Relevance of the Activities-Specific Balance Confidence (ABC) Scale to Urban Community-Dwelling Adults With Diagnosed Vestibular Dysfunction.

OBJECTIVE: To determine how relevant the items on the activities-specific balance confidence (ABC) scale are to patients living in an urban setting and to evaluate additional items relevant to urban populations but not included in the current version of the scale. DESIGN: Cross-sectional clinical survey. SETTING: Urban, tertiary vestibular rehabilitation clinic. PARTICIPANTS: Vestibular rehabilitation clinic outpatients (N=103). INTERVENTIONS: N/A. MAIN OUTCOME MEASURES: Relevance of 16 day-to-day tasks on the ABC scale on a scale of 0 (not performed) to 10 (performed regularly); median relevancy score (MRS) for most relevant items. RESULTS: One hundred three participants (73.7% female, mean age 61.5± years) with vestibular disorders completed the survey. The items with the highest MRS were walking around a house (MRS=10), reaching for a shelved item eye level (MRS=9), taking the stairs (MRS=7), bending over and picking up a slipper (MRS=7), and stepping onto or off an escalator while holding the railing (MRS=7). Lowest MRS items to someone living in an urban environment included walking across a parking lot to the mall (MRS=0) and walking outside the house to a car parked in the driveway (MRS=0). The most common functional activities not addressed by ABC score included navigating the subway/public transit (35.9%) and walking through crowds (32.0%). CONCLUSIONS: This study revealed insights about important activities of daily living for those in an urban setting. Results show that the ABC scale should be modified to better reflect the specific activities of urban dwellers.

Outcomes in primary and revision surgery for pediatric onset stapedial pathology.

OBJECTIVES: To analyze audiometric outcomes of surgery for pediatric onset stapedial pathology (POSP). STUDY DESIGN: Retrospective cohort study. SETTING: Single-institution database. METHODS: Retrospective analysis of 809 stapes procedures performed at a single high-volume tertiary referral otology practice, 75 of which were POSP cases. RESULTS: Oval window drillout for thick footplate and aborting the procedure were more common in POSP cases compared to the rest of the cohort (28.0% versus 9.8% [p < .001] and 5.3% versus 1.2% [p = .007], respectively). Postoperative complications were rare. Postoperative Air-Bone Gap (pABG) closure to ≤20 dB was significantly lower in the POSP group (80.0% versus 89.0%, p = .021). Rates of sensorineural hearing loss (SNHL) were not different between the two groups. Poor audiometric outcomes in the POSP group were largely driven by revision cases; pABG≤10 dB was 60.3% in primary cases but only 11.8% in revisions (p < .001), and postoperative SNHL was significantly higher in revisions (29.4% versus 0.0%, p < .001). In multivariate analysis, POSP was not a predictor of successful closure of the pABG at either level, nor did it predict significant postoperative SNHL. CONCLUSIONS: Surgery for pediatric onset stapedial pathology had significantly worse audiometric outcomes, particularly in revision cases, as compared to the rest of the cohort.

The utility of augmented reality in lateral skull base surgery: A preliminary report.

OBJECTIVE: To discuss the utility of augmented reality in lateral skull base surgery. PATIENTS: Those undergoing lateral skull base surgery at our institution. INTERVENTION(S): Cerebellopontine angle tumor resection using an augmented reality interface. MAIN OUTCOME MEASURE(S): Ease of use, utility of, and future directions of augmented reality in lateral skull base surgery. RESULTS: Anecdotally we have found an augmented reality interface helpful in simulating cerebellopontine angle tumor resection as well as assisting in planning the incision and craniotomy. CONCLUSIONS: Augmented reality has the potential to be a useful adjunct in lateral skull base surgery, but more study is needed with large series.

Nuances in transcanal endoscopic surgical technique for glomus tympanicum tumors.

