3D printed temporal bones for preoperative simulation and planning.

OBJECTIVE: Demonstrate the utility of 3D printed temporal bone models in individual patient preoperative planning and simulation. METHODS: 3D models of the temporal bone were made from 5 pediatric and adult patients at a tertiary academic hospital with challenging surgical anatomy planned for cochlear implantation or exteriorization of cholesteatoma with complex labyrinthine fistula. The 3D models were created from CT scan used for preoperative planning, simulation and intraoperative reference. The utility of models was assessed for ease of segmentation and production and impact on surgery in regard to reducing intraoperative time and costs, improving safety and efficacy. RESULTS: Three patients received cochlear implants, two exteriorization of advanced cholesteatoma with fistulas (1 internal auditory canal/cochlea, 1 all three semicircular canals). Surgical planning and intraoperative referencing to the simulations by the attending surgeon and trainees significantly altered original surgical plans. In a case of X-linked hereditary deafness, optimal angles and rotation maneuvers for cochlear implant insertion reduced operating time by 93 min compared to the previous contralateral side surgery. Two cochlear implant cases planned for subtotal petrosectomy approach due to aberrant anatomy were successfully approached through routine mastoidectomy. The cholesteatoma cases were successfully exteriorized without necessitating partial labyrinthectomy or labyrinthine injury. There were no complications. CONCLUSION: 3D printed models for simulation training, surgical planning and use intraoperatively in temporal bone surgery demonstrated significant benefits in designing approaches, development of patient-specific techniques, avoidance of potential or actual complications encountered in previous or current surgery, and reduced surgical time and costs.

Repair of tegmen defect using cranial particulate bone graft.

Bone paté is used to repair cranial bone defects. This material contains bone-dust collected during the high-speed burring of the cranium. Clinical and experimental studies of bone dust, however, have shown that it does not have biological activity and is resorbed. We describe the use of bone paté using particulate bone graft. Particulate graft is harvested with a hand-driven brace and 16mm bit; it is not subjected to thermal injury and its large size resists resorption. Bone paté containing particulate graft is much more likely than bone dust to contain viable osteoblasts capable of producing new bone.

Round window reinforcement for superior semicircular canal dehiscence: a retrospective multi-center case series.

PURPOSE: To evaluate the outcome of round window (RW) tissue reinforcement in the management of superior semicircular canal dehiscence (SSCD). MATERIALS AND METHODS: Twenty-two patients with confirmed diagnosis of SSCD by clinical presentation, imaging, and/or testing were included in the study. Six surgeons at four institutions conducted a multicenter chart review of patients treated for symptomatic superior canal dehiscence using RW tissue reinforcement or complete RW occlusion. A transcanal approach was used to reinforce the RW with various types of tissue. Patients completed a novel postoperative survey, grading preoperative and postoperative symptom severity. RESULTS: Analysis revealed statistically significant improvement in all symptoms with the exception of hearing loss in 19 patients who underwent RW reinforcement. In contrast, 2 of 3 participants who underwent the alternate treatment of RW niche occlusion experienced worsened symptoms requiring revision surgery. CONCLUSION: RW tissue reinforcement may reduce the symptoms associated with SSCD. The reinforcement technique may benefit SSCD patients by reducing the "third window" effect created by a dehiscent semicircular canal. Given its low risks compared to middle cranial fossa or transmastoid canal occlusion, RW reinforcement may prove to be a suitable initial procedure for intractable SSCD. In contrast, complete RW occlusion is not advised.

Pediatric cerebrospinal fluid rhinorrhea caused by low flow vascular anomaly of the temporal bone: A case series.

