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PURPOSE: For patients without pathologic evidence of cervical disease after neck dissection for cutaneous squamous cell carcinoma involving the parotid region, inclusion of the ipsilateral cervical neck in the postparotidectomy radiation volume is routinely performed. We report our experience with selective avoidance of the ipsilateral neck for patients undergoing postoperative radiation to the parotid bed. METHODS AND MATERIALS: From January 2014 to December 2023, a total of 30 consecutive patients underwent postoperative radiation after parotidectomy for cutaneous squamous cell carcinoma involving the parotid area. All patients had previously had a neck dissection confirming pathologic N0 disease. Treatment was delivered using intensity modulated radiation therapy to a median dose of 60 Gy (range, 56-66 Gy). The radiation target volumes included the parotid bed only, with deliberate avoidance of the ipsilateral cervical neck. The median pathologic tumor size of the parotid tumor was 3.3 cm (range, 0.2-9.4 cm). Final pathologic evaluation showed positive microscopic margins in 8 patients (27%), perineural invasion in 17 patients (57%), and facial nerve involvement in 6 patients (20%). RESULTS: There were no isolated nodal failures. One patient developed an ipsilateral neck recurrence approximately 8 months after completion of radiation therapy. This occurred 2 months subsequent to the development of local recurrence. The 5-year actuarial rates of local (parotid) control, neck control, and overall survival were 87%, 97%, and 76%, respectively. CONCLUSIONS: Omission of the ipsilateral neck from the parotid volume does not compromise disease control for pathologically N0 patients undergoing postoperative radiation for cutaneous squamous cell carcinoma involving the parotid region. Practical implications are discussed.

This systematic review and meta-analysis investigates the objective evidence regarding outcomes in head and neck free flap surgeries using vasoactive agents in the perioperative period. A search was performed in PubMed, Cochrane, Web of Science, and Scopus databases. Inclusion criteria were clinical studies in which vasopressors were used in head and neck free flap surgery during the intraoperative and perioperative period. Eighteen studies (n = 5397) were included in the qualitative analysis and nine (n = 4381) in the meta-analysis. There was no difference in flap failure outcomes with perioperative vasopressor use in head and neck free flap surgery (n = 4015, OR = 0.93, 95% CI [0.60, 1.44]). When patients received vasopressors perioperatively, there was an associated decrease in flap-specific complications (n = 3881, OR = 0.69, 95% CI [0.55, 0.87]). Intraoperative vasopressor use does not negatively impact free tissue transfer outcomes in head and neck surgery and may reduce overall free flap complications.

OBJECTIVES: To evaluate the influence of facility case-volume on survival in patients with locally advanced papillary thyroid cancer (PTC), and to identify prognostic case-volume thresholds for facilities managing this patient population. STUDY DESIGN: Retrospective database study. METHODS: The 2004-2017 National Cancer Database was queried for patients receiving definitive surgery for locally advanced PTC. Using K-means clustering and multivariable Cox proportional-hazards (CPH) regression, two groups with distinct spectrums of facility case-volumes were generated. Multivariable CPH regression and Kaplan-Meier analysis assessed for the influence of facility case-volume and the prognostic value of its stratification on overall survival (OS). RESULTS: Of 48,899 patients treated at 1304 facilities, there were 34,312 (70.2%) females and the mean age was 48.0 ± 16.0 years. Increased facility volume was significantly associated with reduced all-cause mortality (HR 0.996; 95% CI, 0.992-0.999; p = 0.008). Five facility clusters were generated, from which two distinct cohorts were identified: low (LVF;

OBJECTIVE: To explore if antiplatelet or anticoagulant therapy increases the risk of transfusion requirement or postoperative hematoma formation in patients undergoing microvascular reconstruction for head and neck defects. STUDY DESIGN: Retrospective cohort study. SETTING: Departments of Otolaryngology-Head and Neck Surgery at the University of Alabama at Birmingham, the University of Colorado, and the University of California Irvine. METHODS: A multi-institutional, retrospective review on microvascular reconstruction of the head and neck between August 2013 to July 2021. Perioperative antithrombotic data were collected to examine predictors of postoperative transfusion and hematoma. RESULTS: A total of 843 free flaps were performed. Preoperative hemoglobin, hematocrit, operative time, and flap type were positive predictors of postoperative transfusion in both bivariate (P

OBJECTIVE: To evaluate the prognostic strengths of American Joint Committee on Cancer (AJCC) staging and American Thyroid Association (ATA) risk classification in well-differentiated thyroid cancer (DTC), and their implications in guiding medical decision-making and epidemiological study designs. METHODS: The 2004-2017 National Cancer Database was queried for DTC patients. Cox proportional hazards (CPH) and Kaplan-Meier analyses modeled patient mortality and overall survival, respectively. Each CPH model was evaluated by its concordance index, measure of explained randomness (MER), Akaike information criterion (AIC), and area under receiver operating characteristic curve (AUC). RESULTS: Overall, 134,226 patients were analyzed, with an average age of 48.1 ± 15.1 years (76.9% female). Univariate CPH models using AJCC staging demonstrated higher concordance indices, MERs, and AUCs than those using ATA risk classification (all p

BackgroundWhile female head and neck surgeons have made significant contributions to the field, women's achievements in scientific communication have traditionally been underreported.MethodsA search of high-impact journals in the field of head and neck surgery was performed in the Elsevier's Scopus database to identify the top 100 most-cited articles.ResultsThe top 100 most-cited articles (during the span of 1953 and 2016) had the highest total number of citations between 2005 and 2009. Women accounted for 36% of first authors and 25% of corresponding authors. Change in the relative number of first female authors in these top 100 articles did not increase significantly between 1950 and 2019.ConclusionThe proportion of female first authors in head and neck surgery has not significantly increased over the past several decades, despite greater numbers of female trainees. Our findings support the need for additional research on female representation in head and neck surgery.

