International Consensus Statement on Allergy and Rhinology: Sinonasal Tumors

BACKGROUND

Sinonasal neoplasms, whether benign and malignant, pose a significant challenge to clinicians and represent a model area for multidisciplinary collaboration in order to optimize patient care. The International Consensus Statement on Allergy and Rhinology: Sinonasal Tumors (ICSNT) aims to summarize the best available evidence and presents 48 thematic and histopathology-based topics spanning the field.

METHODS

In accordance with prior International Consensus Statement on Allergy and Rhinology documents, ICSNT assigned each topic as an Evidence-Based Review with Recommendations, Evidence-Based Review, and Literature Review based on the level of evidence. An international group of multidisciplinary author teams were assembled for the topic reviews using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses format, and completed sections underwent a thorough and iterative consensus-building process. The final document underwent rigorous synthesis and review prior to publication.

RESULTS

The ICSNT document consists of four major sections: general principles, benign neoplasms and lesions, malignant neoplasms, and quality of life and surveillance. It covers 48 conceptual and/or histopathology-based topics relevant to sinonasal neoplasms and masses. Topics with a high level of evidence provided specific recommendations, while other areas summarized the current state of evidence. A final section highlights research opportunities and future directions, contributing to advancing knowledge and community intervention.

CONCLUSION

As an embodiment of the multidisciplinary and collaborative model of care in sinonasal neoplasms and masses, ICSNT was designed as a comprehensive, international, and multidisciplinary collaborative endeavor. Its primary objective is to summarize the existing evidence in the field of sinonasal neoplasms and masses.

Subglottic Stenosis After Endonasal Resection of Juvenile Nasopharyngeal Angiofibroma

Subglottic stenosis (SGS), the narrowing of the upper trachea, can be an acquired condition in pediatric patients. Presenting with varying degrees of dyspnea and stridor, acquired SGS is most commonly due to intubation. Airway stenosis is often not considered a surgical complication, and no literature on acquired SGS after endoscopic sinus surgery exists. We present a unique case of a 13-year-old male with juvenile nasopharyngeal angiofibroma (JNA), who developed SGS in the setting of progressive dyspnea six weeks after endonasal resection of his mass. He required urgent intubation prior to preoperative embolization and endonasal surgery, which prolonged his total intubation period. After the patient was found to have acquired SGS, he eventually required serial dilation to treat his stenosis. The presentation and operative course of this patient, along with images and pathologic findings, are discussed. Based on an extensive literature review of PubMed, Medline, and Google Scholar, there have been no cases discussing SGS development post-intubation after endonasal surgery or in association with JNA. Acquired SGS can present as a life-threatening airway obstruction in pediatric patients. With the rise of endoscopic skull base surgery and the prevalence of JNA, this case study sheds light on the detection and management of SGS post-operatively.

Effect of Hospital Safety Net Burden on Survival for Patients With Sinonasal Squamous Cell Carcinoma

OBJECTIVE

To examine factors associated with hospital safety net burden and its impact on survival for patients with sinonasal squamous cell carcinoma (SNSCC).

STUDY DESIGN

Retrospective database study.

SETTING

National Cancer Database from 2004 to 2016.

METHODS

SNSCC cases were identified in the National Cancer Database. Hospital safety net burden was defined by percentage of uninsured/Medicaid patients treated, namely ≤25% for low-burden hospitals, 26% to 75% for medium-burden hospitals, and >75% for high-burden hospitals (HBHs). Univariate and multivariate analyses were used to investigate patient demographics, clinical characteristics, and overall survival.

RESULTS

An overall 6556 SNSCC cases were identified, with 1807 (27.6%) patients treated at low-burden hospitals, 3314 (50.5%) at medium-burden hospitals, and 1435 (21.9%) at HBHs. On multivariate analysis, Black race (odds ratio [OR], 1.39; 95% CI, 1.028-1.868), maxillary sinus primary site (OR, 1.31; 95% CI, 1.036-1.643), treatment at an academic/research program (OR, 20.63; 95% CI, 8.868-47.980), and treatment at a higher-volume facility (P < .001) resulted in increased odds of being treated at HBHs. Patients with grade III/IV tumor (OR, 0.70; 95% CI, 0.513-0.949), higher income (P < .05), or treatment modalities other than surgery alone (P < .05) had lower odds. Survival analysis showed that hospital safety net burden status was not significantly associated with overall survival (log-rank P = .727).

