Otolaryngology residency program factors associated with female resident representation.

Objective: Female representation in the field of otolaryngology is lacking. Residency is the first point at which medical school graduates specialize in a chosen field and thus represents an opportunity to recruit and train more female otolaryngologists. This study sought to identify program factors associated with greater female representation among resident physicians. Methods: Departmental websites of all 124 otolaryngology residency programs in the United States and Puerto Rico were examined for a list of residents. For programs with a resident roster available, the genders of residents, faculty, program directors, and chairpersons were recorded. Location and city population for each program was also recorded, as was female resident representation. Programs were compared using Pearson Chi-squared univariate tests. Results: 1,632 residents and 2,605 faculty were included in the analysis of 109 programs. The median female resident representation was 40%. Programs with larger faculty sizes, more female faculty, and urban location were associated with an above-median female resident representation. Programs with a larger residency cohort approached significance regarding above-median female resident representation. Higher female faculty representation, program director gender, chairperson gender, and US region were not associated with variation in female resident representation. Conclusions: Greater female otolaryngology residency representation was associated with programs having an urban location and greater numbers of female and total faculty. It was also likely that a larger resident cohort size may affect female resident representation. The proportions of female faculty, program director, and chairperson gender, as well as the US region, were not associated with variation in female resident gender representation.

Language Patterns in Letters of Recommendation for Residency Applicants in Otolaryngology.

OBJECTIVE: Assess for gender and race patterns in agentic and communal language used in letters of recommendation for Otolaryngology-Head and Neck Surgery (OHNS) residency applicants. STUDY DESIGN: Retrospective content analysis. SETTING: Applications from OHNS applications at a single training institution for the 2019 and 2020 match cycles. METHODS: A total of 2283 letters of recommendation for 611 OHNS applicants were analyzed. Applicant and letter writer gender, applicant race and ethnicity, and applicant characteristics including United States Medical Licensing Examination® Step 1 score, research productivity, and medical school rank were extracted. Agentic and communal word use from the letters of recommendation was compared across applicant and writer characteristics using multilevel negative binomial regression modeling. RESULTS: Letter writers use a greater rate of agentic terms when describing applicants who self-identify as Asian (incidence rate ratio [IRR] = 1.16, p < .01) or "Other/not reported" (IRR = 1.23, p < .01) as compared to white applicants. Further, standardized letters of evaluation had significantly more communal language and less agentic language. Although there was an increase in communal language in letters for female applicants compared to male applicants, these gender differences disappeared in the multivariate model. CONCLUSION: Multivariate analysis demonstrated no significant gender-based patterns in the communal or agentic language in letters of recommendation for OHNS residency applicants. However, letters for applicants identifying as Asian or "other/not reported" had more frequent use of agentic terms. Future studies should investigate other components of residency applications to assess how gender and race bias might unfairly influence an applicant's chances at a given program.

Soft Tissue Trauma: Critical Recognition and Timing of Intervention in Emergency Presentations.

The facial trauma surgeon will see a variety of facial injuries. Recognition of emergency cases and proper intervention is and this article aims to highlight those cases and the respective proper interventions.

The Role of Postoperative Imaging after Orbital Floor Fracture Repair.

Obtaining postoperative images of maxillofacial fractures does not affect the clinical management of asymptomatic patients; however, few studies have evaluated the role of postoperative imaging in the context of orbital floor fractures. In this study, we evaluate current practice techniques and the role of postoperative imaging in the management of orbital floor fractures in isolation and with concomitant facial fractures. Retrospective review of patients who underwent open reduction and internal fixation of orbital floor fractures between 2005 and 2015 at a single medical institution. Operative and perioperative records were reviewed to characterize postoperative imaging as routine or as indicated by concerning clinical symptoms, and to correlate clinical outcomes to postoperative imaging patterns across all identified orbital floor fractures. A total of 139 patients underwent open reduction and internal fixation of orbital floor fractures. Of these, 75 (54%) had zygomaticomaxillary (ZMC) involvement. The remaining 64 (46%) were isolated orbital floor fractures. Overall, 54 (39%) patients underwent postoperative imaging. Of these, 38 (70%) had postoperative imaging in the absence of concerning clinical symptoms. There was no observed difference in complication rates in those who underwent postoperative imaging, and those who did not. Patients with orbital + ZMC fractures underwent a significantly higher number of postoperative imaging studies ( p < 0.001); however, there was no observed difference in complications between isolated orbital and orbital + ZMC fractures. Routine postoperative imaging is not warranted in the absence of persistent clinical symptoms following open reduction and internal fixation of orbital floor fractures.