OBJECTIVE: Atraumatic cerebrospinal fluid (CSF) rhinorrhea is uncommon in children and necessitates a multi-disciplinary evaluation for an etiology. Underlying osseous abnormality due to extensive or multifocal low flow vascular anomaly should be considered as a potential cause of spontaneous CSF leak. Treatment of multifocal low flow vascular anomalies may include medical and surgical approaches. In this series, we seek to determine the presenting signs and symptoms and medical and surgical treatment options for multifocal or extensive low flow vascular anomalies. METHODS: A retrospective case series at a quaternary care children's hospital was compiled. All children with CSF rhinorrhea diagnosed and treated for multifocal low flow vascular anomalies at our institution were included. A total of four patients were identified. RESULTS: All four patients had delay in initial diagnosis of underlying cause of meningitis and CSF rhinorrhea. Average age at diagnosis of multifocal low flow vascular anomaly was 7 years. This was on average 4 years after initial presentation for medical attention. Treatment approach was multidisciplinary and included medical management with sirolimus and bisphosphonates as well as surgical approaches to the skull base (lateral and anterior) to prevent CSF egress. CONCLUSION: Consideration of multifocal low flow vascular anomaly should be included in any pediatric patient presenting with CSF rhinorrhea.

Patulous Eustachian Tube Dysfunction Symptoms Following Balloon Dilation.

OBJECTIVE: Clinicians increasingly perform balloon dilation of the Eustachian tube (BDET) to treat obstructive Eustachian tube dysfunction (OETD) refractory to medical management. Reported complications have been limited and include patulous Eustachian tube dysfunction (PETD). This multicenter study investigates the incidence of PETD and associated factors. METHODS: Consecutive patients at three academic centers undergoing BDET (January 2014-November 2019) for OETD refractory to medical therapy were included. PETD was diagnosed by patient-reported symptoms of autophony of voice and/or breathing. Associated factors studied include age, sex, comorbidities, balloon size, duration of inflation, repeat BDET, and adjunctive procedures. RESULTS: BDET procedures (n = 295 Eustachian tubes) were performed on 182 patients. Mean age was 38.4 years (SD 21.0; range 7-78) and 41.2% were female. Twenty cases of PETD (6.8% of procedures; 9.3% of patients) occurred following BDET. Risk of PETD did not vary by institution, comorbidities, or adjunctive procedure. Age ≤18 years (adjusted risk ratio [RR] = 3.26; 95% confidence interval [CI]: 1.24, 8.54; p = 0.02), repeat BDET (RR = 3.26; 95% CI: 2.15, 4.96; p < 0.001), and severe preoperative Eustachian tube inflammation (RR = 2.83; 95% CI: 1.10, 7.28; p = 0.03) were associated with increased risk of developing PETD in the multivariable model. Most symptoms were reported as mild or intermittent. CONCLUSION: BDET caused PETD symptoms in approximately 7% of dilated Eustachian tubes in this study with increased risk for younger patients and those with severe inflammation or undergoing repeat dilations. Although most cases were self-limited, symptoms can persist. Awareness of risk factors may aid clinicians in limiting this complication. LEVEL OF EVIDENCE: 4 Laryngoscope, 133:3152-3157, 2023.

Surfactant proteins and innate immunity of otitis media.

Otitis media (OM) is the most common disease among young children and one of the most frequent reasons to visit the pediatrician. Development of OM requires nasopharyngeal colonization by a pathogen which must gain access to the tympanic cavity through the eustachian tube (ET) along with being able to overcome the defense mechanisms of the immune system and middle ear mucosa. OM can be caused by viral or bacterial infection. The three main bacterial pathogens are Streptococcus pneumoniae, nontypeable Haemophilus influenzae (NTHi), and Moraxella catarrhalis. Innate immunity is important in OM resolution as the disease occurs in very young children before the development of specific immunity. Elements of innate immunity include natural barriers and pattern recognition receptors such as Toll like receptors (TLRs), and Nod like receptors (NLRs). Surfactant proteins A (SP-A) and D (SP-D) act as pattern recognition receptors and are found in the lung and many other tissues including the ET and the middle ear where they probably function in host defense. Surfactant has a potential for use in the treatment of OM due to surface tension lowering function in the ET, and the possible immune functions of SP-D and SP-A in the middle ear and ET.

Balloon dilation of the cartilaginous portion of the eustachian tube: initial safety and feasibility analysis in a cadaver model.

