Publications by authors named "Brian D Thorp"

52 Publications

Predictors of otolaryngology applicant success using the Texas STAR database.

Laryngoscope Investig Otolaryngol 2021 Apr 10;6(2):188-194. Epub 2021 Mar 10.

Department of Otolaryngology/Head and Neck Surgery University of North Carolina School of Medicine Chapel Hill North Carolina USA.

Objectives: To examine applicant characteristics and behaviors associated with a successful match into otolaryngology residency.

Methods: Self-reported survey data from applicants to otolaryngology residency between 2018 and 2020 were obtained from the Texas STAR database. Characteristics and predictors associated with a successful match were examined using Chi-square tests, two-sided t-tests, and logistic regression models.

Results: A total of 315 otolaryngology residency applicants responded to the survey of whom 274 matched (87%) and 41 did not match (13%). Matched applicants had a significantly higher mean USMLE Step 1 score ( = .016) and Step 2 CK score ( = .007). There were no significant differences in AOA status (45% vs 36%; = .207), mean number of applications submitted (70 vs 69; = .544), and mean number of away rotations (2.1 vs 2.0; = .687) between matched and unmatched applicants. Significant predictors of a successful match included receiving honors in 5 or more clerkships (OR 2.0, 95% CI 1.0-4.0; = .040), receiving honors in an ENT clerkship (OR 3.7, 95% CI 1.0-12.9; = .044), and having 3 or more peer-reviewed publications (OR 2.3, 95% CI 1.1-4.5; = .020). The majority of applicants (79.9%) matched at a program where they either did an away rotation, had a personal geographic connection, or attended medical school in the same geographic region.

Conclusions: Board scores, excelling on clinical rotations, and having productive research experience appear to be strong predictors of a successful match in otolaryngology. The majority of applicants report a personal or geographic connection to the program at which they match.

Level Of Evidence: 4.
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http://dx.doi.org/10.1002/lio2.549DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8035942PMC
April 2021

Prolonged Implantation of Sinus Devices and Implications for Chronic Rhinosinusitis: A Case Report and Review of the Literature.

Surg Case Rep (Tallinn) 2020 Apr 28;3(4). Epub 2020 Apr 28.

Department of Otolaryngology/Head and Neck Surgery, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, United States.

Background: Implantation of sinus stents and spacers can be used as adjuvant management to maintain patency of sinuses after endoscopic sinus surgery for chronic rhinosinusitis. These implants are typically removed several weeks after surgery. We present two cases of different patients who were initially treated by different physicians and were found to have retained sinus spacers in their paranasal sinuses 6-10 years after implantation.

Case Presentation: Case 1: a 40-year old male with chronic rhinosinusitis and history of balloon sinuplasty six years prior presented with worsening symptoms of chronic rhinosinusitis refractory to medical management. He underwent revision functional endoscopic sinus surgery and was found to have retained sinus implants in the left and right frontal sinus recesses. Case 2: a 48-year-old female with long-standing chronic rhinosinusitis refractory to medical management presented after two prior sinus surgeries most recently 10 years ago. She underwent revision functional endoscopic surgery and was found to have a retained sinus implant from prior surgery in the right frontal recess outflow tract embedded within scar tissue and reactive hyperostosis. Foreign bodies from both patients were removed without complication and patients were healing appropriately in the post-operative period.

Conclusions: While sinus stents and spacers can help with post-operative scarring, leaving then unmonitored and in place will eventually result in them becoming a nidus for scarring and infection. It is critical that patients are aware of any foreign bodies we place, if they need scheduled removal or routine observation, and what symptoms may indicate that they are causing a problem.
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http://dx.doi.org/10.31487/j.scr.2020.04.10DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7771652PMC
April 2020

Quantification of Aerosol Concentrations During Endonasal Instrumentation in the Clinic Setting.

Laryngoscope 2021 05 5;131(5):E1415-E1421. Epub 2020 Oct 5.

Department of Otolaryngology/Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, U.S.A.

Objective: Recent anecdotal reports and cadaveric simulations have described aerosol generation during endonasal instrumentation, highlighting a possible risk for transmission of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) during endoscopic endonasal instrumentation. This study aims to provide a greater understanding of particle generation and exposure risk during endoscopic endonasal instrumentation.

Study Design: Prospective quantification of aerosol generation during office-based nasal endoscopy procedures.

Methods: Using an optical particle sizer, airborne particles concentrations 0.3 to 10 microns in diameter, were measured during 30 nasal endoscopies in the clinic setting. Measurements were taken at time points throughout diagnostic and debridement endoscopies and compared to preprocedure and empty room particle concentrations.

Results: No significant change in airborne particle concentrations was measured during diagnostic nasal endoscopies in patients without the need for debridement. However, significant increases in mean particle concentration compared to preprocedure levels were measured during cold instrumentation at 2,462 particles/foot (95% CI 837 to 4,088; P = .005) and during suction use at 2,973 particle/foot (95% CI 1,419 to 4,529; P = .001). In total, 99.2% of all measured particles were ≤1 μm in diameter.

Conclusion: When measured with an optical particle sizer, diagnostic nasal endoscopy with a rigid endoscope is not associated with increased particle aerosolization in patient for whom sinonasal debridement is not needed. In patients needing sinonasal debridement, endonasal cold and suction instrumentation were associated with increased particle aerosolization, with a trend observed during endoscope use prior to tissue manipulation. Endonasal debridement may potentially pose a higher risk for aerosolization and SARS-CoV-2 transmission. Appropriate personal protective equipment use and patient screening are recommended for all office-based endonasal procedures.

Level Of Evidence: 3 Laryngoscope, 131:E1415-E1421, 2021.
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http://dx.doi.org/10.1002/lary.29122DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7675733PMC
May 2021

Quantification of Aerosol Particle Concentrations During Endoscopic Sinonasal Surgery in the Operating Room.

Am J Rhinol Allergy 2020 Oct 4:1945892420962335. Epub 2020 Oct 4.

Department of Otolaryngology/Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.

Background: Recent indirect evidence of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) transmission during endoscopic endonasal procedures has highlighted the dearth of knowledge surrounding aerosol generation with these procedures. As we adapt to function in the era of Coronavirus Disease 2019 (COVID-19) a better understanding of how surgical techniques generate potentially infectious aerosolized particles will enhance the safety of operating room (OR) staff and learners.

