Otolaryngology–Head and Neck Surgery

Special Focus Section: Patient Safety/Quality Improvement

Invited Article

Patient Safety/Quality Improvement Primer, Part II: Prevention of Harm Through Root Cause Analysis and Action (RCA2) Karthik Balakrishnan, MD, MPH, Michael J. Brenner, MD, John W. Gosbee, MD, MS, Cecelia E. Schmalbach, MD, MSc First Published October 1, 2019; pp. 911–921 Abstract Hide Preview With increasing emphasis on patient safety/quality improvement, health care systems are mirroring industry in the implementation of root cause analysis (RCA) for the identification and mitigation of errors. RCA uses a team approach with emphasis on the system, as opposed to the individual, to accrue empirical data on what happened and why. While many otolaryngologists have a broad understanding of RCA, practical experience is often lacking. Part II of this patient safety/quality improvement primer investigates the manner in which RCA is utilized in the prevention of medical errors. Attention is given to identifying system errors, recording adverse events, and determining which events warrant RCA. The primer outlines steps necessary to conduct an effective RCA, with emphasis placed on actions that arise from the RCA process through the root cause analysis and action (or RCA2) rubric. In addition, the article provides strategies for the implementation of RCA into clinical practice and medical education. |

Risk Factors for Blood Transfusion with Neck Dissection Monica C. Azmy, Juanita Pinto, Nirali M. Patel, Aparna Govindan, Evelyne Kalyoussef, MD First Published April 2, 2019; pp. 922–928 Abstract Hide Preview Objectives To identify risk factors of perioperative blood transfusions (PBTs) for neck dissection and identify the association of PBTs with other postoperative outcomes. Methods This is a retrospective study of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. The database was queried for neck dissection procedures performed by otolaryngologists from 2006 to 2014. Multivariable logistic regression was used to determine associations between demographic and preoperative factors, mortality, unplanned reoperation, and unplanned readmission with PBTs. Results Of the 3090 patients included in our study, 346 (11.2%) received a PBT, 249 patients (72.0%) received blood intraoperatively or on postoperative day (POD) 0, and 97 patients (28.0%) received blood within 5 PODs. American Society of Anesthesiologists (ASA) class ≥3 (odds ratio [OR], 2.1; 95% confidence interval [CI], 1.4-3.2), preoperative weight loss (OR, 2.2; 95% CI, 1.5-3.2), and anemia (OR, 5.5; 95% CI, 4.1-7.6) were independently associated with PBTs. Free flaps were also significantly associated with PBTs. PBTs were significantly associated with unplanned return to the operating room within 30 days (OR, 4.31; 95% CI, 3.01-6.18) but not with 30-day unplanned readmission or 30-day mortality. Discussion Eleven percent of patients undergoing neck dissection receive a PBT. Identifying associated risk factors may reduce PBT among patients with cancer. Comorbid data, such as weight loss, anemia, and ASA class, may be useful in determining risk for transfusion during these procedures. Implications for Practice Awareness of preoperative risk factors for PBT may lead surgeons to reduce the risk of PBT, anticipate the need for transfusion, and manage these patients carefully to prevent unplanned reoperation. |

A Critical Analysis of Medicare Claims for Otolaryngology Procedures Stephanie J. Youssef, Krishna S. Vyas, MD, PhD, MHS First Published June 25, 2019; pp. 929–938 Abstract Hide Preview Objective This study was performed to outline and analyze the overall Medicare landscape with respect to otolaryngologists and beneficiaries, services, and reimbursements. Methods This is a retrospective analysis of publicly available Medicare utilization and payment data for all otolaryngologists in facility and nonfacility practice settings who provided services to Medicare beneficiaries between January 1, 2012, and December 31, 2016. Results In 2016, a total of $701,195,375 was distributed to 8572 otolaryngology physician providers for 815 unique Healthcare Common Procedure Coding System codes for 13,942,536 procedure claims. Of specialty care, otolaryngology ranks 20th among 54 subspecialties for total Medicare payments. The average number of services coded per provider was 1627. The average otolaryngologist was paid $81,800.67. Thirty-two percent of otolaryngologists did not receive reimbursement for services from Medicare in 2016. Discussion In 2016, the most significant contributors to Medicare payments to otolaryngologists were large-scale, low-cost events that are relatively short procedures done in clinic. Utilization of nasal endoscopy was up trending from 2012 to 2016. Some of the Current Procedural Terminology codes with the greatest discrepancies between submitted charge and Medicare payment among nonfacility otolaryngology providers are more involved than simple office procedures. Implications for Practice It is increasingly valuable for physicians to know factors that affect reimbursement for procedures and operations in different settings and to be aware of the trends in variation in their specialty. Otolaryngologists should communicate with policy makers in efforts toward sustainable reimbursement models. |

