OBJECTIVE:To compare clinical outcomes of a 445-nm blue light (BL) laser with the established 532-nm potassium titanyl phosphate (KTP) laser for office-based treatment of benign vocal fold lesions. METHODS:In this parallel-group, open-label randomized controlled trial, adults (≥ 18 years) with benign vocal fold lesions underwent baseline VHI-10 and laryngeal stroboscopy, followed by in-office laser treatment. Pain visual analogue scale (VAS) scores were collected at baseline and daily for 7 days after the procedure. The primary outcome was the between-group difference in the change in Voice Handicap Index-10 (VHI-10) scores. Secondary outcomes included between-group comparisons of post-procedural pain and stroboscopic parameters at 90 days after treatment. Linear mixed-effects model assessed changes in VHI-10 and pain VAS over time, while Cochran-Mantel-Haenszel and logistic regression tests compared stroboscopy outcomes. RESULTS:Ninety-eight patients were enrolled (49 per group). Baseline characteristics were similar aside from a slightly younger age in the KTP group (p = 0.048). VHI-10 scores improved significantly in both groups at postoperative day (POD)7 (-5.98), POD30 (-9.28), and POD90 (-12.43) (all p ≤ 0.001), with no between-group differences (p = 0.596). Pain decreased significantly over time (p < 0.001), without group differences (p = 0.47). At POD90, complete vocal fold closure occurred in 91.2% (BL) and 85.7% (KTP) of patients (p = 0.74). Normal mucosal wave was observed in 79.4% (BL) and 81.0% (KTP), with no significant differences. CONCLUSION:BL laser demonstrated clinical outcomes comparable to KTP, with similar voice improvement, pain reduction, and stroboscopic results. LEVEL OF EVIDENCE: 2:

BACKGROUND:First described in 1972, idiopathic subglottic stenosis (iSGS) is a serious chronic orphan disease characterised by recurrent scarring of the subglottis. Although the cause is unknown, iSGS is almost exclusively restricted to Caucasian females typically in their fourth to sixth decade. However, given its rare incidence (1:400,000), understanding the clinical trajectory and molecular factors associated with iSGS disease development and prognosis has been difficult. In the current study we sought to unravel the pathogenesis of iSGS at the clinical, transcriptional, and genetic level in a prospective cohort. METHODS:We prospectively enrolled 126 patients with iSGS, 104 controls, and 13 patients with traumatic SGS. Within this cohort, we profiled 114 human epiglottis and 121 human subglottis biopsies across three different conditions: control, iSGS, and intubation-related traumatic stenosis using bulk and single nucleus RNA-sequencing. Whole exome sequencing for germline variants was performed for 70 controls and 75 patients with iSGS. FINDINGS:Patients with iSGS received a median number of five (range 0-18) surgical dilations at a rate of 1.031 dilations (range: 0.12-6.2) per year. Older age at diagnosis and higher Cotton-Myers grade were associated with increased number of surgical dilations over time. Cohort-level bulk transcriptomics found that iSGS pathology was restricted within the subglottis and did not affect anatomically adjacent epiglottis, opposite to previous hypotheses. We further identified cellular subsets associated with iSGS prognosis and severity. Finally, patients with iSGS exhibit lower testosterone predicted using a polygenic score. INTERPRETATION:Together, our data refines our understanding of laryngeal biology and provides insights into the clinical trajectory of subglottic stenoses. Future research should explore the role of testosterone in the development of iSGS. FUNDING:This study was funded by a grant from the American Laryngology Association (#1082), an Academic Medical Organization of Southwestern Ontario innovation fund grant (INN21-016), grant support from the Departments of Otolaryngology-Head and Neck Surgery at University of Toronto and Western University. ACN was supported by the Wolfe Surgical Research Professorship in the Biology of Head and Neck Cancers Fund. PYFZ was supported by a Vanier Canada Graduate Scholarship and PSI foundation fellowship.

