The Safety of Pediatric Bedside Tracheostomy.

OBJECTIVE: Traditionally, pediatric tracheostomy has been viewed as a technically demanding procedure with a high complication rate, requiring the routine use of a formal operating room. Pediatric bedside tracheostomy in an intensive care unit (ICU) setting has not been widely reported, in contrast to the widespread adult bedside ICU tracheostomy. Transport of these critically ill, multiple life support systems dependent patients can be technically difficult, labor intensive, and potentially risky for these patients. Our study aimed to demonstrate the safety and efficacy of bedside tracheostomy in the pediatric ICU. MATERIALS AND METHODS: A retrospective analysis of all pediatric patients undergoing tracheostomy at a tertiary care center, between 1st of January 2013 and 31st of December 2019. RESULTS: During the study period, 117 pediatric patients underwent tracheostomy, 57 (48.7%) were performed bedside while 60 (51.3%) were performed in the operating room. Patients' ages ranged from 2 weeks to 17 years of age, with a median age of 16 months. No case of bedside tracheostomy necessitated a shift to the operating room. There was no difference in 30-day morbidity and mortality between the 2 groups. CONCLUSIONS: Our results suggest that pediatric open bedside tracheostomy in an ICU setting is a safe procedure, with similar complications and outcomes compared to tracheostomy performed in the operating room.

ChatGPT's adherence to otolaryngology clinical practice guidelines.

OBJECTIVES: Large language models, including ChatGPT, has the potential to transform the way we approach medical knowledge, yet accuracy in clinical topics is critical. Here we assessed ChatGPT's performance in adhering to the American Academy of Otolaryngology-Head and Neck Surgery guidelines. METHODS: We presented ChatGPT with 24 clinical otolaryngology questions based on the guidelines of the American Academy of Otolaryngology. This was done three times (N = 72) to test the model's consistency. Two otolaryngologists evaluated the responses for accuracy and relevance to the guidelines. Cohen's Kappa was used to measure evaluator agreement, and Cronbach's alpha assessed the consistency of ChatGPT's responses. RESULTS: The study revealed mixed results; 59.7% (43/72) of ChatGPT's responses were highly accurate, while only 2.8% (2/72) directly contradicted the guidelines. The model showed 100% accuracy in Head and Neck, but lower accuracy in Rhinology and Otology/Neurotology (66%), Laryngology (50%), and Pediatrics (8%). The model's responses were consistent in 17/24 (70.8%), with a Cronbach's alpha value of 0.87, indicating a reasonable consistency across tests. CONCLUSIONS: Using a guideline-based set of structured questions, ChatGPT demonstrates consistency but variable accuracy in otolaryngology. Its lower performance in some areas, especially Pediatrics, suggests that further rigorous evaluation is needed before considering real-world clinical use.

Deep learning in voice analysis for diagnosing vocal cord pathologies: a systematic review.

OBJECTIVES: With smartphones and wearable devices becoming ubiquitous, they offer an opportunity for large-scale voice sampling. This systematic review explores the application of deep learning models for the automated analysis of voice samples to detect vocal cord pathologies. METHODS: We conducted a systematic literature review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines. We searched MEDLINE and Embase databases for original publications on deep learning applications for diagnosing vocal cord pathologies between 2002 and 2022. Risk of bias was assessed using Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2). RESULTS: Out of the 14 studies that met the inclusion criteria, data from a total of 3037 patients were analyzed. All studies were retrospective. Deep learning applications targeted Reinke's edema, nodules, polyps, cysts, unilateral cord paralysis, and vocal fold cancer detection. Most pathologies had detection accuracy above 90%. Thirteen studies (93%) exhibited a high risk of bias and concerns about applicability. CONCLUSIONS: Technology holds promise for enhancing the screening and diagnosis of vocal cord pathologies. While current research is limited, the presented studies offer proof of concept for developing larger-scale solutions.

Paradigm Change for Intraoperative Surgical Margin Assessment for Oral Squamous Cell Carcinoma.