BACKGROUND: Balloon catheter dilation of diseased sinus ostia has recently demonstrated efficacy and safety in the treatment of chronic sinus disease with 2 years of follow-up. Similar to sinus surgery, initial studies of partial resection of inflamed mucosa from within the cartilaginous eustachian tube (ET) have demonstrated efficacy and safety in the treatment of medically refractory otitis media with effusion. Therefore, balloon dilation of the cartilaginous ET was investigated as a possible treatment modality for otitis media. METHODS: A protocol for sinus balloon catheter dilation was evaluated in each of the cartilaginous ETs in 8 fresh human cadaver heads. Computed tomographic scans and detailed endoscopic inspections with video or photographic documentation were performed pre- and posttreatment, and gross anatomical dissections were done to analyze the effects of treatment and to look for evidence of undesired injury. RESULTS: Catheters successfully dilated all cartilaginous ETs without any significant injuries. There were no bony or cartilaginous fractures, and 3 specimens showed minor mucosal tears in the anterolateral or inferior walls. Volumetric measurements of the cartilaginous ET lumens showed a change from an average of 0.16 to 0.49 cm(3) (SD, 0.12), representing an average increase of 357% (range, 20-965%). CONCLUSIONS: Balloon catheter dilation of the nasopharyngeal orifice of the ET was shown to be feasible and without evidence of untoward injury. A significant increase in volume of the cartilaginous ET was achieved. A clinical study is now indicated to determine whether balloon dilation will demonstrate lasting benefits and safety in the treatment of otitis media.

Intradermal Testing Doubles Identification of Allergy among 110 Immunotherapy-Responsive Patients with Eustachian Tube Dysfunction.

The purpose of this study was to determine whether the sensitivity advantage of intradermal dilutional testing (IDT) is clinically relevant in patients with obstructive Eustachian tube dysfunction (ETD) or otitis media with effusion (OME). This retrospective, private-practice cohort study compared the sensitivity of skin prick tests (SPT) vs. IDT in 110 adults and children with suspected allergy and OME. Primary outcome measure was symptom resolution from allergy immunotherapy (AIT). IDT identified 57% more patients as being allergic, and 8.6 times more reactive allergens than would have been diagnosed using only SPT. Patients diagnosed by IDT had the same degree of symptom improvement from immunotherapy, independent of allergen sensitivity (66% by SPT vs. 63% by IDT; p = 0.69, not different). Low-sensitivity allergy tests, which may fail to identify allergy in over two thirds of children aged 3 to 15 as being atopic, or among 60% of patients with ETD, may explain why many physicians do not consider allergy as a treatable etiology for their patient's OME/ETD. IDT offers superior sensitivity over SPT for detecting allergens clinically relevant to treating OME/ETD. These data strongly support increased utilization of intradermal testing and invite additional clinical outcome studies.

Further Research Needed to Understand Relationship Between Tubarial Glands and Eustachian Tube Dysfunction.

The pathophysiology of eustachian tube dysfunction (ETD) remains poorly characterized, and it may result in significant patient morbidity. A recent study has identified a collection of previously unidentified salivary glands in the nasopharynx that overlay the torus tubarius. While salivary gland tissue has been described in the nasopharynx, the newly discovered salivary gland tissue has been denoted tubarial glands (TGs) and theorized to be a distinct organ. The TGs have been suggested to aid in lubrication of the oropharynx and nasopharynx. However, the exact clinical significance of TGs is unknown. Given the proximity of the TG to the eustachian tube, it is possible that the TGs may be related to the development of ETD. Future studies of the TGs and related pathophysiology may improve approaches to developing future ETD treatments.

International Pediatric Otolaryngology Group (IPOG) Consensus Recommendations: Congenital Cholesteatoma.

