Current Issues With Pediatric Cochlear Implantation.

Cochlear implants (CIs) have demonstrated a clear functional benefit in children with severe-to-profound sensorineural hearing loss (SNHL) and thus have gained wide acceptance for treating deafness in the pediatric population. When evaluating young children for cochlear implantation, there are unique considerations beyond the standard issues addressed during surgery in adults. Because of advances in genetic testing, imaging resolution, CI technology, post-implant rehabilitation, and other factors, issues related to CI surgery in children continue to evolve. Such factors have led to changes in candidacy guidelines, vaccine requirements, and lowering of age requirement for surgery. In addition, differences in the anatomy and physiology of infants require special attention to ensure safety when operating on young children. This review summarizes these issues and provides guidance for surgeons treating children with SNHL.

Temporal Trends in Early Pediatric Cochlear Implantations in California from 2018 to 2020.

OBJECTIVE: To characterize the demographics of children receiving cochlear implantations, identify factors associated with delayed implantations, and trend these factors over time. DESIGN: Retrospective cross-sectional study. SETTING: Healthcare Cost and Utilization Project California State Ambulatory Surgery Database for calendar years 2018-2020. PATIENTS: Children 5 years or younger undergoing cochlear implantation. INTERVENTIONS: Cochlear implantation. MAIN OUTCOMES MEASURES: The population-controlled number of cochlear implantations was calculated and stratified by race and insurance. Early implantation was defined as implantation at age 2 years or younger. A mixed-effects logistic regression model was generated to identify factors associated with early implantation and how that association changed from 2018 to 2020. RESULTS: The final cohort included 467 children. The number of implantations increased from 141 to 175 implants from 2018 to 2020 (24.1% increase); 229 (49.0%) children were implanted at 2 years or younger. Medicaid insurance was associated with decreased odds of early implantation (odds ratio, 0.18 [95% confidence interval, 0.15-0.23], p < 0.001); this association with Medicaid insurance was significant when stratified across all racial groups. The percentage of children with Medicaid who were implanted at 2 years or younger increased from 20.9 to 62.0% from 2018 to 2020. CONCLUSIONS AND RELEVANCE: Among children in California, socioeconomic factors, in particular public insurance, are correlated with age of cochlear implantation. These disparities improved significantly from 2018 to 2020. Further investigation into changes and initiatives in California during this time frame may aid in directing national efforts to improve pediatric cochlear implantation access.

Morphometric Analysis and Linear Measurements of the Scala Tympani and Implications in Cochlear Implant Electrodes.

HYPOTHESIS: The objective of this study was to perform detailed height and cross-sectional area measurements of the scala tympani in histologic sections of nondiseased human temporal bones and correlate them with cochlear implant electrode dimensions. BACKGROUND: Previous investigations in scala tympani dimensions have used microcomputed tomography or casting modalities, which cannot be correlated directly with microanatomy visible on histologic specimens. METHODS: Three-dimensional reconstructions of 10 archival human temporal bone specimens with no history of middle or inner ear disease were generated using hematoxylin and eosin histopathologic slides. At 90-degree intervals, the heights of the scala tympani at lateral wall, midscala, and perimodiolar locations were measured, along with cross-sectional area. RESULTS: The vertical height of the scala tympani at its lateral wall significantly decreased from 1.28 to 0.88 mm from 0 to 180 degrees, and the perimodiolar height decreased from 1.20 to 0.85 mm. The cross-sectional area decreased from 2.29 (standard deviation, 0.60) mm 2 to 1.38 (standard deviation, 0.13) mm 2 from 0 to 180 degrees ( p = 0.001). After 360 degrees, the scala tympani shape transitioned from an ovoid to triangular shape, corresponding with a significantly decreased lateral height relative to perimodiolar height. Wide variability was observed among the cochlear implant electrode sizes relative to scala tympani measurements. CONCLUSION: The present study is the first to conduct detailed measurements of heights and cross-sectional area of the scala tympani and the first to statistically characterize the change in its shape after the basal turn. These measurements have important implications in understanding locations of intracochlear trauma during insertion and electrode design.

Geographic Variations in Medicare Cochlear Implantations in the United States.

