Search

OBJECTIVES To characterize the relationship between cochlear duct length (CDL) and initial hearing preservation among cochlear implant recipients of a fully inserted 31.5 mm flexible lateral wall electrode array. STUDY DESIGN Retrospective review. SETTING Tertiary academic referral center. PATIENTS Adult cochlear implant recipients who presented preoperatively with unaided hearing detection thresholds of ≤ 65 dB HL at 125 Hz and underwent cochlear implantation with a 31.5 mm flexible lateral wall array. INTERVENTION Cochlear implantation with a hearing preservation surgical approach. MAIN OUTCOME MEASURES Computed tomography was reviewed to determine CDL. Hearing preservation was characterized by the shift in low-frequency pure-tone average (LFPTA; 125, 250, and 500 Hz), and shift in individual unaided hearing detection thresholds at 125, 250, and 500 Hz. RESULTS Nineteen patients met the criteria for inclusion. The mean CDL was 34.2 mm (range: 30.8-36.5 mm). Recipients experienced a mean LFPTA shift of 27.6 dB HL (range: 10-50 dB HL). Significant, negative correlations were observed between CDL and smaller threshold shifts at individual frequencies and LFPTA (p ≤ 0.048). CONCLUSION A longer CDL is associated with greater likelihood of preserving low-frequency hearing with long arrays. Low-frequency hearing preservation is feasible with fully inserted long flexible arrays within the initial months after cochlear implantation. Preoperative measurement of CDL may facilitate a more individualized approach in array selection to permit optimal cochlear coverage while enhancing hearing preservation outcomes.

We describe how an unusual facultative scavenger, the black-billed magpie (Pica hudsonia (Sabine)), took advantage of the compromised nature of burnt skin to scavenge porcine remains with extensive...

OBJECTIVES/HYPOTHESIS This study aims to 1) report revision cochlear implantation (CI) rates at a high-volume CI center, 2) describe classifications for revision CI, 3) analyze audiologic and surgical outcomes in patients who undergo revision CI, and 4) describe a new subcategory of soft failures, named presumed soft failures. STUDY DESIGN Retrospective case series. SETTING Tertiary care otologic center. PATIENTS Adults and children undergoing revision CI from 2005 to 2015. MAIN OUTCOME MEASURE Type and etiology of CI failure, preoperative, and postoperative outcomes (audiologic, surgical). RESULTS During the study period, 1,469 CI surgeries were performed with a total of 81 (5.51%) revision cochlear implantations, 64 of these meeting inclusion criteria with adequate follow up and clear indications for revision surgery. The most common indication for revision surgery was hard failure (53.1%), followed by soft failure (29.7%), and medical/surgical failure (17.2%). 78.1% (50/64) of revision CI patients showed improvement postoperatively (defined as 15% improvement of speech perceptions scores or improvement of aversive symptoms, according to the 2005 consensus statement guidelines). Hard failures showed improvement in 85.3% (29/34) of cases, medical and surgical failures showed improvement in 72.7% (8/11) of cases, and soft failures showed improvement in 68.4% (13/19) of cases. There was a statistically significant difference in percentage of adult versus pediatric patients by failure subtype, with 84.2% of soft failure patients classified as adults (18 or older) at the time of revision surgery compared with 50% and 36.3% for hard failure and medical/surgical failure patients, respectively (p = 0.02). Similarly, there was a trend, though not statistically significant, towards older age in the soft failure group compared with hard and medical/surgical failure groups (median 43 yr versus 18 and 16, respectively). Within the soft failure group there was a subset of patients that failed to show improvement in audiologic performance or experienced continued aversive symptoms referred to as "presumed soft failures." These patients, by definition, experienced worse outcomes after revision surgery (p

Objectives/hypothesis To measure and report noise exposure at urban music venues and assess the risk of noise-induced hearing loss by comparing these measures to the National Institute of Occupations Safety and Health (NIOSH) guidelines. Study design Observational study. Methods A commercially available smartphone and external calibrated microphone were used to measure sound levels at urban music venues. The maximum sound level, equivalent continuous sound level, and statistical noise levels (L10, L50, L75, L90) were recorded. Results The average equivalent continuous sound level was 112.0 (±4.9) dBA, and the average maximum sound level was 127.0 (±3.2) dBA. The L90 average (sound levels at or above this loudness for 90% of measured exposure time) was 101.1 (±5.5) dBA, and the L10 average was 115.2 (±5.0) dBA. Based off of NIOSH guidelines, noise exposure duration at the L10 average should not exceed 28 seconds, and those at the L90 average should not exceed 12 minutes. Conclusions Smartphone applications using external calibrated microphones can provide useful sound measurements. Data show that randomly sampled music venues may have noise levels that place patrons without hearing protection at risk for noise-induced hearing loss with prolonged exposure. Level of evidence NA Laryngoscope, 131:25-27, 2021.

The utility of surgery for tympanosclerosis has been a controversial topic among otologic surgeons for many decades. Knowing the variations in tympanosclerotic involvement, different aspects of surgical technique, and audiologic outcomes data can help inform the discussion of optimal management between surgeon and patient. Tympanosclerosis can involve all structures in the middle ear, and the distribution of that involvement determines the likelihood of surgical success in hearing improvement. Most recent studies indicate that having a mobile stapes is a key prognostic factor and increases the chance of meaningful hearing improvement following surgery. Stapes surgery for tympanosclerosis can also be successful, but results are more variable. Tympanosclerosis is a challenging condition to treat, and the decision regarding surgical management should be thoughtful and carefully weighed against benefits obtained from amplification alone.

