Detection of endolymphatic hydrops using traditional MR imaging sequences.

PURPOSE: The purpose of this study was to determine whether Meniere's disease (MD) produces endolymphatic cavity size changes that are detectable using unenhanced high-resolution T2-weighted MRI. MATERIALS & METHODS: This retrospective case-control study included patients with documented MD who had a high-resolution T2-weighted or steady-state free procession MRI of the temporal bones within one month of diagnosis, between 2002 and 2015. Patients were compared to age- and sex- matched controls. Cross sectional area, length, and width of the vestibule and utricle were measured in both ears along with the width of the basal turn of the cochlea and its endolymphatic space. Absolute measurements and ratios of endolymph to perilymph were compared between affected, contralateral, and control ears using analysis of variance and post-hoc pairwise comparisons. RESULTS: Eighty-five case-control pairs were enrolled. Mean utricle areas for affected, contralateral, and control ears were 0.038cm2, 0.037cm2, and 0.033cm2. Mean area ratios for affected, contralateral, and control ears were 0.32, 0.32, and 0.29. There was a statistically significant difference between groups for these two variables; post-hoc comparisons revealed no difference between affected and contralateral ears in Meniere's patients, while ears in control patients were different from the ears of patients with MD. All other measurements failed to show significant differences. CONCLUSIONS: Enlargement of the endolymphatic cavity can be detected using non-contrast T2-weighted MRI. MRI, using existing protocols, can be a useful diagnostic tool for the evaluation of MD, and intratympanic or delayed intravenous contrast may be unnecessary for this diagnosis.

CyberKnife Stereotactic Radiosurgery for Growing Vestibular Schwannoma: Longitudinal Tumor Control, Hearing Outcomes, and Predicting Post-Treatment Hearing Status.

OBJECTIVES: (1) To determine tumor control rates for treating growing vestibular schwannoma (VS) with CyberKnife stereotactic radiosurgery (CK SRS); (2) to determine hearing outcomes after CK SRS; (3) to propose a set of variables that could be used to predict hearing outcomes for patients receiving CK SRS for VS. STUDY DESIGN: Retrospective case series review. METHODS: 127 patients who received CK SRS for radiographically documented growing VS were reviewed. Tumors were monitored for post-procedure growth radiographically with linear measurements and three-dimensional segmental volumetric analysis (3D-SVA). Hearing outcomes were reviewed for 109 patients. Cox proportional hazard modeling was used to identify variables correlated with hearing outcomes. RESULTS: Tumor control rate was 94.5% for treating VS with CK SRS. Hearing outcomes were categorized using the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) classification system. As of their last available audiogram, 33.3% of patients with pre-treatment class A and 26.9% of patients with class B retained their hearing in that class. 15.3% of patients starting with class A or B with extended follow-up (>60 months), maintained hearing within this same grouping. Our final model proposed to predict hearing outcomes included age, fundal cap distance (FCD), tumor volume, and maximum radiation dose to the cochlea; however, FCD was the only statistically significant variable. CONCLUSION: CK SRS is an effective treatment for control of VS. Hearing preservation by class was achieved in a third of patients. Finally, FCD was found to be protective against hearing loss. LEVEL OF EVIDENCE: 4 Laryngoscope, 134:S1-S12, 2024.

Pain and Pain Control With Opioid and Nonopioid Medications After Otologic Surgery.

OBJECTIVE: To prospectively analyze pain and pain medication use following otologic surgery. STUDY DESIGN: Prospective cohort study with patient reported pain logs and medication use logs. SETTING: Tertiary academic hospital.Patients: Sixty adults who underwent outpatient otologic surgeries. INTERVENTIONS: Surveys detailing postoperative pain levels, nonopioid analgesic (NOA) use, and opioid analgesic use. MAIN OUTCOME MEASURES: Self-reported pain scores, use of NOA, and use of opioid medications normalized as milligrams morphine equivalents (MME). RESULTS: Thirty-two patients had surgery via a transcanal (TC) approach, and 28 patients had surgery via a postauricular (PA) approach. TC surgery had significantly lower reported pain scores than PA surgery on both postoperative day (POD) 1 (median pain score 2.2, IQR 0-5 vs. median pain score 4.8, IQR 3.4-6.3, respectively; p = 0.0013) and at POD5 (median pain score 0, IQR 0-0 vs. median pain score 2.0, IQR 0-3, respectively; p = 0.0002). Patients also used significantly fewer opioid medications with TC approach than patients who underwent PA approach at POD1 (median total MME 0, IQR 0-5 vs. median total MME 5.0, IQR 0-15, respectively; p = 0.03) and at POD5 (median total MME 0, IQR 0-0 vs. median total MME 0, IQR 0-5, respectively; p = 0.0012). CONCLUSIONS: Surgery with a postauricular approach is associated with higher pain and opioid use following otologic surgery. Patient- and approach-specific opioid prescribing is feasible following otologic surgery.

