Publications by authors named "David A Kasle"

20 Publications

  • Page 1 of 1

Adverse Events Associated With Corticosteroid-Eluting Sinus Stents: A MAUDE Database Analysis.

Otolaryngol Head Neck Surg 2021 Apr 13:1945998211006930. Epub 2021 Apr 13.

Division of Otolaryngology, Department of Surgery, School of Medicine, Yale University, New Haven, Connecticut, USA.

Objective: Corticosteroid-eluting stents (CESs) are increasingly used after endoscopic sinus surgery to reduce the need for revision surgery, but their use is not without risks. The objective of this study is to describe adverse events related to CESs.

Study Design: Retrospective cross-sectional study.

Setting: The US Food and Drug Administration's MAUDE database (2011-2020; Manufacturer and User Facility Device Experience).

Methods: The MAUDE database was queried for reports of adverse events involving the use of CESs approved by the Food and Drug Administration, including Propel, Propel Mini, Propel Contour, and Sinuva (Intersect ENT).

Results: There were 28 reported adverse events in total, with all events being related to the Propel family of stents and none related to Sinuva stents. Overall, 22 were categorized as patient-related adverse events and 6 as device-related events. The most common adverse event was related to postoperative infection, accounting for 39% (n = 11) of all complications. Four of these patients developed periorbital cellulitis, and 5 developed a fungal infection. The second-most common adverse event was migration of the stent, representing 21% of all complications (n = 6). Overall, 8 patients (29%) in our cohort required reintervention in the operating room, with subsequent removal of the CES.

Conclusion: The most commonly reported adverse events were postoperative infection, including multiple cases of fungal infection, followed by migration of the stent. An increased awareness of the complications associated with CESs can be used to better inform patients during the consenting process as well as surgeons in their surgical decision making.
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http://dx.doi.org/10.1177/01945998211006930DOI Listing
April 2021

A 2020 Update on Public Awareness of Head and Neck Cancers.

Otolaryngol Head Neck Surg 2021 Apr 13:1945998211006932. Epub 2021 Apr 13.

Division of Otolaryngology, Department of Surgery, School of Medicine, Yale University, New Haven, Connecticut, USA.

Objective: To assess knowledge regarding head and neck cancers (HNCs) in 2020, factors associated with knowledge of the role of human papillomavirus (HPV) in HNCs, and factors associated with exposure to Oral, Head and Neck Cancer Awareness Week (OHANCAW).

Study Design: Cross-sectional survey.

Setting: Online.

Methods: The survey was distributed to 517 participants via a paid panel and utilized US Census-built quotas to represent the US population.

Results: Participants surpassed 50% awareness rates in only 5 of 10 (50.0%), 2 of 6 (33.3%), and 5 of 9 (55.5%) preselected answer choices for subsites, risk factors, and signs/symptoms of HNCs, respectively. Knowledge of HPV's role in oropharyngeal cancer was also low, at 30.6%. However, of the controlled variables, exposure to OHANCAW was closely associated with knowledge of HPV's role in HNC (odds ratio, 10.25; 95% CI, 5.36-19.62). Women and elderly individuals were less likely to be exposed to OHANCAW, while those with higher education, those who drink heavily (>4 drinks/d), and current but not former tobacco users were more likely to be exposed.

Conclusions: Knowledge of HNCs and the causal role of HPV remains suboptimal, though our results suggest that OHANCAW remains a viable educational pathway. However, certain at-risk populations, such as former smokers and older individuals, whom we may not be effectively reaching and screening, represent a priority for future outreach efforts.
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http://dx.doi.org/10.1177/01945998211006932DOI Listing
April 2021

Role and Growth of Independent Medicare-Billing Otolaryngologic Advanced Practice Providers.

Otolaryngol Head Neck Surg 2021 Mar 9:194599821994820. Epub 2021 Mar 9.

Department of Surgery, Division of Otolaryngology, Yale University School of Medicine, New Haven, Connecticut, USA.

Objective: To evaluate the role and growth of independently billing otolaryngology (ORL) advanced practice providers (APPs) within a Medicare population.

