Citations

Objective: To evaluate the predictors of remnant tumor regrowth and need for salvage therapy after less than gross total resection (GTR) of vestibular schwannoma (VS). Study Design: Retrospective chart review. Setting: Tertiary neurotologic referral center. Patients: Patients who underwent VS resection between 2008 and 2019 either with GTR, near total resection (NTR), and subtotal resection (STR). Interventions: Microsurgical resection, salvage radiosurgery. Main Outcome Measures: Regrowth free interval, salvage free interval, tumor doubling rate. Results: Three hundred eighty five cases (GTR = 236, NTR = 77, and STR = 71) from 2008 to 2019 were included. STR cohort had much larger and complex tumors with significant differences in tumor volume, ventral extension and brainstem compression (p < 0.001). On single predictor analysis, tumor volume, ventral extension, brainstem compression as well as STR strategy was associated with significant increased risk of regrowth and need for salvage therapy. Multivariate analysis revealed STR strategy as significant predictor of regrowth (hazard ratio 3.79, p < 0.0005). Absolute remnant volume and extent of resection (EOR) did not predict regrowth. A small proportion of cases (NTR = 4%, STR = 15%) eventually needed salvage radiosurgery with excellent ultimate local tumor control with no known recurrence to date. Conclusions: Conservative surgical strategy employing NTR or STR can be employed safely in large and complex VS. While there is increased risk of regrowth in the STR cohort, excellent local control can be achieved with appropriate use of salvage radiosurgery. No disceret radiologic or operative predictors of regrowth were identified.

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.

Objective: To report and discuss the effectiveness of stereotactic radiosurgery (SRS) or fractionated radiotherapy (FRT) for tumor control following surgical resection of endolymphatic sac tumors (ELST). Study Design: Retrospective case series. Setting: Multi-institutional academic referral centers. Patients: Patients undergoing surgical resection for ELST followed by SRS or FRT. Intervention(s): Surgical resection followed by radiotherapy. Main Outcome Measures: Local tumor control. Results: Two of the five patients experienced tumor recurrence after gross total microsurgical at 78 and 11 months, respectively. The former patient received salvage 3D conformal radiotherapy (3D-CRT) and while the latter patient underwent three courses of salvage SRS for recurrence, two of which were in-field and was disease-free at last follow up. Two additional patients underwent subtotal tumor resection (STR) followed by intensity-modulated radiation therapy (IMRT) and are currently without disease. One patient underwent STR followed by proton-beam therapy (PBT) and was free of disease at most recent follow-up. Conclusion: SRS/FRT remains a useful adjuvant for treatment of residual or recurrent ELSTs, where the risk of revision microsurgical resection is high.

Objective: To describe histologic and radiographic findings associated with insertion of a new lateral wall electrode in human temporal bones, as well as quantify the ease of insertion as characterized by multiple cochlear implant surgeons. Setting: Multi-institutional cadaveric study. Methods: The Slim J electrode was inserted in cadaveric temporal bones via a standard mastoidectomy and facial recess approach. Insertion was performed by five cochlear implant surgeons with no previous experience with the Slim J electrode array. Electrode array insertion was performed via a round window, an extended round window, or a cochleostomy approach. Intracochlear trauma, and angular insertion depth was assessed histologically and radiologically, respectively, after placement of the Slim J electrode array. Results: Scala tympani insertion was accomplished in all 40 specimens. Thirty-eight specimens (95%) showed minimal trauma (Esrhaghi grade 0 or 1). One patient had rupture of basilar membrane (grade 2 trauma) at 380 degrees. One patient had grade 4 trauma with scalar translocation beginning at 210 degrees. The mean angular insertion depth was 416.4 degrees (range: 338.7–509.2 degrees, SD 44 degrees). Surgical handling was described as easy in 38 cases (95%). Conclusion: In a human cadaveric model the lateral wall Slim J electrode produced minimal intracochlear trauma that was positioned completely within the scala tympani in 97.5% of cases.

