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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.

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.

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.

Understanding the mechanisms of neural stimulation is necessary to improve the management of sensory disorders. Neurons can be artificially stimulated using electrical current, or with newer stimulation modalities, including optogenetics. Electrical stimulation forms the basis for all neuroprosthetic devices that are used clinically. Off-target stimulation and poor implant performance remain concerns for patients with electrically based neuroprosthetic devices. Optogenetic techniques may improve cranial nerve stimulation strategies used by various neuroprostheses and result in better patient outcomes. This article reviews the fundamentals of neural stimulation and provides an overview of recent major advancements in light-based neuromodulation."

Despite advances in implant hardware, neuroprosthetic devices in otolaryngology have sustained evolutionary rather than revolutionary changes over the past half century. Although electrical stimulation has the capacity for facile activation of neurons and high temporal resolution, it has limited spatial selectivity. Alternative strategies for neuronal stimulation are being investigated to improve spatial resolution. In particular, light-based neuronal stimulation is a viable alternative and complement to electrical stimulation. This article provides a broad overview of light-based neuronal stimulation technologies. Specific examples of active research on light-based prostheses, including cochlear implants, auditory brainstem implants, retinal implants, and facial nerve implants, are reviewed.

The pathophysiology of eustachian tube dysfunction (ETD) remains poorly characterized, and it may result in significant patient morbidity. A recent study has identified a collection of previously unidentified salivary glands in the nasopharynx that overlay the torus tubarius. While salivary gland tissue has been described in the nasopharynx, the newly discovered salivary gland tissue has been denoted tubarial glands (TGs) and theorized to be a distinct organ. The TGs have been suggested to aid in lubrication of the oropharynx and nasopharynx. However, the exact clinical significance of TGs is unknown. Given the proximity of the TG to the eustachian tube, it is possible that the TGs may be related to the development of ETD. Future studies of the TGs and related pathophysiology may improve approaches to developing future ETD treatments.

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.

The binocular operative microscope has been the workhorse of otologic and neurotologic surgeons since the 1950s. Since its advent, however, surgeons recognized that the operative microscope could not "look around corners" and its line-of-sight technology required soft tissue and bony dissection to enable light to reach the surgical plane. Endoscopic technology has evolved to address many of the limitations of operative microscopy. While the endoscope is often viewed as a recent development in otologic surgery, in the following historical article, we highlight the contributions of two mid-20th century pioneers of endoscopic ear surgery: Georg von Békésy and Bruce Mer. In the 1940s, Dr von Békésy envisioned an endoscope for determining stapes mobility. Dr Mer, with a team of engineers, created an otoendoscope to perform some of the first endoscopic ear procedures in the 1960s. Lessons gleaned from von Békésy and Mer's research include the need for counterculture thinking and the challenges of pioneering ideas beyond technical capacity.

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.

Superior canal dehiscence (SCD) is a bony defect of the superior semicircular canal that is called SCD syndrome (SCDS) when associated with vestibular and auditory dysfunction. Surgical management of SCD is reserved for patients with intractable auditory and/or vestibular symptoms. As direct visualization of an arcuate eminence defect is most easily achieved from above, the majority of cases use a microscope-assisted middle fossa craniotomy. However, approximately 30% of SCD cases have a medial arcuate eminence defect along a downsloping tegmen. These defects can be difficult to visualize without a large cranial window, drilling down a prominent lateral skull base ridge, and/or prolonged brain retraction. In line with recent development of endoscopic ear surgery, the endoscope has been employed at our institution via a middle fossa craniotomy approach to repair a SCD. We believe that skull base endoscopy is a safe and effective way to identify and repair a medial or blue-lined SCD when used with a middle fossa craniotomy approach. The angled endoscope enhances visualization and transillumination of the SCD and reduces temporal lobe retraction. The following chapter highlights an endoscopic-assisted middle fossa craniotomy repair of SCD.

Patients with superior canal dehiscence syndrome may present with a myriad of auditory and/or vestibular complaints. Treatment of superior canal dehiscence syndrome depends on severity of symptoms and impact on quality of life. Surgery is recommended for patients with debilitating auditory and/or vestibular symptoms. The goal of surgery is to create a durable and watertight seal of the bony superior semicircular canal defect, thereby eliminating the “third window”. Repair involves either resurfacing and/or plugging of the dehiscent superior canal to eliminate the third window and reduce symptoms. Surgical options include middle fossa craniotomy or transmastoid (TM) approach. The main advantages of a TM approach includes (1) avoidance of a craniotomy, (2) lower risk of CSF leak, and (3) no brain retraction. The TM approach is ideal for superior petrosal sinus superior canal dehiscence cases as the defect is found medial along the skull base and can be isolated indirectly without direct manipulation of the brain and sinus. This chapter discusses the surgical technique of TM approach.

