Rural-urban otolaryngologic observational workforce analysis: The state of Nebraska.

Objective: To analyze the rural-urban access to otolaryngology (OHNS) care within the state of Nebraska. Design: Cross-sectional study. Methods: Counties in Nebraska were categorized into rural versus urban status based upon the 2013 National Center for Health Statistics urban-rural classification scheme with I indicating most urban and VI indicating most rural. The information on otolaryngologists was gathered utilizing the Health Professions Tracking System. Otolaryngologists were categorized based on the county of their primary and outreach clinic location(s). Travel burden was estimated using census tract centroid distance to the nearest clinic location, aggregated to county using weighted population means to determine the average county distance to the nearest otolaryngologist. Results: Nebraska is a state with a population of 1.8 million people unequally distributed across 76,824 square miles, with rural counties covering 2/3 of the land area. Nebraska has 78 primary OHNS clinics and 70 outreach OHNS clinics distributed across 93 counties. More than half (54.8%) of the counties in Nebraska lacked any OHNS clinic. Overall, a statistically significant difference was found when comparing mean primary OHNS per 100,000 population and mean miles to a primary OHNS clinic with Level III counties being 5.17 linear miles from primary OHNS compared to Level V counties being 29.94 linear miles. Conclusion: Overall, a clear discrepancy between rural and urban primary OHNS clinics in Nebraska can be seen visually and statistically with rural Nebraskans having to travel at least 5.5 times farther to primary OHNS clinics when compared to urban Nebraskans.

The Multimodal Diagnostic Approach Necessary in Detecting Elusive Submucosal Laryngeal Cancer.

Submucosal laryngeal lesions have proven themselves to be a diagnostic challenge in the field of medicine, often presenting inconsistently between endoscopic visualization, various imaging modalities, and biopsy. The conflicting clinical picture can lead to a delay in definitive diagnosis and treatment. A variety of laryngeal imaging modalities exist that give a unique perspective of the tumor being evaluated and can be used in combination to clarify discrepancies in presentation.  This report describes the clinical course of an undiagnosed laryngeal squamous cell carcinoma (SCC) presenting with persistent dysphonia, dysphagia, and unilateral vocal fold immobility. A negative head and neck computerized tomography (CT) scan reduced the concern for cancer, so symptomatic treatment with vocal fold augmentation was performed. Augmentation curiously worsened the dysphonia and also may have delayed the process of definitive diagnosis. Upon presenting to the laryngology clinic, stroboscopy demonstrated no vibration of the affected vocal fold. Submucosal vascular irregularity was noted with narrow band imaging with a very subtle keratotic mucosal change raising suspicion for underlying malignancy. Despite two CT scans that failed to visualize the lesion initially, a biopsy revealed keratinizing SCC, which was subsequently staged as T3N0M0. The patient elected to receive radiation therapy alone given his medical comorbidities. This case showcases the elusive ability submucosal laryngeal cancers have in diagnostic workups. Heavy reliance on any single diagnostic modality may be misleading, resulting in delayed diagnosis and treatment. An early, thorough, and multimodal approach that analyzes the cumulative results of a variety of diagnostic tools is essential in identifying and treating these elusive cancers in a timely manner.

Quality Versus Quantity: Using Scholarly Activity to Assess Otolaryngology Residency Candidates.

Selecting qualified candidates each year for residency positions has become more difficult in recent years, due to the sharp increase in Otolaryngology applicants. Although there are objective measures that can be used to directly compare medical students during the initial screening process, most information in the application is highly subjective and/or variable across institutions. Many programs count the total posters/presentations and publications to gauge scholarship. This measure of quantity may lead to negative bias toward those who have no home program, limited time outside of academics, and/or inadequate resources to engage in volunteer research. Evaluating the quality of research may be superior to quantity. A first-author publication is a viable proxy that demonstrates applicants have developed skills that set them apart from their peers. They likely possess non-clinical, translatable skills including internal motivation, self-regulation, curation of information, and task completion that map closely with qualities that make for excellent residents.

Transcervical intubation for massive self-inflicted neck wound transecting the epiglottis.

