Citations

Objective:To address variance in clinical care surrounding sporadic vestibular schwannoma, a modified Delphi study was performed to establish a general framework to approach vestibular schwannoma care. A multidisciplinary panel of experts was established with deliberate representation from key stakeholder societies. External validity of the final statements was assessed through an online survey of registered attendees of the 8th Quadrennial International Conference on Vestibular Schwannoma.Study Design:Modified Delphi method.Methods:The panel consisted of 16 vestibular schwannoma experts (8 neurotology and 8 neurosurgery) and included delegates representing the AAOHNSF, AANS/CNS tumor section, ISRS, and NASBS. The modified Delphi method encompassed a four-step process, comprised of one prevoting round to establish a list of focus areas and three subsequent voting rounds to successively refine individual statements and establish levels of consensus. Thresholds for achieving moderate consensus, at ≥67% agreement, and strong consensus, at ≥80% agreement, were determined a priori. All voting was performed anonymously via the Qualtrics online survey tool and full participation from all panel members was required before procession to the next voting round.Results:Through the Delphi process, 103 items were developed encompassing hearing preservation (N = 49), tumor control and imaging surveillance (N = 20), preferred treatment (N = 24), operative considerations (N = 4), and complications (N = 6). As a result of item refinement, moderate (4%) or strong (96%) consensus was achieved in all 103 final statements. Seventy-nine conference registrants participated in the online survey to assess external validity. Among these survey respondents, moderate (N = 21, 20%) or strong (N = 73, 71%) consensus was achieved in 94 of 103 (91%) statements, and no consensus was reached in 9 (9%). Of the four items with moderate consensus by the expert panel, one had moderate consensus by the conference participants and three had no consensus.Conclusion:This modified Delphi study on sporadic vestibular schwannoma codifies 100% consensus within a multidisciplinary expert panel and is further supported by 91% consensus among an external group of clinicians who regularly provide care for patients with vestibular schwannoma. These final 103 statements address clinically pragmatic items that have direct application to everyday patient care. This document is not intended to define standard of care or drive insurance reimbursement, but rather to provide a general framework to approach vestibular schwannoma care for providers and patients.

Objective: To assess vestibular schwannoma (VS) practice patterns among providers. Study Design: Cross-sectional survey. Setting: 8th Quadrennial International Conference on Vestibular Schwannoma and Other CPA Tumors. Subjects: Clinicians who specialize in the management of VS. Main Outcome Measures: Responses to questions on the management and anticipated outcomes of VS for a series of common clinical scenarios were compared by specialty (otolaryngology versus neurosurgery), level of experience, scope of practice (surgery versus radiation and surgery), and geographic location of practice (United States versus international). Results: Responses from 110 participants were analyzed. Overall, 53% of respondents were otolaryngologists, 60% had greater than 10 years of experience, and 57% practiced within the United States. In total, 86% of respondents would pursue initial observation for themselves if diagnosed with a 4 mm distal intracanalicular VS; however, practicing radiosurgeons were more likely to select stereotactic radiosurgery for this scenario compared with providers who solely practice surgery (14 versus 0%; p = 0.032). Otolaryngologists and neurosurgeons alike report that radiosurgery should not be considered a long-term hearing preservation strategy. Otolaryngologists were more optimistic regarding microsurgical hearing preservation outcomes for small distal intracanalicular tumors compared with neurosurgeons (11 versus 3% selected a high likelihood of maintaining class A/B hearing; p = 0.007). Ninety-five percent of respondents prioritized facial nerve outcome over complete disease removal in the context of microsurgical resection of large tumors. Conclusions: Management decision-making and expected outcomes for various clinical scenarios were largely similar among providers; however, variances in several key clinical areas exist. This study points to the feasibility of developing a widely accepted consensus statement among VS experts across specialties.

