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The coronavirus pandemic has illuminated long-standing inequities in America's health care system and societal structure. While numerous studies have identified health care disparities within our specialty, few have progressed beyond detection. Otolaryngologists have the opportunity and the responsibility to act. Within this article, leaders from otolaryngology share their experience and perspective on health care disparities, including (1) a discussion of disparities in otolaryngology, (2) a summary of health care system design and incentives, (3) an overview of implicit bias, and (4) practical recommendations for providers to advance their awareness of health care disparities and the actions to mitigate them. While the path forward can be daunting, it should not be a deterrent. Throughout the course of this article, numerous resources are provided to support these efforts. To move ahead, our specialty needs to advance our level of understanding and develop, implement, and disseminate successful interventions toward the goal of eliminating health care disparities.

Purpose of review This article will provide an overview of recent disruptions to the otolaryngology residency match process and conclude with questions and resources that can guide future selection system design. Recent findings During the implementation of the single accreditation system, the loss of osteopathic programs, reduction of osteopathic leadership positions, and lack of interest in Osteopathic Recognition represent serious threats to the profession; this has implications for the distribution of the otolaryngology workforce, plausibly decreasing healthcare access in less-populated communities. Next, the impacts of COVID-19 reverberated throughout the application process, including the reduction/elimination of away rotations, modification of application requirements, conversion to virtual interviews, and initiation of preference signaling. Soon, the transition to pass/fail scoring for the United States Medical Licensing Exam Step 1 could stimulate a paradigm shift, with a heightened emphasis on holistic review. Summary The last two match cycles have been the most dynamic and unpredictable in decades. Out of the commotion, the otolaryngology community has an opportunity for a fresh start, combining insights from past literature with recent articles compiled for this review. Moving forward, it will be advantageous to approach residency selection as a well-executed quality improvement project, requiring continuous assessment and adjustment.

To characterize the geographic distribution of US otolaryngology residents based on geographical population density to determine current status and identify potential opportunities for otolaryngology residency program expansion.The locoregional population of otolaryngology residency programs was analyzed (as defined by the US Census) and the number of resident trainees per 100,000 people in each region was calculated. Otolaryngology residency program location was determined by mailing address, and program size was determined by AAMC public data.The average metropolitan city in the United States contained 2.07 otolaryngology trainees per 100,000 people. Cities with low trainee numbers per population included Phoenix, AZ (0.20 trainees per 100,000 people); Las Vegas, NV (0.26 per 100,000); Dallas, TX (0.26 per 100,000), Atlanta, GA (0.33 per 100,000); and Miami, FL (0.34 per 100,000). Comparing otolaryngology to other surgical subspecialties demonstrated similar distributions. Metropolitan centers with a population over 1 million without full academic representation in otolaryngology were also identified and included Charlotte, NC; Orlando, FL; Austin, TX; Providence, RI; Jacksonville, FL; Raleigh, NC; and Grand Rapids, MI.Strategic residency training program expansion should be considered in cities that exhibit a low trainee to population ratio. Although many factors ultimately determine program expansion or development of new training programs, this study provides substantiated population data describing where expansion could be prioritized.NA Laryngoscope, 2022.

Otolaryngology resident learning has historically relied on didactic lectures, textbook reading, and practical hands-on patient care. However, evidence suggests that an increasing proportion of residents in other specialties are deviating from this paradigm. This work aims to characterize otolaryngology residents' current asynchronous learning practices (i.e., personal learning outside of didactics and patient care).A thirteen-question survey of otolaryngology residents in the United States was performed from 10/1/2020-12/1/2020 assessing demographics, educational resource utilization, and educational resource preference.Nearly all (99 %) respondents reported engaging with educational materials outside of didactics and case prep. Textbook reading comprised 27 % of residents' total study time, with additional time split between board-review book reading (20 %), searching the web (18 %), watching online videos (15 %), and listening to podcasts (10 %). Residents' highest ranked resources were videos, board-review books, textbooks, podcasts, and recorded lectures. Among electronic and multimedia resources, more than half of residents used the following resources: Iowa Head and Neck Protocols (91 %), Board Vitals (75 %), UpToDate (60 %), YouTube (57 %), Google (56 %), and Headmirror (54 %).Current otolaryngology resident learning involves substantial use of asynchronous learning, including videos, web-based learning, and podcasts, which currently outpace traditional textbook- and didactic-based education. This underscores the need to consider a paradigm shift within academic otolaryngology education away from textbooks and other tradition media to the generation of high-quality multimedia resources for resident learning.

