Association Between Saccule and Semicircular Canal Impairments and Cognitive Performance Among Vestibular Patients.

OBJECTIVES: Growing evidence suggests that vestibular function impacts higher-order cognitive ability such as visuospatial processing and executive functioning. Despite evidence demonstrating vestibular functional impairment impacting cognitive performance, it is unknown whether cognitive ability is differentially affected according to the type of vestibular impairment (semicircular canal [SCC] versus saccule) among patients with diagnosed vestibular disease. DESIGN: Fifty-four patients who presented to an academic neurotologic clinic were recruited into the study. All patients received a specific vestibular diagnosis. Forty-one patients had saccule function measured with the cervical vestibular-evoked myogenic potential, and 43 had SCC function measured using caloric irrigation. Cognitive tests were administered to assess cognitive performance among patients. One hundred twenty-five matched controls were recruited from the Baltimore Longitudinal Study of Aging to compare cognitive performance in patients relative to age-matched healthy controls. RESULTS: Using multivariate linear regression analyses, patients with bilaterally absent cervical vestibular-evoked myogenic potential responses (i.e., bilateral saccular impairments) were found to take longer in completing the Trail-Making test (ß = 25.7 sec, 95% confidence interval = 0.3 to 51.6) and to make significantly more errors on the Benton Visual Retention test part-C (ß = 4.5 errors, 95% confidence interval [CI] = 1.2 to 7.8). Patients with bilateral SCC impairment were found to make significantly more errors on the Benton Visual Retention test part-C (ß = 9.8 errors, 95% CI = 0.2 to 19.4). From case-control analysis, for each SD difference in Trail-Making test part-B time, there was a corresponding 142% increase in odds of having vestibular impairment (odds ratio = 2.42, 95% CI = 1.44 to 4.07). CONCLUSIONS: These data suggest that bilateral saccule and SCC vestibular impairments may significantly affect various domains of cognitive performance. Notably, the cognitive performance in patients in this study was significantly poorer relative to age-matched healthy adults. Cognitive assessment may be considered in patients with saccule and SCC impairments, and cognitive deficits in vestibular patients may represent an important target for intervention.

Factors associated with the accuracy of subjective assessments of hearing impairment.

OBJECTIVES: Self-reported hearing impairment is often used to gauge objective hearing loss in both clinical settings and research studies. The aim of this study was to examine whether demographic factors affect the accuracy of subjective, self-reported hearing in older adults. DESIGN: We examined 3557 participants aged 50 and older in the National Health and Nutrition Examination Survey cycles 1999-2006 and 2009-2010. We examined the relationship between objective and subjective hearing impairment using percent correct classification and misclassification bias in analyses stratified by gender, age group, race/ethnicity, and education. RESULTS: We found that younger participants tended to overestimate and older participants underestimate their hearing impairment. Older women, blacks, and Hispanics were less accurate in self-reporting than their respective younger age groups. CONCLUSIONS: The association between subjective and objective hearing differs across gender, age, race/ethnicity, and education, and this observation should be considered by clinicians and researchers employing self-reported hearing.

Transoral resection of stylopharyngeus calcification: a unique manifestation of a stylohyoid complex syndrome.

BACKGROUND: Eagle syndrome is often considered in the work-up of odynophagia and neck pain. Classically, this is manifested by ossification or calcification of the stylohyoid ligament or styloid process. There are no reported cases of stylopharyngeal calcification leading to these symptoms. CASE: We describe a patient with a suspected submucosal pharyngeal foreign body who was found to have a calcified stylopharyngeus muscle and tendon during surgery. The patient experienced full resolution of symptoms after transoral robotic resection. This diagnosis was initially missed because the radiology was inconsistent with Eagle syndrome. CONCLUSION: This is the first report of isolated stylopharyngeal calcification, and this unique manifestation of a stylohyoid complex syndrome should be considered in patients with symptoms of Eagle syndrome without styloid elongation.

