Reduction in epistaxis and emergency department visits in patients taking warfarin after implementation of an education program.

BACKGROUND: Anticoagulated patients are often seen unnecessarily in the emergency department (ED) for epistaxis, leading to increased healthcare costs. Patients are often unaware of preventative and management techniques for handling epistaxis in the home. METHODS: In 2016, the Michigan Anticoagulation Quality Improvement Initiative (MAQI2), a Blue Cross Blue Shield of Michigan-sponsored consortium of 6 anticoagulation clinics in Michigan, implemented an epistaxis-management educational program for warfarin-treated patients with the goal of reducing unnecessary ED visits. A pre-implementation cohort (2014-2015) consisted of patients who did not receive epistaxis-related educational materials. A post-implementation cohort (2017-2018) received epistaxis educational materials covering home treatment and prevention strategies. Patient characteristics and outcomes (rates of epistaxis and epistaxis ED visits) were compared using Chi-square, Poisson regression, and t-tests. RESULTS: Of the 4473 patients included, 2634 (58.9%) initiated warfarin in the pre-implementation phase and 1839 (41.1%) initiated warfarin in the post-implementation phase. The post-implementation cohort had a lower overall epistaxis rate (13.4 vs 10.4 per 100 patient-year, pre- vs. post-implementation; p = 0.029), a lower epistaxis-related ED visit rate (5.6 vs. 3.1 per 100 patient-year; p = 0.003), and a lower proportion of nosebleeds that led to an ED visit (42% vs. 30%; p = 0.032). After controlling for antiplatelet use, renal disease, and time in therapeutic range, both cohorts were equally likely to have nosebleeds (RR 0.77, 95% CI: 0.58-1.02); however, the post-implementation cohort was less likely to visit the ED for epistaxis (RR 0.52, 95% CI: 0.32-0.84). CONCLUSION: An epistaxis education program was associated with a reduction in epistaxis-related ED visits among warfarin-treated patients.

Optimal Timing of Entry-Level Otolaryngology Simulation.

OBJECTIVE: Appropriate timing of subspecialty simulation is critical to maximize learner benefit and guide resource utilization. We aimed to determine optimal timing of a simulation-based curriculum designed to teach entry-level procedural skills for otolaryngology residency. STUDY DESIGN: Simulation curriculum intervention tested among 3 comparison groups of varying clinical levels. SETTING: Academic otolaryngology training program and medical school. SUBJECTS AND METHODS: We developed a simulation-based technical skills curriculum incorporating the following task trainers: flexible laryngoscopy, peritonsillar abscess drainage, and myringotomy and tube insertion. Preclinical medical students (n = 40), subintern rotators (n = 35), and midyear interns (n = 8) completed the simulation-based curriculum. Pre- and postintervention knowledge/confidence and "level appropriateness" were rated on a 5-point Likert scale, and effect size was calculated. RESULTS: Overall self-reported knowledge/confidence levels improved in all 3 groups preintervention (1.05, 2.15, 3.17) to postintervention (2.79, 3.45, 4.38, respectively; all P < .01). Preclinical medical students uniformly reported very little to no familiarity with the procedures prior to the curriculum, while interns approached independence following the intervention. Large effect sizes were seen in all tasks for preclinical students (d = 3.13), subinterns (d = 1.46), and interns (d = 2.14). Five-point Likert scale measures of level appropriateness (1 = too challenging, 5 = too easy) for preclinical students, subinterns, and interns were 2.70 (95% CI, 2.56-2.84), 3.11 (95% CI, 2.97-3.25), and 3.75 (95% CI, 3.35-4.15), respectively. CONCLUSION: Subinternship may represent the optimal timing for entry-level skills simulation training. The proposed curriculum shows utility for clinical levels ranging from medical students to postgraduate year 1 resident levels, with large effect sizes for all tested groups.

Integrated Otolaryngology-Anesthesiology Clinical Skills and Simulation Rotation: A Novel 1-Month Intern Curriculum.

