Potential Clinical and Economic Outcomes of Over-the-Counter Hearing Aids in the US.

Importance: Over-the-counter (OTC) hearing aids are now available in the US; however, their clinical and economic outcomes are unknown. Objective: To project the clinical and economic outcomes of traditional hearing aid provision compared with OTC hearing aid provision. Design, Setting, and Participants: This cost-effectiveness analysis used a previously validated decision model of hearing loss (HL) to simulate US adults aged 40 years and older across their lifetime in US primary care offices who experienced yearly probabilities of acquiring HL (0.1%-10.4%), worsening of their HL, and traditional hearing aid uptake (0.5%-8.1%/y at a fixed uptake cost of $3690) and utility benefits (0.11 additional utils/y). For OTC hearing aid provision, persons with perceived mild to moderate HL experienced increased OTC hearing aid uptake (1%-16%/y) based on estimates of time to first HL diagnosis. In the base case, OTC hearing aid utility benefits ranged from 0.05 to 0.11 additional utils/y (45%-100% of traditional hearing aids), and costs were $200 to $1400 (5%-38% of traditional hearing aids). Distributions were assigned to parameters to conduct probabilistic uncertainty analysis. Intervention: Provision of OTC hearing aids, at increased uptake rates, across a range of effectiveness and costs. Main Outcomes and Measures: Lifetime undiscounted and discounted (3%/y) costs and quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratios (ICERs). Results: Traditional hearing aid provision resulted in 18.162 QALYs, compared with 18.162 to 18.186 for OTC hearing aids varying with OTC hearing aid utility benefit (45%-100% that of traditional hearing aids). Provision of OTC hearing aids was associated with greater lifetime discounted costs by $70 to $200 along with OTC device cost ($200-$1000/pair; 5%-38% traditional hearing aid cost) due to increased hearing aid uptake. Provision of OTC hearing aids was considered cost-effective (ICER<$100 000/QALY) if the OTC utility benefit was 0.06 or greater (55% of the traditional hearing aid effectiveness). In probabilistic uncertainty analysis, OTC hearing aid provision was cost-effective in 53% of simulations. Conclusions and Relevance: In this cost-effectiveness analysis, provision of OTC hearing aids was associated with greater uptake of hearing intervention and was cost-effective over a range of prices so long as OTC hearing aids were greater than 55% as beneficial to patient quality of life as traditional hearing aids.

Sponsorship in Otolaryngology-Head and Neck Surgery: A Pathway to Equity, Diversity, and Inclusion.

Importance: Sponsorship, distinct from mentorship or coaching, involves advancing the careers of individuals by nominating them for roles, increasing the visibility of their work, or facilitating opportunities. Sponsorship can open doors and enhance diversity; however, achieving desirable outcomes requires equitable approaches to cultivating potential in sponsees and promoting their success. The evidence on equitable sponsorship practices has not been critically examined, and this special communication reviews the literature, highlighting best practices. Observations: Sponsorship addresses an unmet need for supporting individuals who have historically been afforded fewer, less visible, or less effective opportunities for upward career mobility. Barriers to equitable sponsorship include the paucity of sponsors of underrepresented identity; smaller and underdeveloped networks among these sponsors; lack of transparent, intentional sponsorship processes; and structural inequities that are associated with recruitment, retention, and advancement of diverse individuals. Strategies to enhance equitable sponsorship are cross-functional, building on foundational principles of equity, diversity, and inclusion; patient safety and quality improvement; and insights from education and business. Equity, diversity, and inclusion principles inform training on implicit bias, cross-cultural communication, and intersectional mentoring. Practices inspired by patient safety and quality improvement emphasize continuously improving outreach to diverse candidates. Education and business insights emphasize minimizing cognitive errors, appreciating the bidirectional character of interactions, and ensuring that individuals are prepared for and supported in new roles. Collectively, these principles provide a framework for sponsorship. Persistent knowledge gaps are associated with timing, resources, and systems for sponsorship. Conclusions and Relevance: The nascent literature on sponsorship is limited but draws on best practices from various disciplines and has potential to promote diversity within the profession. Strategies include developing systematic approaches, providing effective training, and supporting a culture of sponsorship. Future research is needed to define best practices for identifying sponsees, cultivating sponsors, tracking outcomes, and fostering longitudinal practices that are sustainable at local, regional, and national levels.