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

Traumatic brain injury (TBI) is the leading cause of acquired long-term disability during childhood, and it may result in wide range of negative developmental consequences. Auditory dysfunction is generally recognized to be a possible sequela of pediatric TBI. Unfortunately, few contemporary studies have quantified the association between head injury and hearing loss in the pediatric population. The National Survey of Children's Health (NSCH) for the combined years 2017-2018 was used to determine the association of hearing loss with TBI. Deafness or problems with hearing were more commonly reported in children with a history or current brain injury/concussion compared to those without any such history (3.2% [70,000] and 1.2% [830,000] children, respectively; odds ratio, 2.67; P < .001). Findings suggest a notable association between TBI and hearing loss. Children with a history of TBI are 2.67 times more likely to have concurrent hearing complaints.Level of Evidence: IV.

Because endoscopic technology has matured over the past several decades, ear surgeons have increasingly used endoscopy to address some of the limitations of operative microscopy. The wide field of view and high-resolution images provided by endoscopes allow for improved visualization of the tympanic cavity using minimally invasive surgical portals compared with the standard operative binocular microscope. The endoscope is becoming an essential tool in the otologist's armamentarium. In this article, the authors discuss rationale for endoscopic ear surgery, terminology and classification, surgical indications, essential equipment, surgical ergonomics, and practical steps to incorporate endoscopic ear surgery into practice.

Objective Endoscopic ear surgery (EES) has been increasingly adopted to enhance visualization during otologic surgery including pediatric cholesteatoma resection. The purpose of this study is to systematically review the current literature reporting rates of residual cholesteatoma to evaluate outcomes of EES in the pediatric population. Data sources PubMed, Embase, Cochrane. Study selection Using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis recommendations (PRISMA), we systematically reviewed studies that reported outcomes for cholesteatoma surgery in children using the endoscope. Studies were included if they described the use of the endoscope for middle ear surgery and measured outcomes following cholesteatoma resection in pediatric patients. Data extraction Identified articles were assessed for study design, sample size, inclusion of pediatric population, the presence of a comparison group, outcomes measured such as: residual disease rate, recurrent cholesteatoma, audiologic outcome, quality of life measures, and complications. Data synthesis Fourteen articles in the literature discussed cholesteatoma outcomes in children when the endoscope was employed. Residual disease rate ranged from 0 to 22% when endoscope was used for dissection compared with 11 to 55% when endoscope was used for inspection or not at all. A meta-analysis was conducted on 11 studies. There was a significant risk reduction in residual disease rates for endoscopic dissection when compared with microscope (RR = 0.48, 95% CI = 0.37-0.63, p Conclusion Among the studies included in this review, EES was associated with lower rates of residual cholesteatoma compared with traditional microscopic techniques. Additional prospective studies are needed to further assess these findings.

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.

Objective: We aim to examine the existing literature on, and identify knowledge gaps in, the study of adverse animal and human audiovestibular effects from exposure to acoustic or electromagnetic waves that are outside of conventional human hearing. Design/Setting/Participants: A review was performed, which included searches of relevant MeSH terms using PubMed, Embase, and Scopus. Primary outcomes included documented auditory and/or vestibular signs or symptoms in animals or humans exposed to infrasound, ultrasound, radiofrequency, and magnetic resonance imaging. The references of these articles were then reviewed in order to identify primary sources and literature not captured by electronic search databases. Results: Infrasound and ultrasound acoustic waves have been described in the literature to result in audiovestibular symptomology following exposure. Technology emitting infrasound such as wind turbines and rocket engines have produced isolated reports of vestibular symptoms, including dizziness and nausea and auditory complaints, such as tinnitus following exposure. Occupational exposure to both low frequency and high frequency ultrasound has resulted in reports of wide-ranging audiovestibular symptoms, with less robust evidence of symptomology following modern-day exposure via new technology such as remote controls, automated door openers, and wireless phone chargers. Radiofrequency exposure has been linked to both auditory and vestibular dysfunction in animal models, with additional historical evidence of human audiovestibular disturbance following unquantifiable exposure. While several theories, such as the cavitation theory, have been postulated as a cause for symptomology, there is extremely limited knowledge of the pathophysiology behind the adverse effects that particular exposure frequencies, intensities, and durations have on animals and humans. This has created a knowledge gap in which much of our understanding is derived from retrospective examination of patients who develop symptoms after postulated exposures. Conclusion and Relevance: Evidence for adverse human audiovestibular symptomology following exposure to acoustic waves and electromagnetic energy outside the spectrum of human hearing is largely rooted in case series or small cohort studies. Further research on the pathogenesis of audiovestibular dysfunction following acoustic exposure to these frequencies is critical to understand reported symptoms.

Facial analysis is a foundational aspect of facial plastic and reconstructive surgery. Unfortunately, ideal proportions of beauty are commonly discussed without much thought regarding their historical derivation and associated cultural implications. Facial analysis often is limited to narrow ethnic and gender-normative aesthetics. As we evolve as a specialty that treats disparate patient populations and embraces a diverse community of surgical trainees, it may be time to reframe our approach to facial analysis education.