ObjectiveTo review overall survival (OS), recurrence patterns, and prognostic factors of de novo sinonasal squamous cell carcinoma (DN-SCC).Data sourcesPubMed, Scopus, OVID Medline, and Cochrane databases from 2006 to December 23, 2020.Review methodsThe study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Articles were required to report either recurrence patterns or survival outcomes of adults with DN-SCC. Case reports, books, reviews, meta-analyses, and database studies were all excluded.ResultsForty-one studies reported on survival or recurrence outcomes. The aggregate 5-year OS was 54.5% (range, 18%-75%) from 35 studies (n = 1903). Patients undergoing open surgery were more likely to receive radiation therapy and present at an advanced stage compared to those receiving endoscopic surgery (all P < .001). Advanced T stage, presence of cervical nodal metastases, maxillary sinus primary site, and negative human papillomavirus (HPV) status were all correlated with significantly worse 5-year OS. Direct meta-analysis of 8 studies demonstrated patients with surgery were more likely to be alive at 5 years compared to those who did not receive surgery (odds ratio, 2.26; 95% CI, 1.48-3.47; P < .001). Recurrence was reported in 628 of 1471 patients from 26 studies (42.7%) with an aggregate 5-year locoregional control rate of 67.1% (range, 50.4%-93.3%).ConclusionThis systematic review and meta-analysis suggests that the 5-year OS rate for DN-SCC may approach 54.5% and recurrence rate approaches 42.7%. In addition, various tumor characteristics including advanced T stage, positive nodal status, maxillary sinus origin, and negative HPV status are all associated with decreased survival.

BackgroundThis study evaluates the influence of facility case-volume on nasopharyngeal carcinoma (NPC) treatments and overall survival (OS).MethodsThe 2004-2015 National Cancer Database was queried for patients with NPC receiving definitive treatment.ResultsA total of 8260 patients (5-year OS: 63.4%) were included. The 1114 unique facilities were categorized into 854 low-volume (treating 1-8 patients), 200 intermediate-volume (treating 9-23 patients), and 60 high-volume (treating 24-187 patients) facilities. Kaplan-Meier log-rank analysis demonstrated significantly improved OS with high-volume facilities (p

ObjectiveTo review overall survival (OS), recurrence patterns, and prognostic factors of de novo sinonasal squamous cell carcinoma (DN-SCC).Data sourcesPubMed, Scopus, OVID Medline, and Cochrane databases from 2006 to December 23, 2020.Review methodsThe study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Articles were required to report either recurrence patterns or survival outcomes of adults with DN-SCC. Case reports, books, reviews, meta-analyses, and database studies were all excluded.ResultsForty-one studies reported on survival or recurrence outcomes. The aggregate 5-year OS was 54.5% (range, 18%-75%) from 35 studies (n = 1903). Patients undergoing open surgery were more likely to receive radiation therapy and present at an advanced stage compared to those receiving endoscopic surgery (all P < .001). Advanced T stage, presence of cervical nodal metastases, maxillary sinus primary site, and negative human papillomavirus (HPV) status were all correlated with significantly worse 5-year OS. Direct meta-analysis of 8 studies demonstrated patients with surgery were more likely to be alive at 5 years compared to those who did not receive surgery (odds ratio, 2.26; 95% CI, 1.48-3.47; P < .001). Recurrence was reported in 628 of 1471 patients from 26 studies (42.7%) with an aggregate 5-year locoregional control rate of 67.1% (range, 50.4%-93.3%).ConclusionThis systematic review and meta-analysis suggests that the 5-year OS rate for DN-SCC may approach 54.5% and recurrence rate approaches 42.7%. In addition, various tumor characteristics including advanced T stage, positive nodal status, maxillary sinus origin, and negative HPV status are all associated with decreased survival.

BackgroundThis study develops machine learning (ML) algorithms that use preoperative-only features to predict discharge-to-nonhome-facility (DNHF) and length-of-stay (LOS) following complex head and neck surgeries.MethodsPatients undergoing laryngectomy or composite tissue excision followed by free tissue transfer were extracted from the 2005 to 2017 NSQIP database.ResultsAmong the 2786 included patients, DNHF and mean LOS were 421 (15.1%) and 11.7 ± 8.8 days. Four classification models for predicting DNHF with high specificities (range, 0.80-0.84) were developed. The generalized linear and gradient boosting machine models performed best with receiver operating characteristic (ROC), accuracy, and negative predictive value (NPV) of 0.72-0.73, 0.75-0.76, and 0.88-0.89. Four regression models for predicting LOS in days were developed, where all performed similarly with mean absolute error and root mean-squared errors of 3.95-3.98 and 5.14-5.16. Both models were developed into an encrypted web-based interface: https://uci-ent.shinyapps.io/head-neck/.ConclusionNovel and proof-of-concept ML models to predict DNHF and LOS were developed and published as web-based interfaces.

