Publications by authors named "Stacey T Gray"

165 Publications

Diversifying Researchers and Funding in Otolaryngology.

Otolaryngol Clin North Am 2021 Jun;54(3):653-663

Department of Otolaryngology - Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA; Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark, NJ, USA; Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA; Department of Ophthalmology and Visual Science, Rutgers New Jersey Medical School, Newark, NJ, USA; Department of Otolaryngology and Facial Plastic Surgery, Saint Barnabas Medical Center - RWJBarnabas Health, Livingston, NJ, USA. Electronic address:

Research productivity is a key metric used in evaluation for advancement and promotion in academic medicine. There are known gender, race, and ethnicity disparities in otolaryngology research and funding. Female academic otolaryngologists have been shown to lag in scholarly productivity, representation at national meetings, leadership positions on journal editorial boards, and National Institutes of Health and industry funding. Underrepresented minorities have been shown to be less successful at obtaining Centralized Otolaryngology Research Efforts grant funding. Directed approaches, such as research funding for women and minorities or targeted recruitment and retention of underrepresented faculty, may move the field toward parity.
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http://dx.doi.org/10.1016/j.otc.2021.01.008DOI Listing
June 2021

Graduate Medical Education in Otolaryngology: Making Dollars and Sense of Reform.

Otolaryngol Head Neck Surg 2021 Apr 13:1945998211004263. Epub 2021 Apr 13.

Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, Massachusetts, USA.

Graduate medical education (GME) is funded by the Centers for Medicare and Medicaid Services through both direct and indirect payments. In recent years, stakeholders have raised concerns about the growth of spending on GME and distribution of payment among hospitals. Key stakeholders have proposed reforms to reduce GME funding such as adjustments to statutory payment formulas and absolute caps on annual payments per resident. Otolaryngology departmental leadership should understand the potential effects of proposed reforms, which could have significant implications for the short-term financial performance and the long-term specialty workforce. Although some hospitals and departments may elect to reduce resident salaries or eliminate positions in the face of GME funding cuts, this approach overlooks the substantial Medicare revenue contributed by resident care and high cost of alternative labor sources. Commitment to resident training is necessary to align both the margin and mission of otolaryngology departments and their sponsoring hospitals.
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http://dx.doi.org/10.1177/01945998211004263DOI Listing
April 2021

Socioeconomic Factors Affect Presentation Stage and Survival in Sinonasal Squamous Cell Carcinoma.

Laryngoscope 2021 Apr 12. Epub 2021 Apr 12.

Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, U.S.A.

Objectives: Socioeconomic factors affect oncologic outcome in sinonasal squamous cell carcinoma (SNSCC). However, the relationship between these factors and stage at presentation (SAP)-a critical, early point in the care cycle-is not known. This study sought to determine the role of race/ethnicity, treatment facility type, insurance status/carrier, and other socioeconomic factors in SAP and survival among patients with advanced SNSCC.

Study Design: Retrospective cohort study.

Methods: Using the National Cancer Database, 6,155 patients with SNSCC were identified and divided into those with "early" (Stage I or II; 2,212 (35.9%)) versus "advanced" (Stage III or IV; 3,943 (64.1%)) disease. Associations between sociodemographic and socioeconomic factors on SAP and survival were analyzed using multivariable logistic regression and Cox proportional hazard models.

Results: Black (odds ratio [OR]: 2.18, CI: 1.74-2.76), Asian and Pacific Islander (API) (OR: 2.37, CI: 1.43-4.14), and Medicaid or uninsured (OR: 2.04, CI: 1.66-2.53) patients were more likely to present with advanced disease. Among patients with advanced disease, API patients demonstrated the highest 10-year survival rate (30.2%), and Black patients had the lowest 2-, 5-, and 10-year survival rates (47.7%, 31.9% and 19.2%, respectively). Older age (HR:1.03, CI:1.03-1.04), Black race (HR:1.39, CI:1.21-1.59), Medicaid or uninsured status (HR:1.48, CI:1.27-1.71), and treatment at a community hospital (HR:1.25, CI:1.14-1.37) were associated with poorer overall survival among patients with advanced disease.

Conclusions: Factors including race/ethnicity, treatment facility type, insurance status/carrier, and other socioeconomic factors influence SAP and survival in SNSCC. An improved understanding of how these factors relate to outcomes may elucidate opportunities to address gaps in education and access to care in vulnerable populations.

Level Of Evidence: 4 Laryngoscope, 2021.
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http://dx.doi.org/10.1002/lary.29568DOI Listing
April 2021

Gender and authorship trends in rhinology, allergy, and skull-base literature from 2008 to 2018.

Int Forum Allergy Rhinol 2021 Mar 16. Epub 2021 Mar 16.

Department of Otolaryngology-Head and Neck Surgery, Emory University Atlanta, Atlanta, Georgia, USA.

Background: A recent analysis suggested potential narrowing of the gender gap in research productivity in the field of rhinology. This analysis did not, however, provide insight into how the genders are represented in the rhinologic literature. This study aimed to evaluate 11 years of literature to evaluate for gender differences in authorship position, collaborations, category and content of research, citations, and funding to gain perspective on how gender and authorship has changed over time.

Methods: Authorship data for all articles on rhinologic subject matter published between January 1, 2008 and December 31, 2018 in four otolaryngology journals was collected. The gender of authors was determined by protocol. Category and content of research and funding status/source were additionally obtained.

Results: Data were collected from 2666 articles. Gender of 14,510 authors was determined. Female authors accounted for 23% of the overall authors and male authors accounted for 77%. Female first authorship increased significantly over time, but there was no change in female senior authorship. The percentage of female authors steadily increased over time, whereas male authorship decreased slightly. Mixed gender teams were shown to be increasing in frequency. Women published more than expected in basic science and allergy and less than expected in skull base. On funded studies, women were significantly underrepresented as senior authors.

