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Basal cell carcinoma (BCC), cutaneous squamous cell carcinoma (cSCC), and Merkel cell carcinoma (MCC) comprise the majority of nonmelanoma skin cancers. Advances have been made in treatment. Sentinel node biopsy should be considered for locally advanced, clinically node-negative cSCCs and MCCs. BCC patients failing traditional surgery and/or radiation are candidates for systemic hedgehog inhibitor therapy. Immune checkpoint inhibitor treatment is available for patients who failed traditional treatment with surgery and/or radiation or who are not candidates for these modalities. Specifically, cemiplimab is approved for advanced BCC; cemiplimab and pembrolizumab for advanced cSCC; and avelumab, pembrolizumab, and retifanlimab-dlwr for recurrent/metastatic MCC., Competing Interests: Disclosure None to disclose., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Nonsurgical management of congenital ear anomalies using molding devices shows efficacy but lacks standardization of treatment protocols and outcome measures. Learning Objective: To compare ear molding techniques and identify factors related to treatment outcomes. Design Type: Systematic review of the literature (1990-2021). Methods: Studies reporting molding for congenital ear anomalies were assessed. PRISMA guidelines were used. Data extracted included: age at treatment initiation, treatment duration, correction rates, and complications. Data analysis included descriptive statistics and outcomes were compared using the Student t -test. Results: In total, 37 studies with 3,341 patients (mean patients per study, 95; range, 5-488) were included. Infants in whom treatment was initiated at 4.8 weeks (median, 3.7; range, 0.9-8.8 weeks) were treated for 5.1 weeks (median 4.7, range 2.6-7.6 weeks) with 11.0 months follow-up (median 11.4, range 1.4-21.0 months). Individualized devices (physician-customized) were used more (62.2% of studies) than commercial devices. No difference in correction ( p = 0.44) or complication rates ( p = 0.19) was identified between devices. Totally, 70.3% of studies reported complications and 40.5% of studies included long-term follow-up data. Conclusions: The available evidence supports initiating ear molding in the first weeks of life to be most effective, yet outcome data should be standardized in future studies to improve evidence quality.

Purpose of Review: Surgery remains the mainstay of treatment for non-melanoma skin cancer (NMSC). Immunotherapy (IO) has emerged as an alternative option. This review provides a contemporary summary of how to incorporate IO into the management of advanced NMSC. Evidence-based outcomes and recent clinical trials are provided with emphasis on the three most common NMSC diagnoses: cutaneous squamous cell carcinoma (cSCC), basal cell carcinoma (BCC), and merkel cell carcinoma (MCC)., Recent Findings: Surgical resection while preserving form and function remains the standard of care for the majority of NMSCs. In recalcitrant cases failing traditional surgery and/or primary radiation, patient ineligible for such treatments, or unresectable disease, IO has emerged as a promising alternative. In the majority of cases, it is a supplanting primary chemotherapy. Surgery remains the standard of care for NMSC. Immunotherapy has emerged as an alternative option for non-surgical candidates and as a neoadjuvant means to minimize morbidity., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Voice restoration following laryngectomy has a significant influence on quality of life (QOL). Three main techniques exist to provide voice: esophageal speech (ES), artificial larynx (electrolarynx [EL]), and tracheoesophageal puncture (TEP). Although the EL was historically the most used technique, TEP has quickly become the gold standard. ES remains the least frequently used technique in developed countries. Technique selection must be made on an individual basis, considering the patient's cancer history and comorbidities. Ultimately, the choice in voice-restoration technique requires joint decision making with the surgeon, speech pathologist, and patient., Competing Interests: Disclosure The authors have no commercial or financial conflicts of interest; no funding sources were used for this article., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Psychological safety is the concept that an individual feels comfortable asking questions, voicing ideas or concerns, and taking risks without undue fear of humiliation or criticism. In health care, psychological safety is associated with improved patient safety outcomes, increased clinician engagement, and greater creativity. A culture of psychological safety is imperative for physician well-being and satisfaction, which in turn directly affect delivery of care. For health care professionals, psychological safety creates an environment conducive to trust and openness, enabling the team to focus on high-quality care. In contrast, unprofessional behavior reduces psychological safety and threatens the culture of the organization. This patient safety/quality improvement primer considers the barriers and facilitators to psychological safety in health care; outlines principles for creating a psychologically safe environment; and presents strategies for managing conflict, microaggressions, and lapses in professionalism. Individuals and organizations share the responsibility of promoting psychological safety through proactive policies, conflict management, interventions for microaggressions, and cultivation of emotional intelligence., (© 2022 American Academy of Otolaryngology-Head and Neck Surgery Foundation.)

Background: A position statement put forth by the American Head and Neck Society (AHNS) was constructed to provide evidence-based treatment recommendations for PD-1 inhibitor use in advanced cutaneous squamous cell carcinoma (cSCC). Secondarily, we sought to identify knowledge gaps warranting further investigation., Methods: A literature search utilizing key terms: cutaneous squamous cell carcinoma, cutaneous cancer, checkpoint inhibitors, systemic therapy, Program Cell Death, PD-1 (PubMed, Cochrane, and Google Scholar) was carried out to generate evidence-based statements. The statements were distributed among the AHNS membership. Delphi methodology was applied to identify statements achieving 70% or greater consensus among the leadership team., Results: Twenty-six position statements achieved consensus. Knowledge gaps for future research included: impact of immunosuppression on cSCC staging and associated treatment; role of PD-1 inhibitors in immunosuppressed patients., Conclusion: This comprehensive position statement put forth by the AHNS represents majority consensus by practicing head and neck surgeons throughout the country., (© 2022 Wiley Periodicals LLC.)