CONCLUSION

In patients with SNSCC, certain clinicopathologic factors, including Black race, lower income, treatment at an academic/research program, and treatment at facilities in the West region, were associated with treatment at HBHs. Hospital safety net burden status was not associated with differences in overall survival.

LEVEL OF EVIDENCE: 4

Percutaneous Endoscopic Gastrostomy Tube Timing in Head and Neck Cancer Surgery

OBJECTIVE

To examine outcomes and complications in patients receiving a percutaneous endoscopic gastrostomy (PEG) tube on the same day of head and neck cancer (HNC) surgery versus later in hospitalization.

METHODS

The 2003-2014 Nationwide Inpatient Sample was queried for patients undergoing ablative HNC procedures who had a PEG tube placed. Cases were stratified by PEG tube timing into an early (on the same day as ablative procedure) and late (later in hospitalization) group. Demographics and outcomes were compared using univariate analysis and multivariate regression modeling.

RESULTS

A total of 4,068 cases were included, of which 2,206 (54.23%) underwent early PEG and 1,862 (45.77%) received a late PEG tube. Late PEG tube patients were more likely to have a diagnosis of malnutrition (18.0% vs. 15.3%, p = 0.018) or renal failure (4.7% vs. 3.0%, p = 0.006). On multivariate regression analysis, patients receiving late PEG tubes were more likely to experience aspiration pneumonia, acute pulmonary disease, infectious pneumonia, sepsis, hematoma, wound disruption, surgical site infection, and fistula formation (all p < 0.05). The mean length of stay and hospital charges in the late PEG group were significantly greater (17.1 vs. 12.6 days, p < 0.001) and ($159,993 vs. $125,705, p < 0.001), respectively.

CONCLUSIONS

Patients undergoing HNC surgery who received a PEG tube on the day of ablative surgery had lower complication rates, shorter length of stay, and decreased hospital costs compared to those who had a PEG tube placed later during hospitalization. Further research is needed to determine the causal relationships behind these findings.

LEVEL OF EVIDENCE

3 Laryngoscope, 133:109-115, 2023.

COVID-19 and rhinological surgery

The Coronavirus-19 (COVID-19) pandemic has caused disruptions in the normal patient care workflow, necessitating adaptations within the healthcare profession. The objective of this article is to outline some of these adaptations and considerations necessitated by COVID-19 within the subspeciality of rhinology and endoscopic skull base surgery.

Analysis of the Treatment and Survival of Sinonasal Extramedullary Plasmacytoma

BACKGROUND

While extramedullary plasmacytomas are infrequently encountered plasma cell malignancies, most cases occur in the head and neck, with a predilection for the sinonasal cavity. Due to the rarity of this disease, the majority of studies on sinonasal extramedullary plasmacytoma (SN-EMP) are case reports or small retrospective case series.

OBJECTIVE

To investigate the impact of patient, disease, and treatment factors on the survival of patients with SN-EMP.

METHODS

The National Cancer Database was queried for all patients with SN-EMP between 2004-2016 (N = 381 cases). Univariate and multivariate analyses were used to examine patient demographics, tumor characteristics, and survival.

RESULTS

The majority of SN-EMP patients were over 60 years old (57.0%), male (69.8%), and white (86.2%). The most common treatment modality was radiotherapy alone (38.6%), followed by surgery plus radiotherapy (37.8%). Five-year overall survival was 74.0% and median survival was 9.1 years. Accounting for patient demographics and tumor characteristics in a multivariate model, the following groups had worse prognosis: 60 and older (HR 1.99, p = 0.031) and frontal sinus primary site (HR 11.56, p = 0.001). Patients who received no treatment (HR 3.89, p = 0.013), chemotherapy alone (HR 5.57, p = 0.008) or radiotherapy plus chemotherapy (HR 2.82, p = 0.005) had significantly lower survival than patients who received radiotherapy alone. Patients who received surgery with radiotherapy (HR 0.57, p = 0.039) had significantly higher survival than patients who received radiotherapy alone.

CONCLUSION

In patients with SN-EMP five-year overall survival was found to be 74.0% with decreased survival associated with a frontal sinus primary site and being aged 60 or older. Patients receiving no treatment, chemotherapy alone, or radiotherapy with chemotherapy was associated with lower survival. Receiving surgery plus radiotherapy was associated with the highest five-year overall survival.

Sex Disparities in Pediatric Acute Rhinosinusitis: A National Perspective

OBJECTIVE

This study aims to provide an age-stratified analysis of associations with patient sex in pediatric inpatients with acute rhinosinusitis (ARS).

STUDY DESIGN

Retrospective cohort study.