Model-Projected Cost-Effectiveness of Adult Hearing Screening in the USA.

BACKGROUND: While 60% of older adults have hearing loss (HL), the majority have never had their hearing tested. OBJECTIVE: We sought to estimate long-term clinical and economic effects of alternative adult hearing screening schedules in the USA. DESIGN: Model-based cost-effectiveness analysis simulating Current Detection (CD) and linkage of persons with HL to hearing healthcare, compared to alternative screening schedules varying by age at first screen (45 to 75 years) and screening frequency (every 1 or 5 years). Simulated persons experience yearly age- and sex-specific probabilities of acquiring HL, and subsequent hearing aid uptake (0.5-8%/year) and discontinuation (13-4%). Quality-adjusted life-years (QALYs) were estimated according to hearing level and treatment status. Costs from a health system perspective include screening ($30-120; 2020 USD), HL diagnosis ($300), and hearing aid devices ($3690 year 1, $910/subsequent year). Data sources were published estimates from NHANES and clinical trials of adult hearing screening. PARTICIPANTS: Forty-year-old persons in US primary care across their lifetime. INTERVENTION: Alternative screening schedules that increase baseline probabilities of hearing aid uptake (base-case 1.62-fold; range 1.05-2.25-fold). MAIN MEASURES: Lifetime undiscounted and discounted (3%/year) costs and QALYs and incremental cost-effectiveness ratios (ICERs). KEY RESULTS: CD resulted in 1.20 average person-years of hearing aid use compared to 1.27-1.68 with the screening schedules. Lifetime total per-person undiscounted costs were $3300 for CD and ranged from $3630 for 5-yearly screening beginning at age 75 to $6490 for yearly screening beginning at age 45. In cost-effectiveness analysis, yearly screening beginning at ages 75, 65, and 55 years had ICERs of $39,100/QALY, $48,900/QALY, and $96,900/QALY, respectively. Results were most sensitive to variations in hearing aid utility benefit and screening effectiveness. LIMITATION: Input uncertainty around screening effectiveness. CONCLUSIONS: We project that yearly hearing screening beginning at age 55+ is cost-effective by US standards.

Estimated Monetary Value of Future Research Clarifying Uncertainties Around the Optimal Adult Hearing Screening Schedule.

Importance: Adult hearing screening is not routinely performed, and most individuals with hearing loss (HL) have never had their hearing tested as adults. Objective: To project the monetary value of future research clarifying uncertainties around the optimal adult hearing screening schedule. Design, Setting, and Participants: In this economic evaluation, a validated decision model of HL (DeciBHAL-US: Decision model of the Burden of Hearing loss Across the Lifespan) was used to simulate current detection and treatment of HL vs hearing screening schedules. Key model inputs included HL incidence (0.06%-10.42%/y), hearing aid uptake (0.54%-8.14%/y), screening effectiveness (1.62 × hearing aid uptake), utility benefits of hearing aids (+0.11), and hearing aid device costs ($3690). Distributions to model parameters for probabilistic uncertainty analysis were assigned. The expected value of perfect information (EVPI) and expected value of partial perfect information (EVPPI) using a willingness to pay of $100 000 per quality-adjusted life-year (QALY) was estimated. The EVPI and EVPPI estimate the upper bound of the dollar value of future research. This study was based on 40-year-old persons over their remaining lifetimes in a US primary care setting. Exposures: Screening schedules beginning at ages 45, 55, 65, and 75 years, and frequencies of every 1 or 5 years. Main Outcomes and Measures: The main outcomes were QALYs and costs (2020 US dollars) from a health system perspective. Results: The average incremental cost-effectiveness ratio for yearly screening beginning at ages 55 to 75 years ranged from $39 200 to $80 200/QALY. Yearly screening beginning at age 55 years was the optimal screening schedule in 38% of probabilistic uncertainty analysis simulations. The population EVPI, or value of reducing all uncertainty, was $8.2 to $12.6 billion varying with willingness to pay and the EVPPI, or value of reducing all screening effectiveness uncertainty, was $2.4 billion. Conclusions and Relevance: In this economic evaluation of US adult hearing screening, large uncertainty around the optimal adult hearing screening schedule was identified. Future research on hearing screening has a high potential value so is likely justified.

