Modern Trends in Otologic Surgery and Implications for Residency Training

OBJECTIVE

Placing a middle ear prosthesis is considered a key competency for the general otolaryngologist, but surgeons struggle to obtain and maintain this skill. The current study aims to characterize pre-coronavirus disease 2019 trends in stapedectomy and ossiculoplasty.

STUDY DESIGN

Database review.

SETTING

Tricare beneficiaries are treated at civilian and military facilities.

METHODS

The Department of Defense beneficiary population of more than nine million persons per year was reviewed for patients undergoing either stapedectomy or ossiculoplasty between 2010 and 2019, identified by the current procedural terminology code.

RESULTS

A total of 3052 stapedectomies and 7197 ossiculoplasties were performed. Over the 10-year study period, stapedectomy decreased by 23%, with an average annual rate of -2.7% per year (Pearson r = -.91, P = .0003). Ossiculoplasties declined by 18%, an average annual rate of -1.9% (r = -.8, P = .006). In combination, cases declined by 20%, an average annual rate of -2.2% (r = -.87, P = .001).

CONCLUSION

While declines in stapedectomy surgery have been well reported, here we show steady declines in ossiculoplasty as well. If these trends continue, more cochlear implantations may be performed annually than stapedectomy and ossiculoplasty combined, with cochlear implantation likely to overtake ossicular chain surgery in the near future. These changes in surgical volume have a direct implication on resident education and general otolaryngology expectations after graduation. Strong consideration should be made to replace "Stapedectomy/Ossiculoplasty" as resident key indicator with "Cochlear Implantation," a more professionally meaningful skill.

Leveraging Technology for Vestibular Assessment and Rehabilitation in the Operational Environment: A Scoping Review

INTRODUCTION

The vestibular system, essential for gaze and postural stability, can be damaged by threats on the battlefield. Technology can aid in vestibular assessment and rehabilitation; however, not all devices are conducive to the delivery of healthcare in an austere setting. This scoping review aimed to examine the literature for technologies that can be utilized for vestibular assessment and rehabilitation in operational environments.

MATERIALS AND METHODS

A comprehensive search of PubMed was performed. Articles were included if they related to central or peripheral vestibular disorders, addressed assessment or rehabilitation, leveraged technology, and were written in English. Articles were excluded if they discussed health conditions other than vestibular disorders, focused on devices or techniques not conducive to the operational environment, or were written in a language other than English.

RESULTS

Our search strategy yielded 32 articles: 8 articles met our inclusion and exclusion criteria whereas the other 24 articles were rejected.

DISCUSSION

There is untapped potential for leveraging technology for vestibular assessment and rehabilitation in the operational environment. Few studies were found in the peer-reviewed literature that described the application of technology to improve the identification of central and/or peripheral vestibular system impairments; triage of acutely injured patients; diagnosis; delivery and monitoring of rehabilitation; and determination of readiness for return to duty.

CONCLUSIONS

This scoping review highlighted technology for vestibular assessment and rehabilitation feasible for use in an austere setting. Such technology may be leveraged for prevention; monitoring exposure to mechanisms of injury; vestibular-ocular motor evaluation; assessment, treatment, and monitoring of rehabilitation progress; and return-to-duty determination after vestibular injury.

FUTURE DIRECTIONS

The future of vestibular assessment and rehabilitation may be shaped by austere manufacturing and 3D printing; artificial intelligence; drug delivery in combination with vestibular implantation; organ-on-chip and organoids; cell and gene therapy; and bioprinting.

National Trends in Cochlear Implantation Across the Department of the Defense: A Case for Inclusion as a General Otolaryngology Core Competency

OBJECTIVE

With ongoing national expansions in cochlear implantation (CI) candidacy criteria, more patients qualify for CI today than ever before. Among US veterans and military service members, the prevalence of qualifying degrees of hearing loss secondary to occupational noise exposure exceeds the general population. The primary aim of the current work was to evaluate CI trends across the military health system.

STUDY DESIGN

Database review.

SETTING

Military and civilian practices.

PATIENTS

Department of Defense (DoD) beneficiaries who underwent CI.

