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OBJECTIVE: Smoking in movies is associated with adolescent and young adult smoking initiation. Public health efforts to eliminate smoking from films accessible to youth have been countered by defenders of the status quo, who associate tobacco imagery in 'classic' movies with artistry and nostalgia. The present work explores the mutually beneficial commercial collaborations between the tobacco companies and major motion picture studios from the late 1920s through the 1940s. METHODS: Cigarette endorsement contracts with Hollywood stars and movie studios were obtained from internal tobacco industry documents at the University of California, San Francisco (UCSF) Legacy Tobacco Documents Library and the Jackler advertising collection at Stanford. RESULTS: Cigarette advertising campaigns that included Hollywood endorsements appeared from 1927 to 1951, with major activity in 1931-2 and 1937-8 for American Tobacco Company's Lucky Strike, and in the late 1940s for Liggett & Myers' Chesterfield. Endorsement contracts and communication between American Tobacco and movie stars and studios explicitly reveal the cross-promotional value of the campaigns. American Tobacco paid movie stars who endorsed Lucky Strike cigarettes US$218,750 in 1937-8 (equivalent to US$3.2 million in 2008) for their testimonials. CONCLUSIONS: Hollywood endorsements in cigarette advertising afforded motion picture studios nationwide publicity supported by the tobacco industry's multimillion US dollar advertising budgets. Cross-promotion was the incentive that led to a synergistic relationship between the US tobacco and motion picture industries, whose artefacts, including 'classic' films with smoking and glamorous publicity images with cigarettes, continue to perpetuate public tolerance of onscreen smoking. Market-based disincentives within the film industry may be a solution to decouple the historical association between Hollywood films and cigarettes. [ABSTRACT FROM AUTHOR]

Objective: To evaluate lipomas of the internal auditory canal (IAC) and cerebellopontine angle (CPA).Study Design: Retrospective review.Methods: Review of a multi-institutional series of 17 lipomas of the IAC/CPA, combined with a Medline review of the 67 cases reported in the world literature.Results: This series of 17 IAC/CPA lipomas is the largest reported series to date, bringing the total number of documented cases to 84. There appears to be a nearly 2:1 male to female predominance. Sixty percent were left-sided lesions, and three were bilateral. Hearing loss, dizziness, and tinnitus were the most common presenting symptoms. Surgical resection was performed in 52 (62%) of these lesions; however, total tumor removal was accomplished in only 17 (33%), which is most likely because of the fact that these tumors tend to have a poorly defined matrix and a dense adherence to neurovascular structures. Sixty-eight percent of patients experienced a new deficit postoperatively, 11% were unchanged, and only 19% improved with no new deficit. Only one documented case of tumor growth was identified; however, the reported follow-up was short (average, less than 3 years).Conclusion: With the magnetic resonance imaging techniques now available, lipomas can be reliably differentiated from other masses within the CPA and IAC, so histopathologic diagnosis is rarely necessary. Because of the potential for significant morbidity with resection of these lesions, we believe that conservative follow-up is the best treatment option for patients with these rare lesions. Surgery is indicated only when significant progressive or disabling symptoms are present. [ABSTRACT FROM AUTHOR]

Vestibular schwannoma (VS) may present clinically in one of two forms: sporadic unilateral or hereditary bilateral. Almost all cases of familial transmission have been associated with the diagnosis of neurofibromatosis type II (NF-2). In this report, we describe nine families (18 individuals) presenting with unilateral VS without evidence of NF-2. In four of the nine families, the affected individuals were of parent-offspring relationship, in three families they were cousin-cousin, and in the remaining two families, they were sibling-sibling and aunt-nephew. No other members of the families were diagnosed with NF-2. There was no evidence for gender predilection or genomic imprinting among affected individuals. This study suggests that familial occurrence of unilateral VS may be genetically inherited as it occurs more commonly than would be estimated by chance alone. Future genetic studies will elucidate whether occurrence of unilateral VS in these families represents a variable expression of NF-2, chance occurrence of unilateral VS in families, or a new genetic disorder. [ABSTRACT FROM AUTHOR]

Mammalian inner ear hair cell loss leads to permanent hearing and balance dysfunction. In contrast to the cochlea, vestibular hair cells of the murine utricle have some regenerative capacity. Whether human utricular hair cells regenerate in vivo remains unknown. Here we procured live, mature utricles from organ donors and vestibular schwannoma patients, and present a validated single-cell transcriptomic atlas at unprecedented resolution. We describe markers of 13 sensory and non-sensory cell types, with partial overlap and correlation between transcriptomes of human and mouse hair cells and supporting cells. We further uncover transcriptomes unique to hair cell precursors, which are unexpectedly 14-fold more abundant in vestibular schwannoma utricles, demonstrating the existence of ongoing regeneration in humans. Lastly, supporting cell-to-hair cell trajectory analysis revealed 5 distinct patterns of dynamic gene expression and associated pathways, including Wnt and IGF-1 signaling. Our dataset constitutes a foundational resource, accessible via a web-based interface, serving to advance knowledge of the normal and diseased human inner ear., (© 2024. The Author(s).)

Competing Interests: Funding and Conflict of Interests: None.