Study Design: Retrospective cross-sectional study.

Setting: Medicare Provider Utilization and Payment Data: Physician and Other Supplier Data Files, 2012-2017.

Methods: This retrospective review included data and analysis of independent Medicare-billing ORL APPs. Total sums and medians were gathered for Medicare reimbursements, services performed, number of patients, and unique () codes used, along with geographic and sex distributions.

Results: There has been near-linear growth in number of ORL APPs (13.7% to 18.4% growth per year), with a 115.4% growth from 2012 to 2017. Similarly, total Medicare-allowed reimbursement (2012: $15,568,850; 2017: $35,548,446.8), total number of services performed (2012: 313,676; 2017: 693,693.7), and total number of Medicare fee-for-service (FFS) patients (2012: 108,667; 2017: 238,506) increased. Medians of per APP number of unique codes used, Medicare-allowed reimbursement, number of services performed, and number of Medicare FFS patients have remained constant. There were consistently more female APPs than male APPs (female APP proportion range: 71.3%-76.7%). Compared to ORL physicians, there was a significantly greater proportion of APPs practicing in a rural setting as opposed to urban settings (2017: APP proportion 13.6% vs ORL proportion 8.4%; < .001).

Conclusion: Although their scope of practice has remained constant, independently billing ORL APPs are rapidly increasing in number, which has led to increased Medicare reimbursements, services, and patients. ORL APPs tend to be female and are used more heavily in regions with fewer ORL physicians.
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http://dx.doi.org/10.1177/0194599821994820DOI Listing
March 2021

Adverse Events Associated With ClariFix Posterior Nasal Nerve Cryoablation: A MAUDE Database Analysis.

Otolaryngol Head Neck Surg 2021 Feb 2:194599820986581. Epub 2021 Feb 2.

Division of Otolaryngology, Yale University School of Medicine, New Haven, Connecticut, USA.

Posterior nasal nerve (PNN) cryoablation is a novel surgical technique used to address chronic rhinitis. The purpose of this study is to review the medical device reports (MDRs) submitted to the Food and Drug Administration's (FDA) Manufacturer and User Device Facility Experience (MAUDE) database to identify adverse events related to the use of ClariFix, a device designed for office-based cryosurgical ablation of the PNN. A total of 12 adverse events associated with ClariFix from January 2017 to August 2020 were identified and analyzed. The most common adverse events associated with ClariFix PNN cryoablation include epistaxis and nasal swelling. Further studies are needed to clarify whether PNN cryoablation is associated with epistaxis in certain populations.
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http://dx.doi.org/10.1177/0194599820986581DOI Listing
February 2021

Characterizing the providers of and reimbursement for chronic migraine chemodenervation among the Medicare population.

Headache 2021 Feb 18;61(2):373-384. Epub 2020 Dec 18.

Division of Otolaryngology, Department of Surgery, Yale University School of Medicine, New Haven, CT, USA.

Objective: To characterize reimbursement trends and providers for chronic migraine (CM) chemodenervation treatment within the Medicare population since the introduction of the migraine-specific CPT code in 2013.

Methods: We describe trends in procedure volume and total allowed charge on cross-sectional data obtained from 2013 to 2018 Medicare Part B National Summary files. We also utilized the 2017 Medicare Provider Utilization and Payment Data to analyze higher volume providers (>10 procedures) of this treatment modality.

Results: The total number of CM chemodenervation treatments rose from 37,863 in 2013 to 135,023 in 2018 in a near-linear pattern (r = 0.999) and total allowed charges rose from ~$5,217,712 to $19,166,160 (r = 0.999). The majority of high-volume providers were neurologists (78.4%; 1060 of 1352), but a substantial proportion were advanced practice providers (APPs) (10.2%; 138 of 1352). Of the physicians, neurologists performed a higher mean number of procedures per physician compared to non-neurologists (59.6 [95% CI: 56.6-62.6] vs. 45.4 [95% CI: 41.0-50.0], p < 0.001). When comparing physicians and APPs, APPs were paid significantly less ($146.5 [95% CI: $145.6-$147.5] vs. $119.7 [95% CI: $117.6-$121.8], p < 0.001). As a percent of the number of total beneficiaries in each state, the percent of Medicare patients receiving ≥1 CM chemodenervation treatment from a high-volume provider in 2017 ranged from 0.024% (24 patients of 98,033 beneficiaries) in Wyoming to 0.135% (997 of 736,521) in Arizona, with six states falling outside of this range.