Objective: To provide greater understanding of possible SARS-CoV-2 exposure risk during endonasal surgeries by quantifying increases in airborne particle concentrations during endoscopic sinonasal surgery.

Methods: Aerosol concentrations were measured during live-patient endoscopic endonasal surgeries in ORs with an optical particle sizer. Measurements were taken throughout the procedure at six time points: 1) before patient entered the OR, 2) before pre-incision timeout during OR setup, 3) during cold instrumentation with suction, 4) during microdebrider use, 5) during drill use and, 6) at the end of the case prior to extubation. Measurements were taken at three different OR position: surgeon, circulating nurse, and anesthesia provider.

Results: Significant increases in airborne particle concentration were measured at the surgeon position with both the microdebrider (p = 0.001) and drill (p = 0.001), but not for cold instrumentation with suction (p = 0.340). Particle concentration did not significantly increase at the anesthesia position or the circulator position with any form of instrumentation. Overall, the surgeon position had a mean increase in particle concentration of 2445 particles/ft3 (95% CI 881 to 3955; p = 0.001) during drill use and 1825 particles/ft3 (95% CI 641 to 3009; p = 0.001) during microdebrider use.

Conclusion: Drilling and microdebrider use during endonasal surgery in a standard operating room is associated with a significant increase in airborne particle concentrations. Fortunately, this increase in aerosol concentration is localized to the area of the operating surgeon, with no detectable increase in aerosol particles at other OR positions.
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http://dx.doi.org/10.1177/1945892420962335DOI Listing
October 2020

A Comparison of Sphenoid Sinus Osteoneogenesis in Aspirin-Exacerbated Respiratory Disease.

Am J Rhinol Allergy 2021 Mar 13;35(2):172-178. Epub 2020 Jul 13.

Department of Otolaryngology-Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.

Background: Aspirin-exacerbated respiratory disease (AERD) is characterized by excessive leukotriene production, diffuse polyp burden and osteitic bone changes. These bony changes have not been previously characterized.

Objective: The aim of this radiographic study is to characterize the bony changes noted on computed tomography (CT) scans of the sphenoid sinus in patients with AERD compared to other diseased sinonasal inflammatory states and non-diseased controls.

Methods: A retrospective review of 43 patients with clinically confirmed AERD were included and compared to 22 non-diseased, 9 allergic fungal sinusitis, and 43 chronic rhinosinusitis controls (23 without polyps and 18 with polyps). Comparative measurements were performed using fine-cut CT scans. Sites of comparison were the intersinus septum, the left and right lateral sphenoid wall, the roof, and left and right floor of the sphenoid sinus. Standardized measurements were averaged by two separate rhinologists.

Results: Patients with AERD had an average statistically significant increase in bone thickness compared to healthy and diseased controls in nearly every site with the most pronounced changes in the intersinus septum (p < 0.05).

Conclusion: Patients with AERD have significantly increased thickness of the sphenoid bone compared to control groups with the most pronounced difference in the intersinus septum. These findings may help clinicians increase suspicion for a diagnosis of AERD who clinically have diffuse nasal polyposis.
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http://dx.doi.org/10.1177/1945892420941732DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7874380PMC
March 2021

Radiologic Analysis of Balloon Sinuplasty in a Human Cadaver Model: Observed Effects on Sinonasal Anatomy.

Am J Rhinol Allergy 2021 Jan 7;35(1):107-113. Epub 2020 Jul 7.

Department of Otolaryngology-Head and Neck Surgery, University of North Carolina Chapel Hill, Chapel Hill, North Carolina.

Background: Balloon sinuplasty is increasingly used in the outpatient clinic for treatment of chronic rhinosinusitis, but radiologic analysis of its effects on sinonasal anatomy is largely uncharacterized in the known literature.

Objective: The purpose of this study is to examine the anatomic effects of balloon sinuplasty in a cadaveric model.

Methods: Five fresh cadaver heads underwent sequential endoscopic balloon dilation of maxillary ostia, frontal recess outflow tracts, and sphenoid ostia bilaterally by fellowship-trained rhinologists. Pre- and post-procedural CT imaging was obtained. CT scans were imported into Mimics™ software and sinonasal anatomy was analyzed systematically.

Results: Visual confirmation of balloon dilation was achieved in all 3 sites bilaterally in each cadaver. Radiologic analysis demonstrated that the frontal sinus outflow tract was appropriately dilated 60% (6/10 sites) of the time while the agger was inadvertently dilated 30% of the time (3/10). The sphenoid os was successfully dilated 70% (7/10 sites) of the time. In two cases, a posterior sphenoethmoid (Onodi) cell was dilated instead of the sphenoid. Successful dilation of maxillary os was noted 60% of the time (6/10 sites). No significant change in maxillary os was noted after balloon dilation. Normal middle turbinates were significantly medialized following balloon dilation 75% (6/8 sites) of the time.

Conclusions: While the goal of balloon sinuplasty is to improve natural sinonasal drainage by dilating existing outflow tracts, as evidenced by radiologic evaluation the procedure appears not to achieve this in all cases, while occasionally creating unintended changes in sinonasal anatomy as well. These unrecognized changes in anatomy may be responsible for the post-procedure change in symptomatology that some patients experience.
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http://dx.doi.org/10.1177/1945892420939430DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7874344PMC
January 2021

Numerical evaluation of spray position for improved nasal drug delivery.

Sci Rep 2020 06 29;10(1):10568. Epub 2020 Jun 29.

Department of Otolaryngology/Head and Neck Surgery, School of Medicine - University of North Carolina, Chapel Hill, NC, 27599, United States.

Topical intra-nasal sprays are amongst the most commonly prescribed therapeutic options for sinonasal diseases in humans. However, inconsistency and ambiguity in instructions show a lack of definitive knowledge on best spray use techniques. In this study, we have identified a new usage strategy for nasal sprays available over-the-counter, that registers an average 8-fold improvement in topical delivery of drugs at diseased sites, when compared to prevalent spray techniques. The protocol involves re-orienting the spray axis to harness inertial motion of particulates and has been developed using computational fluid dynamics simulations of respiratory airflow and droplet transport in medical imaging-based digital models. Simulated dose in representative models is validated through in vitro spray measurements in 3D-printed anatomic replicas using the gamma scintigraphy technique. This work breaks new ground in proposing an alternative user-friendly strategy that can significantly enhance topical delivery inside human nose. While these findings can eventually translate into personalized spray usage instructions and hence merit a change in nasal standard-of-care, this study also demonstrates how relatively simple engineering analysis tools can revolutionize everyday healthcare. Finally, with respiratory mucosa as the initial coronavirus infection site, our findings are relevant to intra-nasal vaccines that are in-development, to mitigate the COVID-19 pandemic.
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http://dx.doi.org/10.1038/s41598-020-66716-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7324389PMC
June 2020

Sinus Development and Pneumatization in a Primary Ciliary Dyskinesia Cohort.

