Patient Reported Outcome Measures used in Surgical Evaluation of Obstructive Sleep Apnea: A Systematic Review.

OBJECTIVE: To identify patient-reported outcome measures (PROMs) used to measure adult obstructive sleep apnea (OSA)-related quality of life in sleep surgery and analyze key psychometric properties in the original design and development of each PROM. DATA SOURCES: PubMed, Web of Science, Embase, PsychINFO, and CINAHL. REVIEW METHODS: A systematic review was performed using Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Disease-specific instruments assessing sleep-related quality of life that were used in sleep surgery studies and validated in patients with sleep disorders were included. The Consensus-based Standards for the Selection of Health Status Measurement Instruments (COSMIN) criteria were used to evaluate methodological quality. RESULTS: A total of 2494 abstracts were retrieved, and 216 underwent full-text review. Seven PROMs assessing sleep-related quality of life were identified. Only one (14%) PROM (SAQLI) was developed using both patient and physician input, and none were rated as "adequate" for content validity. Two PROMs utilized patients with sleep-disordered breathing during content development and none specifically queried patients considering surgery. Six (86%) PROMs demonstrated "very good" analysis of internal consistency per COSMIN criteria, and six (86%) included data on test-retest reliability. CONCLUSION: Several PROMs are utilized in sleep-related quality-of-life assessments for patients treated with OSA surgery. The measurement properties of these PROMs are of variable quality, and notably, no PROMs meet adequate quality measurements for content validity. New and updated PROMs for OSA-related quality of life should consider input from sleep surgery patients and providers. Laryngoscope, 2024.

Analysis of Internet-Based Written Materials on Surgery for Obstructive Sleep Apnea.

Objective: Obstructive sleep apnea (OSA) has many treatment options and the Internet is an important resource for patients. The quality of information reviewed by patients about sleep surgery is unknown. We assessed readability, accessibility, actionability, and quality of online content for OSA surgeries. Study Design: Review of webpages by 2 independent reviewers. Setting: Internet-based search. Methods: We queried Google for sleep apnea surgery and included top 100 English language webpages. Content was scored by 2 reviewers using the Flesch-Kincaid (FK), Simple Measure of Gobbledygook (SMOG), JAMA benchmarks, CDC Clear Communication Index (CCI), and Patient Education Materials Assessment Tool (PEMAT) understandability and actionability scores. Results: Eighty-seven webpages were evaluated including 40 hosted by academic hospitals, 23 private practices, 10 general knowledge, 4 national organizations, 3 industry, 3 non-profit hospitals, and 2 government-sponsored. Mean CCI ranged from 22.7% to 84.9%. No sources met the 90% CCI cutoff. Average PEMAT understandability score was 80.4% (±7.8; 62.5%-93.3%), with 91% meeting the 70% standard score. Average PEMAT-actionability score was 38.4% (±16.5; 0%-70%), with 5% meeting the standard score. The average readability of webpages was the 10th grade reading level. Only 5% of pages met the recommended 6th grade reading level or lower. Only 21% of pages addressed surgical risks. Conclusion: Most online resources regarding OSA surgery do not meet recommended standards for communication. Providers should be aware of limitations of materials when counseling patients on sleep surgery treatments. Future patient education resources should meet health communication and readability standards.

Opioid Prescription Trends Among Sleep Surgeons in the United States.

OBJECTIVE: This study aimed to describe trends in opioid prescriptions among US sleep surgeons between 2013 and 2021 via a retrospective analysis conducted using publicly available data. METHODS: Utilizing the CMS part D database, we analyzed data from 82 sleep surgeons, focusing on metrics including number of opioid beneficiaries and claims, opioid cost, and opioid day supply per beneficiary. We employed statistical methods including ANOVA, t-tests, Fisher's exact test with Monte Carlo Simulation, and regression models. RESULTS: There were no significant changes in the number of opioid claims (p = 0.782) or beneficiaries per provider (p = 0.590) nor was there a decrease in opioid day supply per beneficiary (p = 0.489) over time. Surgeons who graduated residency before 2000 prescribed significantly more opioids over the course of the study period compared to those graduating after 2000 with higher opioid day supply per beneficiary (13.34 vs. 7.42, p < 0.001), higher opioid beneficiaries per provider (21.62 vs. 19.36, p = 0.028), and higher opioid claims per provider (30.30 vs. 21.78, p < 0.001). A significant annual decrease in opioid cost per beneficiary (ANOVA, p = 0.006) was noted. CONCLUSIONS: This study illuminates a significant impact of provider years in practice on opioid prescribing trends, alongside a decreasing trend in opioid cost per beneficiary. Despite the evolving paradigm emphasizing opioid reduction and evidence of decreasing opioid prescriptions in other otolaryngology subspecialties, our findings depict that opioid prescriptions among sleep surgeons remained stable from 2013 to 2021. LEVEL OF EVIDENCE: III Laryngoscope, 2024.