Assessments of Otolaryngology Resident Operative Experiences Using Mobile Technology: A Pilot Study Jenny X. Chen, MD, Elliott Kozin, MD, Jordan Bohnen, MD, Brian George, MD, Daniel G. Deschler,Kevin Emerick, MD, Stacey T. Gray, MD First Published August 13, 2019; pp. 939–945 Abstract Hide Preview Objectives Surgical education has shifted from the Halstedian model of “see one, do one, teach one” to a competency-based model of training. Otolaryngology residency programs can benefit from a fast and simple system to assess residents’ surgical skills. In this quality initiative, we hypothesize that a novel smartphone application called System for Improving and Measuring Procedural Learning (SIMPL) could be applied in an otolaryngology residency to facilitate the assessment of resident operative experiences. Methods The Plan Do Study Act method of quality improvement was used. After researching tools of surgical assessment and trialing SIMPL in a resident-attending pair, we piloted SIMPL across an otolaryngology residency program. Faculty and residents were trained to use SIMPL to rate resident operative performance and autonomy with a previously validated Zwisch Scale. Results Residents (n = 23) and faculty (n = 17) were trained to use SIMPL using a standardized curriculum. A total of 833 assessments were completed from December 1, 2017, to June 30, 2018. Attendings completed a median 20 assessments, and residents completed a median 14 self-assessments. All evaluations were resident initiated, and attendings had a 78% median response rate. Evaluations took residents a median 22 seconds to complete; 126 unique procedures were logged, representing all 14 key indicator cases for otolaryngology. Discussion This is the first residency-wide application of a mobile platform to track the operative experiences of otolaryngology residents. Implications for Practice We adapted and implemented a novel assessment tool in a large otolaryngology program. Future multicenter studies will benchmark resident operative experiences nationwide. |

Review Article

Submental Island Flap versus Free Flap Reconstruction for Complex Head and Neck Defects Mads Gustaf Jørgensen, MD, Siavosh Tabatabaeifar, MD, Navid Mohamadpour Toyserkani, MD, PhD,Jens Ahm Sørensen, MD, PhD First Published September 10, 2019; pp. 946–953 Abstract Hide Preview Objective Complex soft tissue reconstruction of the head and neck requires a viable, versatile, and dependable flap. Free flaps, such as the radial forearm and anterolateral thigh flap, have been the mainstay of complex head and neck reconstruction. However, a local pedicled flap, such as the submental island flap (SIF), could be a more effective and less demanding alternative. This systematic review and meta-analysis aim to compare free tissue transfer (FTT) with the SIF for head and neck reconstruction. Data Sources We performed a systematic search in PubMed and EMBASE databases. Meta-analysis was performed on outcomes reported in ≥3 studies. Review Methods Candidate articles were assessed for eligibility by 2 authors. Three authors performed data extraction and methodological quality of the included studies using the Newcastle-Ottawa Quality Assessment Form for Cohort Studies. Results The search strategy resulted in 450 studies, of which 7 were included in the analysis, yielding 155 SIF and 198 FTT cases. Operating time and length of stay were significantly lower for the SIF than for FTT (P = .05 and P = .0008). There was no significant difference between the groups for complete flap loss, debulking revisions, and oncologic recurrence. Conclusion These results suggest that the SIF reduces length of stay and operating time as compared with FTT in head and neck reconstruction. These findings suggest that the SIF can be considered an alternative reconstructive option to FTT when evaluating intraoral, lateral facial, skull base, and parotidectomy defects, given comparable defect size and tumor biology. |

Endocrine Surgery

Pattern of Intraoperative Parathyroid Hormone and Calcium in the Treatment of Tertiary Hyperparathyroidism André Luís Maion Casarim, MD, Fernando Antonio Maria Claret Arcadipane, MD, PhD, Antonio Santos Martins, MD, PhD, André Del Negro, MD, PhD, André Afonso Nimtz Rodrigues, MD, PhD, Alfio Jose Tincani, MD, PhD, Evaldo Marchi, MD, PhD First Published July 30, 2019; pp. 954–959 Abstract Hide Preview Objective Tertiary hyperparathyroidism, an autonomous hyperproduction of parathyroid hormone (PTH), has a challenge in its treatment. This study asked whether the intraoperative PTH and calcium drop can confirm the resection of all parathyroid tissues. Study Design Case series with planned data collection. Setting Tertiary referral medical center. Subjects and Methods The study assessed patients with tertiary hyperparathyroidism who were treated at the Hospital of the State University of Campinas from 2007 to 2015. All patients underwent total parathyroidectomy with autotransplantation of parathyroid fragments. PTH and calcium were collected during the preoperative period; at 10, 20, and 240 minutes after resection of the glands; and at 1 year after the procedure. Data were analyzed by analysis of variance and logistic regression analysis with statistical values of P < .05. Results Thirty-five patients were assessed: 17 women (48.57%) and 18 men (51.43%). The percentage of PTH drop was statistically significant at all times, unlike the calcium analysis, but only PTH collected at 20 minutes was able to confirm the removal of all parathyroid tissues (P = .029). Based on the receiver operating characteristic curve, the 71.2% drop obtained high sensitivity and specificity (P = .028). Conclusions Treatment success can be predicted by analyzing the decrease of intraoperative PTH and not by calcium. The 71.2% PTH drop at 20 minutes after parathyroidectomy had high sensitivity and specificity to predict surgical cure. |

