Otolaryngology–Head and Neck Surgery Reviewer Instructions

Getting Involved

Reviewing for Otolaryngology–Head and Neck Surgery is an easy way to begin or increase your involvement with the Academy and with the journal, and over time, reviewing can lead to more senior positions within the journal itself. Ten star reviewers are selected per year, and these positions are often promoted to the journal’s editorial board and associate editor positions, bringing recipients greater responsibility and recognizing achievement. Reviewers who complete over four or more reviews a year are listed in the journal’s January issue every year. You have the opportunity to improve patient care and public health by providing thoughtful, timely reviews of journal articles. Reviewers are also able to earn up to 15 AMA PRA Category 1 Credits™ per year. The journal welcomes reviewer applicants. Residents wishing to review for the journal must complete the Resident Reviewer Development Program.

Reviewers may also want to look over the Editorial Policies section of our Author Guidelines, including the Publication Criteria: https://www.editorialmanager.com/otohns/accounts/AuthorPg.htm#policies


How to Apply: Download and complete the Reviewer Application Form (Adobe Reader required). Submit the form, along with your CV, to the Editorial Office by email (otomanager@entnet.org) or fax (1-703-299-1136), or send them by snail mail to:

Collin Grabarek, MFA
Managing Editor
Otolaryngology–Head and Neck Surgery
1650 Diagonal Road
Alexandria, VA 22314

Please be sure to fill out the correct classifications. Our associate editors will use these classifications when searching for reviewers. Click here to view a sample completed form:

Click to Show/Hide Reviewer Application Form


Resident Reviewer Development Program

The Resident Reviewer Program gives residents interested in peer review the opportunity to shadow a seasoned peer reviewer mentor. By completing reviews alongside a mentor, participants gain the skills needed to comprehensively review a scientific article. Excelling as a peer reviewer is often the first step toward positions as a journal Editorial Board member or Associate Editor.

NOTE: Due to the high volume of applications the editors receive, you may not be enrolled in the program upon application. The editors will keep your application on file for consideration when a slot opens.

Applicants must: Participation
Once the Deputy Editor approves the application, the participant must read and watch the Reviewer Development Resources available below. The participant must then contact the journalís Editorial Office. The editors will pair the participant with a reviewer mentor, and the Editorial Office will provide detailed instructions on submitting reviews for the journal. The Editorial Office will assign the participant to review articles also being reviewed by his or her mentor. Participants must log the dates on which they submitted their reviews and the dates on which they received feedback from their mentors.

After completing 6 mentored reviews (or fewer, at the mentor's discretion), the participant will complete a review independently and receive a review rating from the editors (see the Ratings Chart here). If the editors score the review at 75 or above, the participant will join the main peer reviewer pool. If the editors score the review below 75, the participant may continue with the mentored program or withdraw.


Ratings Chart

After a review is completed and the Associate Editor has completed his or her assessment, the manuscript is routed to the Editor in Chief. The Editor in Chief assesses the quality of the manuscript and the quality of each review. While not every review is eligible for CME credit, each review is given a quality score. Reviews are assessed as follows:

Score Rating; description Comments for Editor Comments for Authors
90 Outstanding; clear review Concise, insightful, and accurate Demonstrate a clear understanding of strengths and weaknesses, and revisions based on these suggestions will significantly improve the manuscript
80 Excellent; good review Thoughtful and accurate Demonstrates a good understanding of strengths and weaknesses. Revisions based on most of these suggestions will improve the manuscript. Occasional suggestion unclear or of minor importance
70 Helpful; adequate review but lacking in detail Does not clearly define strengths and weaknesses Confusing and/or miss the big picture and dwell on minor facets of the manuscript
60 Marginal; missed key strengths and weaknesses Of limited value in aiding the editorial decision Does not adequately assess the manuscript or offer useful suggestions for revisions
50 Not helpful; superficial review Arbitrary and unsupported Very negative and does not suggest opportunities for revision
40 Poor; reviewer clearly needs direction Of limited value at best Not helpful and at times too critical or inconsistent


