Wiedermann, Joshua P.

ABSTRACT Objective To identify and compare how patient perceptions contribute to Type 1 Delays, defined as delays in deciding to seek care, among individuals with head and neck cancer (HNC) in high‐income countries (HICs) and low‐ and middle‐income countries (LMICs). Methods We conducted a scoping review and systematic search of MEDLINE, Embase, Cochrane Library, and Scopus from inception through November 20, 2023. Eligible studies included patients with HNC in HICs or LMICs who reported patient perceptions contributing to Type 1 Delays. Data extraction was performed in duplicate, and barriers were categorized thematically. Fisher's exact test was used to compare the frequency of reported barriers between HIC and LMIC studies. Results Seventeen studies met inclusion criteria, of which 64.7% ( n = 11) were conducted in HICs and 35.3% ( n = 6) in LMICs, representing 9 countries and 1410 participants. The most frequently cited perceptions contributing to delay were symptom unawareness, misinterpretation, and minimization. Additional barriers included fear of diagnosis, stigma, alternative medicine use, financial challenges, and geographic barriers. Transport/geographic barriers showed a trend toward being more common in LMIC studies ( p = 0.05). Descriptive patterns suggested LMIC patients more often reported structural and sociocultural barriers, whereas HIC patients more commonly cited psychosocial or perceptual barriers. Conclusion Type 1 Delays in HNC are common across both HICs and LMICs, with overlapping and region‐specific contributors. Tailored interventions, such as patient education, stigma reduction, and improved access to diagnostic services, may promote earlier detection and improve global HNC outcomes. Level of Evidence 3.

ABSTRACT Background Preoperative vascular embolization (PVE) is commonly used in managing juvenile nasopharyngeal angiofibroma (JNA) to improve outcomes. However, few studies have evaluated how embolization patterns and vascular features affect prognosis. Methods A 15‐year retrospective review was performed on 44 patients with JNA undergoing surgery at one institution. Data included demographics, vascular supply, embolization techniques, surgical outcomes, and recurrence. Results Forty‐three patients underwent PVE. Most tumors were embolized transarterially (93.0%) using polyvinyl alcohol‐based agents (79.1%). The internal maxillary artery was most commonly embolized (93.0%). Internal carotid artery supply was present in 34.9%, and more than two vessels were embolized in 23.3%. Postembolization tumor blush occurred in 60.5%, with a median of 5% of the pre‐embolization blush remaining after embolization. Neither internal carotid involvement, number of vessels embolized, nor residual blush significantly impacted operative time, surgical outcomes, or recurrence. Conclusion With effective embolization, vascular complexity might not affect JNA resection outcomes. Multicenter studies are required to confirm those findings.

Importance Adverse events in otolaryngology–head and neck surgery (OHNS) are inconsistently reported. The Clavien-Dindo Classification has been modified and validated in several surgical subspecialties but has yet to be validated in OHNS. Objective To create and validate a modified Clavien-Dindo Classification for OHNS that reflects the severity and duration of harm for complications experienced by patients undergoing OHNS. Design, Setting, and Participants This is a multicenter survey study of subject matter experts (SMEs) from OHNS subspecialties from academic institutions within the US. A literature review identified publications reporting surgical complications in OHNS in the English language between January 2019 and April 2020. Complications were summarized and used to inform a modified Clavien-Dindo Classification. Feedback from internal SMEs was incorporated. Thirty-five clinical vignettes were created, and an electronic survey was sent to SMEs at outside institutions. Each SME was randomly assigned to 1 of 4 groups to evaluate 8 to 9 vignettes. The survey was conducted in September 2023, and data were analyzed from February to May 2024. Exposure Participation in the electronic survey. Main Outcomes and Measures Vignette scores were assessed and the Comprehensive Complication Index (CCI) calculator was used to assess cumulative morbidity. The scale is based on the grading by the Clavien-Dindo Classification and reflects overall morbidity on a scale from 0 (no complication) to 100 (death). Variability of the CCIs between reviewers, the primary outcome, was summarized with the SD. The percentage of reviewers with a high (≥26.2) or low (<26.2) CCI within a vignette was reported. Reliability was summarized using Krippendorff α. Results Of 106 SMEs, 43 (response rate, 40.6%) completed at least 1 vignette. Eighteen of 35 vignettes (51.4%; 95% CI, 34.9%-68.0%) had unanimous high CCI, and 8 of 35 vignettes (22.9%; 95% CI, 8.9%-36.8%) had unanimous low CCI (overall categorical agreement, 74.3%; 95% CI, 59.8%-88.8%). On average, the Krippendorff α was 0.74, indicating moderate reliability. A total of 21 850 OHNS complications were reviewed and categorized as surgical or medical with 12 including subcategorization for specificity. Each category was then assigned a modified OHNS Clavien Dindo classification grade. Conclusions and Relevance In this survey study of OHNS experts, a modified OHNS Clavien-Dindo Classification was developed and validated using case vignettes. The modified Clavien-Dindo Classification provided a granular subcategorization for each complication category and grade, duration of harm, and an overall summary complication score (CCI). Results suggest the modified OHNS Clavien-Dindo Classification reliably differentiated between high-grade and low-grade OHNS complications and could be utilized for assessing surgical outcomes.

