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Objective: To evaluate the cost-effectiveness of various topical prophylaxis strategies against posttympanostomy otorrhea using a break-even analysis.

Study design: An economic decision analysis of data collected from purchasing records and the literature.

Setting: An academic center.

Methods: Costs of various strategies were calculated by querying our institution's pharmacy as well as GoodRX.com drug prices. Posttympanostomy otorrhea rates were acquired from a review of the literature. Costs for treatment of otorrhea were based upon our institution's self-pay patient charges. A break-even analysis was performed to determine the required absolute risk reduction ( $\mathrm{ARR}$ ) in otorrhea rate to make prophylactic treatment cost-effective.

Results: The most expensive strategy ciprofloxacin/hydrocortisone otic ($626.83) was not cost-effective unless the rate of postoperative otorrhea was greater than 92% or if the cost of otorrhea treatment exceeded $4477.36. The cheapest antibiotic/steroid combination, ciprofloxacin/dexamethasone otic ($72.25) was cost-effective ( $\mathrm{ARR}$ 10%). Using a conservative initial otorrhea rate (14%) and weighted cost of treatment ($683.39), the most expensive cost-effective prophylactic intervention possible was $95.67.

Conclusion: Prophylaxis against posttympanostomy otorrhea can be cost-effective. Physicians should consider the cost of prophylaxis at their institution as well as the patient's postoperative risk of otorrhea when making treatment decisions.

Objective: To identify the impact of race, ethnicity, and socioeconomic status (SES) on the rate of tympanostomy tube placement.

Study design: Retrospective medical review and population-level analyses.

Setting: Tertiary referral center.

Methods: Demographic and population-level characteristics (age, gender, race, insurance status, and ZIP code) compared to the regional, health system, and otolaryngology clinic demographics.

Results: Among 38,461 children diagnosed with otitis media (OM) 61.4% were white, 27.4% were black, 32.7% had private insurance, and 18.2% were Hispanic. Among patients seen in the pediatric ear, nose, and throat (ENT) clinics, 70.0% were white, 20.0% were black, 46.6% had private insurance, and 14.9% were Hispanic. Further disparity was noted among those receiving tympanostomy tubes: 75.6% white, 15.6% black, 61.9% private insurance, and 11.7% Hispanic. Higher rates of tube placement were noted for those of white race [odds ratio, OR: 1.96, (95% confidence interval, CI: 1.85-2.04), <.001] and non-Hispanic ethnicity [OR: 1.67, (95% CI: 1.56-1.75), <.001]. Geographically, rates of tube placement were significantly lower in areas with higher deprivation indices, areas with lower proportions of white residents, and areas with the lowest median incomes. These markers correlate strongly with black race and Hispanic ethnicity. Lower rates of tube placement were also seen in majority white locales with higher deprivation indices and lower median incomes.

Conclusion: Rates of access to pediatric ENT clinics, and of tube placement, are significantly lower for those of Hispanic ethnicity and black race than for non-Hispanic white children. Higher rates of tube placement were noted among white children and those with private insurance. Lower rates of tube placement were seen in areas of lower SES regardless of racial demographics.

Objective: Pediatric tracheostomy is associated with high morbidity and mortality, yet clinician knowledge and quality of tracheostomy care may vary widely. In situ simulation is effective at detecting and mitigating related latent safety threats, but evaluation via retrospective video review has disadvantages (eg, delayed analysis, and potential data loss). We evaluated whether a novel mobile application is accurate and reliable for assessment of in situ tracheostomy emergency simulations.

Methods: A novel mobile application was developed for assessment of tracheostomy emergency in situ simulation team performance. After 1.25 hours of training, 6 raters scored 10 tracheostomy emergency simulation videos for the occurrence and timing of 12 critical steps. To assess accuracy, rater scores were compared to a reference standard to determine agreement for occurrence or absence of critical steps and a timestamp within ±5 seconds. Interrater reliability was determined through Cohen's and Fleiss' kappa and intraclass correlation coefficient.

Results: Raters had 86.0% agreement with the reference standard when considering step occurrence and timing, and 92.8% agreement when considering only occurrence. The average timestamp difference from the reference standard was 1.3 ± 18.5 seconds. Overall interrater reliability was almost perfect for both step occurrence (Fleiss' kappa of 0.81) and timing of step (intraclass correlation coefficient of 0.99).

Discussion: Using our novel mobile application, raters with minimal training accurately and reliably assessed videos of tracheostomy emergency simulations and identified areas for future refinement.

Implications for practice: With refinements, this innovative mobile application is an effective tool for real-time data capture of time-critical steps in in situ tracheostomy emergency simulations.

Objective: Health care is a significant contributor to the climate crisis. Multidisciplinary clinics (MDC) may reduce carbon emissions by combining multiple appointments into one. This is the first program evaluation study to quantify the carbon footprint associated with multidisciplinary pediatric airway clinics.

