Opioid prescribing practices in academic otolaryngology: A single institutional survey.

OBJECTIVES: Opioids are highly addictive medications and otolaryngologists have a responsibility to practice opioid stewardship. We investigated postoperative opioid prescribing patterns among resident and attending physicians as an educational platform to underscore the importance of conscientious opioid prescribing. METHODS: This quality improvement study was designed as a cross-sectional electronic survey. Residents and attending clinical faculty members at a single academic institution were queried from February through April 2020. An electronic survey was distributed to capture postoperative opioid prescribing patterns after common procedures. At the conclusion of the study, results were sent to all faculty and residents. RESULTS: A total of 29 attending otolaryngologists and 22 residents completed the survey. Resident physicians prescribed on average fewer postoperative opioid pills than attendings. Among attendings, the largest number of opioids were prescribed following tonsillectomy (dose varied by patient age), neck dissection (12.6 pills), brow lift (13.3 pills), facelift (13.3 pills), and open reduction of facial trauma (10.7 pills). For residents, surgeries with the most postoperatively prescribed opioids were for tonsillectomy (varied by patient age), neck dissection (13.4 pills), open reduction of facial trauma (10.5 pills), parotidectomy (10.0 pills), and thyroid/parathyroidectomy (9.0 pills). The largest volume of postoperative opioids for both groups was prescribed following tonsillectomy. Attendings prescribed significantly more opioids after facelift and brow lift than did residents (p = 0.01 and p = 0.003, respectively). CONCLUSION: There was good concordance between resident and attending prescribers. Improvement in opioid prescribing and pain management should be an essential component of otolaryngology residency education and attending continuing medical education. LEVEL OF EVIDENCE: 4.

ENT trainees' experience of redeployment during the coronavirus disease 2019 pandemic: a qualitative study.

BACKGROUND: As a response to the acute strain placed on the National Health Service during the first wave of coronavirus disease 2019 in the UK, a number of junior doctors including ENT trainees were redeployed to other clinical specialties. This presented these trainees with novel challenges and opportunities. METHODS: A qualitative study was performed to explore these experiences, undertaking semi-structured interviews with ENT trainees between 17th and 30th July. Participants were recruited through purposeful sampling. Interview transcripts underwent thematic analysis using Dedoose software. RESULTS: Seven ENT trainees were interviewed, ranging from specialty trainee years four to eight ('ST4' to 'ST8') in grade. Six core themes were identified: organisation of redeployment, utilisation of skill set, emotional impact of redeployment, redeployed team dynamics, concerns about safety and impact on training. CONCLUSION: The ENT trainees' experiences of redeployment described highlight some important lessons and considerations for future redeployments.

Online Ratings and Perceptions of Pediatric Otolaryngologists.

OBJECTIVE/HYPOTHESIS: To assess and characterize online ratings and comments on pediatric otolaryngologists and determine factors that correlate with higher ratings. STUDY DESIGN: Online database analysis. METHODS: All American Society of Pediatric Otolaryngology (ASPO) members were queried on Healthgrades, Vitals, RateMDs, and Yelp for their online ratings and comments as of June 2020. Ratings were normalized for comparison on a five-point Likert scale. All comments were categorized based on context and positive or negative quality. RESULTS: Of the 561 ASPO members, 489 (87%) were rated on at least one online platform. Of those rated, 410 (84%) were on Healthgrades, 429 (88%) on Vitals, 236 (48%) on RateMDs, and 72 (15%) on Yelp. Across all platforms, the average overall rating was 4.13 ± 0.03 (range, 1.00-5.00). We found significant positive correlations between overall ratings and specific ratings (P < .001) on all individual topics. In addition, the majority of all narrative comments were related to perceived physician bedside manner and clinical outcome, with negative comments correlating negatively with overall score (P < .05). Time spent with the physician was the only category in which both positive and negative comments showed significant correlation with the overall physician rating (P = .016 and P = .017, respectively). Attending a top-ranked medical school or residency program did not correlate with higher or lower ratings. CONCLUSIONS: Online ratings and comments for pediatric otolaryngologists are largely influenced by patient and parent perceptions of physician competence, comforting bedside manner, and office and time management. LEVEL OF EVIDENCE: NA Laryngoscope, 131:2356-2360, 2021.