OBJECTIVE: To provide recommendations to otolaryngologists and allied physicians for the comprehensive management of children who present with signs and symptoms of congenital cholesteatoma. METHODS: A two-iterative Delphi method questionnaire was used to establish expert recommendations by the members of the International Pediatric Otolaryngology Group, on the preoperative work-up, the perioperative considerations, and follow-up. RESULTS: Twenty-two members completed the survey, in 14 tertiary-care center departments representing 5 countries. The main consensual recommendations were: a precise otoscopic description of the quadrants involved, extensive audiological workup (bilateral tonal, vocal audiometry, and BERA), and a CT scan are required. Facial nerve monitoring and a combination of microscope and telescope are recommended for surgical removal. Clinical and audiological follow-up should be pursued yearly for at least 5 years. First MRI follow-up should be done at 18 months postoperatively if the removal violated the matrix. MRI follow-up duration depends on the initial extent of the cholesteatoma. CONCLUSION: The goal of preoperative and follow-up consensus from International Pediatric Otolaryngology Group participants is to help manage infants and children with congenital cholesteatoma. The operative techniques may vary, and experienced surgeons must perform these procedures.

Twelve-month outcomes of Eustachian tube procedures for management of patulous Eustachian tube dysfunction.

OBJECTIVE: To determine the 12-month effectiveness of transnasal-transoral endoscopic surgical procedures for eliminating symptoms of patulous Eustachian tube dysfunction (PETD). STUDY DESIGN: Retrospective chart review METHODS: Patients with medically refractory PETD underwent one of the following procedures: 1) shim (catheter) insertion, 2) calcium hydroxyapatite injection, 3) patulous Eustachian tube (ET) reconstruction, or 4) obliteration of the ET lumen. Time to recurrence of any PETD symptoms was recorded, and success was determined as complete symptom resolution at 12 months. The frailty model, an extension of the Cox proportional hazards model, was used for the survival analysis. RESULTS: A total of 241 procedures were performed in 80 patients. Median duration of symptom relief after surgery was 5.0 months (interquartile range [IQR]: 1.1-15.5 months) and varied by procedure type, ranging from 3.0 months (IQR: 0.7-7.0 months) for calcium hydroxyapatite injection to 20.6 months (3.4-35.9 months) for obliteration. Compared to shim insertion, the risk of 12-month failure was significantly higher for calcium hydroxyapatite injection (hazard ratio [HR] = 2.18; 95% confidence interval [CI] 1.29, 3.67; P = 0.004) and patulous ET reconstruction (HR = 1.62; 95% CI 1.04, 2.52; P = 0.035). Patients undergoing shim insertion (52.2%) and obliteration (81.8%) were likely to require pressure equalization tubes or to have had otitis media with effusion. CONCLUSION: Although all procedures potentially resulted in symptom resolution, placement of a shim or obliteration of the ET lumen was more likely to achieve 12-month resolution of PETD symptoms and more likely to result in otitis media with effusion than hydroxyapatite injection or patulous ET reconstruction. LEVEL OF EVIDENCE: Level 4 Laryngoscope, 129:222-228, 2019.

Hairy polyps: A new case presentation and a pathogenetic hypothesis.

Hairy polyps are benign lesions found in the oropharynx or nasopharynx that are thought to be present at birth and can lead to upper airway obstruction in infants. Also known as naso-oropharyngeal choristoma, they are increasingly viewed as aggregates of bigeminal tissue, likely from the first or second branchial arches, found in aberrant locations. They are benign lesions that are usually successfully treated by surgical excision. Here we present a rare case of a hairy polyp originating in the eustachian tube of a 7-week-old male, discuss our management of the patient, and put forth a new hypothesis as to the origin of these lesions. Laryngoscope, 129:2398-2402, 2019.

Clinical Consensus Statement: Balloon Dilation of the Eustachian Tube.