Am J Rhinol Allergy 2021 Jan 19;35(1):72-76. Epub 2020 Jun 19.

Department of Otolaryngology-Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.

Background: Primary ciliary dyskinesia (PCD) is a genetically diverse disease which causes impaired mucociliary clearance, and results in pulmonary, otologic, and rhinologic disease in affected patients. Genetic mutations in multiple genes impair the ability of patients to clear mucous from the lungs, middle ear, and sinonasal cavity and lead to chronic pulmonary and sinonasal symptoms.

Methods: We identified 17 PCD patients who had available CT scans. Volumes for bilateral maxillary, sphenoid, and frontal sinuses were calculated. A control population of patients who had preoperative CT scans for endoscopic endonasal resection of skull base pathology without sinonasal cavity involvement was also identified.

Results: The mean age of PCD was 33 and ranged from 13 to 54 years. Patients were age- and gender-matched to a control group that underwent resection of anterior skull-base tumors and had a mean age of 35 that ranged between 17-53 years old. The volumes for all thee sinus cavities were significantly smaller (p < 0.007) compared to the control population. The average Lund-Mackay score was 10.6 in the PCD cohort (range 6-16) in comparison to an average of 0.7 in the control cohort (range 0-2).

Conclusions: Overall sinus volumes were smaller in patients with PCD compared to our control population. Future studies will be aimed at understanding defects in sinus development as a function of specific genetic mutations in PCD patients. Ultimately, a better understanding of the underlying pathophysiology of PCD will allow us to identify the optimal treatment practices for this unique patient group.
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http://dx.doi.org/10.1177/1945892420933175DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7750665PMC
January 2021

Extramedullary Hematopoiesis in the Sinonasal Cavity: A Case Report and Review of the Literature.

Allergy Rhinol (Providence) 2020 Jan-Dec;11:2152656720918874. Epub 2020 Apr 21.

Department of Otolaryngology-Head and Neck Surgery, University of North Carolina, Chapel Hill, North Carolina.

Background: Extramedullary hematopoiesis (EMH) occurs in patients with hematologic disorders, but rarely within the paranasal sinuses. We report a case of EMH in a 17-year-old male with sickle cell disease (SCD) who presented with occipital pain and sinusitis. A computed tomography (CT) scan demonstrated heterogeneous opacification of the right maxillary sinus concerning for allergic fungal sinusitis or a fungal ball with bony erosion. He was taken to the operating room for endoscopic biopsy and a limited endoscopic sinus surgery. Grossly, his maxillary sinus was filled with spiculated osseous tissue. Final pathology demonstrated active hematopoietic bone marrow filling the sinus.

Methods: We present a case report and literature review of sinonasal EMH.

Results: We identified 14 articles with 15 patients. EMH was typically associated with SCD or beta thalassemia. The average age of presentation was 30. There was a male sex predilection with a ratio of 11:15. The most common presenting symptom was a headache and nasal obstruction (33% for both). The most common finding on CT was a soft tissue expansile mass (73%). The most commonly affected location was the maxillary sinus (60%).

Conclusions: This case report serves as a reminder to consider EMH as an uncommon cause of sinus opacification, particularly in patients with SCD or beta thalassemia. The expansion of hematopoietic tissue may be identified as a sinus mass on CT. By recognizing the potential manifestations of chronic anemia, an accurate and timely diagnosis can be made.
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http://dx.doi.org/10.1177/2152656720918874DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7177988PMC
April 2020

Understood? Evaluating the readability and understandability of intranasal corticosteroid delivery instructions.

Int Forum Allergy Rhinol 2020 06 13;10(6):773-778. Epub 2020 Apr 13.

Department of Otolaryngology/Head and Neck Surgery, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC.

Background: Allergic rhinitis is a widespread disease that has significant quality-of-life ramifications. Symptoms include rhinorrhea, nasal obstruction, cough, and postnasal drip. Intranasal corticosteroids are a hallmark of treatment of allergic rhinitis. However, the benefits of treatment are dependent on correct nasal spray technique, of which many patients are not aware. Patient instructions are included with the purchase of these medications. The readability and understandability for these educational materials has been minimally assessed in the medical literature. The aim of this study was to evaluate the readability and understandability of commonly used intranasal steroids.

Methods: Three readability measures (Gunning Fog, Simple Measure of Gobbledygook [SMOG], and FORCAST) and an understandability assessment (Patient Education Materials Assessment Tool for Printable Materials [PEMAT-P]) were used to evaluate the instructions for use of commonly prescribed intranasal steroids. Instructions with 6th grade readability level or lower were considered to meet health literacy experts' recommendations. Higher understandability values correlate to easier understandability.

Results: Instructions for 10 intranasal corticosteroid brands were reviewed. Gunning Fog consistently estimated easiest readability, whereas FORCAST estimated most difficult readability. Twenty percent (20%) of analyzed instructions met National Institutes of Health and health literacy experts' recommended reading levels. Understandability of instructions ranged from 33% to 90%, with an average of 66%.

Conclusion: The benefit of intranasal corticosteroids is contingent on correct use by patients. However, the prepackaged instructions provided are most often above recommended reading levels and are difficult to understand. Future development of intranasal steroid instructions should meet recommended readability levels and be understandable to maximize their utility.
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http://dx.doi.org/10.1002/alr.22550DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7266716PMC
June 2020

Repair of Septal Perforation with Endoscopic-Assisted Pericranial Flap Harvest and Open Rhinoplasty Approach.

Facial Plast Surg Aesthet Med 2020 May/Jun;22(3):225-226. Epub 2020 Mar 26.

Department of Otolaryngology-Head and Neck Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.

