Intersectionality of Race, Ethnicity, and Gender in the Otolaryngology Match From 2013 to 2019.

OBJECTIVES: Racial, ethnic, and gender disparities in the otolaryngology-head and neck surgery (OHNS) match have been described individually, but not intersectionally. Intersectionality recognizes how multiple forms of discrimination (e.g., sexism, racism) can have a combined effect. The objective of this study was to analyze racial, ethnic, and gender disparities in the OHNS match using an intersectional approach. METHODS: Cross-sectional evaluation of data from otolaryngology applicants from the Electronic Residency Application Service (ERAS) and of corresponding otolaryngology residents from the Accreditation Council for Graduate Medical Education (ACGME) from 2013 to 2019. Data were stratified by race, ethnicity, and gender. The Cochran-Armitage tests assessed trends over time in the proportions of applicants and corresponding residents. Chi-square tests with Yates' continuity correction were performed to evaluate differences between the aggregate proportions of applicants and corresponding residents. RESULTS: The proportion of White men in the resident pool was increased compared to the applicant pool (ACGME 0.417, ERAS 0.375; Δ + 0.042; 95% CI 0.012 to 0.071; p = 0.03). This was also the case for White women (ACGME 0.206, ERAS 0.175; Δ + 0.031; 95% CI 0.007 to 0.055; p = 0.05). In contrast, there was a smaller proportion of residents compared to applicants among Multiracial men (ACGME 0.014, ERAS 0.047; Δ - 0.033; 95% CI -0.043 to -0.023; p < 0.001) and Multiracial women (ACGME 0.010, ERAS 0.026; Δ - 0.016; 95% CI -0.024 to -0.008; p < 0.001). CONCLUSION: The findings of this study imply that White men have a persistent advantage, while several racial, ethnic, and gender minorities are disadvantaged in the OHNS match. Further research is necessary to examine why these differences exist in residency selection, including evaluation during the screening, reviewing, interviewing, and ranking stages. Laryngoscope, 133:2558-2563, 2023.

Implementing a "Distance Traveled" Question to Improve Resident Diversity: Process and Feasibility.

Increasing diversity in the physician workforce is important to improving racial and ethnic disparities in health outcomes in the United States. We describe the implementation of a "distance traveled" question (DTQ) in our residency application process. For the 2021-2022 cycle, all applicants to the University of Washington otolaryngology residency program were allowed to complete an optional DTQ. Responses were shared with the application review committee. Following the distribution of interview invites, an anonymous survey was sent to all faculty reviewers. The response rate was 26 of 36 (72%). Among respondents, 20 (77%) felt that the DTQ helped them learn something new about the applicant, and 19 (73%) reported that the DTQ influenced their decision making about the applicant. Thus, a DTQ may provide faculty with new and influential information regarding residency applicants.

Oncologic outcomes of salvage surgery and immune checkpoint inhibitor therapy in recurrent head and neck squamous cell carcinoma: A single-institution retrospective study.

BACKGROUND: Survival outcomes in recurrent head and neck squamous cell carcinoma (HNSCC) are poor. This study aimed to compare survival outcomes between salvage surgery and immunotherapy in patients with recurrent advanced HNSCC. METHODS: Patients with advanced stage (stage III or IV) recurrent HNSCC following treatment with platinum-based chemotherapy were included. Survival was estimated using the Kaplan-Meier method, and Cox regression was used for multivariate logistic regression. RESULTS: Two-year overall survival after salvage surgery was 68.6% and after immunotherapy patients was 24.6%. Multivariate logistic regression showed that salvage surgery was associated with improved survival without statistical significance (hazard ratio [HR] 0.12, p = 0.25). Subgroup analysis of patients with oral cavity/oropharyngeal cancer noted improved survival with salvage surgery over immunotherapy (HR 0.006, p = 0.01) and decreased survival with neutrophil-to-lymphocyte ratio (NLR) > 5 (HR 6.4, p = 0.02). CONCLUSION: Our retrospective single-institutional data suggest that resectable advanced stage recurrent HNSCC may have improved survival with salvage surgery in appropriately selected patients, but larger prospective studies are required.

Endoscopic Paramaxillary Approach to the Infratemporal Fossa and Pterygomaxillary Space: Computer Modeling Analysis and Clinical Series.