Objectives: (1) Assess overall COVID-19 mortality in ventilated patients with and without tracheostomy. (2) Determine the impact of tracheostomy on mechanical ventilation duration, overall length of stay (LOS), and intensive care unit (ICU) LOS for patients with COVID-19., Study Design: Case series with planned chart review., Setting: Single-institution tertiary care center., Methods: Patients with COVID-19 who were ≥18 years old and requiring invasive positive pressure ventilation (IPPV) met inclusion criteria. Patients were stratified into 2 cohorts: IPPV with tracheostomy and IPPV with intubation only. Cohorts were analyzed for the following primary outcome measures: mortality, LOS, ICU LOS, and IPPV duration., Results: An overall 258 patients with IPPV met inclusion criteria: 46 (18%) with tracheostomy and 212 (82%) without (66% male; median age, 63 years [interquartile range, 18.75]). Average LOS, time in ICU, and time receiving IPPV were longer in the tracheostomy cohort ( P < .01). Ability to wean from IPPV was similar between cohorts ( P > .05). The number of deaths in the nontracheostomy cohort (54%) was significantly higher than the tracheostomy cohort (29%, P < .01)., Conclusions: While tracheostomy placement in patients with COVID-19 did not shorten overall LOS, mechanical ventilation duration, or ICU LOS, patients with a tracheostomy experienced a significantly lower number of deaths vs those without. One goal for tracheostomy is improved pulmonary toilet with associated shortened IPPV requirements. Our study did not identify this advantage among the COVID-19 population. However, this study demonstrates that the need for tracheostomy in the COVID-19 setting does not portent a poor prognostic factor, as patients with a tracheostomy experienced a significantly higher survival rate than their nontracheostomy counterparts.

Laryngeal inhalation injury carries a significant increase in mortality rate and often indicates immediate airway evaluation. This may be difficult in the setting of clinical deterioration necessitating immediate intubation, which itself can synergistically cause mucosal damage. Prior studies do not encompass predictive factors or long-term outcomes for the laryngotracheal complex. This systemic review of PubMed, Embase, and Cochrane identified studies investigating inhalational injuries of the upper airway. Demographic data as well as presentation, physical findings, and delayed sequelae were documented. Laryngotracheal burn patients were divided into two cohorts based on timing of laryngeal injury diagnosis (before- versus after-airway intervention). 1051 papers met initial search criteria and 43 studies were ultimately included. Airway stenosis was more common in patients that were intubated immediately (50.0%, n = 18 versus 5.2%, n = 13; p = 0.57). Posterior glottic involvement was only identified in patients intubated prior to airway evaluation (71.4%, n = 15). All studies reported a closed space setting for those patients in whom airway intervention preceded laryngeal evaluation. Laryngeal inhalational injuries are a distinct subset that can have a variety of minor to severe laryngotracheal delayed sequelae, particularly for thermal injuries occurring within enclosed spaces. Given these findings, early otolaryngology referral may mitigate or treat these effects., (Published by Elsevier Ltd.)

Fractures of the zygomaticomaxillary complex and zygomatic arch are common athletic injuries. Fracture displacement can lead to midfacial retrusion and widening, causing noticeable deformity. Associated signs and symptoms include hypoesthesia of the infraorbital nerve distribution, trismus, and subjective malocclusion. Operative treatment is indicated in cases of significant displacement or functional disturbance. The approach and details of osteosynthesis are catered to the specific characteristics of the fracture. Technology, such as virtual surgical planning, intraoperative navigation, and intraoperative imaging, has the potential to improve accuracy of treating challenging fractures., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Simulation training has taken a prominent role in otolaryngology-head and neck surgery (OTO-HNS) as a means to ensure patient safety and quality improvement (PS/QI). While it is often equated to resident training, this tool has value in lifelong learning and extends beyond the individual otolaryngologists to include simulation-based learning for teams and health systems processes. Part III of this PS/QI primer provides an overview of simulation in medicine and specific applications within the field of OTO-HNS. The impact of simulation on PS/QI will be presented in an evidence-based fashion to include the use of run and statistical process control charts to assess the impact of simulation-guided initiatives. Last, steps in developing a simulation program focused on PS/QI will be outlined with future opportunities for OTO-HNS simulation.