SETTING

National administrative database.

METHODS

The 2016 Kids' Inpatient Database was queried for pediatric inpatients (<21 years old) with ARS (ICD-10 J01). Orbital and intracranial sequelae were selected via ICD-10 codes. Statistical associations by sex were determined via univariate and multivariable analyses. Weighted measures are reported to provide national estimates.

RESULTS

Of the 5882 patients identified with ARS, 2404 (40.9%) were female and 3478 (59.1%) were male. Male patients were younger than female patients (mean, 9.3 vs 9.9 years; P < .001). Multivariable analysis indicated that males and females had similar total charges ($71,094 vs $66,892, P = .464) and length of stay (5.8 vs 6.1 days, P = .263). However, male patients underwent more procedures (1.8 vs 1.5, P < .001). Mortality was similar between male and female patients (odds ratio [OR], 0.91; P = .664). Male patients also had increased odds for having orbital (OR, 1.58; P < .001) and intracranial (OR, 1.99; P < .001) complications. Differences in sex-dependent sequela risk were starkest in patients aged 14 to 20 years, with male patients being more likely to have orbital (OR, 2.91; P < .001) and intracranial (OR, 3.86; P < .001) complications.

CONCLUSION

In a cohort of pediatric inpatients with ARS, males have increased odds for orbital and intracranial sequelae and undergo more procedures than females. However, males and females have similar charges and length of stay. Our study highlights age-stratified differences in ARS across patient sex.

Trends in HPV Testing for Patients With Sinonasal Squamous Cell Carcinoma: A National Analysis

OBJECTIVE

The objective of this study was to analyze national trends in human papillomavirus (HPV) testing for patients diagnosed with sinonasal squamous cell carcinoma (SNSCC).

STUDY DESIGN

Retrospective database study.

SETTING

National Cancer Database (2010-2016).

METHODS

Cases from 2010 to 2016 with a primary SNSCC diagnosis and known HPV testing status were extracted from the National Cancer Database. Univariate and multivariate analyses were then performed to assess differences in socioeconomic, hospital, and tumor characteristics between tested and nontested patients.

RESULTS

A total of 2308 SNSCC cases were collected, with 1210 (52.4%) HPV tested and 1098 (47.6%) not tested. On univariate analyses, patient age, insurance, income quartile, population density, treatment facility location, and tumor grade were significantly associated with HPV testing status. After multivariate logistic regression modeling, living in a suburban area had lower odds of HPV testing as compared with living in urban areas (odds ratio, 0.74 [95% CI, 0.55-0.99]; P = .041), while tumor grade III/IV had higher odds than grade I (odds ratio, 1.73 [95% CI, 1.29-2.33]; P < .001). HPV-tested patients had a similar 5-year overall survival to nontested patients (48.3% vs 45.3%, log-rank P = .405). A sharp increase in HPV testing rates was observed after 2010 (P < .001).

CONCLUSION

Among patients with SNSCC, those with high-grade tumors were more likely to be tested for HPV, while patients with a suburban area of residence were less likely. Additionally, there was no significant survival benefit to HPV testing, with tested and nontested groups having similar overall survival.

LEVEL OF EVIDENCE

4.

ASA Physical Status Classification and Complications Following Facial Fracture Repair

BACKGROUND

To investigate the association between American Society of Anesthesiologists (ASA) physical status classification and rates of postoperative complications in patients undergoing facial fracture repair.

METHODS

Patients were divided into 2 cohorts based on the ASA classification system: Class I/II and Class III/IV. Chi-square and Fisher's exact tests were used for univariate analyses. Multivariate logistic regressions were used to assess the independent associations of covariates on postoperative complication rates.

RESULTS

A total of 3575 patients who underwent facial fracture repair with known ASA classification were identified. Class III/IV patients had higher rates of deep surgical site infection (P = .012) as well as bleeding, readmission, reoperation, surgical, medical, and overall postoperative complications (P < .001). Multivariate regression analysis found that Class III/IV was significantly associated with increased length of stay (P < .001) and risk of overall complications (P = .032). Specifically, ASA Class III/IV was associated with increased rates of deep surgical site infection (P = .049), postoperative bleeding (P = .036), and failure to wean off ventilator (P = .027).

CONCLUSIONS

Higher ASA class is associated with increased length of hospital stay and odds of deep surgical site infection, bleeding, and failure to wean off of ventilator following facial fracture repair. Surgeons should be aware of the increased risk for postoperative complications when performing facial fracture repair in patients with high ASA classification.