MAIN OUTCOME MEASURES

CI rates between 2010 and 2019.

RESULTS

A total of 3,573 cochlear implant operations were performed among DoD beneficiaries from 2010 to 2019. A majority of patients (55%) were older than 64 years, with the next most commonly implanted age group being 0 to 4 years of age (14%). From 2010 to 2019, annual CI increased at a rate of 7.9% per year for all implantation over the study period ( r = 0.97, p < 0.0001); there was a statistically significant difference of this rate compared with tympanoplasty, which was used as a reference procedure (rate, -1.9%; p = 0.03). This trend was similar for beneficiaries implanted both in military (11.9% per year, r = 0.77, p = 0.009) and civilian facilities (7.7% per year, r = 0.96, p < 0.0001); there was no statistically significant difference between the annual growth rates of these groups ( p = 0.68).

CONCLUSIONS

Although the number of devices implanted is rapidly increasing among DoD beneficiaries, reported national utilization rates remain low. This disparity likely exists in the general public, considering the aging demographic in the West and continual expansions in US Federal Drug Administration labeling. These data suggest that widespread expansion of the procedure to general otolaryngology practices will be required to meet current and future demands for CI. For this reason, CI should be considered for "key indicator" designation among residency training programs.

Exposomic Signatures of Tinnitus and/or Hearing Loss

INTRODUCTION

We evaluated the risk factors associated with tinnitus and/or hearing loss (THL) among active duty (AD) members of the U.S. Army and Marine Aviation Community (AMAC) using an exposomic approach. Specifically, we aimed to determine the factors associated with the reported THL in the Military Health System.

METHODS

Longitudinal data were obtained from the Medical Assessment and Readiness System housed at Womack Army Medical Center, Fort Bragg, NC, for a retrospective cohort study that included 78,546 AD AMAC members from October 2015 to December 2019. Multivariable mixed-effects logistic regression was used to assess the relationship between THL and numerous variables to include rank, service time, deployment, tobacco use, alcohol use, age, gender, race, ethnicity, and body mass index.

RESULTS

Our analysis included a total of 220,044 person-years of observations. The THL incidence rate was 6.7 per 100 person-years, with an 8.1% period prevalence. THL was associated with age, gender, body mass index, race, deployment, service time, marital status, and tobacco use (all P < .05). Service time greater than 16 years had the greatest odds ratio of THL (4.46, 95% CI: 3.58-5.55, P < .001).

CONCLUSIONS

Our assessment shows the utility of using an exposomic approach to create member-specific personalized clinical algorithms for health outcomes. We examined individuals with THL diagnoses and identified a combination of risk factors from biomedical, lifestyle, environmental, and stochastic sources. Taken together, the risk factors identified across the four exposomic domains could help understand the etiology of THL. Our exposomic methodology could be the foundation for generating predictive models. Finally, a specific evaluation of occupational risk factors may provide insight into aspects not readily available from civilian literature. In upcoming years, as the Medical Assessment and Readiness System matures, we will expand our analyses to include prospective, untargeted metabolites and biomarker data.

Department of Defense Medical Examination Review Board Audiogram Screening Comparative Analysis

INTRODUCTION

The Department of Defense Medical Examination Review Board (DoDMERB) plays a pivotal role in the assessment of medical fitness for aspiring military officers. A crucial component of this process is the screening audiogram, designed to evaluate hearing capabilities. However, recent observations of high disqualification rates following screening audiograms led to concerns about their accuracy.

MATERIALS AND METHODS

This quality improvement project, conducted between 2017 and 2019, aimed to assess the concordance between screening audiograms and reference-standard audiometry, as well as to investigate the relationship between disqualification status and hearing thresholds at different frequencies. A sample of 134 candidates, drawn from various locations across the United States, was analyzed.

