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Background Gender disparities are prevalent in medicine, but their impact on surgical training is not well studied. Objective To quantify gender disparities in trainee intraoperative experiences and explore the variables associated with ratings of surgical autonomy and performance. Methods From September 2015 to May 2019, attending surgeons and trainees from 71 programs assessed trainee autonomy on a 4-level Zwisch scale and performance on a 5-level modified Dreyfus scale after surgical procedures. Multivariable regression models were used to examine the association of trainee gender with autonomy and performance evaluations. Results A total of 3255 trainees and attending surgeons completed 94 619 evaluations. Attendings gave lower ratings of operative autonomy to female trainees than male trainees when controlling for training level, attending, and surgical procedure (effect size B = −0.0199, P = .008). There was no difference in ratings of autonomy at the beginning of training (P = .32); the gap emerged as trainees advanced in years (B = −0.0163, P = .020). The gender difference in autonomy was largest for the most complex cases (B = −0.0502, P = .002). However, there was no difference in attending ratings of surgical performance for female trainees compared to male trainees (B = −0.0124, P = .066). Female trainees rated themselves as having less autonomy and worse performance than males when controlling for training level, attending, procedure, case complexity, and attending ratings (autonomy B = −0.0669, P < .001; performance B = −0.0704, P < .001). Conclusions While there was no significant difference in ratings of operative performance, a small difference between ratings of operative autonomy for female and male surgical trainees was identified.

OBJECTIVE: To investigate the influence of the COVID-19 pandemic on operative practices of otology and neurotology providers internationally. STUDY DESIGN: Cross-sectional survey. METHODS: A 78-question survey was distributed to otologists and neurotologists between May 12, 2020 and June 8, 2020 to assess the impact of the pandemic on surgical practices. Sections within the survey delineated time periods: prior to the crisis, onset of the crisis, during the crisis, postcrisis transition. RESULTS: Of 396 survey respondents, 284 participants from 38 countries met inclusion criteria.Respondents were 16.9% female and 82.4% male, with a most common age range of 40 to 49 years (36.3%). 69.8% of participants had been in practice for over 10 years and most respondents worked in an academic medical center (79.2%). The average operative weekly caseload was 5.3 (SD 3.9) per surgeon prior to the crisis, 0.7 (SD 1.2) during the COVID-19 crisis, and 3.5 (SD 3.3) for those who had begun a postcrisis transition at the time of survey administration (p 

Objectives Stapedotomy is performed to address conductive hearing deficits. While hearing thresholds reliably improve at low frequencies (LF), conductive outcomes at high frequencies (HF) are less reliable and have not been well described. Herein, we evaluate post‐operative HF air‐bone gap (ABG) changes and measure HF air conduction (AC) thresholds changes as a function of frequency. Methods Retrospective review of patients who underwent primary stapedotomy with incus wire piston prosthesis between January 2016 and May 2020. Pre‐ and postoperative audiograms were evaluated. LF ABG was calculated as the mean ABG of thresholds at 250, 500, and 1000 Hz. HF ABG was calculated at 4 kHz. Results Forty‐six cases met criteria. Mean age at surgery was 54.0 ± 11.7 years. The LF mean preoperative ABG was 36.9 ± 11.0 dB and postoperatively this significantly reduced to 9.35 ± 6.76 dB, (P

Objective As large single‐surgeon series in the literature are lacking, we sought to review a single‐surgeon's experience with parotidectomy in an academic center, with a focused analysis of pathology, technique, and facial nerve (FN) weakness. Benchmark values for complications and operative times with routine trainee involvement and without continuous FN monitoring are offered. Materials and Methods All patients who underwent parotidectomy, performed by D. G. D., for benign and malignant disease between January 2004 and December 2018 at an academic center were reviewed. Results A total of 924 parotidectomies, with adequate evaluatable data were identified. The majority of patients had benign tumors (70.9%). Partial/superficial parotidectomy was the most common approach (65.7%). Selective FN branch sacrifice was rare (12.3%), but significantly more common among patients with malignant pathology (33.8% vs 3.5% for benign, P