Sociodemographic and Healthcare System Barriers to PAP Alternatives for Adult OSA: A Scoping Review.

OBJECTIVE: To investigate sociodemographic and healthcare system barriers to access and utilization of alternative treatments to positive airway pressure (PAP) in the management of adult obstructive sleep apnea (OSA). DATA SOURCES: PubMed, Embase, and Web of Science databases were searched from 2003 to 2023 for English-language studies containing original data on sociodemographic and healthcare system barriers to PAP-alternative treatments for adult OSA. REVIEW METHODS: Studies were assessed using the Preferred Reporting Items for Systematic Reviews and Meta-analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines. Title and abstract screening, full-text review, and data collection were conducted by two investigators independently. RESULTS: Out of 1,615 studies screened, 13 studies met inclusion criteria and reported on a total of 1,206,115 patients who received PAP alternative treatments, including surgery (n = 9 studies), and oral appliances (OAs) (n = 3 studies). The chance of receiving a PAP-alternative treatment such as surgery was greater among patients aged 39 years or younger, had body mass index below 30 kg/m2, fewer comorbidities, private insurance, and a higher occupational and income status. The decision of individuals to receive PAP alternative treatments was influenced by increased patient education from providers, as well as improvements in daytime sleepiness and partner perception of snoring and apnea. CONCLUSION: Cumulative evidence suggests that several sociodemographic and healthcare system factors are associated with decreased use of PAP alternatives when PAP therapy fails. Investigation of interventions to eliminate these potential barriers may improve access and treatment outcomes. Laryngoscope, 2024.

Sex Differences in Obstructive Sleep Apnea Including Pregnancy and Response to Treatment.

This article highlights the sex differences in obstructive sleep apnea (OSA) and sheds light on the varying presentations, diagnostic challenges, as well as treatment responses observed in men and women. The disparities in prevalence, manifestations, and therapeutic outcomes underscore the need for a nuanced approach to OSA diagnosis and management that considers sex-specific factors. Furthermore, this article highlights the importance of recognizing and treating OSA during pregnancy, as it poses unique challenges and potential risks to both maternal and fetal health.

Leadership Training Curriculum for Otolaryngology-Head and Neck Surgery Residents: A Scoping Review.

OBJECTIVE: Otolaryngologists take on various leadership roles throughout their daily practice, but specific training focused on leadership development during otolaryngology-head and neck surgery (OHNS) residency is not well-defined. This project explores the current state of leadership curricula for OHNS residents. DATA SOURCES: Google Scholar, Embase, PubMed, and MedEdPORTAL. REVIEW METHODS: A scoping review was performed on English-language, full-text, peer-reviewed articles that describe leadership curricula for OHNS residents. Investigators reviewed curriculum settings, content, delivery methods, and assessment; curriculum effectiveness was evaluated using Kirkpatrick effectiveness scores and article quality was assessed using the Best Evidence in Medical Education (BEME) index. CONCLUSION: Three thousand four hundred sixteen articles met search criteria, 198 articles were included for full-text review, and 4 articles met inclusion criteria. Curriculum content and delivery methods were diverse. Curriculum cadence ranged from 2-day immersion trainings to year-long longitudinal programs. Only one of the included studies utilized a needs assessment to inform curriculum development. Two articles achieved Kirkpatrick effectiveness scores of 2, indicating changes in the attitudes or perceptions among participants and a quality measure of 3, indicating clear conclusions drawn from the results. IMPLICATIONS FOR PRACTICE: The current state of leadership training in OHNS residency is limited and nonuniform. These data align with descriptions of leadership training in other surgical residencies which are reported as heterogenous and lacking in effectiveness. This review highlights the need for standardized leadership training for OHNS residents. The high-quality leadership development initiatives within graduate medical education are reviewed to inform future directions for effective curriculum development and assessment.

