Faculty Bibliography

OBJECTIVES/HYPOTHESIS: The h-index is an accurate and reliable indicator of scholarly productivity that takes into account relevance, significance, and influence of research contributions. As such, it is an effective, objective bibliometric that can be used to evaluate academic otolaryngologists for decisions regarding appointment and advancement. In this study, we evaluate the impact of NIH funding on scholarly productivity in otolaryngology. STUDY DESIGN: Analysis of bibliometric data of academic otolaryngologists. METHODS: Funding data for the 20 otolaryngology departments with the largest aggregate total of NIH grants for the fiscal years (FY) 2011 and 2012 was obtained using the National Institutes of Health Research Portfolio Online Reporting Tools Expenditures and Reports (RePORTER) Database. H-indices were calculated using the Scopus online database, and then compared to funding data at both the departmental and individual level. RESULTS: Faculty members in otolaryngology departments who received NIH funding had significantly greater research productivity and impact, as measured by the h-index, than their nonfunded peers. H-indices increased with greater NIH funding levels, and investigators with MD degrees tended to have higher mean NIH funding levels than those with PhDs. While there was no correlation between average h-index and NIH funding totals at the level of departments, there was greater correlation upon examination of NIH funding levels of individual investigators. CONCLUSIONS: The h-index has a strong relationship with, and may be predictive of, grant awards of NIH-funded faculty members in otolaryngology departments. This bibliometric may be useful in decisions regarding appointment and advancement of faculty members within academic otolaryngology departments. Laryngoscope, 2013.

Traditional upper blepharoplasty typically involves resection of excess upper eyelid skin and muscle with or without fat excision. Well-established concepts in periorbital aging have been challenged by newer morphologic and histologic studies that have characterized the changes that occur in the various periorbital soft tissue components. Several modified or adjunctive techniques have recently emerged to improve esthetic outcomes in upper blepharoplasty. The authors review surgical technique in detail: nasal fat repositioning, orbicularis oculi preservation, increasing lateral upper eyelid fullness, lacrimal gland resuspension, internal brow elevation, and glabellar myectomy, along with complications and aftercare involved with procedures.

OBJECTIVES AND IMPORTANCE: Children with certain congenital malformations of the inner ear, including those with a common cavity defect, have a higher incidence of spontaneous cerebrospinal fluid (CSF) leak and resulting meningitis. However, they may also benefit from cochlear implantation. We suggest that surgical management may be possible that both prevents meningitis and provides hearing rehabilitation during the same procedure. CLINICAL PRESENTATION: A 2-year-old girl with bilateral common cavity defects who had previously undergone cochlear implantation developed contralateral CSF leak resulting in meningitis. INTERVENTION: After resolution of the infection, cochlear implantation was performed at the same time as definitive CSF leak repair. Simultaneous cochlear implantation and repair of the CSF leak successfully decreased the chance of recurrent meningitis in this case. She has been deriving hearing benefit from the bilateral implants. CONCLUSION: This case suggests a role for cochlear implantation to be combined with simultaneous CSF leak repair in children with a cochlear malformation. Furthermore, bilateral cochlear implantation at an early age may be warranted in these patients before CSF leaks and meningitis have occurred.

Primary malignant melanoma arising from the eustachian tube is extremely rare. We report the case of a 63-year-old white man who presented with a 1-month history of left-sided hearing loss and aural fullness. Flexible fiberoptic laryngoscopy detected a blue-purple mass that appeared to arise from the left lateral nasopharynx. Computed tomography demonstrated an enhancing mass arising from an orifice of the left eustachian tube. The tumor was debulked endoscopically and was confirmed to have originated in the left eustachian tube. Histologically, the tumor was made up of heavily pigmented pleomorphic spindle cells with frequent mitoses. The tumor cells were immunohistochemically positive for S-100 protein, HMB-45, Melan-A, and PNL-2. The final diagnosis was a mucosal malignant melanoma. We also performed a nested polymerase chain reaction assay for several genes of interest, including CTLA-4, IL-17A, IL-17B, IL-17C, IL-17D, IL-17E, IL-17F, PLZF, Foxp3, RORgammat, CD27, and CD70. These genes have been studied mainly in cutaneous melanomas, especially for the development of immunotherapy, but only very limited studies have been done on mucosal melanomas. Our investigation found upregulation of CTLA-4, IL-17A, IL-17C, and IL-17E. Based on our finding of CTLA-4 upregulation, it may be suggested that our patient might have had low antitumor immunity and that he might have benefited from CTLA-4 blockade. On the other hand, upregulation of IL-17A and IL-17E might reflect increased antitumor immunity, which could suggest that patients with a mucosal melanoma might benefit from immunomodulators associated with the effect of Th17. These genes also have great potential to help melanoma patients obtain tailored treatment, and they can be used as biomarkers for predicting prognosis.