Earning CME Credit

The American Academy of Otolaryngology—Head and Neck Surgery Foundation offers AMA PRA Category 1 Credit™ for reviewing manuscripts submitted to the journal Otolaryngology–Head and Neck Surgery. Only reviews meeting existing requirements will be awarded credit. Three types of articles are eligible for earning CME credit: Original Research, Literature Reviews, and State of the Art Reviews. Case Reports, Clinical Photographs, Clinical Techniques and Technologies, and Short Scientific Communications do not meet CME credit requirements. The review must meet existing requirements and be at a depth and scope that requires a review of the literature and knowledge of the evidence base for the manuscript reviewed. This assessment is built into the review process.

How to Earn CME Credit
  1. Read the Reviewer Step by Step Directions.
  2. Conduct a literature search by using the link in Editorial Manager to Similar Articles in MEDLINE.
  3. Complete the manuscript rating questions.
  4. Complete the activity evaluation.

The credit is calculated annually and will appear on the AAO-HNSF Annual Education Transcript sent by February of the following year. Reviewers will receive 3 AMA PRA Category 1 Credits™ per review with an annual limit of 15 AMA PRA Category 1 Credits.™

Accreditation Information

The American Academy of Otolaryngology—Head and Neck Surgery Foundation (AAO-HNSF) has a responsibility to maintain an ongoing knowledge and understanding of the most current issues in otolaryngology-head and neck surgery, thus ensuring physicians and other healthcare practitioners are providing the highest standards of patient care. To that end, they must maintain a thorough knowledge and competence of the most recent issues and developments in the field of otolaryngology-head and neck surgery to ensure the highest standard of care for patients with otolaryngology disorders. One means of providing that knowledge and competence is the process of manuscript review. Review of manuscripts being considered for publication in the AAO-HNSF journal Otolaryngology–Head and Neck Surgery provides a format for learning, helps reviewers improve their skills in performing critical analysis of the medical literature, and ultimately improves the quality of the published science by ensuring assessment based on expert perspectives from practice and via a mechanism free from conflict of interest.

Accreditation Statement: The American Academy of Otolaryngology—Head and Neck Surgery Foundation (AAO-HNSF) is accredited by the Accreditation Council on Continuing Medical Education to provide continuing medical education for physicians. The AAO-HNSF designates this manuscript review activity for 3.0 AMA PRA Category 1 Credits™ with a maximum of 15 credits per year. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Target Audience/Scope of Practice: The target audience consists of researchers, clinicians, and other health professionals practicing in otolaryngology-head and neck surgery who possess expertise in the content areas assigned and wish to gain competence by means of service as an expert reviewer.
Physician Attributes: The following physician attributes are addressed in this education activity: Outcome Objectives:
Upon completion of this activity, reviewers should be able to:
Content Areas: The content of the manuscript review education activity includes principles of manuscript review and emerging basic science and medical research in Otolaryngology–Head and Neck Surgery.

Disclosure Information: In compliance with the AAO-HNSF's policies on Relevant Financial Relationship Disclosure and Personal Conflict of Interest Resolution, anyone in a position to influence education content is required to disclose any real or apparent conflicts of interest relating to the topics addressed in this activity. On the basis of disclosed information, AAO-HSNF identifies and resolves all conflicts of interest before delivery of content. Please click here to review a list of the editorial staff of Otolaryngology–Head and Neck Surgery and their disclosures:
Otolaryngology-Head and Neck Surgery Editorial Board.


