Gun shot injuries to the temporal bone: Anatomic predictors of mortality.

PURPOSE: To explore anatomic predictors of mortality from gunshot wounds involving the temporal bone. METHODS: A retrospective search of radiology reports was performed for all patients with CT reports suggestive of gunshot wounds (GSW) to the TB (2000-2020). All cases were reviewed by the senior author to confirm injury to the temporal bone. Detailed demographic and radiographic data were collected. MAIN FINDINGS: A total of 120 patients met inclusion criteria. The majority of patients were male (n = 101) and the average age was 32.9. The squamosa was the most commonly involved subsite (n = 90), followed by the mastoid (n = 43). Squamosal entry site had the highest associated mortality (89.7 %). For those with known disposition, 65.8 % (79 of 120) expired on the same hospital admission. Inpatient otolaryngology consultation was noted in 18.3 % (n = 22) of patients, with poor outpatient follow-up. CONCLUSIONS: This series represents the largest survey of GSW to the temporal bone to date. Although associated mortality is high and outpatient follow-up poor, otolaryngologists should be aware of associated morbidities to facilitate both inpatient and subsequent outpatient management.

Dural Venous Sinus Arachnoid Granulations in Patients with Pulsatile Tinnitus.

OBJECTIVE: To determine the relationship, if any, between dural venous sinus arachnoid granulations (AGs) and pulsatile tinnitus. STUDY DESIGN: Retrospective case-control study. METHODS: Between October 1999 and March 2020, magnetic resonance imaging of patients with tinnitus (pulsatile [PT] and nonpulsatile [NPT]) were assessed for the presence of dural venous sinuses AG. During the same interval, patients with AGs found incidentally on all magnetic resonance imagings ordered without an indication of tinnitus were reviewed. Demographic variables recorded included patient age, sex, race, body mass index, and a history of idiopathic intracranial hypertension (IIH) or obstructive sleep apnea. Location of AGs, when present, were recorded. RESULTS: A total of 651 (PT 250, NPT 401) were found to have AGs. AGs had a higher prevalence in PT patients (10.4% [n = 26]) versus NPT patients (0.3% [n = 1]; odds ratio, 31.0; confidence interval 4.1-234; p < 0.001). Of the 77,607 patients who had an indication for imaging other than tinnitus, 230 patients (0.30%) were found to have incidental AGs, suggesting that the NPT cohort was an adequate control. Patients with PT were more likely to have a higher body mass index, be female, be non-White, and have an existing diagnosis of IIH. For all patients with AGs, AGs were more likely to be found in the lateral sinuses (i.e., sigmoid, transverse) in the PT group (odds ratio, 8.1; confidence interval, 1.1-61.1; p = 0.0218). CONCLUSIONS: This study evaluates the association between AG and PT, finding higher rates of AG in patients with PT than in NPT. However, despite the increased prevalence of AG in patients with IIH, these data combined with existing literature would suggest that AGs are not necessarily the missing link to explain PT pathophysiology in IIH.

Quality of Otology and Neurotology Research in Otolaryngology Journals.

OBJECTIVE: To identify trends in the quality of otology studies published in general otolaryngology journals over a 20-year period. STUDY DESIGN: Retrospective analysis. METHODS: Otologic and neurotologic papers from 1997, 2007, and 2017 were identified in the three general otolaryngology journals with the highest Eigenfactor scores: the Laryngoscope, European Archives of Otorhinolaryngology, and Otolaryngology-Head and Neck Surgery. The studies were reviewed and assigned level of evidence (LoE) based on standards set by the Centres for Evidence Based Medicine (CEBM). One-way analysis of variance were calculated with a 95% bootstrap sensitivity analysis performed. RESULTS: A total of 786 otology articles were reviewed for level of evidence, of which 557 (70.8%) were original, clinical research, eligible for LoE assignation. Total publications increased for each year in all three journals. Both the absolute number and proportion of high evidence studies (level of evidence 1 and 2) increased with respect to time in all three journals. Lower evidence studies (level of evidence 3, 4, or 5) made up 66.8% of total publications in 2017. There was a reduction in average level of evidence (towards higher quality evidence) by 0.431 units from 1997 to 2017 (Diff = -0.431 between 1997 and 2017, p < 0.001). There was no significant difference in rate of change of level of evidence between 1997 and 2007 and 2007 and 2017 (0.033, p = 0.864). CONCLUSION: Over a 20-year period the number of total publications increased with time. The majority of otology publications in 2017 were lower evidence studies, though significant increases in the number and proportion of high evidence studies in general otolaryngology journals were observed throughout the study period.

Malignant Otitis Externa Outcomes: A Study of the University HealthSystem Consortium Database.