Background: Penetrating trauma to the larynx is a rare phenomenon with a high risk of mortality and morbidity due to the density of vital structures in the area (Demetriades et al., 1996). Most commonly, this type of injury is due to a gunshot wound or knife injury (Snow and Ballenger, 2003). In cases of suicidal cutthroat injury, it is relatively rare to penetrate the airway (Symbas et al., 1976). Case report: We present a case of self-penetrating trauma to the anterior neck allowing access for direct laryngeal visualization and transcervical intubation in the field. We describe the immediate workup, surgical intervention, and postoperative management. We focus on managing postoperative cough, secretion management, decannulation, and resultant dysphagia. Conclusion: Penetrating laryngeal trauma resulting in airway transection is a rare but potentially fatal phenomenon in which airway management and aggressive post-operative care for severe coughing and dysphagia should be performed to help improve patient outcomes.

Recurrent Lingual Abscess in an Elderly Female With Bulbar Amyotrophic Lateral Sclerosis.

A lingual abscess is a rare condition that was scarcely described in clinical textbooks. A lingual abscess recurrence is rare and has only been described twice in the literature. Typically, the tongue and oral cavity have multiple intrinsic properties which stave off intralingual infection; however, there may be situations in which these properties are compromised, as demonstrated in oro-motor disability. Lingual abscesses have the potential to develop into catastrophic obstructive airway issues; therefore, early detection and management are paramount. The following is a presentation of an elderly female with Bulbar Amyotrophic Lateral Sclerosis (ALS) treated conservatively for a lingual abscess with recurrence at eleven months post-treatment. Due to her baseline neuromuscular disorder and elevated anesthesia risk, she was treated in the interventional radiology suite with drain placement and Povidone-Iodine sclerotherapy under conscious sedation with excellent results.

Just-In-Time Simulation Training for Nasopharyngeal Specimen Collection During the SARS-CoV-2 Pandemic.

INTRODUCTION: Rapid and accurate detection of the novel coronavirus using a nasopharyngeal specimen requires training for professionals who may have limited experience. To respond to the urgent need, an interprofessional team created a just-in-time (JIT) module to provide only what was needed, precisely when needed, and rapidly deployed training sessions to a large group of health professionals. METHODS: In April and May 2020, health professionals from the hospital, ambulatory clinics, and public health attended training. Procedural comfort/knowledge and perception of the training were assessed with pre-survey and post-survey. RESULTS: Comfort level in collecting a nasopharyngeal specimen among participating health professionals increased from 2.89 (n = 338) on the pre-survey to 4.51 (n = 300) on the postsurvey on a 5-point scale. Results revealed a significant difference (P < .01) between pre-post knowledge questions regarding the correct angle and depth of the swab to obtain an adequate sample from the nasopharynx. DISCUSSION: This study demonstrates that a JIT intervention can improve knowledge and comfort regarding the nasopharyngeal swab procedure. In preparation for the prevention and mitigation of future viral outbreaks (ie, coronavirus and influenza), educators should consider creating JIT skills training for health care professionals who may be deployed to assist in mass testing efforts.

A Novel Just-In-Time-Online-Training for Nasopharyngeal Swab Specimen Collection During the COVID-19 Pandemic.

INTRODUCTION:  The spread of coronavirus disease 2019 (COVID-19) is controlled by timely detection of infected patients using a nasopharyngeal (NP) swab test, followed by isolation and treatment. One challenge encountered with NP swab collection was to train healthcare providers (HCPs) with different training backgrounds and experience for collecting NP swab specimens across Nebraska, including a sizeable rural area. In-person training for NP swab collection skills was challenging due to social distancing. We developed a Just-In-Time-Online Training (JITOT) and delivered it using Facebook Live (TM) to meet our HCPs' training needs. METHODS:  Online training was held on April 21, 2020, and attended by 453 HCPs. A quasi-experimental study based on a survey and a multiple choice questionnaire (MCQ) was conducted to evaluate its effectiveness in improving the participants' knowledge and attitudes. RESULTS:  Group mean knowledge score increased from a pre-test score of 57%-95% in the post-test showing a large effect size (Hedges' g = 0.976877). On a five-point Likert scale, the majority (86.21%) of the survey respondents agreed/strongly agreed that this training increased their overall comfort for nasal swab specimen collection as compared to their pre-training comfort (37.93%) with this procedure. The majority of respondents (96.55%) in the post-training evaluation agreed/strongly agreed that "the delivery method was appropriate." CONCLUSION:  A JITOT session is helpful to teach, demonstrate, clarify doubts, and improve the knowledge and comfort of the participants. It can be quickly delivered using a free social media platform for broader outreach during public health emergencies.

