Survival in Middle Ear Malignancy: A Population-Based Analysis Based on the SEER Database.

OBJECTIVE: The purpose of this study was to investigate the clinical features and survival outcomes of patients with middle ear malignancies at a population level. STUDY DESIGN: Retrospective cohort study with data from a national database. SETTING: National database of middle ear malignancy. METHODS: Records of patients diagnosed with a middle ear malignancy from 1973 to 2016 were extracted from the SEER database (Surveillance, Epidemiology, and End Results). SPSS (version 27; IBM) was used to conduct 5-year survival analysis. RESULTS: The average survival for all 431 patients was 61.4 months. Five-year disease-specific survival for squamous cell carcinoma (SCCA), adenocarcinoma, other carcinoma, and noncarcinoma subtypes varied significantly at 54.6%, 82.1%, 71.8%, and 82.6%, respectively (P < .0001). There was an improved 5-year survival for patients with adenocarcinoma who received surgery versus those who did not (91.7% vs 65.1%; P = .023, log-rank). Five-year disease-specific survival was significantly better in patients aged <55 years (mean ± SD, 77.8% ± 0.39%) as compared with those >70 years (55.1% ± 5.1%) and those aged 55 to 69 years (60.2% ± 4.9%; P < .01 and P < .001, respectively, log-rank). Patients with SCCA were significantly older than those with adenocarcinoma (P < .0001). Noncarcinoma subtypes were more likely to present with local disease, as opposed to regional or distant disease, when compared with SCCA (P = .0027). CONCLUSION: Prognosis and treatment outcomes for primary middle ear malignancies depend on histologic subtype and age at diagnosis. The noncarcinoma and adenocarcinoma subtypes carry the best prognoses. Patients with adenocarcinoma were most likely to benefit from surgery.

American Neurotology Society, American Otological Society, and American Academy of Otolaryngology - Head and Neck Foundation Guide to Enhance Otologic and Neurotologic Care During the COVID-19 Pandemic.

: This combined American Neurotology Society, American Otological Society, and American Academy of Otolaryngology - Head and Neck Surgery Foundation document aims to provide guidance during the coronavirus disease of 2019 (COVID-19) on 1) "priority" of care for otologic and neurotologic patients in the office and operating room, and 2) optimal utilization of personal protective equipment. Given the paucity of evidence to inform otologic and neurotologic best practices during COVID-19, the recommendations herein are based on relevant peer-reviewed articles, the Centers for Disease Control and Prevention COVID-19 guidelines, United States and international hospital policies, and expert opinion. The suggestions presented here are not meant to be definitive, and best practices will undoubtedly change with increasing knowledge and high-quality data related to COVID-19. Interpretation of this guidance document is dependent on local factors including prevalence of COVID-19 in the surgeons' local community. This is not intended to set a standard of care, and should not supersede the clinician's best judgement when managing specific clinical concerns and/or regional conditions.Access to otologic and neurotologic care during and after the COVID-19 pandemic is dependent upon adequate protection of physicians, audiologists, and ancillary support staff. Otolaryngologists and associated staff are at high risk for COVID-19 disease transmission based on close contact with mucosal surfaces of the upper aerodigestive tract during diagnostic evaluation and therapeutic procedures. While many otologic and neurotologic conditions are not imminently life threatening, they have a major impact on communication, daily functioning, and quality of life. In addition, progression of disease and delay in treatment can result in cranial nerve deficits, intracranial and life-threatening complications, and/or irreversible consequences. In this regard, many otologic and neurotologic conditions should rightfully be considered "urgent," and almost all require timely attention to permit optimal outcomes. It is reasonable to proceed with otologic and neurotologic clinic visits and operative cases based on input from expert opinion of otologic care providers, clinic/hospital administration, infection prevention and control specialists, and local and state public health leaders. Significant regional variations in COVID-19 prevalence exist; therefore, physicians working with local municipalities are best suited to make determinations on the appropriateness and timing of otologic and neurotologic care.

The diagnostic value of cytology in parotid Warthin's tumors: international multicenter series.