OBJECTIVE: To characterize factors that affect outcomes for patients with malignant otitis externa (MOE). METHODS: Retrospective review of inpatients with MOE was performed. Patient demographics, comorbid conditions, complications, procedures, and mortalities were analyzed. RESULTS: A total of 786 patients with MOE were identified. The mean hospitalization length of stay (LOS) was 18.6 days (SD = 19.7). The overall mortality rate was 2.5% (n = 20), and complication rate was 4.3% (n = 34). Increasing age significantly and positively correlated with the incidence of MOE (r = 0.979, P < .0001). Factors that were associated with an increased rate of mortality were sepsis (odds ratio [OR] = 18.5; ES = 0.94; 95% CI, 0.47-1.42), congestive heart failure (OR = 3.1; ES = 0.42; 95% CI, 0.02-0.82), weight loss (OR = 10.2; ES = 1.23; 95% CI, 0.61-1.85), and coagulopathy (OR = 8.8; ES = 1.84; 95% CI, 0.91-2.77). Surgical intervention was performed in 19.2% (n = 151) of patients. Facial nerve involvement was present in 15.5% (n = 122) of patients and was associated with a significantly longer LOS of 12.9 days (SD = 19.6; ES = 0.21; 95% CI, 0.03-0.41). CONCLUSIONS: This large multi-institutional database study of MOE demonstrates that several patient factors impact the LOS and mortality. Patients at risk for unfavorable outcomes include the elderly, male gender, comorbidities, or cranial nerve involvement.

National Trends in Vestibular Schwannoma Surgery: Influence of Patient Characteristics on Outcomes.

Objective To characterize current vestibular schwannoma (VS) surgery outcomes with a nationwide database and identify factors associated with increased complications and prolonged hospital course. Study Design Retrospective review utilizing the University HealthSystem Consortium national inpatient database. Setting US academic health centers. Subjects and Methods Data from patients undergoing VS surgery were analyzed over a 3-year time span (October 2012 to September 2015). Surgical outcomes, such as length of stay (LOS), complications, and mortality, were analyzed on the basis of race, sex, age, and comorbidities during the 30-day postoperative period. Results A total of 3697 VS surgical cases were identified. The overall mortality rate was 0.38%, and the overall complication rate was 5.3%. Advanced age significantly affected intensive care unit LOS, mortality, and complications ( P = .04). Comorbidities, including hypertension, obesity, and depression, also significantly increased complication rates ( P = .02). Sixty-eight patients (1.8%) had a history of irradiation, and they had a significantly increased LOS ( P = .03). Conclusion Modern VS surgery has a low mortality rate and a relatively low rate of complications. Several factors contribute to high complication rates, including age and comorbidities. These data will help providers in counseling patients on which treatment course might be best suited for them.

Audiometric assessment of pediatric patients with cystic fibrosis.

BACKGROUND: The purpose of this study was to evaluate hearing impairment in pediatric patients with cystic fibrosis (CF). METHODS: This is a retrospective analysis of the AudGen database generated by Children's Hospital of Philadelphia. Audiograms were analyzed for type of hearing loss (HL), pure-tone-average (PTA), laterality, and change in hearing over time. Medical charts were reviewed to identify factors that influence development and progression of hearing loss. RESULTS: 217 patients with CF were included in this study. 69 (31.8%) had hearing loss on initial audiogram. Chronic otitis media (OR: 2.4, 95% CI: 1.3-4.5, p<0.01), Eustachian tube dysfunction (OR: 2.4, 95% CI: 1.4-5.4, p<0.01), and otorrhea (OR: 6.3, 95% CI: 1.6-24.7, p<0.01) were positive predictors of HL. Children with a diagnosis of diabetes had more decline in hearing over time than those without diabetes (12.4±17.2dB worsening vs. -5.7±9.8dB improvement in PTA, p=0.014). CONCLUSION: This is the largest comprehensive analysis of all types of hearing loss in pediatric patients with CF. Our data suggest that children with more severe sinus disease may be at lower risk for inflammatory middle ear disease and subsequent hearing loss. Patients who develop complications of CF such as diabetes should be monitored frequently, and the use of ototoxic drugs should be limited if possible.

Does Hospital Volume Affect Outcomes in Patients Undergoing Vestibular Schwannoma Surgery?

