The Pursuit of Otolaryngology Subspecialty Fellowships

Objectives

To examine otolaryngology resident interest in subspecialty fellowship training and factors affecting interest over time and over the course of residency training

Study Design

Cross-sectional study of anonymous online survey data.

Setting

Residents and fellows registered as members-in-training through the American Academy of Otolaryngology–Head and Neck Surgery.

Subjects and Methods

Data regarding fellowship interest and influencing factors, including demographics, were extracted from the Section for Residents and Fellows Annual Survey response database from 2008 to 2014.

Results

Over 6 years, there were 2422 resident and fellow responses to the survey. Senior residents showed a statistically significant decrease in fellowship interest compared with junior residents, with 79% of those in postgraduate year (PGY) 1, 73% in PGY-2 and PGY-3, and 64% in PGY-4 and PGY-5 planning to pursue subspecialty training (P < .0001). Educational debt, age, and intended practice setting significantly predicted interest in fellowship training. Sex was not predictive. The most important factors cited by residents in choosing a subspecialty were consistently type of surgical cases and nature of clinical problems.

Conclusions

In this study, interest in pursuing fellowship training decreased with increased residency training. This decision is multifactorial in nature and also influenced by age, educational debt, and intended practice setting.

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Oral Steroid Usage for Otitis Media with Effusion, Eustachian Tube Dysfunction, and Tympanic Membrane Retraction

Objectives

Avoiding oral steroids for otitis media with effusion (OME) is endorsed as a performance measure by the National Quality Foundation, but data regarding current gaps and practice patterns are lacking. Our objectives were to evaluate oral steroid use for OME and the related diagnoses of eustachian tube dysfunction (ETD) and tympanic membrane retraction (TMR), to assess variations by visit setting, and to identify opportunities for measurable performance improvement.

Study Design

Cross-sectional analysis of a national database.

Setting

Ambulatory visits in the United States.

Subjects

Children and adults in the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey (2005-2010).

Methods

Data were coded for patient demographic information, potential confounders (eg, concurrent conditions managed by oral steroids), and diagnosis of OME, ETD, or TMR (OME/ETD/TMR). The latter 2 diagnoses were included to meet minimum numbers for reliability of weighted estimates, but OME constituted the majority of cases. Multivariate regression was used to determine the variables associated with oral steroid use.

Results

Among 590,772 observations representing 7,191,711,480 visits for OME/ETD/TMR, 3.2% resulted in a new prescription for oral steroid medication (2.3% for children, 7.0% for adults). Adults were more likely to receive steroids (odds ratio = 3.50, P < .001) than those with other diagnoses, but a similar association was not found for children. Patients seen by an otolaryngologist or in the emergency department were less likely to receive steroids than those seen in other settings.

Conclusions

OME/ETD/TMR is infrequently treated with oral steroids, particularly in children. Opportunities for performance improvement are limited.

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Human Papillomavirus Vaccination Counseling in Pediatric Training: Are We Discussing Otolaryngology-Related Manifestations?

Objective

Demonstrate the need for increased education regarding otolaryngology-related manifestations of human papillomavirus (HPV). Highlight a need to incorporate otolaryngology-related manifestations of HPV in vaccine counseling.

Study Design

Survey.

Setting

Tertiary care academic children's hospital.

Subjects

Pediatric residents, fellows, and staff.

Methods

An online survey was made available regarding HPV education and vaccination.

Results

Participants (N = 348) initiated the survey representing 28.4%, 25.6%, and 19.0% postgraduate year 1, 2, and 3 residents, respectively, as well as 17.5% chief residents/fellows and 9.5% attendings. Participants rated their prior education as none or fair regarding recurrent respiratory papillomatosis (63.8%) and oropharyngeal squamous cell carcinoma (68.3%). In contrast, 60.6% and 70.9% rated their education on genital warts and cervical cancer correspondingly as good or excellent. When asked what was routinely discussed during HPV vaccine counseling, 63.3% reported "never" discussing recurrent respiratory papillomatosis and 52.9% "never" discussing oropharyngeal squamous cell carcinoma. A range from 92.7% to 95.5% responded that there was a need for increased education regarding HPV and its role in recurrent respiratory papillomatosis and oropharyngeal squamous cell carcinoma.

Conclusions

Increased education about HPV and its otolaryngology-related manifestations should be undertaken to increase provider, patient, and parent awareness of recurrent respiratory papillomatosis and oropharyngeal squamous cell carcinoma. We propose that discussing the risks of otolaryngology-related disease be routinely included in HPV vaccination counseling.