Objective Several different open and endoscopic approaches for the pterygomaxillary space and infratemporal fossa have been described. Limitations to these approaches include restricted exposure of the infratemporal fossa and difficult surgical manipulation. Study Design Consecutive clinical cases utilizing a novel approach to access lesions in the infratemporal fossa and pterygomaxillary space were reviewed. Data was collected on pathology, lesion location, and surgical approach(es) performed. Computer modeling was performed to analyze the full extent of surgical access provided by the paramaxillary approach to the range of target locations. Results Ten consecutive cases met inclusion criteria. Surgical access to the target lesion was achieved in all cases. Computer modeling of the approach derived the anatomical boundaries of the paramaxillary approach. Wide access to the posterior maxilla, and lateral or medial to the mandibular condyle allows for variability in endoscopic angles and access to more medial pterygomaxillary space lesions. The lateral extent is limited proximally only by the extent of cheek/soft tissue retraction and by the zygomatic arch more superiorly. The superior limit of dissection is at the temporal line. Conclusion The endoscopic paramaxillary approach is a transoral minimally disruptive approach to the ITF and PS that provides excellent surgical exposure for resection of lesions involving these areas. Compared with previously described endoscopic approaches, there are no external incisions; tumor manipulation is straightforward without angled endoscopy, and all areas of the infratemporal fossa and pterygomaxillary space can be accessed.

Real-time virtual intraoperative CT in endoscopic sinus surgery.

PURPOSE: Endoscopic sinus surgery (ESS) is typically guided under preoperative computed tomography (CT), which increasingly diverges from actual patient anatomy as the surgery progresses. Studies have reported that the revision surgery rate in ESS ranges between 28 and 47%. This paper presents a method that can update the preoperative CT in real time to improve surgical completeness in ESS. APPROACH: The work presents and compares three novel methods that use instrument motion data and anatomical structures to predict surgical modifications in real time. The methods use learning techniques, such as nonparametric filtering and Gaussian process regression, to correlate surgical modifications with instrument tip positions, tip trajectories, and instrument shapes. Preoperative CT image sets are updated with modification predictions to serve as a virtual intraoperative CT. RESULTS: The three methods were compared in eight ESS cadaver cases, which were performed by five surgeons and included the following representative ESS operations: maxillary antrostomy, uncinectomy, anterior and posterior ethmoidectomy, and sphenoidotomy. Experimental results showed accuracy metrics that were clinically acceptable with dice similarity coefficients > 86%, with F-score > 92% and precision > 89.91% in surgical completeness evaluation. Among the three methods, the tip trajectory-based estimator had the highest precision of 96.87%. CONCLUSIONS: This work demonstrated that virtually modified intraoperative CT scans improved the consistency between the actual surgical scene and the reference model, and could lead to improved surgical completeness in ESS. Compared to actual intraoperative CT scans, the proposed method has no impact on existing surgical protocols, does not require extra hardware, does not expose the patient to radiation, and does not lengthen time under anesthesia.

Automated atlas-based segmentation for skull base surgical planning.

PURPOSE: Computational surgical planning tools could help develop novel skull base surgical approaches that improve safety and patient outcomes. This defines a need for automated skull base segmentation to improve the usability of surgical planning software. The objective of this work was to design and validate an algorithm for atlas-based automated segmentation of skull base structures in individual image sets for skull base surgical planning. METHODS: Advanced Normalization Tools software was used to construct a synthetic CT template from 6 subjects, and skull base structures were manually segmented to create a reference atlas. Landmark registration followed by Elastix deformable registration was applied to the template to register it to each of the 30 trusted reference image sets. Dice coefficient, average Hausdorff distance, and clinical usability scoring were used to compare the atlas segmentations to those of the trusted reference image sets. RESULTS: The mean for average Hausdorff distance for all structures was less than 2 mm (mean for 95th percentile Hausdorff distance was less than 5 mm). For structures greater than 2.5 mL in volume, the average Dice coefficient was 0.73 (range 0.59-0.82), and for structures less than 2.5 mL in volume the Dice coefficient was less than 0.7. The usability scoring survey was completed by three experts, and all structures met the criteria for acceptable effort except for the foramen spinosum, rotundum, and carotid artery, which required more than minor corrections. CONCLUSION: Currently available open-source algorithms, such as the Elastix deformable algorithm, can be used for automated atlas-based segmentation of skull base structures with acceptable clinical accuracy and minimal corrections with the use of the proposed atlas. The first publicly available CT template and anterior skull base segmentation atlas being released (available at this link: http://hdl.handle.net/1773/46259 ) with this paper will allow for general use of automated atlas-based segmentation of the skull base.