Purpose To examine how patients self-administer ear drops, ascertain their perceived difficulty in performing the task and determine if they are able to deliver the correct dosage. Materials and methods This is a prospective cohort study performed in an otology outpatient clinic with twenty-one subjects with a condition requiring ototopical antibiotics. The number of ear drops applied as well as skills performed during ear drop application was measured. Patient reported difficulty and confidence in application of ear drops data was also obtained. Results The mean number of drops applied was 2.91 ± 2.1 (target = 3 drops) with a large variance in drop application, range of 0.6 to 9.2 drops. If “correct dosage” is considered 85–115% of the intended dose, then almost half of patients, 47.6%, underdosed with 23.8% that over dosed. Patients reported that the average difficulty in applying drops to themselves was 3.6 (1 being easy and 10 being difficult). Patients reported a high confidence level in applying the correct dose of ear drops of 6.7 (1 being not confident and 10 being very confident). Conclusions In our study of 21 patients self-administering ear drops, only 28.6% of patients were able to correctly apply the appropriate treatment dose, with almost half of patients underdosing. Questionnaire data indicated that most patients were unaware they were administering an incorrect dose. Inaccurate administration of ear drops could be problematic and lead to longer durations of symptoms, false treatment failures, and increased costs.

OBJECTIVES/HYPOTHESIS Speech recognition with a cochlear implant (CI) tends to be better for younger adults than older adults. However, older adults may take longer to reach asymptotic performance than younger adults. The present study aimed to characterize speech recognition as a function of age at implantation and listening experience for adult CI users. STUDY DESIGN Retrospective review. METHODS A retrospective review identified 352 adult CI recipients (387 ears) with at least 5 years of device listening experience. Speech recognition, as measured with consonant-nucleus-consonant (CNC) words in quiet and AzBio sentences in a 10-talker noise masker (10 dB signal-to-noise ratio), was reviewed at 1, 5, and 10 years postactivation. RESULTS Speech recognition was better in younger listeners, and performance was stable or continued to improve through 10 years of CI listening experience. There was no indication of differences in acclimatization as a function of age at implantation. For the better performing CI recipients, an effect of age at implantation was more apparent for sentence recognition in noise than for word recognition in quiet. CONCLUSIONS Adult CI recipients across the age range examined here experience speech recognition benefit with a CI. However, older adults perform more poorly than young adults for speech recognition in quiet and noise, with similar age effects through 5 to 10 years of listening experience. LEVEL OF EVIDENCE 3 Laryngoscope, 131:2106-2111, 2021.

OBJECTIVES The objectives were to characterize the effects of wearing face coverings on: 1) acoustic speech cues, and 2) speech recognition of patients with hearing loss who listen with a cochlear implant. METHODS A prospective cohort study was performed in a tertiary referral center between July and September 2020. A female talker recorded sentences in three conditions: no face covering, N95 mask, and N95 mask plus a face shield. Spectral differences were analyzed between speech produced in each condition. The speech recognition in each condition for twenty-three adult patients with at least 6 months of cochlear implant use was assessed. RESULTS Spectral analysis demonstrated preferential attenuation of high-frequency speech information with the N95 mask plus face shield condition compared to the other conditions. Speech recognition did not differ significantly between the uncovered (median 90% [IQR 89%-94%]) and N95 mask conditions (91% [IQR 86%-94%]; P = .253); however, speech recognition was significantly worse in the N95 mask plus face shield condition (64% [IQR 48%-75%]) compared to the uncovered (P

Objective Cochlear nerve preserving translabyrinthine vestibular schwannoma (VS) resection enables concurrent cochlear implantation. Implantation in patients with VS raises important concerns including the ability to undergo postoperative magnetic resonance imaging (MRI) monitoring of residual tumor growth or tumor recurrence, specifically with a retained magnet. We aim to assess the feasibility of MRI monitoring and the impact on image quality with retained cochlear implant (CI) magnets. Methods Retrospective review of post-operative head MRI scans in CI recipients with a retained CI magnet, after cochlear nerve preserving translabyrinthine excision of VS. The ability to visualize the ipsilateral and contralateral internal auditory canal (IAC) and cerebellopontine angle (CPA) were assessed. Results A total of eight surveillance head MRI were performed in six patients. In one case, in which the receiver was positioned lower, the view of the ipsilateral IAC and CPA was distorted. In all other cases, the views of both the ipsilateral and contralateral IAC and CPA were overall unimpaired. Discussion Imaging artifact only very rarely impedes adequate visualization of the ipsilateral IAC or CPA in CI recipients. In anticipation of the need for further IAC and CPA imaging, it would be advisable to place the receiver in an exaggerated superior-posterior position to further decrease obscuring artifact. Thus, serial monitoring of VS tumors can be performed safely with preservation of image quality with a retained receiver magnet. Conclusions When placing the CI receiver-stimulator farther posterior-superiorly, excellent visualization of the IAC and CPA can be accomplished without significantly impairing the image quality.