OBJECTIVES:In-office nasolaryngoscopy in otolaryngology is a short but frequently performed procedure that can lead to substantial ergonomic risk. This study seeks to compare the ergonomic difference between pistol and conventional grip techniques during in-office nasolaryngoscopy. METHODS:Twelve otolaryngology staff, residents, and speech language pathologists were prospectively enrolled. Each practitioner was observed performing nasolaryngoscopy on 20 to 40 patients using either the conventional or pistol grips. Ergonomic assessments were conducted using the Rapid Upper Limb Assessment (RULA) Employee Assessment Worksheet. Descriptive statistics were used to summarize practitioner characteristics, raw RULA scores, and RULA risk categories. Linear mixed models with random intercepts were used to compare the raw RULA scores of the two grips. RESULTS:Of the total 403 procedures observed, 211 were performed using the conventional grip and 192 using the pistol grip. According to RULA risk categorization, 77.08% of the pistol grip procedures were classified as low ergonomic risk, compared to 58.29% for the conventional grip. Mean RULA scores were 4.1 ± 1.3 for the pistol grip and 4.7 ± 1.3 for the conventional grip. There was a significant mean difference of 0.65 (95% CI: 0.48, 0.82; p < 0.0001) between the two groups. CONCLUSION:Overall, both the pistol grip and conventional grip techniques fell into the same RULA ergonomic risk category. However, the pistol grip had a significantly lower average final RULA score than the conventional grip. Further studies are needed to evaluate the feasibility and broader adoption of the pistol grip across various otolaryngology endoscopic procedures. LEVEL OF EVIDENCE: 3:

Objective Health literacy is defined as the ability of individuals to gain access to, understand, and use information in ways that promote and maintain good health. This study aimed to assess the health literacy of patients seeking care at an adult tertiary care Otolaryngology-Head and Neck Surgery (OHNS) clinic and its correlation with sociodemographic information. Study Design Prospective cross-sectional study. Setting Tertiary care OHNS clinic. Participants New adult patients who presented to a tertiary OHNS clinic from July 2022 to March 2023. Interventions Patients were asked to complete a sociodemographic questionnaire and the BRIEF Health Literacy Screening Tool. The BRIEF is scored out of 20 with scores of 17 and higher showing adequate health literacy. Main Outcome Measures Bivariate and multivariate analyses were performed to determine whether sociodemographic variables were associated with health literacy. Results Two hundred eighteen patients were recruited (59% females, 32% were above age 65). Although the average score on the BRIEF was 17.0 ± 3.6, about 33% of participants were found to have inadequate health literacy. Non-native English speakers, racial minorities, immigrants, and those with a lower income were more likely to have poor health literacy. Conclusion This study highlights that a significant number of patients presenting to a tertiary OHNS clinic have inadequate health literacy, with certain socioeconomic factors serving as predictors. Future research is needed to evaluate targeted interventions aimed at improving and advocating for health literacy among OHNS patients.

OBJECTIVE:Idiopathic subglottic stenosis (iSGS) is a rare disease characterized by narrowing of the upper airway and affects near-exclusively females. Patients often experience recurrent disease and require repeated surgical dilations. The pathophysiology underlying the broad spectrum of disease severity within iSGS remains unknown. In the current study, we sought to identify transcriptomic differences between iSGS patients with markedly different recurrence rates. METHODS:Prospectively collected clinical and bulk RNA sequencing data from subglottic tissues of 56 female iSGS patients with 1-4 years of follow-up were analyzed. DESeq2 was used to perform differential expression analysis, comparing samples from the highest (1.19-1.87 dilations/year) versus the lowest (0.30-0.65 dilations/year) quartile of surgical dilation rate (i.e., high vs. low recurrence groups). RESULTS:In total, 220 genes were significantly differentially expressed between the high and low recurrence groups (adjusted p < 0.1 and log2 fold change > |1|). Pathway enrichment analyses showed that the high recurrence group had significantly increased expression of genes involved in adaptive immune responses (e.g., immunoglobulin subunit genes) and extracellular matrix organization (e.g., COMP, NID2) (adjusted p < 0.1). In contrast, the low recurrence group had significantly increased expression of genes involved in cilia structure and function (e.g., CFAP43, DNAI2) (adjusted p < 0.1), suggesting a relatively increased abundance of respiratory cilia. CONCLUSION:Transcriptomic profiling suggests that lower recurrence rates in iSGS are associated with retention of respiratory cilia, while adaptive immune responses and increased extracellular matrix deposition are present in those with higher recurrence rates. These results hold promise for the development of prognostic markers and identification of therapeutic targets for iSGS.

