Safety of Nebulized Ciprodex for Postoperative Management of Tracheal Resection.

OBJECTIVE: Anastomotic complications after tracheal resection/cricotracheal resection (TR/CTR), such as granulation tissue formation, can lead to severe morbidity. The off-label use of nebulized ciprofloxacin-dexamethasone (Ciprodex) for granulation tissue prophylaxis has anecdotally been used after TR/CTR, especially in pediatric patients. However, its use in the adult population, and its safety and side effect profile post-TR/CTR has not been reported. This study aims to characterize the incidence of adverse side effects associated with nebulized Ciprodex in post-TR/CTR patients. METHODS: A retrospective review of all patients who underwent TR/CTR from June 2015 to July 2023 was performed. The use of nebulized Ciprodex (1 mL ciprofloxacin-dexamethasone 0.3%-0.1% otic suspension in 4 mL normal saline) while inpatient was evaluated. Potential side effects were defined as oral thrush, ageusia, arthralgia, and allergic reaction, and were recorded for all patients. RESULTS: Seventy-three patients underwent TR/CTR from June 2015 to July 2023. Of these, 53 (72.6%) had documented Ciprodex administration during their postoperative course. One (1.9%) patient reported at least one side effect, including one instance of skin rash (1.9%) and one instance of allergic reaction (1.9%). There were no other side effects attributed to Ciprodex use. CONCLUSIONS: The incidence of side effects related to the use of nebulized Ciprodex is felt to be minimal in post-TR/CTR. Although Ciprodex may have the potential to treat granulation tissue in the airway, further studies are needed to verify its efficacy and safety. LEVEL OF EVIDENCE: 4 Laryngoscope, 2024.

Timing of Complications in Open Airway Reconstruction.

OBJECTIVE: Tracheal resection (TR) and cricotracheal resection (CTR) are performed for patients with airway stenosis, tracheal tumor, and tracheoesophageal fistula. Post-operative complications include airway edema requiring reintubation, hematoma, anastomotic dehiscence, restenosis, and death. Although these complications and associated risk factors have been well described, the time where clinical suspicion should be highest post operatively has not been characterized. METHODS: Patients who underwent TR or CTR at a single center between 2015 and 2022 were reviewed. Variables including demographics and comorbidities were recorded. Rate, nature, and time in days of post-operative complications were evaluated. RESULTS: Sixty-nine cases were reviewed. Average patient age was 46.8 years old and 63.8% were male. The average follow-up period was 625 ± 724 days. 19 (27.5%) patients experienced one or more major complications including four (5.8%) who died. Eight (11.6%) patients required reintubation and 4 (5.8%) patients underwent revision tracheostomy. Most complications occurred within 8 days of surgery. Restenosis was noted an average of 42.6 days after surgery, with no new restenosis occurring after 3 months. CONCLUSIONS: In this single-center study, most post-operative complications after TR or CTR, including hematoma and anastomotic dehiscence, occurred within 8 days post-operatively. Restenosis was noted approximately 1-3 months after surgery. This may inform clinical decision-making regarding patient monitoring and surveillance after open airway surgery. LEVEL OF EVIDENCE: 4 Laryngoscope, 2024.

Training for Awake, Office-Based Laryngeal Procedures-The Laryngology Fellow's Perspective.