Comparison of Endoscopic Endonasal Approach and Lateral Microsurgical Infratemporal Fossa Approach to the Jugular Foramen: An Anatomical Study.

Objective The jugular foramen is one of the most challenging surgical regions in skull base surgery. With the development of endoscopic techniques, the endoscopic endonasal approach (EEA) has been undertaken to treat some lesions in this area independently or combined with open approaches. The purpose of the current study is to describe the anatomical steps and landmarks for the EEA to the jugular foramen and to compare it with the degree of exposure obtained with the lateral infratemporal fossa approach. Materials and Methods A total of 15 osseous structures related to the jugular foramen were measured in 33 adult dry skulls. Three silicone-injected adult cadaveric heads (six sides) were dissected for EEA and three heads (six sides) were used for a lateral infratemporal fossa approach (Fisch type A). The jugular foramen was exposed, relevant landmarks were demonstrated, and the distances between relevant landmarks and the jugular foramen were obtained. High-quality pictures were obtained. Results The jugular foramen was accessed in all dissections by using either approach. Important anatomical landmarks for EEA include internal carotid artery (ICA), petroclival fissure, inferior petrosal sinus, jugular tubercle, and hypoglossal canal. The EEA exposed the anterior and medial parts of the jugular foramen, while the lateral infratemporal fossa approach (Fisch type A) exposed the lateral and posterior parts of the jugular foramen. With EEA, dissection and transposition of the facial nerve was avoided, but the upper parapharyngeal and paraclival ICA may need to be mobilized to adequately expose the jugular foramen. Conclusion The EEA to the jugular foramen is anatomically feasible but requires mobilization of the ICA to provide access to the anterior and medial aspects of the jugular foramen. The lateral infratemporal approach requires facial nerve transposition to provide access to the lateral and posterior parts of the jugular foramen. A deep understanding of the complex anatomy of this region is paramount for safe and effective surgery of the jugular foramen. Both techniques may be complementary considering the different regions of the jugular foramen accessed with each approach.

Epithelioid hemangioendothelioma of the middle ear in a child.

The differential diagnosis of middle ear masses encompasses a wide variety of pathologic conditions. In this report, we describe the case of a 6-year-old girl who presented with facial nerve weakness and was found to have a middle ear mass. The mass was excised, and final pathology revealed hemangioendothelioma. This report describes the youngest patient with this diagnosis presenting as a middle ear mass in the Western literature. This article provides this patient's presentation, imaging and histopathologic findings, and clinical course and reviews the current literature on this unique pathologic diagnosis.

Scoping review of cochlear implantation in Susac's syndrome.

OBJECTIVE: Scoping review of published literature to establish clinical characteristics and audiologic outcomes in patients diagnosed with Susac's Syndrome(SS) who have undergone cochlear implantation (CI). DATA SOURCES: All published studies of CI in SS and contribution of two of our own patients who have not been reported previously. METHODS: A comprehensive search of MEDLINE (via PubMed) was carried out in March 2020 using the following keywords and related entry terms: Susac's Syndrome, Cochlear Implantation. RESULTS: Our search identified a total of five case reports of CI in SS. With the addition of our two patients reported here, we analyzed characteristics and outcomes in seven patients. Mean age at implantation was 30 years old (range 19-46), with six women and one man implanted. Mean time from onset of hearing loss to implantation was 17 months (range three months to four years). Best reported postoperative speech understanding was reported via different metrics, with six of seven patients achieving open set speech scores of 90% or better, and one subject performing at 68%. Vestibular symptoms were present preoperatively in four of seven patients (57%), with vestibular testing reported in two patients, and showing vestibulopathy in one patient. No complications were reported following cochlear implantation. CONCLUSION: Cochlear implantation is a viable option for hearing rehabilitation in patients with SS, with levels of attainment of open set speech comparable to other populations of CI candidates.