Conclusion: This study represents the first assessment of gender differences in the rhinology literature. Areas where female representation can improve include senior authorship, increased involvement in skull base publications, and increased funding.
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http://dx.doi.org/10.1002/alr.22793DOI Listing
March 2021

Markup on Services Provided to Medicare Beneficiaries by Otolaryngologists in 2017: Implications for Surprise Billing.

Otolaryngol Head Neck Surg 2021 Feb 23:194599821994826. Epub 2021 Feb 23.

Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA.

The degree of markup between provider charges and Medicare prices reflects the potential balance bill for out-of-network commercially insured patients. Using publicly available Medicare data, we performed a retrospective cross-sectional analysis of markup ratios (MRs; ie, the ratio of submitted charges to Medicare-allowed prices) for services commonly performed by otolaryngologists in 2017. Median MRs were as follows: 2.9 (interquartile range, 2.0-4.3) in facility settings (eg, hospital) and 2.1 (interquartile range, 1.7-2.9) in nonfacility settings (eg, physician office). Among the 10 highest-markup procedures performed by otolaryngologists in facility and nonfacility settings, there was no consistent increase in median MRs between 2012 and 2017 (compound annual growth rates, -4.6% for labyrinthotomy to 24.6% for ultrasound-guided biopsy). Median MRs for these procedures were not consistently lower in states with surprise billing protection laws. These findings may reflect the comparatively low potential to "balance bill" patients for elective otolaryngologic services and the limitations of state-level protections against surprise billing.
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http://dx.doi.org/10.1177/0194599821994826DOI Listing
February 2021

Diagnosing odontogenic sinusitis of endodontic origin: A multidisciplinary literature review.

Am J Otolaryngol 2021 May-Jun;42(3):102925. Epub 2021 Jan 15.

Medical College of Wisconsin, Department of Otolaryngology- Head and Neck Surgery, Milwaukee, WI, United States of America; Zablocki VAMC, Division of Surgery, Milwaukee, WI, United States of America.

Purpose: Endodontic disease is one of the most common causes of bacterial odontogenic sinusitis (ODS). Diagnosing ODS of endodontic origin involves otolaryngologists confirming sinusitis, and dental specialists confirming endodontic sources. The purpose of this study was to conduct a multidisciplinary literature review to highlight clinical and microbiological features of ODS, and the most optimal diagnostic modalities to confirm endodontic disease.

Methods: An extensive review of both medical and dental literature was performed by rhinologists, endodontists, and an infectious disease specialist. Frequencies of various clinical and microbiological features from ODS studies were collected, and averages were calculated. Different endodontic testing and imaging modalities were also evaluated on their abilities to confirm endodontic disease.

Results: ODS patients most often present with unilateral sinonasal symptoms for over 3 months, purulence on nasal endoscopy, and overt dental pathology on computed tomography (CT). Subjective foul smell, and maxillary sinus cultures demonstrating anaerobes and α-streptococci (viridans group) may be more specific to ODS. For endodontic evaluations, cold pulp testing and cone-beam CT imaging are most optimal for confirming pulpal and periapical disease.

Conclusion: Diagnosing ODS requires collaboration between otolaryngologists and dental specialists. Clinicians should suspect ODS when patients present with unilateral sinonasal symptoms, especially foul smell. Patients will generally have purulent drainage on nasal endoscopy, and both sinus opacification and overt dental pathology on CT. However, some patients will have subtle or absent dental pathology on CT. For suspected endodontic disease, endodontists should be consulted for at least cold pulp testing, and ideally cone-beam CT.
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http://dx.doi.org/10.1016/j.amjoto.2021.102925DOI Listing
January 2021

Prophylactic antibiotics after endoscopic sinus surgery for chronic rhinosinusitis: a randomized, double-blind, placebo-controlled noninferiority clinical trial.

Int Forum Allergy Rhinol 2020 Dec 19. Epub 2020 Dec 19.

Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, MA.

Background: Surgeons commonly prescribe prophylactic antibiotics after endoscopic sinus surgery (ESS), yet minimal data exist to support this practice. In this study we aimed to assess the impact of post-ESS antibiotics on infection, quality of life (QOL), and endoscopic scores.

Methods: This was a randomized, double-blind, placebo-controlled, noninferiority trial comparing amoxicillin-clavulanate vs placebo after ESS (NCT01919411, ClinicalTrials.gov). Adults (N = 77) with chronic rhinosinusitis (CRS) refractory to appropriate medical therapy who underwent ESS were randomized to antibiotics (N = 37) or placebo (N = 40) and followed clinically (mean ± standard deviation: 1.3 ± 0.3 and 8.8 ± 3.9 weeks postoperatively). At baseline and follow-up, QOL was measured with 22-item Sino-Nasal Outcome Test questionnaires and Lund-Kennedy endoscopic scores were evaluated. Outcomes were analyzed with repeated-measures analysis of variance and analysis of covariance and z tests for proportions.

Results: Placebo was noninferior to antibiotic prophylaxis with regard to postoperative SNOT-22 scores (β = 0.18, 2-tailed p < 0.05). There were no significant differences between the antibiotic and placebo groups in LK score trajectories over time (p = 0.63) or in postoperative infection rates (2.6% vs 2.4%, respectively; p = 0.96). The rate of diarrhea was significantly higher in the antibiotic group (24.3% vs 2.5%; relative risk = 10.8; p = 0.02).

Conclusion: Although statistically underpowered, the results suggest placebo was noninferior to prophylactic antibiotics after ESS for CRS regarding postoperative sinonasal-specific QOL. There were no significant differences in postoperative endoscopic scores or rates of infection, but the rate of diarrhea was significantly higher in the antibiotic group. These findings add to the growing evidence that routine use of prophylactic postoperative antibiotics does not improve outcomes post-ESS and significantly increases the rate of diarrhea.
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http://dx.doi.org/10.1002/alr.22756DOI Listing
December 2020

Problematic Reporting of Gender Differences in Clinical Productivity Among Otolaryngologists-Reply.

JAMA Otolaryngol Head Neck Surg 2021 02;147(2):222

Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, Massachusetts.

