International experience with coronavirus 2019 (COVID-19) suggests it poses a significant risk of infectious transmission to skull base surgeons, due to high nasal viral titers and the unknown ...potential for aerosol generation during endonasal instrumentation. The purpose of this study was to simulate aerosolization events over a range of endoscopic procedures to obtain an evidence-based aerosol risk assessment.
Aerosolization was simulated in a cadaver using fluorescein solution (0.2 mg per 10 mL) and quantified using a blue-light filter and digital image processing. Outpatient sneezing during endoscopy was simulated using an intranasal atomizer in the presence or absence of intact and modified surgical mask barriers. Surgical aerosolization was simulated during nonpowered instrumentation, suction microdebrider, and high-speed drilling after nasal fluorescein application.
Among the outpatient conditions, a simulated sneeze event generated maximal aerosol distribution at 30 cm, extending to 66 cm. Both an intact surgical mask and a modified VENT mask (which enables endoscopy) eliminated all detectable aerosol spread. Among the surgical conditions, cold instrumentation and microdebrider use did not generate detectable aerosols. Conversely, use of a high-speed drill produced significant aerosol contamination in all conditions tested.
We confirm that aerosolization presents a risk to the endonasal skull base surgeon. In the outpatient setting, use of a barrier significantly reduces aerosol spread. Cold surgical instrumentation and microdebrider use pose significantly less aerosolization risk than a high-speed drill. Procedures requiring drill use should carry a special designation as an "aerosol-generating surgery" to convey this unique risk, and this supports the need for protective personal protective equipment.
Objective
In the era of SARS-CoV-2, the risk of infectious airborne aerosol generation during otolaryngologic procedures has been an area of increasing concern. The objective of this investigation ...was to quantify airborne aerosol production under clinical and surgical conditions and examine efficacy of mask mitigation strategies.
Study Design
Prospective quantification of airborne aerosol generation during surgical and clinical simulation.
Setting
Cadaver laboratory and clinical examination room.
Subjects and Methods
Airborne aerosol quantification with an optical particle sizer was performed in real time during cadaveric simulated endoscopic surgical conditions, including hand instrumentation, microdebrider use, high-speed drilling, and cautery. Aerosol sampling was additionally performed in simulated clinical and diagnostic settings. All clinical and surgical procedures were evaluated for propensity for significant airborne aerosol generation.
Results
Hand instrumentation and microdebridement did not produce detectable airborne aerosols in the range of 1 to 10 μm. Suction drilling at 12,000 rpm, high-speed drilling (4-mm diamond or cutting burs) at 70,000 rpm, and transnasal cautery generated significant airborne aerosols (P < .001). In clinical simulations, nasal endoscopy (P < .05), speech (P < .01), and sneezing (P < .01) generated 1- to 10-μm airborne aerosols. Significant aerosol escape was seen even with utilization of a standard surgical mask (P < .05). Intact and VENT-modified (valved endoscopy of the nose and throat) N95 respirator use prevented significant airborne aerosol spread.
Conclusion
Transnasal drill and cautery use is associated with significant airborne particulate matter production in the range of 1 to 10 μm under surgical conditions. During simulated clinical activity, airborne aerosol generation was seen during nasal endoscopy, speech, and sneezing. Intact or VENT-modified N95 respirators mitigated airborne aerosol transmission, while standard surgical masks did not.
The aim of this study was to evaluate sex differences in full professorship among a comprehensive, contemporary cohort of US academic surgeons.
Previous work demonstrates that women are less likely ...than men to be full professors in academic medicine, and in certain surgical subspecialties. Whether sex differences in academic rank exist across all surgical fields, and after adjustment for confounders, is not known.
A comprehensive list of surgeons with faculty appointments at US medical schools in 2014 was obtained from Association of American Medical Colleges (AAMC) faculty roster and linked to a comprehensive physician database from Doximity, an online physician networking website, which contained the following data for all physicians: sex, age, years since residency, publication number (total and first/last author), clinical trials participation, National Institutes of Health grants, and surgical subspecialty. A 20% sample of 2013 Medicare payments for care was added to this dataset. Multivariable regression models were used to estimate sex differences in full professorship, adjusting for these variables and medical school-specific fixed effects.