Objective Gender differences in personality have long been a subject of interest. This study assessed personality traits within female and male residents and faculty and evaluated for meaningful differences between the groups. Methods A series of web-based, commercially available, self-administered five factor-based personality assessments were given to otolaryngology residents and faculty at nine academic training programs. The psychometrically validated assessments evaluate innate personality 1) strengths, 2) challenges, and 3) motivators/values. Differences between groups were evaluated using the Mann-Whitney U test. A standardized measure of effect size, Cohen’s d, was calculated to indicate the magnitude of gender differences. Subset analysis was done to examine differences between female and male residents and female and male faculty. Results Seventy-eight faculty (42.6%) and 104 residents (70.3%), responded, which included 63 female (34.6%) participants. Significant differences between females and males overall were found across four traits (mischievous, imaginative, altruistic, and commercial) out of twenty-eight (4/28; 14.3%). Subset analysis of residents revealed two statistically significant differences related to motivators/values (increased altruism in females and increased commercial in males). Faculty exhibited a statistically significant difference in one stress tendency (increased imaginative in males). When examining the seven total traits that exhibited a statistically significant difference between any of the groups (7/84; 8.3%), four were considered a small difference and three a moderate difference. Conclusion When personality trait differences were identified in both otolaryngology resident and faculty populations based on gender, they were relatively small. Overall, females and males in otolaryngology exhibit significant overlap in the distribution of their personality traits. Therefore, personality-based initiatives should focus on the individual, rather than perceived gender “norms.”

Current literature suggests that infant oral anatomy may impact breastfeeding outcomes. Our research seeks to evaluate superior labial frenulum (SLF) attachment site grade utilizing a modified existing system and investigate the correlation with breastfeeding outcomes.Two hundred and eight dyads were recruited from the nursery at Brooke Army Medical Center. The neonate's SLF and lingual frenulum were evaluated and photo-documented. Photos were assessed by blinded reviewers utilizing a modified Stanford SLF grade. Breastfeeding mothers completed surveys on attitudes and associated pain with feedings 24 h postdelivery, at 2 weeks and at 2 months. Categorical data were analyzed using chi-squared tests or Fisher's exact tests. Means and standard deviations were analyzed using analysis of variance or Wilcoxon's test.At 2 weeks and 2 months, 86.8% and 72.8% were breastfeeding, respectively. At 2 months, SLF grade 1 newborn dyads had a significantly lower breastfeeding rate (50.0%) compared to SLF grade 2 (75.3%) and SLF grade 3 (85.7%) subjects (p = 0.0384). At 2 weeks and 2 months, there was no difference between SLF groups with regard to maternal breastfeeding attitudes or pain scores. There was no significant difference in terms of weight, referrals, or lingual-labial frenulectomy between SLF groups.Our study shows no correlation between SLF attachment grade and breastfeeding outcomes to include length of breastfeeding, maternally reported confidence, maternal pain, or infant weight. Our findings do not support labial frenulectomy based on SLF grade alone and highlight the need for a more robust functional grading system.2 Oxford Center for Evidence-Based Medicine. http://www.cebm.net/index.aspx?o=5653 Laryngoscope, 132:2498-2504, 2022.

Session Description: The COVID-19/SARS-CoV2 pandemic has highlighted concerns regarding disease transmission to both surgeons and assisting staff during procedures that generate droplets and aerosols. Aerosol and droplet formation is known to occur during otologic and lateral skull base surgery, particularly when powered instrumentation is used. This expert panel will review both the basic science and clinical studies regarding risk identification. Recommendations regarding minimization of these risks will be thoroughly discussed in both scientific and practical terms that can be utilized by practicing otolaryngologists in real-life scenarios. In addition, the panel will address controversies regarding these risks and mitigation schemes and address real-life situations using case-based examples relevant to both the general otolaryngologist and neurotologic specialist. The discussion will focus not only on mitigation of spread of SARS-CoV2 virus but also on other currently identified pathogens of the middle ear and mastoid and future threats. This panel will address emerging pathogens that have not yet become threats in the United States and Western Europe but have affected otolaryngologists in other areas of the world. It will also provide guidance for hypothetical novel future threats that have not yet presented in clinical practice. This presentation is highly relevant to practicing otolaryngologists, including general otolaryngologists, pediatric otolaryngologists, and neurotologists and will provide the attendee with a thorough update clinical practice patterns, potential spread of contagion, and strategies of spread mitigation. Outcome Objectives: (1) Examine the basic and clinical science of pathogens of the middle ear, mastoid, and cerebrospinal fluid and the patterns of spread of these pathogens during otologic and lateral skull base procedures. (2) Understand and implement strategies to mitigate spread of currently known pathogens in otologic and lateral skull base procedures, including limitation of the spread of SARS/CoV2. (3) Understand a framework of strategies and best practices for mitigation of spread of emerging pathogens and future pathogens.