Noninvasive optical spectroscopy for identification of non-melanoma skin cancer: Pilot study.

OBJECTIVE: Optical spectroscopy offers a noninvasive alternative to biopsy as a first-line screening tool for suspicious skin lesions. This study sought to define several optical parameters across malignant and benign tissue types. STUDY DESIGN: Prospective pilot trial utilizing the Zenalux IM1 optical spectroscopy device from April 2016 to February 2017. For each skin lesion, provider pre-biopsy probability of malignancy was compared to histolopathologic diagnosis. Optical data were characterized across basal cell carcinoma (BCC; n = 9), squamous cell carcinoma (SCC; n = 5), actinic keratosis (AK; n = 4), scar tissue (n = 6), nevus (n = 2), and neurofibroma (NF; n = 1). Across all patients, agreement was determined between control measurements collected adjacent to the lesion and from the upper extremity. METHODS: Prospective single center pilot study. The optical properties of 27 cutaneous lesions were collected from 18 adult patients presenting to Otolaryngology and Dermatology clinics with suspicious skin lesions warranting biopsy. Spectroscopy measurements were recorded for each lesion: two at the lesion site, two at an adjacent site (internal control), and one at the central medial upper extremity (arm control). Variables of interest included absolute oxygenated hemoglobin (Hb), Hb saturation, total Hb concentration, and Eumelanin concentration. For each lesion, internal control averages were subtracted from lesion averages to provide delta parameter values, and lesion averages were divided by internal control averages to provide ratio parameter values. RESULTS: Mean percent difference between pre-biopsy probability of malignancy and histology was 29%, with a difference of 75% or greater seen in 5 of 25 lesions. Mean values for BCC, SCC, AK, and scar tissue varied most between extracted mean reduced scatter estimate (µa'; cm- ) delta values (BCC: -2.2 ± 3.8; SCC: -3.9 ± 2.0; AK: -3.3 ± 4.2, Scar: -1.7 ± 1.2) and total Hb (µM) ratio (BCC: 2.0 ± 3.3; SCC: 3.0 ± 1.3; AK: 1.1 ± 0.6; Scar: 1.4 ± 1.1). Agreement between local and arm controls was poor. CONCLUSION: This pilot trial utilizes optical spectroscopy as a noninvasive method for determining cutaneous lesion histology. Effect sizes observed across optical parameters for benign and malignant tissue types will guide larger prospective studies that may ultimately lead to prediction of lesional histology without need for invasive biopsy. Lasers Surg. Med. 50:246-252, 2018. © 2018 Wiley Periodicals, Inc.

Survey of Current Practice Patterns in the Management of Frontal Sinus Fractures.

The management of frontal sinus fractures has evolved in the endoscopic era. The development of functional endoscopic sinus surgery (FESS) has been incorporated into management algorithms proposed by otolaryngologists, but the extent of its influence on plastic surgeons and oral and maxillofacial surgeons is heretofore unknown. A cross-sectional survey was performed to assess the practice pattern variations in frontal sinus fracture management across multiple surgical disciplines. A total of 298 surveys were reviewed. 33.5% were facial plastic surgeons with otolaryngology training, 25.8% general otolaryngologists, 25.5% plastic surgeons, and 15.1% oral and maxillofacial surgeons. 74.8% of respondents practiced in an academic setting. 61.7% felt endoscopic sinus surgery changed their management of frontal sinus fractures. 91.8% of respondents favored observation for uncomplicated, nondisplaced frontal sinus outflow tract fractures. 36.4% favored observation and 35.9% favored endoscopic sinus surgery for uncomplicated, displaced frontal sinus outflow tract fractures. For complicated, displaced frontal sinus outflow tract fractures, obliteration was more frequently favored by plastic surgeons and oral and maxillofacial surgeons than those with otolaryngology training. The utility of FESS in managing frontal sinus fractures appears to be recognized across multiple surgical disciplines.

