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Objective: Otic drops are one of the most frequently prescribed medications in otolaryngology. However, some forms of these drops can be very expensive, and ophthalmic formulations are sometimes used by practitioners to decrease the cost for their patients. The goal of this study is to determine the cost differential between otic and ophthalmic drops., Methods: Pharmacies in New York City, Chicago, and Portland were surveyed in the span of 6 weeks by telephone to evaluate the current prices of various otic and ophthalmic drops commonly prescribed by otolaryngologists., Results: A total of 83 pharmacies were surveyed. Surveyed drugs included ciprofloxacin/dexamethasone (cip/dex) otic, neomycin/polymyxin B sulfates/hydrocortisone (neo/poly/HC) otic, acetic acid (AA) otic, acetic acid/hydrocortisone (AA/HC) otic, ofloxacin otic, ofloxacin ophthalmic, and tobramycin/dexamethasone (tob/dex) ophthalmic. Per milliliter, cip/dex otic was consistently the most expensive, with a median price of $38.00 per milliliter. Among the antibiotic drops, neo/poly/HC otic was the least expensive formulation with a median price of $11.60 per milliliter. Ofloxacin ophthalmic was significantly less expensive than the otic formulation, at $11.00 and $31.00 per milliliter, respectively (adjusted p < 0.001). In general, otic and ophthalmic formulations were not significantly different according to manufacturing information, although ophthalmic drops were more often packaged in a sterile fashion and with less abrasive ingredients for use in the more sensitive tissue of the eye., Conclusion: Significant and meaningful price differences exist between otic and ophthalmic drops. Given the safety of ophthalmic drops used in the ears, they may be a more cost-effective alternative to traditionally prescribed otic drops when clinically appropriate., Competing Interests: The authors disclose no conflicts of interest., (Copyright © 2020, Otology & Neurotology, Inc.)

Objective: To provide an overview of biotechnology and pharmaceutical companies active in the field of inner ear and central hearing disorders and their therapeutic approaches., Methods: Scientific and grey literature was searched using broad search terms to identify companies and their hearing-related therapeutic approaches. For each approach its lead indication, product, therapeutic modality, target, mechanism of action and current phase of clinical development was collated., Results: A total of 43 biotechnology and pharmaceutical companies have been identified that are developing therapeutics for inner ear and central hearing disorders. Their therapeutics include drug-, cell- and gene-based approaches to prevent hearing loss or its progression, restore hearing, and regenerate the inner ear. Their therapeutic targets and specific mechanisms of action are wide-ranging, reflecting the complexity of the hearing pathways and the diversity of mechanisms underlying inner ear disorders. While none of the novel products under investigation have yet made it to the clinical market, and a large proportion are still at preclinical phase, many therapeutics have already entered clinical testing with more expected to do so in the next few years., Conclusion: A wide range of novel therapeutics targeting different hearing, balance and tinnitus pathways, and patient populations are approaching the clinical domain. It is important that clinicians involved in the care of patients with hearing loss prepare for what may become a radically different approach to the management of hearing disorders, and develop a true understanding of the new therapies' mechanisms of action, applications, and indications.

In 1863, Anton von Tröltsch, Adam Politzer, and Hermann Schwartze began the first journal dedicated solely to disorders of the ear, Archiv für Ohrenheilkund (Archives of Otology). In the inaugural edition, Hermann Schwartze, the youngest of the three, took on the responsibility for summarizing all the prevailing advances in otology recorded in the previous 10 years leading up to its publication. This work represents a concise summary of all major advances and theories regarding diseases of the ear circa 1863, providing a valuable window on the practice of otology during its inception as an independent subspecialty. In this first of an anticipated two-part article, we provide a translation of what is perhaps the most interesting portion: pathology and therapy of the outer ear and middle ears. The second part of the manuscript will translate the pathology and treatment of inner ear disorders. It is hoped that this work will spark contemporary otologists not only to reflect how far we have come as a subspecialty but also to reflect what we still must accomplish as physicians and scientists.

Objective: To evaluate the clinical features leading to diagnosis in patients with acoustic neuroma (AN) who present with normal or symmetrical hearing. Underlying tumor characteristics are also studied to identify a possible explanation for this unique presentation in the AN population., Study Design: Retrospective case review comprising patients who were identified as having AN that presented with normal audiometry., Setting: A tertiary referral center., Patients: Patients with AN who met the criteria for normal were included in the report. For this study, abnormal audiometry is defined as an interaural difference of > or =15 dB at a single frequency or > or =10 dB at two or more frequencies, and an interaural speech reception threshold difference of > or =20 dB, or a speech discrimination score of > or =20%., Main Outcome Measures: Presenting symptoms and signs, clinical features that led to the diagnosis of AN, auditory brain stem response results, tumor location, size and relationship to temporal bone landmarks, surgical intervention, surgical outcome, and results of hearing preservation attempts were tabulated for each patient., Results: A total of 29 patients (5%) were identified who had normal or symmetrical pure-tone audiograms between 500 and 4,000 Hz. The average difference in speech reception threshold between tumor and nontumor ear was 3.2 dB, and the average difference in speech detection score was 2.6%. The most common presenting symptoms that led to the diagnosis of the AN were dysequilibrium/vertigo (12 cases), cranial nerve V and VII abnormalities (11 cases), routine screening for families with neurofibromatosis type 2 (5 cases), asymmetrical tinnitus (4 cases), headaches (4 cases), unilateral subjective hearing difficulty (4 cases), and incidental finding during evaluation for another problem (4 cases). The average tumor size was 19 mm, with five cases presenting with tumors of size > or =30 mm. Nineteen patients underwent a hearing preservation procedure (middle fossa or retrosigmoid), 11 of whom had useful hearing postoperatively., Conclusions: Despite normal audiometry, patients presenting with imbalance or vertigo, Vth or VIIth cranial nerve deficits, or unilateral hearing complaints may warrant further evaluation to rule out the possibility of AN or other retrocochlear lesion. To seek an explanation for this phenomenon, the incidence of various tumor characteristics (e.g., depth of penetration into the internal auditory canal and degree of porous erosion) is discussed and compared with the entire AN population.