OBJECTIVE: To develop a clinical consensus statement on the use of balloon dilation of the eustachian tube (BDET). METHODS: An expert panel of otolaryngologists was assembled with nominated representatives of general otolaryngology and relevant subspecialty societies. The target population was adults 18 years or older who are candidates for BDET because of obstructive eustachian tube dysfunction (OETD) in 1 or both ears for 3 months or longer that significantly affects quality of life or functional health status. A modified Delphi method was used to distill expert opinion into clinical statements that met a standardized definition of consensus. RESULTS: After 3 iterative Delphi method surveys, 28 statements met the predefined criteria for consensus, while 28 statements did not. The clinical statements were grouped into 3 categories for the purposes of presentation and discussion: (1) patient criteria, (2) perioperative considerations, and (3) outcomes. CONCLUSION: This panel reached consensus on several statements that clarify diagnosis and perioperative management of OETD. Lack of consensus on other statements likely reflects knowledge gaps regarding the role of BDET in managing OETD. Expert panel consensus may provide helpful information for the otolaryngologist considering the use of BDET for the management of patients with OETD.

Complications with hydroxyapatite cement in mastoid cavity obliteration.

OBJECTIVE: To determine whether hydroxyapatite (HA) bone cement is a suitable material for mastoid cavity obliteration. STUDY DESIGN & SETTING: Retrospective case review; tertiary care pediatric hospital. PATIENTS: Three patients, aged 11 to 16 years, underwent canal wall down mastoidectomy for removal of cholesteatomas. INTERVENTION: Mastoid cavity obliteration was performed with hydroxyapatite bone cement. MAIN OUTCOME MEASURES: Failure was defined as the necessity for HA explantation. RESULTS: All three patients required revision surgery to remove the HA cement. Two patients (one primary and one second look with obliteration) presented with granulations in the mastoid cavity, surrounding the cement. The third patient's intraoperative findings included extensive skull base osteitis with erosion of the posterior and middle fossa dural plates, and fistulae of the lateral and superior semicircular canals. All patients recovered fully after removal of the HA cement. CONCLUSION: This study raises concerns over the use of HA cement for mastoid cavity obliteration. Three of three implanted patients required revision surgery, two with delayed failure of integration and infection, and one with severe osteitis and significant complications.

Laser eustachian tuboplasty: two-year results.

OBJECTIVE/HYPOTHESIS: Laser eustachian tuboplasty (LETP) combined with appropriate medical management will eliminate the chronic presence of middle ear effusions in selected patients. METHODS: The study population consisted of 13 adults with otitis media with effusion (OME). Patients underwent slow-motion video endoscopy to identify the location and extent of surgical resection. A diode or argon laser was used to vaporize areas of hypertrophic mucosa and submucosa along the cartilaginous eustachian tube. Patients were evaluated at 6, 12, and 24 months. Successful outcome was defined as absence of OME. Patients with evidence of reflux disease or allergic rhinitis were treated with medical therapy before surgery and throughout the follow-up period as indicated. RESULTS: LETP combined with medical management eliminated OME in 36% (4 of 11) of patients at 6 months, 40% (4 of 10) at 1 year, and 38% (3 of 8) at 2 years. Failure of LETP correlated with presence of laryngopharyngeal reflux (P = .01) or allergic disease (P = .05) for the results at 1 year but not at 2 years. CONCLUSIONS: LETP combined with appropriate medical management may be an effective treatment in select patients with chronic persistent eustachian tube dysfunction. A controlled trial with a larger number of subjects will be necessary to determine the efficacy of LETP and identify those factors predictive of successful outcome.

Diagnosis and management of the patulous eustachian tube.

