Academic Otolaryngology Practice Research Articles

Status and trends of general otolaryngology in academia.

This article focuses on the hiring trends of academic general otolaryngology practices to clarify the status of academic general otolaryngology in the face of today's changing medical landscape. Cross-sectional study. We conducted a survey to evaluate past, present, and projected hiring issues in academic otolaryngology, specifically related to general otolaryngology. Surveys were sent via e-mail to all academic chairpersons of accredited otolaryngology residency programs in the United States. Data included faculty appointments, work hours, clinical and research roles, academic productivity, patient load, promotions, and criteria for future hires. The response rate was 34.3%. On average, general otolaryngologists (generalists) represented 17% of otolaryngology faculty in academic practices. Whereas most generalists were employed as assistant professors (65%), nearly half of promotions in recent years were given to generalists (49%). Between 2009 and 2014, there was an average of six new hires per academic otolaryngology practice (range: 1-13); of these new hires, 21% were generalists. Chairpersons estimated that in the next 5 years they would hire an average of three new otolaryngologists per practice (range: 0-7), of whom 39% would be generalists. Although 82% of chairpersons reported an increase in subspecialty hires, 94% reported that they would also require the same or increasing numbers of generalists. Despite the increase in subspecialization in academic otolaryngology, the role of general otolaryngologists in academic practices will continue to be important and perhaps will increase. N/A. Laryngoscope, 126:1995-1998, 2016.

Laryngeal Manipulation for Dysphagia from Muscle Tension Dysphonia

Objectives: (1) Appreciate the use of laryngeal manipulation as treatment for perceived dysphagia resulting from excessive paralaryngeal muscle tension. (2) Describe the patients likely to have symptomatic improvement. Methods: A retrospective review identified patients from 2007-2011 with laryngeal manipulation for muscle tension-caused dysphagia in an academic otolaryngology practice. Subjects with dysphagia not attributable to anatomic cause who attended therapy twice or more had symptoms, demographic information, treatment, and response to therapy abstracted. Results: Thirty-five subjects were included, consisting of 28 women and 7 men. Race was recorded as black (11), Hispanic (8), white (9), and other (7). Improvement in dysphagia was seen in 25 (71.4%, 95% confidence interval 53.7% to 86.4%). No significant differences were seen in improvement based on sex ( P = .381) or race ( P = .439) in chi-square testing. The combination of age and number of sessions were predictive of improvement ( P = .041) but were not individually significant (age P = .096, sessions P = .084) using logistic regression. Conclusions: We found improvement with laryngeal manipulation among individuals with muscle-tension-caused dysphagia. No significant differences in efficacy were seen among racial and sex subgroups. A model with age and number of sessions was significant. A prospective trial of this therapy appears warranted.

Nasal Mucus Glucose and Chronic Rhinosinusitis

Objectives: Respiratory secretion glucose concentration is tightly regulated and contributes to airway innate immunity. Thus, we set out to quantify nasal mucus glucose concentration in chronic rhinosinusitis (CRS) patients and correlate these values to CRS symptoms. Methods: Prospective, single-center study measuring nasal mucus glucose concentration in patients diagnosed with chronic rhinosinusitis and age/race matched controls from July 1, 2013, to January 1, 2014. Enrollment included subjects >18 years of age evaluated in academic otolaryngology practice. Subjects completed questionnaires including extensive history of medical and surgical therapies as well as CRS-specific quality of life measurements (SNOT-22). Subjects underwent nasal secretion sampling with sterilized Pope ear wicks. The nasal glucose concentrations of controls and subjects were analyzed with multivariate analysis to assess for confounding variables including systemic and topical glucocorticoid treatment. Results: Ninety-five patients enrolled, and 3 patients were excluded because of history of sinonasal radiation. A statistically significant difference was measured between mean nasal glucose secretions of control subjects, 11.1 mg/dL (±1.0 mg/dL), compared to patients diagnosed with CRS, 18.4 mg/dL (±1.6 mg/dL) ( P < .01). No significant correlation was evident comparing nasal glucose concentrations to SNOT-22 nor use of glucocorticoid (topical or systemic) therapy. Conclusions: CRS patients demonstrate elevated nasal glucose concentrations independent of therapeutic glucocorticoid use. However, nasal mucus glucose concentrations do not appear to correlate to CRS symptoms. The role of nasal mucus glucose concentrations in CRS pathophysiology has yet to be determined.

