Clinical Practice Guideline: Age-Related Hearing Loss Executive Summary.

OBJECTIVE: Age-related hearing loss (ARHL) is a prevalent but often underdiagnosed and undertreated condition among individuals aged 50 and above. It is associated with various sociodemographic factors and health risks including dementia, depression, cardiovascular disease, and falls. While the causes of ARHL and its downstream effects are well defined, there is a lack of priority placed by clinicians as well as guidance regarding the identification, education, and management of this condition. PURPOSE: The purpose of this clinical practice guideline is to identify quality improvement opportunities and provide clinicians trustworthy, evidence-based recommendations regarding the identification and management of ARHL. These opportunities are communicated through clear actionable statements with an explanation of the support in the literature, the evaluation of the quality of the evidence, and recommendations on implementation. The target patients for the guideline are any individuals aged 50 years and older. The target audience is all clinicians in all care settings. This guideline is intended to focus on evidence-based quality improvement opportunities judged most important by the Guideline Development Group (GDG). It is not intended to be a comprehensive, general guide regarding the management of ARHL. The statements in this guideline are not intended to limit or restrict care provided by clinicians based on their experience and assessment of individual patients. ACTION STATEMENTS: The GDG made strong recommendations for the following key action statements (KASs): (KAS 4) If screening suggests hearing loss, clinicians should obtain or refer to a clinician who can obtain an audiogram. (KAS 8) Clinicians should offer, or refer to a clinician who can offer, appropriately fit amplification to patients with ARHL. (KAS 9) Clinicians should refer patients for an evaluation of cochlear implantation candidacy when patients have appropriately fit amplification and persistent hearing difficulty with poor speech understanding. The GDG made recommendations for the following KASs: (KAS 1) Clinicians should screen patients aged 50 years and older for hearing loss at the time of a health care encounter. (KAS 2) If screening suggests hearing loss, clinicians should examine the ear canal and tympanic membrane with otoscopy or refer to a clinician who can examine the ears for cerumen impaction, infection, or other abnormalities. (KAS 3) If screening suggests hearing loss, clinicians should identify sociodemographic factors and patient preferences that influence access to and utilization of hearing health care. (KAS 5) Clinicians should evaluate and treat or refer to a clinician who can evaluate and treat patients with significant asymmetric hearing loss, conductive or mixed hearing loss, or poor word recognition on diagnostic testing. (KAS 6) Clinicians should educate and counsel patients with hearing loss and their family/care partner(s) about the impact of hearing loss on their communication, safety, function, cognition, and quality of life. (KAS 7) Clinicians should counsel patients with hearing loss on communication strategies and assistive listening devices. (KAS 10) For patients with hearing loss, clinicians should assess if communication goals have been met and if there has been improvement in hearing-related quality of life at a subsequent health care encounter or within 1 year. The GDG offered the following KAS as an option: (KAS 11) Clinicians should assess hearing at least every 3 years in patients with known hearing loss or with reported concern for changes in hearing.

Clinical Practice Guideline: Age-Related Hearing Loss.

