Incidence of audiologic or otolaryngologic evaluation in patients with external ear anomalies.

PURPOSE: The relationship between specific external ear anomalies (EEA) and hearing loss has been previously described. However, there is no literature regarding the appropriate evaluation of patients with EEA by audiology or otolaryngology. The objective of this study was to determine the incidence of audiologic or otolaryngologic evaluation of patients with EEA. MATERIALS AND METHODS: A retrospective review of charts was conducted following approval from the institutional review board at Boston Medical Center. Charts of patients younger than 18 years old with EEA, identified using International Classification of Diseases (ICD)-9 codes 380-380.99, 744, and 744.4 and ICD-10 codes H61.90-92, Q16.0-16.9, Q17.0-17.9, Q18.0-18.2, from January 2012 to January 2019 were reviewed. Primary variables included incidence of audiologic and otolaryngologic evaluation, newborn hearing screen and audiometry results, and completion of surgical intervention. Binary logistic regressions were conducted for each group for diagnostic, procedural, and demographic characteristics. RESULTS: A total of 723 patients were diagnosed with EEA from January 2012 to January 2019. Of these patients, 327 (45.2 %) were evaluated by audiology and 327 (45.2 %) were evaluated by otolaryngology. Of the 364 patients who obtained audiograms, 63 (17.3 %) demonstrated hearing loss. Surgical procedures were performed on 119 (16.5 %) patients, with the most common procedure being excision of the EEA (n = 79, 66.4 %). A total of 468 patients had a documented newborn hearing screen. Failure of newborn hearing screen and presence of microtia were associated with increased otolaryngologic and audiologic evaluation. CONCLUSIONS: A majority of patients with EEAs do not obtain audiologic or otolaryngologic evaluation.

Current Practices and Trends in Midface Rejuvenation.

BACKGROUND: Cosmetic approaches to midface aging are complex and vary in their treatment methodology. The nature of cosmetic surgery limits clinical trial data, forcing surgeons to rely on small studies and professional preferences when choosing an approach. Our study aimed to quantitatively assess national trends in midface rejuvenation practices. METHODS: We conducted a cross-sectional study consisting of a survey administered through the American Academy of Facial Plastic and Reconstructive Surgery and the American Society of Plastic Surgeons listservs. To evaluate trends, techniques were grouped into 2 categories: minimally invasive (injectable fillers, fat transfer, fat repositioning) or invasive (deep plane facelift, subperiosteal lift, malar/cheek alloplastic implant, bone grafting/bone advancement). RESULTS: Two hundred thirty-two survey responses were received. Of the total respondents, 46.52% were certified by the American Board of Facial Plastic and Reconstructive Surgery, and 48.26% were certified by the American Board of Plastic Surgery. Minimally invasive techniques were far more preferred (66.67%) over invasive (33.33%) techniques, with injectable fillers as the most common technique (34.88%), followed by fat transfer (20.93%). Deep plane facelift was preferred over subperiosteal lift (18.60% vs 7.91%, respectively). Surgeons board certified by the American Board of Facial Plastic and Reconstructive Surgery were more inclined to perform invasive techniques over those board certified by the American Board of Plastic Surgery (P = 0.0427). CONCLUSION: This study quantitatively assessed national trends in cosmetic approaches to midface aging. Our data suggest that trends among surgeons across the United States have shifted toward favoring minimally invasive techniques over more invasive approaches.

Age criteria for polysomnography and inpatient management for adenotonsillectomy.