Nonautologous graft materials may solve several dilemmas in tympanoplasty by obviating the need for graft harvest, facilitating consistent wound healing, and permitting graft placement in the clinical setting. Prior studies of nonautologous grafts in humans have shown variable outcomes. In this systematic review, we aim to 1) summarize clinical outcomes and 2) discuss limitations in the literature regarding nonautologous grafts for tympanoplasty in humans.A literature review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations. The study size, etiology and duration of perforation, type of nonautologous graft, and postoperative closure rate were assessed.The PRISMA approach yielded 61 articles, including 3,247 ears that met inclusion criteria. Studies evaluated nonautologous grafts including paper patch, gelatin sponge, growth factors, porcine small-intestinal submucosa, among others. Traumatic perforations (62.3%) were most commonly studied, whereas postinfectious perforations (31.9%) and other etiologies (5.8%) comprised a minority of cases. Acute perforations of8 weeks duration constituted just over half of all treated ears. Overall closure rate was 82.1%, with significantly higher closure rates in acute (89.9%) versus chronic perforations (64.9%, P .01), regardless of material. A median postoperative air-bone gap of 5.6 dB was found in the 23% of studies reporting this metric.The majority of publications reviewing nonautologous materials in tympanoplasty evaluate acute or traumatic perforations, and few rigorously report hearing outcomes. Given available data, porcine submucosa and basic fibroblast growth factor may hold promise for chronic perforation closure. Future studies should report closure rates and hearing outcomes in perforations8 weeks duration. Laryngoscope, 131:392-400, 2021.

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.

OBJECTIVES/HYPOTHESIS The recent addition of mandatory program-specific paragraphs within the personal statement during the otolaryngology match process has been controversial. It is unclear whether applicants customize these paragraphs for programs, or if they are largely uniform across applications. The objective of our study was to assess the degree of variability among program-specific paragraphs. STUDY DESIGN Retrospective cohort analysis. METHODS An analysis of deidentified program-specific paragraphs of 2016 otolaryngology residency applicants at two institutions was performed. Applicants who applied to both and had program-specific paragraphs were included. Paragraphs were assessed for 24 parameters, including quantitative content analysis. Subjective and objective similarity scores were assigned to each pair, using a five-point scale and Levenshtein distance function respectively. Differences between institutions were calculated using χ2 and two-sided t tests. RESULTS Two hundred eight-five applications were reviewed, and 181 applied to both programs and had program-specific paragraphs. The median subjective similarity score among all paragraphs was "mildly similar" (2/5). The mean objective similarity score was 0.59. There were statistical differences between institutions in 13 parameters. One institution garnered more applicants who mentioned interest in research or global surgery (71.3% vs. 57.5%, P = .006; 17.7% vs. 4.4%, P

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.

The aim of this report is to review the literature regarding the value of care provided for urgent and emergent otolaryngologic conditions and to investigate alternative models of health care delivery. Ear, nose, and throat problems comprise a large portion of chief complaints in emergency departments (EDs). Otolaryngologic conditions are predominantly low acuity and may be handled on an outpatient basis, leading to a potential mismatch between the needs of the patient and the level of resources expended. Alternative models have been investigated both in otolaryngology and in other medical specialties, but the implications for quality of care and cost are uncertain. Urgent and emergent care for ear, nose, and throat conditions is not well studied and is ripe for new models of health care delivery, which may include specialty-specific EDs, clinics, and urgent care centers. Economic analysis of the models will be essential to provide evidence of value and is currently lacking.

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.

Objective While hearing loss following temporal bone fracture is a well-described phenomenon, few data exist on auditory dysfunction in patients with traumatic brain injury (TBI) without temporal bone fracture. Herein, we aim to systematically review hearing loss after TBI without bony fracture and describe its etiologies. Data sources Pubmed, Embase, Cochrane databases. Review methods A systematic review of the literature from 1966 to January 2017 was performed using Preferred Reporting Items for Systematic Reviews and Meta-analyses recommendations. Data were obtained from studies that investigated hearing loss in TBI without skull fracture according to an a priori protocol with inclusion and exclusion criteria. Variables included type and severity of hearing loss, as well as pathophysiology of hearing loss. Results There were 13 studies with 773 patients that met study criteria. Overall, there was one prospective cohort study, four retrospective cohort studies, two case-control studies, and six case reports. The studies with the highest level of evidence report a change in hearing of at least 10–15 dB across a range of frequencies in as many as 58% percent of TBI patients without bony fracture, which was transient or chronic. The mechanism/severity of injury may impact the rate of hearing loss. Conclusions Hearing loss after TBI in the absence of bony injury appears to be a clinically significant but poorly characterized phenomenon.

