Vestibular Migraine Confounds Management of Superior Canal Dehiscence Syndrome.

OBJECTIVE: To investigate the prevalence of vestibular migraine (VM) in a cohort of patients with radiologic confirmation of superior canal dehiscence (SCD) and to compare management of superior canal dehiscence syndrome (SCDS) in patients with and without comorbid VM. STUDY DESIGN: Retrospective review of a SCD database. SETTING: University-based tertiary medical center. PATIENTS: Ninety-one patients identified with SCD from 2009 to 2017. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Coincidence of VM and SCD, and resolution of symptoms. RESULTS: Ninety-one patients with SCD met the inclusion and exclusion criteria. VM was diagnosed in 36 (39.6%) patients. Of those receiving medical therapy for VM alone, five (45.5%) reported symptom resolution, five (45.5%) reported partial improvement, one (9.1%) had no change, and none worsened. Fifteen patients (41.7%) were treated with both surgery (for SCD) and medical therapy (for VM). Seven (46.7%) reported symptom resolution, seven (46.7%) reported partial improvement, and one (6.7%) worsened. There was no statistically significant difference in symptom resolution between SCD + VM patients who were treated medically compared with those treated with medical therapy and surgery (p = 0.951). There was no significant difference in symptom resolution after surgery between SCD + VM and SCD-only cohorts (p = 0.286). CONCLUSIONS: This is the first study describing the incidence of VM in a cohort of patients with SCDS. The symptoms of VM confound those of SCDS and unrecognized or undertreated VM may contribute to surgical failure in SCDS. Therefore, we recommend a high index of suspicion for VM in patients with SCDS and a trial of medical therapy in the setting of suspected VM.

Comparative Analysis of Recidivism After Endoscopic and Microscopic-Based Cholesteatoma Resection.

OBJECTIVES: 1) To analyze outcomes of cholesteatoma resection utilizing postauricular microscopic and endoscopic ear surgery (EES) approaches.2) To analyze predictors of residual and recurrent cholesteatoma. STUDY DESIGN: Retrospective cohort study. SETTING: Tertiary referral center. PATIENTS: Three hundred seventy-five adult and pediatric patients with cholesteatoma (2012-2017). INTERVENTIONS: Patients underwent surgical resection of cholesteatoma with EES (n = 122) and microscopic (n = 253) approach. MAIN OUTCOME MEASURES: Residual cholesteatoma, recurrent cholesteatoma, second-look procedures. RESULTS: The endoscopic cohort included significantly more pediatric cases (p = 0.0008). There was no difference in laterality, gender distribution, congenital or acquired cholesteatoma, and revision cases between the cohorts. Out of 122 EES cases, 16 (13%) developed residual disease and 9 (7%) developed recurrent disease. Of 253 microscopic cases 16 (6%) developed residual disease while 11 (4%) developed recurrent disease. Second look procedures were more commonly used in EES cohort (50 vs 18%). Single predictor analysis revealed 12 predictors for residual disease and 5 for recurrent disease. Multivariable model identified pediatric case distribution and higher disease stage to be significant predictors for both residual (p = 0.04, 0.007) and recurrent disease (p = 0.02, 0.01). EES approach was associated with a weak significance for residual disease (p = 0.049) but not recurrent disease (p = 0.34). CONCLUSIONS: EES approach for cholesteatoma resection seems to perform similarly to microscopic approach with no difference in rates of recurrent disease. However, it is associated with a higher rate of residual disease; this may be a reflection of a greater rate of second look procedures done in this group.

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.

Computational study of a novel catheter for liver radioembolization.

