A proposed association between subjective nonpulsatile tinnitus and migraine.

Objective: Tinnitus is defined as the perception of sound in the absence of an external source. We propose the hypothesis that migraine can cause exacerbation of tinnitus in some patients. Methods: English literature from PubMed has been reviewed. Results: Studies have reported a high prevalence of cochlear symptoms in patients with migraine headaches and up to 45% of tinnitus patients have been shown to concomitantly suffer from migraine. Both conditions are thought to stem from central nervous system disturbances, involving disruption of the auditory and trigeminal nerve pathways. One proposed mechanism of this association is the modulation of sound sensitivity by trigeminal nerve activation of the auditory cortex during migraine attacks, resulting in tinnitus fluctuation in some patients. Increased brain and inner ear vascular permeability resulting from trigeminal nerve inflammation, can also cause observed headache and auditory symptoms. Tinnitus and migraine also share a number of symptom triggers including stress, sleep disturbances, and dietary factors. These shared features may help explain promising results of migraine therapies for the treatment of tinnitus. Conclusion: Given the complex association between tinnitus and migraine, further investigation is needed to identify the underlying mechanisms and determine the optimal treatment strategies for managing migraine-related tinnitus patients.

Postoperative Obstructive Sleep Apnea Management Following Endoscopic Pituitary Surgery: A Systematic Review.

OBJECTIVE: There is currently no consensus on the appropriate timing of noninvasive positive pressure ventilation (PPV) resumption in patients with obstructive sleep apnea (OSA) after endoscopic pituitary surgery. We performed a systematic review of the literature to better assess the safety of early PPV use in OSA patients following surgery. METHODS: The study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Databases in English were searched using the keywords: "sleep apnea," "CPAP," "endoscopic," "skull base," "transsphenoidal" and "pituitary surgery." Case reports, editorials, reviews, meta-analyses, unpublished and abstract-only articles were all excluded. RESULTS: Five retrospective studies were identified, comprising 267 patients with OSA who underwent endoscopic endonasal pituitary surgery. The mean age of patients in four studies (n = 198) was 56.3 years (SD = 8.6) and the most common indication for surgery was pituitary adenoma resection. The timing of PPV resumption following surgery was reported in four studies (n = 130), with 29 patients receiving PPV therapy within two weeks. The pooled rate of postoperative cerebrospinal fluid leak associated with PPV resumption was 4.0% (95% CI: 1.3-6.7%) in three studies (n = 27) and there were no reports of pneumocephalus associated with PPV use in the early postoperative period (<2 weeks). CONCLUSIONS: Early resumption of PPV in OSA patients after endoscopic endonasal pituitary surgery appears relatively safe. However, the current literature is limited. Additional studies with more rigorous outcome reporting are warranted to assess the true safety of re-initiating PPV postoperatively in this population.

Tympanostomy tube placement for pressure-sensitive vertigo.

Objective: To evaluate tympanostomy tube placement in patients with pressure-sensitive vertigo. Methods: Retrospective case series. Results: Six patients with pressure-sensitive vertigo reported resolution of their vertigo and other vestibular symptoms after placement of the tympanostomy tubes. All recurrences of symptoms were due to either extrusion or plugging of the tubes. All patients fulfilled the criteria for vestibular migraine. None of the patients had superior canal dehiscence on imaging or precedent event that triggered the problem, and all had a negative fistula test. Conclusion: Tympanostomy tube placement should be considered in selected patients with vertigo exacerbated by seemingly small changes in atmospheric pressure (e.g., just prior to thunderstorms, air travel, or travel to the mountains). By eliminating the capability of the tympanic membrane to sense changes in pressure with a tube, patients with pressure-induced vertigo (in the absence of perilymph fistula or superior canal dehiscence) may have relief of their symptoms.

Otolaryngology residency programs' perspectives on virtual interviews during the COVID-19 pandemic.