How to Submit a Review

Please follow these directions for submitting a review:
  1. Log in to Editorial Manager as a reviewer.
  2. On the Reviewer Main Menu, click on "New Reviewer Invitations."
  3. In the Action Column on the left, click on "View Abstract." This will help you decide whether you are able to review the manuscript. Please note the timeframe: you must respond to the invitation within three (3) days and complete the review within ten (10) days. If you are unable to meet this schedule, please decline the invitation.
  4. You may also wish to do a brief literature search by clicking the link "View Similar Articles in MEDLINE," particularly if you are planning on claiming CME credit. Clicking this link will open a new window linked with MEDLINE.
  5. If you decide to review, click "Agree to Review."
  6. Click on "Pending Assignments." To access the submission, click on "View Submission."
  7. Conduct a brief literature search by clicking the "View Similar Articles in MEDLINE" link so that you have knowledge of the evidence base for the manuscript. This is required in order to receive CME credit. Clicking this link will open a new window linked with MEDLINE.
  8. After reviewing the submission and conducting a literature review, read the Continuing Medical Education Credit for Reviewers located above as a requirement for receiving CME credit for your review.
  9. After reviewing the submission, click on "Submit Recommendation."
  10. Open the drop-down menu at the top of the page and select your recommendation.
  11. Enter the overall manuscript rating score from 1-100, with 100 being the best, as well as the manuscript ratings questions.
  12. The first box, "Reviewer Blind Comments to Author," is intended for your comments to the author.
  13. The second box, "Reviewer Confidential Comments to Editor," is intended for any comments you intend for only the Associate Editor and Editor in Chief. Neither the author nor the other reviewer will see this field. Answer each question in the second box and enter any comments you wish to make to the Associate Editor and Editor in Chief.
  14. You may hit "Proof and Print" if you want a hard copy of your decision, or hit "Proceed."
  15. You may now review your recommendation. To approve, click "Submit Review to Journal Office." The review process is now complete. (NOTE: If you don't receive a confirmation e-mail, your review has not been completed.)
  16. If you need more detailed instructions or are having trouble, please contact the journal office at otomanager@entnet.org.


Star Reviewers

The journal runs yearly reports assessing the quality and timeliness of each review, and reviewers who excel in the selected areas are chosen for a Star Reviewer award. Their names are published in the journal's AAO-HNSF Annual Meeting program issue, and they receive a ribbon identifying them as a Star Journal Reviewer to wear at that year's AAO-HNSF Annual Meeting. If they are members of the Academy, they will also receive one honor point.

How to Earn a Star Reviewer Award

There are several things the Editorial Office and the Editor in Chief look for when selecting star reviewers every year. Submit your reviews on time. Complete multiple (we suggest at least 10) reviews a year. Reread the article "How to review a journal manuscript" and view the videos below to make sure your reviews are meeting our standards. Each review, except for reviews of revised manuscripts, is given a quality score. A great review is thoughtful, comprehensive, constructive, and submitted on time.

The criteria for the 2016 Star Reviewers were as follows:
  1. Eight or more reviews completed in the prior year
  2. Five or more reviews of original papers (i.e., not revisions)
  3. Majority of reviews submitted on time
  4. Average rating of 85 or higher
  5. Three or more ratings of 90 or above

2016 Star Journal Reviewers
  1. Samantha Anne, MD
  2. Karthik Balakrishnan, MD
  3. Sarah N. Bowe, MD (Star Reviewer 2015)
  4. Thomas Q. Gallagher, DO (Star Reviewer 2014, 2015)
  5. Elliott D. Kozin, MD
  6. Helene J. Krouse, PhD, ANP-BC, FAAN (Star Reviewer 2010, 2012, 2013, 2014, 2015)
  7. Jose Florencio Lapena, Jr., MD (Star Reviewer 2015)
  8. Alex J. McKinlay, MD
  9. James M. Ruda, MD (Star Reviewer 2015)
  10. Andrew G. Shuman, MD (Star Reviewer 2015)
  11. Lawrence M. Simon, MD (Star Reviewer 2014, 2015)
2015 Star Journal Reviewers

