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OBJECTIVES/HYPOTHESIS Despite controversy regarding their impact and validity, there is a rising national focus on patient satisfaction scores (PSS). We describe the landscape of online PSS as posted by academic otolaryngology practices. STUDY DESIGN Retrospective cross-sectional study. METHODS Websites of academic otolaryngology programs were reviewed for PSS scores, provider type, and geographic location. Gender was determined by picture or profile pronouns. Years of experience were determined by year of initial American Board of Otolaryngology-Head and Neck Surgery certification. We defined PSS derived from Press-Ganey or Clinician and Group Consumer Assessment of Healthcare Providers and Systems surveys as "standardized PSS". We determined potential associations between provider characteristics and standardized PSS. RESULTS Out of 115 Otolaryngology-Head and Neck Surgery academic programs, 40 (35%) posted a total of 64,638 online PSS surveys (nonstandardized plus standardized) of 507 unique otolaryngology care providers. Standardized PSS were posted for 473 providers (370 [78%] male; 446 physicians; 27 advanced practice providers). Median overall standardized PSS was 4.8 (interquartile range 4.7-4.9; range 3.8-5.0). PSS were similar between gender, provider type, and years of experience. Male providers had more surveys than female providers (149 vs. 93; P

Objective Describe long-term hearing outcomes with audiologic data with modern stereotactic radiosurgery techniques for vestibular schwannoma tumors. Background Since the mid-20th century, stereotactic radiosurgery has been an option for central nervous system tumors. Due to the non-invasive manner of treatment, this was extended to treatment for benign vestibular schwannomas without intracranial surgery. Modern advances have localized radiation and reduced dosage, but data are still lacking in the long-term hearing outcomes of this method of treatment. As one of the national leaders in this procedure, we present our full database of these outcomes over the full time period of our institutions utility of this modality. Methods A retrospective review was performed of all patients undergoing stereotactic radiotherapy for vestibular schwannomas within the study period of 1998 to 2019 and their audiograms analyzed along with patient data. Laterality Gardner-Robertson hearing score changes were the primary outcome analyzed for each patient; and controls were placed to accommodate for patient demographic data. Results Long-term, multi-year audiometric evaluation showed statistically significant loss of serviceable hearing and reduction in hearing ability with the use of stereotactic radiosurgery for treatment of vestibular schwannomas. Conclusions Little long-term data exists on the audiometric outcomes related to stereotactic radiosurgery treatment for vestibular schwannomas. Our institution has performed more than 300 stereotactic radiosurgery treatments showing a continued reduction over time in serviceable hearing. Practitioners should advise patients undergoing treatment for vestibular schwannomas with this treatment of long-term results.

Objectives: Describe the current state of otolaryngologic residency training with recent changes to the program requirements by the Accreditation Council for Graduate Medical Education (ACGME) which increased the amount of time on intern year otolaryngology rotations from 3 to 6 months. Methods: A cross-sectional study was performed and recruitment was done via personalized email sent to program coordinators of 113 ACGME-accredited otolaryngology training programs within the Unites States. The message requested a breakdown of the amount of time and specialty in which first year otolaryngologic residents rotated. Interval follow ups were sent at 3 and 6 months for coordinators who had not responded. Results: Response rate was 79.7% (90/113). General surgery and surgical intensive care unit were the two most common non-otolaryngologic rotations (92.2% and 96.6% respectively) while ophthalmology and radiation oncology were the least common at 7.8% each. All first year residents spend time on an inpatient otolaryngologic rotation, while 30.7% spend time on outpatient rotations. The most common subspecialties were head and neck oncology (40.0%) followed by pediatric otolaryngology (36.0%). Conclusions: Otolaryngologic training continues to become more slanted towards specialty-specific training and a concurrent reduction in “off-service” rotations. General inpatient services still predominate the intern year both inter- and intra-departmentally. These data provide insight into the training environment of the otolaryngologic trainees set to graduate residency for the first time this year.

