Patient Factors and Preferences in Choosing Sleep Surgery for Obstructive Sleep Apnea: A Qualitative Study.

OBJECTIVE: There are several obstructive sleep apnea (OSA) treatment options available to patients, including surgery and less invasive therapies. Little is known about the factors that influence patient preferences for treatment. We aimed to understand factors influencing patient experience and decision making for undergoing sleep surgery. STUDY DESIGN: Retrospective qualitative study. SETTING: Tertiary sleep surgery clinic. METHODS: We conducted semistructured interviews with adults who previously underwent any nasal and/or pharyngeal sleep surgery. We asked open-ended questions about their decision-making process within a preconceived thematic framework of chief OSA symptoms, expectations for recovery, and sources of information. The interviews were audio recorded and transcribed, and content was analyzed for defined, emergent, and prevalent themes. RESULTS: Ten patients were interviewed from December 11, 2020 through January 29, 2021. Six patients underwent nasal surgery, 1 underwent pharyngeal surgery, and 3 underwent staged nasal and pharyngeal procedures. All patients were beyond the acute recovery phase. Reasons for pursuing surgical consultation varied from sleep apnea burden to external factors, such as recommendations from significant others. Duration of sleep surgery consideration varied from months to years. Major concerns about sleep surgery involved anesthesia and postoperative pain. External factors influencing patients' decisions to pursue sleep surgery included family and friend support. Postoperative outcomes of surgery included patient satisfaction with decision for surgery, given OSA improvements. CONCLUSION: Understanding patient factors that influence decision making for sleep surgery may guide clinicians in patient-centered counseling that engages patients in decision making, aligning with clinical symptoms and patient preferences.

Evaluating the Effect of Recurrent Respiratory Papillomatosis on Work Productivity.

OBJECTIVE: Patients with recurrent respiratory papillomatosis (RRP) have significant vocal dysfunction which affects their performance at work. This study aimed to evaluate voice-related work productivity before and after ablative treatment for RRP. METHODS: This is a prospective case series conducted at 2 academic laryngology outpatient clinics. Adult employed patients with RRP completed the Work Productivity & Activity Impairment instrument (WPAI), Voice Handicap Index (VHI-10), WorkHoarse, Hospital Anxiety and Depression Scale (HADS), and a demographics questionnaire immediately before and 1 month after ablative treatment of papilloma. The primary outcome measure was the change in work productivity impairment domain of the WPAI, and changes in ratings before and after ablation were compared using a Wilcoxon Signed-Rank test. RESULTS: The 32 participants (mean age 45, 84% male) had a median (interquartile range) voice-related work productivity impairment score of 48.8% (30.0) at baseline which was improved to 5.0% (10.0) at 1 month after surgical ablation of papillomata (difference 30.0% (30.0) improvement). For the secondary outcome measures, there were significant improvements in VHI-10 (P < .001), self-reported voice quality (P = .002), and Workhoarse (P = .001), but no significant change in HADS. CONCLUSION: Patients with RRP experience significant voice-related work productivity impairment, and ablation of papillomata significantly improves work productivity.

Initial Assessment of the Facial Trauma Patient.

The initial evaluation of the craniofacial trauma patient must be systematic, thorough, and consistent to ensure that injuries are not missed. Life-threatening conditions are first identified using ATLS principles, and focused head and neck examination conducted by a specialist then follows. Imaging is used to guide operative planning, as many craniofacial injuries ultimately benefit from repair to prevent permanent cosmetic or functional deformity. Peri-operative care is often multi-disciplinary in nature, and specialist consultation should be performed in an efficient fashion. Finally, it should be noted that surgeons operating in the maxillofacial region are at high risk for transmission of COVID-19, and risk of COVID-19 sequelae must be balanced with risks associated with the delay of treatment of craniofacial injury.

The learning community faculty experience: how longitudinal relationships with learners enhance work meaning.