Background: In January 2020, the US Food and Drug Administration prohibited the sale of flavours (except for menthol and tobacco) in prefilled pod devices such as JUUL to decrease youth vaping. Excluded from the prohibition were disposable devices., Objectives: To determine the scope and scale of flavours marketed by Puff Bar, a leading disposable brand, and related products., Methods: Disposable e-cigarette flavours were identified via online searches encompassing vendor websites, wholesale distributors, manufacturers (eg, made-in-china.com), and social media channel, Instagram, between June and August 2020., Results: The 'Puff' brand name and iconic cloud logo appear on a variety of products of differing sizes and nicotine e-liquid volumes. Among Puff Bar and its copycats (Puff-a-Likes), 139 flavours were identified. Fruit flavours predominated comprising 82.2% of the flavour varieties (fruit 50%, fruit and menthol/mint 23.6%, and fruity drinks 8.6%). A prevalent new flavour category which combines fruit with menthol/mint (Ice) was offered in 33 varieties such as Lychee Ice, Lush Ice and Banana Ice. Disposable e-cigarette brands are undertaking measures to escape tobacco regulation (eg, non-tobacco-sourced nicotine) and flavour limitations via post-market flavour additions to unflavoured nicotine e-liquid., Conclusions: The proliferation of flavoured disposable e-cigarette products, many of which are designed to emulate popular pod devices, illustrates that narrowly limited flavour regulations covering only a single category are destined to fail. To be effective in youth protection, flavour regulations need to apply to all recreational nicotine-containing products and need to include measures to counter post-market flavour addition., Competing Interests: Competing interests: RKJ serves as an expert witness in JUUL Labs litigation., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: A recent paper in Annals of Anatomy (The human masseter muscle revisited: First description of its coronoid part) claimed to have discovered a previously unrecognized anatomical component of the deep layer of the masseter muscle. The goal of this study is to emphasize the importance of undertaking comprehensive exploration of the historical literature before asserting primacy of an anatomical discovery., Methods: A search was conducted of historical texts describing the anatomical structure of the masseter muscle, spanning the 18th, 19th, and early 20th centuries. Historical sources were obtained via Google Books, the Internet Archive, and the digital collections of Stanford Lane Library Medical History Center, Paris University Numerical library Medica (France), and the State Library of Bavaria (Germany). Contemporary anatomical studies were identified via PUBMED search RESULTS: Rather than a "first description" of newly discovered anatomical feature, the paper we comment upon has added important anatomical details of the length, width, thickness, and fiber orientation of coronoid portion of the deep layer of the masseter. As early as the 18th century, anatomists had described the masseter as possessing a three rather than two-layer structure with a deep layer which inserts on the coronoid process., Discussion: Assertions of primacy (ie. "first description") of an anatomical structure in the 21st century necessitates a diligent search of literature, including sources which were published during the era when anatomical studies reigned supreme at the forefront of medical science. Systematic scanning of historical medical material has made older texts widely and freely available and digital translation tools have helped to remove language barriers. It is important to study original articles as secondary citations of historical material are less reliable. Without rigorous historical investigation, assertions of primacy cannot be made with confidence., Competing Interests: Conflicts of Interest Neither author has a relevant conflict of interest., (Copyright © 2022 Elsevier GmbH. All rights reserved.)

Petroclival meningiomas are extremally challenging lesions due to their deep location and close relation to critical neurovascular structures. Several approaches have been described to achieve gross-total resection with low morbidity and mortality. In this 2-dimensional operative video, the authors show a simultaneous combined transpetrosal approach. The patient is a 44-year-old woman with an 8-month history of gait imbalance with evidence of a giant petroclival meningioma on neuroimaging. She underwent a combined middle fossa approach with anterior petrosectomy and retrosigmoid/retrolabyrinthine approach to achieve gross-total tumor resection. The postoperative course was characterized by trigeminal neuralgia, and neuroimaging showed gross-total resection of the tumor. The video can be found here: https://stream.cadmore.media/r10.3171/2022.1.FOCVID21248., Competing Interests: Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this publication.The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this publication., (© 2022, The Authors.)

Background: To better counsel vestibular schwannoma patients, it is necessary to understand the tumor control rates of stereotactic radiosurgery (SRS)., Objectives: To determine tumor control rates, factors determining control and complication rates following SRS., Methods: Tertiary hospital retrospective cohort., Results: 579 tumors (576 patients) were treated with SRS. 477 tumors (474 patients, 82%) had ≥1 year follow up and 60% (344) ≥3 years follow up. 88% of tumors had primary SRS and 6.7% salvage SRS. Median follow up time was 4.6 years. At 3 years, the tumor control rate of primary SRS was 89% (258 of 290) in sporadic tumors compared to 43% in Neurofibromatosis type II (3 of 17) (p < 0.01). Our bivariable survival data analysis showed that Neurofibromatosis type II, documented pre-SRS growth, tumor measured by maximum dimension, SRS given as nonprimary treatment increased hazard of failure to control. There was one case of malignancy and another of rapid change following intra-tumoral hemorrhage. For tumors undergoing surgical salvage (25 of 59), 56% had a total or near-total resection, 16% had postoperative CSF leak, with 12% new facial paralysis (House-Brackmann grade VI) and worsening of facial nerve outcomes (House-Brackmann grade worse in 59% at 12 mo)., Conclusions: Control of vestibular schwannoma after primary SRS occurs in the large majority. Salvage surgical treatment was notable for higher rates of postoperative complications compared to primary surgery reported in the literature., Competing Interests: Iris C Gibbs receives honoraria for lectures from Accuray, Inc. All other authors report no conflict of interest concerning the materials or methods in this study or the findings specified in this paper., (Copyright © 2021, Otology & Neurotology, Inc.)