Otolaryngology is a small and highly sought-after surgical subspecialty with sparse residency positions, making it competitive to match into. Allopathic (MD) students without home otolaryngology residency programs, osteopathic (DO) medical students, and underrepresented minorities have historically faced additional challenges in matching into otolaryngology. These specific populations generally experience limited opportunities in establishing mentors, engaging in scholarly activity, and gaining early exposure to clinical settings. Even though the American Osteopathic Association and the Accreditation Council for Graduate Medical Education merger was in part established to create equity among applicants, there remains a substantial disparity among the match rates of medical students of various educational and cultural backgrounds. The National Otolaryngology Interest Group is a student-led interest group created to provide all medical students, especially those facing barriers, with the resources needed to best prepare for matching into an otolaryngology residency program and ultimately a career in otolaryngology.

Stapedectomy remains a joint key-indicator case with ossiculoplasty for otolaryngology residents in the United States. Yet, residents consistently report feeling inadequately prepared to perform stapes surgery following graduation. Applying recently described age- and sex-standardized incidence rates of surgically confirmed cases of otosclerosis to the US populace, upper and lower estimates of residents' case exposure to stapedectomy can be approximated. With this, uppermost projections estimate 6484 new cases of stapes surgery are performed annually nationwide. With approximately 1424 otolaryngology residents nationally, the average case exposure is 7.8 stapedectomies throughout their training, with upper and lower estimates of 17.1 and 4.2 cases, respectively. As such, proficiency in stapedectomy is no longer a realistic expectation for US graduating residents. This reality supports the removal of "stapedectomy" from the list of 14 key-indicator case requirements, leaving ossiculoplasty as its own key-indicator case, thereby reinforcing true competence in this fundamental procedure for the graduating otolaryngologist.

There is an extensive amount of data available from the leading organizations involved in the residency selection process. Tracking trends in otolaryngology residency applications and match outcomes is vital to understand the pipeline of individuals joining our profession. As we make changes to the application or match process, proper interpretation of available data is vital to prevent erroneous analyses and inappropriate conclusions. In the commentary, we explore the nuances of data from the Electronic Residency Application Service and National Residency Matching Program to help our specialty direct research endeavors and policy changes that will ultimately affect the makeup of our future workforce.

Vocal fold immobility (VFI) is a common cause of dysphonia and dysphagia in children. Laryngeal electromyography (LEMG) is an important adjunctive test in its diagnosis and treatment. In this study, we present an alternative technique in which bipolar double hookwire electrodes allow simultaneous placement and recordings from the bilateral thyroarytenoid and posterior cricoarytenoid muscles. Details of the technique are shown for a 5 y/o F with history of Neurofibromatosis Type 2 with left VFI and aspiration and dysphonia. This modified technique for pediatric LEMG has the potential to be a useful tool in predicting return of laryngeal function.

The residency selection process is challenging for both applicants and programs. This is particularly true in competitive specialties such as otolaryngology. The importance of noncognitive competencies in successful residents has been well demonstrated in both medicine and surgery. Unfortunately, there is no streamlined or uniform process for incorporating this information into the selection and training of residents. This review provides a summary of innovative approaches in the selection of residents in otolaryngology and the important role these methods and associated data can play in resident selection and training. The goal of these processes is to create a holistic view of potential residents so programs can enhance the development of current residents and boost long-term success in our specialty. Laryngoscope, 130:65-68, 2020.

Beyond educational and institutional requirements, there is a need for trainees (residents and fellows) to learn patient safety and quality improvement skills in order to achieve the ultimate goal of providing better patient care. Key steps to engagement include creating a safety and quality culture, supporting faculty development, and selecting appropriate curricular resources. Efforts to align the goals and processes of the graduate medical education institution and teaching hospital can foster a unified mission. Faculty must be prepared to teach and reinforce these topics on a regular basis. Both didactic instruction and experiential learning are necessary components for trainee education.

