Otolaryngology Resident Education and the Accreditation Council for Graduate Medical Education Core Competencies: A Systematic Review.

IMPORTANCE: To date, there have been no reports in the current literature regarding the use of the Accreditation Council for Graduate Medical Education (ACGME) core competencies in otolaryngology residency training. An evaluation may help educators address these core competencies in the training curriculum. OBJECTIVES: To examine the quantity and nature of otolaryngology residency training literature through a systematic review and to evaluate whether this literature aligns with the 6 core competencies. EVIDENCE REVIEW: A medical librarian assisted in a search of all indexed years of the PubMed, Embase, Education Resources Information Center (via EBSCOhost), Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, and Cochrane Methodology Register), Thomson Reuters Web of Science (Science Citation Index Expanded, Social Sciences Citation Index Expanded, Conference Proceedings Citation Index-Science, and Conference Proceedings Citation Index-Social Science and Humanities), Elsevier Scopus, and ClinicalTrials.gov databases to identify relevant English-language studies. Included studies contained original human data and focused on otolaryngology resident education. Data regarding study design, setting, and ACGME core competencies addressed were extracted from each article. Initial searches were performed on May 20, 2015, and updated on October 4, 2016. FINDINGS: In this systematic review of 104 unique studies, interpersonal communication skills were reported 15 times; medical knowledge, 48 times; patient care, 44 times; practice-based learning and improvement, 31 times; professionalism, 15 times; and systems-based practices, 10 times. Multiple studies addressed more than 1 core competency at once, and 6 addressed all 6 core competencies. CONCLUSIONS AND RELEVANCE: Increased emphasis on nonclinical core competencies is needed, including professionalism, interpersonal and communication skills, and systems-based practices in the otolaryngology residency training curriculum. A formal curriculum addressing nonclinical core competencies should be integrated into otolaryngology residency training.

High-Quality Feedback Regarding Professionalism and Communication Skills in Otolaryngology Resident Education.

Objective The Accreditation Council for Graduate Medical Education (ACGME) requires competency-based education for residents and recommends 5 basic features of high-quality feedback. Our aim was to examine the incorporation of feedback in articles regarding professionalism and interpersonal/communication skills for otolaryngology residency training curriculum. Data Sources PubMed, Embase, ERIC, Cochrane Library, Web of Science, Scopus, and ClinicalTrials.gov . Methods We used studies identified during a systematic review of all indexed years through October 4, 2016. Results Eighteen studies were included in this review. Professionalism was discussed in 16, of which 15 (94%) examined aspects of feedback. Interpersonal/communication skills were the focus of 16 articles, of which 14 16 (88%) discussed aspects of feedback. Our assessment demonstrated that timeliness was addressed in 8 (44%) articles, specificity in 4 (22%), learner reaction and reflection in 4 (22%), action plans in 3 (20%), and balancing reinforcing/corrective feedback in 2 (13%). Two articles did not address feedback, and 6 did not address aspects of high-quality feedback. The ACGME-recommended feedback systems of ADAPT (ask, discuss, ask, plan together) and R2C2 (relationship, reactions, content, and coach) were not reported in any of the studies. Conclusion Feedback is an essential component of graduate medical education and is required by the ACGME milestones assessment system. However, the core feedback components recommended by the ACGME are rarely included in the otolaryngology resident education literature.

First Report: Linear Incision for Placement of a Magnetically Coupled Bone-Anchored Hearing Implant.

OBJECTIVES: Discuss use of a linear incision for placement of a magnetically coupled bone anchored hearing implant. METHODS: Case series. RESULTS: Two patients underwent placement of magnetically coupled bone-anchored hearing implants (BAHI) through linear incisions. The first, a 40-year-old female with congenital single-sided deafness, previously had successful implantation of a percutaneous bone anchored hearing implant through a linear incision; unfortunately, she developed pain and intermittent drainage at her abutment site with time, resulting in a request for removal of her device. As an alternative to complete removal, we offered to replace the percutaneous implant with a magnetically coupled BAHI, employing the same linear incision previously. The second patient, a 53-year-old obese female with limited neck mobility and mixed hearing loss, underwent primary placement of a magnetically coupled BAHI through a linear incision. Limitations in neck mobility and patient body habitus precluded use of a traditional C-shaped incision. Both patients underwent surgery successfully, healed without incident, had their devices activated 6 weeks after their procedures, and are able to wear their implants more than 8 hours per day without discomfort. CONCLUSION: Surgical techniques for bone-anchored implants continue to evolve. Though manufacturers of magnetically coupled devices recommend using C-shaped incisions with large skin flaps, our first reported cases suggest that a small linear incision immediately overlying the implant magnet may be an acceptable alternative. Potential benefits include a smaller incision, less hair removal, smaller flap, decreased surgical time, and less postoperative pain.

Office-Based vs Traditional Operating Room Management of Recurrent Respiratory Papillomatosis: Impact of Patient Characteristics and Disease Severity.