INTRODUCTION: Warthin's tumor (WT) is a common benign salivary gland neoplasm with a negligible risk of malignant transformation. However, there is a risk of malignant tumors being misdiagnosed as WT on cytology and inappropriately managed conservatively. METHODS: Patients from nine centers in Italy and the United Kingdom undergoing parotid surgery for cytologically diagnosed WT were included in this multicenter retrospective series. Definitive histology was compared with preoperative cytological diagnoses. Surgical complications were recorded. RESULTS: A total of 496 tumors were identified. In 88.9%, the final histological diagnosis was WT. In 21 cases (4.2%) a malignant neoplasm was diagnosed, which had been incorrectly labeled as WT on cytology. CONCLUSIONS: The risk of undiagnosed malignancy should be balanced against surgical risks when considering the management of WT. Although nonsurgical management remains an appropriate option, there may be a rationale for serial clinical or radiological evaluation if surgical excision is not performed.

An animal model of deep brain stimulation for treating tinnitus: A proof of concept study.

OBJECTIVE: This proof-of-concept study aimed to demonstrate therapeutic effects of deep brain stimulation (DBS) on noise-induced tinnitus. STUDY DESIGN: Experimental animal study. METHODS: After Institutional Animal Care and Use Committee approval, nine adult rats were implanted in the caudate nucleus with custom-made electrode array. The rats were exposed to noise to induce tinnitus. Auditory brainstem response was performed to evaluate hearing threshold changes. Noise-induced tinnitus and its suppression by DBS were evaluated using the gap-detection acoustic startle reflex behavioral paradigm and electrophysiological evaluation of modulatory effects on neural correlates of tinnitus. Various stimulation parameters were used to determine the most effective ones in affecting behavioral changes, along with corresponding neural activity in the caudate nucleus. The correlation between the caudate nucleus and auditory cortex also was determined. Analysis of variance with Bonferroni correction was performed to examine DBS-induced effects on behavioral evidence of tinnitus. RESULTS: Bursting activity, a neural marker of tinnitus, was noted to decrease compared to baseline in tinnitus (+) animals. After stimulation, spontaneous and bursting activity increased in the tinnitus (+) animals but decreased in the tinnitus (-) animals. Behavioral data suggested suppression of tinnitus after DBS. These effects lasted up to 5 days. To our knowledge, this is the first development of an animal model to test deep brain stimulation of the caudate region for the treatment of tinnitus. CONCLUSIONS: Deep brain stimulation of the caudate nucleus can modulate tinnitus in a rat model of tinnitus. LEVEL OF EVIDENCE: NA. Laryngoscope, 128:1213-1222, 2018.

Long-term Hearing Preservation After Resection of Vestibular Schwannoma: A Systematic Review and Meta-analysis.

OBJECTIVE: The objective is to perform a systematic review and meta-analysis of the literature on the long-term results of hearing preservation after vestibular schwannoma resection. DATA SOURCES: Ovid/Medline, PubMed, Embase, and the Cochrane library from January 1980 to January 2015. STUDY SELECTION: Inclusion criteria: age ≥18 years, minimum 10 patients in the treatment group, hearing preserving microsurgery, no previous radiation treatment, serviceable hearing at immediate postop follow-up, hearing outcomes reported using Gardner Robinson or the American Academy of Otolaryngology-Head and Neck Surgeons hearing grading scales, and average follow-up of 5 years. Preoperative, immediate postoperative, and last follow-up audiograms were required. Exclusion criteria included neurofibromatosis type 2 patients and surgery for salvage therapy or decompression. DATA EXTRACTION: Quality evaluated using Methodological Index for Non-Randomized Studies. DATA SYNTHESIS: Meta-analysis was performed using R v3.2.2, Metafor package v 1.9-7. Cohen's D was used to determine effect size. Ten reports had at least 5-year follow-up and used standardized hearing grading scales. The systematic review found that if hearing was preserved at Class A or B at early postop visit, the chance of preserving hearing at 5 years was excellent. Those who maintained speech discrimination score ≥ 89% at the early postoperative follow-up had better long-term hearing preservation. The meta-analysis reveals that only preoperative and postoperative pure-tone average was associated with long-term hearing preservation. CONCLUSION: Long-term (>5 yr) hearing durability rates are generally very good. Most studies do not report patient and tumor characteristics, therefore precluding combining studies for meta-analysis. Only preoperative and postoperative postoperative pure-tone average was associated with long-term hearing durability.

