OBJECTIVE To characterize Otolaryngology residency program strategies for recruiting underrepresented minorities in medicine (URiM) residents and their perceived effectiveness, and explore perceived barriers to recruitment. DESIGN We conducted a survey of Otolaryngology program directors (PDs) at the 122 accredited programs within the United States, utilizing a validated and previously published survey utilized within the OB-GYN literature. We solicited information regarding recruitment of underrepresented minorities in medicine (URiM) applicants, effectiveness of strategies, and perceived barriers in recruitment. SETTING A national survey of U.S. accredited residency programs in Otolaryngology in 2022-2023. RESULTS A total of 42 (34%) PDs responded. 55% of programs reported an increase in URiM residents, of which 18(43%) described an intentional change. Almost all PDs reported placing at least “some” significance in the recruitment of URiM residents (95%). Statistically significant differences were seen in recruitment methods between programs that saw an increase in URiM resident recruitment an those that did not. Additionally, Program Directors believed that increased face-face interaction with applicants were the most effective forms of recruitment. PDs found the biggest challenge to recruitment was a lack of diverse applicants (6.3/10) and faculty (5.8/10). This perception did not change when adjusted for programs that saw an increase in URiM trainee recruitment. CONCLUSIONS This study demonstrates the URiM resident recruitment practices and perceived effectiveness of these strategies within otolaryngology programs nationally. The results and analysis may provide programs who are looking to diversify their workforce with some effective and meaningful strategies to start the process.

Importance:Involvement of deep margins represents a significant challenge in the treatment of oropharyngeal cancer, and given practical limitations of frozen-section analysis, a need exists for real-time, nondestructive intraoperative margin analysis. Wide-field optical coherence tomography (WF-OCT) has been evaluated as a tool for high-resolution adjunct specimen imaging in breast surgery, but its clinical application in head and neck surgery has not been explored.Objective:To evaluate the utility of WF-OCT for visualizing microstructures at margins of excised oral and oropharyngeal tissue.Design, Setting, and Participants:This nonrandomized, investigator-initiated qualitative study evaluated the feasibility of the Perimeter Medical Imaging AI Otis WF-OCT device at a single academic center. Included participants were adults undergoing primary ablative surgery of the oral cavity or oropharynx for squamous cell carcinoma in 2018 and 2019. Data were analyzed in October 2019.Exposures:Patients were treated according to standard surgical care. Freshly resected specimens were imaged with high-resolution WF-OCT prior to routine pathology. Interdisciplinary interpretation was performed to interpret WF-OCT images and compare them with corresponding digitized pathology slides. No clinical decisions were made based on WF-OCT image data.Main Outcomes and Measures:Visual comparisons were performed between WF-OCT images and hematoxylin and eosin slides.Results:A total of 69 specimens were collected and scanned from 53 patients (mean [SD] age, 59.4 [15.2] years; 35 [72.9%] men among 48 patients with demographic data) undergoing oral cavity or oropharynx surgery for squamous cell carcinoma, including 42 tonsillar tissue, 17 base of the tongue, 4 buccal tissue, 3 mandibular, and 3 other specimens. There were 41 malignant specimens (59.4%) and 28 benign specimens (40.6%). In visual comparisons of WF-OCT images and hematoxylin and eosin slides, visual differentiation among mucosa, submucosa, muscle, dysplastic, and benign tissue was possible in real time using WF-OCT images. Microarchitectural features observed in WF-OCT images could be matched with corresponding features within the permanent histology with fidelity.Conclusions and Relevance:This qualitative study found that WF-OCT imaging was feasible for visualizing tissue microarchitecture at the surface of resected tissues and was not associated with changes in specimen integrity or surgical and pathology workflow. These findings suggest that formal clinical studies investigating use of WF-OCT for intraoperative analysis of deep margins in head and neck surgery may be warranted.