OBJECTIVE: To describe the utility and nuances of transcanal endoscopic surgery (TCES) on glomus tympanicum tumors from a single surgeon's experience. PATIENTS/INTERVENTION: Twelve patients, eight female and four males, diagnosed pre-operatively with glomus tympanicum tumors. They all underwent endoscopic resection by a single surgeon. MAIN OUTCOME MEASURES: Feasibility of endoscopic resection of glomus tympanicum tumors without conversion to a microscopic approach. Secondary outcomes include tumor stage, pre and post-operative audiometry, vertigo, sensorineural hearing loss (SNHL) and integrity of the facial nerve, ossicles, chorda tympani and tympanic membrane. RESULTS: Twelve patients underwent TCES, eight patient's pathology results were glomus tympanicum, ranging from Glasscock-Jackson grade I-III. Due to loss in follow up, 6/8 patients had complete audiometric data, which were analyzed. Average pre-operative air-bone-gap (ABG) was 5.41 compared to post-operative ABG of 5.08 (p > 0.89). No patients resulted in any, post-operative vertigo, tinnitus, SNHL, facial nerve injury or chorda tympani nerve injury. Two patients had intentional tympanic membrane perforations secondary to tumor adherence to the membrane. They were repaired with tragal perichondrium graft. No patients have had any recurrences. CONCLUSIONS: Endoscopic resection of glomus tympanicum tumors is a feasible and effective, alternative visualization modality for the neurotologist. Surgical pearls are described herein.

Microdrill in endoscopic stapes surgery: Is it safe?

PURPOSE: To assess the safety of using a microdrill in endoscopic vs microscopic stapes surgery. MATERIALS AND METHODS: A retrospective review of 29 adult ears with otosclerosis who underwent either an endoscopic or microscopic approach to microdrill stapedotomy. PRIMARY OUTCOME: Determine if transcanal endoscopic stapes surgery with the microdrill is as safe as microscopic stapes surgery. Secondary outcome: Bone and air pure-tone averages, air-bone gap, speech discrimination, overall surgical cost, and operative time were measured and analyzed. Complications such as post-operative dysgeusia, vertigo, readmission, revision and hearing loss were noted. RESULTS: 29 patients with otosclerosis were retrospectively reviewed, in total 14 endoscopic and 15 microscopic approaches were included, all performed over one-year period. None of the endoscopic surgeries require conversion to the microscope. No statistically significant audiometric differences between the endoscopic vs microscopic approaches in air pure-tone averages and air-bone gap. There were 82.8% air-bone gap closure to <15 dB with no significant difference in the percent of such closures between the endoscopic (85.7%) and microscopic groups (80%, P = .68). Three prostheses were used: 4.25 mm (17.2%), 4.5 mm (58.6%) and the 4.75 mm (24.1%) smart/eclipse. Endoscopic median operative time was 51 min vs 42 min for microscopic approach (P =.004). CONCLUSIONS: The endoscopic with microdrill approach is criticized to lack depth perception, especially when using a microdrill to perform in stapedotomies. Our study showcases that using the microdrill use produces minimal differences in outcomes, cost, and is a safe modality to stapes surgery in both approaches.

Purely intracranial vagal schwannoma: A case report of a rare lesion.

We present a rare intracranial vagal schwannoma along with its preoperative, intraoperative, and postoperative course.

Angiolymphoid hyperplasia with eosinophilia of the external ear.

Herein we present the rare case of angiolymphoid hyperplasia with eosinophilia of the external ear treated by surgical resection and full-thickness skin graft. Current diagnosis and management options are reviewed.

National 30-day readmission and prolonged length of stay after vestibular schwannoma surgery: Analysis of the Nationwide Readmissions Database.

PURPOSE: To determine the risk factors for unanticipated readmission, prolonged index admission, and discharge to a facility after vestibular schwannoma surgery. MATERIALS AND METHODS: Retrospective cohort study of those undergoing surgery for vestibular schwannoma in the Nationwide Readmissions Database (2013-2014). Main outcome measures included readmission rate, length of stay, discharge destination. RESULTS: There were 4585 cases identified. The overall unanticipated readmission rate was 8.1%, and 9.1% had a prolonged length of stay (PLOS) of ≥7 days. Mean and median LOS were 4.63 and 4.00 days, respectively, and >90% of patients were discharged after 7 days. Disposition to a facility occurred in 6.7% of cases. Teaching hospitals were protective against unintended readmission (odds ratio [OR] 0.44, p < .001). Major functional loss was associated with PLOS (OR 12.55, p < .001). High volume centers were associated with decreased risk of PLOS (OR 0.46, p < .001) and facility discharge (OR 0.68, p < .001). The most common readmission diagnoses included "other nervous system complications" (n = 128), cerebrospinal fluid leak (n = 71), "other postoperative infection" (n = 61), and meningitis (n = 59). CONCLUSIONS: Unanticipated readmission and prolonged LOS following vestibular schwannoma surgery are common, with varied sociodemographic, hospital, and patient factors independently associated with each. Further studies are needed to investigate targeted interventions aimed at minimizing readmission and prolonged LOS using the factors outlined above.