Radioembolization (RE) is a medical treatment for primary and secondary liver cancer that involves the transcatheter intraarterial delivery of micron-sized and radiation-emitting microspheres, with the goal of improving microsphere deposition in the tumoral bed while sparing healthy tissue. An increasing number of in vitro and in silico studies on RE in the literature suggest that the particle injection velocity, spatial location of the catheter tip and catheter type are important parameters in particle distribution. The present in silico study assesses the performance of a novel catheter design that promotes particle dispersion near the injection point, with the goal of generating a particle distribution that mimics the flow split to facilitate tumour targeting. The design is based on two factors: the direction and the velocity at which particles are released from the catheter. A series of simulations was performed with the catheter inserted at an idealised hepatic artery tree with physiologically realistic boundary conditions. Two longitudinal microcatheter positions in the first generation of the tree were studied by analysing the performance of the catheter in terms of the outlet-to-outlet particle distribution and split flow matching. The results show that the catheter with the best performance is one with side holes on the catheter wall and a closed frontal tip. This catheter promotes a flow-split-matching particle distribution, which improves as the injection crossflow increases.

Standardized Workflow for Precise Mid- and High-Throughput Proteomics of Blood Biofluids.

BACKGROUND: Accurate discovery assay workflows are critical for identifying authentic circulating protein biomarkers in diverse blood matrices. Maximizing the commonalities in the proteomic workflows between different biofluids simplifies the approach and increases the likelihood for reproducibility. We developed a workflow that can accommodate 3 blood-based proteomes: naive plasma, depleted plasma and dried blood. METHODS: Optimal conditions for sample preparation and data independent acquisition-mass spectrometry analysis were established in plasma then automated for depleted plasma and dried blood. The mass spectrometry workflow was modified to facilitate sensitive high-throughput analysis or deeper profiling with mid-throughput analysis. Analytical performance was evaluated by the linear response of peptides and proteins to a 6- or 7-point dilution curve and the reproducibility of the relative peptide and protein intensity for 5 digestion replicates per day on 3 different days for each biofluid. RESULTS: Using the high-throughput workflow, 74% (plasma), 93% (depleted), and 87% (dried blood) displayed an inter-day CV <30%. The mid-throughput workflow had 67% (plasma), 90% (depleted), and 78% (dried blood) of peptides display an inter-day CV <30%. Lower limits of detection and quantification were determined for peptides and proteins observed in each biofluid and workflow. Based on each protein and peptide's analytical performance, we could describe the observable, reliable, reproducible, and quantifiable proteomes for each biofluid and workflow. CONCLUSION: The standardized workflows established here allows for reproducible and quantifiable detection of proteins covering a broad dynamic range. We envisage that implementation of this standard workflow should simplify discovery approaches and facilitate the translation of candidate markers into clinical use.

Endoscope-Assisted Superior Semicircular Canal Dehiscence Repair: Single Institution Outcomes.

OBJECTIVE: To compare outcomes of endoscope-assisted middle cranial fossa MCF) repair of superior semicircular canal dehiscence (SSCD) compared to microscopic MCF repair. STUDY DESIGN: Retrospective cohort. SETTING: Tertiary medical center neurotology practice. METHODS: Retrospective chart review and cohort study of patients who underwent surgical repair of SSCD via MCF approach from 2010 to 2019 at our institution. Patients were categorized according to use of endoscope intraoperatively. Pre- and post-operative symptom number was calculated from 8 patient-reported symptoms. Pre- and post-operative changes in symptom number were assessed using paired t-tests. Single-predictor binary logistic regression was used to compare final reported symptoms between cohorts. Linear regression was performed to assess air-bone gap (ABG) changes postoperatively between cohorts. RESULTS: Forty-six patients received surgical management for SSCD. Of these, 27 (59%) were male and 19 (41%) were female. Bilateral SSCD was present in 14 cases (29%), of which 3 underwent surgical management bilaterally, for a total of 49 surgical ears. Surgery was performed on the right ear in 19 cases (39%) and on the left in 30 cases (61%). Forty ears (82%) underwent microscopic repair while 9 (18%) underwent endoscope-assisted repair. Microscopic and endoscope-assisted MCF repair both demonstrated significantly improved symptom number postoperatively (P < .001 for each). There was no significant difference in change in ABG between the 2 cohorts. On average, patient-reported symptoms and audiometrically-tested hearing improved postoperatively in both groups. CONCLUSION: While endoscopic-assisted MCF repair has the potential to provide better visualization of medial and downslope defects, repair via this technique yields similar results and is equivalent to MCF repair utilizing the microscope alone.