Robotics in Pediatric Otolaryngology-Head and Neck Surgery and Advanced Surgical Planning.

Robotic surgery has been shown to be feasible and successful in several areas of pediatric head and neck surgery. However, adoption has been limited. Robotic surgery may be better integrated into practice with advanced preoperative surgical planning and the design of new robotic platforms with instrumentation specific for the application. With continued investigations, computer-aided surgical planning techniques including three-dimensional printing, virtual reality, multiobjective cost function for optimization of approach, mirror image overlay, and flexible robotic instruments may demonstrate value and utility over current practice.

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

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

Primary management of atypical meningioma: treatment patterns and survival outcomes by patient age.

PURPOSE: The initial management of atypical meningiomas poses a distinct clinical challenge in that treatment protocols have not been fully established, and outcomes, especially differences by patient age, have not been broadly measured. The National Cancer Database (NCDB) allows for analysis of a large, diverse patient population to determine clinical parameters and survival outcomes based on the initial treatment of patients with atypical meningiomas. METHODS: Analysis of the NCDB yielded 3611 atypical meningioma patients treated between 2008 and 2012. Principal treatment paradigms included surgery with or without radiation. Survival estimates were calculated using Kaplan-Meier curves stratified by age at diagnosis for each treatment paradigm. Subset analysis was performed for socio-economic factors. RESULTS: Overall 5-year survival rate was 77.6% and declined with increasing patient age (p < 0.0001). Five-year survival for patients ≤ 45 years undergoing surgery alone was 89.3 vs. 44.4% for those > 75 years (p < 0.0001). For patients undergoing surgery with adjuvant radiation, 5-year survival was 93.7% in those ≤ 45 years and 54.1% in those > 75 years (p < 0.0001). Use of adjuvant radiation was stable over time. Private-insured patients were more likely to receive adjuvant radiation (p = 0.0001). CONCLUSIONS: Patients treated for atypical meningioma have high rates of 5-year survival. A marginal survival benefit of adjuvant radiation was observed for patients < 55 and > 75 years, while patients between 55 and 75 years tended to have slightly improved survival with surgery alone. Though surgery remains the standard of care in the primary treatment of atypical meningioma, the decision to administer radiation post-operatively has remained controversial.

Referral patterns from emergency department to otolaryngology clinic.

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

A systematic review of secondary cerebrospinal fluid leaks.

BACKGROUND: Secondary cerebrospinal leaks (CSF) are leaks that recur after an initial endoscopic repair of CSF leaks. Identification of characteristics that could predict secondary leaks may allow surgeons to plan repairs with the knowledge that these defects are more likely to fail. OBJECTIVE: To identify characteristics that could predict secondary CSF leaks. METHODS: A search of all studies that reported outcomes after endoscopic repair of CSF leaks was conducted by using medical literature data bases. Studies with the following criteria were included: written in the English language, secondary CSF leaks after primary repair, and assessment of success of fistula repair. Data extracted included the etiology of the leak, site of the leak, reconstructive materials used, and success of the repair. RESULTS: Ninety-four studies, from 1988 to 2015, with a total of 3149 primary CSF leaks were included. Sixty-three studies (67%) had a success rate of ≥80%; 77 studies (82%) had secondary leak rates of <40%. For 88 of the 94 studies (94%), the success rate after secondary repair improved to 81.0-100%. Of 48 studies that included leaks of more than one site, the sphenoid was the most common site of leak in 26 studies (55%), the ethmoid was the most common site in 16 studies (34%), and the cribriform was the most common site in 11 studies (23%). CONCLUSION: The rate of secondary CSF leaks was low due to advances in endoscopic repair techniques. Spontaneous and iatrogenic CSF leaks were more likely to recur, especially without adequate control of underlying factors, such as increased intracranial pressure and obesity. Further studies with consistent reporting are required for more definitive conclusions about secondary CSF leaks.

Prognostic significance of Kadish staging in esthesioneuroblastoma: An analysis of the National Cancer Database.