International Consensus Statement on Obstructive Sleep Apnea.

BACKGROUND: Evaluation and interpretation of the literature on obstructive sleep apnea (OSA) allows for consolidation and determination of the key factors important for clinical management of the adult OSA patient. Toward this goal, an international collaborative of multidisciplinary experts in sleep apnea evaluation and treatment have produced the International Consensus statement on Obstructive Sleep Apnea (ICS:OSA). METHODS: Using previously defined methodology, focal topics in OSA were assigned as literature review (LR), evidence-based review (EBR), or evidence-based review with recommendations (EBR-R) formats. Each topic incorporated the available and relevant evidence which was summarized and graded on study quality. Each topic and section underwent iterative review and the ICS:OSA was created and reviewed by all authors for consensus. RESULTS: The ICS:OSA addresses OSA syndrome definitions, pathophysiology, epidemiology, risk factors for disease, screening methods, diagnostic testing types, multiple treatment modalities, and effects of OSA treatment on multiple OSA-associated comorbidities. Specific focus on outcomes with positive airway pressure (PAP) and surgical treatments were evaluated. CONCLUSION: This review of the literature consolidates the available knowledge and identifies the limitations of the current evidence on OSA. This effort aims to create a resource for OSA evidence-based practice and identify future research needs. Knowledge gaps and research opportunities include improving the metrics of OSA disease, determining the optimal OSA screening paradigms, developing strategies for PAP adherence and longitudinal care, enhancing selection of PAP alternatives and surgery, understanding health risk outcomes, and translating evidence into individualized approaches to therapy.

Survey of Pediatric Otolaryngology Frenotomy Practice Patterns.

OBJECTIVES: Assess current frenotomy practice patterns of pediatric otolaryngologists via a cross-sectional survey. STUDY DESIGN: Survey study. METHODS: A 31-question electronic survey assessing frenotomy practice patterns was distributed to all American Society of Pediatric Otolaryngology (ASPO) members. Descriptive statistics were used to summarize responses and demographics of respondents. RESULTS: Of all ASPO members, 41% (240/588) completed the survey. Most respondents, 185 (77%), reported increased frenotomy referrals over the last 5 years and 144 (60%) described the current number of referrals as "too many." The two primary lingual frenotomy indications identified in infants were: breastfeeding/nipple pain (92%) and inability to latch (83%). For older children, speech difficulty (87%) was the primary indication. Maxillary frenotomy indications in infants varied amongst respondents. For analgesia during in-office frenotomy procedures, respondents used glucose/sucrose drops (48%), topical lidocaine (29%), or no pain control measure (27%). For post-procedure care, respondents recommended continuing lactation support (45%), massaging/stretching the wound (38%), or none (40%). Most respondents, 143 (60%), reported having seen a complication from frenotomy, and the most reported frenotomy complications were frenulum re-attachment and excessive bleeding. CONCLUSIONS: In the last 5 years, otolaryngologists have seen an increase in referrals for frenotomy. Pediatric otolaryngologists have varying practice patterns with regards to ankyloglossia diagnosis and treatment. The reported indications for frenotomy varied amongst pediatric otolaryngologists especially with respect to maxillary frenotomy. Practice patterns also varied with respect to procedural pain control and frenotomy aftercare recommendations. More frenotomy research is needed to establish a standard of care for patients with ankyloglossia. LEVEL OF EVIDENCE: 4 Laryngoscope, 132:2505-2512, 2022.

Patient-Defined Goals for Obstructive Sleep Apnea Treatment.