BACKGROUND Theoretical disadvantages are associated with the use of heat-crimped piston prostheses in stapedotomy. Loose crimping could result in prosthesis displacement or slippage. Alternatively, overly tight crimping may cause trauma to the incus with resultant necrosis. OBJECTIVES 1) Analyze outcomes of patients undergoing stapedotomy with heat-activated piston-style prostheses, and 2) compare outcomes between prostheses made by different manufacturers. STUDY DESIGN Retrospective. SETTING Vanderbilt Medical Center. PATIENTS AND METHODS Cases undergoing stapedotomy between 2005 and 2016 were reviewed. Audiometric assessments were recorded in accordance with American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) guidelines. Patients who lacked audiometric follow-up before 6 months or after 1 year were excluded. INTERVENTION(S) Diagnostic, therapeutic, and rehabilitative. MAIN OUTCOME MEASURE(S) Postoperative air-bone gap (ABG) and achievement of an ABG is less than or equal to 10 dB. RESULTS Three hundred fifty-eight patients met inclusion criteria. At short-term follow-up (

Evaluate outcomes following primary endoscopic stapes surgery.Retrospective case series.Two tertiary otologic centers.Eighty-one ears with surgically confirmed stapes fixation.Total endoscopic stapedotomy or stapedectomy.Surgical and audiologic outcomes.Eighty-one subjects were included (60% women) with a median age of 47.6 years (range, 19.1-73.6 yr). Etiologies of hearing loss included otosclerosis (96.3%), stapedial ankylosis (2.5%), and congenital stapes fixation (1.2%). The median follow-up was 5.3 months (range, 1.2-50.4 mo). 74.1% required scutum removal, and the chorda tympani nerve was sacrificed in 7.4%. Two techniques were used: 51.9% underwent stapedectomy and 48.1% underwent stapedotomy (with use of laser, drill, or both in 74.4, 20.5, and 5.1% of cases, respectively). The median air-bone gap (ABG) improved from 31.3 dB preoperatively to 6.25 dB postoperatively at last follow-up (p 0.0001). The ABG closed to less than 15 dB in 96.3% of patients and less than 10 dB in 84%. There were no instances of postoperative sensorineural hearing loss (defined as15 dB change from baseline) or facial nerve injury. Postoperatively, 29.6% of patients reported dysgeusia, of which 8.3% was persistent at last follow-up. Postoperative disequilibrium was reported in 17.3% of cases, with 100% resolution at last follow-up. Comparison of the stapedotomy and stapedectomy groups revealed no significant differences in audiologic or surgical outcomes.Endoscopic stapedotomy and stapedectomy are effective techniques to manage stapes fixation resulting in a median postoperative ABG of 6.25 dB and ABG closure to within 10 dB in 84% of patients.

Objective To describe the incidence and clinical course of patients who develop delayed facial nerve paralysis (DFNP) after surgical resection of vestibular schwannoma. Setting Tertiary skull base center. Methods Retrospective chart review. Results Two hundred and forty six consecutive patients, who underwent surgical resection for vestibular schwannoma at a single center between 2010 and 2015, were analyzed. Of these patients, 22 (8.9%) developed DFNP, defined here as deterioration of function by at least 2 House–Brackmann (HB) grades within 30 days in patients with immediate postoperative HB ≤ 3. The mean age of DFNP patients was 47.2 years (range: 17–67) and 16 (73%) were female. The mean tumor size in greatest dimension was 2.1 cm (range: 0.7–3.5 cm). At the conclusion of each case, the facial nerve stimulated at the brainstem. Mean immediate postoperative facial nerve function was HB 1.8 (range: 1–3). Average facial nerve function at the 3-week-postoperative visit was 4.4 (range: 2–6). In 1-year, 8 patients (36%) recovered HB 1 function, 10 patients (46%) recovered to HB 2, and 2 patients (9%) were HB 3. The remaining 2 patients did not recover function and were HB 6 at last follow-up. Initial postoperative facial nerve function (HB 1 or HB 2) was associated with improved recovery to normal (HB 1) function (p = 0.018). Conclusion A majority of patients that develop delayed paralysis will recover excellent facial nerve function. Patients should be counseled; however, a small percentage of patients will not recover function long-term, despite having a previously functioning and anatomically intact nerve.

Determine the effect of cochleostomy and facial recess packing on cochlear implant electrode distance from the modiolus.Two otolaryngology residents (PGY5 and PGY6) and one attending ear surgeon performed electrode insertions on a human cochlea model using perimodiolar (Cochlear® Slim Modiolar 532™, CI532) and lateral wall electrodes (Cochlear® Slim Straight 522™, CI522) via a cochleostomy. Packing material was simulated using cotton and placed in the cochleostomy and facial recess under the following conditions: 1) inferior to the electrode, 2) superior, 3) both inferior and superior, and 4) no packing. Distance of the electrode from the modiolus at the proximal, middle, and distal basal turn of the cochlea were measured by photomicrograph analysis.Packing superior to the CI532 resulted in a significant decrease in distance from the modiolus at the middle and distal basal turn compared to the inferior condition, with the largest effect in the middle basal turn (0.25 mm vs. 1.92 mm, respectively, p 0.001). For the CI522, packing superior similarly resulted in decreased distance to the modiolus when compared to the inferior packing condition at the middle and distal basal turn regions, with the largest effect in the middle basal turn (1.25 mm vs. 1.75 mm, respectively, p = 0.002).Packing of the cochleostomy site and facial recess has a significant effect on electrode distance from the modiolus in the middle and distal basal turn using a model of a human cochlea. Effects were more pronounced when using the perimodiolar (CI532) electrode.