BACKGROUND: Given the rarity of esthesioneuroblastoma, it is difficult to validate a staging system. The purpose of this study was to investigate the utility of the Kadish staging system in esthesioneuroblastoma using the National Cancer Database (NCDB). METHODS: One thousand one hundred sixty-seven patients with esthesioneuroblastoma were identified from the NCDB. RESULTS: Five-year survival was 80.0% for Kadish A, 87.7% for Kadish B, 77.0% for Kadish C, and 49.5% for Kadish D. Kadish B had higher survival than Kadish A. More Kadish B patients received surgery with adjuvant therapy than Kadish A patients (41.6% vs 32.5%; P = .0038) and also had more positive margins (21.6% vs 11.3%; P = .03). There was no difference in age distribution, sex, race, or neck dissection status between the 2 groups. CONCLUSION: Kadish B had greater survival than Kadish A, but the treatment characteristics could not account for this difference. The utility of early-stage Kadish staging is uncertain and requires further study.

Use of pharyngeal packs in functional endoscopic sinus surgery: A randomized controlled trial.

OBJECTIVE: To determine if pharyngeal packs have an effect on postoperative pain and postoperative nausea and vomiting in functional endoscopic sinus surgery (FESS). STUDY DESIGN: Forty-six patients scheduled for routine endoscopic sinus surgery were recruited into this study. The patients were randomly allocated to have or to not have pharyngeal packing prior to surgery. METHODS: The placement of pharyngeal packs during FESS is controversial. Theoretically, pharyngeal packs may prevent postoperative nausea and vomiting by preventing ingestion of blood during sinus surgery. However, prior studies have not conclusively demonstrated this to be the case in FESS. Pharyngeal packs have been associated with complications including throat pain, aspiration, and death. The objective of this randomized control trial was to determine if pharyngeal packs have an effect on postoperative throat pain, nausea, and vomiting in order to determine their importance during FESS. Patients were blinded to intervention. Postoperatively, throat pain and nausea/vomiting scores were recorded. RESULTS: There was no significant difference in mean throat pain at 4 hours following surgery (P = 0.860). At 24 hours after surgery, patients without pharyngeal packing experienced more pain than those who had a throat pack placed (P = 0.002). There was no significant difference in the level of nausea at 4 hours after surgery (P = 0.315) or at 24 hours after surgery (P = 0.315). CONCLUSION: We recommend against the routine use of placing pharyngeal packs during FESS. LEVEL OF EVIDENCE: 1b. Laryngoscope, 127:2460-2465, 2017.

Outcomes in Adult Sinonasal Rhabdomyosarcoma.

Objective To describe patient demographics, histology, treatment modalities, and survival associated with adult sinonasal rhabdomyosarcoma. Study Design Retrospective review of a national database. Setting Tertiary medical center. Subjects and Methods Patient demographics, tumor histology, treatment modalities, and survival trends were examined for patients aged ≥18 years who were diagnosed with sinonasal rhabdomyosarcoma between 2004 and 2013 with the National Cancer Database. Kaplan-Meier analysis and the log-rank tests were performed to determine the unadjusted association between overall survival and various patient and disease characteristics. Results A total of 186 patients were identified; 5-year overall survival was 28.4%. Over half of patients were between 18 and 35 years old at diagnosis (53.8%), which was associated with improved 5-year overall survival over patients >35 years old (31.9% vs 24.4%, P = .014). Alveolar sinonasal rhabdomyosarcoma was most common (66.7%). There was no statistical difference in 5-year overall survival between alveolar and embryonal subtypes (30.5% vs 41.6%, P > .05). Metastatic disease was present in 27.7% of patients and was associated with worse 5-year overall survival (14.7% vs 33.9%, P < .0001). The majority of patients were treated with chemotherapy with adjuvant radiation (49.5%). A quarter of patients were treated with surgery plus chemoradiation (25.8%). Conclusion We present the largest analysis of adult sinonasal rhabdomyosarcoma using a standardized national based database. Adult sinonasal rhabdomyosarcoma has a very poor prognosis independent of histologic subtype. The small number of surgical cases limits the ability of the analysis to accurately compare treatment with chemoradiation with and without surgery.

Treatment modalities in sinonasal undifferentiated carcinoma: an analysis from the national cancer database.