ABSTRACT Introduction Laryngotracheoesophageal clefts (LTEC) are aspiration‐related lesions often assessed using swallow studies and symptoms like respiratory or feeding difficulties. However, these indicators are unreliable predictors of disease severity. Lung inflammation and injury, though significant concerns, are rarely and inconsistently evaluated or reported. As a result, the correlation between swallow study findings and actual pulmonary disease remains unclear. Methods A retrospective cohort of children with LTEC seen in our Aerodigestive Program between October 1, 2012, and September 30, 2023, who underwent videofluoroscopic swallow study (VFSS) or flexible endoscopic evaluation of swallowing (FEES) were included. Data collected included clinical history, risk factors, BAL, chest CT, impedance probe, VFSS/FEES findings, and FOIS‐P/I scores at baseline and follow‐up. Results Eight‐two subjects identified. Lung inflammation and bronchiectasis were common and correlated. Clinical factors, impedance probe, and the presence/severity of swallowing abnormalities on VFSS/FEES were not predictive of lung disease. Fifty‐seven patients underwent LTEC repair for a range of indications, only 49% based on CT and/or BAL findings. Of 57 children who had LTEC repair, only 49% were based on CT or BAL findings. LTEC repair was associated with modest improvement feeding and swallowing. Discussion Children with LTEC have a high prevalence of inflammatory lung disease and injury and undergo repair for a variety of reasons. Swallow studies detect functional swallowing issues but do not reliably identify lung disease. Despite this limitation, LTEC repair is linked to improved feeding and swallowing in some patients, though not all benefit.

ImportanceUnderstanding the global barriers to otolaryngology–head and neck surgery (OHNS) care is crucial in addressing disparities in access to care, particularly in low-income and middle-income countries (LMICs).ObjectiveTo characterize barriers to comprehensive otolaryngology care across World Bank income groups.Design, Setting, and ParticipantsUsing an online cross-sectional survey that was administered by the Global OHNS Initiative via international and national professional societies, personal contacts, and social media, this study captured the perceptions of otolaryngologists regarding barriers to OHNS care at the levels of the country, health sector, clinician, and patient. Participants included otolaryngologists from the 194 World Health Organization member states and Taiwan. Eligibility criteria included a medical degree and specialized training in managing conditions of the ear, nose, and throat. The nonresponse rate was not recorded. The data collection period spanned from October 2022 to June 2023.ExposuresExposures included World Bank income group classification.Main Outcomes and MeasuresThe primary outcomes were Likert scale responses regarding frequency of barriers to OHNS care. The a priori hypothesis was that LMICs would report more frequent barriers to OHNS care.ResultsThe study involved 146 otolaryngologists (47 female individuals [32%]), with 69 (47%) from high-income countries and 77 (53%) from LMICs. Male individuals represented 45 high-income country respondents (65%) and 54 LMIC respondents (70%). Barriers were reported across income groups at all levels of the health system, with a higher frequency in LMICs. Several barriers were reported to be more substantial in LMICs, such as the national volume and distribution of otolaryngologists, financial compensation for clinicians, and patient stigma, and others were common across income settings, such as the availability of operating rooms and inflexible working hours. Common concerns included national and health sector barriers: OHNS workforce, referral networks, government support; clinician barriers: excessive clinician workloads, understaffing, poor administration support; patient barriers: distance to health care facilities, financial burdens such as medical costs and foregone wages, stigma, and health literacy.Conclusions and RelevanceThe results of this cross-sectional study suggest that there are barriers to otolaryngology care globally that affected all levels of the health care system. This work may inform prioritization of otolaryngology within research and policy, and it emphasizes the need for effective strategies to expand access to otolaryngology care, particularly in lower-income settings.

Background: Surgical registries have been widely adopted in high-income countries to improve patient outcomes. However, similar data-driven initiatives are still scarce in low- and middle-income countries (LMICs). Aims: This study aimed to address the challenges of implementing a perioperative registry for otolaryngology-head and neck surgery (OHNS) in Mekelle, Ethiopia, and to assess strategies for ensuring its long-term sustainability. Methods: The registry was developed using REDCap, through a collaborative effort between otolaryngologists in the United States and Ethiopia, ensuring its relevance to the local context. On-site training sessions were conducted for 13 OHNS residents and four senior surgeons to facilitate their use of the registry. A Wi-Fi router was installed in the operating room to enable real-time data entry. Continuous support was provided through remote communication between the local team and the U.S. research team. Sustainability strategies focused on fostering local ownership, integrating the registry into existing workflows, and maintaining continuous data monitoring. Results: Despite facing challenges like intermittent internet connectivity and issues with workflow integration, the local team successfully integrated the registry into routine clinical and surgical practices. Key strategies included providing dedicated Wi-Fi routers, modifying registry fields for improved efficiency, and emphasizing the registry’s value to the institution. Ongoing collaboration between the local team and the U.S. team enabled continuous optimization and data collection. Conclusion: The successful implementation of this perioperative registry underscores the importance of engaging local stakeholders and integrating sustainable workflows. This initiative serves as a model for other LMICs seeking to establish surgical registries that enhance data-driven decision-making at both the patient and institutional levels.

