Jennifer A. Villwock

Recent Trends in Epistaxis Management in the United States: 2008-2010

IMPORTANCE The treatment of epistaxis is variable. It is important to analyze the effect of the available interventions on patient outcomes. OBJECTIVE To determine demographic, management, and outcome trends in patients admitted with a primary diagnosis of epistaxis and treated with conservative management, nasal packing, arterial ligation, or embolization. DESIGN, SETTING, AND PARTICIPANTS A review of the data reported by hospitals to the 2008-2010 Nationwide Inpatient Sample for patients admitted with a primary diagnosis of epistaxis was conducted. INTERVENTIONS Conservative management, nasal packing, arterial ligation, or embolization for epistaxis control. MAIN OUTCOMES AND MEASURES Descriptive statistics for hospital and patient demographic data. Multivariate models were constructed to compare treatment modalities, controlling for patient- and hospital-level variation while reporting the treatment outcomes of mortality, stroke, blindness, length of stay, and total cost. Comparisons were made between patients undergoing embolization, surgical ligation, or nasal packing. Descriptive statistics for patients treated conservatively are reported. RESULTS A total of 57, 039 cases of primary epistaxis were identified. Of these, 21, 872 patients (38.3%) were treated conservatively, 30, 389 (53.3%) received nasal packing or cauterization, 2706 (4.7%) underwent arterial ligation, and 1956 (3.4%) underwent embolization The odds of stroke in patients following embolization were significantly higher than in patients who underwent nasal packing (odds ratio, 4.660; P = .003), with no significant difference seen compared with surgical ligation (P = .70). There were no significant differences in the odds of mortality or blindness between any of the study groups. Patients undergoing embolization incurred the highest total hospital costs, nearly doubling the cost of ligation (P < .001), without a corresponding increase in the length of hospital stay (P = .20). CONCLUSIONS AND RELEVANCE Treatment for epistaxis is highly variable. No significant differences in clinical outcomes were noted between arterial ligation and embolization in the population studied, although embolization resulted in significantly higher costs. Further prospective studies are needed to elucidate variables affecting outcomes of the various treatment options for epistaxis.

Significant increases of pituitary tumors and resections from 1993 to 2011

Pituitary tumors comprise 10% to 15% of all diagnosed intracranial tumors; 90% are adenomas. Though benign, significant morbidity via compression of surrounding structures or aberrant hormone secretion can occur. This study investigated rates of pituitary tumor diagnoses and treatment trends from 1993 to 2011.

Outcomes of early versus late Tracheostomy: 2008–2010

The ideal timing of tracheostomy varies. This study sought to determine demographic, management, and outcome differences in patients undergoing early tracheostomy (ET) versus late tracheostomy (LT) (<10 days vs. >10 days postintubation, respectively).

Early versus delayed treatment of primary epistaxis in the United States

Epistaxis treatment is variable. This study sought to determine demographic, management, and outcome differences in patients treated with early (<24 hours) vs late ligation or embolization.

Current trends in surgical approach and outcomes following pituitary tumor resection

The goals of pituitary tumor resection include normalizing endocrine function, relieving mass effect, and minimizing risk of recurrence. This study investigated current trends in costs and complications for transfrontal and transsphenoidal pituitary surgery.

The Role of the Away Rotation in Otolaryngology Residency

Objective To determine the availability and purpose of away rotations during otolaryngology residency. Study Design Cross-sectional survey. Setting Otolaryngology residency programs. Subjects and Methods An anonymous web-based survey was sent to 98 allopathic otolaryngology training program directors, of which 38 programs responded. Fisher exact tests and nonparametric correlations were used to determine statistically significant differences among various strata of programs. A P value of <.05 was considered statistically significant. Results Thirty-nine percent (n = 38) of queried programs responded. Mandatory away rotations and elective away rotations were both present in 6 of 38 programs (16%). Neither number of faculty (P = .119) nor residents (P = .88) was predictive of away rotation. Away rotations were typically >151 miles from the home institution and typically used to address deficiencies in clinical exposure (67%) or case volume (50%). Participants of mandatory away rotations were universally provided housing, with other consideration such as stipend (33%), relocation allowance (33%), or food allowance (16%) sometimes offered. In contrast to mandatory rotations, half of elective rotations were to obtain a unique international mission trip experience. Nearly one-third of surveyed program directors (29%) would consider adding an away rotation to their curriculum in the next 3 years. Conclusions Mandatory and elective away rotations play a role in a small, but not insignificant, number of training programs. The rationale for these rotations is variable. Given that nearly one-third of program directors would consider adding an away rotation in the near future, further research into components of a meaningful away rotation and how to optimize the away rotation experience is warranted.

