Faculty Bibliography

OBJECTIVE:Our institution serves a diverse patient population across a large metropolitan city. Literature has shown pediatric otolaryngology patients with lower socioeconomic status (SES) have higher rates of sleep-disordered breathing, delays in treatment time, and greater risks of complications post-tonsillectomy. This study aims to examine the effects of SES on adenotonsillectomy outcomes performed at our institution. STUDY DESIGN/METHODS:A retrospective chart review including 1560 pediatric patients (ages 0-18) who underwent adenotonsillectomy between January 2015 and December 2020. SETTING/METHODS:Large metropolitan hospital, level 1 trauma center. METHODS:Outcome variables included postoperative hospital admission, phone calls, 30-day follow-up, and persistent obstructive sleep apnea (OSA). Descriptive statistics using Wilcoxon Signed Rank Tests and univariate and multivariate logistic regression modeling were used to determine statistically significant covariates at α = 0.05. RESULTS:The cohort included Non-Hispanic White (n = 488, 31 %), Non-Hispanic Black (n = 801, 51 %), Hispanic (n = 210, 13 %), and other (n = 61, 4 %) groups. Using multivariate regression, privately insured patients were less likely to have moderate-to-severe OSA before surgery (0.65 95 % CI 0.45, 0.93 p = 0.017) and be admitted postoperatively (0.73, 0.55-0.96, p < 0.01), while more likely to have postoperative follow-up phone calls (1.57, 1.19-2.09, p < 0.01) and visits (1.53, 1.22-1.92, p < 0.01). Increased income was associated with decreased rehospitalizations within three months of surgery (0.98, 0.97-1.00, p < 0.01). CONCLUSION/CONCLUSIONS:This study suggests SES significantly affects adenotonsillectomy outcomes. Further studies are warranted to provide better care for all pediatric patients.

Head and neck squamous cell carcinoma (HNSCC) encompasses a spectrum of heterogeneous diseases originating in the oral cavity, pharynx, and larynx. Within the United States, head and neck cancer (HNC) accounts for 66,470 new cases, or 3% of all malignancies, annually.¹ The incidence of HNC is rising, largely driven by increases in oropharyngeal cancer.^2-4 Recent molecular and clinical advancements, particularly with regard to molecular and tumor biology, reflect the heterogeneity of the subsites contained within the head and neck. Despite this, existing guidelines for post-treatment surveillance remain broad without much consideration given to different anatomic subsites and etiologic factors (such as human papillomavirus [HPV] status or tobacco exposure).⁵ Surveillance incorporating the physical examination, imaging, and emerging molecular biomarkers is an essential part of care for patients treated for HNC and allows for the detection of locoregional recurrence, distant metastases, and second primary malignancies aiming for better functional and survival outcomes. Additionally, it allows for evaluation and management of post-treatment complications.

OBJECTIVES:To identify risk factors of perioperative blood transfusions (PBTs) for neck dissection and identify the association of PBTs with other postoperative outcomes. METHODS:This is a retrospective study of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. The database was queried for neck dissection procedures performed by otolaryngologists from 2006 to 2014. Multivariable logistic regression was used to determine associations between demographic and preoperative factors, mortality, unplanned reoperation, and unplanned readmission with PBTs. RESULTS:Of the 3090 patients included in our study, 346 (11.2%) received a PBT, 249 patients (72.0%) received blood intraoperatively or on postoperative day (POD) 0, and 97 patients (28.0%) received blood within 5 PODs. American Society of Anesthesiologists (ASA) class ≥3 (odds ratio [OR], 2.1; 95% confidence interval [CI], 1.4-3.2), preoperative weight loss (OR, 2.2; 95% CI, 1.5-3.2), and anemia (OR, 5.5; 95% CI, 4.1-7.6) were independently associated with PBTs. Free flaps were also significantly associated with PBTs. PBTs were significantly associated with unplanned return to the operating room within 30 days (OR, 4.31; 95% CI, 3.01-6.18) but not with 30-day unplanned readmission or 30-day mortality. DISCUSSION:Eleven percent of patients undergoing neck dissection receive a PBT. Identifying associated risk factors may reduce PBT among patients with cancer. Comorbid data, such as weight loss, anemia, and ASA class, may be useful in determining risk for transfusion during these procedures. IMPLICATIONS FOR PRACTICE:Awareness of preoperative risk factors for PBT may lead surgeons to reduce the risk of PBT, anticipate the need for transfusion, and manage these patients carefully to prevent unplanned reoperation.