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.

Predictors of Completion of Sublingual Immunotherapy.

OBJECTIVES: Sublingual immunotherapy (SLIT) has emerged as an effective treatment alternative to subcutaneous immunotherapy (SCIT) given its improved safety profile and more convenient dosing. However, SLIT still relies on daily dosing for many years to optimize effectiveness. This study sought to investigate factors that influence patient completion of SLIT. METHODS: We performed an institutional retrospective review of patients who received SLIT (2008-2020). Completion was defined as completing at least 36 months of SLIT. Patient demographics and characteristics, including the number of allergens treated, history of asthma and sinus surgery, number of clinic visits, and total time undergoing SLIT, were documented. Multivariate models were used to analyze predictors of SLIT completion. Subgroup analysis was performed among pediatric patients and patients who discontinued SLIT. RESULTS: Of the 404 total patients, 249 (61.6%) discontinued, 47 (11.6%) completed, and 108 (26.7%) were currently undergoing SLIT. The mean duration of therapy was 11.2 months for those who discontinued and 49.4 months for patients who completed SLIT. The odds of SLIT completion were twice as high with each additional clinic visit (P < .001), and twice as high when the dosage was increased during therapy (P = .06). Pediatric patients younger than age 12 with a history of asthma were over five times more likely to complete therapy (P = .045). Patients with more clinic visits (P < .001) and higher associated costs (P = .003) were less likely to be lost to follow-up. CONCLUSION: Increasing the frequency of clinic visits, improving therapy availability, and mitigating concerns about clinical efficacy may increase patient completion of SLIT. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:E2111-E2115, 2021.

Detection of Wandering Behaviors Using a Body-Worn Inertial Sensor in Patients With Cognitive Impairment: A Feasibility Study.

Patients with Alzheimer's disease (AD) and AD related dementias (ADRD) often experience spatial disorientation that can lead to wandering behavior, characterized by aimless or purposeless movement. Wandering behavior has been associated with falls, caregiver burden, and nursing home placement. Despite the substantial clinical consequences of wandering, there is currently no standardized approach to objectively quantify wandering behavior. In this pilot feasibility study, we used a lightweight inertial sensor to examine mobility characteristics of a small group of 12 older adults with ADRD and mild cognitive impairment in their homes. Specifically, we evaluated their compliance with wearing a sensor for a minimum of 4 days. We also examined the ability of the sensor to measure turning frequency and direction changes, given that frequent turns and direction changes during walking have been observed in patients who wander. We found that all patients were able to wear the sensor yielding quantitative turn data including number of turns over time, mean turn duration, mean peak turn speed, and mean turn angle. We found that wanderers make more frequent, quicker turns compared to non-wanderers, which is consistent with pacing or lapping behavior. This study provides preliminary evidence that continuous monitoring in patients with dementia is feasible using a wearable sensor. More studies are needed to explore if objective measures of turning behaviors collected using inertial sensors can be used to identify wandering behavior.

The Role of Preoperative Briefing and Postoperative Debriefing in Surgical Education.