OBJECTIVE: Achieving clear surgical margins is one of the primary surgical goals in treating oral squamous cell carcinoma (OSCC) and thus aiming to improve overall and disease-specific survival. Therefore, we developed the Goal-Oriented Assessment for Intraoperative Margin ('GAIM') protocol, a novel intraoperative approach for margin assessment, and present here our 5-year experience and outcomes. METHODS: 'GAIM' is a 7-step procedure comprising systematic ruler-aided resection of labeled tumor-bed margins, frozen section (FS) co-produced by both pathologists and operating surgeons, and immediate extension of resection according to FS findings. Data from all patients operated using the 'GAIM' protocol at a single tertiary center between 2018 to 2022 were analyzed, including margin status on FS and final pathology (FP) records, recurrence, and mortality. RESULTS: A total of 196 patients were included, 56.6% (n = 111) stages I-II, and 43.4% (n = 85) stages III-IV. Using the 'GAIM' protocol, we achieved an overall 94.4% of clean and revised clean surgical margins. Patients with a 2-year and longer follow-up (n = 141) had local recurrence in 3.5% when both FS and final margins were clean, 8.1% when FP margins were clean, and 16.7% with close/positive final margins. CONCLUSIONS: The proposed 'GAIM' protocol is a novel, effective, reproducible, and safe approach for margin evaluation that can be systematically applied. It can increase the rate of final clean surgical margins and potentially improve patients' outcomes. LEVEL OF EVIDENCE: 3 Laryngoscope, 134:1725-1732, 2024.

A Five-Decade Text Mining Analysis of Cochlear Implant Research: Where We Started and Where We Are Heading.

Background and Objectives: Since its invention in the 1970s, the cochlear implant (CI) has been substantially developed. We aimed to assess the trends in the published literature to characterize CI. Materials and Methods: We queried PubMed for all CI-related entries published during 1970-2022. The following data were extracted: year of publication, publishing journal, title, keywords, and abstract text. Search terms belonged to the patient's age group, etiology for hearing loss, indications for CI, and surgical methodological advancement. Annual trends of publications were plotted. The slopes of publication trends were calculated by fitting regression lines to the yearly number of publications. Results: Overall, 19,428 CIs articles were identified. Pediatric-related CI was the most dominant sub-population among the age groups, with the highest rate and slope during the years (slope 5.2 ± 0.3, p < 0.001), while elderly-related CIs had significantly fewer publications. Entries concerning hearing preservation showed the sharpest rise among the methods, from no entries in 1980 to 46 entries in 2021 (slope 1.7 ± 0.2, p < 0.001). Entries concerning robotic surgery emerged in 2000, with a sharp increase in recent years (slope 0.5 ± 0.1, p < 0.001). Drug-eluting electrodes and CI under local-anesthesia have been reported only in the past five years, with a gradual rise. Conclusions: Publications regarding CI among pediatrics outnumbered all other indications, supporting the rising, pivotal role of CI in the rehabilitation of children with sensorineural hearing loss. Hearing-preservation publications have recently rapidly risen, identified as the primary trend of the current era, followed by a sharp rise of robotic surgery that is evolving and could define the next revolution.

Is There a Role for Molecular Testing for Low-Risk Differentiated Thyroid Cancer? A Cost-Effectiveness Analysis.

Molecular testing for thyroid nodules has been rapidly developed in recent years, aiming to predict the presence of malignancy and aggressive features. While commonly utilized to predict malignancy, its role in guiding the management approach is still developing. The high cost of genetic tests and long-term sequences of thyroid cancer is limiting to real-life studies. Objective: To evaluate the cost effectiveness of molecular testing for low-risk differentiated thyroid cancer (lrDTC). Methods: We developed a Markovian decision tree model of a simulated lrDTC cohort, comparing two management strategies: (I) Conducting genetic tests (GT)-patients are stratified into three risk groups for distant metastasis by the identified molecular markers: low-, intermediate- and high-risk molecular profile; followed by management accordingly: patients with low-risk will undergo hemithyroidectomy (HT), patients with intermediate-risk will undergo total thyroidectomy (TT), and high-risk patients will undergo TT with central neck dissection; (II) Without genetic tests (wGT)-all patients will undergo HT according to the ATA recommendations for lrDTC. Outcomes were measured as quality-adjusted life years (QALYs) and costs of each strategy. Results: GT was found as cost effective, leading to a gain of 1.7 QALYs with an additional cost of $327 per patient compared to wGT strategy. This yielded an incremental cost-effectiveness ratio of $190 per QALY. Sensitivity analysis demonstrated robust results across the variables' ranges. The most impactful variable was the benefit from performing TT rather than HT for intermediate to high-risk patients. Conclusions: Our model found that molecular testing for lrDTC is cost-effective, allowing tailored management according to the patient's personal risk level reflected in the genetic profile, hence improving outcomes.