OBJECTIVES: To characterize the treatment goals and values of adult patients with obstructive sleep apnea (OSA). STUDY DESIGN: Mixed methods design based on semistructured interviews followed by cross-sectional surveys. SETTING: Academic medical center and integrated managed care consortium. METHODS: Phase 1 involved qualitative analysis of focus groups and interviews to define treatment goal categories. Phase 2 included analysis of cross-sectional surveys on most important treatment goals from patients with OSA presenting to sleep surgery clinic. Positive airway pressure (PAP) use, Epworth Sleepiness Scale score, and apnea-hypopnea index were obtained to determine influences on goal choices. RESULTS: During focus groups and interviews, treatment goal themes identified included improving sleep quality, reducing daytime sleepiness, snoring sound reduction, and health risk reduction. In phase 2, 536 patients were surveyed, and they reported the primary treatment goals of health risk reduction (35%), sleep quality improvement (28%), daytime sleepiness improvement (21%), and snoring sound reduction (16%). The primary treatment goal was associated with age (P < .0001), excessive daytime sleepiness (Epworth Sleepiness Scale score >10, P < .0001), PAP use status (P < .0001), and OSA severity (apnea-hypopnea index, P < .0001). Severity of OSA was associated with increasing proportion of patients choosing health risk reduction as the main treatment goal (P < .05). CONCLUSIONS: Adult OSA treatment goal choices vary with age, symptoms, PAP history, and OSA severity. Understanding patient-specific goals is the essential first step in the shared decision-making process when choosing surgical or nonsurgical treatments. Ultimately, goal-focused discussions ensure alignment of priorities and definitions of success between the patient and the provider.

Ten-year Thyroid Cancer Incidence in an Integrated Healthcare Delivery System.

INTRODUCTION: The incidence of papillary thyroid cancer (PTC) has increased in recent decades, but data from community-based settings are limited. This study characterizes PTC trends in a large, integrated healthcare system over 10 years. METHODS: The annual incidence of PTC (2006-2015) was examined among Kaiser Permanente Northern California adults aged 21 to 84 years using Cancer Registry data, including tumor size and stage. Incidence estimates were age-adjusted using the 2010 US Census. RESULTS: Of 2990 individuals newly diagnosed with PTC (76.8% female, 52.7% non-Hispanic White), 38.5% and 61.5% were aged < 45 and < 55 years, respectively. At diagnosis, 60.9% had PTC tumors ≤ 2 cm, 9.2% had tumors > 4 cm, and 66.1% had Stage I disease. The annual age-adjusted incidence of PTC increased from 9.4 (95% confidence interval [CI] = 8.1-10.7) to 14.5 (95% CI = 13.1-16.0) per 100,000 person-years and was higher for female patients than for male patients. Incidence tended to be higher in Asian/Pacific Islanders and lower in Black individuals. Increasing incidence was notable for Stage I disease (especially 2006-2012) and evident across a range of tumor sizes (3.0-4.6 for ≤ 1 cm, 2.5-3.5 for 1-2 cm, and 2.4-4.7 for 2-4 cm) but was modest for large tumors (0.9-1.5 for > 4 cm) per 100,000 person-years. DISCUSSION: Increasing PTC incidence over 10 years was most evident for tumors ≤ 4 cm and Stage I disease. Although these findings may be attributable to greater PTC detection, the increase across a range of tumor sizes suggests that PTC burden might also have increased.

Otolaryngology Residency Interviews in a Socially Distanced World: Strategies to Recruit and Assess Applicants.

Due to concerns surrounding travel during the COVID-19 pandemic, the 2020-2021 otolaryngology residency application cycle will be conducted virtually for the first time. Residency programs should consider the logistics of video interviews, drawing on experiences of other programs that have successfully performed virtual interviews in the past. The lack of in-person interviews will create challenges in assessing applicants, and we recommend that programs develop structured and targeted questions and even consider having candidates answer standardized questions prior to the virtual interview day. From an applicant perspective, gauging the intangibles of individual residency programs, such as resident camaraderie, program culture, and program location, will be difficult. To address this, programs should consider hosting informal virtual gatherings, create videos that highlight the resident experience, and ensure that program websites are up-to-date. Ultimately, adaptability, resilience, and innovation will allow residency programs to achieve a successful 2021 otolaryngology match.

Evolving Otolaryngology Resident Roles and Concerns at the Peak of the US COVID-19 Pandemic.

