Faculty Bibliography

OBJECTIVE/HYPOTHESIS: Glucocorticoids (GCs) are commonly used in the treatment of laryngeal disorders despite the absence of clear guidelines regarding their use. We sought to assess clinical practice patterns regarding GC use for various vocal fold diseases and to ascertain factors underlying the selection of particular GCs for different vocal fold pathology. STUDY DESIGN: Prospective, survey. METHODS: A web-based 20-question survey querying clinical indications for GC use and other factors influencing decision making in GC administration was distributed to 5280 otolaryngologists via e-mail using a commercially available database. RESULTS: The overall response rate for the survey was 4% (212/5280). Of the respondents, 99% reported GCs to be valuable in their practice. Previous experience/results, familiarity, and use in practice (68%, 54%, and 37%, respectively) were the most commonly cited reasons for choosing a particular GC; pharmacokinetic profile and academic literature were infrequently cited reasons. Fifty-four percent of respondents were more likely to prescribe GCs for vocal performers compared with other patients. Additionally, most respondents stated that the potential for side effects only occasionally prevented GC utilization. CONCLUSIONS: GC prescription practices vary greatly among otolaryngologists. Drug choice appears to be driven primarily by clinician preference and personal experience rather than by specific pharmacologic or physiologic rationale. These findings likely reflect the current lack of well-constructed studies in the laryngology literature to guide GC selection and administration for benign disorders of the larynx and highlight an important potential area for future studies.

OBJECTIVES/HYPOTHESIS: To characterize the videoendoscopic laryngeal findings in patients with a prior established diagnosis of laryngopharyngeal reflux disease (LPR) as the sole etiology for their chief complaint of hoarseness. We hypothesized that many, if not all, of these patients would present with discrete laryngeal pathology, divergent from LPR. STUDY DESIGN: Prospective, nonintervention. METHODS: Patients presenting to a tertiary laryngology practice with an established diagnosis of LPR as the sole etiology of their hoarseness were included. All subjects completed the Voice Handicap Index and Reflux Symptom Index, in addition to a questionnaire regarding their reflux diagnosis and prior treatment. Laryngoscopic examinations were reviewed by the laryngologist caring for the patients. Reliability of findings was assessed by interpretation of videoendoscopic findings by three outside laryngologists not involved in the care of the patients. RESULTS: Laryngeal pathology distinct from LPR was identified in all 21 patients felt to be causative of the chief complaint of dysphonia. Specifically, the most common findings were benign mucosal lesions and vocal fold paresis (29% each), followed by muscle tension dysphonia (14%). Two patients were found to have vocal fold leukoplakia, of which one was confirmed to be a microinvasive carcinoma upon removal. CONCLUSION: LPR may be overdiagnosed; other etiologies must be considered for patients with hoarseness who fail empiric LPR treatment. LEVEL OF EVIDENCE: 4. Laryngoscope, 2013.

Should one use an open or closed rhinoplasty approach? How appropriate is the endonasal approach in modern-day rhinoplasty? Should the tip lobule be divided or preserved? Are alloplastic implants inferior to autologous implants? Does release and reduction of the upper lateral cartilages from the nasal dorsal septum always require spreader graft placement to prevent mid one-third nasal pinching in reduction rhinoplasty? Over past 5 years, how have rhinoplasty techniques and approaches evolved?

OBJECTIVES/HYPOTHESIS: Patients are increasingly using the Internet as a source of information on medical conditions. Because the average American adult reads at a 7th- to 8th-grade level, the National Institutes of Health recommend that patient education material be written between a 4th- and 6th-grade level. In this study, we assess and compare the readability of patient education materials on major surgical subspecialty Web sites relative to otolaryngology. STUDY DESIGN: Descriptive and correlational design. METHODS: Patient education materials from 14 major surgical subspecialty Web sites (American Society of Colon and Rectal Surgeons, American Association of Endocrine Surgeons, American Society of General Surgeons, American Society for Metabolic and Bariatric Surgery, American Association of Neurological Surgeons, American Congress of Obstetricians and Gynecologists, American Academy of Ophthalmology, American Academy of Orthopedic Surgeons, American Academy of Otolaryngology-Head and Neck Surgery, American Pediatric Surgical Association, American Society of Plastic Surgeons, Society for Thoracic Surgeons, and American Urological Association) were downloaded and assessed for their level of readability using 10 widely accepted readability scales. RESULTS: The readability level of patient education material from all surgical subspecialties was uniformly too high. Average readability levels across all subspecialties ranged from the 10th- to 15th-grade level. CONCLUSIONS: Otolaryngology and other surgical subspecialties Web sites have patient education material written at an education level that the average American may not be able to understand. To reach a broader population of patients, it might be necessary to rewrite patient education material at a more appropriate level. Laryngoscope, 2013.