Objective: To evaluate perceptions of otolaryngology residency program directors (PDs) and department chairs (DCs) on virtual interviews (VIs) at the conclusion of the 2021 residency match. Study design: Cross-sectional survey study. Methods: An anonymous and voluntary survey was administered to PDs and DCs of U.S. otolaryngology residency programs from March 1, 2021 to April 11, 2021. Utilizing Likert scale ratings, the survey measured overall satisfaction with the VI format, perceived ability to assess key candidate attributes, relative importance of traditional candidate metrics, and likelihood to implement VIs in future cycles. Results: Ninety-four surveys were completed by PDs (48.9%) and DCs (51.1%). Sixty (63.8%) respondents found the VI experience to be satisfactory or strongly satisfactory. Sixty-six (70.2%) respondents felt confident in their ability to assess a candidate's professionalism and communication skills through VIs; however, confidence in gauging an applicant's clinical skills/knowledge (41.2%) and overall program fit (47.3%) was lower. Regarding candidate metrics, 64 (68.1%) respondents believed that personal prior knowledge of the applicant gained increased importance with VIs. Forty-four (46.8%) and 45 (47.9%) participants believed that letters of recommendation in the specialty and perceived commitment to their program similarly attained increased significance in evaluating applicants, respectively. Conclusion: Most PDs and DCs were satisfied with their VI experiences and expect the quality of interns to be unaffected by virtual assessment modalities. Majority opinion on the relative importance of traditional applicant metrics remained largely unchanged, the exception being an increase in importance of prior knowledge of the applicant.Level of Evidence: N/A.

Long-term outcomes in sinonasal squamous cell carcinoma arising from inverted papilloma: Systematic review.

Long-term survival and recurrence patterns of squamous cell carcinoma arising from inverted papilloma (IP-SCC) have not been thoroughly investigated. Four electronic databases were searched and primary studies describing overall survival (OS), recurrence, and mean time to recurrence of patients with IP-SCC were included for review. Our search yielded 662 studies. The 28 studies selected for inclusion identified 663 patients with IP-SCC. In 596 patients with reported T classification, 439 (73.7%) were T3/T4 on presentation. Of the 650 participants with recurrence data (local, regional, and distant), 155 (23.8%) experienced a recurrence, with an aggregate mean time-to-recurrence of 24.3 months. In 565 patients with 5-year OS rates, the aggregate 5-year OS was 62%. Based on the literature to date, IP-SCC is associated with a 5-year OS rate of 62%. 23.8% of patients experienced recurrence at a mean time of 24.3 months, suggesting the need for long-term surveillance.

Prognostic Factors and Outcomes of De Novo Sinonasal Squamous Cell Carcinoma: A Systematic Review and Meta-analysis.

OBJECTIVE: To review overall survival (OS), recurrence patterns, and prognostic factors of de novo sinonasal squamous cell carcinoma (DN-SCC). DATA SOURCES: PubMed, Scopus, OVID Medline, and Cochrane databases from 2006 to December 23, 2020. REVIEW METHODS: The study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Articles were required to report either recurrence patterns or survival outcomes of adults with DN-SCC. Case reports, books, reviews, meta-analyses, and database studies were all excluded. RESULTS: Forty-one studies reported on survival or recurrence outcomes. The aggregate 5-year OS was 54.5% (range, 18%-75%) from 35 studies (n = 1903). Patients undergoing open surgery were more likely to receive radiation therapy and present at an advanced stage compared to those receiving endoscopic surgery (all P < .001). Advanced T stage, presence of cervical nodal metastases, maxillary sinus primary site, and negative human papillomavirus (HPV) status were all correlated with significantly worse 5-year OS. Direct meta-analysis of 8 studies demonstrated patients with surgery were more likely to be alive at 5 years compared to those who did not receive surgery (odds ratio, 2.26; 95% CI, 1.48-3.47; P < .001). Recurrence was reported in 628 of 1471 patients from 26 studies (42.7%) with an aggregate 5-year locoregional control rate of 67.1% (range, 50.4%-93.3%). CONCLUSION: This systematic review and meta-analysis suggests that the 5-year OS rate for DN-SCC may approach 54.5% and recurrence rate approaches 42.7%. In addition, various tumor characteristics including advanced T stage, positive nodal status, maxillary sinus origin, and negative HPV status are all associated with decreased survival.

A Comparison of Near-Infrared Imaging and Computerized Tomography Scan for Detecting Maxillary Sinusitis.

OBJECTIVE: To investigate the use of near-infrared (NIR) imaging as a tool for outpatient clinicians to quickly and accurately assess for maxillary sinusitis and to characterize its accuracy compared to computerized tomography (CT) scan. METHODS: In a prospective investigational study, NIR and CT images from 65 patients who presented to a tertiary care rhinology clinic were compared to determine the sensitivity and specificity of NIR as an imaging modality. RESULTS: The sensitivity and specificity of NIR imaging in distinguishing normal versus maxillary sinus disease was found to be 90% and 84%, normal versus mild maxillary sinus disease to be 76% and 91%, and mild versus severe maxillary sinus disease to be 96% and 81%, respectively. The average pixel intensity was also calculated and compared to the modified Lund-Mackay scores from CT scans to assess the ability of NIR imaging to stratify the severity of maxillary sinus disease. Average pixel intensity over a region of interest was significantly different (P < .001) between normal, mild, and severe disease, as well as when comparing normal versus mild (P < .001, 95% CI 42.22-105.39), normal versus severe (P < .001, 95% CI 119.43-174.14), and mild versus severe (P < .001, 95% CI 41.39-104.56) maxillary sinus disease. CONCLUSION: Based on this data, NIR shows promise as a tool for identifying patients with potential maxillary sinus disease as well as providing information on severity of disease that may guide administration of appropriate treatments.