OBJECTIVE: To determine the effect of hospital surgical case volume on the outcomes of vestibular schwannoma surgery. STUDY DESIGN: Retrospective case review. SETTING: University HealthSystem Consortium member hospitals (includes nearly every US academic medical center). PATIENTS: Three thousand six hundred ninety-seven patients who underwent vestibular schwannoma resection over a 3-year timespan (2012-2015) grouped by race, age, comorbidities, payer, and sex. INTERVENTION: Surgical resection of vestibular schwannoma. MAIN OUTCOME MEASURES: Morbidity and mortality following vestibular schwannoma excision are compared by hospital volume (low, medium, and high) including deciles. RESULTS: There was significantly longer length of stay (p ≤ 0.005) among groups with low-volume hospitals followed by medium-volume hospitals and high-volume hospitals. Low-volume hospitals had a significantly higher rate of complications including stroke, aspiration, and respiratory failure (p ≤ 0.0175). Patient characteristics of age, sex, sex, and baseline comorbidities were similar between hospital groups. However, patients at high-volume hospitals were more likely to be Caucasian (83.1%, p = 0.0001) and have private insurance (76.7%, p < 0.0001). There was a strong negative correlation between complication rates and hospital volume (r = -0.8164, p = 0.0040). CONCLUSION: The volume of vestibular schwannoma surgeries performed at a hospital impacts length of stay and rates of postoperative complications. Demographics among hospital groups were similar though high-volume hospitals had significantly more patients who were privately insured and Caucasian.

Meta-analysis of Cochlear Implantation Outcomes Evaluated With General Health-related Patient-reported Outcome Measures.

OBJECTIVE: Determine the change in general health-related quality of life (HRQOL) after cochlear implantation and association with speech recognition. STUDY DESIGN: Meta-analysis. METHODS: Search was performed following the PRISMA statement using PubMed, Medline, Scopus, and CINAHL. Studies on adult cochlear implant (CI) patients measuring HRQOL before and after cochlear implantation were included. Standardized mean difference (SMD) for each measure and pooled effects were determined. A meta-analysis of correlations was also performed between all non-disease-specific patient-reported outcome measures (PROMs) and speech recognition after cochlear implantation. RESULTS: Twenty-two articles met criteria for meta-analysis of HRQOL improvement, but 15 (65%) were excluded due to incomplete statistical reporting. From the seven articles with 274 CI patients that met inclusion criteria, pooled analyses showed a medium positive effect of cochlear implantation on HRQOL (SMD = 0.79). Subset analysis of the HUI-3 measure showed a large effect (SMD = 0.84). Nine articles with 550 CI patients met inclusion criteria for meta-analysis of correlations between non-disease specific PROMs and speech recognition after cochlear implantation. Pooled analysis showed a low correlation between non-disease-specific PROMs and word recognition in quiet (r = 0.35), sentence recognition in quiet (r = 0.40), and sentence recognition in noise (r = 0.32). CONCLUSION: Although regularly used, HRQOL measures are not intended to measure nor do they accurately reflect the complex difficulties facing CI patients. Only a medium positive effect of cochlear implantation on HRQOL was observed along with a low correlation between non-disease-specific PROMs and speech recognition. The use of such instruments in this population may underestimate the benefit of cochlear implantation.

The Utility of Plain Films for Nonoperative Fifth Metacarpal Fractures: Are Follow-up Radiographs Necessary?

BACKGROUND: Fifth metacarpal fractures are often treated nonoperatively with serial radiographs; however, the utility of these radiographs in altering clinical management has not been investigated. We hypothesize that follow-up plain films will not alter clinical management and are therefore unnecessary for most patients. METHODS: Between 2007 and 2014, patients with a fifth metacarpal fracture at our level I trauma center were retrospectively reviewed. Patients with inadequate documentation or imaging, ipsilateral upper extremity injuries, or who underwent initial surgical fixation were excluded. Initial and postreduction radiographs were reviewed by 4 board-certified attending hand surgeons and 2 hand fellows who indicated their preferred management. At a later date, blinded to their initial management, the reviewers assessed follow-up films taken at least 2 weeks later and indicated their preferred management. RESULTS: In total, 60 patients met inclusion criteria, and of those, 30 were randomly selected. There were 9 base, 7 shaft, and 14 neck fractures. Initially, reviewers opted for nonoperative management in 72.2% of base, 71.4% of shaft, and 91.7% of neck fractures. After reviewing follow-up films, reviewers changed from nonoperative to operative management in 0.0% of base, 9.5% of shaft, and 1.2% of neck fractures. CONCLUSIONS: Follow-up radiographs may not be indicated for most fifth metacarpal base and neck fractures. Follow-up radiographs may change management in select fifth metacarpal shaft fractures as these fractures may displace. Follow-up radiographs should be performed at the discretion of the treating surgeon on an as-needed basis for fractures at risk for displacement.

Meta-analysis of quality-of-life improvement after cochlear implantation and associations with speech recognition abilities.