OBJECTIVES: Current Accreditation Council for Graduate Medical Education (ACGME) requirements allow PGY-1 otolaryngology-head and neck surgery (ORL-HNS) residents to spend 6 months on service, prompting reconsideration of educational best practices for the first-year resident experience. The aim of this study was to determine feasibility and value of a 1-month PGY-1 otolaryngology clinical skills rotation integrated with anesthesiology to complement clinical ORL-HNS rotations. METHODS: Our institution developed a 1-month rotation focusing on procedural simulation and airway management as a collaborative effort between ORL-HNS and anesthesiology. Logistics of curriculum design and implementation in the first 2 years are described. Learner outcome measures include pre- and postintervention Likert scale measures of knowledge and confidence. Statistical assessment of curriculum efficacy includes Wilcoxon sign rank test and effect size (Cohen's d). RESULTS: The described rotation was successfully implemented for 8 entering PGY-1 residents in the 2016-2017 and 2017-1018 academic years. Learners reported significant improvement in knowledge and confidence (5-point Likert scale, all P < .0001) in each of the following grouped domains following the intervention: anesthesia skills (pre 2.79, post 4.02), anesthesia knowledge (pre 2.31, post 3.50), anesthesia overall preparedness (pre 2.75, post 4.04), otolaryngology skills (pre 2.90, post 4.19), otolaryngology scenarios (pre 2.80, post 4.00), and otolaryngology overall preparedness (pre 2.38, post 3.75). Very large effect sizes (Cohen's d, range = 1.6-2.9) were observed. CONCLUSION: Changing rotation structure in ORL-HNS training programs provides an opportunity to develop novel rotations with high educational impact. Early outcome data suggest that the described clinical skills rotation is practically feasible and was perceived to have measurable value as part of the PGY-1 curriculum.

Trends in Post-Interview Communication Practices.

OBJECTIVES/HYPOTHESIS: Postinterview communication between residency programs and applicants is common during the US residency match process. To date, current communication practices between otolaryngology residency programs and applicants have not been studied. The objectives of this study were to characterize the frequency and type of postinterview communication and perceptions of how this communication influences ranking behavior of match participants. STUDY DESIGN: Survey. METHODS: A national survey of Accreditation Council for Graduate Medical Education-accredited otolaryngology programs was distributed via the Otolaryngology Program Directors Organization. RESULTS: Program directors were surveyed regarding methods and content of postinterview communication, perceived impact that communication has on final rank lists, and current interpretations of the National Resident Matching Program (NRMP) Code of Conduct. Thirty-three of 106 program directors (31.1%) responded. Thirty-eight percent of programs that responded initiate at least some form of postinterview communication. The program director most commonly initiated communication, typically in the form of an email. A minority of respondents (12.1%) indicated that specific information is revealed regarding rank status. Thirty-two percent of respondents indicated that communication initiated by applicants may influence final rank list. Twenty percent of respondents interpret the current NRMP Code of Conduct as allowing programs to reveal rank positions to applicants, and 63.6% of respondents as allowing applicants to reveal intended rank positions. CONCLUSIONS: The results of this study demonstrate that postinterview communication practices within otolaryngology vary widely. Program directors perceive that postinterview contact between applicants and programs has limited impact on ranking behavior. NRMP rules for postinterview communication between programs and candidates are interpreted variably by program directors. LEVEL OF EVIDENCE: NA Laryngoscope, 129:607-612, 2019.

National trends in otolaryngology intern curricula following Accreditation Council for Graduate Medical Education changes.

OBJECTIVES/HYPOTHESIS: In 2016, Accreditation Council for Graduate Medical Education (ACGME) requirements for curriculum and resident experiences were modified to require entering postgraduate year (PGY)-1 residents to spend 6 months of structured education on otolaryngology-head and neck surgery (ORL-HNS) rotations. We aimed to determine how ORL-HNS training programs have adapted curricula in response to 2016 ACGME curriculum requirement changes. STUDY DESIGN: Survey study. METHODS: A national survey of ACGME-accredited ORL-HNS programs was distributed via the Otolaryngology Program Directors Organization. RESULTS: Thirty-seven program directors responded (34.9%). Most common ORL-HNS rotations included general otolaryngology (80.6% of programs, up to 6 months) and head and neck oncology (67.7%, up to 4 months), though more months are also spent on other subspecialty rotations (laryngology, otology, rhinology, and pediatrics) than previously. All programs continue at least 1 month of anesthesiology, intensive care unit, and general surgery. Programs have preferentially eliminated rotations in emergency medicine (77% decrease) and additional months on general surgery (48% decrease). Curricula have incorporated supplemental teaching modalities including didactic lectures (96.3% of programs), simulation (66.7%), dissection courses (63.0%), and observed patient encounters (55.5%), to a greater degree following ACGME changes. More interns are involved in shared call responsibilities than in previous years (70.4% vs. 51.8%). A stable minority of interns take the Otolaryngology Training Examination (approximately 20%). CONCLUSIONS: New ACGME requirements have challenged ORL-HNS training programs to develop effective 6-month rotation schedules for PGY-1 residents. Significant variation exists between programs, and evaluation of first-year curricula and readiness for PGY-2 year is warranted. LEVEL OF EVIDENCE: NA Laryngoscope, 1811-1816, 2018.