Competing Interests: Competing interests: None declared.

Objectives: Two pilot studies of AR-42, a pan-histone deacetylase inhibitor, in human neurofibromatosis type 2 (NF2), vestibular schwannomas (VS), and meningiomas are presented. Primary endpoints included safety, and intra-tumoral pharmacokinetics (PK) and pharmacodynamics (PD)., Methods: Pilot 1 is a subset analysis of a phase 1 study of AR-42 in solid tumors, which included NF2 or sporadic meningiomas. Tumor volumes and treatment-related adverse events (TRAEs) are reported (NCT01129193).Pilot 2 is a phase 0 surgical study of AR-42 assessing intra-tumoral PK and PD. AR-42 was administered for 3 weeks pre-operatively. Plasma and tumor drug concentrations and p-AKT expression were measured (NCT02282917)., Results: Pilot 1: Five patients with NF2 and two with sporadic meningiomas experienced a similar incidence of TRAEs to the overall phase I trial. The six evaluable patients had 15 tumors (8 VS, 7 meningiomas). On AR-42, tumor volume increased in six, remained stable in eight, and decreased in one tumor. The annual percent growth rate decreased in eight, remained stable in three, and increased in four tumors. Pilot 2: Four patients with sporadic VS and one patient with meningioma experienced no grade 3/4 toxicities. Expression of p-AKT decreased in three of four VS. All tumors had higher AR-42 concentrations than plasma., Conclusions: AR-42 is safe. Tumor volumes showed a mixed response, but most slowed growth. On a 40-mg regimen, drug concentrated in tumors and growth pathways were suppressed in most tumors, suggesting this may be a well-tolerated and effective dose. A phase 2 study of AR-42 for NF2-associated tumors appears warranted., Level of Evidence: 1b, 4., Competing Interests: D. Bradley Welling is a consultant for CereXis, Science 24/7, NFBio, NF2 Biosolutions, and Mulberry Bio. Craig C. Hofmeister has received research grants from Takeda and Oncolytics Biotech; research and personal grants from Janssen, BMS, Sanofi, Nektar, Karyopharm, Imbrium, and Oncopeptides, all outside the submitted work. Amir Mortazavi is on the advisory board for Seattle Genetics and Pfizer and is on the scientific advisory board for Debiopharm Group. His institution (but not him) has received research funding from Acerta Pharma, Genentech, Roche, Merck, Novartis, Seattle Genetics, Astellas Pharma, Mirati Therapeutics, and Bristol‐Myers Squibb. The other authors declare no potential conflict of interest. The Ohio State University (OSU) holds the patent on the investigational drug AR‐42 (US 10/597022). The Technology Commercialization Office has licensed AR‐42 (now called REC‐2282) to Recursion Pharmaceuticals using the institution's standard terms, conditions, and approval process, in which no author participated. To assure absence of institutional conflict of interest in assessment of response and attribution of toxicity, both were reviewed by the Cancer Therapy Evaluation Program of the National Cancer Institute prior to reporting results for the phase I study. Safety issues related to dose increases and attribution of response were monitored by The OSU Data Safety Monitoring Committee and The OSU Cancer Center Institutional Review Board for the phase 1 pilot. A separate Data Safety and Monitoring Board of Massachusetts Eye and Ear oversaw pilot study 2., (© 2021 The Authors. Laryngoscope Investigative Otolaryngology published by Wiley Periodicals LLC on behalf of The Triological Society.)

Objectives/hypothesis: From the 1970s-1990s the U.S. Smokeless Tobacco Company (USST) conducted aggressive campaigns to solicit college students to buy their smokeless tobacco (ST) products. The scope, scale, methods, and impact of this youth marketing campaign have yet to be analyzed in the academic literature., Study Design: Historical research study., Methods: Internal industry documents describing the USST campaigns were obtained via the University of California, San Francisco's repository of tobacco company records. Marketing materials were obtained from Stanford University's Research Into the Impact of Tobacco Advertising (SRITA) collection of 657 USST advertisements., Results: USST's College Marketing Program (1978-mid 1980s) sponsored events in some 350 campuses and hired student representatives in at least 175 colleges and universities across America. College representatives were trained to provide free samples to fellow students. Over a typical school year approximately a quarter million Happy Days, Skoal, and Skoal Bandits samples were handed out to undergraduates. USST paid their student representatives well and offered them a variety of incentives based upon sales growth. During the 1990s, USST's Skoal Music program engaged students on campuses and at "spring break" venues such as Daytona Beach., Conclusions: Targeting of college students on campus was a common tobacco industry practice between the 1940s and early 1960s. From the 1970s through 1990s USST resurrected the method and pursued it with vigor including: distribution of free samples; sponsored events and concerts, branded intramural teams; visits by sports celebrities; logo wearables and merchandise; contests and incentives; and displays and promotions in stores on and surrounding campuses. Laryngoscope, 131:E1860-E1872, 2021., (© 2021 American Laryngological, Rhinological and Otological Society Inc, "The Triological Society" and American Laryngological Association (ALA).)