The 50 Most Cited Articles in Facial Plastic Surgery.

Bibliometric analysis is a common method to determine the most influential articles in medical specialties, as it is an objective measure of peer recognition of scientific work. This study is the first bibliometric analysis of the literature in facial plastic surgery, to determine the most cited papers in the field. Bibliometric analysis was performed using the Science Citation Index from the Institute for Scientific Information, accessed through the Web of Science™. Filter terms relevant to the field of facial plastic surgery were used to identify the 50 most cited journal articles between 1900 and 2016. The median number of citations was 150 (range 116-1091). The articles spanned a wide range of topics in the field, with the most common topics being free flap reconstruction (n = 10), nasal surgery (n = 9), and rhytidectomy (n = 6). The majority of these articles (n = 29) presented findings supported by level IV or V evidence. This analysis provides an overview of the most cited articles in facial plastic surgery, many of which introduced some of the most fundamental principles and techniques in the field. These landmark articles represent important educational points that should be reviewed by all clinicians and trainees in this field. Level of Evidence III This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Utility of Extended High-Frequency Audiograms in Clinical Practice.

OBJECTIVES: Extended high-frequency (EHF) audiometry elicits pure-tone thresholds at frequencies above 8 kHz, which are not included in routine clinical testing. This study explores the utility of EHF audiometry in patients with various audiologic symptoms despite normal-hearing thresholds at ≤8 kHz. METHODS: A retrospective review was performed of all patients receiving conventional (250-8 kHz) and EHF (9-20 kHz) audiometry at a tertiary otological referral center between April 2021 and August 2022. Only patients with audiologic symptoms and pure-tone thresholds ≤25 dB HL at ≤8 kHz bilaterally on routine testing were included in subsequent analysis. EHF-PTA was defined for each ear as an average of the air conduction thresholds at 9.0, 10.0, 11.2, 12.5, 14.0, 16.0, 18.0, and 20.0 kHz. RESULTS: Of the 50 patients who received EHF testing, 40 had audiologic symptoms and normal conventional audiograms at ≤8 kHz. Twenty-five of the 40 (62.5%) were found to have hearing loss in the highest frequencies. Patients with EHF hearing loss (EHF-HL) were more likely to report subjective hearing loss. Age was significantly greater in those with EHF-HL compared with those without EHF-HL, and age was positively correlated with the degree of EHF-HL. CONCLUSION: EHF testing correlates with audiologic symptoms in patients with normal testing at ≤8 kHz and may be considered when standard audiometry is normal. Additional data are warranted to create an evidenced-based, clinical algorithm for EHF audiometry that can guide treatment, direct mitigation strategies, and potentially identify those at higher risk of hearing loss over time. LEVEL OF EVIDENCE: 4 Laryngoscope, 134:907-910, 2024.

Cost-Effectiveness of Diffusion-Weighted Magnetic Resonance Imaging Versus Second-Look Surgery in Treating Cholesteatoma: A Modeling Study.