Enhancement of a low-fidelity surgical simulator. Is it possible?

BACKGROUND: Simulation training has become a core component in the training of ENT surgeons. It provides the opportunity for the repetitive practice of a surgical technique. Simulators are broadly categorised into low- and high-fidelity simulators. A method using a home microprocessor to enhance a low-fidelity surgical simulator is introduced. METHOD: The Yorick tonsil tie trainer was enhanced using an Arduino microcontroller attached to the simulated inferior pole of the tonsil. The Arduino was coded to give a visual stimulus when linear motion exceeded parameters. The prototype simulator was tested to gain information on whether the enhancement could identify differences between novice and expert users. CONCLUSION: An enhanced low-fidelity tonsil trainer was produced using a low-cost, simple home microprocessing board. The enhanced simulator gives objective feedback allowing for self-directed learning. Further research is required to evaluate the benefits of these enhancements above non-enhanced simulation training.

Synthetic Simulator for Surgical Training in Tracheostomy and Open Airway Surgery.

OBJECTIVE(S): To create and validate a synthetic simulator for teaching tracheostomy and laryngotracheal reconstruction (LTR) using anterior costal cartilage and thyroid ala cartilage grafts. METHODS: A late adolescent/adult neck and airway simulator was constructed based on CT scans from a cadaver and a live patient. Images were segmented to create three-dimensional printed molds from which anatomical parts were casted. To evaluate the simulator, expert otolaryngologists - head and neck surgeons performed tracheostomy and LTR using anterior costal cartilage and thyroid ala cartilage grafts on a live anesthetized porcine model (gold standard) followed by the synthetic simulator. They evaluated each model for face validity (realism and anatomical accuracy) and content validity (perceived effectiveness as a training tool) using a five-point Likert scale. For each expert, differences for each item on each simulator were compared using Wilcoxon Signed-Rank tests with Sidak correction. RESULTS: Nine expert faculty surgeons completed the study. Experts rated face and content validity of the synthetic simulator an overall median of 4 and 5, respectively. There was no difference in scores between the synthetic model and the live porcine model for any of the steps of any of the surgical procedures. CONCLUSION: The synthetic simulator created for this study has high face and content validity for tracheostomy and LTR with anterior costal cartilage and thyroid ala cartilage grafts and was not found to be different than the live porcine model for these procedures. LEVEL OF EVIDENCE: 5 Laryngoscope, 131:E2378-E2386, 2021.

Timing and volume of information produced for the Otolaryngologist during the COVID-19 pandemic in the UK: A review of the volume of online literature.

BACKGROUND: The SARS-CoV-2 was first reported in December 2019 in Wuhan, China and has been declared a pandemic in March 2020. COVID-19 has caused unprecedented and lasting biopsychosocial effects worldwide. All healthcare professionals have faced life-threatening risks by attending their daily jobs. The daily emergence of advice and guidelines was necessary to ensure the safety of patients and staff. To this effect, all elective services came to a halt to preserve hospitals' capacity for dealing with the sickest. This retrospective, descriptive review aims to assess the volume and timing of the advice released specifically relevant to UK ENT specialists. METHODS: Two separate searches were performed. One involved online advice published in English by international, national and ENT-specific organisations between January 1 and May 31. The date, title, source, type of advice and link to the advice were recorded in Excel. The resources were analysed per week of publication. A second separate search for peer-reviewed publications was conducted using PubMed Central and Cochrane databases. FINDINGS: COVID-19-related guidance was considered, of which 175 were identified. 52/175 (29.7%) articles were published by international organisations. 56/175 (32%) were produced by national organisations, and 67/175 (38.28%) were produced by ENT specific organisations. The peak guidance production took place in the third and fourth week of March (16/03/2020-29/03/2020) with 72/175 publications. Of these, 27/70 came from the international category, 17/70 from national bodies and 26/70 from ENT-specific organisations. 13 863 total publications relating to COVID-19 were found using PubMed and Cochrane search strategies; 76% were relevant to ENT. CONCLUSION: The challenges faced by ENT relate to the unprecedented, sudden and daily changes to clinical practice. Multiple bodies interpreted the guidance, giving an opportunity for confusion and delay in treatments for patients. Implementing a system with clear lines of communication and dissemination of information will improve our response to future pandemic events whilst maintaining a commercial awareness to better use the human and financial resources of an already financially restricted NHS.