Clinical and pathologic characteristics of intranasal abuse of combined opioid-acetaminophen medications.

The nonmedical abuse of prescription opioids via intranasal administration is a growing problem. The objective of this study is to investigate of the typical presentation of intranasal opioid-acetaminophen abuse and outline optimal therapy. This study was a retrospective chart review. Patients with intranasal pathology from inhalation of combined opioid-acetaminophen medications (COAMs) from 3 academic otolaryngology practices in western Pennsylvania from January 2012 to October 2012 were included in the review. Seven adults ranging in age from 23 to 46 years were identified with nasal complaints from the intranasal inhalation of COAMs. All patients presented with nasal pain and were found to have fibrinous necrotic nasal mucosa involving the posterior nasal cavity and nasopharynx. Of the 7 patients, 6 (85.7%) presented with a septal perforation. Pathology and culture revealed fungus in 85.7% of the patients; however, no invasive fungal disease was noted in any of the specimens. Patients did not improve with either systemic or topical antifungal therapy. Polarizable material characteristic of talc used as a tablet binder was present in the histopathology of 4 of 7 (57.1%) patients. Patients who abstained from intranasal drug use along with serial debridement demonstrated the greatest improvement. Intranasal COAM abuse causes nasal pain, tissue necrosis with potential septal and palatal perforation, and noninvasive fungal colonization. Antifungal therapy was of no benefit in the current series of patients. Current therapy should focus on recognition of the etiology of patients' pathology and encourage abstinence from intranasal use of these drugs along with serial debridements.

Prospective Outcomes Study of the Impact of Nasal Surgery on Sleep Quality

Objectives: Evaluate the impact of functional nasal airway surgery on the quality of sleep in patients using validated outcomes measurements. Study Design: Prospective, single center, outcome study of sleep quality before and after functional nasal surgery in patients with nasal airway obstruction treated from August 1, 2011, to August 1, 2013. Patients >18 years old with symptomatic structural nasal airway obstruction treated surgically at an academic otolaryngology practice. Intervention: Primary septoplasty, revision septoplasty, functional septorhinoplasty. Methods: Patients completed the Nasal Obstruction Symptom Evaluation (NOSE) scale (0-100 scale), Epworth Sleepiness Scale (ESS) (0-21 scale), the Pittsburgh Sleep Quality index (PSQI) (0-21 scale), and Likert scales pre-operatively and at 3 months post-operatively. The impact of nasal surgery outcome on sleep quality was analyzed. Linear regression analyses were carried out to identify independent variables affecting sleep outcomes in nasal surgery patients. Results: 48 patients enrolled, and 7 were lost to follow-up. 41 patients for preliminary analysis: 19 septoplasty, 4 revision, and 18 functional septorhinoplasty. Mean NOSE scores decreased from 67 pre-op to 17 at 3 month follow-up. ESS scores decreased from 7.8 to 5.8. PSQI decreased from 7.9 pre-op to 5.0 post-op. Additional analyses are ongoing. Conclusions: Nasal airway surgery does have an effect on sleep quality when evaluated using validated outcomes measurements. The NOSE score showed the most significant improvement in symptomatology. The ESS and PSQI also showed improved sleep quality after nasal surgery.

