Socioeconomic Disparities in Patient Use of Telehealth During the Coronavirus Disease 2019 Surge.

Importance: The coronavirus disease 2019 (COVID-19) pandemic required the rapid transition to telehealth with the aim of providing patients with medical access and supporting clinicians while abiding by the stay-at-home orders. Objective: To assess demographic and socioeconomic factors associated with patient participation in telehealth during the COVID-19 pandemic. Design, Setting, and Participants: This cohort study included all pediatric and adult patient encounters at the Department of Otolaryngology-Head & Neck Surgery in a tertiary care, academic, multisubspecialty, multisite practice located in an early hot spot for the COVID-19 pandemic from March 17 to May 1, 2020. Encounters included completed synchronous virtual, telephone, and in-person visits as well as visit no-shows. Main Outcomes and Measures: Patient demographic characteristics, insurance status, and 2010 Census block level data as a proxy for socioeconomic status were extracted. Univariate and multivariate logistic regression models were created for patient-level comparisons. Results: Of the 1162 patients (604 females [52.0%]; median age, 55 [range, 0-97] years) included, 990 completed visits; of these, 437 (44.1%) completed a virtual visit. After multivariate adjustment, females (odds ratio [OR], 1.71; 95% CI, 1.11-2.63) and patients with preferred provider organization insurance (OR, 2.70; 95% CI, 1.40-5.20) were more likely to complete a virtual visit compared with a telephone visit. Increasing age (OR per year, 0.98; 95% CI, 0.98-0.99) and being in the lowest median household income quartile (OR, 0.60; 95% CI, 0.42-0.86) were associated with lower odds of completing a virtual visit overall. Those patients within the second (OR, 0.53; 95% CI, 0.28-0.99) and lowest (OR, 0.33; 95% CI, 0.17-0.62) quartiles of median household income by census block and those with Medicaid, no insurance, or other public insurance (OR, 0.47; 95% CI, 0.23-0.94) were more likely to complete a telephone visit. Finally, being within the lower 2 quartiles of proportion being married (OR for third quartile, 0.49 [95% CI, 0.29-0.86]; OR for lowest quartile, 0.39 [95% CI, 0.23-0.67]) was associated with higher likelihood of a no-show visit. Conclusions and Relevance: These findings suggest that age, sex, median household income, insurance status, and marital status are associated with patient participation in telehealth. These findings identify vulnerable patient populations who may not engage with telehealth, yet still require medical care in a changing health care delivery landscape.

A study of adherence to the AAO-HNS "Clinical Practice Guideline: Adult Sinusitis".

A retrospective study was conducted to determine if physicians in otolaryngology practice adhered to the clinical practice guideline for adult sinusitis that had been issued by the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) 3 years earlier. We analyzed data obtained from the charts of 90 adults who had presented to an otolaryngology outpatient department with a diagnosis of chronic rhinosinusitis (CRS), acute bacterial rhinosinusitis (ABRS), or acute viral rhinosinusitis (AVRS); there were 76 cases of CRS, 11 cases of ABRS, and 3 cases of AVRS. Our goal was to ascertain how closely the treating physician had adhered to the AAO-HNS recommendations with respect to diagnosis, treatment, and prevention of these diseases. The study group was made up of 10 otolaryngologists. We evaluated 7 clinical practice metrics for CRS, 7 metrics for ABRS, and 3 for AVRS. We found that individual physician adherence rates for cases of CRS ranged from 0 to 100%; average scores for the 7 metrics ranged from 4 to 88%. For cases of ABRS, adherence scores ranged from 0 to 100%; average scores for the 7 metrics ranged from 0 to 41%. For AVRS, the rate of adherence for all 3 metrics was 0%. This study revealed wide variations in adherence to the AAO-HNS guideline, but overall adherence was generally poor. Adherence appeared to be worse for the acute types of rhinosinusitis than for chronic rhinosinusitis. In view of these findings, a worksheet was developed that clinicians could use to improve compliance with the guidelines.

Novel DICER1 mutation as cause of multinodular goiter in children.

