Screening for Eustachian Tube Dysfunction in Clinical Practice Using the Eustachian Tube Dysfunction Questionnaire-7

OBJECTIVES/HYPOTHESIS

To evaluate the ability of the Eustachian Tube Dysfunction Questionnaire-7 (ETDQ-7) to discriminate between patients with Eustachian tube dysfunction (ETD) and Non-ETD diagnoses, and identify symptom information to improve ability to discriminate these groups.

STUDY DESIGN

Cohort study.

METHODS

Pilot retrospective study with consecutive adult patients presenting to otology clinics and one general otolaryngology clinic in an academic health system. Patients were administered ETDQ-7 with eight additional symptom items. Electronic health records were reviewed for demographic and diagnostic information. Patients were grouped into diagnosis categories: 1) True ETD, 2) experiencing ear fullness (EF) not due to ETD, and 3) Control patients without ETD-related disorders or EF. ETDQ-7 and symptom item scores were compared by the diagnosis group. Receiver-operative characteristics curves and area under the curve (AUC) were generated for each ETD diagnosis group based on ETDQ-7 and symptom scores.

RESULTS

Of the 108 patients included in this study 74 (68.5%) were diagnosed with ETD. Patients with ETD had higher (indicating worse symptom burden) overall ETDQ-7 scores than Control group (Median [Q1, Q3] 3.0, [1.7, 4.1]; versus 1.5 [1.0, 3.4] P = .008). There was no statistically significant difference between overall ETDQ-7 scores for ETD and Non-ETD EF patients (P = .389). The AUC for the ETDQ-7 in discriminating ETD from other conditions that cause EF was 0.569; the addition of 8 symptom questions to the ETDQ-7 improved AUC to 0.801.

CONCLUSION

Additional patient-reported symptom information may improve the ability to discriminate ETD from other similarly presenting diagnoses when using ETDQ-7.

LEVEL OF EVIDENCE

3 Laryngoscope, 2022.

Using Google Trends to Predict Pediatric Respiratory Syncytial Virus Encounters at a Major Health Care System

To assess whether Google search activity predicts lead-time for pediatric respiratory syncytial virus (RSV) encounters within a major health care system. Internet user search and health system encounter database analysis. Pediatric RSV encounter volumes across all clinics and hospitals in the Duke Health system were tabulated from 2005 to 2016. North Carolina Google user search activity for RSV were obtained over the same time period. Time series analysis was used to compare RSV encounters and search activity. Cross-correlation was used to determine the 'lag' time difference between Google user search interest for RSV and observed Pediatric RSV encounter volumes. Google search activity and Pediatric RSV encounter volumes demonstrated strong seasonality with predilection for winter months. Granger Causality testing revealed that North Carolina RSV Google search activity can predict pediatric RSV encounters at our health system (F = 5.72, p < 0.0001). Using cross-correlation, increases in Google search activity provided lead time of 0.21 weeks (1.47 days) prior to observed increases in Pediatric RSV encounter volumes at our health system. RSV is a common cause of upper airway obstruction in pediatric patients for which pediatric otolaryngologists are consulted. We demonstrate that Google search activity can predict RSV patient interactions with a major health system with a measurable lead-time. The ability to predict when illnesses in a population result in increased health care utilization would be an asset to health system providers, planners and administrators. Prediction of RSV would allow specific care pathways to be developed and resource needs to be anticipated before actual presentation.

Investigating the effects of laryngotracheal stenosis on upper airway aerodynamics

OBJECTIVE

Very little is known about the impact of laryngotracheal stenosis (LTS) on inspiratory airflow and resistance, especially in air hunger states. This study investigates the effect of LTS on airway resistance and volumetric flow across three different inspiratory pressures.

METHODS

Head-and-neck computed tomography scans of 11 subjects from 2010 to 2016 were collected. Three-dimensional reconstructions of the upper airway from the nostrils to carina, including the oral cavity, were created for one subject with a normal airway and for 10 patients with LTS. Airflow simulations were conducted using computational fluid dynamics modeling at three different inspiratory pressures (10, 25, 40 pascals [Pa]) for all subjects under two scenarios: 1) inspiration through nostrils only (MC), and 2) through both nostrils and mouth (MO).

RESULTS

Volumetric flows in the normal subject at the three inspiratory pressures were considerably higher (MC: 11.8-26.1 L/min; MO: 17.2-36.9 L/min) compared to those in LTS (MC: 2.86-6.75 L/min; MO: 4.11-9.00 L/min). Airway resistances in the normal subject were 0.051 to 0.092 pascal seconds per milliliter (Pa.s)/mL (MC) and 0.035-0.065 Pa.s/mL (MO), which were approximately tenfold lower than those of subjects with LTS: 0.39 to 0.89 Pa.s/mL (MC) and 0.45 to 0.84 Pa.s/mL (MO). Furthermore, subjects with glottic stenosis had the greatest resistance, whereas subjects with subglottic stenosis had the greatest variability in resistance. Subjects with tracheal stenosis had the lowest resistance.