BACKGROUND: The purpose of this study was to examine litigation involving epistaxis and analyze factors that determine liability. METHODS: Jury verdicts and settlements regarding cases involving epistaxis were gathered utilizing the Westlaw database. Factors involved in litigation gathered included demographics, defendant specialty, procedure, alleged cause of malpractice, outcome, monetary award, and other variables. RESULTS: A total of 26 cases were analyzed. The majority of cases (57.7%) were decided in favor of the plaintiff or settled out of court. Total awards amounted to $24,501,252. Average awards for cases decided in favor of the plaintiff were $2,260,893 and ranged from $499,845 to $9,022,643. Settlements averaged $1,084,375 and ranged from $300,000 to $3,800,000. Common causes of malpractice encountered included delay in diagnosis, complications from medical procedures, and failure to recognize complications in a timely manner. CONCLUSION: Contrary to previous reports analyzing malpractice for varying medical procedures and complications, litigation in epistaxis is more commonly resolved in favor of the plaintiff or resolved through out-of-court settlements. Substantial financial awards and therapeutic complications from blindness to death make epistaxis a candidate for litigation. Of importance from a medicolegal stand is the fact that 30.8% (8) of the patients involved in epistaxis litigation died, either from complications of therapy or from experiencing epistaxis as a complication of another procedure/pathology. Using necessary diagnostic imaging, ensuring proper management techniques, and recognizing complications in a timely manner can serve to limit legal liability and enhance patient safety.

BACKGROUND: To determine whether American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) Centralized Otolaryngology Research Efforts (CORE) grants influence career paths and scholarly impact of fellowship-trained rhinologists, and whether funding from the National Institutes of Health (NIH) and CORE programs is associated with increased scholarly impact among rhinologists. Another aim was to explore whether obtaining CORE grant funding is associated with NIH award acquisition. METHODS: Practice setting, academic rank, and fellowship-training status were determined for individuals in the CORE grant database. The h-index and publication experience of practitioners was calculated using the Scopus database. Faculty listings were used to determine this data for a non-CORE-grants-funded "control" group of academic rhinologists. Active and past NIH funding was obtained using the NIH RePORTER database. RESULTS: Fifteen of 26 (57.7%) fellowship-trained rhinologists receiving CORE grants were funded for rhinologic projects. Five of 6 rhinologists receiving NIH funding had a CORE-grants-funding history. Twenty-two of 26 (84.6%) rhinologists receiving CORE funding are currently in academic practice. Academic rhinologists receiving CORE or NIH funding had higher h-indices, a result reaching significance among promoted faculty and those with greater than 10 years of publication experience. CONCLUSION: Encouraging the pursuit of CORE grants among junior faculty as well as trainees interested in rhinology may be a strategy for developing highly effective research habits that pay dividends after the first few years of one's career. Fellowship-trained rhinologists with a CORE funding history predominantly pursue careers in academic medicine, although their CORE projects are not necessarily related to rhinologic topics.

Background: The incidence of well-differentiated thyroid cancer (WDTC) in the United States is increasing rapidly. Much of this increase is due to the detection by imaging of small, nonpalpable tumors. The incidence of advanced WDTC is also increasing, suggesting a true increase in the incidence of WDTC. This study was performed to determine how WDTCs of all sizes and stages are initially detected. Methods: A retrospective chart review of 519 patients who underwent surgery for WDTC from January 1, 2007, through August 31, 2010, was performed. A total of 473 patients suitable for inclusion in this study were divided into three groups based upon the method by which the tumor was initially detected: tumors detected by an imaging study (184 patients-39%), those detected because a mass was felt in the neck (218 patients-46%), and those detected incidentally on pathological study of the surgical specimen (71 patients-15%). Method of detection was correlated with age and sex of the patient, and size, stage, and nodal status of the tumor. Results: Patients in the Palpation group were more likely to be female (79% vs. 67% vs. 74%), younger (46 vs. 51 vs. 52), and to have larger tumors than those in the Imaging or Incidental groups. In the Imaging group, the tumor was detected on thyroid sonogram in 98 (53%), computed tomography in 38 (21%), magnetic resonance imaging in 19 (10%), carotid duplex scan in 14 (8%), and positron-emission tomography or other imaging studies in 15 (8%). Thirty-three percent of tumors <1 cm, 51% 1-2 cm, 29% 2-4 cm, and 38% >4 cm were first detected on an imaging study. Forty-seven percent of Stage III and IV cancers in patients aged >/=45 years and 39% of patients with positive central nodes were in the Imaging group. Conclusion: This study demonstrates that while most tumors discovered by imaging were small and early stage, almost half of advanced (Stage III and IV) WDTCs were initially discovered by imaging studies. These findings are consistent with the hypothesis that the frequent use of imaging studies may explain not only the increasing incidence of early WDTC, but more advanced thyroid cancers as well.