Objectives: To investigate tumor control rate and hearing outcomes following stereotactic radiosurgery (SRS) for vestibular schwannoma (VS) cases with perfect (100%) word recognition score (WRS)., Study Design: A retrospective cohort study., Setting: Tertiary referral center., Patients: Inclusion criteria were receiving primary SRS, a pretreatment WRS of 100%, and availability of both pre- and posttreatment audiometric data for evaluation., Intervention: SRS delivered by Cyberknife., Main Outcome Measures: Tumor growth rates and audiological outcomes after SRS., Results: The cohort consisted of 139 patients, with more than 1-year follow-up (mean 6.1 yrs). SRS tumor control rate was 87% for the whole cohort. Growth before SRS was documented in 24% (n = 34 of 139). The proportion of sporadic VS cases who maintained hearing (decline <10 dB of pure-tone audiometry or <20% of WRS) at 3 years was 50%, at 5 years was 45%, and at 10 years was 42%. In multivariate analysis, increased age was found to be predictive of increased hearing loss (p = 0.03), while the following factors were shown not to be significant: sex (p = 0.5), tumor size (p = 0.2), pre-SRS tumor growth (p = 0.5), and target volume (p = 0.42)., Conclusions: Among patients with VS who had perfect WRS and underwent SRS, the overall tumor control rate was 87% comparable to observation. Hearing maintenance and preservation of "serviceable" hearing rates after 5 years in VS patients with perfect WRS treated by SRS is less than that when comparing to similar observation cohorts. Given this finding we do not advocate using SRS to preserve hearing, over observation, in tumors with perfect WRS., Competing Interests: The authors disclose no conflicts of interest., (Copyright © 2020, Otology & Neurotology, Inc.)

Objectives: The post-traumatic ear deformity, known today as cauliflower ear, has been described since antiquity. It has long been associated with pugilistic sports (wrestling, boxing) as well as among the mentally ill. The aim of this study is to present the various terms used since antiquity to describe these traumatic deformations of the auricle and to trace the origin of the modern moniker "cauliflower ear.", Methods: Historical study, only based on original documentation accessed through personal libraries and universities repositories, completed with online sources and etymological dictionaries., Results: We were able to identify no fewer than 39 names for the deformity. The term cauliflower ear is of relatively recent origin. It was coined in the first decade of the 20th century, initially in the popular press and subsequently adopted by the medical profession., Conclusion: Ironically, the deformity has only superficial resemblance to a cauliflower. The vegetable, which is part of the cabbage family, has a symmetrical and highly ordered fractal geometry with well-circumscribed excrescences. Cauliflower ear, by contrast, notably lacks symmetry and its rounded protuberances flow into one another. Although somewhat a misnomer, the term is deeply rooted in both popular and medical culture., Level of Evidence: N/A Laryngoscope, 131:E1315-E1321, 2021., (© 2020 American Laryngological, Rhinological and Otological Society Inc, "The Triological Society" and American Laryngological Association (ALA).)

Lack of ergonomic training and poor ergonomic habits during the operation leads to musculoskeletal pain and affects the surgeon's life outside of work. The objective of the study was to evaluate the severity of ergonomic hazards in the surgical profession across a wide range of surgical subspecialties. We conducted intraoperative observations using Rapid Entire Body Assessment (REBA) score system to identify ergonomic hazards. Additionally, each of the ten surgical subspecialty departments were sent an optional 14 question survey which evaluated ergonomic practice, environmental infrastructure, and prior ergonomic training or education. A total of 91 surgeons received intraoperative observation and were evaluated on the REBA scale with a minimum score of 0 (low ergonomic risk <3) and a maximum score of 10 (high ergonomic risk 8-10). And a total of 389 surgeons received the survey and 167 (43%) surgeons responded. Of the respondents, 69.7% reported suffering from musculoskeletal pain. Furthermore, 54.9% of the surgeons reported suffering from the highest level of pain when standing during surgery, while only 14.4% experienced pain when sitting. Importantly, 47.7% stated the pain impacted their work, while 59.5% reported pain affecting quality of life outside of work. Only 23.8% of surgeons had any prior ergonomic education. Both our subjective and objective data suggest that pain and disability induced by poor ergonomics are widespread among the surgical community and confirm that surgeons rarely receive ergonomic training. Intraoperative observational findings identified that the majority of observed surgeons displayed poor posture, particularly a poor cervical angle and use of ergonomic setups, both of which increase ergonomic risk hazards. This data supports the need for a comprehensive ergonomic interventional program for the surgical team and offers potential targets for future intervention., Competing Interests: The authors have declared that no competing interests exist.

: 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.