OBJECTIVE: To describe national practice patterns and detail geographic and temporal changes in cochlear implantations (CIs) in the Medicare population. STUDY DESIGN: Cross-sectional analysis. SETTING: Medicare B Public Use Files. PATIENTS: Medicare B fee-for-service patients who underwent CI from 2012 to 2019. INTERVENTIONS: Cochlear implantations (Current Procedural Terminology code 69930). MAIN OUTCOME MEASURES: Medicare Part B Public Use Files were used to identify all individual providers who performed CIs from 2012 to 2019. The total number of CIs performed annually was calculated for hospital referral regions (HRRs) as well as U.S. census regions to describe geographic variations and changes over the study period. Average Medicare reimbursement rates were tabulated. RESULTS: From 2012 of 2019, the number of CIs performed in the Medicare population increased from 1,239 to 2,429, representing a 96.0% increase. In each of the four U.S. census regions, there was a statistically significant increase in the number of CIs performed over the study period. However, of 306 HRR in the United States, cochlear implants were performed in only 117 (38.2%), with the median number of CIs in each HRRs 16.7 (interquartile range, 13-24.2) per year. The median weighted average Medicare reimbursement was $1205.49 (interquartile range, 1161.65-1253.46). CONCLUSIONS: The number of CIs in the Medicare population has increased from 2012 to 2019. However, widespread geographic variations continue to persist in the United States and represent opportunities toward identifying and acting on the etiologies of persistent disparities in CI.

Association of Socioeconomic Characteristics With Receipt of Pediatric Cochlear Implantations in California.

Importance: Earlier cochlear implantation among children with bilateral severe to profound sensorineural hearing loss is associated with improved language outcomes. More work is necessary to identify patients at risk for delayed cochlear implantation and understand targets for interventions to improve cochlear implantation rates among children. Objective: To describe the demographics among children receiving cochlear implantations and variability in implantation rates in California and to investigate sociodemographic and parental factors associated with early pediatric cochlear implantation. Design, Setting, and Participants: This retrospective cross-sectional study was conducted using data from the Healthcare Cost and Utilization Project California State Ambulatory Surgery Database in calendar year 2018. Included patients were children aged 9 years old or younger undergoing cochlear implantation. Sociodemographic factors, location of treatment, and parental factors were collected. Data were analyzed from March through August 2021. Main Outcomes and Measures: Binary logistic regression was performed to investigate sociodemographic factors associated with early cochlear implantation (ie, before age 2 years). Geographic variability in pediatric cochlear implantation across hospital referral regions in California was described, and various parental factors associated with implantation before age 2 years were analyzed. Results: Among 182 children receiving cochlear implantations, the median (IQR) age was 3 (1-5) years and 58 children (31.9%) received implantations at ages 2 years or younger. There were 90 girls (49.5%) and 92 boys (50.5%), and among 170 children with race and ethnicity data, there were 27 Asian or Pacific Islander children (15.9%), 63 Hispanic children (37.1%), and 55 White children (32.4%). The risk of CI was significantly decreased among Black children compared with Asian or Pacific Islander children (relative risk [RR], 0.18 [95% CI, 0.07-0.47]; P = .001) and White children (RR, 0.24 [95% CI, 0.10-0.59]; P = .002) and among Hispanic children compared with Asian or Pacific Islander children (RR, 0.32 [95% CI, 0.21-0.50]; P < .001) and White children (RR, 0.42 [95% CI, 0.29-0.59; P < .001). Compared with private insurance, Medicaid insurance was associated with decreased odds of implantation at ages 2 years or younger (odds ratio [OR], 0.19 [95% CI, 0.06-0.64]; P = .007), and every 1 percentage point increase in maternal high school completion percentage in a given California hospital referral region was correlated with a 5-percentage point increase in percentage of cochlear implants performed at age 2 years or younger (b = 5.18 [95% CI, 1.34-9.02]; P = .008). There were no significant differences in rates of early implantation by race or ethnicity. Conclusions and Relevance: This study found significant variability in pediatric cochlear implantation rates in California. These findings suggest that socioeconomic and parental factors may be associated with differences in access to early cochlear implantation and suggest the need to invest in initiatives to address barriers to appropriate and timely access to care.

The impact of a double vein anastomoses on doppler's loss of signal rates.