General Otolaryngology

Postoperative Opioid Prescribing and Consumption Patterns after Tonsillectomy Stephanie Choo, Stephen Nogan, MD, Laura Matrka, MD First Published July 30, 2019; pp. 960–966 Abstract Hide Preview Objectives Despite increased concern with the opioid epidemic, literature remains scant regarding narcotic prescription and use following tonsillectomy. Study Design Retrospective cohort study with telephone interview. Subject and Methods A chart review from January to August 2018 evaluated the difference between prescribed amounts of narcotic and patient-reported usage following tonsillectomy (Current Procedural Terminology codes 42821 and 42826). Patients were excluded if they used opioids for chronic pain, had a history of chronic opioid use or substance abuse, or underwent tonsillectomy to exclude malignancy. A telephone interview assessed opioid and nonopioid usage and pain control postoperatively, including amount and form of narcotics remaining. Results Sixty-four patients were enrolled at a mean 4.47 months after tonsillectomy. The mean ± SD prescribed morphine milligram equivalent (MME) was 456.1 ± 281.7, with only 302.8 ± 206.2 consumed. The mean MME prescribed per day was 74.1 ± 44.8, and average days of narcotic usage postoperatively was 9.6 ± 4.6, correlating with a mean MME per day of 49.2 ± 34.3 if the maximum prescribed dose per day was consumed. Fifty-four (84.4%) patients reported pain as well controlled. Forty-three (67.2%) patients reported residual narcotic medication, with 228.1 ± 208.5 MMEs remaining per patient. Narcotic solutions were more completely consumed than tablet forms, with 23.1% and 44.0% remaining, respectively. Patients cited uncertainty about safe disposal and safeguarding for future use as reasons for keeping residual narcotic. Conclusions Patient-reported narcotic use is significantly lower than the amount prescribed after tonsillectomy for benign disease. Providers can use these data to adjust narcotic-prescribing patterns while maintaining appropriate pain management for patients undergoing tonsillectomy. |

Analysis of Potential Conflicts of Interest among Otolaryngologic Patient Advocacy Organizations in 2016 Neil S. Kondamuri, Vinay K. Rathi, MD, Matthew R. Naunheim, MD, MBA, Rosh V. Sethi, MD, MPH,Ashley L. Miller, MD, Mark A. Varvares, MD First Published September 3, 2019; pp. 967–969 Abstract Hide Preview Patient advocacy organizations (PAOs) are nonprofits dedicated to benefiting patients and their families through activities such as education/counseling and research funding. Although medical drug/device companies may serve as important partners, industry donations may bias the efforts of PAOs. We conducted a retrospective cross-sectional analysis of the Kaiser Health News nonprofit database to identify and characterize otolaryngologic PAOs (n = 32) active in 2016. Among these PAOs, half (n = 16, 50.0%) focused on otologic diseases, and mean total annual revenue was $3.1 million. Among the 15 PAOs (46.9%) with publicly available donor lists, 10 (66.7%) received donations from industry. Few PAOs publicly reported the total amount donated by industry (n = 3, 9.4%) or published policies for mitigating potential financial conflicts of interest with donors (n = 3, 9.4%). Requiring drug and device companies to publicly report donations to PAOs may help patients, providers, and policy makers to better understand advocacy by these influential stakeholders. |

