Delayed Diagnoses in Patients With Dizziness in the US Commonwealth of Virginia and the Tidewater Region.

Objective: In a region of approximately 1.7 million people (Tidewater, coastal Virginia), identify secondary diagnoses in persons with dizziness. Methods: This cross-sectional study utilizing TriNetX included individuals in the region of interest diagnosed with dizziness between 2010 and 2020. Subsequent diagnoses of vestibular disease or medical conditions possibly associated with dizziness in the same subjects were catalogued. Results: During the study period, 31,670 subjects were identified with diagnoses of dizziness as a symptom; 18,390 subjects were subsequently given a dizziness-related nonvestibular diagnosis, and 930 were given a subsequent vestibular disease diagnosis. The proportion of subjects diagnosed with vestibular disease (3%) after the dizziness diagnosis is far below expected norms (25%-34%) in the general population. There were greater proportions of delayed diagnoses of labyrinth dysfunction (odds ratio [OR], 4.8; P < 0.0001), superior semicircular canal dehiscence (OR, 3.1; P = 0.0023), otolith disease (OR, 3.1; P = 0.0023), among others, and a decreased proportion of delayed diagnosis of benign paroxysmal positional vertigo (OR, 0.56; P < 0.0001). Conclusions: The discrepancy between expected and observed prevalence in our region indicates that vestibular disease is likely underdiagnosed.

Remission of Mucosal Melanoma of the Middle Ear and Petrous Temporal Bone and Reversal of Cranial Nerve Paresis Following Radiation and Single Agent Nivolumab: Clinical Capsule and Review of the Literature.

OBJECTIVE: We report disease remission and recovery of fifth and seventh nerve paresis in a case of primary mucosal melanoma of the middle ear and petrous temporal bone. PATIENT: A 74-year-old man developed sudden, profound, right sided sensorineural hearing loss, disequilibrium, otalgia, and cranial nerve V and VII dysfunction. Imaging demonstrated an unresectable, osteolytic lesion involving the middle ear and anterior petrous apex. Melanoma was diagnosed via in-office biopsy; whole-body metabolic imaging revealed no other primary site. INTERVENTION: Multidisciplinary management included radiation therapy (30 Gy, 10 fractions) followed by induction (five cycles, q2w) and maintenance nivolumab (six cycles, q3w). MAIN OUTCOME MEASURE: Complete metabolic response of primary site and metastases on imaging, recovery of cranial neuropathies. RESULTS: Following palliative radiation therapy and induction nivolumab, cranial neuropathies resolved. With maintenance-dose nivolumab, primary site and metastases exhibited a complete response. Therapy was stopped at 16 months post-diagnosis. Complete remission was maintained until 22 months after diagnosis. The patient developed a solitary cerebral metastasis which was refractory to radiosurgery and biopsy confirmed melanoma. He expired 2 years, 8 months post-diagnosis. CONCLUSIONS: Mucosal melanoma of the middle ear and petrous temporal bone is exceedingly rare. Management is individualized and surgery is undertaken when possible. Key observations in this case are the complete metabolic response and reversal of cranial nerve neuropathies following radiation and anti-programed cell death receptor ligand 1 therapy. Non-surgical treatment is worthy of study as initial management for similar lesions.

Hydroxyapatite cement cranioplasty following translabyrinthine approach: Long-term study of 369 cases.