INTRODUCTION: Work meaning has gained attention as an important contributor to physician job engagement and well-being but little is known about how faculty participation in medical school learning communities might influence this phenomena. Our study goals were to determine how physician faculty members may derive meaning from serving as mentors for longitudinal learning communities of medical students, to understand how that meaning may impact other areas of their work, and relate our findings to existing literature and theoretical frameworks. METHODS: The research team conducted, recorded, transcribed, and coded 25 semi-structured telephone interviews of faculty mentors from four US medical schools with curricular learning communities. The team used an iterative interview coding process to generate final themes and relate these themes to existing literature. RESULTS: The authors identified five themes of meaning faculty derive from participation as learning community mentors: "I am a better professional," "I am more connected," "I am rejuvenated," "I am contributing," and "I am honored." A sixth theme, "I am harmed," encompassed the negative aspects of the learning community faculty experience. The authors found that their identified themes related closely to the theoretical framework for pathways to meaningful work proposed by Rosso et al. DISCUSSION: The alignment of the themes we identified on the experience of learning community faculty to existing literature on work meaning corroborates the theoretical framework and deepens understanding of beneficial and harmful learning community effects on faculty. As learning communities become increasingly common within medical schools, this understanding may be important for leaders in academic medicine considering potential indirect benefits of this educational model.

Barriers Pushed Aside: Insights on Career and Family Success from Women Leaders in Academic Otolaryngology.

OBJECTIVE: Although the literature adequately identifies the current gender inequality that exists in academic otolaryngology and describes the barriers to advancement of women in academic medicine, there is little information regarding the daily details of how successful women in academic otolaryngology achieve work-life balance. This study was designed to better understand how women in academic otolaryngology achieve work-life balance while negotiating family and childrearing commitments, clinical workload, and scholarly activity, as well as to highlight coping strategies and behaviors that women have used to achieve these successes. STUDY DESIGN: Qualitative research design. METHODS: Thirteen successful women in academic otolaryngology with children were recruited using a networking/snowball sampling methodology to participate in a semistructured qualitative interview about the daily process of work-life balance in an academic otolaryngology practice. A focus group of 7 additional participants was held to validate critical topics/themes. RESULTS: Four broad categories of findings emerged from the study: (1) participants' strong commitment to academic medicine, (2) the fluid/elusive nature of work-life balance, (3) specific approaches to successfully managing home life, and (4) insights related to achieving psychoemotional health. CONCLUSIONS: The conflicting demands between home and professional life are one of the barriers to recruiting, promoting, and retaining women in academic otolaryngology. Fostering a better environment for work-life balance is critical to promote the advancement of women in otolaryngology and otolaryngology leadership.

Craniofacial Actinomyces osteomyelitis evolving from sinusitis.

Craniofacial Actinomyces osteomyelitis progression is rare, as patients are soon treated. A 56-year-old male smoker presented with sinusitis and was managed medically. This patient failed to follow up and presented 1 year later with erosive bony disease. He was managed medically and surgically; however, his disease evolved to include his midface, skull base, and cranium. He underwent staged debridement and free tissue reconstruction. His disease is controlled but not cured. The literature includes case reports and small series describing limited disease treated successfully with surgical and medical management. Although craniofacial Actinomyces osteomyelitis is uncommon, it can become debilitating. This case demonstrates how craniofacial Actinomyces osteomyelitis can progress and highlights the benefit of a multidisciplinary approach.

Physical Models and Virtual Reality Simulators in Otolaryngology.

The increasing role of simulation in the medical education of future otolaryngologists has followed suit with other surgical disciplines. Simulators make it possible for the resident to explore and learn in a safe and less stressful environment. The various subspecialties in otolaryngology use physical simulators and virtual-reality simulators. Although physical simulators allow the operator to make direct contact with its components, virtual-reality simulators allow the operator to interact with an environment that is computer generated. This article gives an overview of the various types of physical simulators and virtual-reality simulators used in otolaryngology that have been reported in the literature.

Face, content, and construct validation of a low-cost, non-biologic, sinus surgery task trainer and knowledge-based curriculum.