Postoperative Analgesic Requirement and Pain Perceptions after Nonaerodigestive Head and Neck Surgery Elizabeth D. Stephenson, MD, Zainab Farzal, MD, Maryam Jowza, MD, Trevor Hackman, MD, Adam Zanation, MD, Eugenie Du, MD First Published September 3, 2019; pp. 970–977 Abstract Hide Preview Objectives Little data exist on associations between patient factors and postoperative analgesic requirement after head and neck (H&N) surgeries. Such information is important for optimizing postoperative care considering concerns regarding opioid misuse. We analyzed factors associated with narcotic use and pain perception following H&N surgery sparing the upper aerodigestive tract. Study Design Prospective cohort. Setting Tertiary referral center. Subjects and Methods From May to October 2017, data were collected for patients undergoing nonaerodigestive H&N procedures requiring hospitalization. Patients completed a preoperative survey querying chronic pain history, narcotic usage, and postoperative pain expectation. Demographics, surgical data, postoperative narcotic use defined by morphine milligram equivalents (MME), pain scores, and Overall Benefit of Analgesia Score (OBAS) were analyzed. Results Seventy-six patients, 44 (57.9%) females and 32 (42.1%) males with a mean age of 54.0 years, met inclusion criteria. The most common procedures were parotidectomy (27.6%) and total thyroidectomy (19.7%). Average cumulative 24-hour postoperative MME and calculated MME per hospital day (MME/HD, cumulative MME for hospitalization divided by length of stay) were 40.5 ± 30.6 and 60.8 ± 60.1, respectively. Average pain score throughout the initial 24 hours after surgery was 3.7/10 ± 2.0. Female sex and prior chronic pain diagnosis were associated with higher OBAS after multivariate linear adjustments. Conclusion Postoperative narcotic requirement in nonaerodigestive H&N surgery is overall low. Female sex and prior chronic pain diagnosis may be associated with higher postoperative OBAS, a validated assessment of pain and opioid-related side effects. This study may serve as a comparison for future studies evaluating narcotic-sparing analgesia and pain perception in nonaerodigestive H&N surgery. |

Head and Neck Surgery

Predictive Value of First Posttreatment Imaging Using Standardized Reporting in Head and Neck Cancer Derek Hsu, MD, Falgun H. Chokshi, MD, Patricia A. Hudgins, MD, Suprateek Kundu, PhD, Jonathan J. Beitler, MD, Mihir R. Patel, MD, Ashley H. Aiken, MD First Published July 23, 2019; pp. 978–985 Abstract Hide Preview Objective The Neck Imaging Reporting and Data System (NI-RADS) is a standardized numerical reporting template for surveillance of head and neck squamous cell carcinoma (HNSCC). Our aim was to analyze the accuracy of NI-RADS on the first posttreatment fluorodeoxyglucose positron emission tomography/contrast-enhanced computed tomography (PET/CECT). Study Design Retrospective cohort study. Setting Academic tertiary hospital. Subject and Methods Patients with HNSCC with a 12-week posttreatment PET/CECT interpreted using the NI-RADS template and 9 months of clinical and radiologic follow-up starting from treatment completion between June 2014 and July 2016 were included. Treatment failure was defined as positive tumor confirmed by biopsy or Response Evaluation Criteria in Solid Tumors criteria. Cox proportional hazards models were performed. Results This study comprised 199 patients followed for a median of 15.5 months after treatment completion (25% quartile, 11.8 months; 75% quartile, 20.2 months). The rates of treatment failure increased with each incremental increase in NI-RADS category from 1 to 3 (4.3%, 9.1%, and 42.1%, respectively). A Cox proportional hazards model demonstrated a strong association between NI-RADS categories and treatment failure at both primary and neck sites (hazard ratio [HR], 2.60 and 5.22, respectively; P < .001). In the smaller treatment subgroup analysis, increasing NI-RADS category at the primary site in surgically treated patients and treatment failure did not achieve statistically significant association (HR, 0.88; P = .82). Conclusion Increasing NI-RADS category at the baseline posttreatment PET/CECT is strongly associated with increased risk of treatment failure in patients with HNSCC. |

Margins in Laryngeal Squamous Cell Carcinoma Treated with Transoral Laser Microsurgery: A National Database Study Jonathan Hanna, Philip R. Brauer, Elliot Morse, Saral Mehra, MD, MBA First Published September 3, 2019; pp. 986–992 Abstract Hide Preview Objectives To determine national positive margin rates in transoral laser microsurgery, to compare patients with positive and negative margins, and to identify factors associated with positive margins. Study Design Retrospective review of the National Cancer Database. Setting Population based. Subjects/Methods Patients included those with TIS-T3 laryngeal squamous cell carcinoma (2004-2014). Univariable and multivariable logistic regression were used to identify predictors. Results A total of 1959 patients met inclusion criteria. The national positive margin rate was 22.3%. Sixty-five percent of patients had T1 disease; 94.3% were N-negative; and 74.0% had glottic tumors. Fifty-eight percent of patients were treated at academic centers, and 60.6% were treated at facilities performing <2 cases per year. On multivariable analysis, factors associated with margin status included facility volume (odds ratio [95% CI]; in cases per year: 0.93 [0.89-0.97], P = .001), academic status (vs nonacademic; academic: 0.70 [0.54-0.90], P = .008), T-stage (vs T1; T2: 2.74 [2.05-3.65], T3: 5.53 [3.55-8.63], TIS: 0.59 [0.38-0.92], P < .001), and N-stage (vs N0; N1: 3.42 [1.79-6.54], N2: 2.01 [1.09-3.69], P < .001). Tumor subsite was not associated with margin status. Conclusion The national positive margin rate for laryngeal laser surgery is 22%, which is concerning given the equivalent survival benefit offered by surgery and primary radiation and the increased likelihood of bimodal therapy in the situation of positive margins. Cases treated at nonacademic centers and those with lower caseloads had a higher likelihood of positive margins. There was a linear association between T-stage and likelihood of positive margins, with T3 tumors being 5 times as likely as T1 to yield positive margins. This study highlights the importance of proper patient selection for transoral laser microsurgery resections. |