A Collective Review on Hazards of Powder on Surgical and Examination Gloves.

This article reviews information on the hazards associated with dusting powders on latex surgical and examination gloves. Dusting powders were first applied to latex gloves to facilitate donning. After 1980, manufacturers devised innovative techniques to manufacture gloves without dusting powders. It has been well documented that the powders on gloves present a health hazard to patients, as well as to operating-room personnel. First, these powders elicit tissue toxicity in every tissue in the body. Second, these powders serve as carriers of latex allergen and may precipitate a life-threatening allergic reaction in sensitized patients. These well-documented hazards of glove powders have caused a growing number of hospitals in the world to abandon the use of examination and surgical gloves coated with powder, and instead to use only powder-free gloves.

Update on reconstructive options for nasal Mohs defects 1.5 cm or less.

PURPOSE OF REVIEW: The article reviews the current literature to provide an overview on contemporary reconstructive options for closure of Mohs defects of the nose that are 1.5 cm or less. RECENT FINDINGS: Although some of the techniques described in the literature are of historical importance only, others have undergone modification and metamorphosis to be broadly used in their contemporary form. Others are implemented in their original design, irrespective of relative age or multiple attempted adaptations. The increase in variable closure options available provides the surgeon with the ability to tailor reconstruction in such a way as to maximize form and function for the patient. SUMMARY: Here we will provide an update on the core techniques in terms of subtle modifications, expanded applications, and examination of outcomes as well as newly described closure techniques that may fill a certain niche in nasal reconstruction.

A Computational Study of Nasal Spray Deposition Pattern in Four Ethnic Groups.

BACKGROUND: Very little is known about the role of nasal morphology due to ethnic variation on particle deposition pattern in the sinonasal cavity. This preliminary study utilizes computational fluid dynamics (CFD) modeling to investigate sinonasal airway morphology and deposition patterns of intranasal sprayed particles in the nose and sinuses of individuals from four different ethnic groups: African American (Black); Asian; Caucasian; and Latin American. METHODS: Sixteen subjects (four from each ethnic group) with "normal" sinus protocol computed tomography (CT) were selected for CFD analysis. Three-dimensional reconstruction of each subject's sinonasal cavity was created from their personal CT images. CFD simulations were carried out in ANSYS Fluent(™) in two phases: airflow phase was done by numerically solving the Navier-Stokes equations for steady state laminar inhalation; and particle dispersed phase was solved by tracking injected (sprayed) particles through the calculated airflow field. A total of 10,000 particle streams were released from each nostril, 1000 particles per diameter ranging from 5 µm to 50 µm, with size increments of 5 µm. RESULTS: As reported in the literature, Caucasians (5.31 ± 0.42 cm(-1)) and Latin Americans (5.16 ± 0.40cm(-1)) had the highest surface area to volume ratio, while African Americans had highest nasal index (95.91 ± 2.22). Nasal resistance (NR) was highest among Caucasians (0.046 ± 0.008 Pa.s/mL) and Asians (0.042 ± 0.016Pa.s/mL). Asians and African Americans had the most regions with particle deposition for small (5 µm-15 µm) and large (20 µm-50 µm) particle sizes, respectively. Asians and Latin Americans individuals had the most consistent regional particle deposition pattern in the main nasal cavities within their respective ethnic groups. CONCLUSIONS: Preliminary results from these ethnic groups investigated showed that Caucasians and Latin Americans had the least patent nasal cavity. Furthermore, Caucasians and African Americans had the lowest inter-subject consistency in regional particle deposition pattern; this may be due to greater inter-subject variability in their respective nasal vestibule morphology.