OBJECTIVE: The patulous eustachian tube (ET) seems to be caused by a longitudinal concave defect in the mucosal valve at the superior aspect of its anterolateral wall and causes troublesome autophony of one's own voice and breathing sounds. Patulous ET reconstruction was evaluated to analyze whether submucosal graft implantation to fill in the concavity within the patulous tubal valve may produce lasting relief of symptoms. STUDY DESIGN: Prospective trial. SETTING: Tertiary referral center, ambulatory surgery. PATIENTS: Fourteen ETs in 11 adults with 1 or more years of confirmed continuous patulous ET symptoms refractory to medical care. INTERVENTION: Endoluminal patulous ET reconstruction was performed in 14 separate cases using a combined endoscopic transnasal and transoral approach under general anesthesia. A submucosal flap was raised along the anterolateral wall of the tubal lumen up to the valve and mobilized superiorly off of the basisphenoid. The pocket was filled with autologous cartilage graft or Alloderm implant, restoring the normal convexity and competence to the mucosal lumen valve. MAIN OUTCOME MEASURE: Autophony symptoms were scored as 1) complete relief; 2) significant improvement, satisfied; 3)significant improvement, dissatisfied; 4) unchanged; or 5)worse. RESULTS: All 14 cases reported immediate complete relief of autophony. Results with an average follow-up of 15.8 months are as follows: 1 (7%) case had complete relief; 5 (36%) had significant improvement, satisfied; 7 (50%) had significant improvement, dissatisfied; and 1 (7%) was unchanged. There were no complications. Correlation between patulous ET and other conditions was strongest with previous tubal dysfunction. Autophony of voice, but not breathing sounds, was also found to be experienced by 17 (94%) of 18 patients with superior semicircular canal dehiscence syndrome and could be easily mistaken for patulous ET autophony. CONCLUSION: Patulous ET seems to be caused by a concave defect in the tubal valve's anterolateral wall. Submucosal graft implantation to restore the normal convexity to the valve wall seems to provide lasting relief of symptoms. Long-term study is needed. It is important to differentiate between the autophony of semicircular canal dehiscence syndrome and patulous ET.

Clinical and diagnostic characterization of canal dehiscence syndrome: a great otologic mimicker.

OBJECTIVE: To identify otologic and audiologic characteristics of superior (and posterior) semicircular canal dehiscence (SCD). STUDY DESIGN: Retrospective case review. SETTING: Tertiary referral center. PATIENTS: Sixty-five adult patients were evaluated for SCD; 26 of 65 (35 ears) had dehiscence. INTERVENTION(S): Otologic examination, high-resolution computerized tomography (CT), air and bone audiometry, tympanometry, acoustic reflex, and vestibular evoked myogenic potential (VEMP). MAIN OUTCOME MEASURE(S): Imaging demonstrating canal dehiscence, preferentially including Poschel and Stenvers reconstructions. Audiologic findings of pseudoconductive loss, intact ipsilateral stapedial reflex, and abnormally low VEMP thresholds. RESULTS: The most common presenting complaints were autophony of voice and a "blocked ear" (94%), mimicking patulous eustachian tube, including relief with Valsalva or supine position (50%), but without autophony of nasal breathing. Pseudoconductive loss was found in 86% of dehiscence ears, and 60% (21 of 35) of these ears had better than 0-dB-hearing-loss bone conduction thresholds at 250 and/or 500 Hz. Acoustic reflex was present in 89%. Assuming CT as the criterion standard, VEMP resulted in 91.4% sensitivity and 95.8% specificity. One false-positive CT, with abnormal VEMP, resulted in surgical explorations negative for superior SCD but positive for posterior SCD. CONCLUSION: Semicircular canal dehiscence may present with various symptoms such as autophony, ear blockage, and dizziness/vertigo. A combination of high-resolution CT and audiologic testing is recommended for diagnosis. Low-frequency conductive loss with better than 0 dB hearing level (HL) bone conduction threshold and normal tympanometry, with intact acoustic reflexes, are audiologic signs of SCD. Vestibular evoked myogenic potential is highly sensitive and specific for SCD, possibly better than CT.

Microdebrider eustachian tuboplasty: A preliminary report.

OBJECTIVE: To evaluate microdebrider eustachian tuboplasty for treatment of patients with eustachian tube dysfunction. STUDY DESIGN: A prospective study of 20 patients with eustachian tube dysfunction who underwent microdebrider eustachian tuboplasty (mETP) was performed at an academic medical center. Surgery involved use of a microdebrider to remove hypertrophied mucosa from the posterior eustachian tube cushion. All patients had concurrent sinonasal disease and underwent endoscopic sinus surgery at the time of mETP. RESULTS: There were no surgical complications. Following mETP, subjective symptoms of ear blockage improved in 14 of 20 patients (70%). Mean pure tone average improved by 6 dB (27 dB pre-op vs 21 dB post-op; P = 0.013). Abnormal tympanogram improved in 11 of 17 patients (65%). Failure of the procedure correlated with severity of mucosal disease as measured by both elevated tissue eosinophil count and advanced sinus CT stage (P = 0.018 and P = 0.014, respectively). Mean follow-up was 13 months (range 3-34 months). CONCLUSION: Microdebrider eustachian tuboplasty appears to be a safe procedure for the treatment of eustachian tube dysfunction.