BackgroundFusion of diffusion‐weighted imaging (DWI) to computed tomography (CT) has been touted as a possible technique to improve cholesteatomas localization. This study set out to assess the ability of DWI images fused with thin‐slice heavily T2‐weighted images to similarly localize surgically‐confirmed cholesteatomas.Materials and MethodsA retrospective review was completed of consecutive patients that underwent MR temporal bone imaging (9/2011–3/2020) with both DWI and thin‐slice T2‐weighted imaging. Included patients underwent surgical resection of primary or recidivistic cholesteatoma after preoperative MR imaging. A neuroradiologist, who was blinded to operative and clinical notes, localized each lesion on both DWI and fused DWI‐T2 images in 11 anatomic subdivisions of the temporal bone. Surgical confirmation of cholesteatoma location was used as the gold standard for comparison.ResultsOf 24 included examinations, the average age at time of MR was 48.2 ± 24.7 years; 12/24 (50.0%) were female. Five of 24 had primary cholesteatoma, while the remainder had recidivistic disease. Sensitivity, specificity, and accuracy of unfused DWI images were 52.1%, 88.9%, and 75.8%, respectively. Sensitivity, specificity, and accuracy of fused DWI‐T2 images were 57.1%, 94.8%, and 81.8%, respectively.ConclusionFused DWI‐T2 images outperformed unfused DWI images in the anatomic localization of temporal bone cholesteatomas. This method represents a potential alternative to MR‐CT fusion for pre‐operative cholesteatoma evaluation, and warrants future investigations. Opposed to MR‐CT fusion, this method only necessitates MR sequences and removes the need for additional CT acquisition.Level of Evidence3 Laryngoscope, 131:E1662–E1667, 2021

Objective This study sought to determine whether a history of pregnancy or bilateral oophorectomy is associated with subsequent otosclerosis development or disease severity. Study Design Population‐based case‐control study. Setting Olmsted County, Minnesota. Methods Women diagnosed with otosclerosis were matched to 3 women without otosclerosis based on age and historical depth of medical records. Associations of prior delivery and bilateral oophorectomy with subsequent development of otosclerosis and with pure‐tone average (PTA) at the time of otosclerosis diagnosis were evaluated. Results We studied 1196 women: 299 cases of otosclerosis and 897 matched controls. The odds ratio for the association of ≥1 delivery with otosclerosis was 1.16 (95% confidence interval [CI] 0.85‐1.60; P =. 35). Odds ratios for the associations of 1, 2, 3, or ≥4 deliveries with otosclerosis were 1.22 (0.83‐1.80), 1.09 (0.71‐1.68), 1.28 (0.77‐2.12), and 1.00 (0.54‐1.84), respectively. The odds ratio for the association of prior bilateral oophorectomy with otosclerosis was 1.12 (0.58‐2.18; P =. 73). In cases with otosclerosis, PTA at diagnosis was not significantly higher for women with ≥1 delivery as compared with those without (median 45 dB hearing loss [HL] [interquartile range {IQR} 36‐55] vs 43 [IQR 34‐53]; P = 0.18) but was significantly higher for women with bilateral oophorectomy compared with those without (median 54 dB HL [IQR 44‐61] vs 44 [IQR 34‐53]; P =. 03). Conclusion These data do not support a relationship between endogenous estrogen exposure and development of otosclerosis. Women with otosclerosis who had a history of pregnancy did not have significantly worse hearing at the time of diagnosis, suggesting that pregnancy is not associated with disease severity.

Objective: To evaluate adverse events and feasibility of performing 1.5-T MRI in patients with cochlear implants (CI) and auditory brainstem implants (ABI). Setting: Single tertiary academic referral center. Patients: CI and ABI recipients undergoing 1.5-T MRI without internal magnet removal. Intervention(s): MRI after tight headwrap application. Main Outcome Measures: Adverse events, patient tolerance. Results: A total of 131 MR studies in 79 patients were performed, with a total of 157 study ears. Sixty-one patients (77%) had unilateral devices. Four patients (5%) underwent MRI with ABI magnets in place. Sixteen patients (20%) had MRI-compatible devices that did not require a head wrap. There were no instances of device stimulation, device malfunction, or excessive heating of the receiver-stimulator package. Magnet tilt requiring manual repositioning occurred during seven studies (4.5%) and magnet displacement requiring operative intervention occurred during seven studies (4.5%). Significant pain where imaging had to be discontinued occurred during three episodes (2%). No adverse events were noted among patients who underwent MRI with an MRI-compatible magnet. Conclusions: MRI with CI or ABI magnets in place is associated with a low prevalence of adverse events when performed in a controlled setting. Many partial magnet displacements can be corrected with firm manual pressure. Devices with magnets that align with the field within their housing were not associated with any adverse events and do not require immobilization of the magnet during the scan. These may be valuable in patients with known or anticipated need for MRI.