Purpose: To report a single‐institutional experience with hypofractionated radiation therapy alone for human papillomavirus (HPV)‐positive oropharyngeal cancer. Methods and materials: A total of 101 consecutive patients were treated by radiation therapy alone using a regimen of 66 Gy in 30 fractions (60 patients) or 70 Gy in 33 fractions (41 patients) for newly diagnosed p16‐positive squamous cell carcinoma of the oropharynx. Sixty‐seven patients (67%) were never smokers. Results: The 3‐year actuarial rates of overall survival, local‐regional control, and progression‐free survival were 94%, 93%, and 89%, respectively. Among never‐smokers, the 3‐year rates of overall survival and local–regional control were 98% and 100%, respectively. The grade 3+ acute toxicity rate was 21%, with the most commonly observed side effects related to mucositis. Conclusion: Hypofractionated radiation alone resulted in excellent outcomes for patients with HPV‐positive oropharyngeal cancer. A prospective clinical trial investigating this modality in the setting of de‐escalation is currently underway. [ABSTRACT FROM AUTHOR]

Objective:To evaluate the change in quality of life (QOL) of patients with Meniere's disease (MD) after treatment with migraine prophylaxis therapy.Methods:Patients with definite MD were given the Meniere's Disease Outcomes Questionnaire-Retrospective (MDOQ-R) after migraine prophylactic therapy to assess QOL. Changes in physical, emotional, and social parameters affected by MD were calculated, along with a global pre- and posttreatment QOL scores.Results:The MDOQ-R was given to 27 consecutive patients with definite MD. Patients who had at least an 18-month follow-up were included, resulting in 25 questionnaires. The mean change in QOL score was 25 ± 16 (range, -3 to 55), P = .02. Quality of life was improved in 23 (92%) of the respondents in every metric measured, unchanged in 1 (4%), and poorer in 1 (4%) of patients after migraine prophylaxis treatment.Conclusions:Majority of MD patients who had all failed diuretic therapy responded positively to medications used for migraine prophylaxis, as indicated by a significant improvement in QOL. This study may further suggest a correlation between the pathophysiologic basis of disease in MD and vestibular migraine. Patients with MD may be successfully managed with medications intended to treat migraine.

OBJECTIVES/HYPOTHESIS:Laryngeal muscles (LMs) are controlled by the recurrent laryngeal nerve (RLN), injury of which can result in vocal fold (VF) paralysis (VFP). We aimed to introduce a bioelectric approach to selective stimulation of LMs and graded muscle contraction responses. STUDY DESIGN:Acute experiments in cats. METHODS:The study included six anesthetized cats. In four cats, a multichannel penetrating microelectrode array (MEA) was placed into an uninjured RLN. For RLN injury experiments, one cat received a standardized hemostat-crush injury, and one cat received a transection-reapproximation injury 4 months prior to testing. In each experiment, three LMs (thyroarytenoid, posterior cricoarytenoid, and cricothyroid muscles) were monitored with an electromyographic (EMG) nerve integrity monitoring system. Electrical current pulses were delivered to each stimulating channel individually. Elicited EMG voltage outputs were recorded for each muscle. Direct videolaryngoscopy was performed for visualization of VF movement. RESULTS:Stimulation through individual channels led to selective activation of restricted nerve populations, resulting in selective contraction of individual LMs. Increasing current levels resulted in rising EMG voltage responses. Typically, activation of individual muscles was successfully achieved via single placement of the MEA by selection of appropriate stimulation channels. VF abduction was predominantly observed on videolaryngoscopy. Nerve histology confirmed injury in cases of RLN crush and transection experiments. CONCLUSIONS:We demonstrated the ability of a penetrating MEA to selectively stimulate restricted fiber populations within the feline RLN and selectively elicit contractions of discrete LMs in both acute and injury-model experiments, suggesting a potential role for intraneural MEA implantation in VFP management. LEVEL OF EVIDENCE:NA. Laryngoscope, 128:1606-1614, 2018.

BackgroundOptimal antibiotic prophylaxis duration in head and neck clean-contaminated free-flap cases is unknown.MethodsA systematic review/meta-analysis was conducted using PubMed/MEDLINE, Cochrane Library, Web-of-Science, and Scopus databases.ResultsOf the 3755 searched articles, 5 articles were included for a total of 861 patients. The recipient surgical site infection risk was significantly higher in patients receiving prophylactic antibiotics for ≤24 hours compared to >24 hours (relative risk [RR] 1.56; 95% confidence interval [CI] 1.13-2.14). In the post hoc multivariate analysis based on available individual-level data on 697 patients from 3 studies, the risk of surgical site infection for ≤24 hours versus >24 hours was not significant after adjusting for antibiotic type (RR 1.09; 95% CI 0.78-1.55). When compared to ampicillin-sulbactam, patients who received clindamycin prophylaxis had an increased likelihood of recipient surgical site infection (RR 2.85; 95% CI 1.95-4.17).ConclusionLess than or equal to 24 hours of antibiotic prophylaxis in head and neck clean-contaminated free-flap is likely sufficient but a strong conclusion remains elusive. Clindamycin prophylaxis increases the risk of recipient surgical site infection. Further prospective trials are necessary to clarify.