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Laryngeal Preservation in Glottic Cancer: A Comparison of Hospital Charges and Morbidity among Treatment Options

Objective

When total laryngectomy is not required, organ preservation surgery or radiotherapy is considered the standard of care for primary glottic cancer. These accepted treatment options are available for early and advanced glottic cancers due to equivalent locoregional control and survival rates. However, in today's climate of accountable care, the financial burden of treatment choices continues to increase in significance. We therefore compared hospital charges and treatment-related morbidity between organ-preserving surgery and radiation with or without chemotherapy—herein, (chemo)radiation—in the primary treatment of glottic cancer.

Study Design

Nationwide Inpatient Sample Database was analyzed to assess clinical and financial information.

Setting

Population-based analysis.

Subjects

Patients (N = 5499) with primary glottic cancer undergoing treatment with laryngeal preservation strategies.

Methods

Patients were subdivided by ICD-9 codes into 3 treatment groups: endoscopic resection, open partial laryngectomy, and (chemo)radiation. Treatment-related outcomes, charges, and length of hospitalization were analyzed among treatment groups.

Results

When adjusting for sex, age, race, comorbidity, and primary payer, (chemo)radiotherapy was associated with increased direct charges (P < .001; coefficient, $23,658.99; 95% confidence interval [95% CI]: $10,227.15-$37,090.84) and length of hospitalization (P < .001; hazard ratio, 0.593; 95% CI: 0.502-0.702) when compared with endoscopic surgery. As compared with open surgery, endoscopic surgery was associated with reduced hospital charges (P = .012; coefficient, $11,967.01; 95% CI: $2,784.17-$21,249.85) and duration of hospitalization (P < .001; hazard ratio, 0.749; 95% CI: 0.641-0.876).

Conclusions

This analysis suggests that increased utilization of endoscopic surgery in patients with primary glottic cancer not requiring total laryngectomy may lead to reduced financial burden and duration of hospitalization when compared with open surgery or (chemo)radiation therapy.

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Peritonsillar Abscess: Complication of Acute Tonsillitis or Webers Glands Infection?

Objective

To review the literature concerning the 2 primary hypotheses put forth to explain the pathogenesis of peritonsillar abscess: "the acute tonsillitis hypothesis" (peritonsillar abscess is a complication of acute tonsillitis) and "the Weber gland hypothesis" (peritonsillar abscess is an infection of Weber's glands).

Data Sources

PubMed, EMBASE.

Review Methods

Data supporting or negating one hypothesis or the other were elicited from the literature.

Conclusions

Several findings support the acute tonsillitis hypothesis. First, the 2 main pathogens in peritonsillar abscess have been recovered from pus aspirates and bilateral tonsillar tissues with high concordance rates, suggesting that both tonsils are infected in patients with peritonsillar abscess. Second, studies report signs of acute tonsillitis in the days prior to and at the time of peritonsillar abscess. Third, antibiotic treatment reduces the risk of abscess development in patients with acute tonsillitis. However, some findings suggest involvement of the Weber's glands in peritonsillar abscess pathogenesis. First, high amylase levels have been found in peritonsillar pus. Second, the majority of peritonsillar abscesses are located at the superior tonsillar pole in proximity of the Weber's glands. We propose a unified hypothesis whereby bacteria initially infect the tonsillar mucosa and spread via the salivary duct system to the peritonsillar space, where an abscess is formed.

Implications for Practice

Our findings support the rationale for antibiotic treatment of patients with severe acute tonsillitis to reduce the risk of abscess development. Improved understanding of peritonsillar abscess pathogenesis is important for the development of efficient prevention strategies.

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Olfactory and Gustatory Functions after Anterior Palatoplasty in Patients with Primary Snoring

Objective

In this study, we investigated the chemical senses (namely, olfaction), the 4 basic tastes, and umami taste in patients who underwent anterior palatoplasty (AP) for primary snoring.

Study Design

Prospective clinical study.

Setting

Multicenter, tertiary care hospitals.

Subjects and Methods

The age range of the 28 participants was 22 to 47 years, and all had been diagnosed with primary snoring by polysomnography. Orthonasal and retronasal olfactory testing was performed using the respective "Sniffin' Sticks." Tests for the 4 basic tastes (sweet, sour, salty, and bitter) and umami were performed before and 6 months after AP.

Results

The changes between the preoperative and postoperative results for the 4 basic tastes, which were applied to the anterior tongue region, were not significant. Retronasal olfactory function improved significantly 6 months after AP (P = .007). After AP, umami scores for the soft palate but not those of the anterior and posterior tongue decreased significantly (P = .001).

Conclusion

Patients scheduled for AP should be properly informed about potential postoperative taste and flavor changes. They should also be warned of a possible loss of appetite due to a postoperative decrease in the umami taste sensation of the soft palate.

