The Utility of a "Second-Look" Debridement Following Endonasal Skull Base Surgery in the Pediatric Population.

Background Sinonasal debridement is typically performed in the weeks following endonasal skull base surgery (ESBS). In the pediatric population, this second-look procedure may require general anesthesia; however, there is currently little evidence assessing the benefit of this practice. Methods This was a multicenter retrospective study of pediatric patients (age <18 years) undergoing a planned second-look debridement under general anesthesia following ESBS. Intraoperative findings, interventions performed, and perioperative complications were reviewed. Multivariate regression analysis was performed to identify associations between intraoperative findings and clinical factors. Results We reviewed 69 cases of second-look debridements (age mean 8.6 ± 4.2 years, range: 2-18 years), occurring a mean of 18.3 ± 10.3 days following ESBS. All abnormal findings were noted in patients age ≤12 years. Synechiae were noted in 8.7% of cases, bacterial rhinosinusitis in 2.9%, and failed reconstruction with cerebrospinal fluid leak in 4.5% (two cases of flap malposition and one case of flap necrosis). All failed reconstructions were noted following expanded endonasal cases for craniopharyngioma, and in each case, a revision reconstruction was performed during the second-look surgery. Synechiae were not significantly associated with younger age, revision cases, or cases with reconstructive flaps. There were no perioperative complications. Conclusion Second-look debridement under general anesthesia may be useful in the identification and intervention of sinonasal pathology following endoscopic skull base surgery, particularly in children ≤12 years old or those with pedicled flap reconstructions. Larger controlled studies are warranted to validate this practice and refine indications and timing of this second procedure.

Racial Disparities in 30-day Readmissions after Surgery for Head and Neck Cancer.

BACKGROUND: Native Hawaiians and other Pacific Islanders (NHPI) patients with head and neck cancer are often aggregated with Asian individuals despite evidence of heterogeneous health outcomes and mortality. The aim of this study was to determine the association of race with unplanned 30-day hospital readmission rate after head and neck surgery across the five federally recognized racial categories. METHODS: This retrospective cohort study used a national hospital-based database and included patients ≥18 years old with diagnostically confirmed, nonmetastatic head and neck cancer of any subsite treated surgically between 2004 and 2017. The primary endpoint was unplanned readmission within 30 days of discharge after primary surgery. RESULTS: A total of 365,834 patients were included who were predominantly White (87%), treated at academic cancer centers (47%), lower income (63%), with early-stage disease (60%), and with thyroid (47%) or oral cavity (23%) cancers. Median follow-up duration was 47 months. Of the 10,717 (3%) readmissions, 5,845 (1.6%) were unplanned. Adjusted for confounders and compared with White patients, NHPI patients had the highest likelihood of unplanned (aOR 2.07, 95%CI 1.16-3.40, p = 0.008) readmissions. Within the NHPI group, patients with lower income (aOR 4.27, 95%CI 1.28-20.4, p = 0.035) and those residing in an urban or rural area (aOR 7.42, 95%CI 1.14-49.5, p = 0.034) were more likely to be readmitted. CONCLUSIONS: NHPI patients with head and neck cancers experience significantly higher 30-day readmissions following definitive surgical treatment. These results highlight the importance of racial disaggregation in clinical studies. LEVEL OF EVIDENCE: 4 Laryngoscope, 134:1282-1287, 2024.

Difficult Tracheal Intubation and Airway Outcomes after Radiation for Nasopharyngeal Carcinoma.

OBJECTIVE: The aim of the study was to characterize the incidence and management of difficult tracheal intubations (DTIs) in nasopharyngeal carcinoma (NPC) after primary radiation therapy (RT). METHODS: The study was a retrospective review of airway assessment and outcomes in post-RT NPC patients. Primary analysis was performed on patients who underwent post-RT procedures, who were split into non-DTI and DTI groups. Patients were classified as DTI if they (i) required >1 attempt to intubate, (ii) failed to be intubated, or (iii) experienced complications attributed to airway management. Secondary analysis was performed between patients who underwent post-RT procedures (procedure group) and those who did not (control group). RESULTS: One-hundred and fifty patients were included, and 71.3% underwent post-RT procedures, with no differences in characteristics between the procedure and control groups. One-hundred and fifty procedures were identified, and 28.0% were categorized as DTI. There was no difference in patient characteristics or airway assessment measures between DTI and non-DTI groups. Regression analysis revealed concurrent cervical mobility restriction, and trismus increased DTI incidence by 7.1-fold (p = 0.011). Being non-White was an independent predictor of DTI. The incidence of high-grade intraoperative laryngoscopic view was lower in the non-DTI compared to the DTI group (20.4% vs. 64.3%, p < 0.0001). Failure to intubate occurred in 2.0% of cases, and 6.0% cases had perioperative complications. Based on preoperative assessment, sensitivity of predicting DTI was 54.8% and specificity was 63.9%. CONCLUSION: NPC patients frequently undergo post-RT procedures requiring complex airway management. Rates of DTI and failed intubation are significantly higher than those in the general surgical population, and the ability to predict DTI with standard preoperative airway measures is poor. LEVEL OF EVIDENCE: 4 Laryngoscope, 134:120-126, 2024.