OBJECTIVE: To study the impact of a new preoperative briefing and postoperative debriefing tool on the perceived quality of surgical education and to assess attitudes of residents and attendings regarding this tool. DESIGN: Surrounding introduction and use of the tool (JHFIRE: Joint Huddles for Improving Resident Education), perceived quality of surgical education was assessed with pre- and postintervention System for Evaluation of Teaching Qualities (SETQ) surveys. Additionally, a postintervention Likert survey regarding the JHFIRE tool itself was completed by residents and faculty. SETTING: Johns Hopkins University Department of Otolaryngology-Head and Neck Surgery, a tertiary care academic institution. PARTICIPANTS: All residents and attendings who used the tool were invited to participate. 40 participants (13 residents, 27 attendings) completed the preintervention SETQ. 11 participants (3 residents, 7 attendings, 1 unspecified) completed the postintervention SETQ. For postintervention qualitative assessment of the tool itself, 12 participants (3 residents, 7 attendings, 2 unspecified) provided feedback. RESULTS: The tool was well-received with large subjective benefit in improving resident surgical education. A total of 88% thought that the time spent on the debriefings was "just right" and 91% planned to make the debriefings a regular part of operative performance assessments. Despite this overwhelmingly positive feedback, there was no overall difference in pre- and postintervention SETQ scores for climate of surgical education in the Department (4.25 ± 0.55 vs. 4.10 ± 0.88, p = 0.63). CONCLUSIONS: Introduction of 4 item preoperative briefing and 4 item postoperative debriefing checklists was welcomed by both residents and faculty for its ability to shape surgical education in the operating room into a guided discovery model of hands-on education. Overall SETQ scores did not change, but most participants found value in the tool and plan to continue its use.

Preoperative Briefings and Postoperative Debriefings to Increase Resident Operative Autonomy and Performance.

OBJECTIVE: To implement the use of standardized preoperative briefings and postoperative debriefings for surgical cases involving residents in an effort to improve resident autonomy and skill acquisition. DESIGN: Prospective longitudinal study. SETTING: Johns Hopkins Department of Otolaryngology-Head and Neck Surgery. PARTICIPANTS: Resident and attending physicians. RESULTS: Joint Huddles for Improving Resident Education (JHFIRE) tool was created and successfully implemented by 19 residents and 17 faculty members. Over the course of three data collection periods spanning an academic year, overall scores improved though not statistically significantly in the metrics of Zwisch autonomy, Resident Performance, and Objective Structured Assessment of Technical Skills (OSATS) scores. Female residents were scored significantly higher by attendings than their male counterparts in the assessment of baseline Resident Performance. CONCLUSIONS: (1) JHFIRE tool implemented a standardized preoperative briefing and postoperative debriefing to improve communication and resident skill acquisition; (2) The tool was accepted and utilized throughout an academic year; (3) Zwisch, Resident Performance, and OSATS scores improved though not significantly.

Pediatric Rhinoplasty: A national surgical quality improvement program analysis.

OBJECTIVES: Rhinoplasty is commonly performed in children with congenital anomalies and resultant nasal deformity causing airway obstruction. Little is known regarding patient factors or perioperative sequelae. We define demographic characteristics and perioperative complications for children undergoing rhinoplasty within a large national cohort. STUDY DESIGN: Retrospective cohort study of children aged ≤ 18 years undergoing rhinoplasty utilizing data from the 2012 to 2015 American College of Surgeons National Surgery Quality Improvement Program-Pediatric public use file. METHODS: All children who underwent rhinoplasty were identified. Postoperative complications were defined as 30-day postoperative infection, unplanned readmission and reoperation, and death. Multivariate logistic regression was used to identify predictors of complications. Subgroup analysis was performed based on child age (age < 5 years vs. 5-13 years vs. ≥ 14 years). RESULTS: Of 1,378 children undergoing rhinoplasty, 21(1.52%) children experienced complications, with the most common being unplanned readmission. Younger children were more likely to experience complications (3.79% aged < 5 years vs. 0.66% aged ≥ 14 years; P = 0.001). Using multivariate logistic regression analysis, we observed a 61% decreased odds of complication with each age group (odds ratio 0.39, 95% confidence interval 0.19, 0.77; P = 0.007). Younger children were more likely to be male (56.2% male aged < 5 years vs. 46.6% male aged ≥ 14 years; P = 0.011), have developmental delay (11.7% aged < 5 years vs. 3.65% aged ≥ 14 years; P < 0.001), and have craniofacial abnormalities (73.2% aged < 5 years vs. 42.1% aged ≥ 14 years; P < 0.001). CONCLUSION: Children undergoing rhinoplasty experience few major complications, with the most common being unplanned readmission. Younger children are at greater risk and are more likely to be male with craniofacial abnormalities. LEVEL OF EVIDENCE: 4 Laryngoscope, 129:494-499, 2019.