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http://dx.doi.org/10.1089/fpsam.2020.0008DOI Listing
November 2020

Cystic Fibrosis Transmembrane Conductance Regulator Modulator Therapy: A Review for the Otolaryngologist.

Am J Rhinol Allergy 2020 Jul 13;34(4):573-580. Epub 2020 Mar 13.

Department of Otolaryngology/Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.

Background: Cystic fibrosis (CF) is a genetic disease that may result in multiple systemic disorders and potentially fatal severe respiratory compromise. However, the advent of CF transmembrane conductance regulator (CFTR) modulators has changed the management of CF for patients with select mutations. Although clinical trials have highlighted increased pulmonary function and decreased exacerbations as a result of these novel therapies, their effect on the sinuses has not been well-described.

Objective: Our objective is to review the CFTR modulators to provide otolaryngologists, physicians who frequently care for patients with CF, a basic understanding of these drugs and their effects on chronic rhinosinusitis (CRS) in patients with CF.

Methods: The clinically approved and available CFTR modulators and specific indications for their use are reviewed. Additionally, a systematic review of these therapies and effects on CRS in CF was performed.

Results: Four Food and Drug Administration approved CFTR modulators are available for patients with CF. Current drugs are approved for gating, residual function, or F508del mutations. Multiple reports describe CFTR modulators' increase in transepithelial ion transport in nasal epithelial cultures; however, clinical studies regarding effects of these modulators on sinonasal health are limited to 5 studies that present new data of the effects of CFTR modulators in CRS.

Conclusions: CFTR modulators have changed management of CF. Initial studies of these medications demonstrate promising results in CF; however, there is a paucity of literature describing the effect of CFTR modulators on CF-associated CRS, although initial results are encouraging.
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http://dx.doi.org/10.1177/1945892420912368DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7573678PMC
July 2020

Streamlining care in cystic fibrosis: survey of otolaryngologist, pulmonologist, and patient experiences.

Int Forum Allergy Rhinol 2020 05 17;10(5):591-603. Epub 2020 Jan 17.

Department of Otolaryngology/Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC.

Background: Care coordination for cystic fibrosis (CF) is essential. The objectives of this study were to: (1) compare otolaryngologists' and pulmonlogists' understanding of long-term chronic rhinosinusitis (CRS) management; and (2) query patient perceptions of otolaryngologic care and CRS.

Methods: A cross-sectional survey was administered by the Cystic Fibrosis Foundation in 2018 to patients with CF or their caregivers, otolaryngologists, and pulmonologists. Statistical analysis was performed comparing specialists. Descriptive statistics were computed for patient/caregiver-reported data.

Results: Respondents included 126 otolaryngologists, 115 pulmonologists, and 186 patients with CF or their caregivers. Pulmonologists had greater experience caring for CF patients compared with otolaryngologists (66.7% vs 43.2% with 13 years of experience, respectively), but more otolaryngologists cared for both adult and pediatric CF patients (39.2% vs 10.4%, respectively). Significantly more otolaryngologists advocated for establishing otolaryngologic care at time of CF diagnosis (64.8%) compared with pulmonologists (14.4%, p < 0.001), of whom 60.4% recommended otolaryngologist referral when sinonasal symptoms affect quality of life. More otolaryngologists perceived sinus surgery as beneficial for pulmonary function (74.5% vs 57.7%, p = 0.009); 60.8% of patients first sought otolaryngologic care in infancy or childhood (<13 years). Median number of sinus surgeries was 3 (interquartile range, 2-5). The most common perceived benefits of surgery according to patients/caregivers included improved breathing (31.2%) and improved sinonasal symptoms (23.7%). Top patients/caregiver otolaryngologic priorities included symptom/infection control (49.0%) and care coordination (15.0%).

Conclusion: Our results highlight variable patient/caregiver experiences, and suggest that otolaryngologist and pulmonologist perceptions of CF otolaryngologic care also differ in some respects requiring improved interspecialty coordination/education.
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http://dx.doi.org/10.1002/alr.22522DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7278084PMC
May 2020

Nasopharyngeal Hyalinizing Clear Cell Carcinoma: A Case Report and Review of the Literature.

Allergy Rhinol (Providence) 2019 Jan-Dec;10:2152656719889030. Epub 2019 Nov 20.

Department of Otolaryngology-Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.

Background: Hyalinizing clear cell carcinomas (HCCCs) are rare, low-grade, malignant tumors which most often arise from the minor salivary glands primarily in palate and tongue but can arise in any location with minor salivary glands including the nasopharynx.

Methods: A case report of primary nasopharyngeal HCCC is presented. Because of the rarity of this tumor and location, a literature search was conducted to determine the most common presenting symptoms, treatment strategies, and outcomes.

Results: A 48-year-old man underwent biopsy of a 4.5 cm mass of the right nasopharynx with pathology suggesting an intermediate grade mucoepidermoid carcinoma. After discussing management with the patient, an endoscopic resection was performed. Final pathology revealed an HCCC which was confirmed after negative Mastermind-like 2 (MAML2) and positive Ewing sarcoma breakpoint region 1 (ESWR1) gene rearrangements on fluorescence in situ hybridization (FISH) studies. Literature review of other nasopharyngeal HCCC cases shows diverse presentation and overall excellent prognosis through surgical and radiation therapy.

Conclusion: HCCCs are rare, low-grade malignant tumors of the minor salivary glands and can present as a nasopharyngeal mass. Presenting symptoms are diverse but frequently involve otologic and sinonasal disturbances. HCCC is an indolent tumor with an excellent prognostic outcome when treated appropriately with surgical resection and adjuvant radiotherapy.
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http://dx.doi.org/10.1177/2152656719889030DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6883668PMC
November 2019

A Novel Porcine Model for the Study of Cerebrospinal Fluid Dynamics: Development and Preliminary Results.

Front Neurol 2019 23;10:1137. Epub 2019 Oct 23.

Department of Radiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States.