ObjectivesUrine leukotriene E4 (uLTE4) is a biomarker of leukotriene synthesis and is elevated in patients with aspirin‐exacerbated respiratory disease (AERD). It can also be useful to help delineate aspirin‐tolerant chronic rhinosinusitis with nasal polyposis (CRSwNP) patients from AERD patients. The purpose of this study is to determine if uLTE4 biomarker levels are associated with objective and subjective markers of disease severity in patients with CRSwNP.MethodsA retrospective analysis of CRSwNP patients who underwent uLTE4 testing was completed to determine the association of uLTE4 levels to markers of disease severity. uLTE4 levels, as well as presenting subjective (Sinonasal Outcome Test 22 [SNOT22] scores, asthma control test [ACT] scores) and objective data (Lund‐Mackay CT score, spirometry and lab values) were collected.ResultsAmong the 157 CRSwNP patients who met inclusion criteria, uLTE4 levels were associated with history of asthma (P< .001), aspirin sensitivity (P< .001), worse Lund‐Mackay CT scores (P= .002) and other objective markers of disease severity including serum IgE (P= .05), presenting blood eosinophil level (P< .001), and the highest recorded eosinophil level (P< .001). In subgroup analysis, associations of uLTE4 to disease markers had stronger correlations in the aspirin sensitive CRSwNP group (Rrange 0.31–0.52) than the aspirin tolerant CRSwNP group (Rrange −0.30–0.24). uLTE4 levels were not associated with subjective symptom scores (SNOT22 and ACT scores).ConclusionElevated uLTE4 biomarker levels are associated with worsened objective markers of disease severity in CRSwNP patients but not patient‐reported symptom measures.Level of Evidence3Laryngoscope, 131:961–966, 2021

ObjectiveTo ascertain the prevalence of and associations with distress and professional burnout among academic otolaryngology attending physicians.Study DesignCross‐sectional survey.SettingTwelve US academic otolaryngology programs.MethodsA questionnaire was administered that encompassed sociodemographic and professional features, the Expanded Physician Well‐being Index for distress, the 2‐item Maslach Burnout Inventory for professional burnout, the Patient Health Questionnaire–2 screen for major depressive disorder, and the Generalized Anxiety Disorder–2 screen for generalized anxiety disorder.ResultsThe survey response rate was 56% and included 186 attending physicians. The average respondent age was 47 years; 72% were men; 93% were married or partnered; and 86% had children. Distress was present in 40%, professional burnout in 26%, positive depression screening in 8%, and positive anxiety screening in 11%. In a univariable setting, age, hours worked in a typical week, nights on call in a typical week, and years of practice were significantly associated with distress, although in a multivariable setting, only hours worked in a typical week remained significantly associated with a positive Expanded Physician Well‐being Index screen (odds ratio for each 10‐hour increase, 2.61; 95% CI, 1.73‐3.93; P <. 001). In a univariable setting, hours worked in a typical week was significantly associated with a positive Maslach Burnout Inventory screen.ConclusionDistress or professional burnout occurs in more than a quarter of academic otolaryngology attending physicians, whereas the prevalence of depression or anxiety is approximately 10%. The number of hours worked per week had the strongest association with distress and burnout. These findings may be used to develop and implement programs to promote physician well‐being and mitigate professional burnout.

ObjectiveTo assess the prevalence of distress and burnout in otolaryngology trainees, including associations with relevant sociodemographic and professional factors, and to compare these results with those of attending otolaryngologists.Study DesignA cross‐sectional survey of trainees and attending physicians.SettingTwelve academic otolaryngology programs.MethodsDistress and burnout were measured with the Expanded Physician Well‐being Index and the 2‐item Maslach Burnout Inventory. The Patient Health Questionnaire–2 and Generalized Anxiety Disorder–2 were used to screen for depressive disorders and anxiety disorders, respectively. Associations with sociodemographic and professional characteristics were assessed.ResultsOf the 613 surveys administered to trainees and attending physicians, 340 were completed (56%). Among 154 trainees, distress was present in 49%, professional burnout in 35%, positive depressive disorder screening in 5%, and positive anxiety disorder screening in 16%. In univariable analysis, female gender, hours worked in a typical week (HW), and nights on call in a typical week (NOC) were significantly associated with distress. In multivariable analysis, female gender (odds ratio, 3.91; P =. 001) and HW (odds ratio for each 10 HW, 1.89; P =. 003) remained significantly associated with distress. Female gender, HW, and NOC were significantly associated with burnout univariably, although only HW (odds ratio for each 10 HW, 1.92; P =. 003) remained significantly associated with burnout in a multivariable setting. Attending physicians had less distress than trainees (P =. 02) and felt less callous and less emotionally hardened than trainees (P <. 001).ConclusionOtolaryngology trainees experience significant work‐place distress (49%) and burnout (35%). Gender, HW, and NOC had the strongest associations with distress and burnout.