The 2015 Star Journal Reviewers were: Sarah N. Bowe, MD; Thomas Q. Gallagher, DO (Star Reviewer 2014); Babak Givi, MD (Star Reviewer 2012, 2013, 2014); Helene J. Krouse, PhD, ANP-BC, FAAN (Star Reviewer 2010, 2012, 2013, 2014); Jose Florencio Lapena, Jr., MD; Philip D. Littlefield, MD; Jeffrey C. Liu, MD; James M. Ruda, MD; Andrew G. Shuman, MD; Lawrence M. Simon, MD (Star Reviewer 2014)

2014 Star Journal Reviewers

The 2014 Star Journal Reviewers were: Eelam A. Adil, MD, MBA; Scott E. Brietzke, MD, MPH (Star Reviewer 2007, 2008); Erika M. Celis-Aguilar, MD; Joseph E. Dohar, MD (Star Reviewer 2008); Michael Friedman, MD (Star Reviewer 2006, 2008, 2009, 2011, 2012, 2013); Thomas Q. Gallagher, DO; Babak Givi, MD (Star Reviewer 2012, 2013); Christopher M. Johnson, MD; Helene J. Krouse, PhD, ANP-BC, FAAN (Star Reviewer 2010, 2012, 2013); Jivianne T. Lee, MD; Judith E. Lieu, MD, MSPH (Star Reviewer 2011, 2013); Ho-Sheng F. Lin, MD (Star Reviewer 2013); David Reiter, MD, DMD, MBA; Lawrence M. Simon, MD; Gordon H. Sun, MD, MS (Star Reviewer 2013)

2013 Star Journal Reviewers

The 2013 Star Journal Reviewers were: Lee M. Akst, MD; Eugenia Allegra, MD, PhD; Jacqui E. Allen, MBChB, FRACS; Mark E. Boston, MD; Michael Friedman, MD (Star Reviewer 2006, 2008, 2009, 2011, 2012); Babak Givi, MD (Star Reviewer 2012); Helene J. Krouse, PhD, ANP-BC, FAAN (Star Reviewer 2010, 2012); Daniel B. Kuriloff, MD; Judith E. Lieu, MD (Star Reviewer 2011); Ho-Sheng F. Lin, MD; Sonya Malekzadeh, MD; Stephen C. Maturo, MD (Star Reviewer 2011, 2012); and Gordon H. Sun, MD, MS

2012 Star Journal Reviewers

The 2012 Star Journal Reviewers were: Matthew T. Brigger, MD (Star Reviewer 2010); David H. Darrow, MD, DDS (Top Ten Reviewer 2009, 2011); Michael Friedman, MD (Star Reviewer 2006, 2008, 2009, 2011); M. Boyd Gillespie, MD (Star Reviewer 2011); Babak Givi, MD; Maureen T. Hannley, PhD; Jack J. Jiang, MD, PhD (Star Reviewer 2006); Helene Krouse, PhD, ANP-BC, FAAN (Star Reviewer 2010); Stephen Maturo, MD (Star Reviewer 2011); and Edward McCoul, MD, MPH.

2011 Star Journal Reviewers

The 2011 Star Journal Reviewers were: Cristina M. Baldassari, MD; David Darrow, MD, DDS (Star Reviewer 2009); Michael Friedman, MD (Star Reviewer 2006, 2008, 2009); M. Boyd Gillespie, MD; Jack J. Jiang, MD, PhD; Judith E.C. Lieu, MD; Stephen C. Maturo, MD; Matthew W. Ryan, MD (Star Reviewer 2008, 2009, 2010); Cecelia E. Schmalbach, MD (Star Reviewer 2010); and David W. Stepnick, MD (Star Reviewer 2008).