Objective: Postoperative prescription narcotics increase access to opioids and associated abuse among patients, family, and acquaintances. Judicious opioid stewardship is required. Best practice questions remain for larger head and neck surgeries. We aim to review opioid utilization patterns in an urban patient population to identify patients at risk for poor postoperative pain control., Study Design: Case series with planned chart review for patients undergoing head and neck surgery (2015-2018)., Setting: Single urban hospital., Methods: Outcome measures included postoperative phone calls and emergency room visits as markers for inadequate pain control. Age, sex, race, body mass index (BMI), smoking status, comorbidities, prior narcotic filling behavior, surgery type, and duration were evaluated as potential risk factors for pain control. Chi-square and Wilcoxon tests were used for group comparisons., Results: In total, 215 patients met inclusion criteria: male (22%), white/Hispanic (47%), and African American (44%). Median BMI was 31.6 kg/m 2 ; median age was 52 years. Surgeries included total thyroidectomy (41%), hemithyroidectomy (27%), and parathyroidectomy (15%). The 23-hour observation patients (n = 175, 81%) had a median of 20 morphine milligram equivalents (MMEs). Sixteen patients experienced inadequate pain control. Female sex ( P = .03), younger age ( P = .02), current smoker ( P = .03), and higher inpatient MME ( P = .006) were associated with inadequate pain control., Conclusion: Female sex, younger age, smokers, and high inpatient opioid dose requirements are associated with inadequately controlled pain. These patients may benefit from additional education, earlier postoperative visits, and a more comprehensive nonopioid regimen.

Background: Preoperative laboratory tests (PLTs) are not associated with complications among healthy patients in various ambulatory procedures. This association has not been studied in ambulatory endocrine surgery., Methods: The 2015-2018 NSQIP datasets were queried for elective outpatient thyroid and parathyroid procedures in ASA class 1 and 2 patients. Outcomes were compared between those with and without PLTs. Multivariate regression examined factors predictive of receiving PLTs. Testing costs were calculated., Results: 58.7% of the cohort received PLTs. There were no differences in outcomes between those who were and those who were not tested. Non-white ethnicity, dyspnea, and non-general anesthesia were strongly predictive of receiving PLTs. Over $2.6 million is spent annually on PLTs in this population., Conclusions: Over half of healthy patients undergoing elective thyroid and parathyroid surgery receive PLTs. Complication rates did not differ between those with and without PLTs. Preoperative testing should be used more judiciously in these patients, which may lead to cost savings., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: (1) To describe the patient and membership cohort captured by the otolaryngology-based specialty-specific Reg-ent registry. (2) To outline the capabilities of the Reg-ent registry, including the process by which members can access evidence-based data to address knowledge gaps identified by the American Academy of Otolaryngology-Head and Neck Surgery/Foundation and ultimately define "quality" for our field of otolaryngology-head and neck surgery., Methods: Data analytics was performed on Reg-ent (2015-2020)., Results: A total of 1629 participants from 239 practices were enrolled in Reg-ent, and 42 health care specialties were represented. Reg-ent encompassed 6,496,477 unique patients and 24,296,713 encounters/visits: the 45- to 64-year age group had the highest representation (n = 1,597,618, 28.1%); 3,867,835 (60.3%) patients identified as Caucasian; and "private" was the most common insurance (33%), followed by Blue Cross/Blue Shield (22%). Allergic rhinitis-unspecified and sensorineural hearing loss-bilateral were the top 2 diagnoses (9% each). Overall, 302 research gaps were identified from 17 clinical practice guidelines., Discussion: Reg-ent benefits are vast-from monitoring one's practice to defining otolaryngology-head and neck surgery quality, participating in advocacy, and conducting research. Reg-ent provides mechanisms for benchmarking, quality assessment, and performance measure development, with the objective of defining and guiding best practice in otolaryngology-head and neck surgery. To be successful, patient diversity must be achieved to include ethnicity and socioeconomic status. Increasing academic medical center membership will assist in achieving diversity so that the quality domain of equitable care is achieved., Implications for Practice: Reg-ent provides the first ever registry that is specific to otolaryngology-head and neck surgery and compliant with HIPAA (Health Insurance Portability and Accountability Act) to collect patient outcomes and define evidence-based quality care.

The immunosuppressed (IS) population encompasses a diverse cohort of patients to include iatrogenically immunocompromised organ transplant recipients as well as patients with chronic lymphoid malignancies, human immunodeficiency virus/acquired immunodeficiency syndrome, and autoimmune disorders. Cutaneous cancers in this high-risk patient group are clinically distinct from the general immunocompetent population, showing aggressive behavior with associated poor outcomes. This article reviews the pathogenesis, epidemiology, incidence, prognosis, and special considerations required in managing cutaneous cancers in the IS patient population., Competing Interests: Disclosure The authors have no related financial disclosures or conflicts of interest., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: The current landscape of patient safety/quality improvement (PS/QI) research dedicated to Otolaryngology-Head and Neck Surgery (OHNS) has not been established. This systematic review aims to define the breadth and depth of PS/QI research dedicated to OHNS and to identify knowledge gaps as well as potential areas of future study., Methods: The study protocol was developed a priori using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) process. A computerized Ovid/Medline database search was conducted (January 1, 1965-September 30, 2019). Similar computerized searches were conducted using Cochrane Database, PubMed, and Google Scholar. Articles were classified by year, subspecialty, PS/QI category, Institute of Medicine (IOM) Crossing the Chasm categories, and World Health Organization (WHO) subclass., Results: Computerized searches yielded 11,570 eligible articles, 738 (6.4%) of which met otolaryngology PS/QI inclusion criteria; 178 (24.1%) were not specific to any one subspecialty. The most prevalent subspecialty foci were head and neck (29.9%), pediatric otolaryngology (16.9%), and otology/neurotology (11.0%). Studies examining complications or risk factors (32.0%) and outcomes/quality measures (16.3%) were the most common foci. Classification by the IOM included effective care (31.4%), safety (29.9%), and safety/effective care (25.3%). Most research fell into the WHO categories of understanding causes (28.5%) or measuring harm (28.3%)., Conclusion: Most OHNS PS/QI projects (32.0%) focus on reporting complications or risk factors, followed by outcomes/quality measures (16.3%). Knowledges gaps for future research include healthcare disparities, multidisciplinary care, and the WHO category of studies translating evidence into safer care., Level of Evidence: NA Laryngoscope, 131:33-40, 2021., (© 2020 The American Laryngological, Rhinological and Otological Society, Inc.)