BACKGROUND: Impact on blood flow by double vein anastomosis in head and neck free flaps is unclear. We aimed to assess venous doppler loss of signal (LOS) rates of double vein system compared with a single vein system. METHODS: Consecutive free flaps with implanted venous flow couplers between 2015-2017 were included. LOS rates were compared between groups and with regard to flap type, defect site and recipient vein within double vein group. RESULTS: 92 double-vein (184 veins) and 48 single-vein flaps were included. LOS was similar in single- and double-vein flaps (11/48 (25%) versus 46/184 (25%), p = 0.765). Double veins had fewer flap takebacks compared with single vein (4.3% vs. 12.5%, p = 0.075). Common facial vein (CFV) anastomosis showed superior LOS rates compared with external jugular and CFV branches (p = 0.026). CONCLUSIONS: Double vein anastomosis does not impact LOS rates, results in fewer flap takebacks, yet LOS rates depend on selected recipient vein.

Cochlear Meniere's: A Distinct Clinical Entity With Isolated Cochlear Hydrops on High-Resolution MRI?

Objective: Describe the clinical characteristics of patients with isolated cochlear endolymphatic hydrops (EH). Study design: Clinical case series. Setting: Tertiary Neurotology referral clinic. Patients: All subjects presenting to a University Neurotology clinic during a 1-year period from July 2015 until August 2016 who had isolated cochlear EH on MRI. Patients with a history of temporal bone surgery prior to the MRI were excluded. Intervention: High-resolution delayed-intravenous contrast MRI. Main outcome measures: Audiometric and vestibular testing, clinical history analysis. Results: 10 subjects demonstrated isolated, unilateral cochlear hydrops on MRI. None of these patients met the criteria for Meniere's disease. Mean age of the group was 66.4 years and most were males (70%). Unilateral aural fullness (70%), tinnitus (80%), and hearing loss (90%) were frequently observed. Only one patient presented with unsteadiness (10%) and one patient had a single isolated spell of positional vertigo 1 month prior to the MRI (10%) but no further vertigo spells in the 4 years following the MRI. The mean PTA was 37.8 dB which was significantly decreased from the non-affected ear with PTA of 17.9 (p < 0.001). One patient developed vertiginous spells and unsteadiness 4 years after initial presentation and a repeat MRI revealed progression to utricular, saccular and cochlear hydrops. Vestibular testing was obtained in five patients with one patient presenting with 50% caloric paresis and all others normal. The most common treatment tried was acetazolamide in seven patients with 86% reporting subjective clinical improvement. Two out of the 10 patients had a history of migraine (20%). Conclusions: Patients with MRI exhibiting isolated cochlear EH present with predominantly auditory symptoms: mild to moderate low-frequency hearing loss, aural fullness, tinnitus without significant vertigo. Isolated cochlear hydrops is more common in males, average age in mid-60's and there is a low comorbidity of migraine headaches. This contrasts significantly with patients with isolated saccular hydrops on MRI from our prior studies. We believe that isolated cochlear EH with hearing loss but no vertigo is distinct from Meniere's disease or its variant delayed endolymphatic hydrops. We propose that cochlear Meniere's disease represents a distinct clinical entity that could be a variant of Meniere's disease.

Temporal Trends and Regionalization of Acute Mastoiditis Management in the United States.

OBJECTIVE: To describe demographics and to analyze temporal trends in the inpatient management of acute mastoiditis admissions. STUDY DESIGN: Cross-sectional analysis. SETTING: National Inpatient Sample, 2002-2014. PATIENTS: 26,072 nonelective inpatient admissions with primary diagnosis of acute mastoiditis. INTERVENTION: Myringotomy, mastoidectomy, or no procedure. MAIN OUTCOME MEASURES: We described the patient- and hospital-level demographics of acute mastoiditis admissions and the frequency of complications. We evaluated the percentage of patients requiring surgical management. Binary logistic regression was performed to determine whether there was a significant increase in the percentage of patients treated at academic institutions. RESULTS: The majority of patients were ≤40 years old (64.9%) and Elixhauser comorbidity index ≥4 (57.4%); 23.3% (SE 0.8%) presented with complications associated with acute mastoiditis, the most common of which was a subperiosteal abscess (11.5%, SE 0.7%). Among all admissions, 30.9% (SE 1.1%) underwent myringotomy, 13.8% (SE 0.8%) required both myringotomy and mastoidectomy. On multivariate analysis, there was a statistically significant increase in the percentage of mastoiditis admissions to teaching hospitals for all admissions (OR 1.55 [CI 1.22-1.97], p < 0.001) and even more evident for cases with associated complications (OR 1.85 [CI 1.21-2.83], p = 0.004). CONCLUSIONS AND RELEVANCE: A sizeable percentage of patients with acute mastoiditis present with complications which may require surgical intervention. From 2002 to 2014, inpatient care of acute mastoiditis became increasingly regionalized to teaching hospitals, suggestive of increased specialization within certain facilities. This trend may have significant impacts on the cost and subsequent quality of care provided to these patients.