RESULTS

Results revealed that the screening audiogram mean thresholds were twice that of the reference-standard audiogram, particularly in the lower frequencies. Additionally, we found that 84% of candidates were incorrectly disqualified by the screening exam when followed up by the reference-standard. Overall, Bland-Altman analysis revealed significant disagreement between these two tests. This discrepancy prompted a fundamental policy shift in 2020, where candidates who fail screening audiograms now automatically undergo reference-standard audiometry before any disqualification decision. This policy change reflects the commitment of DoDMERB to refining the medical screening process. It reduces the burden on candidates, provides a more comprehensive assessment, and ensures that qualified individuals are not erroneously disqualified.In addition to policy changes, this quality improvement project explored potential courses of action to enhance the screening audiogram process. Among these, improving contract specifications for testing facilities to minimize ambient noise emerged as the most practical and cost-effective approach.

CONCLUSION

In conclusion, the project underscores the importance of refining medical screening processes to accurately assess candidates' qualifications while retaining the utility of screening audiograms. These efforts not only benefit aspiring military officers but also contribute to maintaining the high standards required for military service.

COVID-19 and transtympanic injections for sudden sensorineural hearing loss

BACKGROUND

Multiple reports have linked COVID-19 infection with sudden sensorineural hearing loss (SSNHL), although other studies have failed to demonstrate this association. The current study was conceived to examine the rates of SSNHL across a large, principally national, population by characterizing the rate of transtympanic injections for SSNHL during the pandemic.

METHODS

Retrospective review of all patients that underwent transtympanic injection from 2019 to 2020.

RESULTS

Covering a unique beneficiary population of 9.6 million individuals of all ages in the United States, a statistically significant decrease in transtympanic injections for SSNHL was performed from 2019 to 2020 (p = 0.04, IRR = 0.91, 95 % CI = 0.84-0.99). No patient receiving a transtympanic injection also had a COVID-19 diagnosis.

CONCLUSIONS

These findings support the idea that COVID-19 infections do not clinically significantly increase patients' risk of developing SSNHL. In fact, the decreased exposure through social isolation to other common viruses implicated in causing SSNHL may have actually led to a lower rate of SSNHL during the pandemic.

New Medical Device and Therapeutic Approvals in Otolaryngology: State of the Art Review of 2021

Objective

To evaluate new medical devices and drugs pertinent to otolaryngology–head and neck surgery that were approved by the Food and Drug Administration (FDA) in 2021.

Data Sources

Publicly available FDA device and drug approvals from ENT (ear, nose, and throat), anesthesia, neurosurgery, plastic surgery, and general surgery FDA committees.

Review Methods

FDA device and therapeutic approvals were identified and reviewed by members of the American Academy of Otolaryngology–Head and Neck Surgery’s Medical Devices and Drugs Committee. Two independent reviewers assessed the relevance of devices and drugs to otolaryngologists. Medical devices and drugs were then allocated to their respective subspecialty fields for critical review based on available scientific literature.

Conclusions

The Medical Devices and Drugs Committee reviewed 1153 devices and 52 novel drugs that received FDA approval in 2021 (67 ENT, 106 anesthesia, 618 general surgery and plastic surgery, 362 neurosurgery). Twenty-three devices and 1 therapeutic agent relevant to otolaryngology were included in the state of the art review. Advances spanned all subspecialties, including over-the-counter hearing aid options in otology, expanding treatment options for rhinitis in rhinology, innovative laser-safe endotracheal tubes in laryngology, novel facial rejuvenation and implant technology in facial plastic surgery, and advances in noninvasive and surgical treatment options for obstructive sleep apnea.

Implications for Practice

FDA approvals for new technology and pharmaceuticals present new opportunities across subspecialties in otolaryngology. Clinicians’ nuanced understanding of the safety, advantages, and limitations of these innovations ensures ongoing progress in patient care.

New Medical Device and Therapeutic Approvals in Otolaryngology: State of the Art Review 2020

Objectives

To evaluate new drugs and devices relevant to otolaryngology–head and neck surgery that were approved by the US Food and Drug Administration (FDA) in 2020.

Data Sources

Publicly available device and therapeutic approvals from ENT (ear, nose, and throat), anesthesia, neurology (neurosurgery), and plastic and general surgery FDA committees.

Review Methods

Members of the American Academy of Otolaryngology–Head and Neck Surgery’s Medical Devices and Drugs Committee reviewed new therapeutics and medical devices from a query of the FDA’s device and therapeutic approvals. Two independent reviewers assessed the drug’s or device’s relevance to otolaryngology, classified to subspecialty field, with a critical review of available scientific literature.