OBJECTIVE: The aim was to explore recent laryngology graduates' perspectives on their experience, competency, and challenges learning office-based procedures during fellowship training in the United States and Canada. METHODS: Anonymous 22-item questionnaire survey was distributed electronically to fellowship-trained laryngologists having completed fellowship within past 5 years. RESULTS: Ninety fellowship-trained laryngologists between 2018 and 2022 were surveyed. Response rate was 48.9% (n = 44), 1 declined participation, with 20 different fellowship programs represented. Fellows were frequently provided the opportunity to act as primary surgeon for most procedures, except for laryngeal botulinum toxin injection, diagnostic laryngeal electromyography, trans-nasal esophagoscopy, secondary tracheoesophageal puncture, and high-resolution pharyngeal manometry. A majority reported high (n = 27, 62.8%) or moderate (n = 12, 27.9%) confidence with vocal fold injection augmentation. Various techniques were taught: transoral (74.4%), cricothyroid (74.4%), thyrohyoid (69.8%), transcartilagenous (14.0%), and catheter-needle (25.6%). Numerous statistically significant associations with independent procedure involvement and competence were identified. Laryngeal botulinum toxin injection was a procedure performed with high frequency but low volume of independent fellow involvement, and the procedure with which fellows reported wanting more practice learning. Most common training barriers included patient being awake, patient consenting to trainee performing the procedure, and the technical challenge/complexity of the procedure. Teaching methods/tools largely focused on informal debriefing (97.3%) and case by case troubleshooting (81.1%). CONCLUSIONS: Laryngology fellows are well trained with favorable perceived levels of competence for numerous office-based procedures, particularly vocal fold injection augmentation. Procedures for which fellows reported a low level of independent participation trended towards lower perceived competency. LEVEL OF EVIDENCE: 5 Laryngoscope, 134:873-881, 2024.

Prospective >12 Months Outcomes After Vocal Fold Injection Medialization With Silk Microparticle-Hyaluronic Acid Material.

OBJECTIVE: Vocal fold injection medialization (VFIM) is widely used as an initial treatment for unilateral vocal fold paralysis (UVFP). Current practices employ materials that share the limitation of temporary clinical effect from variable resorption rates. A novel silk protein microparticle-hyaluronic acid-based material (silk-HA) has demonstrated cellular infiltration and tissue deposition that may portend a durable medialization effect. We report on ≥12 months outcomes after VFIM with silk-HA. METHODS: Prospective open-label study of patients with UVFP that elected treatment with VFIM with silk-HA. Blinded experts rated laryngeal stroboscopic exams. RESULTS: Seventeen patients with UVFP underwent VFIM with silk-HA. Twelve of the 17 patients have ≥12 months follow-up. Seven patients demonstrated durable treatment benefit ≥12 months after injection with median improvement of 19 (p = 0.0156) in VHI-10. There was no significant change in VHI-10 between 1 and 12 months for these patients. Blinded ratings indicated that 5/7 patients with sustained improvements in VHI-10 exhibited complete or touch glottal closure at 12 months. Two of the seven patients exhibited a small (<1 mm) glottal gap at 12 months. Seven patients experienced initial benefit with later regression 3-4 months after injection. CONCLUSION: VFIM with silk-HA can offer durable improvement in voice-related outcomes for UVFP past 12 months. A subset of patients treated with silk-HA experienced early loss of effect around 3-4 months postinjection. Clinical factors predictive of sustained treatment response to silk-HA injection require further exploration. LEVEL OF EVIDENCE: 3 Laryngoscope, 2023.

Role of Sex in Participation During Virtual Grand Rounds in Ophthalmology.

Importance: Sex disparities exist in academia. Female attendees consistently ask fewer questions in scientific meetings than male attendees, even when they constitute half of the audience. Objective: To assess the role of sex in participation during virtual grand rounds (GR) at a major academic center. Design, Setting, and Participants: In this prospective cohort study, attendees of the Department of Ophthalmology at the University of California, San Francisco, GR from April 2020 to April 2021 were included. All GR were held via a synchronous live video communication platform. During each GR session, a predesignated attendee collected the sex of all attendees, sex of the GR speaker, and sex of each individual who asked a question to the GR speaker in order of inquiry. The GR speakers and audience were unaware of the study. Data were analyzed from June 2021 to April 2023. Main Outcome and Measures: The main analysis assessed the association between being female and asking one of the first 3 questions. Results: A total of 31 virtual ophthalmology GR sessions were observed. The sex of the GR speaker was female in 13 of 31 sessions (42%). The mean (SD) percentage of audience sex at each of the GR sessions was 47% (0.05) female, 45% (0.06) male, and 8% (0.03) unknown. Male attendees were more likely to ask one of the first 3 questions compared with female attendees (prevalence ratio, 3.1; 95% CI, 2.1-4.5; P < .001). Conclusions and Relevance: Male attendees were more likely to ask questions during virtual ophthalmology GR compared with female attendees at an academic medical center. Strategies to encourage equal participation of sex in academic discourse should be encouraged.

