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Background Homeless individuals frequently experience poor access to healthcare, delayed clinical presentation, and higher disease burden. Providing subspecialty otolaryngology care to this population can be challenging. We previously reported on the prevalence of hearing impairment in Toronto’s homeless community. As a secondary objective of this study, we sought to define otolaryngology specific need for this population. Methods One hundred adult homeless individuals were recruited across ten homeless shelters in Toronto, Canada using a stratified random sampling technique. An audiometric evaluation and head and neck physical examination were performed by an audiologist and otolaryngology resident, respectively. Basic demographic and clinical information was captured through verbal administration of a survey. Descriptive statistics were used to estimate frequency of otolaryngology specific diseases for this population. Results Of the 132 individuals who were initially approached to participant, 100 (76%) agreed. There were 64 males, with median age of 46 years (IQR 37–58 years). The median life duration of homelessness was 24 months (IQR 6–72 months). Participants had a wide range of medical comorbidities, with the most common being current tobacco smoking (67%), depression (36%), alcohol abuse (32%), and other substance abuse (32%). There were 22 patients with otolaryngology needs as demonstrated by one or more abnormal findings on head and neck examination. The most common finding was nasal fracture with significant nasal obstruction (6%). Eleven patients required referral to a staff otolaryngologist based on concerning or suspicious findings, including two head and neck masses, 6 were later seen in follow-up. Conclusion There were substantial otolaryngology needs amongst a homeless population within a universal healthcare system. Future research should focus on further elucidating head and neck related issues in this population and expanding the role of the otolaryngologist in providing care to homeless individuals.

BACKGROUND: Given that hearing loss is associated with increased social isolation, reduced earning potential and neurocognitive disease, findings of uncorrected hearing loss in the homeless population have important policy implications. We sought to estimate the prevalence of hearing impairment in an adult homeless population. METHODS: We recruited adult (age ≥ 18 yr) homeless people across 10 homeless shelters in Toronto between April and June 2018 using a 2-stage sampling technique. Participants were interviewed by 1 interviewer using a modified survey that had been used in previous studies looking at other health needs in homeless populations. A comprehensive head and neck examination and audiometric evaluation were performed in each participant by an otolaryngologist and an audiologist. Descriptive statistics were estimated. Audiometric data were standardized directly for age and sex to facilitate direct comparisons with the general Canadian population. RESULTS: Of the 132 people invited, 100 (75.8%) agreed to participate. The median age was 46 (interquartile range [IQR] 37–58) years. The median duration of homelessness was 24 (IQR 6–72) months. Although most participants (78) had some form of extended health care benefits through social assistance, only 22/78 (28%) were aware that hearing tests and hearing aids were covered through these programs. After direct standardization for age and sex, the proportions of participants with a speech-frequency and high-frequency hearing loss were 39.5% (95% confidence interval [CI] 30.4%–49.3%) and 51.9% (95% CI 42.2%–61.4%), respectively. Nineteen participants were hearing aid candidates, only 1 of whom owned functional hearing aids. Rates of speech-frequency hearing loss (39.5%, 95% CI 30.4%–49.3% v. 19.2%, 95% CI 16.9%–21.7%) and high-frequency hearing loss (51.9%, 95% CI 42.2%–61.4% v. 35.5%, 95% CI 33.1%–37.7%) were substantially higher than in the general Canadian population. INTERPRETATION: Our results suggest that homeless adults have a high prevalence of hearing impairment, even when living within a system of universal health insurance; awareness of health care benefits through social assistance programs was poor. Results from this study may prompt initiatives surrounding homeless outreach and health screening.

Objectives: Within Otolaryngology—Head and Neck Surgery (OHNS), obstructive sleep apnea (OSA) patients are frequently encountered. To implement policies and screening measures for admission of OSA patients undergoing ambulatory surgery, actual rates of admission must first be determined. We aimed to evaluate rates and reasons for admission of OSA patients after ambulatory OHNS surgery. Methods: Retrospective chart review was undertaken of all OSA patients undergoing elective day-surgery OHNS procedures at a tertiary center from January 1, 2018 to December 31, 2019. The primary outcome measure was percentage of OSA patients admitted to hospital after ambulatory OHNS surgery. Secondary outcome measures included reasons for admission. American Society of Anesthesiologists (ASA) score, perioperative complications, and patient demographics were captured. Results: There were 118 OSA patients, out of 1942 cases performed during the review period. Thirty-eight were excluded as the procedures were not considered ambulatory. The remaining 80 OSA patients were included for analysis, with an average age of 51.7, SD 13.8, and 30 (38%) females. The admission rate was 47.5% (38/80 patients). Admitted patients were older ( P = .0061), and had higher ASA ( P = .039). Indication for surgery or type of surgery did not differ among admitted and non-admitted patients. The majority of patients, 97% (37/38 patients), were admitted for post-operative monitoring. Conclusion: More than half of OSA patients did not require admission to hospital after ambulatory OHNS surgery, unaffected by indications for surgery or type of surgery. Higher ASA score and older age were found in admitted as compared to non-admitted patients.

