Quality appraisal of clinical practice guidelines for the evaluation and management of primary hyperparathyroidism.

PURPOSE: Multiple groups have created clinical practice guidelines (CPGs) for the management of primary hyperparathyroidism (PHPT). This report provides a rigorous quality assessment using the Appraisal of Guidelines for Research & Evaluation Instrument (AGREE II) to identify high-performing guidelines and areas for improvement. METHODS: A systematic review was conducted to isolate CPGs addressing the management of PHPT. Guideline data was extracted and quality ratings were assigned by four independent reviewers. Intraclass correlation coefficients (ICC) were calculated to ensure interrater reliability. RESULTS: Twelve guidelines were assessed. The American Association of Endocrine Surgeons (AAES) guideline had the highest mean scaled score across all domains (73.6 ± 31.4%). No other published guideline achieved a "high" quality designation. The highest scoring domain was "clarity of presentation" (mean 60.5 ± 26.5%). The lowest scoring domain was "applicability" (mean 19.8 ± 18.2%). Scoring reliability was excellent, with ICC ≥ 0.89 for all AGREE II 6 domains. CONCLUSION: Although several working groups have developed guidelines to address PHPT management, only those published by the AAES meet all methodologic quality criteria necessary to ensure incorporation of recommendations into clinical practice. Future guidelines would benefit from the development of tools, resources, monitoring criteria that enhance applicability.

Comparing adverse events associated with LigaSure and Harmonic devices in head and neck surgery.

OBJECTIVE: To characterize adverse events, provide a safety profile, and understand patient outcomes after complications arising from LigaSure and Harmonic use in the head and neck region. METHODS: Retrospective analysis of adverse events from the Manufacturer and User Facility Device Experience (MAUDE) between January 2013 and 2023. RESULTS: A total of 158 LigaSure and 159 Harmonic events were extracted. There were significantly more reports of Harmonic device overheating (6.9% vs. 0.6%, p = 0.003) and spontaneous self-activation (4.4% vs. 0%, p = 0.032). Although intra-operative and post-operative complications were similar among both groups, there were significantly more intra-operative bleeding events for LigaSure as compared to Harmonic (8.2% vs. 0.0%, p = 0.001). CONCLUSION: Understanding technical complications and adverse events attributable to LigaSure and Harmonic devices enables the development of clinically relevant risk mitigation strategies. Surgeons should avoid improper use by remaining vigilant of device functionality and temperature changes.

Quantifying the effect of shoulder size on operation duration: an analysis of stapes surgery outcomes.

OBJECTIVE: To investigate the effect of body mass index on hearing outcomes, operative time and complication rates following stapes surgery. METHOD: This is a five-year retrospective review of 402 charts from a single tertiary otology referral centre from 2015 to 2020. RESULTS: When the patient's shoulder was adjacent to the surgeon's dominant hand, the average operative time of 40 minutes increased to 70 minutes because of a significant positive association between higher body mass index and longer operative times (normal body mass index group (<25 kg/m2) r = 0.273, p = 0.032; overweight body mass index group (25-30 kg/m2) r = 0.265, p = 0.019). Operative times were not significantly longer upon comparison of low and high body mass index groups without stratification by laterality (54.9 ± 19.6 minutes vs 57.8 ± 19.2 minutes, p = 0.127). CONCLUSION: There is a clinically significant relationship between body mass index and operating times. This may be due to access limitations imposed by shoulder size.

Medico-legal liability of injuries arising from laryngoscopy.

OBJECTIVE: Dental and mucosal injuries from laryngoscopy in the peri-operative period are common medico-legal complaints. This study investigated lawsuits arising from laryngoscopy. METHODS: Westlaw, a legal database containing trial records from across the USA, was retrospectively reviewed. Plaintiff and/or defendant characteristics, claimed injuries, legal outcomes and awards were extracted. RESULTS: Of all laryngoscopy-related dental or mucosal injuries brought before a state or federal court, none (0 per cent) resulted in a defence verdict against the provider or monetary gain for the patient. Rulings in the patient's favour were observed only when laryngoscopy was found to be the proximate cause of multiple compounding complications that culminated in severe medical outcomes such as exsanguination, septic shock or cardiopulmonary arrest. CONCLUSION: Proper laryngoscopy technique and a robust informed-consent process that accurately sets patients' expectations reduces litigation risk. Future litigation pursuits should consider the low likelihood of malpractice allegation success at trial.