OBJECTIVE: Age-related hearing loss (ARHL) is a prevalent but often underdiagnosed and undertreated condition among individuals aged 50 and above. It is associated with various sociodemographic factors and health risks including dementia, depression, cardiovascular disease, and falls. While the causes of ARHL and its downstream effects are well defined, there is a lack of priority placed by clinicians as well as guidance regarding the identification, education, and management of this condition. PURPOSE: The purpose of this clinical practice guideline is to identify quality improvement opportunities and provide clinicians trustworthy, evidence-based recommendations regarding the identification and management of ARHL. These opportunities are communicated through clear actionable statements with explanation of the support in the literature, evaluation of the quality of the evidence, and recommendations on implementation. The target patients for the guideline are any individuals aged 50 years and older. The target audience is all clinicians in all care settings. This guideline is intended to focus on evidence-based quality improvement opportunities judged most important by the guideline development group (GDG). It is not intended to be a comprehensive, general guide regarding the management of ARHL. The statements in this guideline are not intended to limit or restrict care provided by clinicians based on their experience and assessment of individual patients. ACTION STATEMENTS: The GDG made strong recommendations for the following key action statements (KASs): (KAS 4) If screening suggests hearing loss, clinicians should obtain or refer to a clinician who can obtain an audiogram. (KAS 8) Clinicians should offer, or refer to a clinician who can offer, appropriately fit amplification to patients with ARHL. (KAS 9) Clinicians should refer patients for an evaluation of cochlear implantation candidacy when patients have appropriately fit amplification and persistent hearing difficulty with poor speech understanding. The GDG made recommendations for the following KASs: (KAS 1) Clinicians should screen patients aged 50 years and older for hearing loss at the time of a health care encounter. (KAS 2) If screening suggests hearing loss, clinicians should examine the ear canal and tympanic membrane with otoscopy or refer to a clinician who can examine the ears for cerumen impaction, infection, or other abnormalities. (KAS 3) If screening suggests hearing loss, clinicians should identify sociodemographic factors and patient preferences that influence access to and utilization of hearing health care. (KAS 5) Clinicians should evaluate and treat or refer to a clinician who can evaluate and treat patients with significant asymmetric hearing loss, conductive or mixed hearing loss, or poor word recognition on diagnostic testing. (KAS 6) Clinicians should educate and counsel patients with hearing loss and their family/care partner(s) about the impact of hearing loss on their communication, safety, function, cognition, and quality of life (QOL). (KAS 7) Clinicians should counsel patients with hearing loss on communication strategies and assistive listening devices. (KAS 10) For patients with hearing loss, clinicians should assess if communication goals have been met and if there has been improvement in hearing-related QOL at a subsequent health care encounter or within 1 year. The GDG offered the following KAS as an option: (KAS 11) Clinicians should assess hearing at least every 3 years in patients with known hearing loss or with reported concern for changes in hearing.

Musculoskeletal disorders and discomfort for female surgeons or surgeons with small hand size when using hand-held surgical instruments: a systematic review.

BACKGROUND: Work-related musculoskeletal disorders (WMSDs), also referred to as work-related musculoskeletal injuries (MSKIs), cause surgeons pain and discomfort. Implementing ergonomics in the operating room has helped reduce such symptoms. However, there are still many issues that surgeons face when dealing with medical instruments, especially among female surgeons or surgeons with smaller hands. METHODS: The Cochrane methodology for performing a systematic review was utilized to search five databases for pertinent literature based on the study question "Do female surgeons or surgeons with smaller hand size, who use surgical instruments have an increased risk of musculoskeletal disorders and discomfort compared to male or larger handed surgeons?". The literature search strategy was designed around the three conceptual domains of surgeons/surgery, smaller hand size, and instrumentation. We searched PubMed, Embase.com, CINAHL Plus with Full Text (EBSCOhost), Scopus, and Web of Science Core Collection. This exploration identified 2165 research publications, and after specific inclusion and exclusion criteria, 19 studies were included in the systematic review. Risk of bias analysis was conducted to assess the quality of the included studies. After conducting a heterogeneity test, a meta-analysis was not performed due to high heterogeneity. RESULTS: Using certain surgical instruments presents challenges in the form of MSKIs for female and smaller-handed surgeons. Studies showed that 77% of females and 73% of surgeons who wear < 6.5 glove size report musculoskeletal issues ranging from difficulty of use to pain. Difficulties using surgical instruments and reported injuries have a greater impact on surgical trainees which might deter interest in surgical fields for future proceduralists. Recommendations for improved ergonomic tool design are suggested by some of the included studies to help tackle the MSKIs that surgeons face when performing operations. CONCLUSIONS: The number of female surgeons has increased substantially in the last decade. Hence, there exists an urgent need to address the major challenges they encounter by focusing on this specific aspect of workplace safety and health to mitigate injury. Doing so will yield a productive environment while simultaneously protecting the health and safety of both surgeons and patients. SYSTEMATIC REVIEW REGISTRATION: The study protocol was registered on PROSPERO (ID: CRD42022283378).