Many college campuses now prohibit tobacco use. At a private U.S. university, the current study assessed cigarette and e-cigarette use and characterized the climate for adopting a comprehensive tobacco-free policy. Data were gathered January-August 2018 via an: environmental scan; cigarette-urn audit; and representative surveys with campus community members. Despite low prevalence of tobacco (0.5%-8%) and e-cigarette use (0.9%-6%) among all groups, campus cigarette clean-up costs exceeded $114,000 for an estimated >1 million butts left on campus annually. A majority of respondents (63% of N = 2218) favored a campus-wide tobacco-free policy, 16% opposed, and 21% abstained. Most respondents endorsed benefits of supporting health (93%), ensuring tobacco-free air to breathe (92%), reducing litter (88%), preventing tobacco use (84%) and fires (83%), and helping tobacco users quit (65%). Identified challenges included policy enforcement (69%) and stigmatization of smoking (57%); 30% viewed a policy as compromising personal freedoms. In a model explaining 35% of variance in policy support, those more likely to favor comprehensive tobacco-free campus policy were Asian respondents; diagnosed with asthma; exposed to secondhand smoke on campus; who viewed campus cigarette butt litter as problematic; and identified health, prevention, and cessation benefits of a tobacco-free campus. Those less likely in favor were students, those who smoke, and those perceiving impingement upon personal freedoms, stigmatization, and broader (slippery slope) implications. Findings indicate low tobacco use prevalence among the campus community, yet a large volume of butt litter and high tobacco clean-up costs. Predictors of policy support can inform campus outreach efforts., Competing Interests: Disclosures Dr. Prochaska has served as an expert witness against the tobacco companies in lawsuits and has provided consultation to pharmaceutical and technology companies that make medications and other treatments for quitting smoking. No other authors have disclosures to report related to this work., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: To compare outcomes in otolaryngology between overlapping and nonoverlapping surgeries., Study Design: Retrospective cohort study., Setting: Tertiary referral center., Subjects and Methods: All patients undergoing otolaryngologic procedures at Stanford University Hospital between January 2009 and June 2016 were included (n = 13,479). Cases were divided into 2 cohorts: overlapping (n = 1806, 13.4%) vs nonoverlapping (n = 11,673, 86.6%). Variables reviewed were type of operation performed, multidisciplinary team involvement, complications, reoperations, readmissions, and deaths., Results: The total complication rate over 7.5 years studied was 3.3% (n = 450). Complication rates were lower for overlapping cases (0.77%) compared to nonoverlapping cases (3.73%) with an odds ratio of 0.2014, which was statistically significant ( P < .0001). When examined by subspecialty, the complication rate for rhinology and endoscopic skull base procedures was approximately 10 times lower when overlapping (0.30%) was compared to nonoverlapping (3.15%), with an odds ratio of 0.094 ( P = .0001). There was no difference in complication rates for other surgical subspecialties. There were no deaths associated with overlapping surgery. The rate of major complications requiring reoperation was similarly lower for overlapping procedures (0.276%) compared to nonoverlapping procedures (1.35%) with an odds ratio of 0.2023 ( P = .0004). Readmission rates were lower for overlapping cases (0.49%) when compared to nonoverlapping cases (1.09%), with an odds ratio of 0.4553 ( P = .0229)., Conclusions: Patients undergoing overlapping surgery had lower overall complication rates, lower reoperation rates, lower readmission rates, and no mortalities. The institutional experience presented provides evidence that with appropriate patient and case selection, otolaryngologists may safely perform overlapping surgery without increased risk of adverse patient outcomes.

Objective: To estimate the prevalence and significance of cranial nerve (CN) imaging abnormalities in patients with hereditary neuropathy and discuss clinical implications., Methods: We retrospectively analyzed data from patients at four tertiary academic medical centers with hereditary neuropathy diagnoses who had undergone gadolinium-enhanced magnetic resonance imaging (MRI) of the brain or skull base between 2004 and 2018. MRI scans, as well as computed tomography imaging when available, were reviewed and bivariable analysis was performed to identify predictors of CN abnormalities on imaging., Results: Among 39 patients meeting study criteria, 11 had clinical CN deficits (28%) and 8 had CN abnormalities on imaging (21%). Of the patients with CN abnormalities on imaging, half had CN deficits (4/8) and only a quarter had imaging abnormalities of the CNs with the deficits (2/8). Imaging abnormalities were found in varied CNs, including CNs III, V, VII, and the VII/VIII complex in the internal auditory canal. MRI obtained for the purpose of evaluating CN deficits had a statistically significant increased likelihood of containing CN imaging abnormalities. However, CN deficits themselves were not predictive of imaging abnormalities., Conclusion: Thickening and enhancement of CNs on MRI may be found in approximately 1/5 of patients with hereditary neuropathies and are inconsistently associated with clinical deficits. These imaging findings should not be mistaken for neoplastic and infectious processes as they may be manifestations of the patients' underlying genetic neuropathy., Level of Evidence: 4., (© 2020 The Authors. Laryngoscope Investigative Otolaryngology published by Wiley Periodicals, Inc. on behalf of The Triological Society.)