This combined American Neurotology Society, American Otological Society, and American Academy of Otolaryngology - Head and Neck Surgery Foundation document aims to provide guidance during the coronavirus disease of 2019 (COVID-19) on 1) "priority" of care for otologic and neurotologic patients in the office and operating room, and 2) optimal utilization of personal protective equipment. Given the paucity of evidence to inform otologic and neurotologic best practices during COVID-19, the recommendations herein are based on relevant peer-reviewed articles, the Centers for Disease Control and Prevention COVID-19 guidelines, United States and international hospital policies, and expert opinion. The suggestions presented here are not meant to be definitive, and best practices will undoubtedly change with increasing knowledge and high-quality data related to COVID-19. Interpretation of this guidance document is dependent on local factors including prevalence of COVID-19 in the surgeons' local community. This is not intended to set a standard of care, and should not supersede the clinician's best judgement when managing specific clinical concerns and/or regional conditions.Access to otologic and neurotologic care during and after the COVID-19 pandemic is dependent upon adequate protection of physicians, audiologists, and ancillary support staff. Otolaryngologists and associated staff are at high risk for COVID-19 disease transmission based on close contact with mucosal surfaces of the upper aerodigestive tract during diagnostic evaluation and therapeutic procedures. While many otologic and neurotologic conditions are not imminently life threatening, they have a major impact on communication, daily functioning, and quality of life. In addition, progression of disease and delay in treatment can result in cranial nerve deficits, intracranial and life-threatening complications, and/or irreversible consequences. In this regard, many otologic and neurotologic conditions should rightfully be considered "urgent," and almost all require timely attention to permit optimal outcomes. It is reasonable to proceed with otologic and neurotologic clinic visits and operative cases based on input from expert opinion of otologic care providers, clinic/hospital administration, infection prevention and control specialists, and local and state public health leaders. Significant regional variations in COVID-19 prevalence exist; therefore, physicians working with local municipalities are best suited to make determinations on the appropriateness and timing of otologic and neurotologic care.

Powered air-purifying respirators (PAPRs) are used as personalized protective equipment for health care personnel. PAPRs offer health care workers added protection when dealing with patients who have high-risk infectious disease such as COVID-19. Unfortunately, PAPRs can produce notable levels of background noise. We hypothesize that PAPR use may be associated with increased hearing thresholds and impaired word discrimination and may ultimately have a negative impact on effective communication. Herein, we (1) determined sound levels generated by PAPRs and (2) measured hearing thresholds and word discrimination with and without operational PAPRs. All participants had normal hearing. When the PAPR was operational, mean ± SD thresholds increased from 4.5 ± 3.6 to 38.6 ± 5.6 dB HL (P < .001). Word discrimination dropped from 100% in all participants in quiet to a mean 48% ± 14% with operational PAPR (P < .001). Thus, we find that use of PAPR hoods results in hearing impairment comparable to moderate to severe hearing loss, and we suspect that users will experience communication difficulties as a result.Level of Evidence. Prospective study.

Objective To investigate small-particle aerosolization from mastoidectomy relevant to potential viral transmission and to test source-control mitigation strategies. Study Design Cadaveric simulation. Setting Surgical simulation laboratory. Methods An optical particle size spectrometer was used to quantify 1- to 10-µm aerosols 30 cm from mastoid cortex drilling. Two barrier drapes were evaluated: OtoTent1, a drape sheet affixed to the microscope; OtoTent2, a custom-structured drape that enclosed the surgical field with specialized ports. Results Mastoid drilling without a barrier drape, with or without an aerosol-scavenging second suction, generated large amounts of 1- to 10-µm particulate. Drilling under OtoTent1 generated a high density of particles when compared with baseline environmental levels (P < .001, U = 107). By contrast, when drilling was conducted under OtoTent2, mean particle density remained at baseline. Adding a second suction inside OtoTent1 or OtoTent2 kept particle density at baseline levels. Significant aerosols were released upon removal of OtoTent1 or OtoTent2 despite a 60-second pause before drape removal after drilling (P < .001, U = 0, n = 10, 12; P < .001, U = 2, n = 12, 12, respectively). However, particle density did not increase above baseline when a second suction and a pause before removal were both employed. Conclusions Mastoidectomy without a barrier, even when a second suction was added, generated substantial 1- to 10-µm aerosols. During drilling, large amounts of aerosols above baseline levels were detected with OtoTent1 but not OtoTent2. For both drapes, a second suction was an effective mitigation strategy during drilling. Last, the combination of a second suction and a pause before removal prevented aerosol escape during the removal of either drape.

Objectives Conventional reporting of postoperative hearing outcomes utilizes a pure‐tone averaged air‐bone gap (ABG) that is biased toward low frequencies. Consequently, a high‐frequency ABG after otologic surgery may go unnoticed. In this study, we evaluate changes in low‐ and high‐frequency ABG following ossiculoplasty. Study design Retrospective review. Subjects and setting Consecutive series of patients who underwent ossiculoplasty at a single tertiary care center. Patients with pre‐ and postoperative audiograms were included. Methods Low‐frequency ABG was calculated as the mean ABG at 250, 500, and 1000 Hz. High‐frequency ABG was calculated at 4 kHz. Pre‐ and postoperative ABGs were compared. Results Thirty‐seven consecutive patients were included. Mean age at surgery was 38 years (range, 7‐77 years). Reconstruction materials included: cartilage (N = 4), hydroxyapatite cement (N = 5), and partial or total ossicular replacement prostheses (N = 20 and N = 8, respectively). Postoperatively, the mean low‐frequency ABG improved by 11.9 ± 15.1 dB (P

