Individual Patient Comorbidities and Effect on Cochlear Implant Performance.

OBJECTIVE: To examine the association between preoperative comorbidities and cochlear implant speech outcomes. STUDY DESIGN: Retrospective cohort. SETTING: Tertiary referral center. PATIENTS: A total of 976 patients who underwent cochlear implantation (CI) between January 2015 and May 2022. Adult patients with follow-up, preoperative audiologic data, and a standardized anesthesia preoperative note were included. EXPOSURE: Adult Comorbidity Evaluation 27 (ACE-27) based on standardized anesthesia preoperative notes. MAIN OUTCOME MEASURES: Postoperative change in consonant-nucleus-consonant (CNC) score, AzBio Sentence score in quiet, and AzBio + 10 dB signal-to-noise ratio (SNR). Sentence score of the implanted ear at 3, 6, and 12 months. RESULTS: A total of 560 patients met inclusion criteria; 112 patients (20%) had no comorbidity, 204 patients (36.4%) had mild comorbidities, 161 patients (28.8%) had moderate comorbidities, and 83 patients (14.8%) had severe comorbidities. Mixed model analysis revealed all comorbidity groups achieved a clinically meaningful improvement in all speech outcome measures over time. This improvement was significantly different between comorbidity groups over time for AzBio Quiet ( p = 0.045) and AzBio + 10 dB SNR ( p = 0.0096). Patients with severe comorbidities had worse outcomes. From preop to 12 months, the estimated marginal mean difference values (95% confidence interval) between the no comorbidity group and the severe comorbidity group were 52.3 (45.7-58.9) and 32.5 (24.6-40.5), respectively, for AzBio Quiet; 39.5 (33.8-45.2) and 21.2 (13.6-28.7), respectively, for AzBio + 10 dB SNR; and 43.9 (38.7-49.0) and 31.1 (24.8-37.4), respectively, for CNC. CONCLUSIONS: Comorbidities as assessed by ACE-27 are associated with CI performance. Patients with more severe comorbidities have clinically meaningful improvement but have worse outcome compared to patients with no comorbidities.

Predictors of Recurrence After Sub-total or Near-total Resection of Vestibular Schwannoma: Importance of Tumor Volume and Ventral Extension.

OBJECTIVE: To evaluate the predictors of remnant tumor regrowth and need for salvage therapy after less than gross total resection (GTR) of vestibular schwannoma (VS). STUDY DESIGN: Retrospective chart review. SETTING: Tertiary neurotologic referral center. PATIENTS: Patients who underwent VS resection between 2008 and 2019 either with GTR, near total resection (NTR), and subtotal resection (STR). INTERVENTIONS: Microsurgical resection, salvage radiosurgery. MAIN OUTCOME MEASURES: Regrowth free interval, salvage free interval, tumor doubling rate. RESULTS: Three hundred eighty five cases (GTR = 236, NTR = 77, and STR = 71) from 2008 to 2019 were included. STR cohort had much larger and complex tumors with significant differences in tumor volume, ventral extension and brainstem compression (p  < 0.001). On single predictor analysis, tumor volume, ventral extension, brainstem compression as well as STR strategy was associated with significant increased risk of regrowth and need for salvage therapy. Multivariate analysis revealed STR strategy as significant predictor of regrowth (hazard ratio 3.79, p  < 0.0005). Absolute remnant volume and extent of resection (EOR) did not predict regrowth. A small proportion of cases (NTR = 4%, STR = 15%) eventually needed salvage radiosurgery with excellent ultimate local tumor control with no known recurrence to date. CONCLUSIONS: Conservative surgical strategy employing NTR or STR can be employed safely in large and complex VS. While there is increased risk of regrowth in the STR cohort, excellent local control can be achieved with appropriate use of salvage radiosurgery. No disceret radiologic or operative predictors of regrowth were identified.

The Utility of Preoperative Phone Calls for Endoscopic Sinus Surgery Procedures.

OBJECTIVE: Perioperative patient education improves patient satisfaction, surgical outcomes, and can reduce postoperative call volume. Here, we investigate whether the use of standardized preoperative phone calls elicits similar results in patients undergoing endoscopic sinus surgery (ESS). METHODS: Patients undergoing ESS at a tertiary rhinology center were identified prospectively through the electronic medical record (EMR). In the intervention cohort, a standardized preoperative educational phone call was performed. A postoperative survey was utilized to collect self-assessment of satisfaction and understanding in all patients. Postoperative call rates were obtained from the EMR. Wilcoxon rank sum and chi-squared analyses were conducted to compare results. Demographics of the otology and rhinology cohorts were compared with a Mann Whitney U-test. RESULTS: Data from 43 cases and 58 controls were collected. Patients receiving the intervention were similar to controls with regard to patient-reported understanding (case:9.1 ± 1.1 vs control:9.0 ± 1.4, p = 0.801) and satisfaction (case:9.4 ± 1.1 vs 8.9 ± 1.4, p = 0.155). Both cases and controls called the clinic regarding surgical outcomes more often than for postoperative medications or administrative concerns. Independent of receiving the intervention, patients that did not call clinic postoperatively had significantly better understanding of their procedures (call:8.6 ± 1.6 vs no-call:9.5 ± 1.0, p < 0.015) and satisfaction with their experience (call:8.8 ± 1.4 vs no-call:9.5 ± 1.1, p < 0.028). Patient age may contribute to lack of impact in the rhinology cohort, as compared to the otology group, but socioeconomic status does not seem to differentiate the two samples. CONCLUSION: Though shown in other settings, a significant impact of educational phone calls prior to surgery was not observed in this sample. Patient education calls prior to endoscopic sinus surgery were not associated with changes in postoperative call volume to the clinic. Patient understanding and satisfaction may be related to other factors, such as patient selection or demographics. Future studies may target such patients prior to ESS.