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http://dx.doi.org/10.1001/jamaoto.2020.4631DOI Listing
February 2021

Moving Toward Equitable Telemedicine in Otolaryngology-Head and Neck Surgery-Reply.

JAMA Otolaryngol Head Neck Surg 2021 02;147(2):220

Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts.

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http://dx.doi.org/10.1001/jamaoto.2020.4323DOI Listing
February 2021

International consensus statement on allergy and rhinology: rhinosinusitis 2021.

Int Forum Allergy Rhinol 2021 Mar;11(3):213-739

Rutgers New Jersey Medical School, Newark, NJ.

I.

Executive Summary: BACKGROUND: The 5 years since the publication of the first International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICAR-RS) has witnessed foundational progress in our understanding and treatment of rhinologic disease. These advances are reflected within the more than 40 new topics covered within the ICAR-RS-2021 as well as updates to the original 140 topics. This executive summary consolidates the evidence-based findings of the document.

Methods: ICAR-RS presents over 180 topics in the forms of evidence-based reviews with recommendations (EBRRs), evidence-based reviews, and literature reviews. The highest grade structured recommendations of the EBRR sections are summarized in this executive summary.

Results: ICAR-RS-2021 covers 22 topics regarding the medical management of RS, which are grade A/B and are presented in the executive summary. Additionally, 4 topics regarding the surgical management of RS are grade A/B and are presented in the executive summary. Finally, a comprehensive evidence-based management algorithm is provided.

Conclusion: This ICAR-RS-2021 executive summary provides a compilation of the evidence-based recommendations for medical and surgical treatment of the most common forms of RS.
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http://dx.doi.org/10.1002/alr.22741DOI Listing
March 2021

Adenoid Cystic Carcinoma of the Skull Base: Response to Radiation Therapy and Outcomes in a Retrospective Case Series.

J Neurol Surg B Skull Base 2020 Oct 18;81(5):505-510. Epub 2019 Sep 18.

Department of Otolaryngology Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, United States.

 The main purpose of this article is to examine a single-center cohort of patients with nasopharyngeal adenoid cystic carcinoma (ACC) for pathologic features, skull base invasion, overall survival, and disease-free survival, with a focus on response to proton beam radiation therapy.  Single-center institutional cancer registry was used to retrospectively identify and analyze outcomes for 12 patients treated for ACC of the nasopharynx from 2000 to 2016.  Primary outcomes included 5-year overall survival and locoregional control. Statistical analysis was performed using STATA 12.0 (STATACorp, College Station, Texas, United States). Spearman's rank order correlation was used for ordinal, monotonic variables with -values <0.05 considered statistically significant. Survival analysis was performed by Kaplan-Meier method; comparison between groups was performed using log-rank test.  Twelve patients with ACC of the nasopharynx were included. All patients presented with advanced disease and were treated with primary radiation therapy, typically proton beam therapy. Only two underwent a surgical attempt at resection. A majority of cases had a cribriform growth pattern. The 5-year survival was 75% and rate of locoregional control rate at 5 years was 50%, comparable to other ACC cohort studies that included earlier stage tumors in various subsites that were surgically resected.  Although ACC is traditionally noted to be radioresistant, ACC of the nasopharynx was responsive to radiotherapy in our cohort, despite advanced stage and skull base invasion. Reasons for this improved survival are unclear and suggest the need for further pathologic and genetic characterization of nasopharyngeal ACC.
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http://dx.doi.org/10.1055/s-0039-1696706DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7591356PMC
October 2020

Unbiased Measure of General Quality of Life in Chronic Rhinosinusitis Reveals Disease Modifiers.

Laryngoscope 2021 06 2;131(6):1206-1211. Epub 2020 Oct 2.

Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A.

Introduction: Chronic rhinosinusitis (CRS) is associated with a significant decrease in general health-related quality of life (QOL). The EuroQol 5-dimensional questionnaire measures general health-related quality of life through a health utility value (EQ-5D HUV)-based on five domains reflecting mobility, self-care, activities of daily life, pain/discomfort, and anxiety/depression-and an unbiased visual analog scale (EQ-5D VAS). We sought to identify characteristics of CRS patients with a high EQ-5D HUV but low EQ-5D VAS score.

Materials And Methods: Retrospective cross-sectional study of 300 CRS patients with EQ-5D HUV equal to 1.0 (reflecting perfect health). All patients completed a 22-item Sinonasal Outcome Test (SNOT-22)-from which nasal, sleep, ear/facial discomfort, and emotional subdomain scores were calculated, as well as the EQ-5D. Low EQ-5D VAS was defined as a score less than 80.

Results: On multivariate analysis, low EQ-5D VAS was associated with only the SNOT-22 sleep subdomain score (odds ratio [OR] = 1.07, 95%CI: 1.02-1.12, P = .003). Comorbid asthma was also associated with lower EQ-5D VAS (OR = 2.16, 95%CI: 1.02-4.59, P = .045). In contrast, polyps were negatively associated with having a lower EQ-5D VAS (OR = 0.34, 95%CI: 0.17-0.69, P = .003).

Conclusion: There are patients with perfect general health-related QOL according to a health utility value-based methodology (like the EQ-5D HUV) who report low general health-related QOL on an unbiased measure like the EQ-5D VAS. In CRS patients with perfect EQ-5D HUV, poor sleep and asthma were associated with low QOL on the EQ-5D VAS, while polyps were negatively associated with low QOL.

Level Of Evidence: 3 Laryngoscope, 131:1206-1211, 2021.
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http://dx.doi.org/10.1002/lary.29139DOI Listing
June 2021

Chronic rhinosinusitis disease burden is associated with asthma-related emergency department usage.

Eur Arch Otorhinolaryngol 2021 Jan 4;278(1):93-99. Epub 2020 Aug 4.

Department of Otolaryngology-Head and Neck Surgery, Medical Sciences Building, University of Cincinnati College of Medicine, Room 6410, 231 Albert Sabin Way, Cincinnati, OH, 45267-0528, USA.