A pragmatic clinical trial of hearing screening in primary care clinics: cost-effectiveness of hearing screening.

BACKGROUND: Hearing loss is a high prevalence condition among older adults, is associated with higher-than-average risk for poor health outcomes and quality of life, and is a public health concern to individuals, families, communities, professionals, governments, and policy makers. Although low-cost hearing screening (HS) is widely available, most older adults are not asked about hearing during health care visits. A promising approach to addressing unmet needs in hearing health care is HS in primary care (PC) clinics; most PC providers (PCPs) do not inquire about hearing loss. However, no cost assessment of HS in community PC settings has been conducted in the United States. Thus, this study conducted a cost-effectiveness analysis of HS using results from a pragmatic clinic trial that compared three HS protocols that differed in the level of support and encouragement provided by the PC office and the PCPs to older adults during their routine visits. Two protocols included HS at home (one with PCP encouragement and one without) and one protocol included HS in the PC office. METHODS: Direct costs of the HS included costs of: (1) educational materials about hearing loss, (2) PCP educational and encouragement time, and (3) access to the HS system. Indirect costs for in-office HS included cost of space and minimal staff time. Costs were tracked and modeled for each phase of care during and following the HS, including completion of a diagnostic assessment and follow-up with the recommended treatment plan. RESULTS: The cost-effectiveness analysis showed that the average cost per patient is highest in the patient group who completed the HS during their clinic visit, but the average cost per patient who failed the HS is by far the lowest in that group, due to the higher failure rate, that is, rate of identification of patients with suspected hearing loss. Estimated benefits of HS in terms of improvements in quality of life were also far greater when patients completed the HS during their clinic visit. CONCLUSIONS: Providing HS to older adults during their PC visit is cost-effective and accrues greater estimated benefits in terms of improved quality of life. TRIAL REGISTRATION: clinicaltrials.gov (Registration Identification Number: NCT02928107).

Centralized Otolaryngology Research Efforts: Stepping-stones to Innovation and Equity in Otolaryngology-Head and Neck Surgery.

The Centralized Otolaryngology Research Efforts (CORE) grant program coordinates research funding initiatives across the subspecialties of otolaryngology-head and neck surgery. Modeled after National Institutes of Health study sections, CORE grant review processes provide comprehensive reviews of scientific proposals. The organizational structure and grant review process support grant-writing skills, attention to study design, and other components of academic maturation toward securing external grants from the National Institutes of Health or other agencies. As a learning community and a catalyst for scientific advances, CORE evaluates clinical, translational, basic science, and health services research. Amid the societal reckoning around long-standing social injustices and health inequities, an important question is to what extent CORE engenders diversity, equity, and inclusion for the otolaryngology workforce. This commentary explores CORE's track record as a stepping-stone for promoting equity and innovation in the specialty. Such insights can help maximize opportunities for cultivating diverse leaders across the career continuum.

New Age Mentoring and Disruptive Innovation-Navigating the Uncharted With Vision, Purpose, and Equity.

For individuals aspiring to a career in otolaryngology-head and neck surgery, mentorship can shape destiny. Mentorship helps assure safe passage into the specialty, and it influences the arc of professional development across the career continuum. Even before the novel coronavirus disease 2019 (COVID-19) pandemic, technology and social networking were transforming mentorship in otolaryngology. Now, in an increasingly virtual world, where in-person interactions are the exception, mentorship plays an even more pivotal role. Mentors serve as trusted guides, helping learners navigate accelerating trends toward early specialization, competency-based assessments, and key milestones. However, several structural barriers render the playing field unlevel. For medical students, cancellation of visiting clerkships, in-person rotations, and other face-to-face interactions may limit access to mentors. The pandemic and virtual landscape particularly threaten the already-leaky pipeline for underrepresented medical students. These challenges may persist into residency and later career stages, where structural inequities continue to subtly influence opportunities and pairings of mentors and mentees. Hence, overreliance on serendipitous encounters can exacerbate disparities, even amid societal mandates for equity. The decision to take deliberate steps toward mentoring outreach and engagement has profound implications for what otolaryngology will look like in years to come. This article introduces the concept of new age mentoring, shining a light on how to modernize practices. The key shifts are from passive to active engagement; from amorphous to structured relationships; and from hierarchical dynamics to bidirectional mentoring. Success is predicated on intentional outreach and purposefulness in championing diversity, equity, and inclusion in the progressively technology-driven landscape.

