4D-CT facilitates focused parathyroidectomy in patients with primary hyperparathyroidism by maintaining a high negative-predictive value for uninvolved quadrants.

INTRODUCTION: Improved preoperative localization facilitates minimally invasive parathyroidectomy for removal of parathyroid lesions therefore preventing an invasive bilateral neck exploration. As 4D-CT has emerged, its high specificity has helped with preoperative parathyroid lesion localization. A high negative predictive value (NPV) would serve to further confirm parathyroid lesion localization and limit unnecessary surgical exploration. This study's objective was to determine the NPV of preoperative 4D-CT and its facilitation of minimally invasive parathyroidectomy. METHODS: A retrospective review was compiled for patients undergoing parathyroidectomy for primary hyperparathyroidism with a preoperative 4D-CT. Included patients were sorted into various groups for comparison: those with 4D-CT localizing to a single lesion, localizing to multiple lesions, and those with nonlocalizing findings; multiple hypercellular parathyroid gland versus single gland findings; extent of surgical exploration; lesion location; and patients with concomitant thyroid nodules. Negative predictive value was calculated and used to quantify the ability for 4D-CT to rule out biochemically significant parathyroid lesions. RESULTS: In our review of 68 patients: sensitivity was 81.3%, specificity was 95.5%, positive predictive value was 87.1%, and negative predictive value was 93.3%. 86% had a single localizing 4D-CT, 7% had a non-localizing 4D-CT, and 7% had a multiple quadrant localizing 4D-CT. NPV for single and multi-localizing 4D-CT were 96.8% and 88.9%, respectively. CONCLUSION: Preoperative 4D-CT has a high negative predictive value (93.3%), suggesting in the majority of cases, a quadrant with no 4D-CT radiographic findings suspicious for parathyroid is unlikely to harbor biochemically significant parathyroid lesions.

Quality of Life With Cochlear Implantation Using the CIQOL-35 at a Tertiary Urban Medical Center: Our Experience.

OBJECTIVE: Assessment of quality-of-life (QOL) outcomes after cochlear implantation (CI) using the Cochlear Implant Quality of Life-35 questionnaire (CIQOL-35). STUDY DESIGN: Retrospective cohort. SETTING: Single-institution tertiary care center. PATIENTS: Patients 18 years and older who have undergone CI and CIQOL-35 survey. INTERVENTIONS: Implementing CIQOL-35 from 2019 to 2022 to measure change in QOL after CI. Statistical analysis included nonparametric, univariate, and multivariate analyses. Significance was set at 0.05. MAIN OUTCOME MEASURES: Differences in QOL among CI patients in each of the CIQOL-35 domains. RESULTS: Ninety-three patients (40 female, 53 male) aged 20 to 93 years (median 70 years) turned in 164 QOL surveys (68 preactivation, 96 postactivation). Postactivation median QOL was 5 to 15 points higher across all domains ( p < 0.001). QOL score distributions among unilateral CI only, bilateral CI, and unilateral CI with contralateral hearing aid users were not statistically different ( p > 0.05). Multivariate analysis identified that male sex ( ß = -2.0; 95% confidence interval, -3.9 to -0.1) was a negative predictor for environment scores and not being married ( ß = 2.0; 95% confidence interval, 0.02 to 4.0) was a positive predictor for entertainment scores. Median follow-up time was 13 months post-CI (interquartile range [IQR], 7.1-21.5 months). CONCLUSIONS: CI patients experienced improved QOL postactivation among all QOL domains, whereas specific CI use pattern in regard to unilateral, bilateral, or bimodal did not affect QOL. Multivariate analysis identified marital status and sex as possible QOL predictors.

Sound-seeking before and after hearing loss in mice.

How we move our bodies affects how we perceive sound. For instance, head movements help us to better localize the source of a sound and to compensate for asymmetric hearing loss. However, many auditory experiments are designed to restrict head and body movements. To study the role of movement in hearing, we developed a behavioral task called sound-seeking that rewarded freely moving mice for tracking down an ongoing sound source. Over the course of learning, mice more efficiently navigated to the sound. Next, we asked how sound-seeking was affected by hearing loss induced by surgical removal of the malleus from the middle ear. After bilateral hearing loss sound-seeking performance drastically declined and did not recover. In striking contrast, after unilateral hearing loss mice were only transiently impaired and then recovered their sound-seek ability over about a week. Throughout recovery, unilateral mice increasingly relied on a movement strategy of sequentially checking potential locations for the sound source. In contrast, the startle reflex (an innate auditory behavior) was preserved after unilateral hearing loss and abolished by bilateral hearing loss without recovery over time. In sum, mice compensate with body movement for permanent unilateral damage to the peripheral auditory system. Looking forward, this paradigm provides an opportunity to examine how movement enhances perception and enables resilient adaptation to sensory disorders.