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Survival Impact of Initial Therapy in Patients with T1-T2 Glottic Squamous Cell Carcinoma

Objective

Laryngeal cancer most commonly arises from the glottis. Comparable outcomes in survival have been shown in patients with early glottic squamous cell carcinoma treated with either surgery or radiotherapy.

Study Design and Setting

Administrative database study.

Subjects and Methods

The US National Cancer Institute's SEER database (Surveillance, Epidemiology, and End Results) was queried for cases of early glottic cancer (T1-T2N0M0, 1988-2012). We identified 13,312 qualifying cases. Patient demographics, therapeutic measures, and survival outcomes were examined with appropriate univariate and multivariate analyses.

Results

Early glottic cancer has a mean age at diagnosis of 64.8 ± 11.6 years and a male:female ratio of 6.9:1. The most common treatment modality was radiotherapy alone (51.6%), followed by combination therapy with surgery first (31.5%). Overall, the 5-year disease-specific survival (DSS) rate was 88.4%. When stratified by treatment modality and stage, 5-year DSS for T1 tumors was 93.2% with surgery alone and 89.0% with radiation alone (P < .0001). With combination therapy, the 5-year DSS was 91.3% for surgery first and 84.9% for radiation first (P = .0239). In T2 tumors, 5-year DSS was improved with single-modality therapy versus multimodality therapy (81.1% vs 76.4; P = .0255).

Conclusion

In T1 disease, surgery alone shows improved 5-year DSS versus radiation alone, but this difference was not observed in T2 tumors. Additionally, surgery, rather than radiation, shows improved 5-year DSS when implemented as a first-line therapy. Combination therapy does not show improved 5-year DSS for early glottic cancer.

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Reply: Salvage Palmar Fasciectomy following Initial Treatment with Collagenase Clostridium Histolyticum

No abstract available

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Selective Sentinel Lymph Node Dissection in Lower Extremity Melanoma: Correction

No abstract available

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A Prospective, Randomized, Controlled Trial of Paravertebral Block versus General Anesthesia Alone for Prosthetic Breast Reconstruction

Background: Paravertebral blocks have gained popularity because of ease of implementation and a shift toward ambulatory breast surgery procedures. Previous retrospective studies have reported potential benefits of paravertebral blocks, including decreased narcotic and antiemetic use. Methods: The authors conducted a prospective controlled trial of patients undergoing breast reconstruction over a 3-year period. The patients were randomized to either a study group of paravertebral blocks with general anesthesia or a control group of general anesthesia alone. Demographic and procedural data, in addition to data regarding pain and nausea patient-reported numeric scores and consumption of opioid and antiemetic medications, were recorded. Results: A total of 74 patients were enrolled to either the paravertebral block (n = 35) or the control group (n = 39). There were no significant differences in age, body mass index, procedure type, or cancer diagnosis between the two groups. Patients who received a paravertebral block required less opioid intraoperatively and postoperatively combined compared with patients who did not receive paravertebral blocks (109 versus 246 fentanyl equivalent units; p

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Validated Assessment Tools and Maintenance of Certification in Plastic Surgery: Current Status, Challenges, and Future Possibilities

Background: The transition to the Next Accreditation System is well underway, and a shift toward competency-based assessment in the form of milestones is now the standard. A significant effort has been completed by the Plastic Surgery Milestones Working Group to develop specific milestones and assessment tools for plastic surgery training. Methods: The history of the development toward competency-based assessment was reviewed. Data regarding the trends and regulations associated with board certification and the role of maintenance of certification were reviewed. Results: The work of the Plastic Surgery Milestones Working Group has sparked interest in assessment and created an opportunity for further development. The efforts toward validating assessment tools by our colleagues working in other surgical specialties serve as a suitable roadmap for further progress. Board certification is an integral part of successful practice and should be regarded as an expectation. Despite the burdens associated with maintenance of certification, it serves a valuable function in ensuring optimal patient care and is often retrospectively seen as an important component of practice. Conclusions: The competency-based milestones are the new standard, and work on this new methodology of assessing plastic surgery trainees is expected to continue. Accurate assessment is critical to the pathways for board certification and maintenance of certification, which serve important roles for all parties involved in the delivery of medical care.

