Public Perception of Ménière's Disease: A Social Media Analysis.

OBJECTIVE: To analyze tweets associated with Ménière's disease (MD), including type of users who engage, change in usage patterns, and temporal associations, and to compare the perceptions of the general public with healthcare providers. METHODS: An R-program code, academictwitterR API, was used to query Twitter. All tweets mentioning MD from 2007 to 2021 were retrieved and analyzed. Valence Aware Dictionary and Sentiment Reasoning was used as a model to assess sentiment of tweets. Two reviewers assessed 1,007 tweets for qualitative analysis, identifying the source and the topic of the tweet. RESULTS: A total of 37,402 tweets were analyzed. The number of tweets per user ranged from 1 to 563 (M = 33.7, SD = 91.1). Quantitative analysis showed no temporal or seasonal association; however, tweeting increased when celebrities were diagnosed with MD. Of the 1007 representative tweets analyzed, 60.6% of tweets came from the general public and were largely of negative sentiment focusing on quality of life and support, whereas healthcare providers accounted for 23% of all tweets and focused on treatment/prevention. Tweets by news sources accounted for the remaining 13% of all tweets and were primarily positive in sentiment and focused on awareness. CONCLUSIONS: MD is commonly tweeted about by the general public, with limited input regarding the disease from healthcare providers. Healthcare providers must provide accurate information and awareness regarding MD, especially when awareness is highest, such as when celebrities are diagnosed. LEVEL OF EVIDENCE: Level IV.Indicate IRB or IACUCNot applicable.

An Elusive Diagnosis: Delays in Treatment and Opportunities for Improvement in Temporal Encephalocele and CSF Leak.

Objective: Symptoms of temporal encephalocele or cerebrospinal fluid (CSF) leak causing middle ear effusion or otorrhea can be nonspecific and mistaken for other common diagnoses, leading to delays in diagnosis, failed treatments, and a risk of meningitis. This study sought to investigate the association between symptomatology and time to definitive surgical management. Study Design: Retrospective cohort. Setting: Single tertiary care academic medical center. Patients: Adults treated surgically for temporal encephalocele or CSF leak. Revision cases were excluded. Interventions: Chart review was performed to identify pertinent symptoms at presentation. Multivariable regression was performed to analyze the association between symptoms and time to definitive management. Main Outcome Measures: Otologic and related symptoms present prior to middle cranial fossa (MCF). Time between symptom onset and surgical treatment. Results: Thirty-four patients had symptoms present a median of 15.5 months (interquartile range, 8-35 months; range, 1 month to 12 years) prior to surgery. The most common symptoms were subjective hearing loss in the affected ear (76.5%) and aural fullness (73.5%). Otorrhea was present in 55.9%, and 42.9% had a history of otorrhea after myringotomy with or without tube insertion. Meningitis occurred in 5 patients (14.7%). Only the absence of otalgia was statistically significantly associated with decreased time between symptoms onset and surgery (P = 0.01). Conclusions: Encephalocele and CSF leak were most commonly associated with aural fullness and hearing loss. Medical treatment for presumed Eustachian tube dysfunction or chronic ear disease were commonly observed. Patients had symptoms for a median of almost 1 and a half years prior to surgical management.

Frailty in middle cranial fossa approach for encephalocele or cerebrospinal fluid leak repair.

Objective: The modified 5-item frailty index (mFI-5) is a concise, comorbidity-based risk stratification tool that can predict adverse outcomes after surgery. The goal of this study was to understand the frailty of patients undergoing surgery for temporal encephalocele or cerebrospinal fluid (CSF) leak and the utility of mFI-5 for predicting increased post-operative outcomes. Methods: A retrospective review of adults with temporal encephalocele or CSF leak who underwent middle cranial fossa (MCF) approach craniotomies with or without mastoidectomy from January 2015 through August 2021 at a tertiary care academic medical center was performed. Patients who underwent additional surgeries or extended surgical approaches were excluded. The mFI-5 was calculated for all patients. Demographic and clinical data were obtained from the medical record. Results: Thirty-six patients underwent 40 MCF approach craniotomies for temporal encephalocele or CSF leak, including three revision cases and one patient with sequential bilateral operations. Mean age was 54.1 ± 10.8 years, and 66.7% were female. In the univariable regression analysis, mFI-5 score, age, and procedure time use were significantly associated with increased hospital length of stay (LOS) but not increased intensive care unit (ICU) LOS. Anesthesia time and lumbar drain were significantly associated with increased hospital LOS and ICU LOS, and they remained significantly associated with increased hospital LOS in the multivariable model. Conclusion: Frailty is associated with increased hospital LOS stay among patients undergoing MCF approach for CSF leak or encephalocele. Reducing anesthesia time and avoiding lumbar drain use are potentially modifiable risk factors that can reduce the LOS and associated costs. Level of Evidence: 4.