BACKGROUND:Serial intralesional steroid injections (ILSIs) have been suggested to be an effective adjunct treatment for idiopathic subglottic stenosis (iSGS) by maintaining airway patency and extending inter-surgical intervals. However, evidence for the effectiveness of serial ILSIs remains inconclusive. The current study aimed to assess whether ILSIs reduce the risk of subsequent surgical dilation (i.e., recurrence) in a cohort of patients with iSGS. METHODS:Prospectively collected clinical data for 75 female iSGS patients with 1-4 years of follow-up were analyzed. To assess the effect of ILSI use on the risk of recurrence, we assessed both the time-to-first recurrence using a standard Cox proportional hazards model and all recurrences per patient using a recurrent-events model. Overall, there were 36 patients who had received ILSIs at any point in the follow-up period and 39 patients who had not. RESULTS:ILSI use was associated with a significantly reduced risk of recurrence in both time-to-first event (hazard ratio (HR) = 0.20, 95% confidence interval (CI) 0.08-0.49) and recurrent events (HR = 0.44, 95% CI 0.26-0.75) multivariate Cox proportional hazard models, along with older age at diagnosis and longer time since diagnosis (all p < 0.05). In the time-to-first event analysis, the median time to recurrence among those who had received ILSIs was 2.5 years compared to 1.4 years among those who had not. The number needed to treat with ILSIs to avoid one recurrence by 2 years follow-up was two. CONCLUSION:Serial ILSIs were associated with reduced risk of recurrence, along with older age at diagnosis and longer time since diagnosis. LEVEL OF EVIDENCE:3 (non-randomized controlled cohort/follow-up study).

BACKGROUND:The larynx consists of the supraglottis, glottis, and subglottis and each differ in tissue composition, lymphatic drainage, ability to counter infections, and response to injuries. However, the cellular mechanisms driving laryngeal homoeostasis remain largely unexplored. As a result, understanding disease pathogenesis within the larynx including idiopathic subglottic stenosis (iSGS) and intubation-related traumatic stenosis has been challenging. Here, we sought to characterise the cellular processes governing laryngeal health and disease. METHODS:As part of the prospective Canadian Airways Research (CARE) iSGS study, we characterised 122,004 high-quality transcriptomes using single nucleus RNA-sequencing to profile 11 human epiglottis and 17 human subglottis biopsies across three different conditions: control, iSGS, and intubation-related traumatic stenosis to define cell populations and pathways associated with disease. We validated our results using cohort-level bulk transcriptomics using 114 human epiglottis and 121 human subglottis. FINDINGS:We defined the single-cell taxonomy of the human subglottis and epiglottis using single-nucleus sequencing in both healthy and disease states. Mechanistically, we discovered the presence of unique epithelial and fibroblast progenitor subsets within the control subglottis but not within the anatomically adjacent epiglottis. The uncontrolled proliferation of these cellular subsets exhibited skewed sex hormone signalling and orchestrated a fibro-inflammatory cascade. We leveraged cohort-level bulk transcriptomics to define hallmarks of iSGS associated with disease covariates and introduced the first biomarker associated with recurrent relapse. Longitudinal sampling demonstrated that the subglottic microenvironment in patients with iSGS is changing dynamically with and without therapeutic intervention. INTERPRETATION:Together, our data refines our understanding of laryngeal biology, nominates candidate compounds for iSGS treatment, and serves as a transformative platform for future clinical investigations to further precision laryngology. FUNDING:This study was funded by a grant from the American Laryngology Association (#1082), an Academic Medical Organisation of Southwestern Ontario innovation fund grant (INN21-016), grant support from the Departments of Otolaryngology-Head and Neck Surgery at University of Toronto, Canada and Western University, Canada. ACN was supported by the Wolfe Surgical Research Professorship in the Biology of Head and Neck Cancers Fund. PYFZ was supported by a Vanier Canada Graduate Scholarship and PSI Foundation fellowship.