An evidenced-based diagnostic tool for superior semicircular canal dehiscence syndrome.

Purpose: To construct a symptoms-based prediction tool to assess the likelihood of superior canal dehiscence (SSCD) on high-resolution CT. Materials and methods: Mathematical modeling was employed to predict radiologic evidence of SSCD at a tertiary neurotology referral center. Results: A total of 168 patients were included, of which 118 had imaging-confirmed SSCD. On univariate analysis significant predictors of SSCD presence were: sound/pressure-induced vertigo (p = 0.006), disequilibrium (p = 0.008), hyperacusis (p = 0.008), and autophony (p = 0.034). Multivariate analysis enabled a 14-point symptom-weighted tool to be developed, wherein a score of ≥6 raised the suspicion of SSCD (≥70% likelihood of being present), R2 = 0.853. Conclusions: The likelihood of SSCD on CT scan can be determined with a high degree of certainty based on symptoms recorded at presentation. Using the evidenced-based diagnostic tool validated herein, a score ≥6 with any symptom combination justifies ordering a CT scan.

The fragility index: how robust are the outcomes of head and neck cancer randomised, controlled trials?

BACKGROUND: The fragility index represents the minimum number of patients required to convert an outcome from statistically significant to insignificant. This report assesses the fragility index of head and neck cancer randomised, controlled trials. METHODS: Studies were extracted from PubMed/Medline, Scopus, Embase and Cochrane databases. RESULTS: Overall, 123 randomised, controlled trials were included. The sample size and fragility index medians (interquartile ranges) were 103 (56-213) and 2 (0-5), respectively. The fragility index exceeded the number of patients lost to follow up in 42.3 per cent (n = 52) of studies. A higher fragility index correlated with higher sample size (r = 0.514, p < 0.001), number of events (r = 0.449, p < 0.001) and statistical significance via p-value (r = -0.367, p < 0.001). CONCLUSION: Head and neck cancer randomised, controlled trials demonstrated low fragility index values, in which statistically significant results could be nullified by altering the outcomes of just two patients, on average. Future head and neck oncology randomised, controlled trials should report the fragility index in order to provide insight into statistical robustness.

Does labyrinthectomy have an impact on hearing in the contralateral ear during long-term follow-up?

OBJECTIVE: To quantify contralateral hearing outcomes after labyrinthectomy for unilateral Ménière's disease (MD). STUDY DESIGN: Retrospective case series. SETTING: Tertiary neurotology referral center. PATIENTS: Labyrinth removal for the management of MD or translabyrinthine (TLAB) acoustic neuroma resection between 2008 and 2012. MAIN OUTCOME MEASURE: Long-term hearing changes via pure tone averages (PTA). RESULTS: Upon comparison of low-frequency PTA (250, 500, 1000 Hz), MD patients experienced a greater degree of hearing loss during the follow-up period when compared to the TLAB lab group (7.54 ± 2.11 dB vs 2.39 ± 1.10 dB, p = 0.035). This difference as attributable to 12 (28.6 %) MD patients experiencing a ≥30 dB increase in low-frequency PTA, whereas none (0.0 %) of the TLAB surpassed this threshold. CONCLUSIONS: At 10 years post-labyrinthectomy there is a heightened risk for MD patients to develop low-frequency sensorineural hearing loss. Clinicians should monitor for audiometric changes through regular testing in the decade following labyrinth removal.

Simultaneous Cochlear Implantation and Salvage Translabyrinthine Resection of Vestibular Schwannoma after Radiotherapy.

OBJECTIVE: To report on the novel use of simultaneous cochlear implantation (CI) during salvage translabyrinthine resection of vestibular schwannoma (VS) after failed stereotactic radiosurgery (SRS). PATIENT: A 52-year-old woman presented with a medium-sized right VS. She experienced continued tumor growth despite previous SRS, resulting in medial extension beyond the internal auditory canal into the cerebellopontine angle. Associated symptoms included asymmetrical right moderate to severe sensorineural hearing loss, poor word recognition, tinnitus, and dizziness. INTERVENTION: Simultaneous CI with translabyrinthine VS resection. MAIN OUTCOME MEASURE: CI-aided pure-tone averages. RESULTS: After 4 months of device use, CI-aided speech audiometry revealed hearing thresholds in the normal range, with a four-tone pure-tone, average of 16.3 dB. Speech perception with consonant-nucleus-consonant testing in the CI-only condition was 46%, representing a 12% improvement compared with preoperatively. Tinnitus and dizziness burden were subjectively reduced. CONCLUSIONS: Despite challenges inherent to second procedures after radiotherapy failure, successful CI outcomes can be achieved. The current study demonstrates the feasibility of simultaneous CI during salvage VS resection after SRS. A larger study should be undertaken to further substantiate these preliminary findings.