Supplemental Digital Content is available in the text, Background: COVID-19 has become a global pandemic with a dramatic impact on healthcare systems. Concern for viral transmission necessitates the investigation of otologic procedures that use high-speed drilling instruments, including mastoidectomy, which we hypothesized to be an aerosol-generating procedure. Methods: Mastoidectomy with a high-speed drill was simulated using fresh-frozen cadaveric heads with fluorescein solution injected into the mastoid air cells. Specimens were drilled for 1-minute durations in test conditions with and without a microscope. A barrier drape was fashioned from a commercially available drape (the OtoTent). Dispersed particulate matter was quantified in segments of an octagonal test grid measuring 60 cm in radius. Results: Drilling without a microscope dispersed fluorescent particles 360 degrees, with the areas of highest density in quadrants near the surgeon and close to the surgical site. Using a microscope or varying irrigation rates did not significantly reduce particle density or percent surface area with particulate. Using the OtoTent significantly reduced particle density and percent surface area with particulate across the segments of the test grid beyond 30 cm (which marked the boundary of the OtoTent) compared with the microscope only and no microscope test conditions (Kruskall–Wallis test, p = 0.0066). Conclusions: Mastoidectomy with a high-speed drill is an aerosol-generating procedure, a designation that connotes the potential high risk of viral transmission and need for higher levels of personal protective equipment. A simple barrier drape significantly reduced particulate dispersion in this study and could be an effective mitigation strategy in addition to appropriate personal protective equipment.

Objective In cases of a severe to profound sensorineural hearing loss following head injury, the cochlear implant (CI) is the primary option for auditory rehabilitation. Few studies, however, have investigated long‐term CI outcomes in patients following head trauma, including those without temporal bone fracture (TBF). Herein, the aim of this study is to examine CI outcomes following cases of head injury with and without TBF. Methods Audiometric outcomes of patients who received a CI due to a head injury resulting in severe to profound hearing loss at two tertiary care hospitals were analyzed. Patients were divided into those who received a CI in a fractured temporal bone (group A, n = 11 patients corresponding to 15 ears) and those who received a CI in a non‐fractured temporal bone (group B, n = 8 patients corresponding to nine ears). Primary outcomes included duration of deafness prior to CI and postoperative consonant‐nucleus‐constant whole word (CNC) scores. Results Nineteen patients (84% male), corresponding to 24 CIs, were identified. Fifteen CI were performed on ears with TBF (group A), and nine CI were performed on ears without TBF (group B). No patients had an enlarged vestibular aqueduct (EVA). The mean duration of deafness was 5.7 and 11.3 years in group A and group B, respectively. The mean duration of CI follow‐up (CI experience) was 6.5 years in group A and 2.1 years in group B. The overall mean postoperative CNC score for all subjects was 68.6% (±21.2%, n = 19 with CNC testing). There was no difference in CNC score between group A and group B (69.8% and 66% respectively, P = .639). Conclusion The study is among the largest series examining long‐term outcomes of CI after head injury. CI is an effective method for auditory rehabilitation in patients after head injury. Level of evidence IV.

Objective The term “labyrinthine concussion” has evolved to mean audiovestibular dysfunction in the absence of a temporal bone fracture (TBF). Despite a multitude of case descriptions of labyrinthine concussion, the precise pathophysiology remains poorly understood. Herein, we explore the historical otopathologic underpinnings of the diagnosis of labyrinthine concussion with a focus on the auditory pathway during the late 19th to the mid‐20th centuries and conclude with a discussion of its contemporary relevance. Methods and Data Sources A review of primary and secondary medical sources written in English, German, and French on otopathology labyrinthine concussion studies from the late‐19th to the mid‐20th centuries. Results Around the turn of the 20th century, otopathologists identified histologic changes in the temporal bones of individuals that sustained head injury without TBFs. Based on these otopathologic findings in humans, early experiments investigating the pathophysiology of labyrinthine concussion were performed in animals through either the delivery of blows to the head or direct introduction of a pressure wave into the labyrinthine fluid. Collectively, otopathologists hypothesized that predominant mechanisms for labyrinthine concussion included inner ear hemorrhage, cochleovestibular nerve traction injury, direct damage from a labyrinthine fluid pressure wave, or vasomotor dysfunction. Conclusion Historical study shows a variety of inner ear pathologies potentially responsible for auditory dysfunction following head injury. Understanding the history and otopathology of labyrinthine concussion may help clinicians focus on new pathways toward novel research and improved patient care.