Conclusion: Chemodenervation is an increasingly popular treatment for CM among neurologists and other providers, but the reason for this increase is unclear. There is substantial geographic variation in its use.
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http://dx.doi.org/10.1111/head.14040DOI Listing
February 2021

In Reference to Is Expecting the Emergency Department to Adhere to AAO-HNS Bell's Palsy Guidelines Unrealistic?

Laryngoscope 2021 02 7;131(2):E358. Epub 2020 Dec 7.

Department of Surgery (Division of Otolaryngology), Yale University School of Medicine, New Haven, Connecticut, U.S.A.

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http://dx.doi.org/10.1002/lary.29288DOI Listing
February 2021

High-Volume Billing and Reimbursement Trends for Endoscopic Swallowing Studies in the Medicare Population.

Dysphagia 2020 Nov 19. Epub 2020 Nov 19.

Department of Surgery, Division of Otolaryngology, Yale University School of Medicine, 800 Howard Avenue, Fl 4., New Haven, CT, 06519, USA.

The aim of this study is to delineate the reimbursement trends in fiberoptic endoscopic evaluation of swallowing with sensory testing (FEESST) and without sensory testing (FEES) in relation to that of speech-language pathology's (SLP) portion of modified barium swallow studies (MBS), as well as to document the types of providers billing for these procedures. We performed descriptive analyses of the volume of FEES/FEESST and MBS, and total reimbursements data obtained from 2013-2018 Medicare Part B National Summary files. We also utilized the 2017 Medicare Provider Utilization and Payment Data to analyze the higher volume providers (> 10 procedures annually) of either FEES and/or FEESST. From 2003 to 2018, there has been an average, annual increase of approximately 318 FEES/FEESST performed within the Medicare fee-for-service population (R = 0.9505 [95% CI 0.860-0.983]; p < 0.001) covered under Part B (which is largely outpatient coverage). Similarly, there was an increase in Medicare-specific FEES/FEESST reimbursement from $302,840 in 2003 to $1.2 million in 2018 (R = 0.9721 [95% CI 0.920-0.990; p < 0.001]). Prior to 2010, FEESST was performed more frequently than FEES (maximum annual difference of 1174), though from 2010 onward, relatively more annual FEES was performed. From 2003-2018, the reimbursement per procedure increased by $16.79 and $35.36 for FEESST and FEES, respectively, and by $32.84 for the SLP portion of the MBS. Among high-volume FEES/FEESST billers, 65.4% were otolaryngologists and 32.3% were independently billing SLPs. From 2003 to 2018, there has been a significant rise in the number of performed and reimbursed FEES/FEESST. From 2014 onward, compared to SLP-involved MBS, there has been a relative increase in performance of FEES/FEESST.
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http://dx.doi.org/10.1007/s00455-020-10215-xDOI Listing
November 2020

In Response to Telemedicine in Otorhinolaryngology Practice in Developing Nations.

Laryngoscope 2021 04 7;131(4):E1068. Epub 2020 Nov 7.

Division of Otolaryngology, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, U.S.A.

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http://dx.doi.org/10.1002/lary.29255DOI Listing
April 2021

COVID-19's Impact on the 2020-2021 Resident Match: A Survey of Otolaryngology Program Directors.

Ann Otol Rhinol Laryngol 2021 Jul 22;130(7):666-673. Epub 2020 Oct 22.

Division of Otolaryngology, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA.

Objective: To determine the impact coronavirus disease of 2019 (COVID-19) will have on the 2020-2021 otolaryngology (OTO-HNS) resident application cycle.