Characterizing the most Popular Tinnitus Inquiries: Is Tinnitus Incidence on the Rise Since COVID-19?

OBJECTIVE: Approximately 50 million US adults experience chronic tinnitus, yet search behaviors and topics of concern to these patients have not been investigated on a national level. STUDY DESIGN: Observational. SETTING: Online database and tertiary otology clinic. PATIENTS: Nationwide and institutional samples. INTERVENTIONS: None. MAIN OUTCOME MEASURE: A search engine optimization tool was utilized to extract metadata on "People Also Ask" (PAA) questions pertaining to tinnitus. Website quality was assessed using JAMA benchmark criteria. Search volume trends were investigated along with institutional-level data on tinnitus incidence. RESULTS: Of the 500 PAA questions assessed, the majority (54.0%) contained value-type content. The most popular question categories pertained to tinnitus treatment (29.3%), alternative treatment approaches (21.5%), technical details (16.9%), and timeline of symptoms (13.4%). Patients were most interested in treatment with wearable masking devices and most commonly searched for tinnitus as being attributable to a neurologic etiology. Online searches pertaining to unilateral tinnitus symptoms have increased >3-fold since the onset of the COVID-19 pandemic. Likewise, review of patient encounters at our tertiary otology clinic revealed a nearly 2-fold increase in tinnitus consultations since 2020. CONCLUSIONS: Topics of interest and concern identified herein may inform the development of patient education materials and help guide clinical practice. Online search data suggest an increase in tinnitus searches since the onset of COVID-19, which did correlate clinically with an increase in tinnitus consultations at our institution.

Twelve-Month Outcomes of Simultaneous Translabyrinthine Resection and Cochlear Implantation.

OBJECTIVE: Audiometric outcomes at 12 months following simultaneous translabyrinthine (TL) resection of vestibular schwannoma (VS) and cochlear implantation (CI). STUDY DESIGN: Prospective cohort study. SETTING: Tertiary referral center. METHODS: Adult patients undergoing TL resection of sporadic, unilateral VS ≤ 2 cm were prospectively enrolled. Preoperative testing included binaural AZBio in noise and quiet and unilateral Consonant-Nucleus-Consonant (CNC). Tinnitus Handicap Index (THI) and Speech, Spatial, and Qualities of Hearing (SSQ) questionnaires were also completed. Patients underwent TL resection with simultaneous CI. The preoperative test battery was repeated at 1, 3, 6, and 12 months after activation. Statistical analysis was performed to characterize short-term outcomes (preoperative to 3 months), longer-term outcomes (3-12 months), and overall changes during the preoperative to 12-month period. RESULTS: AZBio, CNC, and THI improved at 3 months with no significant changes thereafter and showed durable improvement at 12 months compared to preoperative testing. While SSQ did not improve at 12 months, a subset of patients showed either recovery or improvement of SSQ-spatial subscores. Patients with cerebellopontine angle tumors had poorer performance, although the impact of tumor size and location could not be deduced based on the small sample size. CONCLUSION: Patients undergoing simultaneous CI and TL resection of VS had durable improvements in speech perception and tinnitus severity 12 months following surgery. Subjective improvements in localization were not observed. Additional studies are needed to determine which VS patients are optimal candidates for CI.

Allegations of Failure to Obtain Informed Consent in Otolaryngology: Evidenced-Based Recommendations for Sinus Surgeons.