Airway management following head and neck microvascular reconstruction: is tracheostomy mandatory?

Abstract Objectives: Airway management following maxillofacial microvascular reconstruction is a fundamental part of the perioperative management. In oral cavity microvascular reconstruction, the airway is potentially compromised by airway edema, flap edema or bulkiness, hematoma formation, or upper airway sequelae from surgery. Classical teaching advocates elective tracheostomy in patients undergoing maxillofacial free flap reconstruction, while others keep patients intubated overnight (delayed extubation). The optimal method for perioperative airway management is still debated. This study aim was to evaluate the morbidity associated with elective tracheostomy in patients undergoing maxillofacial microvascular reconstruction and to recognize those patients who can avoid elective tracheostomy. Methods: Retrospective review of patients who underwent maxillofacial microvascular free flap reconstruction, between November 1st 2010 and October 31st 2019 in our center. Results: One-hundred and nine patients underwent microvascular reconstruction in the maxillofacial region. Sixty-one patients underwent an elective tracheostomy upon the primary surgery. Forty-eight patients were left intubated overnight. Seven patients underwent a late tracheostomy which was performed upon a neck re-exploration for postoperative complications, except for one patient which was due to failed extubation attempt. Conclusions: Our results suggest, the routine use of elective tracheostomy in maxillofacial microvascular free flap reconstruction is unnecessary. Elective tracheostomy should be considered on case-to-case basis. Level of evidence: 4. HIGHLIGHTS Airway management following maxillofacial microvascular reconstruction is complex. Lack of consensus exists regarding the optimal airway management perioperatively. Routine use of tracheostomy is unnecessary. Tracheostomy should be considered on a case-to-case basis.

Is molecular testing in patients with low risk papillary thyroid carcinoma justified? A Markovian model.

BACKGROUND: Current guidelines consider all cases of papillary thyroid carcinoma (PTC) smaller than 4 cm and without extrathyroidal extension (ETE) and/or lymph node metastases as belonging to the same prognostic group, and therefore the recommendation is for uniform treatment. Xing draws our attention to a small subgroup with Duet Mutations (BRAF E600 and TERT 3636 genes) that are aggressive biologically and should be treated differently. Thus the aim of the present study is to test the validity of this recommendation. METHODS: A Markovian Model is used to evaluate the above hypothesis. RESULTS: A Monte Carlo sensitivity test shows a 5.6 year survival advantage for patients with low-grade PTC, who have the Duet Mutations, and were treated by total thyroidectomy rather than hemithyroidectomy. CONCLUSIONS: We conclude that there is a place for routine molecular tests in low-risk patients with PTC.

Applicability of Transnasal Echography for Identification of Internal Carotid Artery.

OBJECTIVE: To study the applicability of transnasal echography for the internal carotid artery (ICA) imaging during endoscopic procedures, primarily nasopharyngectomy. STUDY DESIGN: Non-randomized controlled cohort. METHODS: The tip of a pediatric transducer for transesophageal echography was inserted into each nostril under endoscopic control and placed in the ipsilateral Rosenmuller's fossa. The ICA's internal diameter and distance between the nasopharyngeal wall and the artery's closest point were measured on each side. Two independent examiners measured the same parameters on the axial plane of the skull base computer tomography (CT). Agreement between CT and echography measurements was estimated by the Bland-Altman approach. RESULTS: Twenty-seven ICAs (sides) were available for the echography-CT agreement analysis. Inter method agreement for both parameters was similar to the inter examiner agreement for the CT measurements. CONCLUSIONS: Our first study on endoscopic echography demonstrated that this method is applicable, potentially allowing safer transnasal surgery in the ICA vicinity. LEVEL OF EVIDENCE: 3 Laryngoscope, 132:1184-1188, 2022.

Comparison of lateral neck X-ray to neck CT in patients with suspicious bone impaction: "Old habits die hard".