BACKGROUND: The purpose of this study was to evaluate face and content validity of a low-cost, low-technology, non-biologic endoscopic sinus surgery (ESS) task trainer and knowledge-based curriculum followed by construct validation of the task trainer. METHODS: A sinus surgery task trainer and curriculum were developed. Attending otolaryngologists were surveyed regarding the utility of the task trainer and curriculum. A cross-sectional construct validation study was performed including medical students, residents, and attending otolaryngologists. Nine tasks were performed on the task trainer and graded using a global rating scale (GRS). Predictors of task trainer performance were evaluated, and spatial performance was measured. Regression analyses were performed to assess main associations. RESULTS: All attending physicians (n = 7) agreed that the task trainer accelerates the learning curve and incorporates essential ESS techniques and that the knowledge-based curriculum describes anatomical and technical knowledge germane to ESS. Twelve medical students, 9 otolaryngology residents, and 5 attending otolaryngologists completed task trainer testing. GRS score varied by level of training after adjusting for potential confounders (slope = 2.63; p = 0.001). There was evidence of an association between a history of video gaming (slope = 1.33; p = 0.077), sports experience (slope = 2.08; p = 0.033), and sinus surgery simulation (slope = 2.72; p = 0.023) with GRS score, although not statistically significant. CONCLUSION: This study demonstrated validity of a knowledge-based sinus surgery curriculum and low-cost, sinus task trainer supporting use in early training. Participants with prior video gaming, sports participation, and sinus surgery simulation experience perform better at baseline on the task trainer.

Wrist Motion Variation between Novices and Experienced Surgeons Performing Simulated Airway Surgery.

OBJECTIVE: To determine whether wrist motion measured by a smartphone application can be used as a performance metric for a simulated airway procedure requiring both wrist and finger dexterity. We hypothesized that this accelerometer application could detect differences between novices and experienced surgeons performing simulated cricothyrotomy. SETTING: Academic medical center. STUDY DESIGN: Prospective pilot cohort study. METHODS: Voluntary surgeons and nonsurgeons were recruited. After viewing a training video, smartphones with accelerometer applications were attached to both wrists while subjects performed a cricothyrotomy on a validated task trainer. Procedure time and motion parameters, including average resultant acceleration (ARA), total resultant acceleration (TRA), and suprathreshold acceleration events (STAEs), were collected for dominant and nondominant hands. Subjects were stratified by prior experience. Blinded experts scored each performance using Objective Structured Assessment of Technical Skills (OSATS), and t tests were used to compare performance. RESULTS: Thirty subjects were enrolled. Median age was 26 years, and 20 subjects were male. In the dominant hand, significant differences were seen between novice and experienced surgeons in TRA (P = .005) and procedure time (P = .006), while no significant differences were seen in STAEs (P = .42) and ARA (P = .33). In the nondominant hand, all variables were significantly different between the 2 groups: STAEs (P = .012), ARA (P = .007), TRA (P = .004), and procedure time (P = .006). CONCLUSIONS: Wrist motion measured by a low-cost smartphone application can distinguish between novice and experienced surgeons performing simulated airway surgery. This tool provides cost-effective and objective performance feedback.

Impact of patient-related factors on the outcomes of office-based injection laryngoplasty.

OBJECTIVES/HYPOTHESIS: In-office percutaneous injection laryngoplasty (IL) is a common treatment for glottal insufficiency. The objective of this prospective study was to determine if voice outcomes from IL are affected by age, gender, or initial disease severity. STUDY DESIGN: Prospective case series. METHODS: Consecutive adult patients undergoing awake injection laryngoplasty were recruited from a subspecialty laryngology clinic. Voice Handicap Index (VHI-30); Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V); and Grade, Roughness, Breathiness, Asthenia and Strain (GRBAS) Dysphonia Scale were evaluated prior to and 2 months after injection. Patients who had more severe disease were defined as those patients with greater initial perception of handicap, with a VHI score greater than 60. RESULTS: Thirty-five subjects were enrolled, and 27 (16 male; mean age 61.6 ± 13.2 years) had complete data. No impact from age or gender was seen on outcomes from IL as measured by VHI-30 (P = 0.397 for age; P = 0.764 for gender), CAPE-V (P = 0.675 for age, P = 0.975 for gender), or GRBAS (P = 0.213 for age, P = 0.983 for gender). Patients with poorer initial VHI tended to have more significant improvement (P = 0.002), which may represent a ceiling effect. CONCLUSIONS: In this prospective clinical study, age and gender did not affect outcome in IL. Patients with more severe disease appeared to have greater improvement. LEVEL OF EVIDENCE: 4. Laryngoscope, 126:1806-1809, 2016.