Factors Associated With Distribution of Female Otolaryngology Residents in United States.

OBJECTIVE: The gender balance within medicine, and specifically within otolaryngology, is equalizing. It is important to determine the factors that impact the distribution of female residents among otolaryngology programs in the United States to better understand factors that may affect these changing trends. STUDY DESIGN: Retrospective Study. METHODS: Cross-sectional analysis was performed using data from 2018 of otolaryngology residents at 90 programs across the United States. Each program's website was searched for a current resident roster. Data of geography, number of female faculty, number of female physicians in leadership positions, program setting, and program size were obtained. Statistical comparison of these factors with number of female residents was performed with P < .05 as significant. RESULTS: There was a significant association between programs having a higher-than-average female faculty representation and a greater representation of female residents (P < .001). Larger residency programs were more likely to have greater female representation (P = .010). There was a slight predominance of both female residents and female faculty at urban programs (odds ratio [OR] = 1.27, P = .04; OR = 1.28, P = .03). Geographic location, presence of a female chairperson, and presence of a female residency program director were not associated with higher female-to-male resident ratio. CONCLUSION: Availability of female role models in faculty, along with program setting and size, may be more likely to promote greater female representation. Focusing on gender equality in the workplace can help promote diversity in the workforce and improve patient outcomes. LEVEL OF EVIDENCE: NA Laryngoscope, 131:E367-E372, 2021.

Prevalence of and Associations With Distress and Professional Burnout Among Otolaryngologists: Part I, Trainees.

OBJECTIVE: To assess the prevalence of distress and burnout in otolaryngology trainees, including associations with relevant sociodemographic and professional factors, and to compare these results with those of attending otolaryngologists. STUDY DESIGN: A cross-sectional survey of trainees and attending physicians. SETTING: Twelve academic otolaryngology programs. METHODS: Distress and burnout were measured with the Expanded Physician Well-being Index and the 2-item Maslach Burnout Inventory. The Patient Health Questionnaire-2 and Generalized Anxiety Disorder-2 were used to screen for depressive disorders and anxiety disorders, respectively. Associations with sociodemographic and professional characteristics were assessed. RESULTS: Of the 613 surveys administered to trainees and attending physicians, 340 were completed (56%). Among 154 trainees, distress was present in 49%, professional burnout in 35%, positive depressive disorder screening in 5%, and positive anxiety disorder screening in 16%. In univariable analysis, female gender, hours worked in a typical week (HW), and nights on call in a typical week (NOC) were significantly associated with distress. In multivariable analysis, female gender (odds ratio, 3.91; P = .001) and HW (odds ratio for each 10 HW, 1.89; P = .003) remained significantly associated with distress. Female gender, HW, and NOC were significantly associated with burnout univariably, although only HW (odds ratio for each 10 HW, 1.92; P = .003) remained significantly associated with burnout in a multivariable setting. Attending physicians had less distress than trainees (P = .02) and felt less callous and less emotionally hardened than trainees (P < .001). CONCLUSION: Otolaryngology trainees experience significant work-place distress (49%) and burnout (35%). Gender, HW, and NOC had the strongest associations with distress and burnout.