Long term outcomes with linear accelerator stereotactic radiosurgery for treatment of jugulotympanic paragangliomas.

BACKGROUND: Data supporting linear accelerator (linac) stereotactic radiosurgery (SRS) for jugulotympanic paragangliomas (JTPs) come from small series with minimal follow-up. Herein, we report a large series of JTPs with extended follow-up after frameless linac-based SRS. METHODS: JTPs treated with linac-based SRS from 2002 to 2019 with 1+ follow-up image were reviewed for treatment failure (radiographic or clinical progression, or persistent symptoms after SRS requiring intervention) and late toxicities (CTCAE v5.0). RESULTS: Forty JTPs were identified; 30 were treated with a multifraction regimen. Median clinical and radiographic follow-up was 79.7 (interquartile range [IQR] 31.7-156.9) and 54.4 months (IQR 17.9-105.1), respectively, with a median 4.5 follow-up scans (IQR 2-9). Seven-year progression-free survival (PFS) was 97.0% (95% confidence interval 91.1%-100.0%). PFS was similar between single- and multifraction regimens (log rank P = .99). Toxicity was seen in 7.7% (no grade III). CONCLUSIONS: With extended clinical and radiographic follow-up, frameless linac-based SRS provides excellent local control with mild toxicity <8%.

Cochlear implantation in a patient with superficial siderosis: an update.

OBJECTIVE: The purpose of this study is to present follow-up on a previously reported case of successful cochlear implantation in a patient with superficial siderosis. STUDY DESIGN: Retrospective case review. RESULTS: For the first 6 years after implantation, the patient had maintained a successful result; however, she developed a progressive decline in the benefit from her implant. CONCLUSION: Benefit from cochlear implants in patients with superficial siderosis is variable and may not be long standing.

Atypical Cogan's syndrome: a case report.

Cogan's syndrome is a rare presumed autoimmune disorder characterized by nonsyphilitic interstitial keratitis and progressive audiovestibular symptoms. The initial report by David G. Cogan in 1945 was modified by Haynes et al in 1980 who proposed diagnostic criteria for patients with other ocular or vestibular symptoms and suggested this to be atypical Cogan's syndrome. In a more typical presentation of Cogan's syndrome, ocular and audiovestibular signs and symptoms usually appear alone and are bilateral. We report a case of 50-year-old woman with an atypical Cogan's syndrome manifested by unusual relatively rapid clinical deterioration.

Metachronous Sudden Sensorineural Hearing Loss: Patient Characteristics and Treatment Outcomes.

OBJECTIVES: Idiopathic sudden sensorineural hearing loss (ISSNHL) is a distressing condition that can significantly affect quality of life. Unilateral ISSNHL, occurring first in 1 ear and then the contralateral ear at a separate and discrete time, is a rare presentation that we refer to as metachronous ISSNHL. Our objective was to characterize the presentation of metachronous ISSNHL and report on management and hearing outcomes. STUDY DESIGN: Retrospective case series. SETTING: Otology clinic at an academic tertiary referral center. SUBJECTS AND METHODS: Patients ≥18 years old presenting with metachronous ISSNHL between April 2008 to November 2017 were identified through review of the clinic electronic medical record. Metachronous ISSNHL was defined as unilateral ISSNHL occurring in temporally discrete episodes (>6 months apart) affecting both ears. Patients with identifiable causes for sudden hearing loss were excluded. Patient demographics, comorbidities, management, and audiologic outcomes were recorded. RESULTS: Eleven patients with metachronous ISSNHL were identified out of 558 patients with ISSNHL. In patients with metachronous ISSNHL, the mean ± standard deviation age at the time of ISSNHL in the second ear was 58.6 ± 15.2 years (range, 31-77 years). The mean interval between episodes was 9.6 ± 7.5 years (range, 1-22 years). Patients were treated with systemic and intratympanic steroids with variable hearing recovery; 5 patients with resultant bilateral severe to profound hearing loss underwent successful cochlear implantation. CONCLUSION: Metachronous ISSNHL is uncommon. Treatment is similar to ISSNHL, and cochlear implantation can successfully restore hearing in individuals who do not experience recovery.