BACKGROUND:COVID-19 had a tremendous impact on surgical residency education and training. With little experience or training in using online learning in pedagogically informed ways, some surgical educators and learners experienced the disadvantages of online learning which may have contributed to a greater sense of burnout in the pandemic. The purpose of this study is to survey the level of burnout in surgical educators and assess educators' perspectives on factors that increased or decreased burnout in synchronous online teaching during the pandemic. METHODS:A cross-sectional study consisting of 4 sections was sent to surgical educators at the University of Toronto. Demographic data, validated surveys on burnout and videoconferencing fatigue (the Maslach Burnout Inventory-Educators Survey (MBI-ES) and the Zoom Exhaustion and Fatigue (ZEF) scale respectively), and quantitative questions about teaching factors in synchronous online environments were collected and analyzed. RESULTS:The MBI-ES demonstrated a high degree of emotional exhaustion, and depersonalization and a moderate degree of personal accomplishment in surgeon educators. The ZEF scale noted moderate fatigue across all domains. Although educators noted online learning to be a moderate factor contributing to burnout during the pandemic, there was no correlation between the number of hours or percentage of time teaching online to burnout or zoom fatigue scores. The largest reported contributing factor to online learning leading to burnout was lack of connection to learners, whereas the largest mitigating factor was decreased travel time. INTERPRETATIONS:The study found a moderate degree of exhaustion and burnout among surgical educators in Canada during COVID-19 and examined how aspects of online synchronous learning may have contributed to or helped mitigate these experiences. Based on this, we present approaches and educational theories to improve the online learning experience for surgical educators going forward.

Importance The reported rates of malignant transformation of dysplastic laryngeal lesions are highly variable, as is time to malignant degeneration. Objective To evaluate the rate of and time to malignant transformation of dysplastic laryngeal lesions based on the World Health Organization (WHO) dysplasia classification system. Data Sources PubMed, MEDLINE, Embase, CINAHL, CENTRAL, and Cochrane Reviews were searched from the date of database inception to June 8, 2023. Study Selection English-language articles assessing the rate of malignant transformation using the 2005 WHO dysplasia classification system were included in this systematic review and meta-analysis. Data Extraction and Synthesis The study was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. Data extraction was performed by 2 independent investigators. Study quality was assessed using a validated quality tool. When possible, data were pooled using random-effects meta-analysis. Main Outcome Measures The primary outcome measure was the malignant transformation rate in each laryngeal dysplasia category. Secondary outcome measure was the time interval over which malignant transformation had occurred. Results A total of 5585 records were screened, 61 full texts were assessed, and 18 retrospective cohort studies with 3243 participants were included in the final review. The weighted pooled mean malignant transformation rates of mildly, moderately, and severely dysplastic lesions were 10.9%, 23.3%, and 30.5%, respectively. Malignant transformation rate of nondysplastic laryngeal lesions was 4.5%. Moderately and severely dysplastic lesions had significantly higher odds of malignant transformation compared with mildly dysplastic lesions (moderate: odds ratio [OR], 2.90 [95% CI, 2.06-4.09]; I-2 = 0%; severe: OR, 3.42 [95% CI, 2.11-5.52]; I-2 = 40%). Lesions without dysplasia had a significantly lower odds of malignant transformation compared with lesions with mild dysplasia (OR, 0.48; 95% CI, 0.28-0.81; I-2 = 0%). The overall mean time to malignant transformation was 28.8 months (range, 22.0-35.6 months) for all dysplasia grades. Conclusion and Relevance This systematic review and meta-analysis found that the rate of malignant transformation increased with the grade of laryngeal dysplasia. Moderately dysplastic lesions were more likely to undergo malignant degeneration compared with mildly dysplastic lesions.

