COSM 2023 Sessions: A Review of Otolaryngology Topics

Editor’s note: In the April 2023 issue, we listed a variety of topics at the 2023 Combined Otolaryngology Spring Meetings (COSM) in Boston that had piqued the interest of ENTtoday’s physician editor Robin W. Lindsay, MD. This issue, we’ve taken a closer look and highlighted some of the topics chosen. —Amy E. Hamaker

Number of Tube Procedures Falls After Guidelines Issued

The 2013 Clinical Practice Guidelines (CPG) on tympanostomy tube procedures led to a drop in the number of procedures performed, according to a new analysis. The findings are an indication that the guidelines are more than just a publication in a journal; they have real-life effects on clinical care.

“We showed a 19% decrease in procedure rate following the publication of the CPG in 2013 in both military and civilian practices, suggesting that CPGs do impact clinical practice and decision-making,” said Jason Adams, MD, an otolaryngologist and researcher at Brooke Army Medical Center in San Antonio, Texas.

Tympanostomy tube insertion is the most common ambulatory procedure performed on U.S. children, with an annual healthcare cost of $1.8 billion, Dr. Adams said. “Nearly one in 10 children will have a set of ear tubes placed by the time they’re 17,” he added.

The 2013 CPG were meant to give clinicians evidence-based recommendations on patient selection for tube insertions, as well as surgical indications and management. Among other statements, the group recommended that the procedures shouldn’t be performed on children with a single episode of otitis media with effusion (OME) lasting for less than three months, that clinicians should offer bilateral insertion to children with bilateral OME lasting for three months or longer and documented hearing difficulties, that clinicians shouldn’t perform the procedures on children with acute otitis media (AOM) who don’t have middle ear effusion in either ear, and that clinicians should offer bilateral insertion to children with recurrent AOM who have unilateral or bilateral middle ear effusion (Otolaryngol Head Neck Surg. 2013 Jul;149:S1-35).

Researchers set out to capture all tympanostomy tube procedures done within the Department of Defense, looking at the CPT codes for insertions for children 17 years old or younger in the Tricare System, the healthcare program for uniformed service members, retirees, and their families.

We showed a 19% decrease in procedure rate following the publication of the Clinical Practice Guidelines in both military and civilian practices, suggesting that they do impact clinical practice and decision-making. —Jason Adams, MD

There were 62,700 procedures performed between 2010 and 2012, compared to 50,700 procedures between 2014 and 2016, amounting to a 19% decrease. The 19% drop was comparable between military and civilian cases, Dr. Adams reported.

In 2018, researchers at Weill Cornell Medicine in New York City reported that 16% more cases of AOM and OME were identified in 2014, after the guidelines were published, as compared with 2012, noted Dr. Adams (Otolaryngol Head Neck Surg. 2018;159:914–919). Studies in 2019 and 2023 also examined the number of tympanostomy tube insertions before and after the guidelines were published (Int J Pediatr Otorhinolaryngol. 2019;122:40–43; Otolaryngol Head Neck Surg. [Published online ahead of print Feb. 5, 2023]).

“We know that increased adherence to the guidelines decreases the number of operative procedures,” said Dr. Adams, “thereby decreasing the operative risk for otorrhea, persistent perforation, and repeat tube placement.”

Lower Socioeconomic Status, Medicaid Linked to Lower Chance of OSA Surgery

People with obstructive sleep apnea (OSA) who are on Medicaid or state-subsidized insurance, and those in lower socioeconomic tiers, were less likely to undergo surgery for their condition. The findings, from an analysis of data from Kaiser Permanente Northern California, give insight into the patients who might be more at risk of not obtaining procedures that could help them.

“It’s estimated that 26% of adults between age 30 and 70 have OSA,” said Nikolas Block-Wheeler, MD, MS, an otolaryngology–head and neck surgery specialist and researcher at the Kaiser Permanente Oakland Medical Center. “Its effects are far-reaching and associated with systemic disease.” Up to 50% of those prescribed CPAP will stop using it, he said, and only about 1.3% of the OSA patient population will have soft-tissue surgery. “Very little data exist regarding demographic characteristics or potential disparities in access to surgical care for this population,” he said.

The analysis looked at the adult OSA population treated in the Kaiser Northern California system between 2009 and 2016, excluding those treated with hypoglossal nerve stimulation—which was not yet widely implemented during this period—as well as those receiving tracheostomy and bariatric surgery.

Those not receiving surgery tended to be older, with an average age of 55, compared to 40 for those receiving surgery. A lower proportion of those not receiving surgery were male—62% compared to 67%. Those MDnot receiving surgery also had a higher BMI—34.2 versus 32.0—and had a lower comorbidity burden, with 53% having a 0 score on the Charlson Comorbidity Index, versus 74.1% for those undergoing sleep surgery (P < 0.0001 for all).