OBJECTIVE: To determine whether differences exist in the descriptors used in letters of recommendations for Otolaryngology Head and Neck Surgery (OHNS) residency candidates, comparing race and gender as depicted in visual letters of recommendation (VLORs) from the 2014 and 2019 application cycles. DESIGN: Four hundred thirty-three LORS (284 narrative LORs and 149 standardized LORs) and 63 medical student performance evaluations for 104 candidates who interviewed at the University of Cincinnati OHNS residency program in 2014 and 2019 were analyzed. Descriptors from LORs and medical student performance evaluations were collected by two reviewers and QSR NVivo 12 was used to generate a word cloud that grouped words by synonym and weighted them by frequency. Reviewers coded these synonyms into one of eight descriptor categories. Race and gender were self reported from residency applications. The average of each category frequency for each race and gender were compared using student t-tests. SETTING: University of Cincinnati OHNS Residency Program. PARTICIPANTS: 104 OHNS applicants that interviewed at the University of Cincinnati in 2014 and 2019. RESULTS: Of the 104 candidates reviewed, 39 were female (37.5%). 66/104 (63%) of applicants identified as white, 31/104 (30%) as non-white, and 7/104 (7%) preferred not to say. No significant differences were found between male vs female descriptors. However, white applicants had more "leadership" descriptors (1.3% vs 0.5%, p = 0.01) and fewer "intelligence" words (6.6% vs 4.8%, p = 0.02) than non-white applicants. Applicants in 2019 were described with more team player (14.2% vs 9.6%, p < 0.0001), leadership (1.6% vs 0.7%, p = 0.047), and reserved (1.7% vs 0.7%, p = 0.02) words, but fewer grindstone (25.2% vs 32.1%, p < 0.0001) and ability/agentic (27.9% vs 32.6%, p < 0.0001) words than applicants in 2014. CONCLUSIONS: In VLORs for OHNS residency, male and female applicants are described similarly, but white applicants are described as leaders more frequently and as intelligent less frequently than non-white counterparts. Regardless, it is encouraging to see applicants described with a more humanistic vocabulary in 2019. ( J Surg Ed 79:935-942. (c) 2022 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Importance There is epidemiologic evidence that the increasing incidence of thyroid cancer is associated with subclinical disease detection. Evidence for a true increase in thyroid cancer incidence has also been identified. However, a true increase in disease would likely be heralded by an increased incidence of thyroid-referable symptoms in patients presenting with disease. Objectives To evaluate whether modes of detection (MODs) used to identify thyroid nodules for surgical removal have changed compared with historic data and to determine if MODs vary by geographic location. Design, Setting, and Participants This was a retrospective analysis of pathology and medical records of 1328 patients who underwent thyroid-directed surgery in 16 centers in 4 countries: 4 centers in Canada, 1 in Denmark, 1 in South Africa, and 12 in the US. The participants were the first 100 patients (or the largest number available) at each center who had thyroid surgery in 2019. The MOD of the thyroid finding that required surgery was classified using an updated version of a previously validated tool as endocrine condition, symptomatic thyroid, surveillance, or without thyroid-referable symptoms (asymptomatic). If asymptomatic, the MOD was further classified as clinician screening examination, patient-requested screening, radiologic serendipity, or diagnostic cascade. Main Outcomes and Measures The MOD of thyroid nodules that were surgically removed, by geographic variation; and the proportion and size of thyroid cancers discovered in patients without thyroid-referable symptoms compared with symptomatic detection. Data analyses were performed from April 2021 to February 2022. Results Of the 1328 patients (mean [SD] age, 52 [15] years; 993 [75%] women; race/ethnicity data were not collected) who underwent thyroid surgery that met inclusion criteria, 34% (448) of the surgeries were for patients with thyroid-related symptoms, 41% (542) for thyroid findings discovered without thyroid-referable symptoms, 14% (184) for endocrine conditions, and 12% (154) for nodules with original MOD unknown (under surveillance). Cancer was detected in 613 (46%) patients; of these, 30% (183 patients) were symptomatic and 51% (310 patients) had no thyroid-referable symptoms. The mean (SD) size of the cancers identified in the symptomatic group was 3.2 (2.1) cm (median [range] cm, 2.6 [0.2-10.5]; 95% CI, 2.91-3.52) and in the asymptomatic group, 2.1 (1.4) cm (median [range] cm, 1.7 [0.05-8.8]; 95% CI, 1.92-2.23). The MOD patterns were significantly different among all participating countries. Conclusions and Relevance This retrospective analysis found that most thyroid cancers were discovered in patients who had no thyroid-referable symptoms; on average, these cancers were smaller than symptomatic thyroid cancers. Still, some asymptomatic cancers were large, consistent with historic data. The substantial difference in MOD patterns among the 4 countries suggests extensive variations in practice.

