Otolaryngology- Head and Neck Surgery最新文献

Objective: To identify the risk factors for Otolaryngology-Head and Neck Surgery (OHNS) resident attrition.

Study design: Retrospective cohort study.

Setting: Annual Graduate Medical Education track survey.

Methods: We conducted a retrospective analysis of OHNS residents who matriculated between 2006 and 2015. Variables analyzed included age at matriculation, sex, race/ethnicity, medical degree type, program location, attrition status, and matriculation year period (2006-2010, 2011-2015). A logistic regression model was used to determine factors predictive of attrition, with a significance level set at P < .05.

Results: A total of 3073 residents were analyzed. The overall attrition rate was 3.7%. Multivariable regression showed older residents (≥30 years) had a 2.1 times higher risk of attrition compared to younger residents (≤29 years) (adjusted odds ratio [aOR]: 2.1; 95% confidence interval, CI [1.383-3.316], P < .001). Underrepresented minorities in medicine (URiM) residents had a 3.5 times higher risk of attrition compared to whites (aOR: 3.5; 95% CI [1.823-6.806], P < .001). Southern US programs had a 2.5 times higher risk of attrition compared to northeastern programs (aOR: 2.5; 95% CI [1.480-4.315], P < .001). There was no statistically significant difference in attrition based on sex, medical degree type, or matriculation year period.

Conclusion: A higher risk of attrition was found among OHNS trainees who were older, self-identified as URiM, and in the southern US programs. There was no significant difference in attrition risk based on gender, medical degree type, or matriculation period. Further research is needed to understand the reasons for attrition and to develop strategies to promote inclusion and diversity in OHNS.

Objective: To review and synthesize the available evidence for use of perioperative systemic steroids for otolaryngologic surgical procedures.

Data sources: A comprehensive literature review with evidence-informed recommendations.

Review methods: Databases were queried for medical subject heading terms and keywords related to perioperative systemic corticosteroids use for comprehensive otolaryngology and subspecialty procedures including otologic, sinonasal, sleep, laryngeal, head and neck, facial plastics, and pediatric surgery. Perioperative period included preoperative (up to 7 days prior to surgery), intraoperative (on the day of surgery), and postoperative (initiated within 24 hours after surgery) timeframes.

Conclusions: Evidence from clinical practice guidelines, systematic reviews, and original research studies supports perioperative systemic corticosteroid use for specific otolaryngologic indications. Numerous studies support perioperative steroid use for nausea, vomiting, or edema in tonsillectomy, rhinoplasty, and thyroidectomy, although formal guideline recommendations are limited. Strong evidence supports perioperative steroid use before and after endoscopic sinus surgery for chronic rhinosinusitis with polyposis and fungal sinusitis. Evidence of benefit is sparse or absent on systemic perioperative steroid use for the middle and inner ear, laryngeal, salivary gland surgery, and reconstructive facial plastic surgery.

Implications for practice: Although perioperative administration of systemic steroids is routinely performed for many otolaryngologic surgeries, high-level evidence is limited to specific contexts. Evidence supports the benefit for reducing nausea, vomiting, or edema for several otolaryngologic procedures, as well as for either chronic rhinosinusitis with polyposis or fungal sinusitis. However, these benefits need to be weighed against risks, and further investigations are needed to define the role for perioperative steroids in otolaryngology.

Objective: To quantify the otolaryngologic diagnoses encountered in outpatient clinics by otolaryngology-head and neck surgery (OHNS) residents during their 5 years of postgraduate training.

Methods: This is a retrospective review at a single institution following 5 consecutive graduating resident cohorts throughout their training. The electronic health record was queried for OHNS clinic encounters from 2013 through 2022 during which the resident physicians were included as the visit provider or assistant to an attending physician. Diagnoses were sorted into categories as adapted from the Accreditation Council for Graduate Medical Education OHNS Milestones 2.0.