Vestibular Function and Beta-Amyloid Deposition in the Baltimore Longitudinal Study of Aging.

Beta-amyloid (Aß) plaque deposition is a key feature of Alzheimer's disease (AD), and occurs years before the onset of symptoms. Aß plaque deposition has been shown to be present in ~30% of cognitively normal older adults using amyloid C-11 labeled Pittsburgh Compound B (11C-PiB) Positron Emission Tomography (PET) imaging. Prior studies have reported a link between reduced vestibular function and poorer cognition in healthy older adults. It is unknown whether vestibular impairment occurs in association with AD pathology among individuals in the preclinical phase of AD, which could contribute to the observed association between vestibular and cognitive function in healthy older adults. Using the Baltimore Longitudinal Study of Aging (BLSA), we analyzed the association between a comprehensive set of vestibular function measures and PiB status in 98 healthy participants with a mean age of 77.3 (±8.26). We did not observe a significant relationship between any vestibular function measure and PiB status in cognitively-intact older adults in the BLSA. This finding suggests that Aß deposition does not explain the observed association between reduced vestibular function and poorer cognition in healthy older adults.

Vestibular Function and Hippocampal Volume in the Baltimore Longitudinal Study of Aging (BLSA).

OBJECTIVE: This study evaluated whether reduced vestibular function in aging adults is associated with lower hippocampal volume. STUDY DESIGN: Cross-sectional study. SETTING: Baltimore Longitudinal Study of Aging, a long-running longitudinal cohort study of healthy aging. PATIENTS: Eligible participants were aged ≥ 60 years and had both vestibular physiological testing and brain magnetic resonance imaging at the same visit. INTERVENTION: Vestibular function testing consisted of the cervical vestibular-evoked myogenic potential (cVEMP) to assess saccular function, ocular VEMP to assess utricular function, and video head-impulse testing to assess the horizontal semicircular canal vestibulo-ocular reflex. MAIN OUTCOME MEASURE: Hippocampal volume calculated using diffeomorphometry. RESULTS: The study sample included 103 participants (range of 35-90 participants in subanalyses) with mean (±SD) age 77.2 years (±8.71). Multivariate linear models including age, intracranial volume, sex, and race showed that 1 µV amplitude increase of cVEMP was associated with an increase of 319.1 mm (p = 0.003) in mean hippocampal volume. We did not observe a significant relationship between ocular VEMP amplitude or vestibulo-ocular reflex gain and mean hippocampal volume. CONCLUSIONS: Lower cVEMP amplitude (i.e., reduced saccular function) was significantly associated with lower mean hippocampal volume. This is in line with previous work demonstrating a link between saccular function and spatial cognition. Hippocampal atrophy may be a mechanism by which vestibular loss contributes to impaired spatial cognition in older adults. Future work using longitudinal data will be needed to evaluate the causal nature of the association between vestibular loss and hippocampal atrophy.

Electronic Health Record Use Among American Neurotology Society Members.

OBJECTIVE: To describe the use of electronic health records (EHR) among members of the American Neurotology Society (ANS). STUDY DESIGN: Cross-sectional. SETTING: Active ANS members in November 2017. INTERVENTION: Internet-based survey. MAIN OUTCOME MEASURE: Survey that assessed the use of EHR in practice, types of EHR programs, different elements of EHR employed, and respondents' satisfaction and efficiency with EHR. RESULTS: One hundred twenty-seven ANS members responded to the survey with 67 (52.8%) respondents working in academic practice and 60 (47.2%) respondents working in private practice. Epic was the most commonly used EHR with 89 (70.1%) respondents using this system. Among all respondents, 84 (66.1%) respondents reported their efficiency was reduced by EHR use, and there was an even split between respondents who reported they were satisfied versus dissatisfied with their EHR (∼40% each). We found that younger members were more likely to feel EHR increased their efficiency compared with the older members (p = 0.04). In all other analyses, we found no significant difference in efficiency and satisfaction between age groups, practice settings, presence of residents or fellows, or specific EHR used. The main challenges reported by ANS members related to the EHR were increased time burden, poor user interface, lack of customizability, and the focus away from patients. CONCLUSIONS: The majority of ANS members felt their efficiency decreased as a result of EHR. These findings provide specific changes to the EHR that would improve efficiency and satisfaction among neurotologists.