In this case series, we set out to describe the clinical entity of isolated, prolonged aural fullness (AF) and its relationship with migraine. Patients with isolated, persistent AF for 6 months or more were included with all possible etiologies ruled out. Migraine dietary and lifestyle changes and medical migraine prophylactic therapy were prescribed to all. Eleven patients were included (mean age, 52 years). Six (54%) patients fulfilled International Headache Society criteria for migraine with or without aura. Changes in perceived sensation of AF using the visual analog scale and quality of life questionnaires resulted in a statically significant improvement ( P < .001, 95% confidence interval [CI], 4.7 to 6.72, and P < .001, 95% CI, -5.3 to -2.7, respectively). As such, an improvement of isolated, prolonged AF with migraine lifestyle changes and prophylactic treatment may suggest an etiological association between migraine and prolonged aural fullness.

ObjectiveTo report findings from a cohort of vestibular schwannoma (VS) patients presenting with vertigo from a secondary comorbid vestibular disorder; and to discuss management strategies for this subset of patients presenting with both episodic vertigo and VS.PatientsAll VS patients who presented with vertigo as the primary symptom from 2012 to 2015 and endorsing no other major complaints were examined.InterventionTreatment with migraine lifestyle and prophylactic therapy, or Epley maneuver.Main outcome measureResolution of vertigo following medical treatment alone.ResultsOf the nine patients studied, seven (78%) suffered from vestibular migraine, and two (22%) experienced benign positional vertigo. All patients experienced complete resolution of symptoms after treatment. As a result of symptomatic improvement, seven patients (78%) avoided surgery in favor of observation, while two patients (22%) underwent radiosurgery due to continued tumor growth and other nonvertigo symptoms.ConclusionVS patients can sometimes present with a history of recurrent episodic vertigo. The etiology of the vertigo could be due to the tumor itself or may be due to an underlying comorbidity such as vestibular migraine or benign positional vertigo. VS patients presenting with vertigo should undergo a standard vertigo history and examination to identify other potential causes of vertigo. Most VS patients in our cohort avoided intervention and had resolution of their vertigo.

ObjectiveTo describe persistent post-stapedotomy vertigo (PSV) and its treatment using migraine prophylaxis.PatientsA retrospective review of all patients with persistent PSV spanning 10 years at a tertiary academic hospital was performed. Patients who experienced persistent vertigo for a minimum of 3 months after surgery were included. Those with possible perilymph fistula, long prosthesis, and benign paroxysmal positional vertigo were excluded.InterventionsAll patients received instructions on migraine dietary and lifestyle changes and Vitamin B2 and magnesium. In addition, prophylactic treatment with nortriptyline, verapamil, or a combination thereof was started.Main outcome measureChanges in vertigo frequency was the main outcome variable. The secondary outcome variables included the time period and medications necessary to achieve symptomatic resolution.ResultsFour women and one man with an average age of 53 years were identified that met criteria for persistent PSV indicating an incidence of 0.9% at our institution. The onset of vertigo symptoms was on average 20 days postoperatively. All five patients had daily vertigo episodes and experienced complete resolution with no vertigo episodes after treatment. Symptomatic resolution was achieved over an average of 9 weeks after initiating treatments.ConclusionsPersistent PSV beyond 3 months is a rare occurrence and its treatment can be challenging when there is no evidence of an underlying pathology. This subset of patients may be suffering from migraine, which was triggered postoperatively. Treatment with migraine prophylaxis in this cohort of patients may result in resolution of vertigo.

ObjectivesTo determine the effectiveness of a customized sound therapy and compare its effectiveness to that of masking with broadband noise.MethodsSubjects were randomized to receive either customized sound therapy or broadband noise for 2 hours per day for 3 months and then switched to the other treatment after a washout period. The outcome variables were tinnitus loudness (scored 0-10), Tinnitus Handicap Inventory (THI), Beck Anxiety Inventory (BAI), minimum masking levels (MML), and residual inhibition (RI).ResultsEighteen subjects completed the study. Mean age was 53 ± 11 years, and mean tinnitus duration was 118 ± 99 months. With customized sound therapy, mean loudness decreased from 6.4 ± 2.0 to 4.9 ± 1.9 ( P = .001), mean THI decreased from 42.8 ± 21.6 to 31.5 ± 20.3 ( P < .001), mean BAI decreased from 10.6 ± 10.9 to 8.3 ± 9.9 ( P = .01), and MML decreased from 22.3 ± 11.6 dB SL to 17.2 ± 10.6 dB SL ( P = .005). After 3 months of broadband noise therapy, only BAI and, to a lesser degree, MML decreased ( P = .003 and .04, respectively).ConclusionsCustomized sound therapy can decrease the loudness and THI scores of tinnitus patients, and the results may be superior to broadband noise.