BACKGROUND: Informed consent requires preoperative discussion of surgical risks, complications, and alternative treatment options. Allegations of incomplete informed consent are common in the field of otolaryngology. OBJECTIVES: Analyze outcomes and case variables in cases of alleged informed consent failure involving otolaryngologists. METHODS: A legal research database containing state and federal case records from across the United States was retrospectively reviewed for malpractice claims involving informed consent and otolaryngology. RESULTS: Among the 128 informed consent cases identified, 72.6% resulted in favorable verdicts for otolaryngologists. Functional endoscopic sinus surgery (FESS) was the most common source of informed consent litigation in the field of otolaryngology, with an incidence four-fold higher than the next most litigated procedure of uvulopalatopharyngoplasty (21.9% vs 5.4%). The top four factors cited in FESS-related cases were CSF leak (10), inadequate discussion of alternative therapies (4), diplopia (3), and meningitis (3). Cases resulting in a transient injury were significantly less likely to result in a payment from a plaintiff verdict or settlement (9.1%) as compared to payment-rates among cases involving permanent complications (34.6%) (p = 0.005). CONCLUSIONS: Failure to obtain informed consent is an important factor in medical malpractice litigation. This report identifies specific, actionable recommendations aimed at protecting sinus surgeons from liability and ensuring that patients are better informed.

Patient Sentiments Influencing Management Strategy for Single-sided Deafness.

OBJECTIVE: Assess opinions that influence treatment choice for single sided deafness (SSD). STUDY DESIGN: Retrospective chart review. SETTING: Tertiary neurotology referral center. PATIENTS: Patients with SSD were recruited between December 2020 and February 2021. Included patients were self-selected by voluntary completion of the study questionnaire. MAIN OUTCOME MEASURES: Tinnitus Handicap Inventory (THI), Hearing Handicap Inventory for Adults (HHIA), and a questionnaire containing 25 areas of inquiry relevant to management strategy decision making. RESULTS: In comparison to the surgical management group, patients opting for nonsurgical amplification were significantly more concerned about device visibility (p = 0.005, 1.32 ±â€Š0.22 versus 2.67 ±â€Š0.37), undergoing surgery (p = 0.017, 1.64 ±â€Š0.23 versus 2.89 ±â€Š0.51), and the thought of harboring an implanted device (p = 0.003, 1.46 ±â€Š0.22 versus 2.82 ±â€Š0.35). Patients with a major hearing handicap (grade 2-4) placed significantly less emphasis on out-of-pocket costs (p = 0.049, 2.38 ±â€Š0.17 versus 2.94 ±â€Š0.21) and were less concerned about experiencing discomfort from the device (p = 0.033, 3.13 ±â€Š0.11 versus 3.56 ±â€Š0.16) or ease of device use (p = 0.040, 3.20 ±â€Š0.13 versus 3.63 ±â€Š0.13) when compared with the minor handicap group. CONCLUSIONS: Lingering concerns about device visibility, undergoing surgery, and harboring an implanted device underscore the need for thorough patient counseling during SSD device selection consultations. These efforts should aim to address esthetic and surgical risk concerns while emphasizing the potential for improvements in quality of life.

Hearing Outcomes After Surgical Manipulation of the Membranous Labyrinth During Superior Semicircular Canal Dehiscence Plugging or Posterior Semicircular Canal Occlusion.

OBJECTIVE: To analyze audiometric data after surgical manipulation of the membranous labyrinth during plugging of superior semicircular canal dehiscence (SSCD) or posterior semicircular canal occlusion (PSCO) for benign paroxysmal positional vertigo. STUDY DESIGN: Retrospective chart review. SETTING: Tertiary referral center. PATIENTS: Patients undergoing plugging of SSCD or PSCO between 2009 and 2019. MAIN OUTCOME MEASURES: Pre- and postoperative audiometric data were collected per AAO-HNS guidelines. Hearing outcomes at initial and last follow-up were compared. Subanalyses were performed for surgical approach and age. RESULTS: Eighty-seven total procedures in 76 patients including 43 middle cranial fossa for SSCD, 29 transmastoid SSCD, and 15 PSCO. Mean preoperative air-conduction-pure-tone averages was 21.1±14.9 dB compared with 26.1 ±â€Š19.6 dB at initial follow-up and 24.4 ±â€Š18.6 dB at last follow-up (p = 0.006). Mean preoperative bone-conduction-pure-tone average was 14.3 ±â€Š11.9 dB compared with 18.3 ±â€Š15.6 dB at initial follow-up and 18.5 ±â€Š16.9 dB at last follow-up (p < 0.001). There were five cases of hearing loss >20 dB including one case of profound sensorineural hearing loss >55 dB. PSCO resulted in the most hearing loss at initial follow-up but largely resolves with time. Transmastoid approaches for SSCD resulted in more hearing loss compared with middle cranial fossa. Hearing outcomes were generally stable for SSCD approaches but showed improvement over time for PSCO. Age >50 was associated with greater hearing loss of 5.2 ±â€Š11.1 dB compared with 1.3 ±â€Š10.5 dB but did not reach statistical significance (p = 0.110). CONCLUSIONS: Surgical manipulation of the membranous labyrinth results in statistically significant hearing loss in a pooled analysis. Transient hearing loss is observed in PSCO and TM SSCD plugging was associated with postoperative hearing loss. There was a trend toward increased hearing loss in patients >50 years old.

