Gender Disparity in Non-ACGME (Accreditation Council for Graduate Medical Education) Otolaryngology Fellowship Leadership.

OBJECTIVE: Women are underrepresented among practicing otolaryngology physicians with increasing disparities in leadership roles and higher levels of professional attainment in academic medicine. The purpose of this study is to determine the gender gap among fellowship directors within specific otolaryngology subspecialties, and how this compares to disparities among all academic appointments held by otolaryngologists. Additionally, we seek to better understand how years practiced, H-index, professorship status, and academic productivity differ between men and women in fellowship director roles. DESIGN: Cross-sectional. Publicly available data from non-ACGME accredited otolaryngology fellowships was collected from department websites and Doximity including gender, years of practice, and professor status of fellowship directors. Scopus was used to find H-index for identified fellowship directors. Fisher's Exact tests were used to determine if significant gender disparity existed between each fellowship and academic otolaryngology as whole. H-index and years of practice were plotted for men and women comparing the slope of lines of best fit as a measure of academic productivity. SETTING: Non-ACGME accredited otolaryngology fellowships in the US. PARTICIPANTS: Fellowship directors in non-ACGME accredited otolaryngology fellowships. RESULTS: Among 174 fellowship positions in our analysis, head and neck (17.3% women), laryngology (17.2% women), rhinology (5.7% women), and facial plastics (8.1% women) had significantly lower overall women representation compared to academic otolaryngology (36.6% women) (p < 0.05). As fellowship directors, women were significantly more productive than men given years practiced and H-index (p = 0.008). CONCLUSIONS: Gender disparities among otolaryngologists are amplified in the role of fellowship directors compared to broader academic otolaryngology. This is true despite women in these roles demonstrating higher academic productivity.

Voice Pathologies and the General Population's Perception.

OBJECTIVES: To examine how the general population perceives voice pathology based on subjective qualities. STUDY DESIGN: Descriptive, cross-sectional, survey-based study. METHODS: This is an IRB-approved Qualtrics survey on Amazon MTurk for respondents ages 18 and older. Ten subjects with voice pathologies supplied voice recordings of the Rainbow Passage to be assessed by the respondents. Respondents then assessed the voice conditions on perceived qualities of intelligence, leadership ability, and employability. One-way analysis of variance (ANOVA) and Dunnett's multiple comparison test with Sidak correction compared the mean scores of the samples (alpha = 0.05). RESULTS: A total of 1754 responses were included in the final dataset. The female control voice was scored as more likely to be a Fortune 500 leader as well as more intelligent, friendly, attractive, and employable when compared to the female vocal fry and muscle tension dysphonia (MTD) recordings (P < 0.0001). Conversely, the male MTD was the only male pathology that received a significantly lower score on friendliness, attractiveness, Fortune 500 leader status and employability than the male control (P = 0.0102, P = 0.0007, P = 0.0338, and P = 0.0039, respectively). CONCLUSIONS: This study demonstrates the more critical appraisal of voice pathologies of female patients compared to their male counterparts. People with voice disorders are perceived as being less successful, a disadvantage to potential leadership and career opportunities.

Predictors of voice therapy efficacy in vocal cord dysfunction at a tertiary care center.

OBJECTIVE: Vocal cord dysfunction is inappropriate adduction of vocal cords during inspiration that causes dyspnea and is commonly mistaken for exercise-induced asthma. To improve diagnostic accuracy, this study aims to identify demographics associated with vocal cord dysfunction and to determine their impact on the efficacy of voice therapy in improving vocal cord function. STUDY DESIGN: Retrospective chart review. SETTING: Single tertiary care institution between January 2015 and December 2021. METHODS: 184 patients who underwent voice therapy for vocal cord dysfunction were included. The primary outcome was patient self-reported percent improvement of symptoms. The secondary outcome was number of voice therapy treatments. RESULTS: The mean duration of symptoms was 2 ± 3 years. The mean number of voice therapy treatments was 2.2 ± 1.5. Of the 107 (58.2 %) patients with documented perceived breathing improvement percentages recorded, the mean maximal percent improvement was 72.5 ± 21.5 %. Mean maximal percent improvement of symptoms increased with each voice therapy treatment (p = 0.01). This association remained significant when controlling for comorbid conditions such as allergic rhinitis with postnasal drip, anxiety, asthma, and gastroesophageal reflux disease in multivariate analysis (p = 0.005). Patients with asthma had significantly higher maximum percent breathing improvement compared to those without asthma (p = 0.026). Similarly, patients who played sports had significantly higher maximum percent breathing improvement compared to those who did not (p = 0.022). CONCLUSION: Patient perceived breathing improvement with voice therapy is higher among those with concomitant asthma and those who play sports. Voice therapy is a safe and effective first line treatment of vocal cord dysfunction even when controlling for comorbid conditions.