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Does Increased Experience with Tissue Oximetry Monitoring in Microsurgical Breast Reconstruction Lead to Decreased Flap Loss? The Learning Effect

Background: Early studies have shown that near-infrared monitoring with tissue oximetry shows promise in providing earlier detection of free flap vascular compromise. However, large-scale clinical evaluation of this technology on flap outcome has not previously been established. This study examines the effect of tissue oximetry on flap reexploration rates and salvage over a 10-year period. The learning curve for this new technology is also assessed. Methods: A retrospective review was performed of prospectively maintained data on all microsurgical breast reconstructions performed at an academic institution from 2004 to 2014. Patients were divided into two separate cohorts—standard clinical monitoring and standard clinical monitoring plus tissue oximetry—and rates of reexploration and flap salvage were compared. Subgroup analysis (tertiles) was performed to assess outcomes with increasing experience. Results: A total of 380 flaps (36.2 percent) received standard clinical monitoring, and 670 flaps (63.8 percent) received additional tissue oximetry monitoring. The rate of flap salvage before implementation of tissue oximetry monitoring was 57.7 percent and increased to 96.6 percent (p

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Reply: Anatomical Considerations to Prevent Facial Nerve Injury

No abstract available

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Discussion: Does Increased Experience with Tissue Oximetry Monitoring in Microsurgical Breast Reconstruction Lead to Decreased Flap Loss? The Learning Effect

No abstract available

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Impact of Prior Tissue Expander/Implant on Postmastectomy Free Flap Breast Reconstruction

Background: Implant-based breast reconstructions can result in unsatisfactory results requiring surgical revision or salvage reconstructive surgery with autologous tissue. This study compares the outcomes and complications of salvage (tertiary) flap reconstruction after failed prosthesis placement to those of primary/secondary flap reconstruction. Methods: All patients undergoing free flap breast reconstruction after failed prosthesis between July 1, 2005, and June 30, 2014, were identified. A matched number of patients who underwent a de novo free flap breast reconstruction were selected randomly for review. The indication for prosthesis removal, demographic and operative data, flap type and inset, and complication rates were evaluated. Results: Eighty-nine women with a history of failed implant-based reconstruction required free flap reconstruction for salvage in 121 breasts. Capsular contracture was the most common indication for prosthesis removal (62.0 percent). Recipient vessel scarring was 5.23 times more likely to occur in the prior prosthesis group (p

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Seroma in Prosthetic Breast Reconstruction

Background: Seroma, as a complication of prosthetic breast reconstruction, results in patient distress, increased office visits, undesirable aesthetic outcomes, and—importantly—may escalate to infection and frank prosthesis loss. Herein, the authors review the pathophysiology and risk factors and attempt to collate published practices for avoidance and management of seroma. Methods: A systematic literature review was performed using MEDLINE, Web of Science, Embase, and Cochrane Library for studies published between 2000 and January of 2015. Random-effects meta-analysis was used to estimate the overall pooled incidence of seroma and to examine the effect of drain number and acellular dermal matrix use. Results: Seventy-two relevant primary articles and three systematic reviews were identified. Fifty-one citations met inclusion criteria, including two randomized controlled trials. The overall pooled incidence was 5.4 percent (95 percent CI, 4.1 to 6.7 percent). Obesity, acellular dermal matrix, and preoperative irradiation were cited risk factors. Pooled relative risk for acellular dermal matrix was 1.83 (95 percent CI, 1.28 to 2.62). Drain practices were collated from 34 articles. Conclusions: Seromas following prosthetic breast reconstruction are complicated by the hypovascular, proinflammatory milieu of the mastectomy skin flap, the geometrically complex dead space, and the presence of a foreign body with potential contamination and biofilm. There is reasonable evidence to suggest that these factors contribute to a progression of seroma to infection and prosthesis loss. These findings have motivated this summary article on current practice guidelines and strategies to prevent and treat seromas. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

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Plastic Surgery Review: A Study Guide for the In-Service, Written Board, and Maintenance of Certification Exams

No abstract available

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Breast Implant Informed Consent Should Include the Risk of Anaplastic Large Cell Lymphoma

Summary: Breast implant–associated anaplastic large cell lymphoma (ALCL) is a rare T-cell lymphoma arising around breast implants. Public awareness has increased following a safety communication warning of the association of breast implant–associated ALCL by the U.S. Food and Drug Administration in 2011. Difficulty with determining an accurate assessment of risk, including diagnosis, or standardized treatment regimen has led surgeons to commonly omit preoperative discussion of this rare and frequently misunderstood cancer. Risk disclosure is a form of respect for patient autonomy, and informed consent has positive practical and moral consequences for the practice of plastic surgery. A model of breast implant–associated ALCL informed consent implementation and health care provider education are reviewed with 1-year process follow-up at a tertiary cancer center. Breast implant–associated ALCL should be included during preoperative counseling on the risks of breast implantation when obtaining informed consent. Pertinent aspects of decision-making include disease awareness, presenting symptoms, and resources for concerned patients. Education of health care professionals and provision of patient-focused materials ensures effectiveness of the informed consent process.

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Reply: Effects of Nitroglycerin Ointment on Mastectomy Flap Necrosis in Immediate Breast Reconstruction: A Randomized Controlled Trial

No abstract available

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Discussion: Breast Implant Informed Consent Should Include the Risk of Anaplastic Large Cell Lymphoma

No abstract available

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