OBJECTIVE: To evaluate whether canal wall-up (CWU) tympanomastoidectomy with diffusion-weighted magnetic resonance imaging (DW-MRI) is a cost-effective method of treating cholesteatoma compared with CWU with second-look surgery. DESIGN AND SETTING: Cost-effectiveness analysis was conducted using a Markov state transition model. The simulation model adhered to the Panel Recommendations on Cost-Effectiveness in Health and Medicine established by the US Public Health Service. One-way and Monte Carlo probability sensitivity analyses were conducted for validation. INTERVENTIONS: Tympanomastoidectomy with DW-MRI versus tympanomastoidectomy with second-look surgery. MAIN OUTCOME MEASURES: Effectiveness and health utility were measured using quality-adjusted life years (QALYs). Costs were derived from Medicare reimbursement using the perspective of the payer. Probabilities for outcomes and complications were taken from existing literature. Cost-effectiveness was assessed using the incremental cost-effectiveness ratio. RESULTS: With base case analysis, the total cost was $15,069 when treated with CWU and second-look surgery versus $13,126 when treated with CWU and DW-MRI. The second-look treatment pathway yielded 17.05 QALYs, whereas the DW-MRI pathway yielded 16.91 QALYs in terms of health benefit accrued across the lifetime of the patient. The cost-effectiveness incremental cost-effectiveness ratio was $21,800/QALY. Using the conventional $50,000 willingness-to-pay threshold, second-look surgery was the more cost-effective approach 63.7% of the time by simulation. CONCLUSIONS: Both treatment pathways were found to be cost-effective, with second-look surgery incrementally cost-effective 63.7% of the time. Assumptions were validated by one-way and Monte Carlo probability sensitivity analysis. PROFESSIONAL PRACTICE GAP AND EDUCATIONAL NEED: There is ample variation in treatment pathways regarding usage of DW-MRI and second-look surgery for cholesteatoma. LEARNING OBJECTIVE: To evaluate the cost-effectiveness of DW-MRI and second-look surgery approaches, accounting for health-related quality-of-life outcomes and costs for the duration of the patient lifetimes. DESIRED RESULT: To inform the discussion on the treatment for cholesteatoma given emergent noninvasive technologies.Level of Evidence: Level III.Indicate IRB or IACUC: Exempt.

Cochlear Implant Device Failures Falling Under the 2020 FDA Voluntary Field Corrective Action: A Systematic Review and Meta-analysis.

OBJECTIVE: To compare the rate of device failure for those cochlear implants (CIs) involved in the 2020 Food and Drug Administration (FDA) voluntary field corrective action (VFCA). DATABASES REVIEWED: Medline, Embase, and Scopus. METHODS: A systematic review was performed according to the PRISMA guidelines. Publications reporting institutional experiences with implants affected by the VFCA were included. Outcomes assessed included etiology of, rate of, and time to failure and pre-/post-device failure speech perception testing. All outcomes reported in at least two independent studies were included in a meta-analysis. RESULTS: Six studies met criteria for analysis. The overall pooled failure rate was 23.7% (95% CI, 11.6-38.4%). The pooled device, inconclusive, and medical failure rates were 21.5%, 0.2%, and 0.7%, respectively. Pediatric failure rates were higher than those of adults (46.9% [95% CI, 11.2-84.5%] versus 32.6% [95% CI, 8.2-63.7%]). WRS declined with primary implant failure (55.1% [95% CI, 48.0-62.1%] to 34.1% [95% CI, 30.2-38.0%]) but improved after reimplantation (34.1% [95% CI, 30.2-38.0%] to 50.1% [95% CI, 45.2-55.1%]). CONCLUSIONS: The rate of pooled reported failure for CIs falling under the 2020 VFCA in the literature thus far is 23.7%. The overwhelming majority of these failures were device related, the rates of which were higher in children. Speech perception improved significantly after reimplantation.

Use of Soft Cervical Collar Improves Surgeon Ergonomics During Simulated Otologic Surgery.