Pre-existing Vestibular Symptoms Are Associated With Acute Vestibular Symptoms After Gamma Knife Therapy for Vestibular Schwannoma.

OBJECTIVE: To identify pretreatment variables associated with the development of acute vestibular symptoms after Gamma Knife (GK) treatment for Vestibular Schwannoma (VS). STUDY DESIGN: Retrospective case series. SETTING: Tertiary neurotology referral center. PATIENTS: Patients treated with GK radiosurgery for VS between March 2007 and March 2017 were considered for this study. Patients with neurofibromatosis type II, previous VS surgery, follow-up less than 6 months, or the lack of T2 magnetic resonance imaging (MRI) sequences from the day of treatment were excluded. MAIN OUTCOME MEASURES: The presence of acute vestibular symptoms arising within 6 months after GK was the main outcome variable. Tumor, patient, and treatment characteristics were gathered from the medical record. RESULTS: In total, 98 patients met inclusion criteria. The incidence of acute vestibular symptoms occurring within 6 months after GK treatment was 46.9%. Post-GK vestibular symptoms were reported at a significantly higher frequency among subjects who had reported vestibular symptoms before their treatment (p = 0.001). Tumor size was not associated with a propensity to develop acute vestibular symptoms (p = 0.397). The likelihood of receiving a referral to vestibular rehabilitation services was not significantly different among patients with larger versus smaller tumor size, as defined by 1.6 cm and 1.4 cm thresholds (p = 0.896, p = 0.654). CONCLUSIONS: Inquiries aimed at revealing a history of vestibular complaints may prove useful in counseling patients on the likelihood of experiencing acute vestibular symptoms after treatment of Vestibular Schwannoma with Gamma Knife therapy.

Hearing Outcomes With a Novel Total Ossicular Replacement Prosthesis.

INTRODUCTION: A total ossicular replacement prosthesis (TORP) is used to reconstruct the ossicular chain in the absence of the stapes suprastructure. The Wildcat prosthesis is a novel TORP that eliminates the need for a separate footplate shoe prosthesis and aims to improve ease-of-use and stability. This study evaluates hearing outcomes using the Wildcat prosthesis. STUDY DESIGN: Case series with chart review. SETTING: Tertiary neurotology referral center. METHODS: Retrospective chart review of 64 patients undergoing ossicular chain reconstruction using the Wildcat TORP. Hearing outcomes after surgery were assessed with air conduction pure-tone average, bone conduction pure-tone average, air-bone gap (ABG), speech recognition threshold , and word recognition score as primary outcome measures. The stability of hearing outcomes was evaluated on subsequent long-term follow-up. RESULTS: At mean short-term follow-up of 4.4 ±â€Š2.7 months, ABG improved from 31.0 ±â€Š13.0 dB preoperatively to 22.5 ±â€Š10.0 dB (p < 0.001) with 51.6% achieving ABG less than 20 dB. No significant difference in any primary outcome measures was found when analyzing outcomes by initial versus revision surgery, use of cartilage graft, or type of mastoidectomy. The only exception was a smaller reduction in ABG of 4.2 dB for patients with canal wall down mastoidectomy compared with a 13.7 dB ABG closure in patients with canal wall up mastoidectomy (p = 0.039). CONCLUSION: Total ossicular chain reconstruction using the Wildcat demonstrates versatility in challenging cases to provide hearing outcomes that are comparable to published data using TORPs.

A Protective Cap: Fundal Fluid Cap Facilitates a Reduction in Inner Ear Radiation Dose in the Radiosurgical Treatment of Vestibular Schwannoma.