Audiometric Outcomes After Surgical Repair of Congenital Aural Atresia: Does Age Matter?

OBJECTIVE: To determine if there is an age-based difference in audiometric outcomes for patients undergoing primary congenital aural atresia (CAA) repair. STUDY DESIGN: Retrospective chart review. SETTING: Single academic, high-volume, tertiary care hospital. PATIENTS: Individuals undergoing primary CAA repair by a single surgeon between 2004 and 2020. INTERVENTIONS: CAA repair. MAIN OUTCOME MEASURES: Preoperative and postoperative four tone (500, 1,000, 2,000, 4,000 Hz) air-conduction pure-tone average (PTA), bone-conduction PTA, air-bone gap and speech reception threshold, and preoperative to postoperative change in values. RESULTS: We identified 247 patients (262 ears) who underwent repair. The mean and median ages were approximately 12 and 8.5 years, respectively, both of which served as cutoff ages to compare younger versus older patients. The average preoperative to postoperative improvement values in air-conduction PTA, air-bone gap, and speech reception threshold for individuals younger than 12 years were 26.6 ± 10.2, 23.8 ± 12.6, and 30.1 ± 12.1 dB hearing level (HL), respectively, and those for individuals 12 years or older were 25.9 ± 15.7, 26.2 ± 10.3, and 31.3 ± 12.8 dB HL, respectively. For individuals younger than 8.5 years, the values were 25.8 ± 9.5, 24.9 ± 9.4, and 30.0 ± 10.6 dB HL, respectively, and those for individuals 8.5 years or older were 27.1 ± 13.5, 25.7 ± 11.0, and 30.0 ± 14.6 dB HL, respectively. The improvement did not differ significantly between the younger and older groups, using both cutoff ages. There was no difference in revision surgery rates or complications between groups. CONCLUSION: An individual at any age can enjoy audiometric improvement from atresia repair.

Congenital Aural Stenosis With Cholesteatoma.

OBJECTIVE: Compare surgical and audiological outcomes of patients with congenital aural stenosis (CAS) with cholesteatoma to patients with CAS without cholesteatoma and patients with complete congenital aural atresia (CCAA). STUDY DESIGN: Retrospective case series. SETTING: Tertiary care hospital. PATIENTS: Patients with CAS (with and without cholesteatoma) and CCAA. INTERVENTION: Surgery for CAS/CAA. MAIN OUTCOME MEASURES: Patients with CAS and CAA undergoing surgical repair from June 2004 to July 2020 were identified from an institutional database. Included patients were divided by presence of a canal cholesteatoma. Clinical history, pre- and postoperative audiometric data, and clinical outcomes were compared. RESULTS: Of the 283 patients (300 ears), 18 (19 ears) had a canal cholesteatoma. When compared to ears without cholesteatoma (CCAA ears plus CAS ears without cholesteatoma), ears with cholesteatoma were more likely to be younger (9.2 ±â€Š6.6 vs. 11.5 ±â€Š9.2; p = 0.015), female (66.7% vs. 38.1%; p = 0.02; OR 3.2, 95% CI 1.18-8.9), and have normal/Grade I microtia (47.4% vs. 9.6%; p < 0.0001; OR 0.12, 95% CI 0.044-0.32), but not a history of draining ear (5.3% vs. 0%; p = 0.05; OR 0.06, 95% CI 0.004-0.999). Preoperative audiometric data demonstrated a lower mean air-bone gap (45.8 dB vs. 52.3 dB; p = 0.009) and better speech reception threshold (48.7 dB vs. 57.4 dB; p = 0.0004) in cholesteatoma ears. Postoperatively, ears with cholesteatoma were more likely to close the ABG within 20 dB (p = 0.001; OR 0.19, 95% CI 0.072-0.52). No patient in the cholesteatoma group developed post-operative bony/soft-tissue stenosis (0% vs. 9.7%; p = 0.65; OR 1.61; 0.21-12.6) or required revision surgery (0% vs. 11%; p = 0.38; OR 2.46, 0.32-19). CONCLUSIONS: Patients with CAS and cholesteatoma have better audiometric outcomes and likely a more durable repair with a decreased need for revision possibly secondary to greater embryologic development of the meatus, ear canal, and middle ear space despite the cholesteatoma.