Survey and analysis of knowledge, attitude and practice among otolaryngologists in a state in eastern India in relation to the coronavirus disease 2019 pandemic.

BACKGROUND: The coronavirus disease 2019 pandemic has resulted in various changes in knowledge, attitude and practice among doctors. A survey was conducted of otolaryngologists in India regarding these aspects in relation to the coronavirus disease 2019 pandemic. METHOD: Otolaryngologists from West Bengal (India) were invited to participate in an online self-administered survey. Data were collected and analysed using appropriate methods. RESULTS: Responses from 133 participants, grouped into 4 groups by their career stage, were collected and analysed. Of the participants, 36.8 per cent were directly involved in treating a known or suspected coronavirus disease 2019 patient, although 66.2 per cent considered the personal protective equipment inadequate. Ninety-four per cent indicated that their willingness to perform procedures depended on personal protective equipment availability. Of the respondents, 83.5 per cent revealed additional mental stress due to the pandemic. Of the participants, 41.4 per cent took hydroxychloroquine as coronavirus disease 2019 prophylaxis. CONCLUSION: This study provides an insight into which issues may need attention, to help ENT surgeons tackle the coronavirus disease 2019 pandemic more effectively based on analysis of responses in the survey.

What do otolaryngologists want to learn? An educational targeted needs assessment study / O que os otorrinolaringologistas querem aprender? Um estudo de avaliação das necessidades educacionais específicas

Abstract Introduction: Targeted needs assessment which includes identifying the needs of learners is a key step of program development. However, this step is commonly underestimated in postgraduate medical education programs, including otolaryngology residency training. Determining the needs of otolaryngologists may help educators to design more purposeful continuing medical education training programs. Furthermore, needs of specialists may provide a clearer insight about effectiveness of the residency programs in that specialty. Objective: To determine training needs of otolaryngology specialists and to identify deficiencies in otolaryngology residency training programs. Methods: Seventy-eight otolaryngology specialists, who completed all data gathering forms properly, were included in this descriptive, cross-sectional study. Demographic data of the participants were collected. Training needs of the participants were determined in seven basic areas of otolaryngology via two-round Delphi method. The basic areas were otology-neurotology, rhinology, laryngology, head and neck surgery, pediatric otolaryngology, sleep disorders and facial plastic surgery. Additionally, we asked an open-ended question to investigate the reasons why the participants perceived themselves incompetent and undereducated, or why they needed further training in some of the basic otolaryngology areas. Results: Facial plastic surgery, otology-neurotology and head and neck surgery were the most cited training areas in the needs assessment. Training needs differed according to experience and place of work. Financial expectations, deficiencies in residency training, regression in knowledge and skills, and special interest were effective determinants on decisions of the participants while determining their training needs. Conclusion: Otolaryngologists need further training in some areas of their field due to different reasons. Determining these areas and reasons will help in designing more effective continuous medical education activities and residency training programs in otolaryngology.