Surgical Instrument Designers and Inventors-Where are the Women?

Historically, surgical instruments were designed by men for male surgeons. Although instrumentation has changed with the changing paradigms of surgery, it has failed to adapt to the changing surgical workforce. Almost 30% of surgeons are female and nearly 90% of surveyed female surgeons report poor instrument design and associated musculoskeletal injuries from use. Understanding the current state of handheld surgical instrument design, published literature was reviewed, surgical instrument collections were contacted, and the U.S. Patent and Trademark databases were queried to identify public patents and pre-granted applications of female inventors of handheld surgical instruments. Twenty-five female inventors were identified from published literature and 1551 unique females hold patents. This number pales when the denominator of male inventors is considered. Hence, to address the female surgeon's lack of instrumentation and design, there is a critical need for participatory ergonomics whereby both the female surgeon and engineer collaborate on design.

Gender-differences of proceduralists in perception of hand-held surgical instrument fit - A cross-sectional survey.

OBJECTIVE: Determining perception of hand size as it relates to instrument use and ability to perform a procedure in a diverse population of proceduralists across surgical and medical specialties. METHODS: Cross-sectional survey was distributed via electronic format to a convenience sample of surgeons/physicians. Secondary analysis included identified instrument use and choice of/perception of ability to learn and perform procedures. RESULTS: 488 respondents, 84.4% (female), 75.8% (glove size ≤6.5), and 82.2% (surgical specialties). 67.8% reported trouble using surgical instruments, primarily endoscopes, laparoscopic instruments, and needle drivers. Latent class analysis identified two groups of female respondents with similar hand sizes but differ in the perception of their hand's abilities. CONCLUSIONS AND RELEVANCE: Instruments beyond laparoscopic instruments do not fit all hands. Even among female with physicians with similar hand size, there is a sub-set who struggle using surgical tools. Beyond gender and hand size, the operator's perception of their hand and their ability is critical in determining the viability of instrument mastery.

Otolaryngology Resident Education and Perceptions of e-cigarettes.

OBJECTIVE: To date, there are no reports of otolaryngology residents' knowledge and confidence in discussing e-cigarette use. The purpose of this study was to evaluate otolaryngology resident e-cigarette knowledge and confidence in counseling patients on e-cigarette use. STUDY DESIGN: Cross-sectional national survey. SETTING: Accreditation Council for Graduate Medical Education otolaryngology residents in the United States. METHODS: US otolaryngology residents were distributed surveys electronically in September 2020. RESULTS: A total of 150 participants replied for a response rate of 8.88%. The majority, 93.10% have not received formal education on e-cigarettes during their residency training. The most common resource of e-cigarette information overall was social media (78.46%). Within academia, the most common resources of e-cigarette education were patient interactions (63.16%) and colleagues (54.74%). Patients commonly inquire residents about e-cigarettes for smoking cessation (85.07%) and their long-term health effects (83.58%). Almost 67% of residents rarely or never ask patients about e-cigarette use. Only 4.35% of residents are not confident discussing traditional cigarette use, while 58.70% are not confident discussing e-cigarettes. CONCLUSION: Otolaryngology residents have not received formal education in e-cigarettes and are not confident discussing e-cigarettes with their patients. This highlights the need for e-cigarette education during otolaryngology residency to improve patient e-cigarette counseling.

Tracheostomy During the COVID-19 Pandemic: Comparison of International Perioperative Care Protocols and Practices in 26 Countries.

