This investigation analyzed the top 50 most cited articles of all time in rhinology and evaluated trends in authorship with a particular emphasis on gender disparities. Overall, our findings were consistent with the literature describing a disparity in the rhinology workforce. The present study serves as the first cumulative review of the most impactful literature in rhinology.

Overall, the Laryngoscope published the most articles (N = 15, 30%) followed by Otolaryngology-Head and Neck Surgery (N = 10, 20%) and Archives of Otolaryngology-Head and Neck Surgery (N = 6, 12%). The most cited article was the “European Position Paper on Rhinosinusitis and Nasal Polyps'' published by Fokkens et al. [20], containing 3283 citations. The article is a summary of definitions and classifications, as well as epidemiology, differentials, and management of rhinosinusitis polyps [20]. It was particularly noteworthy for its discussions of variations in the pathophysiology and treatment of chronic rhinosinusitis with and without nasal polyps.

The oldest article on the list is “The Pathogenesis of Orbital Complications in Acute Sinusitis” published in 1970 by Chandler et al. in The Laryngoscope [21]. This article, deemed a “classic” article of rhinology, set a framework for the presentation, pathogenesis, classification, and treatment of infections of the orbit following sinusitis [21, 22]. Although some principles discussed in the original manuscript have changed since its inception, many aspects involving the classification and treatment remain relevant today [22].

Our findings were both consistent and in contrast to literature describing trends in rhinology authorship. We found that overall 26% of first authors (N = 13, 26%) and 14% of senior authors (N = 7, 14%) were female, highlighting a stark disparity in authorship. A 2021 study by Halderman et al. analyzing authorship of allergy and rhinology publications between 2008 and 2018 in 4 journals, found that females composed 23% of authors overall and female first authorship increased significantly, but there was no change in female senior authorship [23]. Despite this increase and an increase in the overall number of women in medicine, there has not been a proportional increase in the number of papers published by female authors [24]. Our findings were consistent with the literature regarding a disparity in authorship; however, our findings captured data outside of the 2018 range as reported by Halderman et al. publishing in high-impact journals is an essential component of academia. Women’s underrepresentation in high-impact journals may have an impact on the representation and promotion of female faculty within otolaryngology [25]. Identifying these trends in female authorship may help shed light on the current and future directions of females in academic rhinology.

Previous studies on female representation in otolaryngology leadership demonstrated that women hold only 18% of directorship positions and 5% of chair positions [26]. This disparity extends into fellowship leadership. Females comprise only 5.7% of rhinology fellowship director positions. Despite this, female fellowship directors have been found to have higher research productivity than males [27]. Other studies suggest that a lack of women in leadership is a key reason for an overall lack of publications from women compared to men, even though there is an increasing number of female physicians [24]. The lack of females in leadership positions suggests the need for female-oriented mentorship programs, which have been shown to promote and retain females in academic medicine [28]. Female tailored mentorship programs have been demonstrated to be associated with an increase in productivity and promotion of medical faculty, which in turn could increase the number of women in leadership positions within rhinology.

Currently, no published literature has analyzed the top rhinology papers for gender disparities in authorship. The current study found notable disparities in authorship regarding first author gender and publication type. Out of the 50 articles examined, there were significantly more female first authors who published guidelines/position papers/expert opinions compared to other article types (clinical studies, reviews, basic science studies). The authors of position papers and clinical practice guidelines are often front runners in the field who are typically selected by invitation. A year-long study of gender differences in the authorship of Canadian and North American published otolaryngology clinical practice guidelines over 17 years found that females accounted for 21.2% of authors overall [29]. Moreover, they found that female otolaryngologist representation was highest in rhinology (28.3%); however, they found that there were no gender differences across first or senior authors and by subspecialty [29]. Although only 5.7% of rhinology fellowship leaders are female, females have been found to have higher research productivity than males [27].

A 2022 study that analyzed the top 3 medical journals, found that female scientists published fewer clinical trials across all fields, which is mirrored in our results regarding otolaryngology [30]. It has been suggested that this difference may be due to differences in training and career decisions between genders [30]. Additionally, previous studies have demonstrated that at senior levels, the research productivity of female otolaryngologists equals or exceeds that of males [31]. Our results suggest that despite the increase in female first authorship during the time studied, female leaders remain underrepresented in rhinology.

This bibliometric analysis includes the top 50 publications between 1970 and 2023. We found that after 2000, the number of female-authored studies increased over time; however, authorship disparities still existed over time. This trend has been seen in both radiology and ophthalmology where female authorship has been increasing over the past decade, but remains underrepresented [32, 33]. Additionally, a Canadian study from 2023, found that female otolaryngologists had equal research productivity compared to their male counterparts, but remained underrepresented in publications [34]. It can be hypothesized that these disparities may exist across disciplines due to bias from the journals themselves or simply a lower number of papers being submitted for review from female first authors. In contrast, other studies have shown that women have lower academic productivity compared to men in plastic surgery in junior positions [35]. Productivity plays a significant role in grant funding as well as academic promotion meaning that men receive the majority of grant funding and can submit more papers for publication than women [35]. Gender disparities are prevalent in society in many other fields in addition to medicine, which can hinder female professional development and undervalue the contributions of females [36].

Most of the top articles were published in the United States (N = 25, 50%) followed by England (N = 5, 10%). These results support previous research in other disciplines such as stem cell transplantation and oncology which demonstrated that high-income countries, such as the United States, had more publications than low-income countries [37, 38]. It is possible that high-income countries are able to produce more publications due to increased research capabilities, especially in research that requires highly specialized and expensive equipment. These fiscal limitations as well as other cultural and social norms could potentially be responsible for the global disparities seen in top publications.

Additionally, England had significantly more female first authors compared to other countries. The United States and Germany had significantly fewer female first authors compared to other countries depicted in Table 6. The United States had significantly more female senior authors compared to other countries (p = 0.04). A 2023 German study found that female otolaryngologists demonstrated most resident and specialist positions, but this dominance flipped once they reached the attending level which could potentially account for the lower number of female first authors seen in the top 50 rhinology papers assessed in this study [39]. This same pattern has been demonstrated in the field of otolaryngology in the United States as well, where women are underrepresented at all leadership levels [26]. To the best of our knowledge, there have been no published works that investigate the gender disparity in otolaryngology in England.

In conclusion, we analyzed the top 50 most frequently cited articles in rhinology of all time. The top 3 papers were a position paper on the classification and treatment of chronic rhinosinusitis with and without nasal polyps, a multicenter clinical study on olfactory and gustatory dysfunction relating to COVID-19, and a technique study on the vascular pedicle nasoseptal flap [20, 40, 41]. Overall, most articles had male first authors and male senior authors. There seems to be a trend towards increasing female authorship as there was a significant increase in female first authors after 2000; however, women remain underrepresented in rhinology paper authorship. The most common publication type was clinical research studies. The United States published the most articles but had the lowest number of female first authors compared to England. The trends seen in rhinology publications are a positive step forward to decrease gender disparities in academic medicine and to encourage continued efforts to reach equity and adequate representation.

There are several limitations to our study. Firstly, regarding the time-sensitive nature of the data collection, articles published near or after we performed our data collection would not have had time to accumulate many citations regardless of if they were the most impactful. Most of the articles in our study were from 1990 to 2010, which makes this issue less likely but still a consideration. As has been done in other studies, the only database utilized was the Web of Science, thus it is possible that other articles were not considered in our analysis. Articles were considered “top articles” solely based on the number of citations therefore it is possible that the determination of “top articles” was not completely comprehensive considering all aspects of the papers.