Objective: Review the clinical presentation and management of meningeal hemangiopericytomas of the lateral skull base and cerebellopontine angle (CPA), and describe a case of anaplastic hemangiopericytoma of the CPA presenting as a middle ear mass. Study design: Case report and literature review. Case description: A 51-year-old male presented with a one year history of hearing loss, pulsatile tinnitus, and disequilibrium. Physical examination demonstrated a mass in the left middle ear. Magnetic resonance imaging revealed a 4 cm, T1-/T2-isointense, contrast-enhancing mass in the middle cranial fossa. The erosive mass extended into the middle ear and surrounding temporal lobe. A trans-zygomatic approach with a pterional craniotomy exposed a well-encapsulated, highly vascular mass. Manipulation of the tumor resulted in significant hemorrhage. Following removal from the temporal lobe and middle ear, an anterior petrosectomy was performed to remove tumor from the internal auditory canal (IAC) and carotid artery. The facial nerve near the IAC was encased in tumor, and all but a small amount of tumor adherent to the nerve was successfully removed. The final pathologic diagnosis was anaplastic hemangiopericytoma (WHO Grade III). Metastatic workup revealed no extracranial disease, and the patient underwent adjuvant radiation therapy. He continues to do well with only mild disequilibrium at one year follow-up. Conclusions: Hemangiopericytomas are rare, malignant neoplasms that are aggressive and highly vascular. Current management recommendations include excision followed by radiotherapy. Close surveillance is required for patients with anaplastic hemangiopericytoma due to the aggressive nature of this tumor and its propensity for recurrence or metastasis. Keywords: Hemangiopericytoma, Transzygomatic, Skull base, Middle ear mass, Middle cranial fossa, Tumor

OBJECTIVE To report short (∼4 mo) and long-term (>12 mo) audiometric outcomes following ossiculoplasty using a titanium clip partial ossicular reconstruction prosthesis. METHODS Case series at a single tertiary referral center reviewing 130 pediatric and adult patients with conductive hearing loss (CHL) secondary to chronic otitis media (n = 121, 93%) or traumatic ossicular disruption (n = 9, 7%) who underwent partial ossiculoplasty from January 2005 to December 2015 with the CliP prosthesis. RESULTS At both short and long-term follow-up, postoperative air-bone gap (ABG) was significantly improved (18 dB HL, IQ range 13-26, p

To evaluate the use of porcine small intestinal submucosal grafts for tympanic membrane repair.Adult and pediatric patients with tympanic membrane perforations with and without chronic otitits media, and perforations after removal of cholesteatoma.Endoscopic or microscopic tympanic membrane repair using porcine small intestinal submucosal grafts (Biodesign).Perforation closure, bone and air pure-tone averages (PTA), air-bone gap (ABG), and word recognition scores (WRS) were recorded as outcome measures.Thirty-seven patients were included with a mean age of 25.4 years (range, 6-75), 57% men. Twenty-six cases (70%) were performed endoscopically and 34 (92%) had concomitant cartilage grafting. Three patients (8%) had postoperative pinpoint (1% surface area) perforation, and two patients (5%) had postoperative perforation, with an overall success rate of 86.5%. The mean improvement in air-bone gap was 7.6 dB and (p = 0.006). There were no statistically significant differences in closure rates when comparing primary versus revision cases, endoscopic versus microscopic cases, size of perforation, cholesteatoma, concomitant mastoidectomy, age, tobacco exposure, or comorbid diabetes mellitus. Patients with concomitant cartilage graft were more likely to be successful when compared with those without cartilage graft (p = 0.04).Porcine small intestinal submucosal grafts are effective in the repair of the tympanic membrane. These grafts are an excellent choice in total endoscopic cases as it avoids incisions necessary for allograft harvest.

The objectives of this review are as follows: (1) examine the audiologic benefits of hearing preservation, (2) review rates of successful hearing preservation, and (3) analyze variables that impact hearing preservation success. Hearing preservation has been shown to confer the following audiologic benefits: better speech understanding in complex listening environments, superior sound localization, and improved music appreciation. There is a notable lack of standardized criteria for reporting of hearing preservation outcomes—this leads to considerable heterogeneity across studies. Rates of functional (i.e., aidable) hearing preservation generally range between 50 and 90%. Studies demonstrate higher preservation rates and more durable hearing outcomes with shorter, straight electrode arrays. With advances in CI technology and surgical techniques, residual hearing can be preserved after CI surgery in the majority of patients. Cochlear implant recipients with preserved hearing demonstrate better speech understanding, sound localization, and improved music appreciation.

Endoscopic ear surgery (EES) is an emerging technique requiring single-handed dissection with limited depth perception. Current options for EES simulation and training are limited. Herein, we introduce a versatile, low-cost surgical skills trainer that aims to improve the fine motor control necessary for EES.Prospective validation study.Surgical simulation laboratory.Seven subjects ranging in experience from medical students ("Novices") to experienced ear surgeons ("Experts") participated in the validation study. Experts (n = 3) were defined as performing10 EES cases per year.The skills trainer was constructed from a 3" diameter polyvinyl chloride pipe cap modified with two ports for instrument passage. A wooden platform was placed inside at an appropriate working distance for ear surgery. Eight interchangeable skills modules were fabricated on wooden squares (3 cm × 3 cm) using materials such as #19 wire brads, 1.6 mm glass beads, and 26-gauge jewelry wire. The material cost of this reusable model was $15. Subjects completed each skills module in triplicate, followed by a Likert-based survey.Expert performance was superior to novices in 100% (8/8) of skills modules, i.e., threading beads on a wire (43 versus 127 s, p 0.001) and placing a simulated prosthesis (13 versus 68 s, p = 0.01). Most participants (86%) agreed the trainer orientation was accurate and all participants (100%) were satisfied with the experience.This low-cost modular task trainer may help fill a void in otologic training by allowing efficient, deliberate practice of validated exercises designed to improve fine motor control with EES instrumentation.