To assess the prevalence of distress and burnout in otolaryngology trainees, including associations with relevant sociodemographic and professional factors, and to compare these results with those of attending otolaryngologists.A cross-sectional survey of trainees and attending physicians.Twelve academic otolaryngology programs.Distress and burnout were measured with the Expanded Physician Well-being Index and the 2-item Maslach Burnout Inventory. The Patient Health Questionnaire-2 and Generalized Anxiety Disorder-2 were used to screen for depressive disorders and anxiety disorders, respectively. Associations with sociodemographic and professional characteristics were assessed.Of the 613 surveys administered to trainees and attending physicians, 340 were completed (56%). Among 154 trainees, distress was present in 49%, professional burnout in 35%, positive depressive disorder screening in 5%, and positive anxiety disorder screening in 16%. In univariable analysis, female gender, hours worked in a typical week (HW), and nights on call in a typical week (NOC) were significantly associated with distress. In multivariable analysis, female gender (odds ratio, 3.91;Otolaryngology trainees experience significant work-place distress (49%) and burnout (35%). Gender, HW, and NOC had the strongest associations with distress and burnout.

To ascertain the prevalence of and associations with distress and professional burnout among academic otolaryngology attending physicians.Cross-sectional survey.Twelve US academic otolaryngology programs.A questionnaire was administered that encompassed sociodemographic and professional features, the Expanded Physician Well-being Index for distress, the 2-item Maslach Burnout Inventory for professional burnout, the Patient Health Questionnaire-2 screen for major depressive disorder, and the Generalized Anxiety Disorder-2 screen for generalized anxiety disorder.The survey response rate was 56% and included 186 attending physicians. The average respondent age was 47 years; 72% were men; 93% were married or partnered; and 86% had children. Distress was present in 40%, professional burnout in 26%, positive depression screening in 8%, and positive anxiety screening in 11%. In a univariable setting, age, hours worked in a typical week, nights on call in a typical week, and years of practice were significantly associated with distress, although in a multivariable setting, only hours worked in a typical week remained significantly associated with a positive Expanded Physician Well-being Index screen (odds ratio for each 10-hour increase, 2.61; 95% CI, 1.73-3.93;Distress or professional burnout occurs in more than a quarter of academic otolaryngology attending physicians, whereas the prevalence of depression or anxiety is approximately 10%. The number of hours worked per week had the strongest association with distress and burnout. These findings may be used to develop and implement programs to promote physician well-being and mitigate professional burnout.

OBJECTIVE To assess the health utility of chronic Eustachian tube dysfunction (ETD). METHODS This is a prospective study of 53 patients with chronic ETD recruited from a tertiary clinic from April 2017 to July 2018. The 7-Item Eustachian Tube Dysfunction Questionnaire (ETDQ-7) was administered, and health utility was evaluated using the EuroQol-5 Dimensions-3 Level Instrument (EQ-5D-3L), the visual analogue scale (VAS), time tradeoff (TTO), and standard gamble (SG). Participants were grouped into medical or procedural management groups. One-week follow-up included repeated health utility measures and ETDQ-7. RESULTS Fifty-three patients were included in the final analysis. Of those, 34 were managed medically, and 19 received myringotomies ± PE tubes. The mean baseline ETDQ-7 was 4.26 ± 1.31; whereas health utility measures were different depending on the method utilized: EQ-5D-3L 0.90 ± 0.11; VAS 0.76 ± 0.21; TTO 0.85 ± 0.23; and SG 0.94 ± 0.11 (P