BACKGROUND:Ventral skull base (VSB) surgery has associated morbidity and mortality that is poorly defined. In this study we aim to identify factors associated with adverse events in VSB surgery. METHODS:We queried the database of the American College of Surgeons National Surgical Quality Improvement Program for cases of VSB surgery during the period 2005-2014. Patients with complications, readmissions, reoperations, or mortality were compared to those without adverse events. RESULTS:Nine hundred patients were included; 253 (28.1%) had complications, underwent reoperation, were readmitted, or died. These patients were older (42.6% vs 32.8, p = 0.032) and had higher rates of congestive heart failure (CHF) (3.2% vs 0.2%, p < 0.0001), disseminated cancer (8.3% vs 4.6%, p = 0.032), and preoperative sepsis (8.7% vs 2.2%, p < 0.0001). Other comorbidities included long-term steroid use (13.4% vs 9.0%, p = 0.046) and higher rates of preoperative transfusion (2.4% vs 0%, p < 0.0001). The most common complication was bleeding (13.7%). Preoperative systemic sepsis (odds ratio [OR], 2.6; 95% confidence interval [CI], 1.0-6.6) and lower hematocrit (OR, 2.1; 95% CI, 1.4-3.4) were more likely to be associated with a complication. Those with disseminated cancer (OR, 12.0; 95% CI, 2.9-50.5) were more likely to experience 30-day mortality. Black patients had lower rates of reoperation (OR, 0.3; 95% CI, 0.1-0.8), whereas patients with CHF (OR, 12.6; 95% CI, 1.7-94.4) and hypertension (OR, 2.1; 95% CI, 1.1-4.0) had higher rates of reoperation. Predictors of extended length of stay were Hispanic ethnicity (OR, 2.2; 95% CI, 1.2-4.1) and lower hematocrit (OR, 2.3; 95% CI, 1.5-3.6). CONCLUSION:VSB surgery can involve significant morbidity and mortality, and thus identifying risk factors allows for better prognostication and delivery of care in these patients.

OBJECTIVE/HYPOTHESIS:Research has long been acknowledged as important to successfully matriculate into an otolaryngology residency position. The objective of this study is to perform a bibliometric analysis to quantify the importance of scholarly productivity in the otolaryngology match process. STUDY DESIGN:Retrospective database review. METHODS:A list of all Accreditation Council for Graduate Medical Education-accredited otolaryngology residency programs were identified. Websites of programs were reviewed to identify first-year otolaryngology residents for the 2016 to 2017 academic year and compared to two previous academic years. Research output measures were collected. Residencies were tiered 1 to 5 by departmental research output. RESULTS:Two hundred twenty-two records of first-year otolaryngology residents starting residency in 2016 were identified. After adjusting for number of total publications, number of original research articles, number of review articles, number of case reports, number of first author publications, number of otolaryngology-related publications, highest journal impact factor, average journal impact factor, and years since publication, h-index and number of total publications were associated with increasing tier of matriculation based on research output (P < .0001). Only number of publications correlated with increasing h-index (B = 1.11). With regard to applicant trends, there has been an increase in scholarly productivity as measured across all research parameters in the past 3 years. CONCLUSIONS:Research is an important component of successfully matriculating into an otolaryngology residency program. The h-index is a reliable tool to quantify research output and predict the tier of matriculation with regard to institutional research output. There has been a steadily increasing level of scholarly output among applicants in the past 3 years. LEVEL OF EVIDENCE:NA Laryngoscope, 129:1561-1566, 2019.

BACKGROUND:Paragangliomas of the nasal cavity and paranasal sinuses, although exceedingly rare, can exhibit frequent and aggressive recurrences. Our objective was to evaluate tumor characteristics, clinical course, management, and associated complications of sinonasal paragangliomas METHODS: A systematic review of the literature was performed utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, searching for sinonasal paraganglioma. Studies meeting inclusion criteria were assessed for level of evidence. Patient demographics, tumor characteristics, primary intervention, and other clinical characteristics were evaluated. RESULTS:Forty-five relevant studies encompassing 54 patients with sinonasal paraganglioma were identified. The most common tumor locations were the nasal cavity (66.7%), ethmoid sinuses (22.2%), maxillary sinuses (7.4%), and sphenoid sinuses (3.7%). Common presenting symptoms included recurrent epistaxis (68.5%), nasal obstruction (53.7%), and headache (13.0%). Tumors were malignant in 28.6% of patients. Only 4 cases (7.4%) involved functional tumors. Initial management was always surgical, via either an open (63.0%) or endoscopic (33.3%) approach. Radiotherapy was used as adjunctive treatment in 10 cases (18.5%). Recurrence rate was 21.7% and occurred between 12 to 156 months after initial resection. The overall survival was 87.0% with a metastatic rate of 8.7%. CONCLUSION:Sinonasal paragangliomas are vascular neoplasms manifesting clinically with recurrent epistaxis and nasal obstruction. Management goals are total resection with clear margins and long-term follow-up due to tendency for local recurrence. Radiotherapy has been utilized as adjuvant therapy with variable results. Further randomized controlled studies may be invaluable in elucidating these findings.