Among 11,549 surgeon faculty at US medical schools in 2014, 1692 (14.7%) were women. Women comprised 19.4% of assistant professors (1072/5538), 13.8% of associate professors (404/2931), and 7.0% of full professors (216/3080). After multivariable analysis, women were less likely to be full professors than men (adjusted odds ratio: 0.76, 95% confidence interval: 0.6-0.9).
Among surgical faculty at US medical schools in 2014, women were less likely than men to be full professors after adjustment for multiple factors known to impact faculty rank.
Competency-based surgical education requires practical assessments and meaningful benchmarks. In otolaryngology, key indicator procedure (KIP) minima are indicators of surgical exposure during ...training, yet it remains unknown how many times trainees must be evaluated on KIPs to ensure operative competence. Herein, we used Bayesian mixed effects models to compute predicted performance expectations for KIPs.
From November 2017 to September 2021, a smartphone application (SIMPL OR) was used by attendings at five otolaryngology training programs to rate resident operative performance after each case on a five-level scale. Bayesian mixed effects models were used to estimate the probability that postgraduate year (PGY) 3, 4, or 5 trainees would earn a "practice-ready" (PR) rating on a subsequent evaluation based on their previously earned PR ratings for each KIP. Probabilities of earning a subsequent PR rating were examined for interpretability, and cross-validation was used to assess predictive validity.
A total of 842 assessments of KIPs were submitted by 72 attendings for 92 residents PGY 2-5. The predictive model had an average Area Under the Receiver Operating Curve of 0.77. The number of prior PR ratings that senior residents needed to attain a 95% probability of earning a PR rating on a subsequent evaluation was estimated for each KIP. For example, for mastoidectomies, PGY4 residents needed to earn 10 PR ratings whereas PGY5 residents needed 4 PR ratings on average to have a 95% probability of attaining a PR rating on a subsequent evaluation.
Predictive modeling can inform assessment benchmarks for competency-based surgical education.
NA Laryngoscope, 133:3341-3345, 2023.
Objectives/Hypothesis
To determine trends in survival patterns for cranial chordoma in the United States.
Study Design
A cross‐sectional analysis of a national healthcare database.
Methods
All cases ...of microscopically confirmed cranial chordoma between 1973 and 2009 from the Surveillance, Epidemiology, and End Results (SEER) program of the National Cancer Institute were examined. Age‐adjusted incidence and survival rates were calculated and stratified by treatment. Additionally, in order to assess trends over time, comparisons in survival were conducted for 3 calendar year cohorts: 1975 to 1984, 1985 to 1994, and 1995 to 2004.
Results
A total of 594 cases of microscopically confirmed chordoma involving cranial sites were identified, which accounted for 42% of all chordomas. Age‐adjusted incidence rate (IR) of all chordomas was 0.089 per 100,000. Overall median survival time with surgery plus radiation was 9.2 years. Age and treatment modality were found to influence patient survival. Specifically, age > 50 years was associated with a significant increase in mortality rate (P < .05). Five‐year survival for the 1975 to 1984, 1985 to 1994, and 1995 to 2004 cohort was 48.5%, 73.0%, and 80.7%, respectively, with improved survival in the more recent cohorts (P < 0.01).
Conclusion
This study provides new data regarding survival patterns of cranial chordoma in the United States, with a trend toward improvement in survival in recent decades.
Level of Evidence
NA. Laryngoscope, 124:1097–1102, 2014
Objectives
The COVID‐19 pandemic affected the epidemiology of several diseases. This study aims to compare the incidence of surgically treated odontogenic sinusitis (ODS) before and during the ...COVID‐19 pandemic and identify unique features.
Methods
A retrospective chart review of patients who underwent at least maxillary antrostomy at a tertiary referral center was performed. The patients were divided into two cohorts: “pre‐COVID” (March 2018 to February 2020) and “COVID” (March 2020 to February 2022). Data on demographics, comorbidities, and treatment interventions were collected and analyzed.
Results
Of the 734 patients who underwent maxillary antrostomy, 370 (50.4%) were operated on during the COVID period, with a mean age of 53.1 ± 15.7 years. ODS was found as the etiology of 22 (6%) and 45 (12.2%) of the pre‐COVID and COVID cases, respectively (p = 0.006). Although no difference was found in the incidence of diabetes (p = 0.9) or obesity (p = 0.7) between groups, a trend toward higher incidence of immunosuppression was found in the pre‐COVID patients (18.2% vs. 0%, p = 0.06). A higher incidence of sphenoid sinus involvement (31.8% vs. 8.9%, p < 0.05) was identified in the pre‐COVID group; however, no differences in ethmoid (86.4% vs. 86.7%, p = 0.999) or frontal sinus involvement (54.5% vs. 37.8%, p = 0.3) were found between the groups.