Moving Beyond GDP: Cost Effectiveness of Cochlear Implantation and Deaf Education in Latin America.

HYPOTHESIS: Cochlear implantation (CI) and deaf education are cost effective management strategies of childhood profound sensorineural hearing loss in Latin America. BACKGROUND: CI has been widely established as cost effective in North America and Europe and is considered standard of care in those regions, yet cost effectiveness in other economic environments has not been explored. With 80% of the global hearing loss burden existing in low- and middle-income countries, developing cost effective management strategies in these settings is essential. This analysis represents the continuation of a global assessment of CI and deaf education cost effectiveness. METHODS: Brazil, Colombia, Ecuador, Guatemala, Paraguay, Trinidad and Tobago, and Venezuela participated in the study. A Disability Adjusted Life Years model was applied with 3% discounting and 10-year length of analysis. Experts from each country supplied cost estimates from known costs and published data. Sensitivity analysis was performed to evaluate the effect of device cost, professional salaries, annual number of implants, and probability of device failure. Cost effectiveness was determined using the World Health Organization standard of cost effectiveness ratio/gross domestic product per capita (CER/GDP)<3. RESULTS: Deaf education was very cost effective in all countries (CER/GDP 0.07-0.93). CI was cost effective in all countries (CER/GDP 0.69-2.96), with borderline cost effectiveness in the Guatemalan sensitivity analysis (Max CER/GDP 3.21). CONCLUSION: Both cochlear implantation and deaf education are widely cost effective in Latin America. In the lower-middle income economy of Guatemala, implant cost may have a larger impact. GDP is less influential in the middle- and high-income economies included in this study.

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.

Measuring Success: Cost-Effectiveness and Expanding Access to Cochlear Implantation.

Only a small fraction of patients with profound sensorineural hearing loss have access to cochlear implantation with the majority of these affected people living in developing countries. Cost effectiveness analysis (CEA) is an important tool to demonstrate the value of this technology to healthcare policy makers. This approach requires that hearing healthcare professionals incorporate methods of assessing long-term benefits of cochlear implantation that include psychosocial, quality of life, and disability outcomes. This review explores different aspects of CEA methodology relevant to cochlear implants and discusses ways that we can improve global access by addressing factors that influence cost-effectiveness.

GDP Matters: Cost Effectiveness of Cochlear Implantation and Deaf Education in Sub-Saharan Africa.

HYPOTHESIS: Cochlear implantation and deaf education are cost effective in Sub-Saharan Africa. BACKGROUND: Cost effectiveness of pediatric cochlear implantation has been well established in developed countries but is unknown in low resource settings, where access to the technology has traditionally been limited. With incidence of severe-to-profound congenital sensorineural hearing loss 5 to 6 times higher in low/middle-income countries than the United States and Europe, developing cost-effective management strategies in these settings is critical. METHODS: Costs were obtained from experts in Nigeria, South Africa, Kenya, Rwanda, Uganda, and Malawi using known costs and published data, with estimation when necessary. A disability adjusted life years (DALY) model was applied using 3% discounting and 10-year length of analysis. Sensitivity analysis was performed to evaluate the effect of device cost, professional salaries, annual number of implants, and probability of device failure. Cost effectiveness was determined using the WHO standard of cost-effectiveness ratio/gross domestic product per capita (CER/GDP) less than 3. RESULTS: Cochlear implantation was cost effective in South Africa and Nigeria, with CER/GDP of 1.03 and 2.05, respectively. Deaf education was cost effective in all countries investigated, with CER/GDP ranging from 0.55 to 1.56. The most influential factor in the sensitivity analysis was device cost, with the cost-effective threshold reached in all countries using discounted device costs that varied directly with GDP. CONCLUSION: Cochlear implantation and deaf education are equally cost effective in lower-middle and upper-middle income economies of Nigeria and South Africa. Device cost may have greater impact in the emerging economies of Kenya, Uganda, Rwanda, and Malawi.