OBJECTIVE: Bone impaction (BI) is a common cause for emergency room visits. Among foreign bodies, fish bone is considered the most common. The sensitivity of symptoms in predicting BI is relatively low, making imaging a central tool to aid diagnosis. Current imaging practices include both neck plain film radiography and none-contrast CT scans of the neck. We evaluated the accuracy of neck plain film radiography and CT scans of the neck for the diagnosis of BI. METHODS: Retrospective review of all patients who presented to the emergency room between 2009 and 2016 with a suspicious history of BI whom underwent plain film neck radiography or CT. All Images were reviewed by two neuro-radiologist blinded to the clinical symptoms and findings. Symptoms, clinical findings and images results were compared to the final diagnosis. RESULTS: 89 patients (30.7%), out of 290 patients who presented with complaints of BI, were diagnosed with BI. Mean age was 44.7 years old. Plain film neck radiography failed to predict BI (sen. 14.4%, spe 89.8% accuracy 63.2%), neck CT has an improved accuracy and sensitivity in locating BI (sen. 83.3%, spe. 94.1% accuracy 92.5%). Interobserver agreement between the two neuro-radiologists was moderate (0.46) and substantial (0.77) in neck radiography and CT images, respectively. Neck radiography missed 60 (out of 61) oropharyngeal BI's. CONCLUSION: Neck radiography has high inter-observer variability and low sensitivity for the diagnosis of BI. Neck CT should be the first imaging modality in patients with suspicious complaints for BI and negative physical exam.

Is intraoperative margin sampling necessary in inverted papilloma resection?

PURPOSE: To explore the association between intraoperative surgical margin sampling by the frozen sections and recurrence in inverted papilloma surgery. METHODS: A multicenter, retrospective study of patients who underwent attachment-oriented IP resection in four tertiary care medical centers with a minimal follow-up of 36 months. RESULTS: The study included 220 surgeries with a mean follow-up period of 49 months (range 36-204). The endoscopic approach was used in all but 4 cases; 73% of procedures were primary. Overall recurrence was 10.45% (n = 23). Squamous cell carcinoma was found in 5 cases (2.2%). Intraoperative margin sampling was obtained in 145 cases. There was no difference in the recurrence rate between frozen section and no-frozen section groups (p = 0.44). Furthermore, margin sampling in various sites of tumor origin, in cases with concomitant nasal polyps (p = 0.53) and in revision cases (p = 0.08) showed no correlation with recurrence. In 26 cases when the surgery was extended following a positive frozen section, there was a significantly higher recurrence rate (OR = 6.94). CONCLUSIONS: According to our results, intraoperative margin sampling did not affect the recurrence rate of IP, and therefore, its routine use should be questioned.

Airway management following head and neck microvascular reconstruction: is tracheostomy mandatory?

OBJECTIVES: Airway management following maxillofacial microvascular reconstruction is a fundamental part of the perioperative management. In oral cavity microvascular reconstruction, the airway is potentially compromised by airway edema, flap edema or bulkiness, hematoma formation, or upper airway sequelae from surgery. Classical teaching advocates elective tracheostomy in patients undergoing maxillofacial free flap reconstruction, while others keep patients intubated overnight (delayed extubation). The optimal method for perioperative airway management is still debated. This study aim was to evaluate the morbidity associated with elective tracheostomy in patients undergoing maxillofacial microvascular reconstruction and to recognize those patients who can avoid elective tracheostomy. METHODS: Retrospective review of patients who underwent maxillofacial microvascular free flap reconstruction, between November 1st 2010 and October 31st 2019 in our center. RESULTS: One-hundred and nine patients underwent microvascular reconstruction in the maxillofacial region. Sixty-one patients underwent an elective tracheostomy upon the primary surgery. Forty-eight patients were left intubated overnight. Seven patients underwent a late tracheostomy which was performed upon a neck re-exploration for postoperative complications, except for one patient which was due to failed extubation attempt. Patients who didn't receive an elective tracheostomy were younger and had a shorter duration of postoperative hospitalization. Seven patients suffered from tracheostomy- related complications, all of them underwent elective tracheostomy and none were from the late tracheostomy group. CONCLUSIONS: Our results suggest, the routine use of elective tracheostomy in maxillofacial microvascular free flap reconstruction is unnecessary. Elective tracheostomy should be considered on case-to-case basis.

A Novel Nonsurgical Technique for Correcting Congenital Auricular Anomalies.