Comparison of Spontaneous Temporal Bone Cerebrospinal Fluid Leaks From the Middle and Posterior Fossa.

OBJECTIVES: To compare patients surgically managed for spontaneous cerebrospinal fluid (CSF) leaks of the temporal bone arising from the middle cranial fossa (MCF) and posterior cranial fossa (PCF) and to describe the surgical management of posterior fossa CSF leaks. STUDY DESIGN: Retrospective case review. SETTING: Academic tertiary center. PATIENTS: Adult patients presenting with spontaneous temporal bone CSF leaks undergoing operative repair between January 2010 and August 2018. Patients with a history of trauma, previous mastoid surgery, and iatrogenic CSF leaks were excluded. INTERVENTION: Transmastoid or MCF CSF leak repair. MAIN OUTCOME MEASURES: Patient demographics, body mass index (BMI), comorbidities, presenting features, and lumbar puncture opening pressures were compared between groups and the management of the PCF CSF leaks described. RESULTS: Forty-six patients (26 women, 20 men) were included. The mean age at the time of repair was 58.0 ±â€Š12.9 years (±SD). The origin of the CSF leak was from the PCF in three patients and MCF in 43 patients. All three patients with PCF leaks presented with an acute history of meningitis compared with only seven (16%) in the MCF group. This difference was statistically significant (p = 0.01, Fisher's exact test). There were no statistically significant differences in age, sex, BMI, or lumbar puncture opening pressures. The PCF leaks were repaired using a transmastoid approach with multilayer closure of the bony defect and fat graft obliteration of the mastoid. CONCLUSIONS: Spontaneous CSF leaks arising from the PCF are rare and may present more commonly with meningitis. Identification requires careful review of imaging.

Cochlear Implant Performance in Adult Patients with Absent Intraoperative Electrically Evoked Compound Action Potentials.

OBJECTIVE: To describe cochlear implant performance outcomes in adult patients in whom no intraoperative electrically evoked compound action potential (ECAP) responses were able to be obtained despite intracochlear electrode placement. STUDY DESIGN: Retrospective case review. SETTING: Academic tertiary center. SUBJECTS AND METHODS: Patients 18 years of age and older undergoing cochlear implantation between May 2010 and September 2018 with absent ECAP measurements intraoperatively with intracochlear electrode positioning were identified. Patient performance on sentence recognition testing using the Hearing in Noise Test (HINT) and AzBio at 6 to 12 months postoperatively was compared to preimplantation scores. Additional collected data included patient demographics, etiology of hearing loss, and preoperative pure-tone average (PTA) and word recognition scores (WRSs). RESULTS: Intraoperative ECAP measurements were unable to be obtained in 15 cochlear implants performed on 14 patients out of 383 cochlear implant cases. Of the patients with absent ECAP measures, the mean ± SD age was 61.7 ± 15.7 years. Causes of hearing loss included congenital hearing loss, meningitis, autoimmune inner ear disease, otosclerosis, presbycusis, and Ménière's disease. The average preoperative PTA was 103.5 ± 17.0 dB. Twelve implanted ears had a WRS of 0% and 9 had a HINT score of 0% prior to surgery. The mean HINT score at 6 to 12 months postimplantation was 57.8% ± 37.8% and had improved by 42.6% ± 35.6% compared to the mean preimplantation HINT score (95% confidence interval, 22.0%-63.1%, P = .001, paired Student t test). CONCLUSION: There is a wide range of cochlear implant performance in patients with absent intraoperative ECAP measures ranging from sound awareness to HINT scores of 100%.

Evaluation of 3D Printed Temporal Bone Models in Preparation for Middle Cranial Fossa Surgery.