Results: From 2013 to 2022, 10 residents participated in 25,447 unique clinic encounters, averaging 2544 total clinic encounters per resident. Of these, 13,957 (54.8%) listed the resident as a visit provider. The most frequently coded categories included otologic diseases (25.3%), head and neck neoplasms (14.8%), and rhinologic diseases (10.8%). Most frequently coded diagnoses included postoperative care, benign subcutaneous masses, ear infections, cerumen impaction, and maxillofacial fractures.

Discussion: To our knowledge, this is the first study to quantify the OHNS resident clinic experience. Additional data from other institutions is needed to better evaluate clinical competency regarding these nonprocedural facets in residency training.

Implications for practice: As OHNS residency training continues to evolve, it is important to evaluate the outpatient clinical experience and ensure it reflects educational needs, including adequate exposure to a range of otolaryngologic diagnoses and conditions to prepare trainees for independent practice.

Objective: The objective of this study was to evaluate the role of diet quality in children with tympanostomy tube placement (TTP) complicated by tympanostomy tube otorrhea (TTO).

Study design: Three-day 24-hour diet recall.

Setting: Tertiary care medical center.

Methods: Children between the ages of 2 to 6 years old with TTP performed 6 months to 2 years prior to enrollment were included. Children with a history of Down syndrome, cleft palate, craniofacial syndromes, known immunodeficiency, g-tube dependent, or a non-English speaking family were excluded. The primary outcome variable was TTO. The primary predictor was total caloric intake measured by percent estimated energy rate (%EER).

Results: A total of 120 families completed the 3-day diet recall. The median age was 27 months (interquartile range: 7.9-68.5), with 57% male sex. Most children reported dietary intake within the recommended range percent intake for carbohydrates and fat and less than recommended range for percent vitamin D. Within this cohort 63 (52.5%) participants had >1 TTO episode and 57 (47.5%) 1 TTO episode. Children with an EER% that was average or high were at higher odds of >1 TTO episodes compared to participants with a low EER% with ORs of 4.6 (95% confidence interval [CI]: 1.4, 15.6) and 5.7 (95% CI: 1.5, 22.1) respectively.

Conclusion: Children with a typical or high total daily caloric intake are approximately 5 to 6 times more likely to have multiple TTO episodes compared to those with low intake.

Objective: With a rising number of otolaryngology (ORL) graduates completing a fellowship, the number of generalists (also known as comprehensive ORLs [c-ORLs]), arguably the group of ORLs most needed, is likely to decrease. However, the practice and reimbursement patterns of c-ORLs have yet to be examined.

Study design: Cross-sectional retrospective analysis.

Setting: 2019 Medicare Provider Utilization and Payment Datasets.

Methods: All ORLs were isolated (n = 8959), and then a random 10% sample was obtained. These 897 ORLs were queried for fellowship completion, isolating out those who have not completed a fellowship, and characterizing their practice patterns with regards to Medicare, the largest insurer in the US.

Results: Within the random sample, 554 (61.8%) were c-ORLs, of which 47 (8.5%) practiced in an academic setting. c-ORLs billed a mean of 52.9 (SD: 26.6) Current Procedural Terminology (CPT), and community-based c-ORLs had a more diverse practice (P < .001). On average, Medicare paid $138,942 ($117,563) to each c-ORL for 1982.2 (2614.7) services for 451.7 (296.9) patients. Ninety-five percent of their total reimbursements were office-based. Of 250 unique CPT codes billed, 52.8% of all c-ORLs reimbursements were from evaluation and management services, 17.8% from rhinology, 9.7% from otology/neurotology, and 9% from laryngology.

Conclusion: Though surgery is an integral aspect of all ORLs' training and practice, c-ORLs practice in a largely office-based setting, at least with regard to Medicare patients. While c-ORLs clearly practice with a diverse skill set, their reimbursement patterns suggest rhinology makes up the largest proportion of their procedural practice.

Surgical coaching has made a positive contribution to surgical training and practice; however, the otolaryngology-head and neck surgery literature is lacking. The operating environment for practicing surgeons, and specifically otolaryngologists, is continually changing due to advancements in technology and new practice patterns. These changes in practice, however, have not come with a coordinating system for operative feedback once surgical training is completed. In this commentary, we explore surgical coaching, its applicability to otolaryngology, and encourage its more widespread acceptance and implementation.