Idiopathic intracranial hypertension, space-flight associated neuro-ocular syndrome (SANS), and glaucoma are conditions that are among a spectrum of cerebrospinal fluid (CSF)-related ophthalmologic disease. This implies that local CSF pressures at the level of the optic nerve are involved to variable extent in these disease processes. However, CSF pressure measurements are problematic due to invasiveness and interpretation. The pressure measured by a lumbar puncture is likely not the same as the orbital CSF pressure. It is believed this is at least in part due to the flow restrictive properties of the optic canal. To investigate CSF flow within the orbit, a model for CSF dynamics was created using three medium-sized pigs. Contrast was administered through a lumbar subarachnoid space access. The contrast front was imaged with repeated computed tomographic (CT) imaging. Once contrast entered the orbit, rapid, sequential CT imaging was performed until the contrast reached the posterior globe. Head tilting was performed to highlight the role of gravitational dependence within the subarachnoid space.
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http://dx.doi.org/10.3389/fneur.2019.01137DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6819502PMC
October 2019

Mometasone absorption in cultured airway epithelium.

Int Forum Allergy Rhinol 2019 12 21;9(12):1451-1455. Epub 2019 Oct 21.

Marsico Lung Institute, University of North Carolina at Chapel Hill, Chapel Hill, NC.

Background: Topical mometasone is frequently used as an intranasal spray, on drug-eluting stents, and compounded by specialty pharmacies as a sinus rinse. A typical sinus rinse contains 1.2 mg of mometasone dissolved in 240 mL of buffered saline and is flushed through the sinonasal cavity. The mometasone irrigation rapidly flows to the contralateral sinonasal cavity or the nasopharynx with a contact time on the order of 5 to 10 seconds. However, no information is available on the absorption rate of topical mometasone on the sinonasal surface.

Methods: To determine the absorption characteristics of mometasone, we harvested nasal epithelium from 2 healthy donors and differentiated them into a mature ciliated epithelium on Millicell membranes. We applied mometasone to the apical surface for various time intervals and then rinsed off non-absorbed mometasone with phosphate-buffered saline. Millicell membranes with the adherent epithelial cells were then harvested and stored in guanidine hydrochloride for quantification using high-performance liquid chromatography-mass spectrometry.

Results: Fifty percent of the maximal absorption occurred after an average of 38 minutes after application, and maximal absorption occurred after an average of 114 minutes.

Conclusion: Our data provide an estimate for rates of absorption of mometasone applied to the sinonasal cavity and suggest that the absorption rates poorly match contact time during saline lavage.
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http://dx.doi.org/10.1002/alr.22441DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6927533PMC
December 2019

Readability of patient-reported outcome measures for chronic rhinosinusitis and skull base diseases.

Laryngoscope 2020 10 11;130(10):2305-2310. Epub 2019 Oct 11.

Department of Otolaryngology/Head and Neck Surgery, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, U.S.A.

Objective: Outcome measures in healthcare that presume a higher level of patient health and overall literacy may inadequately estimate the disease experiences of less-educated patients and further disadvantage them. Patient-Reported Outcome Measures (PROMs) are widely used communication tools for clinical practice and are often used to evaluate and guide management for chronic rhinosinusitis (CRS) and skull base diseases. However, their readability and subsequent incomprehensibility for patients have not been assessed. The aim of this study is to evaluate the readability of commonly used PROMs for these conditions and whether they meet recommended readability levels.

Methods: Three readability measures, Gunning Fog, Simple Measure of Gobbledygook (SMOG), and FORCAST were used in the evaluation of commonly used PROMs for CRS and skull base disease. PROMs with sixth-grade readability level or lower were considered to meet health literacy experts' recommendations.

Results: A total of 11 PROMs were reviewed (8 CRS, 3 skull base). Gunning Fog consistently estimated the easiest readability, whereas FORCAST the most difficult. One hundred percent of CRS and 67% of skull base PROMs were above National Institutes of Health and health literacy experts' recommended reading levels. PROMs developed more recently had easier readability.

Conclusion: PROMs are important clinical tools in otolaryngology that help guide management of disease for improved patient-centered care. Like many other fields of medicine, those used in otolaryngology are beyond recommended reading levels. Development of PROMs in the future should meet recommended readability levels to fully assess the disease experience of our patients.

Level Of Evidence: 4 Laryngoscope, 130:2305-2310, 2020.
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http://dx.doi.org/10.1002/lary.28330DOI Listing
October 2020

Effect of Zileuton Treatment on Sinonasal Quality of Life in Patients with Aspirin-Exacerbated Respiratory Disease.

Am J Rhinol Allergy 2019 Nov 4;33(6):791-795. Epub 2019 Sep 4.

Department of Otolaryngology/Head and Neck Surgery, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina.

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http://dx.doi.org/10.1177/1945892419873211DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6843740PMC
November 2019

Identifying the Critical Factors Governing Translaminar Pressure Differential Through a Compartmental Model.

Invest Ophthalmol Vis Sci 2019 07;60(8):3204-3214

North Carolina State University, Raleigh, North Carolina, United States.

Purpose: The effective management of glaucoma is hindered by an incomplete understanding of its pathologic mechanism. While important, intraocular pressure (IOP) alone is inadequate in explaining glaucoma. Non-IOP-mediated risk factors such as cerebrospinal fluid (CSF) pressure have been reported to contribute to glaucomatous optic neuropathy. Due to the difficulty associated with experimental measurement of the salient variables, such as the retrobulbar CSF pressure, porosity of the subarachnoid space (SAS), and especially those concerned with the perioptic SAS, there remains a limited understanding of the CSF behavior contributing to the translaminar pressure gradient (TLPG), hypothesized to be a critical factor in the development of glaucoma.

Method: An integrated compartmental model describing the intracranial and orbital CSF dynamics, coupled with intraocular dynamics, is developed based on first principles of fluid mechanics. A sensitivity analysis is performed to identify anatomic characteristics that significantly affect the retrobulbar subarachnoid space (RSAS) pressure and, consequently, the TLPG.

Results: Of the 28 parameters considered, the RSAS pressure is most sensitive to CSF flow resistance in the optic nerve SAS and the potential lymphatic outflow from the optic nerve SAS into the orbital space. A parametric study demonstrates that a combination of resistance in the range of 1.600 × 1012 - 1.930 × 1012 Pa s/m3 (200.0 - 241.3 mm Hg min/mL) with 5% to 10% lymphatic CSF outflow yields RSAS pressures that are consistent with the limited number of studies in the literature.

Conclusions: The results suggest that a small percentage of lymphatic CSF outflow through the optic nerve SAS is likely. In addition, flow resistance in the orbital CSF space, hypothesized to be a function of patient-specific optic nerve SAS architecture and optic canal geometry, is a critical parameter in regulating the RSAS pressure and TLPG.
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http://dx.doi.org/10.1167/iovs.18-26200DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6657705PMC
July 2019

ICAR: endoscopic skull-base surgery.