OBJECTIVE: Clinical practice guidelines (CPG) by the American Academy of Otolaryngology recommend that children <2yo with sleep disordered breathing (SDB) undergo preoperative polysomnography (PSG) and children <3yo be admitted following adenotonsillectomy (TA) for inpatient management. As the rationale for preoperative PSG and postoperative admission in the CPG are the same, there is an inconsistency in the age recommendations between <2yo and two to three-years-old (2-3yo). This study compared the characteristics of <2yo versus 2-3yo patients undergoing workup and treatment for SDB, with the goal of determining whether 2-3yo should be classified with <2yo. STUDY DESIGN: Case series with retrospective review. SETTING: Boston Medical Center, a tertiary academic hospital. METHODS: Patients ≤3yo who underwent PSG 2015 to 2019 were identified using a filter through the electronic medical record. 448 patients underwent PSG. Bivariate analysis via Pearson chi-square test and multivariate analysis via multinomial logistic regression were performed using SPSS. RESULTS: Of the 427 patients included in this study, 217 patients were in the age group of <2yo while 210 patients were in the age group of 2-3yo. Severity of OSA (p = 0.069) and surgical outcomes (defined by presence or resolution of OSA on follow-up PSG) (p = 0.260) were similar between the two groups. Children <2yo were more likely to have smaller tonsils (p < 0.024) than 2-3yo. CONCLUSION: Characteristics, such as severity of OSA, were similar between the age groups. Further studies should be conducted to determine if consideration should be taken for routine preoperative PSG children <3yo. LEVEL OF EVIDENCE: IV.

Pediatric septorhinoplasty: Current attitudes and practices by facial plastic and reconstructive surgeons.

OBJECTIVE: There is hesitation to offer pediatric patients rhinoplasty due to concerns about postoperative effect on midface growth. A cross-sectional survey of members of the American Academy of Facial Plastic and Reconstructive Surgery was conducted regarding practice information and attitudes towards pediatric septorhinoplasty. The goal of the study is to describe the current attitudes on pediatric septorhinoplasty. STUDY DESIGN: Cross-sectional survey. SETTING: Community members of the American Academy of Facial Plastic and Reconstructive Surgery society. METHODS: A 19-question survey was distributed to surgeons surveying background information and current attitudes towards pediatric septorhinoplasty practices. Fisher's exact tests were implemented using Monte Carlo methods. RESULTS: There were 94 total respondents. A majority believed septorhinoplasty is safe in patients <16 years of age (n = 68, 72.34 %) with most choosing either 16 years (n = 30, 31.91 %) or 14 years (n = 29, 30.85 %) as the minimum age to consider the procedure. A majority of respondents would not perform any nasal procedures in patients ≤12 years (n = 40, 43.48 %). CONCLUSION: Trends in pediatric rhinoplasty practices have evolved overtime. Despite prior beliefs and studies cautioning against performing septorhinoplasty in pediatric patients (<16 years of age), a majority of practicing facial plastic surgeons believe that pediatric septorhinoplasty can be performed in patients >14 years old. LEVEL OF EVIDENCE: IV.

Approach to the Transgender Patient: Preoperative Counseling, Setting Expectations, Avoiding Potential Postoperative Pitfalls.

An increasing number of transgender patients are seeking gender-affirming facial surgery, also known as facial feminization surgery. Physicians offering these services must be well versed in how to compassionately care for this patient population. We recommend having a well-informed staff that is knowledgeable about proper verbiage, use of pronouns, and preferred names for transgender patients. We also recommend helping patients to manage expectations and seek realistic goals from the first consultation. A frank discussion about the limits of facial feminization is essential. Discussing the prolonged recovery and expected outcome is of paramount importance preoperatively to avoid postoperative disappointment.

Geographic Barriers Affect Follow-Up Care in Head and Neck Cancer.

OBJECTIVES/HYPOTHESIS: Follow-up care in head and neck cancers (HNC) is critical in managing patient health. However, social determinants of health (SDOH) can create difficulties in maintaining follow-up care. The study goal is to explore how SDOH impacts maintenance of HNC follow-up care appointments. METHODS: A systematic retrospective chart review of 877 HNC patients diagnosed in the past 10 years a safety-net tertiary care hospital with systems to help reduce care disparities. Cohort groups were identified and compared against protocols for follow-up. Data were analyzed using analysis of variance, chi-square tests, Fisher's exact tests, two-sample t-tests, and simple linear regression. RESULTS: The average length of follow-up time in months and average total number of follow-ups over 5 years were 32.96 (34.60) and 9.24 (7.87), respectively. There was no significant difference in follow-up care between United States (US) versus non-US born and English versus non-English speaking patients. Race/ethnicity, county median household income, insurance status, and county educational attainment were not associated with differences in follow-up. However, living a greater distance from the hospital was associated with lower follow-up length and less frequency in follow-up (P < .0001). CONCLUSION: While income, primary language, country of birth, race/ethnicity, insurance status, and markers of educational attainment do not appear to impact HNC follow-up at our safety-net, tertiary care institution, and distance from hospital remains an important contributor to disparities in care. This study shows that many barriers to care can be addressed in a model that addresses SDOH, but there are barriers that still require additional systems and resources. Laryngoscope, 132:1022-1028, 2022.