Purpose of review Provide an up to date review of the diagnosis, workup and treatment of dermatofibrosarcoma protuberans (DFSP). DFSP can be a challenging disease to manage and adequate understanding of the most up to date literature can help provide comprehensive treatment strategies. Recent findings DFSP is an infiltrative cutaneous sarcoma. It tends to have deep local invasion with a high risk of local recurrence, but a low risk of distant metastasis. It presents typically as a slow growing, asymptomatic skin lesion. It presents rarely in the head and neck, only 15% of the time. Recent data has discussed the role of wide local excision (WLE) vs. Mohs surgery. In addition, for unresectable disease the role of systemic therapy and immunomodulatory agents such as Imatinib has shown success. Summary Typically, surgical management is the first line for DFSP, however the risk for local recurrence still remains high with negative margins. Due to this risk, lifelong surveillance is required after initial diagnosis and management. Similar to other head and neck tumors, most recurrences happen within the first 3 years after treatment. DFSP can be treated with WLE or Mohs. For aggressive disease that is considered unresectable systemic therapy does exist, including molecular targeted therapies.

The LaryngoscopeVolume 131, Issue 12 p. 2671-2673 Comprehensive Otolaryngology The Role of a Social Media-Based Surgical Education Platform: "OtoNotes" Rohini R. Bahethi BS, Corresponding Author Rohini R. Bahethi BS rohini.bahethi@icahn.mssm.edu orcid.org/0000-0002-7041-5346 Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, U.S.A. Send correspondence to Rohini R. Bahethi, 1 Gustave L. Levy Place, New York, NY 10029. E-mail: rohini.bahethi@icahn.mssm.eduSearch for more papers by this authorJay Agarwal MD, Jay Agarwal MD Hackensack University Medical Center, New York, New York, U.S.A.Search for more papers by this authorArvind Badhey MD, Arvind Badhey MD orcid.org/0000-0003-0730-0500 Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A.Search for more papers by this author Rohini R. Bahethi BS, Corresponding Author Rohini R. Bahethi BS rohini.bahethi@icahn.mssm.edu orcid.org/0000-0002-7041-5346 Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, U.S.A. Send correspondence to Rohini R. Bahethi, 1 Gustave L. Levy Place, New York, NY 10029. E-mail: rohini.bahethi@icahn.mssm.eduSearch for more papers by this authorJay Agarwal MD, Jay Agarwal MD Hackensack University Medical Center, New York, New York, U.S.A.Search for more papers by this authorArvind Badhey MD, Arvind Badhey MD orcid.org/0000-0003-0730-0500 Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A.Search for more papers by this author First published: 20 May 2021 https://doi.org/10.1002/lary.29607 r.b. contributed to the manuscript preparation and data analysis. j.a. contributed to the manuscript preparation, data analysis, design and conceptions. a.b. contributed to the manuscript preparation, data analysis, design and conception. Editor's Note: This Manuscript was accepted for publication on April 29, 2021. The authors have no funding, financial relationships, or conflicts of interest to disclose. Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article. Volume131, Issue12December 2021Pages 2671-2673 RelatedInformation

Palatomaxillary reconstruction presents a unique challenge for the reconstructive surgeon. The maxillofacial skeleton preserves critical aerodigestive functions-it provides a stable hard palate to support mastication and separate the nasal and oral cavities, and buttress support to provide adequate midface contour. Free tissue transfer has become a routine part of the reconstructive ladder in managing palatomaxillary defects. While there is a wide variety of options for bony reconstruction within the head and neck, the fibula and the scapula, and their variations, have become two of the most commonly used options for midface reconstruction. This review will discuss the advantages and disadvantages of both in specific regard to reconstruction of the palatomaxillary area.

The vessel-depleted neck presents a unique and challenging scenario for reconstructive surgery of the head and neck. Prior surgery and radiation often result in significant scarring and damage to the neck vasculature, making identification of suitable recipient vessels for microvascular free tissue transfer exceedingly difficult. Therefore, alternative reconstructive techniques and/or vessel options must be considered to obtain a successful reconstructive outcome for a patient. In this article, we discuss our experience and approach to the management of the vessel-depleted neck, emphasizing the importance of preoperative planning and having multiple backup options prior to surgery. The various preoperative imaging modalities and available options for recipient arteries and veins are presented in detail. Additionally, we discuss modifications of select free flaps to maximize their utility in successful reconstruction. Together with thoughtful preoperative planning, these techniques can help aid the reconstructive surgeon in addressing the complex decisions associated with the vessel-depleted neck.