Trends and patterns of neurotology drug prescriptions on a nationwide insurance database.

OBJECTIVE: To examine neurotologists' 2013 to 2016 Medicare Part-D data and evaluate commonly prescribed medications, longitudinal changes in prescribing patterns, presumed associated pathologies, and cost distribution across United States. METHODS: Comprehensive prescription data of Part-D-participating neurotologists was quiered from the 2013 to 2016 Medicare Part-D database. Outcome variables consisted of the 25 most commonly prescribed + refilled medications, cost distribution per medication, presumed associated pathologies, and standardized prescription cost across United States. RESULTS: Of the 594 available U.S. neurotologists, 336 (57%) were found in the Medicare Part-D database. In 2016, total prescription costs were $4 483 268 with an averaged $13 343 ± $18 698 per neurotologist. The three most frequently filled drugs were fluticasone propionate, ciprofloxacin, and triamterene-hydrochlorothiazide. From 2013 to 2016, the greatest change in prescription pattern was observed with azelastine (+188%), montelukast sodium (+104%), mupirocin (+63%), and mometasone (-91%), whereas the greatest change in relative drug cost distribution was seen in ofloxacin, (+695.7%) neomycin-polymyxin-hydrocortisone (+262.1%), and mometasone (-83%). Triamterene-hydrochlorothiazide, prednisone, montelukast, amoxicillin-clavulanate, azelastine, spironolactone, and mupirocin had statistically significant increases in average number of prescriptions per physician, whereas ofloxacin and mometasone had significant decreases. Medications presumably treating Eustachian tube dysfunction, Meniere's disease, and vestibular migraine had the greatest percent changes across years. Cost distribution of four drugs increased upwards of 100%. Geographic analysis demonstrated that Southern and Midwest regions had higher standardized prescription costs. CONCLUSIONS: This study is the first to analyze neurotologists' trends in prescribing patterns, regional prescription cost distributions, and commonly treated pathologies. This can lead to better standardization of prescribing patterns and cost in the future.

Migraine Features in Patients With Isolated Aural Fullness and Proposal for a New Diagnosis.

OBJECTIVE: To compare the presence of migraine features between patients with isolated aural fullness (AF) who meet the diagnostic criteria for migraine headache and those who do not, and to propose diagnostic criteria for migraine-related AF based on our results. METHODS: We performed a retrospective study of patients presenting to a tertiary-care neurotology clinic between 2014 and 2020 with migraine-related AF. This was defined as isolated, prolonged aural fullness concurrent with migraine features once other etiologies were ruled out via examination, audiometry, and imaging. Migraine features were compared between patients meeting the diagnostic criteria for migraine headache and those not meeting the criteria. RESULTS: Seventy-seven patients with migraine-related AF were included. The mean age was 56 ±â€Š15 years and 55 (71%) patients were female. Eleven (14%) patients fulfilled the criteria for migraine headache (migraine group). Of the 66 patients who did not meet the criteria (nonmigraine group), 17 (26%) met 4/5 criteria, and 32 (48%) met 3/5 criteria, for a total of 49 (74%) patients. The migraine and nonmigraine groups were only different in 5 of 20 features, including family history of migraine (p = 0.007), sound sensitivity (p < 0.001), mental fogginess (p = 0.008), visual motion sensitivity (p = 0.008), and light sensitivity (p < 0.001). CONCLUSION: There are minimal differences in the overall prevalence of migraine features between patients with migraine-related AF who meet and do not meet the diagnostic criteria for migraine. Our findings suggest that the criteria may be too stringent and exclude many patients from potentially benefitting from treatment with migraine prophylaxis.

Tinnitus and Subjective Hearing Loss are More Common in Migraine: A Cross-Sectional NHANES Analysis.