Researchers used the Neighborhood Deprivation Index (NDI) to assess the relationship of socioeconomic status to OSA surgery. NDI is a more granular approach than using ZIP codes, factoring in 13 variables in the categories of wealth and income, education, occupation, and housing conditions, Dr. Block-Wheeler said.

Compared to the least deprived NDI quartile, those in the most deprived quartile were 16% less likely to receive surgery, while those in the second- and third-most deprived quartiles were 20% and 23% less likely to receive surgery, respectively.

Those on Medicaid or state-subsidized insurance were 43% less likely to receive surgery compared to those with other insurance types, researchers found.

The findings based on NDI also indicate access problems, he said. In the analysis of race and ethnicity, the groups compared were non-Hispanic White, Black, Asian/Pacific Islander, Hispanic, and Other/Unknown. Dr. Block-Wheeler emphasized that these were opt-in categories that were predefined. Those identifying as Black were 12% less likely than Whites to undergo surgery, Asian/Pacific Islander 17% less likely, and Hispanics 18% more likely, researchers reported.

Researchers also looked at marital status, which Dr. Block-Wheeler said was “an interesting category.” Those who were single were 13% less likely to receive surgery than those who were married, but those who were separated or divorced were 45% more likely. Dr. Block-Wheeler suggested that those separated or divorced might have been diagnosed at the behest of their prior partner, and then the patient pursued surgical treatment once the relationship ended.

“Future work,” Dr. Block-Wheeler said, “will begin to look at changes over time and investigate drivers of these differences.”

Family Assistance Predictive of Discharge Location After Free Flaps

A lack of family assistance was the top predictor of whether a patient undergoing free flap reconstruction needed inpatient rehabilitation after the surgery, according to a recent analysis.

“Discharge disposition can be unpredictable, with recovery sometimes changing baseline functional status,” said Megha Chandna, BS, an otolaryngology research fellow at Thomas Jefferson University in Philadelphia. “We believe that this is important because home discharge after surgery has been described as a performance metric at a variety of hospitals, and other studies have found a relationship of discharge disposition with functional abilities at admission,” including walking, basic activities of daily living, and cognition, as well as with age, gender, BMI, and comorbidities.

Researchers examined all elective admissions for head and neck free flap reconstruction at Jefferson between January 2017 and November 2022. The patients all had a postoperative evaluation by physical therapy and occupational therapy. The researchers looked only at whether a patient was discharged to their home or to inpatient rehabilitation. Of the 544 patients whose cases were assessed, 20.3% were discharged to inpatient rehab and 79.7% to home. Neoplasm was the most common indication for the procedure, and an anterolateral thigh free flap was the most common type of procedure.

Researchers found that the group needing inpatient rehab tended to be older, needed more assistance, had lower cognitive function, had fewer stairs at home, and had a longer length of stay. There were no differences according to gender, donor site, tube feeds, or use of assistive devices.

A lack of family assistance made a patient 4.5 times more likely to be discharged to inpatient rehab compared to those not needing this assistance, Chandna noted. Needing assistance at baseline for activities of daily living made a patient 3.9 times more likely to be discharged to inpatient rehab compared to those not needing this kind of assistance. Other predictors included baseline cognitive dysfunction (2.4 times more likely), age 80 or older (2.3 times), and change in weight-bearing status following the surgery (2.2 times).

Chandna said the findings confirmed researchers’ expectations that these factors could help predict patients’ path of care. “Our hypothesis is that these metrics are predictive of head and neck free flap discharge destination,” she said. “And, ultimately, we would like to prescreen and counsel patients and families prior to free flap regarding their expected postop course.”

She noted that the research team hopes to continue examining factors related to discharge destination. “In the future,” she said, “we would hope to expand our sample size, look at a greater distribution of race, gender, different types of free flaps, to hopefully make a revised head and neck free-flap, pre-procedure checklist to become a predictive algorithm.”

Index Helps Predict Complications in Geriatric Tracheostomy

Nutritional risk assessed with the Geriatric Nutritional Risk Index (GNRI) was predictive of outcomes after a tracheostomy in the geriatric population, according to a new study. The findings suggest the index could be a valuable tool when performing this procedure, said Afash Haleem, BA, a medical student and researcher at Rutgers New Jersey Medical School in Newark.

[GNRI scores] can be quite useful for clinicians when looking at patients who will undergo a planned tracheostomy—patients and their families can be appropriately counseled. —Afash Haleem, BA

Tracheostomy, commonly used for prolonged mechanical ventilation due to acute respiratory failure, neuromuscular disease, aspiration, or other issues, has an incidence of about 100,000 per year. “These patients undergo a variety of different complications, including surgical site infections, hemorrhage, and pneumothorax,” Haleem said. “Unfortunately, malnutrition is a commonly discussed preoperative comorbidity for patients undergoing a variety of different surgical procedures.” There is no universal definition of malnutrition, however, with a variety of definitions in the literature and, subsequently, a wide range of prevalence estimates in the geriatric population—between 20% and 60%, he said.