OBJECTIVE: Assess inner ear radiation dose magnitude as it relates to fundal cap length and hearing outcomes in the radiosurgical treatment of vestibular schwannoma. STUDY DESIGN: Retrospective case series. SETTING: Tertiary neurotology referral center. PATIENTS: Patients treated with Gamma Knife radiosurgery for vestibular schwannoma between March 2007 and March 2017 were considered for this study. Exclusion criteria included pretreatment pure-tone average (PTA) >90 dB, neurofibromatosis type II, history of previous surgical resection, and follow-up less than 1 year. MAIN OUTCOME MEASURE: (s): Hearing function was assessed by maintenance of class A/B hearing level and maintenance of baseline hearing (≤20 dB change in PTA following Gamma Knife radiosurgery). RESULTS: Lower radiation doses delivered to the inner ear were associated with longer fundal cap lengths: mean cochlear dose (r = -0.130; p = 0.184), mean labyrinth dose (r = -0.406; p < 0.001), max cochlear dose (r = -0.326; p = 0.001), and max labyrinth dose (r = -0.360; p < 0.001). Kaplan-Meier analysis with log-rank testing revealed that patients with a mean labyrinth dose < 3 Gy achieved higher rates of preserving baseline hearing (≤20 dB change in PTA) following radiosurgery, compared to patients with a mean labyrinth dose ≥3 Gy (p < 0.001). A fundal fluid cap length of 2.5 mm was associated with the 3 Gy mean labyrinth dose threshold. CONCLUSIONS: We report that fundal cap presence facilitated the creation of treatment plans with a lower dose delivered to the labyrinth. By affording this dose reduction, a fundal cap may be associated with a slight improvement in hearing outcomes.

Fundal Fluid Cap Is Associated With Hearing Preservation in the Radiosurgical Treatment of Vestibular Schwannoma.

OBJECTIVE: To evaluate the relationship between fundal fluid and hearing outcomes after treatment of vestibular schwannoma (VS) with Gamma Knife radiosurgery (GKRS). STUDY DESIGN: Retrospective case series. SETTING: Tertiary neurotology referral center. PATIENTS: Patients treated with GKRS for vestibular schwannoma between March 2007 and March 2017 were considered for this study. Exclusion criteria included pretreatment pure-tone average (PTA) >90 dB, neurofibromatosis type II, history of previous surgical resection, and follow-up less than 1 year. MAIN OUTCOME MEASURE(S): Hearing function was assessed both by preservation of serviceable hearing and by preservation of baseline hearing (≤20 dB change in PTA) after GKRS. Hearing preservation comparisons were made between groups of patients with and without a fundal fluid cap. RESULTS: Patients with a fundal cap had significantly higher rates of baseline hearing preservation (≤20 dB change in PTA) according to Kaplan-Meier survival analysis of all 106 patients (p = 0.006). By the 3rd year posttreatment, 70.9% of patients with a fundal cap had maintained a ≤20 dB change in PTA, while only 43.6% of patients without a fundal fluid cap achieved this outcome (p = 0.004). CONCLUSIONS: Fundal fluid present on pretreatment magnetic resonance imaging is predictive of improved baseline hearing preservation rates in patients undergoing GKRS for vestibular schwannoma when considering all patients with PTA ≤90 dB. Fundal fluid cap presence may serve as a favorable prognostic indicator to help set hearing expectations and guide patient selection efforts.

Surgical Explantation of Bone-Anchored Hearing Devices: A 10-year Single Institution Review.

OBJECTIVE: To identify clinical variables associated with the decision to surgically discontinue bone-anchored hearing device function. STUDY DESIGN: Retrospective chart review. SETTING: Tertiary neurotology referral center. SUBJECTS AND METHODS: This study examines surgical interventions performed on existing bone-anchored hearing devices at a single institution from 2008 to 2018. Patient characteristics, indications for implantation, and complications prompting surgical intervention were assessed. RESULTS: Seventy-seven cases were included in this study. Among patients in the younger cohort (<37 years old), 100% (13 of 13) of those discontinuing their device had a contralateral normal-hearing ear. Conversely, 0% (0 of 14) of the younger patients with bilateral hearing loss surgically discontinued their devices. Within the older cohort (≥37 years old), female patients (P = .002) and those with an increased body mass index (P = .035) were more likely to surgically discontinue their devices. Multivariate analysis revealed that a contralateral normal-hearing ear (P = .001) and infection without soft tissue overgrowth of the abutment (P = .026) were the strongest predictors of device discontinuation, after adjusting for potential confounders. CONCLUSION: Surgical discontinuation is associated with several clinical variables. Targeted interventions that are viable alternatives to removal, such as device relocation, should be presented to younger patients with a contralateral normal-hearing ear who experience persistent complications. Patients with persistent infection in the absence of soft tissue overgrowth would especially benefit from enhanced counseling on proper hygiene.