Purpose: Chronic rhinosinusitis (CRS) disease burden is associated with pulmonary status in asthmatic CRS patients. Asthma-related emergency department (ED) usage is a predictor of asthma-related mortality. We sought to determine whether measures of CRS disease burden are associated with asthma-related ED usage.

Methods: We prospectively recruited 263 asthmatic CRS patients for this cross-sectional study. CRS burden was measured using the 22-item Sinonasal Outcome Test (SNOT-22), and patient-reported CRS-related antibiotic usage and CRS-related oral corticosteroids usage over the preceding year. Asthma-related ED visits over the prior year were also assessed.

Results: Of all participants, 18.6% had at least 1 asthma-related ED visit (mean 0.3 ED visits for the whole cohort). Asthma-related ED usage was associated with SNOT-22 score [adjusted rate ratio (RR) = 1.02, 95% CI 1.01-1.03, p = 0.040] and CRS-related oral corticosteroids usage in the past year (RR = 1.52, 95% CI 1.26-1.83, p < 0.001). From the SNOT-22 score, asthma-related ED usage was only associated with the nasal subdomain score (RR = 1.08, 95% CI 1.03-1.13, p = 0.001). These measures of CRS disease burden could be used with good sensitivity and specificity to detect patients with asthma-related ED usage in the past year, the majority of whom were undertreated for their asthma.

Conclusions: Measures of CRS disease burden are associated with and can be used to detect, patients having asthma-related ED usage. These results further solidify the connection between CRS and asthma disease courses, and also present an opportunity to use CRS disease burden as a tool for identifying-and implementing greater treatment of-patients at highest risk for asthma-related mortality.
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http://dx.doi.org/10.1007/s00405-020-06259-2DOI Listing
January 2021

Assessment of Gender Differences in Clinical Productivity and Medicare Payments Among Otolaryngologists in 2017.

JAMA Otolaryngol Head Neck Surg 2020 09;146(9):1-10

Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston.

Importance: Women comprise an increasing proportion of the otolaryngology workforce. Prior studies have demonstrated gender-based disparity in physician practice and income in other clinical specialties; however, research has not comprehensively examined whether gender-based income disparities exist within the field of otolaryngology.

Objective: To determine whether diversity of practice, clinical productivity, and Medicare payment differ between male and female otolaryngologists and whether any identified variation is associated with practice setting.

Design, Setting, And Participants: Retrospective cross-sectional analysis of publicly available Medicare data summarizing payments to otolaryngologists from January 1 through December 31, 2017. Male and female otolaryngologists participating in Medicare in facility-based (FB; hospital-based) and non-facility-based settings (NFB; eg, physician office) for outpatient otolaryngologic care were included.

Main Outcomes And Measures: Number of unique billing codes (diversity of practice) per physician, number of services provided per physician (physician productivity), and Medicare payment per physician. Outcomes were stratified by practice setting (FB vs NFB).

Results: A total of 8456 otolaryngologists (1289 [15.2%] women; 7167 [84.8%] men) received Medicare payments in 2017. Per physician, women billed fewer unique codes (mean difference, -2.10; 95% CI, -2.46 to -1.75; P < .001), provided fewer services (mean difference, -640; 95% CI, -784 to -496; P < .001), and received less Medicare payment than men (mean difference, -$30 246 (95% CI, -$35 738 to -$24 756; P < .001). When stratified by practice setting, women in NFB settings billed 1.65 fewer unique codes (95% CI, -2.01 to -1.29; P < .001) and provided 633 fewer services (95% CI, -791 to -475; P < .001). In contrast, there was no significant gender-based difference in number of unique codes billed (mean difference, 0.04; 95% CI, -0.217 to 0.347; P = .81) or number of services provided (mean difference, 5.1; 95% CI, -55.8 to 45.6; P = .85) in the FB setting. Women received less Medicare payment in both settings compared with men (NFB: mean difference, -$27 746; 95% CI, -$33 502 to -$21 989; P < .001; vs FB: mean difference, -$4002; 95% CI, -$7393 to -$612; P = .02), although the absolute difference was lower in the FB setting.

Conclusions And Relevance: Female sex is associated with decreased diversity of practice, lower clinical productivity, and decreased Medicare payment among otolaryngologists. Gender-based inequity is more pronounced in NFB settings compared with FB settings. Further efforts are necessary to better evaluate and address gender disparities within otolaryngology.
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http://dx.doi.org/10.1001/jamaoto.2020.1928DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7393586PMC
September 2020

Telemedicine Services Provided to Medicare Beneficiaries by Otolaryngologists Between 2010 and 2018.

JAMA Otolaryngol Head Neck Surg 2020 Sep;146(9):816-821

Department of Otolaryngology, Massachusetts Eye and Ear, Boston.

Importance: Clinicians are increasingly adopting telemedicine in an effort to expand patient access and efficiently deliver care. However, the extent to which otolaryngologists provide telemedicine services is unclear.

Objective: To characterize recent trends in the use of telemedicine by otolaryngologists to deliver care to Medicare beneficiaries.

Design, Setting, And Participants: A retrospective cross-sectional analysis was conducted between January 1, 2010, and December 31, 2018, using publicly available Medicare Physician/Supplier Procedure Summary data on physicians practicing in the field of otolaryngology and benchmark specialties (dermatology and psychiatry) that provided telemedicine services to Medicare beneficiaries.

Main Outcomes And Measures: Primary outcomes were the mean annual number of telemedicine services delivered per active physician and mean annual payment per active physician for these services. Secondary outcomes included the number, setting, and complexity of telemedicine services.