Positive surgical margins in parotid malignancies: Institutional variation and survival association.

OBJECTIVES/HYPOTHESIS: To establish benchmarks for positive margin incidence in parotid cancers, associate positive margin status with patient, tumor, and institutional factors and overall survival, and characterize institutional variation in positive margin incidence. STUDY DESIGN: Retrospective database analysis. METHODS: We identified patients surgically treated for a parotid malignancy 2004 to 2013 in the National Cancer Database. We associated positive margins with patient, tumor, and treatment factors by multivariable logistic regression and with overall survival by Cox proportional hazards regression. We characterized institutional variation in positive margin rates by facility type and volume. RESULTS: A total of 5,639 patients were identified. The overall positive margin rate was 31%. By institution, positive margin rates varied from 0% to 100%, with a median rate of 31% (interquartile range = 18%-43%). Adenoid cystic carcinoma was associated with increased, and low-grade mucoepidermoid carcinoma with decreased, odds of positive margins, (odds ratio [OR] = 1.91 [95% confidence interval {CI}: 1.54-2.38], P < .001 and OR = 0.68 [95% CI: 0.53-0.87], P = .002, respectively). Treatment at academic or high-volume facilities was associated with decreased odds of positive margins (OR = 0.79 [95% CI: 0.68-0.91], P = .001 and OR = 0.76 [95% CI: 0.63-0.91], P = .004). Positive surgical margins were associated with decreased overall survival (62% vs. 79% 5-year overall survival, hazard ratio [HR] = 1.34 [95% CI: 1.20-1.49], P < .001). Upon stratification by histology, this association was maintained for high-grade, but not low-grade, mucoepidermoid carcinoma (52% vs. 74%, HR = 1.56 [95% CI: 1.31-1.86], P < .001 and 89% versus 91%, HR = 1.05 [95% CI: 0.60-1.83], P = .874, respectively). CONCLUSIONS: Tumor and institutional factors are associated with positive surgical margins. Positive margin rates vary substantially between facilities and are less likely at academic and high-volume facilities. Positive surgical margins are associated with decreased overall survival and could be considered quality indicators in parotid malignancies. LEVEL OF EVIDENCE: 2c Laryngoscope, 129:129-137, 2019.

Industry Payments to Physicians and Prescriptions of Brand-Name Proton-Pump Inhibitors.

OBJECTIVE: To characterize the association between industry payments and prescriptions of 2 brand-name proton-pump inhibitors (PPIs). STUDY DESIGN: Cross-sectional retrospective. SETTING: Physicians nationwide. SUBJECTS AND METHODS: We identified all physicians receiving industry payments for Dexilant and Nexium 2014-2015 from the Open Payments database. We linked this to records of prescriptions for PPIs paid for by Medicare Part D these same years and compared the proportion of prescriptions written for Dexilant and Nexium in industry-compensated vs nonindustry compensated physicians. The number and dollar amount of payments were associated with the rate of drug prescriptions. RESULTS: We identified 254,452 physicians prescribing PPIs; 8586 and 2766 physicians received industry payments for Dexilant and Nexium, respectively. A total of 5052 of 7876 (64%) physicians compensated for Dexilant prescribed Dexilant vs 39,778 of 246,571 (16%) noncompensated physicians ( P < .001). For Nexium, 2525 of 2654 (95%) compensated physicians prescribed Nexium, compared to 123,913 of 252,067 (49%) noncompensated physicians. For both Dexilant and Nexium, there was a significant correlation between the number (ρ = 0.22, P < .001 and ρ = 0.12, P < .001) and dollar amount (ρ = 0.22, P < .001 and ρ = 0.13, P < .001) of payments and the percentage of prescriptions written for the compensated drug. Industry payments for Nexium remained associated with rate of prescription even after generic esomeprazole became available. CONCLUSION: Both the number and dollar amount of industry payments were associated with increased prescriptions for both Dexilant and Nexium. Although unable to show causality, this study suggests that industry payments may increase physician prescriptions of costly, brand-name drugs.