Inpatient Sinus Surgery Patient Morbidity and Outcomes: A National Analysis

OBJECTIVES/HYPOTHESIS

To investigate the morbidity and mortality of patients undergoing endoscopic sinus surgery (ESS) in the inpatient setting.

STUDY DESIGN

Retrospective database review.

METHODS

The Nationwide Inpatient Sample was queried for all ESS between 2008 and 2014. Using All Patients Refined Diagnosis Related Groups (APR-DRG) codes, cases with APR-DRG codes under Major Diagnostic Category 3 (Diseases and Disorders of the Ear, Nose, Mouth, and Throat) were designated as patients with primary otolaryngology diagnoses undergoing ESS (ORL), and all other codes were designated as patients with non-otolaryngology pathologies as their primary reason for admission but undergoing ESS (non-ORL). A univariate analysis and a logistic regression were used to compare patient demographics, comorbidities, disease severity, and mortality.

RESULTS

There were 8,305 ORL patients and 6,342 non-ORL patients. ORL patients were more likely to be elective admissions (61.3% vs. 48.5%, P < .001), have a deviated nasal septum (17.9% vs. 12.3%, P < .001), nasal polyps (15.8% vs. 5.0%, P < .001), obstructive sleep apnea (10.7% vs. 5.2%, P < .001), and pulmonary disease (15.9% vs. 10.5%, P < .001). Non-ORL patients had a higher likelihood of in-hospital mortality (odds ratio [OR] 6.22, 95% confidence interval [CI] 3.29-11.78, P < .001), length of stay in the highest quartile (OR 2.43, 95% CI 2.16-2.74, P < .001), and a higher proportion had APR-DRG subclasses indicating extreme severity of illness (19.3% vs. 4.3%, P < .001) or extreme risk of mortality (12.5% vs. 2.0%, P < .001).

CONCLUSION

Patients undergoing ESS in the inpatient setting have a higher than expected mortality rate which can be associated with a non-otolaryngology pathology as the primary reason for their admission.

LEVEL OF EVIDENCE

4 Laryngoscope, 2021.

Survival Predictors of Head and Neck Burkitt's Lymphoma: An Analysis of the SEER Database

OBJECTIVE

To analyze population-level data for Burkitt's lymphoma of the head and neck.

STUDY DESIGN

Retrospective study of a national cancer database.

SETTING

Academic medical center.

METHODS

The SEER database (Surveillance, Epidemiology, and End Results) identified all patients with primary Burkitt's lymphoma of the head and neck from 1975 to 2015. Demographic, clinicopathologic, and treatment characteristics were analyzed. Multivariable Cox regressions analyzed factors associated with survival while controlling for baseline differences.

RESULTS

A total of 920 patients with a mean (SD) age of 37.6 years (25.0) were identified. A majority of patients were White (82.8%) and male (72.3%). The most primary common sites included the lymph nodes (61.3%), pharynx (17.7%), and nasal cavity/paranasal sinuses (5.2%). The majority of patients received chemotherapy (90.5%), while fewer underwent surgery (42.1%) or radiotherapy (12.8%). Choice of treatment differed significantly among patients of different ages, year of diagnosis, primary site, nodal status, and Ann Arbor stage. Overall 10-year survival was 67.8%. On multivariable Cox regression, patients with older age (hazard ratio [HR], 1.05 per year; P < .001) and higher stage at presentation had increased risk of mortality (P < .001). Furthermore, cases diagnosed between 2006 and 2015 (HR, 0.35; P < .001) and 1996 and 2005 (HR, 0.53; P = .001) had lower mortality when compared with those diagnosed between 1975 and 1995. Treatment including surgery and chemotherapy tended to have the best survival (P < .001).

CONCLUSION

Burkitt's lymphoma of the head and neck diagnosed in more recent years has had improved survival. Factors significantly associated with survival include age, Ann Arbor stage, and treatment regimen. Treatment including surgery and chemotherapy was associated with the highest survival.

The Relationship Between Open Access Article Publishing and Short-Term Citations in Otolaryngology

OBJECTIVES

The purpose of this study is to compare the number of citations received by open access articles versus subscription access articles in subscription journals in the Otolaryngology literature.

METHODS

Using the Dimensions research database, we examined articles indexed to PubMed with at least 5 citations published in 2018. Articles were included from Otolaryngology-Head and Neck Surgery, The Laryngoscope, JAMA Otolaryngology-Head and Neck Surgery, Annals of Otology, Rhinology, and Laryngology, and American Journal of Otolaryngology. Multivariate Poisson regression modeling was used to adjust for journal, article type, and topic. Practice guidelines, position statements, or retractions were excluded as potential outliers.