OBJECTIVE: To determine whether surgeon use of a soft cervical collar during endoscopic and microscopic otologic surgery is feasible and impacts surgeon ergonomics as measured by inertial sensors. STUDY DESIGN: Prospective crossover trial. SETTING: US-based otolaryngology training program. PATIENTS: Otolaryngology residents and fellows. INTERVENTIONS: Therapeutic-use of a soft cervical collar during simulated otologic surgery. MAIN OUTCOME MEASURES: Time spent in high-risk angles of neck and back flexion and extension; average angle of neck flexion, extension, rotation, and lateral bending; validated assessment of neck pain; average daily phone use. RESULTS: Fifteen subjects met criteria for inclusion. Ten of 15 (67%) were male. Seven of 15 (47%) were postgraduate year 1-2. Seven of 15 (47%) reported a history of neck pain. None reported prior spinal steroid injections or surgery. Across all subjects, use of the soft cervical collar significantly reduced time spent in high-risk angles of neck flexion/extension during both endoscopic (56% vs. 35%, p < 0.05) and microscopic (60% vs. 32%, p < 0.05) otologic surgery. There was no effect on back flexion or extension. There was no difference in time spent in high-risk neck or back angles between endoscopic and microscopic surgery. Average angles of neck or back flexion, extension, lateral bending, and rotation were not significantly different for subgroups with more operative experience, increased phone use, perception of good posture, or history of neck pain. CONCLUSIONS: Use of a soft cervical collar during simulated otologic surgery significantly reduced time spent in high-risk neck positions. These data support feasibility of soft collar use during otologic surgery and hold promise for reduction in the high rates of neck pain reported by neurotologists. PROFESSIONAL PRACTICE GAP AND EDUCATIONAL NEED: Improving surgeon ergonomics for otologic surgery. LEARNING OBJECTIVE: To identify a therapeutic intervention to mitigate neck pain in surgeons caused by assumption of high-risk cervical neck flexion and extension. DESIRED RESULT: To demonstrate that use of a readily available soft cervical collar reduces risk of neck pain in otologic surgeons. LEVEL OF EVIDENCE: II. INDICATE IRB OR IACUC: Exempt.

The Role of Lumbar Drains in the Perioperative Management of Primary Spontaneous Temporal Lobe Encephaloceles and Cerebrospinal Fluid Leaks.

OBJECTIVE: To examine the role of lumbar drains (LDs) in the success of spontaneous temporal cerebrospinal fluid (CSF) leak and encephalocele repair. STUDY DESIGN: Retrospective cohort study. SETTING: Tertiary academic health system. PATIENTS: Patients undergoing repair of spontaneous temporal lobe encephaloceles or middle fossa CSF leaks during years 2017 to 2023. INTERVENTIONS: Transmastoid, middle fossa craniotomy, or combination approaches to CSF leak repair. OUTCOME MEASURES: Failure rate, complication rate, length of stay (LOS), readmission. RESULTS: Sixty-nine patients were included, with a combination approach performed in 78.3%, transmastoid in 17.4%, and isolated middle fossa craniotomy in 4.3%. Mean body mass index was 33.2, mean bony defect size width was 6.51 mm, and defect locations included the epitympanum, antrum, mastoid, and petrous apex. Multilayer closure with three or more layers was performed in 87.0%. LD was used in 73.9% of cases for a mean duration 2.27 days and was associated with longer LOS (3.27 vs. 1.56 d, p = 0.006) but not with failure rate, complications, discharge destination, or readmission. Only one major complication occurred as a result of the drain, but low-pressure headache was anecdotally common. CONCLUSIONS: Use of LD in the repair of spontaneous CSF leaks and temporal lobe encephaloceles is associated with longer LOS but not failure rates or other admission-level outcomes.

Management of phaeochromocytoma and paraganglioma in patients with germline SDHB pathogenic variants: an international expert Consensus statement.

Adult and paediatric patients with pathogenic variants in the gene encoding succinate dehydrogenase (SDH) subunit B (SDHB) often have locally aggressive, recurrent or metastatic phaeochromocytomas and paragangliomas (PPGLs). Furthermore, SDHB PPGLs have the highest rates of disease-specific morbidity and mortality compared with other hereditary PPGLs. PPGLs with SDHB pathogenic variants are often less differentiated and do not produce substantial amounts of catecholamines (in some patients, they produce only dopamine) compared with other hereditary subtypes, which enables these tumours to grow subclinically for a long time. In addition, SDHB pathogenic variants support tumour growth through high levels of the oncometabolite succinate and other mechanisms related to cancer initiation and progression. As a result, pseudohypoxia and upregulation of genes related to the hypoxia signalling pathway occur, promoting the growth, migration, invasiveness and metastasis of cancer cells. These factors, along with a high rate of metastasis, support early surgical intervention and total resection of PPGLs, regardless of the tumour size. The treatment of metastases is challenging and relies on either local or systemic therapies, or sometimes both. This Consensus statement should help guide clinicians in the diagnosis and management of patients with SDHB PPGLs.