Surgical Correction of Nasal Obstruction and Its Effect on Eustachian Tube Dysfunction Symptoms.

OBJECTIVES: To investigate how eustachian tube dysfunction symptoms change following surgical treatment of nonsinusitis-related nasal obstruction. STUDY DESIGN: Retrospective chart review. SETTING: Single academic center. METHODS: We assessed patients who underwent septoplasty, turbinate reduction, or both for nasal obstruction. Chronic sinusitis patients were excluded. Eustachian tube dysfunction (ETD) symptoms were studied using the Eustachian Tube Dysfunction Questionnaire (ETDQ-7), collected preoperatively and postoperatively (1 week, 1 month, 3 months, 6 months postop). Patients with preoperative ETDQ-7 > 14.5 were considered to have clinically significant symptoms. Sinonasal outcomes test scores were also assessed. Pre- and postoperative ETDQ-7 scores were compared using t test. Multivariate linear regression analysis identified factors associated with ETDQ-7 change. RESULTS: We analyzed 259 patients. Preoperatively, 37.5% of patients with nasal obstruction had clinically significant ETD symptoms. These patients exhibited significant improvement in ETDQ-7 at all postoperative timepoints from 23.3 ± 7.6 at baseline to 19.1 ± 9.1 at 1 week, 16.5 ± 8.0 at 1 month, 16.2 ± 7.8 at 3 months, and 16.7 ± 10.4 at 6 months (all P < .01). In patients without baseline ETD symptoms, (baseline ETDQ-7: 9.1 ± 2.3) ETDQ-7 scores did not change significantly at postoperative timepoints, except for an acute worsening at 1 week postoperatively (10.7 ± 5.1, P < .001). Regression analysis showed that higher preoperative ETDQ-7 score (ß = -0.84, 95% confidence interval [CI]: -1.10 to -0.59) and postoperative antihistamine spray usage (ß = -8.70, 95% CI: -14.20 to -3.20) were associated with ETDQ-7 improvement, while comorbid GERD (ß = 7.50, 95% CI: 3.42-11.58) and asthma (ß = 5.62, 95% CI: 0.80-10.45) were negatively associated with improvement. CONCLUSION: Surgical correction of nasal obstruction may improve ETD symptoms.

Social Media Utilization in Otolaryngology: A Scoping Review.

OBJECTIVE: Social media (SM) is an increasingly popular medium for the medical community to engage with patients, trainees, and colleagues. This review aimed to identify reported uses of SM in otolaryngology-head and neck surgery (OHNS), assess the quality of evidence supporting these uses, and identify gaps in the literature. With the relative lack of regulatory guidelines for the development of SM content, we hypothesized that the quality of content available on SM would be highly variable. DATA SOURCES AND METHODS: A scoping review was performed of English-language peer-reviewed studies published to date discussing SM use in any form within OHNS. Three reviewers independently screened all abstracts. Two reviewers independently extracted data of interest from the full text of articles identified from the preliminary abstract screen. RESULTS: 171 studies were included, with 94 (54.9%) studies published between 2020 and 2022. 104 (60.8%) studies were conducted in the US. 135 (78.9%) used cross-sectional or survey-based methodology; only 7 (4.1%) were controlled studies. SM was most commonly employed for professional networking (n = 37 [21%]), and within subspecialties of otology (n = 38 [22%]) and rhinology/allergy (n = 25 [15%]). Facebook was most frequently used for study recruitment (n = 23 [13.5%]), YouTube for patient education (n = 15 [14.6%]), and Twitter for professional networking (n = 16 [9.4%]). CONCLUSION: SM use within OHNS is increasing rapidly, with applications including patient education, professional networking, and study recruitment. Despite myriad articles, there remains a paucity of well-controlled studies. As SM becomes integrated into healthcare, particularly for applications directly impacting patient care, higher levels of evidence are needed to understand its true impact. Laryngoscope, 133:2447-2456, 2023.