An Analysis of Otolaryngology's NIH Research Funding Compared to Other Specialties.

OBJECTIVE: To compare NIH funding in the field of Otolaryngology to other medical and surgical specialties between 2009 and 2019. METHODS: Data was collected from the NIH RePORTER database on funding dollars received by each specialty from 2009 to 2019. Along with data on total active physicians per specialty using the Physician Specialty Data Book, comparisons were drawn between Otolaryngology and other medical and surgical specialties with regards to trends in total funding and NIH funding dollars per physician. The distributions of grant funding, within Otolaryngology from various NIH institutes among principal investigators, organizations, and subspecialties were further explored. RESULTS: There were 3810 grants (1147 unique projects) for a total of $1 276 198 555 funded by the NIH to Otolaryngology departments from 2009 to 2019. Statistically insignificant funding increases (P > .05) caused otolaryngology to fall from first to fourth in funding among studied specialties. The National Institute on Deafness and Other Communication Disorders funded 57% of all unique projects, and 57.2% of all unique NIH projects were otology related. Most projects were basic science related. The top 10 principal investigators obtained 22.3% of the total NIH funding for Otolaryngology. The top 3 organizations over the studied period comprised 26.55% of the total funding, generating a combined 729 grants. Among principal investigators, 63.0% had a PhD degree, 25.3% had an MD, and 9.6% had an MD/PhD. CONCLUSION AND RELEVANCE: NIH funding in Otolaryngology has remained stable and is highly concentrated among a small number of organizations, geographic regions, and principal investigators. Recent initiatives by academic communities have sought to address funding disparities by incorporating diversity and inclusion into clinician-scientist pipelines. We urge our colleagues to strive toward identification of the factors that contribute to successful acquisition of funding and implementation of a more conducive institutional infrastructure to produce research.

Otolaryngology Department and Society Leadership: Evaluation of Diversity in a Nationwide Study.

OBJECTIVES/HYPOTHESIS: Diversity in medicine positively influences healthcare delivery. As we aim to make otolaryngology more diverse, it is essential to analyze our current leadership. STUDY DESIGN: Observational study. METHODS: A total of 262 department chairs and chiefs, residency program directors, and assistant and associate directors from 117 otolaryngology residency programs as well as 92 society leaders from nine otolaryngology national societies from 2010 to 2020 in the United States are included in this study. The position, academic rank, name, gender, inferred race (based on name and image), and h-index are collected and recorded from publicly available data. Fisher's exact test, unpaired t tests, and analysis of variance tests are used. RESULTS: The ethno-racial breakdown of all otolaryngology residency leaders is as follows: 78.63% non-Hispanic (NH) White, 16.03% NH Asian, 2.29% Middle Eastern, 1.91% NH Black, and 1.15% Latinx. Male gender is found to be a predictor of full professorship title (P < .0001) with an odds ratio (OR) of 4.066. NH White male is also a predictor of full professorship (P < .0001) with an OR 3.05. When comparing h-index, males and females differ (P < .0001) across all residency leadership positions. There is a higher h-index among full professors compared to non-full professors (P < .0001). The ethno-racial breakdown of society leaders is 84% NH White, 11% NH Asian, 2% NH Black, 2% Latinx, and 1% Middle Eastern. CONCLUSIONS: In conclusion, otolaryngology leadership has an under-representation of women and certain ethno-racial groups. Continued efforts should be made to diversify our specialty's leadership. LEVEL OF EVIDENCE: NA Laryngoscope, 132:1729-1737, 2022.

Diversity in Academic Laryngology: An Evaluation of Academic Advancement and Research Productivity.

