Postoperative care for children after ventilation tube surgery: A qualitative study of parents' experiences over time in Norway.

OBJECTIVE: To explore the parents' experience of postoperative care during the first two years after ventilation tube (VT) surgery in a setting where the check-ups were conducted either by otolaryngologists or their regular general practitioner (GP). METHODS: 55 individual interviews of parents at up to three different time points (<1, 6, and 24 months) after their child received VT-surgery, analyzed with reflexive thematic analysis. RESULTS: 1. Parents' trust in the healthcare system and responsibility for booking check-ups. Nearly all parents seemed to maintain trust in the healthcare system and felt safeguarded regardless of where they had their check-ups. Still, they would prefer otolaryngologist-led care if they could choose from the top shelf. They took responsibility for seeking healthcare when needed and experienced that their GP referred their child if necessary. 2. As time goes by, parental worries are reduced. Most experienced that their child stayed healthy after surgery, and their demand for postoperative check-ups decreased. For the children who faced ongoing issues, most parents experienced that their child's challenges had been handled professionally, and they became less worried. Some parents attribute other diagnoses to their child's behavior or speech delays, refining their understanding of their child's condition. 3. The desire for closure. Parents sought reassurance about their child's recovery and desired professional evaluation for closure. While some advocated for audiometry, others trusted their own assessments about hearing. The transition to school marked a pivotal time, prompting concerns about social inclusion. CONCLUSION: Overall, the parents experienced that their child was safeguarded irrespective of whether postoperative care was provided by otolaryngologists or GPs. Still, many preferred check-ups by an otolaryngologist. The parental worries and focus on the VTs were reduced as time went by after surgery, but even so many wanted a 'closure' to be sure that the hearing was as good as it could be and the VTs rejected. We advocate for an individualized approach to postoperative care that addresses specific medical needs without imposing unnecessary check-ups.

Show Me the Money, I'll Show You My Complications: Impacts of Incentivized Incident Self-Reporting Among Surgeons.

INTRODUCTION: Trial and error have the propensity to generate knowledge. Near misses and adverse event reporting can improve patient care. Professional ridicule or litigation risks after an incident may lead to decreased reporting by physicians; however, the lack of incident reporting can negatively affect patient safety and halt scientific advancements. This study compares reporting patterns after distribution of financial incentives to surgeons for self-reporting quality incidents. METHODS: Retrospective review of an internal incident reporting system, RL6, from September 2018 to September 2019 was performed. Incident reporting patterns after incentive distributions across professional classifications and surgical specialties were evaluated. Engagement surveys on incident reporting were completed by physicians. The primary outcomes were changes in reporting patterns and perceptions after distribution of incentives. RESULTS: Two hundred and eighteen surgical patients were identified in the incidents reported. Financial incentives significantly increased incidents reported (35 to 183) by physicians (37.1% to 67.8%; P < 0.001) and physician assistants (2.9% to 18.6%; P < 0.001). Acute care surgery displayed the largest increase in incidents reported among surgical specialties (5.7% to 20.2%; P = 0.040). Surgeons exhibited an increase in reporting (60.0% to 94.5%; P < 0.001) compared with witnesses after incentivization (2.9% to 1.6%). CONCLUSIONS: Financial incentives were associated with increased incident reporting. After the establishment of incentives, physicians were more likely to report their incidents, which may dispel professional embarrassment and display incident ownership. Institutions must encourage reporting while supporting providers. Future quality-improvement studies targeting reporting should incorporate incentives aimed to engage and empower health-care providers.

Perception of male otolaryngologists on gender discrimination: a comparative study.