The Association of Industry Payments to Physicians with Prescription of Brand-Name Intranasal Corticosteroids.

Objectives To examine the association of industry payments for brand-name intranasal corticosteroids with prescribing patterns. Study Design Cross-sectional retrospective analysis. Setting Nationwide. Subjects and Methods We identified physicians prescribing intranasal corticosteroids to Medicare beneficiaries 2014-2015 and physicians receiving payment for the brand-name intranasal corticosteroids Dymista and Nasonex. Prescription and payment data were linked by physician, and we compared the proportion of prescriptions written for brand-name intranasal corticosteroids in industry-compensated vs non-industry-compensated physicians. We associated the number and dollar amount of industry payments with the relative frequency of brand-name prescriptions. Results In total, 164,587 physicians prescribing intranasal corticosteroids were identified, including 7937 (5%) otolaryngologists; 10,800 and 3886 physicians received industry compensation for Dymista and Nasonex, respectively. Physicians receiving industry payment for Dymista prescribed more Dymista as a proportion of total intranasal corticosteroid prescriptions than noncompensated physicians (3.1% [SD = 9.6%] vs 0.2% [SD = 2.5%], respectively, P < .001). Similar trends were seen for Nasonex (12.0% [SD = 16.8%] vs 4.8% [SD = 13.6%], P < .001). The number and dollar amount of payment were significantly correlated to the relative frequency of Dymista (ρ = 0.26, P < .001 and ρ = 0.20, P < .001, respectively) and Nasonex prescriptions (ρ = 0.09, P < .001 and ρ = 0.15, P < .001, respectively). For Dymista, this association was stronger in otolaryngologists than general practitioners ( P < .001). There was a stronger correlation between the percentage of prescriptions and the number and dollar amount of payments for Dymista than for Nasonex ( P = .014 and P < .001). Conclusions Industry compensation for brand-name intranasal corticosteroids is significantly associated with prescribing patterns. The magnitude of association may depend on physician specialty and the drug's time on the market.

Treatment delays in laryngeal squamous cell carcinoma: A national cancer database analysis.

OBJECTIVE: To characterize treatment delays in laryngeal cancer and associate delays with patient, tumor, and treatment factors and with overall survival. METHODS: We identified 33,819 adults with laryngeal squamous cell carcinoma (LSCC) in the National Cancer Database from 2004 to 2013. We calculated durations of diagnosis-to-treatment initiation, surgery-to-adjuvant treatment, radiotherapy duration, total treatment package, and diagnosis-to-treatment end intervals. Delays were associated with patient, tumor, and treatment characteristics via multivariable logistic regression and with overall survival by Cox proportional hazards regression. RESULTS: Median durations of diagnosis-to-treatment initiation, surgery-to-radiation initiation, radiation treatment, total treatment package, and diagnosis-to-treatment end were 28, 42, 48, 91, and 107 days in surgical patients; median durations of diagnosis-to-treatment initiation, radiation treatment, and diagnosis-to-treatment end were 33, 50, and 85 days in nonsurgical patients. Race and insurance status were linked to delays in most intervals. Academic and high-volume facilities had less delayed radiation treatment but increased delays in most other intervals. Delayed surgery-to-radiation and total treatment package intervals were associated with overall survival in surgical patients (hazard ratio [HR] = 1.15 [1.03-1.29], P = 0.015; HR = 1.16 [1.02-1.31], P = 0.025). Diagnosis-to-treatment initiation and diagnosis-to-treatment end intervals were associated with overall survival in nonsurgical patients (HR = 1.08 [1.02-1.14], P = 0.007; HR = 1.09 [1.03-1.16], P = 0.003, respectively) but not in surgical patients (HR = 0.96 [0.87-1.06] P = 0.440; HR = 1.13 [0.99-1.29], P = 0.062). Radiation delays were associated with overall survival in surgical and nonsurgical patients (HR = 1.21 [1.09-1.36], P = 0.001; HR = 1.37 [1.30-1.44], P < 0.001). CONCLUSION: These durations can serve as national benchmarks. Delays could be considered quality indicators in LSCC. LEVEL OF EVIDENCE: 2b Laryngoscope, 128:2751-2758, 2018.

