Segmentation of Vestibular Schwannomas on Postoperative Gadolinium-Enhanced T1-Weighted and Noncontrast T2-Weighted Magnetic Resonance Imaging Using Deep Learning.

OBJECTIVE: Surveillance of postoperative vestibular schwannomas currently relies on manual segmentation and measurement of the tumor by content experts, which is both labor intensive and time consuming. We aimed to develop and validate deep learning models for automatic segmentation of postoperative vestibular schwannomas on gadolinium-enhanced T1-weighted magnetic resonance imaging (GdT1WI) and noncontrast high-resolution T2-weighted magnetic resonance imaging (HRT2WI). STUDY DESIGN: A supervised machine learning approach using a U-Net model was applied to segment magnetic resonance imaging images into pixels representing vestibular schwannoma and background pixels. SETTING: Tertiary care hospital. PATIENTS: Our retrospective data set consisted of 122 GdT1WI and 122 HRT2WI studies in 82 postoperative adult patients with a vestibular schwannoma treated with subtotal surgical resection between September 1, 2007, and April 17, 2018. Forty-nine percent of our cohort was female, the mean age at the time of surgery was 49.8 years, and the median time from surgery to follow-up scan was 2.26 years. INTERVENTIONS: N/A. MAIN OUTCOME MEASURES: Tumor areas were manually segmented in axial images and used as ground truth for training and evaluation of the model. We measured the Dice score of the predicted segmentation results in comparison to manual segmentations from experts to assess the model's accuracy. RESULTS: The GdT1WI model achieved a Dice score of 0.89, and the HRT2WI model achieved a Dice score of 0.85. CONCLUSION: We demonstrated that postoperative vestibular schwannomas can be accurately segmented on GdT1WI and HRT2WI without human intervention using deep learning. This artificial intelligence technology has the potential to improve the postoperative surveillance and management of patients with vestibular schwannomas.

Impact of COVID-19 on Otolaryngology Literature.

OBJECTIVES/HYPOTHESIS: To understand the effect of the COVID-19 pandemic on the volume, quality, and impact of otolaryngology publications. STUDY DESIGN: Retrospective analysis. METHODS: Fifteen of the top peer-reviewed otolaryngology journals were queried on PubMed for COVID and non-COVID-related articles from April 1, 2020 to March 31, 2021 (pandemic period) and pre-COVID articles from the year prior. Information on total number of submissions and rate of acceptance were collected from seven top-ranked journals. RESULTS: Our PubMed query returned 759 COVID articles, 4,885 non-COVID articles, and 4,200 pre-COVID articles, corresponding to a 34% increase in otolaryngology publications during the pandemic period. Meta-analysis/reviews and miscellaneous publication types made up a larger portion of COVID publications than that of non-COVID and pre-COVID publications. Compared to pre-COVID articles, citations per article 120 days after publication and Altmetric Attention Score were higher in both COVID articles (citations/article: 2.75 ± 0.45, P < .001; Altmetric Attention Score: 2.05 ± 0.60, P = .001) and non-COVID articles (citations/article: 0.03 ± 0.01, P = .002; Altmetric Attention Score: 0.67 ± 0.28, P = .016). COVID manuscripts were associated with a 1.65 times higher acceptance rate compared to non-COVID articles (P < .001). CONCLUSIONS: COVID-19 was associated with an increase in volume, citations, and attention for both COVID and non-COVID articles compared to pre-COVID articles. However, COVID articles were associated with lower evidence levels than non-COVID and pre-COVID articles. LEVEL OF EVIDENCE: 3 Laryngoscope, 132:1364-1373, 2022.

Establishing an Office-Based Framework for Resuming Otolaryngology Care in Academic Practice During the COVID-19 Pandemic.

OBJECTIVE: The COVID-19 health crisis abruptly disrupted the practice of otolaryngology. This article aims to define the changes needed to operate an academic otolaryngology practice safely and efficiently from within the epicenter of the pandemic. We define the areas of normal patient workflow that have been affected by COVID-19, and we offer mitigation strategies with attention paid to the specific needs of subspecialties. DATA SOURCES: The article includes data specific to the office practice metrics of the Weill Cornell Medicine Department of Otolaryngology-Head and Neck Surgery, as well as publically available data from New York Presbyterian Hospital system and the New York Times. REVIEW METHODS: Expert opinion. CONCLUSIONS: Through careful planning and execution, it is possible to reestablish safe otolaryngologic patient care during the COVID-19 pandemic. It will require a significant change from prior practice models for successful implementation. Additionally, telemedicine can be positively integrated into the treatment of otolaryngology diseases for new and established patients. IMPLICATIONS FOR PRACTICE: The information conveyed in this review can be used as a guide by large and small otolaryngology groups to identify aspects of the patient visit that are "at risk" due to COVID-19, and it suggests sensible responses that can be made without a significant disruption to normal practice. The methods used to identify vulnerabilities with the patient visit process can be applied to future unforeseen crises, such as a resurgence of COVID-19 or a novel pandemic.