Results: Between 2010 and 2018, otolaryngologists provided 2127 total telemedicine services (7 unique service types) to Medicare beneficiaries and received $88 574 in total payment for these services. During this period, the mean number of telemedicine services increased at a compound annual growth rate (CAGR) of 11.0%, and the mean Medicare payment per otolaryngologist increased at a CAGR of 21.8%. In comparison, telemedicine use during this period generally increased at a higher rate in the fields of dermatology (mean number of services per active physician at CAGR of 13.0%; mean Medicare payment per active physician at CAGR of 12.5%) and psychiatry (mean number of services per active physician at CAGR of 25.8%; mean Medicare payment per active physician at CAGR of 26.6%). In 2018, outpatient evaluation and management visits accounted for most telemedicine services provided (337 of 353 [95.5%]) and the payments received ($17 542.13 of $18 470.47 [95.0%]) by otolaryngologists. In contrast, physicians in other specialties also provided substantial portions of telemedicine services in the inpatient (psychiatry, 18 403 of 198 478 [9.3%]; dermatology, 231 of 1034 [22.3%]) and skilled nursing facility settings (psychiatry, 14 690 of 198 478 [7.4%]; dermatology, 46 of 1034 [4.4%]).

Conclusions And Relevance: This study suggests that the extent to which otolaryngologists used telemedicine to deliver care to Medicare beneficiaries between 2010 and 2018 was rare. Although there was relative growth in the use of telemedicine by otolaryngologists during this period, absolute growth remained low. Policy makers and provider organizations should support otolaryngologists in the adoption of telemedicine technologies, especially while coronavirus disease 2019 (COVID-19) viral suppression efforts necessitate prolonged restriction of physical clinic throughput.
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http://dx.doi.org/10.1001/jamaoto.2020.1911DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7378874PMC
September 2020

Nonopioid Adjuncts and Alternatives.

Otolaryngol Clin North Am 2020 Oct 15;53(5):831-842. Epub 2020 Jul 15.

Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, 243 Charles Street, Boston, MA 02114, USA.

Multimodality nonopioid analgesia can be effective for pain control. Balancing risks and benefits of treatment should guide the appropriateness of opioid versus nonopioid pain control.
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http://dx.doi.org/10.1016/j.otc.2020.05.012DOI Listing
October 2020

Gender Representation at Conferences, Executive Boards, and Program Committees in Otolaryngology.

Laryngoscope 2021 02 16;131(2):E373-E379. Epub 2020 Jul 16.

Department of Otolaryngology - Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, U.S.A.

Objective: Women represent approximately 28.0% of academic otolaryngologists. Previous studies have shown that women in academic medicine, including surgical subspecialties, have disparate career advancement opportunities and grant funding compared to male counterparts. Representation at major academic meetings is an important career advancement opportunity. In this study, we assess the representation of women at otolaryngology conferences.

Study Design: Cross-sectional analysis of otolaryngology conference programs.

Methods: All publicly available scientific programs from The American Academy of Otolaryngology-Head and Neck Surgery Foundation Annual Meeting (AAO-HNSF), the Triological Society Annual Combined Sections Meeting (TS), and the Triological Society Annual Meeting at Combined Otolaryngology Spring Meetings (TS-COSM) were obtained and analyzed. Name and gender were collected, along with the type of role: speaker, panelist, oral session moderator, and other leadership positions. Yearly trends were analyzed and compared between the conferences and in aggregate.

Results: AAO-HNSF had available scientific programs from 2012-2017, while TS and TS-COSM had programs available from 2003-2018. Across all conferences and years, 16.9% of recorded opportunities were occupied by women, with an upward trend from 2005 to 2018. Program committees had the highest proportion of women (21.4%) and presidential citation and guest of honor recipients had the lowest (9.1%). Of all panels, 87.5% did not have any women panelists in 2003, but by 2018 only 24.0% panels were male-only. There was marked repetition among women occupying roles, with only 423 unique women occupying a total of 1,733 filled spots.

Conclusion: Measured representation of women in academic otolaryngology conferences has improved from 2003-2018. Despite this improvement, gender disparity still exists.

Level Of Evidence: 5 Laryngoscope, 131:E373-E379, 2021.
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http://dx.doi.org/10.1002/lary.28823DOI Listing
February 2021

Emotional and Personality Traits are Determinants of Activity Avoidance in Chronic Rhinosinusitis Patients.

Laryngoscope 2021 04 6;131(4):707-712. Epub 2020 Jul 6.

Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A.

Objectives: Chronic rhinosinusitis (CRS), like other sinonasal diseases, may be associated with avoidance of daily activities. Our goal was to identify characteristics associated with avoidance of activities due to CRS.

Materials And Methods: A total of 194 CRS patients were recruited. CRS symptom burden was assessed with the 22-item Sinonasal Outcome Test (SNOT-22). SNOT-22 nasal, sleep, ear/facial discomfort and emotional/psychological subdomain scores were calculated. Depressed mood was assessed using the two-item Patient Health Questionnaire (PHQ-2). Personality traits including conscientiousness, neuroticism, agreeableness, openness, and extraversion were assessed using the Big Five Inventory-10 (BFI-10) questionnaire. As the primary outcome, participants rated how often in the prior week that they had avoided any activities in day-to-day life due to their nasal or sinus symptoms on a scale of "never," "rarely," "sometimes," "often," or "extremely often." Ordinal regression models, with bootstrap validation, were used to identify associations between activity avoidance and participants' characteristics.

Results: On multivariable analysis, SNOT-22 score (odds ratio [OR] = 1.03, 95% CI, 1.01-1.04, P = .026), and conscientiousness personality trait (OR = 1.38, 95% CI, 1.05-1.81, P = .019) were positively associated with activity avoidance while age (OR = 0.98, 95% CI, 0.96-0.99, P = .049) was negatively associated with activity avoidance. Of CRS symptom burden/SNOT-22 subdomains, only the emotional/psychological subdomain score (OR = 1.28, 95% CI, 1.12-1.46, P < .001) was associated with activity avoidance.

Conclusion: Younger age and the conscientiousness personality trait were associated with activity avoidance in CRS patients. Of CRS-associated symptomatology, sadness and embarrassment were associated with activity avoidance. Emotional traits and personality most strongly predict avoidance of activities in CRS patients.