Preapproval of Sinus Computed Tomography for Evaluation of Chronic Rhinosinusitis Does Not Save Healthcare Costs

Objectives: Evaluate cost effectiveness of required pre-approval for computed tomography (CT) of the sinuses for chronic rhinosinusitis (CRS) evaluation by weighing the associated cost of pre-approval against savings from rejected claims. Study design: Retrospective analysis of prospectively collected data. Setting: An academic otolaryngology practice. Methods: Over a 6-month period, all sinus CT scans ordered and requiring pre-approval by a third-party payer were tabulated. Characteristics of the pre-approval process that were recorded and analyzed included time spent by office administrative staff, need for peer-to peer review, and time spent by the ordering physician. Results: All 111 sinus CT scans ordered required pre-approval based on insurer requirements—38 performed by computer, 71 by telephone, and 2 required both–costing an average of 8.1 minutes per scan by administrative staff (range: 2.0 – 20.0 minutes). 13 pre-approvals required peer-to-peer telephone interaction by the ordering physician, using an average of 7.7 minutes (range 5 – 12 minutes). In no case was the insurance company “peer” an otolaryngologist. Moreover, no sinus CT scan pre-approval was ultimately rejected by the third party payer. Conclusions: Pre-approval for sinus CTs ordered by otolaryngologists neither saves costs for third-party payers nor leads to appropriate rejection of scan requests because sinus CT for the evaluation of CRS is well-established and the standard of care. However, pre-approval in this context comes at the expense of practice administrative and physicians’ time. Pre-approval for sinus CT scans ordered by an otolaryngologist for evaluation of CRS is an unnecessary and costly requirement.

Reducing Readmission Rates at a Large Academic Otolaryngology Practice

Objectives: Hospital readmissions are an important focus of national quality and cost containment efforts. With increased emphasis on readmissions in the current healthcare climate, it is critical to evaluate factors contributing to readmission rates and strategies aimed at reducing these rates. The objectives of this study are to analyze the reasons for hospital readmission within 30 days of discharge and discuss methods implemented to reduce readmissions. Methods: A retrospective chart analysis was performed from 2010 to 2012 at a tertiary-care medical center. A quality plan was developed and implemented during this time to reduce readmissions. All patients who were admitted to an otolaryngology inpatient service and readmitted within 30 days of discharge were identified. Results: There were 763, 820, and 804 admissions during the years 2010, 2011, and 2012, respectively. The number of readmissions during this time were 51 (6.7%), 54 (6.6%), and 28 (3.5%), respectively. Common diagnoses for readmissions included dehydration, syncope, venous thromboembolism, postoperative bleeding, and cellulitis. There were no statistically significant differences in demographics and subsequent length of stay for those patients requiring readmission. The reduction in number of readmissions in 2012 compared to 2011 and 2010 was statistically significant. Conclusions: Readmission within 30 days in a large otolaryngology practice can be multifactorial. In order to reduce rates of readmission it is essential to understand post-operative complications, diagnoses, and comorbidities contributing to readmission. Implementation of a quality plan comprising comprehensive discharge planning efforts and close post-discharge follow-up can lead to a reduction in readmissions.

Amitriptyline for Symptomatic Treatment of Idiopathic Chronic Laryngeal Irritability

We evaluated the safety and efficacy of amitriptyline hydrochloride in treating idiopathic chronic laryngeal irritability. A retrospective chart review identified patients treated with amitriptyline for laryngeal irritability in an academic otolaryngology practice. Subjects who had documented medication compliance and a follow-up evaluation performed within 3 months after initiation of treatment were included. Symptoms, demographic information, and response to therapy were abstracted from the records. Sixty-six subjects were identified, comprising 48 women and 18 men. The ethnicities were black, 42%; Hispanic, 27%; white, 20%; Asian, 6%; and other or unspecified, 5%. The response to treatment was judged complete in 32% of subjects, partial in 24%, and without improvement in 36%; the remaining 8% were unable to tolerate treatment. Overall, 56.1% of subjects improved (95% confidence limit, 43.3% to 68.3%). No significant differences in response rates were seen based on gender (p = 0.484), age (p = 0.590), or race (p = 0.846). Sedation was reported by 23% of individuals. We found that more than 50% of subjects who received amitriptyline for chronic laryngeal irritability experienced improvement, and most subjects tolerated this treatment. No differences in efficacy were seen among racial, age, and gender subgroups. A prospective randomized trial of this therapy appears warranted.