Dissemination of Information During Public Health Crises: Early COVID-19 Data From The Laryngoscope.

OBJECTIVES: During a public health crisis, it is important for medical journals to share information in a timely manner while maintaining a robust peer-review process. This review reports and analyzes The Laryngoscope's publication trends and practices during the COVID-19 pandemic, before the COVID-19 pandemic, and during previous pandemics. METHODS: Comprehensive review of two databases (PubMed and The Laryngoscope) was performed. COVID-19 manuscripts (published in The Laryngoscope during the first 4 months of the pandemic) were identified and compared to manuscripts pertaining to historic pandemics (published in The Laryngoscope during the first 2 years of each outbreak). Keywords included "Laryngoscope", "flu", "pandemic", "influenza", "SARS", "severe acute respiratory syndrome", "coronavirus", "COVID-19", and "SARS-CoV-2". Data were obtained from The Laryngoscope to characterize publication trends during and before the COVID-19 pandemic. RESULTS: From March 1, 2020 to June 30, 2020, The Laryngoscope had 203 COVID-19 submissions. As of July 8, 2020, 20 (9.9%) were accepted, 117 (57.6%) under review, and 66 (32.5%) rejected. During the first 4 months of the pandemic, 18 COVID-19 manuscripts were published. The mean number of days from submission to online publication was 45, compared to 170 in 2018 and 196 in 2019. A total of 4 manuscripts concerning previous pandemics were published during the initial 2 years of each outbreak. CONCLUSIONS: The Laryngoscope rapidly disseminated quality publications during the COVID-19 pandemic by upholding a robust peer-review process while expediting editorial steps, highlighting relevant articles online, and providing open access to make COVID-19-related publications available as quickly as possible. Laryngoscope, 130:2508-2515, 2020.

Trends in hearing rehabilitation use among vestibular schwannoma patients.

OBJECTIVE: Most patients with vestibular schwannoma (VS) have significant hearing loss in the affected ear as a result of either their tumor or treatment. There is a paucity of data on which hearing rehabilitation options, if any, are preferred by patients with VS. Our study analyzed the use of hearing rehabilitation devices among VS patients. METHODS: Patients with unilateral VS treated at our institution from January 2008 to August 2018 were identified. Those with bilateral VS, profound hearing loss in the contralateral ear, neurofibromatosis type 2, or inadequate follow-up were excluded. Patients who met inclusion criteria were given two online questionnaires: an 8-item instrument that assesses use of hearing rehabilitation devices and the Abbreviated Profile of Hearing Aid Benefit. RESULTS: Of 212 eligible patients, 61 completed both surveys. The majority (88%) were able to hear "poorly" or "not at all" in the affected ear, but less than one-third had ever used a hearing rehabilitation device. Most had used conventional hearing aids (30%) or contralateral routing of signal/bilateral contralateral routing of signal (30%), whereas only a handful had used bone-anchored hearing devices or cochlear implant. Patients who did not pursue hearing rehabilitation were either not bothered by their deficit or were unaware of their options. Most had good functionality despite their deficit. CONCLUSION: Whereas 88% of patients treated for VS had a significant hearing loss, the majority did not pursue hearing rehabilitation but maintained good functional performance. Many did not remember being counseled about hearing rehabilitation options, indicating that regular and repeated counseling may be needed to increase patient utilization of hearing rehabilitation after VS treatment. LEVEL OF EVIDENCE: 4 Laryngoscope, 130:1558-1564, 2020.

Stapes prosthesis length and hearing outcomes.

OBJECTIVES: First, to determine if prosthesis length plays a role in optimizing successful hearing outcomes in stapedotomy surgery; and second, to determine if patient factors such as height are correlated with prosthesis length. STUDY DESIGN: Retrospective chart review. METHODS: Retrospective chart review of patients undergoing stapedotomy surgeries with adequate follow up. Length of prosthesis, pre-/postoperative audiograms, and follow-up data were obtained. RESULTS: The primary group consisted of 227 cases. The prosthesis length ranged from 3.75 mm to 4.75 mm (median 4.25 mm). The greatest improvement in postoperative air-bone gap (ABG) occurred in the 4.25 mm group, and the least in the 3.75 mm group. Patient height showed a positive, although weak, correlation with prosthesis length. No findings reached statistical significance. CONCLUSION: Accurate measurement of prosthesis length is important for successful postoperative hearing outcomes. There is a positive but not significant correlation between patient height and prosthesis length. LEVEL OF EVIDENCE: 4. Laryngoscope, 128:722-726, 2018.

Incidence of Prolonged Systemic Steroid Treatment after Surgery for Acoustic Neuroma and Its Implications.