Objectives: Dizziness, vertigo, and unsteadiness are common complaints of patients who present to primary care providers. These patients often are referred to otology for assessment and management. Unfortunately, there are a small number of specialists to manage these patients. However, there are several dizziness disorders that can be successfully managed by primary care providers if the disorder is properly identified. To assist in the identification of several of the most common dizziness disorders, we developed the dizziness symptom profile (DSP). The DSP is a self-report questionnaire designed to generate one or more differential diagnoses that can be combined with the patient’s case history and physical examination. Design: This report describes three investigations. Investigations 1 and 2 (i.e., exploratory and confirmatory investigations, N = 514) describe the development of the DSP. Investigation 3 (N = 195) is a validation study that describes the level of agreement between the DSP completed by the patient, and, the differential diagnosis of the otologist. Results: The final version of the DSP consists of 31 items. Preliminary findings suggest that the DSP is in agreement with the differential diagnoses of ear specialists for Meniere’s disease (100% agreement), vestibular migraine (95% agreement), and benign paroxysmal positional vertigo (82% agreement). Conclusions: Early results suggest that DSP may be useful in the creation of differential diagnoses for dizzy patients that can be evaluated and managed locally. This has the potential to reduce the burden on primary care providers and reduce delays in the diagnosis of common dizziness and vertigo disorders.

Objectives/HypothesisTo highlight the phenomenon of cholesteatoma arising from the vascular strip following tympanoplasty and tympanomastoidectomy.Study DesignMulti‐institutional retrospective chart review.MethodsConsecutive adult and pediatric patients evaluated between 2000 and 2015 with acquired cholesteatoma arising from the skin of a prior vascular strip were identified. Patients with evidence of residual or recurrent cholesteatoma elsewhere in the middle ear, mastoid, or ear canal were excluded.ResultsSeventeen cases (71% female, 53% right‐sided) were identified, and the mean age at presentation was 39.2 years. Patients presented on average 12.9 years following prior otologic surgery, which was most commonly tympanoplasty without mastoidectomy (59%). However, younger patients presented with symptoms sooner following prior surgery (r = 0.61, r2 = 0.37, P = 0.0095). The most common presenting symptom was otorrhea (76%). All patients were found to have mastoid cholesteatoma with bony erosion, and three patients exhibited additional tegmen or posterior fossa bone defects. The middle ear was not involved with cholesteatoma in any case. A canal wall down procedure was performed due to extensive bony canal erosion in 29% of cases.ConclusionThe vascular strip is an uncommon source of iatrogenic cholesteatoma that can present years following an otherwise uncomplicated otologic surgery. The findings presented herein highlight the importance of careful vascular strip orientation at the conclusion of otologic surgery.Level of Evidence4. Laryngoscope, 127:698–701, 2017

ObjectivesTo analyze factors that influence hearing preservation over time in cochlear implant recipients with conventional‐length electrode arrays located entirely within the scala tympani.Study DesignCase series with planned chart review.SettingSingle tertiary academic referral center.Subjects and MethodsA retrospective review was performed to analyze a subgroup of cochlear implant recipients with residual acoustic hearing. Patients were included in the study only if their electrode arrays remained fully in the scala tympani after insertion and serviceable acoustic hearing (≤80 dB at 250 Hz) was preserved. Electrode array location was verified through a validated radiographic assessment tool. Patients with <6 months of audiologic follow‐up were excluded. The main outcome measure was change in acoustic hearing thresholds from implant activation to the last available follow‐up.ResultsA total of 16 cases met inclusion criteria (median age, 70.6 years; range, 29.4‐82.2; 50% female). The average follow‐up was 18.0 months (median, 16.1; range, 6.2‐36.4). Patients with a lateral wall electrode array were more likely to have stable acoustic thresholds over time (P <. 05). Positive correlations were seen between continued hearing loss following activation and larger initial postoperative acoustic threshold shifts, though statistical significance was not achieved. Age, sex, and noise exposure had no significant influence on continued hearing preservation over time.ConclusionsTo control for hearing loss associated with interscalar excursion during cochlear implantation, the present study evaluated patients only with conventional electrode arrays located entirely within the scala tympani. In this group, the style of electrode array may influence residual hearing preservation over time.