Conclusions

The Medical Devices and Drugs Committee reviewed 53 new therapeutics and 1094 devices (89 ENT, 140 anesthesia, 511 plastic and general surgery, and 354 neurology) approved in 2020. Ten drugs and 17 devices were considered relevant to the otolaryngology community. Rhinology saw significant improvements around image guidance systems; indications for cochlear implantation expanded; several new monoclonal therapeutics were added to head and neck oncology’s armamentarium; and several new approvals appeared for facial plastics surgery, pediatric otolaryngology, and comprehensive otolaryngology.

Implications for Practice

New technologies and pharmaceuticals offer the promise of improving how we care for otolaryngology patients. However, judicious introduction of innovations into practice requires a nuanced understanding of safety, advantages, and limitations. Working knowledge of new drugs and medical devices approved for the market helps clinicians tailor patient care accordingly.

Global Incidence of Sporadic Vestibular Schwannoma: A Systematic Review

OBJECTIVE

Ubiquitous throughout the literature and during patient counseling, vestibular schwannoma is often quoted to affect about 1 per 100,000 people. Yet, reports from distinct international populations suggest that the incidence is likely much higher. The objective of the current work was to systematically characterize the global incidence of sporadic vestibular schwannoma.

DATA SOURCES

Scopus, Embase, and PubMed.

REVIEW METHODS

Population-based studies reporting incidence rates of sporadic vestibular schwannoma between January 2010 and August 2020 were searched with language restrictions requiring reports to be published in Chinese, English, German, Italian, or Spanish. The protocol was registered with PROSPERO (CRD42021228208) prior to commencement of data collection. PRISMA guidelines for transparent reporting of systematic reviews were followed.

RESULTS

Among 424 citations, 6 publications covering 4 distinct populations from Denmark, the Netherlands, Taiwan, and the United States met inclusion criteria. Most recent incidence rates of among all ages ranged between 3.0 and 5.2 per 100,000 person-years. Highest incidence rates were reported among patients aged ≥70 years, peaking at 20.6 per 100,000 person-years. One study from the United States reported the incidence of asymptomatic, incidentally diagnosed tumors at a rate of 1.3 per 100,000 person-years from 2012 to 2016.

CONCLUSIONS

Recent international incidence rates of sporadic vestibular schwannoma exceed the commonly quoted "1 per 100,000" figure by up to 5-fold among all ages and by up to 20-fold among age groups at highest risk. Based on modern incidence rates, the lifetime prevalence of developing sporadic vestibular schwannoma likely exceeds 1 per 500 persons.

Preoperative Differences in Intracranial Facial Versus Vestibular Schwannomas: A Four Nerve Assessment

OBJECTIVES

Assesses whether preoperative functional testing can distinguish vestibular schwannomas from facial nerve schwannomas medial to the labyrinthine segment.

STUDY DESIGN

Retrospective cohort.

METHODS

Retrospectively review surgically managed intracranial facial and vestibular schwannomas between January 2015 and December 2019 at two tertiary care centers. Patients with neurofibromatosis 2 and surgery for recurrence were excluded. Preoperative functional testing to include House-Brackmann scores, electroneuronography (ENoG), cervical vestibular evoked myogenic potentials (cVEMP), caloric testing, acoustic brainstem responses (ABRs), acoustic reflexes, and audiograms was compared between the two groups of schwannomas.

RESULTS

Twelve facial and 128 vestibular schwannomas met inclusion criteria. In only one case was a facial schwannoma diagnosed preoperatively from imaging. No statistically significant difference was found in preoperative House-Brackmann scores, ENoG, cVEMP, caloric testing, ABRs, or acoustic reflexes. Pure tone average was worse in the vestibular schwannoma group (63 dB [95% CI: 58-68 dB] vs. 46 dB [95% CI: 34-58 dB], P = .01), and the difference was more apparent in the lower frequencies. Word recognition score was better in the facial schwannoma group (66% [95% CI: 45-86%] vs. 41% [95% CI: 34-47%], P = .02).