OBJECTIVES/HYPOTHESIS Studies across multiple specialties of medical students, residents, and attending physicians demonstrate increased retention, breadth of knowledge, and literature awareness when podcasts are used as an adjunctive educational tool. This Contemporary Review aims to 1) quantify podcast availability and episode frequency for medical learners across a broad range of specialties, and 2) compare these metrics between otolaryngology-specific podcasts with those of other specialties. DATA SOURCES Top five podcast platforms: Spotify (Stockholm, Sweden 2006), Apple Podcasts (Cupertino, CA 2012), Google Podcasts (Mountain View, CA 2018), Stitcher (San Francisco, CA 2008), and TuneIn (San Francisco, CA 2002). METHODS The selected podcast platforms were queried with a comprehensive set of keywords and manually searched for medically-relevant podcasts. Specialty, content, and number of episodes annually for the last 10 years were recorded for each podcast. RESULTS Otolaryngology has a comparable number of podcasts and breakdown of podcast category compared to other specialties, but reduced total episodes and episode frequency compared to other specialties. This may limit otolaryngologists' ability to engage in this validated form of medical education. CONCLUSIONS Podcast-based education provides a valuable resource for medical professionals to reinforce learning, broaden general knowledge base, and stay updated on current literature, particularly in light of increased demand for mobile and on-demand learning options. There is room for an increased number of podcasts and, particularly, increased episode frequency within the field of otolaryngology to extend these benefits to otolaryngologists and otolaryngologists in training. Laryngoscope, 131:E2131-E2138, 2021.

COVID-19 has created new challenges and opportunities regarding the way in which programs and applicants will interact in the 2020-2021 otolaryngology residency match cycle. Social media and other virtual platforms offer a flexible and efficient medium for applicants and programs to gain information, communicate, and align interests. In this commentary, we explore ways in which social media may facilitate recruitment and networking in the virtual otolaryngology match.

Podcasts are online digital audio programs that are disseminated via online subscription that are easily accessible through computers or smartphones. Increasingly, residents and medical students are prioritizing podcasts for asynchronous medical education due to ease of use, convenience (eg, use while exercising or commuting), and repeatability. Some trainees have found podcasts more useful than traditional didactic lectures. Given the increasing requirements of social distancing and the need for distance medical education platforms, podcast production can serve as a useful tool to complement resident and medical student education and is a resource that will remain accessible in perpetuity. An otolaryngology specialty podcast, "Headmirror's ENT in a Nutshell," was created to augment asynchronous learning and address the acute need for distance learning opportunities. Over the first 7 weeks of production, 50 episodes were created. Episodes were posted on www.headmirror.com, with subscription services available through Apple Podcast, Spotify, and other platforms.

Objective Assess construct validity of a low-cost medium-fidelity silicone injection molded model task trainer for endoscopic sinus surgery (ESS) training. Methods Fellowship-trained rhinologists, otolaryngology attendings, and otolaryngology residents at various levels of training performed sinus endoscopy and seven procedures on the model. Construct validity was evaluated by comparing novice to various levels of experienced performance using a validated checklist. Results Thirty-two subjects participated in this study. Otolaryngology attendings and postgraduate year (PGY) 3 to 5 otolaryngology residents significantly outperformed PGY 1 to 2 otolaryngology residents on most tasks in the task-specific checklist. Conclusions This study demonstrated the construct validity of the low-cost medium-fidelity ESS model. Level of evidence NA Laryngoscope, 129:1505-1509, 2019.