BackgroundOur group has previously shown that activation of specific facial nerve (FN) fiber populations and selective activation of facial musculature can be achieved through acute intraneural multichannel microelectrode array (MEA) implantation in the feline model.HypothesisSelective stimulation of facial muscles will be maintained in the setting of 1) chronic and 2) acute MEA implantation after FN injury and subsequent recovery.MethodsThis study included seven cats. In three cats with normal facial function, 4-channel penetrating MEAs were implanted chronically in the FN and tested biweekly for 6 months. Electrical current pulses were delivered to each channel individually, and elicited electromyographic (EMG) voltage outputs were recorded for each of several facial muscles. For FN injury experiments, two cats received a standardized hemostat-crush injury, and two cats received a transection-reapproximation injury to the FN main trunk. These four underwent acute implantation of MEA and EMG recording in terminal experiments 4 months postinjury.ResultsStimulation through individual channels selectively activated restricted nerve populations, resulting in activation of individual muscles in cats with chronic MEA implantation and after nerve injury. Increasing stimulation current levels resulted in increasing EMG voltage responses in all patients. Nerve histology showed only minor neural tissue reaction to the implant.ConclusionWe have established in the animal model the ability of a chronically implanted MEA to selectively stimulate restricted FN fiber populations and elicit activations in specific facial muscles. Likewise, after FN injury, selective stimulation of restricted FN fiber populations and subsequent activation of discrete facial muscles can be achieved after acute MEA implantation.

A modified lateral temporal bone resection (mLTBR) is a unique technique that spares the tympanic membrane (TM) and ossicles in select patients with squamous cell carcinoma (SCCa). The records of 5 patients with SCCa of the temporal bone with negative frozen-section biopsy at the tympanic annulus were reviewed. The mean follow-up time for the patients was 29.2 months. One patient received postoperative radiation due to cervical nodal extracapsular spread. All patients were recurrence free as of the most recent follow-up (range, 8-50 months). Postoperative audiometry demonstrated an average conductive hearing loss of 9 dB (range, 0-17 dB). The mLTBR with sparing of the TM can be an effective alternative to the traditional lateral temporal bone resection (LTBR) with better hearing results for patients with SCCa involving the bony external auditory canal. In the short term, oncologic results of mLTBR appear equivalent to the LTBR. However, long-term follow-up is needed for >5-year outcomes.

Objectives/hypothesisTo evaluate the variability and discrepancies among the most commonly prescribed ear drops sold at pharmacies in southern California.Study designProspective study evaluating 11 commonly used ear drops to treat otologic disorders.MethodsRandomly selected drug stores in three major counties in Southern California (Los Angeles, Orange, and San Diego) were included. Mean, range, minimum, and maximum prices for each drug were calculated and analyzed. The median income of pharmacy ZIP code was also cross-referenced.ResultsData were collected from 108 pharmacies. The mean prices are noted for each of the individual drugs: Cortisporin (brand) 10 mL, $82.70; neomycin, polymyxin B sulfates, and hydrocortisone (Cortisporin-generic) 10 mL, $34.70; ofloxacin (generic) 10 mL, $99.95; sulfacetamide (generic) 15 mL, $40.18; Ciprodex (brand) 7.5 mL, $194.44; Cipro HC (brand) 10 mL, $233.32; Vosol (brand) 15 mL, $120.75; acetic acid (Vosol-generic) 10 mL, $116.55; VosolHC (brand) 10 mL, $204.14; acetic acid/aluminum acetate (Domeboro-generic) 60 mL, $22.91; and Tobradex (brand) 5 mL, $166.47.ConclusionsThere is significant variability among the prices of ear drops across Southern Californian pharmacies, which can be a financial burden to patients paying out of pocket or with high deductibles. A state-mandated, publically accessible report of drug prices may help decrease variability and cost by promoting competition among pharmacies. Price negotiations by governmental payers may assist in reducing prices. In the treatment of otologic disorders, clinicians can help reduce costs for patients by prescribing generic ear drop medications and cheaper alternatives when clinically appropriate.Level of evidence4. Laryngoscope, 127:1780-1784, 2017.

ObjectiveMal de debarquement syndrome (MdDS) is a balance disorder that typically starts after an extended exposure to passive motion, such as a boat or plane ride. Management is typically supportive (e.g. physical therapy), and symptoms that persist beyond 6 months have been described as unlikely to remit. This study was conducted to evaluate the response of patients with MdDS to management with migraine prophylaxis, including lifestyle changes and medical therapy.Study designProspective review.SettingAmbulatory setting at a tertiary care medical center.MethodsClinical history, detailed questionnaires, and audiograms were used to diagnose patients with MdDS. Those patients with the diagnosis of the MdDS were placed on our institutional vestibular migraine management protocol. Treatment response was assessed with a quality-of-life (QOL) survey and visual analog scale.ResultsFifteen patients were diagnosed with MdDS, with a predominance of females (73%) and a mean age of 50 ± 13 years. Eleven patients (73%) responded well to management with a vestibular migraine protocol, which included lifestyle changes, as well as pharmacotherapy with verapamil, nortriptyline, topiramate, or a combination thereof. In comparison, a retrospective control group of 17 patients demonstrated a lower rate of improvement when treated with vestibular rehabilitation and physical therapy.ConclusionManagement of MdDS as vestibular migraine can improve patients' symptoms and increase the QOL. Nearly all the patients suffering from MdDS had a personal or family history of migraine headaches or had signs or symptoms suggestive of atypical migraine.Level of evidence4 Laryngoscope, 127:1670-1675, 2017.