OBJECTIVES. Conventional reporting of posttympanoplasty hearing outcomes use a pure-tone averaged air-bone gap (ABG) largely representing a low-frequency sound conduction. Few studies report high-frequency conductive hearing outcomes. Herein, we evaluate high-frequency ABG in patients following temporalis fascia total drum replacement. STUDY DESIGN. Case series with chart review. SETTING. Tertiary care center. SUBJECTS AND METHODS. All patients who underwent type 1 tympanoplasty using a lateral graft total drum replacement technique between August 2016 and February 2019 were identified. Patients with pre- and postoperative audiograms were included. Low-frequency ABG was calculated as the mean ABG at 250, 500, and 1000 Hz. High-frequency ABG was calculated at 4 KHz. Pre- and postoperative ABGs were compared. RESULTS. Twenty-three patients were included, and the mean age at surgery was 44 years (range, 9–68 years). Perforation etiology was from trauma (n = 14) or chronic otitis media (n = 9). Preoperative mean low-frequency ABG was 27.8 ± 12.6 dB and mean high-frequency ABG was 21.5 ± 15.1 dB (P = .044). Postoperatively, the mean low-frequency ABG was significantly reduced by 15.5 ± 13.3 dB (P < .001) while the mean high-frequency ABG insignificantly changed (reduced by 2.6 ± 16.2 dB, P = .450). CONCLUSION. In a series of patients undergoing temporalis fascia total drum replacement, low-frequency ABG improved; however, high-frequency conductive hearing loss persists. Conventional methods of reporting ABG may not identify persistent high-frequency ABG. These results merit further study across a range of tympanoplasty graft materials and surgical techniques.

Objective While cochlear ossification is a common sequalae of meningitic labyrinthitis, less is known about the effects of meningitis on peripheral vestibular end organs. Herein, we investigate histopathologic changes in the peripheral vestibular system and cochlea in patients with a history of meningitic labyrinthitis. Methods Temporal bone (TB) specimens from patients with a history of meningitis were evaluated and compared to age-matched controls. Specimens were evaluated by light microscopy and assessed for qualitative changes, including the presence of vestibular and/or cochlear endolymphatic hydrops, presence and location of inflammatory cells, new bone formation, and labyrinthitis ossificans; and quantitative changes, including Scarpa's ganglion neuron (ScGN) and spiral ganglion neuron (SGN) counts. Results Fifteen TB from 10 individuals met inclusion and exclusion criteria. Presence of inflammatory cells and fibrous tissue was found in 5 TB. Of these, evidence of labyrinthitis ossificans was found in 2 TB. In the peripheral vestibular system, mild to severe degeneration of the vestibular membranous labyrinth was identified in 60% of cases (n = 9 TBs). There was a 21.2% decrease (range, 3%-64%) in the mean total count of ScGN in patients with meningitis, compared to age-matched controls. In the cochlea, there was a 45% decrease (range, 25.3%-80.9%) in the mean total count of SGN compared to age-matched controls (n = 14 TBs). Conclusions Otopathologic analysis of TB from patients with a history of meningitic labyrinthitis demonstrated distinct peripheral vestibular changes. Future research may help to delineate potential mechanisms for the observed otopathologic changes following meningitis. Level of evidence N/A.

During the COVID-19 pandemic, the utility of portable audiometry became more apparent as elective procedures were deferred in an effort to limit exposure to health care providers. Herein, we retrospectively evaluated mobile-based audiometry in the emergency department and outpatient otology and audiology clinics. Air conduction thresholds with mobile audiometry were within 5 dB in 66% of tests (95% CI, 62.8%-69.09%) and within 10 dB in 84% of tests (95% CI, 81.4%-86.2%) as compared with conventional audiometry. No significant differences were noted between mobile-based and conventional audiometry at any frequencies, except 8 kHz (P < .05). The sensitivity and specificity for screening for hearing loss were 94.3% (95% CI, 91.9%-96.83%) and 92.3% (95% CI, 90.1%-94.4%), respectively. While automated threshold audiometry does not replace conventional audiometry, mobile audiometry is a promising screening tool when conventional audiometry is not available.

Background Approximately 80,000 primary brain tumors are diagnosed annually. Social media provides a source of information and support for patients diagnosed with brain tumors; however, use of this forum for dissemination of information about brain tumors has not been evaluated. The objective of this study was to evaluate social media utilization and content related to brain tumors with an emphasis on patients’ trends in usage. Methods Social media platforms were systematically evaluated using two search methods: systematic manual inquiry and a keyword-based social media tracker. The search terms included brain tumor, glioblastoma, glioma, and glioblastoma multiforme. Social media content (which includes Facebook pages and groups, YouTube videos, and Twitter or Instagram accounts) and posts were assessed for activity (as quantified by views of posts) and analyzed using a categorization framework. Results The manual and keyword searches identified 946 sources of social media content, with a total count of 7,184,846 points of engagement. Social media platforms had significant variations in content type. YouTube was the largest social media platform for sharing content related to brain tumors overall, with an emphasis on surgical videos and documented patient experiences. Facebook accounted for the majority of patient-to-patient support, and Twitter was the most common platform for scientific dissemination. Overall social media content was mostly focused on treatment overviews and patient experience. When evaluated by search term, most social media posts by the “brain tumor” community shared illness narratives, and searches specific to “glioma” and “glioblastoma” demonstrated a higher proportion of educational and treatment posts. Conclusions This study presents novel observations of the characteristics of social media utilization for the online brain tumor community. A robust patient community exists online, with an emphasis on sharing personal narratives, treatment information, patient-to-patient support, treatment options, and fundraising events. This study provides a window to the role of social media utilization by patients, their families, and health professionals. These findings demonstrate the different roles of Facebook, YouTube, and Twitter in the rapidly changing era of social media and its relationship with neurosurgery and neuro-oncology.