Methods: A cross-sectional survey targeting OTO-HNS program directors (PD) was created and disseminated via email to PDs on May 28th 2020. Descriptive analyses of the 19-question survey was performed, and free text responses for certain suitable questions were thematically categorized into groups determined to be relevant during analysis.

Results: Twenty-nine of 123 solicited PDs (23.6%) completed the survey. Nineteen (65.5%) respondents indicated they would not host away rotations (AR) in 2020, and 9 (31.0%) reported that they would consider away rotators without home programs. Regarding the historical importance of AR, 21 (72.4%) PDs stated they were either "extremely" or "very" important in evaluating candidates. Sixteen (55.2%) PDs stated that virtual interviews would impact their ability to properly gauge candidates and 12 (41.4%) were unsure. Eight PDs (27.6%) stated their evaluation of candidates will likely change, with a shift toward an increased reliance on letters of recommendation, research involvement, and clerkship grades. The large majority of PDs-25 (86.2%)-were not worried that the COVID-19 pandemic would affect the abilities of new interns beginning in 2021.

Conclusion: Virtual interviews and engagement activities will mostly supplant sub-Is and AR for the 2020-2021 OTO-HNS application cycle. Surveyed PDs largely believe these will be insufficient in providing a comprehensive assessment of candidates, and will similarly limit applicants' ability to gauge residency programs. Criteria utilized to evaluate students is expected to change.
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http://dx.doi.org/10.1177/0003489420967045DOI Listing
July 2021

Resumption of Otolaryngology Surgical Practice in the Setting of Regionally Receding COVID-19.

Otolaryngol Head Neck Surg 2021 04 22;164(4):788-791. Epub 2020 Sep 22.

Department of Surgery, Division of Otolaryngology, Yale University School of Medicine, New Haven, Connecticut, USA.

The practice of otolaryngology has been drastically altered as a consequence of the ongoing coronavirus disease 2019 (COVID-19) pandemic. Geographic heterogeneity in COVID-19 burden has meant different regions have experienced the pandemic at different stages. Regional dynamics of COVID-19 incidence has dictated the available resources for the provision of surgical care. As regions navigate their own COVID-19 dynamics, illustrative examples of areas affected early by the COVID-19 pandemic may provide anticipatory guidance. In this commentary, we discuss our experience with performed and canceled surgical procedures across the various otolaryngology specialties at our institution over the course of regionally rising and falling incident COVID-19 cases.
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http://dx.doi.org/10.1177/0194599820959671DOI Listing
April 2021

A Review of Telemedicine Applications in Otorhinolaryngology: Considerations During the Coronavirus Disease of 2019 Pandemic.

Laryngoscope 2021 04 1;131(4):744-759. Epub 2020 Oct 1.

Division of Otolaryngology, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, U.S.A.

Objective/hypothesis: Review the published literature of telemedicine's use within otorhinolaryngology (ORL), highlight its successful implementation, and document areas with need of future research.

Study Design: State of the Art Review.

Methods: Three independent, comprehensive searches for articles published on the subject of telemedicine in ORL were conducted of literature available from January 2000 to April 2020. Search terms were designed to identify studies which examined telemedicine use within ORL. Consensus among authors was used to include all relevant articles.

Results: While several, small reports document clinical outcomes, patient satisfaction, and the cost of telemedicine, much of the literature on telemedicine in ORL is comprised of preliminary, proof-of-concept reports. Further research will be necessary to establish its strengths and limitations.

Conclusions: Particularly during the coronavirus disease of 2019 pandemic, telemedicine can, and should, be used within ORL practice. This review can assist in guiding providers in implementing telemedicine that has been demonstrated to be successful, and direct future research. Laryngoscope, 131:744-759, 2021.
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http://dx.doi.org/10.1002/lary.29131DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7537247PMC
April 2021

Otolaryngology Match 2020-21: Survey of Prospective Applicants in the Setting of COVID-19.

Ann Otol Rhinol Laryngol 2021 May 19;130(5):450-458. Epub 2020 Aug 19.