OBJECTIVE: To report the authors' experience with hydroxyapatite cement (HAC) cranioplasty and analyze the material's long-term safety and efficacy in repairing translabyrinthine skull-base defects by examining adverse events, specifically cerebrospinal fluid (CSF) leaks and surgical site infections. STUDY DESIGN: Retrospective case-control study (primary study arm); prospective cross-sectional study of patients not examined within the last 5 years (secondary arm). SETTING: tertiary-care neurotology private practice and academic practice (two centers). METHODS: Hydroxyapatite cement implanted following translabyrinthine approach, with or without fat graft, was included. Combined approaches were excluded. Implant-associated adverse events were defined as 1) CSF leaks requiring reoperation or spinal drainage, and (2) infections requiring reoperation. Patients not examined within 5 years were interviewed by telephone to update their condition. Incidence of adverse events was compared to published data for translabyrinthine cranioplasty using fat graft alone. Implant survival analysis was performed. RESULTS: The study cohort included 369 HAC implants in the same number of patients. There were seven CSF leaks and seven infections. Combined (n = 14) incidence of adverse events was 3.8% (2.09%, 6.28%). Compared to fat graft alone, the adverse events associated with HAC were fewer (P < 0.001). Up to 15 years (5,475 days), HAC cement maintained 95% adverse event-free survival. There were no cases of meningitis. CONCLUSION: Cranioplasty using HAC with autologous fat following translabyrinthine skull-base surgery is safer and more effective than fat graft alone, up to 15 years after surgery. LEVEL OF EVIDENCE: 4. Laryngoscope, 127:2120-2125, 2017.

Fungal skull base osteomyelitis: Emerging microbial identification techniques.

Culture-based pathogen identification in skull base osteomyelitis, particularly for fungi, is often inaccurate. We report the case of patient with fungal skull base osteomyelitis cured by sustained antifungal therapy after 16 months of debilitating illness. Due to medical complications, a strong clinical rationale was needed to justify long-term antifungal therapy. The offending fungus was identified by experimental molecular technology (Ibis T5000 universal biosensor); invasive fungal disease was corroborated by biochemical assays. Our discussion will help familiarize the otolaryngologist with existing biochemical and molecular diagnostics for invasive fungal disease. We encourage future investigators to study their application in cases of skull base osteomyelitis. Laryngoscope, 127:E5-E7, 2017.

Sympathetic hearing loss: A review of current understanding and report of 2 cases.

Sympathetic hearing loss (SHL) is a rare complication that appears to occur when the immune system is primed against sequestered inner ear antigens. SHL has been implicated in delayed hearing loss after acoustic tumor removal, revision stapedectomy, and temporal bone fractures. We present 2 cases of suspected SHL after excision of skull base tumors during which the surgical approach had violated the otic capsule. Both patients experienced delayed contralateral sensorineural hearing loss. In comparing our cases with those previously reported, we hope to inspire others to do likewise and to develop an understanding of this clinical entity.

Laryngoscope Illuminance in a Tertiary Care Medical Center: Industry Standards and Implications for Quality Laryngoscopy.

OBJECTIVE: To test the hypothesis that a substantial proportion of laryngoscopes exhibit substandard illuminance by comparing laryngoscope illuminance in a tertiary-level medical center to established standards and identifying features associated with poor illuminance. STUDY DESIGN: Cross-sectional observational study. SETTING: Academic tertiary care medical center (level 1 trauma center, specialty cardiac hospital, and general hospital). SUBJECTS AND METHODS: Laryngoscopes from main, cardiac, and outpatient operating rooms; emergency department; and code carts were tested using a standard technique. Illuminance (lux) was chosen as the outcome measure. Benchmarks were derived from the International Standards Organization and medical literature. Light types included incandescent bulb, light-emitting diode, and xenon. Personnel were surveyed regarding maintenance practices. RESULTS: Across all hospitals, 691 laryngoscopes were tested. Mean (SD) illuminance was 810 (700) lux for incandescent bulb-on-blade designs (n = 237), 1860 (1220) lux for incandescent bulb in-handle designs (n = 79), 4730 (3210) lux for LED (n = 354), and 28,800 (34,500) lux for xenon (n = 21). Seven percent of units failed to turn on (n = 45). Using an established threshold of 867 lux, 28% of devices (47% of incandescent, 12% of LED, and 10% of xenon) were substandard. All laryngoscopes were cleaned according to standard protocols following use; no preventive maintenance was reported. CONCLUSION: Twenty-eight percent of laryngoscopes in a tertiary care hospital exhibit substandard illuminance; these results corroborate the findings of our inaugural study on this subject. Consequently, our hospital is instituting changes to reduce the likelihood of substandard performance by laryngoscopes in circulation.

Laryngoscope illuminance in a tertiary children's hospital: implications for quality laryngoscopy.