Surgical Correction of an Extensive Skull Base Defect as a Result of Pneumocele.

Pneumocele is a condition involving the pathologic expansion of paranasal sinuses with corresponding bony erosion of the skull base. Extensive pneumocele can lead to pneumocephalus, especially in patients with long-term cerebrospinal fluid shunts. Here, the authors present a case of pneumocele in an adult with a history of congenital hydrocephalus managed with a ventriculoperitoneal shunt. The patient underwent reconstruction of a posterior table defect with a pericranial flap followed by frontal sinus obliteration with abdominal fat.

Dysphagia, hoarseness, and globus in a postoperative patient.

Sore throat, hoarseness, and dysphagia are known and recognized postoperative complications of laryngeal mask airway use during operative procedures. The patient's symptoms, present immediately after surgery, are thought related to airway manipulation. Airway foreign bodies, although low on the differential, can cause similar symptoms. We present a case of a single patient who presented to a tertiary care center after an elective outpatient procedure with postoperative sore throat, hoarseness, and dysphagia. A foreign body was found lodged in the patient's hypopharynx. The differential diagnosis of sore throat, hoarseness, and dysphagia in the postoperative patient is explored in further detail.

Complications in facial flap surgery.

Local flaps are a common reconstructive technique of the head and neck. Consequently, knowledge of fundamental concepts and pitfalls to avoid will reduce surgical complications. These complications result from tension-related, ischemic, hematologic, and infectious causes. This paper seeks to address each of these causes with pearls to accomplish a successful outcome.

Intraoperative angiography using laser-assisted indocyanine green imaging to map perfusion of forehead flaps.

OBJECTIVE: To quantify the perfusion of forehead flaps and compare blood flow from the supratrochlear artery with vascular in-growth at the recipient bed. METHODS: Patients with nasal defects necessitating forehead flap closure were prospectively enrolled to study flap perfusion dynamics. Laser-assisted indocyanine green angiography was used to obtain the measurements. When possible, patients returned for weekly recording of flap perfusion from the recipient bed with the pedicle clamped. Analysis of the data was performed using SPY-Q software. RESULTS: Six patients were prospectively enrolled. All patients had intraoperative angiography at flap transfer, pedicle division, and at least 1 postoperative visit between these surgical procedures. Flow was measured as a percentage of perfusion of normal surrounding tissue. A higher percentage of perfusion was seen at the distal end of the flap when compared with the pedicle when the pedicle was clamped. This phenomenon was seen as early as the 1-week postoperative visit. CONCLUSIONS: This is the first study attempting to quantify forehead flap perfusion from the supratrochlear artery and recipient bed. Data obtained suggest evidence of vascular in-growth 1 week following flap transfer.

Reconstruction of nasal defects 1.5 cm or smaller.

OBJECTIVES: To review the repair of smaller nasal defects (≤1.5 cm) and their associated complications, elaborating on nasal obstruction and techniques to avoid it, and to determine outcomes with functional cartilage grafting. METHODS: The medical records of patients requiring nasal reconstruction for Mohs defects 1.5 cm or smaller were reviewed. Variables analyzed included defect location, defect size, use of cartilage, flap design, smoking status, and postoperative complications (nasal obstruction and flap/graft necrosis). RESULTS: A total of 208 patients with 213 nasal defects 1.5 cm or smaller were identified. The most common location was the alar subunit, followed by the tip, dorsum, and sidewall. Ninety-eight of the defects (46.0%) used cartilage grafts for reconstruction. Seventy-three of 84 alar defects (86.9%) were reconstructed with cartilage as a composite or batten graft. The sidewall and dorsum were the least likely to require cartilage grafting: 1 of 15 (6.7%) and 0 of 21, respectively. Ten patients (4.8%) had a postoperative complication: 6 of 19 smokers (31.6%) and 4 of 189 nonsmokers (2.1%). Overall, nasal obstruction was an infrequent complication (1.4%). CONCLUSIONS: Regardless of defect size, defect location, and flap design, smokers were at higher risk for postoperative complications. Subtle modifications in the classic flap design and liberal use of cartilage grafting reduce the risk of postoperative nasal obstruction.