OBJECTIVE: The coronavirus disease 2019 (COVID-19) pandemic has led to a global surge in critically ill patients requiring invasive mechanical ventilation, some of whom may benefit from tracheostomy. Decisions on if, when, and how to perform tracheostomy in patients with COVID-19 have major implications for patients, clinicians, and hospitals. We investigated the tracheostomy protocols and practices that institutions around the world have put into place in response to the COVID-19 pandemic. DATA SOURCES: Protocols for tracheostomy in patients with severe acute respiratory syndrome coronavirus 2 infection from individual institutions (n = 59) were obtained from the United States and 25 other countries, including data from several low- and middle-income countries, 23 published or society-endorsed protocols, and 36 institutional protocols. REVIEW METHODS: The comparative document analysis involved cross-sectional review of institutional protocols and practices. Data sources were analyzed for timing of tracheostomy, contraindications, preoperative testing, personal protective equipment (PPE), surgical technique, and postoperative management. CONCLUSIONS: Timing of tracheostomy varied from 3 to >21 days, with over 90% of protocols recommending 14 days of intubation prior to tracheostomy. Most protocols advocate delaying tracheostomy until COVID-19 testing was negative. All protocols involved use of N95 or higher PPE. Both open and percutaneous techniques were reported. Timing of tracheostomy changes ranged from 5 to >30 days postoperatively, sometimes contingent on negative COVID-19 test results. IMPLICATIONS FOR PRACTICE: Wide variation exists in tracheostomy protocols, reflecting geographical variation, different resource constraints, and limited data to drive evidence-based care standards. Findings presented herein may provide reference points and a framework for evolving care standards.

Utilization of Invasive Procedures for Adult Eustachian Tube Dysfunction.

OBJECTIVE: Eustachian tube dysfunction (ETD) is a common diagnosis among adults presenting for outpatient care. We sought to determine national utilization and the associated cost of invasive procedures for adult ETD. STUDY DESIGN: Cross-sectional study. SETTING: National health care database. SUBJECTS AND METHODS: The Truven Health MarketScan Databases (2010-2014) analytic cohort included health care encounters of patients ≥18 years of age with a diagnosis of ETD or related conditions of otitis media with effusion (OME) or tympanic membrane retraction (TMR). Visits associated with recent diagnoses of acute upper respiratory infection, head and neck cancer, or radiation therapy were excluded. Invasive procedure usage was subdivided into nasal and otologic procedures. RESULTS: ETD, OME, or TMR was diagnosed in 1,298,987 patients, 11.1% of which were chronic. The most common procedure was diagnostic endoscopy (including nasal endoscopy and laryngopharyngoscopy), which was used most frequently in the first 3 months after diagnosis, during which it was performed in 120,971 (9.3%) patients. The most frequent therapeutic nasal procedure was eustachian tube inflation without catheterization, performed in 11,412 patients over 5 years at a total cost of $1,210,939 ($106 per person annually). The most common therapeutic otologic procedure was myringotomy with tympanostomy, performed on 56,137 patients over 5 years at a total cost of $47,713,708 ($810 per person annually). CONCLUSION: Several nasal and otologic procedures are associated with a diagnosis of adult ETD at substantial cost. Development of therapeutic alternatives should be sought to mitigate the need for invasive procedures to treat this condition.

Perilymphatic Fistulas and Superior Semi-Circular Canal Dehiscence Syndrome.

Perilymphatic fistulas (PLF) and superior semi-circular canal dehiscence syndrome (SCDS) are 2 conditions that can present with sound and/or pressure-induced vertigo. PLF should be suspected in cases of trauma or surgery, while a spontaneous PLF is a diagnosis of exclusion. Research is ongoing to identify an ideal biomarker for perilymph. The diagnosis of SCDS continues to evolve with further research into vestibular-evoked myogenic potentials, electrocochleography, and higher resolution CT imaging. Treatment advances include the transmastoid approach, smaller middle fossa craniotomies, and usage of endoscopes. Temporal bone studies have furthered the understanding of pressure dynamics within the ear and how this relates to recommendations for repair versus alternative treatments such as round window plugging.

Health Care Utilization and Prescribing Patterns for Adult Eustachian Tube Dysfunction.