Objective The implementation of a universal surgical safety protocol in 2004 was intended to minimize the prevalence of wrong-site surgery (WSS). However, complete elimination of WSS in the operating room continues to be a challenge. The purpose of this study is to evaluate the prevalence and etiology of WSS in the state of California. Study Design A retrospective study of all WSS reports investigated by the California Department of Public Health between 2007 and 2014. Methods Prevalence of overall and specialty-specific WSS, causative factors, and recommendations on further improvement are discussed. Results A total of 95 cases resulted in incident reports to the California Department of Public Health and were included in our study. The most common errors were operating on the wrong side of the patient's body (n = 60, 62%), performing the wrong procedure (n = 21, 21%), operating on the wrong body part (n = 12, 12%), and operating on the wrong patient (n = 2, 2%). WSS was most prevalent in orthopedic surgery (n = 33, 35%), followed by general surgery (n = 26, 27%) and neurosurgery (n = 16, 17%). All 3 otolaryngology WSS cases in California are associated with the ear. Conclusion WSS continues to surface despite national efforts to decrease its prevalence. Future research could establish best practices to avoid these "never events" in otolaryngology and other surgical specialties.

Objective To examine the relationship between the prescribed target dose and the dose to healthy neurovascular structures in patients with vestibular schwannomas treated with stereotactic radiosurgery (SRS). Study Design Case series with chart review. Setting SRS center from 2011 to 2013. Subjects Twenty patients with vestibular schwannomas treated at the center from 2011 to 2013. Methods Twenty patients with vestibular schwannomas were included. The average radiation dose delivered to healthy neurovascular structures (eg, carotid artery, basilar artery, facial nerve, trigeminal nerve, and cochlea) was analyzed. Results Twenty patients with vestibular schwannomas who were treated with fused computed tomography/magnetic resonance imaging-guided SRS were included in the study. The prescribed dose ranged from 10.58 to 17.40 Gy over 1 to 3 hypofractions to cover 95% of the target tumor volume. The mean dose to the carotid artery was 5.66 Gy (95% confidence interval [CI], 4.53-6.80 Gy), anterior inferior cerebellar artery was 8.70 Gy (95% CI, 4.54-12.86 Gy), intratemporal facial nerve was 3.76 Gy (95% CI, 3.04-4.08 Gy), trigeminal nerve was 5.21 Gy (95% CI, 3.31-7.11 Gy), and the cochlea was 8.70 Gy (95% CI, 7.81-9.59 Gy). Conclusions SRS for certain vestibular schwannomas can expose the anterior inferior cerebellar artery (AICA) and carotid artery to radiation doses that can potentially initiate atherosclerotic processes. The higher doses to the AICA and carotid artery correlated with increasing tumor volume. The dose delivered to other structures such as the cochlea and intratemporal facial nerve appears to be lower and much less likely to cause immediate complications when shielded.

Objectives/hypothesisTo develop a novel completely-in-the-canal device capable of directly driving the tympanic membrane (TM) and ossicular chain from the ear canal.Study designDevelopment and feasibility study.MethodsA voice coil actuator design was developed to drive the TM. Bench testing of the device using laser Doppler vibrometry (LDV) and sound recording was performed. Temporal bone studies using LDV were performed using different designs of the contact tip-TM interface to find the most efficient method of sound transmission. Two short-term clinical performance studies were performed using the latest 3-mm-wide device. Comparison was made to natural sound and to the Vibrant SoundBridge floating mass transducer simulator.ResultsOn bench testing, the device was found to have a low (

IntroductionPhysicians in the ambulatory setting face challenges in adequately educating patients in a brief office encounter.ObjectiveTo evaluate the efficacy of an iPad-based interactive educational module (iBook) in various otologic pathologies.MethodsPatients presenting with symptoms of tinnitus, dizziness, hearing loss, or cochlear implant evaluation were included. In total, 44 patients received the iBook and 22 patients served as controls. Prior to viewing the iBook, patients completed a pre-survey to assess baseline knowledge. After viewing the iBook, patients completed a post-survey to assess changes in perception and knowledge of their disease. Results were compared to that of the control group who did not receive iBook supplementation prior to being seen by the physician.ResultsPaired t-test analysis showed significant improvements (p

