The future of otology

Neurotology Workforce in the United States: Gender Diversity and Geographic Distribution

OBJECTIVE

The workforce of neurotology has changed with increasing numbers of accredited programs and diverse representation among trainees over the past several decades. This study aims to describe the characteristics, density, and geographic variation of the current neurotology workforce in the United States.

STUDY DESIGN

Cross-sectional study.

SETTING

American Board of Otolaryngology-Head and Neck Surgery portal and online search.

METHODS

The study cohort included physicians certified in Neurotology by the American Board of Otolaryngology as of 2021 (n = 372). Physician characteristics including years of practice, gender, practice setting, and location were collected. Geographic variation analysis was performed by the state, county, and hospital referral region. Associations between the number of neurotologists per population and socioeconomic characteristics were assessed using multivariable regression analysis.

RESULTS

Among 372 neurotologists, 65% practiced in academic settings and 13% were female. The percentage of female neurotologists increased from 0% among neurotologists with ≥30 years of practice to 23% among <10 years of practice. There were no differences in a practice setting by gender. The geographical analysis demonstrated that the average number of neurotologists was 1.1 per 1 million Americans. In a multivariable model, the density of neurotologists was significantly higher within counties with the highest quartiles of college education (β = .6 [95% confidence interval, CI: 0.3-0.8]) and income (β = .3 [95% CI: 0.1-0.6]).

CONCLUSION

The number of board-certified neurotologists has gradually increased and there have been trends toward greater gender diversity. The geographical distribution of neurotology practice was concentrated in counties with higher socioeconomic status as expected given the referral-based nature of the subspecialty. There should be efforts to reach out to low socioeconomic communities to ensure equivalent access to neurotological care.

Insights into Inner Ear Function and Disease Through Novel Visualization of the Ductus Reuniens, a Seminal Communication Between Hearing and Balance Mechanisms

The sensory end-organs responsible for hearing and balance in the mammalian inner ear are connected via a small membranous duct known as the ductus reuniens (also known as the reuniting duct (DR)). The DR serves as a vital nexus linking the hearing and balance systems by providing the only endolymphatic connection between the cochlea and vestibular labyrinth. Recent studies have hypothesized new roles of the DR in inner ear function and disease, but a lack of knowledge regarding its 3D morphology and spatial configuration precludes testing of such hypotheses. We reconstructed the 3D morphology of the DR and surrounding anatomy using osmium tetroxide micro-computed tomography and digital visualizations of three human inner ear specimens. This provides a detailed, quantitative description of the DR's morphology, spatial relationships to surrounding structures, and an estimation of its orientation relative to head position. Univariate measurements of the DR, inner ear, and cranial planes were taken using the software packages 3D Slicer and Zbrush. The DR forms a narrow, curved, flattened tube varying in lumen size, shape, and wall thickness, with its middle third being the narrowest. The DR runs in a shallow bony sulcus superior to the osseus spiral lamina and adjacent to a ridge of bone that we term the "crista reuniens" oriented posteromedially within the cranium. The DR's morphology and structural configuration relative to surrounding anatomy has important implications for understanding aspects of inner ear function and disease, particularly after surgical alteration of the labyrinth and potential causative factors for Ménière's disease.

Bioinformatic Analysis of the Perilymph Proteome to Generate a Human Protein Atlas

The high complexity of the cellular architecture of the human inner ear and the inaccessibility for tissue biopsy hampers cellular and molecular analysis of inner ear disease. Sampling and analysis of perilymph may present an opportunity for improved diagnostics and understanding of human inner ear pathology. Analysis of the perilymph proteome from patients undergoing cochlear implantation was carried out revealing a multitude of proteins and patterns of protein composition that may enable characterisation of patients into subgroups. Based on existing data and databases, single proteins that are not present in the blood circulation were related to cells within the cochlea to allow prediction of which cells contribute to the individual perilymph proteome of the patients. Based on the results, we propose a human atlas of the cochlea. Finally, druggable targets within the perilymph proteome were identified. Understanding and modulating the human perilymph proteome will enable novel avenues to improve diagnosis and treatment of inner ear diseases.

Automated detection of electrically evoked stapedius reflexes (eSR) during cochlear implantation

Introduction

In cochlear implantation, objective fitting methods are needed to optimize audiological results in small children or patients with poor compliance. Intraoperatively measured electrically evoked stapedius reflexes (eSR) can be used as a marker for the patient’s discomfort level. The aim of this study was to develop and evaluate an automated detection method for eSR and to compare it to the detection rate of the surgeon and independent observers.

Methods

Cochlear implantation using a fully digital surgical microscope was performed. Movements of the stapedius tendon were recorded and analyzed by means of computer vision technique. Differences in eSR elicited by stimulating electrodes at different cochlear locations (basal, middle and apical) were analyzed. The eSR detection rate of the image processing algorithm was compared to the surgeon’s detection rate and to those of two less experienced observers.

Results

A total of 387 electrically impulses were applied. The stimulation of middle turn electrodes showed significantly higher detection rates (50.4%) compared to the basal (40.0%; p = 0.001) and apical (43.6%; p = 0.03) turn. The software identified significantly more of the applied stimuli (58.4%) compared to the surgeon (46.3%; p = 0.0007), the intermediate observer (37.7%; p < 0.0001) and the unexperienced observer (41.3%; p < 0.0001).

Conclusion

The feasibility of an automated intraoperative software-based detection of eSR is demonstrated. By improving the eSR detection methods and their clinical applicability, their utility in objective cochlear implant fitting may be substantially increased.