PURPOSE:Surface reconstructions from laryngoscopic videos have the potential to assist clinicians in diagnosing, quantifying, and monitoring airway diseases using minimally invasive techniques. However, tissue movements and deformations make these reconstructions challenging using conventional pipelines. METHODS:To facilitate such reconstructions, we developed video frame pre-filtering and featureless dense matching steps to enhance the Alicevision Meshroom SfM pipeline. Time and the anterior glottic angle were used to approximate the rigid state of the airway and to collect frames with different camera poses. Featureless dense matches were tracked with a correspondence transformer across subsets of images to extract matched points that could be used to estimate the point cloud and reconstructed surface. The proposed pipeline was tested on a simulated dataset under various conditions like illumination and resolution as well as real laryngoscopic videos. RESULTS:Our pipeline was able to reconstruct the laryngeal region based on 4, 8, and 16 images obtained from simulated and real patient exams. The pipeline was robust to sparse inputs, blur, and extreme lighting conditions, unlike the Meshroom pipeline which failed to produce a point cloud for 6 of 15 simulated datasets. CONCLUSION:The pre-filtering and featureless dense matching modules specialize the conventional SfM pipeline to handle the challenging laryngoscopic examinations, directly from patient videos. These 3D visualizations have the potential to improve spatial understanding of airway conditions.

BACKGROUND:The CO2 laser is frequently used during microlaryngeal surgery (MLS) for a variety of pathology including laryngeal malignancy and stenosis. Learning how to use the laser safely is part of the curriculum for every otolaryngology resident. However, assessment of laryngoscopy technical skills can be challenging for supervisors, making it difficult to adequately provide feedback to trainees. OBJECTIVES:"LAser Surgical skills Evaluation for Residents" (LASER) Scale aims to facilitate the evaluation of residents' performance and promote constructive feedback. METHODS:The initial evaluation grid was based on a literature review of CO2 laser laryngoscopy (with an emphasis on indications, technique, safety, and efficacy) using Covidence systematic review software (Veritas Health Innovation). The final version was produced after 4 rounds of Delphi surveys. RESULTS:This study was an international collaboration including 15 otolaryngologists with either laryngology or head and neck surgery subspecialties. Panelists were based in Canada (8), the United States (3), France (1), Spain (1), Belgium (1), and Lebanon (1). The process involved 4 rounds of Delphi surveys. Assessment categories included: anesthesia considerations, pre- and perioperative laser safety measures, and surgical technique. Consensus was reached on final survey completion. CONCLUSIONS:Through a modified Delphi method, a novel scale was developed through an international collaborative effort that evaluates resident skillset in CO2 laser MLS. Future studies are warranted to validate this assessment tool.

Objective(s) Voice rest is commonly recommended following phonomicrosurgery to minimize vocal fold scarring, but associated quality of life (QoL) is low resulting in poor compliance. This study aimed to explore patients' experiences with voice rest following phonomicrosurgery to identify facilitators and barriers. Methods This qualitative study used prospective, typical case technique for purposive sampling of consecutive patients who underwent voice rest following phonomicrosurgery for benign vocal fold lesions. Participants were enrolled at a single tertiary Laryngology center located at Unity Health Toronto – St. Michael's Hospital from 2020 to 2022. Semi‐structured virtual interviews were conducted 4 weeks following patients' surgery. All interview transcripts were transcribed verbatim and underwent thematic analysis. Participant recruitment was stopped once thematic saturation was achieved. Results Twenty participants were recruited and 4 withdrew due to scheduling conflicts. Sixteen participants completed interviews, all of whom reported minimal impact of postoperative voice rest on QoL. The participants attributed their success to facilitators such as notifying close contacts of their situation beforehand and adopting nonverbal forms of communication. No participant endorsed a negative attitude toward voice rest. Understanding the rationale for voice rest and the consequences of noncompliance were reported to be effective in encouraging compliance. Conclusion Overall, the participants tolerated voice rest well owing to facilitators such as early preparation, lifestyle modifications, and understanding the rationale for voice rest. Social disconnect and work demands were barriers of voice rest. Moving forward, facilitators and barriers should be addressed in efforts to optimize the voice rest experience for future patient populations. Level of Evidence 4 Laryngoscope , 134:361–366, 2024