BACKGROUND: Diversity within the medical profession with respect to sex and racial minorities has been shown to have a positive effect on health and healthcare. Characterization of a field is key to evaluating trends and the advancement of diversity in an otolaryngology subspecialty. STUDY DESIGN: Observational study. METHODS: A comprehensive list of all the academic laryngologists was compiled from the Accreditation Council for Graduate Medical Education accredited otolaryngology residency programs in 2020. The last 20 past presidents of the American Laryngological Association (ALA) and American Broncho-Esophogological Association (ABEA) were analyzed. Academic rank and years in practice were determined from departmental websites, with online search tools used as secondary resources. The h-index was utilized as a measure of research productivity. Regression analysis was performed to analyze these variables. RESULTS: There are 184 academic laryngologists in the 124 programs. The majority of the population is Caucasian 76.6% (141/184), followed by Asian 16.3% (30/184), African American 4.34% (8/184), and then Hispanic 1% (2/184). There are 47 full professors with 83% Caucasian, 14.1% Asian, and 2.1% African American and 91.5% male and only 8.5% female. Past ALA presidents were 90% male and for the ABEA 75% male. H-index revealed a statistically significant difference between Caucasian and African American colleagues [P value (<.0005)]. CONCLUSIONS: Minorities are disproportionately underrepresented in laryngology. Women are less likely to be in leadership roles in laryngology and become full professors. Laryngology lags behind other surgical specialties in the representation of minorities and women. Continued efforts should be made to increase diversity in the field of laryngology, especially in regard to underrepresented minorities. LEVEL OF EVIDENCE: NA Laryngoscope, 132:1245-1250, 2022.

Impact of nutritional status on prevalence of left ventricular hypertrophy in children undergoing liver transplant.

OBJECTIVE: We sought to (1) determine the prevalence of cardiac changes in patients with ESLD awaiting OLT (2) determine relationship between nutritional indices and cardiac changes. METHODS: Retrospective review of transthoracic ECHO, clinical and nutritional information of pediatric patients evaluated for OLT. ECHO was analyzed for LVH, defined as LVMI > 95 g/m2.7 and/or RWT > 0.42. These findings were correlated with age, ESLD etiology, growth and nutritional parameters as well as pre- and post-OLT. RESULTS: Sixty-five patients were included, all had normal left ventricular systolic function. Nine patients (14%) had LVMI > 95 g/m2.7 , five patients (8%) had RWT > 0.42, none met both criteria. None had thickened interventricular septal wall. Fourteen patients (20%) had significant left ventricular dilation. Nutritional deprivation was modestly present-weight under third percentile in 22%, length under third percentile in 24%, and both weight and length under third percentile in 17%. There were 12 patients (17%) with MUAC below two standard deviations for age; of these one had an elevated LVMI and another had an RWT > 0.42. CONCLUSIONS: In this contemporary cross-sectional evaluation, a smaller proportion of patients with ESLD had LVH in contrast to prior studies. Despite a comparable disease burden, our cohort had better nutritional status. Though there was a trend between nutritional and LVH indices, this correlation may be better assessed prospectively in a larger cohort.

Unexpected blunt neck trauma resulting in laryngeal fracture, the case of the dangerous wooden box: A case report.

BACKGROUND: Laryngeal fracture is a rare condition but is potentially lethal. These injuries are usually caused by major blunt trauma from motor vehicle accidents, physical assaults, or sports injuries. The high mortality associated with these injuries requires prompt recognition and treatment. CASE REPORT: We present a case of laryngeal fracture caused by falling from standing height and landing onto the edge of a wooden box- a seemingly minor blunt trauma. The patient fractured her thyroid lamina and had a comminuted fracture of the cricoid cartilage. The patient was able to be decannulated and required injection augmentation for return of normal voice. CONCLUSION: This case highlights the importance of maintaining a high level of suspicion for laryngeal fracture in a patient that falls and strikes the anterior neck. Early identification of laryngeal fractures not only allows for airway protection but helps ensure the preservation of voice, swallowing and airway functions.

Dysphagia in the elderly population: A Videofluoroscopic study.