Objectives 1) Examine angular insertion depths (AID) and scalar location of Med-El (GmbH Innsbruck, Austria) electrodes; and 2) determine the relationship between AID and audiologic outcomes controlling for scalar position. Study Design Retrospective review. Methods Postlingually deafened adults undergoing cochlear implantation with Flex 24, Flex 28, and Standard electrode arrays (Med-El) were identified. Patients with preoperative and postoperative computed tomography scans were included so that electrode location and AID could be determined. Outcome measures were 1) speech perception in the cochlear implant (CI)-only condition, and 2) short-term hearing preservation. Results Forty-eight implants were included; all electrodes (48 of 48) were positioned entirely within the scala tympani. The median AID was 408° (interquartile [IQ] range 373°–449°) for Flex 24, 575° (IQ range 465°–584°) for Flex 28, and 584° (IQ range 368°–643°) for Standard electrodes (Med-El). The mean postoperative CNC score was 43.7% ± 21.9. A positive correlation was observed between greater AID and better CNC performance (r = 0.48, P < 0.001). Excluding patients with postoperative residual hearing, a strong correlation between AID and CNC persisted (r = 0.57, P < 0.001). In patients with preoperative residual hearing, mean low-frequency pure-tone average (PTA) shift was 27 dB ± 14. A correlation between AID and low-frequency PTA shift at activation was noted (r = 0.41, P = 0.04). Conclusion Favorable rates of scala tympani insertion (100%) were observed. In the CI-only condition, a direct correlation between greater AID and CNC score was noted regardless of postoperative hearing status. Deeper insertions were, however, associated with worse short-term hearing preservation. When patients without postoperative residual hearing were analyzed independently, the relationship between greater insertion depth and better performance was strengthened. Level of Evidence 4. Laryngoscope, 127:2352–2357, 2017

RA is a chronic systemic inflammatory disease that primarily affects the small joints of the hands and feet, and results in a mean reduction in life expectancy of 3–10 years. RA is a multigene disorder with a substantial genetic component and a heritability estimate of 60%. Large-scale Genome-Wide Association Studies (GWAS) and meta-analyses have revealed common disease-associated variants in the population that may contribute cumulatively to RA pathogenesis. This review identifies the most significant genetic variants associated with RA susceptibility to date, with particular focus on the contribution of the HLA class II genes across different ethnic groups. Also discussed are the potential applications of pharmacogenomics to RA management by identifying polymorphisms associated with variation in treatment response or toxicity. The use of genetic variants to guide treatment strategy has the potential to not only reduce National Health Service costs, but also drastically improve patient experience and quality of life.

Objectives Healthy individuals have significant beat-to-beat variability in heart rate, and this variability decreases with mental stress. We aim to use heart rate variability (HRV) to objectively compare mental stress levels in otologic surgeons at rest and during key portions of procedures. Design Pilot study. Setting Operating room and laboratory. Participants Two neurotology fellows performed six mastoidectomy and facial nerve (FN) dissections in the operating room and six in a cadaver lab while continuous electrocardiograms were measured wirelessly. Five-minute samples were recorded during resting, preoperative, mastoidectomy, and FN dissection. Beat-to-beat time intervals were analyzed in time and frequency domains. The standard deviation of normal beat-to-beat intervals (SDNN) and the ratio of low frequency to high frequency power (LF/HF, measure of sympathetic tone) were calculated. Decreases in SDNN and increases in LF/HF indicate elevated mental stress. Results Mean resting SDNN was 43.9 ± 9.2 ms, not statistically different from preoperative SDNN (34.1 ± 8.2 ms, p = 0.13). SDNN decreased during mastoidectomy (29.4 ± 11.7 ms) and FN dissection (22.8 ± 3.1 ms), which was significant compared to preoperative values (p = 0.03). Intraoperative LF/HF increased for FN dissection (6.8 ± 2.6) compared to resting (2.2 ± 0.7, p = 0.004), indicating increased sympathetic tone. Mastoid and FN cadaveric procedures resulted in SDNN of 33.6 ± 3.8 and 32.9 ± 4.7 ms, respectively, not statistically different from preoperative values (p = 0.82 and p = 0.94, respectively). Cadaveric FN dissection did not result in increased LF/HF (2.4 ± 0.9) compared to resting (p = 0.94). Conclusions Decreased HRV and increased sympathetic tone were observed intraoperatively, indicating high levels of mental stress, particularly with FN dissection. Similar changes were not found during cadaveric dissections.

Objectives Review outcomes of lateral temporal bone resections for ear and temporal bone malignancy. Design, Setting, and Participants Retrospective review of all lateral temporal bone resections performed from 2008 to 2015 at a single tertiary care center. Main Outcome Measures Patient demographics, perioperative variables, overall survival, disease-free survival (DFS), and comparison of Kaplan–Meier curves. Results Overall, 56 patients were identified with a mean follow-up period of 2.3 ± 1.8 years. The predominant histopathologic diagnosis was squamous cell carcinoma (SCC, 54%), followed by salivary gland tumors (18%), and basal cell carcinoma (9%). Tumor stages were T1-T2 in 23%, T3-T4 in 73%, and two unknown primary lesions. Mean overall survival was 4.6 ± 0.4 years. Comparison of tumors with and without lymph node involvement or perineural invasion approached statistical significance for overall survival ( p = 0.07 and 0.06, respectively). DFS was 2.5 ± 0.3 years. Stratification by lymph node status had a statistically significant difference in DFS ( p = 0.03). Subgroup analysis of SCC patients did not reveal significant differences. Conclusions Based on our cohort, most patients with temporal bone malignancies present with advanced disease, making it difficult to achieve negative margins. Overall, lymph node status was the strongest predictor of survival in this group.

Vascular malformations of the central nervous system such as cavernous malformations and arteriovenous malformations are rare lesions with controversial management recommendations in the pediatric population. We report a case of a 3-year-old male who presented with multiple discrete episodes of focal neurological deficits including ataxia and an abducens nerve palsy. Imaging revealed a 1.5 cm hemorrhagic mass located in the pons that was concerning for a cavernous malformation. This lesion was completely excised via a combined transpetrosal approach, and the patient had complete resolution of neurologic symptoms at three-month follow-up.