Congenital ear anomalies are associated with psychological morbidity. Ear deformities can usually be corrected by nonsurgical techniques such as splinting or molding in the neonatal period, initiated before 6 weeks. Without early corrections, many will require otoplasty during childhood. We introduce a novel silicone-based custom mold technique for congenital ear anomalies. The highly malleable silicone was pushed into every part of the auricle, enabling the auricle to remain in the desired shape, with new molds made weekly. Of 31 newborns (18 males, 13 females), 54 ears were treated. Average age at treatment initiation was 26.8 days. The mean treatment duration was 43.2 days, with a median of 28 days. Normal appearance and parent's satisfaction were achieved in 30 patients with 49 deformed ears and also in four newborns older than 6 weeks. Three concha type microtia in two patients achieved great improvements and parents' satisfaction. No complications were reported. Marked aesthetic improvements and normal appearance were achieved for all deformed auricles treated, and improvements in the concha type microtia will partially alleviate future surgical corrections. The results are not inferior to other techniques. The advantages are as follows: cost-effective, time-saving, simple to master, no need for hair shaving, and easy use for parents. Patients older than 6 weeks of age achieved normal auricle appearance, enabling the correction in older newborns. Custom made silicone auricle molding offers a simple nonsurgical technique for correcting congenital ear anomalies, alleviating the need for future surgical corrections.

Endoscopic Management of Benign Laryngo-Tracheal Stenosis: Balloon vs. Rigid Dilatation.

BACKGROUND: Management of acquired laryngotracheal stenosis (LTS) is challenging and often requires recurrent procedures. OBJECTIVES: To compare the efficacy and safety of balloon dilatation (BD) versus rigid dilatation (RD) in the treatment of LTS. METHODS: A retrospective study of patients undergoing endoscopic intervention for LTS was performed. RESULTS: The study included 69 balloon (BD) and 48 rigid dilations (RD). Most cases were grade 3 Cotton-Meyer stenosis. Mean time interval to recurrence after BD and RD were 27.9 and 19.6 weeks, respectively. Remission of over 8 weeks was achieved in 71% of BD compared to 31.2% of RD (P < 0.05). In the BD group, dilatation of subglottic stenosis showed higher rates of remission of over 8 weeks compared to upper and mid-tracheal stenosis (92% vs. 62% and 20%, respectively, P < 0.05). Complications were encountered in 4.2% of RD and 2.9% of BD. CONCLUSIONS: BD and RD are effective and safe procedures. Overall, BD achieved slightly better long-term results compared to RD.

Thyroid malignancy rates according to the Bethesda reporting system in Israel - A multicenter study.

INTRODUCTION: The Bethesda System for Reporting Thyroid Cytopathology was developed in 2007 to facilitate an accurate, reproducible communication of thyroid fine-needle aspiration (FNA) interpretations between clinicians and cytopathologists and to serve as a guide for treatment. Based on large patient series, the system details the risk of malignancy for each category as well as a suggested management for each FNA result. Though this system has been widely adopted, there are only few studies to determine whether results are applicable for Israel. METHODS: A multicenter, retrospective analysis of medical charts of all patients who underwent thyroid surgery between January 1st, 2012 and December 31st, 2016 in four medical centers in Israel was performed. Data was analyzed for the overall risk of malignancy for the Bethesda system groups as well as comparison between the different laboratories performing the test. RESULTS: Records of 810 thyroidectomies in which preoperative cytological reports and final pathology were available and reviewed. The malignancy rates according to the Bethesda groups' I-VI for our cohort were: 27.8%, 17.6%, 41.4%, 41.4%, 86.9%, and 98.1% respectively. Similar results were seen when results were analyzed according to the different laboratories performing the tests. CONCLUSIONS: Post-surgical review of all Bethesda groups had higher malignancy rates than those reported in the original report. These results indicate a difference in the malignancy rates for the different Bethesda system groups in Israel compared to those reported. Physicians are encouraged to use data validated for their own country or patients' community in addition to published values.

Restricted Mouth Opening in Head and Neck Cancer: Etiology, Prevention, and Treatment.