IMPORTANCE: Laryngoscopes are used by otolaryngologists in a variety of hospital emergency and critical care settings. However, only rarely have quality-related aspects of laryngoscope function and application been studied. OBJECTIVES: To compare the illuminance of laryngoscopes commonly used in a hospital setting to established standards and to assess the potential effects of maintenance practices on laryngoscope illuminance. DESIGN, SETTING, AND PARTICIPANTS: Observational study of laryngoscope light output and cross-sectional survey of individuals charged with laryngoscope maintenance in a tertiary care children's hospital. INTERVENTIONS: Illuminance was chosen as the unit of measurement (lux). Laryngoscopes in the operating room, emergency department, and pediatric intensive care unit were tested according to a standard technique. Illuminance standards for laryngoscopes, published by the International Organization for Standardization (ISO) (500 lux) and in the medical literature (867 lux) were used as benchmarks. MAIN OUTCOMES AND MEASURES: Mean laryngoscope illuminance by type of laryngoscope and light source and percentage of laryngoscopes with illuminance below established standards as well as nonfunctioning units. Maintenance practices were evaluated as a secondary outcome. RESULTS: A total of 319 laryngoscopes were tested; 283 were incandescent bulb units used by anesthesiologists, emergency physicians, and intensivists and 36 were xenon light units used by otolaryngologists. Mean (SD) illuminance was 1330 (1160) lux in the incandescent group and 16,600 (13,000) lux in the xenon group (P < .001). Substandard illuminance was observed only in the incandescent group, in 29% to 43% of laryngoscopes; 5% of the incandescent group did not turn on at all. Maintenance of laryngoscopes was performed on a reactive rather than a preventive basis. CONCLUSIONS AND RELEVANCE: At our facility, approximately one-third of incandescent laryngoscopes exhibited substandard light output. On the basis of these findings, our hospital has converted all of its incandescent laryngoscopes to light-emitting diode (LED) devices. Such changes, as well as the institution of a quality-control program including scheduled laryngoscope inspection and battery and bulb replacement for incandescent laryngoscopes, may reduce adverse events associated with poor-quality direct laryngoscopy.

Documenting immunization of children in a cochlear implant program.

PURPOSE: Assess the effectiveness of an immunization verification protocol (IVP) to achieve and document pneumococcal vaccination of patients with cochlear implants. STUDY DESIGN: Chart review. SETTING: Academic tertiary medical center. PATIENTS: Pediatric patients with cochlear implants (n = 76). OUTCOME MEASURES: 1) Status of pneumococcal immunization for cochlear implant patients, before and after initiation of the IVP; 2) final number of existing cochlear implant patients successfully immunized after institution of the IVP; and 3) effectiveness of communication between our office and patient/parent or pediatrician. RESULTS: Subjects were grouped according to whether their cochlear implantation was performed before (Group 1, n = 63) or after (Group 2, n = 18) initiation of the IVP in September 2010. In the 28 months between IVP initiation and January 2013, the number of fully immunized age-eligible patients increased in Group 1 from 2% (n = 1) to 63% (n = 40). Of 18 subjects in Group 2, 56% (n = 10) were fully vaccinated at the time of surgery, and 94% were fully vaccinated at the conclusion of the study (n = 17). Of all 81 children, complete immunization was documented in 70% (n = 57), incomplete documentation was noted in 16% (n = 13); and 14% (n = 11) were lost to follow-up. CONCLUSION: It is a challenge to achieve and document immunizations recommended for cochlear implantation, even in a relatively small cochlear implant program. In our practice, those patients who were required to document immunizations before surgery had the highest rates of compliance. Access to a vaccination registry and the ability to administer vaccines in the otolaryngology office also improved compliance.

Adenotonsillectomy vs observation for management of mild obstructive sleep apnea in children.

