Two Simultaneous Rare Head and Neck Lipomas: Vallecular Lipoma and Giant Intermuscular Neck Lipoma.

Lipomas are benign soft tissue neoplasms, involving the head and neck in roughly 15% of cases. We review a patient who presented with a palpable, anterior neck mass and progressive dysphagia, throat clearing, and dysphonia. He was found to have two simultaneous rare sites for head and neck lipomas: vallecular and intermuscular, anterior neck. He elected for surgical resection of both masses resulting in significant symptom improvement. Though originally referred for evaluation of an anterior neck mass, we underscore the importance of prompt investigation with reported laryngeal symptoms. We provide considerations for preoperative evaluation and surgical approaches. Laryngoscope, 2024.

Using Lean to Improve Patient Safety and Resource Utilization After Pediatric Adenotonsillectomy.

OBJECTIVE: The objective of this quality improvement project was to decrease the rate of nonemergent use of emergency department (ED) resources in children undergoing adenotonsillectomy by 50% and/or reach a future state of 5% or less overall ED visits among all postoperative patients within 1 year. A secondary objective was to standardize the preoperative, intraoperative, and postoperative management of these patients. METHODS: The study was a quality improvement project using Lean. The target population was children younger than 18 years undergoing tonsillectomy with or without adenoidectomy. A retrospective review of adenotonsillectomy was performed for a 12-month period. Lean tools including A3 Thinking, Ishikawa "fishbone" diagram, and value stream mapping were used to analyze the problem and identify interventions. Postintervention data were collected for a 10-month period. RESULTS: Compared with the baseline period, the ED visit rate after adenotonsillectomy decreased from 36.2% to 15.5% (P = 0.0095). The rate of ED visits for nonbleeding complaints decreased from 30.4% to 12.1% (P = 0.01748). There was no significant change in rate of ED visits for bleeding (decreased from 5.8% to 3.5% [P = 0.6873]). There was no significant change in the use of intraoperative dexamethasone and acetaminophen. CONCLUSIONS: Postadenotonsillectomy patients often use emergency resources better reserved for other patients. Addressing this problem with Lean principles significantly decreased postoperative ED visit rates by more than 50%. IMPLICATIONS FOR PRACTICE: To our knowledge, this is the first reported use of Lean principles to decrease utilization of emergency resources in the postoperative period. Lean can be applied to other processes in our field to eliminate waste and add value to improve patient outcomes. LEVEL OF EVIDENCE: NA.

The role of doxycycline in the management of chronic rhinosinusitis with nasal polyps.

INTRODUCTION: Many theories on the pathophysiology of chronic rhinosinusitis with nasal polyposis (CRSwNP) exist. The most effective management of CRSwNP has not been elucidated. Doxycycline, which has anti-inflammatory and anti-bacterial properties, has shown durable effects; however, its efficacy in combination with standard therapy has not been examined. We hypothesized that its addition to the standard anti-inflammatory regimen would improve patient outcomes. METHODS: We performed a double-blind, placebo-controlled trial at a tertiary level institution. Patients with moderate or severe CRSwNP were randomized into two groups, each receiving a 20-day course of oral corticosteroids and doxycycline or placebo. The 22-item Sinonasal Outcome Test (SNOT-22), nasal polyp scores, and visual analog scale (VAS) scores were recorded at the initial, 3-, 8- and 12-week visits. RESULTS: 49 patients were enrolled, 24 in the experimental and 25 in the placebo group with 3 moderate disease patients in each group. There were 12 dropouts in the treatment group and 14 in the placebo group. The most common reasons for dropout were severe CRS and asthma exacerbations. There was no significant difference in SNOT-22 scores, nasal polyp scores, and VAS scores between the two arms. CONCLUSIONS: Non-surgical management of patients with CRSwNP remains challenging. Our conclusions are limited given the high dropout rate and thus, limited sample size with inadequate power. This study is important, however, because a high dropout rate of mostly severe disease patients may illustrate that this patient population may not be optimally managed with medical therapy alone.

An Evaluation of the Program-Specific Paragraph in the Otolaryngology Residency Application.