Integrated Comprehensive Care for Transcare and Gender Diverse Clinic Patients: An Assessment of Physical, Mental, and Social Needs.

Introduction There is a large body of research reporting the healthcare needs of groups identifying as lesbian, gay, bisexual, transgender, and/or queer (LGBTQ); however, a gap exists in the research literature because many epidemiological studies focus on sexual orientation rather than gender identify/incongruence. To address the lack of specific data from transgender and gender diverse (TGD) individuals, our organization designed and deployed a survey to assess the gender-affirming physical, mental, and social care needs of current patients. Methods A group of subspecialty physicians currently working with TGD patients created a list of questions and requested feedback from medical professionals familiar with the healthcare needs of this population. In addition, patients reviewed the survey for content and clarity. The final 68-item survey was distributed in April 2020 to patients or patients' representatives with an email address on file at the Nebraska Medicine Transgender Care Clinic (NMTCC). Participants were asked to respond to questions regarding their gender identity, their transition-related medical decisions, and their interest in services. Results Invitations were sent to 690 patients and 168 surveys were completed (response rate: 24.3%). Over 90% (n = 153) of the participants were patients and 9% (n = 15) answered survey questions on the patient's behalf. A majority (77.2%) had started the medical transition (hormones or puberty blockers) in the past four years. Nearly half (46.4%) identified as trans women, 43.4% identified as trans men, and 10.2% indicated they were nonbinary or gender expansive. Participants' sex assigned at birth was 50.9% female and 46.1% male. Most patients (n = 149; 92%) reported currently receiving hormone treatment within the Nebraska Medicine healthcare system. Results indicated the highest level of clinical services interest was primary care (38.4%), gender-affirming surgery (73.5%), voice therapy (49.0%), and hair removal (37.5%). In addition, participants were very likely to participate in support groups with "people of similar gender identity" (32.9%), with "others around my age" (28.6%), and "including a mix of ages and identities" (26.9%). Discussion This study suggests that our TGD patients would utilize integrated services to access a variety of clinical and non-clinical services. Ongoing community engagement and direct feedback from patients are critical to the success and growth of our gender-affirming care clinic. The results of this study will inform the planning and further evolution of a program designed to build trust and address health inequities for TGD individuals throughout the region.

Diffuse Spontaneous Laryngeal Hemorrhage with Trastuzumab.

Drug-induced epithelial hemorrhage of the endolarynx is an unusual etiology of hemoptysis. We present a case of hemoptysis in a young female patient undergoing treatment for metastatic breast cancer with trastuzumab emtansine. Though previously associated with diffuse spontaneous hemorrhage of the gingiva, there have not been reports of laryngeal hemorrhage with trastuzumab emtansine treatment. In this case report, we suggest that trastuzumab emtansine played a contributory role in the development of diffuse epithelial laryngeal hemorrhage and describe the pathophysiology, history, laryngoscopic findings, and management of this condition.

Examining the Otolaryngology Match and Relationships Between Publications and Institutional Rankings.

This study examines associations among publication number, National Institutes of Health (NIH) funding rank, medical school research rank, and otolaryngology department ranks of otolaryngology applicants during the 2018-2019 match cycle. Information regarding 2018-2019 otolaryngology applicants was collected from Otomatch.com and verified via department websites. Information was also collected regarding 2018 NIH funding rank and 2020 US News & World Report research rank of medical schools and otolaryngology departments. T tests and chi-square analyses were performed. Top 40 NIH funding rank, top 40 medical school research rank, and home institution department rank were separately associated with more publications and higher rates of matching into highly reputed otolaryngology departments (all P < .01). Furthermore, applicants who matched into ranked otolaryngology departments averaged significantly more publications (P < .01). Prospective otolaryngology applicants should take into account NIH funding rank, medical school research rank, and otolaryngology department rank, as they are associated with matching into high-ranking institutions.