As the coronavirus disease 2019 (COVID-19) pandemic continues to evolve through the United States and other countries, differing rates of progression and decline are occurring based on varied population densities. While some health systems are reaching a steady state of new patient cases, others are seeing a leveling off or decline, allowing for restoration of normal practices. This "reverse-surge" planning and implementation process is a colossal undertaking for health systems trying to reacquire patient access and financial stability while preserving necessary resources and maintaining precautions for another potential surge. For the otolaryngologist, reverse-surge planning involves additional workflow adjustments in the outpatient and operating room settings given the abundance of COVID-19 virus in the upper aerodigestive tract. As the reverse-surge best practices are still under development, open communication between otolaryngology colleagues and health system leadership is paramount to optimize efficiency and maintain an adequate measure of safety for patients and our health care teams.

On March 11, 2020, the World Health Organization declared coronavirus disease 2019 a global pandemic. In addition to massive social disruption, this pandemic affected the traditional fellowship interview season for otolaryngology subspecialties, including head and neck surgical oncology, facial plastic and reconstructive surgery, laryngology, rhinology, neurotology, and pediatric otolaryngology. The impact on the fellowship interview process, from the standpoint of the institution and the applicant, necessitated the use of alternative interview processes. This change may alter the future of how interviews and the match proceed for years to come, with nontraditional methods of interviewing becoming a mainstay. While the impact this pandemic has on the fellowship match process is not yet fully realized, this commentary aims to discuss the challenges faced on both sides of the equation and to offer solutions during these unprecedented times.

As otolaryngologists, we identify as subspecialists and fellowship-trained surgeons and may even identify as "super-subspecialists." The likelihood of being redeployed and drawing from knowledge learned during our postgraduate year 1 training seemed exceedingly unlikely until physician resources became scarce in some health care systems during the COVID-19 pandemic. More now than ever, it is evident that our broad training is valuable in helping patients and allowing the otolaryngologist to meaningfully contribute to the larger health care community, especially while the majority (70%-95%) of elective care is delayed. With our skill set, otolaryngologists are poised to support various aspects of hospital wards, intensive care units, emergency departments, and beyond.

With increasing emphasis on patient safety/quality improvement, health care systems are mirroring industry in the implementation of root cause analysis (RCA) for the identification and mitigation of errors. RCA uses a team approach with emphasis on the system, as opposed to the individual, to accrue empirical data on what happened and why. While many otolaryngologists have a broad understanding of RCA, practical experience is often lacking. Part II of this patient safety/quality improvement primer investigates the manner in which RCA is utilized in the prevention of medical errors. Attention is given to identifying system errors, recording adverse events, and determining which events warrant RCA. The primer outlines steps necessary to conduct an effective RCA, with emphasis placed on actions that arise from the RCA process through the root cause analysis and action (or RCA 2 ) rubric. In addition, the article provides strategies for the implementation of RCA into clinical practice and medical education.

Office-based otolaryngology procedures provide a safe and efficient alternative to the traditional operating room. Physicians are responsible for knowing their state regulations and subspecialty guidelines. Although the clinic setting has fewer regulations than hospitals and ambulatory surgery centers, the clinic has the same standards as a hospital with respect to emergency equipment, trained personnel, protocols, and safety measures. Sedation occurs along a continuum; it is impossible to predict a patient's response to sedation. Otolaryngologists performing office-based sedation must be prepared to rescue with airway and advanced life support in the event that the sedation level encountered is deeper than expected., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: The primary objective was to define and quantify the relationship between immunosuppression and prognosis in patients with cutaneous squamous cell carcinoma of the head and neck., Data Sources: Ovid/Medline, PubMed, Embase, and Scopus were searched from inception through June 5, 2017, with cross-referenced subject headings of squamous cell carcinoma, skin neoplasms, head and neck neoplasms, and prognosis. Additional gray literature was queried., Review Methods: All prospective, retrospective, and cohort studies in the English literature investigating prognosis in patients with head and neck cutaneous squamous cell carcinoma were eligible for inclusion. Meta-analysis data were pooled using the fixed-effects model. The main outcome measures were hazard ratios detailing subgroup analysis between immunosuppressed and immunocompetent patients., Results: Seventeen studies were eligible for inclusion; 317 of the 2886 patients were immunosuppressed. Meta-analysis with pooled hazard ratios was performed for all outcome variables with at least 3 reported hazard ratios. Immunosuppression portended a worse prognosis across all outcome variables of interest: locoregional recurrence (2.20; 95% confidence interval [CI], 1.45-3.36), disease-free survival (2.69; 95% CI, 1.60-4.51), disease-specific survival (3.61; 95% CI, 2.63-4.95), and overall survival (2.09; 95% CI, 1.64-2.67)., Conclusion: This is the largest investigation into the impact of immunosuppression on head and neck cutaneous squamous cell carcinoma. Immunosuppressed patients experience worse recurrence and survival outcomes compared to immunocompetent counterparts. The data support formal inclusion of immunosuppression in head and neck cutaneous squamous cell carcinoma staging systems.