Sound-seeking before and after hearing loss in mice.

How we move our bodies affects how we perceive sound. For instance, we can explore an environment to seek out the source of a sound and we can use head movements to compensate for hearing loss. How we do this is not well understood because many auditory experiments are designed to limit head and body movements. To study the role of movement in hearing, we developed a behavioral task called sound-seeking that rewarded mice for tracking down an ongoing sound source. Over the course of learning, mice more efficiently navigated to the sound. We then asked how auditory behavior was affected by hearing loss induced by surgical removal of the malleus from the middle ear. An innate behavior, the auditory startle response, was abolished by bilateral hearing loss and unaffected by unilateral hearing loss. Similarly, performance on the sound-seeking task drastically declined after bilateral hearing loss and did not recover. In striking contrast, mice with unilateral hearing loss were only transiently impaired on sound-seeking; over a recovery period of about a week, they regained high levels of performance, increasingly reliant on a different spatial sampling strategy. Thus, even in the face of permanent unilateral damage to the peripheral auditory system, mice recover their ability to perform a naturalistic sound-seeking task. This paradigm provides an opportunity to examine how body movement enables better hearing and resilient adaptation to sensory deprivation.

Natural History of Hearing Loss in Sporadic Vestibular Schwannoma.

Hearing loss is the most common and earliest symptom of sporadic vestibular schwannoma (VS). The most common pattern of hearing loss is asymmetric sensorineural hearing loss. Throughout its natural history, patients with serviceable hearing (SH) maintain SH at 94% to 95% after 1 year, 73% to 77% after 2 years, 56% to 66% after 5 years, and 32% to 44% after 10 years. For patients newly diagnosed with VS, it is likely their hearing will worsen despite small initial tumor size or lack of tumor growth.

Radiotherapy-induced Pathology of the Ear.

Acute radiotherapy (RT)-induced external ear soft tissue changes start with erythema and dry desquamation and may progress to moist desquamation and epidermal ulceration. Chronic RT-induced changes include epithelial atrophy and subcutaneous fibrosis. Although RT-induced radiation dermatitis has been well studied, interventions for soft tissue disease involving the external auditory canal (EAC) warrant investigation. Medical management includes topical steroid treatment for EAC radiation dermatitis and topical antibiotic therapy for suppurative otitis externa. Hyperbaric oxygen and pentoxifylline-vitamin E therapy have shown promise for other applications, but their clinical effect on soft tissue EAC disease is currently undefined.

Otolaryngologic manifestations of Mpox: the Atlanta outbreak.

BACKGROUND: In 2022, Mpox (MPX) has become clinically relevant as otolaryngologists are evaluating this exotic disease process due to its many otolaryngologic manifestations. AIMS/OBJECTIVE: To characterize our cohort of otolaryngology-relevant MPX confirmed cases. MATERIALS AND METHODS: A descriptive case series was performed via retrospective review. Adult patients who underwent inpatient or emergency department otolaryngology consultation at an Emory University-affiliated tertiary care level hospital for MPX were included. RESULTS: Seven patients (age 18-58 years; median 32 years) were identified. All patients were male. Six patients (86%) were black and six patients (86%) were HIV positive with varied immunocompetence. Otolaryngology was consulted for lymphadenopathy (n = 2), pharyngeal involvement (n = 1), and airway evaluation (n = 4). All 6 patients with active MPX developed the classic rash, which developed after oropharyngeal symptoms in 3 patients. Three patients had laryngeal involvement. CONCLUSION: MPX manifests with symptoms requiring otolaryngology expertise, especially when the airway is involved. Infectious disease consultation is key. Mpox can be identified with a specific constellation of demographic identifiers and physical exam findings, which is key to determining appropriate treatment and protection for the consulting otolaryngologist. SIGNIFICANCE: This is the first otolaryngologic study of Mpox and first description of Mpox laryngeal involvement.

Migraine management for the otolaryngologist.