OBJECTIVE: To examine the impact of age and underlying comorbid conditions on swallowing in elderly patients with dysphagia. METHODS: Charts of consecutive patients aged >64 studied by Videofluoroscopic swallowing study (VFSS) between 2010 and 2018 at our institution were reviewed (n = 731). Patients were categorized based on age into young old (aged 65-74), older old (aged 75-84) and oldest old (aged 85+). The underlying comorbidities and VFSS results were compared between different age groups. RESULTS: Dysphagia was more likely to be caused by presbyphagia (p < 0.01) and dementia (p < 0.0001) in the oldest old, whereas, head and neck cancers (p < 0.0001) were more common in the young old cohort. In the absence of organic disease (e.g. cancer, stroke, dementia), aging was associated with prolonged oral transit time (OTT) (p < 0.05) and aspiration after swallow (p < 0.05). Compared to those with presbyphagia, patients with organic disease were more likely to have delayed pharyngeal swallow response (p < 0.05) and aspiration during swallow (p < 0.005). CONCLUSION: There are significant differences in the etiology of dysphagia between different age cohorts amongst the dysphagic elderly population. In addition, organic diseases affect swallowing differently than does mere aging. The rate of prolonged OTT and post-swallow aspiration increase with aging in patients with presbyphagia, likely due to age-related sarcopenia of the swallowing muscles. Whereas, those with organic diseases have a higher rate of delayed pharyngeal swallow response and aspiration during swallow, likely due to sensorineural impairment. Thus, it is important to view the elderly as a heterogeneous group when evaluating patients with dysphagia.

Evaluation of SMOFlipid in Pediatric Intestinal-Failure Patients and Its Effects on Essential Fatty Acid Levels.

BACKGROUND: SMOFlipid is a mixed-lipid emulsion approved for adults in the United States as an alternative to soybean oil-based lipid (SO). There are limited data on the use of SMOFlipid in pediatrics and its effect on the fatty acid (FA) profile. Our objective was to characterize changes in FA profile, liver function, and growth in pediatric patients with intestinal failure (IF), following transition from SO or a fish-oil (FO) and SO combination to SMOFlipid. METHODS: A retrospective case series was conducted on pediatric parenteral nutrition-dependent IF patients transitioned to SMOFlipid. Demographics, anthropometrics, labs, and achievement of nutrition goals were assessed. Linear mixed-effect models assessed effects on FA levels and clinical outcomes. RESULTS: One hundred thirty-nine FA panels were collected from 20 patients. Median SMOFlipid dose at study completion was 2 g/kg/d (interquartile range, 1.6-2). During the 1.5 years after SMOFlipid initiation, ω-6 FA increased to physiologic levels, arachidonic acid increased from 298 to 461 nmol/mL (P < .001), and linoleic acid increased from 1172 to 1922 nmol/mL (P < .001). ω-3 FA remained within normal limits. Body mass index z-score and length z-score increased, though no significant changes were found. In addition, no significant changes were found in mead acid, hepatic function, triene-to-tetraene ratio, or triglycerides. CONCLUSION: In 20 pediatric IF patients, SMOFlipid allowed greater ω-6 FA provision while maintaining ω-3 FA, hepatic function, and patient growth. This longitudinal study identified improved FA profile associated with SMOFlipid use in comparison with SO with or without FO.

Laryngopharyngeal reflux: Comparing improvements in reflux symptom index with reflux finding score.

PURPOSE: The objective of this study was to determine the correlation of reported symptom improvement in laryngopharyngeal reflux (LPR) with physical findings on laryngoscopic examination following medical therapy. MATERIALS AND METHODS: This IRB-approved, retrospective, single-institution study included all patients who were diagnosed and medically treated for LPR from Jan. 1, 2015-October 21st, 2019. Only patients who received at least six weeks of treatment with a proton pump inhibitor and those with pre- and post-treatment Reflux Symptom Index; RSI (n = 91) and Reflux Finding Score; RFS (n = 33) were included in the study. RESULTS: A total of 91 patients were included in the analysis (61.54% female). There was a 19.99% improvement in total RSI (p = 0.0034) and a 25.20% improvement in total RFS (p = 0.0011) following at least six weeks of treatment (average = 253 ± 213 SD days). RSI symptoms were significantly decreased between pre- and post-treatment for hoarseness (p = 0.0005), clearing of the throat (p = 0.0066), excess throat mucus or postnasal drip (p = 0.0004), troublesome cough (p = 0.0231), and heartburn/chest pain (p = 0.0053). RFS demonstrated a statistically significant decrease in only subglottic edema (p < 0.0001) and ventricular obliteration (p = 0.0295). Pearson's correlation test did not demonstrate a relationship between RSI and RFS in the pre- and post-treatment analyses alone, but did demonstrate a statistically significant relationship when analyzed across all captured pre and post data (r = 0.265, p = 0.006). CONCLUSIONS: RSI and RFS are complimentary to one another when assessing for treatment response, but improvement in RSI does not correlate with that in RFS.