IMPORTANCE: Tracheomalacia is characterized by weakness of the tracheal wall, resulting in dynamic airway collapse during respiration. Severe tracheomalacia accounts for approximately half of all cases and often requires surgical intervention. Off-label external splints from degradable materials have been reported in human use, however, there remains a need to develop resorbable splints with tunable mechanical properties and degradation profiles for use in the pediatric population. OBJECTIVE: The objective of this pilot study was to assess the safety and efficacy of a silk fibroin-based splint in a clinically relevant model of tracheomalacia and to provide quantitative clinical outcomes. DESIGN: Prospective controlled pre-clinical trial SETTING: Animal care facility PARTICIPANTS: New Zealand white rabbits INTERVENTIONS: The implant was evaluated in a surgically induced model of severe tracheomalacia in N=3 New Zealand white rabbits for durations of 17, 24, and 31 days. The dynamic change in airway diameter during spontaneous respiration was measured in the native trachea (control), after surgical intervention, after splint placement, and at the time of explant. MAIN OUTCOMES AND MEASURES: An image based assay was developed to quantify the change in dynamic airway diameter, providing a metric to assess both the severity of the surgically induced malacia as well as the efficacy of the implant. In addition, histopathology was used to study the surrounding tissue response. RESULTS: The average dynamic change of the native rabbit trachea was 22.8% during spontaneous respiration; surgically induced tracheal collapse resulted in a significant increase to 85.6% (p < 0.001). The average dynamic airway change after splint placement was not statistically different than that of the native trachea at the time of explants in all rabbits (17, 24, and 31 days). Histopathology showed localized inflammatory response suggestive of early fibrosis and tissue integration with the splint. CONCLUSIONS AND RELEVANCE: This pilot study of a resorbable silk fibroin splint suggested that the splint design and material were well tolerated and efficacious in a rabbit model of severe tracheomalacia, with marked reduction in airway collapse following implantation and good tissue-integration and tolerability over the studied time course. Further preclinical work in a larger study with longer follow-up will be required to fully assess potential clinical utilization of this implant.

Successful simulation requires effective facilitation and debriefing to achieve educational goals. Simulation educational methods are diverse, ranging from partial task training to complicated, interdisciplinary team training. Various debriefing models have emerged based on method of instruction, learner experience, time and equipment capability, and physical facilities. The general structure of most debriefing sessions focuses on participant reactions, followed by analysis, and ending with a discussion of lessons learned. Two leading debriefing models, the Structured and Supported Debriefing Model and the Debriefing with Good Judgment Model, are described in further detail.

Introduction Tumor immunotherapy have broadened therapeutic options for tumor treatment. The role of immune function in juvenile recurrent respiratory papillomatosis (JRRP) has not been investigated. Applying immunoblockade inhibitors as a novel disease treatment is unclear. Our study, for the first time, evaluates immune infiltration and immuno-suppressive molecule expression in JRRP. Our study provides insights in possibly treating this disease with tumor immunotherapies. We aimed to determine expression of programmed death-ligand 1 (PD-L1), a cancer escape protein, and presence of CD8+ T cell infiltration in tumor microenvironment. Material and methods Seven patients with JRRP (mean age: 7.43; age range 3–17) in this study routinely have their tumors surgical debulked at Massachusetts Eye and Ear Infirmary. Following surgery, samples were de-identified and sent to pathology where they were stained and analyzed. Results Six out of seven patients expressed PD-L1 on tumor cells to various extents. Three patients showed concurrent PD-L1 expression on tumor cells and abundant CD8+ tumor infiltrating lymphocytes as well as PD-L1+ stromal lymphocytes, while PD-L1 expression on tumor cells were not associated with CD8+ tumor infiltrating T cells nor PD-L1+ stromal lymphocytes in the other three patients. HPV 6/11 and p16 was detected in all the patients. There appeared to be no correlation between either PD-L1 expression and CD8+ infiltration and clinical severity as measured by both the number of surgeries per year or Derkay score. Conclusions Despite a small cohort, the expression of p16 and HPV 6/11 in all of the patients confirms the tissues were HPV tumor cells. PD-L1 expression was detected in the vast majority of tumor samples, while inflammatory cell compartments showed a higher degree of variation. Expression of PD-L1 on tumor cells but not inflammatory cells raises the possibility of a tumor cell intrinsic manner of PD-L1 expression. In contrast, a group of patients showed PD-L1 positivity in both tumor and inflammatory cells along with abundant CD8+ tumor infiltrating lymphocytes, suggesting adoptive immune resistance in these tumors and potential benefits from tumor immunotherapy.

There has been a heightened focus on improving the resident selection process, particularly within highly competitive specialties. Previous research, however, has generally lacked a theoretical background, leading to inconsistent and biased results. Our recently published systematic review examining applicant characteristics and performance in residency can provide historical insight into the predictors (ie, constructs) and outcomes (ie, criteria) previously deemed pertinent by the otolaryngology community. Personnel psychology uses evidence-based practices to identify the most qualified candidates for employment using a variety of selection methods. Extensive research in this discipline has shown that integrity tests, structured interviews, work samples, and conscientiousness offer the greatest increase in validity when combined with general cognitive ability. Blending past research knowledge with the principles of personnel selection can provide the necessary foundation with which to engage in theory-driven, longitudinal studies on otolaryngology resident selection moving forward.