OBJECTIVES: To investigate whether migraine is independently associated with tinnitus and subjective hearing loss (HL) in a large national database. METHODS: The de-identified 1999 to 2004 National Health and Nutrition Examination Survey database was retrospectively queried for subjects aged 18 to 65. HL and tinnitus were subjectively reported by subjects. RESULTS: A total of 12,962 subjects (52.9% female) with a mean age of 38.1 ±â€Š14.6 years were included. This consisted of 2,657 (20.5%), 2,344 (18.1%), and 2,582 (19.9%) subjects who had migraine, subjective-HL, and tinnitus, respectively. In patients with tinnitus or subjective-HL, migraine was reported in 35.6% and 24.5%, respectively. Migraineurs were more likely to have subjective-HL (25.0% vs. 16.6%, p < 0.001) and tinnitus (34.6% vs. 16.9%, p < 0.001) compared to the nonmigraineurs. This corresponded to migraine having an odds ratio of 1.5 (95% confidence interval [CI] 1.3-1.7, p < 0.001) and 2.2 (95% CI 2.0-2.4, p < 0.001) for subjective-HL and tinnitus, respectively. After adjusting for confounders, subjective-HL (odds ratio [OR] = 1.2, 95% CI 1.1-1.4, p = 0.003), tinnitus (OR = 2.1, 95% CI 1.9-2.3, p < 0.001), and neck pain (OR = 4.0, 95% CI 3.6-4.5, p < 0.001) were more common in migraineurs. Among migraineurs, a higher proportion of those with tinnitus also had subjective-HL compared to those without tinnitus (40.0% vs. 15.3%, p < 0.001), and a higher proportion of those with subjective-HL also had tinnitus compared to those without HL (58.1% vs. 27.3%, p < 0.001). CONCLUSIONS: This study suggests an independent association between migraine with subjective-HL and tinnitus. Otologic migraine, which is the effects of migraine on the ear, may be partly responsible for the link between HL, tinnitus, neck pain, and migraine.

A Web-Based Deep Learning Model for Automated Diagnosis of Otoscopic Images.

OBJECTIVES: To develop a multiclass-classifier deep learning model and website for distinguishing tympanic membrane (TM) pathologies based on otoscopic images. METHODS: An otoscopic image database developed by utilizing publicly available online images and open databases was assessed by convolutional neural network (CNN) models including ResNet-50, Inception-V3, Inception-Resnet-V2, and MobileNetV2. Training and testing were conducted with a 75:25 breakdown. Area under the curve of receiver operating characteristics (AUC-ROC), accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were used to compare different CNN models' performances in classifying TM images. RESULTS: Our database included 400 images, organized into normal (n = 196) and abnormal classes (n = 204), including acute otitis media (n = 116), otitis externa (n = 44), chronic suppurative otitis media (n = 23), and cerumen impaction (n = 21). For binary classification between normal versus abnormal TM, the best performing model had average AUC-ROC of 0.902 (MobileNetV2), followed by 0.745 (Inception-Resnet-V2), 0.731 (ResNet-50), and 0.636 (Inception-V3). Accuracy ranged between 0.73-0.77, sensitivity 0.72-0.88, specificity 0.58-0.84, PPV 0.68-0.81, and NPV 0.73-0.83. Macro-AUC-ROC for MobileNetV2 based multiclass-classifier was 0.91, with accuracy of 66%. Binary and multiclass-classifier models based on MobileNetV2 were loaded onto a publicly accessible and user-friendly website (https://headneckml.com/tympanic). This allows the readership to upload TM images for real-time predictions using the developed algorithms. CONCLUSIONS: Novel CNN algorithms were developed with high AUC-ROCs for differentiating between various TM pathologies. This was further deployed as a proof-of-concept publicly accessible website for real-time predictions.

Migraine Features in Patients with Persistent Postural-Perceptual Dizziness.

OBJECTIVES: To evaluate the presence of migraine features in patients with persistent postural-perceptual dizziness (PPPD). METHODS: In a retrospective survey study, consecutive patients presenting to a tertiary care neurotology clinic during an 18-month period were given questionnaires about headache and dizziness symptoms. The survey responses plus history and examination of the patient were used to diagnose patients with PPPD. The prevalence of migraine headache, vestibular migraine (VM), and migraine characteristics was evaluated. RESULTS: In total, 36 subjects with PPPD were included in the study. The mean age of the subjects was 56 ± 16 years with a female (72%) predominance. A total of 19 (53%) patients met the International Classification of Headache Disorders criteria for migraine headache, and 6 of those (17%) met the criteria for definite VM. Of the patients who did not meet full migraine headache criteria, 6 (17%) patients met 4 of 5 criteria, and 5 (14%) patients met 3 of 5 criteria. There was no significant difference between PPPD patients who fulfilled full migraine headache criteria and those who did not in sensitivity to light, sound, smells, weather changes, feelings of mental fog/confusion, and sinus pain/facial pressure. CONCLUSIONS: This study demonstrates that a majority of patients with PPPD fulfill the criteria for migraine headache. A large proportion of PPPD patients who do not meet the full criteria for migraine headache still meet a majority of the migraine headache criteria. This suggests an association between the 2 conditions. PPPD may be a part of the spectrum of otologic migraine, where migraine manifests as otologic symptoms.