Restricted mouth opening or trismus is often encountered in patients with head and neck cancer. The restriction may be the presenting sign of malignancy, a sequela of tumor site or growth, an adverse effect of oncologic treatment, or a first sign of tumoral recurrence. In general, any insult to the temporomandibular joint, masticatory muscles, or their neural innervation may cause limitation in mouth opening. The etiologies leading to trismus are as follows: myospasm secondary to tumor infiltration; reflectory myospasm; radiation-induced myositis and myofibrosis; temporomandibular joint involvement with tumor; unfavorable postsurgical scarring; muscle and joint atrophy secondary to immobilization; pain; jaw fracture and hardware failure; and infection. Preventive measures should be implemented before, during, and after treatment. These measures include identification of high-risk patients, utilization of dose-sculpting radiation techniques whenever possible, performing reconstruction at the same time of resective surgery whenever feasible, and initiating mobilization exercises as early as possible. When trismus develops, treatments are often challenging and disappointing. These include physical therapy, mouth opening appliances, drug therapy, and release surgery. All medical specialties dealing with head and neck cancer should be familiar with the diagnosis and prevention of trismus and make an effort to ensure patients are referred to the appropriate care when needed. Trismus should not be considered a trivial sequela of head and neck cancer.

Mucous membrane pemphigoid-otorhinolaryngological manifestations: a retrospective cohort study.

INTRODUCTION: Mucous membrane pemphigoid (MMP) refers to a heterogeneous group of rare, chronic, inflammatory, mucous membrane-dominated, sub-epithelial blistering diseases that manifest with a varying constellation of oral, ocular, cutaneous, genital, nasopharyngeal, esophageal, and laryngeal lesions. MMP can progress to scarring in affected areas, which may lead to devastating complications including ocular involvement leading to blindness as well as laryngeal involvement leading to airway obstruction. MATERIALS AND METHODS: A retrospective chart review was conducted for patients that were followed in two tertiary academic centers between 2009 through 2017 for upper aerodigestive tract manifestations of MMP. Patients with significant underlying skin involvement suggestive of bullous pemphigoid as well as MMP with isolated ocular involvement were excluded. RESULTS: Twenty-seven patients were diagnosed with MMP and followed in two tertiary referral medical centers. The most common site of initial presentation was the oral cavity, and all patients had oral cavity involvement at some point. Two-thirds of our patients had complete remission or remission with intermittent relapses disease. Patients with mild to moderate disease showed excellent response to topical steroid treatment. For more severe disease, high-dose prednisone was insufficient, as in most cases relapse occurred at some point of time during tapering down. CONCLUSIONS: MMP is a rare autoimmune disorder that may present with a wide spectrum of head and neck manifestations and, potentially, catastrophic sequelae. This work highlights the experience of two tertiary centers with MMP in an attempt to draw attention to this unusual disorder.

Epistaxis in the setting of antithrombotic therapy: A comparison between factor Xa inhibitors, warfarin, and antiplatelet agents.

OBJECTIVES/HYPOTHESIS: To describe the characteristics and severity of epistaxis in patients taking factor Xa inhibitors novel anticoagulants. STUDY DESIGN: Retrospective cohort study. METHODS: A study of adult patients hospitalized due to spontaneous epistaxis under the treatment of warfarin, rivaroxaban, or apixaban between the years 2011 and 2017 was performed. A control group of patients under antiplatelet therapy (acetylsalicylic acid, clopidogrel) was included. The mean follow-up periods in the warfarin, rivaroxaban, apixaban, and antiplatelet groups were 18, 14.5, 13.5, and 18.2 months, respectively. We compared demographics, location and severity of bleeding, treatment methods, and outcome between the groups. RESULTS: The study included 109 patients (35 under factor Xa inhibitors), the majority of whom presented with anterior epistaxis (68%). The antiplatelet group had more episodes of epistaxis prior to admission, and required endoscopic surgical control of bleeding more often, in comparison with anticoagulants (2.23 vs. 1.44, P < .05 and 23% vs. 6%, respectively, P < .05). Among anticoagulants, combined therapy (cauterization and packing) was required more frequently in the apixaban group compared to the rivaroxaban and warfarin groups (64% vs. 25% and 33%, respectively, P < .05). The rate of readmissions due to epistaxis, within 1 year of follow-up was lower in the factor Xa inhibitor groups compared with the warfarin and antiplatelet groups (16% vs. 9% and 4%, respectively, P < .05). Cessation of factor Xa inhibitor therapy was effective and uneventful with no further epistaxis events. CONCLUSIONS: Epistaxis under factor Xa inhibitors was effectively treated with no worse and perhaps even a better outcome when compared to other anticlotting medications. LEVEL OF EVIDENCE: 4 Laryngoscope, 129:119-123, 2019.