OBJECTIVES/HYPOTHESIS: The recent addition of mandatory program-specific paragraphs within the personal statement during the otolaryngology match process has been controversial. It is unclear whether applicants customize these paragraphs for programs, or if they are largely uniform across applications. The objective of our study was to assess the degree of variability among program-specific paragraphs. STUDY DESIGN: Retrospective cohort analysis. METHODS: An analysis of deidentified program-specific paragraphs of 2016 otolaryngology residency applicants at two institutions was performed. Applicants who applied to both and had program-specific paragraphs were included. Paragraphs were assessed for 24 parameters, including quantitative content analysis. Subjective and objective similarity scores were assigned to each pair, using a five-point scale and Levenshtein distance function respectively. Differences between institutions were calculated using χ2 and two-sided t tests. RESULTS: Two hundred eight-five applications were reviewed, and 181 applied to both programs and had program-specific paragraphs. The median subjective similarity score among all paragraphs was "mildly similar" (2/5). The mean objective similarity score was 0.59. There were statistical differences between institutions in 13 parameters. One institution garnered more applicants who mentioned interest in research or global surgery (71.3% vs. 57.5%, P = .006; 17.7% vs. 4.4%, P < .0001, respectively), whereas the other attracted mention of clinical aspects and geographical ties (80.0% vs. 45.3%, P < .0001; 72.4% vs. 45.3%, P < .0001, respectively). CONCLUSIONS: Our study suggests that applicants tailor program-specific paragraphs to the individual residency programs. These findings may aid programs and students in understanding the role of this new element of the application. LEVEL OF EVIDENCE: 4 Laryngoscope, 2508-2513, 2018.

Referral patterns from emergency department to otolaryngology clinic.

OBJECTIVES/HYPOTHESIS: Patients who present to the emergency department (ED) with various otolaryngologic disorders are frequently referred to an otolaryngologist for follow-up care. Our aim was to further characterize this group as it has not been well described in the literature. STUDY DESIGN: Cross-sectional retrospective study. METHODS: We reviewed the charts of patients seen during an 18-month period in an urban public hospital trauma center adult ED and referred to an otolaryngology clinic for follow-up care. RESULTS: Seven hundred thirty-eight patients were seen and referred; the most common diagnoses made by ED providers were peripheral vertigo (12%), otitis externa (8%), and nasal fractures (8%). Nine percent of patients were evaluated during their ED visit by an otolaryngology provider. Three hundred seventy-two (50%) patients returned for their otolaryngology clinic visit; facial trauma patients were least likely to return. The most common diagnoses made by otolaryngology providers were otitis externa (12%), peripheral vertigo (12%), and nasal fractures (7%). There was 50% concordance between patients' diagnoses made by ED and otolaryngology providers. The most common differences were otitis media versus otitis externa (10%) and acute pharyngitis versus laryngopharyngeal reflux (8%). During 37% of follow-up visits, an in-office procedure was performed, most commonly flexible fiberoptic laryngoscopy, cerumen removal, and nasal endoscopy. CONCLUSIONS: Our analysis reports comprehensive characteristics of this referral group, identifying potential areas for improvement in patient management, resident education and efficiency. Otolaryngologists covering EDs should be familiar with this population in terms of types of cases that may affect their practices. LEVEL OF EVIDENCE: 4. Laryngoscope, 128:1062-1067, 2018.

Use of Lean and CAHPS Surgical Care Survey to Improve Patients' Experiences with Surgical Care.

OBJECTIVES: (1) Measure patients' experiences with surgical care using the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Surgical Care Survey. (2) Use lean thinking to analyze and improve quality of patient care. STUDY DESIGN: A prospective quality improvement study. SETTING: Hospital-based otolaryngology clinic. SUBJECTS AND METHODS: The CAHPS Surgical Care Survey was distributed to 17 surgical patients to determine their perception of the current state of care. Survey results were analyzed with lean thinking, and changes were made to improve critical areas. A second set of surveys was distributed to 10 patients to assess the success of the interventions immediately and 2 months later. The data were analyzed with the Mann-Whitney U test. RESULTS: Seventeen patients completed the CAHPS Surgical Care Survey to determine the initial state. A3 Thinking was used to analyze the results and design an improvement. Overall positive patient experience was 57% at the postoperative visit with 3 key aspects of care: time spent during visit, encouragement to ask questions, show of respect to the patient. Two causes were postulated; then, solution approaches were developed and tested in a series of rapid experiments. Two groups of 10 patients completed the CAHPS Surgical Care Survey to determine the postintervention state. Overall positive patient experience significantly improved to 93% (U = 474, P < .001) and 83% (U = 546, P = .009) immediately and 2 months later, respectively. CONCLUSION: Lean thinking helps to eliminate defects by breaking down complex problem solving into a scientific process. When combined with the CAHPS Surgical Care Survey, it can be successfully used to improve patients' surgical experiences.