The coronavirus disease 2019 (COVID-19) pandemic resulted in widespread unprecedented changes to the health care system. Herein, we sought to assess the impact of the viral outbreak on clinical presentations of sudden sensorineural hearing loss (SSNHL) at a single academic center. Our results demonstrate a decrease in the absolute number of patients presenting with SSNHL to our institution during the initial onset of the COVID-19 pandemic compared to an analogous time frame 1 year prior. However, the ratio of patients with SSNHL compared to total patients evaluated was largely similar during the 2 time periods. Based on data from our institution, the COVID-19 virus does not appear to confer a significantly increased risk for the development of SSNHL.

Background In the era of duty hour restrictions, otolaryngology residents may not gain the operative experience necessary to function autonomously by the end of training. This study quantifies residents' autonomy during key indicator cases, defined by the Accreditation Council for Graduate Medical Education. Study Design Prospective cohort study. Methods Faculty and residents at a large academic institution were surveyed on the surgical autonomy trainees should achieve for otolaryngology key indicator surgeries at each training level. Residents and faculty used the mobile application “System for Improving and Measuring Procedural Learning” (SIMPL) between December 2017 and July 2018 to log trainees' operative autonomy during cases on a validated four‐level Zwisch scale, from “show and tell” to “supervision only.” Results The study included 40 participants (23 residents and 17 attendings). The survey response rate was 83%. In surveys, residents overestimated the autonomy PGY5 residents should achieve for parotidectomy, rhinoplasty, thyroid/parathyroidectomy, and airway procedures compared with faculty (P

Objective Transcanal endoscopic operative approaches provide for a minimally invasive surgical portal to the lateral skull base. Traditional preoperative imaging evaluation involves computed tomography (CT) acquisition in the axial and coronal planes that are not optimized for the transcanal surgical corridor. Herein, we describe a novel CT-based “transcanal view” for preoperative surgical planning and intraoperative navigation. Study Design Present study is a cadaveric imaging study. Methods Cadaveric temporal bones (n = 6) from three specimens underwent high-resolution CT (0.625 mm slice thickness). Using three-dimensional (3D) Slicer 4.8, reformatted “transcanal” views in the plane of the external auditory canal (EAC) were created. Axial and coronal reformats were used to compare and measure distances between anatomic structures in the plane of the EAC. Results The degree of oblique tilt for transcanal CT reformats was 6.67 ± 1.78 degrees to align the EAC in axial and coronal planes. Anticipated critical landmarks were identified easily using the transcanal view. Mean values were 8.68 ± 0.38 mm for annulus diameter, 9.5 ± 0.93 mm for isthmus diameter, 10.27 ± 0.73 mm for distance between annulus and isthmus, 2.95 ± 0.13 mm for distance between annulus and stapes capitulum, 5.12 ± 0.35 mm for distance between annulus and mastoid facial nerve, and 19.54 ± 1.22 mm for EAC length. Conclusion This study is the first to illustrate a novel “transcanal” CT sequence intended for endoscopic lateral skull base surgery. Future studies may address how incorporation of a transcanal CT reformat may influence surgical decision making.

Brain injuries are a significant cause of morbidity and mortality worldwide. Auditory and vestibular dysfunction may occur following trauma to the temporal bone (TB), including the lateral skull base. The porcine model is a commonly used large animal model for investigating brain injury. Reports detailing porcine TB anatomy based on high resolution computed tomography (HRCT) imaging, however, are limited. Herein, we employ HRCT to evaluate and describe the bony anatomy of the porcine TB and lateral skull base. High-resolution multi-detector and cone beam CT were used to image porcine TBs (n = 16). TBs were analyzed for major anatomical structures and compared to human species. Porcine temporal bone anatomy was readily identifiable by HRCT. Although some variability exists, the ossicular chain, vestibule, cochlea, course of the facial nerve, and skull base are similar to those of humans. Major differences included position of the external auditory canal and mastoid, as well as presence of the petrous carotid canal. Study findings may serve as an atlas to evaluate the porcine middle and inner ear, as well as lateral skull base injuries for future porcine brain injury models or other studies that require CT-based analysis.