2010 Star Journal Reviewers

The 2010 Star Journal Reviewers were: Peter Belafsky, MD, MPH, PhD; Brandon G. Bentz, MD; Matthew T. Brigger, MD, LCDR; Daniel I. Choo, MD; A. Julianna Gulya, MD; Eric J. Kezirian, MD, MPH (Star Reviewer 2007); Helene J. Krouse, PhD; Matthew W. Ryan, MD (Star Reviewer 2008, 2009); Cecelia E. Schmalbach, MD; and Erik K. Weitzel, MD.

2009 Star Journal Reviewers

The 2009 Star Journal Reviewers were: Brian W. Blakley, MD, PhD (Star Reviewer 2008); Rakesh K. Chandra, MD; Kay W. Chang, MD; David H. Darrow, MD, DDS; Robert A. Dobie, MD; Michael Friedman, MD (Star Reviewer 2006, 2007; Vicente A. Resto, MD, PhD; Matthew W. Ryan, MD (Star Reviewer 2008); David J. Terris, MD; and Robert L. Witt, MD.

2008 Star Journal Reviewers

The 2008 Star Journal Reviewers were: Brian W. Blakley, MD, PhD; Scott E. Brietzke, MD, MPH (Star Reviewer 2007); Craig S. Derkay, MD; Robert A. Dobie, MD; Joseph E. Dohar, MD; Ravindhra Elluru, MD; D. Gregory Farwell, MD; Michael Friedman, MD (Star Reviewer 2006; Matthew W. Ryan, MD; David W. Stepnick, MD.

2007 Star Journal Reviewers

The 2007 Star Journal Reviewers were: Peter C. Belafsky, MD, PhD; Joel H. Blumin, MD; Scott E. Brietzke, MD, MPH; A. Simon Carney, FRACS; Marion E. Couch, MD, PhD; Berrylin J. Ferguson, MD; Eric J. Kezirian, MD, MPH; Bruce H. Matt, MD; David J. Myssiorek, MD; and Mark A. Varvares, MD.

2006 Star Journal Reviewers

The journal first began recognizing star performers in 2006. The fourteen chosen for that year were: Kenneth W. Altman, MD; Sanford M. Archer, MD; Roy R. Casiano, MD; Daniel G. Deschler, MD; Michael Friedman, MD; Gady Har-El, MD; Jack J. Jiang, MD; Charles F. Koopmann, MD; Pierre Lavertu, MD; James S. McMurray, MD; Rodney J. Schlosser, MD; John M. Schweinfurth, MD; James A. Stankiewicz, MD; and Mark K. Wax, MD.


Reviewer Development Resources

1) Instruction Course: How to Review Journal Manuscripts

This Instruction Course, delivered at the 2015 AAO-HNSF Annual Meeting & OTO EXPOSM, highlights several important aspects of peer review.

Participants: Richard M. Rosenfeld, MD, MPH (Editor in Chief 2006-2014, Associate Editor 2003-2006); John H. Krouse, MD, PhD, MBA (Editor in Chief 2014-present, Associate Editor 2006-2014).

2) Videocast: Tips for Reviewers

This videocast, recorded at the 2012 AAO-HNSF Annual Meeting & OTO EXPO, is a panel discussion with tips for reviewers on writing efficient, meaningful, and quality reviews.

Participants: Richard M. Rosenfeld, MD, MPH (Editor in Chief 2006-2014, Associate Editor 2003-2006); Cecelia E. Schmalbach, MD (Deputy Editor 2014-present, Associate Editor 2011-2014, 2-time Star Reviewer); Mark K. Wax, Associate Editor 2006-2014).

3) Videocast: How to Be a Star Reviewer

The journal's first ever videocast, recorded at the 2010 AAO-HNSF Annual Meeting & OTO EXPO.

Participants: Richard M. Rosenfeld, MD, MPH (Editor in Chief 2006-2014, Associate Editor 2003-2006); John H. Krouse, MD, PhD, MBA (Editor in Chief 2014-present, Associate Editor 2006-2014); Cecelia E. Schmalbach, MD (Deputy Editor 2014-present, Associate Editor 2011-2014; 2-time Star Reviewer); Matthew W. Ryan, MD (Associate Editor 2011-present, 2-time Star Reviewer).