Objective: Until recently, purveyors of vaping products marketed e-liquids in the 1%-3% range of nicotine concentration with those at 3% described as 'super high' intended for two packs/day smokers. The goal of this study is to evaluate the degree to which JUUL, with its 5% nicotine and 75% US market share, has spurred other e-liquid vendors to raise the nicotine levels of their products., Methods: Online search to identify brands offering e-liquid in exceptionally high nicotine concentration (≥5%) and to catalogue the appearance of devices which emulate JUUL., Results: JUUL compatible pods (14) and JUUL knock off devices (39) were identified which offer equal or higher nicotine than JUUL. More than 70 e-liquid brands sell high-nicotine products (≥5%) in bulk (≥30 mL) equivalent to >40 cigarette packs. All of these products come in multiple youth appealing sweet and fruity flavours. It was noted that nicotine percentage is inconsistently reported (eg, JUUL is 5% by weight vs 5.9% by volume)., Conclusions: JUUL has triggered a widespread rush among aerosol purveyors to market e-liquid in unprecedentedly high nicotine concentrations. The rapidly rising popularity of high-nicotine e-liquids threatens to addict a generation of youth. When sold in large quantity bottles (eg, 30 mL) they represent a childhood poisoning risk. Labelling of nicotine concentration in e-liquids needs to be standardised to avoid consumer confusion. The addictiveness and toxicity of these products makes it imperative that regulators act swiftly to enact protective measures., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: An understanding of the hearing outcomes is needed for treatment counseling for patients with vestibular schwannomas (VS)., Objective: To determine long-term hearing results following stereotactic radiosurgery (SRS) for VS and identify any influential variables., Methods: Tertiary hospital retrospective cohort., Results: There were 579 tumors (576 patients) treated with SRS. Eighty-two percent (473) of tumors had ≥1 yr and 59% (344 ≥3 yr follow-up. In the 244 tumor ears, with measurable hearing before SRS who were followed ≥1 yr, 14% (31) had improved hearing, 13% (29) unchanged hearing, and 74% (158) had worsened hearing. In 175 patients with ≥3 yr follow-up and who had measurable hearing pretreatment, 6% (11 ears) improved hearing, 31% (54 ears) unchanged hearing, and 63% (110 ears) had worsened hearing. Patients with tumors with larger target volumes (P = .040) and with neurofibromatosis type 2 (NF2; P = .017) were associated with poorer hearing (P = .040). Patients with word recognition scores (WRS) of 50% or poorer had tumors with a larger volume (P = .0002), larger linear size (P = .032), and NF2 (P = .045). Traditionally reported hearing outcomes using the Gardner Robertson maintenance of PTA ≤50 db or WRS ≥50% were 48% at 3 yr, which overestimates hearing outcomes compared to the above reporting standards., Conclusion: Hearing declines over time in VS treated with SRS in a high proportion of cases. The frequency and magnitude of long-term hearing decline following SRS argues against prophylactic radiation for small tumors in hearing ears with undetermined growth behavior., (Copyright © 2018 by the Congress of Neurological Surgeons.)

Background: The field of otology is increasingly at the forefront of innovation in science and medicine. The inner ear, one of the most challenging systems to study, has been rendered much more open to inquiry by recent developments in research methodology. Promising advances of potential clinical impact have occurred in recent years in biological fields such as auditory genetics, ototoxic chemoprevention and organ of Corti regeneration. The interface of the ear with digital technology to remediate hearing loss, or as a consumer device within an intelligent ecosystem of connected devices, is receiving enormous creative energy. Automation and artificial intelligence can enhance otological medical and surgical practice. Otology is poised to enter a new renaissance period, in which many previously untreatable ear diseases will yield to newly introduced therapies., Objective: This paper speculates on the direction otology will take in the coming decades., Conclusion: Making predictions about the future of otology is a risky endeavour. If the predictions are found wanting, it will likely be because of unforeseen revolutionary methods.

Objectives: The Clinical Practice Guideline of the American Academy of Otolaryngology-Head & Neck Surgery (2014) stated that clinicians should not recommend dietary supplements for the treatment of tinnitus. The aim of this study is to characterize over-the-counter tinnitus remedies (OTCTR) on the U.S. market, describe the ingredients and prices, and characterize the methods of promoting these products., Methods: OTCTR were identified via Web search and visits to retail establishments. Information was collected regarding OTCTR chemical composition, product labeling, advertisements and marketing, price, and customers reviews., Results: A wide array of unproven OTCTR exist on today's market. All make unfounded claims of relief from ear ringing. Most of the products considered in this study consist of mixtures of inexpensive and common vitamins, minerals, and/or herbs sold at a premium compared to similar preparations not expressly advertised for tinnitus. Certain brands, most notably Arches Tinnitus Formula (Arches Natural Products Inc., Salt Lake City, UT) and Lipo-Flavonoid (Clarion Brands Inc., Solon, OH), target otolaryngologists by advertising in specialty journals and prominently featuring supposed endorsement by "Ear-Nose-and-Throat Doctors" in their marketing., Conclusion: It is important for otolaryngologists who are caring for tinnitus sufferers to be aware that a robust and diverse market exists for unproven OTC tinnitus remedies. It is troubling that heavily advertised brands profess support by otolaryngologists. Responsible specialty organizations in the field should consider opposing such commercially motivated representations. Otolaryngology journals may wish to adopt a policy along the lines of The Journal of the American Medical Association publications to decline advertisements of dietary supplements that make unproven therapeutic claims., Level of Evidence: 5 Laryngoscope, 129:1898-1906, 2019., (© 2018 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: To evaluate the presence of postural-related strain and musculoskeletal discomfort, along with the level of ergonomics training and the availability of ergonomic equipment among otolaryngology surgeons., Study Design: Intraoperative observations and survey study., Methods: Using the Rapid Entire Body Assessment score system to identify ergonomic hazards, we conducted intraoperative observations assessing operating room personnel during different otolaryngological subspecialty procedures. Based on these findings, otolaryngology surgeons at a single academic institution in the United States were sent a survey that evaluated ergonomic practice, environmental infrastructure, and prior ergonomic training or education., Results: A response rate of 69% was obtained from 70 surgeons, with 72.9% of responding surgeons suffering from some level of back pain, with cervical spine pain being the most common. Interestingly, residents were equally affected when compared to more senior surgeons both in subjective survey reports and from observational risk analysis. Furthermore, 43.8% of surgeons reported suffering from the highest level of pain when standing, whereas only 12.5% experienced pain when sitting. Importantly, 10% stated that pain impacted their work. Only 24% of surgeons had any prior ergonomic training or education., Conclusions: Our data suggest that pain and disability induced by poor ergonomics are widespread among the otolaryngology community and confirm that surgeons rarely receive ergonomic training in the surgical context. Additionally, intraoperative observational findings identified that the majority of observed surgeons display poor posture, particularly a poor cervical angle and use of ergonomic setups, both of which increase ergonomic risk hazard. These data provide guidance for future interventional studies., Level of Evidence: NA Laryngoscope, 129:370-376, 2019., (© 2018 The American Laryngological, Rhinological and Otological Society, Inc.)