Late tracheotomy is associated with higher morbidity and mortality in mechanically ventilated patients.

OBJECTIVES/HYPOTHESIS: To determine whether the timing of tracheotomy placement impacts ventilation weaning status and mortality. STUDY DESIGN: Multi-institution retrospective cohort study. METHODS: Demographic data, procedural details, and clinical outcomes were recorded for patients undergoing tracheotomy for prolonged mechanical ventilation across eight sites. The study group was divided into two groups: those undergoing tracheotomy within 14 days of initiation of mechanical ventilation and those undergoing tracheotomy at or after 14 days. Groups were compared for primary outcome measures of mortality and ability to wean from mechanical ventilation within the study period. RESULTS: Of the 539 patients intubated for ventilator dependence with complete data available, 280 (51.9%) underwent tracheotomy within 14 days. Patients who underwent late tracheotomy were 1.72 times more likely to remain ventilator dependent during the follow-up period (95% confidence interval [CI]: 1.12-2.66), and had a 40% increased risk of death (odds ratio: 1.4, 95% CI: 0.96-1.99). CONCLUSIONS: In this multicenter retrospective review of tracheotomy outcomes, late tracheotomy placement (>14 days) was associated with increased mortality and prolonged ventilator dependence. Standardized multidisciplinary management protocols for prolonged mechanical ventilation are recommended, and future work should confirm these results in a prospective manner. LEVEL OF EVIDENCE: 4.

A need for otolaryngology education among primary care providers.

OBJECTIVE: Otolaryngic disorders are very common in primary care, comprising 20-50% of presenting complaints to a primary care provider. There is limited otolaryngology training in undergraduate and postgraduate medical education for primary care. Continuing medical education may be the next opportunity to train our primary care providers (PCPs). The objective of this study was to assess the otolaryngology knowledge of a group of PCPs attending an otolaryngology update course. METHODS: PCPs enrolled in an otolaryngology update course completed a web-based anonymous survey on demographics and a pre-course knowledge test. This test was composed of 12 multiple choice questions with five options each. At the end of the course, they were asked to evaluate the usefulness of the course for their clinical practice. RESULTS: Thirty seven (74%) PCPs completed the survey. Mean knowledge test score out of a maximum score of 12 was 4.0±1.7 (33.3±14.0%). Sorted by area of specialty, the mean scores out of a maximum score of 12 were: family medicine 4.6±2.1 (38.3±17.3%), pediatric medicine 4.2±0.8 (35.0±7.0%), other (e.g., dentistry, emergency medicine) 4.2±2.0 (34.6±17.0%), and adult medicine 3.9±2.1 (32.3±17.5%). Ninety one percent of respondents would attend the course again. CONCLUSION: There is a low level of otolaryngology knowledge among PCPs attending an otolaryngology update course. There is a need for otolaryngology education among PCPs.

Trainee perceptions of laryngology in otolaryngology residency programs.

OBJECTIVES: There is no standardized curriculum for laryngology within otolaryngology residency programs despite the fact that laryngology is a significant portion of the Royal College of Physicians and Surgeons of Canada examination. Our objective was to evaluate trainee perceptions of laryngology within otolaryngology residency programs. DESIGN: Cross-sectional survey. SETTING: Canadian otolaryngology residency programs. METHODS: A Web-based, anonymous survey was conducted among otolaryngology residents. The survey was based on Royal College learning objectives for laryngology. The survey was administered using Dillman's Total Design Method and distributed in English and French. RESULTS: Sixty-four of 150 (42.6%) residents responded to the survey (55.6% male; mean age 29.3 years). About half of the respondents agreed or strongly agreed that the amount of didactic and clinical laryngology instruction was adequate. About 41.0% agreed or strongly agreed that the amount of operative laryngology instruction was adequate. Cited areas for improvement included injection laryngoplasty, botulinum toxin injection, medialization thyroplasty, care of the professional voice, phonosurgery, and videostroboscopy. Areas of strength included flexible nasopharyngoscopy, laryngeal anatomy, hoarseness, stridor, laryngopharyngeal reflux disease, and vocal cord paralysis. Overall, 40.7% felt somewhat comfortable providing laryngology care. The presence of a laryngology fellowship at the training program, respondent interest in pursuing a fellowship, completion of a laryngology elective, and previous laryngology research did not affect the residency experience. Senior residents are more comfortable with providing laryngology care than juniors. CONCLUSIONS: Several areas of strengths and areas for improvement in laryngology appear to exist within otolaryngology residency programs as perceived by current trainees.