OBJECTIVE: To determine the impact of adenotonsillectomy vs observation on quality of life (QOL) in children with mild obstructive sleep apnea (OSA). STUDY DESIGN: Prospective, nonrandomized trial. SETTING: Tertiary children's hospital. SUBJECTS AND METHODS: Sixty-four children (ages 3-16 years) with mild OSA (apnea hypopnea index between 1 and 5 on polysomnogram) completed the study. Caregivers chose between management options of adenotonsillectomy and observation and completed validated QOL instruments (OSA-18 and Children's Health Questionnaire) at baseline, early, and late follow-ups. The primary outcome measure was QOL. RESULTS: Thirty patients chose adenotonsillectomy, while 34 were observed. Total OSA-18 scores at baseline were significantly poorer (P = .01) in the surgery group (72.3) compared with the observation group (58.5). Four months following surgery, OSA-18 scores improved by 39.1 points over baseline (P = .0001), while there was no change for the observation group (P = .69). After 8 months, OSA-18 scores remained improved in the surgery group, and observation group scores improved by 13.4 points over baseline (P = .005). While OSA-18 scores at the late follow-up visit were poorer in the observation group, the difference was not statistically significant (P = .05). Six observation patients opted for adenotonsillectomy during the study. CONCLUSION: Quality of life significantly improves in children with mild OSA after adenotonsillectomy. In children with mild OSA who are observed, QOL improvements at early follow-up are less pronounced, but significant improvements in QOL are evident after 8 months. QOL instruments may be useful tools to help providers determine which children with mild OSA may benefit from early intervention.

Current use of intralesional cidofovir for recurrent respiratory papillomatosis.

OBJECTIVES/HYPOTHESIS: The authors sought to define the indications, administration, and adverse events associated with intralesional cidofovir use for recurrent respiratory papillomatosis (RRP). STUDY DESIGN: Cross-sectional study. METHODS: A 21-question online survey was distributed to 115 selected adult and pediatric laryngeal surgeons internationally. Results were used to draft statements of best practice, which were approved by the full membership of the RRP Task Force. RESULTS: Eighty-two surgeons, who altogether presently manage 3,043 patients with RRP, responded to the survey. Seventy-four surgeons previously used cidofovir, reporting 1,248 patients in the last decade (estimated 801 adults and 447 children). Single indications for adjuvant cidofovir included six or more surgeries per year, increasing frequency of surgery, and extralaryngeal spread (in children). Most adult surgeons use 20 to 40 mg in <4 mL; pediatric surgeons use <20 mg in <2 mL. Scheduled administration following an initiation trial of five injections is common; cidofovir is discontinued following a complete response. Most surgeons biopsy routinely, use special informed consent, and are willing to participate in multi-institutional clinical trials on cidofovir uses, efficacy, and safety. CONCLUSIONS: Eighteen statements were approved by the RRP Task Force after discussion of the survey results. Intralesional cidofovir may be initiated if surgical debulking is required every 2 to 3 months. The concept of an adjuvant regimen with regular biopsy is favored. Administration should remain below established safe limits of dosing (3 mg/kg) and volume. Informed consent, including discussion of off-label use and acute kidney injury in children, is important. A special consent form sample is included. There remains a need for high-quality data.

Global health initiatives of US otolaryngology residency programs: 2011 global health initiatives survey results.

OBJECTIVES/HYPOTHESIS: The objectives of this work were to quantify the involvement of US otolaryngology residency programs in global health endeavors, identify goals and services provided, and determine the participation of residents and fellows. STUDY DESIGN: Cross-sectional survey of US otolaryngology faculty. METHODS: A 10-point online questionnaire was distributed to 103 US otolaryngology residency program directors; all faculty involved in global health volunteerism were invited to participate. RESULTS: Twenty-nine global health initiatives were represented. Most of the 24 residency programs involved (66%) had organized global health offices at their institutions; only 4% actually cooperated with these offices. Most often, only one attending (55%) was involved at each institution. Residents/fellows participated 65% of the time. Abroad, US otolaryngologists worked with freestanding hospitals or clinics (24%), American nongovernmental organizations (17%), academic centers (14%), and remote locations (14%). Most (96%) provided specialty surgical services, but some provided primary care (28%) and general surgical services (14%); 72% trained foreign surgeons. Most respondents (79%) reported that the clinical work done abroad was substantial enough for Accreditation Council for Graduate Medical Education (ACGME) standards. Only one fifth of respondents knew the name of the nearest otolaryngology training institution. Humanitarian aid was the most prevalent goal (100%), followed by resident/fellow exchange (45%) and faculty exchange (21%). CONCLUSIONS: At least a quarter of US otolaryngology residency programs engage in global health volunteerism. Most do not utilize institutional global health resources and are unaware of otolaryngology training programs abroad. There may be a role for global health education within the ACGME competency of systems-based practice.