Objective Otogenic brain abscesses are one of the most significant life-threatening complications of otologic infections. Given their low prevalence, otogenic brain abscesses require a high index of suspicion for diagnosis. In this systematic review, we aim to provide an analysis of otogenic brain abscesses and describe common clinical signs and symptoms, bacteriology, location, treatment options, morbidity, and mortality. Data sources PubMed, Cochrane CENTRAL database, Google Scholar, and Scopus. Methods A systematic review of literature was performed using the Preferred Reporting Items for Systematic Reviews and Meta-analyses recommendations. Variables assessed included clinical signs and symptoms, bacteriology, location, treatment, morbidity, and mortality. Results Twenty-nine studies met inclusion and exclusion criteria, corresponding to a total of 1307 otogenic abscess cases for review. Fifty-five percent of abscesses were found in the temporal lobe and 28% in the cerebellum. Most patients (88.3%) had a history of suppurative chronic otitis media. The most common symptoms were headache, altered mental status, papilledema, and meningeal irritation. Fever, nausea, and vomiting affected about 40% of patients. The most commonly cultured bacterial species was Proteus mirabilis. In addition to antibiotics, most otogenic brain abscesses were treated by burr hole aspiration. Average mortality following advent of computed tomography was 8.11%. Conclusion Although rare, otogenic brain abscesses may occur as a complication of suppurative otitis media and require a high index of suspicion. Appropriate imaging studies and multidisciplinary expertise are crucial in the diagnosis and management. Level of evidence 4.

OBJECTIVE Mobile hearing applications (apps) are available for hearing testing, personal sound amplification, as well as hearing aid modulation. Hearing testing apps are gaining popularity, especially in resource-limited settings. The reliability of mobile hearing testing apps, however, is not well characterized. PATIENTS/INTERVENTIONS A case study of a single patient with a complaint of sudden hearing loss presenting to a tertiary-care hospital. MAIN OUTCOME MEASURE Comparison of a mobile hearing testing app results with standard audiogram. RESULTS A commercially available mobile hearing testing app was used after hours to determine if a patient's hearing complaints were consistent with sudden sensorineural hearing loss. The hearing app produced a rudimentary audiogram that was consistent with unilateral SSNHL. Given contraindications to oral treatment, preparations for possible intratympanic dexamethasone after a full audiometric evaluation were completed. Confirmatory audiogram the following day demonstrated normal hearing without evidence of hearing loss. Steroid treatment was aborted and appropriate counseling provided. CONCLUSION While mobile hearing testing apps offer improved access to hearing screening in resource-limited settings, caution must be exercised when interpreting data and making clinical decisions based upon results. The role of professional audiologists remains critical. Further testing and validation of specific apps is required.

Objectives The auditory brainstem implant (ABI) provides sound awareness to patients who are ineligible for cochlear implantation. Auditory performance varies widely among similar ABI cohorts. We hypothesize that differences in electrode array position contribute to this variance. Herein, we classify ABI array position based on postoperative imaging and investigate the relationship between position and perception. Design Retrospective review of pediatric and adult ABI users with postoperative computed tomography. To standardize views across subjects, true axial reformatted series of scans were created using the McRae line. Using multiplanar reconstructions, basion and electrode array tip coordinates and array angles from vertical were measured. From a lateral view, array angles (V) were classified into types I to IV, and from posterior view, array angles (T) were classified into types A to D. Array position was further categorized by measuring distance vertical from basion (D1) and lateral from midline (D2). Differences between array classifications were compared with audiometric thresholds, number of active electrodes, and pitch ranking. Results Pediatric (n = 4, 2 with revisions) and adult (n = 7) ABI subjects were included in this study. Subjects had a wide variety of ABI array angles, but most were aimed superiorly and posteriorly (type II, n = 7) from lateral view and upright or medially tilted from posterior view (type A, n = 6). Mean pediatric distances were 8 to 42% smaller than adults for D1 and D2. In subjects with perceptual data, electrical thresholds and the number of active electrodes differed among classification types. Conclusions In this first study to classify ABI electrode array orientation, array position varied widely. This variability may explain differences in auditory performance.

Objective This study aims to define a reliable protocol for radiographic identification of placement and tip foldover of newly designed precurved and straight electrodes. Study Design Prospective imaging study. Setting Academic institution. Methods Three models of cochlear implants (Cochlear, MED-EL, and Advanced Bionics) were inserted into fresh cadaveric specimens (n = 2) in 3 configurations (normal positioning in the scala tympani, intracochlear tip foldover, and placement into the vestibular system) for a total of 9 implant scenarios. Specimens were imaged with plain radiography in Stenvers projection, as well as by high-resolution computed tomography. Results Electrode placement and presence or absence of electrode tip foldover were easily identified in all 9 scenarios on plain radiography based on the described technique. Each was confirmed with high-resolution computed tomography. Plain film temporal bone images of new electrode designs with proper and improper placement are provided for reference. Conclusion A defined protocol for intraoperative plain film radiography allowed for reliable imaging of 3 newly designed cochlear implant electrodes and immediate identification of extracochlear placement and tip foldover. Findings may be used for intraoperative confirmation of electrode array placement.