Endoscopic endonasal surgery has been established as the safest approach to pituitary tumors, yet its role in other common skull base lesions has not been established. To answer this question, we carried out a systematic review of reported series of open and endoscopic endonasal approaches to four major skull base tumors: olfactory groove meningiomas (OGM), tuberculum sellae meningiomas (TSM), craniopharyngiomas (CRA), and clival chordomas (CHO). Data from 162 studies containing 5,701 patients were combined and compared for differences in perioperative mortality, gross total resection (GTR), cerebrospinal fluid (CSF) leak, neurological morbidity, post-operative visual function, post-operative anosmia, post-operative diabetes insipidus (DI), and post-operative obesity/hyperphagia. Weighted average rates for each outcome were calculated using relative study size. Our findings indicate similar rates of GTR and perioperative mortality between open and endoscopic approaches for all tumor types. CSF leak was increased after endoscopic surgery. Visual function symptoms were more likely to improve after endoscopic surgery for TSM, CRA, and CHO. Post-operative DI and obesity/hyperphagia were significantly increased after open resection in CRA. Recurrence rates per 1,000 patient-years of follow-up were higher in endoscopy for OGM, TSM, and CHO. Trends for open and endoscopic surgery suggested modest improvement in all outcomes over time. Our observations suggest that endonasal endoscopy is a safe alternative to craniotomy and may be preferred for certain tumor types. However, endoscopic surgery is associated with higher rates of CSF leak, and possibly increased recurrence rates. Prospective study with long-term follow-up is required to verify these preliminary observations.

Understanding the biology of Waldenström macroglobulinemia is hindered by a lack of preclinical models. We report a novel cell line, RPCI-WM1, from a patient treated for WM. The cell line secretes human immunoglobulin M (h-IgM) with κ-light chain restriction identical to the primary tumor. The cell line has a modal chromosomal number of 46 and harbors chromosomal changes such as deletion of 6q21, monoallelic deletion of 9p21 (CDKN2A), 13q14 (RB1) and 18q21 (BCL-2), with a consistent amplification of 14q32 (immunoglobulin heavy chain; IgH) identical to its founding tumor sample. The clonal relationship is confirmed by identical CDR3 length and single nucleotide polymorphisms as well as a matching IgH sequence of the cell line and founding tumor. Both also harbor a heterozygous, non-synonymous mutation at amino acid 265 in the MYD88 gene (L265P). The cell line expresses most of the cell surface markers present on the parent cells. Overall, RPCI-WM1 represents a valuable model to study Waldenström macroglobulinemia.

BACKGROUND/PURPOSE/OBJECTIVE:Children and adolescents with airway stenosis pose a clinical challenge. Recently, balloon dilation has been described, primarily for the treatment of early, immature, less severe airway stenosis. We describe our experience with 8 children and adolescents managed with balloon dilation, including severe, mature subglottic and tracheal stenosis. METHODS:This is a case series of 8 children and adolescents with acquired subglottic and tracheal stenosis treated by the primary author with balloon dilation between August 2006 and April 2010 at an academic tertiary care center. In the four patients who were tracheotomy-dependent at the time of presentation, suprastomal stents or Montgomery T-tubes were used. In 1 patient with 99% subglottic stenosis (SGS), balloon dilation and stenting were used to create a lumen prior to laryngotracheal reconstruction (LTR). RESULTS:All 4 patients with tracheotomy were decannulated. The remaining 4 patients were successfully managed without tracheotomy. CONCLUSIONS:Mature, severe laryngeal and tracheal stenosis in pediatric patients can be successfully managed with balloon dilation. In the most severe cases with prior tracheotomy, stenting is necessary. Balloon dilation with stenting can also facilitate LTR. In patients without prior tracheotomy, tracheotomy and stenting can often be safely avoided with appropriate postoperative management.