Study design: Retrospective.

Setting: Children's Hospital at London Health Sciences Center, London, Canada.

Methods: Pediatric airway MDC allows patients to see otolaryngology and respirology in one appointment. The carbon and financial savings (Canadian Dollars) of all patients attending the MDC from January 1, 2018 to December 31, 2022 were calculated. Patient postal codes and institutional parking rates were inputted into the CASCADES carbon accounting tool. Total distance was divided into unsustainable (vehicles) and sustainable (transit, walking, cycling) transportation to calculate carbon emissions. Travel costs included cost/kilometer for vehicles (maintenance, license/registration, insurance, fuel) and costs/ride for transit.

Results: A total of 560 MDC appointments for 300 patients saved 77,785 km. Total carbon emissions saved from travel averted was 16.21 tonnes. The total carbon emissions saved, minus public transit, was 15.60 tonnes. Using the Natural Resources Canada Greenhouse Gas Equivalencies Calculator, 16.21 tonnes are approximately equivalent to 5 passenger vehicles, 6906 L of gasoline, 3.8 homes' energy, and 10.8 homes' electricity use for one year, 36.6 barrels of oil consumed, and 675 propane cylinders. Travel costs of $28,891.83 (no parking), $30,519.40 ($4 minimum parking fee), or $33,774.55 ($12 maximum parking fee) were saved.

Conclusion: MDC effectively reduced carbon emissions and offered patients financial savings. Similar models can be adapted across institutions to help mitigate climate change.

Objective: Evaluate ergonomic differences of various modalities for performing middle ear surgery.

Study design: Observational study.

Setting: Two academic tertiary care centers.

Methods: Attending physicians and residents performing middle ear surgery were photographed intraoperatively. Intraoperative photographs were analyzed using the validated Rapid Upper Limb Assessment (RULA) tool to measure musculoskeletal disease (MSD) risk. Descriptive statistics and significance testing were used to characterize and compare ergonomic differences between surgical modalities. Multivariable ordinal regression was performed to assess factors associated with increased MSD risk, as determined by the final RULA score.

Results: Most of our 110 intraoperative photos featured attendings (82.7%) performing combined middle ear surgery and mastoidectomy (60.0%). Body angles and the final RULA score varied significantly among modalities. On subset analysis, microscopic surgery exhibited significantly worse wrist, trunk, and neck angles compared to endoscopic and exoscopic surgery. Exoscopic surgery had significantly lower final RULA scores than both endoscopic and microscopic surgery, indicating significantly lower MSD risk. Microscopic and endoscopic surgery final scores did not vary significantly. In a multivariable ordinal regression of factors associated with increased RULA score, exoscopic surgery had statistically significantly less ergonomic risk relative to microscopic surgery (odds ratio = 0.12, 95% confidence interval = [0.03-0.43]).

Conclusion: Exoscopic, endoscopic, and microscopic surgery all featured low ergonomic risk, although exoscopic middle ear surgery demonstrated the lowest risk profile among studied surgical modalities. This demonstrates the importance of using each modality in combination with other ergonomic interventions to provide meaningful musculoskeletal benefits.

Objective: Advances in deep learning and artificial intelligence (AI) have led to the emergence of large language models (LLM) like ChatGPT from OpenAI. The study aimed to evaluate the performance of ChatGPT 3.5 and GPT4 on Otolaryngology (Rhinology) Standardized Board Examination questions in comparison to Otolaryngology residents.

Methods: This study selected all 127 rhinology standardized questions from www.boardvitals.com, a commonly used study tool by otolaryngology residents preparing for board exams. Ninety-three text-based questions were administered to ChatGPT 3.5 and GPT4, and their answers were compared with the average results of the question bank (used primarily by otolaryngology residents). Thirty-four image-based questions were provided to GPT4 and underwent the same analysis. Based on the findings of an earlier study, a pass-fail cutoff was set at the 10th percentile.

Results: On text-based questions, ChatGPT 3.5 answered correctly 45.2% of the time (8th percentile) (P = .0001), while GPT4 achieved 86.0% (66th percentile) (P = .001). GPT4 answered image-based questions correctly 64.7% of the time. Projections suggest that ChatGPT 3.5 might not pass the American Board of Otolaryngology Written Question Exam (ABOto WQE), whereas GPT4 stands a strong chance of passing.

Discussion: The older LLM, ChatGPT 3.5, is unlikely to pass the ABOto WQE. However, the advanced GPT4 model exhibits a much higher likelihood of success. This rapid progression in AI indicates its potential future role in otolaryngology education.

Implications for practice: As AI technology rapidly advances, it may be that AI-assisted medical education, diagnosis, and treatment planning become commonplace in the medical and surgical landscape.

Level of evidence: Level 5.