BACKGROUND: The roles of US otolaryngology residents have changed in response to the coronavirus disease 2019 (COVID-19) pandemic. As the pandemic peaked in the United States, we characterized resident activities and concerns. METHODS: A cross-sectional study of US otolaryngology residents between April 20, 2020 and May 2, 2020. RESULTS: A total of 219 residents at 65/118 (55%) institutions responded. Thirty (14%) residents had been redeployed. Residents reported greatest concerns regarding education (P < .00001). Assuming adequate protective equipment, 55% desired active participation in high-risk procedures on COVID-19-positive patients. Redeployed residents had greater concern for burnout and reduced in-hospital well-being (P < .05). Resident satisfaction correlated with comfort communicating concerns to their department (odds ratio [OR] = 4.9, 95% confidence interval [CI] 1.4-17.3, P = .01) and inversely correlated with low perceived meaning in work (OR = 3.1, CI 1.1-9.1, P = .03). CONCLUSION: Otolaryngology resident concerns have evolved as the pandemic progressed. Residency programs should prioritize resident education, well-being in redeployed residents, and open communication as they transition toward recovery.

Diagnostic techniques and surgical outcomes for persistent pediatric obstructive sleep apnea after adenotonsillectomy: A systematic review and meta-analysis.

OBJECTIVE: To evaluate the efficacy of upper airway surgery for children with persistent obstructive sleep apnea after adenotonsillectomy and to assess sleep study outcomes when Drug Induced Sleep Endoscopy, Cine MRI, or other imaging procedure is performed to assist in identifying the location of obstruction and planning surgery. METHODS: Systematic review and meta-analysis was performed. Inclusion criteria was English-language studies with original data including pediatric patients with persistent OSA after T&A. Exclusion criteria included case reports and lack of pre and post-operative sleep study data. Data Sources were PubMed, Cochrane Central, and Embase from 2000 to 2018. PRISMA standards were followed for the selection and review of articles. The Newcastle-Ottawa Quality Assessment scale was used to score the quality of evidence of the studies. All manuscripts were reviewed independently by two investigators. Primary outcome measures were apnea-hypopnea index and minimum oxygen saturation. Data was pooled using a random-effects model. RESULTS: Of the 1902 abstracts identified, 11 studies (214 patients) met inclusion criteria for systematic review, 5 with Drug Induced Sleep Endoscopy as the diagnostic technique, 4 with Cine MRI, and 2 with MRI/CT. All studies were case series. Most subjects had syndromic comorbidities and/or obesity. Ten studies (198 patients) were included in the meta-analysis. Overall, there was a change in apnea hypopnea index of -6.51 (95% CI, -8.17 to - 4.85; p < 0.001) and an increase in minimum oxygen saturation by 3.24% (95% CI, 1.49%-4.98%; p < 0.001) following surgical intervention. Both Drug Induced Sleep Endoscopy and Cine MRI directed surgeries resulted in significant improvement in sleep study parameters. The two techniques could not be directly compared due to significant differences in co-morbidity rates between patients. CONCLUSIONS: Surgery for pediatric persistent obstructive sleep apnea improves apnea hypopnea index and minimum oxygen saturation but does not resolve the disease. This is true when both Drug Induced Sleep Endoscopy and Cine MRI findings were used to direct surgery.

Factors Impacting Online Ratings for Otolaryngologists.

OBJECTIVE: To identify factors associated with online patient ratings and comments for a nationwide sample of otolaryngologists. METHODS: Ratings, demographic information, and written comments were obtained for a random sample of otolaryngologists from HealthGrades.com and Vitals.com . Online Presence Score (OPS) was based on 10 criteria, including professional website and social media profiles. Regression analyses identified factors associated with increased rating. We evaluated for correlations between OPS and other attributes with star rating and used chi-square tests to evaluate content differences between positive and negative comments. RESULTS: On linear regression, increased OPS was associated with higher ratings on HealthGrades and Vitals; higher ratings were also associated with younger age on Vitals and less experience on HealthGrades. However, detailed correlation studies showed weak correlation between OPS and rating; age and graduation year also showed low correlation with ratings. Negative comments more likely focused on surgeon-independent factors or poor bedside manner. CONCLUSION: Though younger otolaryngologists with greater online presence tend to have higher ratings, weak correlations suggest that age and online presence have only a small impact on the content found on ratings websites. While most written comments are positive, deficiencies in bedside manner or other physician-independent factors tend to elicit negative comments.

Systematic Review of Drug-Induced Sleep Endoscopy Scoring Systems.