Trends in common rhinologic illnesses: analysis of U.S. healthcare surveys 1995-2007.

BACKGROUND: Up to date information on the epidemiology of, and recent changes in, allergic rhinitis (AR), acute sinusitis (AS), and chronic sinusitis (CS) office and emergency department (ED) visits and prevalence is sparse. Current studies may quote data that is outdated or based solely on patient self-report. The purpose of this work was to describe basic epidemiologic measures of office and ED visits for AR, AS, and CS between 1995 and 2007, and to analyze trends over time for each of these diseases. METHODS: Survey data from the National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) were examined from 1995 to 2007 for AR, AS, and CS by International Classification of Diseases, 9th edition (ICD-9) code, using the STATA statistical package survey-specific commands to obtain appropriate estimates. Subgroup analyses were performed for age, sex (male and female), race (white and black), and region. Logistic regression was used in order to investigate the predictors mentioned above in a multivariate model, and to analyze trends over time. RESULTS: For AR, there has been an increase in visits in both the office and ED settings between 1995 and 2007. For CS, there has been a decrease in the proportion of both office and ED visits over this time period, as well as in the visit rate. For CS office visits, there has been an increase in the total number of visits. For AS, descriptive data show an increase in both the total number and proportion of office visits, but logistic regression did not validate these findings. There has been a decrease in ED visits for AS. Age, sex, race, and region have differing effects on each these diseases, and these factors appear to be setting-dependent as well. CONCLUSION: While regression did not show statistically significant changes for AS, the odds ratio along with the number and proportion of visits suggests that an increase for AS at a similar rate of AR is possible, lending support to a relationship between these disease processes. The relatively small increase in the prevalence of AR in the United States when compared with the worldwide increase in developing countries suggests that the hygiene theory and environmental factors play a leading role in the development of AR. The relative decrease in the prevalence of CS may be the result of successful medical therapy with the increased use of nasal steroids and nasal saline irrigation.

Nasal and facial analysis.

Rhinoplasty remains one of the most challenging aesthetic procedures to master. Astute surgeons must consider a continually evolving societal perception of beauty with their own sense of aesthetic proportion when planning surgical intervention. Optimal results are achieved when the outcome is anticipated and satisfying to patient and surgeon. This requires a careful, thoughtful, systematic approach to preoperative analysis. Patients should leave with a clear understanding of the surgeon's perspective of their nose, aesthetically and anatomically. Understanding the interplay of surface deformities and their underlying anatomic counterpart is critical, involving a systematic analysis to create a surgical plan that avoids landmines leading to a suboptimal result.

Role of hypoxia in inflammatory upper airway disease.

PURPOSE OF REVIEW: Hypoxia is a potent stimulus for inflammation and remodeling. Hypoxia develops in chronic sinusitis as shown via tissue oxygen concentrations and colonization with obligate anaerobes. This hypoxia reflects occlusion of the sinus ostia and thereby failure of transepithelial oxygenation, nonvascularized exudates, and the tendency of inflammatory hyperplasia to exceed neovascularization. RECENT FINDINGS: Hypoxia-induced transcription factors are responsible for transcription of numerous inflammatory cytokines and growth factors, including vascular endothelial growth factor, CXCL8, CCL11, transforming growth factor-beta, inducible nitric oxide synthase, as well as matrix remodeling proteins such as procollagen and matrix metalloproteinases. SUMMARY: Many diseases, such as asthma, share the tendency to afflict respiratory epithelium of the lower (bronchi) and upper (sinus) airway. Although the histopathology and inflammation of asthma and its associated sinusitis share many features, aggressive fibrosis, polyp formation and intense hyperplasia are not features of asthma, a disease seldom associated with significant chronic hypoxia. In contrast, fibrosis is a cardinal feature of hypoxic diseases of the lungs such as interstitial lung diseases and primary pulmonary hypertension. Arguably, chronic sinusitis can be viewed as reflecting both 'asthma' and 'primary pulmonary hypertension' of the upper airway.