Resumo: Introdução: A avaliação de necessidades específicas, que inclui a identificação das necessidades dos alunos, é um passo fundamental no desenvolvimento de programas educacionais. No entanto, essa etapa costuma ser subestimada em programas de pós-graduação em educação médica, inclusive na residência em otorrinolaringologia. Determinar as necessidades dos otorrinolaringologistas pode ajudar os educadores a projetar programas mais direcionados de treinamento em educação médica continuada. Além disso, a análise das necessidades dos especialistas pode oferecer uma visão clara sobre a eficácia dos programas de residência nessa especialidade. Objetivo: Determinar as necessidades de treinamento de especialistas em otorrinolaringologia e identificar deficiências nos programas de residência em otorrinolaringologia. Método: Este estudo descritivo e transversal incluiu 78 especialistas em otorrinolaringologia que preencheram todos os formulários de coleta de dados adequadamente. Os dados demográficos dos participantes foram coletados. As necessidades de treinamento dos participantes foram determinadas em sete áreas básicas da otorrinolaringologia com o método Delphi em duas rodadas. As áreas básicas foram otologia/neurotologia, rinologia, laringologia, cirurgia de cabeça e pescoço, otorrinolaringologia pediátrica, distúrbios do sono e cirurgia plástica facial. Além disso, uma pergunta aberta foi usada para investigar os motivos pelos quais os participantes consideravam ter pouco conhecimento ou ser incapazes de atuar nessa área, ou por que precisavam de mais treinamento em algumas dessas áreas básicas. Resultados: Na avaliação das necessidades, cirurgia plástica facial, otologia-neurotologia e cirurgia de cabeça e pescoço foram as áreas de treinamento mais relatadas. As necessidades de treinamento variaram de acordo com a experiência e o local de trabalho. Expectativas financeiras, deficiências no treinamento durante a residência, regressão do conhecimento e habilidades, além de interesse especial, foram determinantes efetivos nas decisões dos participantes ao identificar suas necessidades de treinamento. Conclusão: Por diferentes motivos, os otorrinolaringologistas precisam de mais treinamento em algumas áreas. A determinação dessas áreas e motivos ajudará a planejar atividades de educação médica continuada e programas de treinamento em residência em otorrinolaringologia mais eficazes.

Resident Education in Laryngeal Stroboscopy and Perceptual Voice Evaluation: An Assessment.

OBJECTIVES: To evaluate otolaryngology residents' level of confidence and understanding in interpreting laryngeal stroboscopy. METHODS: Otolaryngology residents from three residency programs with fellowship-trained laryngologists on faculty were invited to participate. An assessment consisting of a survey and five stroboscopic exams was administered. Each exam consisted of questions on perceptual voice evaluation, laryngoscopic findings, and stroboscopic findings. Scores were compared to answers provided by three fellowship-trained laryngologists. RESULTS: Thirty-eight of 47 invited residents (80.8%) enrolled in the study. On a five-point likert scale, residents reported low confidence (median = 2, range = 1-4) in interpreting stroboscopy, regardless of training program (P = 0.81). Mean assessment scores were 56.5% ± 11.9, with scores in perceptual voice evaluation = 68.5% ± 10.6; laryngoscopy = 70.2% ± 12.8; and stroboscopy = 45.3% ± 17.8. Residents performed worse on stroboscopy questions compared to laryngoscopy questions (P < 0.0001). There was a significant difference in scores by postgraduate year (P = 0.03), but not by institution (P = 0.34). A moderately positive correlation between reported level of confidence and overall scores (ρ = .47, P = 0.003) was demonstrated. CONCLUSIONS: Despite didactic and clinical exposure, residents report low confidence in interpreting stroboscopy and scored lower on stroboscopy-specific questions compared to other assessment items. Additional resources and learning opportunities are needed to improve resident confidence and comprehension of stroboscopy.

What do otolaryngologists want to learn? An educational targeted needs assessment study.

INTRODUCTION: Targeted needs assessment which includes identifying the needs of learners is a key step of program development. However, this step is commonly underestimated in postgraduate medical education programs, including otolaryngology residency training. Determining the needs of otolaryngologists may help educators to design more purposeful continuing medical education training programs. Furthermore, needs of specialists may provide a clearer insight about effectiveness of the residency programs in that specialty. OBJECTIVE: To determine training needs of otolaryngology specialists and to identify deficiencies in otolaryngology residency training programs. METHODS: Seventy-eight otolaryngology specialists, who completed all data gathering forms properly, were included in this descriptive, cross-sectional study. Demographic data of the participants were collected. Training needs of the participants were determined in seven basic areas of otolaryngology via two-round Delphi method. The basic areas were otology-neurotology, rhinology, laryngology, head and neck surgery, pediatric otolaryngology, sleep disorders and facial plastic surgery. Additionally, we asked an open-ended question to investigate the reasons why the participants perceived themselves incompetent and undereducated, or why they needed further training in some of the basic otolaryngology areas. RESULTS: Facial plastic surgery, otology-neurotology and head and neck surgery were the most cited training areas in the needs assessment. Training needs differed according to experience and place of work. Financial expectations, deficiencies in residency training, regression in knowledge and skills, and special interest were effective determinants on decisions of the participants while determining their training needs. CONCLUSION: Otolaryngologists need further training in some areas of their field due to different reasons. Determining these areas and reasons will help in designing more effective continuous medical education activities and residency training programs in otolaryngology.