Background: Facebook has a comprehensive set of policies intended to inhibit promotion and sales of tobacco products. Their effectiveness has yet to be studied., Methods: Leading tobacco brands (388) were identified via Nielsen and Ranker databases and 108 were found to maintain brand-sponsored Facebook pages. Key indicators of alignment with Facebook policy were evaluated., Results: Purchase links (eg, 'shop now' button) on brand-sponsored pages were found for hookah tobaccos (41%), e-cigarettes (74%), smokeless (50%) and cigars (31%). Sales promotions (eg, discount coupons) were present in hookah tobacco (48%), e-cigarette (76%) and cigar (69%) brand-sponsored pages. While conventional cigarettes did not maintain brand-sponsored pages, they were featured in 80% of online tobacco vendors' Facebook pages. The requirement for age gating, to exclude those <18 from viewing tobacco promotion, was absent in hookah tobacco (78%), e-cigarette (62%) and cigar (21%) brand-sponsored pages and for 90% of online tobacco stores which promote leading cigarette brands (eg, Marlboro, Camel). Many of the brand-sponsored tobacco product pages had thousands of 'likes'., Conclusions: It is laudable that Facebook has policies intended to interdict tobacco promotion throughout its platform. Nevertheless, widespread tobacco promotion and sales were found at variance with the company's policies governing advertising, commerce, page content and under age access. Vetting could be improved by automated screening in partnership with human reviewers., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2019. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Background: Some consumers wish to use vapour devices discreetly so that family members, teachers and coworkers do not recognise their use of nicotine or t etrahydrocannabinol (THC) laden vapour., Methods: Stealthy vapour devices, as well as low-odour and low-vapour e-juices, were identified via a comprehensive online search between March and June 2018., Results: As evidence of their popularity, a search for 'stealth vaping' on YouTube found 18 200 videos. A variety of cleverly designed vapour devices disguised as USB sticks, pens, remote controls, car fobs, smart phones, sweatshirt drawstrings and even asthma inhalers are on the market. JUUL, which resembles a USB stick, is the archetype of these devices and is especially popular among youth. A search of 'JUUL' on YouTube yielded 148 000 videos with 57 videos having >100 000 views. Searches on 'JUUL at school' (15 500), 'JUUL in class' (6840), 'hiding JUUL in school ' (2030) and 'JUUL in school bathroom' (1040) illustrate the product's popularity among students. Some e-juices promote themselves as having low visibility plumes while others profess to be of subtle odour to avoid detection. Numerous techniques have been described to hide the exhaled vapour plume such as by swallowing it or blowing it into one's clothing or into a backpack., Conclusions: The vaping industry has demonstrated much ingenuity in devising discreet vaporisers and de-emphasising exhaled vapour plumes and their aroma. The US market for vaping devices with stealthy characteristics is anything but inconspicuous, with JUUL alone accounting for 70.5% of sales (July 2018)., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2018. No commercial re-use. See rights and permissions. Published by BMJ.)

Background and Aim: During the mid-20th century tobacco companies placed advertisements in medical journals to entice physicians to smoke their brand and, more importantly, to recommend it to their patients. They have been little studied, in part because advertising sections in medical journals are almost universally discarded before binding. This study aimed to define the themes and techniques used in doctor-targeted tobacco advertisements that appeared in American medical journals in the mid-20th century and determine the motivations and tactics of the tobacco industry in engaging the medical profession in this way., Methods: Doctor-targeted tobacco advertisements from JAMA and the New York State Medical Journal appearing between 1936 and 1953 were studied. These were obtained from the New York Academy of Medicine and the UCSF Truth database of tobacco industry documents. Content analysis of advertising slogans and imagery was conducted. Using internal tobacco industry documents, we examined the relationship between tobacco advertisers and medical journals., Results: Among the 519 doctor-targeted advertisements, 13 brands were represented, with two (Philip Morris and Camel) accounting for 84%. Correspondence between tobacco advertisers and medical journal editors reveals the potent influence of revenue to the sponsoring society and personal compensation derived from consulting arrangements. Content analysis of the advertisements revealed much flattery of doctors and arguments professing the harmlessness of the company's brand., Conclusions: Analysis of doctor-targeted tobacco advertisements in American medical journals from 1936 to 1953 suggest that tobacco companies targeted physicians as a potential sales force to assuage the public's fear of health risks and to recruit them as allies against negative publicity. Tobacco companies also appeared to try, through the substantial advertising revenue passed by journals to their parent medical societies, to temper any possible opposition by organized medicine., (© 2018 Society for the Study of Addiction.)