Dual action of TGF-beta1 on nasal-polyp derived fibroblasts.

OBJECTIVES: Transforming growth factor beta-1 (TGF-beta1) is a known fibrogenic factor with immunosuppressive properties. We wanted to determine the effect of stimulation with TGF-beta1 on nasal polyp-derived fibroblasts and assess the role this molecule would have in polyp formation and growth. STUDY DESIGN: Nasal-polyp derived fibroblasts were cultured with or without TGF-beta1, and proliferation and cytokine secretion were measured. METHODS: Fibroblasts were isolated from nasal polyps following endoscopic surgery. Cells were plated and grown until confluent, after which they were split and used in assays. Cells were stimulated with TGF- beta1 and mRNA collected after 16 hours, supernatants after 72 hours, and proliferation measured after 96 hours of culture. RESULTS: TGF-beta1 significantly (P < .02) increased proliferation of nasal-polyp derived fibroblasts. We examined the expression of inflammatory cytokines and found that TGF-beta1 decreased expression of CCL2 (MCP-1), CCL5 (RANTES), CCL11 (eotaxin), granulocyte-colony stimulating factor (G-CSF), and GM-CSF (P < .05). In contrast, incubation with TGF-beta1 increased fibronectin, procollagen, vascular endothelial growth factor (VEGF), and TGF-beta2 protein production (P < .05). For select samples, we confirmed that the increased protein production was due to increased mRNA expression. CONCLUSION: These studies suggest that TGF-beta1 expression in polyp tissue can have dual effects. One role is to act as an anti-inflammatory agent shown by the ability to inhibit pro-inflammatory mRNA and protein production. At the same time, TGF-beta1 expression leads to increases in factors involved in fibrosis and angiogenesis, promoting remodeling and cell growth.

Massive soft tissue infections: necrotizing fasciitis and purpura fulminans.

Necrotizing fasciitis and purpura fulminans are two destructive infections that involve both skin and soft tissue. Necrotizing fasciitis is characterized by widespread necrosis of subcutaneous tissue and the fascia. Historically, group A beta-hemolytic streptococcus has been identified as a major cause of this infection. However, this monomicrobial infection is usually associated with some underlying cause, such as diabetes mellitus. During the last two decades, scientists have found that the pathogenesis of necrotizing fasciitis is polymicrobial. The diagnosis of necrotizing fasciitis must be made as soon as possible by examining the skin inflammatory changes. Magnetic resonance imaging is strongly recommended to detect the presence of air within the tissues. Percutaneous aspiration of the soft tissue infection followed by prompt Gram staining should be conducted with the "finger-test" and rapid-frozen section biopsy examination. Intravenous antibiotic therapy is one of the cornerstones of managing this life-threatening skin infection. Surgery is the primary treatment for necrotizing fasciitis, with early surgical fasciotomy and debridement. Following debridement, skin coverage by either Integra Dermal Regeneration Template or AlloDerm should be undertaken. Hyperbaric oxygen therapy complemented by intravenous polyspecific immunoglobulin are useful adjunctive therapies. Purpura fulminans is a rare syndrome of intravascular thrombosis and hemorrhagic infarction of the skin; it is rapidly progressive and accompanied by vascular collapse. There are three types of purpura fulminans: neonatal purpura fulminans, idiopathic or chronic purpura fulminans, and acute infectious purpura fulminans. Clinical presentation of purpura fulminans involves a premonitory illness followed by the rapid development of a septic syndrome with fever, shock, and disseminated intravascular coagulation. The diagnosis and treatment of these conditions is best accomplished in a regional burn center in which management of multiple organ failure can be conducted with aggressive debridement and fasciotomy of the necrotic skin. The newest revolutionary advancement in the treatment of neonatal purpura fulminans is the use of activated protein C.