Extended Anterior Inferior Approach to Endoscopic Medial Maxillectomy for Maxillary Sinus Lesions.

BACKGROUND: Myriad open and endoscopic approaches are employed to resect maxillary sinus lesions, each with associated advantages and disadvantages. The inferior and anterior portion of the sinus remains a challenging space to access. OBJECTIVES: To describe the extended anterior inferior approach to endoscopic medial maxillectomy (EAMM) as a novel and valuable addition to a stepwise approach for minimizing surgical morbidity without compromising tumor outcomes. To report the outcomes of patients treated with this approach. METHODS: A retrospective case series study of 9 patients who underwent EAMM between 2016 and 2019 at a tertiary care referral center was performed. The endoscopic technique is described. The duration of follow-up ranged from 1 to 53 months. Intraoperative steps, including transection of the nasolacrimal duct and execution of an intraoperative dacryocystorhinostomy, were reviewed. Postoperative outcomes, including patient symptoms at follow-up and tumor recurrence, were recorded. RESULTS: Adequate exposure with gross total tumor resection or margin-negative tumor resection was achieved in all cases. Sparing of the nasolacrimal duct was achieved in 2 patients. No patients reported persistent epiphora, empty nose syndrome, or changes in cosmesis such as alar or nasal tip collapse. One patient reported unilateral V2 hypoesthesia at 6 months postoperatively that had resolved by his next follow-up 18 months after surgery. Postoperative tumor surveillance was achieved by endoscopic examinations in all patients and there was no evidence of tumor recurrence at a median follow-up of 22 months. CONCLUSIONS: The EAMM provides improved access to the inferior-posterior-medial maxillary sinus. This approach minimizes the risk of hypoesthesia and change in cosmesis present in other approaches, and obviates division of the nasolacrimal duct for inferior, posterior-medial attached lesions. This progressive escalation of approach for maxillary sinus lesions minimizes injury to nasal and nasolacrimal structures without compromising tumor outcomes.

The Influence of Vestibular Schwannoma Tumor Volume and Growth on Hearing Loss.

OBJECTIVE: To ascertain the relationship among vestibular schwannoma (VS) tumor volume, growth, and hearing loss. STUDY DESIGN: Retrospective cohort study. SETTING: Single tertiary center. SUBJECTS AND METHODS: Adults with observed VS and serviceable hearing at diagnosis were included. The primary outcome was the development of nonserviceable hearing as estimated using the Kaplan-Meier method. Associations of tumor volume with baseline hearing were assessed using Spearman rank correlation coefficients. Associations of volume and growth with the development of nonserviceable hearing over time were assessed using Cox proportional hazards models and summarized with hazard ratios (HRs). RESULTS: Of 230 patients with VS and serviceable hearing at diagnosis, 213 had serial volumetric tumor data for analysis. Larger tumor volume at diagnosis was associated with increased pure-tone average (PTA) (P < .001) and decreased word recognition score (WRS) (P = .014). Estimated rates of maintaining serviceable hearing at 6 and 10 years following diagnosis were 67% and 49%, respectively. Larger initial tumor volume was associated with development of nonserviceable hearing in a univariable setting (HR for 1-cm3 increase: 1.36, P = .040) but not after adjusting for PTA and WRS. Tumor growth was not significantly associated with time to nonserviceable hearing (HR, 1.57; P = .14), although estimated rates of maintaining serviceable hearing during observation were poorer in the group that experienced growth. CONCLUSION: Larger initial VS tumor volume was associated with poorer hearing at baseline. Larger initial tumor volume was also associated with the development of nonserviceable hearing during observation in a univariable setting; however, this association was not statistically significant after adjusting for baseline hearing status.

A Journey Through 100 Years of Vestibular Schwannoma Surgery at Mayo Clinic: A Historical Illustrative Case Series.

: The present state of vestibular schwannoma (VS) management is the product of over a century of technical progress by revolutionary surgeons who transformed a once perilous operation. At the beginning of the 1900s, patients who did not succumb to their disease were treated exclusively with surgery, which itself was almost assuredly devastating. Through the pioneering work of surgeons such as Harvey Cushing, Walter Dandy, William House, and others, safer surgical approaches were established with concurrent advances in neuromonitoring, neuroanesthesia, radiology, and adoption of the operating microscope. Owing to refinements in radiosurgical treatment and a greater understanding of the natural history of disease, there has been a dramatic shift toward more conservative management in recent years. For more than 100 years, the Mayo Clinic in Rochester, MN, has maintained an active and uninterrupted VS practice with activities that are well documented and preserved through the Mayo Clinic historical archives. We herein report representative early cases to illustrate the fascinating evolution in VS surgery over the past century at a single-tertiary referral center. Original clinical, imaging, pathology, and operative reports are presented from each era of management. To accurately portray the medical context of each era, antiquated terminology is intentionally preserved as originally transcribed.