Department of Surgery (Division of Otolaryngology), Yale University School of Medicine, New Haven, CT, USA.

Objectives: To capture the perspectives of candidates applying for otolaryngology residency positions in the 2020-21 cycle, in the context of disruption caused by the coronavirus disease 2019 (COVID-19) pandemic.

Subjects And Methods: Candidates planning to apply to the otolaryngology 2020-21 match were invited to complete a cross-sectional online survey. Distribution was via otomatch.com and word of mouth. Descriptive statistics were performed.

Results: Of 85 eligible responses (estimated 18.9% of all applicants), many have had at least one board examination (71.8%) disrupted. A majority (85.9%) believe evaluation of candidates will change due to the pandemic, and 54.1% report they were now less confident in matching. Female applicants (37.6% of respondents) were found to have significantly higher odds of decreased confidence in matching (OR 2.781 [95% CI 1.045-7.4044]; = .041). Many report a move to virtual interviews would increase the number of applications submitted (45.9%) and the number of interviews attended (77.6%). Some applicants (36.5%) did not believe residency programs would gather sufficient information about their candidacy to make an informed decision, and most (62.4%) did not believe that they would gather sufficient information to inform their own rank list.

Conclusions: We find that candidates believe their candidacy will be assessed differently in light of the COVID-19 pandemic, are largely less confident in successfully matching, and are planning to apply and interview more broadly. These data are relevant to otolaryngology residency leadership to inform clear dialogue and a smooth transition into an unprecedented application cycle.
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http://dx.doi.org/10.1177/0003489420952470DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7481654PMC
May 2021

A Manufacturer and User Facility Device Experience Analysis of Upper Aerodigestive Endoscopy Contamination: Is Flexible Laryngoscopy Different?

Laryngoscope 2021 03 19;131(3):598-605. Epub 2020 Jun 19.

Division of Otolaryngology, Department of Surgery, Yale School of Medicine, New Haven, Connecticut, U.S.A.

Objectives/hypothesis: Several recent studies have observed a high incidence of duodenoscope microbial contamination and an association of contamination with healthcare-acquired infections. This study sought to quantify nasopharyngoscope microbial contamination relative to that of other endoscope categories and characterize the manufacturers, outcomes, and microbial profiles associated with these cases.

Study Design: Retrospective, cross-sectional study.

Methods: A total of 3,865 adverse events were collected from 2013 to 2019 using the US Food and Drug Administration Manufacturer and User Facility Device Experience database. The fraction of total device failures associated with contamination was quantified for nasopharyngoscopes, bronchoscopes, duodenoscopes, and gastroscopes. Odds ratios of nasopharyngoscope contamination compared to that of bronchoscopes, duodenoscopes, or gastroscopes were calculated, and significance was assessed by χ analysis. The Kruskal-Wallis test was used for nonparametric testing of significance.

Results: Nasopharyngoscope device failures were reported at an incidence of 0.646 per month; 34.1% involved contamination, comparable to the frequency observed for bronchoscopes (23.4%, P = .118), duodenoscopes (29.2%, P = .493), and gastroscopes (45.3%, P = .178). The frequency of device contamination was observed to be significantly higher for a particular endoscope manufacturer regardless of endoscope category (Kruskal-Wallis P = .021). In instances of contamination, nasopharyngoscopes were significantly less associated with patient harm or death than bronchoscope (odds ratio [OR] = 10.2) and duodenoscope (OR = 4.81) cases.

Conclusions: Although the rates of contamination were comparable across all endoscope categories, nasopharyngoscope contamination was less commonly associated with patient harm or death. In an era of rising healthcare costs, determining adequate disinfection standards for nasopharyngoscopes and their impact on patient safety is crucial.

Level Of Evidence: NA Laryngoscope, 131:598-605, 2021.
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http://dx.doi.org/10.1002/lary.28826DOI Listing
March 2021

Outpatient Otolaryngology in the Era of COVID-19: A Data-Driven Analysis of Practice Patterns.