To describe and characterize facial nerve stimulation (FNS) patterns in patients with labyrinthitis ossificans who underwent cochlear implantation (CI) for sensorineural hearing loss.Five ears in four patients with labyrinthitis ossificans who underwent CI and subsequently developed FNS.CI, electrode mapping, and/or explantation to resolve FNS.FNS, postoperative computed tomography imaging, and resolution of FNS.Fourteen ears with labyrinthitis ossificans underwent CI over an 11-year period at a single institution; 5 of these ears exhibited postoperative FNS (35.7% incidence). Four cases had involvement of basal electrodes, while all five cases had middle and/or apical electrode stimulation. All cases had resolution of FNS with CI reprogramming, however, the resultant map in two cases provided minimal audiologic benefit and patients became nonusers in that ear.FNS arising from all cochlear regions is possible in patients with labyrinthitis ossificans who undergo CI. Mapping and electrode deactivation can resolve symptoms, but resultant audiologic benefit is variable and may lead to explantation.

Background Internal cochlear anatomy is difficult to discern from external inspection, hindering cochlear implant electrode insertion. Methods A user study characterized the repeatability of standard surgical technique and examined the role of visual inspection and guidance cues in reducing electrode array insertion misalignment. Results Without guidance, a large spread in angles of insertion, up to 30°, was observed, highlighting the need for intraoperative guidance. Visual inspection did not significantly improve overall orientation, suggesting the need for alternate intracochlear visualization methods and/or increased training to effectively improve surgeon understanding of the visualized images. Visual cues and guidance software increased repeatability of surgeon performance, reducing one metric of repeatability to ±2°. Conclusions This study establishes a baseline for surgeon variability in cochlear implant insertion and supports the need and lays the groundwork for future intraoperative guidance techniques.

This study aimed to assess the ability for exercise training performed before and during biweekly doxorubicin (DOX) administration to attenuate adverse effects of DOX on skeletal muscle. We hypothesized that DOX treatment would increase REDD1, impair mammalian target of rapamycin (mTOR) signaling, and reduce muscle fiber size, and that exercise training would attenuate these responses.Eight-week-old ovariectomized female Sprague-Dawley rats were randomized to one of four treatments: exercise + DOX (Ex-Dox), Ex + vehicle (Ex-Veh), sedentary + DOX (Sed-Dox), and Sed + Veh (Sed-Veh). DOX (4 mg·kg) or vehicle (saline) intraperitoneal injections were performed biweekly for a total of three injections (cumulative dose, 12 mg·kg). Ex animals performed interval exercise (4 × 4 min, 85%-90% V˙O2peak) 5 d·wk starting 1 wk before the first injection and continued throughout study duration. Animals were euthanized ~5 d after the last injection, during which the soleus muscle was dissected and prepared for immunoblot and immunohistochemical analyses.REDD1 mRNA and protein were increased only in Sed-Dox (P0.05). The phosphorylation of mTOR and 4E-BP1 and MHC I and MHC IIa fiber size were lower in Sed-Dox versus Sed-Veh (P0.05). By contrast, REDD1 mRNA and protein, mTOR, 4E-BP1, and MHC I fiber size were not different between Ex-Dox and Ex-Veh (P0.05). LC3BI was higher, and the LC3BII/I ratio was lower in Sed-Dox versus Sed-Veh (P0.05) but not between Ex-Dox and Ex-Veh (P0.05).These data suggest that DOX may inhibit mTORC1 activity and reduce MHCI and MHCIIa fiber size, potentially through elevated REDD1, and that exercise may provide a therapeutic strategy to preserve skeletal muscle size during chronic DOX treatment.

Purpose There are no controlled prospective studies evaluating the effect of dominant handedness in left- and right-sided surgery in otolaryngology. Endoscopic microlaryngeal phonosurgery is an ideal procedure to assess technical aspects of handedness and laterality, due to anatomic symmetry. In this study, we analyzed (1) choice of surgical approach and (2) outcomes based on handedness and laterality in a microlaryngeal simulator. Methods Using a validated high-fidelity phonosurgery model, a prospective cohort of 19 expert laryngologists undertook endoscopic resection of a simulated vocal fold lesion. These resections were video-recorded and scored by 2 blinded expert laryngologists using a validated global rating scale, procedure-specific rating scale, and a hand preference analysis. Results There were 18 right-handed participants and 1 left-handed. 12 left and 7 right excisions were evaluated. Cronbach's alpha for inter-rater reliability was good (0.871, global scale; and 0.814, procedure-specific scale). Surgeons used their dominant hand 78.9% of the time for both incision and dissection. In cases where the non-dominant hand would have been preferred, surgeons used the non-dominant hand only 36.4% of the time for incision and dissection. Use of the non-dominant hand did not influence global or procedural rating ( p = 0.132 and p = 0.459, respectively). Conclusions In this simulation of microlaryngeal surgery, there were measurable differences in surgical approaches based on hand dominance, with surgeons preferring to cut and perform resection with the dominant hand despite limitations in the instrumentation and exposure. Regardless of hand preference, overall outcomes based on global rating and technique specific rating scales were not significantly different.

Purpose Lateral osteotomies are important during rhinoplasty and represent a challenging technique that otolaryngology and plastic surgery trainees must learn. The approaches for osteotomies are difficult to teach as they are accomplished through tactile feedback. Trends in teaching and practice patterns of lateral osteotomies are poorly described in the literature, and this study aims to fill this knowledge gap. Materials and methods Members of the American Academy of Facial Plastic and Reconstructive Surgery were surveyed to characterize surgeon preferences for intranasal versus percutaneous lateral osteotomies and understand how techniques are taught. Results Among surgeons who completed the survey (n = 172), 87% reported that they “always” or “mostly” use intranasal lateral osteotomies whereas only 8% “always” or “mostly” use percutaneous approaches. There is no significant trend towards changing osteotomy techniques when teaching trainees. Only 15% of respondents allow trainees to perform lateral osteotomies in more than half of operations. Conclusions Most facial plastic surgeons prefer to use intranasal lateral osteotomies. However, many do not allow trainees to perform this critical step during rhinoplasty. This study has implications for both patient care and surgical education.