Transorbital neuroendoscopic management of sinogenic complications involving the frontal sinus, orbit, and anterior cranial fossa.

Transnasal endoscopic surgery has remained at the forefront of surgical management of sinogenic complications involving the frontal sinus, orbit, and anterior skull base. However, the difficulty in accessing certain areas of these anatomical regions can potentially limit its use. Transorbital neuroendoscopic surgery (TONES) was recently introduced to transgress the limits of transnasal endoscopic surgery; the access that it provides could add additional surgical pathways for treating sinogenic complications involving the frontal sinus, orbit, and anterior cranial fossa. We describe a prospective series of 13 patients who underwent TONES for the management of various sinogenic complications, including epidural abscess, orbital abscess, and fronto-orbital mucocele or mucopyocele, as well as subperiosteal abscess presenting with orbital apex syndrome. The primary outcome measurement was the efficacy of TONES in treating these pathologies. TONES provided effective access to the frontal sinus, orbit, and the anterior cranial fossa. All patients demonstrated postoperative resolution of initial clinical symptoms with well-hidden surgical scars. There were no ophthalmologic complications or recurrence of pathology. Based on our experience, TONES appears to provide a valuable addition to the current surgical armamentarium for treating selected complications of sinusitis.

A multi-institutional analysis of tracheotomy complications.

OBJECTIVES/HYPOTHESIS: To define the prevalence of tracheotomy tube complications and evaluate risk factors (RFs) associated with their occurrence. STUDY DESIGN: Multi-institution historical cohort. METHODS: Data regarding tracheotomy tube complications from consecutive surgeries performed across eight participating institutions between January 1, 2008 and December 31, 2009 were retrospectively collected. Patient demographics, comorbidities, physician specialty, and surgical technique were recorded and statistically analyzed to identify the incidence of surgical complications following tracheotomy and associated RFs. RESULTS: The charts of 1,175 tracheotomy procedures were reviewed from eight academic institutions. Otolaryngologists performed 66.2% of the tracheotomies. Intraoperative, early (<1 week), and late complication rates were 1.4%, 5.6%, and 7.1%, respectively. Postoperative bleeding was identified as the most common early complication (2.6%), whereas airway stenosis was the most common late complication (1.7%). The use of outer flange security sutures to anchor the tracheostomy tube was negatively associated with the incidence of early complication (P<.0001). The use of large endotracheal tubes (size>7.5) and obesity were associated with the development of airway stenosis (P<.05).Twenty-two percent of patients undergoing tracheotomy died during hospitalization. CONCLUSIONS: Perioperative tracheotomy complications are rare; however, the rate of death for all causes is high (22%) in this population. Obesity and the use of endotracheal tubes over 7.5 in size are major risk factors for the development of airway stenosis. Although percutaneous tracheotomy resulted in a significantly higher rate of postoperative bleeding (6.6%) than the open method (1.9%) (P<.05), the use of outer flange tracheostomy tube sutures may reduce this complication.

Recent progress in facial paralysis: advances and obstacles.

PURPOSE OF REVIEW: Facial paralysis is a devastating and debilitating condition for which a range of management options exists; all of them continue to have limitations. We review the recent scientific literature and highlight key developments and opportunities for further exploration with the goal that this may help direct clinical practice and research endeavor. RECENT FINDINGS: We reviewed recent findings in the evaluation of facial paralysis, pharmacological management, nerve injury prevention and treatment. This includes review of novel techniques using photography and videography. Review of surgical and adjunctive techniques identifies several refinements of existing techniques, some novel techniques, and the value of adjunctive materials and therapies. SUMMARY: Management of facial paralysis remains an area of active investigation and innovation. The challenge to researchers and care providers will be to continue to explore and refine management strategies while maintaining rigorous and standardized means of evaluation and follow-up, such that outcomes may be determined and reported accurately and in a way that they can be transferred to other clinical practices. Further study of the role of growth factors and stem cells in facial nerve regeneration is critical, and is the most likely means of surmounting the remaining barriers to successful outcomes in alleviating the ravages of this devastating malady.