Treatment of Long-term Sudden Sensorineural Hearing Loss as an Otologic Migraine Phenomenon.

OBJECTIVES: To describe a cohort of patients presenting with long-term sudden sensorineural hearing loss (SSNHL) treated with prophylactic migraine and intratympanic steroid therapy. METHODS: Patients presenting to a neurotology clinic at least 6 weeks from SSNHL onset were included. All patients received migraine prophylactic medication (nortriptyline, topiramate, and/or verapamil) and lifestyle changes for at least 6 weeks, as well as intratympanic steroid injections, if appropriate. RESULTS: Twenty-one patients (43% female) with a mean age of 64 ±â€Š11 years who presented 9 ±â€Š8 months (median = 5) from symptom onset were included. Posttreatment hearing thresholds were significantly improved compared with pretreatment thresholds at 500 Hz (49 ±â€Š19 dB versus 55 ±â€Š20 dB, p = 0.01), 1000 Hz (52 ±â€Š19 dB versus 57 ±â€Š21 dB, p = 0.03), low-frequency pure-tone average (53 ±â€Š15 dB versus 57 ±â€Š17 dB, p = 0.01), and speech-frequency pure-tone average (57 ±â€Š13 dB versus 60 ±â€Š15 dB, p = 0.02). Posttreatment word-recognition-score (WRS) and speech-recognition-threshold (SRT) were also significantly improved (45 ±â€Š28% versus 70 ±â€Š28% and 57 ±â€Š18 dB versus 50 ±â€Š16 dB, respectively, both p < 0.01). Notably, ≥15% improvement in WRS and ≥10 dB improvement in SRT was observed in 13 (68%) and 8 (40%) patients, respectively. Of the 11 patients who presented with initial < 50% WRS, 8 (73%) had improved posttreatment >50% WRS with an average improvement of 39 ±â€Š9%. CONCLUSIONS: Migraine medications in addition to intratympanic steroid injections significantly improved SRT and hearing frequencies in 40% and 29% of SSNHL patients, respectively, while significant WRS recovery was observed in most (68%) patients. This suggests SSNHL may be an otologic migraine phenomenon, which may be at least partially reversible even after the traditional 30-day postonset window.

Online Ratings and Perceptions of Pediatric Otolaryngologists.

OBJECTIVE/HYPOTHESIS: To assess and characterize online ratings and comments on pediatric otolaryngologists and determine factors that correlate with higher ratings. STUDY DESIGN: Online database analysis. METHODS: All American Society of Pediatric Otolaryngology (ASPO) members were queried on Healthgrades, Vitals, RateMDs, and Yelp for their online ratings and comments as of June 2020. Ratings were normalized for comparison on a five-point Likert scale. All comments were categorized based on context and positive or negative quality. RESULTS: Of the 561 ASPO members, 489 (87%) were rated on at least one online platform. Of those rated, 410 (84%) were on Healthgrades, 429 (88%) on Vitals, 236 (48%) on RateMDs, and 72 (15%) on Yelp. Across all platforms, the average overall rating was 4.13 ± 0.03 (range, 1.00-5.00). We found significant positive correlations between overall ratings and specific ratings (P < .001) on all individual topics. In addition, the majority of all narrative comments were related to perceived physician bedside manner and clinical outcome, with negative comments correlating negatively with overall score (P < .05). Time spent with the physician was the only category in which both positive and negative comments showed significant correlation with the overall physician rating (P = .016 and P = .017, respectively). Attending a top-ranked medical school or residency program did not correlate with higher or lower ratings. CONCLUSIONS: Online ratings and comments for pediatric otolaryngologists are largely influenced by patient and parent perceptions of physician competence, comforting bedside manner, and office and time management. LEVEL OF EVIDENCE: NA Laryngoscope, 131:2356-2360, 2021.

Sphenoid Wing Meningioma Presenting as Sudden Sensorineural Hearing Loss: A Case Report and Literature Review.

Sphenoid wing meningiomas are tumors that typically present with vision deterioration and neurological changes due to their proximity to the sella, cavernous sinus, and other vital structures. Some unusual symptoms have also been described in the literature, such as cognitive dysfunction, parkinsonism, and intracerebral hemorrhage. In this report, we detail another unusual case of sphenoid wing meningioma in a 63-year-old female who presented with left sudden sensorineural hearing loss. A brief review of the literature is also included.