PURPOSE: To gather information on perception of male otolaryngologists (MORLs) about gender discrimination towards female otolaryngologists (FORLs). METHODS: MORLs were invited to participate to an online survey. Minimum participation requirement was completion of at least their first year of residency. The responses were analyzed and compared vis-a-vis with the previously conducted similar survey among FORLs. RESULTS: Statistically significant responses on the Likert scale are classified in four main groups. MORLs and FORLs share the same views about financial factors, benefits and opportunities, housework as burden, establishing work-life balance and physical strength requirements. They have opposing views about FORLs being meticulous, exposed to more negative attitude of the opposite gender and men's dominance in decision-making. FORLs don't have consensus, but MORLs disagree about MORLs being favored in pursuing academic careers. On the other hand, MORLs don't have consensus, but FORLs agree about patients having more confidence in MORLs. CONCLUSION: MORLs don't usually have any confrontation with FORLs in regards to the roles of women in the society such as their motherhood role. On the other hand, MORLs show rather a contradiction on their perception towards the gender discrimination mainly in achieving career goals by FORLs such as growing in the profession and holding managing roles. When the views of the both gender group are compared, MORLs don't seem to fully acknowledge FORLs' gender discrimination experience.

Probiotics for the management of upper respiratory diseases.

Probiotics represent an intriguing challenge in clinical practice. They are currently used worldwide in all fields of Medicine. The present Supplement reports some Italian experiences concerning a probiotic mixture (Abincol®) employed in patients with upper respiratory diseases. A group of Italian otolaryngologists conducted these experiences in a real-world setting. The results demonstrated that this compound might represent a useful therapeutic option in clinical practice. In particularly, this probiotic mixture was tested in patients with rhinosinusitis, pharyngotonsillitis, otitis media, and laryngotracheitis.

Could a mannequin simplify rhinopharyngeal swab collection in COVID 19 patients?

Rhinopharyngeal swab collection is used to test patients for COVID-19; unfortunately, the false negative rate is around 30% in symptomatic patients, and maybe even higher in asymptomatic ones. A correct swab collection is consequently critical. Swabs are usually performed by dedicated personnel, but at the present moment, the methods for its training are not standardized. In a Letter to the Editor recently published in the European Archives of Otorhinolaringology, Tagliabue et al. describe the training method used in their Institution: the personnel dedicated to swab collection increases its confidence with the procedure by observing endoscopic anatomy, while an otolaryngologist performs rigid endoscopy. Although we found this paper interesting, we think that the author's proposal has timing and financial drawbacks that should be considered in daily activity, especially in an emergency period like the pandemic we are experiencing. In this Letter to the Editor, we discuss some pre-analytic and analytic issues that should be considered while performing rhinopharyngeal swabs, and we propose the use of a mannequin to train personnel, thus reducing the risk of infection for health workers, and patient's discomfort.

Network Analysis of Women in Otolaryngology and Demographic Trends.

OBJECTIVE: This study analyzes gender disparities between men and women otolaryngology faculty in the top 20 otolaryngology departments ranked by research output and discusses the implications of these disparities. METHODS: This was a cross-sectional study of all articles published by faculty from January 2020 to December 2021 at the top 20 otolaryngology departments as ranked by Doximity's 2022 research output report. Integrated data from Web of Science, faculty directories, and NIH RePORT were used to collect data on faculty. Social network analysis was performed using ORA-LITE. Student's and Welch's t-tests and Pearson chi-squared tests were used to evaluate gender differences in academic metrics. RESULTS: The findings revealed significant gender disparities, with men holding higher academic positions (men = 3.16, women = 2.69, p < 0.0001), higher H-indices (22.4, 13.8, p < 0.0001), more NIH grants (0.15, 0.07, p = 0.0032), and greater total degree centrality (3.98E-4, 2.4E-4, p < 0.0001) and betweenness centrality (4.47E-3, 3.00E-3, p = 0.0021). Men also had more publications (9.8, 6.8, p < 0.0001) with more distinct co-authors, both within (4, 3.1, p = 0.0074) and across (38.1, 25.8, p < 0.0001) institutions. Disparities persisted after accounting for career length. Notably, total degree centrality differences between men and women were statistically significant from 1991 to 2017 (p < 0.0001), but not from 2018 to 2022 (p = 0.83). CONCLUSIONS: This study highlights gender inequities in otolaryngology, encouraging mentors to foster new collaborations with female peers. Importantly, it identifies a trend toward narrowing the gender gap within the specialty, particularly over the past 5 years, emphasizing the need to sustain these positive changes for enhanced gender equity. LEVEL OF EVIDENCE: NA Laryngoscope, 2024.