Increasing Industry Involvement in Otolaryngology: Insights from 3 Years of the Open Payments Database.

Objectives To characterize industry payments to otolaryngologists in 2016 versus 2014 and 2015. Study Design Cross-sectional retrospective analysis. Setting Open Payments Database. Subjects and Methods Using the Open Payments Database, we identified otolaryngologists receiving payments from industry sponsors from 2014 to 2016. We characterized the number and value of payments per physician overall and by census region, as well as by sponsor subspecialty and payment type. Study years were compared via analysis of variance and Kruskal-Wallis tests. Trends in payments to otolaryngologists were compared with trends in 21 other specialties. Results Payment to otolaryngologists increased 67% from 2014 to 2016-from $8.7 million in 2014 to $9.9 and $14.5 million in 2015 and 2016, respectively ( P < .001). While mean payment per compensated otolaryngologist increased ($1095, $1243, and $1834 in 2014, 2015, and 2016, respectively, P < .001), median payments stayed relatively constant ($169, $165, and $172), suggesting an increasingly unequal distribution. Much of the increase is accounted for by an increased number of payments for consulting fees and physician ownership. Most payments were made by companies specializing in rhinology. Otolaryngology received the lowest industry compensation per physician among the surgical specialties examined and lower compensation than most nonsurgical specialties. The increase in payments to otolaryngologists was proportionally greater than all but 1 of the other 21 specialties examined. Conclusions Industry compensation to otolaryngologists is increasing and increasingly unequal, although it is still less than that in most other specialties. In otolaryngology, the Open Payments Database has not decreased physician-industry relationships as intended.

Pediatric Salivary Cancer: Epidemiology, Treatment Trends, and Association of Treatment Modality with Survival.

Objective To characterize the epidemiology of pediatric salivary cancer and associate patient, tumor, and treatment factors with treatment modality and survival. Study Design Cross-sectional analysis. Setting US national database. Subjects and Methods We identified 588 patients 19 years or younger diagnosed with salivary cancer in the National Cancer Database 2004-2013. We characterized patient, tumor, and treatment factors as proportions and associated these factors with treatment modality and overall survival via multivariable logistic regression and multivariable Cox proportional hazards regression, respectively. Results In total, 588 patients were included. Mucoepidermoid carcinoma was identified in 234 of 588 patients (40%) and acinar cell carcinoma in 215 of 588 (37%). Parotid tumors were seen in 504 (86%) of patients. Surgery alone was used to treat 351 (60%) of patients; surgery plus adjuvant radiation was used to treat 145 (25%). Overall 5-year survival was 93%. Controlling for patient and tumor characteristics, treatment with surgery and radiation vs surgery alone was associated with improved overall survival (hazard ratio [HR] = 0.15; 95% confidence interval [CI], 0.02-0.92; P = .041). High tumor grade was associated with decreased overall survival (HR = 33.17; 95% CI, 5.89-186.8; P < .001). Treatment with surgery plus radiation remained associated with improved overall survival in the subset of patients with high tumor grade (HR = 0.12; 95% CI, 0.02-0.64; P = .014). Conclusion Tumor grade is an important predictor of survival in pediatric patients with salivary gland cancer. Surgery plus adjuvant radiation vs surgery alone is associated with improved overall survival and may be considered for high-risk patients, particularly those with high-grade tumors.

Treatment Times in Salivary Gland Cancer: National Patterns and Association with Survival.