Patient experience in the pediatric otolaryngology clinic: Does the teaching setting influence parent satisfaction?

ObjectivesPatient experience scores are now recognized as a chief indicator of healthcare quality. This report compares outpatient pediatric otolaryngology patient satisfaction in the teaching and non-teaching settings. Study designCross-sectional, multi-site, patient-level analysis of satisfaction surveys (Press Ganey™ Medical Practice©) completed by parents of pediatric otolaryngology patients in FY2010. MethodsSurveys were stratified by teaching/non-teaching affiliation. The survey has 29 Likert-scaled questions which comprise an overall score and subscores in 6 domains: access, visit, nursing, provider, personal issues, and assessment. The item likelihood-to-recommend was measured to indicate practice loyalty. Mean scores were compared by Kruskal–Wallis rank test. Multivariate logistic regression was performed to evaluate the association of teaching status with receipt of highest scores (HI-SCORES). Results4704 pediatric surveys were analyzed, with 1984 (42%) from the teaching setting. For the teaching setting, mean scores were lower overall (88.1 vs. 89.0; p<0.001) and in domains of access (includes scheduling ease, promptness in returning calls; 86.7 vs. 89.4; p<0.001) and personal issues (includes office hour convenience, sensitivity to needs; 87.0 vs. 88.5; p<0.001). Differences in access scores were largest for young children (0–<6 years; 86.0 vs. 89.5; p<0.001). Children in the teaching setting were less likely to have HI-SCORES overall (OR 0.78; 95%CI 0.65–0.95; p=0.011) and for access (OR 0.8; 95%CI 0.67–0.95; p=0.012); probability of HI-SCORES was similar for the two settings for all other domains. ConclusionsParents of pediatric otolaryngology patients evaluated in the teaching setting report lower satisfaction related to access, but similar scores for care providers and practice loyalty. Academic otolaryngology practices might focus on access issues to improve the overall care experience for children and families.

Intranasal hydrocodone‐acetaminophen abuse induced necrosis of the nasal cavity and pharynx

Two million new users will abuse prescription narcotics this year, most commonly hydrocodone. The most commonly prescribed form is hydrocodone-acetaminophen (HA). Many individuals crush the tablets and snort the product to take advantage of the rapid transmucosal delivery of narcotics. The resultant pathology of intranasal hydrocodone acetaminophen abuse (INHAA) has been described only in a few case studies. Retrospective chart review. Two private and one academic otolaryngology practices in Kentucky searched their patient charts for patients with morbidity from intranasal abuse of hydrocodone acetaminophen tablets. We identified thirty-five patients who presented for treatment between 2004 and 2011. The majority of patients will initially deny the behavior, frequently delaying diagnosis. Physical exam findings of white powder covering an underlying nasal mucosal necrosis are characteristic of this condition during active INHAA. Follow up was limited as only 26% returned for follow-up care. Patients commonly presented with orofacial-nasal pain (43%) and sino-nasal congestion and discharge (43%). Active necrosis or prior tissue loss was noted in 77% of patients. Fifty-one percent of patients presented with septal perforations, and 26% with palatal perforations. Two cases of invasive fungal sinusitis were clearly documented, with one resulting in death. The vast majority of cases presented with characteristic physical findings that included acute necrosis of soft tissue, which can progress to destroy oronasal structures. In the absence of invasive fungal disease, the condition is self-limited after cessation of INHAA and performance of local nasal debridement and nasal hygiene.

Patient satisfaction in otolaryngology: Can academic institutions compete?