Forecasting Rural and Urban Otolaryngologists, Radiation Oncologists, and Oropharyngeal Carcinoma.

OBJECTIVE: To forecast oropharyngeal carcinoma (OPC) incidence with otolaryngologist and radiation oncologist numbers per population by rural and urban counties through 2030. METHODS: Incident OPC cases were abstracted from the Surveillance, Epidemiology, and End Results 19 database, and otolaryngologists and radiation oncologists from the Area Health Resources File by county from 2000 to 2018. Variables were analyzed by metropolitan counties with over 1,000,000 people (large metros), rural counties adjacent to a metro (rural adjacent), and rural counties not adjacent to a metro (rural not adjacent). Data were forecasted via an unobserved components model with regression slope comparisons. RESULTS: Per 100,000 population, forecasted OPC incidence increased from 2000 to 2030 (large metro: 3.6 to 10.6 cases; rural adjacent: 4.2 to 11.9; rural not adjacent: 4.3 to 10.1). Otolaryngologists remained stable for large metros (2.9 to 2.9) but declined in rural adjacent (0.7 to 0.2) and rural not adjacent (0.8 to 0.7). Radiation oncologists increased from 1.0 to 1.3 in large metros, while rural adjacent remained similar (0.2 to 0.2) and rural not adjacent increased (0.2 to 0.6). Compared to large metros, regression slope comparisons indicated similar forecasted OPC incidence for rural not adjacent (p = 0.58), but greater for rural adjacent (p < 0.001, r = 0.96). Otolaryngologists declined for rural regions (p < 0.001 and p < 0.001, r = -0.56, and r = -0.58 for rural adjacent and not adjacent, respectively). Radiation oncologists declined in rural adjacent (p < 0.001, r = -0.61), while increasing at a lesser rate for rural not adjacent (p = 0.002, r = 0.96). CONCLUSIONS: Rural OPC incidence disparities will grow while the relevant, rural health care workforce declines. LEVEL OF EVIDENCE: NA Laryngoscope, 134:136-142, 2024.

Online Training or Face-to-Face Training from the Perspective of Ear, Nose, and Throat and Head and Neck Surgeons?

PURPOSE: To determine the preferences of Ear, Nose, and Throat (ENT) and Head-Neck Surgery (HNS) specialists and residents undergoing training for online or face-to-face training and the factors affecting the preference. METHODS: An 16-item questionnaire was created using Google Forms and was administered to residents undergoing training in ENT departments and to specialists working in the same field. The questionnaires were distributed online and requested to be completed between August and October 2020. The study participants were analyzed in two groups according to the preference for online training or face-to-face training. RESULTS: Evaluation was made of a total of 173 participants, as 68 (39.3%) in online training, and 105 (60.7%) in face-to-face training. Online training comprised 47 (69.1%) females and 21 (30.9%) males with a mean age of 38.9 ± 8years and face-to-face training comprised 68 (64.8%) females and 37 (35.2%) males with a mean age of 37.9 ± 7.5years (gender: P = 0.55, age: P = 0.10). Of the total sample, 39 (22.5%) subjects were single and 134 (77.5%) were married. Face-to-face training was preferred by 61.2% of the married respondents and by 59% of those who were single. While 43.4% stated that visuals and documents were similar in both forms of training, those who stated that documentation was better in face-to-face training constituted 90.2% of the group that preferred face-to-face training (P = 0.0001). Of the total participants, 65.4% stated that concentration was easier in face-to-face training (P = 0.0001). When the groups were compared according to areas of interest, more of those involved in rhinology and head-neck surgery were in face-to-face training, and those with an interest in otology were seen to be in online training (P = 0.002). A wish to continue online training after the pandemic was expressed by 80.9% of the whole sample, and 68.6% wished to continue with face-to-face training (P = 0.0001). Hybrid meetings were determined to have been selected by 86.1% (P = 0.0001). CONCLUSION: Online web seminars have an important role as a teaching and learning tool. There is a need for further research to evaluate how these clinically focused seminars can be presented at high quality and how they can provide benefit in training.