Assessment of health-related quality of life 6 years after childhood cochlear implantation.

PURPOSE: To examine the impact of cochlear implant (CI) intervention on health-related quality of life (HRQOL) assessed by both self- and parent-reported measures. METHODS: In this national study of children implanted between ages 6 months and 5 years, HRQOL of 129 children 6-year post-CI was compared to 62 internal study (NH1) and 185 external (NH2) samples of hearing children frequency-matched to the CI group on sociodemographic variables. HRQOL ratings of children and their parents in each group, measured using the Child Health and Illness Profile-Child Edition, were compared, and their associations with the Family Stress Scale were investigated. RESULTS: CI children reported overall and domain-specific HRQOL that was comparable to both NH1 and NH2 peers. CI parents reported worse child scores than NH1 parents in Achievement, Resilience, and Global score (p's < 0.01) but similar or better scores than socioeconomically comparable NH2 parents. Higher family stress was negatively associated with all parent-reported HRQOL outcomes (p's < 0.01). Parent-child correlations in HRQOL global scores trended higher in CI recipients (r = 0.50) than NH1 (r = 0.42) and NH2 (r = 0.35) controls. CONCLUSIONS: CI recipients report HRQOL comparable to NH peers. These results, from both child and parent perspective, lend support to the effectiveness of CI intervention in mitigating the impact of early childhood deafness. Family stress was associated with worse HRQOL, underscoring a potential therapeutic target. Parent-child agreement in HRQOL scores was higher for CI families than NH families, which may reflect higher caregiver insight and involvement related to the CI intervention.

Is there a "July effect" for head and neck cancer surgery?

OBJECTIVES/HYPOTHESIS: A "July effect" of increased complications when new trainees begin residency has been reported widely by the media. We sought to determine the effect of admission month on in-hospital mortality, complications, length of hospitalization, and costs for patients undergoing head and neck cancer (HNCA) surgery. STUDY DESIGN: Retrospective cross-sectional study. METHODS: Discharge data from the Nationwide Inpatient Sample for 48,263 patients who underwent an ablative procedure for a malignant oral cavity, laryngeal, hypopharyngeal, or oropharyngeal neoplasm in 2005 to 2008 were analyzed using cross-tabulations and multivariate regression modeling. RESULTS: There were 3,812 cases admitted in July (8%). July admission was significantly associated with Medicaid (RRR 1.40, P = 0.011) or self-pay payor status (RRR 1.40, P = 0.022), medium hospital bed size (RRR 1.63, P = 0.033) and large hospital bed size (RRR 1.73, P = 0.013). There was no association between July admission and other patient or hospital demographic characteristics. Major procedures and comorbidity were significantly associated with in-hospital death, surgical and medical complications, length of hospitalization, and costs, but no association was found for July admission, July through September discharge, or teaching hospital status and short-term morbidity or mortality. Teaching hospitals and large hospital bed size were predictors of increased length of hospitalization and costs; and private, for profit hospitals were additionally associated with increased costs. No interaction between July admission and teaching hospitals was found for any of the outcome variables studied. CONCLUSIONS: These data do not support evidence of a "July effect" or an increase in morbidity or mortality at teaching hospitals providing HNCA surgical care.

The timely completion of objective assessment tools for evaluation of technical skills.

OBJECTIVES/HYPOTHESIS: To this date the effect of the time taken to complete an evaluation on the psychometric properties of the instrument has not been reported. The goal of our study was to assess the effect of time taken to complete an evaluation on its validity. STUDY DESIGN: Cross-sectional validation study. METHODS: The global and checklist parts of tonsillectomy, mastoidectomy, rigid bronchoscopy, and endoscopic sinus surgery were used in the operating room by the otolaryngology faculty to evaluate the surgical skills of the residents. We categorized evaluations into two groups depending on the time taken to complete an evaluation (group A ≤ 6 days, group B >6 days). Construct validity was calculated for both groups by comparing the mean global and checklist scores of the residents across advancing postgraduate year levels. RESULTS: A total of 468 evaluations, consisting of global and checklist parts, were completed for 29 residents by 32 evaluators. Mean number of days taken to complete an evaluation was 7.7 days. For all the evaluations completed within a 6-day time period, the construct validity was significant for both global and checklist parts of the four instruments. In cases of the evaluations completed after 6 days, the construct validity was significant for the tonsillectomy instrument only. CONCLUSIONS: Our results indicate that the time taken to complete an evaluation has a significant effect on the construct validity of the objective instrument. In the future, efforts should be focused on faculty development to ensure timely completion of the evaluation for a more valid assessment process.