RESULTS

137 open access articles and 337 subscription access articles meeting inclusion criteria were identified, with a median citation number of 8 (IQR 6-11). The most common article type was original investigation (82.5%), and the most common study topic was head and neck (28.9%). Open access articles had a higher median number of citations at 9 (IQR 6-13) when compared to subscription access articles at 7 (IQR 6-10) (P = .032). Open access status was significantly associated with a higher number of citations than subscription access articles when adjusting for journal, article type, and topic (β = .272, CI 0.194-0.500, P < .001).

CONCLUSIONS

Although comprising a minority of articles examined in this study of subscription journals, open access articles were associated with a higher number of citations than subscription access articles. Open access publishing may facilitate the spread of novel findings in Otolaryngology.

Exploratory analysis on the association of mental health disorders with in-hospital postoperative complications and mortality in head and neck cancer surgery

BACKGROUND

The objective was to assess the association of mental health disorders with in-hospital complication and mortality rates in patients undergoing head and neck cancer surgery.

METHODS

In this exploratory retrospective study, the Nationwide Inpatient Sample was queried from 2003 to 2014 for all patients with a diagnosis of head and neck cancer who underwent surgery. Univariate cross-tabulation, logistic regression, and propensity score matching (PSM) were used to compare demographics, procedure-related variables, and in-hospital postoperative complications and mortality between patients with and without selected comorbid mental health disorders.

RESULTS

Of 39 600 included patients, 3390 (8.6%) had a selected comorbid mental health disorder diagnosis. After PSM, patients with selected mental health disorders had increased risk of overall medical complications on multivariable analysis (OR 1.28 [CI 1.12-1.46], P < 0.001) but not overall surgical complications or mortality.

CONCLUSIONS

Patients with a mental health disorder diagnosis have increased risk of in-hospital medical, certain surgical, and total complications.

Factors Associated With Unanticipated Admission After Outpatient Endoscopic Sinonasal Surgery

OBJECTIVES/HYPOTHESIS

To identify factors that may increase the risk of unplanned admission following elective outpatient endoscopic sinonasal surgery (ESS).

STUDY DESIGN

Retrospective analysis of the National Surgical Quality Improvement Program (NSQIP).

METHODS

All cases of ESS were extracted from the 2010 to 2018 NSQIP database using Current Procedural Terminology codes. Only cases coded as outpatient, elective, and nonemergent procedures were included. Unplanned admissions were defined as cases with a total hospital stay of 1 day or more. Univariate and multivariate analyses were performed to identify variables that independently predicted unanticipated admission.

RESULTS

A total of 971 cases met inclusion criteria, of which 274 (28.2%) were unanticipated admissions. Patients in the unplanned admission group were more likely to be older (46.8 vs. 41.1 years, P < .001), male (57.7% vs. 48.4%, P = .009), obese (54.8% vs. 43.8%, P = .003), and have hypertension (35.0% vs. 25.0%, P = .002). Unplanned admitted patients were also more likely to be included under American Society of Anesthesiologists (ASA) classification III-IV (43.1% vs. 27.2%, P < .001). There were no significant differences in race, smoking, diabetes, or chronic steroid use. Unplanned admitted patients had a higher rate of surgical complications (2.9% vs. 1.0%, P = .041). Upon multivariate analysis, independent preoperative risk factors for unplanned admission included age (OR: 1.018, P = .002), male gender (OR: 1.415, P = .025), obesity (OR: 1.527, P = .008), and ASA III-IV (OR 1.501, P = .018).

CONCLUSIONS

Factors independently associated with unplanned admission following outpatient ESS were older age, male gender, obesity, and higher ASA. Identification of patients at risk may reduce unanticipated hospital admission after ESS.

LEVEL OF EVIDENCE

4 Laryngoscope, 2021.

Adverse Events Associated with Intranasal Sprays: An Analysis of the Food and Drug Administration Database and Literature Review

BACKGROUND

Intranasal sprays (INSs) are commonly used medications for the treatment of many rhinologic conditions. Despite their popularity, an analysis of a nationwide reporting database and comparison to the available literature has never been performed.

METHODS

The Food and Drug Administration Adverse Event Reporting System (FAERS) database was accessed to obtain adverse event (AE) records from 2014 to 2019 for varying INSs, including: 10 corticosteroids, 1 alpha adrenergic, and 3 antihistamines. The Proportional Reporting Ratios (PRR) and Reporting Odds Ratios (ROR) were calculated for dyspnea, anosmia, ageusia/dysgeusia, epistaxis, and headache. A PRR ≥ 2 or ROR ≥ 1 was considered significant.