Otolaryngol Head Neck Surg 2020 07 12;163(1):138-144. Epub 2020 May 12.

Division of Otolaryngology, School of Medicine, Yale University, New Haven, Connecticut, USA.

Introduction: Coronavirus disease 2019 (COVID-19) has induced a prioritization of acute care and telehealth, affecting the quantity of patients seen and the modality of their care.

Study Design: Retrospective review.

Setting: Single-institution study conducted within the Division of Otolaryngology at the Yale School of Medicine.

Subjects And Methods: Data on all outpatient appointments within the Division of Otolaryngology were obtained from administrative records of billing and scheduling from March 16 to April 10, 2020. For comparison, a corresponding period from 2019 was also utilized.

Results: Of 5913 scheduled visits, 3665 (62.0%) were seen between March 18 and April 12, 2019, in comparison with 649 of 5044 (12.9%) during the corresponding COVID-19-affected period. The majority of completed visits performed in weeks 1 and 2 were in person, while the majority in weeks 3 and 4 were via telehealth. Among subspecialties, a larger proportion of completed visits in 2020 were performed by pediatric and head and neck oncology otolaryngologists as compared with general/specialty otolaryngologists ( < .001). Older adults (≥65 years) were less likely to have telehealth visits than younger adults (18-64 years; 45.6% vs 59.6%, = .003).

Conclusions: A major decrease in the completion rates of scheduled visits was seen in the COVID-19-affected period, though this was not proportional among subspecialties. An associated increase in telehealth visits was observed. After COVID-19-related hospital policy changes, approximately 2 weeks passed before telehealth visits surpassed in-person visits, though this was not true among older adults.
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http://dx.doi.org/10.1177/0194599820928987DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7218354PMC
July 2020

Medicare Reimbursement for Balloon Catheter Dilations Among Surgeons Performing High Volumes of the Procedures to Treat Chronic Rhinosinusitis.

JAMA Otolaryngol Head Neck Surg 2020 03;146(3):264-269

Division of Otolaryngology, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut.

Importance: Chronic rhinosinusitis is among the most common and costly conditions treated by physicians. After failure of medical treatment, surgical intervention in the form of endoscopic sinus surgery is traditionally offered. Balloon catheter dilation (BCD) has become a less-invasive alternative with increasing popularity among otolaryngologists.

Objective: To evaluate the most recent BCD data in the Medicare population, with a specific focus on the percentage of procedures performed by surgeons who perform high volumes of this procedure, their reimbursements, and their national geographic distributions.

Design, Setting, And Participants: This retrospective review included data from 2011 through 2017 from Medicare Part B National Summary Data Files and Medicare Provider Utilization and Payment Data. Patients with procedures including Current Procedural Terminology codes 31295 (maxillary sinus dilation), 31296 (frontal sinus dilation), and 31297 (sphenoid sinus dilation) were included.

Exposures: Balloon catheter dilation of the paranasal sinuses.

Main Outcomes And Measures: Total and mean reimbursements over time to physicians for BCDs, as well as the percentage of BCDs performed by and reimbursed to ear, nose, and throat (ENT) surgeons who perform high volumes of BCDs (>10 procedures) in a given year.

Results: The total number of BCDs rose from 7496 in 2011 to 43 936 in 2017 (a 486% increase). The overall reimbursement increased from $11 773 049 in 2011 to $63 927 591 in 2017 (a 433% increase). From 2012 to 2016, ENT surgeons who performed high volumes of the procedures rose from 101 to 382 surgeons (a 270% increase). In 2016, 25 214 of 41 960 BCDs (60.1%) were performed by ENT surgeons performing high volumes of the procedure, compared with 5603 of 13 109 procedures (42.7%) in 2012. In a line of best fit, at the 75th percentile of procedure volume, there was an increase of 4.2 BCDs in the median number of procedures done per physician per year, compared with an increase of 1.5 BCD procedures per physician per year in the line of best fit for the 50th percentile.