Vestibular schwannoma surgical volume and short-term outcomes in Maryland.

OBJECTIVE: To characterize contemporary practice patterns and outcomes of vestibular schwannoma surgery. DESIGN: Cross-sectional analysis. SETTING: Maryland Health Service Cost Review Commission database. PATIENTS: The study included patients who underwent surgery for vestibular schwannoma between 1990 and 2009. MAIN OUTCOME MEASURES: Temporal trends and relationships between volume and in-hospital deaths, central nervous system (CNS) complications, length of hospitalization, and costs. RESULTS: A total of 1177 surgical procedures were performed by 57 surgeons at 12 hospitals. Most cases were performed by high-volume surgeons (47%) at high-volume hospitals (79%). The number of cases increased from 474 in 1999-2000 to 703 in 2000-2009. Vestibular schwannoma surgery in 2000-2009 was associated with a decrease in CNS complications (odds ratio [OR] 0.4; P < .001) and an increase in cases performed by intermediate-volume (OR, 4.2; P = .002) and high-volume (OR, 3.2; P = .005) hospitals and intermediate-volume (OR, 1.9; P = .004) and high-volume (OR, 1.8; P = .006) surgeons. High-volume care was inversely related to the odds of urgent and emergent surgery (OR, 0.2; P < .001) and readmissions (OR, 0.1; P = .02). Surgeon volume accounted for 59% of the effect of hospital volume for urgent and emergent admissions and 20% for readmissions. After all other variables were controlled for, there was no significant association between hospital or surgeon volume and in-hospital mortality or CNS complications; however, surgery at high-volume hospitals was associated with significantly lower hospital-related costs (P < .001). CONCLUSIONS: These data suggest increased centralization of vestibular schwannoma surgery, with an increase in cases performed by intermediate- and high-volume providers and meaningful differences in high-volume surgical care that are mediated by surgeon volume and are associated with reduced hospital-related costs. Further investigation is warranted.

Prevalence, characteristics, and management of swallowing disorders following cerebellopontine angle surgery.

OBJECTIVE: To describe swallowing disorders encountered after cerebellopontine angle surgery and to explore variables associated with increased incidence of postoperative dysphagia. STUDY DESIGN: Case series with chart review. SETTING: Single academic medical institution. SUBJECTS AND METHODS: Chart review of 181 consecutive patients undergoing surgical excision of cerebellopontine angle pathology from January 2008 to December 2010 at the Johns Hopkins Hospital. Presence and characteristics of dysphagia were determined by review of speech pathologist reports. Other clinical variables were extracted from the electronic medical record, and statistical analyses were applied to determine factors associated with postoperative dysphagia. RESULTS: Immediate postoperative dysphagia was identified in 57 of 181 patients (31%). Oral, oropharyngeal, and pharyngeal deficits accounted for 51%, 37%, and 12% of dysphagic symptoms, respectively. Facial nerve weakness in the immediate postoperative period was noted in 91% of dysphagic subjects compared with 43% of those without. Mean House-Brackmann score for dysphagic individuals was 4 compared with 2 in the nondysphagic group. Diet alterations were required for 65% of dysphagic individuals, and an additional 9% required tube feeding. Common findings during videofluoroscopic swallowing studies were pharyngeal residue, reduced pharyngeal constriction, and anterior bolus loss. Abnormal penetration-aspiration scores (≥3) were found in 59% of those undergoing videofluoroscopic swallow studies. CONCLUSIONS: Oral and pharyngeal swallowing deficits are commonly encountered after cerebellopontine angle surgery. Consultation with the speech-language pathologist appears most critical for any individuals demonstrating postoperative cranial nerve dysfunction, particularly for those with evidence of facial nerve weakness. Early consultation may help to manage short- and long-term functional difficulties.