OBJECTIVES: Determine the impact of cochlear implantation on quality of life (QOL) and determine the correlation between QOL and speech recognition ability. STUDY DESIGN: Two authors independently searched PubMed, Medline, Scopus, and the Cumulative Index to Nursing and Allied Health Literature to identify studies reporting hearing-specific or cochlear implant (CI)-specific QOL outcomes before and after cochlear implantation, and studies reporting correlations between QOL and speech recognition after cochlear implantation. Data from the included articles were obtained independently by two authors. Standardized mean difference (SMD) for each measure and pooled effects were determined to assess improvement in QOL before and after cochlear implantation. RESULTS: From 14 articles with 679 CI patients who met the inclusion criteria, pooled analyses of all hearing-specific QOL measures revealed a very strong improvement in QOL after cochlear implantation (SMD = 1.77). Subset analysis of CI-specific QOL measures also showed very strong improvement (SMD = 1.69). Thirteen articles with 715 patients met the criteria to evaluate associations between QOL and speech recognition. Pooled analyses showed a low positive correlation between hearing-specific QOL and word recognition in quiet (r = 0.213), sentence recognition in quiet (r = 0.241), and sentence recognition in noise (r = 0.238). Subset analysis of CI-specific QOL showed similarly low positive correlations with word recognition in quiet (r = 0.213), word recognition in noise (r = 0.241), and sentence recognition in noise (r = 0.255). CONCLUSIONS: Using hearing-specific and CI-specific measures of QOL, patients report significantly improved QOL after cochlear implantation. However, widely used clinical measures of speech recognition are poor predictors of patient-reported QOL with CIs. Laryngoscope, 128:982-990, 2018.

The influence of obesity on operating room time and perioperative complications in cochlear implantation.

OBJECTIVE: The rising incidence of obesity in the United States is associated with increased healthcare expenditures and resource allocation. Obesity has been associated with prolonged operating times during surgical procedures. The primary objective of this study is to compare body mass index (BMI) to length of surgery during cochlear implantation. METHODS: A retrospective case control study from a tertiary academic referral center was performed. Patients included were adults who underwent primary, single-sided cochlear implantation with documented BMI and operating room (OR) times from January 2009 to July 2015. The following data were collected: BMI, total operating room time (TORT), surgical operating room time (SORT), ASA status, perioperative and postoperative complications, age, and gender. RESULTS: Two hundreds and thirty-four patients were included and stratified into obese (BMI >30) and non-obese (BMI < 30) categories. Statistical analysis was performed comparing TORT against the obesity category along with other variables. Independent sample t-test demonstrated that obesity increases TORT and SORT by 16.8 min (P = 0.0002) and 9.3 min (P = 0.03), respectively, compared to the non-obese group. Multivariate linear regression analysis demonstrated no statistically significant impact of gender, or ASA status on total operating or surgical time. Obesity was associated with increased perioperative complications (odds ratio [OR], 6.21; 95% CI, 1.18-32.80; P = 0.03) and postoperative complications (OR, 3.97; 95% CI, 1.29-12.26; P = 0.02). CONCLUSIONS: Obesity leads to longer TORT and SORT during primary cochlear implant surgery. Obesity is also associated with increased perioperative and postoperative complications compared to non-obese patients. These data have implications with utilization of operating room resources.

Overcoming radioresistance in head and neck squamous cell carcinoma.

Radiation therapy plays an essential role in the treatment of head and neck squamous cell carcinoma (HNSCC), yet therapeutic efficacy is hindered by treatment-associated toxicity and tumor recurrence. In comparison to other cancers, innovation has proved challenging, with the epidermal growth factor receptor (EGFR) antibody cetuximab being the only new radiosensitizing agent approved by the FDA in over half a century. This review examines the physiological mechanisms that contribute to radioresistance in HNSCC as well as preclinical and clinical data regarding novel radiosensitizing agents, with an emphasis on those with highest translational promise.

Computer-Enhanced Visual Learning Method to Teach Endoscopic Correction of Vesicoureteral Reflux: An Invitation to Residency Training Programs to Utilize the CEVL Method.

Herein we describe a standardized approach to teach endoscopic injection therapy to repair vesicoureteral reflux utilizing the CEVL method, an internet-accessed platform. The content was developed through collaboration of the authors' clinical and computer expertises. This application provides personnel training, examination, and procedure skill documentation through the use of online text with narration, pictures, and video. There is also included feedback and remediation of skill performance and teaching "games." We propose that such standardized teaching and procedure performance will ultimate in improved surgical results. The electronic nature of communication in this journal is ideal to rapidly disseminate this information and to develop a structure for collaborative research.