Objectives To determine the incidence of prolonged postoperative systemic corticosteroid therapy after surgery for acoustic neuroma as well as the indications and associated risk factors that could lead to prolonged steroid administration, and the incidence of steroid-related adverse effects. Study Designs Retrospective chart review. Methods Retrospective chart review of patients undergoing resection of acoustic neuroma between 2010 and 2017 at two tertiary care medical centers. Patient and tumor characteristics, operative approach, hospital length of stay, initial postoperative taper length, number of discrete postoperative steroid courses, and postoperative complications were analyzed. Results There were 220 patients (99 male, 121 female) with an average age of 49.4 (range 16-78). There were 124 left-sided tumors and 96 right-sided tumors. Within the group, 191 tumors were operated through a retrosigmoid approach, 25 tumors through a translabyrinthine approach, and 4 tumors with a combined retrosigmoid-translabyrinthine approach under the same anesthetic. In total, 35 (15.9%) patients received an extended initial course of postoperative systemic steroids, defined as a taper longer than 18 days. Twenty six (11.8%) patients received additional courses of systemic steroids after the initial postoperative taper. There were 5 (2.3%) patients who required an extended initial taper as well as additional courses of steroids. Aseptic meningitis, often manifested as headache, was the most common indication for additional steroids (14 cases of prolonged taper and 17 cases of additional courses). None of the patient or tumor factors including age, gender, side, size, and approach were statistically significantly associated with either a prolonged initial steroid taper or additional courses of steroids. An extended hospital length of stay was associated with a prolonged initial steroid taper ( p = 0.03), though the initial taper length was not predictive of additional courses of steroids. The cumulative number of days on steroids was associated with need for additional procedures ( p < 0.01) as well as steroid-related side effects ( p = 0.05). The administration of steroids was not found to significantly improve outcomes in postoperative facial paresis. Steroid-related complications were uncommon, seen in 9.26% of patients receiving steroids, with the most common being psychiatric side effects such as agitation, anxiety, and mood lability. Conclusions Systemic corticosteroids are routinely administered postoperatively for patients undergoing craniotomy for the resection of acoustic neuromas. In a review of 220 patients operated by a single neurotologist, no patient or tumor factors were predictive of requiring prolonged initial steroid taper or additional courses of steroids. The cumulative number of days on systemic steroids was associated with undergoing additional procedures and steroid-related side effects. The most common indications for prolonged or additional steroids were aseptic meningitis, cerebrospinal fluid leak, and facial paresis. Additional steroids for postoperative facial paresis did not significantly improve outcomes. Patient-reported steroid-related complications were infrequent and were most commonly psychiatric including agitation, anxiety, and mood lability.

Protection against cisplatin-induced ototoxicity by adeno-associated virus-mediated delivery of the X-linked inhibitor of apoptosis protein is not dependent on caspase inhibition.

HYPOTHESIS: Gene therapy with an adeno-associated viral (AAV) vector encoding the X-linked inhibitor of apoptosis protein (XIAP) in an animal model of cisplatin-induced ototoxicity can elucidate apoptotic pathways in the inner ear. BACKGROUND: Cisplatin is limited clinically by ototoxicity associated with apoptosis in the inner ear. The relevant intracellular apoptotic pathways, however, are unknown. XIAP is an antiapoptotic protein that both inhibits caspases and reciprocally regulates the proapoptotic Smac/Omi proteins. AAV-mediated delivery of various XIAP mutants could distinguish between these antiapoptotic pathways in the ear and further the development of specific reagents for gene therapy- mediated prevention of cisplatin-induced ototoxicity. METHODS: We administered unilaterally through the round-window AAV-harboring genes encoding wild-type dXIAP, yellow fluorescent protein, or either of two dXIAP point mutants-one deficient in caspase inhibition (dXIAP-d) and the other additionally deficient in the binding of Smac/Omi (dXIAP-t). All rats received a 3-day systemic course of cisplatin. Functional hearing loss was measured by shifts in auditory brainstem response (ABR) thresholds after cisplatin treatment, and hair-cell loss was assessed by whole-mount phalloidin staining of cochlear turns. RESULTS: Uninjected ears universally displayed high-frequency-specific hair-cell loss and ABR threshold shifts upon cisplatin treatment. Although yellow fluorescent protein had no effect, ears injected with dXIAP exhibited 68% less ABR threshold shift at 32 kHz and 50% less basal-turn outer-hair-cell loss compared with contralateral untreated ears. This protection was maintained in ears injected with dXIAP-d but was abolished in those expressing dXIAP-t, which is incapable of blocking Smac/Omi. CONCLUSION: Hair-cell apoptosis induced by cisplatin involves the Smac/Omi pathway. Thus, gene therapy with either wild-type dXIAP or Smac/Omi-selective dXIAP-d may be effective to protect against cisplatin-mediated ototoxicity.

LINAC radiosurgery and radiotherapy treatment of acoustic neuromas.

This article provides an introduction to radiation therapy as it applies to intracranial tumors. It also provides a review of the natural growth progression of acoustic neuromas and accuracy of tumor size determination. Literature on the use of linear accelerator stereotactic radiosurgery and fractionated radiotherapy in acoustic neuroma management is reviewed and summarized. Specifically, the rates of reported tumor control, hearing preservation, facial and trigeminal nerve complications, and hydrocephalus are analyzed. Although the complication rates associated with linear accelerator therapy are relatively low, hearing preservation is poor and acoustic neuroma control is variable.