Objective To systematically review the scoring systems used to report findings during drug-induced sleep endoscopy (DISE) for adults and children with obstructive sleep apnea. Data Sources PubMed, CINAHL, EBM Reviews, Embase, and Scopus databases. Review Methods This is a systematic review of all indexed years of publications referring to scoring of DISE for children and adults with obstructive sleep apnea. The type of DISE scoring system utilized was the primary outcome. PRISMA guidelines were followed to carry out this review; articles were independently reviewed by 2 investigators. All pediatric and adult studies that utilized ≥1 DISE grading systems were included. Results Of 492 identified abstracts, 44 articles (combined population, N = 5784) were ultimately included; 6 reported on children, 35 on adults, and 1 on children and adults. Twenty-one reporting methods were used in these studies, with the most common being the VOTE system (velum, oropharynx, tongue base, and epiglottis; 38.6%) and the Pringle and Croft classification (15.9%). The sites of obstruction most commonly included in a scoring system were the tongue base (62%), lateral pharynx/oropharynx (57%), palate (57%), epiglottis/supraglottis (38%), and hypopharynx (38%). Less commonly included sites were the larynx (29%), velum (23%), nose (23%), tongue (14%), adenoids (10%), and nasopharynx (10%). Conclusion There is no consensus regarding which scoring system should be utilized to report findings during DISE. The VOTE system and the Pringle and Croft classification were the most frequent scoring systems reported for patients undergoing DISE. Standardization of the reporting of DISE findings would improve comparability among studies.

Trends in sleep studies performed for Medicare beneficiaries.

OBJECTIVES/HYPOTHESIS: To quantify trends and characteristics of sleep studies performed for Medicare beneficiaries in the United States. STUDY DESIGN: Retrospective longitudinal study of the Centers for Medicare and Medicaid Services' Part B National Summary Data and Medicare Provider Utilization and Payment Data from 2000 to 2014. METHODS: Sleep study data were analyzed according to type of study performed, total expenditure amount, provider specialty, and geographic location. RESULTS: In 2014, 845,569 sleep studies were completed by 1.4% of Medicare beneficiaries for a total of $189 million. Since 2010, annual expenditures for sleep studies have declined, whereas the number of studies performed has increased by 9.1%. In 2014, polysomnography, split-night polysomnography, and unattended home sleep studies accounted for 40%, 48%, and 12%, respectively, of total sleep studies. This represents a dramatic growth in the number of unattended sleep studies performed since 2000, when they represented only 0.9%. Pulmonologists, independent diagnostic testing facilities, and neurologists are the top specialties that bill for sleep studies. Sleep medicine is a growing specialty and ranked fifth among providers, whereas otolaryngologists ranked eighth. CONCLUSIONS: The healthcare burden of administering sleep studies is substantial, although the annual cost is declining. Unattended sleep studies contribute to decreasing costs and should be considered for patients who meet the correct indications. LEVEL OF EVIDENCE: 4. Laryngoscope, 127:2891-2896, 2017.

Sleep-disordered breathing in pediatric head and neck vascular malformations.

OBJECTIVES: To determine the prevalence of sleep-disordered breathing (SDB) symptoms among children with head and neck vascular malformations and to compare obstructive sleep apnea (OSA)-18 scores between children with head and neck vascular malformations and children with non-head and neck vascular malformations. STUDY DESIGN: Retrospective cohort and prospective cross-sectional studies METHODS: Forty-three pediatric subjects with head and neck vascular malformations evaluated at a tertiary-care multidisciplinary vascular anomalies center were included in a retrospective cohort study. Eighty-three consecutive pediatric subjects with vascular malformations evaluated at the same center were included in the prospective cross-sectional study. RESULTS: In the retrospective cohort study, 20 (47%) subjects with head and neck malformations had documented SDB symptoms. Of those with SDB symptoms, five (25%) required long-term tracheotomy. The children with SDB symptoms had greater vascular malformation size, more extensive pharyngeal involvement, greater vascular malformation mass effect on airway, and closer proximity of malformation to airway when compared to children without SDB symptoms. For the prospective cross-sectional study, 23% of pediatric subjects had malformations of the head and neck. Those with head and neck malformations had a higher OSA-18 score and a lower overall quality of life (QOL) score when compared to subjects with non-head and neck malformations. CONCLUSION: Nearly half of children with head and neck vascular malformations have SDB symptoms. Children with head and neck vascular malformations have a higher OSA-18 score and lower overall QOL score when compared to children with non-head and neck vascular malformations. LEVEL OF EVIDENCE: 4. Laryngoscope, 127:2159-2164, 2017.