Conclusion
There was an increase in the incidence of ODS during the first 2 years of the COVID‐19 pandemic compared to the 2 years prior. Similar clinical characteristics were found in both groups. Future studies focusing on specific etiologies to explain ODS preponderance may help determine optimal treatment and prevention strategies.
Level of Evidence
3 Laryngoscope, 134:1597–1602, 2024
In this study of 734 patients undergoing maxillary antrostomy at a single institution, odontogenic sinusitis (ODS) incidence was found to rise sharply after the onset of the pandemic. Additionally, the presentation of ODS during the COVID‐19 pandemic was found to be more advanced.
Objectives/Hypothesis
To determine the association between the frequency of acute chronic rhinosinusitis (CRS) exacerbations (AECRS) and the degree of asthma control in asthmatic CRS patients.
Study ...Design
Cross‐sectional study.
Methods
We prospectively recruited 108 asthmatic CRS patients as participants. Asthma control was assessed using the Asthma Control Test (ACT). The frequency of AECRS was assessed using three previously described indirect metrics for AECRS: the frequency of patient‐reported sinus infections, CRS‐related antibiotics use, and CRS‐related oral corticosteroids use in the last 3 months. CRS symptom severity was measured using the 22‐item Sinonasal Outcome Test (SNOT‐22). Associations between ACT score and metrics for AECRS were performed using linear regression while controlling for clinical and demographic characteristics, including SNOT‐22 score.
Results
ACT score was significantly and negatively associated with the frequency of patient‐reported sinus infections (adjusted linear regression coefficient β = −1.2, 95% confidence interval CI: −2.3 to −0.1, P = .033), CRS‐related antibiotics courses (adjusted β = −1.4, 95% CI: −2.3 to −0.5, P = .004), and CRS‐related oral corticosteroid courses (adjusted β = −1.5, 95% CI: −2.5 to −0.5, P = .004) in the last 3 months, independent of characteristics including SNOT‐22 score. Poor asthma control could be detected using one or more sinus infections (70.6% sensitivity, 47.3% specificity), CRS‐related antibiotics (50.0% sensitivity, 73.0% specificity), or CRS‐related oral corticosteroids (58.8% sensitivity, 71.6% specificity) in the last 3 months.
Conclusions
AECRS are negatively associated with the level of asthma control in asthmatic CRS patients, independent of CRS symptom severity. These results highlight AECRS as a distinct clinical manifestation of CRS that should be routinely assessed in CRS patients.
Level of Evidence
2c. Laryngoscope, 128:1033–1038, 2018
Objective
Primary chronic rhinosinusitis (CRS) is typically a diffuse process and the extent of endoscopic sinus surgery (ESS) performed for medically recalcitrant CRS is impacted by many factors. ...However, some third‐party payors have implemented policies to authorize coverage for ESS in a sinus‐by‐sinus manner based on a minimal measurement of millimeters of mucosal thickening or sinus opacification in the corresponding sinus that is being surgically addressed. Our objective was to determine whether such policies are based on scientific evidence that in patients with medically recalcitrant CRS, a minimum measurement of mucosal thickening or sinus opacification is a predictor of CRS in that sinus or improved outcomes after ESS on a sinus‐by‐sinus basis.
Data Sources
Medline, Embase, Scopus, and Web of Science databases, from inception through May 2022.
Review Methods
A systematic review was performed. The Preferred Reporting Items for Systematic Reviews and Meta‐Analysis (PRISMA) guidelines were followed.
Results
We identified 6070 s which were screened and from which 112 studies ultimately underwent a full‐text review. From these studies, we found that none investigated (or provided evidence of) whether any minimal degree of radiographic mucosal thickening or sinus opacification predicted CRS or better outcomes after ESS in a sinus‐specific manner.
Conclusion
We were unable to find evidence supporting a minimum millimeter measurement of mucosal thickening or sinus opacification as predictors of CRS or better post‐ESS outcomes in a sinus‐specific manner in patients with medically recalcitrant CRS. The extent of ESS for CRS should be determined through personalized medical decision‐making that considers all patient‐specific factors.
PDF