Level Of Evidence: 2c. Laryngoscope, 131:707-712, 2021.
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http://dx.doi.org/10.1002/lary.28879DOI Listing
April 2021

Endoscopic management of lateral sphenoid cerebrospinal fluid leaks: Identifying a radiographic parameter for surgical planning.

Laryngoscope Investig Otolaryngol 2020 Jun 8;5(3):375-380. Epub 2020 Jun 8.

Department of Otolaryngology-Head and Neck Surgery Harvard Medical School Boston Massachusetts USA.

Objective: Repair of cerebrospinal fluid (CSF) leaks of the lateral recess of the sphenoid (LRS) sinus can be challenging to accomplish via an endoscopic transphenoidal approach. The endoscopic transpterygoid approach can improve surgical access to the lateral recess but requires more extensive surgical dissection. We review our experience with LRS CSF leak repair via both techniques to determine whether preoperative radiologic data can help predict the most appropriate surgical approach.

Methods: Electronic medical records of patients with LRS CSF leaks were retrospectively reviewed at a single tertiary referral center. Radiographic measurements from preoperative computed tomography images were reviewed.

Results: Twenty-two LRS CSF leaks were identified. The transphenoidal and transpterygoid approach were used in 6 (27.3%) and 16 (72.7%) cases, respectively.The mean vidian canal to foramen rotundum angle of the repairs accessed transphenoidally as compared to the transptyergoid approach were not significantly different (41.93° ±10.91, 40.72° ±19.49, respectively; .63). However, the mean volume of the LRS accessed by the transpterygoid approach was significantly greater compared to those accessed through the transphenoidal approach (0.97 cm ± 0.48, 0.39 cm ± 0.40, respectively; .04). A LRS volume of 0.400 cm or greater predicted the use of the transpterygoid approach with 93.3% sensitivity and 60.0% specificity.

Conclusion: This study demonstrated that LRS CSF leaks that necessitated repair by the transpterygoid approach, rather than transphenoidal approach, were in the context of significantly larger lateral recess. Assessment of the LRS volume is a quantifiable parameter to aid in preoperative surgical planning.

Level Of Evidence: Level 4.
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http://dx.doi.org/10.1002/lio2.412DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7314466PMC
June 2020

Aspirin-exacerbated respiratory disease: A review.

Laryngoscope Investig Otolaryngol 2020 Jun 1;5(3):360-367. Epub 2020 May 1.

Division of Otolaryngology-Head and Neck Surgery Brigham and Women's Hospital Boston Massachusetts USA.

Objectives: Aspirin-exacerbated respiratory disease (AERD) is a chronic respiratory condition characterized by a triad of symptoms: asthma, chronic rhinosinusitis with nasal polyposis, and a respiratory reaction to aspirin and other cyclooxygenase-1 inhibitors, also known as nonsteroidal anti-inflammatory drugs. The objective of this review is to provide otolaryngologists with an overview of the pathophysiology, diagnosis, and treatment of this under-recognized condition.

Data Sources And Methods: Foundational papers on AERD were reviewed, focusing on the clinical otolaryngology and allergy/immunology literature and other high impact journals or trials.

Results: AERD results from increased production of pro-inflammatory leukotrienes and a decrease in production of anti-inflammatory prostaglandins associated with the dysregulation of multiple enzymes influencing eicosanoid metabolism. Diagnosis hinges on a high index of suspicion, careful history, and confirmatory testing for all three elements. Treatments include endoscopic sinus surgery; topical, inhaled, or oral corticosteroids; aspirin desensitization; leukotriene modifying drugs; and the new class of biologics such as dupilumab.

Conclusion: AERD is an under-recognized disease associated with substantial patient-reported morbidity. We expect rapid progress in the pathophysiological understanding of this disease and available treatments in the coming decades.

Level Of Evidence: 5.
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http://dx.doi.org/10.1002/lio2.387DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7314471PMC
June 2020

Management of odontogenic sinusitis: multidisciplinary consensus statement.

Int Forum Allergy Rhinol 2020 07 7;10(7):901-912. Epub 2020 Jun 7.

Department of Otolaryngology, Medical College of Wisconsin, Milwaukee, WI.

Background: Odontogenic sinusitis (ODS) can present a therapeutic dilemma because multiple treatment strategies have been reported. ODS review articles have been published, but they have lacked multidisciplinary collaboration and an evidence-based methodology. The purpose of this article was to perform an evidence-based review of ODS management options, and develop a multidisciplinary consensus statement on ODS management options.

Methods: An evidence-based review of dental and medical literature on ODS management was performed using PubMed, EMBASE, and Cochrane Review Databases up to December 2019. Exclusion criteria included non-English-language articles, case series with fewer than 10 patients, fungal sinusitis, and studies that did not report treatment success rates. Because aggregate levels of evidence for recommendations were no higher than level C, a clinical consensus statement was conducted using a modified Delphi method.

Results: Sixteen articles met inclusion criteria for the evidence-based review on the following ODS management options: dental treatment alone or combined with ESS for various dental pathologies, and endoscopic sinus surgery (ESS) alone for dental implant-related ODS. Strong consensus was achieved for 9 of the 10 clinical statements, the strongest being the use of shared decision-making for selecting management strategies. No consensus was reached for determining the extent of ESS necessary for uncomplicated ODS.

Conclusion: Strong consensus was reached that ODS management should involve shared decision-making between the otolaryngologist, dental provider, and patient, where the benefits and risks of dental treatment and ESS are discussed. Higher-quality studies are necessary to develop evidence-based treatment recommendations for ODS.
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http://dx.doi.org/10.1002/alr.22598DOI Listing
July 2020

Drug-eluting implants in chronic rhinosinusitis: an evidence-based review with recommendations.

Int Forum Allergy Rhinol 2020 07 1;10(7):856-870. Epub 2020 Jun 1.

Division of Otolaryngology-Head and Neck Surgery, University of Utah, Salt Lake City, UT.