Quality of Internet information in pediatric otolaryngology: a comparison of three most referenced websites.

OBJECTIVE: Patients commonly refer to Internet health-related information. To date, no quantitative comparison of the accuracy and readability of common diagnoses in Pediatric Otolaryngology exist. STUDY AIMS: (1) identify the three most frequently referenced Internet sources; (2) compare the content accuracy and (3) ascertain user-friendliness of each site; (4) inform practitioners and patients of the quality of available information. METHODS: Twenty-four diagnoses in pediatric otolaryngology were entered in Google and the top five URLs for each were ranked. Articles were accessed for each topic in the three most frequently referenced sites. Standard rubrics were developed to include proprietary scores for content, errors, navigability, and validated metrics of readability. RESULTS: Wikipedia, eMedicine, and NLM/NIH MedlinePlus were the most referenced sources. For content accuracy, eMedicine scored highest (84%; p<0.05) over MedlinePlus (49%) and Wikipedia (46%). The highest incidence of errors and omissions per article was found in Wikipedia (0.98±0.19), twice more than eMedicine (0.42±0.19; p<0.05). Errors were similar between MedlinePlus and both eMedicine and Wikipedia. On ratings for user interface, which incorporated Flesch-Kinkaid Reading Level and Flesch Reading Ease, MedlinePlus was the most user-friendly (4.3±0.29). This was nearly twice that of eMedicine (2.4±0.26) and slightly greater than Wikipedia (3.7±0.3). All differences were significant (p<0.05). There were 7 topics for which articles were not available on MedlinePlus. CONCLUSIONS: Knowledge of the quality of available information on the Internet improves pediatric otolaryngologists' ability to counsel parents. The top web search results for pediatric otolaryngology diagnoses are Wikipedia, MedlinePlus, and eMedicine. Online information varies in quality, with a 46-84% concordance with current textbooks. eMedicine has the most accurate, comprehensive content and fewest errors, but is more challenging to read and navigate. Both Wikipedia and MedlinePlus have lower content accuracy and more errors, however MedlinePlus is simplest of all to read, at a 9th Grade level.

Construct validity of a simulator for myringotomy with ventilation tube insertion.

OBJECTIVES: To establish construct validity of an anatomic model as a simulator for myringotomy with ventilation tube insertion and to assess its subjective appeal. STUDY DESIGN: Cross-sectional, repeated-measures comparative evaluation of simulator. SETTING: University academic otolaryngology residency program. SUBJECTS AND METHODS: Using an anatomic model of the human auricle, ear canal, eardrum, and middle ear space, 18 otolaryngologists of various levels of training performed 10 timed procedures: myringotomy with ventilation tube insertion. Errors were recorded, and participants reported the quality of their experience. RESULTS: Both time-to-completion and errors per trial discriminated novices from non-novice participants; novices (02:23, 95% confidence interval [CI], 01:42-03:04) were 3.6 times slower than non-novices (00:39, 95% CI, 00:35-00:43) and 6.5 times more error prone (novices 2.16 errors/trial, 95% CI, 1.68-2.64; non-novices 0.33 errors/trial, 95% CI, 0.21-0.45). Errors were strongly correlated with prior surgical experience. All participants required more time to complete the first trial, and their performance stabilized thereafter. Overall, the simulation was perceived as a valuable experience. CONCLUSION: Our model is a valid platform for simulating myringotomy with ventilation tube insertion. The model discriminates novices from non-novices, has a learning curve, and is perceived to be a valuable and realistic teaching tool by users.