Evaluation of Noise Exposure Secondary to Wind Noise in Cyclists.

Objective Determine if the noise levels of wind exposure experienced by cyclists reach levels that could contribute to noise-induced hearing loss. Study Design Industrial lab research. Setting Industrial wind tunnel. Subjects and Methods A commercial-grade electric wind tunnel was used to simulate different speeds encountered by a cyclist. A single cyclist was used during the simulation for audiometric measurements. Microphones attached near the ears of the cyclist were used to measure the sound (dB sound pressure level) experienced by the cyclist. Loudness levels were measured with the head positioned at 15-degree increments from 0 degrees to 180 degrees relative to the oncoming wind at different speeds (10-60 mph). Results Wind noise ranged from 84.9 dB at 10 mph and increased proportionally with speed to a maximum of 120.3 dB at 60 mph. The maximum of 120.3 dB was measured at the downwind ear when the ear was 90 degrees away from the wind. Conclusions Wind noise experienced by a cyclist is proportional to the speed and the directionality of the wind current. Turbulent air flow patterns are observed that contribute to increased sound exposure in the downwind ear. Consideration of ear deflection equipment without compromising sound awareness for cyclists during prolonged rides is advised to avoid potential noise trauma. Future research is warranted and can include long-term studies including dosimetry measures of the sound and yearly pre- and postexposure audiograms of cyclists to detect if any hearing loss occurs with long-term cycling.

Mapping Direct Observations From Objective Structured Clinical Examinations to the Milestones Across Specialties.

BACKGROUND: Little is known about residents' performance on the milestones at the institutional level. Our institution formed a work group to explore this using an institutional-level curriculum and residents' evaluation of the milestones. OBJECTIVE: We assessed whether beginner-level milestones for interpersonal and communication skills (ICS) related to observable behaviors in ICS-focused objective structured clinical examinations (OSCEs) for postgraduate year (PGY) 1 residents across specialties. METHODS: The work group compared ICS subcompetencies across 12 programs to identify common beginner-level physician-patient communication milestones. The selected ICS milestone sets were compared for common language with the ICS-OSCE assessment tool-the Kalamazoo Essential Elements of Communication Checklist-Adapted (KEECC-A). To assess whether OSCE scores related to ICS milestone scores, all PGY-1 residents from programs that were part of Next Accreditation System Phase 1 were identified; their OSCE scores from July 2013 to June 2014 and ICS subcompetency scores from December 2014 were compared. RESULTS: The milestones for 10 specialties and the transitional year had at least 1 ICS subcompetency that related to physician-patient communication. The language of the ICS beginner-level milestones appears similar to behaviors outlined in the KEECC-A. All 60 residents with complete data received at least a beginner-level ICS subcompetency score and at least a satisfactory score on all 3 OSCEs. CONCLUSIONS: The ICS-OSCE scores for PGY-1 residents appear to relate to beginner-level milestones for physician-patient communication across multiple specialties.

Partial Hearing Preservation after Translabyrinthine Vestibular Schwannoma Resection: Case Report and Review of the Literature.

Objectives To describe a unique case report of a patient who had partial hearing preservation after translabyrinthine (TL) removal of a vestibular schwannoma (VS). Study Design Case report. Methods The patient's chart was reviewed for hearing levels before and after surgery. Preoperative magnetic resonance imaging (MRI) was compared with postoperative MRI for determination of completeness of tumor removal. The literature on hearing preservation after TL resection is reviewed. Results A 42-year-old woman underwent a TL removal of a VS. The patient's preoperative pure tone average (PTA) was 70 dB and word recognition score (WRS) was 40%. Postoperatively, the patient was able to hear ambient noise in the surgical ear. Her bone conduction PTA was 70 dB, but the WRS score dropped to 2%. One year later, she continues to hear ambient noise and sound in the operative ear. Discussion This is the fifth reported case of partial hearing preservation after TL VS resection. It suggests that by preserving the vestibule and the fluids within the vestibule when possible, there maybe enough residual auditory neural structures for a traditional cochlear implant to benefit such a patient. In addition, preserving the incus when possible may help maintain air conduction to help patients with sound localization.

Current opinion: the management of tinnitus.