Laryngology and Neurolaryngology

Plasma Ablation–Assisted Endoscopic Management of Postintubation Laryngotracheal Stenosis: An Alternate Tool for Management Ramandeep Singh Virk, MS, Sandeep Bansal, MS, Gyanaranjan Nayak, MS, DNB, Lokesh P, MS First Published October 8, 2019; pp. 993–995 Abstract Hide Preview The current study was conducted to highlight the use of plasma ablation as a promising method in management of adult laryngotracheal stenosis. We present our institutional experience with a minimum follow-up of 6 months. Seventy adult patients with acquired postintubation laryngotracheal stenosis were included. Efficacy and clinical outcomes of plasma ablation in endoscopic management and eventual decannulation rate were studied. Number of patients with Myer-Cotton stenosis grades 1, 2, 3, and 4 were 20, 25, 18, and 7, respectively. The mean number of surgical interventions required in each grade of stenosis were 1, 2, 3.8, and 4, respectively. Overall, 47 patients (67%) were without tracheotomy by the end of 6 months. Plasma ablation is an effective treatment option for adult laryngotracheal stenosis, with a better success rate for lower-grade stenosis. It has lesser complications and requires fewer surgical interventions. |

Otology and Neurotology

Association of Midlife Hypertension with Late-Life Hearing Loss Nicholas S. Reed, AuD, Matthew G. Huddle, MD, Joshua Betz, MS, Melinda C. Power, ScD, James S. Pankow, PhD, MPH, Rebecca Gottesman, MD, PhD, A. Richey Sharrett, MD, Thomas H. Mosley, PhD,Frank R. Lin, MD, PhD, Jennifer A. Deal, PhD First Published August 6, 2019; pp. 996–1003 Abstract Hide Preview Objective To investigate the association of midlife hypertension with late-life hearing impairment. Study Design Data from the Atherosclerosis Risk in Communities study, an ongoing prospective longitudinal population-based study (baseline, 1987-1989). Setting Washington County, Maryland, research field site. Subjects and Methods Subjects included 248 community-dwelling men and women aged 67 to 89 years in 2013. Systolic blood pressure (SBP) and diastolic blood pressure were measured at each of 5 study visits from 1987-1989 to 2013. Hypertension was defined by elevated systolic or diastolic blood pressure or antihypertensive medication use. A 4-frequency (0.5-4 kHz) better-hearing ear pure tone average in decibels hearing loss (dB HL) was calculated from pure tone audiometry measured in 2013. A cutoff of 40 dB HL was used to indicate clinically significant moderate to severe hearing impairment. Hearing thresholds at 5 frequencies (0.5-8 kHz) were also considered separately. Results Forty-seven participants (19%) had hypertension at baseline (1987-1989), as opposed to 183 (74%) in 2013. The SBP association with late-life pure tone average differed by the time of measurement, with SBP measured at earlier visits associated with poorer hearing; the difference in pure tone average per 10–mm Hg SBP measured was 1.43 dB HL (95% CI, 0.32-2.53) at baseline versus −0.43 dB HL (95% CI, −1.41 to 0.55) in 2013. Baseline hypertension was associated with higher thresholds (poorer hearing) at 4 frequencies (1, 2, 4, 8 kHz). Conclusion Midlife SBP was associated with poorer hearing measured 25 years later. Further analysis into the longitudinal relationship between hypertension and hearing impairment is warranted. |