Objective: To characterize migraine pathophysiology, presentation, and current treatment strategies, specifically in regard to vestibulocochlear manifestations of migraine. Methods: Narrative review of available literature. Results: Migraine disorder can be described as a spectrum of otologic manifestations, with vestibular migraine now recognized with fully-fledged diagnostic criteria. Otologic manifestations are theorized to be due, in part, to trigeminal innervation of the inner ear structures and calcitonin gene-related peptide (CGRP) expression within the labyrinth. Patients can experience vertigo, aural fullness, enhanced tinnitus, and hearing loss without the characteristic migraine headache, leading to under recognition of these symptoms as migraine-related. Meniere's disease, mal de débarquement syndrome, persistent postural perceptual dizziness, and recurrent benign paroxysmal positional vertigo have close associations to migraine and may exist on the migraine spectrum. Migraine treatment consists of two goals: halting acute attacks (abortive therapy) and preventing attacks (prophylactic therapy). Abortive medications include triptans, corticosteroids, anti-histamines, and anti-emetics. Pharmacologic prophylaxis in conjunction with lifestyle modifications can decrease frequency and severity of symptoms and include tricyclic antidepressants, calcium channel blockers, anti-epileptic medications, selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, beta-blockers, gepants, and monoclonal antibodies to CGRP. Promising evidence is emerging regarding the ability of migraine medications to positively treat the various otologic symptoms of migraine. Conclusion: Migraine disorder manifesting with primarily cochleovestibular symptoms can be challenging to diagnose and manage for practicing clinicians. Patients with various vestibulopathies that are closely related to migraine may benefit from migraine treatment. Lifestyle choices and prophylactic medications are key to satisfactorily preventing acute migrainous attacks and improve function.

External airway splint placement for severe pediatric tracheobronchomalacia.

OBJECTIVE: To present external airway splinting with bioabsorbable airway supportive devices (ASD) for severe, life-threatening cases of pediatric tracheomalacia (TM) or tracheobronchomalacia (TBM). METHODS: A retrospective cohort was performed for 5 pediatric patients with severe TM or TBM who underwent ASD placement. Devices were designed and 3D-printed from a bioabsorbable material, polycaprolactone (PCL). Pre-operative planning included 3-dimensional airway modeling of tracheal collapse and tracheal suture placement using nonlinear finite element (FE) methods. Pre-operative modeling revealed that triads along the ASD open edges and center were the most effective suture locations for optimizing airway patency. Pediatric cardiothoracic surgery and otolaryngology applied the ASDs by suspending the trachea to the ASD with synchronous bronchoscopy. Respiratory needs were trended for all cases. Data from pediatric patients with tracheostomy and diagnosis of TM or TBM, but without ASD, were included for discussion. RESULTS: Five patients (2 Females, 3 Males, ages 2-9 months at time of ASD) were included. Three patients were unable to wean from respiratory support after vascular ring division; all three weaned to room air post-ASD. Two patients received tracheostomies prior to ASD placement, but continued to experience apparent life-threatening events (ALTE) and required ventilation with supraphysiologic ventilator settings. One patient weaned respiratory support successfully after ASD placement. The last patient died post-ASD due to significant respiratory co-morbidity. CONCLUSION: ASD can significantly benefit patients with severe, unrelenting tracheomalacia or tracheobronchomalacia. Proper multidisciplinary case deliberation and selection are key to success with ASD. Pre-operative airway modeling allows proper suture placement to optimally address the underlying airway collapse.

Adherence to Long-Term Follow-up in Patients With Sporadic Vestibular Schwannomas Managed With Serial Observation.

OBJECTIVES: To examine the long-term adherence to serial imaging of patients with sporadic vestibular schwannoma and analyze factors associated with being lost to follow-up. STUDY DESIGN: Retrospective chart review with telephone interview. SETTING: Single tertiary care center. METHODS: Patients with a sporadic vestibular schwannoma and started on observational surveillance management between January 2005 and December 2010 were included. Demographic data, tumor size, hearing and vestibular changes, and follow-up length were recorded. Patient factors were analyzed for association with being lost to follow-up. RESULTS: In total, 122 patients were included with a median length of follow-up of 5 months (range, 0-146). After initial surveillance, 22.1% (n = 27) of patients had a change in management to either microsurgery or radiosurgery. Of the remaining 77.9% (n = 95), nearly half (44.2%, n = 42) never returned for a second visit, and all but 3 were eventually lost to follow-up. There was no association between sex, race, age at diagnosis, initial tumor size, insurance status, household income, or driving distance to hospital and being lost to follow-up. Of 26 interviewed patients initially lost to follow-up, 11 (42.3%) sought care at another institution, 5 (19.2%) chose to no longer receive care, 1 (3.8%) had transportation difficulties, and 9 (36.4%) had poor understanding of their diagnosis or instructions. CONCLUSIONS: The length of follow-up for patients undergoing surveillance of sporadic vestibular schwannoma varies widely, and patients are commonly lost to follow-up. Further efforts should be made to identify at-risk patients and provide adequate education to improve long-term surveillance.