Objectives Predicting the course of cranial nerves (CNs) VII and VIII in the cerebellopontine angle on preoperative imaging for vestibular schwannoma (VS) may help guide surgical resection and reduce complications. Diffusion magnetic resonance imaging dMRI is commonly used for this purpose, but is limited by its resolution. We investigate the use of super-resolution reconstruction (SRR), where several different dMRIs are combined into one dataset. We hypothesize that SRR improves the visualization of the CN VII and VIII. Design Retrospective case review. Setting Tertiary referral center. SRR was performed on the basis of axial and parasagittal single-shot epiplanar diffusion tensor imaging on a 3.0-tesla MRI scanner. Participants Seventeen adult patients with suspected neoplasms of the lateral skull base. Main Outcome Measures We assessed separability of the two distinct nerves on fractional anisotropy (FA) maps, the tractography of the nerves through the cerebrospinal fluid (CSF), and FA in the CSF as a measure of noise. Results SRR increases separability of the CN VII and VIII (16/17 vs. 0/17, p = 0.008). Mean FA of CSF surrounding the nerves is significantly lower in SRRs (0.07 ± 0.02 vs. 0.13 ± 0.03 [axial images]/0.14 ± 0.05 [parasagittal images], p = 0.00003/p = 0.00005). Combined scanning times (parasagittal and axial) used for SRR were shorter (8 minute 25 seconds) than a comparable high-resolution scan (15 minute 17 seconds). Conclusion SRR improves the resolution of CN VII and VIII. The technique can be readily applied in the clinical setting, improving surgical counseling and planning in patients with VS.

Objective Audiometric outcomes following cochlear implantation (CI) in patients with temporal bone fracture (TBF) are variable and the pathophysiology is not well understood. Herein, we describe otopathologic findings in two such cases to provide insight into pathophysiology and outcomes. Patients Two patients had a history of head trauma resulting in bilateral TBF and sudden, profound, sensorineural hearing loss. Intervention Both cases underwent unilateral CI following head trauma. Main outcome measures Both TBs from each patient were harvested postmortem and histologically analyzed to determine fracture lines, intralabyrinthine fibroosseous changes, and spiral ganglion neuron (SGN) counts. Clinical histories and audiometric outcomes were also reviewed. Results In both cases, the implanted TB showed extensive intracochlear ossification, which was greater when fracture involved the cochlea. In contrast, the nonimplanted cochleae were patent with small osseous deposits at the round window membrane. Interaural SGN counts were lower on the implanted side and hearing results were moderate to poor. Conclusions Otopathologic analyses of patients with a CI after bilateral TBF are rare. Based on otopathology of two patients with bilateral TBF and subsequent CI, implanted TBs show extensive intracochlear fibroosseous changes greater than the nonimplanted side. Findings have implications for auditory rehabilitation after TBF.

Objective: Otologic methicillin-resistant Staphylococcus aureus (MRSA) infection has historically been rare, but given the rise in community-acquired MRSA carriage and infection at other body sites, prevalence rates may be changing. The goal of this study was to determine the prevalence of MRSA in recent otologic cultures from patients with acute otitis externa (AOE). Study design: Retrospective review of an institutional microbiologic database. Methods: A retrospective analysis was performed on serial culture isolates taken from the ear at a quaternary care hospital from January 2014 to April 2016. The causative pathogen and antibiotic sensitivity was determined by culture isolation and end point mean inhibitory concentration (MIC) testing. Medical records were reviewed to document patient characteristics, chronicity of infection, symptomatology, and previous treatments. Results: Over the study period, 173 patients were diagnosed with AOE and underwent otologic cultures of the ear. Fifty-three (30.6%) of cultures grew S. aureus (SA). Of SA infections, 15 (28.3%) were identified as MRSA. MRSA patients were typically older than patients with methicillin-sensitive SA (MSSA) (mean age 46.7 ± 17.9 vs 29 ± 19.4, P = 0.003) and had more medical comorbidities (4 vs 1.7, P = 0.001). Compared to patients with MSSA, patients with MRSA were significantly more likely to have had prior ototopical antibiotic exposure (37% vs 73%, P = 0.019). Conclusion: Contemporary ear culture isolates at quaternary care center show higher rates of MRSA compared to historical reports in the literature. Clinicians should consider ear cultures to identify MRSA AOE. Level of Evidence: IV. Key words: Acute otitis externa; Staphylococcus aureus; Methicillin-resistant Staphylococcus aureus, MRSA

Age-related hearing loss (presbycusis) is a prevalent condition attributed primarily to inner ear dysfunction. Little is known about age-related changes in the ossicular joints or their contribution to presbycusis. Herein, we performed a histopathologic analysis of the incudomalleolar joint (IMJ) in specimens from the National Temporal Bone Registry with audiometrically confirmed presbycusis but without histologically observed sensory, neural, strial or mixed features. Twenty-two ‘indeterminate’ presbycusis (IP) cases and thirteen young, normal hearing ears were examined. The age for the IP group was 76.3 ± 10.9 and 32.1 ± 9.5 for the young group (p < 0.05). The joint space between the two ossicles was 22% wider in the IP group (138 ± 58.0 μm) compared to young ears (113 ± 49.0 μm) (p < 0.05). We report that IP ears have a wider IMJ than young ears. Findings have implications for understanding a potential source of presbycusis in indeterminate cases.