ObjectiveCochlear explantation for purely elective (e.g. psychological and emotional) reasons is not well studied. Herein, we aim to provide data and expert commentary about elective cochlear implant (CI) removal that may help to guide clinical decision-making and formulate guidelines related to CI explantation.Data sourcesWe address these objectives via three approaches: case report of a patient who desired elective CI removal; review of literature and expert discussion by surgeon, audiologist, bioethicist, CI user and member of Deaf community.Review methodsA systematic review using three scientific online databases was performed. Included articles addressed the benefits and/or complications of cochlear implantation in young children, CI explantation with or without revision surgery and the ethical debate between the medical and Deaf communities on cochlear implantation and explantation.ConclusionsThe medical and audiological perspectives identify a host of risks related to implant removal without reimplantation, including risk from surgery, general anaesthesia, cochlear ossification and poor audiometric outcomes. The member of the deaf community and bioethicist argue that physicians need to guide the principles of beneficence, non-maleficence and patient autonomy. Taken together, patient desires should be seen as paramount, if the patient is otherwise fit for surgery and well informed.Implications for practiceSimilar to the case of device implantation, device explantation should be a multidisciplinary and collaborative decision with the patient and the family’s desires at the centre. While every case is different, we offer a CI explantation discussion to assist in clinical decision-making, patient counselling and education.

Endoscopic ear surgery (EES) is an emerging technique requiring single-handed dissection with limited depth perception. Current options for EES simulation and training are limited. Herein, we introduce a versatile, low-cost surgical skills trainer that aims to improve the fine motor control necessary for EES.Prospective validation study.Surgical simulation laboratory.Seven subjects ranging in experience from medical students ("Novices") to experienced ear surgeons ("Experts") participated in the validation study. Experts (n = 3) were defined as performing10 EES cases per year.The skills trainer was constructed from a 3" diameter polyvinyl chloride pipe cap modified with two ports for instrument passage. A wooden platform was placed inside at an appropriate working distance for ear surgery. Eight interchangeable skills modules were fabricated on wooden squares (3 cm × 3 cm) using materials such as #19 wire brads, 1.6 mm glass beads, and 26-gauge jewelry wire. The material cost of this reusable model was $15. Subjects completed each skills module in triplicate, followed by a Likert-based survey.Expert performance was superior to novices in 100% (8/8) of skills modules, i.e., threading beads on a wire (43 versus 127 s, p 0.001) and placing a simulated prosthesis (13 versus 68 s, p = 0.01). Most participants (86%) agreed the trainer orientation was accurate and all participants (100%) were satisfied with the experience.This low-cost modular task trainer may help fill a void in otologic training by allowing efficient, deliberate practice of validated exercises designed to improve fine motor control with EES instrumentation.

Objective The US Food and Drug Administration (FDA) clears moderate-risk devices via the 510(k) process based on substantial equivalence to previously cleared devices; evidence of safety and effectiveness is not required. We characterized the premarket evidence supporting FDA clearance of otolaryngologic devices. Study Design Retrospective cross-sectional analysis. Setting Publicly available FDA documents. Subjects and Methods Recently cleared (1997-2016) moderate-risk otolaryngologic devices were categorized by type (diagnostic/therapeutic), subspecialty, implantable designation (yes/no), and recall history (yes/no). Supporting evidence was categorized by type (clinical/nonclinical/none; nonclinical and clinical mutually inclusive) and public availability of nonclinical and clinical performance data (available/not provided/not applicable). Results Between 1997 and 2016, the FDA cleared 377 moderate-risk otolaryngologic devices. The majority were therapeutic (n = 240/377 [63.7%]) and otologic (n = 311/377 [82.5%]); roughly one-third (n = 121/377 [32.1%]) were implantable. Few (n = 10/377 [2.7%]) devices were subject to recall. FDA documents summarizing premarket evidence were accessible for two-thirds (n = 247/377 [65.5%]) of devices. Among these devices, one-quarter (n = 66/247 [26.7%]) were supported by clinical evidence. The majority (n = 177/247 [71.7%]) were supported by nonclinical evidence, although nearly one-quarter (n = 58/247 [23.5%]) were cleared without supporting evidence. Therapeutic devices were more often cleared without supporting evidence (therapeutic: n = 53/170 [31.2%]; diagnostic: n = 5/77 [6.5%]; P < .0001). Nonclinical and clinical performance data were rarely available (nonclinical: n = 49/247 [19.8%]; clinical: n = 32/247 [13.0%]) within public summaries. Conclusion The FDA cleared most moderate-risk otolaryngologic devices for marketing via the 510(k) process without clinical evidence of safety and effectiveness. Otolaryngologists should be aware of limitations in premarket evidence when considering the adoption of new devices into clinical practice.