Objective To characterize treatment times in salivary cancer; associate treatment times with patient, tumor, and treatment characteristics; and examine the association of treatment times and overall survival. Study Design Retrospective cohort. Setting Commission-on-Cancer Accredited Hospitals 2004-2013. Subjects and Methods In total, 5953 patients with salivary cancer included in the National Cancer Database were identified. For each treatment interval, patients in the fourth quartile ("prolonged") were compared to patients in the first and second quartiles ("not prolonged"). Patient, tumor, and treatment characteristics were associated with prolonged times via multivariable binary logistic regression. Prolongation of each interval was associated with overall survival via multivariable Cox proportional hazards regression, controlling for clinically relevant factors. Results Median durations for diagnosis-to-treatment initiation, surgery-to-radiation treatment (RT), RT duration, total treatment package, and diagnosis-to-treatment end were 31, 44, 47, 92, and 110 days, respectively. Race, insurance status, comorbidities, age, T and N stage, facility volume and location, and a facility care transition from diagnosis to initial treatment were associated with prolonged treatment time. Prolonged RT duration was associated with decreased overall survival (OS) (62% vs 75% 5-year OS, HR = 1.26 [95% confidence interval (CI), 1.09-1.47]; P = .002), but prolonged diagnosis-to-treatment initiation, surgery-to-RT, total treatment package, and diagnosis-to-treatment end intervals were not (70% vs 67% 5-year OS, HR = 1.11 [95% CI, 0.92-1.34], P = .284; 72% vs 68%, HR = 0.93 [95% CI, 0.79-1.09], P = .370; 70% vs 70%, HR = 1.00 [95% CI, 0.84-1.20], P = .974; 66% vs 71%, HR = 0.99 [95% CI, 0.84-1.18], P = .920, respectively). Conclusion The median durations identified here can serve as reference points. Radiation therapy duration is associated with overall survival in salivary cancer and could be considered a quality indicator.

Assessment of Nonresearch Industry Payments to Otolaryngologists in 2014 and 2015.

Objective To characterize, describe, and compare nonresearch industry payments made to otolaryngologists in 2014 and 2015. Additionally, to describe industry payment variation within otolaryngology and among other surgical specialties. Study Design Retrospective cross-sectional database analysis. Setting Open Payments Database. Subjects and Methods Nonresearch payments made to US otolaryngologists were characterized and compared by payment amount, nature of payment, sponsor, and census region between 2014 and 2015. Payments in otolaryngology were compared with those in other surgical specialties. Results From 2014 to 2015, there was an increase in the number of compensated otolaryngologists (7903 vs 7946) and in the mean payment per compensated otolaryngologist ($1096 vs $1242), as well as a decrease in the median payment per compensated otolaryngologist ($169 vs $165, P = .274). Approximately 90% of total payments made in both years were attributed to food and beverage. Northeast census region otolaryngologists received the highest median payment in 2014 and 2015. Compared with other surgical specialists, otolaryngologists received the lowest mean payment in 2014 and 2015 and the second-lowest and lowest median payment in 2014 and 2015, respectively. Conclusion The increase in the mean payment and number of compensated otolaryngologists can be explained by normal annual variation, stronger industry-otolaryngologist relationships, or improved reporting; additional years of data and improved public awareness of the Sunshine Act will facilitate determining long-term trends. The large change in disparity between the mean and median from 2014 to 2015 suggests greater payment variation. Otolaryngologists continue to demonstrate limited industry ties when compared with other surgical specialists.

Outcomes and reliability of the flow coupler in postoperative monitoring of head and neck free flaps.

OBJECTIVES/HYPOTHESIS: To assess the accuracy and reliability of the flow coupler relative to the implantable arterial Doppler probe in postoperative monitoring of head and neck free flaps. STUDY DESIGN: Retrospective single-institution study, April 2015 to March 2017. METHODS: Both the venous flow coupler and arterial Doppler were employed in 120 consecutive head and neck free flap cases. When Doppler signal loss occurred, flaps were evaluated by physical exam to determine whether signal loss was a true positive necessitating operating room takeback. Sensitivity, specificity, and false positive rate (FPR) were recorded for each device. Logistic regression was conducted to identify user trends over time. RESULTS: Eleven of 120 patients (9.2%) required takeback, 10 from venous thrombosis and one from arterial thrombosis. Permanent signal loss (PSL) occurred in the flow coupler in all takebacks; PSL occurred in the arterial Doppler only in the case of arterial thrombosis. Salvage rate was 9/11 (81.8%). For the flow coupler, sensitivity was 100%, specificity 86.4%, and FPR 13.6%. For the arterial probe, sensitivity was 9.1%, specificity 97.1%, and FPR 2.9%. A 4.1% decrease in false positives with each additional flow coupler use was observed. CONCLUSIONS: Monitoring the vein via flow coupler has high sensitivity in identifying vascular compromise compared to the arterial probe, especially for venous thrombosis. There is moderate FPR; this decreases with increased usage and, when supplemented with physical examination, does not result in unnecessary takebacks. The flow coupler can be a valuable tool in postoperative monitoring of head and neck free flaps. LEVEL OF EVIDENCE: 4. Laryngoscope, 128:812-817, 2018.