Objective Report a unique case of absent posterior belly of digastric muscle, with a literature review and discussion of its clinical importance. Methods Present a case report and review the current literature including PUBMED search terms; “absent posterior digastric”, “digastric muscle”, “posterior belly”. Results While there were multiple reports of accessory anterior and posterior bellies and absence of anterior belly, there is a paucity of literature on absence of posterior belly of digastric muscle. Conclusion To our knowledge, this is the first report of an absent posterior belly of the digastric muscle. The posterior belly of the digastric muscle is an important landmark in neck dissection, and its absence makes knowledge of other anatomic landmarks critically important. Laryngoscope , 131:1501–1502, 2021

a COVID-19 Intensive Care Unit Run by Otolaryngology Residents Elmhurst Hospital Center (EHC) sits tightly wedged between the cramped apartments of Jackson Heights and the bustle of Flushing Meadows, in central Queens, New York City (NYC).The hospital provides primary, emergency, and inpatient care for one of the poorest and most diverse districts in the nation.Like the city that surrounds it, EHC is a true melting pot, with physicians, nurses, and other essential workers from around the world.Owing to the economic and cultural roots of the patient population, EHC acts as the truest version of a safety net for some of NYC's most disenfranchised patients. 1Unfortunately, its diversity and open arms caused it to be a prime target for coronavirus disease 2019 .At the height of the pandemic in NYC, 95% of EHC inpatients tested positive, and our hospital was operating at 500% surge intensive care unit (ICU) capacity.Eventually, EHC aptly began to be referred to as "the epicenter of the epicenter." 2 As the pandemic reared its ugly head with 1 of every 25 people infected with the disease and over 700 patients a day dying in NYC, 3 it was at EHC that we found ourselves, a few otolaryngology residents, wondering what was going to happen to us, the patients we treat, and our city.We saw the numbers begin to climb at the hospital.Emergency department wings turned into COVID-19 wards; surgeries were cancelled left and right.Our training became paused.We waited.As this happened, other departments in our hospital system dispatched clinicians to the front lines in the emergency department (ED), the floors, and the ICUs.In contrast, in an effort to reduce our exposure, keep us healthy, and not lose our emergency airway teams, our residency program divided us otolaryngology (ENT) residents into hospital-specific "pods," often alternating weeks on and off, sheltering us from the rising tide.With days passing, and clinical exposure replaced with endless virtual education sessions, we watched as many of our colleagues, family members, and friends responded on the front lines, and we worried for them.However, for some of us, especially those stationed at EHC, it began to feel as if we were hiding.We felt useless, while others put themselves in harm's way.Because of this fear and empathy for those working on the front lines, one of us (A.K.B.) led the charge and was the first in our residency to volunteer at EHC.The first 24-hour shift in that ICU was harrowing.Working in the freshly minted "SURGE/Overflow COVID ICU" (EHC's former postanesthesia care unit), the day was spent praying no patients were admitted.That changed soon enough as patient after patient was transported up from the ED-what had unfortunately become a medical war zone with rows of intubated patients on every REFLECTIONS

ObjectiveTo compare rates of unexpected high‐risk pathologic features between Chinese and non‐Asian patients who underwent thyroidectomy for papillary thyroid cancer.MethodsThis was a retrospective cohort study at a tertiary academic urban medical center. Patients who underwent thyroidectomy for papillary carcinoma from 2015 to 2017 were included. Patient demographics, tumor characteristics, and tumor histopathology were analyzed. Primary outcome was the presence of adverse histopathologic features such as lymphovascular invasion (LVI) or microscopic/minimal extrathyroidal extension (mETE). Differences between the groups were analyzed using multivariate logistical regression analysis and propensity score‐weighted analysis.ResultsOne hundred seventy‐nine patients were included: 58 Chinese‐born and 121 non‐Asian. The median age of the cohort was 47 years old (36–58). Twenty‐nine percent of patients were male, and 71% were female. There was no statistically significant difference between the two cohorts in rates of LVI, multifocality, extent of surgery, or presence of thyroiditis. Patients with mETE were more likely to have larger tumors (P = 0.00247). Both the multivariate and propensity‐weighted models demonstrated that Chinese ancestry was independently associated with an increased rate of unexpected mETE (adjusted prevalence ratio, 2.52; 95% confidence interval, 1.82–3.48).ConclusionmETE is significantly higher in the immigrant Chinese compared to the non‐Asian population. Given the high prevalence of unexpected mETE in the Chinese population, the added risk of this finding should be brought into the discussion during initial surgical planning.Level of Evidence3 Laryngoscope, 130:1844–1849, 2020

The main goal of head and neck reconstruction is the restoration of form and function. Oncologic surgery makes this process more complex, as the preplanned defect can be very different from its intraoperative counterpart. This emphasizes the role of preoperative planning and a diverse reconstructive tool box that can accommodate a variety of complicated defects. The other reconstructive goals are determined by the patient with the aid of an interdisciplinary team. While multiple local and regional reconstructive options are available, free tissue transfer provides a versatile and reliable option for reconstructionespecially for complex orbital defects. Here the authors discuss free soft tissue transfer options for orbital exenteration. This review will catalog the advantages and disadvantages of the radial forearm, rectus abdominis, latissimus, and anterolateral thigh.

