All Publications

  • Incidence and risk factors of chronic opioid use after sleep apnea surgery. Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine Abdelwahab, M., Marques, S., Howard, J., Huang, A., Lechner, M., Olds, C., Capasso, R. 2022


    STUDY OBJECTIVES: To assess the incidence and risk factors of chronic opioid use after OSA surgery.METHODS: Using IBM MarketScan research database, adults (>18) who underwent a variety of sleep surgery procedures between 2007 and 2015, were identified. Subjects with one year of insurance coverage before and after the surgical procedure were included. Additional anesthesia event(s) in the year following the procedure of interest, and those who filled an opioid prescription within the year prior to surgery (not naive) were excluded. Outcomes included rates of persistent opioid use (additional opioid prescriptions filled 90-180 days postoperatively), prolonged use (additional opioid prescriptions filled 181-365 days postoperatively) and inappropriate use (>100 MME). Evaluated variables include demographics, surgical procedures, and comorbidities.RESULTS: A total of 10,766 surgical procedures met inclusion criteria. There was a trend of increased rates of perioperative opioid prescription. After multivariable logistic regression analysis, perioperative opioid prescription and smoking were independent risk factors for inappropriate opioid use (OR= 31.51, p<0.001; OR= 1.41, p=0.016 respectively). Opioid prescription and hypertension were independent risk factors for persistent opioid use (OR=37.8, p<0.001, OR=1.38, p=0.008). Perioperative opioid prescription, previous opioid dependence diagnosis, smoking and male gender were associated with continuous prolonged opioid use (OR=73.1, 8.13, 1.95, 1.55, respectively; p<0.001, 0.020, 0.024, 0.032, respectively).CONCLUSIONS: While efforts by different societies are being implemented to control the opioid crisis, we found that perioperative opioid prescription for airway surgery targeting OSA is an independent risk factor for persistent, prolonged, and inappropriate opioid use.

    View details for DOI 10.5664/jcsm.9978

    View details for PubMedID 35393936

  • Use of Polysomnography and CPAP in Children Who Received Adenotonsillectomy, US 2004 to 2018. The Laryngoscope Qian, Z. J., Howard, J. M., Cohen, S. M., Jin, M. C., Bhargava, S., Cheng, A. G., Valdez, T. A. 2022


    OBJECTIVES: 1) To determine the prevalence polysomnogram (PSG) and continuous positive airway pressure (CPAP) therapy use in children who received adenotonsillectomy (AT) for sleep symptoms. 2) To identify health care disparities in these regards.STUDY DESIGN: Retrospective database analysis.METHODS: This study used data from Optum (Health Services Innovation Company) to identify 92,490 children who received AT for sleep symptoms between 2004 and 2018. Prevalence of preoperative PSG and postoperative PSG and CPAP were described. Clinical and demographic characteristics were compared between children who had preoperative PSG and those who did not. Characteristics of children with trisomy 21 (T21) were compared to assess PSG and CPAP use in a high-risk cohort. Predictive modeling was used to identify patient characteristics associated with postoperative PSG and CPAP use.RESULTS: Preoperative PSG was obtained in 5.5% of children overall and 33.2% of children with T21. Male sex, obesity, other medical comorbidities, non-White race/ethnicity, and higher parent education were associated with preoperative PSG. Fewer than 3% of children received postoperative PSGs and approximately 3% went on to receive CPAP therapy postoperatively. Multiple logistic regression showed that age at surgery, male sex, obesity, other medical comorbidities, non-White race/ethnicity, and higher parent education were associated with postoperative PSG and CPAP use.CONCLUSIONS AND RELEVANCE: This study described the prevalence pre-AT PSG use and post-AT PSG and CPAP use for persistent symptoms and identified sleep health care disparities in these regards. These results show that increased, equitable access to PSG is needed in children, particularly in the workup and treatment persistent symptoms after AT.LEVEL OF EVIDENCE: 4 Laryngoscope, 2022.

    View details for DOI 10.1002/lary.30103

    View details for PubMedID 35285524

  • Descriptors in Letters of Recommendation for Otolaryngology Residency Across Gender, Race, and Time. Journal of surgical education Aunins, B., Badhey, A., Conroy, Z., Howard, J. J., Myer, C. 3., Altaye, M., Tang, A. L. 2022


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

    View details for DOI 10.1016/j.jsurg.2022.02.009

    View details for PubMedID 35241396

  • Racial Disparities in Surgical Treatment of Obstructive Sleep Apnea. OTO open Cohen, S. M., Howard, J. J., Jin, M. C., Qian, J., Capasso, R. 2022; 6 (1): 2473974X221088870


    Objective: Determine risk factors for failure to receive surgical treatment among patients with obstructive sleep apnea.Study Design: Population-based observational longitudinal cohort study.Setting: Population-based database.Methods: Multivariate analysis of 500,792 individuals with obstructive sleep apnea from Optum's deidentified Clinformatics Data Mart database (2004-2018).Results: Black race, increased age, diabetes, atrial fibrillation, obesity, and congestive heart failure were independently associated with a decreased rate of surgery for obstructive sleep apnea. Asian race, hypertension, arrhythmias other than atrial fibrillation, pulmonary disease, and liver disease were independently associated with an increased rate of surgery for obstructive sleep apnea.Conclusion: Racial disparities in health outcomes related to health care access and in economic resources have an enormous impact on public health and social equity. We found differences in rates of surgery for obstructive sleep apnea based on race. These data are consistent with others demonstrating disparities in medical treatment of sleep apnea with positive pressure and underline a need for a change in awareness and treatment in these populations.