Importance Clinicians are increasingly adopting telemedicine in an effort to expand patient access and efficiently deliver care. However, the extent to which otolaryngologists provide telemedicine services is unclear. Objective To characterize recent trends in the use of telemedicine by otolaryngologists to deliver care to Medicare beneficiaries. Design, Setting, and Participants A retrospective cross-sectional analysis was conducted between January 1, 2010, and December 31, 2018, using publicly available Medicare Physician/Supplier Procedure Summary data on physicians practicing in the field of otolaryngology and benchmark specialties (dermatology and psychiatry) that provided telemedicine services to Medicare beneficiaries. Main Outcomes and Measures Primary outcomes were the mean annual number of telemedicine services delivered per active physician and mean annual payment per active physician for these services. Secondary outcomes included the number, setting, and complexity of telemedicine services. Results Between 2010 and 2018, otolaryngologists provided 2127 total telemedicine services (7 unique service types) to Medicare beneficiaries and received $88 574 in total payment for these services. During this period, the mean number of telemedicine services increased at a compound annual growth rate (CAGR) of 11.0%, and the mean Medicare payment per otolaryngologist increased at a CAGR of 21.8%. In comparison, telemedicine use during this period generally increased at a higher rate in the fields of dermatology (mean number of services per active physician at CAGR of 13.0%; mean Medicare payment per active physician at CAGR of 12.5%) and psychiatry (mean number of services per active physician at CAGR of 25.8%; mean Medicare payment per active physician at CAGR of 26.6%). In 2018, outpatient evaluation and management visits accounted for most telemedicine services provided (337 of 353 [95.5%]) and the payments received ($17 542.13 of $18 470.47 [95.0%]) by otolaryngologists. In contrast, physicians in other specialties also provided substantial portions of telemedicine services in the inpatient (psychiatry, 18 403 of 198 478 [9.3%]; dermatology, 231 of 1034 [22.3%]) and skilled nursing facility settings (psychiatry, 14 690 of 198 478 [7.4%]; dermatology, 46 of 1034 [4.4%]). Conclusions and Relevance This study suggests that the extent to which otolaryngologists used telemedicine to deliver care to Medicare beneficiaries between 2010 and 2018 was rare. Although there was relative growth in the use of telemedicine by otolaryngologists during this period, absolute growth remained low. Policy makers and provider organizations should support otolaryngologists in the adoption of telemedicine technologies, especially while coronavirus disease 2019 (COVID-19) viral suppression efforts necessitate prolonged restriction of physical clinic throughput.

As a result of the COVID-19 pandemic, telemedicine has been thrust to the forefront of health care. Despite its inherent limitations, telemedicine offers many advantages to both patient and physician as an alternative to in-person evaluation of select patients. In the near term, telemedicine allows nonpandemic care to proceed while observing appropriate public health concerns to minimize the spread of pandemic pathogens. Thus, it behooves practitioners to use telemedicine consultations for common otolaryngology complaints. Assessment of the dizzy patient is well-suited to an algorithmic approach that can be adapted to a telemedicine setting. As best practices for telemedicine have yet to be defined, we present herein a practical approach to the history and limited physical examination of the dizzy patient in the telemedicine setting for the general otolaryngologist. Indeed, once the acute crisis has abated, we suspect that this approach will continue to be an effective way to manage dizzy patients.

Objective The auditory brain stem implant (ABI) is a neuroprosthesis placed on the surface of the cochlear nucleus (CN) to provide hearing sensations in children and adults who are not candidates for cochlear implantation. Contemporary ABI arrays are stiff and do not conform to the curved brain stem surface. Recent advancements in microfabrication techniques have enabled the development of flexible surface arrays, but these have only been applied in animal models. Herein, we measure the surface curvature of the human CN and adjoining regions to assist in the design and placement of next-generation conformable clinical ABI arrays. Three-dimensional (3D) reconstructions from ultrahigh T1-weighted brain magnetic resonance imaging (MRI) sequences and histologic reconstructions based on postmortem adult human brain stem specimens were used. Design This is a retrospective review of radiologic data and postmortem histologic axial sections. Setting This is set at the tertiary referral center. Participants Data were acquired from healthy adults. Main Outcome Measures The main outcome measures are principal curvature values (Kmin and Kmax) and global radius of curvature. Results The CN was successfully extracted and rendered as a 3D surface in all cases. Significant curvatures of the CN in both histologic and radiographic reconstructions were found with global radius of curvature ranging from 2.08 to 8.5 mm. In addition, local curvature analysis revealed that the surface is highly complex. Conclusion Detailed rendering of the human CN is feasible using histology and 3D MRI reconstruction and highlights complex surface topography that is not recapitulated by contemporary stiff ABI arrays.