Resource Utilization and Billing in a Resident-Managed Inpatient Consult Service.

OBJECTIVE: Patient care delivered by residents is an educational opportunity to foster autonomy. These services, however, may not be billed without direct faculty supervision. This quality improvement project analyzes descriptive data, procedures, and billing from an academic otolaryngology-head and neck surgery department's inpatient consult service. METHODS: This prospective cohort study collected descriptive and billing data on all consults over 30 consecutive days. Data collected described bedside procedures and operative interventions. Encounters were Current Procedural Terminology coded and equivalent work relative value unit (wRVU) calculated. Codes submitted for billing were reviewed to identify opportunities for inpatient billing improvement. RESULTS: Ninety-eight new consults were included, and 105 bedside procedures were performed. Flexible laryngoscopy (n = 27), I&D (incision and drainage; n = 11), and suturing (n = 11) were the most performed bedside procedures. Operative intervention was required in 15 encounters. The inpatient consult team provided the equivalent of 391.39 wRVU. Seventy-three percent of operative compared to 3% of bedside procedures were submitted for billing. DISCUSSION: The productivity of our team approximated 61.8% of a full-time general otolaryngologist but with decreased billing submissions. Balance between resident autonomy, education, quality patient care, and the ability to capture service revenue is complex. Strategies other institutions have used to capture missed billing opportunities have included a hospitalist model, mid-level providers, and resident billing. IMPLICATIONS FOR PRACTICE: This study characterizes an academic inpatient consult service. Results describe a case for improving the structure of the inpatient consult service, caution that studies collecting data via department billing may underrepresent services, and suggest alternative service structures to overcome identified billing limitations.

Acoustic Characteristics of Voice Before and After Endoscopic Partial Laryngectomy in Early Glottic Cancer.

OBJECTIVES: To evaluate the voice changes after narrow-margin endoscopic partial laryngectomy in subjects with T1N0M0 glottic cancer. STUDY DESIGN: Uncontrolled retrospective comparison of preoperative and postoperative mean phonation time; fundamental frequency, jitter, shimmer, and noise-to-harmonic ratio; and voice-related quality of life (V-RQOL) survey scores. METHODS: Seventeen adults diagnosed with T1N0M0 glottic cancer who underwent narrow-margin endoscopic partial laryngectomy were included. All subjects had preoperative and postoperative acoustic evaluation and V-RQOL scores. Subjects were separated into three groups based on age and depth of resection. Group A (mean age, 52 years) consisted of seven subjects who underwent superficial resection (superficial layer of lamina propria) and were younger than 60 years. Group B (mean age, 76 years) consisted of six subjects who were older than 60 years and underwent superficial resection (superficial layer of lamina propria). The four subjects in group C were older than 60 years and underwent deep resection (into the vocal ligament and/or into the thyroarytenoid muscle). RESULTS: There was a statistically significant improvement in V-RQOL in group A. The acoustic measures did not change after surgery (no P<0.05). CONCLUSION: For early-stage cancer, patients younger than 60 years and superficial resection of cancer are predictive for better voice.

The Role of the Modified Barium Swallow Study and Esophagram in Patients with Globus Sensation.

Globus sensation (GS) is a common benign finding that is often associated with frequent throat clearing and is commonly a result of laryngopharyngeal reflux. The primary objective of this investigation was to examine the role of the modified barium swallow study (MBSS) with esophagram in the diagnosis and management patients who present with chief complaints of a GS. We hypothesize that these radiographic swallow studies do not add clinically significant information in the investigation of this common complaint. Retrospective chart review of patients with chief complaints of GS between 2000 and 2009 who underwent both MBSS and esophagram was conducted. Of the 380 patients who underwent MBSS, only 68 patients were eligible for this study. Over 70 % of patients were on reflux medicines, 81 % of the MBSS studies were normal, 62 % of the esophagram results were normal, 18 % of patients had a hiatal hernia, and 10 % exhibited signs of reflux. Esophagoscopy was performed in 45 % of patients, of which 35 % were normal. One patient initially had a normal esophagogastroduodenoscopy and then was subsequently diagnosed with gastric CA. Fifty-nine percent of patients underwent CT Neck with IV contrast, of which 67 % had minor findings. Positive findings are often benign and can be treated with reflux medications. Esophagoscopy was often normal and most sensitive only for hiatal hernia. No hypopharyngeal cancer was noted. Therefore, MBSS and esophagram for patients with GS are most often negative and fail to add significant diagnostic information.