    View details for DOI 10.1177/2473974X221088870

    View details for PubMedID 35321423

  • The Long "Race" to Diversity in Otolaryngology. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery Tusty, M., Flores, B., Victor, R., Fassiotto, M., Maldonado, Y., Howard, J., Valdez, T. A. 2020: 194599820951132


    The number of health disparities disproportionately affecting minority communities continue to rise. Thus, it is imperative to assess whether equity within medical school enrollment and along the academic pipeline has mirrored this growth, especially among elite surgical specialties such as otolaryngology. Census and educational data from 2010 and 2018 were used to assess the current otolaryngology, surgery, and internal medicine physician and faculty workforce diversity across each stage of the academic medicine trajectory by race and ethnicity. We found that disparities exist in medical school enrollment for minority students such that Hispanic/Latinx representation was only 30% and Black representation only 50% of their respective proportions in the US population in 2018. Disparities in achieving full professorship were also observed across all 3 specialties but most prominently in otolaryngology, with 1% Black representation among otolaryngology professors in 2018. A collective strategy toward diversifying the otolaryngology workforce should be explored.

    View details for DOI 10.1177/0194599820951132

    View details for PubMedID 32838654

  • Outcomes in children with down syndrome and mild obstructive sleep apnea treated non-surgically. The Laryngoscope Howard, J. J., Sarber, K. M., Yu, W. n., Smith, D. F., Tikhtman, R. O., Simakajornboon, N. n., Ishman, S. L. 2020; 130 (7): 1828–35


    Nasal steroids, oral anti-leukotrienes and supplemental oxygen are effective in the treatment of mild obstructive sleep apnea (OSA) in otherwise healthy children. However, their efficacy is unknown in children with Down syndrome (DS). Here we examine the effect of single medication therapy versus observation versus oxygen on polysomnographic outcomes in these children.We reviewed children (<18 years) diagnosed with DS and mild OSA (obstructive apnea-hypopnea index [oAHI] ≥1 to <5 events/hour) treated non-surgically (with supplemental oxygen, one medication, or observation) between 2012 and 2017. Demographic data, comorbid diagnoses, and pre- and posttreatment polysomnograms were analyzed. We assessed pre- and posttreatment oAHI, oxyhemoglobin saturation nadir, percent total sleep time (%TST) in rapid eye movement (REM), and end-tidal carbon dioxide (ETCO2 ) >50 mmHg.Twenty-four children met inclusion criteria; 10 treated with medication, one with oxygen, and 13 with observation (baseline oAHI was 3.5, 3.3, and 2.9 events/hour, respectively). There was no significant change in oAHI, oxyhemoglobin saturation nadir, ETCO2 , or percent TST in REM after treatment for any treatment group (P = .21-.94). There was no association between reported symptoms and AHI severity or change in AHI. OSA resolved in one patient treated with observation and two treated with medication, but worsened in two each in the medication and observation groups. Resolution of OSA occurred in 20% treated with medication, 7.7% with observation, and 0% with oxygen (P = .82).In our cohort, resolution of mild OSA was low. This suggests that consideration should be given to multimodality treatments in children with DS and mild OSA. Prospective studies will help establish effectiveness in this cohort.4 Laryngoscope, 130:1828-1835, 2020.

    View details for DOI 10.1002/lary.28325

    View details for PubMedID 31603543

  • Children with Down syndrome and mild OSA: treatment with medication versus observation. Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine Yu, W. n., Sarber, K. M., Howard, J. J., Huang, G. n., Hossain, M. M., Heubi, C. H., Lu, X. n., Simakajornboon, N. n. 2020; 16 (6): 899–906


    Children with Down syndrome (DS) have a high prevalence of obstructive sleep apnea (OSA). Anti-inflammatory medications have been shown to be an effective treatment for mild OSA in otherwise healthy children. However, the efficacy in children with DS and mild OSA has not been investigated. Our aim was to examine the polysomnographic changes of children with DS and mild OSA treated with medication.A retrospective chart review was performed in children with DS (< 18 years) and mild OSA (obstructive apnea-hypopnea index ≤ 5 events/h) diagnosed by polysomnography (PSG) between 2006 and 2018. Patients were included if they were treated with medications (intranasal corticosteroids and/or montelukast) or by observation with a duration of at least 3 months and had baseline and follow-up PSGs. Demographic data, comorbid diagnoses, and PSG data were collected and analyzed.Forty-five children met inclusion criteria. In the medication group, 29 children were identified. The median age was 7.4 years (interquartile range [IQR] 4.9-9.3). In the observation group, 16 children were identified. The median age was 4.0 years (IQR 3.2-5.3). The median time from baseline to follow-up PSG was 14.0 months (IQR 10.0-22.9) for the medication group and 10.5 months (IQR 6.5-33.5) for the observation group. There were no significant changes in the median obstructive apnea-hypopnea index from the baseline to follow-up PSG in either the medication group (2.8 [IQR 2.2-3.6) versus 3.5 [IQR 1.4-4.8) events/h; P = .25) or the observation group (2.3 [IQR 1.3-3.1] versus 2.9 [IQR 1.9-6.8] events/h; P = .12). Similarly, there were no significant differences in apnea-hypopnea index, oxygen nadir or end-tidal carbon dioxide between the groups (P = .07-1).In our cohort, medication therapy did not significantly improve polysomnographic measures in children with DS and mild OSA. Several factors such as hypotonia and relative macroglossia may explain the ineffectiveness of medical therapy for OSA in this population. Further prospective studies are necessary to confirm these results and to evaluate if a subgroup of DS children may benefit from medical therapy.