Objective Describe current practices and challenges in personal protective equipment (PPE) use among US otolaryngologists during the COVID-19 pandemic. Study design Online survey. Setting Academic and non-academic healthcare institutions. Subjects and methods Subjects included US otolaryngology physicians. Emails were sent on April 17, 2020 to program coordinators at 121 residency programs, who were requested to forward the email to program directors for distribution. Further recruitment occurred through snowball recruitment. The survey was closed on June 15, 2020. Results Sixty-one participants completed the survey. 95.1% reported routine access to full PPE (N95 ± powered air purifying respirator [PAPR], gown, gloves, eye protection) for aerosol-generating procedures (AGPs) in COVID-19 patients, while 68.9% had routine access to full PPE for AGPs in patients without confirmed COVID-19. 88.5% had routine access to full PPE for potential aerosol-generating procedures (pAGPs) in COVID patients, while 80.3% had routine access to full PPE for pAGPs in patients without confirmed COVID. All participants felt that they “always” or “usually” had necessary PPE to safely perform procedures and surgeries on COVID patients. 83.6% received N95 fitting in the past year, and 93.4% reported adequate PPE training. Conclusion The majority of participants reported routine access to full PPE for AGPs and pAGPs in all patients, regardless of COVID status. There was a high perception of security, as well as adequate N95 fitting and PPE training. Areas for improvement include: optimizing PPE availability for AGPs in patients without confirmed COVID and wider recognition of otolaryngologic procedures as high risk for aerosolization.

A comparison of bimodal hearing and bilateral cochlear implants (CIs) was completed using a within-subjects, repeated-measures study for eight adult sequential recipients who despite achieving incredibly high performance with the first CI, self-selected for bilateral implantation. Speech understanding was assessed with the minimum speech test battery (MSTB) as well as sentences in semi-diffuse noise using the R-SPACE™ system. Conditions included unilateral hearing aid (HA) in the non-implanted ear, unilateral CI, bimodal (CI+HA), and bilateral CI. Additionally, three participants had bilateral hearing preservation and were also tested with bilateral CIs and bilateral HAs (BiBi). All testing was completed in the bimodal hearing configuration and repeated at least six months following activation of the second CI. Bilateral CIs afforded significant individual improvement in a complex listening environment even for individuals demonstrating near perfect sentence scores with both the 1st CI alone as well as the bimodal condition. The 3 BiBi participants demonstrated additional significant benefit over the bilateral CI condition—presumably due to the availability of interaural time difference cues. These data suggest that for noisy environments, adding a second implant can significantly improve speech understanding—even for high performing unilateral CI with bimodal hearing. In diffuse noise conditions, bilateral acoustic hearing can yield even greater benefit beyond that offered by bilateral implantation.

Program Description:Otogenic pain and aural fullness can be some of the more frustrating chief complaints to work up and address. Many patients with this complaint are frustrated with lack of diagnosis and treatment. This leads to multiple visits in search of the answer to their affliction. In this miniseminar, our panel of experts will continue their discussion on how to evaluate and treat these difficult patients. Paradigms for management of these patients will be discussed. Case presentations will highlight proper workup and management of these confusing cases. Sponsored by the Otology and Neurotology Education Committee.Educational Objectives:(1) Describe pathologies that may cause otogenic pain or aural fullness. (2) Conduct workup paradigms to avoid missing potentially dangerous processes. (3) Examine possible treatments for the various pathologies.