OBJECTIVES/HYPOTHESIS: Deficient health literacy remains a widespread public issue. As such, the National Institutes of Health (NIH) recommends that all patient resources should be written around a sixth-grade level. The authors evaluate healthcare-oriented resources specified for patient use on the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) Web site in order to identify potential areas of improvement and highlight those sections that may serve as paradigms for future revisions. STUDY DESIGN: Descriptive and correlational design. METHODS: Seventeen healthcare-oriented resources specifically for patients were downloaded in February 2012 from the American Academy of Facial Plastic and Reconstructive Surgery Web site. Readability assessments of each article were performed using Readability Studio Professional Edition Version 2012.1. These tests included the Flesch Reading Ease, Flesch-Kincaid Grade Level, SMOG Grading, Coleman-Liau Index, Gunning-Fog Index, the New Fog Count, the New Dale-Chall Readability Formula, FORCAST formula, Raygor Readability Estimate, and the Fry Graph. RESULTS: Patient health education material found on the AAFPRS Web site has been found to be written at an average grade level of 12th grade using 10 different readability scales. CONCLUSIONS: Modifications of the patient education section of the AAFPRS Web site can increase the readability of the literature, and allow greater comprehension among a wider audience. Laryngoscope, 2013.

OBJECTIVES/HYPOTHESIS: To evaluate voice disorder differences between deployed and nondeployed US army soldiers. STUDY DESIGN: Cross-sectional study. METHODS: More than 1.3 million health records of active duty US army soldiers with no history of dysphonia were queried for voice disorder diagnoses over a 3.5-year period. A sample of 292 soldiers was further evaluated for known factors linked to dysphonia. RESULTS: US army soldiers were 1.13 times more likely to have a diagnosis of dysphonia if they were deployed. Risk factors and exposures common to patients with dysphonia were not statistically different between deployed and nondeployed soldiers. Additionally, the type of dysphonia diagnosis was not significantly different between deployed and nondeployed soldiers. CONCLUSIONS: US army soldiers deployed to war zones are more likely to be diagnosed with dysphonia. None of the reviewed parameters accounted for the difference in dysphonia rate between deployed and nondeployed soldiers, suggesting that occupational exposures of deployed soldiers account for the increase in the diagnoses of dysphonia.

OBJECTIVES: To determine the frequency and consequences of patient-reported post-thyroidectomy voice disorder (PTVD) after surgery for thyroid cancer. STUDY DESIGN: Retrospective review of data gathered from a survey. PARTICIPANTS: Members of the Thyroid Cancer Survivors' Association (ThyCa). METHODS: ThyCa members were asked about their thyroid disease and surgery, voice disturbance, impact on quality of life, treatment, and non-identifying demographics in a 36-item electronic questionnaire. Patients with preoperative voice disturbance or vocal fold immobility and those reporting postoperative vocal fold paralysis were excluded. RESULTS: A total of 4426 members responded (37% response rate), and PTVD was reported by 51.1% of responders. Most were temporary (85.9%), with a minority reporting permanent hoarseness. Rates of postoperative dysphonia were similar between the extent of surgery and histology. Patients with PTVD predominantly characterized their impairment as loss of loudness and an inability to shout or sing. Nearly a quarter of patients reporting PTVD identified detrimental impact to their professional or personal lives. Only 57 patients (3.4%) were offered voice therapy; however, more than two-thirds of them (73.7%) experienced at least partial improvement. CONCLUSIONS: We report the results of a large-scale patient survey to underscore the commonness of postoperative hoarseness and its impact on patients. LEVEL OF EVIDENCE: 4.

OBJECTIVES/HYPOTHESIS/OBJECTIVE:In 2% to 3% of patients with cancer metastatic to cervical lymph nodes, a primary tumor will not be found despite exhaustive diagnostic efforts. The treatment for these patients includes cervical lymphadenectomy followed by radiation to areas with increased risk of harboring a mucosal primary. Wide-field radiation therapy increases the incidence of xerostomia and dysphagia. Localizing a primary tumor has thus both therapeutic and quality-of-life implications, allowing possible complete surgical excision, concentrated radiation therapy, and potential deintensification of adjuvant therapy. With improved visualization and freedom of motion, transoral robotic surgery (TORS) is an innovative surgical modality that allows resection of oropharyngeal subsites with minimal morbidity. STUDY DESIGN/METHODS:Retrospective chart review. METHODS:Ten patients with unknown primary tumors of the head and neck were identified. All patients underwent a cervical biopsy, positron-emission tomography/computed tomography, formal endoscopy, and bilateral tonsillectomy. When the initial endoscopy and biopsies did not localize a primary tumor, all patients underwent transoral robotic base of tongue resection. RESULTS:Evaluation of the patients' oropharyngeal mucosa using the robot did not reveal an obvious lesion and no palpable tumors were appreciated in the resected specimens. In 9/10 (90%) patients, pathologic examination revealed invasive squamous cell carcinoma (SCCA) with a mean diameter of 0.9 cm. CONCLUSIONS:Unknown primary SCCA presents a diagnostic challenge to the head and neck surgeon. We present a small series of tumors that would have been treated as unknown primaries under traditional diagnostic and therapeutic algorithms. TORS base of tongue resection identified primary tumors in 90% patients with minimal morbidity.