Purpose: To understand the knowledge, competency and influencing factors regarding postoperative opioid prescribing practices among Otolaryngology Residents. To understand the educational background and resources regarding pain management and opioid prescribing among Otolaryngology Residency Programs. Materials and methods: An anonymous electronic survey was distributed to Otolaryngology residents in the greater New York City area. Subjects reported their preferred pain management prescription for eight common otolaryngology surgeries. Questions addressed opioid and non-opioid prescribing influences, use/knowledge of pain management resources, and prior opioid prescribing education (OPE). An anonymous survey was distributed to US Otolaryngology Program Directors addressing resident prescribing influences and OPE in residency training programs. Results: Thirty-Five residents and fifteen PDs participated. Resident opioid prescribing was widely variable with averages ranging from 3.8 to 21.1 narcotic pills among eight standard otolaryngology surgeries. Attending/ senior preference was believed to largely influence resident prescribing habits among residents (3.66, +/- 6.68), and PDs (4.73, +/- 0.46). Only 20% of programs had formal OPE in place, consistent with the 65.71% of residents who reported no prior OPE. Conclusions and relevance: A large inconsistency in Otolaryngology resident postoperative pain management exists, despite their responsibility to provide analgesic therapy. The lack of formal OPE programs in US Otolaryngology residency programs may lead to outside factors unrelated to surgery influencing these prescribing practices. This brings light to the need of Otolaryngology Resident OPE to assist in standardizing prescribing practices, provide meaningful patient education on opioid use and disposal and educate residents on the risk assessment tools offered to provide the most appropriate and safe analgesic therapy to patients.

Background: Most late-stage breast cancer occurs in those who have never been screened. Uninsured women have lower screening rates than insured women. Student-run free clinics (SRFCs) caring for uninsured women can test interventions that attempt to increase screening rates.Methods: The United States Preventive Task Force guidelines were used to determine patient eligibility for screening mammography in a SRFC. Medical students began receiving education on screening mammography on May 31, 2013 while a simultaneous intervention to streamline workflow related to mammography referrals was implemented. We assessed the change in counseling and referral rates pre- and post-intervention as well as the impact of race/ethnicity, chronic disease status, and preferred language on the likelihood of getting counseled and referred for screening mammography. We also investigated the impact of the intervention on screening mammography attendance rates.Results: We collected data from the medical records of 106 women (171 patient visits) pre-intervention and 113 women (193 patient visits) post-intervention. The intervention significantly improved the rate of mammography counseling (from 54.4% to 81.9%) and mammography screening referrals (from 37.7% to 70.6%). Preferred language, race/ethnicity, and chronic disease status were not associated with counseling and referral rates. The intervention did not improve mammography attendance.Conclusions: An education and workflow intervention in a SRFC that improved counseling and referral rates did not improve mammography attendance. Further studies are needed to investigate patient-level barriers that may be affecting mammography appointment attendance.

Objective: Syphilis is a sexually transmitted infection with various presentations. Although, oropharyngeal manifestations are known to occur, the purpose of this study is to present the first case series in which the lesions were initially mistaken for human-papillomavirus (HPV)-related oropharyngeal squamous cell carcinoma (OPSCC). Methods: A multi-institutional retrospective review. Results: Six cases of oropharyngeal syphilis were initially thought to be secondary to OPSCC due to presentation. Symptoms were vague and exam findings consisted of either a tonsillar or base of tongue mass, or lymphadenopathy. Biopsies were negative for OPSCC. Further workup diagnosed syphilis, with resolution of symptoms and lesions after antibiotic treatment. Conclusions: Head and neck manifestations of syphilis have been reported in the literature. However, this is the first series reporting on oropharyngeal syphilis masquerading as HPV-related OPSCC. Ultimately, otolaryngologists must maintain a high suspicion for syphilis in order to ensure prompt diagnosis and treatment.