Patulous Eustachian Tube Dysfunction: Patient Demographics and Comorbidities.

OBJECTIVE: The objective is to describe a large cohort of patients presenting with patulous Eustachian tube (pET) dysfunction. STUDY DESIGN: Retrospective patient series. SETTING: Tertiary referral center. PATIENTS: All outpatient visits (2004-2016) that were assigned ICD9 code (381.7-Patulous Eustachian tube) were screened. Only patients with observed tympanic membrane movements during ipsilateral nasal breathing or acoustic reflex decay testing demonstrating transmitted nasal breathing were included (n = 190, n = 239 ears). MAIN OUTCOME MEASURES: Demographics and nasopharyngoscopy/otomicroscopy findings by comorbidities. RESULTS: The majority (54%) was female and mean age of symptom onset was 38.0 (SD 20.0) years. Common symptoms included voice autophony (93%), breath autophony (92%), aural fullness (57%), pulsatile tinnitus (17%), and crackling or rumbling sounds (14%). Symptoms increased in frequency and duration with time (65%), were exacerbated with exercise (27%), and improved with placing the head in a dependent position (65%), sniffing (28%), upper respiratory infection (8%), and ipsilateral internal jugular vein compression (12%). In 52% pET was bilateral. Common comorbidities include environmental allergy (49%), weight loss (35%), laryngopharyngeal reflux (33%), anxiety (31%), autoimmunity (13%), and neuromuscular disease (8%). Allergy and anxiety patients were younger and more likely to have tonic contraction of the tensor veli palatini on exam (p < 0.05, χ). Allergy patients also had relief with sniffing and tympanic membrane retraction (p < 0.01, χ). Weight loss patients reported mean loss of 19.7 kg (SD 23.1), and were older, more rapidly diagnosed, and more likely to have persistent symptoms (p < 0.05). Initially, all patients were treated medically, with 47% eventually electing surgical intervention. CONCLUSION: pET is progressive, often bilateral, and possibly underdiagnosed. In this large series of pET, in addition to weight loss and chronic medical conditions, allergy and stress/anxiety were identified as novel risk factors. Most patients can be treated medically.

Panel 2: Anatomy (Eustachian Tube, Middle Ear, and Mastoid-Anatomy, Physiology, Pathophysiology, and Pathogenesis).

Objective In this report, we review the recent literature (ie, past 4 years) to identify advances in our understanding of the middle ear-mastoid-eustachian tube system. We use this review to determine whether the short-term goals elaborated in the last report were achieved, and we propose updated goals to guide future otitis media research. Data Sources PubMed, Web of Science, Medline. Review Methods The panel topic was subdivided, and each contributor performed a literature search within the given time frame. The keywords searched included middle ear, eustachian tube, and mastoid for their intersection with anatomy, physiology, pathophysiology, and pathology. Preliminary reports from each panel member were consolidated and discussed when the panel met on June 11, 2015. At that meeting, the progress was evaluated and new short-term goals proposed. Conclusions Progress was made on 13 of the 20 short-term goals proposed in 2011. Significant advances were made in the characterization of middle ear gas exchange pathways, modeling eustachian tube function, and preliminary testing of treatments for eustachian tube dysfunction. Implications for Practice In the future, imaging technologies should be developed to noninvasively assess middle ear/eustachian tube structure and physiology with respect to their role in otitis media pathogenesis. The new data derived from these structure/function experiments should be integrated into computational models that can then be used to develop specific hypotheses concerning otitis media pathogenesis and persistence. Finally, rigorous studies on medical or surgical treatments for eustachian tube dysfunction should be undertaken.