Otolaryngology Residency Program Research Resources and Scholarly Productivity

Objective To delineate research resources available to otolaryngology residents and their impact on scholarly productivity. Study Design Survey of current otolaryngology program directors. Setting Otolaryngology residency programs. Subjects and Methods An anonymous web-based survey was sent to 98 allopathic otolaryngology training program directors. Fisher exact tests and nonparametric correlations were used to determine statistically significant differences among various strata of programs. Results Thirty-nine percent (n = 38) of queried programs responded. Fourteen (37%) programs had 11 to 15 full-time, academic faculty associated with the residency program. Twenty (53%) programs have a dedicated research coordinator. Basic science lab space and financial resources for statistical work were present at 22 programs (58%). Funding is uniformly provided for presentation of research at conferences; a minority of programs (13%) only funded podium presentations. Twenty-four (63%) have resident research requirements beyond the Accreditation Council for Graduate Medical Education (ACGME) mandate of preparing a “manuscript suitable for publication” prior to graduation. Twenty-five (67%) programs have residents with 2 to 3 active research projects at any given time. None of the investigated resources were significantly associated with increased scholarly output. There was no uniformity to research curricula. Conclusions Otolaryngology residency programs value research, evidenced by financial support provided and requirements beyond the ACGME minimum. Additional resources were not statistically related to an increase in resident research productivity, although they may contribute positively to the overall research experience during training. Potential future areas to examine include research curricula best practices, how to develop meaningful mentorship and resource allocation that inspires continued research interest, and intellectual stimulation.

The Effect of Surgical Approach on Outcomes following Pituitary Tumor Resection

Objectives: The goals of pituitary tumor resection include normalizing endocrine function, relieving mass effect, and minimizing risk of recurrence. This study sought to determine the effect of surgical approach “transsphenoidal or transfrontal” on outcomes. Methods: Retrospective review of the 2008-2011 Nationwide Inpatient Sample for patients undergoing pituitary lesion resection. Hospital and patient demographics and outcomes were compared between transfrontal and transsphenoidal surgical approaches. Results: A total of 8543 admissions for resection of pituitary lesions met our inclusion criteria. Most (>90%) were treated transsphenoidally. The transfrontal approach was most frequent in the young (<35 years) and in the South. Transfrontal resection led to significant increases in mortality and complications including central diabetes insipidus, iatrogenic panhypopituitarism, and intracerebral hemorrhage. Multivariate analysis found transsphenoidal resection reduced hospital costs and length of stay by over 50%; low-volume hospitals increased cost and length of stay. There was an increased rate of transfrontal approaches at low-volume centers. Conclusions: Multiple factors influence outcomes of pituitary tumor resection. Case specifics, including tumor location and size, influence approach and lead to a selection bias that cannot be controlled for in the present study. The prevalence of transfrontal resections at low-volume centers may indicate that surgeon familiarity rather than contraindication to transsphenoidal surgery serves as the basis for surgical planning.

Delayed Diagnosis of Nasal Natural Killer/T-Cell Lymphoma

Midline destructive lesions of the face have multiple possible etiologies. The majority of these cases are found to be due to an extranodal lymphoma of natural killer/T-cell-type non-Hodgkins lymphoma (NKTL). Unfortunately, diagnosis is often delayed. With variable presenting complaints, including nonspecific issues like chronic rhinosinusitis or nasal congestion, initial treatments are aimed at these presumed diagnoses. Only as the lesion progresses do overt signs of destruction occur. As with our patient, who was initially treated for presumed infection and abscess, final diagnosis often does not occur until several months, and several antibiotic courses, from initial presentation. As such, it is important for this rare entity to remain in the clinicians differential diagnosis for nasal lesion.