BACKGROUND: The aim of this report was to present a rare case of an adolescent with multinodular goiter (MNG) found to have a DICER1 mutation. METHODS AND RESULTS: The methodology includes a presentation and discussion of a chart review including endocrine hormone tests, thyroid ultrasound, and genetic testing for DICER1. A 12-year-old girl presented with a diffusely enlarged thyroid gland. Family history revealed an older sister with a history of bilateral ovarian Sertoli-Leydig cell tumors and MNG. Thyroid function tests were normal. Serial thyroid ultrasounds showed enlarging multiple bilateral nodules. Fine-needle aspiration suggested MNG. Genetic testing revealed a novel heterozygous premature termination mutation (c.1525C>T p.R509X) in the DICER1 gene. CONCLUSIONS: Thyroid nodules are rare in children but carry a higher risk for malignancy. It is essential to inquire about family history and refer for genetic evaluation with a family history of MNG. In patients with DICER1 mutations, tumor surveillance is critical due to the increased risk of multiple tumors, including ovarian tumors and pleuropulmonary blastoma.

Otologic complications of cotton swab use: one institution's experience.

OBJECTIVES/HYPOTHESIS: To evaluate the indications for observation versus surgery in the management of cotton swab-induced tympanic membrane perforations (TMP). STUDY DESIGN: Institutional review board-approved retrospective cohort study of 1,540 patients with a diagnosis of TMP from 2001 to 2010. Patients with a cotton swab injury were subdivided into two groups: observation and surgery. METHODS: Data collection included demographics, symptoms, surgery type, and pre- and postintervention audiometry. Successful outcomes were defined as healed TMP; resolution/improvement of vertigo, tinnitus, or facial nerve paralysis; and/or closure of the air-bone gap (ABG). RESULTS: Fifty-four of 1,540 patients presented with a cotton swab-induced TMP. Four of the 54 patients (7.4%) underwent delayed surgical repair with 100% success. Preoperatively, one patient had a facial nerve paralysis and two had vertigo with confirmed perilymphatic fistulae (PLF). Postoperatively, the facial nerve paralysis resolved, and one patient had mild vertigo. Fifty of 54 patients opted to forego surgery with 35 patients available for follow-up. Thirty-four (97%) of the 35 patients had spontaneous healing. The average time to perforation closure was 1.75 months. Twelve of 35 patients had no ABG after healing. CONCLUSIONS: Observation is an appropriate consideration for patients who have a TMP due to a cotton swab injury. Surgical intervention should be offered early when a PLF is suspected, or if facial paralysis, severe vertigo, and/or profound sensorineural hearing loss are present. As otolaryngologists, we should be reluctant to offer surgical intervention of an acute injury without significant symptoms as most patients will heal spontaneously within 2 months.

Sudden bilateral sensorineural hearing loss following polysubstance narcotic overdose.

BACKGROUND: Auditory disorders associated with substance abuse are rare. Hearing loss secondary to heroin and hydrocodone abuse has been described variously as not always responsive to steroid management, as not always reversible, and in some cases, as nonresponsive profound sensorineural hearing loss requiring cochlear implantation. We present a case of a teenager with sudden-onset moderate to severe bilateral sensorineural hearing loss after documented polysubstance "binging." The hearing loss improved substantially after high-dose steroid and vasoactive therapy. PURPOSE: The purpose of this report is to describe the hearing disorder of a patient who had awakened with a bilateral severe hearing loss following a night of recreational drug abuse. RESEARCH DESIGN: Case report and review of the literature. DATA COLLECTION AND ANALYSIS: The subject of this report is an 18-yr-old patient with a history of substance abuse. Data collected were magnetic resonance /computed tomography brain imaging; metabolic, infectious disease, and autoimmune evaluation; and extensive audiologic evaluation, including pure-tone and speech audiometry, immittance measures, distortion-product otoacoustic emissions, and auditory brainstem response testing. Serial audiograms were collected for 10 mo following the onset of symptoms. RESULTS: Two days of polysubstance abuse (heroin, benzodiazepine, alcohol, and crack [smoked cocaine]) resulted in moderately severe sensorineural hearing loss bilaterally. The loss responded to a 1 mo course of high-dose prednisone and a 10 mo course of pentoxifylline. Hearing sensitivity subsequently improved, leaving only residual high-frequency sensorineural hearing loss. CONCLUSIONS: This case report highlights the importance of "recreational" drug abuse in the evaluation of sudden hearing loss. Potential etiologies include altered pharmacokinetics, vascular spasm/ischemia, encephalopathy, acute intralabyrinthine hemorrhage, and genetic polymorphisms of drug-metabolizing enzymes.