Cochlear Implantation in Craniometaphyseal Dysplasia.

OBJECTIVE: Describe the first case of cochlear implantation (CI) for auditory rehabilitation of a patient with craniometaphyseal dysplasia (CMD) and progressive mixed hearing loss. PATIENTS: A 65-year-old woman with known autosomal dominant CMD presented with progressive mixed hearing loss and declining benefit from conventional hearing aids. Computed tomography and magnetic resonance imaging revealed hyperostosis of the entire craniofacial skeleton. Hearing evaluation demonstrated pure-tone thresholds in the profound range bilaterally by air conduction, and bone conduction thresholds that matched aided thresholds for her left ear, though testing was somewhat limited by inability to mask at high air-conduction thresholds. CI candidacy testing confirmed poor word and sentence scores in the right ear. INTERVENTION: Due to the inability to access the cochlea via a conventional mastoidectomy and facial recess approach, cochlear implantation via a postauricular subtotal petrosectomy approach with ear canal overclosure was performed. MAIN OUTCOME MEASURES: Post-implantation word and sentence testing. RESULTS: Despite extensive internal auditory canal stenosis, the patient demonstrated excellent early speech understanding results 5 weeks after device activation. Postimplantation audiologic evaluation showed thresholds between 20 and 30 dB HL from 250 to 6000 Hz. Word and sentence testing scores were 76% Consonant-nucleus-consonant in quiet (up from 2% preoperatively) and 77% AzBio sentences in quiet (up from 10% preoperatively). CONCLUSION: This report describes the first description of CI for CMD. Despite the extensive radiologic abnormalities, the patient has demonstrated excellent benefit from implantation. Further study of rare temporal bone dysplasias, such as CMD, is critical to better characterize the progression of otologic disease and determine optimal treatment.

Outcomes of Reconstructive Surgery in Traumatic Brachial Plexus Injury with Concomitant Vascular Injury.

OBJECTIVE: To investigate functional outcome from reconstructive surgery in adult traumatic brachial plexus injury (AT-BPI) with associated vascular lesions. METHODS: A retrospective review was performed of 325 patients with AT-BPI who underwent reconstructive surgery between 2001 and 2012. Patients with (vascular group) and without (control group) vascular injuries were identified by review of medical documentation. Patient presentation, characteristics of nerve and associated lesions, and surgical management were evaluated to identify prognostic variables. Postoperative muscle strength, range of motion, and patient-reported disability scores were analyzed to determine long-term outcome. RESULTS: Sixty-eight patients had a concomitant vascular injury. There were no significant differences in age or sex between the control and vascular groups. The vascular group was more likely to have pan-plexus lesions (P < 0.0001), with significantly more associated upper extremity injuries (P < 0.0001). The control group underwent more nerve transfers, whereas the vascular group underwent more nerve grafting (P = 0.003). Complete outcome data were obtained in 139 patients, which included 111 control (43% of all control subjects) and 28 vascular patients (41%). There was no significant difference in patient-reported disability scores between the 2 groups. However, 73% of control subjects had grade 3 or greater postoperative elbow flexion, whereas only 43% of vascular patients achieved this strength (P = 0.003). Control patients demonstrated a greater increase in strength of shoulder abduction as well (P = 0.004). Shoulder external rotation strength was grade 0 in most patients, with no difference between the 2 groups. CONCLUSIONS: Concomitant vascular injury leads to worse functional outcome after reconstructive surgery of traumatic brachial plexus injury.

Same- vs Different-Hospital Readmissions in Patients With Cirrhosis After Hospital Discharge.

