-leaky pipeline for underrepresented medical students. These challenges may persist into residency and later career stages, where structural inequities continue to subtly influence opportunities and pairings of mentors and mentees. Hence, overreliance on serendipitous encounters can exacerbate disparities, even amid societal mandates for equity. The decision to take deliberate steps toward mentoring outreach and engagement has profound implications for what otolaryngology will look like in years to come. This article introduces the concept of new age mentoring, shining a light on how to modernize practices. The key shifts are from passive to active engagement; from amorphous to structured relationships; and from hierarchical dynamics to bidirectional mentoring. Success is predicated on intentional outreach and purposefulness in championing diversity, equity, and inclusion in the progressively technology-driven landscape.

Association of Educational Intervention With Knowledge of Airway Injury After Endotracheal Intubation and Tube Size Selection.

In this nonrandomized controlled trial, an educational intervention for emergency medicine residents was developed to increase knowledge of airway injury following prolonged intubation and reduce the proportion of large-for-height endotracheal tubes placed in the emergency department.

Mycotic Pseudoaneurysm Associated with Skull Base Osteomyelitis Treated with Endovascular Embolization.

Pseudoaneurysms occur due to malformations in arterial wall uniformity, leading to blood collection between the outer arterial layers and resultant outpouching of the vessel. Unlike true aneurysms, pseudoaneurysms do not involve all layers of the blood vessel. Mycotic pseudoaneurysms can occur after associated vessel adventitia infection, leading to transmural dissection. Here we present a case of a 78-year-old man with a history of chronic otitis externa and osteomyelitis who presented with increasing right ear pain with bloody discharge and associated headache. Catheter angiography demonstrated a large pseudoaneurysm in the right middle meningeal artery (MMA) at the base of the skull. Based on the clinical findings and the patient's history, the patient was ultimately diagnosed with mycotic pseudoaneurysms of the MMA. The patient was subsequently treated with antibiotics as well as endovascular embolization and recovered without any complications.

Intracranial Ischemic Infarct Due to Blunt Force Trauma in a High School Football Player.

Ischemic stroke is an uncommon cause of death among teenagers and young adults; however, the etiologies differ when compared to ischemic strokes in older individuals. Large-vessel atherosclerosis and small-vessel disease causing ischemic stroke are rare for the teenage population, while cervicocerebral arterial dissections account for up to 20% of ischemic strokes. Here, we present the case of a 16-year-old male who developed internal carotid artery dissection (ICAD) after a head injury and subsequently developed ischemic stroke and seizures.