Objective A smartphone-enabled otoscope (SEO) can capture tympanic membrane (TM) images. We sought to compare a SEO to microscopic otoscopy in the detection and evaluation of TM pathology in an otology/neurotology practice. Study Design Prospective single-site study in adults presenting over a 3-month period. Setting Neurotology clinic within a tertiary care academic medical center. Subjects and Methods Following consent, 57 patients underwent a medical and microscopic ear examination. Afterward, clinicians photographed bilateral TMs using a SEO. A second "blinded" neurotologist received a SEO-acquired image of each TM and a brief patient history. Our primary end point was identification of TM pathology (or lack thereof) and the blinded neurotologists' corresponding diagnosis. Secondary end points included patient-reported SEO comfort levels. Results A single SEO-acquired TM image and brief patient history resulted in correct diagnosis of 96% (23/24) of normal TMs and identification of 100% (33/33) of microscope-confirmed abnormal TMs. When pathology was identified by the "blinded" physician, the diagnosis was identical to that made by the primary treating physician 82% (27/33) of the time. On patient surveys, 93% (53/57) of patients felt "very comfortable" with SEO utilization, and 88% (50/57) reported viewing acquired images was "very useful" in understanding their condition. Conclusion A SEO is 96% specific in identifying normal TMs and 100% sensitive in identifying pathology. Its 97% positive predictive value and small false-positive rate makes it a useful screening tool. Furthermore, patients are receptive to this technology and felt comfortable with its utilization in a health care or possible telemedicine setting.

Background: We analyzed online rating scores and comments of head and neck surgeons to understand factors that contribute to higher ratings. Methods: Numerical ratings and comments for American Head and Neck Society physicians were extracted from Healthgrades, Vitals, RateMDs, and Yelp, with narrative comments categorized based on content. Physician practice location, education, and residency training were also compiled. Results: Patient ratings were significantly higher with supportive staff and affable physician demeanor but showed significant drops with longer wait times and difficulties scheduling appointments or follow‐ups. Physician education and postgraduate training did not significantly affect ratings. Conclusion: Online ratings and comments correlated to modifiable factors in clinical practice and may be informative in understanding patient needs. [ABSTRACT FROM AUTHOR]

ImportanceIn the current health care era, many medical practices are transitioning to a new electronic health record system. Until now, there has been little information published on the association between electronic medical record (EMR) use and otolaryngologist productivity in the ambulatory setting.ObjectiveTo examine the association between transitioning to an EMR system and physician productivity in otolaryngology.Design, setting, and participantsObservational study at a tertiary care academic ambulatory center. Participants were 5 full-time otolaryngologists in practice, among whom a retrospective analysis of physician productivity was performed from May 5, 2013, through April 30, 2015.Main outcomes and measuresWe examined 5 practicing otolaryngologists for 24 months (12 months before and 12 months after transitioning to a new EMR system). Physician productivity was measured using the mean work relative value units (wRVUs) and the mean number of clinic visits. Each practitioner, with his wRVUs and clinic visit volume, was compared before and after implementation of the EMR system. The overall change in wRVUs and clinic visit volume was measured. The mean time spent after a full clinic day editing documentation before and after implementation of the EMR system for each practitioner was also recorded.ResultsAmong all 5 practitioners (age range, 38-51 years), the monthly wRVUs decreased from a mean of 334 before EMR implementation to a mean of 284 after EMR implementation, with an absolute difference of 50 (95% CI, 6-85). The monthly clinic visit volume decreased from a mean of 132 to 121, with an absolute difference of 11 (95% CI, 0-18). When examined individually, only 1 physician had a significant decrease in wRVUs. The remainder of the physicians did not demonstrate a significant change in wRVUs or clinic visit volume. On average, the physicians spent 2.1 hours after clinic reviewing and editing documentation before the transition to the EMR system and 1.9 hours after the transition.Conclusions and relevanceTransitioning to an EMR system in an ambulatory otolaryngology tertiary care setting slightly decreased physician productivity as measured by wRVUs and clinic visit volume in the 12-month period after implementation in an incentivized compensation system.

Split-thickness skin graft (STSG) continues to be the preferred means of external auditory canal (EAC) reconstruction. We thus sought to describe our experience using skin from the posterior aspect of the auricle (SPAA) as a donor site in EAC reconstruction. Grafts were, on average, 5 × 10 mm in size and obtained with a No. 10 blade after tumescence injection. The cases of 39 patients who underwent 41 procedures were retrospectively reviewed. Of the 38 patients with both 3- and 6-month follow-ups, no postoperative stenosis or bony exposure occurred. STSG from the SPAA can be a good option in EAC reconstruction. Total EAC/tympanic membrane coverage can be obtained with STSG from the SPAA.

ObjectiveTo describe a novel approach for excision of exostoses and evaluate the outcomes of transcanal excision of exostoses using ultrasonic serrated knife-assistance versus microosteotomes only.Study designRetrospective analysis.SettingAcademic Tertiary Care Center.Patients/interventionsPatients receiving a transcanal excision of exostoses between 2007 and 2016.Main outcome measuresThe outcomes and postoperative complications of 138 patients who received transcanal microosteotome only technique were compared to 10 patients who received transcanal excision of exostoses using ultrasonic serrated knife-assistance (Stryker Corporation, Kalamazoo, MI).ResultsA total of 175 ears in 128 patients underwent a transcanal microosteotome only technique. Of these, 11 (6.3%) developed an intraoperative tympanic membrane perforation. One developed anterior canal mobilization requiring prolonged (3 wk) packing. One hundred thirty-five ears (77%) were well healed by the 3-week postoperative visit. All but one ear was well healed by the 6-week visit. In comparison, 11 ears in 10 patients were treated for exostoses using a transcanal approach with the use of ultrasonic serrated knife and microosteotomes. One ear canal (the first in the series) was not well healed by the 3-week postoperative visit due to suspected thermal injury. All patients had well-healed ear canals by 6 weeks, and there were no complications.ConclusionThis is the first series to report the use of an ultrasonic serrated knife in the transcanal excision of exostoses. When compared with a transcanal microosteotome only excision of exostoses, the addition of the Sonopet seems to result in a similarly low complication rate. Sonopet can allow for more controlled transcanal excision of broad-based exostoses in patients with severe obstruction.