Public reporting and transparency of patient experience is an emerging national healthcare priority. The objectives of this report are to describe patient satisfaction scores in ambulatory otolaryngology and examine the association of teaching status across multiple service domains. Cross-sectional patient-level analysis of Press Ganey outpatient medical practice surveys completed by otolaryngology patients in fiscal year 2010. The survey contains 29 Likert-scaled items that comprise an overall score and scores in six service domains: access, visit, nursing, care provider, personal issues, and assessment. The item "likelihood-to-recommend practice" was measured as an indicator of patient loyalty. Surveys were grouped according to teaching or nonteaching setting. Mean scores were compared by Kruskal-Wallis rank test for nonparametric data with Bonferroni's correction for multiple comparisons. A dichotomous variable (ALL-5s) was created to measure percentages of surveys with highest scores in each domain. Multivariate logistic regression adjusting for sex, age, geographical region, urban-rural status, and first visit was performed to evaluate the association of teaching status with ALL-5s in each domain. Pearson correlation (r) was used to evaluate correlation of individual survey items to the "likelihood-to-recommend practice" question. A total of 36,089 surveys were included, of which 16,057 (44%) were from a teaching setting. The mean age of respondents was 54.1 years (range, 0-90 years), and 52.7% were female. Patients seen in the teaching setting had lower mean scores overall and in domains of access, visit, and personal issues (P = .004) but had higher mean scores for likelihood-to-recommend practice (P = .007). No differences were identified between groups in domains of nursing, care provider, and assessment. Multivariate analysis of association of teaching setting with ALL-5s demonstrated that patients in a teaching setting were more likely to have the highest scores (ALL-5s) in the domain of nursing (OR, 1.09; 95% confidence interval [CI], 1.03-1.16; P = .002) and for the loyalty question of "likelihood-to-recommend practice" (OR, 1.12; 95% CI, 1.05-1.19; P = .001), and less likely to have highest scores for the overall survey (OR, 0.88; 95% CI, 0.83-0.93; P < .001) and domains of access (OR, 0.89; 95% CI, 0.84-0.94;P < .001) and visit (OR, 0.89; 95% CI, 0.85-0.94; P < .001). No association was identified between teaching status and domains of care provider, personal issues, and assessment. Survey items correlated with likelihood-to-recommend practice were similar between groups. Items most closely correlated with loyalty were all within the care provider domain consisting of "likelihood-to-recommend care provider" (r = 0.839), "confidence in care provider" (r = 0.785), and "concern care provider showed" (r = 0.733; P < .001). Items least closely correlated were within the visit domain related to waiting room comfort (r = 0.467), registration speed (r = 0.447), and wait time (r = 0.432; P < .001). Otolaryngology patients evaluated in the teaching setting report lower patient satisfaction overall, primarily related to access to care and visit-specific processes; however, they are more likely to display loyalty and recommend their practice and care provider. The teaching setting does not influence care provider satisfaction scores. Because practice loyalty is most closely correlated to provider-specific behaviors, otolaryngologists may consider enhancement of provider-patient communication to improve patient satisfaction regardless of the practice setting. Academic otolaryngology practices should consider focusing on access systems and process improvement to enhance the overall patient experience.

Efficacy of Amitriptyline for Chronic Laryngitis

Objective: 1) Evaluate effectiveness of amitriptyline for the treatment of chronic laryngitis. 2) Compare the effectiveness of amitriptyline by gender, age, and race. Method: A retrospective chart review identified patients treated with amitriptyline for laryngitis in an academic otolaryngology practice. Subjects who had documented compliance with medication and follow-up evaluation within three months after initiation were included. Symptoms, demographic information, and response to therapy were abstracted from their records. Results: A total of 66 subjects were identified, consisting of 48 women and 18 men. Those of African descent constituted 42%, with Hispanic 27%, white 20%, Asian 6%, and other 5%. Response to treatment was complete in 32%, partial in 24% and without improvement in 36%, with the remaining 8% unable to tolerate treatment. Overall, 56% of subjects improved (95% confidence limit 43.3% to 68.3%). No significant differences in response rates were seen based on gender ( P = .289), age (&lt;60 vs 60+) ( P = .149) or race ( P = .254). Conclusion: We found a substantial rate of improvement with amitriptyline treatment among individuals with chronic laryngitis, with most subjects tolerating this treatment. No significant differences in efficacy were seen among racial, age and gender subgroups. A prospective randomized trial of this therapy appears warranted.