Vallecular cysts, largely asymptomatic in adults, are typically described only on incidental discovery during laryngoscopy, where they may present a challenge in airway management. The current literature is limited to case reports despite the potential for life-threatening complications. We describe management of such a case complicated by cyst rupture and intensive care unit admission. A literature review of eligible case reports was conducted, demonstrating an association between incidental vallecular cysts and difficult bag-mask ventilation and laryngoscopy with intraoperative otolaryngology consultation and intervention being common. Anesthetic management recommendations are thus presented, highlighting any conflicts with current difficult airway algorithms.

Objective: Simulation is a tool that has been used successfully in many high performance fields to permit training in rare and hazardous events. Our goal was to develop and evaluate a program to teach airway crisis management to otolaryngology trainees using medical simulation. Methods: A full-day curriculum in the management of airway emergencies was developed. The program consists of three airway emergency scenarios, developed in collaboration between attending otolaryngologists and faculty from the Center for Medical Simulation. Following each scenario, the participants are led in a structured, video-assisted debriefing by a trained debriefer. Didactic material on team leadership and crisis management is built into the debriefings. Pediatric otolaryngology fellows, residents, and medical students have participated in the four courses that have been held to date. Participants evaluated the program on a five-point Likert scale. Results: A total of 17 trainees participated in four pilot training courses. The survey data are as follows: overall program, 5.0 (SD, 0.00); course goals, 4.79 (SD, 0.43); realism, 4.36 (SD, 0.63); value of lecture, 4.71 (SD, 0.47); and quality of debriefings, 4.92 (SD, 0.28). Sample comments include: “This is a valuable tool for students and residents since true emergencies in ORL are often life-threatening and infrequent,” and “This is a great course—really all physicians should experience it.” Overall evaluation was extremely positive and both residents and fellows described the course as filling an important void in their education. Conclusion: Medical simulation can be an extremely effective method for teaching airway crisis management and teamwork skills to otolaryngology trainees at all levels.

Objective: The objective of this study is to determine the feasibility of computerized evaluation of resident performance using hand motion analysis on a virtual reality temporal bone (VR TB) simulator. We hypothesized that both computerized analysis and expert ratings would discriminate the performance of novices from experienced trainees. We also hypothesized that performance on the virtual reality temporal bone simulator (VR TB) would differentiate based on previous drilling experience. Study Design: The authors conducted a randomized, blind assessment study. Methods: Nineteen volunteers from the Otolaryngology–Head and Neck Surgery training program at the University of Toronto drilled both a cadaveric TB and a simulated VR TB. Expert reviewers were asked to assess operative readiness of the trainee based on a blind video review of their performance. Computerized hand motion analysis of each participant's performance was conducted. Results: Expert raters were able to discriminate novices from experienced trainees (P < .05) on cadaveric temporal bones, and there was a trend toward discrimination on VR TB performance. Hand motion analysis showed that experienced trainees had better movement economy than novices (P < .05) on the VR TB. Conclusion: Performance, as measured by hand motion analysis on the VR TB simulator, reflects trainees' previous drilling experience. This study suggests that otolaryngology trainees could accomplish initial temporal bone training on a VR TB simulator, which can provide feedback to the trainee, and may reduce the need for constant faculty supervision and evaluation.

OBJECTIVE: Records of patients presenting with angioedema of the head and neck were analyzed to determine clinical factors that predict the need for airway intervention.METHODS: A review of patients with angioedema of the head and neck over a 10-year period was conducted. Data were collected regarding demographics, cause of edema, and sites of involvement. A logistic regression model was used to ascertain whether any clinical variables were significant in predicting the need for airway intervention.RESULTS: Review of 138 charts with an admitting diagnosis of angioedema yielded 66 cases of angioedema of the head and neck in 48 patients. Twenty-three (34.8%) patients required airway intervention. Logistic regression identified increasing age and angioedema involving the oral cavity/ oropharynx as predictors of airway intervention; involvement of other sites, cause, and sex were not predictive.CONCLUSION: Location of edema and patient age predict which patients with angioedema of the head and neck are likely...