Importance: Management of recurrent respiratory papillomatosis (RRP) in adults has evolved to include office-based laser techniques. Objective: To determine whether demographic or disease characteristics differ between patients undergoing office-based (office group) vs traditional operating room (OR group) surgical approaches for RRP. Design, Setting, and Participants: This study was a medical record review of adult patients with RRP treated between January 2011 and September 2013 at a tertiary care center. Patients were divided into 2 groups according to the setting in which the patient had the most procedures during the past 2 years. Main Outcomes and Measures: Demographic and disease characteristics were compared between patients receiving predominantly office-based vs predominantly OR management. Results: Of 57 patients (47 male and 10 female, with a mean [SD] age of 53.5 [16.4] years) treated during the 2-year period, 34 patients underwent predominantly office-based management and 23 patients underwent predominantly OR management. Sex, age, and weight were not statistically significantly different between the 2 groups. Patients in the OR group had a younger age at RRP diagnosis (mean [SD], 28.7 [22.0] years in the OR group and 45.5 [20.5] years in the office group), with a mean difference of 16.8 years (95% CI, -28.3 to -5.4 years). Patients in the OR group also had a significantly higher Derkay score (mean [SD], 15.1 [5.7] in the OR group and 10.7 [5.0] in the office group), with a mean difference of 4.4 (95% CI, 1.6-7.3). No statistically significant differences in comorbidities were observed between the 2 groups except for type 1 or 2 diabetes, which was more common in the OR group. There were 5 patients (22%) with diabetes in the OR group and 1 patient (3%) with diabetes in the office group, with a mean difference of 19% (95% CI, 2.7%-35%). In a subanalysis that excluded patients with juvenile-onset RRP, Derkay score (mean [SD], 13.9 [4.5] in the OR group and 10.8 [5.1] in the office group), with a mean difference of 3.1 (95% CI, 0.5-6.1), and the incidence of diabetes (25% [4 of 16] in the OR group and 3% [1 of 31] in the office group), with a mean difference of 22% (95% CI, 3%-40%), remained significantly higher in the OR group, while age at diagnosis of RRP was no longer statistically significant (mean [SD], 40.2 [15.6] years in the OR group and 49.6 [16.4] years in the office group), with a mean difference of 9.4 years (95% CI, -19.4 to -0.7 years). Conclusions and Relevance: There were no sex or age differences between patients with RRP treated in the office compared with those treated in the OR. Patients with earlier age at diagnosis of RRP and greater disease severity were more likely to be managed in the OR.

Combined approaches to the skull base for intracranial extension of tumors via perineural spread can improve patient outcomes.

Many neoplasms of the head and neck extend centripetally, gaining access to the central nervous system via nerves through the skull base foramina. Often patients with perineural spread have been excluded from aggressive interventions given the overall poor prognosis and technical difficulty when addressing the perineural components. However, in carefully selected patients combined surgical approaches can provide the greatest potential for disease control as well as neural decompression for symptom relief. We performed a retrospective chart review of 20 consecutive patients who underwent skull base approaches for resection of tumors with intracranial extension via perineural spread from 2011 to 2014. Patients were evaluated for symptom change, surgical approaches, histopathology, adjuvant therapy, outcome, and prognosis. The most common presenting symptoms were pain or cranial nerve palsies. 55% of patients underwent endoscopic endonasal approaches, 50% transcranial approaches, and 15% underwent transfacial approaches. Overall 85% of patients reported symptom improvement in the post-operative period while 40% were completely asymptomatic following surgical resection. Ultimately, we observed a 45% mortality rate with an average survival of 8 months after diagnosis. In carefully selected patients, an aggressive multidisciplinary approach using a combination of surgical avenues to the skull base for the treatment of intracranial tumor via perineural extension can improve patient quality of life.

Tympanosclerosis Presenting as Mass: Workup and Differential.

Introduction. Tympanosclerosis is a commonly encountered entity within ENT clinics and primary care settings. Recognizing ear pathology is essential for correct management. Oftentimes the diagnosis is clear; however in certain cases further workup to rule out other more insidious disease processes is warranted. Case Report. We present a case of tympanosclerosis which presented as an ear mass without classic appearance of tympanosclerosis. Through imaging and biopsy the diagnosis of tympanosclerosis was made. The patient was treated surgically with good outcome. Discussion. Various ear pathologies, with different treatment algorithms, may present as clinically similar to one another. Differential diagnosis for this case included tympanosclerosis, cholesteatoma, or other middle ear masses. We review these entities and discuss their pathophysiology and implications on management.

The Triple Aim and its implications on the management of chronic rhinosinusitis.

INTRODUCTION: Accountable care organizations (ACO) and alternative payment models are a sign of the change in reimbursement from fee-for-service to value-based reimbursement. The focus of health care under ACOs is represented by the Triple Aim: to improve the experience of health care, improve the health of populations, and reduce the per capita costs. Individuals with chronic rhinosinusitis (CRS) are heavy consumers of health care services. Results of recent studies have indicated that there is the potential for improved outcomes and cost savings from early surgical intervention. Adhering to the principles of the Triple Aim may signal a paradigm shift in regard to timing of intervention for CRS in certain patients. METHODS: A scoping review was performed to analyze the current literature related to management of CRS and the impact on cost, population health outcomes, and the patient's experience of health care. RESULTS: A growing body of literature indicates that, in appropriately selected patients, when compared with medical management, endoscopic sinus surgery has the potential to improve patient outcomes and reduce the long-term cost burden of CRS. CONCLUSION: With the advent of ACOs, a paradigm shift in the treatment of CRS is inevitable to better conform to the goals of the Triple Aim. Future treatment algorithms will need to account for the heterogeneity within CRS and seek to identify appropriate timing and interventions for patients on an individual basis if the value of health care is to be improved.