Jigsaw Group-Based Learning in Difficult Airway Management: An Alternative Way to Teach Surgical Didactics.

OBJECTIVE: We describe the effectiveness of the Jigsaw method in the instruction of residents in difficulty airway management. DESIGN: The residents were given a pre-Jigsaw instruction test and a self-assessment of their skills for bag-mask ventilation, Intubation, cricothyrotomy, and tracheostomy. After the completing the pre-test, they were randomly assigned tasks from A-D, with each letter corresponding to a section of reading from Cumming's Otolaryngology and related questions. The residents were given ten minutes to read their portion of the article, and then another ten minutes to discuss their section with others assigned the same responsibilities, thereby becoming "experts." Then, the "experts" were assigned to a second group where they had ten minutes to teach their peers their designated material and learned from their peers the other designated material. A skill simulation lab was then performed involving intubation, cricothyrotomy, and tracheotomy. The residents were then given a post-Jigsaw instruction test and post simulation lab selfassessment of their skills for bag-mask ventilation, intubation, cricothyrotomy and tracheotomy. SETTING: Renaissance School of Medicine at Stony Brook University. PARTICIPANTS: General surgery, otolaryngology, plastic surgery, and oral and maxillofacial surgery residents. RESULTS: Post-Jigsaw tests scores a statistically significant increase in the number of correctly answered questions (P< 0.001) and residents reported a statistically significant increase in confidence in performing difficult airway skills. CONCLUSIONS: The Jigsaw method of learning is an effective alternative to tradition lecture-based methods.

A solitary supraglottic neurofibroma presenting with obstructive sleep apnea in an adolescent.

None: Obstructive sleep apnea (OSA) is commonly encountered in the pediatric population and has a large differential diagnosis. As clinicians, we must determine who needs to undergo flexible laryngoscopy to rule out potential obstructing lesions causing OSA. This report presents a 16-year-old female who presented with snoring, "asthma," dysphagia, and OSA. Flexible laryngoscopy and computed tomography revealed a neurofibroma of the aryepiglottic fold without associated neurofibromatosis type 1. The patient underwent microlaryngoscopy and the lesion was excised using cold steel and a carbon dioxide laser. At 6 months' follow-up, the patient was breathing without difficulty and had no evidence of recurrence. Solitary laryngeal neurofibromas are extremely rare, and this is the first case of an adolescent with OSA caused by a solitary supraglottic neurofibroma. A supraglottic mass needs to be considered in the differential diagnosis of patients with OSA who fail conservative treatment, even a diagnosis as rare as a solitary laryngeal neurofibroma.

Grill-Cleaning Wire Brush Bristle Ingestion: Case Series and Review of the Literature.

OBJECTIVES: The authors report a small case series of an unusual ingested foreign body, wire brush bristles, whose small size can present a challenge for endoscopic removal. The authors describe transnasal endoscopic removal and provide a literature review. METHODS: From 2011 to 2017, 8 patients presented to an academic tertiary medical center with ingestion of wire brush bristles. The patients' medical records were reviewed and are described in this report, along with a literature review. RESULTS: In 4 patients, the bristles were in the lingual tonsils. In 1 patient, a bristle was within the pharyngoepiglottic fold and lingual tonsils. Three patients underwent office removal with a fiber-optic laryngoscope under local anesthesia. Two patients underwent direct laryngoscopy with bristle removal. In 1 patient the wire bristle transected the esophagus, requiring an open procedure. One patient presented with a complicated deep-space neck infection. CONCLUSIONS: Wire brush bristles easily become displaced and subsequently become lodged in the upper aerodigestive tract. Localization of a bristle can be difficult on examination and laryngoscopy. Radiography can be performed, but computed tomographic examination with contrast is superior for precise localization for preparation for an operative approach. Depending on the precise location of the bristle, endoscopic removal using a fiber-optic channeled scope may be a safe and effective solution. LEVEL OF EVIDENCE: Case Series, IV.