Objective Conventional reference images of laryngeal pathologies may provide educational value for Otolaryngology—Head & Neck Surgery (OHNS) residents, but observing dynamic vocal fold function is critical for diagnosis. Our aim was to develop and validate a video atlas of laryngeal pathologies for resident education in OHNS. Design A multi-institution, prospective case-control study. Setting/Participants Ten videos showing 10 representative laryngeal pathologies were verified by two laryngologists. Six videos per category with kappa>0.8 were included in the video database. A collection of the videos was shown to a group of OHNS residents in a quiz fashion to determine if senior trainees would score higher than junior trainees. Another group of residents in OHNS was recruited and randomized to control or intervention. The control group was shown a quiz of 10 laryngeal videos at baseline and 24 weeks later. The intervention group was shown quizzes at baseline and every 6 weeks, ending at 24 weeks. Free-text diagnoses were scored for accuracy. Descriptive statistics, two-tailed tests, and analysis of covariance were performed. Results Twenty-nine residents participated, with 14 (48.3%) randomized to control, and 15 (51.7%) to the intervention. The postgraduate year (PGY) level had a significant impact on diagnostic performance. PGY1 and 2 had a significantly lower score than PGY5 (P = 0.017 and P = 0.035, respectively). PGY3 and PGY4 scores were not statistically different from PGY5 scores. The mean score difference between groups decreases as the PGY level increases (mean difference between groups = 0.87, P = 0.153), but this was not significant. Conclusions The current study has created a validated collection of videos that are representative of common laryngeal pathologies and can be easily incorporated into resident video-based learning. Future directions include larger multi-site studies to further elucidate whether repeated viewing of this video atlas can improve OHNS resident laryngology knowledge.

BACKGROUND/OBJECTIVE:Laryngeal electromyography (LEMG) is a useful diagnostic test in the evaluation of vocal fold paralysis (VFP). This study investigates factors that can make LEMG challenging to perform. METHODS:Patients with subacute unilateral VFP presented for LEMG were prospectively enrolled. Demographic data including BMI, previous neck surgery, and anatomic factors were collected. Patient-reported pain related to the procedure was recorded on a visual analogue scale (VAS). Electromyographer and otolaryngologist recorded a consensus rating of the perceived difficulty in performing the test and confidence in using the results for clinical decision-making. RESULTS:A total of 111 patients (56.8% female) were enrolled between August 2015 and August 2018. The mean age was 55 ± 14 years, and the average body mass index (BMI) was 28.5 ± 6.4. The mean patient-reported VAS score for pain was 35 ± 24. Notably, 31.2% of the tests were considered "very easy," 32.1% were considered "mildly challenging" and 23.9% and 12.8% were considered "moderately challenging" and "extremely challenging," respectively, by the clinicians. Common factors affecting LEMG difficulty included poorly palpable surface anatomy (50.5%) and patient intolerance (15.6%). Clinicians felt confident in 76.1% of the test findings. Bivariate analyses showed that prior neck surgery is associated with elevated VAS (p = 0.02), but clinician-perceived difficulty of performing the test is not associated with elevated VAS scores (p = 0.55). CONCLUSIONS:Majority of LEMG tests are well tolerated by patients. Physicians reported more confidence using LEMG for clinical decision-making when the test was easier to perform. Difficult surface anatomy and patient intolerance affects clinician confidence in integrating the test results with clinical care. LEVEL OF EVIDENCE:3 Laryngoscope, 134:831-834, 2024.

Background Aspiration pneumonia is a preventable condition that has higher rates of recurrence and mortality compared to non-aspiration pneumonia. The primary objective of the study was to examine independent patient factors that are associated with mortality in those requiring acute admission for aspiration pneumonia at a tertiary institution. Secondary goals of the study were to review whether factors such as mechanical ventilation and speech language pathology intervention can impact patient mortality, length of stay (LOS), and costs relating to hospitalization. Methods Patients older than 18 years of age who were admitted with a primary diagnosis of aspiration pneumonia from January 1, 2008 to December 31, 2018 at Unity Health Toronto-St. Michael's hospital in Toronto, Canada, were included in the study. Descriptive analyses were performed on patient characteristics using age as a continuous variable as well as a dichotomous variable with age 65 as a cut-off. Multivariable logistic regression was used to identify independent factors that contributed to in-hospital mortality and Cox proportional-hazard regression was used to identify independent factors that affected LOS. Results A total of 634 patients were included in this study. 134 (21.1%) patients died during hospitalization with an average age of 80.3 ± 13.4. The in-hospital mortality did not change significantly over the ten-year period ( p = 0.718). Patients who died had longer LOS with a median length of 10.5 days ( p = 0.012). Age [Odds Ratio (OR) 1.72, 95% Confidence Interval (95% CI) 1.47–2.02, p < 0.05] and invasive mechanical ventilation (OR 2.57, 95% CI 1.54–4.31, p < 0.05) were independent predictors of mortality while female gender was found to be a protective factor (OR 0.60, 95% CI 0.38–0.92, p = 0.02). Elderly patients had five times higher risk of dying during their hospital course when compared to younger patients [Hazard Ratio (HR) 5.25, 95% CI 2.99–9.23, p < 0.05). Conclusion Elderly patients are a high-risk population for developing aspiration pneumonia and are at higher risk of death when hospitalized for this condition. This warrants improved preventative strategies in the community. Further studies involving other institutions and creating a Canada-wide database are required. Graphical Abstract