Videoconferencing for the pre-operative interaction between patient and surgeon.

We studied the use of videoconferencing for the pre-operative patient-surgeon interaction. Subjects were recruited from otolaryngology patients undergoing surgery at a tertiary hospital. They were randomised to a conventional face-to-face interaction with their surgeon or a videoconference call via tablet computer. Afterwards, subjects and surgeons completed questionnaires about the experience. Various time points in patient flow were also recorded. Thirty-one patients were enrolled and 25 completed the study; five surgeons participated. The mean overall patient satisfaction scores were similar in the face-to-face and videoconferencing groups (9.88 and 9.89, respectively), as were mean interaction times (119 and 82 s, respectively); neither difference was significant. The mean waiting times in the pre-operative holding area were not significantly different between the groups. Surgeons were satisfied with the videoconferencing and 60% indicated they were somewhat likely to incorporate the technology into their daily practice. Overall patient satisfaction with a pre-operative patient-surgeon interaction via videoconferencing did not differ significantly from that for a conventional face-to-face discussion. It is feasible to incorporate videoconferencing into a busy surgical practice and there is the potential for improved efficiency.

Prevalence of severe obstructive sleep apnea in pediatric adenotonsillectomy patients.

OBJECTIVES/HYPOTHESIS: To determine the prevalence of severe obstructive sleep apnea (OSA) in a pediatric population who underwent indicated surgery for sleep disordered breathing (SDB). STUDY DESIGN: Retrospective chart review. METHODS: We reviewed the charts of patients aged 2 to 18 years who underwent tonsillectomy or adenotonsillectomy over a 4-year period. Indications for preoperative polysomnography (PSG), PSG results, and perioperative complications were recorded. RESULTS: Two hundred and thirty-five patients were included in the final analysis. Of these, 160 patients had preoperative PSG performed. The overall prevalence of severe OSA was 38%. The prevalence in patients for whom preoperative PSG was indicated or for which it should have been advocated according to the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) clinical practice guideline was 45% and 40%, respectively, whereas the prevalence in patients with no indication for preoperative PSG was 34%. There was no significant difference between groups (P = 0.39). The overall complication rate was 11%, with the rate being significantly lower (P = 0.0022) in patients who did not have preoperative PSG performed (0%) when compared to those who did (16%). CONCLUSIONS: The prevalence of severe OSA in this pediatric population was high. Specifically, a significant percentage of children who would not have received preoperative PSG under the AAO-HNS recommendations had severe OSA and were consequently admitted for overnight observation. Our results suggest that preoperative PSG should be obtained for all pediatric patients with sleep disordered breathing.

Evaluation of a teaching tool to increase the accuracy of pilot balloon palpation for measuring tracheostomy tube cuff pressure.

OBJECTIVES/HYPOTHESIS: The purpose of this study was to evaluate the efficacy of a novel teaching tool to improve health care providers' ability to inflate tracheostomy tube cuffs to the appropriate pressure. STUDY DESIGN: Single-blinded, randomized, controlled trial. METHODS: Subjects were randomized to a control and study group. The control group viewed a video about inflating tracheostomy tube cuffs to safe pressure levels. The study group viewed the same video and also got to palpate the pilot balloons of tracheostomy tube cuffs inflated to three different pressures. All subjects inflated tracheostomy tube cuffs to pressures they believed to be appropriate based on palpation of the pilot balloon preintervention, and immediately, 2 weeks, and 3 months postintervention. RESULTS: Forty-nine health care providers participated in the study. There was no significant difference in the mean preintervention cuff inflation pressures between the two groups (36 cm H2 O vs. 38 cm H2 O, P = 0.4888), with both initially overinflating. Postintervention, the study group inflated the cuffs to significantly lower pressures than the control group, closer to the ideal of 25 cm H2 O (26 cm H2 O vs. 35 cm H2 O, P = 0.0001). This difference was also observed 2 weeks (28 cm H2 O vs. 37 cm H2 O P <0.0001) and 3 months (28 cm H2 O vs. 36 cm H2 O, P = 0.0002) postintervention. CONCLUSIONS: The novel teaching tool evaluated in this study is simple, easily reproducible, and low-cost. Its use leads to long-lasting improvement in health care providers' ability to more accurately inflate tracheostomy tube cuffs to safe pressures.