Objective: Obstructive sleep apnea (OSA) has many treatment options and the Internet is an important resource for patients. The quality of information reviewed by patients about sleep surgery is unknown. We assessed readability, accessibility, actionability, and quality of online content for OSA surgeries.

Study design: Review of webpages by 2 independent reviewers.

Setting: Internet-based search.

Methods: We queried Google for sleep apnea surgery and included top 100 English language webpages. Content was scored by 2 reviewers using the Flesch-Kincaid (FK), Simple Measure of Gobbledygook (SMOG), JAMA benchmarks, CDC Clear Communication Index (CCI), and Patient Education Materials Assessment Tool (PEMAT) understandability and actionability scores.

Results: Eighty-seven webpages were evaluated including 40 hosted by academic hospitals, 23 private practices, 10 general knowledge, 4 national organizations, 3 industry, 3 non-profit hospitals, and 2 government-sponsored. Mean CCI ranged from 22.7% to 84.9%. No sources met the 90% CCI cutoff. Average PEMAT understandability score was 80.4% (±7.8; 62.5%-93.3%), with 91% meeting the 70% standard score. Average PEMAT-actionability score was 38.4% (±16.5; 0%-70%), with 5% meeting the standard score. The average readability of webpages was the 10th grade reading level. Only 5% of pages met the recommended 6th grade reading level or lower. Only 21% of pages addressed surgical risks.

Conclusion: Most online resources regarding OSA surgery do not meet recommended standards for communication. Providers should be aware of limitations of materials when counseling patients on sleep surgery treatments. Future patient education resources should meet health communication and readability standards.

Objectives: Retraction of publications is critical to maintaining scientific integrity, yet there is a lack of research on its occurrence in Otolaryngology. This study investigates characteristics, trends, and reasons for retraction of publications in otolaryngology journals.

Study design: Bibliometric analysis.

Setting: PubMed, Scopus, Web of Science.

Methods: A PubMed search for publications retracted during 1990 to 2022 from the top 60 journals with the subject "Otorhinolaryngology" using Scopus' CiteScore was performed. Publications were excluded if they were not in English, had missing information or did not have available abstracts or full-text. Publication and retraction dates, journal, country of origin, citation counts, journal impact factor (JIF), topic, and reason for retraction were recorded. Pearson correlation coefficients were calculated to identify potential associations in the data.

Results: Fifty-three publications were included. The 2020s had the highest number of retractions per year (4.33), with publications being retracted on average, 35 months after initial publication. The most common retracted topic and country of origin were head and neck (26.4%) and China (17.0%), respectively. Most publications were retracted because of plagiarism or duplicate publication (52.8%). Mean citation count was 6.92 ± 8.32 and mean JIF was 2.80 ± 1.35. Citation count was positively associated with months until retraction (r = .432, P = .001). There was no significant correlation between months to retraction and JIF (r = .022, P = .878).

Conclusion: The most cited reasons for retraction were plagiarism and duplicate publication. An understanding of the reasons for retraction can better position journals to enforce more meticulous review standards and reduce such publications from being published.

Level of evidence: Level 4.

Objective: To investigate the possibility of hydroxyapatite as a safe and effective alternative to currently used bioavailable materials for repair of tegmen defects and labyrinthine fistulas in the setting of cholesteatoma.

Study design: Retrospective study.

Setting: Tertiary-level-care hospital.

Methods: Electronic medical records of patients 18+ years undergoing cholesteatoma-removal surgery between 2013 and 2022 were reviewed.

Results: Twenty-two patients diagnosed with cholesteatoma who underwent repair of either a tegmen defect or labyrinthine fistula using hydroxyapatite were evaluated. There were 17 canal wall up (CWU) and 5 canal wall down (CWD) surgeries. The cholesteatoma recidivism rate was 18.2% (n = 4) and the recurrence rate was 4.5% (n = 1). To ensure that these rates were similar to cholesteatoma-removal surgeries in which hydroxyapatite was not used, a 22 age, gender, and operative technique-matched cohort was evaluated. For patients with CWU surgeries, the rate of recurrence and recidivism were identical between both cohorts (0% and 23.5%, respectively; P = 1 for both). While in CWD surgeries, there was a nonstatistically significant difference in the recurrence as there was only 1 patient with recurrence in the hydroxyapatite group (P = 1). Three (13.5%) patients in the hydroxyapatite group had a local infection and 1 (4.5%) had a subacute mastoid infection. All patients with semicircular canal fistulas had consistent bone lines on postoperative audiograms, with no worsening sensorineural hearing loss.

Conclusion: In our cohort, hydroxyapatite was safe and successful in repairing skull base defects and inner-ear fistulas in the setting of cholesteatoma with a low rate of postoperative infection and no evidence of a higher rate of cholesteatoma recurrence. Further studies are needed to assess population generalizability.