Comparison of Small Intestinal Submucosal Graft and Autologous Tissue in Prevention of CSF leak after Posterior Fossa Craniotomy.

Objective To compare the use of porcine small intestinal submucosal grafts (SISG) and standard autologous material (fascia) in prevention of cerebrospinal fluid (CSF) leak and pseudomeningocele formation after translabyrinthine resection. Setting Set at the tertiary skull base center. Methods This is a retrospective chart review. After Institutional Review Board approval, we performed a retrospective cohort study evaluating CSF leak in patients who underwent resection of lateral skull base defects with multilayered reconstruction using either fascia autograft or porcine SISGs. Demographics were summarized with descriptive statistics. Logistic regression was used to compare autograft and xenograft cohorts in terms of CSF complications. Results Seventy-seven patients underwent lateral skull base resection, followed by reconstruction of the posterior cranial fossa. Of these patients, 21 (27.3%) underwent multilayer repair using SISG xenograft. There were no significant differences in leak-associated complications between autograft and xenograft cohorts. Ventriculoperitoneal shunt was necessary in one (1.8%) autograft and one (4.8) xenograft cases ( p = 0.49). Operative repair to revise surgical defect was necessary in three (5.4%) autograft cases and none in xenograft cases. Conclusion The use of SISG as a component of complex skull base reconstruction after translabyrinthine tumor resection may help reduce CSF leak rates and need for further intervention.

Progressive Vestibular Schwannoma following Subtotal or Near-Total Resection: Dose-Escalated versus Standard-Dose Salvage Stereotactic Radiosurgery.

Objective Local failure of incompletely resected vestibular schwannoma (VS) following salvage stereotactic radiosurgery (SRS) using standard doses of 12 to 13 Gy is common. We hypothesized that dose-escalated SRS, corrected for biologically effective dose, would have superior local control of high-grade VS progressing after subtotal or near-total resection compared with standard-dose SRS. Design Retrospective cohort study. Setting Tertiary academic referral center. Participants Adult patients treated with linear accelerator-based SRS for progressive VS following subtotal or near-total resection. Main Outcome Measures Dose-escalated SRS was defined by a biologically effective dose exceeding a single-fraction 13-Gy regimen. Study outcomes were local control and neurologic sequelae of SRS. Binary logistic regression was used to evaluate predictors of study outcomes. Results A total of 18 patients with progressive disease following subtotal (71%) and near-total (39%) resection of Koos grade IV disease (94%) were enrolled. Of the 18 patients, 7 were treated with dose-escalated SRS and 11 with standard-dose SRS. Over a median follow-up of 32 months after SRS, local control was 100% in the dose-escalated cohort and 91% in the standard-dose cohort ( p = 0.95). Neurologic sequelae occurred in 28% of patients, including 60% of dose-escalated cohort and 40% of the standard-dose cohort ( p = 0.12), although permanent neurologic sequelae were low at 6%. Conclusions Dose-escalated SRS has similar local control of recurrent VS following progression after subtotal or near-total resection and does not appear to have higher neurologic sequalae. Larger studies are needed.

Outcomes of Transzygomatic Middle Cranial Fossa Approach for Skull Base Tumors-A Single Institutional Experience.

Objective This study aimed to evaluate surgical outcomes after transzygomatic middle cranial fossa (MCF) (TZ-MCF) approach for tumor control in patients with large skull base lesions involving the MCF and adjacent sites. Setting This study was done at the tertiary skull base center. Design This is a retrospective case series. Main Outcome Measures The main outcome measures were tumor control (recurrence), new-onset cranial neuropathies, facial nerve and audiometric outcomes, cerebrospinal fluid (CSF) leak, and wound complications. Results Sixteen patients were identified with a median age of 45 years (range: 20-72). The mean maximum tumor dimension was 5.49 cm (standard deviation [SD]: 1.2, range: 3.1-7.3) and the mean tumor volume was 28.5 cm 3 (SD: 18.8, range: 2.9-63.8). Ten (62.5%) tumors were left sided. The most common pathology encountered was meningioma ( n = 7) followed by chondrosarcoma ( n = 4). Mean follow-up was 36.3 (SD: 26.9) months. Gross total resection or near total resection was achieved in nine (56.2%) and planned subtotal resection was used in seven (43.7%). Postoperative additional new cranial nerve (CN) deficits included CN V ( n = 1), CN III ( n = 2), CN VI ( n = 1), and CN X ( n = 1). Major neurological morbidity (hemiplegia) was encountered in two patients with resolution. There were no cases of CSF leak, meningitis, hemorrhage, seizures, aphasia, or death. There was no recurrence or regrowth of residual tumor. Facial nerve function was preserved in all but one patient (House-Brackmann grade 2). Conclusion Various skull base tumors involving MCF with extension to adjacent sites can be successfully resected using the TZ-MCF approach in a multidisciplinary fashion. This approach yields optimal exposure and permits excellent tumor control with acceptable CN and neurological morbidity.