Objectives/hypothesis Otolaryngology residents are often responsible for triaging after-hours patient calls. However, residents receive little training on this topic. Data are limited on the clinical content, reporting, and management of otolaryngology patient calls. This study aimed to characterize the patient concerns residents handle by phone and their subsequent management and reporting. Study design Retrospective review. Methods Five hundred consecutive after-hours patient calls in a tertiary pediatric hospital were reviewed. Data collected included patient and caller demographics, clinical concerns, surgical history, recommendations, and subsequent emergency department (ED) visits. Results On average, 3.7 calls occurred per shift, 2.8 on weekday and 5.9 on weekend shifts. Mean patient age was 6.6 years. Mothers (71%) called most frequently. The majority of calls were postoperative (64.2%). Of postoperative calls, most occurred within 3 days of surgery (52.3%). Most calls were for surgical site bleeding (19.9%). Residents recommended ED evaluation for 17.2% of calls, of which 20.9% returned to the primary institution ED. ED evaluation was recommended more frequently for postoperative patients (P = .040), particularly following adenotonsillectomy (51.2%) or surgical site bleeding (18.6%). With respect to documentation, 32.8% of medical record numbers were absent, 11.8% had name errors, and 2.2% of patients could not be identified. Conclusions This is the first study to analyze the management and reporting of patient calls by otolaryngology residents. A wide array of clinical concerns are triaged by phone conversations. The study has implications for both resident and patient education. Level of evidence 4. Laryngoscope, 128:E163-E170, 2018.

Objectives/hypothesis To design and validate a classification system for endoscopic ear surgery. Study design Validation study. Methods A classification system was devised that quantifies use of the endoscope during middle ear surgery. Otologic operative reports were reviewed by attending surgeons and trainees. A power analysis was performed to determine number of cases needed to review. The following categories were used: class 0 is defined by using the microscope only; class 1 describes the use of endoscope for inspection without dissection; and class 2 describes mixed use of the endoscope and the microscope. It is further subdivided into 2a and 2b, where the endoscope is used for less than 50% of dissection and more than 50% of dissection, respectively. Class 3 describes the use of the endoscope for the entire surgery. Fifty cases were reviewed by three attending otologic surgeons, one resident, and one medical student. Results Weighted Cohen's Kappa for inter-rater agreement between the two institutional surgeons was 0.79 (95% bias corrected [BC] confidence interval [CI]: 0.58-0.93). Agreement between the external surgeon and the two institutional surgeons was 0.77 (95% BC CI: 0.58-0.89) and 0.76 (95% BC CI: 0.57-0.88). Weighted Kappa between institutional surgeons and a resident was 0.73 (95% BC CI: 0.53-0.88) and 0.62 (95% BC CI: 0.38-0.80), and between institutional surgeons and a medical student was 0.75 (95% BC CI: 0.56-0.89) and 0.70 (95% BC CI: 0.49-0.85). Conclusions There was substantial inter-rater agreement. This classification system can be used as a simple and reliable tool to describe the extent to which an endoscope was used during ear surgery. Level of evidence NA. Laryngoscope, 128:967-970, 2018.

Superior canal dehiscence (SCD) is a bony defect of the superior semicircular canal. SCD syndrome occurs when vestibular or auditory dysfunction accompanies SCD. Although not all patients with SCD are symptomatic, surgical repair is an option in patients with incapacitating symptoms and are unresponsive to conservative treatment. Traditionally, repair of SCD when involving the arcuate eminence can be achieved using a middle fossa craniotomy approach. However, approximately 30% of SCD cases have a medial arcuate eminence defect along a downsloping tegmen, making the defect difficult to visualize with the binocular microscope without a large craniotomy, extensive temporal lobe retraction, and drilling of the skull base. As complete visualization of an arcuate eminence defect is essential for successful repair, we describe an operative approach to visualize the SCD that combines a small middle fossa craniotomy and rigid endoscopy. The wide-field view and superior transillumination with skull base endoscopy can be achieved with a minimal access skin incision, small bony window, less dural dissection, and reduced brain retraction, resulting in unequivocal identification of the entire arcuate eminence defect.

The wide-angle and high-resolution image afforded by endoscopes allows for improved visualization of ear anatomy compared to the operative microscope. Incorporating the endoscope into otologic practice, however, is challenging. A graduated and stepwise introduction of endoscopic ear surgery (EES) into an established otologic practice is recommended to ensure safe and successful implementation. In this article, we discuss (1) rationale for use of the endoscope in ear surgery, (2) indications, (3) surgical ergonomics, (4) relevant instrumentation for EES, and (5) pearls and pitfalls of transcanal EES approaches.