Objective To increase otolaryngology resident experience with drilling and dissection of the internal auditory canal (IAC) via a translabyrinthine approach. Study design Pilot study involving temporal bone education and drilling with completion of pre- and post-drilling surveys. Methods Participants observed an educational presentation on IAC anatomy and drilling, followed by manipulation of IAC nerves using a prosected cadaveric temporal bone. Participants then drilled the IAC and identified nerves using temporal bones with previously drilled mastoidectomies and labyrinthectomies. Pre- and post-drilling 5-point Likert-based surveys were completed. Results 7 participants were included in this study ranging in experience from PGY1 through PGY 5. The median number of times the IAC had been drilled previously was 0. Participants reported statistically significantly improved familiarity with the translabyrinthine approach after the session with median scores increasing from 2 to 3 (p = 0.02), and a near-significant increase in familiarity with IAC anatomy with median scores increasing from 3 to 4 (p = 0.06). Prior to the session, 71% of participants either disagreed or strongly disagreed that they had an idea of what the procedure would be like in a real operating room, whereas after the session 0% reported disagreement. 100% of participants were very satisfied with the overall experience. Conclusions An educational session and temporal bone drilling experience using prosected bones significantly increased the reported familiarity with the translabyrinthine approach. Experiences such as this may enhance resident exposure to advanced lateral skull base approaches in a safe environment, and increase comprehension of the complex anatomic relationships of the IAC.

Insulin stimulates muscle protein synthesis when the levels of total amino acids, or at least the essential amino acids, are at or above their postabsorptive concentrations. Among the essential amino acids, branched-chain amino acids (BCAA) have the primary role in stimulating muscle protein synthesis and are commonly sought alone to stimulate muscle protein synthesis in humans. Fourteen healthy young subjects were studied before and after insulin infusion to examine whether insulin stimulates muscle protein synthesis in relation to the availability of BCAA alone. One half of the subjects were studied in the presence of postabsorptive BCAA concentrations (control) and the other half in the presence of increased plasma BCAA (BCAA). Compared with that prior to the initiation of the insulin infusion, fractional synthesis rate of muscle protein (%/h) did not change ( P > 0.05) during insulin in either the control (0.04 ± 0.01 vs 0.05 ± 0.01) or the BCAA (0.05 ± 0.02 vs. 0.05 ± 0.01) experiments. Insulin decreased ( P < 0.01) whole body phenylalanine rate of appearance (μmol·kg−1·min−1), indicating suppression of muscle proteolysis, in both the control (1.02 ± 0.04 vs 0.76 ± 0.04) and the BCAA (0.89 ± 0.07 vs 0.61 ± 0.03) experiments, but the change was not different between the two experiments ( P > 0.05). In conclusion, insulin does not stimulate muscle protein synthesis in the presence of increased circulating levels of plasma BCAA alone. Insulin's suppressive effect on proteolysis is observed independently of the levels of circulating plasma BCAA.

Surgical simulators are designed to improve operative skills and patient safety. Transcanal Endoscopic Ear Surgery (TEES) is a relatively new surgical approach with a slow learning curve due to one-handed dissection. A reusable and customizable 3-dimensional (3D)-printed endoscopic ear surgery simulator may facilitate the development of surgical skills with high fidelity and low cost. Herein, we aim to design, fabricate, and test a low-cost and reusable 3D-printed TEES simulator.The TEES simulator was designed in computer-aided design (CAD) software using anatomic measurements taken from anthropometric studies. Cross sections from external auditory canal samples were traced as vectors and serially combined into a mesh construct. A modified tympanic cavity with a modular testing platform for simulator tasks was incorporated. Components were fabricated using calcium sulfate hemihydrate powder and multiple colored infiltrants via a commercial inkjet 3D-printing service.All components of a left-sided ear were printed to scale. Six right-handed trainees completed three trials each. Mean trial time (n = 3) ranged from 23.03 to 62.77 s using the dominant hand for all dissection. Statistically significant differences between first and last completion time with the dominant hand (p 0.05) and average completion time for junior and senior residents (p 0.05) suggest construct validity.A 3D-printed simulator is feasible for TEES simulation. Otolaryngology training programs with access to a 3D printer may readily fabricate a TEES simulator, resulting in inexpensive yet high-fidelity surgical simulation.