Establishing an Animal Model of Single-Sided Deafness in Chinchilla lanigera Renee M. Banakis Hartl, MD, AuD, Nathaniel T. Greene, PhD, Victor Benichoux, PhD, Anna Dondzillo,PhD, Andrew D. Brown, PhD, Daniel J. Tollin, PhD First Published October 1, 2019; pp. 1004–1011 Abstract Hide Preview Objectives (1) To characterize changes in brainstem neural activity following unilateral deafening in an animal model. (2) To compare brainstem neural activity from unilaterally deafened animals with that of normal-hearing controls. Study Design Prospective controlled animal study. Setting Vivarium and animal research facilities. Subjects and Methods The effect of single-sided deafness on brainstem activity was studied in Chinchilla lanigera. Animals were unilaterally deafened via gentamycin injection into the middle ear, which was verified by loss of auditory brainstem responses (ABRs). Animals underwent measurement of ABR and local field potential in the inferior colliculus. Results Four animals underwent chemical deafening, with 2 normal-hearing animals as controls. ABRs confirmed unilateral loss of auditory function. Deafened animals demonstrated symmetric local field potential responses that were distinctly different than the contralaterally dominated responses of the inferior colliculus seen in normal-hearing animals. Conclusion We successfully developed a model for unilateral deafness to investigate effects of single-sided deafness on brainstem plasticity. This preliminary investigation serves as a foundation for more comprehensive studies that will include cochlear implantation and manipulation of binaural cues, as well as functional behavioral tests. |

Optimal Head Position Following Intratympanic Injections of Steroids, As Determined by Virtual Reality Omer J. Ungar, MD, Ophir Handzel, MD, Limor Haviv, MS, Solomon Dadia, MD, Oren Cavel, MD, Dan M. Fliss, MD, Yahav Oron, MD First Published September 24, 2019; pp. 1012–1017 Abstract Hide Preview Objectives To study optimal head position after intratympanic steroid injections to enhance drug bioavailability. Study Design Application of virtual and in vitro models of the intratympanic anatomy. Setting The surgical 3-dimensional printing laboratory of a tertiary academic medical center. Subjects and Methods A high-resolution computerized tomographic scan of healthy temporal bone and surrounding soft tissue was segmented and reconstructed to a 3-dimensional model. The tympanic membrane was perforated in the posterior-inferior quadrant. Methylene blue–stained 10-mg/mL dexamethasone was administered to the middle ear cleft, after which a 3-dimensional rotation in space was performed to hypothesize the optimal position in relation to gravity. The same stereolithography file used for the actual model was used for a digital virtual liquid flow simulation. The optimal head position was defined as the one with the maximum vertical distance between the round window membrane and the plane of the aditus ad antrum and eustachian tube orifice. Results The virtual model yielded the following position of the head as optimal: 53º rotation away from the injected ear in the vertical axis (yaw), 27º rotation toward the noninjected ear in the longitudinal axis (roll), and 10º neck extension in the transverse axis (pitch). Conclusions Virtual imaging determined that 53º and 27º yaw and roll, respectively, away and 10º pitch were the optimal position for drug delivery after intratympanic injection to the middle ear and that an erect head position provided optimal passage of steroids from the middle ear to the inner ear. |

Office-Based Stapes Surgery Béatrice Voizard, MD, Anastasios Maniakas, MD, Issam Saliba, MD, FRCSC First Published October 1, 2019; pp. 1018–1026 Abstract Hide Preview Objective The objective of this study was to provide a proof of concept and to assess the success and safety of stapes surgery for otosclerosis under local anesthesia in an office-based setting (OBS) as compared with a hospital operating room setting (ORS). Study Design Retrospective cohort study. Setting We reviewed all patients who underwent stapes surgery by the same surgeon from October 2014 to January 2017 at our tertiary care center (ORS, n = 36, 52%) and in an OBS (n = 33, 48%). Subjects and Methods The surgical technique was identical in both groups. All patients had a temporal bone computed tomography scan and audiogram within the 6 months prior to surgery. Air-bone gaps (ABGs), bone conduction, and air conduction pure tone average values were calculated. Preoperative results for pure tone average, bone conduction, ABG, and word recognition scores were compared with early (4 months) and late (12 months) follow-up audiograms. Intra- and postoperative complications were compared. Results Both groups were comparable in terms of demographic characteristics and severity of disease. The mean 1-year postoperative ABG was 5.66 dB (95% CI = 4.42-6.90) in the ORS group and 6.30 dB (95% CI = 4.50-8.10) in the OBS group (P = .55). ABG improved by 24.27 dB (95% CI = 21.40-27.13) in the ORS group and 23.15 dB (95% CI = 18.45-27.85) in the OBS group (P = .68). Complication rates did not differ, although this study remains underpowered. Conclusions In this small group of patients, the success of stapes surgery performed in an OBS and its complications were comparable to those of an ORS, thus providing an alternative to patients on long operating room waiting lists. |