The commonly used Nutritional Risk Index is calculated using the usual body weight, but this is a disadvantage in the geriatric population because the usual body weight is often misreported in these patients, he said. The GNRI, proposed in 2005, is a way of assessing malnutrition without using usual body weight; instead, it’s calculated using serum albumin, current body weight, and “ideal weight” according to the Lorentz formula, Haleem explained.

Researchers pulled cases from the American College of Surgeons National Surgical Quality Improvement Program from 2005 to 2018, including patients over age 65 but excluding those missing weight, height, and serum albumin data. Those with a GNRI of less than 92 were considered to have severe malnutrition, between 92 and 98, moderate malnutrition, and above 98, normal nutrition.

In the analysis, 29% of patients had severe malnutrition, 17.3% moderate malnutrition, and 53.7% normal nutrition. In the analysis, those with severe malnutrition were more likely to have medical complications. Cumulatively, 69.3% of those severely malnourished had a medical complication, compared to 50.1% of those with moderate malnourishment, and 36.0% of those with normal nutrition (P < 0.001). Researchers found that 46.0% of those with severe malnutrition had cumulative pulmonary complications, compared to 19.0% of those with moderate nutrition, and 15.7% of those with normal nutrition (P < 0.001). Those with severe malnutrition were significantly more likely to get pneumonia and need to be ventilated for more than 48 hours, researchers reported (P = 0.001 and < 0.001, respectively).

“Very clearly, a reduced GNRI of 92 was a consistently significant independent risk factor for multiple different complications for these patients,” Haleem said. “This can be quite useful for clinicians when looking at patients who will undergo a planned tracheostomy—patients and their families can be appropriately counseled,” he said. “In more emergent circumstances of tracheostomies, triaging can be appropriately performed, and patients can be more closely monitored postoperatively to ensure reduction of complications.”

Residency Programs Tweak Student Assessments Following Step 1 Pass/Fail

Most residency programs don’t believe that medical students will be better prepared clinically after the switch of the U.S. Medical Licensing Examination (USMLE) Step 1 to a pass/fail format, and letters of recommendation still ranked highest when evaluating residency applicants before and after the change.

Step 1 is the first of the three-part board exam usually taken after the preclinical years of medical school. Performance had been measured as a score from 1 to 300, but the exam went to a pass/fail format on Jan. 26, 2022. Step 2 Clinical Knowledge, taken after the clinical years of medical school, is still assessed with a three-digit score.

“Our objective was to figure out how otolaryngology residency programs viewed USMLE Step 1 and Step 2 when assessing applicants’ ability and whether the importance of applicant criteria would change after the transition to pass/fail,” said Lydia Yang, BS, a medical student and researcher at the University of Alabama, Birmingham.

Researchers developed a survey of seven multiple choice questions and two questions in which responders were asked to put together a ranked list of applicant criteria. The surveys were sent to 125 otolaryngology residency programs; the response rate was 40% for the survey and 24% for the rankings.

One question was, “Do you believe the USMLE Step scores accurately predict a resident’s ability to perform clinically in otolaryngology?” Fifty-eight percent said no for the Step 1 exam, while 12% said yes. For Step 2, 18% said yes, while 40% said no. Yang noted that while the percentage was low for Step 1, “not many more said yes for Step 2 versus Step 1.”

On, “Do you believe USMLE Step scores adequately predict a resident’s ability to pass otolaryngology board exams?” 52% said yes and 22% said no for Step 1, while 32% said yes and 28% said no for Step 2.

A majority of programs (66%) said that students would not be better prepared clinically with the Step 1 exam scored as pass/fail. Fifty percent of the otolaryngology programs said a student’s ranking would be considered more with the Step 1 exam becoming pass/fail. 

Researchers found that the highest-ranked item in terms of usefulness was letters of recommendation, both before and after the change to pass/fail, when evaluating residency applicants. The mean number of otolaryngology abstracts, presentations, and publications ranked very high both before and after the change, as did the mean number of otolaryngology research experiences.

The item that rose the most in the evaluation was the Step 2 score, from an average ranking of 10.7 before the Step 1 change to the higher ranking of 7.8 after the change, said Yang. “Otolaryngology residency programs don’t believe the transition to pass/fail will better prepare students for residency,” she said. “Step 2 ideally would test clinical knowledge, but as you can see, only a small percentage of programs believe that otolaryngology students would be better prepared for residency.

“However,” she added, “Step 2 scores will still become more important when evaluating applicants, likely because schools are still looking for objective measures to report now that Step 1 scores have gone away.”

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Thomas R. Collins is a freelance medical writer based in Florida.