Social determinants of health and treatment decisions in head and neck cancer.

BACKGROUND: This study compares select social determinants of health (SDOH) with treatment modality selection and treatment completion in head and neck cancer (HNC) patients, to better understand disparities in health outcomes. METHODS: A retrospective cohort study of HNC (n = 1428) patients was conducted. Demographic and disease-specific variables were recorded, including treatment modality selection and completion. Data were analyzed using two-sample t tests, chi-square, and Fisher's exact tests. RESULTS: Primary language was significantly associated with treatment choice, where non-English speakers were less likely to choose treatment as recommended by the Tumor Board. Lower mean distance from the hospital (37.38 [48.31] vs. 16.92 [19.10], p < 0.0001) and a county-based higher mean percentage of bachelor degree or higher education (42.16 [8.82] vs. 44.95 [6.19], p < 0.0003) were associated with treatment selection. CONCLUSION: Language, distance from the hospital, and education affected treatment selection in this study and may be useful in understanding how to counsel patients on treatment selection for HNC.

Frontal Bone Cranioplasty for Facial Feminization: Long-Term Follow-Up of Postoperative Sinonasal Symptoms.

Background: Forehead feminization cranioplasty (FFC) risks entering the frontal sinus to achieve the desired contour. To date, no study has investigated long-term FFC complications. Objective: Determine if long-term sinus and headache symptoms worsen secondary to frontal sinus mucosal violation, measured by patient-reported outcomes. Methods: Single database retrospective chart review of patients who underwent forehead contouring between August 2012 and August 2019 was conducted. Two cohorts-frontal sinus mucosal violation versus mucosal preservation-were surveyed postprocedurely for postprocedure SNOT (Sinonasal Outcome Test)-22 scores and pre- and postprocedure sinus and headache symptoms. Results: Frontal sinus violation, mean time between surgery and response was 4.16 ± 1.88 years (range: 1-8). Without violation, mean time between surgery and response was 2.5 ± 1.10 years (range: 1-5). Postoperative SNOT-22 severity scores were not different (12.55 vs. 8.6, p = 0.20). Postoperative SNOT-22 scores were equivalent to a control nonrhinosinusitis population. No difference was found between violation of the frontal sinus with worse postoperative sinus (22 vs. 5, p = 0.60) or headache symptoms. Conclusion: Our data did not detect a difference in sinus or headache outcomes in patients who experienced violation of the anterior frontal table compared with a similar population with preservation of the frontal sinus, over an 8-year follow-up.

Effects of COVID-19 on telemedicine practice patterns in outpatient otolaryngology.

OBJECTIVE: Otolaryngology is considered high risk for Coronavirus Disease 2019 (COVID-19) exposure and spread. This has led to a transition to telemedicine and directly impacts patient volume, evaluation and management practices. The objective of this study is to determine the impact of COVID-19 on patient characteristics in relation to outpatient attendance, ancillary testing, medical therapy, and surgical decision making. METHODS: A retrospective case series at an academic medical center was performed. Outpatient appointments from October 2019 (pre-COVID) and March 16-April 10, 2020 (COVID) were analyzed. Prevalence rates and odds ratios were used to compare demographics, visit characteristics, ancillary tests, medication prescribing, and surgical decisions between telemedicine and in-person visits, before and during COVID. RESULTS: There was a decrease in scheduled visits during the COVID timeframe, for both in-person and telemedicine visits, with a comparable proportion of no-shows. There was a higher overall percentage of Hispanic/Latino patients who received care during the COVID timeframe (OR = 1.43; 95% CI = 1.07-1.90) in both groups, although primary language was not significantly associated with attendance. There were fewer ancillary tests ordered (OR = 0.54) and more medications prescribed (OR = 1.59) during COVID telemedicine visits compared with pre-COVID in-person visits. CONCLUSION: COVID-19 has rapidly changed the use of telemedicine. Telemedicine can be used as a tool to reach patients with severe disease burden. Continued healthcare reform, expanded access to affordable care, and efficient use of resources is essential both during the current COVID-19 pandemic and beyond. LEVEL OF EVIDENCE: IV.