"Text It" program to track falls in patients with Alzheimer's disease and dementia.

INTRODUCTION: Falls are a significant problem among older adults with Alzheimer's disease, leading to high rates of fracture, hospitalization, and death. Tracking falls in older adults, particularly those with cognitive impairment, is a clinical and research challenge. METHODS: This prospective pilot study evaluated the feasibility of a text message program to track falls among patients with dementia. We also compared this technique with the calendar method of fall data collection. RESULTS: There was a 96% completion rate of text messaging and 100% of calendars; however, the text-gathered data were more accurate. DISCUSSION: A text-messaging platform to track falls shows promise in cognitively impaired individuals.

Case-control study evaluating competing risk factors for angioedema in a high-risk population.

OBJECTIVES/HYPOTHESIS: Black race is a risk factor for angioedema. The primary aim was to examine the relationship between race-ethnicity and risk factors for angioedema. STUDY DESIGN: Using a retrospective case-control study design, data was extracted with the Clinical Looking Glass utility, a data collection and management tool that captures data from electronic medical record systems within the Montefiore Healthcare System. Cases were emergency department (ED) visits with primary or secondary International Classification of Diseases, Ninth Revision, code diagnoses of angioedema in adults aged ≥ 18 years from January 2008 to December 2013 at three Montefiore centers in Bronx, New York. Controls were a random sampling of adult ED visits during the same period. METHODS: In primary analyses, angiotensin-converting enzyme inhibitor (ACE-I) and black race were evaluated for synergy. The influence of different risk factors in the development of angioedema was evaluated using logistic regression models. Finally, race-ethnicity was further explored by evaluating for effect modification by stratification of models by race-ethnicity categories. RESULTS: There were 1,247 cases and 6,500 controls randomly selected from a larger control pool. ACE-I use (odds ratio [OR] 3.70, 95% confidence interval [CI] 2.98, 4.60), hypertension (OR 1.88, 95% CI 1.55, 2.29), and black race (OR 2.25, 95% CI 1.86, 2.72) were the strongest risk factors. ACE-I use and black race were not synergistic (OR 1.10, 95% CI 0.80, 1.51). Race-ethnicity was an effect modifier for certain risk factors. CONCLUSION: Race-ethnicity acts as an effect modifier for particular angioedema risk factors. The two strongest risk factors, ACE-I use and black race, were not synergistic. LEVEL OF EVIDENCE: 3b. Laryngoscope, 126:1823-1830, 2016.

Association of Hearing Impairment With Incident Frailty and Falls in Older Adults.

OBJECTIVE: We aimed to determine whether hearing impairment (HI) in older adults is associated with the development of frailty and falls. METHOD: Longitudinal analysis of observational data from the Health, Aging and Body Composition study of 2,000 participants aged 70 to 79 was conducted. Hearing was defined by the pure-tone-average of hearing thresholds at 0.5, 1, 2, and 4 kHz in the better hearing ear. Frailty was defined as a gait speed of <0.60 m/s and/or inability to rise from a chair without using arms. Falls were assessed annually by self-report. RESULTS: Older adults with moderate-or-greater HI had a 63% increased risk of developing frailty (adjusted hazard ratio [HR] = 1.63, 95% confidence interval [CI] = [1.26, 2.12]) compared with normal-hearing individuals. Moderate-or-greater HI was significantly associated with a greater annual percent increase in odds of falling over time (9.7%, 95% CI = [7.0, 12.4] compared with normal hearing, 4.4%, 95% CI = [2.6, 6.2]). DISCUSSION: HI is independently associated with the risk of frailty in older adults and with greater odds of falling over time.