HYPOTHESIS: Patient-specific 3D printed models are useful presurgical planning tools because they accurately represent the anatomy and drilling characteristics of the middle cranial fossa (MCF) approach to the internal auditory canal (IAC). BACKGROUND: The MCF approach to the IAC can be challenging due to variability of the bony architecture along the floor of the middle fossa. Patient-specific 3D printed models may enhance surgeon knowledge of a given patient's anatomy when preparing for MCF surgery. METHODS: Six temporal bone models were printed from photoacrylic resin based on CT data obtained from cadaveric specimens using a desktop stereolithography 3D printer. Critical structures to avoid injuring, the facial nerve and membranous labyrinth, were modeled as hollow cavities and filled with indicator paint. Two neurotologists each drilled three 3D printed models and the corresponding cadaveric specimens, and then completed a 41-item visual analog scale questionnaire (score range of each item: 0-10) to assess the model's accuracy, utility, and potential as a training tool. RESULTS: Drilling the model was favorably rated (median score 9.2; range 7.3-9.6) for its ability to provide surgeons with an accurate mental image of the corresponding cadaveric anatomy. Overall similarity of feel of drilling the model in comparison to human bone was moderate (median 7.6; range 6.6-9.0). Surgeons would use this model to prepare for future cases (median 9.4; range 5.1-9.9) and felt it had excellent utility for training purposes (median 9.3; range 8.4-9.9). CONCLUSIONS: Patient-specific 3D printed models provide an anatomically accurate and favorable tool for preparing for MCF surgery.

Optimization of Intraoperative Imaging Protocol to Confirm Placement of Cochlear Implant Electrodes.

OBJECTIVES: The need to intraoperatively confirm correct placement of the active electrode of a cochlear implant may occur in various clinical settings. These include a malformed cochlea, difficulty with insertion, or suboptimal or abnormal electrical responses (impedance or evoked action potentials) obtained during intraoperative testing. Frustration with inconsistent images using portable x-ray machines prompted this study to determine the technique needed to reliably image the electrode within the cochlea. Our objective was to establish a radiology protocol that would be reproducible and reliable across institutions. METHODS: Prospective cadaveric imaging study. Access to the round window via the facial recess was established using cadaver heads. Electrodes provided by three cochlear implant manufacturers were inserted into the cochlea. The position of the head, angle of the x-ray tube, and beam settings were varied. A compendium of electrode images was obtained and analyzed by neurotologists and a head and neck radiologist to reach a consensus on an optimal imaging protocol. RESULTS: The optimal position for intraoperative x-ray confirmation of cochlear implant electrode placement is obtained by turning the head 45 degrees toward the contralateral ear. The portable digital x-ray machine and central ray was angled 15 degrees (aiming cephalic) from vertical with exposure settings of 32 mAs at 70 kVp and the digital radiography image receptor was positioned under the mattress of the operating table. CONCLUSION: A protocol for patient and beam source positioning and exposure using a portable digital x-ray unit can provide reliable imaging for intraoperative confirmation of cochlear implant electrode positioning.

High-frequency sensorineural hearing loss after stapedectomy.

OBJECTIVE: To describe the pattern and duration of high frequency sensorineural hearing loss after stapedectomy. STUDY DESIGN: Retrospective case series. SETTING: Tertiary referral center. PATIENTS: All patients who underwent stapedectomy by the senior author during the period between January 1, 1998, and October 1, 2005, with preoperative, 4- to 6-week postoperative, and at least 9-month postoperative audiograms were included. Fifty-three patients met the inclusion criteria, with surgeries performed on 61 ears. INTERVENTION(S): Stapedectomy was performed using a CO2 laser. MAIN OUTCOME MEASURE(S): Mean preoperative and postoperative pure-tone bone thresholds, mean preoperative and postoperative pure-tone air thresholds, and hearing outcomes for 4,000 Hz bone conduction (BC) and 8,000 Hz air conduction (AC) based on the patient's age and interval after the operative procedure. RESULTS: : Mean BC thresholds at 4,000 Hz BC worsened by 6 dB at 4 to 6 weeks and improved by 3 dB by 9 months. There was an 8-dB average loss at 8,000 Hz AC at 4 to 6 weeks with a gain of 4 dB by 9 months. Patients older than 40 years were 4 times more likely to experience early loss at 4,000 Hz BC when preoperative thresholds were held constant. The late outcome for hearing loss was dependent more on the preoperative threshold than was the age of the patient. At 8,000 Hz AC, the preoperative hearing threshold was a predictor of early and late hearing loss at 8,000 Hz. CONCLUSION: High-frequency sensorineural hearing loss is initially seen after stapes surgery, and improvement does occur over time. When preoperative hearing threshold is held constant, patients older than 40 years are more likely to experience short-term hearing loss at high frequencies than patients younger than 40 years. Age was not a predictor of postoperative high-frequency hearing loss in the long term.