Using Simulation Technology to Improve Patient Safety in Airway Management by Practicing Otolaryngologists.

OBJECTIVE: Simulation technology provides a safe environment to learn crisis resource management in stressful clinical scenarios, such as the acute airway. While a number of surgical simulation studies have assessed trainees, there remains a paucity of data on simulation benefits for practicing physicians. The objective of this study was to investigate the impact of a simulation symposium on airway management for practicing otolaryngologists. METHODS: Questionnaires (5-point Likert and open-answer questions) and interviews were distributed and conducted at a simulation symposium on airway management held at an annual meeting. RESULTS: The majority of participants had no prior experience in simulation (62.5%). The data suggested a strong increase in comfort with airway management scenarios (2.93 to 4.09 (p<0.001)). Participants reported the symposium as relevant (4.68) and useful (4.67), with increased confidence about their knowledge of crisis resource management and team training (4.53). Qualitative data suggested great educational value for technical skills and communication strategies. CONCLUSION: Simulation with feedback may provide an opportunity for the practicing otolaryngologist to fulfill Continuing Medical Education and Professional Development requirements. This symposium allowed practicing otolaryngologists, including those in the community, to learn, develop, and refresh technical and communication skills while fulfilling certification requirements.

Current practice trends in microvascular free flap reconstruction by fellowship-trained otolaryngologists.

PURPOSE: In the field of head and neck microvascular surgery, there are currently no clear, universally accepted recommendations on the intraoperative, preoperative, and postoperative management of these patients. MATERIALS AND METHODS: A 23-question cross-sectional survey was distributed to otolaryngologists who perform microvascular reconstruction. Information about practice setting, fellowship training background, intraoperative practice, postoperative practice, and surgical complications were analyzed. RESULTS: Complete survey responses were received from 102 (32.8% response rate) of surveyed otolaryngologists who perform microvascular surgery. A great degree of variability was noted in intraoperative and postoperative care of free flap patients. Overall, self-reported free flap survival-rates were relatively high, despite the variability in practice, with the majority of surgeons (74%) reporting flap survival rate of 96-100%. Complication rates requiring return to the operating room were low; all respondents reported <20% overall complications with <10% re-operation rates due to vascular complications. CONCLUSION: An increasing number of microvascular-trained otolaryngologists are performing free flaps. Self-reported free flap survival rates are high and complication rates are low, despite significant variability in intraoperative and postoperative practices among otolaryngologists performing microvascular flap reconstruction. By identifying these differences among surgeons, we hope to provide the impetus for further academic dialog and prospective trials.

Incorporation of antibiotics and systemic steroids by sinus surgeons: is there widespread consensus?