OBJECTIVE: Eustachian tube dysfunction (ETD) prompts >2 million adult visits in the United States annually. While disease prevalence and health care utilization are established for children, practice patterns for adults remain unknown. Our objective was to determine national resource utilization for adult ETD. STUDY DESIGN: Cross-sectional study. SETTING: National database sample. SUBJECTS AND METHODS: The Truven Health MarketScan Databases (2010-2014) analytic cohort included health care encounters of patients ≥18 years of age with a diagnosis of ETD, otitis media with effusion, or tympanic membrane retraction. Visits associated with recent diagnoses of acute upper respiratory infection, head and neck cancer, or radiation therapy were excluded. Acute ETD (<3 months) and chronic ETD (≥3 months) were subgroups. Medication usage was quantified by class. RESULTS: ETD was diagnosed for 1,298,987 patients, 11% of which was chronic. Over 92% of patients were seen in outpatient clinics, most often by otolaryngology (57%) for chronic ETD and by general medicine (49%) for acute ETD. Medications were frequently utilized, as 530,146 (53.7%) patients received ≥1 prescription. Top prescriptions for chronic ETD included intranasal corticosteroids (22%), antibiotics (22%), oral corticosteroids (13%), and analgesics (6%). The overall annual cost of prescribed medications associated with visits in which either acute or chronic ETD was diagnosed exceeded $8.5 million for a mean of $80.78 per patient who filled a prescription. CONCLUSION: Adult ETD is frequently treated with several medication classes by a variety of provider types. Understanding the potential adverse effects and cost associated with these practices should be a priority.

Assessment of a Statistical Algorithm for the Prediction of Benign Paroxysmal Positional Vertigo.

Importance: Benign paroxysmal positional vertigo (BPPV) is an otologic pathologic condition defined as a sensation of spinning triggered by changes in head position relative to gravity and caused by an entrapment of fragmented endolymph debris most commonly in the posterior semicircular canal. Confirmation of diagnosis requires experience with procedures that are poorly known by those other than practitioners with advanced otologic training. The complexity in the diagnosis of BPPV inspired the design of a questionnaire-based algorithm that would be useful for determining a vestibular diagnosis and treatment options. Objective: To assess a statistical algorithm for the diagnosis of BPPV in a busy tertiary care setting, with the long-term goal of implementing a clinical pathway to efficiently diagnose and treat patients with dizziness. Design, Setting, and Participants: In this retrospective case series, 200 patients who visited the Department of Otolaryngology-Head and Neck Surgery at Johns Hopkins University School of Medicine for their initial vertigo symptoms from September 1, 2016, to December 31, 2016, were assessed. Interventions: Use of a validated patient questionnaire as a tool to differentiate patients with dizziness in an electronic medical record review. Main Outcomes and Measures: Linear predictor (LP) value based on the questionnaire for the diagnosis of BPPV. Results: Of the 200 patient visits reviewed (132 [66%] female), 106 (53.0%; 68 [64%] female) had the information necessary to calculate the LP value and had a confirmed final diagnosis. On the basis of an LP value of 0.2 or greater, the sensitivity for a diagnosis of BPPV was 0.75 and the specificity was 1.0. The positive predictive value was 1.0, whereas the negative predictive value was 0.96. Patients with BPPV had a statistically significantly different LP value (odds ratio, 5.92; 95% CI, 2.73-12.83) than did patients without BPPV. Conclusions and Relevance: The findings of this study suggest that the algorithm is efficient for the diagnosis of BPPV in a clinical care setting.

Panel 1: Epidemiology and Diagnosis.