Importance Over two-thirds of the adult population in the United States use Facebook. Despite the high interest in and use of social media by the general public, the presence and accessibility of health care organizations on social media has not yet been fully evaluated. Objective To determine the use and popularity of social media among otolaryngology residency programs in the United States. Design, setting, and participants A cross-sectional study of the presence of accredited otolaryngology residency programs in the United States in an internet data repository was conducted. Programs were stratified by Doximity Residency Navigator reputation rankings (dividing programs into quartiles) and US News & World Report (comparing programs affiliated with hospitals ranked in the top 50 vs programs affiliated with unranked hospitals). Social media sites and activity for each program were assessed using internet searches. The study was conducted in April 2017. Results Among 101 otolaryngology residency programs, 30 were found to have social media sites (29.7%). Facebook and Twitter were the most commonly used services, with 25 (24.8%) and 14 (13.9%) accounts, respectively. Based on Doximity Residency Navigator rankings, programs in the first quartile were more likely to have Facebook profiles than programs in the fourth quartile (42.3% vs 12.0%; absolute difference, 30%; 95% CI, 2.9% to 52.6%). First- and second-quartile programs showed increased Facebook activity. There was greater Twitter presence in first- vs fourth-quartile programs (19.2% vs 8.0%; absolute difference, 11.2%; 95% CI, -11.6% to 33.0%). Higher-quartile programs were more active on Twitter and exhibited increased numbers of likes and followers. Analysis of US News & World Report rankings revealed that ranked programs had higher rates of presence, activity, and popularity on both Facebook and Twitter. However, these were smaller differences than seen when comparing Doximity Residency Navigator rankings. Correlation between the 2 ranking systems was indicated (Spearman ρ = 0.59; 95% CI, 0.34 to 0.76). Conclusions and relevance This study suggests that otolaryngology residency programs with higher Doximity Residency Navigator reputation rankings have a stronger presence on social media. Smaller trends were observed for programs in the top 50 US News & World Report rankings. Overall, social media use among otolaryngology programs seems relatively low, and this may present an opportunity to increase communication with the public via these technologies.

Objective To characterize our experience with the surgical management of anterior skull base malignancy, and to propose an algorithm for surgical approach to anterior skull base malignancies. Design Retrospective review. Setting Academic cranial base center. Participants Sixty-seven patients who underwent resection of paranasal sinus or anterior skull base malignancy with an endoscopic, cranioendoscopic, or traditional anterior craniofacial approach. Outcome Measures Complications, recurrence, and survival. Results There were 48 males and 19 females, ranging from 6 to 88 years old. There were three groups: endonasal endoscopic resection (n = 10), cranioendoscopic resection (n = 12), and traditional craniofacial resection (n = 45). The most common tumor pathologies included esthesioneuroblastoma, squamous cell carcinoma, and sinonasal undifferentiated carcinoma. Patients with T3/T4 disease were less likely to undergo endoscopic resection (p = 0.007). The 5-year disease-free survival was 82.1% overall, with no statistically significant differences among approaches. There were no differences in orbital complications, meningitis, or cerebrospinal fluid leak. Use of a transfacial incisions predisposed patients to surgical site infection and sinocutaneous fistulae. An algorithm for surgical approach was developed based on these results. Conclusion Sinonasal and skull base malignancies can be safely surgically addressed via several approaches. Surgical approach should be selected algorithmically based on preoperative clinical assessment of the tumor and known postoperative complication rates.

Background Sphenoid sinus fungal balls (SSFB) are rare entities that can result in serious orbital and intracranial complications. There are few published reports of complications that result from SSFB. Objective To review the incidence of skull base erosion and orbital or intracranial complications in patients who present with SSFB. Methods A retrospective review was performed of all the patients with SSFB who were treated at the Massachusetts Eye and Ear Infirmary from 2006 to 2014. Presenting clinical data, radiology, operative reports, pathology, and postoperative course were reviewed. Results Forty-three patients with SSFB were identified. Demographic data were compared between patients with (39.5%) and those without (61.5%) skull base erosion. Two patients underwent emergent surgery for acute complications of SSFB (one patient with blindness, one patient who had a seizure). Both patients with acute complications had evidence of skull base erosion, whereas no patients with an intact skull base developed an orbital or intracranial complication (p = 0.15). All the patients were surgically managed via an endoscopic approach. Conclusion SSFBs are rare but may cause significant skull base erosion and potentially severe orbital and intracranial complications if not treated appropriately. Endoscopic sphenoidotomy is effective in treating SSFB and should be performed emergently in patients who presented with associated complications.

1. Risk factors for coronary heart disease include age, sex, family history, high cholesterol, blood pressure, smoking, and severe obesity. The last four risk factors can be modified with lifestyle changes. 2. Occupational health nurses who provide primary care to workers can assist employees in detecting and treating their elevated cholesterol. Cholesterol screening at the workplace is an effective means for employees to learn their cholesterol level or monitor their dietary progress in lowering their cholesterol. 3. Employees can modify their eating behaviors by developing the skills to make wise dietary choices. Simple dietary self assessment and self monitoring tools will aid employees in monitoring and evaluating their efforts. 4. To successfully implement a cholesterol education program and counsel employees, occupational health nurses need to increase their knowledge of nutrition, specifically the composition of a diet that will help reduce the risks associated with heart disease.

An employee fitness program helped reduce some coronary risk factors, but this is only one measure of success. The author says that long-term changes in diet and exercise habits are the real challenge.

Rabies is a prime example of a neglected tropical disease that mostly affects communities suffering from inequitable health care [1]. The false perception that rabies impacts on society are low is due to case under-reporting and limited awareness of the disease burden [2], [3]. Effective tools for elimination of terrestrial rabies are available [4]. While the sustained deployment of these tools has led to some remarkably successful interventions [5], [6], canine rabies continues to claim lives in rabies-endemic countries and areas of re-emergence, where >95% of human deaths occur as a result of bites by rabid domestic dogs [7], [8]. Control programs targeting dogs can effectively reduce the risk of rabies to humans [3], [9]. However, the design and implementation of such programs still pose considerable challenges to local governments, and a lack of easy-to-use guidelines has been identified as an important reason for this. Global rabies experts from the Partners for Rabies Prevention have therefore gathered to translate evidence-based knowledge on rabies control into user-friendly guidelines. Existing information obtained from different sources, including previously published guidelines by international health and animal welfare organizations and scientific findings, has been packaged into a novel online document, the Blueprint for Rabies Prevention and Control (http://www.rabiesblueprint.com), which we describe herewith.