Early mortality rate of morbidly obese patients after tracheotomy.

OBJECTIVES: To 1) determine the early mortality rate (within 30 days) of morbidly obese patients after tracheotomy; 2) determine the difference between the mortality rate after tracheotomy of morbidly obese patients and patients who are not morbidly obese; and 3) determine the difference between the mortality rate after tracheotomy adjusted for case mix index (CMI) of morbidly obese patients and patients who are not morbidly obese. STUDY DESIGN: Retrospective cohort study of 278 patients who had undergone a tracheotomy by the otolaryngology head and neck surgery department from 2004 to 2006. The patients were subdivided into two groups: 1) body mass index (BMI) <35 (n = 229) and 2) BMI > or =35 (morbidly obese) (n = 49). METHODS: Charts reviewed for age, sex, weight, height, BMI, indication for tracheotomy, date of tracheotomy, type of tracheotomy, date of discharge, date of death, length of hospital stay, and CMI. RESULTS: There is a trend toward significance (P = .09) between the mortality rate after tracheotomy of morbidly obese patients (29%) and patients who are not morbidly obese (18%). There is less significance between the adjusted mortality rate based on CMI after tracheotomy when the patient population is divided into morbidly obese patients and patients who are not morbidly obese (P = .12). CONCLUSION: The mortality rate after tracheotomy of morbidly obese patients is greater than patients who are not morbidly obese.

Direct electrical stimulation of Heschl's gyrus for tinnitus treatment.

OBJECTIVES/HYPOTHESIS: The purpose of the study was to determine the effect of electrical stimulation of the auditory cortex in patients with tinnitus. STUDY DESIGN: Nonrandomized clinical trial. METHODS: Two patients with debilitating tinnitus refractory to conventional therapies were treated. Patients were evaluated with validated questionnaires and psychoacoustic measures to determine the frequency and pitch of their tinnitus. Tones at these frequencies were then presented to the first patient (RP) under magnetoencephalography (MEG) and functional magnetic resonance imaging (fMRI) to determine the tonotopic map for these frequencies in Heschl's gyrus. These tonotopic sites were targeted for implant with a quadripolar electrode. In the second patient (MV), only the fMRI tonotopic map was performed. These fMRI results detected an area of increased activity, which was selected as the site for the implanted bipolar electrode. RESULTS: Patient RP (bilateral tinnitus for 2 years) has experienced a sustained reduction to near elimination of tinnitus with intracerebral implanted electrodes, whereas patient MV (unilateral tinnitus for 7 years) had an unsustained reduction in her tinnitus. CONCLUSION: These findings suggest that the perception and annoyance of tinnitus may be modulated or reduced through electrical stimulation of the auditory cortex. These unsustained effects for patient MV may have been influenced by the longstanding nature of her tinnitus or by another reason as yet undetermined.

Auditory research involving antioxidants.

PURPOSE OF REVIEW: The role of antioxidants in the management of hearing loss has generated considerable interest over the past several years. Research efforts in this field have yielded many new insights into the molecular and cellular nature of several types of hearing impairment, including age-related, noise-induced, and drug-induced hearing loss. The objective of this paper is to highlight some of the important studies published over the past several years that have further contributed to our understanding of the mechanism of antioxidants in attenuating hearing loss. RECENT FINDINGS: There is compelling evidence to suggest that antioxidant therapy is beneficial in attenuating, improving, or reversing the effects of several types of acquired hearing loss. Cellular and subcellular changes resulting from these types of hearing impairment are remarkably similar and seem to have a common putative mechanism of oxidative stress and damage. Recent studies have lent further credibility to the notion that antioxidant therapy can be of considerable benefit in the treatment of hearing loss. The increasing body of literature pertaining to human studies will shed further light into this fascinating area of research. SUMMARY: This review elucidates the role of antioxidants in hearing loss and illustrates the continued evolution of research efforts in this field.