Objective To create a literature review between 2011 and June 1, 2015, on advances in otitis media (OM) epidemiology and diagnosis (including relevant audiology studies). Data Sources Electronic search engines (PubMed, EMBASE, and Cochrane Library) with a predefined search strategy. Review Methods Articles with appropriate epidemiologic methodology for OM, including acute mastoiditis and eustachian tube dysfunction. Items included OM worldwide and in high-risk populations, OM-related hearing loss, news in OM diagnostics, prenatal risk factors and comorbidities, postnatal risk factors, genetics, microbiological epidemiology, guidelines, and quality of life. Conclusions Diagnostic evidence and genetic studies are increasing; guidelines are introduced worldwide; and there is evidence of benefit of pneumococcal conjugate vaccines. New risk factors and comordities are identified in the study period, and quality of life is affected in children and their families. Implications for Practice Chronic suppurative OM occurs worldwide and contributes to lifelong hearing loss. Uniform definitions are still lacking and should be provided. An association between HIV and chronic suppurative OM has been found. Tympanometry is recommended for diagnosis, with or without pneumatic otoscopy. Video otoscopy, algorithms, and validated questionnaires may assist clinicians. Childhood obesity is associated with OM. Heritability accounts for 20% to 50% of OM diagnoses. OM-prone children seem to produce weaker immunologic responses to pneumococcal conjugate vaccines. Clinicians tend to individualize treatment without adhering to guidelines.

Risk Assessment and Prevention of Corneal Complications After Lateral Skull Base Surgery.

OBJECTIVE: To analyze the rate of corneal complications after lateral skull base surgery, and the relative risk of each potential contributing factor. STUDY DESIGN: Retrospective cohort study. SETTING: Tertiary care center. PATIENTS: Adult patients who had undergone lateral skull base surgery involving an otolaryngologist at our institution from 2007 to 2015. INTERVENTION: None. MAIN OUTCOME MEASURE: Relative risk (RR) for each potential contributing factor to corneal complications. RESULTS: Four hundred sixty nine patients met inclusion criteria. Of those, 35 developed mild exposure keratopathy, 13 developed moderate exposure keratopathy, and 5 developed severe exposure keratopathy. Age, sex, previous eye surgery, tumor side, and pathology were not significant predictors of keratopathy. Tumor size greater than 30 mm (RR 4.75), postoperative trigeminal palsy (RR 3.42), postoperative abducens palsy (RR 9.08), House-Brackman score 5-6 (RR 4.77), lagophthalmos (RR 11.85), ectropion (RR 4.29), and previous eye disease (RR 1.83) were all significantly associated with the development of corneal complications. On multivariate analysis, lagophthalmos, abducens palsy, and tumor size were independent predictors of keratopathy. CONCLUSIONS: There are several important risk factors for exposure keratopathy after lateral skull base surgery, and knowledge of these risk factors can help identify high-risk patients in whom early, aggressive preventative therapy is warranted.

Use of Pericranial Flap Coverage in Cochlear Implantation of the Radical Cavity: Rationale, Technique, and Experience.

Cochlear implant (CI) surgery in the setting of an open mastoid cavity is evolving. Two strategies are commonly pursued: a staged approach, clearing the disease, closing the meatus or the external auditory canal (EAC), and reevaluating in 3 to 6 months prior to implantation, or a single-stage procedure with mastoid obliteration without EAC closure. Meatal closure is often employed in the setting of an open mastoid cavity to reduce the risk of electrode extrusion and infection. An open cavity offers the advantages of being a single-stage procedure, permitting direct surveillance for recurrent cholesteatoma, and reducing the need for repeat computed tomography scans. We describe an approach to the coverage of a CI within a dry, open mastoid cavity using an anteriorly-based postauricular pericranial flap.

The link between allergy and Menière's disease.

PURPOSE OF REVIEW: To examine evidence supporting the association of allergy and Menière's disease. RECENT FINDINGS: Animal studies have shown evidence that a provoked systemic immune challenge can result in an allergic reaction within the inner ear, whereas premedication with leukotriene antagonists can prevent the development of endolymphatic hydrops. In human subjects, further data support a heightened allergic response in patients with Menière's disease, whereas pharmacological treatments that target histamine receptors help to control vertiginous symptoms. However, the relationship of migraine with a history of allergy and Menière's disease may confound this association. SUMMARY: Although the evidence of a causal association between allergy and Menière's disease is inconclusive, the inclusion of allergy control as part of the treatment plan for Menière's disease is low risk to the patient and should be considered for patients with indications that include history of seasonal or food allergy, childhood or family history of allergy, bilateral Menière's symptoms, or a development of symptoms within a short time after exposure of food or inhaled allergen.