CONCLUSION

Specialized preoperative functional evaluation of the nerves of the internal auditory canal cannot reliably predict the presence of an intracranial facial schwannoma. Hearing is better in facial schwannomas, particularly in the lower frequencies. This should raise the index of suspicion for an intracranial facial schwannoma, especially in candidates for hearing preservation vestibular schwannoma surgery.

LEVEL OF EVIDENCE

3 Laryngoscope, 131:2098-2105, 2021.

Shared Surgical Decision Making in the Era of COVID-19: Lessons From Hurricane Katrina

The COVID-19 pandemic has challenged every surgical discipline. Lessons learned from Hurricane Katrina have informed our department's management of the current crisis. That experience impressed upon us a profound appreciation for shared decision making in the face of scarce resources, an evolving clinical context, and potential harm to patients and health care workers. To that end, we have formed a Resource Utilization Committee to prospectively review all nonemergent surgical cases during the current crisis. This has allowed "state-of-the-pandemic" otolaryngologic care in a real-time, collaborative, and high-information setting. In addition, to protect our patients and health care workers, it has influenced our institution's thoughtful application of COVID testing and the use of personal protective equipment.

Over-under cartilage tympanoplasty: technique, results and a call for improved reporting

OBJECTIVE

This study aimed to describe the microscopic over-under cartilage tympanoplasty technique, provide hearing results and detail clinically significant complications.

METHOD

This was a retrospective case series chart review study of over-under cartilage tympanoplasty procedures performed by the senior author between January 2015 and January 2019 at three tertiary care centres. Cases were excluded for previous or intra-operative cholesteatoma, if a mastoidectomy was performed during the procedure or if ossiculoplasty was performed. Hearing results and complications were obtained.

RESULTS

Sixty-eight tympanoplasty procedures met the inclusion criteria. The median age was 13 years (range, 3-71 years). The mean improvement in pure tone average was 6 dB (95 per cent confidence interval 4-9 dB; p < 0.0001). The overall perforation closure rate was 97 per cent (n = 66). Revision surgery was recommended for a total of 6 cases (9 per cent) including 2 post-operative perforations, 1 case of middle-ear cholesteatoma and 3 cases of external auditory canal scarring.

CONCLUSION

Over-under cartilage tympanoplasty is effective at improving clinically meaningful hearing with a low rate of post-operative complications.

Over-under cartilage tympanoplasty: technique, results and a call for improved reporting

OBJECTIVE

This study aimed to describe the microscopic over-under cartilage tympanoplasty technique, provide hearing results and detail clinically significant complications.

METHOD

This was a retrospective case series chart review study of over-under cartilage tympanoplasty procedures performed by the senior author between January 2015 and January 2019 at three tertiary care centres. Cases were excluded for previous or intra-operative cholesteatoma, if a mastoidectomy was performed during the procedure or if ossiculoplasty was performed. Hearing results and complications were obtained.

RESULTS

Sixty-eight tympanoplasty procedures met the inclusion criteria. The median age was 13 years (range, 3-71 years). The mean improvement in pure tone average was 6 dB (95 per cent confidence interval 4-9 dB; p < 0.0001). The overall perforation closure rate was 97 per cent (n = 66). Revision surgery was recommended for a total of 6 cases (9 per cent) including 2 post-operative perforations, 1 case of middle-ear cholesteatoma and 3 cases of external auditory canal scarring.

CONCLUSION

Over-under cartilage tympanoplasty is effective at improving clinically meaningful hearing with a low rate of post-operative complications.

Racial Differences of Pigmentation in the Human Vestibular Organs

Objectives

Melanin pigmentation is present in the human inner ear. In this study, we quantify the melanin pigmentation in the vestibular system and examine racial differences of vestibular melanin pigmentation using human cadaveric temporal bone specimens.

Study Design

Basic research.

Setting

Laboratory.