Int Forum Allergy Rhinol 2019 07;9(S3):S145-S365

University of Pittsburgh, Pittsburgh, PA.

Background: Endoscopic skull-base surgery (ESBS) is employed in the management of diverse skull-base pathologies. Paralleling the increased utilization of ESBS, the literature in this field has expanded rapidly. However, the rarity of these diseases, the inherent challenges of surgical studies, and the continued learning curve in ESBS have resulted in significant variability in the quality of the literature. To consolidate and critically appraise the available literature, experts in skull-base surgery have produced the International Consensus Statement on Endoscopic Skull-Base Surgery (ICAR:ESBS).

Methods: Using previously described methodology, topics spanning the breadth of ESBS were identified and assigned a literature review, evidence-based review or evidence-based review with recommendations format. Subsequently, each topic was written and then reviewed by skull-base surgeons in both neurosurgery and otolaryngology. Following this iterative review process, the ICAR:ESBS document was synthesized and reviewed by all authors for consensus.

Results: The ICAR:ESBS document addresses the role of ESBS in primary cerebrospinal fluid (CSF) rhinorrhea, intradural tumors, benign skull-base and orbital pathology, sinonasal malignancies, and clival lesions. Additionally, specific challenges in ESBS including endoscopic reconstruction and complication management were evaluated.

Conclusion: A critical review of the literature in ESBS demonstrates at least the equivalency of ESBS with alternative approaches in pathologies such as CSF rhinorrhea and pituitary adenoma as well as improved reconstructive techniques in reducing CSF leaks. Evidence-based recommendations are limited in other pathologies and these significant knowledge gaps call upon the skull-base community to embrace these opportunities and collaboratively address these shortcomings.
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http://dx.doi.org/10.1002/alr.22326DOI Listing
July 2019

Blinded Evaluation of Endoscopic Skill and Instructability After Implementation of an Endoscopic Simulation Experience.

Am J Rhinol Allergy 2019 Nov 4;33(6):681-690. Epub 2019 Jul 4.

Department of Otolaryngology-Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.

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http://dx.doi.org/10.1177/1945892419860973DOI Listing
November 2019

Intraorbital Dermoid Cyst With Zygomaticofrontal Suture Erosion in an Adult.

J Craniofac Surg 2019 Mar/Apr;30(2):514-515

Department of Otolaryngology-Head and Neck Surgery, University of North Carolina, Chapel Hill, NC.

Background: Dermoid cysts are squamous epithelium-lined sacs that result from abnormal migration of ectodermal cells. They are typically superficial and present in children. This study reviews a rare patient with a congenital dermoid cyst occurring as a superolateral intraorbital and extraconal mas.

Method: Clinical report and review of the literature.

Results: A 27-year-old male presented with progressive left hypoglobus, proptosis, and diplopia. On computed tomography, a 2.0 × 2.1 × 1.1 cm well circumscribed mass centered on, and extended into, the frontozygomatic suture with smooth remodeling of the frontal bone. Magnetic resonance imaging showed heterogeneous T1 and T2 hyperintensity with hypointensity on fat suppression. A dermoid cyst originating from the frontozygomatic suture was suspected. Excision was performed through a left orbitocranial approach with a lateral orbitotomy through an upper eyelid crease incision. The mass occurred in the superior-lateral portion of the left orbit and originated from the intraorbital surface of the zygomaticofrontal suture line with significant bony remodeling without osseous transgression. The mass was removed completely including the lateral portion of the zygomaticofrontal suture. Pathologic examination was consistent with a dermoid cyst. Postoperative examination revealed resolution of his presenting headaches and diplopia.

Conclusion: Congenital dermoid cysts occurring within the craniofacial region occur most commonly in the lateral orbit involving the superficial surface of the frontozygomatic suture. This patient represents the rare occurrence of a dermoid cyst originating from the deep surface of the frontozygomatic suture, resulting in delayed presentation and orbital symptoms of hypoglobus and diplopia. Definitive treatment remains complete surgical excision.
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http://dx.doi.org/10.1097/SCS.0000000000005005DOI Listing
August 2019

Analysis of anterior and posterior maneuvers to enhance intraconal exposure.

Int Forum Allergy Rhinol 2019 05 21;9(5):556-561. Epub 2018 Dec 21.

Department of Otolaryngology-Head and Neck Surgery, University of North Carolina, Chapel Hill, NC.

Background: The medial and inferior recti encompass the ideal surgical corridor to approach the intraconal space endonasally. Here, we describe 3 different maneuvers to achieve greater access to orbital contents through an expanded endonasal approach (EEA).

Methods: Four human cadaver heads were dissected bilaterally (n = 8). EEA to the medial intraconal orbit was executed. The following 3 maneuvers were performed: (1) anterior: extraocular muscles control (EOM); (2) posterior: annulus of Zinn (AZ) release; and (3) anterior/posterior combined. Measurements of the inferior and medial rectus corridor at the level of anterior ethmoidal artery (AEA) and posterior ethmoidal artery (PEA) and extent of optic nerve and medial rectus visualization was performed before and after each maneuver.

Results: Medial rectus length (MRL) and optic nerve length (ONL) achieved were 1.72 ± 0.28 cm and 0.85 ± 0.2 cm, respectively. Mean caudal-rostral distances between the rectus muscles at the level of the AEA and PEA were 3.45 ± 0.7 mm and 1.30 ± 0.3 mm, respectively. After EOM control, mean caudal-rostral distances at the same level were as follows: AEA 4.90 ± 1.15 mm (p = 0.009) and PEA 1.70 ± 0.20 mm (p = 0.016). With AZ release, MRL was 2.20 ± 0.7 cm (p = 0.002) and ONL was 1.30 ± 0.2 cm (p = 0.003), with mean rostral-caudal distance at the level of AEA at 4.03 ± 0.8 mm (p = 0.16) and PEA at 1.71 ± 0.36 mm (p = 0.039). Mean caudal-rostral distances achieved with AZ release and EOM control were as follows: AEA 5.6 ± 1.2 mm (p = 0.001) and PEA 2.15 ± 0.4 mm (p = 0.001).