BACKGROUND:Pediatric sinonasal rhabdomyosarcoma (RMS) is an aggressive and rare malignancy. This is the first multi-institutional study on the prognostic factors associated with outcomes in this population. METHODS:The National Cancer Database was queried for the period from 2004 to 2013 for all cases of malignant sinonasal RMS in the pediatric population. The impact of patients' demographics, tumor characteristics, and Intergroup Rhabdomyosarcoma Study Group (IRSG) staging on survival was assessed using chi-square test, Fisher's exact test, Kaplan-Meier test, and Cox regression analyses. RESULTS:A total of 157 cases of pediatric sinonasal RMS were identified. Mean age at diagnosis was 9.38 years and male patients comprised 48.4% of the cohort. The nasal cavity (31.8%) and maxillary sinus (30.6%) were the most common primary sites. Alveolar was the most common histology (49.7%), followed by embryonal type (32.5%). The majority of patients received solely chemoradiation (52.9%), followed by surgery with adjuvant chemoradiation (30.6%). Five-year overall survival (OS) was 55.2% (±4.5%). Metastatic disease was associated with a poorer 5-year OS rate (24.4% vs 61.5%; p = 0.010). Maxillary sinus site was associated with an improved survival (71.8% vs 47.6%; p = 0.009). On multivariate analysis, chemoradiation with or without surgery was an additional prognostic factor. Although IRSG clinical stages did not correlate with survival, high-risk patients in the IRSG clinical risk groups were associated with poorer survival on multivariate analysis (hazard ratio [HR], 2.005; 95% confidence interval, 1.007-3.993; p = 0.048). CONCLUSION:To date, this is the largest study on pediatric sinonasal RMS. IRSG clinical risk groups may be useful in stratifying high-risk patients with poor prognosis.

IMPORTANCE/OBJECTIVE:Smoking is a highly prevalent risk factor among patients with head and neck cancer. However, few studies have examined the association of this modifiable risk factor on postoperative outcomes following microvascular reconstruction of the head and neck. OBJECTIVE:To analyze the risk associated with smoking in patients undergoing free flap surgery of the head and neck. DESIGN, SETTING, AND PARTICIPANTS/METHODS:In this retrospective, population, database study, the National Quality Improvement Program data sets from 2005 to 2014 were queried for all cases of head and neck surgery involving free flap reconstruction in the United States. The 2193 cases identified were stratified into smoking and nonsmoking cohorts and compared using χ2 and binary logistic regression analyses. Pack-years of smoking data were used to assess the degree of risk associated with a prolonged history of smoking. All analyses were conducted between January 2018 and June 2018. MAIN OUTCOMES AND MEASURES/METHODS:Smoking and nonsmoking cohorts were compared for rates of demographic characteristics, comorbidities, and complications. Following correction for differences in patient demographics and comorbidities, smoking and nonsmoking cohorts were compared for rates of postoperative complications. Complication rates were further assessed within the smoking cohort by number of pack years smoked. RESULTS:Of the 2193 patients identified as having undergone free flap reconstruction of the head and neck, 624 (28.5%) had a history of recent smoking. After accounting for differences in demographic variables and patient comorbidities using regression analyses, smoking status was found to be independently associated with wound disruption (odds ratio, 1.74; 95% CI, 1.17-2.59; P = .006) and unplanned reoperation (odds ratio, 1.50; 95% CI, 1.15-1.95; P = .003). An analysis by pack-years of smoking showed that a longer smoking history was significantly associated with higher rates of numerous comorbidities but not with a corresponding increase in rates of complications. CONCLUSIONS AND RELEVANCE/CONCLUSIONS:Smokers undergoing free flap reconstruction of the head and neck may be at significantly higher risk of postoperative wound disruption and subsequent reoperation. These risks were independent of pack-years of smoking history, suggesting that both risks were associated with perioperative smoke exposure, and preoperative smoking cessation may be of benefit. LEVEL OF EVIDENCE/METHODS:NA.

Mammalian genomes typically contain hundreds of thousands of endogenous retroviruses (ERVs), derived from ancient retroviral infections. Using this molecular 'fossil' record, we reconstructed the natural history of a specific retrovirus lineage (ERV-Fc) that disseminated widely between ~33 and ~15 million years ago, corresponding to the Oligocene and early Miocene epochs. Intercontinental viral spread, numerous instances of interspecies transmission and emergence in hosts representing at least 11 mammalian orders, and a significant role for recombination in diversification of this viral lineage were also revealed. By reconstructing the canonical retroviral genes, we identified patterns of adaptation consistent with selection to maintain essential viral protein functions. Our results demonstrate the unique potential of the ERV fossil record for studying the processes of viral spread and emergence as they play out across macro-evolutionary timescales, such that looking back in time may prove insightful for predicting the long-term consequences of newly emerging viral infections.