Clinical practice guideline: cerumen impaction.

OBJECTIVE: This guideline provides evidence-based recommendations on managing cerumen impaction, defined as an accumulation of cerumen that causes symptoms, prevents assessment of the ear, or both. We recognize that the term "impaction" suggests that the ear canal is completely obstructed with cerumen and that our definition of cerumen impaction does not require a complete obstruction. However, cerumen impaction is the preferred term since it is consistently used in clinical practice and in the published literature to describe symptomatic cerumen or cerumen that prevents assessment of the ear. This guideline is intended for all clinicians who are likely to diagnose and manage patients with cerumen impaction. PURPOSE: The primary purpose of this guideline is to improve diagnostic accuracy for cerumen impaction, promote appropriate intervention in patients with cerumen impaction, highlight the need for evaluation and intervention in special populations, promote appropriate therapeutic options with outcomes assessment, and improve counseling and education for prevention of cerumen impaction. In creating this guideline the American Academy of Otolaryngology-Head and Neck Surgery Foundation selected a panel representing the fields of audiology, family medicine, geriatrics, internal medicine, nursing, otolaryngology-head and neck surgery, and pediatrics. RESULTS: The panel made a strong recommendation that 1) clinicians should treat cerumen impaction that causes symptoms expressed by the patient or prevents clinical examination when warranted. The panel made recommendations that 1) clinicians should diagnose cerumen impaction when an accumulation of cerumen is associated with symptoms, or prevents needed assessment of the ear (the external auditory canal or tympanic membrane), or both; 2) clinicians should assess the patient with cerumen impaction by history and/or physical examination for factors that modify management, such as one or more of the following: nonintact tympanic membrane, ear canal stenosis, exostoses, diabetes mellitus, immunocompromised state, or anticoagulant therapy; 3) the clinician should examine patients with hearing aids for the presence of cerumen impaction during a healthcare encounter (examination more frequently than every three months, however, is not deemed necessary); 4) clinicians should treat the patient with cerumen impaction with an appropriate intervention, which may include one or more of the following: cerumenolytic agents, irrigation, or manual removal other than irrigation; and 5) clinicians should assess patients at the conclusion of in-office treatment of cerumen impaction and document the resolution of impaction. If the impaction is not resolved, the clinician should prescribe additional treatment. If full or partial symptoms persist despite resolution of impaction, alternative diagnoses should be considered. The panel offered as an option that 1) clinicians may observe patients with nonimpacted cerumen that is asymptomatic and does not prevent the clinician from adequately assessing the patient when an evaluation is needed; 2) clinicians may distinguish and promptly evaluate the need for intervention in the patient who may not be able to express symptoms but presents with cerumen obstructing the ear canal; 3) the clinician may treat the patient with cerumen impaction with cerumenolytic agents, irrigation, or manual removal other than irrigation; and 4) clinicians may educate/counsel patients with cerumen impaction/excessive cerumen regarding control measures. DISCLAIMER: This clinical practice guideline is not intended as a sole source of guidance in managing cerumen impaction. Rather, it is designed to assist clinicians by providing an evidence-based framework for decision-making strategies. It is not intended to replace clinical judgment or establish a protocol for all individuals with this condition, and may not provide the only appropriate approach to diagnosing and managing this problem.

Imaging of hearing loss.