Objective: To implement a quality improvement project addressing the knowledge gap in the otolaryngology resident and fellow scientific peer review process., Methods: The creation of the Resident Reviewer Development Program, cohort 1 outcomes, and subsequent lessons learned from the inaugural class are outlined using the plan-do-study-act model. Interested otolaryngology residents were paired with seasoned reviewers and conducted a minimum of 3 mentored peer reviews followed by an independent review test if competency was determined., Results: Twenty-five residents (postgraduate years [PGYs] 2-5) were actively enrolled in cohort 1. At 24 months, 18 (72%) graduated, 6 remained actively enrolled, and 1 did not successfully complete the program. The median number of practice reviews prior to testing was 3 (range, 3-6). The median independent review score was 83 (overall journal mean = 78). Cohort 1 graduates continued on to review 130 articles with a mean score of 85. Five (28%) graduates achieved Star Reviewer status., Discussion: The inaugural cohort demonstrated that the PGY-3 and PGY-4 class is ideal for enrollment given that completion of the program could take up to 24 months. Three mentored reviews were identified as the ideal minimum requirement for education. The accelerated achievement of Star Reviewer status (28%) and mean postgraduation score of 85 demonstrate successful and sustainable outcome measures., Implications for Practice: With appropriate mentorship and administrative support, scientific peer review can be formally incorporated into an educational program. Lessons learned during the educational program are sustained long term as demonstrated by review scores and Star Reviewer status.

Patient safety/quality improvement (PS/QI) is the cornerstone of 21st-century health care. Otolaryngology-Head and Neck Surgery is excited to provide a dedicated PS/QI primer. The overarching goal for this PS/QI series is to provide a comprehensive and practical resource that assists readers, authors, and peer reviewers in understanding PS/QI research, its unique methodology, and the associated reporting standards for trustworthy performance measures. The target audience includes resident and fellows, faculty from the private sector and academia, and allied health professionals. This inaugural primer reviews PS/QI background as it relates to otolaryngology practice. It explores the history, goals, and development of performance measurement. In addition, it highlights opportunities for integrating PS/QI into otolaryngology practice. Payers will drive patients to quality care based on outcomes. Otolaryngologists have a responsibility to embrace a culture of PS/QI. In doing so, we will define optimal, quality otolaryngology care through objective data and metrics.

Objective: Electronic cigarettes (e-cigs) are an emerging trend, yet little is known about their use in the cancer population. The objectives of this study were (1) to describe characteristics of e-cig use among cancer patients, (2) to define e-cig advertising exposure, and (3) to characterize perceptions of traditional cigarettes versus e-cigs., Study Design: Cross-sectional study., Setting: Comprehensive cancer center., Subjects and Methods: Inpatient, current smokers with a cancer diagnosis. E-cig exposure and use were defined using descriptive statistics. Wilcoxon rank test was used to compare perceptions between e-cigs and traditional cigarettes., Results: A total of 979 patients were enrolled in the study; 39 cancer patients were identified. Most cancer patients were women (59%), with an average age of 53.3 years. Of the patients, 46.2% reported e-cig use, most of which (88.9%) was "experimental or occasional." The primary reason for e-cig use was to aid smoking cessation (66.7%), alternative use in nonsmoking areas (22.2%), and "less risky" cigarette replacement (5.6%). The most common sources for e-cig information were TV (76.9%), stores (48.7%), friends (35.9%), family (30.8%), and newspapers or magazines (12.8%). Compared with cigarettes, e-cigs were viewed as posing a reduced health risk ( P < .001) and conferring a less negative social impression ( P < .001). They were also viewed as less likely to satisfy nicotine cravings ( P = .002), to relieve boredom ( P = .0005), to have a calming effect ( P < .001), and as tasting pleasant ( P = .006)., Conclusions: E-cig use and advertising exposure are common among cancer patients. E-cig use is perceived as healthier and more socially acceptable but less likely to produce a number of desired consequences of cigarette use., Competing Interests: Competing interests: None.

The following article is the next installment of the series "Do You Know Your Guidelines?" presented by the Education Committee of the American Head and Neck Society. Guidelines for the prevention, diagnosis, workup, and management of cutaneous melanoma are reviewed in an evidence-based fashion., (© 2018 Wiley Periodicals, Inc.)

Cutaneous malignancy of the head and neck affects a large proportion of elderly patients. The severity ranges from small, easily treatable lesions to large, invasive, potentially metastatic tumors. Surgical treatment is the primary treatment of most skin cancers; however, geriatric patients are more likely to have multiple comorbidities that increase the risk of surgery. Multiple treatment modalities exist, including surgical, radiation, and medical therapy. Recommendations and treatment options for basal cell carcinoma, squamous cell carcinoma, Merkel cell carcinoma, and melanoma are outlined and reviewed., (Copyright © 2018 Elsevier Inc. All rights reserved.)