Prevalence of Complementary and Alternative Medicine use among a Population of Head and Neck Cancer Patients: A Survey-Based Study

We sought to determine the prevalence and patterns of complementary and alternative medicine (CAM) use among head and neck cancer patients who were being treated at an academic otolaryngology practice in the northeastern United States from January 2005 through December 2006. During a 3-month period, we conducted an anonymous survey of 213 new and established patients regarding their use of CAM during their cancer treatment. According to the responses, only 13 of these patients (6.1%) were currently using CAM during treatment. With respect to the various products being taken, 9 patients (69.2% of all CAM users) were taking herbs or supplements. Only 7 patients (53.8%) who used CAM disclosed this fact to their physician during in-office encounters. The most common sources for obtaining CAM were health-food stores, where most patients spent approximately $25 per week. The most frequently cited reason for using CAM was that a particular product had been recommended by family or friends as being potentially helpful. No adverse effects of CAM were reported. We conclude that while CAM use was not very prevalent in this study, patients who did use it were employing modalities with biologic activity that may potentially interact with conventional therapies. Because patients' disclosure of CAM use is frequently not volunteered, otolaryngologists should routinely elicit this information in a highly specific fashion so that we may better serve our unique patient population.

Advanced access to otolaryngology: Lessons learned

Reports of experience with implementing advanced access techniques in specialty practices are few in number. In our facility, we were able to demonstrate that patients' access to care improved from >100 days to 72 hours, patient satisfaction increased 22%, and productivity increased 29%. The lessons we learned after the successful implementation of advanced access in an academic otolaryngology practice are presented here.

Transnasal Esophagoscopy: A High-Yield Diagnostic Tool

Transnasal esophagoscopy (TNE) reveals a wide range of esophageal findings. TNE technique, indications, outcomes, advantages, limitations, and impact on patient care are described. Retrospective chart review. Charts of the first 30 patients to undergo TNE in an academic otolaryngology practice were reviewed. Technique details, patient demographics, and procedure indications and findings as well as the disposition of patients in this series are described. TNE limitations are discussed with areas for future development. Thirty patients who underwent unsedated outpatient TNE by their otolaryngologist are described. TNE was directed toward select indications: dysphagia, screening esophagoscopy given long-standing gastroesophageal reflux (GER) or laryngopharyngeal reflux (LPR), and esophageal surveillance with a new diagnosis of head and neck squamous cell carcinoma. Positive findings included mucosal cobblestoning, Barrett's esophagus, esophagitis, gastritis, candidal esophagitis, esophageal diverticulum, postcricoid mass, patulous esophagus, and absence of secondary esophageal peristalsis. Outcomes included referral to a gastroenterologist for evaluation, with or without biopsy; direct laryngoscopy or esophagoscopy with biopsy by the otolaryngologist; planned cancer resection by the otolaryngologist; and medical management of GER/LPR by the otolaryngologist. With appropriate selection criteria, TNE yields a high percentage of positive findings and wide range of esophageal abnormalities, directly impacting patient management. Available to otolaryngologists in the outpatient setting, TNE expedites interventions by providing a safe, effective alternative to rigid esophagoscopy under general anesthesia and flexible upper endoscopy with sedation. Patients will benefit from the integration of TNE into otolaryngologists' outpatient diagnostic armamentarium.

Is flexible nasopharyngolaryngoscopy good enough in the diagnosis of the hoarse patient?