Absent pyramidal eminence and stapedial tendon associated with congenital stapes footplate fixation: Intraoperative and radiographic findings.

OBJECTIVE: Report an association between congenital stapes footplate fixation (CSFF) and radiological absence of the pyramidal eminence and stapedial tendon. PATIENTS: Children and adults with intraoperatively confirmed CSFF and an absent stapedial tendon. INTERVENTIONS: Computed tomography (CT); exploratory tympanotomy with stapedotomy. MAIN OUTCOME MEASURES: Absence of a pyramidal eminence and stapedial tendon aperture identified on preoperative CT that was confirmed intraoperatively. RESULTS: Eight patients with intraoperative confirmation of CSFF and absent stapedial tendon were retrospectively identified. The average preoperative bone conduction and air conduction pure tone averages were 19.6 dB (SD 15.6 dB) and 55.9 dB (SD 23.6 dB), respectively. The average air-bone gap was 36.3 dB (SD 17.9 dB) preoperatively. In the seven patients who underwent preoperative CT, all were consistently identified to have an absent or hypoplastic pyramidal eminence and absent stapedial tendon aperture at the pyramidal eminence. In six cases, the stapedial footplate appeared normal, while in one case the footplate appeared abnormal which correlated with severe facial nerve prolapse observed intraoperatively. All eight cases underwent exploratory tympanotomy and demonstrated intraoperative stapes footplate fixation, absent stapedial tendon and either absent or hypoplastic pyramidal eminence, which correlated with preoperative CT findings. CONCLUSIONS: This study identifies a clinically pragmatic association between an absent pyramidal eminence identified on high-resolution CT and the diagnosis of CSFF. In a condition that otherwise generally lacks distinctive radiological features, the absence of a pyramidal eminence on CT in a patient with nonprogressive, congenital conductive hearing loss may strengthen clinical suspicion for CSFF.

Cerebrospinal Fluid Leaks of the Posterior Fossa: Patient Characteristics and Imaging Features.

Objective The main purpose of this article is to investigate the prevalence and features of posterior fossa defects (PFD) in spontaneous cerebrospinal fluid leaks (sCSFL). Design This is a retrospective case series. Setting Tertiary skull base center. Participants Consecutive adults undergoing lateral skull base repair of sCSFL between 2003 and 2018. Main Outcome Measures The following data were collected: demographics, comorbidities, radiology and intraoperative findings, and surgical outcomes including complications and need for revision surgery or shunt placement. Patients with incomplete data or leaks following skull base surgery, trauma, or chronic ear disease were excluded. Results Seventy-one patients (74% female, mean age 56.39 ± 11.50 years) underwent repair of spontaneous lateral skull base leaks. Eight ears (7 patients, 11.1%) had leaks involving the posterior fossa plate in addition to defects of the tegmen mastoideum (50%), tegmen tympani (25%), or both (25%). Patients with PFDs more often had bilateral tegmen thinning on imaging (75%, odds ratio [OR]: 10.71, 95% confidence interval [CI]: 2.20-54.35, p = 0.005) and symptomatic bilateral leaks (OR: 9.67, 95% CI: 2.22-40.17, p = 0.01. All PFD patients had arachnoid granulations adjacent to ipsilateral mastoid cell opacification. However, this finding was often subtle and rarely included on the radiology report. There was no significant difference in body mass index, age, presenting complaints, or operative success between the PFD and isolated tegmen defect sCSFL cohorts. Conclusion The posterior fossa is an uncommon location for sCSFL. Careful review of preoperative imaging is often suggestive and can inform surgical approach. PFD patients are similar to those with isolated tegmen-based defects in presentation, comorbidities, and outcomes.