Cross-sectional Analysis of the Relationship between Paranasal Sinus Balloon Catheter Dilations and Industry Payments among Otolaryngologists.

Objective To characterize the relationship between industry payments and use of paranasal sinus balloon catheter dilations (BCDs) for chronic rhinosinusitis. Study Design Cross-sectional analysis of Medicare B Public Use Files and Open Payments data. Setting Two national databases, 2013 to 2014. Subjects and Methods Physicians with Medicare claims with Current Procedural Terminology codes 31295 to 31297 were identified and cross-referenced with industry payments. Multivariate linear regression controlling for age, race, sex, and comorbidity in a physician's Medicare population was performed to identify associations between use of BCDs and industry payments. The final analysis included 334 physicians performing 31,506 procedures, each of whom performed at least 11 balloon dilation procedures. Results Of 334 physicians, 280 (83.8%) received 4392 industry payments in total. Wide variation in payments to physicians was noted (range, $43.29-$111,685.10). The median payment for food and beverage was $19.26 and that for speaker or consulting fees was $409.45. One payment was associated with an additional 3.05 BCDs (confidence interval [95% CI],1.65-4.45; P < .001). One payment for food and beverages was associated with 3.81 additional BCDs (95% CI, 2.13-5.49; P < .001), and 1 payment for speaker or consulting fees was associated with 5.49 additional BCDs (95% CI, 0.32-10.63; P = .04). Conclusion Payments by manufacturers of BCD devices were associated with increased use of BCD for chronic rhinosinusitis. On separate analyses, the number of payments for food and beverages as well as that for speaker and consulting fees was associated with increased BCD use. This study was cross-sectional and cannot prove causality, and several factors likely exist for the uptrend in BCD use.

Treatment guidelines and patterns of care in oral cavity squamous cell carcinoma: Primary surgical resection vs. nonsurgical treatment.

BACKGROUND: The 2017 National Comprehensive Cancer Network Clinical Practice Guidelines recommend surgical resection or definitive radiation therapy for early-stage oral cavity malignancies, and surgical resection or multimodality clinical trials for late-stage disease. Few studies have been conducted to identify predictors of choice of treatment modality for oral cavity malignancies. METHODS: All patients in the National Cancer Data Base (NCDB) diagnosed with oral cavity squamous cell carcinoma (OCSCC) between 1998 and 2011 were identified. Chi-square and binary logistic regression were used to identify factors predictive of surgical or nonsurgical treatment; multiple imputation was used for missing data. Cox proportional hazards models were generated to identify associations between treatment modality and overall survival (OS). RESULTS: Of 23,459 patients, 4139 (17.6%) underwent primary nonsurgical treatment. Among NCDB-registered facilities, there has been a decrease in use of nonsurgical treatment for OCSCC (OR 0.97, p<0.001). Older age, non-white race, Medicaid insurance, low income, low education, and later-stage disease were associated with nonsurgical therapy, while patients at academic/research programs were more likely to undergo surgery (OR 0.38, p<0.001). Nonsurgical treatment was associated with decreased OS (HR=2.02, p<0.001); this was upheld on subgroup analysis of early- and late-stage disease. CONCLUSIONS: Use of primary nonsurgical treatment for OCSCC has decreased over time among NCDB-registered facilities and is associated with factors related to access to care. Surgical resection for the primary treatment of oral cavity cancer may be associated with improved OS, though conclusions regarding survival are limited by the non-randomized nature of the data.