CONCLUSION

This pilot study demonstrates that LTS increases resistance and decreases airflow. Mouth breathing significantly improved airflow and resistance but cannot completely compensate for the effects of stenosis. Furthermore, location of stenosis appears to modulate the effect of the stenosis on resistance differentially.

LEVEL OF EVIDENCE

NA. Laryngoscope, 128:E141-E149, 2018.

Ménière's Disease: A CHEER Database Study of Local and Regional Patient Encounter and Procedure Patterns

OBJECTIVE

(1) Integrate practice-based patient encounters using the Dartmouth Atlas Medicare database to understand practice treatments for Ménière's disease (MD). (2) Describe differences in the practice patterns between academic and community providers for MD.

STUDY DESIGN

Practice-based research database review.

SETTING

CHEER (Creating Healthcare Excellence through Education and Research) network academic and community providers.

SUBJECTS AND METHODS

MD patient data were identified with ICD-9 and CPT codes. Demographics, unique visits, and procedures per patient were tabulated. The Dartmouth Atlas of Health Care was used to reference regional health care utilization. Statistical analysis included 1-way analyses of variance, bivariate linear regression, and Student's t tests, with significance set at P < .05.

RESULTS

A total of 2071 unique patients with MD were identified from 8 academic and 10 community otolaryngology-head and neck surgery provider centers nationally. Average age was 56.5 years; 63.9% were female; and 91.4% self-reported white ethnicity. There was an average of 3.2 visits per patient. Western providers had the highest average visits per patient. Midwest providers had the highest average procedures per patient. Community providers had more visits per site and per patient than did academic providers. Academic providers had significantly more operative procedures per site (P = .0002) when compared with community providers. Health care service areas with higher total Medicare reimbursements per enrollee did not report significantly more operative procedures being performed.

CONCLUSION

This is the first practice-based clinical research database study to describe MD practice patterns. We demonstrate that academic otolaryngology-head and neck surgery providers perform significantly more operative procedures than do community providers for MD, and we validate these data with an independent Medicare spending database.

Does an Otolaryngology-Specific Database Have Added Value? A Comparative Feasibility Analysis

OBJECTIVES

There are multiple nationally representative databases that support epidemiologic and outcomes research, and it is unknown whether an otolaryngology-specific resource would prove indispensable or superfluous. Therefore, our objective was to determine the feasibility of analyses in the National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) databases as compared with the otolaryngology-specific Creating Healthcare Excellence through Education and Research (CHEER) database.

STUDY DESIGN

Parallel analyses in 2 data sets.

SETTING

Ambulatory visits in the United States.

SUBJECTS AND METHODS

To test a fixed hypothesis that could be directly compared between data sets, we focused on a condition with expected prevalence high enough to substantiate availability in both. This query also encompassed a broad span of diagnoses to sample the breadth of available information. Specifically, we compared an assessment of suspected risk factors for sensorineural hearing loss in subjects 0 to 21 years of age, according to a predetermined protocol. We also assessed the feasibility of 6 additional diagnostic queries among all age groups.

RESULTS

In the NAMCS/NHAMCS data set, the number of measured observations was not sufficient to support reliable numeric conclusions (percentage standard error among risk factors: 38.6-92.1). Analysis of the CHEER database demonstrated that age, sex, meningitis, and cytomegalovirus were statistically significant factors associated with pediatric sensorineural hearing loss (P < .01). Among the 6 additional diagnostic queries assessed, NAMCS/NHAMCS usage was also infeasible; the CHEER database contained 1585 to 212,521 more observations per annum.

CONCLUSION

An otolaryngology-specific database has added utility when compared with already available national ambulatory databases.

Variation in the Use of Vestibular Diagnostic Testing for Patients Presenting to Otolaryngology Clinics with Dizziness

OBJECTIVE

We used a national otolaryngology practice-based research network database to characterize the utilization of vestibular function testing in patients diagnosed with dizziness and/or a vestibular disorder.

STUDY DESIGN

Database review.

SETTING

The Creating Healthcare Excellence through Education and Research (CHEER) practice-based research network of academic and community providers

SUBJECTS AND METHODS

Dizzy patients in the CHEER retrospective database were identified through ICD-9 codes; vestibular testing procedures were identified with CPT codes. Demographics and procedures per patient were tabulated. Analysis included number and type of vestibular tests ordered, stratified by individual clinic and by practice type (community vs academic). Chi-square tests were performed to assess if the percentage of patients receiving testing was statistically significant across clinics. A logistic regression model was used to examine the association between receipt of testing and being tested on initial visit.

RESULTS

A total of 12,468 patients diagnosed with dizziness and/or a vestibular disorder were identified from 7 community and 5 academic CHEER network clinics across the country. One-fifth of these patients had at least 1 vestibular function test. The percentage of patients tested varied widely by site, from 3% to 72%; academic clinics were twice as likely to test. Initial visit vestibular testing also varied, from 0% to 96% of dizzy patients, and was 15 times more likely in academic clinics.