INTRODUCTION: There is a lack of data on the impact of readmission to the same vs a different hospital following an index hospital discharge in cirrhosis patients. METHODS: We sought to describe rates and predictors of different-hospital readmissions (DHRs) among patients with cirrhosis and also determine the impact on cirrhosis outcomes including all-cause inpatient mortality and hospital costs. Using the national readmissions database, we identified cirrhosis hospitalizations in 2013. Regression analysis was used to determine the predictors of DHRs. A time-to-event analysis was performed to assess the impact on subsequent readmissions and all-cause inpatient mortality. RESULTS: In 2013, there were 109,039 cirrhosis readmissions with 67% of these being same-hospital readmissions and 33% being DHRs (P < 0.001). Two percent of readmitted patients were treated at ≥4 different hospitals. The 30-day readmission rate was 29.1%. Predictors of DHR included Medicaid payer (adjusted odds ratio [OR] 1.07, 95% confidence interval [95% CI] 1.01-1.14), age (OR 0.98, 95% CI 0.978-0.982), elective admission (OR 1.09, 95% CI 1.01-1.17), hepatic encephalopathy (OR 1.20, 95% CI 1.16-1.25), hepatorenal syndrome (OR 1.09, 95% CI 1.03-1.16), and low socioeconomic status (OR 1.15, 95% CI 1.06-1.25). No difference was observed in 30-day readmission risk following a DHR (adjusted hazard ratio 1.044, 95% CI 0.975-1.118). In addition, there was no increased risk of inpatient death observed during a DHR within 30 days (adjusted hazard ratio 1.08, 95% CI 0.94-1.23). However, patients with DHR had significantly higher hospital costs and length of stay. CONCLUSIONS: Majority of cirrhosis readmissions are same-hospital readmissions. Different-hospital readmissions do not increase the risk of 30-day readmissions and inpatient mortality but are associated with higher hospital costs.

Beyond Science: Effect of Marital Status and Socioeconomic Index on Outcomes of Spinal Cord Tumors: Analysis From a National Cancer Registry.

BACKGROUND: The effect of marital status and living arrangements on health through modified health behaviors and social networks has been well-established in reported studies, with many experts claiming a "protective" effect from married life for individuals. We sought to study the effect of marital and socioeconomic status (SES) on the outcomes of patients with spinal cord tumors. METHODS: The Surveillance, Epidemiology, and End Results program was queried for patients with spinal cord tumors from 2004 to 2014. Patients were separated into 4 groups according to their marital status: single/never married, married/living together, divorced/separated, and widowed. SES was calculated using a validated method. Kaplan-Meier curves and multivariable logistic and Cox regression analyses were used to investigate the relationship between marital status and SES and the mortality rate of patients with available follow-up information. RESULTS: Of the 1188 patients identified (683 women [57.5%] and 505 men [42.5%]), 241 (20.3%) were in the single group, 732 (61.6%) in the married/living together, 109 (9.2%) in the divorced/separated, and 106 (8.9%) in the widowed group. Compared with married patients, divorced/separated and widowed patients had a greater mortality rate (hazard ratio [HR], 1.76; 95% confidence interval [CI], 1.1-2.9; P = 0.02; HR, 2.01; 95% CI, 1.3-3.1; P = 0.001, respectively). Male sex compared with female was associated with lower survival (HR, 1.42; 95% CI, 1.03-1.9; P = 0.03). Patients with greater SES had a lower mortality rate (HR, 0.77; 95% CI, 0.55-1.08; P = 0.143). CONCLUSION: Unmarried and widowed status, lower SES, and male sex resulted in a greater risk of mortality. These factors should be considered when tailoring the treatment plan for such patients.

Low-dose CT for the detection and classification of metastatic liver lesions: Results of the 2016 Low Dose CT Grand Challenge.