'It is difficult for us to assess the severity!' A qualitative analysis of parents' expectations to postoperative care after ventilation tube surgery.

OBJECTIVE: Surgery with ventilation tubes (VT) in children suffering from otitis media with effusion is quite common. However, the knowledge surrounding parents' expectations to the treatment and postoperative care is sparse. The aim of this study was to describe the parents' expectations to VT surgery and postoperative care shortly after surgery. METHODS: A qualitative study was conducted based on semi-structured individual interviews with parents recruited from a study where postoperative care was randomized to either an otolaryngologist or the patient's general practitioner (GP). The interviews were conducted within the first weeks after surgery and analyzed by reflexive thematic analysis. RESULTS: In total, 13 parents aged 29-42 years participated in the study. We identified three main themes elucidating parents' expectations to VT surgery and postoperative care: 1) Preconceptions about VT surgery and hearing - most parents expected surgery to restore the child's normal hearing, and some were uncertain about their knowledge of normal hearing and VT treatment; 2) A safety net to ensure hearing and function - it was reassuring if the child received structured postoperative care that secured and notified appointments and had quick access to a specialist if needed; 3) High-quality care - most parents expected the otolaryngologist to provide the highest level of quality of care due to their specialist competence, special equipment and sufficient understanding of the problem to communicate well with parents. Postoperative care by the GP was perceived as incomplete among most parents due to a lack of both specialist competence and access to audiometry. CONCLUSION: Parents expect postoperative care to safeguard their child as long as needed after VT surgery, and they expect access to high-quality care. Low health literacy among some parents challenges the current method of postoperative care and requires that more emphasis be set on both informing and educating parents regarding hearing and VT treatment.

Factors related to wellness and burnout in academic otolaryngology: A pre- and Post-COVID-19 analysis.

Objectives: Describe demographic and professional factors predictive of burnout in academic otolaryngology before and during the COVID-19 pandemic. Methods: In 2018 and 2020, cross-sectional surveys on physician wellness and burnout were distributed to faculty members of a single academic institution's otolaryngology department. Faculty were dichotomized into low and high burnout groups for 2018 (n = 8 high burnout, 19%) and 2020 (n = 11 high burnout, 37%). To identify protective factors against burnout, three semi-structured interviews were conducted with faculty that reported no burnout. Results: Forty-two participants (59%) in 2018 and 30 out of 49 participants (62%) in 2020 completed the survey. In multivariate analysis of 2018 survey data, full and associate professors had significantly lower odds of high burnout (OR 0.06, 95% CI 0.00-0.53; p = .03). Female gender was associated with increased in odds of high burnout (OR 15.55, 95% CI 1.86-231.74; p = .02). However, academic rank and gender did not remain independent predictors of high burnout in the 2020 survey. We identified significant differences in drivers of burnout brought on by the pandemic, including a shift from a myriad of work-related stressors in 2018 to a focus on patientcare and family obligations in 2020. Interview analysis identified three themes in faculty who reported no burnout: (1) focus on helping others, (2) happiness over compensation as currency, and (3) gratitude for the ability to have an impact. Conclusion: Approximately 20% of faculty reported high burnout before the pandemic, and this proportion nearly doubled during the pandemic. The risk factors and themes identified in this study may help academic otolaryngologists prevent burnout. Lay Summary: Factors driving burnout among academic otolaryngologists during the COVID-19 pandemic transitioned away from research, conferences, and work outside business hours toward family and patient responsibilities. Females report higher burnout and full professors report lower burnout. Level of evidence: III.

Optimizing Workflow in Combined Petrosectomy Approaches: Surgical Technique and Case Series.