The application and utility of melanoma sentinel lymph node biopsy (SLNB) has evolved significantly since its inception over two decades ago. The current focus has shifted from a staging modality to potentially a therapeutic intervention. Recent research to include large multi-institutional randomized trials have attempted to answer the question: is a completion lymph node dissection (CLND) required following a positive SLNB? This review provides an evidence-based, contemporary review of the utility of CLND for SLNB positive head and neck cutaneous melanoma patients., Level of Evidence: NA.

Purpose of Review: The primary purpose of this chapter is to define current recommendations for vascular work-up of patients with craniomaxillofacial (CMF) trauma with emphasis on imaging to include intraoperative fluorescence, angiography, and surgical exploration. The second goal is to review current management recommendations for observation versus surgical exploration based on the neck zones of injury., Recent Findings: Over the past two decades, endovascular techniques are increasingly utilized, particularly in zones I and III of the neck. Additionally, modern advances in radiographic technology have allowed for selective exploration of penetrating zone II injuries. A high suspicion for blunt cerebrovascular injury should be maintained for patients with high-speed deceleration mechanisms of injury, with a majority of patients managed with medical therapy or conservative monitoring over surgical intervention., Summary: CMF fractures are associated with vascular injuries to the intracranial carotid system, extracranial carotid system, or vertebral artery system. A thorough understanding of at risk patients, optimal work-up, and timely treatment algorithms is imperative given the devastating sequellae of stroke and death.

It is an exciting time for head and neck surgical innovation with numerous advances in the perioperative planning and intraoperative management of patients with cancer, trauma patients, and individuals with congenital defects. The broad and rapidly changing realm of head and neck surgical innovation precludes a comprehensive summary. This article highlights some of the most important innovations from surgical planning with sentinel node biopsy and three-dimensional, stereolithic modeling to intraoperative innovations, such as transoral robotic surgery and intraoperative navigation. Future surgical innovations, such as intraoperative optical imaging of surgical margins, are also highlighted., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective This State of the Art Review aims (1) to define recent qualifications of otolaryngology resident applicants by focusing on United States Medical Licensing Examination (USMLE) scores, Alpha Omega Alpha (AOA) status, and research/publications and (2) to summarize the current literature regarding the relationship between these measures and performance in residency. Data Sources Electronic Residency Application Service, National Residency Matching Program, PubMed, Ovid, and GoogleScholar. Review Methods Electronic Residency Application Service and National Residency Matching Program data were analyzed to evaluate trends in applicant numbers and qualifications. Additionally, a literature search was performed with the aforementioned databases to identify relevant articles published in the past 5 years that examined USMLE Step 1 scores, AOA status, and research/publications. Conclusions Compared with other highly competitive fields over the past 3 years, the only specialty with decreasing applicant numbers is otolaryngology, with the rest remaining relatively stable or slightly increased. Additionally, USMLE Step 1 scores, AOA status, and research/publications do not reliably correlate with performance in residency. Implications for Practice The consistent decline in applications for otolaryngology residency is concerning and reflects a need for change in the current stereotype of the "ideal" otolaryngology applicant. This includes consideration of additional selection measures focusing on noncognitive and holistic qualities. Furthermore, otolaryngology faculty should counsel medical students that applying in otolaryngology is not "impossible" but rather a feasible and worthwhile endeavor.

Objective The breadth and depth of patient safety/quality improvement (PS/QI) research dedicated to otolaryngology-head and neck surgery (OHNS) education remains unknown. This systematic review aims to define this scope and to identify knowledge gaps as well as potential areas of future study to improved PS/QI education and training in OHNS. Data Sources A computerized Ovid/Medline database search was conducted (January 1, 1965, to May 15, 2015). Similar computerized searches were conducted using Cochrane Database, PubMed, and Google Scholar. Review Methods The study protocol was developed a priori using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Articles were classified by year, subspecialty, Institute of Medicine (IOM) Crossing the Chasm categories, and World Health Organization (WHO) subclass. Results Computerized searches yielded 8743 eligible articles, 267 (3.4%) of which met otolaryngology PS/QI inclusion criteria; 51 (19%) were dedicated to resident/fellow education and training. Simulation studies (39%) and performance/competency evaluation (23.5%) were the most common focus. Most projects involved general otolaryngology (47%), rhinology (18%), and otology (16%). Classification by the IOM included effective care (45%), safety/effective care (41%), and effective and efficient care (7.8%). Most research fell into the WHO category of "identifying solutions" (61%). Conclusion Nineteen percent of OHNS PS/QI articles are dedicated to education, the majority of which are simulation and focus on effective care. Knowledges gaps for future research include facial plastics PS/QI and the WHO category of "studies translating evidence into safer care."

Patient education is essential in enhancing the physician-patient therapeutic alliance, patient satisfaction, and clinical outcomes. The American Medical Association and National Institute of Health recommend that information be written at a 6th-grade reading level, but online resources often exceed patient literacy. The purpose of this study is to assess readability of online material for facial plastics procedures presented on academic plastic surgery and otolaryngology websites.An Internet search was performed of all academic institutions that had both plastic surgery and otolaryngology training programs who offered patient information on facial plastic surgery procedures. National society websites for both plastic surgery and otolaryngology were also analyzed. All procedural information was compiled and readability analyses were performed. A 2-tailed Z-test was used to compare scores, and statistical significance was set at P < 0.05.Sixty-three programs were identified; 42 had educational material. The overall average readability for all information was at a 10th-grade reading level. The national plastic surgery website had a significantly higher word count and number of syllables per word compared to the national otolaryngology website (P < 0.001, P = 0.04).The complexity of written resources represents an obstacle to online patient education and efforts to improve readability could benefit patients seeking medical information online. Current online education materials are a potential hindrance to patient education, satisfaction, and decision making. Healthcare institutions should consider writing new materials with simpler language that would be accessible to patients.