ABSTRACTObjective(s)We aim to identify the diversity of barriers to care for otolaryngology‐head and neck surgery patients in Harare, Zimbabwe.MethodsInterviews were conducted at four general otolaryngology clinics in Harare in October 2022.The patient population included children and adults presenting to either government or private clinics. Via interpreter, six standardized questions were discussed with each patient. Survey responses were used to categorize patients into one or more of three types of delays: (1) deciding to seek care, (2) reaching the appropriate healthcare facility, and (3) receiving adequate care after reaching that facility.ResultsForty‐six patients participated in this survey. The average time from problem presentation to treatment in this population was 16.3 months. Twenty‐six percent of patients experienced more than one type of delay. The most common type of delay was Type 3 (67%). Many of these patients reached appropriate facilities but could not receive timely treatment due to lengthy wait times. Type 1 delays affected 35% of patients. Notable causes were fear of doctors, preference for traditional healing, or ignorance to a treatable problem. Type 2 delays were also reported in 37%, commonly due to long distance and time to travel and insufficient finances for these journeys.ConclusionsENT patients in Zimbabwe experience a myriad of delays to receiving appropriate care. Systemic issues, including backlogged surgical lists, convoluted referral patterns, and poor transportation infrastructure, are significant contributors to patient delays. The 3‐delay model is useful for identifying barriers to care for future efforts to improve patient access to safe and affordable surgical care.Level of EvidenceLevel VI.

ABSTRACTImportanceHighlighting the global disparities in otolaryngology training and, ultimately, service delivery, emphasizing the need for equitable access to training resources and programs.ObjectiveTo describe the relationship between the quality, content, and location of otolaryngology–head and neck surgery training and education and the resulting impact on the delivery of otolaryngology care globally.DesignAn online cross‐sectional survey to otolaryngologists, gathering information on their training and education experiences, and factors influencing their choice of training location and practice.SettingThe online survey was available in multiple languages, distributed via national and international professional otolaryngology societies, snowballing and social media.ParticipantsThe respondents were practicing otolaryngologists representing all seven World Health Organization regions.ExposuresWorld Bank income groups classification.Main Outcomes and MeasuresOur expected outcome was that subspecialty training and access to educational resources were significantly readily available to respondents from high‐income countries, leading to more confidence in performing complex procedures post training.ResultsA total of 91 participants were included in the analysis, with 47 (52%) practicing in high‐income countries and 44 (48%) in low‐ and middle‐income countries. Sixty‐one participants (67%) were male. Subspecialty training and access to educational resources were significantly less available in low‐ and middle‐income countries, leading to lower confidence among low‐ and middle‐income countries physicians in performing complex procedures. High‐income country respondents reported better access to diverse training resources and felt more prepared for a broader range of procedures.Conclusion and RelevanceSignificant disparities exist in OHNS training resources and subspecialty training opportunities between high‐ and low‐middle‐income countries. There is a critical need to integrate complementary training and educational modalities into local systems. Addressing the shortage of educational resources and promoting open‐access initiatives in low‐middle‐income countries are essential steps toward enhancing surgical education and improving global otolaryngology healthcare outcomes.

ABSTRACT Objective Availability of surgical equipment and access to essential clinical services remains an important barrier to surgical care delivery, particularly in low‐ and middle‐income countries (LMICs). This study aims to characterize the relative availability of essential equipment for otolaryngology‐head and neck surgery (OHNS) care across World Bank income groups. Methods We conducted a cross‐sectional survey on otolaryngologists' perceptions on the availability of surgical equipment and ancillary services in their respective practice settings per a 5‐point Likert scale ranging from never to always available. The study was disseminated online via professional societies, personal contacts, and social media. Eligible participants included otolaryngologists from 194 WHO‐recognized countries, which were grouped by World Bank income group classification and WHO region. Results The study involved 146 otolaryngologists, 69 (47%) from high‐income countries (HICs), and 77 (53%) from LMICs. LMIC respondents were predominantly from the African and South‐East Asian regions, which comprised 48% and 7.8% of all LMIC respondents, respectively. Results revealed significant differences in the availability of otologic, rhinologic, and endoscopic airway equipment between HICs and LMICs. Differences existed among commonly used equipment such as tympanomastoidectomy equipment and rigid bronchoscopy, to subspecialized equipment such as functional endoscopic sinus surgery equipment and cochlear implants ( p < 0.05 each). Conclusions The study highlighted key disparities in the availability of essential equipment for baseline OHNS care, especially for pediatric airway and otologic conditions. These results can be used to guide investment and advocacy efforts to improve specialty‐specific surgical infrastructure relative to the global burden of OHNS diseases in low‐resource settings. Level of Evidence 3