Adaptation of the Standardized Hearing Outcomes Scattergram to Hearing Preservation in Cochlear Implantation.

OBJECTIVE: Encourage adaptation of a standardized format for reporting hearing preservation outcomes in cochlear implantation (CI). STUDY DESIGN: Retrospective chart review. SETTING: Tertiary referral center. PATIENTS: One hundred seventy-eight postlingually deafened adults with bilateral SNHL and a preoperative low-frequency pure-tone average (LFPTA) 80 dB HL or better at 125, 250, and 500 Hz in the ear to be implanted. INTERVENTIONS: Subjects underwent unilateral CI from 2013 to 2019 at a large referral center. Pre- versus postoperative LPFTA was used to generate a scattergram. MAIN OUTCOMES MEASURES: Pre- versus postoperative activation LPFTA, percentage of patients fit with electric and acoustic stimulation, scattergram plot. RESULTS: Average postoperative LFPTA was 68.6 dB HL (range 18-68) compared with 48.7 dB (range 5-80), preoperatively. At activation, the average LFPTA shift at CI activation was 20.5 dB HL (range 0-60) and 83.5% (n = 137) patients had hearing preserved, of whom 41.6% were fit with electric and acoustic stimulation throughout the study period. The scattergram successfully illustrates the distribution and number of patients with their respective audiometric outcomes. CONCLUSIONS: The scattergram developed for reporting hearing outcomes in clinical trials is highly adaptable to reporting hearing preservation results in cochlear implant surgery. It represents a transparent and accessible option for reporting outcomes that can be used as a consistent format to allow for interstudy comparison and future meta-analysis.

Cochlear Implantation and Electric Acoustic Stimulation in Children With TMPRSS3 Genetic Mutation.

BACKGROUND: Mutations in the TMPRSS3 gene, although rare, can cause high frequency hearing loss with residual hearing at low frequencies. Several previous studies have reported cochlear implant (CI) outcomes for adults with TMPRSS3 mutation with mixed results. Although some studies have suggested that TMPRSS3 is expressed in spiral ganglion cells, it remains unclear if previously reported poor CI outcomes in this population were secondary to long durations of deafness or to the effects of the TMPRSS3 mutation. To date, no studies in the literature have reported CI outcomes for children with TMPRSS3 mutation treated with CI. OBJECTIVE: The current case series aimed to describe outcomes for three children with sloping hearing loss caused by TMPRSS3 mutation who underwent bilateral CI. STUDY DESIGN: Case series. SETTING: Academic medical center. PATIENTS: Three children (3-4 yr) with TMPRSS3 mutation and normal sloping to profound high frequency hearing loss. INTERVENTIONS: CI and electric acoustic stimulation (EAS). MAIN OUTCOME MEASURES: Outcome measures were residual hearing thresholds, speech recognition scores, and electrode placement determined via intraoperative CT imaging. RESULTS: All three children maintained residual acoustic hearing and received benefit from EAS. Mean change in low-frequency pure-tone average was 17 dB. Mean postoperative word and sentence recognition scores in the bilateral EAS condition were 80 and 75%, respectively. CONCLUSIONS: Results indicate that CI with EAS is an appropriate treatment for children with TMPRSS3 genetic mutation. Pediatric results from this case series show more favorable CI outcomes than are currently reported for adults with TMPRSS3 mutation suggesting that the intervention may be time sensitive.

Persistent Conductive Hearing Loss After Tympanostomy Tube Placement Due to High-Riding Jugular Bulb.