4) Article: How to Review Journal Manuscripts

This article, published in the journal in 2010 and authored by then Editor in Chief Richard M. Rosenfeld, MD, MPH, provides detailed instructions on reviewing scientific articles.

View Article Here

5) Template: Comprehensive Review

This template, designed by one of the journal's associate editors, provides a foundation upon which to build a useful, thorough review.

View Template Here


More Information

Reviewing Tips

Tips from several of the journal's Star Reviewers, including advice they have for beginners and their thoughts on what constitutes a good review.

Matthew Ryan, MD, four-time star reviewer and now journal associate editor, says: "I think a review (the 'comments to authors' section) should read like a book report. The best reviews briefly describe how the submitted work fits into current knowledge, describe the hypothesis, study population, study design, outcomes measures, and results. The implications of the results may be important to describe. Finally, a good review will highlight the strengths and weaknesses not only of the study design and the project execution, but also the manuscript presentation (length, tables, figures, etc.). The reviewer should make suggestions to help the authors improve their manuscript."

Stephen Maturo, MD, three-time journal star reviewer and former journal editorial board member, urges reviewers to realize that "authors work hard in carrying out the effort that resulted in submission to the journal. The authors deserve an honest review that is thoughtful and fair." He adds: "The biggest hurdle to overcome as a reviewer is the concern for the amount of time needed. Reviewing the first 3-5 articles took some time, but as one becomes more experienced this is not a significant time commitment. I think the YouTube presentation and Dr. Rosenfeld's paper are excellent starting points. I re-read Dr Rosenfeld's article once or twice a year." He adds in 2013: "Being a reviewer helps one's own critical analysis skills and writing skills along with providing insight into improving research abilities. With each review I learn more about the research process, especially after reading the critiques of the editor, associate editor, and fellow reviewers. This is an invaluable educational experience.

Judith E.C. Lieu, MD, three-time journal star reviewer and former journal editorial board member: A star reviewer is motivated by "the desire to help other authors report their work well, balanced by the desire to help readers understand the work. Take time to read the manuscript carefully, make objective criticisms and suggestions for improvement. Read the methods and results sections carefully, and look up anything you are not sure about. Do not gloss over anything you cannot understand regarding what the authors have done or how they achieved the results they present. Make sure the tables and figures are easy to understand and digest. Always consider the clinical and scientific significance of the work, and make sure the introduction and discussion sections reflect that importance appropriately. Think about what would make the paper easier to understand to the reader, and suggest ways to eliminate excessive jargon and redundant verbiage."

Helene Krouse, PhD, ANP-BC, FAAN, five-time star reviewer and journal editorial board member: "I find it very important to use a systematic approach in reviewing each manuscript, allowing adequate time to read the manuscript and prepare the review. I start with a critical reading of the abstract so that I have a clear understanding of the paper's purpose, major content, and conclusions. As I read through the various sections of the manuscript, I make notes and comments for myself that help me focus and organize my thoughts for my written review."

Jacqui E. Allen, MBChB, FRACS, star reviewer: "Reviewing a submitted paper is a privilege and carries responsibility to both the authors and the readership of the Journal. Considerable time and effort goes into a submission and this should always be borne in mind when reading an article. A reviewer should therefore allow appropriate time to assess and understand the study that the authors have presented. Many topics or research questions are not able to undergo RCTs for ethical or practical reasons and valuable information may still be provided by observational studies. I find it helpful to read the full submission initially, then re-read the submission focused on the primary aims of the paper and how the authors set out to investigate these. Robust research is designed to minimize confounding factors but cannot eliminate these and the results must be interpreted with this in mind. Where the authors have genuinely followed good research principles, a study should be respected, no matter whether positive or negative results are obtained. Negative results may actually allow other researchers to refine the study question, identify an alternative study method or population, or avoid unnecessary duplication of ineffective research. Always mention some positive aspects of the study even if the overall manuscript is not suitable for current publication. We should always look to encourage research and researchers."