BACKGROUND:Microlaryngoscopy is a basic technical skill in Oto-HNS. It is essential for residency programs to have a competency-based assessment tool to evaluate residents' performance of this procedure. An Objective Structured Assessment of Technical Skills (OSATS) is a procedure-specific assessment, which consists of the following: (a) Operation-Specific Checklist and (b) Global Rating Scale (GRS).OBJECTIVE:The objective of this study was to create an OSATS for adult microlaryngoscopy.METHODS:This was a prospective study, with an initial qualitative phase for OSATS development (Phase I), and a clinical pilot phase (Phase II). In Phase I, interviews were conducted with three laryngologists to establish a stepwise description of adult microlaryngoscopy and review a previously validated GRS for relevance to microlaryngoscopy. Responses were used to create a framework for the OSATS. The OSATS was then presented to Oto-HNS residents and laryngologists in an alternating fashion, for review of clarity and relevance. A pilot study was then performed to evaluate the resident performance of adult microlaryngoscopy. Multiple regression analysis was carried out to investigate whether training level, case complexity, and previous OSATS exposure could predict participant scores.RESULTS:Phase I of this study led to the creation of a 34-item OSATS. The pilot study (N = 28 procedures) revealed that training level was significantly correlated with increased OSATS scores. There was no statistically significant correlation between case complexity and resident scores. Assessors reported the perceived utility of the OSATS and intent for use in residency training.CONCLUSION:Application of the proposed OSATS will allow for competency-based assessment of the resident performance of microlaryngoscopy.LEVEL OF EVIDENCE:NA Laryngoscope, 133:2719-2724, 2023.

Background: The Queen Bee phenomenon describes the behavioural response that occurs when women achieve success in a male-dominated environment, and in this position of authority, treat their female subordinates more critically. This behavioural response has been demonstrated in fields such as business, academia, the military, and police force. The goal of this study was to determine whether the Queen Bee phenomenon occurs similarly in surgical specialties within medicine. We hypothesized that female surgeons, fellows, and senior surgical residents would be more critical in their assessment of junior female residents than of their male counterparts. Methods: A scenario-based survey was distributed to all Canadian surgical programs, guised as a survey-based study of patterns of interaction among surgical trainees and staff surgeons. Scenario questions were designed to assess either female or male learners. Respondents’ average Likert score for female-based and male-based questions were calculated. The differences in scores were analyzed. Subgroup analyses were performed based on age, seniority, and surgical specialty. Results: We collected 716 survey responses, with 387 respondents identifying as male (54%) and 321 identifying as female (45%); the remaining 8 respondents did not report gender. This included 385 staff surgeons (54%), 66 fellows (9%), and 263 residents (37%); the remaining 2 respondents did not identify their group. The mean Likert scores for female respond ents assessing female learners was significantly lower than when male learners were assessed ( p = 0.008). During sub-group analysis, resident females scored female learners significantly less favourably than the staff and fellow groups ( p = 0.036). Some subspecialties demonstrated significant scoring differences. Female orthopedic surgeons scored female learners more harshly than male learners ( p = 0.049). Conclusion: The Queen Bee phenomenon was shown

# 01. The Queen Bee phenomenon in Canadian surgical subspecialties: an evaluation of gender biases in the resident training environment {#article-title-2} The Queen Bee phenomenon describes the behavioural response that occurs when women achieve success in a male-dominated environment, and in this