Objectives: Blunt cerebrovascular injury (BCVI) is a known sequela of high-energy craniomaxillofacial (CMF) trauma and can result in stroke or death. The objective of this systematic review is to 1) identify CMF trauma patients who may benefit from BCVI screening and 2) describe the optimal diagnostic and treatment modalities., Study Design: Systematic review of the literature (1946-2013)., Methods: An a priori study protocol was created using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis. The authors conducted a search of Ovid/Medline, PubMed, and Cochrane databases for articles related to BCVI and CMF fractures. All abstracts were reviewed, and data was extracted to determine the incidence of BCVI in the setting of CMF trauma. Individual fracture patterns were analyzed using descriptive statistics., Results: Twenty-one studies met inclusion criteria. The overall incidence of CMF fracture-associated BCVI was 0.45%. The majority of patients (86.6%) sustained BCVI in the setting of high-energy trauma. The distribution of CMF fractures among BCVI patients was the mandible (12.5%), followed by the maxilla (11.8%). Computed tomographic angiography (CTA) was the most common diagnostic modality. A total of 63.1% of patients with BCVI were managed medically. The mortality among CMF patients with BCVI was 23.9%, and stroke rate was 47.1%., Conclusion: Blunt cerebrovascular injury is a rare but devastating complication of blunt trauma. The recommended screening modality is CTA, and the most common treatment is antiplatelet/anticoagulant medication. Mandibular and LeFort fractures were the most common isolated CMF injury associated with BCVI, highlighting the need for prospective trials to expand current screening criteria., Level of Evidence: N/A. Laryngoscope, 127:79-86, 2017., (© 2016 The American Laryngological, Rhinological and Otological Society, Inc.)

This article is the next installment of the series "Do You Know Your Guidelines" presented by the Education Committee of the American Head and Neck Society. Guidelines for the prevention, diagnosis, workup, and management of cutaneous squamous cell carcinoma (SCC) are reviewed. © 2016 Wiley Periodicals, Inc. Head Neck 38: 1708-1716, 2016., (© 2016 Wiley Periodicals, Inc.)

Current otolaryngology literature and future scientific direction rely heavily on a rigorous peer review process. Just as manuscripts warrant thoughtful review with constructive feedback to the authors, the same can be said for critiques written by novice peer reviewers. Formal scientific peer review training programs are lacking. Recognizing this knowledge gap, Otolaryngology-Head and Neck Surgery is excited to offer its new Resident Reviewer Development Program. All otolaryngology residents who are postgraduate year 2 and above and in excellent academic standing are eligible to participate in this mentored program, during which they will conduct 6 manuscript reviews under the direction of a seasoned reviewer in his or her subspecialty area of interest. By completing reviews alongside a mentor, participants gain the required skills to master the peer review process-a first step that often leads to journal editorial board and associate editor invitations., (© American Academy of Otolaryngology—Head and Neck Surgery Foundation 2016.)

The most common vascular tumors encountered by the otolaryngologist are rare chromaffin cell tumors termed paragangliomas. Within the head and neck region, they commonly arise from the carotid body, vagus nerve (glomus vagale), and jugular vein (glomus jugulare). Other vascular head and neck tumors include sinonasal malignancies, because of proximity to or involvement of the pterygoid plexus as well as the rich vascularity of the sinonasal mucosa; juvenile nasopharyngeal angiofibroma, a vascular tumor of male adolescents; unusual vascular tumors such as hemangiopericytoma; and metastatic renal cell cancer, which has a proclivity for an unusually rich blood supply., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Surgical resection with negative margins remains the standard of care for high-risk cutaneous squamous cell carcinoma (SCC). However, surgical management is often limited by poor intraoperative tumor visualization and inability to detect occult nodal metastasis. The inability to intraoperatively detect microscopic disease can lead to additional surgery, tumor recurrence, and decreased survival., Methods: A comprehensive literature review was conducted to identify studies incorporating optical imaging technology in the management of cutaneous SCC (January 1, 2000-December 1, 2014)., Results: Several innovative optical imaging techniques, Raman spectroscopy, confocal microscopy, and fluorescence imaging, have been developed for intraoperative surgical guidance. Fifty-seven studies review the ability of these techniques to improve cutaneous SCC localization at the gross and microscopic level., Conclusion: Significant advances have been achieved with real-time optical imaging strategies for intraoperative cutaneous SCC margin assessment and tumor detection. Optical imaging holds promise in improving the percentage of negative surgical margins and in the early detection of micrometastatic disease. © 2015 Wiley Periodicals, Inc. Head Neck 38: E2204-E2213, 2016., (© 2015 Wiley Periodicals, Inc.)