Objectives: The primary assessment of voice disorders in otolaryngology practice conventionally involves the use of flexible fiberoptic examination of the larynx. Rigid videostroboscopy is considered by many to be a useful additional laryngeal diagnostic and teaching tool. The purpose of this study is to compare the efficacy of flexible nasopharyngolaryngoscopic to rigid videostroboscopy in making diagnosis and formulating treatment plans for patients who present to an academic otolaryngology practice with hoarseness. Methods: A retrospective chart review of patients presenting with hoarseness was performed. All patients were examined initially by an otolaryngologist with fiberoptic nasopharyngolaryngoscopy and subsequently with videostroboscopy by our speech pathologist over a period of 6 months. Rigid videostroboscopy served as the standard for definitive diagnosis of functional and anatomical laryngeal pathology. Changes in primary diagnosis were documented as a misdiagnosis by flexible nasopharyngolaryngoscopy. Results: Ninety-one patient charts were reviewed with presenting symptoms of hoarseness. Overall, 23 (25%) patients received a change in primary diagnosis and 5 (5.5%) had a change in management based on this difference. Specifically, 7 of these 23 (30%) were diagnosed with laryngopharyngeal reflux initially and later were found to possess significantly different vocal cord pathology by rigid videostoboscopy. Conclusions: Clinical fiberoptic nasopharyngolaryngoscopy is a useful tool in the diagnosis of hoarseness. A significant rate of misdiagnosis utilizing this modality alone has been shown. Adjunctive examination by trained speech pathologists utilizing rigid videostoboscopic analysis is invaluable. Most importantly, it provides improved diagnostic accuracy, serves as an invaluable platform for resident education, and ultimately delivers better care for the patient.

Contemporary trends in microbiology and antibiotic resistance in otolaryngology

Objective: to determine current microbiologic yields and characterize antibiotic resistance patterns for organisms cultured from head and neck infections. Methods: results of out-patient cultures submitted from an academic otolaryngology practice over the period 1994–1998 were reviewed. A database was constructed, and culture results were analyzed for sites of infection, organism recovery rate, infecting microbiological agent, antibiotic resistance patterns, and 5-year trends. χ 2 analysis was used to determine associations between site of infection, infecting agent and antibiotic resistance over the years of the study. Results: a total of 986 aerobic cultures were reviewed. The most common sites cultured were the nose/paranasal sinuses (469), throat (377), and ear (23). In 465 (47.2%) cultures, normal flora or no growth occurred. Of the throat culture subset, 69.7% were negative, whereas 69.1% of sinonasal cultures recovered organisms. Gram positive cocci were the most commonly recovered organism type (30.9%), followed by Gram negative rods (GNR, 17.2%). These rates remained relatively constant over the years of the study. GNR were found in 39.1 and 25.2% of ear and sinus cultures, respectively. Antibiotic sensitivities were conducted on 257 specimens (49.3% of positive cultures). The average number of antibiotic resistances per bacteria remained stable at approximately 1.59 over the years ( P=0.086, analysis of variance (ANOVA)). Antibiotic resistance rates increased for clindamycin, cefazolin, and erythromycin over the years of the study ( P<0.05, χ 2). Ciprofloxacin, gentamicin and trimethoprim-sulfamethoxazole resistance rates did not increase over the years of the study. Vancomycin resistance did not occur. Conclusions: as a significant proportion of head and neck cultures will be negative, their utility should be re-examined. GNR infections are more common in the head and neck than earlier thought. There is a trend towards increasing antibiotic resistance in head and neck infections, urging careful and appropriate use of antibiotics.

Allergy testing and immunotherapy in an academic otolaryngology practice: A 20-year review

Objective: Allergic disease plays a central role in the clinical practice of otolaryngology. The purpose of this study was to review the 20-year experience of an allergy clinic integrated within an otolaryngology practice at a major academic institution. Study design: We performed a retrospective database review of over 3300 otolaryngology patients referred for allergy skin testing between 1979 and 1999. Results: Approximately 80% of patients referred for allergy testing in our clinic had positive test results, of which 75.7% went on to undergo desensitization. The most common allergen was house dust, with allergies to mites, ragweed, and grass also prevalent. Among current allergy immunotherapy patients, 30.8% have undergone nasal septal, turbinate, and/or endoscopic sinus procedures in addition to allergy management. Nasal obstruction was the symptom most frequently persistent despite immunotherapy and the one most frequently reported to be improved by surgery. Conclusions: The otolaryngologist-head and neck surgeon is uniquely qualified to perform comprehensive medical and surgical management for patients with complex disease processes involving a component of allergy. We believe that an integrated approach to allergy within an otolaryngology practice optimizes the treatment of such patients. (Otolaryngol Head Neck Surg 2001;124:9-15.)