High-riding jugular bulb (HRJB) is a rare condition not often observed in the clinical setting that occurs in 1% to 3% of cases. The jugular bulb is not present at birth, and the precise size and location likely depends on a myriad of postnatal events. This report describes the case of a male adolescent who experienced persistent conductive hearing loss (CHL) unilaterally following bilateral tympanostomy tube placement. Subsequent workup included computed tomography, which identified a very high jugular bulb eroding the posterior semicircular canal and occluding the round window niche. The patient had no hearing or vestibular symptoms aside from CHL and continues to be observed on a regular basis. HRJB is a rare disorder that has been known to erode the posterior semicircular canal, resulting in possible tinnitus, vertigo, dizziness, and/or sensorineural hearing loss. CHL has been reported in HRJB cases, although it is uncommon. HRJB may result in CHL through a third-window defect shunting hydromechanical energy away from the round window or due to middle ear blockage. Imaging is useful in ascertaining rare causes of CHL, such as HRJB. Because HRJB is not easily fixable, it is important to recognize it as a rare cause of CHL for appropriate patient counseling. Possible interventions should be tailored to the patient after careful consideration of contralateral anatomy and likely benefits. Laryngoscope, 131:E1272-E1274, 2021.

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.

Prevalence of and Associations With Distress and Professional Burnout Among Otolaryngologists: Part II, Attending Physicians.

OBJECTIVE: To ascertain the prevalence of and associations with distress and professional burnout among academic otolaryngology attending physicians. STUDY DESIGN: Cross-sectional survey. SETTING: Twelve US academic otolaryngology programs. METHODS: A questionnaire was administered that encompassed sociodemographic and professional features, the Expanded Physician Well-being Index for distress, the 2-item Maslach Burnout Inventory for professional burnout, the Patient Health Questionnaire-2 screen for major depressive disorder, and the Generalized Anxiety Disorder-2 screen for generalized anxiety disorder. RESULTS: The survey response rate was 56% and included 186 attending physicians. The average respondent age was 47 years; 72% were men; 93% were married or partnered; and 86% had children. Distress was present in 40%, professional burnout in 26%, positive depression screening in 8%, and positive anxiety screening in 11%. In a univariable setting, age, hours worked in a typical week, nights on call in a typical week, and years of practice were significantly associated with distress, although in a multivariable setting, only hours worked in a typical week remained significantly associated with a positive Expanded Physician Well-being Index screen (odds ratio for each 10-hour increase, 2.61; 95% CI, 1.73-3.93; P < .001). In a univariable setting, hours worked in a typical week was significantly associated with a positive Maslach Burnout Inventory screen. CONCLUSION: Distress or professional burnout occurs in more than a quarter of academic otolaryngology attending physicians, whereas the prevalence of depression or anxiety is approximately 10%. The number of hours worked per week had the strongest association with distress and burnout. These findings may be used to develop and implement programs to promote physician well-being and mitigate professional burnout.

Prevalence of and Associations With Distress and Professional Burnout Among Otolaryngologists: Part I, Trainees.

OBJECTIVE: To assess the prevalence of distress and burnout in otolaryngology trainees, including associations with relevant sociodemographic and professional factors, and to compare these results with those of attending otolaryngologists. STUDY DESIGN: A cross-sectional survey of trainees and attending physicians. SETTING: Twelve academic otolaryngology programs. METHODS: Distress and burnout were measured with the Expanded Physician Well-being Index and the 2-item Maslach Burnout Inventory. The Patient Health Questionnaire-2 and Generalized Anxiety Disorder-2 were used to screen for depressive disorders and anxiety disorders, respectively. Associations with sociodemographic and professional characteristics were assessed. RESULTS: Of the 613 surveys administered to trainees and attending physicians, 340 were completed (56%). Among 154 trainees, distress was present in 49%, professional burnout in 35%, positive depressive disorder screening in 5%, and positive anxiety disorder screening in 16%. In univariable analysis, female gender, hours worked in a typical week (HW), and nights on call in a typical week (NOC) were significantly associated with distress. In multivariable analysis, female gender (odds ratio, 3.91; P = .001) and HW (odds ratio for each 10 HW, 1.89; P = .003) remained significantly associated with distress. Female gender, HW, and NOC were significantly associated with burnout univariably, although only HW (odds ratio for each 10 HW, 1.92; P = .003) remained significantly associated with burnout in a multivariable setting. Attending physicians had less distress than trainees (P = .02) and felt less callous and less emotionally hardened than trainees (P < .001). CONCLUSION: Otolaryngology trainees experience significant work-place distress (49%) and burnout (35%). Gender, HW, and NOC had the strongest associations with distress and burnout.