The Role for Imaging in the Investigation of Isolated Objective Vestibular Weakness Deanna Gigliotti, MD, Brian Blakley, MD, Paige Moore, MD, Jordan Hochman, MD First Published October 1, 2019; pp. 1027–1030 Abstract Hide Preview Objective Unilateral vestibular weakness has considerable potential etiologies. One source is a vestibular schwannoma. This article evaluates, in the absence of other symptoms and signs, if unilateral vestibular weakness is an analogue to asymmetric sensorineural hearing loss and serves as an indication for lateral skull base imaging. Study Design Retrospective chart review. Setting Academic tertiary center. Subjects and Methods All patients undergoing caloric assessment between January 1, 2012, and June 30, 2018, were investigated. Patients with unilateral vestibular weakness (a left-right difference >25% on electronystagmography) were included in the study. A provincial encompassing image library was surveyed for potential adequate imaging (computed tomography internal auditory canal infused, magnetic resonance imaging [MRI] brain, MRI internal auditory canal) of the target population within the preceding 5 years. Presence/absence of vestibular schwannoma on imaging was determined. Results Of the 3531 electronystagmography reports reviewed during the period, 864 patients were identified with unilateral vestibular weakness. Of these, 542 had sufficient imaging, and 14 vestibular schwannomas were identified. Only 1 individual had a vestibular weakness in isolation, while the remaining 13 patients also suffered from documented sensorineural hearing loss that would have mandated MRI scanning. Conclusion The results of our study suggest that, in isolation, vestibular weakness is an insufficient indicator for lateral skull base imaging. |

Pediatric Otolaryngology

Application-Based Translaryngeal Ultrasound for the Assessment of Vocal Fold Mobility in Children Zahra Sayyid, PhD, Varun Vendra, MD, Kara D. Meister, MD, Catherine D. Krawczeski, MD, Noah J. Speiser, Douglas R. Sidell, MD First Published September 24, 2019; pp. 1031–1035 Abstract Hide Preview Objective To compare the evaluation of vocal fold mobility between flexible nasal laryngoscopy (FNL) and a handheld application-based translaryngeal ultrasound (TLUS) platform. Study Design Prospective analysis included patients with unknown vocal fold mobility status who underwent FNL and TLUS. Setting Tertiary referral center. Subjects and Methods TLUS was performed on 23 consecutive children (<18 years old) presenting for laryngoscopy due to unknown vocal fold mobility status. After the recording of three 10-second TLUS videos as well as FNL, the study was divided into 2 parts: parental assessment of laryngeal ultrasound at the time of patient evaluation and random practitioner assessment of ultrasound videos. Results We describe 23 patients who underwent TLUS and FNL. Ten patients (43.5%) had normal vocal fold function bilaterally, and 13 (56.5%) had either left or right vocal fold immobility. Family members and physicians correctly identified the presence and laterality of impaired vocal fold mobility in 22 of 23 cases (κ = 0.96). The sensitivity, specificity, positive predictive value, and negative predictive value of FLUS in diagnosing vocal fold immobility were 92.3%, 100%, 100%, and 90.9%, respectively. Random practitioners accurately identified the presence and laterality of vocal fold immobility under all circumstances. Conclusion A handheld application-based ultrasound platform is both sensitive and specific in its ability to identify vocal fold motion impairment. Portable handheld TLUS has the potential to serve as a validated screening examination, even by inexperienced providers, and in specific cases may obviate the need for an invasive transnasal laryngoscopy. |

Sinonasal Disorders

Clinical Implications of Carcinoma In Situ in Sinonasal Inverted Papilloma Ivy W. Maina, MD, Charles C. L. Tong, MD, Esther Baranov, MD, Neil N. Patel, MD, MTR, Vasiliki Triantafillou, MD, Edward C. Kuan, MD, MBA, Michael A. Kohanski, MD, PhD, Peter Papagiannopoulos, MD, Carol H. Yan, MD, Alan D. Workman, MD, MTR, Justina L. Lambert, Noam A. Cohen, MD, PhD, David W. Kennedy, MD, Nithin D. Adappa, MD, Michael D. Feldman, MD, PhD, James N. Palmer, MD First Published October 22, 2019; pp. 1036–1042 Abstract Hide Preview Objective Sinonasal inverted papilloma (IP) is a typically benign sinonasal tumor with a tendency to recur and the potential for malignant transformation. Varying degrees of dysplasia may be present, of which carcinoma in situ (CIS) is most advanced. We hereby describe the biological and clinical behavior of IP with CIS (IPwCIS). Study Design Retrospective cohort. Setting Tertiary academic referral center. Subjects and Methods Patients who underwent surgical resection for IP between 2002 and 2017. Pertinent clinical data were obtained, and all IPwCIS cases were histologically confirmed. Results In total, 37 of 215 cases (17.2%) were identified with IPwCIS. Mean age was 57 years and 86.5% of patients were male. Median follow-up was 82 months, and the recurrence rate was 27%. The maxillary sinus was the most common primary site (37.8%) and 14 tumors (37.8%) demonstrated multifocal attachment, which was associated with recurrence (odds ratio [OR], 9.7; 95% confidence interval [CI], 1.4-112.8; P = .028). IPwCIS was also associated with multiple recurrences (OR, 2.71; 95% CI, 1.246-5.814; P = .021). Most patients were treated with surgery alone (89.1%) and 4 patients received adjuvant radiotherapy (8.1%). Only 1 patient (2.7%) demonstrated malignant transformation after definitive surgery. Conclusions IPwCIS represents the most severe degree of dysplasia prior to malignant transformation and is associated with higher recurrence rate and multifocal involvement but low rate of conversion to invasive carcinoma. The need for adjuvant therapy remains controversial, and further research into the etiology of the disease is warranted. |