Bell's palsy, named after the Scottish anatomist, Sir Charles Bell, is the most common acute mono-neuropathy, or disorder affecting a single nerve, and is the most common diagnosis associated with facial nerve weakness/paralysis. Bell's palsy is a rapid unilateral facial nerve paresis (weakness) or paralysis (complete loss of movement) of unknown cause. The condition leads to the partial or complete inability to voluntarily move facial muscles on the affected side of the face. Although typically self-limited, the facial paresis/paralysis that occurs in Bell's palsy may cause significant temporary oral incompetence and an inability to close the eyelid, leading to potential eye injury. Additional long-term poor outcomes do occur and can be devastating to the patient. Treatments are generally designed to improve facial function and facilitate recovery. There are myriad treatment options for Bell's palsy, and some controversy exists regarding the effectiveness of several of these options, and there are consequent variations in care. In addition, numerous diagnostic tests available are used in the evaluation of patients with Bell's palsy. Many of these tests are of questionable benefit in Bell's palsy. Furthermore, while patients with Bell's palsy enter the health care system with facial paresis/paralysis as a primary complaint, not all patients with facial paresis/paralysis have Bell's palsy. It is a concern that patients with alternative underlying etiologies may be misdiagnosed or have unnecessary delay in diagnosis. All of these quality concerns provide an important opportunity for improvement in the diagnosis and management of patients with Bell's palsy.The primary purpose of this guideline is to improve the accuracy of diagnosis for Bell's palsy, to improve the quality of care and outcomes for patients with Bell's palsy, and to decrease harmful variations in the evaluation and management of Bell's palsy. This guideline addresses these needs by encouraging accurate and efficient diagnosis and treatment and, when applicable, facilitating patient follow-up to address the management of long-term sequelae or evaluation of new or worsening symptoms not indicative of Bell's palsy. The guideline is intended for all clinicians in any setting who are likely to diagnose and manage patients with Bell's palsy. The target population is inclusive of both adults and children presenting with Bell's palsy. ACTION STATEMENTS: The development group made a strong recommendation that (a) clinicians should assess the patient using history and physical examination to exclude identifiable causes of facial paresis or paralysis in patients presenting with acute-onset unilateral facial paresis or paralysis, (b) clinicians should prescribe oral steroids within 72 hours of symptom onset for Bell's palsy patients 16 years and older, (c) clinicians should not prescribe oral antiviral therapy alone for patients with new-onset Bell's palsy, and (d) clinicians should implement eye protection for Bell's palsy patients with impaired eye closure. The panel made recommendations that (a) clinicians should not obtain routine laboratory testing in patients with new-onset Bell's palsy, (b) clinicians should not routinely perform diagnostic imaging for patients with new-onset Bell's palsy, (c) clinicians should not perform electrodiagnostic testing in Bell's palsy patients with incomplete facial paralysis, and (d) clinicians should reassess or refer to a facial nerve specialist those Bell's palsy patients with (1) new or worsening neurologic findings at any point, (2) ocular symptoms developing at any point, or (3) incomplete facial recovery 3 months after initial symptom onset. The development group provided the following options: (a) clinicians may offer oral antiviral therapy in addition to oral steroids within 72 hours of symptom onset for patients with Bell's palsy, and (b) clinicians may offer electrodiagnostic testing to Bell's palsy patients with complete facial paralysis. The development group offered the following no recommendations: (a) no recommendation can be made regarding surgical decompression for patients with Bell's palsy, (b) no recommendation can be made regarding the effect of acupuncture in patients with Bell's palsy, and (c) no recommendation can be made regarding the effect of physical therapy in patients with Bell's palsy.

The American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) has published a supplement to this issue featuring the new Clinical Practice Guideline: Bell's Palsy. To assist in implementing the guideline recommendations, this article summarizes the rationale, purpose, and key action statements. The 11 recommendations developed encourage accurate and efficient diagnosis and treatment and, when applicable, facilitate patient follow-up to address the management of long-term sequelae or evaluation of new or worsening symptoms not indicative of Bell's palsy. There are myriad treatment options for Bell's palsy; some controversy exists regarding the effectiveness of several of these options, and there are consequent variations in care. In addition, there are numerous diagnostic tests available that are used in the evaluation of patients with Bell's palsy. Many of these tests are of questionable benefit in Bell's palsy. Furthermore, while patients with Bell's palsy enter the health care system with facial paresis/paralysis as a primary complaint, not all patients with facial paresis/paralysis have Bell's palsy. It is a concern that patients with alternative underlying etiologies may be misdiagnosed or have an unnecessary delay in diagnosis. All of these quality concerns provide an important opportunity for improvement in the diagnosis and management of patients with Bell's palsy.