Translabyrinthine Approach for Sporadic Vestibular Schwannoma: Patient Selection, Technical Pearls, and Patient Outcomes.

Herein we briefly describe the translabyrinthine approach to vestibular schwannoma resection as well as a focused literature review as to the best candidates, technical recommendations, and key outcomes with respect to other approaches.

A Case of HPV+ Squamous Cell Carcinoma of the Perigeniculate Area and Middle Fossa.

Herein we present an unusual case of a primary HPV+ perigeniculate, extra-axial middle fossa skull base tumor and our management thereof. Laryngoscope, 133:3158-3160, 2023.

Institutional Experience With Cochlear Implants Falling Under the 2020 FDA Corrective Action.

OBJECTIVE: To determine the rate of device failure for those cochlear implants falling under the 2020 Food and Drug Administration (FDA) voluntary corrective action. STUDY DESIGN: Retrospective chart review. SETTING: Tertiary otology-neurotology practice. PATIENTS: Those with cochlear implant failure falling under the FDA corrective action. INTERVENTIONS: Cochlear implant explant and reimplantation. OUTCOME MEASURES: Reason for cochlear implant failure, time to failure, symptoms of failure, and benefit from reimplantation. RESULTS: The overall failure rate was 20.0% (18 of 90 ears); of the failures, 15 of 18 (83.3%) were hard device failures, and 3 of 18 (16.7%) were medical or surgical failures. All hard device failures were confirmed with integrity testing as performed by the company. The average time to integrity testing was 38.0 months. Of the hard failures, 14 of 15 had successful initial activation and benefit. Lack of expected progress was seen in 7 of 15 and a sudden decline in function in 8 of 15. Electrodes 9 to 16 were most often defunct. Significant drops in speech perception were often seen in device failure cases. Three medical/surgical failures were explanted; one had migration of the receiver/stimulator causing discomfort, and the other two had electrode migration after partial insertion. Of the reimplanted patients, 11 of 12 are deriving benefit from their new devices. CONCLUSIONS: The rate of device failure for the cochlear implants of interest is significantly higher in our series than reported in the initial FDA voluntary field corrective action publication.

Defining the Learning Curve for Endoscopic Ear Skills Using a Modular Trainer: A Multi-Institutional Study.

OBJECTIVE: Quantify the learning curve for endoscopic ear skills acquisition in otolaryngology residents using a simulator. The secondary objective was to determine if demographic factors or previous endoscopic experience influenced skill development. STUDY DESIGN: Prospective, multicenter study. Resident participants each completed 10 amassed trials using a validated endoscopic ear skill trainer. SETTING: Two academic teaching hospitals. SUBJECTS: Otolaryngology residents. MAIN OUTCOME MEASURES: Trial completion times; rate of improvement over time. RESULTS: Thirty-eight residents completed the study, 26 from program A and 12 from program B. Fifteen participants were women and 23 were men. Mean age was 30 years old (range 26 to 34 years). Previous experience with otoendoscopy (B = -16.7, p = 0.005) and sinus endoscopy (B = -23.4, p = 0.001) independently correlated with lower overall trial times. Age, gender, postgraduate year, handedness, interest in otology, and video gaming were not associated with trial times. On multivariate logistic regression, resident completion times improved with trial number, and residents without previous endoscopy experience improved at a faster rate than those with experience ( p < 0.001). CONCLUSIONS: Novice surgeons may acquire basic endoscopic ear experience with self-directed simulation training. The learning curve for transcanal endoscopic ear surgery is comparable to those demonstrated for other otologic surgeries, and specific task competencies can be achieved within 10 trials, suggesting that previous experiences, or lack thereof, may not dictate the ability to acquire new skills. There may be a translational value to previous endoscopic sinus experience on learning transcanal endoscopic ear surgery.