RESULTS

Corticosteroids had 98 864 total reported AEs to the database, followed by antihistamines (7011) and alpha adrenergics (2071). In total, dyspnea was reported 5843 times, followed by headache (4230), epistaxis (1205), ageusia/dysgeusia (920), and anosmia (312). Overall, PRR and ROR values for dyspnea ranged from 0.51 to 4.25 and 0.51 to 4.49; for dysgeusia/ageusia from 0.56 to 6.09 and 0.56 to 6.12; and for epistaxis from 1.03 to 27.24 and 1.03 to 30.76, respectively. All medications which listed anosmia within the top AEs had PRR and ROR values exceeding 2 and 1, respectively. The PRR for headache exceeded 2 for 1 medication and the ROR exceeded 1 in 7 medications.

CONCLUSION

The AEs of dyspnea, anosmia, ageusia/dysgeusia, epistaxis, and headache are reported within the FAERS database for commonly prescribed INSs. When compared against the existing scientific literature, the clinical significance of this reporting tool from the FDA for these classes of medications remains unvalidated.

Extranodal Extension as an Indicator for Sinonasal Squamous Cell Carcinoma Prognosis

OBJECTIVE

Although extranodal extension (ENE) is a known indicator of poor prognosis for head and neck malignancies, its value as an indicator for sinonasal squamous cell carcinoma (SCC) has not been well characterized. This study seeks to assess the usefulness of ENE as a prognostic marker for sinonasal SCC.

STUDY DESIGN

Retrospective database review.

SETTING

National Cancer Database from 2010 to 2015.

METHODS

The National Cancer Database was queried from 2010 to 2015 for all patients with sinonasal SCC with available ENE status (n = 355). These cases were divided into those with pathologically confirmed ENE (n = 146) and those without ENE (n = 209). Univariate and multivariate analyses were used to examine survival differences and predictors of ENE status.

RESULTS

Most patients with ENE were ≥60 years old (61.7%), male (61.6%), and white (83.6%). Patients aged 60 to 69 and 80+ years were more likely to have ENE than those under 60 years (P < .05). Patients with ENE had worse 1-year overall survival than those without ENE (58.2% vs 70.8%, log-rank P = .008). After multivariate regression, however, there was no survival difference detected between ENE-positive and ENE-negative cases (hazard ratio, 1.14 [0.775-1.672], P = .508).

CONCLUSION

ENE status did not have a significant effect on survival in patients with sinonasal SCC. Thus, ENE alone may not necessarily be a helpful indicator for sinonasal SCC prognosis.

Geographic and Socioeconomic Factors on Survival in Esthesioneuroblastoma

OBJECTIVES

Esthesioneuroblastoma (ENB) is a rare sinonasal malignancy with little known regarding how regional and socioeconomic differences in the United States alter disease survival. The aim of this study is to explore the geographic difference in clinical features, socioeconomic factors, and survival outcomes of ENB patients.

METHODS

ENB cases were extracted from the Surveillance, Epidemiology, and End Results registry from 1975-2016. Patient data were stratified based on geographical location and comparative analyses of socioeconomic features, disease characteristics, and survival patterns were performed. Kaplan-Meier regression analyses were used to estimate disease-specific survival (DSS).

RESULTS

A total of 987 patients were identified: 56.4% West, 14.0% South, 12.7% Midwest, and 16.6% East. The West had the highest proportion of patients with Medicaid coverage (P < .001), stage A malignancy (P < .001), and treated with surgery and adjuvant radiotherapy (P < .001). The South had the highest proportion of patients who were Black (P < .001), uninsured (P < .001), and resided in rural areas (P < .001). Five-year DSS patterns were 81.0% (West), 79.8% (East), 67.4% (Midwest), and 72.7% (South) [P = .018]. Ten-year DSS outcomes were 74.0% (West), 73.7% (East), 60.9% (Midwest), and 63.6% (South) [P = .017].

CONCLUSION

In ENB patients, survival disparity exists in the United States based on geographical region. Patients from the West and East exhibit higher survival than those from the South and Midwest.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E2162-E2168, 2021.