PURPOSE OF REVIEW: The purpose of this review is to describe our experience with management of chronic tinnitus and to review the recent literature on the best treatment options available for treating patients who are troubled by their tinnitus. In addition, we want to highlight our experience and approach to this very common problem. RECENT FINDINGS: Treatment options for patients are based on the severity of the tinnitus and any associated problems. The use of nutritional supplements has a place in the treatment of mild-to-moderate tinnitus. Ginkgo biloba and B-complex vitamins may have an impact on selected patients. Treatment of underlying or accompanying anxiety disorders especially with cognitive behavior therapy can help to reduce the distress associated with tinnitus. Surgical treatment options, such as cochlear implant, have been shown to be very effective in reducing tinnitus in patients with sudden unilateral hearing loss as the cause of tinnitus. Other surgical approaches, such as repetitive transcranial magnetic stimulation and vagal stimulator, have had some limited benefits. SUMMARY: Treatment for subjective tinnitus can range from the conventional to the investigational modalities. Best treatment options take into account the possible cause of the tinnitus and other associated symptoms.

Clinical predictors of abnormal magnetic resonance imaging findings in patients with asymmetric sensorineural hearing loss.

IMPORTANCE: Asymmetric sensorineural hearing loss (ASNHL) is commonly encountered in an otolaryngologic clinical practice. Determining what factors are associated with abnormal magnetic resonance imaging (MRI) findings will help with diagnostic workup. OBJECTIVE: To evaluate the association between clinical and audiometric factors and abnormal MRI findings in patients with ASNHL. DESIGN, SETTING, AND PARTICIPANTS: Retrospective medical record review from an urban, tertiary referral center of 451 patients with ASNHL who underwent MRI testing between January 2005 and December 2011. MAIN OUTCOMES AND MEASURES: Medical records were reviewed for audiometric parameters as well as clinical presentation and compared with MRI results, which were categorized as abnormal, normal, or incidental. Data analysis included χ2 tests, logistic regression analysis, and multivariate analysis. RESULTS: A total of 48 patients (10.6%) had abnormal MRI findings. Only 21 patients (4.7%) had a mass of the cerebellopontine angle/internal auditory canal on MRI, making up 40% of all abnormal MRI findings. The next most common MRI finding was labyrinthitis (n = 13; 25%). Vertigo/dizziness (n = 20; P = .01), tinnitus (n = 18; P = .02), sudden hearing loss (n = 15; P = .054), and 15-dB asymmetry at 3 kHz (n = 39; P = .01) were associated with abnormal MRI findings. Loud noise exposure was associated with normal MRI findings. Logistic regression analysis showed that vertigo/dizziness (odds ratio [OR], 2.14; 95% CI, 1.15-3.96; P = .02), unilateral tinnitus (OR, 2.15; 95% CI, 1.14-4.03; P = .02), and 15-dB asymmetry at 3 kHz (OR, 2.62; 95% CI, 1.24-5.57; P = .01) were significantly associated with abnormal MRI findings. Multivariate analysis showed that only 15-dB asymmetry at 3 kHz (OR, 2.42; 95% CI, 1.07-5.50; P = .03) was significantly associated with an abnormal MRI finding. CONCLUSIONS AND RELEVANCE: This study found that asymmetry of 15 dB at 3 kHz on audiometry was associated with higher positive yield on use of MRI in evaluating patients with ASNHL. We recommend that patients who present with ASNHL with this audiometric characteristic undergo MRI as part of their diagnostic workup.

Systematic review and meta-analysis of Meniett therapy for Meniere's disease.