Incentive spirometry for the tracheostomy patient.

OBJECTIVE: To determine the feasibility of developing and using a customized incentive spirometer device for patients who have undergone a tracheostomy procedure. STUDY DESIGN: The authors performed a prospective case series approved by the institutional review board. SETTING: Academic medical center. SUBJECTS AND METHODS: Patients were eligible for participation if they were older than 18 years and had a new tracheostomy. Spirometry exercises were performed using a protocol adapted from the American Academy of Respiratory Care guidelines. Patient data were recorded, including age, sex, tobacco use, surgical procedure, time under general anesthesia, length of hospital stay, and time until ambulation. The details of the spirometry exercises were also recorded along with any complications that occurred. RESULTS: An incentive spirometer was adapted for use with tracheostomy patients and received an investigational device exemption from the Food and Drug Administration. A total of 10 patients were enrolled (mean age 60 years). Sixty percent were current or former tobacco users, the mean anesthesia time was 9 hours, and 70% underwent a microvascular free flap reconstruction. Patients used the incentive spirometer for a mean of 1.6 days during the postoperative period, averaging 3.3 sessions per day and 6.8 breaths per session. The device was well tolerated by patients, and there were no complications associated with its use. CONCLUSION: This study supports the feasibility of using a customized incentive spirometer for tracheostomy patients and establishes a safety profile for the device to be used in future studies.

Bilateral central serous chorioretinopathy caused by intranasal corticosteroids: a case report and review of the literature.

The relationship between systemic corticosteroids and central serous chorioretinopathy (CSCR) has been well established; however, there also appears to be an association with intranasal corticosteroids. A search of the English literature revealed only three reported cases of CSCR linked to intranasal corticosteroid use, and in each, clinical improvement was observed after cessation of the steroid agent. We present an additional case of bilateral CSCR resulting from intranasal corticosteroid use and review the literature regarding this uncommon side effect. Otolaryngologists, as frequent prescribers of these medications, should be aware of their myriad side effects, including ophthalmologic conditions such as CSCR.

Prefabricated composite free flaps for tracheal reconstruction: a new technique.

OBJECTIVES: Successful laryngotracheal reconstruction requires both structurally supported tissue that withstands airway pressure changes and well-vascularized epithelial lining to prevent granulation and stricture formation. For circumferential defects, end-to-end anastomosis achieves favorable results, but for long-segment or large noncircumferential defects, no proven methods have emerged. Several animal studies describe prefabricated soft tissue flaps wrapped around synthetic materials or cartilage. However, prefabricated flaps have had very little use in human airway reconstruction. We present a patient with laryngeal stenosis and tracheostomy dependence following chemoradiotherapy for hypopharyngeal carcinoma. METHODS: In an attempt to widen the patient's laryngeal airway, a thyrotracheal autograft procedure, previously described by our institution, was performed. We transferred a segment of hemitrachea cephalad using the thyroid gland as a "vascular carrier," thus creating an 8-cm-long trough inferiorly that involved a 40% defect of the anterior tracheal circumference. Severe radiation damage to the cervical skin precluded use of traditional tracheoplasty methods. We used a technique whereby costal cartilage strips were implanted into a radial forearm free flap, designed to replicate the anterior tracheal wall. RESULTS: Four weeks later, we harvested the prefabricated composite flap and placed it into the defect, using forearm skin as tracheal lining. The cervical skin defect was closed with an island deltopectoral flap. A soft stent was kept in the neotrachea for 3 weeks, and a tracheostomy tube was left beneath it. The tracheostomy was subsequently closed with local advancement flaps, and the patient currently maintains an excellent airway. CONCLUSIONS: Prefabricated composite free flaps are an attractive option for certain challenging cases of airway reconstruction.