Objectives For pediatric patients with laryngotracheal stenosis, the ultimate goal is creation of a safe, functional airway. Unfortunately, wound healing in a hollow structure can complicate repair attempts, leading to restenosis. Herein, we present our experience using skin-grafting techniques in two complex pediatric laryngotracheal stenosis cases, leading to successful decannulation or speech production. Methods A chart review was performed examining the evaluation and management of two pediatric patients with laryngotracheal stenosis despite prior reconstructive attempts. Patient history, bronchoscopic evaluation, intra-operative technique, post-operative management, treatment outcomes, and complications were noted. Harvesting and preparation of the split-thickness skin grafts (STSG) proceeded in a similar manner for each case. Stenting material varied based on the clinical scenario. Results Using this technique, our patient with a Type 3 glottic web achieved substantial improvement in exercise tolerance, as well as vocal strength and quality. In addition, our aphonic patient could vocalize for the first time since her laryngotracheal injury. Conclusions Temporary endoluminal stenting with skin graft lining can reproduce epithelial continuity and provide “biological inhibition” to enhance the wound healing process. When previous reconstructive efforts have failed, use of STSG can be considered in the management of complex pediatric laryngotracheal stenosis.

Importance Health care organizations are complex and evolving systems. To date, longitudinal evaluation to ensure the sustainability of quality improvement (QI) initiatives has been missing from the otolaryngology literature. We sought to reassess perioperative management of laryngotracheal reconstruction, which requires adequate sedation. Objective Using principles of continuous QI, the objectives of this study were to (1) describe step-by-step methods to sustain QI efforts and (2) revisit a series of process, outcome, and balance measures for sedation weaning management following implementation of a new electronic health record (EHR). Design, Setting, and Participants A standardized sedation weaning protocol was previously developed and instituted in February 2013. To address healthcare system-wide changes, a 7-step, Institute for Healthcare Improvement methodology was used to reevaluate a series of measures comparing a previous postweaning group (2013-2014; 13 patients) and current post-EHR group (2016; 11 patients). We conducted a focus group review of these 24 patients. Main Outcomes and Measures The primary outcome measure was length of sedation weaning. Secondary outcome, process, and balance measures included total length of sedation, absence of standardized wean document, absence of specific recommendations on weaning regimen, length of stay, continued weaning at discharge, discharge location, absence of discharge instructions on weaning regimen or iatrogenic withdrawal syndrome (IWS), discharge within 72 hours of stopping weaning, and readmission. Results The postweaning and post-EHR groups were similar in age (20.5 months [95% CI, 11.92-29.15] vs 26.5 months [95% CI, 17.68-35.40]), as well as male sex (11 of 13 [85%] vs 10 of 11 [91%]), respectively. In the post-EHR group, the standardized sedation wean document was missing from 9 of 11 (82%) medical records. However, the primary outcome measure, length of sedation weaning, remained stable at 9.45 (95% CI, 7.62-11.29) days in the post-EHR group compared with 9.08 (95% CI, 7.00-11.18) days in the postweaning group. In addition, only 5 of 11 (46%) of discharges in the post-EHR group had specific guidance on weaning since the standardized template was no longer in use. As a result, in the post-EHR group, patients were 15.2 (95% CI, 0.46-242.34) times as likely to lack discharge instructions on weaning or IWS. Conclusions and Relevance Quality improvement is meant to be a continuous process in which reevaluation of care practices are regularly performed. System-wide redesign can be achieved using a formal methodological approach. Moving forward, notable QI opportunities for our institution included the development of a flexible sedation weaning template, as well as enhancements to discharge instructions to include IWS diagnosis and treatment.