Program Description:Otogenic pain and aural fullness can be some of the more frustrating chief complaints to work up and address. Many patients with this complaint are frustrated with a lack of diagnosis and treatment. This leads to multiple visits in search of the answer to their affliction. In this miniseminar, a panel of experts will discuss an appropriate evaluation and workup for these issues. Discussions will highlight appropriate examinations, testing, and imaging, as well as a thorough discussion of the differential diagnoses. Also, recommendations for treatment will be discussed. Case presentations will highlight proper workup and management of these confusing cases.Educational Objectives:1) Recite likely etiologies of aural fullness and otogenic pain. 2) Recognize potentially serious etiologies of these symptoms. 3) Use appropriate workup and treatment of these symptoms and their causes.

Necrotizing (malignant) otitis externa (NOE) is a rare and invasive infection originating in the external acoustic meatus seen most commonly in diabetes and other immunocompromised states. After a protracted course, disease can smolder and extend into the mastoid, skull base, dural sinuses, and intracranially. We present a case of NOE complicated by mastoiditis, dural sinus thrombosis, and Bezold's abscess in an uncontrolled diabetic presenting with a prolonged course of facial nerve palsy. We stress the importance of maintaining a high index of clinical suspicion for NOE in diabetic patients and offering timely, aggressive treatment to mitigate its complications.

Postoperative CSF leak is an uncommon complication after cochlear implantation. The recorded incidence is 0.01%. This chapter discusses CSF leaks and gushers. Preoperative methods to assess the risk of leakage, as well as intraoperative and postoperative methods of repair, are also discussed.

Program Description: Approximately 35% of office visits in a general otolaryngologic practice are otologic in nature. Simple diagnosis such as cerumen impaction, presbycusis, or acute otitis media are very straight forward and rather easily treated. Other ear-related issues can be more challenging and may require additional office time and resources to manage. This miniseminar will discuss the otologic evaluation and management of progressive SNHL, pulsatile tinnitus, referred otalgia, unilateral middle ear effusion, and osteoradionecrosis of the EAC. While the presentation of these issues may appear benign, they may represent a more serious underlying illness. Emphasis will be placed on a detailed differential diagnosis, and appropriate testing that should be considered by the general otolaryngologist. Audience participation will be encouraged through case presentations.Educational Objectives: 1) Recognize common patient presenting complaints that can be harbingers of a more serious problem. 2) Understan...

The mismatch negativity event-related potential (MMN) was elicited in normal school-age children in response to just perceptibly different variants of the speech phoneme /da/. A significant MMN was measured in each subject tested. Child and adult MMNs were similar with respect to peak latency and duration. Measures of MMN magnitude (peak-to-peak amplitude and area) were significantly larger in children than in adults. The results of the present study indicate that the MMN can be elicited in response to minimal acoustic stimulus differences in complex speech signals in school-age children. The results support the feasibility of using the MMN as a tool in the study of deficient auditory perception in children.

The mismatch negativity (MMN) event-related potential is a non-task related neurophysiologic index of auditory discrimination. The MMN was elicited in eight cochlear implant recipients by the synthesized speech stimulus pair /da/ and /ta/. The response was remarkably similar to the MMN measured in normal-hearing individuals to the same stimuli. The results suggest that the central auditory system can process certain aspects of speech consistently, independent of whether the stimuli are processed through a normal cochlea or mediated by a cochlear prosthesis. The MMN shows promise as a measure for the objective evaluation of cochlear-implant function, and for the study of central neurophysiological processes underlying speech perception.