Conclusion: Progressive access to the orbital contents is afforded with the 3 delineated maneuvers. The magnitude of access is optimized with the combined maneuver. The actual anterior/posterior location of the target will determine which maneuvers are required.
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http://dx.doi.org/10.1002/alr.22271DOI Listing
May 2019

The Bipedicled Orbicularis Oculi Myocutaneous Flap for the Repair of Paralytic Ectropion.

JAMA Facial Plast Surg 2019 Mar;21(2):169-171

Department of Otolaryngology-Head and Neck Surgery, University of North Carolina School of Medicine, Chapel Hill.

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http://dx.doi.org/10.1001/jamafacial.2018.1704DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6439808PMC
March 2019

Shoulder symptoms and quality of life impact of limited neck dissection after de-intensified chemoradiotherapy: Secondary analysis of two prospective trials.

Head Neck 2019 05 15;41(5):1213-1219. Epub 2018 Dec 15.

Department of Radiation Oncology, University of North Carolina Hospitals, Chapel Hill, North Carolina.

Background: We investigated the quality of life (QOL) impact of post-radiation therapy (RT) superselective/selective neck dissection after de-intensified chemoradiation for human papillomavirus-associated oropharynx cancer.

Methods: A total of 147 patients received 60 Gy and weekly low-dose cisplatin on two phase 2 trials with planned post-RT neck dissection or surveillance positron emission tomography with neck dissection reserved for salvage. UW-QOL Shoulder Score, EORTC H&N-35, and EAT-10 were assessed.

Results: In all, 48 of 147 patients had post-RT neck dissection. At 2 years, 37% and 13% of patients receiving post-RT neck dissection had Shoulder Score ≥ 1 (any shoulder symptoms) and ≥ 2 (symptoms affecting work/hobbies), respectively, versus only 16% and 3% of patients not receiving post-RT neck dissection. Post-RT neck dissection was associated with Shoulder Score ≥ 1 (P = 0.005) and Shoulder Score ≥ 2 (P = 0.03) at 2 years, but not H&N-35 or EAT-10 scores.

Conclusions: Post-RT superselective/selective neck dissection was associated with modest but persistent shoulder symptoms. These toxicities should be weighed against the probability of persistent disease when evaluating patients for post-RT neck dissection.
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http://dx.doi.org/10.1002/hed.25535DOI Listing
May 2019

How Much Blood Could a JP Suck If a JP Could Suck Blood?

Laryngoscope 2019 08 13;129(8):1806-1809. Epub 2018 Dec 13.

Department of Otolaryngology Head and Neck Surgery at Chapel Hill, Chapel Hill, North Carolina, U.S.A.

Objective: Active surgical drains minimize fluid accumulation in the postoperative period. The Jackson-Pratt (JP) system consists of a silicone drain connected by flexible tubing to a bulb. When air in the bulb is evacuated, negative pressure is applied at the surgical site to aspirate fluid. The objective of this study was to determine if the evacuation method and volume of accumulated fluid affect the pressure generated by the bulb.

Methods: Bulbs were connected to a digital manometer under various experimental conditions. A random number generator determined the initial evacuation method for each bulb, either side-in or bottom-up. Subsequent evacuations were alternated until data was collected in triplicate for each method. Predetermined amounts of water were placed into the bulb; air was evacuated; and pressure was recorded. The digital manometer was allowed to equilibrate for 1 minute prior to data acquisition.

Results: The average amount of pressure after a side-in evacuation of a JP bulb was 87.4 cm H O compared to 17.7 cm H O for a bottom-up evacuation (P < 0.0001). When the drain contained 25 mL, 50 mL, 75 mL, and 100 mL of fluid, the pressure applied dropped to 72.6, 41.3, 37.0, and 35.6 cm H O, respectively.

Conclusions: JP drains generate negative pressure in order to reduce fluid accumulation at surgical sites. Although its function is frequently taken for granted, this study demonstrates that both the specific method for evacuating the bulb as well as the amount of fluid in the bulb significantly affect the performance of this device.

Level Of Evidence: NA Laryngoscope, 129:1806-1809, 2019.
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http://dx.doi.org/10.1002/lary.27710DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6565520PMC
August 2019

Quality of Life for Patients With Favorable-Risk HPV-Associated Oropharyngeal Cancer After De-intensified Chemoradiotherapy.

Int J Radiat Oncol Biol Phys 2019 03 2;103(3):646-653. Epub 2018 Nov 2.

Department of Radiation Oncology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; UNC Lineberger Comprehensive Cancer Center, University of North Carolina Hospitals, Chapel Hill, North Carolina. Electronic address:

Purpose: Oropharynx cancers associated with human papillomavirus (HPV) have a favorable prognosis, but current treatment approaches carry significant long-term morbidity. Strategies to de-intensify treatment in this population are under investigation, but the impact of these approaches on quality of life (QOL) is not well understood. We present patient-reported outcomes from 2 prospective studies examining de-intensified chemoradiotherapy.

Methods And Materials: This study included patients enrolled in 2 prospective phase 2 trials of de-intensified chemoradiotherapy in patients with HPV-associated oropharynx cancer who had at least 1 year of follow-up. Treatment included concurrent radiation therapy (60 Gy) and chemotherapy (weekly cisplatin, 30 mg/m). Patients reported QOL and symptoms using the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-C30, the European Organisation for Research and Treatment of Cancer Head and Neck Cancer Module-35, and the Eating Assessment Tool-10 instruments before treatment and at regular intervals thereafter. Changes in QOL and individual symptoms were examined over time, and multivariate analysis was used to identify clinical factors associated with recovery to baseline symptom levels.

Results: Of the 154 patients enrolled, 126 patients had at least 1 year of follow-up and were included in this study (median follow-up, 25 months). Global QOL, functional indices, and most individual symptoms returned to baseline 3 to 6 months after treatment. Swallowing (Eating Assessment Tool-10 score) returned to baseline function by 2 years, but dry mouth, sticky saliva, and taste/senses did not return to baseline levels. However, from 1 to 2 years, continued improvement occurred in dry mouth score (55 vs 48), sticky saliva score (35 vs 27), and senses score (24 vs 20). On multivariate analysis, unilateral radiation therapy was associated with returning to baseline level of swallowing and sticky saliva.