OBJECTIVES/HYPOTHESIS: To perform a systematic review and meta-analysis of micropressure treatment for Meniere's disease (MD). DATA SOURCES: Medline, Ovid, Web of Science, and Cochrane Library search of the literature from January 1996 to December 2012. REVIEW METHODS: Systematic literature review followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Inclusion criteria required definitive diagnosis of unilateral MD, treatment with Meniett device, vertigo control results, and hearing results before and after treatment. Randomized controlled trials and other types of case-control studies were included. Improvements in vertigo, American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) functional score, and pure tone average (PTA) were assessed. Funnel plots were used to detect bias and Q test was used to assess for heterogeneity. Random effects model was used for meta-analysis. T test was used to assess for significance. RESULTS: Of 113 abstracts screened, 18 studies met criteria for review and 12 were used for meta-analysis. Eight studies reported hearing evaluation and the improvement in PTA after Meniett treatment was significant (P = 0.0085). Data could not be combined for AAO-HNS functional score due to heterogeneity. However, there was a trend toward improvement. Of six studies reporting frequency of vertigo, Meniett treatment significantly reduced frequency of vertigo (P = < .0001). LIMITATIONS: Much of the data used in the analysis was derived from retrospective or level 4 studies. The average follow-up was only 5 months, and there were low number of patients in the treatment and control groups. CONCLUSION: The Meniett device is a safe, nondestructive treatment for patients' refractory to medical therapy for MD.

The costs and utility of imaging in evaluating dizzy patients in the emergency room.

OBJECTIVES/HYPOTHESIS: To determine the usefulness and the costs of computed tomography (CT) and magnetic resonance imaging (MRI) in the evaluation of patients with dizziness in the emergency department (ED). STUDY DESIGN: Retrospective chart review. METHODS: Charts of patients with a specific health maintenance insurance plan presenting with dizziness and vertigo to a large health system's ED between January 2008 and January 2011 were reviewed. Patient demographics, signs/symptoms, and CT and MRI results were assessed. CT and MRI charges were determined based on positive versus unremarkable findings. Data analysis included stepwise logistic regressions. RESULTS: Of 1681 patients identified, 810 (48%) received CT brain/head scan totaling $988,200 in charges. Of these, only 0.74% yielded clinically significant pathology requiring intervention. However, 12.2% of MRI studies yielded discovery of significant abnormalities. Logistic regression analysis revealed that older patients (P = .001) were more likely to receive a CT scan. CONCLUSIONS: In the 3-year period studied, CT scans for ED patients with dizziness and vertigo yielded a low predictive value for significant pathology. These data reveal a great opportunity for cost savings by developing stricter guidelines for ordering CT scans for this set of ED patients. The use of MRI in all cases of dizziness was found to be neither practical nor useful. However, appropriately directed MRI of the brain is recommended in patients with dizziness and other neurological signs or symptoms.

Voltage-gated Ca2+ channel Ca(V)1.3 subunit expressed in the hair cell epithelium of the sacculus of the trout Oncorhynchus mykiss: cloning and comparison across vertebrate classes.

Full-length sequence (>6.5 kb) has been determined for the Ca(V)1.3 pore-forming subunit of the voltage-gated Ca(2+) channel from the saccular hair cells of the rainbow trout (Oncorhynchus mykiss). Primary structure was obtained from overlapping PCR and cloned fragments, amplified by primers based on teleost, avian, and mammalian sources. Trout saccular Ca(V)1.3 was localized to hair cells, as evidenced by its isolation from an epithelial layer in which the hair cell is the only intact cell type. The predicted amino acid sequence of the trout hair cell Ca(V)1.3 is approximately 70% identical to the sequences of avian and mammalian Ca(V)1.3 subunits and shows L-type characteristics. The trout hair cell Ca(V)1.3 expresses a 26-aa insert in the I-II cytoplasmic loop (exon 9a) and a 10-aa insert in the IVS2-IVS3 cytoplasmic loop (exon 30a), neither of which is appreciably represented in trout brain. The exon 9a insert also occurs in hair cell organs of chick and rat, and appears as an exon in human genomic Ca(V)1.3 sequence (but not in the Ca(V)1.3 coding sequence expressed in human brain or pancreas). The exon 30a insert, although expressed in hair cells of chick as well as trout, does not appear in comparable rat or human tissues. Further, the IIIS2 region shows a splice choice (exon 22a) that is associated with the hair cell organs of trout, chick, and rat, but is not found in human genomic sequence. The elucidation of the primary structure of the voltage-gated Ca(2+) channel Ca(V)1.3 subunit from hair cells of the teleost, representing the lowest of the vertebrate classes, suggests a generality of sensory mechanism for Ca(V)1.3 across hair cell systems. In particular, the exon 9a insert of this channel appears to be the molecular feature most consistently associated with hair cells from fish to mammal, consonant with the hypothesis that the latter region may be a signature for the hair cell.