OBJECTIVES/HYPOTHESIS Develop a low-cost, medium-fidelity model for education in endoscopic sinus surgery techniques. Establish face and content validity of the model based on the feedback of otolaryngology faculty including fellowship-trained rhinologists. STUDY DESIGN Survey. METHODS A novel silicone injection molded sinus model was constructed. Three fellowship-trained rhinologists and four general otolaryngologists were recruited to perform seven tasks and provide feedback of the model's performance via a 22-question Likert survey. RESULTS Those surveyed strongly agreed the sinus model is useful for basic endoscopic skill acquisition such as camera skills (86%), hand-eye coordination (100%), nasal endoscopy skills (100%). Ratings of the model for training the specific tasks were consistently high. Neutral or lower were received for inferior turbinoplasty (14%), frontal balloon task (14%), understanding the ethmoid bulla (29%), and advanced sinus techniques (57%). All faculty strongly agreed they would be interested in using the model to train residents. CONCLUSIONS Simulation models have proven efficacy in endoscopic skill and procedural training. The group developed a novel low-cost, medium-fidelity sinus training model utilizing three-dimensional modeling and printing. Testing of this model revealed high ratings for both face and construct validity for a range of endoscopic procedures. Strong interest in using this model for resident training was unanimous among all survey participants. LEVEL OF EVIDENCE NA Laryngoscope, 127:781-786, 2017.

Objectives/Hypothesis To determine the primary diagnoses for which balloon catheter dilation (BCD) of sinus ostia is being employed in a profit-blind health care system, the Department of Defense. Study Design Retrospective chart review. Methods From January 1, 2011 to December 31, 2013, 319 consecutive patient charts were reviewed for International Classification of Diseases, Ninth Edition (ICD-9) diagnoses, presence of chronic rhinosinusitis (CRS) defined by the European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS), preoperative Lund-Mackay scores, nasal endoscopy findings, sinuses dilated, postoperative outcomes, and complications. Results Of the 319 patients identified, 217 had sufficient documentation to be included. A CRS ICD-9 code was applied in 182 of 217 (83.9%) and recurrent acute rhinosinusitis in 12 of 217 (5.6%). Only 50.5% of CRS patient charts met criteria using EPOS guidelines. In contrast, 39.6% met the ICD-9 criteria for atypical facial pain. Patients with Lund-Mackay scores ≤ 4 were reviewed for number of sinuses dilated. Eighty-eight of 123 patients (71.5%) had sinuses dilated that were free from opacification/mucosal edema on preoperative imaging. Conclusions Balloon dilation of sinus ostia has an expanding role in treating sinus disease. In the studied population, BCD is often utilized for alternate indications for which there is currently no evidence of efficacy. Future studies are needed to evaluate the efficacy of this technology in treating these alternate indications. Level of Evidence 4. Laryngoscope, 2016

To date, there is minimal literature discussing quality improvement curricula in otolaryngology. Herein, we present our program, including didactic, web-based, and experiential learning, developed in the setting of a preexisting institutional quality and safety policy. Nine otolaryngology residents were evaluated with assessments focused on learner satisfaction, learner attitudes, and knowledge acquisition according to the Kirkpatrick framework. Wilcoxon signed-rank test was used to compare results. While the total score increased across all assessments, it was significant for only the Quality Improvement Knowledge Application Tool Revised (P < .05). We find our initial learning outcomes encouraging and hope that our comprehensive curriculum can serve as a resource to other programs, which can be adapted to fit within the context of variable training environments. Furthermore, it is imperative to consider continuous assessment and refinement of any educational program, using the same quality improvement principles that we endeavor to teach.

Surgical management of supraglottic collapse at the level of the epiglottis limiting decannulation has historically consisted of placement of epiglottopexy sutures which are technically challenging and often unsuccessful. Herein we describe the use of robotic technology to assist with epiglottopexy for a case of a 9 year old child with severe epiglottic petiole prolapse limiting capping and decannulation. Postoperatively the patient is tolerating capping during waking hours.

Upper airway stimulation with the hypoglossal nerve stimulator is a promising treatment modality for severe obstructive sleep apnea in carefully selected patients with Down syndrome. The pediatric population presents a greater variety in body habitus, including thorax size. A modified surgical approach, utilizing a medially placed, single chest incision, instead of two separate chest incisions, provides an alternative that is particularly useful for pediatric patients with small stature. As this technology is evaluated for Food and Drug Administration clearance in the pediatric population, it is important to consider modifications in surgical technique, partnering prior surgical experience with the technical support of company representatives. Laryngoscope, 128:1490-1492, 2018.

Since the initiation of resident duty hour restrictions, significant controversy has arisen regarding its impact on surgical resident training. We reviewed a singular facet of the otolaryngology residency experience, nasal bone fracture management, to identify if treatment standardization would improve care and efficiency. For 1 year, otolaryngology consults for isolated nasal fractures were analyzed to assess consultation trends, rate of intervention, and resident work hour utilization. Following a review of the literature, an evidence-based algorithm for management of nasal fractures was developed. Analysis revealed a potential improvement in intervention rate from 20% to 100% with utilization of the algorithm, with an 84% decrease in overall emergency room and inpatient consultations. Sixty-three hours of otherwise lost resident time would be gained. In the setting of Accreditation for Graduate Medical Education duty hour restrictions, implementation of protocol-driven management may result in a decrease in work hours and serve as a model for more efficient otolaryngology care.