Hypothesis We hypothesize that human cases of cochlear implantation (CI) with folding of the electrode array will demonstrate greater degrees of intracochlear ossification, lower spiral ganglion neuron (SGN) counts, and poorer audiometric outcomes. Background CI electrode array folding, such folding of the proximal array, is a relatively common surgical complication that can occur with forceful electrode insertion and may be an important and avoidable factor affecting implant outcomes. However, otopathologic findings and audiologic outcomes of human cases where folding of the implant electrode array is observed remain undefined. Methods Specimens from a human temporal bone repository having undergone CI during life were evaluated. Specimens with folding of the electrode array on histological analysis constituted study cases. Electrode-matched specimens without array folding constituted controls. All specimens were examined by light microscopy and histopathologically described. Intracochlear fibrosis and osseous tissue, and SGN counts were measured. Pre- and postoperative word recognition scores were also compared. Results Cases with folded electrodes showed greater volumes of intracochlear osseous tissue than controls, which was most prominent in areas adjacent to array folding. Both cases and controls demonstrated similar amounts of fibrous tissue. Folded cases showed decreased SGNs when compared with the contralateral ear, whereas controls showed stable SGN populations between ears. In this small cohort, postoperative hearing outcomes were similar between groups. Conclusion Atypical fibro-osseous changes and lower SGN counts are observed in cases of CI electrode folding. Future studies are necessary to determine if recognition and correction of folding can prevent long-term intracochlear changes.

Optogenetics is a transformative technology based on light-sensitive microbial proteins, known as opsins, that enable precise modulation of neuronal activity with pulsed radiant energy. Optogenetics has been proposed as a means to improve auditory implant outcomes by reducing channel interaction and increasing electrode density, but the introduction of opsins into cochlear spiral ganglion neurons (SGNs) in vivo has been challenging. Here we test opsin delivery using a synthetically developed ancestral adeno-associated virus (AAV) vector called Anc80L65. Wild-type C57BL/6 mouse pups were injected via the round window of cochlea with Anc80L65 carrying opsin Chronos under the control of a CAG promoter. Following an incubation of 6-22 weeks, pulsed blue light was delivered to cochlear SGNs via a cochleosotomy approach and flexible optical fiber. Optically evoked auditory brainstem responses (oABRs) and multiunit activity in inferior colliculus (IC) were observed. Post-experiment cochlear histology demonstrated opsin expression in SGNs (mean = 74%), with an even distribution of opsin along the cochlear basal/apical gradient. This study is the first to describe robust SGN transduction, opsin expression, and optically evoked auditory electrophysiology in neonatal mice. Ultimately, this work may provide the basis for a new generation of cochlear implant based on light.

Objective Temporalis fascia is a commonly used graft material in tympanoplasty; however, little is known about how the histological structure of fascia remodels postimplantation. Herein, we aim to quantify the pre- and postoperative microstructure of temporalis fascia and compare histological findings to the native tympanic membrane (TM). Methods Temporal bone specimens having undergone successful subtotal or total drum replacement using temporalis fascia were identified (n = 3). Surgically prepared preimplantation temporalis fascia (PreTF, n = 4) and normal TMs (n = 5) were used as controls. Multiple measurements of thickness of PreTF and of normal and fascia reconstructed TMs at the mesotympanum and hypotympanum were obtained. Collagen fiber patterns of normal and reconstructed TMs were histologically described. Results In cases of fascia tympanoplasty, the mean time of surgery to death was 16 years (range 8-28 years). All cases contained an aerated middle ear without residual perforation. There was no significant difference between the thickness of PreTF and fascia of reconstructed TMs (234.9 ± 144.9 μm vs. 162.9 ± 71.9 μm, P = 0.1). The lamina propria and total thicknesses of controls (59.8 ± 39.3 μm and 83.7 ± 42.4 μm, respectively) were thinner than the PreTF and fascia-reconstructed TMs, respectively, in all cases (P ≤ 0.001, P ≤ 0.001). Reconstructed TMs contained a thick, longitudinal fiber structure that was qualitatively similar to PreTF. Conclusion Based on human temporal bone specimens, temporalis fascia does not significantly remodel, change thickness, or change fibrous structure following successful tympanoplasty. Results have implications for selection and surgical preparation of graft materials in TM reconstruction. Level of evidence 4. Laryngoscope, 128:E351-E358, 2018.