Identification of distinct layers within the stratified squamous epithelium of the adult human true vocal fold.

OBJECTIVES/HYPOTHESIS: A precise molecular schema for classifying the different cell types of the normal human vocal fold epithelium is lacking. We hypothesize that the true vocal fold epithelium has a cellular architecture and organization similar to that of other stratified squamous epithelia including the skin, cornea, oral mucosa, and esophagus. In analogy to disorders of the skin and gastrointestinal tract, a molecular definition of the normal cell types within the human vocal fold epithelium and a description of their geometric relationships should serve as a foundation for characterizing cellular changes associated with metaplasia, dysplasia, and cancer. STUDY DESIGN: Qualitative study with adult human larynges. METHODS: Histologic sections of normal human laryngeal tissue were analyzed for morphology (hematoxylin and eosin) and immunohistochemical protein expression profile, including cytokeratins (CK13 and CK14), cornified envelope proteins (involucrin), basal cells (NGFR/p75), and proliferation markers (Ki67). RESULTS: We demonstrated that three distinct cell strata with unique marker profiles are present within the stratified squamous epithelium of the true vocal fold. We used these definitions to establish that cell proliferation is restricted to certain cell types and layers within the epithelium. These distinct cell types are reproducible across five normal adult larynges. CONCLUSION: We have established that three layers of cells are present within the normal adult stratified squamous epithelium of the true vocal fold. Furthermore, replicating cell populations are largely restricted to the parabasal strata within the epithelium. This delineation of distinct cell populations will facilitate future studies of vocal fold regeneration and cancer. LEVEL OF EVIDENCE: N/A.

Removal of a wire brush bristle from the hypopharynx using suspension, microscope, and fluoroscopy.

Wire brush bristles are an increasingly recognized hazard that can present as a foreign body in the aerodigestive tract. Due to their small size and tendency to become embedded in surrounding tissue, these small metallic bristles present a unique operative challenge to otolaryngologists. Here we present a case of a 40-year-old woman who underwent endoscopic extraction of a wire bristle from the posterior pharyngeal wall using suspension, microscopy, and C-arm fluoroscopy. We believe this is the first published case of an endoscopic removal of a buried foreign body in the hypopharynx using these methods of localization concurrently. By leveraging multiple techniques for visualization, surgeons can avoid open exploration while ensuring complete removal of the object. Additionally, this case highlights the importance of regulatory oversight and consumer awareness of the hazards of grill brushes.

Transillumination of the occult submucous cleft palate.

Occult submucous cleft palate is a congenital deformity characterized by deficient union of the muscles that normally cross the velum and aid in elevation of the soft palate. Despite this insufficient muscle coverage, occult submucous cleft palate by definition lacks clear external anatomic landmarks. This absence of anatomic signs makes diagnosis of occult submucous cleft less obvious, more dependent on ancillary tests, and potentially missed entirely. Current diagnostic methodologies are limited and often are unrevealing in the presurgical patient; however, a missed diagnosis of occult submucous cleft palate can result in velopharyngeal insufficiency and major functional impairment in patients after surgery on the oropharynx. By accurately and easily diagnosing occult submucous cleft palate, it is possible to defer or modify pharyngeal surgical intervention that may further impair velopharyngeal function in susceptible patients. In this report, we introduce transillumination of the soft palate using a transnasal or transoral flexible endoscope as an inexpensive and simple technique for identification of submucous cleft palate. The use of transillumination of an occult submucous cleft palate is illustrated in a patient case and is compared to other current diagnostic methodologies.