Defining milestones toward competency in mastoidectomy using a skills assessment paradigm.

OBJECTIVES/HYPOTHESIS: To establish milestones toward achievement of surgical competency by using an objective assessment tool designed to measure the development of mastoidectomy skills in the operating room (OR). STUDY DESIGN: Prospective longitudinal validation study. METHODS: Fifty-six evaluations were conducted in the OR on nine otolaryngology residents from PGY (postgraduate year) 2 to PGY 5 over a period of 3 years. Technical performance was measured over time using a task-based checklist developed for assessment of mastoidectomy skills. RESULTS: Three sets of technical milestones represented achievement of competency for progressively more complicated procedural steps: the first set was achieved after a mean of 6 +/- 4.3 cases, the second set after 9 +/- 6.7 cases (range of mean = 8-10 cases), and the third set after 13 +/- 6.4 cases (range of mean = 12-14 cases). CONCLUSIONS: The acquisition of mastoidectomy skills can be integrated into surgical teaching in the OR, and this approach yields information that can aid individual skill development and program improvement. The identification of milestones in particular can help establish training benchmarks toward achievement of competency and in identifying trainees in need of remediation.

Objective assessment of mastoidectomy skills in the operating room.

OBJECTIVE(S): To determine the feasibility and validity of an objective assessment tool designed to measure the development of mastoidectomy skills by resident trainees in the operating room. STUDY DESIGN: Prospective longitudinal validation study. SETTING: Tertiary referral center and residency training program. SUBJECTS: Otolaryngology residents. MAIN OUTCOME MEASURE: Technical performance as measured over time using Task-Based Checklist (TBC) and Global Rating Scale (GRS) developed for assessment of mastoidectomy skills. RESULTS: : Seventy pairs of evaluations were completed on 15 residents, showing strong correlation between both instruments (r = 0.93; p < 0.0001). Our instrument demonstrated construct validity for both TBC and GRS, showing higher scores with increasing surgical experience in otology. Both instruments showed high interitem reliability with Cronbach alpha coefficients of 0.98 and 0.95 for TBC and GRS, respectively. Regression analysis showed that thinning posterior external auditory canal (p < 0.05) and opening antrum to deepen dissection at sinodural angle (p < 0.05) were the strongest predictors of overall surgical performance. CONCLUSION: Our assessment tool is a feasible and valid method of evaluating acquisition of mastoidectomy skills in the operating room. It can be integrated into surgical teaching in the operating room and yields information for direct formative feedback.

Pilot testing of an assessment tool for competency in mastoidectomy.

OBJECTIVES/HYPOTHESIS: To determine the feasibility, validity, and reliability of an evaluation tool for the assessment of competency in mastoid surgery. This study tests the hypothesis that residents of dissimilar training levels differ in their technical performance as measured by this tool. STUDY DESIGN: Cross-sectional validation study. METHODS: Two or more faculty otolaryngologists evaluated each resident performing a cortical mastoidectomy on a cadaveric temporal bone. Performance was rated using global and checklist components of a mastoidectomy assessment tool. RESULTS: Fifteen internal and external faculty members evaluated 23 residents over 3 years resulting in 118 evaluations. Construct validity was observed as scores increased with clinical training year. These differences were greater for more complex tasks. There was a percentage agreement of 78.5% between evaluator pairs in the determination of pass (score 3-5) versus fail (score 1-2) for the checklist instrument, and an agreement of 74.4% for the global instrument. Although agreement was lower for the exact score on a scale of 1 to 5, differences of 1 or less occurred in over 80% of evaluator pairs. Regression analysis confirmed faculty perception that sharpening of the posterior external auditory canal cortex and opening of the antrum from posterior to anterior are strong predictors of overall surgical performance. CONCLUSIONS: Our results indicate that the tool we have developed is a feasible, valid, and reliable instrument for the assessment of competency in mastoidectomy. The instrument can be used to provide formative feedback and to identify procedural tasks for which additional training may be necessary.