Does Prematurity Play a Role in Newborn Microtia-Anotia?

OBJECTIVE: Microtia-anotia (MA) describes a range of external ear anomalies which is commonly associated with various syndromes and malformations of the head and neck. Previous studies have suggested a strong association between MA and male sex, maternal diabetes, and Hispanic race/ethnicity. This study seeks to evaluate the associations between MA and preterm newborns in the United States. METHODS: Population-based inpatient registry analysis was conducted. Kids' Inpatient Database (2016) was used to identify weighted in-hospital births with diagnosis of prematurity or MA. Demographic information was obtained, and odds ratios (ORs) were used to determine associations between prematurity and MA. RESULTS: Among patients included in our dataset, 8.655% (326 285) were preterm and 0.016% (523) had MA. 0.003% (109) of patients were preterm and had MA. Preterm infants had 2.19 times the odds (95% C.I. = 1.78-2.69) of having MA when compared to the full-term population. The binary logistic regression model accounting for possible confounding variables produced an aOR of 1.48 (95% C.I. = 1.17-1.87) for the association between prematurity and MA. CONCLUSION: Infants who are born preterm are more likely to have MA than full term infants. The current results will allow for improved risk stratification, maternal counseling, and interventions in the case of prematurity.

Cleft Palate in Newborns Diagnosed With Prematurity.

OBJECTIVE: Cleft lip and/or palate (CLP) is the most common major congenital malformation of the head and neck. Although numerous genetic features, syndromes, nutritional deficiencies, and maternal exposures have been implicated in the etiology of CLP, the impact of prematurity on the pathogenesis remains incompletely understood. This study seeks to evaluate the associations between prematurity and the development of CLP in the United States. STUDY DESIGN: Cross-sectional. SETTING: Academic medical center. METHODS: The Kids' Inpatient Database (2016) was used to identify weighted in-hospital births with diagnoses of prematurity or CLP. Demographic information was obtained. Odds ratios were used to determine associations between prematurity and CLP. RESULTS: Among patients included in our data set, 8.653% (n = 326,147) were preterm; 0.136% (n = 5115) had CLP; and 0.021% (n = 808) were preterm and had CLP. Preterm infants had 1.90 times the odds (95% CI, 1.74-2.07) of developing CLP when compared with the nonpreterm population. The binary logistic regression model accounting for possible confounding variables produced an odds ratio of 1.83 (95% CI, 1.66-2.01) for the association between prematurity and CLP. CONCLUSION: Infants who are born preterm are more likely to have CLP than full-term infants. The current results will allow for improved risk stratification, maternal counseling, and interventions in the case of prematurity. LEVEL OF EVIDENCE: 4.

An unexpected cyst of the ear lobule.

Branchial cleft anomalies (BCA) are among the most common congenital anomalies found in the pediatric head and neck. The embryology of these congenital anomalies is well understood, which allows clinicians to anticipate their diagnosis when a pediatric patient presents with a head or neck mass. The predictable anatomy of the various types of BCA allows for improved surgical planning to prevent recurrence and ensure complete resection. This report details an unusual location of a first BCA located in the ear lobule of a 10-month old male. There has been no documented first BCA at the ear lobule in the literature.

Barriers to timely tympanostomy tube placement in trisomy 21.