BACKGROUND AND OBJECTIVE: The combined petrosectomy is one of the workhorse skull base approaches to the petroclival region. Traditionally, this approach starts with a temporosuboccipital craniotomy, followed by the mastoidectomy/anterior petrosectomy, and completed with the dural opening/tumor resection. This sequence of events (neurosurgery-neuro-otology-neurosurgery) involves at least 2 handoffs and change of surgical teams and instrumentation. This report describes a resequencing of events and a modification of the technique used to craft the temporosuboccipital craniotomy, with aims to reducing handoffs between surgical teams and improving operating room workflow. METHODS: Adhering to PROCESS guidelines, a case series is provided in addition to the surgical technique and surgical images. RESULTS: The technique for performing a combined petrosectomy is described with illustrations. This description shows that the temporal bone drilling may be performed before the craniotomy to allow for direct visualization of the dura and sinuses before completing the craniotomy. In doing so, only 1 transition between the otolaryngologist and neurosurgeon is necessary, thereby improving operating room workflow and time management. A series of 10 patients is presented, showing the feasibility of this procedure and providing operative details that were previously absent in the peer-reviewed literature. CONCLUSIONS: Combined petrosectomy, although often performed in a 3-step manner with the neurosurgeon starting the craniotomy, can be performed as described here in a 2-step manner, with similar outcomes and reasonable operating time.

Ethical issues experienced by otolaryngologists: a conventional content analysis.

To deliver effective medical services and establish trust and psychological security in patients, care providers must prioritize ethical principles. Developing a comprehensive clinical education program for learners, along with specific ethical guidelines, and implementing managerial and executive interventions necessitates a thorough understanding of the ethical challenges within this field. This qualitative study aimed to elucidate the ethical issues faced by otolaryngologists. Sixteen otolaryngologists participated in the study, selected through purposive sampling. Data were gathered through semi-structured interviews, and the analysis, conducted through conventional content analysis, revealed eight main categories and 38 subcategories encapsulating the identified ethical issues. The primary categories encompassed ethical issues faced by otolaryngologists concerning patients and companions, education, communication with the treatment team, physicians' rights, medical tourism, medical advertising, cultural considerations, and managerial challenges. resources and treatment approaches in alignment with Iranian cultural norms, address conflicts between treatment and education, and implement sound management plans to uphold rights of the treatment team. Additionally, the study suggests the necessity of ethical advertising programs and the strategic promotion of therapeutic tourism.

Assessment of Saudi Physicians and Physical Therapists' Adherence to the Updated Clinical Practice Guideline for Benign Paroxysmal Positional Vertigo: A Cross-Sectional Study.

Introduction Variations in clinical practice regarding the management of benign paroxysmal positional vertigo (BPPV) among clinicians have been noted in previous studies. Such variations might be related to the different adherence to clinical practice guidelines. Objective To evaluate clinicians' adherence to BPPV guidelines and investigate the variations in the adherence between different specialties and qualifications. Methods This is a cross-sectional study with a vignettes-based survey conducted between June and August, 2020. We included clinicians engaged in managing BPPV that had at least one year of clinical experience. We excluded students, and clinicians who were not involved in the management of individuals with BPPV. Participants were asked to make their management choices based on four hypothetical patient vignettes. The sample ranged from 77 participants for the first vignette to 45 participants for the last vignette. Results We included 77 clinicians in the study, with the majority being Otolaryngologists (31.2%). The respondents' mean adherence to the guideline was of 63.3%. Result showed that Otolaryngologists' adherence was higher than that of clinicians from different specialties ( p = 0.006, d = 0.72). Furthermore, clinicians with a postgraduate degree were more likely to adhere than those with a bachelor's degree only ( p = 0.014, d = 0.58) and participants who were aware of the guideline were more likely to adhere to it ( p < 0.001, d = 1.05). Lastly, regression analysis exhibited that adherence was affected by postgraduate degree and guideline awareness. Conclusion Otolaryngologists were more likely to adhere to the guideline than other specialties. Among all specialties, higher adherence was associated with guideline awareness and postgraduate degrees.

Assessment of Financial Relationships Between Otorhinolaryngologists and Pharmaceutical Companies in Japan Between 2016 and 2019.