Economic and Demographic Characteristics of Cerumen Extraction Claims to Medicare.

IMPORTANCE: Cerumen extractions are performed in a large portion of otolaryngology and head and neck surgery practices. The burden on the health care system of cerumen extractions is unknown and demographics have not been characterized at a population level. OBJECTIVE: To quantify the cost burden and health care burden of cerumen extraction among Medicare recipients in the United States. DESIGN, SETTING, AND PARTICIPANTS: A retrospective cross-sectional study was conducted of all cerumen disimpactions documented in the Centers for Medicare & Medicaid Services Provider Utilization and Payment database from January 1 to December 31, 2012. Data analysis was conducted from August 4, 2014, to July 24, 2015. EXPOSURE: Cerumen disimpaction. MAIN OUTCOMES AND MEASURES: Cerumen extractions were analyzed by state, medical or surgical specialty, reimbursement, and type of health care professional performing the extraction. RESULTS: The Centers for Medicare & Medicaid Services reimbursed $46.8 million for 1.3 million cerumen disimpactions in 2012 (mean, $35.38 per procedure). The mean reimbursement rate per cerumen disimpaction varied by state from $25.41 in Puerto Rico to to $40.24 in New Jersey. The percentage of Medicare beneficiaries receiving cerumen extractions per state ranged from 0.55% in Puerto Rico to 4.92% in New Jersey. California had the overall highest total number of cerumen disimpactions (n = 132 823). The majority of cerumen extractions were performed by otolaryngology-head and neck practitioners (67.60%), although internal medicine (32.66%) and family practice (33.87%) had a higher amount of practitioners performing the procedure. The majority of cerumen extractions are performed by physicians (90.53%). CONCLUSIONS AND RELEVANCE: Cerumen extraction is one of the most common procedures performed by otolaryngology health care professionals. Practice patterns and reimbursement rates vary greatly across the country.

An unusual presentation of a lingual dermoid cyst.

Dermoid cysts are rare lesions of the head and neck that usually present in children as an asymptomatic, slowly growing mass. We report a case that demonstrates that dermoid cysts can present later in life as a recurrent acute infection. Our patient was a 48-year-old man with a 22-year history of recurrent abscesses of the tongue and floor of the mouth that had required a tracheotomy and multiple hospitalizations. Magnetic resonance imaging performed between acute episodes revealed the presence of a 1.8-cm lesion within the tongue musculature. The patient underwent resection, and pathology was consistent with a lingual dermoid cyst. At 2 years of follow-up, he experienced no recurrence of symptoms.

Endoscopic partial medial maxillectomy with mucosal flap for maxillary sinus mucoceles.

PURPOSE: To describe a technique of endoscopic medial maxillectomy with mucosal flap for postoperative maxillary sinus mucoceles and to present a case series of subjects who underwent this procedure. MATERIALS AND METHODS: This case series includes four subjects with postoperative maxillary sinus mucoceles who underwent resection via endoscopic partial medial maxillectomy with a mucosal flap. We will discuss the clinical presentation, imaging characteristics, operative details, and outcomes. RESULTS: Four subjects are included in this study. The average age at the time of medial maxillectomy was 52 years (range 35-65 years). Three subjects (75%) were female. One subject (25%) had bilateral postoperative maxillary sinus mucoceles. Two subjects (50%) had unilateral right sided mucoceles, and the remaining subject had a unilateral left sided mucocele. All subjects had a history of multiple sinus procedures for chronic sinusitis including Caldwell-Luc procedures ipsilateral to the postoperative mucocele. All subjects underwent endoscopic medial maxillectomy without complication and were symptom free at the last follow up appointment, average 24 months (range 3-71 months) after medial maxillectomy. CONCLUSIONS: For postoperative maxillary sinus mucoceles in locations that are difficult to access via the middle meatus antrostomy, we recommend endoscopic medial maxillectomy with mucosal flap. Our preliminary experience with four subjects demonstrates complete resolution of symptoms after this procedure.