Surgical education has shifted from the Halstedian model of "see one, do one, teach one" to a competency-based model of training. Otolaryngology residency programs can benefit from a fast and simple system to assess residents' surgical skills. In this quality initiative, we hypothesize that a novel smartphone application called System for Improving and Measuring Procedural Learning (SIMPL) could be applied in an otolaryngology residency to facilitate the assessment of resident operative experiences.The Plan Do Study Act method of quality improvement was used. After researching tools of surgical assessment and trialing SIMPL in a resident-attending pair, we piloted SIMPL across an otolaryngology residency program. Faculty and residents were trained to use SIMPL to rate resident operative performance and autonomy with a previously validated Zwisch Scale.Residents (n = 23) and faculty (n = 17) were trained to use SIMPL using a standardized curriculum. A total of 833 assessments were completed from December 1, 2017, to June 30, 2018. Attendings completed a median 20 assessments, and residents completed a median 14 self-assessments. All evaluations were resident initiated, and attendings had a 78% median response rate. Evaluations took residents a median 22 seconds to complete; 126 unique procedures were logged, representing all 14 key indicator cases for otolaryngology.This is the first residency-wide application of a mobile platform to track the operative experiences of otolaryngology residents.We adapted and implemented a novel assessment tool in a large otolaryngology program. Future multicenter studies will benchmark resident operative experiences nationwide.

OBJECTIVES/HYPOTHESIS Few studies have specifically addressed auditory complaints in patients with nonblast mild traumatic brain injury (mTBI). Herein, we aimed to investigate auditory symptoms in patients following mTBI using patient-reported outcome measures. STUDY DESIGN Retrospective analysis of prospectively collected data in a tertiary-care hospital. METHODS The patients included those with mTBI (cases) and those without mTBI (controls). Individuals (≥18 years old) with and without mTBI were screened. Exclusion criteria included history of otologic disorders, blast injury, or occupational noise exposure. Primary outcomes included the Hearing Handicap Inventory for Adults (HHIA), Tinnitus Handicap Inventory (THI), and Hyperacusis Questionnaire (HQ). Secondary outcomes included subjective auditory complaints. RESULTS From September 2017 to September 2018, 52 patients with mTBI and 55 controls met inclusion and exclusion criteria. The mean time between mTBI and survey intake was 70.6 months. The mean age and gender were 51.5 years old and 73% female in the mTBI group, and 46.1 years old and 56.3% female in the control group (P = .112 and P = .105, respectively). Patients with mTBI reported hyperacusis (67.3% of all mTBI patients), hearing loss (61.5%), and tinnitus (61.5%), compared to 8.3%, 12.7%, and 16.4%, respectively, for control subjects (P < .0001). The mean HHIA score in the mTBI group was 38.3 versus 8.5 in controls (P = .002). The mean THI score was 27.4 in the mTBI group and 3.1 in controls (P < .0001). The mean HQ score was 26.5 in mTBI group and 7.3 in controls (P = .001). CONCLUSIONS Auditory symptoms and associated handicap were common in patients with nonblast mTBI compared to age-matched controls. Findings have implications for the pathophysiology and management of symptoms in this patient population. LEVEL OF EVIDENCE 3 Laryngoscope, 130:761-767, 2020.

The auditory brainstem implant (ABI) was first developed nearly 40 years ago and provides auditory rehabilitation to patients who are deaf and ineligible for cochlear implant surgery due to abnormalities of the cochlea and cochlear nerve. The aims of the following review are to describe the history of the ABI and innovations leading up to the modern ABI system, as well as highlight areas of future development in implant design.

Objectives/hypothesis Investigate the otopathology of angiosarcoma of the temporal bone, which has not been previously described in the literature. Study design Postmortem evaluation and literature review. Methods Postmortem histological evaluation of the temporal bones and review of the literature for the treatment and prognosis of this rare disease were performed. Results A 50-year-old male with right chronic otitis media presented with progressive hearing loss, disequilibrium, otalgia, and acute facial paresis. Biopsy of the external auditory canal was unrevealing, but specimens from a canal wall down tympanomastoidectomy later showed high-grade angiosarcoma. Magnetic resonance imaging demonstrated an unresectable middle ear and mastoid mass extending superiorly into the temporal lobe. The patient received induction chemotherapy followed by proton beam radiation therapy and concurrent paclitaxel and bevacizumab. His course was complicated by a cerebrospinal fluid leak and cauda equina syndrome from leptomeningeal sarcomatosis. The patient died after developing meningitis and a temporal lobe abscess. Postmortem otopathology revealed persistent angiosarcoma in the internal auditory canal, although none was found in the middle ear or mastoid. There was inflammatory infiltrate throughout the mastoid, with direct extension of neutrophils and bacteria into the cochlea and through the tegmen into the middle cranial fossa. Conclusions Angiosarcoma of the temporal bone can arise in the setting of chronic otitis media. In this case, postmortem temporal bone sections demonstrated viable cancer despite chemoradiation. Inflammatory infiltrates crossing from the middle ear/mastoid into the labyrinth and central nervous system illustrate pathways for the development of otogenic meningitis. Level of evidence 4 Laryngoscope, 129:737-742, 2019.