INTRODUCTION: There are prevalent financial relationships between physicians and the pharmaceutical industry in medical specialties, including otorhinolaryngology. Although these relationships might cause conflicts of interest, no studies have assessed the size and contents of the financial relationships between otorhinolaryngologists and pharmaceutical companies in Japan. This study aims to evaluate the magnitude, prevalence, and trend of the financial relationship between Japanese otolaryngologists and pharmaceutical companies. METHODS:  Using payment data publicly disclosed by 92 pharmaceutical companies, we examined the size, prevalence, and trend in personal payments made to the otorhinolaryngologist board certified by the Japanese Society of Otorhinolaryngology-Head and Neck Surgery (JSO-HNS) between 2016 and 2019 in Japan. Furthermore, differences in payments were evaluated by whether otolaryngologists were clinical practice guideline authors, society board members, and academic journal editors or not. Trends in payments were evaluated by generalized estimating equations. RESULTS:  Of 8,190 otorhinolaryngologists, 3,667 (44.8%) were paid a total of $13,873,562, in payments for lecturing, consulting, and writing by 72 pharmaceutical companies between 2016 and 2019. The median four-year combined payment per physician was $1,022 (interquartile range: $473-$2,526). Top 1%, 5%, and 10% of otorhinolaryngologists received 42.3% (95% confidence interval (95% CI): 37.2%-47.4%), 69.3% (95% CI: 65.9%-72.8%), and 80.6% (95% CI: 78.3%-82.9%) of overall payments, respectively. The median payments per physician were significantly higher among otorhinolaryngologists authoring clinical practice guidelines ($11,522), society board members ($22,261), and journal editors ($35,143) than those without. The payments and number of otorhinolaryngologists receiving payments remained stable between 2016 and 2019. CONCLUSION:  This study demonstrates that a minority but a large number of otorhinolaryngologists received personal payments from pharmaceutical companies for the reimbursement of lecturing, consulting, and writing in Japan. Large amounts of these personal payments were significantly concentrated on a small number of leading otorhinolaryngologists.

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.

Charles F. Ferguson, MD: America's first full time pediatric otolaryngologist.

This historical review highlights the career of Charles F. Ferguson, MD for whom the annual clinical science awards bestowed by the American Society of Pediatric Otolaryngology are named. Dr. Ferguson was the first full time pediatric otolaryngologist in the United States. His career at Boston Children's Hospital spanned almost four decades. Disorders of the larynx, trachea and bronchi were his principal professional focus, with a specific expertise in bronchoesophagology. His pioneering work in pediatric airway endoscopy and the development of techniques to diagnose congenital airway malformations led to his receipt of the Chevalier Jackson Award from the American Bronchoesophagological Association, and the James Newcomb Award from the American Laryngological Society. He notably edited the first Pediatric Otolaryngology textbook in 1972. His life's work help set the foundation for the creation of the American Society of Pediatric Otolaryngology in 1984, six years following his retirement. The Charles Ferguson Clinical Science Awards were established to sustain his legacy.

From a Slave to a Surgeon: David Kearney McDonogh, the First Black Otolaryngologist.

David McDonogh, born into chattel slavery in Louisiana in the early 1800s, accomplished the unfathomable by becoming the first Black otolaryngologist in the United States of America. With tireless determination and profound intellect, Dr McDonogh surmounted immeasurable adversity along his improbable journey to freedom and success as an eye, ear, nose, and throat doctor in New York. His doctorate in medicine was posthumously awarded to his great-great-granddaughter in 2018 by the Columbia University Vagelos College of Physicians and Surgeons. In this History of Otolaryngology piece, we share his extraordinary story.

Idiopathic Intracranial Hypertension: A Comprehensive Overview.

Idiopathic intracranial hypertension (IIH), also called pseudotumor cerebri syndrome, is a disorder defined as elevated intracranial pressure (ICP) of unknown cause. It is a diagnosis of exclusion in most cases, and all other forms of elevated ICP must be ruled out. With its increasing prevalence, it is much more likely for physicians, otolaryngologists included, to encounter this condition. It is important to have a clear understanding of the typical and atypical presentation of this disease, along with its evaluative workup and management options. This article reviews IIH with a focus on those factors that are specifically relevant to otolaryngologic care.