Objective: To discuss a rare but devastating complication following radiotherapy to the head and neck: radiation-induced malignancies of the temporal bone., Study Design: A retrospective case review comprising five patients with radiation-induced tumors involving the temporal bone., Setting: A tertiary referral center., Patients: Patients with tumors involving the temporal bone who have satisfied the criteria for being considered radiation-associated., Main Outcome Measures: Initial tumor histology, radiation-induced tumor histology, latency between radiotherapy and diagnosis of the radiation-associated malignancy, amount of radiation received, therapeutic interventions, and survival statistics for each patient., Results: Five cases of radiation-induced tumors of the temporal bone are presented (two osteosarcomas, two fibrosarcomas, and one squamous cell carcinoma). All five temporal bone tumors occurred in individuals that had previously received > 5,000 cGy of radiation. The initial histologic diagnoses included two astrocytomas, a glomus jugulare, a malignant meningioma, and a vestibular schwannoma. There was an average latency period of 15 years (range, 7-23 years) between completion of radiation and diagnosis of the malignancy. Four patients were treated with resection plus chemotherapy, and one decided against therapy. The prognosis was poor, with survival time of 7-14 months after the diagnosis of the radiation-induced tumor. Only one patient survived > 14 months and is currently free of disease, 3 years after diagnosis of the radiation-induced tumor., Conclusions: Although radiation-induced tumors of the temporal bone occur with a very low incidence, their prognosis is extremely poor. The remote possibility of a radiation-associated tumor should be factored in when deciding upon the most appropriate therapeutic modality for individuals with neoplasms of the CNS and head and neck. Such considerations are particularly germane when contemplating radiation therapy for a benign lesion (e.g., glomus jugulare, acoustic neuroma, or meningioma) in an individual with a long predicted lifespan.

Tumors involving the jugular foramen (JF) have a variable relationship to the neurovascular structures (jugular vein, cranial nerves IX-XI) that traverse this conduit through the skull base. The surgeon familiar with the site of origin, growth pattern, and geometry of each of the common lesions affecting this region with respect to surrounding nerves and vessels is at a considerable advantage when undertaking a function-sparing procedure. Anatomically, the JF has two vascular compartments that may be affected by tumor: the jugular bulb laterally and a passage for the inferior petrosal sinus medially. Tumors may also penetrate the JF along the fibro-osseous diaphragm, which divides these two vascular channels. The lower cranial nerves lie on either side of this partition, which is connected to the posterior cranial fossa via a curved, funnel-shaped cone of dura. Tumors that arise within or penetrate the JF lateral to this neural plane displace the nerves medially, a position favorable for their preservation during tumor extirpation. By contrast, medially positioned tumors displace the cranial nerves onto the lateral tumor surface, where they interpose between surgeon and tumor-an unfavorable location. Glomus tumors consistently arise in the lateral aspect of the JF, displacing the lower cranial nerves medially. This positioning accounts for the high rate of neural preservation in small and medium-size glomus tumors that have not invaded the foramen's central partition. Meningiomas that arise lateral to the JF (e.g., the posterior petrous surface, sigmoid sinus) favorably displace the lower cranial nerves medially. By contrast, tumors that originate medial to the JF (e.g., clivus, foramen magnum) are unfavorable, laterally displacing the multiple small rootlets that coalesce into cranial nerves IX-XI into a vulnerable location. Schwannomas arise within the neural plane and have a variable geometry that depends, in part, upon the nerve of origin. Theoretically, tumors that arise from the ninth nerve, which is located on the lateral surface of the neural plane, should be more favorable than those originating from the tenth or eleventh nerves, which lie on its deep surface. The propensity of these three tumor types toward thrombosis of the jugulosigmoid complex also carries important surgical implications. Because glomus tumors arise from the jugular bulb, the jugulosigmoid complex is nearly always occluded. In both meningiomas and schwannomas, however, the jugular system may occasionally remain patent. This is important to recognize through angiography and/or magnetic resonance venography, since sacrifice of a patent, dominant system risks intracerebral venous infarction.

Beginning in 1977, numerous studies have reported an association between high levels of maternal serum alpha-fetoprotein, measured in early pregnancy, and low birthweight and perinatal death. It has been suggested, however, that these findings may be explained by bias. We reviewed 21 studies and found that they were unanimous in reporting this association and that the association cannot be explained by any of the proposed biases. Comparing women whose alpha-fetoprotein levels were 2.5 times the median or more with all other women, the highest relative risk of fetal death was 21.0, with a 95% confidence interval of 8.4-52.2, and the lowest relative risk of fetal death was 4.4, with a 95% confidence interval of 2.8-7.0. For low birthweight (< 2,500 grams), the highest relative risk was 6.4 (95% confidence interval = 3.1-13.1) and the lowest relative risk was 1.9 (95% confidence interval = 1.5-2.5).