Resolving Malnutrition With Parenteral Nutrition Before Liver Transplant in Biliary Atresia.

OBJECTIVE: Malnutrition is a common complication of end-stage liver disease (ESLD) associated with poor liver transplant outcomes. Nasogastric feeds are used for nutritional supplementation, but some patients remain malnourished. Parenteral nutrition (PN) can be effective, but has potential complications. The primary objective was to evaluate the effect of PN on anthropometric measures in children with ESLD awaiting liver transplant. Secondary objectives were evaluation of PN-associated complications, liver function tests, pediatric end-stage liver disease scores, waitlist time, and post-transplant length of stay (total and time in the intensive care unit). METHODS: A single-center, retrospective chart review analyzing pediatric patients with ESLD receiving PN who were transplanted during a 6-year period. Data were trended and described over time, as were the relationships between anthropometric data and time receiving PN. RESULTS: A total of 44 patients with ESLD were transplanted between January 2010 and December 2015. Eighteen (41%) received PN before transplant; all had biliary atresia with median age at transplant of 10 months (range, 5-18 months). Mid-upper arm circumference and triceps skinfold thickness showed resolution of malnutrition in 7 patients (39%) with normalization of 1 measure in another 4 patients (22%). Of the remaining, 6 had improved z scores and 1 had worsening malnutrition. No deaths occurred in patients receiving PN. Central line infection rates were 3.8/1000 catheter days with 8 total infections in 6 patients over a total of 2117 catheter days. CONCLUSIONS: Children with ESLD and malnutrition who have failed enteral feeding may benefit from PN to improve and/or resolve malnutrition before liver transplant.

Iodine Deficiency in a Parenteral Nutrition-Dependent Adolescent With Intestinal Pseudo-Obstruction.

Routine supplementation of iodine in parenteral nutrition (PN) solutions is not current practice in the United States. In this case study, we describe an incidental finding of goiter in a long-term PN-dependent adolescent. With increased iodine screening, we then identified additional patients with undetectable urinary iodine concentrations in our population of children with short bowel receiving long-term PN. We hypothesize that 2 practice changes are possibly reducing iodine provision to long-term PN-dependent patients: transition to alcohol-based skin preparations and lipid minimization.

Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS): an indication for tonsillectomy.

Children with obsessive compulsive disorder or tic disorders that are associated with streptococcal infections (Group A beta-hemolytic) in the oro-pharyngeal region are given the diagnosis of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS). Tonsillectomy has been reported to resolve the neuro-psychiatric symptoms in these children. We have a case of a 9-year-old boy who was seen in our clinic with multiple recurrent streptococcal infections of the oro-pharyngeal cavity. He also exhibited neuro-psychiatric symptoms including agitation, hyperactivity, and tics. These symptoms followed his recurrent infections. Tonsillectomy was performed and in one year follow-up the patient did not have any recurrent streptococcal infections, and his neuro-psychiatric symptoms resolved completely. Guidelines for medical and surgical management of recurrent strep infections in the face of PANDAS are reviewed.

Laryngeal steroid injection for vocal fold scar.

PURPOSE OF REVIEW: Vocal fold scar is generally caused by trauma or from iatrogenic causes such as intubation, radiation therapy or phonomicrosurgery. Once a vocal fold scar has occurred it becomes a difficult problem to treat. There are many different tools that otolaryngologists use for vocal fold scar treatment. This study reviews the literature and discusses the usefulness of laryngeal steroid injection for the treatment of vocal fold scar. RECENT FINDINGS: Steroid injection can be performed on an outpatient basis using a rigid laryngeal telescope or with a flexible laryngoscope under topical anesthesia. This technique allows easy surgical manipulation with a good visual field and an easy accurate approach to the lesion. The literature is limited regarding the benefits of steroid injection for vocal fold scar. SUMMARY: Steroid injection of the scarred vocal fold using an office-based technique is one of the ways that we can treat vocal fold scarring that may improve the patient's voice outcomes with minimal side effects or complications.