Conclusions: The use of de-intensified chemoradiotherapy in HPV-associated oropharynx cancer led to favorable patient-reported outcomes, with early recovery of QOL and continued improvement of xerostomia and dysphagia beyond 1-year posttreatment.
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http://dx.doi.org/10.1016/j.ijrobp.2018.10.033DOI Listing
March 2019

Outcomes of Open vs Endoscopic Skull Base Surgery in Patients 70 Years or Older.

JAMA Otolaryngol Head Neck Surg 2018 10;144(10):923-928

Department of Otolaryngology-Head and Neck Surgery, University of North Carolina at Chapel Hill.

Importance: The use of skull base surgery in patients 70 years or older is increasing, but its safety in this age group has not been evaluated to date.

Objectives: To describe outcomes in a cohort of patients 70 years or older undergoing skull base surgery and to evaluate whether age, type of disease process, and approach (endoscopic vs traditional open surgery) are associated with increased intraoperative and postoperative complications in this population.

Design, Setting, And Participants: This retrospective cohort study analyzed a population-based sample of 219 patients 70 years or older from a database of 1720 patients who underwent skull base surgery at University of North Carolina Hospitals, Chapel Hill, a tertiary referral center, between October 2007 and June 2017. Data were collected from June 2016 to July 2017 and analyzed in July 2017 and August 2017.

Exposure: Skull base surgery.

Main Outcomes And Measures: Data collected included demographic characteristics, surgical approach, and disease process. Intraoperative findings and postoperative complications were analyzed by age, surgical approach, and malignancy status.

Results: Of the 219 patients, 166 were aged 70.0 to 79.9 years and 53 patients were older than 80 years (mean [SD] age, 76.4 [4.7] years); 120 (54.8%) were men and 160 (73.7%) were white. There were 161 (73.5%) endoscopic and 58 (26.5%) open operations. The most common pathologic processes among the 219 patients were nonsellar malignant (81 [37.0%]), nonsellar benign (53 [24.2%]), and pituitary (49 [22.4%]) tumors. The most common intraoperative and postoperative complications were intraoperative major bleeding (5 of 219 patients [2.3%]) and postoperative bleeding (9 [4.1%]). Thirty-day mortality was zero. There was no clinically meaningful difference in complications between patients aged 70.0 to 79.9 years vs those older than 80 years, endoscopic vs open surgery, or benign vs malignant neoplasms. Specifically, between the endoscopic and open surgery groups, there was no difference in intraoperative major bleeding (3.9%; 95% CI, -0.7% to 12.9%), postoperative cerebrospinal fluid leak (-0.6%; 95% CI, -3.4% to 5.6%), or postoperative bleeding (1.5%; 95% CI, -3.9% to 10.6%).

Conclusions And Relevance: Skull base surgery is a safe option in persons 70 years or older, with similar outcomes across age ranges, surgical approaches, and disease processes.
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http://dx.doi.org/10.1001/jamaoto.2018.1948DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6233820PMC
October 2018

Sinonasal epithelial-myoepithelial carcinoma: Report of a novel subsite and review of the literature.

Allergy Rhinol (Providence) 2018 Jan-Dec;9:2152656718764229. Epub 2018 Apr 9.

Department of Otolaryngology-Head and Neck Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina.

Background: Epithelial-myoepithelial carcinoma (EMC) is a rare tumor of the major and minor salivary glands. Sinonasal EMC is extremely uncommon and hitherto not described within the frontal or ethmoid sinuses.

Objective: To present a novel sinonasal subsite and review the literature regarding sinonasal EMC.

Methods: A case of frontoethmoidal EMC was presented. A medical literature data base was queried from January 1, 1950, to August 8, 2017, for all reports of sinonasal EMC.

Results: A 69-year-old man underwent combined open and endoscopic craniofacial resection of a right frontoethmoidal EMC, a previously undescribed primary location for this tumor. A comprehensive review of the literature revealed 13 additional cases of sinonasal EMC.

Conclusion: EMC is an uncommon neoplasm typically found in the major salivary glands; occurrence in the nose or paranasal sinuses is extremely rare. EMC often follows an indolent clinical course, although, in a minority of cases, particularly in large tumors with nuclear atypia, more aggressive behavior may be observed.
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http://dx.doi.org/10.1177/2152656718764229DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6028158PMC
April 2018

Surgical simulation and applicant perception in otolaryngology residency interviews.

Laryngoscope 2018 11 25;128(11):2503-2507. Epub 2018 Apr 25.

Department of Otolaryngology/Head and Neck Surgery, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, U.S.A.

Objective: The traditional resident applicant interview involves multiple oral interviews. The implementation of surgical simulations adds an additional dimension of assessment but can be perceived in a stressful way by applicants. The purpose of this project is to describe low-fidelity simulations that were implemented for the 2016 to 2017 residency interviews and obtain applicant perception of these simulations.

Methods: Six simulation modules were created, which reflected tasks used in six subspecialties within otolaryngology (pediatrics, otology, laryngology, facial plastics, rhinology, and head/neck). Applicants were guided in the procedures by both an attending and resident. Afterward, applicants were anonymously surveyed on their perception of the tasks using a 5-point Likert scale (1 = Strongly Disagree, 2 = Somewhat Disagree, 3 = Neutral, 4 = Somewhat Agree, 5 = Strongly Agree).

Results: A total of 41 applicants were interviewed. The following were measured: enjoyable (98.5% strongly agree, 2.5% somewhat agree; mean: 4.97; 95% confidence interval [CI], 4.92, 5.02), educational (88% strongly agree, 12% somewhat agree; mean: 4.88; 95% CI, 4.78, 4.98), recommended for future use (92.7% strongly agree, 7.3% somewhat agree; mean: 4.93; 95% CI, 4.85, 5.01), and stressful (63.5% strongly disagree, 19.5% somewhat disagree, 17% neutral; mean: 1.54; 95% CI, 1.30, 1.78).

Conclusion: Implementation of a low-fidelity multi-station surgical simulation experience is feasible in an interview day. Majority of applicants viewed the simulations in a positive manner. Surgical simulations may provide a useful holistic evaluation of an applicant in future interviews, especially if done in a setting that minimizes stress and maximizes the educational experience.

Level Of Evidence: 2b. Laryngoscope, 2503-2507, 2018.
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http://dx.doi.org/10.1002/lary.27211DOI Listing
November 2018