Management of complicated pediatric rhinosinusitis in the COVID-19 era

With the ongoing development of the COVID-19 pandemic, research continues to emerge regarding the pathophysiology, characteristics, and treatment considerations for patients with COVID-19. No reports have highlighted the specific challenges posed in the management of pediatric patients with COVID-19 who present with complicated rhinosinusitis. In this report, we discuss our preoperative, intraoperative, and postoperative multidisciplinary treatment strategy for these cases and provide two examples of complicated rhinosinusitis cases in COVID-19 patients, treated with two different approaches. Pearls, insights, and a brief review of the literature are discussed.

Time is Money: Relative Value Units and Operative Time in Otolaryngology

OBJECTIVES

Physician compensation for procedures is typically rooted in the work relative value unit (wRVU) system. Operative time is one of the factors that goes into the determination of wRVU assignment. There should be consistency between the wRVU/hr rate, irrespective of average operative time required to perform certain procedures. We investigate if wRVU assignment for otolaryngology procedures adequately accounts for increased operative time.

STUDY DESIGN

Retrospective analysis of a surgical database.

METHODS

NSQIP was queried from 2015-2018 for the top 50 most frequently performed otolaryngology Current Procedural Terminology (CPT) codes completed as standalone procedures. Median operative time was determined for each CPT code, and wRVU/hr was calculated. Correlations between operative time, wRVU, and wRVU/hr were investigated using linear regression analysis. A secondary analysis using complication rate as an indicator for procedure complexity was performed to examine the relation between wRVUs and complication rates.

RESULTS

Fifty CPT codes containing 64,084 patients where only one code was reported were included in this analysis. The median operative time was 84 minutes, median wRVU was 11.23, and median wRVU/hour was 7.96. Linear regression analysis demonstrated a strong positive correlation between operative time and wRVU assignment (R² = 0.805, P < .001). Further analysis found no correlation between operative time and wRVU/hr (R² = 0.008, P = .525). Linear regression of wRVU/hr and complication rate showed a statistically significant positive correlation (R² = 0.113, P = .017).

CONCLUSION

This analysis suggests that compensation for otolaryngology procedures is positively correlated with operative time. Surgeries where more than one code is reported could not be evaluated, thus excluding some common combination of procedures performed by otolaryngologists.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E395-E400, 2021.

Gender Representation at Conferences, Executive Boards, and Program Committees in Otolaryngology

OBJECTIVE

Women represent approximately 28.0% of academic otolaryngologists. Previous studies have shown that women in academic medicine, including surgical subspecialties, have disparate career advancement opportunities and grant funding compared to male counterparts. Representation at major academic meetings is an important career advancement opportunity. In this study, we assess the representation of women at otolaryngology conferences.

STUDY DESIGN

Cross-sectional analysis of otolaryngology conference programs.

METHODS

All publicly available scientific programs from The American Academy of Otolaryngology-Head and Neck Surgery Foundation Annual Meeting (AAO-HNSF), the Triological Society Annual Combined Sections Meeting (TS), and the Triological Society Annual Meeting at Combined Otolaryngology Spring Meetings (TS-COSM) were obtained and analyzed. Name and gender were collected, along with the type of role: speaker, panelist, oral session moderator, and other leadership positions. Yearly trends were analyzed and compared between the conferences and in aggregate.

RESULTS

AAO-HNSF had available scientific programs from 2012-2017, while TS and TS-COSM had programs available from 2003-2018. Across all conferences and years, 16.9% of recorded opportunities were occupied by women, with an upward trend from 2005 to 2018. Program committees had the highest proportion of women (21.4%) and presidential citation and guest of honor recipients had the lowest (9.1%). Of all panels, 87.5% did not have any women panelists in 2003, but by 2018 only 24.0% panels were male-only. There was marked repetition among women occupying roles, with only 423 unique women occupying a total of 1,733 filled spots.

CONCLUSION

Measured representation of women in academic otolaryngology conferences has improved from 2003-2018. Despite this improvement, gender disparity still exists.

LEVEL OF EVIDENCE

5 Laryngoscope, 131:E373-E379, 2021.

Systematic Review of Negative Pressure Pulmonary Edema in Otolaryngology Procedures

OBJECTIVE(S)

Negative pressure pulmonary edema (NPPE) is a rare perioperative complication with a potentially fatal outcome. The aim of this study was to perform a systematic review of NPPE in adult otolaryngology procedures with the goal of identifying risk factors, clinical presentation, diagnosis, management and outcomes.

METHODS

Systematic review performed using PubMed, Scopus, Web of Science, and Cochrane databases.