Investigating Predictors of Increased Length of Stay After Resection of Vestibular Schwannoma Using Machine Learning.

OBJECTIVE: To evaluate the predictors of prolonged length of stay (LOS) after vestibular schwannoma resection. STUDY DESIGN: Retrospective chart review. SETTING: Tertiary referral center. PATIENTS: Patients who underwent vestibular schwannoma resection between 2008 and 2019. INTERVENTIONS: Variables of interest included age, body mass index, comorbidities, symptoms, previous intervention, microsurgical approach, extent of resection, operative time, preoperative tumor volume, and postoperative complications. Predictive modeling was done through multivariable linear regression and random forest models with 80% of patients used for model training and the remaining 20% used for performance testing. MAIN OUTCOME MEASURES: LOS was evaluated as the number of days from surgery to discharge. RESULTS: Four hundred one cases from 2008 to 2019 were included with a mean LOS of 3.0 (IQR = 3.0-4.0). Postoperatively, 14 (3.5%) of patients had LOS greater than two standard deviations from the mean (11 days). In a multivariate linear regression model (adjusted R2 = 0.22; p < 0.001), preoperative tumor volume (p < 0.001), coronary artery disease (p = 0.002), hypertension (p = 0.029), and any major complication (p < 0.001) were associated with increased LOS (by 0.12, 3.79, 0.87, and 3.20 days respectively). A machine learning analysis using a random forest identified several potential nonlinear relationships between LOS and preoperative tumor dimensions (length, volume) and operative time that were not captured on regression. The random forest model had lower prediction error compared to the regression model (RMSE 5.67 vs. 44.59). CONCLUSIONS: Tumor volume, coronary artery disease, hypertension, and major complications impact LOS. Machine learning methods may identify nonlinear relationships worthy of targeted clinical investigation and allow for more accurate patient counseling.

The impact of social determinants of health on laryngotracheal stenosis development and outcomes.

OBJECTIVES: The social determinants of health affect a wide range of health outcomes and risks. To date, there have been no studies evaluating the impact of social determinants of health on laryngotracheal stenosis (LTS). We sought to describe the social determinants in a cohort of LTS patients and explore their association with treatment outcome. METHODS: Subjects diagnosed with LTS undergoing surgical procedures between 2013 and 2018 were identified. Matched controls were identified from intensive care unit (ICU) patients who underwent intubation for greater than 24 hours. Medical comorbidities, stenosis characteristics, and patient demographics were abstracted from the clinical record. Tracheostomy at last follow-up was recorded from the medical record and phone calls. Socioeconomic data was obtained from the American Community Survey. RESULTS: One hundred twenty-two cases met inclusion criteria. Cases had significantly lower education compared to Tennessee (P = .009) but similar education rates as ICU controls. Cases had significantly higher body mass index (odds ratio [OR]: 1.04, P = .035), duration of intubation (OR: 1.21, P < .001), and tobacco use (OR: 1.21, P = .006) in adjusted analysis when compared to controls. Tracheostomy dependence within the case cohort was significantly associated with public insurance (OR: 1.33, P = .016) and chronic obstructive pulmonary disease (OR: 1.34, P = .018) in adjusted analysis. CONCLUSION: Intubation practices, medical comorbidities and social determinants of health may influence the development of LTS and tracheostomy dependence after treatment. Identification of at-risk populations in ICUs may allow for prevention of tracheostomy dependence through the use of early tracheostomy and specialized follow-up. LEVEL OF EVIDENCE: Level 3, retrospective review comparing cases and controls Laryngoscope, 130:1000-1006, 2020.

Peri-Incisional Botulinum Toxin Therapy for Treatment of Intractable Head Pain After Lateral Skull Base Surgery: A Case Series.

OBJECTIVE: The objective of this case series was to describe botulinum toxin therapy as a novel treatment of intractable head pain following lateral skull base surgery. BACKGROUND: Intractable headaches following lateral skull base surgery are described in 23%-75% of patients and can significantly impact quality of life. Currently, the etiology of the headaches is unclear and treatment options are limited. Botulinum toxin is indicated for a multitude of functional and cosmetic reasons, including chronic migraine, and has been further described in treatment of various postsurgical pain syndromes. METHODS: In this case series, 4 patients underwent subcutaneous peri-incisional injections of botulinum toxin for intractable headache and head pain syndromes. Three patients had undergone lateral skull base surgery and the fourth patient had undergone a temporoparietal fascial flap harvest. Average injection dose ranged from 20 to 60 units with an average duration of effect ranging from 2 weeks to 4 months. RESULTS: All patients experienced significant relief of chronic head pain and returned for additional peri-incisional botulinum toxin injections, suggesting meaningful patient-perceived value. CONCLUSIONS: Botulinum toxin therapy may represent a novel treatment for intractable head pain following lateral skull base surgery and temporoparietal fascial flap harvest. This study represents a small case series and, although 100% of the patients who were treated significantly improved, future inquiry is necessary to confirm these findings.