Factors affecting operative autonomy and performance during otolaryngology training: A multicenter trial.

Objective: Surgical education is changing in an era of new regulations and evolving training cultures. We sought to understand the factors that affect operative experiences during otolaryngology residency. Methods: From December 2019 to December 2020, five otolaryngology training programs used the SIMPL OR smartphone application to evaluate residents after each operation. Residents and attendings rated the trainee's autonomy on a 4-level Zwisch scale, performance on a 5-level scale, and case complexity on a 3-level scale. We examined associations between ratings of autonomy and performance with variables including postgraduate year (PGY), case complexity, gender, week of the academic year (AY), and whether multiple procedures were logged. Results: 78 attendings and 92 residents logged 2984 evaluations. PGY level and week of the AY were positively associated with attending ratings of autonomy and performance (PGY3 vs. PGY2: B = 0.63, p < .001 for autonomy and B = 1.05, p < .001 for performance; week of the AY: B = 0.013, p = .002 for autonomy; B = 0.025, p < .001 for performance). Multiple procedures logged and increasing case complexity were negatively associated with attending ratings (multiple procedures: B = -0.19, p = .04 for autonomy and B = -0.48, p < .001 for performance; hardest vs. easiest 1/3 of cases: B = -1.01, p < .001 for autonomy and B = -0.59, p < .001 for performance). Attending and trainee genders were not associated with attending ratings of autonomy or performance. Conclusion: Resident autonomy and performance were positively associated with PGY level and week of the academic year, and negatively associated with case complexity and multiple procedures. These findings highlight the need to align training level with case complexity to promote quality operative experiences. Level of Evidence: 2.

Multi-institutional Study of Otolaryngology Resident Intraoperative Experiences for Key Indicator Procedures.

OBJECTIVE: There is concern that current otolaryngology residents may not receive adequate surgical training. We aimed to characterize residents' surgical experiences at 5 academic centers performing the 14 key indicator procedures (KIPs) outlined by the Accreditation Council for Graduate Medical Education. STUDY DESIGN: Prospective study. SETTING: Five otolaryngology training programs. METHODS: Data were gathered from December 2019 to December 2020 with a smartphone application from the Society for Improving Medical Professional Learning. After each operation, residents and faculty rated trainee autonomy on a 4-level Zwisch scale and performance on a 5-level modified Dreyfus scale. RESULTS: Residents and attendings (n = 92 and 78, respectively) logged 2984 evaluations. Attending ratings of resident autonomy and performance increased with training level (P < .001). Resident self-assessments of autonomy and performance were lower than paired attending assessments (P < .001). Among attending evaluations of KIPs performed by senior residents (postgraduate year 4 or 5), 55% of cases were performed with meaningful autonomy (passive help or supervision only). Similarly, attendings rated 55% of these cases as a practice-ready or exceptional performance. Senior residents had meaningful autonomy for ≥50% of cases for most KIPs, with the exception of flaps and grafts (40%), pediatric/adult airway (39%), and stapedectomy/ossiculoplasty (33%). Similarly, senior residents received practice-ready or exceptional performance ratings for ≥50% of cases across all KIPs other than pediatric/adult airway (42%) and stapedectomy/ossiculoplasty (33%). CONCLUSION: In this multicenter study, resident surgical autonomy and performance varied across otolaryngology KIPs. The development of nationwide benchmarks will help programs and residents set educational goals. LEVEL OF EVIDENCE: 2.

Utility of Microporous Polysaccharide Hemosphere on Anterolateral Thigh Free Flap Donor Site Complications.