Mark E. Boston, MD, star reviewer and now journal associate editor: "I agree with and follow the other comments and recommendations outlined by the other reviewers. My goal, as a reviewer, is to help create an understandable article that contributes to the body of otolaryngology knowledge. This is not always possible because some submissions suffer from fatal flaws in construct that limit their external and/or internal validity. However, I approach each paper as if it should be published and try to find the important points that make it worthy of publication. I use a systematic approach that involves reading the entire paper once through and then a more focused read of each section while taking notes. I then briefly review what has already been published on the topic and determine where the submission differs from and/or adds to the current knowledge. I let the quality of the submission guide me as to my comments and critique. For well written, high quality studies I focus on details whereas for lower quality submissions my focus is on the larger validity questions that prevent me from recommending the paper for publication. There is, in my opinion, almost no initial submission that could not benefit from some additional clarification or revision."


Example of a Highly Rated Review

Major Comments:

This is an interesting paper which addresses several issues: A) Is there any validity at looking at post-tracheostomy mortality as a quality measure for the surgery itself; B) What factors influence mortality after tracheostomy; C) Are available data adequate to suggest to the ICU physician and ENT surgeon that tracheostomy is medically futile in definable situations. This article makes useful points about all of these topics, though B) and C) are intrinsically difficult to address. I like the fact that the authors use the tracheostomy consultation as the starting point rather than the operation itself, and that death in the setting of palliative care is accounted for.

One might think that bodies which monitor patient safety following surgery would not be foolish enough to look at a procedure like tracheostomy which has such low intrinsic mortality but such mortality prone patients, but one never knows. The authors can comment briefly about this, since they bring it up. A difficult question is, although there are no obvious post-operative complications leading to death, are there stresses associated with the procedure which might subtly increase mortality (e.g. stress hormone release during surgery) or are there tracheostomy outcomes which subtly decrease mortality (e.g. less work of breathing, better suctioning)? I don't think these questions are answerable by this study design, but I suggest the authors consult these two references and give their opinions about this issue in the discussion section:

Combes A, Luyt CE, Nieszkowska A, Trouillet JL, Gibert C, Chastre J. Is tracheostomy associated with better outcomes for patients requiring long-term mechanical ventilation? Critical Care Medicine. 35(3):802-7, 2007 Mar.

Clec'h C, Alberti C, Vincent F, Garrouste-Orgeas M, de Lassence A, Toledano D, Azoulay E, Adrie C, Jamali S, Zaccaria I, Cohen Y, Timsit JF. Tracheostomy does not improve the outcome of patients requiring prolonged mechanical ventilation: a propensity analysis. Critical Care Medicine. 35(1):132-8, 2007 Jan.

The authors quite justifiably point out that since patients who undergo tracheostomy have high mortality rates, tracheostomy might be a futile procedure in the sickest, most high risk patients. On the first paragraph on page 8, they speculate whether factors found significant in their study might help clinicians decide about the usefulness of the procedure. I suggest that these ideas be expressed more tentatively (abstract and conclusions) for the following reasons. Two of the parameters mentioned: CCI ≥ 5.6 and LOS ≥ 19 are the average exposure levels in cases, but the authors have not calculated the % mortality in groups with exposures above and below these levels. They did this calculation for age ≥ 70 and using the data in table 1, the mortality for age ≥ 70 was 31% and for age ≤ 71, 18% -- not an amazing difference which would halt the procedure in the former group. Predictive models for death usually require many hundreds or thousands of patients (often multicenter), attempts to adjust for effects of multiple inter-related variables, and a validation cohort of another set of hundreds or thousands of patients. So a detailed answer to this question may need to be left to other studies. [As an aside, I recalculated the p value for age>70 using a CDC program (Stat-Calc module of Epi 6) and (with 9 pts dead+ age ≥ 70; 15 pts dead+ age ≤ 70; 20pts alive+ age ≥ 70; 69 pts alive+ age ≤ 70) the Chi square p value was 0.13 and the Yates corrected Chi square p value was 0.22 -- the program doesn't do Fisher's exact for expected values ≥ 5, but I doubt the Fisher's exact would be lower -- please verify this paper's significant p value.]