Background: Drug-eluting implants are becoming increasingly popular in the treatment of chronic rhinosinusitis (CRS). A previous attempt to make an evidence-based recommendation was hindered by limited evidence and experience with these implants. Since that time, the body of literature discussing drug-eluting implants has grown rapidly. The objective of this study was to review drug-eluting implants designed for use in the sinonasal cavity through an evidence-based review with recommendations.

Methods: A systematic review of the literature was performed using PubMed, EMBASE, Cochrane Review, and gray literature databases from January 1990 through February 2019 to examine drug-eluting implants used in CRS. Benefit-harm assessments, value judgments, and recommendations were made based on the available evidence. Study exclusion criteria included studies unavailable in English and non-endoscopic sinus surgeries. All authors agreed on recommendations through an iterative process.

Results: Thirty-one studies were included in the final analysis. Absorbable drug-eluting implants achieved a high aggregate grade of evidence (A), with a recommendation for their use to be considered in carefully selected patients. Nonabsorbable drug-eluting implants were recommended against due to minimal evidence supporting clinical efficacy. Antibiotic and alternative drug-eluting implants lack sufficient evidence for recommendations.

Conclusion: Absorbable steroid-eluting implants are recommended for carefully selected patients with CRS. Additional research to define appropriate patient selection is needed.
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http://dx.doi.org/10.1002/alr.22565DOI Listing
July 2020

Airborne Aerosol Generation During Endonasal Procedures in the Era of COVID-19: Risks and Recommendations.

Otolaryngol Head Neck Surg 2020 09 26;163(3):465-470. Epub 2020 May 26.

Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA.

Objective: In the era of SARS-CoV-2, the risk of infectious airborne aerosol generation during otolaryngologic procedures has been an area of increasing concern. The objective of this investigation was to quantify airborne aerosol production under clinical and surgical conditions and examine efficacy of mask mitigation strategies.

Study Design: Prospective quantification of airborne aerosol generation during surgical and clinical simulation.

Setting: Cadaver laboratory and clinical examination room.

Subjects And Methods: Airborne aerosol quantification with an optical particle sizer was performed in real time during cadaveric simulated endoscopic surgical conditions, including hand instrumentation, microdebrider use, high-speed drilling, and cautery. Aerosol sampling was additionally performed in simulated clinical and diagnostic settings. All clinical and surgical procedures were evaluated for propensity for significant airborne aerosol generation.

Results: Hand instrumentation and microdebridement did not produce detectable airborne aerosols in the range of 1 to 10 μm. Suction drilling at 12,000 rpm, high-speed drilling (4-mm diamond or cutting burs) at 70,000 rpm, and transnasal cautery generated significant airborne aerosols ( < .001). In clinical simulations, nasal endoscopy ( < .05), speech ( < .01), and sneezing ( < .01) generated 1- to 10-μm airborne aerosols. Significant aerosol escape was seen even with utilization of a standard surgical mask ( < .05). Intact and VENT-modified (valved endoscopy of the nose and throat) N95 respirator use prevented significant airborne aerosol spread.

Conclusion: Transnasal drill and cautery use is associated with significant airborne particulate matter production in the range of 1 to 10 μm under surgical conditions. During simulated clinical activity, airborne aerosol generation was seen during nasal endoscopy, speech, and sneezing. Intact or VENT-modified N95 respirators mitigated airborne aerosol transmission, while standard surgical masks did not.
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http://dx.doi.org/10.1177/0194599820931805DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7251624PMC
September 2020

Characterising the potential for recall bias in anchor-based MCID calculation of patient-reported outcome measures for chronic rhinosinusitis.

Clin Otolaryngol 2020 09 14;45(5):768-774. Epub 2020 Jun 14.

Department of Otolaryngology - Head & Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA.

Objective: Anchor-based methods to calculate the minimal clinically important difference (MCID) of a patient-reported outcome measure (PROM) may suffer from recall bias. This has never been investigated for otolaryngic PROMs. We sought to identify evidence of recall bias in calculation of MCIDs of PROMs for patients with chronic rhinosinusitis (CRS).

Design: Retrospective analysis of data from two previous studies calculating the MCID of the 22-item Sinonasal Outcome Test (SNOT-22) and 5-dimensonal EuroQol questionnaire (EQ-5D) in CRS patients.

Setting: Tertiary rhinology clinic.

Participants: Adults with CRS.

Main Outcome Measures: SNOT-22 score, and EQ-5D visual analog scale scores (EQ-5D VAS) and health utility values (EQ-5D HUV) before and after medical treatment for CRS. After treatment, participants were asked to rate the change in sinonasal symptoms and general health (the anchor question) as "Much worse," "A little worse," "About the same," "A little better" or "Much better." Participants' responses to the anchor question were checked for association with post-treatment and pre-treatment scores using ordinal regression.

Results: On univariate association, post-treatment SNOT-22 and EQ-5D scores were associated with respective participants' anchor question responses (P < .001 in all cases). Only pre-treatment SNOT-22 score was associated with anchor question responses (P = .017) on univariate association, in contrast to pre-treatment EQ-5D scores. Pre-treatment EQ-5D scores only associated with anchor question responses when controlling for post-treatment scores.

Conclusion: The anchor-based MCIDs of the SNOT-22, which reflects disease-specific QOL, and the EQ-5D, which reflects general health-related QOL, appear to be largely free of recall bias.
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http://dx.doi.org/10.1111/coa.13589DOI Listing
September 2020

Chronic Rhinosinusitis Patients With and Without Polyps Experience Different Symptom Perception and Quality of Life Burdens.

Am J Rhinol Allergy 2020 Nov 21;34(6):742-750. Epub 2020 May 21.

Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio.

Objective: We sought to determine if chronic rhinosinusitis (CRS) patients with nasal polyps (CRSwNP) differentially perceived CRS symptom burden compared to patients without nasal polyps (CRSsNP) and to what extent CRS symptom severity was associated with quality of life (QOL) and patient-reported symptom control in the 2 groups.