Conclusions And Relevance: Balloon catheter dilation continues to increase in popularity among otolaryngologists treating chronic rhinosinusitis. Most BCDs are performed by ENT surgeons who perform high volumes of the procedure.
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http://dx.doi.org/10.1001/jamaoto.2019.4357DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6990810PMC
March 2020

Clinical characteristics and treatment-associated survival of head and neck Ewing sarcoma.

Laryngoscope 2020 10 27;130(10):2385-2392. Epub 2019 Nov 27.

Division of Otolaryngology, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, U.S.A.

Objectives: Ewing sarcoma of the head and neck (ESHN) is a rare malignancy for which limited data exists. Herein we examine anatomic distribution of ESHN, demographic characteristics, and multi-modal therapy as potential determinants in the overall survival (OS) of patients with ESHN.

Methods: A retrospective study of the National Cancer Database (NCDB) from 2004-2016 was performed. A multivariate Cox regression and univariate Kaplan-Meier survival analyses were conducted.

Results: We identified 284 patients with ESHN eligible for demographic analysis and 223 for survival analysis. Approximately half (50.3%) of patients with ESHN were under the age of 18. Pediatric patients (<18) were less likely to present with distant metastases (≤8.0% vs. 9.5-19.0%, P = .006) and more likely to present with osseous disease (90.2% vs. 75.2%, P = .001) than adults. Adult age (HR: 2.727, 95% CI, 1.381-5.384, P = .004) and distant metastatic disease at the time of presentation (HR: 8.161, 95% CI, 2.922-22.790, P < .001) were independently associated with worse OS. The addition of local therapy (either surgery, radiotherapy, or both) to chemotherapy was not associated with improved survival when compared to treatment with chemotherapy alone.

Conclusion: Predictors of OS in patients with ESHN included age < 18 years and non-metastatic disease at the time of diagnosis. Tumor site of origin (osseous vs. extraosseous primary) or the addition of local therapy to chemotherapy had no impact on OS. Our analysis suggests that chemotherapy serves as the primary modality in treating ESHN, while further study of this rare malignancy is required to discern the utility of combined systemic and local therapy. Laryngoscope, 130:2385-2392, 2020.
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http://dx.doi.org/10.1002/lary.28412DOI Listing
October 2020

Variations in the management of acute Bell's palsy.

Am J Otolaryngol 2020 Jan - Feb;41(1):102299. Epub 2019 Sep 10.

Department of Surgery (Section of Otolaryngology), Yale University School of Medicine, New Haven, CT, United States of America. Electronic address:

Objective: To identify presiding practices among neurotologists (ORL) in the care of acute Bell's palsy, and to compare them to neurologists' treatment patterns.

Study Design And Methods: Cross-sectional survey study.

Subjects: Neurotologists and neurologists.

Results: Ninety-one responses to the survey were obtained. The majority of participants (87.9%) always prescribe steroids. ORL were more likely to prescribe higher doses (≥60 mg) than neurologists (89.7% vs. 58.0%) (p = 0.001). Anti-viral medication was initially prescribed by 46.2% of respondents (56.1% ORL vs. 38.0% neurologists; p = 0.085). An MRI was always ordered by 17 participants (18.7%), while an MRI was sometimes ordered by 45 participants (49.5%). ORL were not only more likely to always order an MRI (24.4% vs. 14.0%), but also more likely to never order an MRI (43.9% vs. 22.0%) (p = 0.009). Laboratory blood work was never ordered by 45.1% of respondents, with 70.7% of OTO and 24.0% of neurologists indicating that they would never order labs (p < 0.001).

Conclusions: ORL almost always prescribe steroids, prescribe antivirals around 50% of the time, and only sometimes obtain imaging for acute Bell's palsy. Compared to neurologists, ORL are more likely to order high dose steroids (≥60 mg), more commonly prescribe antivirals, and are less likely to order laboratory blood work. Regarding the treatment of acute Bell's palsy, there are discrepancies both within otolaryngology, and between otolaryngology and neurology, despite recently published guidelines from both specialties.
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http://dx.doi.org/10.1016/j.amjoto.2019.102299DOI Listing
April 2020

Hypopharyngeal Diverticulum: Toward a Unified Understanding of Its Etiopathogenesis.