    View details for DOI 10.5664/jcsm.8358

    View details for PubMedID 32043964

  • Sleep-Disordered Breathing in Pediatric Patients With Rett Syndrome. Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine Sarber, K. M., Howard, J. J., Dye, T. J., Pascoe, J. E., Simakajornboon, N. n. 2019; 15 (10): 1451–57


    Although respiratory abnormalities occurring during wakefulness are well recognized in patients with Rett syndrome (RS), less has been reported regarding sleep-disordered breathing (SDB) in this population. This study aims to characterize the presenting complaints, types and severity of SDB, and treatment modalities of patients with RS and sleep concerns.Retrospective chart review of pediatric patients with RS referred to our academic tertiary care institution from January 2007 to July 2017.Thirteen patients were identified, 11 female (84.6%); mean age at polysomnography (PSG) was 10.3 years (standard deviation 4.94). Eleven were white (84.6%), 2 were black (15.4%). The most common presenting symptoms were snoring (10/13, 77%) and witnessed apnea (7/13, 53.8%). On baseline PSG, all patients (100%) exhibited hyperapneas followed by a central apnea during wake. Nine (69.2%) had obstructive sleep apnea (OSA) (obstructive apnea-hypopnea index (oAHI) > 1); four had severe OSA (oAHI ≥ 10). One had central sleep apnea (central apnea index > 5) and severe OSA. No patients exhibited hypoventilation on baseline PSG. Mean AHI of all patients was 8.77 ± 8.82 (oAHI 6.51 ± 6.91) events/h. Mean oxyhemoglobin nadir was 88.52 ± 5.6%. Treatment modalities included observation: 5 (38%), acetazolamide: 2 (15%), nasal mometasone: 1 (7.7%), adenotonsillectomy: 3 (23.1%), and positive airway pressure: 2 (15%).Regarding patients with RS referred to the sleep medicine clinic, snoring and witnessed apneas were the most common presenting complaints. In addition to breathing abnormalities during wake, OSA was very common in our cohort. Further studies are needed to examine the pathogenesis of OSA in RS and relationships between disease genotype and respiratory abnormality phenotype.

    View details for DOI 10.5664/jcsm.7974

    View details for PubMedID 31596210

    View details for PubMedCentralID PMC6778339

  • Are Standardized Letters of Recommendation in Residency Applications Correlated With Objective Data? Journal of medical education and curricular development Tang, A. L., Howard, J. J., Singh, E. n., Tabangin, M. E., Wang, J. C., Myer, C. M., Altaye, M. n., Rohde, S. L. 2019; 6: 2382120519893976


    To evaluate whether the standardized letter of recommendation (SLOR), commonly used for medical students applying to otolaryngology residency, correlates with objective data in the application.Standardized letters of recommendation using Likert-type scales for different attributes are commonly used by evaluators because of their high interrater reliability and efficiency in preparation and interpretation. Given that these are subjectively scored, it is unknown how well these correlate with objective data.Applications to the University of Cincinnati otolaryngology residency were evaluated in the academic cycle of 2017-2018. Standardized letters of recommendation were scored to determine whether certain attributes were correlated with objective data (United States Medical Licensing Examination [USMLE] scores and number of presentations/publications) provided in their application. Spearman correlations were used to evaluate the strength of the relationship between the subjective score in certain attributes with objective data.There were 217 applications to the University of Cincinnati that contained SLORs. Of these applications, 474 standardized letters were scored in categories of medical knowledge, research, and commitment to academic medicine. Total publications and presentations were weakly correlated with commitment to academic medicine (0.35, P < .0001, n = 369) and with research (0.44, P < .0001, n = 355). Medical knowledge was weakly correlated with Step 1 scores (0.20, P < .0001) and Step 2 scores (0.18, P = .0002).Subjective research and commitment to academic medicine rating scores were weakly correlated with greater academic productivity. Similarly, medical knowledge scores were weakly correlated with Step 1/2 scores. Further research may be needed to assess how to interpret SLOR scores in addition to the information available in an otolaryngology application.4.

    View details for DOI 10.1177/2382120519893976

    View details for PubMedID 31840080

    View details for PubMedCentralID PMC6902389