Subjects and Methods

Light microscopy was used to examine specimens from 40 left temporal bones from the Johns Hopkins Human Temporal Bone Collection. Color images of (1) ampulla of the horizontal canal, (2) utricular wall, (3) endolymphatic duct, and (4) posterior ampullary nerve as it enters the posterior canal were acquired with a digital camera attached to the microscope and image acquisition software. Acquired images of each anatomic area of interest were processed offline through ImageJ. Melanin content was then compared according to ethnicity, age, sex, and location.

Results

Fifteen African American and 25 Caucasian specimens were analyzed. Mean age was 68.8 years. African American specimens had a significantly greater amount of pigment at all 4 sampled locations as compared with Caucasian specimens ( P < .01). Between sexes, there was a statistically significant difference ( P < .05) at the posterior ampullary nerve, with males having more than females. Melanin content was not associated with age.

Conclusions

There is greater melanin pigmentation within the vestibular system of African Americans than in Caucasians, similar to what has been described in the cochlea. Racial differences in vestibular physiologic function have been observed in the literature and may be explained by differences in melanin pigmentation.

In vitro and in vivo optimization of infrared laser treatment for injured peripheral nerves

BACKGROUND AND OBJECTIVE

Repair of peripheral nerve injuries remains a major challenge in restorative medicine. Effective therapies that can be used in conjunction with surgical nerve repair to improve nerve regeneration and functional recovery are being actively investigated. It has been demonstrated by a number of peer reviewed publications that photobiomodulation (PBM) supports nerve regeneration, reinnervation of the denervated muscle, and functional recovery after peripheral nerve injury. However, a key issue in the use of PBM as a treatment for peripheral nerve injury is the lack of parameter optimization for any given wavelength. The objective of this study was to demonstrate that for a selected wavelength effective in vitro dosing parameters could be translated to effective in vivo parameters.

MATERIALS AND METHODS

Comparison of infra-red (810 and 980 nm wavelengths) laser treatment parameters for injured peripheral nerves was done beginning with a series of in vitro experiments using primary human fibroblasts and primary rat cortical neurons. The primary rat cortical neurons were used for further optimization of energy density for 980 nm wavelength light using measurement of total neurite length as the bioassay. For these experiments, the parameters included a 1 W output power, power density of 10 mW/cm(2) , and energy densities of 0.01, 0.1, 0.5, 2, 10, 50, 200, 1,000, and 5,000 mJ/cm(2) . For translation of the in vitro data for use in vivo it was necessary to determine the transcutaneous penetration of 980 nm wavelength light to the level of the peroneal nerve. Two anesthetized, male White New Zealand rabbits were used for these experiments. The output power of the laser was set at 1.0 or 4.0 W. Power density measurements were taken at the surface of the skin, sub-dermally, and at the level of the nerve. Laser parameters used in the in vivo studies were calculated based on data from the in vitro studies and the light penetration measurements. For the in vivo experiments, a total of 22 White New Zealand rabbits (2.34-2.89 kg) were used. Translated dosing parameters were refined in a pilot study using a transection model of the peroneal nerve in rabbits. Output powers of 2 and 4 W were tested. For the final set of in vivo experiments, the same transection nerve injury model was used. An energy density of 10 mW/cm(2) at the level of the peroneal nerve was selected and the laser parameters were further refined. The dosing parameters used were: 1.5 W output power, 43 seconds exposure, 8 cm(2) area and a total energy of 65 J.

RESULTS

In vitro, 980 nm wavelength light at 10 mW/cm(2) significantly improved neurite elongation at energy densities between 2 and 200 mJ/cm(2) . In vivo penetration of the infrared light measured in anesthetized rabbits showed that on average, 2.45% of the light applied to the skin reached the depth of the peroneal nerve. The in vivo pilot study data revealed that the 4 W parameters inhibited nerve regeneration while the 2 W parameters significantly improved axonal regrowth. For the final set of experiments, the irradiated group performed significantly better in the toe spread reflex test compared to the control group from week 7 post-injury, and the average length of motor endplates returned to uninjured levels.

CONCLUSION

The results of this study demonstrate that treatment parameters can be determined initially using in vitro models and then translated to in vivo research and clinical practice. Furthermore, this study establishes that infrared light with optimized parameters promotes accelerated nerve regeneration and improved functional recovery in a surgically repaired peripheral nerve.