PURPOSE: Using common datasets, to estimate and compare the diagnostic performance of image-based denoising techniques or iterative reconstruction algorithms for the task of detecting hepatic metastases. METHODS: Datasets from contrast-enhanced CT scans of the liver were provided to participants in an NIH-, AAPM- and Mayo Clinic-sponsored Low Dose CT Grand Challenge. Training data included full-dose and quarter-dose scans of the ACR CT accreditation phantom and 10 patient examinations; both images and projections were provided in the training data. Projection data were supplied in a vendor-neutral standardized format (DICOM-CT-PD). Twenty quarter-dose patient datasets were provided to each participant for testing the performance of their technique. Images were provided to sites intending to perform denoising in the image domain. Fully preprocessed projection data and statistical noise maps were provided to sites intending to perform iterative reconstruction. Upon return of the denoised or iteratively reconstructed quarter-dose images, randomized, blinded evaluation of the cases was performed using a Latin Square study design by 11 senior radiology residents or fellows, who marked the locations of identified hepatic metastases. Markings were scored against reference locations of clinically or pathologically demonstrated metastases to determine a per-lesion normalized score and a per-case normalized score (a faculty abdominal radiologist established the reference location using clinical and pathological information). Scores increased for correct detections; scores decreased for missed or incorrect detections. The winner for the competition was the entry that produced the highest total score (mean of the per-lesion and per-case normalized score). Reader confidence was used to compute a Jackknife alternative free-response receiver operating characteristic (JAFROC) figure of merit, which was used for breaking ties. RESULTS: 103 participants from 90 sites and 26 countries registered to participate. Training data were shared with 77 sites that completed the data sharing agreements. Subsequently, 41 sites downloaded the 20 test cases, which included only the 25% dose data (CTDIvol = 3.0 ± 1.8 mGy, SSDE = 3.5 ± 1.3 mGy). 22 sites submitted results for evaluation. One site provided binary images and one site provided images with severe artifacts; cases from these sites were excluded from review and the participants removed from the challenge. The mean (range) per-lesion and per-case normalized scores were -24.2% (-75.8%, 3%) and 47% (10%, 70%), respectively. Compared to reader results for commercially reconstructed quarter-dose images with no noise reduction, 11 of the 20 sites showed a numeric improvement in the mean JAFROC figure of merit. Notably two sites performed comparably to the reader results for full-dose commercial images. The study was not designed for these comparisons, so wide confidence intervals surrounded these figures of merit and the results should be used only to motivate future testing. CONCLUSION: Infrastructure and methodology were developed to rapidly estimate observer performance for liver metastasis detection in low-dose CT examinations of the liver after either image-based denoising or iterative reconstruction. The results demonstrated large differences in detection and classification performance between noise reduction methods, although the majority of methods provided some improvement in performance relative to the commercial quarter-dose images with no noise reduction applied.

Consistency of Renal Stone Volume Measurements Across CT Scanner Model and Reconstruction Algorithm Configurations.

OBJECTIVE: The objective of this prospective study is to evaluate the consistency of renal stone volume estimation using dual-energy CT across scanner model and reconstruction algorithm configurations. SUBJECTS AND METHODS: Patients underwent scanning with routine kidney stone composition protocols on both second- and third-generation dual-source CT scanners. Images were reconstructed using filtered back projection and iterative reconstruction (IR). In addition, a modified IR kernel on the third-generation CT scanner was evaluated. Individual kidney stone volumes were determined and compared. RESULTS: No significant difference was noted in measured volumes between filtered back-projection data, IR data from the second-generation scanner, and the modified IR kernel data (p > 0.05). The third-generation commercially available IR kernel yielded lower volumes than did the other configurations (p < 0.0001). CONCLUSION: With the use of a modified kernel for the third-generation scanner, patients being monitored for changes in kidney stone volume can undergo scanning performed with second- or third-generation dual-energy CT scanners, and the images obtained can be reconstructed with either filtered back projection or IR without the introduction of bias into kidney stone volume measurements.

Quantitative Prediction of Stone Fragility From Routine Dual Energy CT: Ex vivo proof of Feasibility.

RATIONALE AND OBJECTIVES: Previous studies have demonstrated a qualitative relationship between stone fragility and internal stone morphology. The goal of this study was to quantify morphologic features from dual-energy computed tomography (CT) images and assess their relationship to stone fragility. MATERIALS AND METHODS: Thirty-three calcified urinary stones were scanned with micro-CT. Next, they were placed within torso-shaped water phantoms and scanned with the dual-energy CT stone composition protocol in routine use at our institution. Mixed low- and high-energy images were used to measure volume, surface roughness, and 12 metrics describing internal morphology for each stone. The ratios of low- to high-energy CT numbers were also measured. Subsequent to imaging, stone fragility was measured by disintegrating each stone in a controlled ex vivo experiment using an ultrasonic lithotripter and recording the time to comminution. A multivariable linear regression model was developed to predict time to comminution. RESULTS: The average stone volume was 300 mm3 (range: 134-674 mm3). The average comminution time measured ex vivo was 32 seconds (range: 7-115 seconds). Stone volume, dual-energy CT number ratio, and surface roughness were found to have the best combined predictive ability to estimate comminution time (adjusted R2 = 0.58). The predictive ability of mixed dual-energy CT images, without use of the dual-energy CT number ratio, to estimate comminution time was slightly inferior, with an adjusted R2 of 0.54. CONCLUSIONS: Dual-energy CT number ratios, volume, and morphologic metrics may provide a method for predicting stone fragility, as measured by time to comminution from ultrasonic lithotripsy.