Dysphagia 2019 10 22;34(5):713-715. Epub 2019 Jun 22.

Department of Surgery (Section of Otolaryngology), Yale University School of Medicine, New Haven, CT, USA.

The etiopathogenesis of Zenker's diverticulum (ZD) remains uncertain. Increased hypopharyngeal pressure due to a hypertonic upper esophageal sphincter results in herniation proximal to the sphincter producing a pulsion diverticulum. Gastroesophageal reflux, which is known to induce shortening of the injured esophagus, likely plays a prominent role in ZD formation by pulling the cricopharyngeus muscle (CPM) away from the anchored inferior constrictor muscle. This creates a "weak zone" encouraging herniation. A bilobed diverticulum may originate from continuation of the fibrous midline raphe inferiorly to developmentally include part of the CPM. We report using laser endoscopy to divide the inter-diverticular septum followed by transmucosal cricopharyngeus myotomy. Presentation of a rare, bilobed diverticulum emphasizes the importance of the midline prevertebral raphe in anchoring the pharyngeal constrictor muscles with respect to the CPM. This lends support to the hypothesis that the etiopathogenesis of ZD is multifactorial while guiding us to a unified understanding of ZD.
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http://dx.doi.org/10.1007/s00455-019-10030-zDOI Listing
October 2019

Nonsquamous cell laryngeal cancers: Incidence, demographics, care patterns, and effect of surgery.

Laryngoscope 2019 11 10;129(11):2496-2505. Epub 2019 Jan 10.

Department of Surgery, Section of Otolaryngology, Yale University School of Medicine, New Haven, Connecticut, U.S.A.

Objectives: To analyze the incidence and clinical profile of nonsquamous cell (non-SCC) laryngeal carcinomas and to analyze the effect of surgery on survival.

Study Design: A retrospective analysis of the National Cancer Database (2004-2014).

Methods: Adult patients with non-SCC laryngeal cancers were divided into six major histological subtypes. A descriptive clinical profile was obtained for non-SCC patients, and multivariate regressions were performed to analyze the effect of surgery on survival within the non-SCC cohort.

Results: We identified 878 cases of non-SCC laryngeal cancers, representing 1.02% of all malignant laryngeal cancers. Neuroendocrine tumors and bone/cartilage sarcomas made up the largest groups (37.02% and 32.35%, respectively). Metastasis (M) was higher in neuroendocrine tumors, representing 19.1% of those with known clinical M stages. Of those treated, the majority of patients with bone/cartilage sarcomas (80.9%) and minor salivary gland tumors (82.6%) received surgery as part of their treatment. Survival varied significantly based upon histology, with bone/cartilage sarcomas having the highest 5-year survival at 90.4%, and neuroendocrine tumors exhibiting the poorest 5-year survival at 25.7%. Multivariate analyses found surgery to be significantly associated with improved survival (hazard ratio: 0.679; 95% confidence interval: 0.472-0.976; P = 0.036). The specific surgical method (i.e., local excision vs. partial vs. total laryngectomy) did not have any effect on survival.

Conclusion: Approximately 1% of all malignant laryngeal cancers are non-SCC in origin. At presentation, neuroendocrine tumors have the highest rate of distant metastasis and have the worst prognosis of the non-SCC cancers. Most non-SCC patients received surgery as part of their treatment regimen.

Level Of Evidence: NA. Laryngoscope, 129:2496-2505, 2019.
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November 2019

Three Cases of Late Onset Angioedema in Nursing Home Human Immunodeficiency Virus Patients on Ritonavir and Risperidone.

J Clin Psychopharmacol 2016 Feb;36(1):95-7

Department of Psychiatry Albert Einstein College Of Medicine - Bronx Lebanon Hospital Center Bronx, NY Department of Psychiatry Albert Einstein College Of Medicine - Bronx Lebanon Hospital Center Bronx, NY.

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February 2016