ObjectiveTo investigate the 30-day postoperative complication, readmission, and reoperation rates following surgery for cerebellopontine angle (CPA) schwannomas.Study designCross-sectional analysis.SettingNational surgical quality improvement program dataset (NSQIP) 2009 through 2013.PatientsAll surgical cases with an International Classification of Diseases, 9th edition, Clinical Modification (ICD-9-CM) diagnosis code of 225.1, benign neoplasms of cranial nerves, and one of the following current procedural terminology (CPT) codes, were included: 61616, 61526, 61530, and 61520.Intervention(s)Surgical resection as indicated by the CPT codes above.Main outcome measure(s)Demographics, comorbidities, 30-day postoperative complications, readmission rate, and reoperation rate.ResultsOverall, 404 cases were identified, of which 42.6% were men. The average age was 51 years. Comorbidities were present in 45.3%. NSQIP-tracked complications occurred in 9.7% of patients. Most common complications were wound infections including surgical-site infection and wound dehiscence (11 patients, 2.7%), sepsis (10 patients, 2.5%), blood loss (nine patients, 2.2%), and deep vein thrombosis (DVT; seven patients, 1.7%). Mortality occurred in four patients (1.0%). The complication rate was statistically higher in patients with comorbidities versus those without (10.2% versus 4.1%, p = 0.04). Patients with complications were more likely to undergo reoperation (2.5% with versus 4.1% without, p = 0.001). Unplanned readmissions occurred in 41 cases (10.1%) and reoperations occurred in 23 patients (5.7%).ConclusionsMost common NSQIP-tracked complications in excision of CPA neoplasms are infections, sepsis, blood loss, and deep vein thrombosis (DVT). Further, investigation of patients with unplanned readmission and reoperation are warranted. Neurotologists need to take an active role in the data to be gathered in the NSQIP database as it relates to vestibular schwannomas.

Background : When properly utilized, artificial intelligence generated content (AIGC) may improve virtually every aspect of research, from data gathering to synthesis. Nevertheless, when used inappropriately, the use of AIGC may lead to the dissemination of inaccurate information and introduce potential ethical concerns. Research Design : Cross-sectional. Study Sample: 65 top surgical journals. Data Collection: Each journals submission guidelines and portal was queried for guidelines regarding AIGC use. Results : We found that, in July 2023, 60% of the top 65 surgical journals had introduced guidelines for use, with more surgical journals (68%) introducing guidelines than surgical subspecialty journals (52.5%), including otolaryngology (40%). Furthermore, of the 39 with guidelines, only 69.2% gave specific use guidelines. No included journal, at the time of analysis, explicitly disallowed AIGC use. Conclusions : Altogether, this data suggests that while many journals have quickly reacted to AIGC usage, the quality of such guidelines is still variable. This should be pre-emptively addressed within academia. [ABSTRACT FROM AUTHOR]

Objectives: As research in otolaryngology continues to expand rapidly, it is important to identify core journals to keep clinicians updated with the latest advances. This study is the first to characterize core journals in otolaryngology. Methods: Using h‐index and impact factor (IF), the top 15 NLM‐indexed otolaryngology journals were selected for analysis. The references from all articles published in these journals in one randomized quarter were compiled into a citation rank list, with the most cited journal ranked the highest. Citation zonal distribution analysis was conducted to identify the zonal distribution of otolaryngology journals. Results: A total of 3150 journals containing 26876 articles were cited in otolaryngology literature in April–June 2019. Laryngoscope was the most cited journal containing 1762 citations. IF is significantly associated with the h‐index for the top 10 otolaryngology journals (p = 0.032). Three core journal zones were identified, with Zone 1 containing 8 journals, Zone 2 containing 36 journals, and Zone 3 containing 189 journals. A linear relationship between the log journal rank for Zones 1–3 and a cumulative number of citations was found (R2 = 0.9948). Conclusion: Eight core journals for otolaryngology were identified: Laryngoscope, Otolaryngology—Head and Neck Surgery, Otology & Neurotology, JAMA Otolaryngology—Head & Neck Surgery, Head & Neck, European Archives of Oto‐Rhino‐Laryngology, International Journal of Pediatric Otorhinolaryngology, Annals of Otology, Rhinology & Laryngology. In the face of rapidly evolving research and a multitude of journals, the high citation density within these core journals highlights their utility in updating busy clinicians. Level of Evidence: NA Laryngoscope, 133:3346–3352, 2023 [ABSTRACT FROM AUTHOR]