The effects of hearing impairment in older adults on communication partners: a systematic review.

BACKGROUND: Hearing impairment is highly prevalent in older adults and can affect the daily activities of a person who is hard of hearing (HOH). The impact of hearing impairment may also have collateral effects on the primary communication partner (CP; e.g., spouse, close family member, or caregiver) of the person who is HOH. PURPOSE: We aimed to characterize the impact of hearing loss in a person who is HOH on his or her CP. RESEARCH DESIGN: We conducted a systematic review of manuscripts examining the consequences of hearing loss in a person who is HOH on the CP. We searched PubMed, Embase, Scopus, PyscINFO, CINAHL Plus with full text, and Web of Science for peer-reviewed articles using a predefined search string and hand-searched reference lists of relevant articles. DATA COLLECTION AND ANALYSIS: We initially screened abstracts blinded for author and journal to eliminate irrelevant and duplicate articles. Descriptive information on study populations, hearing assessments, outcome metrics, and study findings were extracted from full-length manuscripts. RESULTS: Of the 1,047 abstracts retrieved from database searching and 5 hand-searched articles, 24 articles met inclusion criteria. These articles included observational clinical studies, randomized clinical trials, and epidemiologic studies. Overall, CPs experienced a restricted social life, increased burden of communication, and poorer quality of life (QOL) and relationship satisfaction. Effects of hearing impairment on a CP's mental health were unclear. Treatment of hearing loss in the person who is HOH tended to improve QOL, communication, feelings toward the person who is HOH, and activity participation of the CP. CONCLUSIONS: This review highlights the broad effects of hearing impairment and the importance of involving CPs in hearing loss treatment decisions.

Age and sex disparities in discussions about kidney transplantation in adults undergoing dialysis.

OBJECTIVES: To explore whether disparities in age and sex in access to kidney transplantation (KT) originate at the time of prereferral discussions about KT. DESIGN: Cross-sectional survey. SETTING: Outpatient dialysis centers in Maryland (n = 26). PARTICIPANTS: Individuals who had recently initiated hemodialysis treatment (N = 416). MEASUREMENTS: Participants reported whether medical professionals (nephrologist, primary medical doctor, dialysis staff) and social group members (significant other, family member, friend) discussed KT with them and, when applicable, rated the tone of discussions. Relative risks were estimated using modified Poisson regression. RESULTS: Participants aged 65 and older were much less likely than those who were younger to have had discussions with medical professionals (44.5% vs 74.8%, P < .001) or social group members (47.3% vs 63.1%, P = .005). Irrespective of sex and independent of race, health-related factors, and dialysis-related characteristics, older adults were more likely not to have had discussions with medical professionals (relative risk (RR) = 1.13, 95% confidence interval (CI) = 1.03-1.24, for each 5-year increase in age through 65; RR = 1.28, 95% CI = 1.14-1.42, for each 5-year increase in age beyond 65). Irrespective of age, women were more likely (RR = 1.45, 95% CI = 1.12-1.89) not to have had discussions with medical professionals. For each 5-year increase in age, men (RR = 1.04, 95% CI = 0.99-1.10) and women (RR = 1.17, 95% CI = 1.10-1.24) were more likely not to have discussions with social group members. Of those who had discussions with medical professionals or social group members, older participants described these discussions as less encouraging (all P < .01). CONCLUSION: Older adults and women undergoing hemodialysis are less likely than younger adults and men to have discussions about KT as a treatment option, supporting a need for better clinical guidelines and education for these individuals, their social network, and their providers.