Background: Noise-induced hearing loss is one of the most common occupational hazards in the United States. Several studies have described noise-induced hearing loss in patients following mastoidectomy. Although otolaryngologists care for patients with noise-induced hearing loss, few studies in the English literature have examined surgeons' occupational risk., Methods: Noise dosimeters and sound level meters with octave band analyzers were used to assess noise exposure during drilling of temporal bones intraoperatively and in a lab setting. Frequency specific sound intensities were recorded. Sound produced using burrs of varying size and type were compared. Differences while drilling varying anatomic structures were assessed using drills from two manufacturers. Pure tone audiometry was performed on 7 to 10 otolaryngology residents before and after a temporal bone practicum to assess for threshold shifts., Results: Noise exposure during otologic drilling can exceed over 100 dB for short periods of time, and is especially loud using large diameter burrs > 4 mm, with cutting as compared with diamond burrs, and while drilling denser bone such as the cortex. Intensity peaks were found at 2.5, 5, and 6.3 kHz. Drilling on the tegmen and sigmoid sinus revealed peaks at 10 and 12.5 kHz. No temporary threshold shifts were found at 3 to 6 kHz, but were found at 8 to 16 kHz, though this did not reach statistical significance., Conclusion: This article examines noise exposure and threshold shifts during temporal bone drilling. We were unable to find previous descriptions in the literature of measurements done while multiple people drilling simultaneously, during tranlabyrinthine surgery and a specific frequency characterization of the change in peach that appears while drilling on the tegmen. Hearing protection should be considered, which would still allow the surgeon to appreciate pitch changes associated with drilling on sensitive structures and communication with surgical team members. As professionals who specialize in promoting the restoration and preservation of hearing for others, otologic surgeons should not neglect hearing protection for themselves.

Background: In 2009, the Food and Drug Administration (FDA) banned characterising flavours in cigarettes (except for menthol) due to their appeal to teen starter smokers. In August 2016, the agency deemed all tobacco products to be under its authority and a more comprehensive flavour ban is under consideration., Objectives: To determine the scope and scale of alcohol-flavoured tobacco products among cigars & cigarillos, hookahs and electronic cigarettes (e-cigarettes)., Methods: Alcohol-flavoured tobacco products were identified by online search of tobacco purveyors' product lines and via Google search cross-referencing the various tobacco product types versus a list of alcoholic beverage flavours (eg, wine, beer, appletini, margarita)., Results: 48 types of alcohol-flavoured tobacco products marketed by 409 tobacco brands were identified. Alcohol flavours included mixed drinks (n=25), spirits (11), liqueurs (7) and wine/beer (5). Sweet and fruity tropical mixed drink flavours were marketed by the most brands: piña colada (96), mojito (66) and margarita (50). Wine flavours were common with 104 brands. Among the tobacco product categories, brands offering alcohol-flavoured e-cigarettes (280) were most numerous, but alcohol-flavoured products were also marketed by cigars & cigarillos (88) and hookah brands (41). Brands by major tobacco companies (eg, Philip Morris, Imperial Tobacco) were well represented among alcohol-flavoured cigars & cigarillos with five companies offering a total of 17 brands., Conclusions: The widespread availability of alcohol-flavoured tobacco products illustrates the need to regulate characterising flavours on all tobacco products., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Purpose: To review contributions of the American Otological Society (AOS) over the most recent quarter century (1993-2018) and to comment on possible future evolution of the field during the quarter century to come., Methods: Retrospective review of selected topics from the AOS transactions, distinguished lectureships over the past 25 years, and selective reflection by the authors. Speculation on potential advances of the next quarter century derived from emerging topics in the current literature and foreseeable trends in science and technology are also proffered for consideration (and possible future ridicule)., Results: Integration of multiple disciplines including bioengineering, medical imaging, genetics, molecular biology, physics, and evidence based medicine have substantially benefitted the practice of otology over the past quarter century. The impact of the contributions of members of the AOS in these developments cannot be over estimated., Conclusions: Further scientific advancement will certainly accelerate change in the practice of otologic surgery and medicine over the coming decade in ways that will be marvelous to behold.

Objective: To describe the manner in which hearing was evaluated in American Otological Practice during the late 19th and early 20th centuries before introduction of the electric audiometer., Methods: Primary sources were the Transactions of the American Otological Society and American textbooks, especially those authored by Presidents of the Society., Results: In the era before electric audiometry multiple methods were used for evaluating the thresholds of different frequencies. Tuning forks were important for lower frequencies, whisper, and speech for mid-frequencies, and Galton's whistle and Konig's rod evaluated high frequencies. Hearing threshold was often recorded as in terms of duration of a sound, or distance from the source, rather than intensity. Hearing ability was often recorded a fraction, for example, with the distance a watch tick could be heard over the distance of a normal hearing individual. A variety of devices, such as Politzer's Acoumeter, attempted to deliver sound in a calibrated manner, thus enhancing the accuracy and reproducibility of test results., Conclusion: The early years of the American Otological Society were marked by a number of ingenious efforts to standardize hearing assessment despite the technical limitations. These efforts facilitated the development of the audiometer, and continue to influence clinical practice even today.