RESULTS

Sixty-nine studies including data from 87 individual patients were included in this review. Fifty-six (68%) patients were male and the average patient age was 37 years old. Type 1 NPPE occurred in 63 (72%) cases, while type 2 NPPE accounted for 20 (23%) cases. The most common procedures leading to NPPE were septoplasty, rhinoplasty or sinus surgery (n = 22, 25%), directly laryngoscopy or bronchoscopy (n = 13, 15%), and tracheostomy or cricothyroidotomy (n = 11, 13%). The most employed treatment options included diuretics (n = 55, 63%) and mechanical ventilation (n = 54, 62%). Seventy-eight (90%) patients made a full recovery with an average time to NPPE resolution of 33 hours and an average length of hospitalization of 5.6 days. Five (6%) patients had a long-term morbidity and four (5%) patients died, with age and ICU stay increasing risk for death and long-term morbidity (OR 1.044 and 7.42, respectively, P < .05).

CONCLUSION

Septoplasty, rhinoplasty and sinus surgery account for the majority of NPPE cases in adult otolaryngology procedures. Young, healthy patients are the most commonly involved with a slight male predominance. The vast majority of patients recover fully, however there is a significant risk for morbidity and mortality.

Comparison of Open and Endoscopic Approaches in the Resection of Esthesioneuroblastoma

BACKGROUND

Olfactory neuroblastoma, or esthesioneuroblastoma (ENB), is an uncommon sinonasal malignancy arising from olfactory neuroepithelium that is optimally treated with surgical resection. The objective of this study is to determine preoperative predictors of undergoing open versus endoscopic approach for ENB and to investigate significant postoperative survival outcomes between the two surgical approaches.

METHODS

The National Cancer Database (NCDB) was queried for cases of ENB histology that were treated surgically from 2010 to 2015. Groups were stratified into open or endoscopic approach cohorts. Patient demographics, tumor characteristics, treatment modality, and 5-year overall survival were compared between the two groups using Chi-Square analysis and Kaplan-Meier survival analysis. Cases were classified as Kadish stage A, B, C, or D based on the "Collaborative Stage-Extension" codes in NCDB.

RESULTS

Of 533 patients meeting inclusion criteria, 276 (51.8%) patients underwent open, and 257 (48.2%) patients underwent endoscopic surgical approaches. Patients undergoing endoscopic surgery were more likely to be Kadish stages A and B and less likely to be stages C and D (P = .020). Those undergoing endoscopic approach overall had a shorter mean hospital stay postoperatively (3.8 vs. 7.0 days, P < .001). Endoscopic cases had a greater 5-year overall survival (81.9% vs. 75.6%, P = .030); after multivariate regression, there was a trend toward survival benefit to endoscopic surgery that did not reach clinical significance (HR 0.644, [0.392-1.058], P = .083).

CONCLUSION

Although not statistically significant, there is a trend toward increased overall survival with an endoscopic approach in patients undergoing surgery for ENB as compared to an open approach, regardless of Kadish stage. An endoscopic approach is an adequate alternative to an open approach for the surgical treatment of ENB.

Nasoseptal Flap Necrosis After Endoscopic Skull Base Surgery in the Setting of COVID-19 Pandemic

Background

A novel viral strain known as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has created a worldwide pandemic known as coronavirus 2019 (COVID-19). Early reports from China have highlighted the risks associated with performing endoscopic endonasal skull base surgery in patients with SARS-CoV-2. We present a rare complication of nasoseptal flap (NSF) necrosis associated with COVID-19, further emphasizing the challenges of performing these procedures in this era.

Case Description

A 78-year-old man underwent an extended endoscopic endonasal transplanum resection of a pituitary macroadenoma for decompression of the optic chiasm. The resulting skull base defect was repaired using a pedicled NSF. The patient developed meningitis and cerebrospinal fluid (CSF) leak on postoperative day 13, requiring revision repair of the defect. Twelve days later, he developed persistent fever and rhinorrhea. The patient was reexplored endoscopically, and the NSF was noted to be necrotic and devitalized with evident CSF leakage. At that time, the patient tested positive for SARS-CoV-2. Postoperatively, he developed acute respiratory distress syndrome complicated by hypoxic respiratory failure and death.

Conclusions

To our knowledge, this is the first reported case of NSF necrosis in a patient with COVID-19. We postulate that the thrombotic complications of COVID-19 may have contributed to vascular pedicle thrombosis and NSF necrosis. Although the pathophysiology of SARS-CoV-2 and its effect on the nasal tissues is still being elucidated, this case highlights some challenges of performing endoscopic skull base surgery in the era of COVID-19.