BACKGROUND: The objective of this work was to evaluate factors associated with antibiotic and oral corticosteroid (OCS) prescription among otolaryngologists regularly performing sinus surgery. METHODS: Fellowship-trained rhinologists, including fellowship directors, were identified via the American Rhinologic Society (ARS) website. Non-fellowship-trained otolaryngologists performing ≥25 balloons (frontal/maxillary) or ≥25 functional endoscopic sinus surgeries (FESSs) (frontal/maxillary/ethmoids) were also included in "balloon surgeons" and "sinus surgeon" cohorts, respectively. Prescribing data for Medicare Part D beneficiaries was obtained for 2015. RESULTS: Otolaryngologists included in this analysis wrote a median of 54 scripts for antibiotics, with a 15.1% antibiotic prescription rate. The overall script length per antibiotic was 11.1 days. Of fellowship-trained rhinologists, 90.2% wrote fewer than 100 scripts, compared to 25.6% and 32.5% of sinus surgeons and balloon surgeons, respectively. Fellowship-trained rhinologists wrote lengthier antibiotic scripts (14.1 vs 10.3 days, p < 0.05). Clinicians who have been in practice longer prescribed antibiotics significantly more frequently. Fellowship-trained rhinologists had a greater OCS rate (8.9%) than balloon and sinus surgeons (7.1%), also writing lengthier courses (15.0 vs 8.1 days). Early-career otolaryngologists wrote lengthier steroid prescriptions than those with 11 to 20 years and >20 years in practice. CONCLUSION: Antibiotic and OCS utilization varies by type of training, as non-fellowship-trained sinus surgeons and balloon surgeons tend to utilize antibiotics more aggressively, and fellowship-trained rhinologists utilize OCS more frequently. Otolaryngologists with more years in practice are more likely to incorporate antibiotics in the management of sinus disorders, although these conclusions must be considered in the context of this resource's limitations. Further clarification of guidelines may be helpful for minimizing divergent practices and maintaining a consensus.

A Review of Traditional Vaccine-Preventable Diseases and the Potential Impact on the Otolaryngologist

Abstract Introduction A majority of otolaryngologists have not had direct experience with many vaccine-preventable diseases since the creation of national vaccination programs. Despite the elimination of endemic transmission of some of these diseases in the United States, outbreaks can occur anywhere and still pose a threat to public health around the world. Recent outbreaks and changing trends in exemption rates indicate that it is important for physicians to maintain a working knowledge of how these diseases present and of the recommended treatment guidelines. Objectives This review will evaluate the current state of vaccination rates, vaccine exemption rates and disease incidence in the United States and in the world. It will also examine the clinical presentation and treatment recommendations of these diseases. Data Synthesis United States estimated vaccination rates, vaccine exemption rates and vaccine-preventable disease incidences were obtained from data compiled by the Centers for Disease Control and Prevention. World vaccination rates and disease incidences were obtained from the World Health Organization databases, which compile official figures reported by member states. A PubMed literature review provided information on the current state of vaccination exemptions and outbreaks in the United States. Conclusion Vaccination and vaccine exemption rates continue to put the United States and many areas of the world at risk for outbreaks of vaccine-preventable diseases. Clinical guidelines should be reviewed in the event of a local outbreak.

Surgical Care and Otolaryngology in Global Health.

Surgical access is inadequate for most people. The Lancet Commission on Global Surgery established 6 indicators to measure surgical access: geographic accessibility, density of surgical providers, number of procedures performed, perioperative mortality, impoverishing expenditure, and catastrophic expenditure. Otolaryngology surgical, training, and research efforts use these 6 indicators to maximize impact and coordination of worldwide efforts in surgery. Research must be rigorous and consider the counterfactual. For otolaryngologists who want to contribute, focusing on 1 of the 6 indicators may be most impactful.

The Otolaryngologist's Role in Providing Gender-Affirming Care: An Opportunity for Improved Education and Training.

Currently, there are limited resources and training available for otolaryngologists and otolaryngology practice personnel to provide gender-affirming care for transgender or gender nonconforming patients. This unique patient population may present to our offices for gender-specific care or with complaints of the ear, nose, and throat unrelated to gender identity. Our current practice has unintentional but direct consequences on our patients care, as transgender patients often report negative experiences in the healthcare setting related to their gender identity. The absence of resources and training is also seen in other specialties. Physicians who create an environment where patients of all gender identities feel welcome can better meet their patients' health care needs. In addition, otolaryngologists can play a role in easing the gender dysphoria experienced by transgender patients. We suggest educational content should be created for and made available to otolaryngologists and office staff to provide gender-affirming care.