Assess construct validity of a low-cost medium-fidelity silicone injection molded model task trainer for endoscopic sinus surgery (ESS) training.Fellowship-trained rhinologists, otolaryngology attendings, and otolaryngology residents at various levels of training performed sinus endoscopy and seven procedures on the model. Construct validity was evaluated by comparing novice to various levels of experienced performance using a validated checklist.Thirty-two subjects participated in this study. Otolaryngology attendings and postgraduate year (PGY) 3 to 5 otolaryngology residents significantly outperformed PGY 1 to 2 otolaryngology residents on most tasks in the task-specific checklist.This study demonstrated the construct validity of the low-cost medium-fidelity ESS model.NA Laryngoscope, 129:1505-1509, 2019.

Importance Recurrent respiratory papillomatosis (RRP) is a viral-induced disease caused by human papillomavirus and the second leading cause of dysphonia in children; however, neither a cure nor a definitive surgical treatment is currently available for RRP. Although laser therapy is often used in the treatment of RRP, the lack of real-time laser-tissue interaction feedback undermines the ability of physicians to provide treatments with low morbidity. Therefore, an intraoperative tool to monitor and control laser treatment depth is needed. Objective To investigate the potential of combining optical coherence tomography (OCT) with laser therapy for patient-tailored laryngeal RRP treatments. Design, Setting, and Participants This in vivo study was performed at the Massachusetts Eye and Ear Infirmary from February 1, 2017, to September 1, 2017. Three-dimensional OCT images were acquired before, during, and after photoangiolytic laser therapy in 10 pediatric patients with a history of papilloma growth who presented with lesions and hoarseness. Main Outcomes and Measures Whether intraoperative OCT monitoring of changes in optical scattering and absorption provides quantitative information to control thermal damage in tissue. Results Among the 10 pediatric patients (age range, 4-11 years; 6 male) included in the study, high-resolution OCT images revealed epithelial hyperplasia with clear RRP lesion margins. Images acquired during therapy indicated coagulation deep in tissue, and posttherapy images showed the ability to quantify the amount of tissue ablated by the photoangiolytic laser. Conclusions and Relevance Concurrent use of OCT imaging and laser therapy may improve postoperative outcomes for patients with RRP by delivering an optimal, patient-tailored treatment. Additional studies investigating the correlation between optical properties with vocal outcomes are required.

OBJECTIVE To assess the impact of implementing a dedicated Patient Safety and Quality Improvement (PSQI) curriculum for otolaryngology residents. METHODS Residents in two otolaryngology residency programs were recruited to participate in the study. Residents at institution A (intervention group) participated in a formal, newly developed, year-long PSQI curriculum. Residents at institution B (control group) participated in traditional, morbidity, and mortality conference-based PSQI education, with no formal curriculum in place. Curriculum participants completed anonymous surveys to assess learner satisfaction. Validated instruments were administered to assess for changes in resident confidence in the ability to develop PSQI projects, their attitudes toward patient safety, and PSQI-related knowledge. The number and quality of PSQI-related resident projects were also assessed. RESULTS Survey responses demonstrated excellent learner satisfaction with the curriculum. Based on validated instrument-based responses, both programs demonstrated similar confidence scores (P = 0.05), safety attitudes (P = 0.82), and PSQI knowledge (P = 0.29) at the beginning of the year. The residents of institution A demonstrated significant improvement in confidence (P = 0.00009) and knowledge (P = 0.0006) after completing the curriculum, with no improvement noted for residents at institution B in either confidence (P = 0.06) or knowledge (P = 0.79). Neither program demonstrated improvement in attitudes toward patient safety at the end of the year-long curriculum. CONCLUSION Implementing a formal curriculum dedicated to PSQI led to an improvement in PSQI-related project development confidence and PSQI knowledge. Attitudes toward safety did not improve over the course of a year. Longer-term studies involving multiple institutions and other interventions are needed to evaluate the impact and duration of changes that occur. LEVEL OF EVIDENCE 1b Laryngoscope, 129:1100-1106, 2019.