BACKGROUND: Sinonasal undifferentiated carcinoma (SNUC) is a rare, aggressive malignancy of unknown etiology with a poor overall prognosis. Its relative rarity has made it difficult to determine the impact of different treatment modalities on survival. METHODS: Retrospective study of cases in the National Cancer Data Base (NCDB). NCDB cases that were diagnosed as having SNUC between January 1, 2004, and December 31, 2013 were included in the analysis. Outcomes of patients treated with surgery followed adjuvant chemoradiotherapy were compared with definitive chemoradiotherapy. RESULTS: A 5-year survival rate of 42.2% was observed in the 460 patients in the analysis. American Joint Committee on Cancer (AJCC) clinical staging data were available for 304 patients. Of these patients, 60.2% had advanced tumors (AJCC stage 3 or 4). Surgery followed by adjuvant chemoradiotherapy was associated with better survival than definitive chemoradiotherapy (55.8% vs 42.6%, p = 0.007) in the study population. However, in late-stage tumors, there was no difference in survival between the 2 treatment groups (p = 0.22). For late-stage tumors, the time to initiation of adjuvant therapy was 49.2 ± 5.1 days for the surgery plus adjuvant therapy group as compared with 25.9 ± 2.6 days in the definitive chemoradiotherapy group (p < 0.0001), yet this did not appear to affect outcomes. No differences in age, gender, race, Charlson-Deyo score, facility type (academic vs nonacademic), or radiation dose were found between the 2 treatment groups (p > 0.05). Margin status played a critical role in the success of surgical resection, as no patients with positive margin status receiving adjuvant therapy survived to 5 years. CONCLUSION: Surgery may play a role in a multimodality approach to treatment of late-stage SNUC if the tumor is amenable to surgical resection and negative margins can be reliably obtained. However, in cases where there may be difficulty obtaining negative margins, or this is considered unlikely preoperatively, surgical resection does not appear to provide any additional survival benefit.

The presentation and outcomes of mucosal melanoma in 695 patients.

BACKGROUND: Most data on sinonasal mucosal melanoma come from small institutional studies, and therefore optimal treatment methods are not well understood. The purpose of this study was to analyze the association between treatment and survival in sinonasal mucosal melanoma. METHODS: Six hundred ninety-five patients diagnosed with sinonasal mucosal melanoma between 2004 and 2010 were identified from the National Cancer Data Base. Treatment modalities and overall survival rates were determined. RESULTS: The 5-year overall survival was 21.7%, with a mean survival of 38.4 ± 1.7 months. The majority of patients were treated with surgery alone (31.5%) or surgery with adjuvant radiotherapy (41.4%). There was no statistical difference between survival with surgery alone and surgery with adjuvant radiation therapy (25.1% vs 25.1%, p = 0.93). Between the surgery and surgery-with-adjuvant-therapy groups, there was no difference in the number of patients with positive margins (p = 0.54), regional lymph node metastases at diagnosis (p = 0.55), morbidity scores (p = 0.58), insurance status (p = 0.13), age > 60 years (p = 0.24), or treatment at academic centers (p = 0.12). CONCLUSIONS: Based on this large review of patients with sinonasal mucosal melanoma, adjuvant radiation therapy may not provide a survival benefit as patients tended to do poorly regardless of adjuvant radiation status.

Lineage and species-specific long noncoding RNAs during erythro-megakaryocytic development.

Mammals express thousands of long noncoding (lnc) RNAs, a few of which are known to function in tissue development. However, the entire repertoire of lncRNAs in most tissues and species is not defined. Indeed, most lncRNAs are not conserved, raising questions about function. We used RNA sequencing to identify 1109 polyadenylated lncRNAs expressed in erythroblasts, megakaryocytes, and megakaryocyte-erythroid precursors of mice, and 594 in erythroblasts of humans. More than half of these lncRNAs were unannotated, emphasizing the opportunity for new discovery through studies of specialized cell types. Analysis of the mouse erythro-megakaryocytic polyadenylated lncRNA transcriptome indicates that ~75% arise from promoters and 25% from enhancers, many of which are regulated by key transcription factors including GATA1 and TAL1. Erythroid lncRNA expression is largely conserved among 8 different mouse strains, yet only 15% of mouse lncRNAs are expressed in humans and vice versa, reflecting dramatic species-specificity. RNA interference assays of 21 abundant erythroid-specific murine lncRNAs in primary mouse erythroid precursors identified 7 whose knockdown inhibited terminal erythroid maturation. At least 6 of these 7 functional lncRNAs have no detectable expression in human erythroblasts, suggesting that lack of conservation between mammalian species does not predict lack of function.