In individuals with severe to profound hearing loss, cochlear implants bypass normal inner ear function by applying electrical current directly into the cochlea, thereby stimulating cochlear nerve fibers. Stimulating discrete populations of spiral ganglion cells in cochlear implant users' ears is similar to the encoding of small acoustic frequency bands in a normal-hearing person's ear. Thus, spiral ganglion cells stimulated by an electrode convey the information contained by a small acoustic frequency band. Problems that refer to the current spread and subsequent nonselective stimulation of spiral ganglion cells in the cochlea are reviewed.Cochlear anatomy and tissue properties determine the current path in the cochlea. Current spreads largely via scala tympani and across turns. While most of the current leaves the cochlea via the modiolus, the facial canal and the round window constitute additional natural escape paths for the current from the cochlea. Moreover, degenerative processes change tissue resistivities and thus may affect current spread in the cochlea.Electrode design and coding strategies may result in more spatial stimulation of spiral ganglion cells, resulting in a better performance of the electrode-tissue interface.

Objectives/Hypothesis: In the present series of experiments, the effect of neural degeneration on the cochlear structure electrical resistivities was evaluated to test if it alters the current flow in the cochlea and if increased current levels are needed to stimulate the impaired cochlea. In cochlear implants, frequency information is encoded in part by stimulating discrete populations of spiral ganglion cells along the cochlea. However, electrical properties of the cochlear structures result in shunting of the current away from the auditory neurons. This consumes energy, makes cochlear implants less efficient, and drastically reduces battery life. Models of the electrically stimulated cochlea serve to make predictions on current paths using modified and improved cochlear implant electrodes. However, one of the model's shortcomings is that most of the values for tissue impedances are not direct measurements. They are derived from bulk impedance measurements, which are fitted to lumped-element models. Study Design: The four-electrode reflection–coefficient technique was used to measure resistivities in the gerbil cochlea. In vivo and in vitro (the hemicochlea) models were used. Measurements were made in normal and in deafened animals. Cochlear damage was induced by neomycin injection into the animals' middle ears. Neural degeneration was allowed to occur over 2 months before performing the measurements in the deafened animals. Results: The resistivity values in deafened animals were smaller than in the normal-hearing animals, thus altering the current flow within the cochlea. Conclusions: Resistivity changes and subsequent changes in current path should be considered in future designs of cochlear implants.

Radiosurgery, originally described by Leksell1in 1951, describes the method of focusing multiple beams of radiation on an intracranial target. Many methods can be used to deliver the radiation, regardless of its source. Leksell developed the method of using multiple fixed cobalt sources for radiation. This system was called a "gamma knife," although no incision is made. The gamma knife represents one of many methods to use stereotactically focused radiation to "treat" an intracranial target.2

A case-based, interactive format will be used to present intracranial and skull base complications related to otitis media, disorders of the external auditory canal, consequences of head and neck radiotherapy, and intracranial extension of sino-nasal polyposis. Work-up of patients for otolaryngological sources for meningitis will be included. Panelists will present cases and short didactics to address essential topics related to cost-effective and timely diagnosis and appropriate medical or surgical treatment for serious intracranial sequelae. An emphasis on identification of early warning signs and methods for avoiding complications well be queried from members of the panel and from participants in the audience. At course conclusion, participants will be able to provide or appropriately refer patients for definitive management.

Twelve patients presenting with tegmen defects and requiring surgical repair were retrospectively reviewed from 1982 to 1993. One half of the patients presented with a cerebrospinal fluid leak at some time in the course of their illness. Nine cases were considered to be acquired, secondary to previous mastoid surgery or trauma. All 9 had encephalocoeles. Three spontaneous leaks were considered congenital; 2 of these patients had encephalocoeles. This report represents a long-term follow-up of these cases, with an average follow-up of 7,6 years. Computed tomography and magnetic resonance imaging technology, as well as contrast studies, have tremendously aided in diagnosis and planning of surgical repair. Nine repairs were done through a dual transmastoid and middle fossa approach, with the other 3 done via a transmastoid approach only. We favored temporalis muscle flaps and temporalis fascia over synthetic materials for defect repairs. The long-term results and complications are discussed.