Contemporary Management of Jugular Paragangliomas With Neural Preservation.

OBJECTIVES: Management of jugular paragangliomas (PGL) has evolved toward subtotal resection (STR). The purpose of this study is to analyze neural preservation and adjuvant treatment for long-term local control. STUDY DESIGN: Retrospective chart review. SETTINGS: Tertiary neurotology practice. SUBJECTS AND METHODS: Adults undergoing surgical treatment of jugular PGL between 2006 and 2019. Patients, disease, and treatment variables were collected retrospectively. Single predictor logistic regression was used to ascertain predictors of regrowth or need for salvage radiation. RESULTS: A total of 41 patients (median age, 47 years; 76% female) were identified. Most patients presented with advanced-stage disease (Glasscock-Jackson stage III-IV = 76%). Subtotal resection (STR) was performed in 32 (78%) patients. Extended STR (type 1) was the most commonly performed conservative procedure (n = 19, 59%). Postoperative new low cranial neuropathy (LCN) involving CN X and XII was rare (n = 3 and n = 1, respectively). Seventeen patients (41%) underwent postsurgical therapy for tumor regrowth or recurrence, including 15 patients who underwent adjuvant (n = 4) or salvage (n = 11) radiation. Overall tumor control of 94.7% was achieved at a mean follow-up of 35 months. All patients treated with combined modality treatment had local control at last follow-up. Logistic regression identified no single predictor for postsurgical radiation treatment or salvage-free survival. CONCLUSION: Management of jugular PGL with a conservative approach is safe and effective with a low rate of new LCN deficit. Active surveillance of residual tumor with salvage radiation for growth results in excellent long-term tumor control.

Transient Subacute Facial Nerve Dysfunction After Dual Modality Treatment of Large Vestibular Schwannomas.

OBJECTIVES: 1: Describe subacute facial nerve paralysis after salvage stereotactic radiosurgery (SRS). 2: To analyze predictors of facial nerve weakness after dual modality treatment. PATIENTS: Adult patients with Vestibular Schwannoma who underwent sub-total resection (STR) followed by salvage radiation. INTERVENTIONS: Microsurgical resection of VS, stereotactic radiosurgery, intensity-modulated radiotherapy, proton radiotherapy. MAIN OUTCOME MEASURES: Serial facial nerve function (House-Brackmann scale). RESULTS: Thirteen patients who underwent dual modality treatment for large VS were included (mean age = 43.6 years, 77% females). The mean pre-operative tumor volume was 11.7 cm3 (SD = 6.5) and the immediate mean post-operative remnant volume was 1.5 cm3 (SD = 1.4) with a mean extent of resection of 86.7% (SD = 9.5). The mean salvage-free interval was 20.8 months (SD = 13.3). All patients had excellent one-year FN outcome (HB grade 1, 2) after resection. Three patients developed subacute facial nerve weakness after salvage SRS (4.2-9.4 months after SRS). This paralysis responded to high dose systemic steroids and no surgical interventions for facial rehabilitation were required. At last follow up (mean 61.6 months, SD = 28.5), facial nerve function was favorable (HB grade 1-2 in 12 patients and HB grade 3 in 1 patient). There were no significant associations between various predictors and subacute deterioration of facial nerve function after SRS. CONCLUSIONS: Sub-acute transient facial nerve dysfunction can develop infrequently over a variable time frame after post-operative salvage SRS and usually responds to steroids. Patients should be adequately counseled about potential of transient deterioration of facial nerve function after salvage SRS.

Endoscopic Stapes Surgery: Pearls and Pitfalls.

The endoscopic approach to stapes surgery affords unique advantages but is not without its specific challenges. The following reviews the equipment and surgical steps required to perform endoscopic stapes surgery safely and effectively, highlighting tips and potential points of failure through a series of case examples.