Nasal tip refinement: analysis of surgical technique, efficacy, and secondary effect of skin thickness.

BACKGROUND: Effective control and refinement of the nasal tip is an integral component of the rhinoplasty operation. A multitude of techniques exist to complement the rhinoplasty surgeon's approach, but attaining consistent and long-lasting results is still challenging due to the complex interplay between nasal anatomy and surgical technique. OBJECTIVES: The authors sought to determine whether the degree of tip narrowing with rhinoplasty is associated with the narrowing technique selected by the surgeon and whether there is an association between skin thickness and tip narrowing. METHODS: A retrospective chart review was conducted of all patients undergoing rhinoplasty in a single-surgeon practice between April 2004 and November 2006. Demographic information and specific operative techniques were recorded. Standard basal views of pre- and postoperative photographs were examined by two blinded observers, who measured nasal tip width relative to interpupillary distance with imaging software. Skin thickness was assessed and categorized by a surgical expert according to Fitzpatrick classification. RESULTS: Forty patients were identified with adequate follow-up and complete data sets. A statistically significant reduction in tip width pre- and postoperatively was seen (P = .041). No significant difference in tip narrowing between various techniques was found (P = .309), and no significant association between tip narrowing and skin thickness was identified (P = .186). CONCLUSIONS: Although tip-narrowing techniques are effective in rhinoplasty, the specific technique employed may not be clinically relevant. Furthermore, skin thickness may not be as significant a factor in tip narrowing as is commonly believed.

Influence of age and gender on dose and effectiveness of botulinum toxin for laryngeal dystonia.

OBJECTIVES/HYPOTHESIS: To evaluate the influence of age and gender on the required dose and resulting efficacy of botulinum toxin injection for adductor laryngeal dystonia. DESIGN: Retrospective chart review. METHODS: All patients treated with botulinum toxin for laryngeal dystonia at the University of Washington Medical Center between 1991 and 2008 were identified from a large clinical database. Only patients undergoing thyroarytenoid muscle injection for adductor laryngeal dystonia were included in this study. Each patient's gender, age at treatment, stable dose of botulinum toxin, and patient-reported duration of beneficial effect was recorded. RESULTS: A total of 155 patients (50 males, 105 females) were identified, with average ages of 50.6 years for men and 54.4 years for women. The mean treatment doses of botulinum toxin were 1.85 +/- 0.84 U for males and 2.15 +/- 1.40 U for females. The associated mean durations of beneficial effect were 12.8 +/- 7.7 weeks for males and 13.9 +/- 7.3 weeks for females. Neither the difference in dose nor in duration was found to be statistically significant (P = .395 and P = .511, respectively). When analyzed by age, the mean doses of botulinum toxin were 1.87 +/- 1.00 U for patients younger than 50 years and 2.20 +/- 1.41 U for the older group. The associated mean durations of beneficial effect were 13.7 +/- 7.4 weeks for the younger group and 13.5 +/- 7.4 weeks for the older group. Again, neither difference was found to be statistically significant (P = .113 and P = .730, respectively). CONCLUSIONS: Dosage and duration of beneficial effect of botulinum toxin in treatment of adductor laryngeal dystonia do not appear to vary with age or gender.

Bio-Alcamid: an alternative to fat transfer.

The recent evolution of the philosophy of rejuvenation therapy toward addressing soft tissue loss with aging has prompted growing interest in fat transfer procedures as a means of volume replacement. However, fat transfer has several undesirable characteristics, including the need for a donor site and lack of predictability of fat uptake and volume retention. Injectable fillers are gaining popularity as an alternative to fat transfer because of their lack of donor site morbidity, instant effects, predictability, and vastly reduced recovery period. Because temporary fillers require inconvenient repeat visits, patients have been requesting permanent options. This article describes the author's experience with a permanent adjustable large-volume filler based on polyalkylimide (Bio-Alcamid) and suggests that it could be a preferred and reliable alternative to fat transfer in appropriate patients. Permanent is defined as no decrease in volume of the product over time. However, because the area augmented may eventually decrease from further aging and fat atrophy, more product may need to be reinjected years later.