This invited article reviews the grant process to include the following objectives: (1) to provide an understanding of otolaryngology funding mechanisms in the context of career progression; (2) to outline key components of a well-written grant; (3) to highlight vital members of a successful research team, with emphasis on the mentor-mentee relationship; and (4) to clarify grant scoring with emphasis on common pitfalls to avoid. Current otolaryngology funding mechanisms and up-to-date resources are provided. The review is aimed to assist otolaryngology residents, faculty new to the grant process, as well as experienced researchers striving to improve their grant review scores., (© American Academy of Otolaryngology—Head and Neck Surgery Foundation 2015.)

Objectives: (1) Investigate electronic cigarette (e-cig) use among head and neck (HN) cancer patients; (2) define quit methods, success, motivations, and barriers to smoking cessation; and (3) determine the impact of e-cig use in smoking cessation., Study Design: Cross-sectional study., Setting: Tertiary care center., Methods: An in-office survey was administered to HN cancer patients ≥ 19 years of age with past/present tobacco use. Patient demographics were collected. Quit methods, success, and motivations/barriers were surveyed. The Alcohol Use Disorders Identification Test was used to correlate alcohol use and cessation. Independent variables associated with cessation were studied with Fisher's exact test and Student's t test. Subgroup analysis was performed for e-cig users., Results: Of 110 eligible patients, 106 (96%) enrolled (83% male, 82% Caucasian), of whom 69 (65%) successfully quit. Age of first tobacco use did not differ between the smoking and cessation groups (P = .14), nor did hazardous drinking (30% smoking vs 14% cessation; P = .072). "Cold turkey" (ie, stopping abruptly without smoking cessation aids) was the most common method attempted (n = 88, 83%) and most successful (n = 65, 94%). There was no statistical difference in age, sex, race, drinking, or socioeconomic status between e-cig users and nonusers. Nonusers achieved higher quit rates as compared with e-cig users (72% vs 39%; P = .0057). E-cig use did not decrease the number of cigarettes smoked (463 cigarettes/month) versus that of nonusers (341 cigarettes/month; P = .2). Seventy percent of e-cig users wore a nicotine patch., Conclusions: HN cancer patients desire smoking cessation. E-cig did not decrease tobacco use, and patients who utilize e-cigs are less likely to achieve smoking cessation., (© American Academy of Otolaryngology-Head and Neck Surgery Foundation 2015.)

Objective: Proliferative verrucous leukoplakia (PVL) is a rare and recalcitrant form of leukoplakia. The purpose of this review is to further characterize the risk factors, clinical course, and optimal treatment for this highly aggressive, premalignant lesion., Data Sources: Twenty-six articles on PVL with a total of 329 PVL cases., Review Methods: A systematic review of the literature using Ovid, PubMed, Cochrane Database, and gray literature was conducted of all PVL cases reported between 1985 and 2014. Inclusion criteria required reporting of patient follow-up and recurrence rates. Data were analyzed using descriptive statistics. Student t test and Fisher exact test were used to identify factors associated with malignant transformation., Results: The mean patient age was 63.9 years. Most patients were female (66.9%) and nontobacco users (65.22%). Mean follow-up was 7.4 years, with an average of 9.0 biopsies per patient during this period. Proliferative verrucous leukoplakia exhibited histopathologic features along a progressive spectrum, evolving from leukoplakia to verrucous hyperplasia and ultimately invasive carcinoma. Surgery was the most common treatment implemented, but recurrence rates among 222 patients reached 71.2%. Subgroup analysis of 277 patients identified a 63.9% malignant transformation rate, and 39.6% of patients died of their disease. Age, sex, and tobacco use were not identified as risk factors associated with progression to cancer., Conclusions: Proliferative verrucous leukoplakia is a rare form of leukoplakia with a high rate of malignant transformation. It necessitates high clinical suspicion, to include a lifetime of close follow-up and repeat biopsies by a health care provider well versed in oral carcinoma., (© American Academy of Otolaryngology-Head and Neck Surgery Foundation 2015.)

Purpose: Positive margins dominate clinical outcomes after surgical resections in most solid cancer types, including head and neck squamous cell carcinoma. Unfortunately, surgeons remove cancer in the same manner they have for a century with complete dependence on subjective tissue changes to identify cancer in the operating room. To effect change, we hypothesize that EGFR can be targeted for safe and specific real-time localization of cancer., Experimental Design: A dose escalation study of cetuximab conjugated to IRDye800 was performed in patients (n = 12) undergoing surgical resection of squamous cell carcinoma arising in the head and neck. Safety and pharmacokinetic data were obtained out to 30 days after infusion. Multi-instrument fluorescence imaging was performed in the operating room and in surgical pathology., Results: There were no grade 2 or higher adverse events attributable to cetuximab-IRDye800. Fluorescence imaging with an intraoperative, wide-field device successfully differentiated tumor from normal tissue during resection with an average tumor-to-background ratio of 5.2 in the highest dose range. Optical imaging identified opportunity for more precise identification of tumor during the surgical procedure and during the pathologic analysis of tissues ex vivo. Fluorescence levels positively correlated with EGFR levels., Conclusions: We demonstrate for the first time that commercially available antibodies can be fluorescently labeled and safely administered to humans to identify cancer with sub-millimeter resolution, which has the potential to improve outcomes in clinical oncology., (©2015 American Association for Cancer Research.)