Objectives/Hypothesis 1) Determine feasibility of smartphone-based mobile technology to measure noise exposure; and 2) measure noise exposure in exercise spin classes. Study Design Observational Study. Methods The SoundMeter Pro app (Faber Acoustical, Salt Lake City, UT) was installed and calibrated on iPhone and iPod devices in an audiology chamber using an external sound level meter to within 2 dBA of accuracy. Recording devices were placed in the bike cupholders of participants attending spin classes in Boston, Massachusetts (n = 17) and used to measure sound level (A-weighted) and noise dosimetry during exercise according to National Institute for Occupational Safety and Health (NIOSH) guidelines. Results The average length of exposure was 48.9 ± 1.2 (standard error of the mean) minutes per class. Maximum sound recorded among 17 random classes was 116.7 dBA, which was below the NIOSH instantaneous exposure guideline of 140 dBA. An average of 31.6 ± 3.8 minutes were spent at >100 dBA. This exceeds NIOSH recommendations of 15 minutes of exposure or less at 100 dBA per day. Average noise exposure for one 45-minute class was 8.95 ± 1.2 times the recommended noise exposure dose for an 8-hour workday. Conclusions Preliminary data shows that randomly sampled cycling classes may have high noise levels with a potential for noise-induced hearing loss. Mobile dosimetry technology may enable users to self-monitor risk to their hearing and actively engage in noise protection measures. Level of Evidence NA Laryngoscope, 127:1873–1877, 2017

Objectives Facial nerve schwannomas (FNSs) and vestibular nerve schwannomas (VNSs) may occupy similar locations in the internal auditory canal (IAC). Risk factors for hearing loss in patients with FNS are unknown. Similar to VNSs, we hypothesize that the size and location of FNSs do not correlate with hearing loss. Study Design Retrospective cohort study and otopathology case review. Methods A single institution retrospective review of all patients diagnosed with FNS was performed. Demographic data, tumor size and location, severity and type of hearing loss, and facial nerve function were analyzed. Otopathologic review of a case of FNS was also performed. Results Thirty-three patients with FNS were identified. Mean age was 44 years, and 61% (n = 21) were female. Nine patients had tumors involving the IAC facial nerve, whereas 24 had distal tumors without IAC involvement. Eleven patients (33%) had hearing loss, and 55% of patients with sensorineural hearing loss (SNHL) had tympanic segment tumors without IAC involvement. The presence of SNHL was not associated with IAC tumor location (P = 0.21). Maximal dimensions of FNSs were 3 mm to 42 mm, without correlation between size and SNHL severity (r = −0.017, P = 0.926). Otopathologic review of an untreated 5-mm IAC FNS demonstrated disproportionate spiral ganglion and hair cell loss within the ipsilateral cochlea compared to the contralateral ear. Conclusion Tympanic segment FNS without IAC involvement may result in SNHL. Tumor size is not associated with the presence or severity of SNHL. Otopathologic review suggests degenerative cochlear changes in FNS. Mechanisms for SNHL in schwannomas are likely multifactorial and may be unrelated to cochlear nerve compression. Level of Evidence 4. Laryngoscope, 127:1676–1682, 2017

The tympanic membrane (TM) is an exquisite structure that captures and transmits sound from the environment to the ossicular chain of the middle ear. The creation of TM grafts by multi-material three-dimensional (3D) printing may overcome limitations of current graft materials, e.g. temporalis muscle fascia, used for surgical reconstruction of the TM. TM graft scaffolds with either 8 or 16 circumferential and radial filament arrangements were fabricated by 3D printing of polydimethylsiloxane (PDMS), flex-polyactic acid (PLA) and polycaprolactone (PCL) materials followed by uniform infilling with a fibrin-collagen composite hydrogel. Digital opto-electronic holography (DOEH) and laser Doppler vibrometry (LDV) were used to measure acoustic properties including surface motions and velocity of TM grafts in response to sound. Mechanical properties were determined using dynamic mechanical analysis (DMA). Results were compared to fresh cadaveric human TMs and cadaveric temporalis fascia. Similar to the human TM, TM grafts exhibit simple surface motion patterns at lower frequencies (400 Hz), with a limited number of displacement maxima. At higher frequencies (>1000 Hz), their displacement patterns are highly organized with multiple areas of maximal displacement separated by regions of minimal displacement. By contrast, temporalis fascia exhibited asymmetric and less regular holographic patterns. Velocity across frequency sweeps (0.2–10 kHz) measured by LDV demonstrated consistent results for 3D printed grafts, while velocity for human fascia varied greatly between specimens. TM composite grafts of different scaffold print materials and varied filament count (8 or 16) displayed minimal, but measurable differences in DOEH and LDV at tested frequencies. TM graft mechanical load increased with higher filament count and is resilient over time, which differs from temporalis fascia, which loses over 70% of its load bearing properties during mechanical testing. This study demonstrates the design, fabrication and preliminary in vitro acoustic and mechanical evaluation of 3D printed TM grafts. Data illustrate the feasibility of creating TM grafts with acoustic properties that reflect sound induced motion patterns of the human TM; furthermore, 3D printed grafts have mechanical properties that demonstrate increased resistance to deformation compared to temporalis fascia.