CONCLUSION

There is significant variation in use and timing of vestibular diagnostic testing across otolaryngology clinics. The CHEER network research database does not contain outcome data. These results illustrate the critical need for research that examines outcomes as related to vestibular testing.

Surgical Training and Education in Promoting Professionalism: a comparative assessment of virtue-based leadership development in otolaryngology-head and neck surgery residents

INTRODUCTION

Surgical Training and Education in Promoting Professionalism (STEPP) was developed in 2011 to train tomorrow's leaders during residency. It is based on virtue ethics and takes an approach similar to West Point military academy. The purpose of this research was: (i) to compare the virtue profiles of our residents with that of the military cohort using a standardized virtue assessment tool; and (ii) to assess the value of virtue education on residents.

METHODS

As part of STEPP, otolaryngology residents participated in a virtue-based validated assessment tool called Virtue in Action (VIA) Inventory. This was completed at the initiation of STEPP in July 2011 as well as 1 year later in June 2012. Comparison of the VIA to a military cohort was performed. Leadership 'Basic Training' is a series of forums focused on virtues of initiative, integrity, responsibility, self-discipline, and accountability. A pre- and post-test was administered assessing resident perceptions of the value of this 'Basic Training'.

RESULTS

Virtues are shared between otolaryngology residents (n=9) and military personnel (n=2,433) as there were no significant differences in strength scores between two military comparison groups and otolaryngology-head and neck surgery (OHNS) residents. There was a significant improvement (p<0.001) in the understanding of components of the leadership vision and a significant improvement in the understanding of key leadership concepts based on 'Basic Training'. All residents responded in the post-test that the STEPP program was valuable, up from 56%.

CONCLUSIONS

A virtue-based approach is valued by residents as a part of leadership training during residency.

Treatment-induced changes in vocal cord mobility and subsequent local recurrence after organ preservation therapy for laryngeal carcinoma

BACKGROUND

As multidisciplinary cancer treatment evolves, strategies to identify patients needing early resection/salvage are necessary. Some have suggested that vocal cord function after organ-preservation treatment may be an indicator.

METHODS

A retrospective review was performed of patients presenting with fixed or impaired vocal cord function at a tertiary center. Local recurrence rates were examined in patients with and without improved/normal mobilization after treatment.

RESULTS

Sixty-nine patients met the inclusion criteria, with 35 patients having vocal cord fixation and 34 patients with impaired mobility. After treatment, 44 patients had normalization of vocal cord function, while 25 patients did not, with 2-year local control rates of 70% and 77%, p = .23, respectively. No difference in local control was found between patients with normalized/improved cord function (n = 53) and those who remained the same/worsened (n = 16; p = .81).

CONCLUSION

Therapy-induced changes in vocal cord mobility did not correlate with local recurrence. Other criteria are needed to identify patients most likely to benefit from early surgical resection/salvage after organ preservation.

Studying Life Effects & Effectiveness of Palatopharyngoplasty (SLEEP) study: subjective outcomes of isolated uvulopalatopharyngoplasty

OBJECTIVE

To test the hypothesis that uvulopalatopharyngoplasty (UPPP) improves sleep apnea-related quality of life (measured on the Functional Outcomes of Sleep Questionnaire [FOSQ]) at 3-month follow-up. Secondary objectives were to test (1) the stability of the outcomes at 6 months, (2) the effect on global sleep apnea quality-of-life change, and (3) the effect on sleep apnea symptoms.

STUDY DESIGN

Multicenter, prospective, longitudinal case series.

SETTING

Diverse university- and community-based otolaryngology practices.

SUBJECTS AND METHODS

The cohort included 68 patients from 17 practices, with a mean ± standard deviation age of 44 ± 12 years and mean apnea-hypopnea index of 35 ± 32 events/hour. All patients underwent UPPP, defined as an open procedure modifying the shape and size of the palate, pharynx, and uvula, with or without tonsillectomy. Baseline data were collected on site before surgery, and outcome data were collected by mail 3 and 6 months after surgery, with follow-up rates of 51% and 50%, respectively.

RESULTS

FOSQ scores improved from 14.3 ± 3.4 (scale 5-20, normal ≥17.9) at baseline to 17.2 ± 2.7 at 3 months (mean improvement 2.9; 95% confidence interval, 1.8-4.0; P < .001) and 17.5 ± 2.5 at 6 months (mean improvement 3.1; 95% confidence interval, 2.0-4.2; P < .001). All quality-of-life and symptom measures improved significantly at 3 and 6 months (all P < .05).

CONCLUSION

This prospective, multicenter, university- and community-based study provides evidence that UPPP significantly improves disease-specific quality of life and sleep apnea symptoms in patients with sleep apnea. Validity may be limited by significant loss to follow-up and absence of an unoperated control group.