Lastly, because there are a number of parameters by which survival can be measured (30 day, in hospital, "total"), I found that some of the numbers cited became confusing. The most difficult for me to follow was the analysis adjusted for the 2 patients cited by asterisk in table 1 who "did not have any follow-up data available. Was their in hospital mortality known (if so they would be included in the in-hospital mortality data) but their post-op mortality not known? If so, were they "censored" at the time of discharge in the Kaplan-Meier analysis? Please see my further comments about this below.

Minor Comments
1. Abstract: Case series usually refers to a set of diseased patients, like 18 pts with malignant external otitis. I would call this an observational cohort study (the cohort is pts with tracheostomy consults).
2. Abstract: It is stated that 80 pts survived to discharge. On p.5, 32 patients had in hospital deaths, so 115-32 is 83 not 80. If we don't know if the two pts excluded from table 1 survived to hospital discharge then we really know almost nothing about them so they should be excluded from the study. And this would only account for 2 or the 3 "missing" survivors.
3. p.3. Please indicate which months and year(s) are included in the 10 month time period.
4. p.5. The phrase "study period" is unclear. The survival graph shows some pts followed up to 300 days, but is this the 10 months during which pts were enrolled? If so, pts enrolled at the end of the study period would have had very short follow-ups. If all pts were followed indefinitely, the mortality over the "study period" would, of course, have been 100%. So please clarify 51 deaths over what time parameters.
5. p.5. In hospital study comparison: 22 vs. 27%. I ran these numbers in Epi 6 and got Chi square p=0.84 and Yates corrected Chi square p=0.98. Please recheck.
6. p.5. "other indwelling catheters were already present in these patients." Do "these" refer to the 2 who died? What would the relevance of this be to cause of death?
7. p.5.20.8% died in 30 days so implied survival was 79.2%. However, in the survival curve, the probability of survival at 30 days looks to be about 73%, I presume because 2 pts (table 1) were "censored." These 2 numbers are pretty close and I think it is probably ok to "slide over" this discrepancy, but the authors can decide. The same issue comes up on p. 6 where "70%" survive to discharge but since 32/115 are KNOWN to die in the hospital (28%); 72% survive when one calculates this way. (Is it worth keeping these 2 censored pts in the study?)
8. p.7. The 3rd paragraph would fit better in the "Results" section.
9. p. 7. The reference cited as # 10 should, I believe, be attributed to reference # 8.
10. p.8. Factors are called "mutually exclusive" but this is confusing since this phrase often refers to a multivariate analysis (for example if all patients > 70 yrs. were NOT in the hospital for 20 days or more). The authors may mean that each of the factors mentioned in this paragraph are dichotomous (i.e. can have only one value or another).
11. p. 10. Acknowledgements typically mention what help was offered by each person.
12. p.13. I think a more descriptive title for Figure 1 would be something like "Flow diagram for outcomes following consultation for elective tracheostomy. The figure 2 legend should explain the meaning of the error bars (? 95% confidence for probability; ? "standard error").
13. p.14. Table 1 legend should explain significance of the "+/-" (? standard deviation).
14. p. 15. I think a more descriptive title for table 1 would be something like "Effect of demographic and clinical factors on 30 day mortality following tracheostomy."


Want More Reviews?

If you've completed the reviewer application form but haven't received any invitations to review, or if you would like to receive more invitations, please contact the Editorial Office: otomanager@entnet.org. We are always looking for reviewers and would be happy to circulate your name to our associate editors.