Physiology-based minimum clinically important difference thresholds in adult laryngotracheal stenosis.

OBJECTIVES/HYPOTHESIS: Delivering evidence-based patient care is predicated on the availability of objective and validated outcome measures. We aimed to calculate physiology-based minimum clinically important difference (MCID) values for adult laryngotracheal stenosis (LTS). STUDY DESIGN: Prospective observational study. METHODS: Patient demographics, morbidities, and stenosis severity were assessed preoperatively. Flow-volume loops and Medical Research Council (MRC) dyspnea grades were measured in 21 males and 44 females before and 6 to 8 weeks after airway surgery, and before treating recurrent disease in 10 patients. Anchor and distribution-based methodologies were used to calculate MCIDs for treatment efficacy and disease recurrence respectively. RESULTS: The mean age at treatment was 46 ± 16 years. The most common etiology was idiopathic subglottic stenosis (38%). Most lesions (66%) obstructed >70% of the lumen. There were strong correlations between treatment-related changes in total peak flow (TPF) (ΔTPF) (peak expiratory flow + |peak inspiratory flow|) and the ratio of area under the flow-volume loop (AUC) to forced vital capacity (FVC) (ΔAUCTotal /FVC), and treatment-related changes in the MRC grade (ΔMRC) (r = -0.76 and r = -0.82, respectively). Both TPF and AUCTotal /FVC discriminated between effective (ΔMRC <0) and ineffective (ΔMRC ≥0) interventions, yielding MCID values of 4.2 L/s for TPF and 2.1 L(2) /s for AUCTotal /FVC, respectively. Ten patients required airway treatment for recurrent disease, and TPF and AUCTotal /FVC levels had distribution-based MCID values of 0.9 and 0.6, respectively. CONCLUSIONS: Flow-volume loops provide a quantitative method of objectively assessing outcomes in LTS. TPF is the most convenient index for this purpose, but AUCTotal /FVC provides marginally greater sensitivity and specificity.

Section for Residents and Fellows-in-Training Leaders: Where Are They Now?

The purpose of this study was to examine the experiences of prior governing council (GC) members of the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) Section for Residents and Fellows-in-Training (SRF) and assess the impact of early Academy involvement. A survey was conducted via email on all prior AAO-HNS SRF GC members. The AAO-HNS SRF has elected 52 GC members since its 2003 inception. Each member served an average of 1.5 year-long terms. The mean time since completion of training is 4.1 years. A subspecialty fellowship was pursued in 86%. Fifty-seven percent practice in academic settings, with 3 members advancing to subspecialty division director within their department. More than half (58%) have served on an AAO-HNS committee, and most are frequent attendees of the annual meeting. All prior members felt involvement in the SRF GC was beneficial, enabling them to gain leadership skills and deeper understanding of the specialty.

Section for residents and fellows-in-training survey results.

OBJECTIVES: (1) To present data from the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) Section for Residents and Fellows-in-Training (SRF) annual survey from 2002 to 2011. (2) To compare and analyze trends in resident demographics, residency experiences, and post-training career choices. STUDY DESIGN: Review of cross-sectional survey data. SETTING: Residents and Fellows registered as Members-in-Training through AAO-HNS. METHODS: A review of data from surveys distributed between 2002 and 2011 was conducted. Respondent demographic data including age, postgraduate year, gender, and geographic distribution were analyzed. Responses about training experiences, fellowship selection, debt burden, and post-training practice choice were studied in order to elicit trends. RESULTS: Respondents have consistently rated otolaryngology, anesthesia, and trauma/critical care as the most important intern rotations for otolaryngology residents. Each year, approximately 70% of respondents have reported interest in pursuing a fellowship. Pediatric otolaryngology fellowship is now the most popular fellowship among respondents. There has been a recent increase in the percentage of respondents who are interested in pursuing a career in academics. Location, family, and lifestyle have consistently been the most important factors in determining choice of practice. Respondents have reported increasing levels of educational debt. CONCLUSION: The AAO-HNS SRF survey collects important data regarding resident/fellow training. Several factors limit the generalizability of these results. Despite its limitations, these unique data provide valuable information for continual evaluation and improvement of physician training in the specialty.