A wide range of pathology involving the external, middle, and inner ear contribute to conductive and sensorineural hearing loss. Diagnostic imaging plays a critical role in the evaluation and management of hearing loss. High resolution computed tomography (CT) of the temporal bone and magnetic resonance imaging (MRI) are the preferred imaging modalities to evaluate the ear structures for causes of hearing loss, with the specific type of hearing loss and location of defect dictating which type of imaging is preferred. In general, the external auditory canal, middle ear space, mastoid, petrous apex, and otic capsule are best visualized with CT, whereas suspicion of retrocochlear pathology warrants MRI.

Patient Positioning During In-Office Otologic Procedures Impacts Physician Ergonomics.

OBJECTIVE: The purpose of this study was to evaluate the impact of patient positioning on physician ergonomics during in-office otologic procedures. A previous simulation study suggested that placing patients supine during in-office otology procedures is ergonomically favorable. This study aims to substantiate these findings during the routine care of patients in an otolaryngology practice setting. STUDY DESIGN: Observational study. SETTING: Outpatient otology clinic within tertiary care facility. STUDY SUBJECTS: Two neurotology attending physicians. INTERVENTIONS: Physicians performed cerumen removal procedures in the office with patients either in the seated position (n = 24) or supine position (n = 24). MAIN OUTCOME MEASURES: The rapid upper limb assessment (RULA), a validated instrument that measures body positioning with a focus on the upper arm, was used to measure ergonomic positioning. RULA scores correlate occupational body positioning with a numeric representation of musculoskeletal injury risk ranging from 1 (minimal risk) to 7 (very high risk). RESULTS: Overall median RULA scores were 4.5 (medium risk) with patients in the seated position, and 2 (low risk) with patients in the supine position (p < 0.0001). Similarly, RULA scores were significantly lower with patients in the supine position when each physician was evaluated independently (p < 0.0001, for both). CONCLUSIONS: Placing patients in a supine position for cerumen removal results in more favorable ergonomic positioning for the physician, thus reducing risk for work-related musculoskeletal disorders. This suggests that physicians should consider placing patients in the supine position for in-office otologic procedures. Further study is needed to investigate optimal ergonomic positioning for other common otolaryngology procedures.

Imaging in the Diagnosis and Management of Necrotizing Otitis Externa: A Survey of Practice Patterns.

OBJECTIVE: To survey neurotologists and head and neck radiologists regarding use of imaging in the diagnosis and management of necrotizing otitis externa (NOE). STUDY DESIGN: Cross-sectional survey study. SETTING: Online survey distributed through email to specialty society membership lists. PARTICIPANTS: Neurotologists and head and neck radiologists with membership in either the American Neurotology Society or The American Society of Head and Neck Radiology. MAIN OUTCOME MEASURES: Responses to survey consisting of two demographic and seven clinically oriented questions related to the use of imaging in the diagnosis and management of NOE. RESULTS: One hundred thirty-six participants responded to the survey. The imaging modality of choice in establishing the diagnosis of NOE selected by the respondents was computed tomography (CT) (37.5%) followed by technetium scintigraphy (21.3%). Magnetic resonance imaging (MRI) was the preferred investigation by 41.9% of participants for determining extent of disease. Gallium scanning was the imaging modality preferred by 32.4% of respondents for determining when to cease medical therapy. Ninety-five percent of participants responded that CT scans were always or frequently used in the diagnosis and management of NOE compared with 72.8% for MRI, 34.5% for gallium scans, and 34.2% for technetium scans. CONCLUSIONS: There is considerable heterogeneity in the preferred imaging modalities used in the diagnosis and management of NOE. CT and MRI are the preferred contemporary modalities used by many physicians, demonstrating a shift away from the historic use of nuclear medicine scans.

Cochlear implantation in a patient with bilateral deep brain stimulators.

OBJECTIVE: We report the case of a patient successfully implanted with a Nucleus Contour cochlear implant after placement of a deep brain stimulator for Parkinson disease. METHODS: The authors conducted a case report and literature review. RESULTS: Successful hookup and mapping of the device was performed 1 month after implantation without evidence of aberrant activity of the deep brain stimulators. CONCLUSIONS: To our knowledge, this is the first reported case of successful implantation of both a cochlear implant and a deep brain stimulator in the same patient. We have outlined one approach to avoiding detrimental interactions between cochlear implant and deep brain stimulator devices.