OBJECTIVES: Trisomy 21 is the most common chromosomal abnormality in the United States with an incidence of 1 in 700 in live-born children. Children with trisomy 21 are at increased risk for chronic ear disease, as well as other medical issues that may complicate healthcare access. In this study, we investigate whether children with trisomy 21 experience delays in tympanostomy tube insertion, and if there are any factors that contribute to a delay in care. METHODS: We performed a retrospective analysis on patients with trisomy 21 undergoing tympanostomy tube insertion at Boston Medical Center between 2005 and 2019 by analyzing the electronic medical record. This cohort was matched to patients without trisomy 21 by age, gender, surgery date and surgeon. The primary outcome was time elapsed between surgery decision date and date of tympanostomy tube insertion. RESULTS: A total of 20 patients with trisomy 21 underwent tympanostomy tube insertion at Boston Medical Center between 2005 and 2019. The trisomy 21 cohort was matched to 39 patients in the general population. The average time elapsed from decision to undergo surgery to tympanostomy tube insertion was 43.1 days in the general population and 119.0 days in the trisomy 21 cohort (p < .01). CONCLUSION: Patients with trisomy 21 experience greater delays in tympanostomy tube insertion than the general population, which may be due to the increased burden of comorbid conditions in people with trisomy 21.

Robot-assisted epiglottopexy as a method for managing adult obstructive sleep apnea.

INTRODUCTION: Patients who do not tolerate continuous positive airway pressure (CPAP) for treatment of obstructive sleep apnea (OSA) often seek surgical management. A variety of procedures exist to address the nasal passages, oropharynx, hypopharynx, and larynx. Diagnostic studies including drug-induced sleep endoscopy (DISE) are helpful in identifying areas of obstruction. One potential site of obstruction is at the level of the epiglottis. We describe the use of robotic technology to assist with epiglottopexy to manage epiglottic retroflexion as a cause of two patients' OSA. This is the first reported robot-assisted epiglottopexy in the adult otolaryngology literature. METHODS: This is a case series of two patients with OSA who demonstrated epiglottis collapse into the airway during DISE. They were evaluated by polysomnographic testing (PSG), Epworth Sleepiness Scale (ESS), and physical exam. Given their epiglottic collapse seen on DISE, they underwent robot-assisted epiglottopexy. RESULTS: Both patients had moderate to severe OSA preoperatively. They successfully underwent robot-assisted epiglottopexy as a surgical intervention. They tolerated the procedure, and there have been no complications. Each reported improved symptoms, with patient one showing a decrease in total AHI and a substantial decrease in oxygen desaturations at night. The second patient reported a significant decrease in AHI and ESS. CONCLUSION: There are many options for surgical intervention in patients with OSA. Epiglottopexy is one method for addressing collapse of the epiglottis and can be achieved successfully through robot-assisted epiglottopexy in adult patients with OSA. LEVEL OF EVIDENCE: IV.

Factors associated with retained tympanostomy tubes a case-controlled study.

OBJECTIVE: To determine factors associated with retained tympanostomy tubes in order to improve parent counseling on procedure risks and outcomes. METHODS: This is a case-control study; we conducted a retrospective chart review from 2012 to 2019 of cases of retained tympanostomy tubes compared to controls with confirmed tympanostomy tube extrusion. The study was conducted at a single tertiary care center, Boston Medical Center. A retained tympanostomy tube was defined as in place for more than two years requiring removal in the operating room. Cases were matched to two controls and assessed for the following factors: indication for tympanostomy tube insertion, frequency of otitis media and otorrhea after tympanostomy tube insertion, duration tympanostomy tubes were in place, numbered set of tympanostomy tubes, sinopulmonary conditions, and adenoidectomy status prior to tympanostomy tube removal or extrusion. RESULTS: 46 cases were identified and matched to 92 controls. Cases had a significantly longer tympanostomy tube duration (3.273, IQR 1.099 vs 1.611, IQR 0.894 years, p < 0.001). The indication for tympanostomy tube placement for cases compared to controls was significantly more likely to be recurrent otitis media only (odds ratio 2.36, CI 1.121 to 5.003). A multiple logistic regression model was performed with the indication for tympanostomy tube placement (chronic or recurrent otitis media) and a history of more than two sets of tympanostomy tubes. The model had a low sensitivity, 9.09%, and high specificity, 98.91%. CONCLUSION: Patients whose only indication for surgery is recurrent otitis media are possibly at higher risk for retained tympanostomy tubes that require removal in the operating room.