Does drug-induced sleep endoscopy predict surgical success in transoral robotic multilevel surgery in obstructive sleep apnea?

OBJECTIVES/HYPOTHESIS: The aim of this study was to determine if drug-induced sleep endoscopy (DISE) was predictive of success for patients undergoing transoral robotic surgery (TORS) and multilevel procedures for sleep apnea. STUDY DESIGN: Retrospective case series of patients who underwent TORS surgery for sleep apnea METHODS: Before and after polysomnograms were analyzed to assess improvement, success, and cure. Improvement was defined as any decrease in apnea-hypopnea index (AHI), success as an AHI <20 with a decrease >50%, and cure as an AHI <5. DISE videos were scored using the NOHL (nose, oropharynx, hypopharynx, larynx) and VOTE (velum, oropharynx, tongue, epiglottis) classification systems. RESULTS: One hundred one patients were available for analysis. Eighty-seven percent of patients had an improvement in their AHI. Fifty-one percent met criteria for success, whereas 17% were cured. The degree of collapse at individual NOHL and VOTE subsites as well as total additive scores did not predict improvement, success, or cure. Patients with no oropharyngeal lateral collapse in the VOTE classification system were more likely to improve following surgery (P = .001); however, this effect did not hold for success or cure. Multivariate analysis of DISE variables was not predictive of success. CONCLUSIONS: In obstructive sleep apnea patients, there is a 51% success rate and a 17% cure rate. DISE, as scored by the NOHL and VOTE system, did not readily identify patients who would benefit most from surgery. Patients with lateral oropharyngeal collapse may be poorer candidates. Prospective, larger studies are required to further evaluate the use of DISE in predicting success following TORS. LEVEL OF EVIDENCE: 4 Laryngoscope, 127:971-976, 2017.

Pulse-synchronous tinnitus and sigmoid sinus wall anomalies: descriptive epidemiology and the idiopathic intracranial hypertension patient population.

OBJECTIVE: Describe the clinical features of a population of patients with sinus wall anomalies (SWA) and pulse-synchronous tinnitus (PST). STUDY DESIGN: Retrospective review. SETTING: Tertiary referral center. PATIENTS: Patients with PST and SWA undergoing surgical management between 2007 and 2012. INTERVENTION: Transmastoid sinus wall reconstruction. MAIN OUTCOME MEASURE: Age, sex, BMI, and postoperative course. Two-tailed t tests (p ≤ 0.05) compared BMI and age of the study group with negative and positive controls. RESULTS: Thirteen patients presented with sigmoid sinus diverticulum (39.4%) and 20 (60.6%) with sinus wall dehiscence. Thirty ears were successfully treated with surgery (responders), and 3 were not (nonresponders). Responders' mean age was 38 years, with 26 female patients (92.9%) and 2 male (7.1%). BMI of responders compared with nonresponders did not differ significantly (35.5 versus 33.4 kg/m2, p = 0.08). BMI of responders was elevated compared with an asymptomatic control group (35.5 versus 27.4 kg/m2, p < 0.0001). BMI of responders did not differ significantly compared with a cohort of patients with spontaneous CSF otorrhea and temporal bone encephaloceles (35.5 versus 40.7 kg/m2, p = 0.17). CONCLUSION: The patients in this study had elevated BMI and were more likely to be female. This patient population strongly resembles that of patients with IIH, suggesting the possibility that SWA may be a cause of PST in some patients with IIH. Illustrative cases supporting this hypothesis are presented.