The opioid epidemic continues to concern the CDC and public health officials but recent trends in opioid prescribing rates following common pediatric otolaryngology surgeries are unexplored. This retrospective cohort study queried the TriNetX Research database from January 1, 2010, through December 31, 2023, for pediatric patients who underwent tonsillectomy and/or adenoidectomy and received oral opioids within 5 days of surgery. Prescription trends from 2010 to 2017 were compared to 2022 to 2023, after the publication of multiple clinical practice guidelines (CPGs). Of 286,572 surgeries, 29% of patients received postoperative opioids. Comparing the 2 time periods, a significant decrease was observed in the risk of postoperative opioid prescriptions following 2022 (RR 0.87, CI_95% 0.86-0.88). Prescribing rates decreased between 2018 and 2023 from 34% to 24%. Publication of CPGs were associated with a decrease in opioid prescribing rates and may have contributed to an encouraging trend in opioid stewardship.

Qualitative methods have been increasingly applied in our literature, providing richness to data and incorporating the nuances of patient and family perspectives. These qualitative research techniques provide breadth and depth beyond what can be gleaned through quantitative methods alone. When both quantitative and qualitative approaches are coupled, their findings provide complementary information which can further substantiate study conclusions. We thus aim to provide insight into qualitative and quantitative methods in comparison and contrast to each other, as well as guidance on when each approach is most apt. In relation, we also describe mixed methods and the theory supporting their framework. In doing so, we provide the foundation for an ensuing, more detailed exposition of qualitative methods.

Significant costs associated with obtaining cadaveric temporal bones (TBs) have led many to seek more cost-effective alternatives for TB surgical simulation. Multiple studies support the face validity of resin 3-dimensional (3D)-printed TBs as high-fidelity, useful alternatives for simulating TB dissection. However, a paucity of literature describes the cost or time associated with in-house manufacturing of resin TBs at scale. This paper reviews the hardware and manufacturing costs, and time required for in-house development of resin TB models for an annual dissection course. An open-source library of TB models was queried for a candidate model which was edited for optimal printing on a recently developed resin 3D printer. In the described workflow, we were able to 3D-print 60 TB models at $6.40 each, for a total material cost of $384.10, less than the price of a single cadaveric TB specimen (∼$400-$700).

Objective: The extent of parotidectomy for benign tumors has de-escalated in the United States. We aim to define modern benchmarks for operative time and hospital length of stay (LOS) in parotidectomy and identify risk factors that may prolong these benchmarks.

Study design: This is a retrospective cross-sectional study of all adults who underwent parotidectomy for a primary parotid neoplasm between January 2011 and December 2021 using the American College of Surgeons National Surgical Quality Improvement Program database.

Methods: The extent of parotidectomy was defined using Current Procedural Terminology codes. Prolonged operative time and LOS were defined as above the 75th percentile (longer than 194 minutes and more than 1 day, respectively). Multivariable logistic regression was used to identify patient and surgical risk factors that predict prolonged operative time or LOS.

Results: Benign parotidectomies are mostly performed as outpatient procedures in the United States (average LOS <1 day). Prolonged operative time was independently associated with malignant tumors versus benign tumors (adjusted odds ratio [aOR]: 2.7, 95% confidence interval [CI]: 2.4-3.0), total parotidectomy with facial nerve sacrifice versus lesser extent of parotidectomy (aOR: 2.3, 95% CI: 1.7-3.0), and simultaneous reconstructive procedures versus none (P < .001 for all). These features were similarly independently associated with prolonged LOS (P < .001 for all). Complication rates were universally low.

Conclusion: The majority of superficial parotidectomies in this country are performed as outpatient procedures requiring <3 hours of operative time, with low complication rates. Malignant tumors, greater extent of parotidectomy, and simultaneous procedures were independently associated with prolonged operative time and LOS. These national benchmarks can inform operating room and hospital bed resource assignments.