Background: Anterolateral thigh (ALT) microvascular free tissue transfer is an integral part of head and neck reconstructive surgery, but it can be complicated by postoperative donor site fluid collections. Objective: To measure the rate of hematoma and seroma formation in the ALT donor site in those treated with microporous polysaccharide hemosphere (MPH) and those without. Methods: This was a retrospective cohort study examining patients undergoing ALT free tissue transfer for head and neck reconstruction at a single academic center between 2014 and 2017. Primary outcomes were interventional hematomas and seromas and drain duration. Results: In total, 118 patients underwent ALT free flap reconstruction for head and neck defects. Of these, 57 patients received MPH at the donor site and 61 did not. Eleven patients had a clinically significant seroma in the non-MPH group compared with three in the MPH group (p = 0.045). Drain duration for the MPH group compared with that for the non-MPH group was 6.9 versus 8.2 days (p = 0.020), and drains were removed when output was <60 mL over 24 h. Conclusion: This study supports the use of MPH in ALT free flap donor sites for reduction of clinically significant postoperative seromas. Further investigation with larger prospective randomized clinical trials is warranted.

Evolving Otolaryngology Resident Roles and Concerns at the Peak of the US COVID-19 Pandemic.

BACKGROUND: The roles of US otolaryngology residents have changed in response to the coronavirus disease 2019 (COVID-19) pandemic. As the pandemic peaked in the United States, we characterized resident activities and concerns. METHODS: A cross-sectional study of US otolaryngology residents between April 20, 2020 and May 2, 2020. RESULTS: A total of 219 residents at 65/118 (55%) institutions responded. Thirty (14%) residents had been redeployed. Residents reported greatest concerns regarding education (P < .00001). Assuming adequate protective equipment, 55% desired active participation in high-risk procedures on COVID-19-positive patients. Redeployed residents had greater concern for burnout and reduced in-hospital well-being (P < .05). Resident satisfaction correlated with comfort communicating concerns to their department (odds ratio [OR] = 4.9, 95% confidence interval [CI] 1.4-17.3, P = .01) and inversely correlated with low perceived meaning in work (OR = 3.1, CI 1.1-9.1, P = .03). CONCLUSION: Otolaryngology resident concerns have evolved as the pandemic progressed. Residency programs should prioritize resident education, well-being in redeployed residents, and open communication as they transition toward recovery.

Otolaryngology Resident Practices and Perceptions in the Initial Phase of the U.S. COVID-19 Pandemic.

OBJECTIVE: The coronavirus 2019 (COVID-19) pandemic has had widespread implications on clinical practice at U.S. hospitals. These changes are particularly relevant to otolaryngology-head and neck surgery (OHNS) residents because reports suggest an increased risk of contracting COVID-19 for otolaryngologists. The objectives of this study were to evaluate OHNS residency program practice changes and characterize resident perceptions during the initial phase of the pandemic. STUDY DESIGN: A cross-sectional survey of U.S. OHNS residents at 81 programs was conducted between March 23, 2020, and March 29, 2020. RESULTS: Eighty-two residents from 51 institutions (63% of invited programs) responded. At the time of survey, 98% of programs had enacted policy changes to minimize COVID-19 spread. These included filtered respirator use for aerosol-generating procedures even in COVID-19-negative patients (85%), decreased resident staffing of surgeries (70%), and reduced frequency of tracheotomy care (61%). The majority of residents (66%) perceived that residents were at higher risk of contracting COVID-19 compared to attendings. Residents were most concerned about protective equipment shortage (93%) and transmitting COVID-19 to patients (90%). The majority of residents (73%) were satisfied with their department's COVID-19 response. Resident satisfaction correlated with comfort level in discussing concerns with attendings (r = 0.72, P < .00001) and inversely correlated with perceptions of increased risk compared to attendings (r = -0.52, P < .00001). CONCLUSION: U.S. OHNS residency programs implemented policy changes quickly in response to the COVID-19 pandemic. Sources of resident anxieties demonstrate the importance of open communication and an integrated team approach to facilitate optimal patient and provider care during this unprecedented crisis. LEVEL OF EVIDENCE: 4. Laryngoscope, 130:2550-2557, 2020.