Methods: A total of 600 patients (266 CRSwNP and 334 CRSsNP) presenting with CRS were recruited. CRS symptom burden was assessed with the 22-item Sinonasal Outcome Test (SNOT-22). SNOT-22 nasal, sleep, ear/facial discomfort, and emotional subdomain scores were calculated. General health-related QOL was assessed with the visual analog scale of the 5-dimensional EuroQol questionnaire (EQ-5D VAS). Patients rated their CRS symptom control on a 5-point scale.

Results: SNOT-22 scores did not differ between CRSwNP (mean: 35.6) and CRSsNP (mean: 36.3). There were no differences in nasal, sleep, and emotional subdomains of the SNOT-22. CRSsNP had higher ( = .003) ear/facial subdomain scores than CRSwNP, while CRSwNP reported greater hyposmia ( < .001). EQ-5D VAS was significantly lower ( = .011) in CRSsNP (mean: 68.9) compared to CRSwNP (mean: 73.2). However, CRSwNP patients reported significantly less symptom control, compared to CRSsNP, in association with nasal and emotional symptoms.

Conclusion: CRSwNP and CRSsNP have differences in symptom profile, effect on health-related QOL, and patient-perceived symptom control. CRSsNP experience significantly greater burden of ear/facial discomfort, while CRSwNP report greater hyposmia. Although CRSsNP reports lower general health-related QOL overall, CRSwNP patients had lower levels of CRS symptom control for every incremental increase in symptom burden suggesting greater sensitivity/intolerance to CRS symptoms.
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http://dx.doi.org/10.1177/1945892420927244DOI Listing
November 2020

Trends in Ambulatory Surgery Center Utilization for Otolaryngologic Procedures among Medicare Beneficiaries, 2010-2017.

Otolaryngol Head Neck Surg 2020 Jun 14;162(6):873-880. Epub 2020 Apr 14.

Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, Massachusetts, USA.

Objective: Surgical care is increasingly shifting to freestanding ambulatory surgical centers (ASCs). The extent to which otolaryngologists use ASCs has implications for patient safety and health care spending. This study characterizes trends in utilization and resultant financial implications for common otolaryngologic procedures performed at ASC and hospital outpatient departments (HOPDs).

Study Design: Retrospective cross-sectional analysis.

Setting: ASCs, HOPDs.

Subjects And Methods: Subjects included Medicare beneficiaries undergoing outpatient otolaryngologic procedures between 2010 and 2017. Procedures included the 20 highest-volume procedures performed by otolaryngologists at ASCs in 2017. Main outcomes included absolute and relative percentage difference in the proportion of procedures furnished at ASCs and HOPDs and estimated Medicare cost savings resulting from increased ASC utilization between 2011 and 2017.

Results: The proportion of outpatient otolaryngologic procedures performed at ASCs increased by 1.8% (relative difference: 10.0%; mean annual relative increase: 1.60%), and the proportion located at HOPDs decreased by 6.0% (relative difference: -11.8%; mean annual relative decrease: -1.6%) between 2010 and 2017. Rhinoplasty accounted for the largest absolute increase in ASC utilization over the study period (absolute [relative] 8.9% [33.5%]). Increased ASC utilization resulted in an estimated $7.1 million in cost savings to Medicare between 2011 and 2017.

Conclusion: Otolaryngologists shifted outpatient surgical care from HOPDs to ASCs between 2010 and 2017, with resultant reductions in Medicare expenditures. Further research is necessary to examine the impact of this shift on patient safety.
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http://dx.doi.org/10.1177/0194599820914298DOI Listing
June 2020

Opioid Use and Sinus Surgery.

Authors:
Stacey T Gray

Int Forum Allergy Rhinol 2020 03;10(3):275-277

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http://dx.doi.org/10.1002/alr.22555DOI Listing
March 2020

Endonasal instrumentation and aerosolization risk in the era of COVID-19: simulation, literature review, and proposed mitigation strategies.

Int Forum Allergy Rhinol 2020 Jul 22;10(7):798-805. Epub 2020 May 22.

Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, MA.

Background: International experience with coronavirus 2019 (COVID-19) suggests it poses a significant risk of infectious transmission to skull base surgeons, due to high nasal viral titers and the unknown potential for aerosol generation during endonasal instrumentation. The purpose of this study was to simulate aerosolization events over a range of endoscopic procedures to obtain an evidence-based aerosol risk assessment.

Methods: Aerosolization was simulated in a cadaver using fluorescein solution (0.2 mg per 10 mL) and quantified using a blue-light filter and digital image processing. Outpatient sneezing during endoscopy was simulated using an intranasal atomizer in the presence or absence of intact and modified surgical mask barriers. Surgical aerosolization was simulated during nonpowered instrumentation, suction microdebrider, and high-speed drilling after nasal fluorescein application.

Results: Among the outpatient conditions, a simulated sneeze event generated maximal aerosol distribution at 30 cm, extending to 66 cm. Both an intact surgical mask and a modified VENT mask (which enables endoscopy) eliminated all detectable aerosol spread. Among the surgical conditions, cold instrumentation and microdebrider use did not generate detectable aerosols. Conversely, use of a high-speed drill produced significant aerosol contamination in all conditions tested.

Conclusion: We confirm that aerosolization presents a risk to the endonasal skull base surgeon. In the outpatient setting, use of a barrier significantly reduces aerosol spread. Cold surgical instrumentation and microdebrider use pose significantly less aerosolization risk than a high-speed drill. Procedures requiring drill use should carry a special designation as an "aerosol-generating surgery" to convey this unique risk, and this supports the need for protective personal protective equipment.
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http://dx.doi.org/10.1002/alr.22577DOI Listing
July 2020

The Rationale for Multidisciplinary Management of Chronic Rhinosinusitis with Nasal Polyposis.

J Allergy Clin Immunol Pract 2020 05 12;8(5):1565-1566. Epub 2020 Mar 12.

Division of Allergy, Asthma, and Clinical Immunology, Mayo Clinic, Scottsdale, AZ. Electronic address:

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http://dx.doi.org/10.1016/j.jaip.2020.03.001DOI Listing
May 2020