The Potential of High-Throughput DNA Sequencing of the Paranasal Sinus Microbiome in Diagnosing Odontogenic Sinusitis Asad A. Haider, Michael J. Marino, MD, William C. Yao, MD, Martin J. Citardi, MD, Amber U. Luong,MD, PhD First Published August 6, 2019; pp. 1043–1047 Abstract Hide Preview Objective High-throughput DNA sequencing of the paranasal sinus microbiome has potential in the diagnosis and treatment of sinusitis. The objective of this study is to evaluate the use of high-throughput DNA sequencing to diagnose sinusitis of odontogenic origin. Study Design Case series with chart review. Setting Single tertiary care academic medical center. Subjects and Methods A chart review was performed of DNA sequencing results from the sinus aspirates obtained under endoscopic visualization in 142 patients with sinusitis. The identification of any potentially pathogenic bacteria associated with oral flora in a sample was classified as a positive result for sinusitis of odontogenic etiology. The sensitivity, specificity, and predictive values of using high-throughput DNA sequencing to diagnose sinusitis of odontogenic etiology were determined, with the patient’s computed tomography sinus scan as the reference standard. On computed tomography scans, an odontogenic source was determined by the presence of a periapical lucency perforating the schneiderian membrane. Results Seven of the 142 patients enrolled in this study had an odontogenic source based on computed tomography scans. Relative to this reference standard, high-throughput DNA sequencing produced a sensitivity of 85.7% (95% CI, 42.1%-99.6%), a specificity of 81.5% (95% CI, 73.9%-87.6%), a positive predictive value of 19.4% (95% CI, 13.1%-27.7%), and a negative predictive value of 99.1% (95% CI, 94.7%-99.9%). Conclusion This study supports the use of high-throughput DNA sequencing in supplementing other methods of investigation for identifying an odontogenic etiology of sinusitis. |

Sleep Medicine and Surgery

Effects of OSA Surgery on Leptin and Metabolic Profiles Chien-Hung Chin, MD, Pei-Wen Lin, MD, Hsin-Ching Lin, MD, Michael Friedman, MD, Meng-Chih Lin,MD First Published October 1, 2019; pp. 1048–1055 Abstract Hide Preview Objectives This study is designed to investigate the effects of obstructive sleep apnea/hypopnea syndrome (OSA) surgery on serum leptin levels and metabolic disturbances, both of which contribute to the risk of cardiovascular diseases. Study Design Case series with planned data collection. Setting Tertiary referral medical center. Subjects and Methods A retrospective chart review of 101 consecutive patients with OSA who refused or failed conservative therapy and who then underwent upper airway surgery for OSA treatment was conducted. The personal medical history, anthropometric measurements, subjective symptoms, and objective polysomnographic parameters and fasting morning blood samples for leptin and metabolic biomarkers measurements were collected preoperatively and at a minimum of 3 months postoperatively. Results Eighty patients with OSA (69 men and 11 women; mean [SD] age of 42.2 [10.2] years) with complete data were included in the final analysis. At least 3 months after surgery, serum leptin, low-density lipoprotein cholesterol (LDL-C), and triglyceride levels and the mean systolic blood pressure (SBP) (night and morning) significantly decreased. According to the classical definition of surgical success, 40 subjects had successful surgery and were categorized as surgical responders, and the other 40 patients who failed surgery were categorized as surgical nonresponders. Significant reductions in serum leptin, total cholesterol, LDL-C, and triglyceride levels and improvement of mean SBP (morning) occurred in surgical responders but not in nonresponders. Conclusions Effective OSA surgery improves serum leptin, lipid profiles, and SBP. Further studies are needed to investigate the role of serial measurements of these biomarkers in monitoring surgical outcome of OSA treatment. |

Clinical Photograph

Plaut-Vincent’s Ulcerative Gingivitis and Tonsillitis Francesco Maccarrone, MD, Matteo Alicandri-Ciufelli, MD, FEBORL-HNS First Published August 6, 2019; pp. 1056–1057 Abstract