Comparing two different techniques to repair pediatric anterior tympanic membrane perforations.

OBJECTIVE: Compare outcomes between a microscopic and endoscopic technique for anterior tympanic membrane (TM) perforation. METHODS: Results of microscopic overlay (MT) and endoscopic tympanoplasty (ET) for management of anterior TM perforations from a single surgeon. RESULTS: There were 28 patients in the MT group and 35 in the ET group. The mean age was 7.1 years and 10.9 years (p < 0.001) MT and ET groups respectively. There was no statistical differences in perforation location (p = 0.1), etiology (p = 0.52) or size (p = 0.1) between both groups. Mean operating time was 119.0 min and 131.0 min in the MT and ET groups respectively (p = 0.23). Follow up was 30.9 months and 9.0 months (p = 0.001) MT and ET respectively. The perforation was successfully closed in 29 patients at 6 weeks in the ET (82.9%) and 25 in the MT (89.3%), p = 0.47. Adjusting for age revealed no significant difference between groups. Long term follow up, resulted in 10 failures (28.6%) and 7 patients (25.0%) in the ET and MT groups respectively, p = 0.75. Adjusting for the follow-up period or age, there was no significant difference between groups. The change in ABG and PTA measures were not statistically different between groups. CONCLUSIONS: An anteriorly based ET is a novel technique for management of anterior TM perforations. Results from this pilot study indicate that this ET approach may be an appropriate alternative to MT for difficult to repair anterior perforations. A longer follow-up will be necessary to determine its role in these perforations.

When to Say When-Reasons to Abort Surgery for Congenital Aural Atresia.

OBJECTIVE: To determine reasons for premature termination in surgery for congenital aural atresia (CAA). STUDY DESIGN: Retrospective chart review. SETTING: High-volume tertiary care center. PATIENTS: Patients undergoing primary surgical repair of CAA whose surgeries were aborted for various indications. INTERVENTION: Patients with CAA who underwent elective aural atresia surgery at the University of Virginia from July 2004 to January 2020 were identified from the medical record and an institutional database of patients with CAA. Patients undergoing revision surgery or surgery not for hearing correction were excluded. All included candidates were noted to be good surgical candidates for atresia repair based on preoperative Jahrsdoerfer score of 6 or greater. Reasons for terminating surgery prematurely were categorized by anatomical constraints (inability to identify middle ear space, position of the facial nerve, or other anatomic abnormality), stapes fixation, and middle ear and/or mastoid inflammatory disease. MAIN OUTCOME MEASURES: Reasons for premature termination in CAA surgery. RESULTS: Over the interval, 319 patients underwent primary surgery for CAA. Surgery was terminated prematurely without completing the primary objective in 14 patients (4.4%); surgery was terminated in 8 (57%) due to anatomic constraints, 4 (29%) due to stapes fixation, and 2 (14%) due to middle ear space and/or mastoid inflammatory disease. CONCLUSIONS: Premature termination in surgery for CAA is a rare occurrence with careful study of the preoperative high-resolution computed tomography of the temporal bone. Of the reasons for premature termination, anatomic constraints were the most common. Knowing limitations in surgery-both technical and anatomic-is critical to optimize outcomes and prevent complications.

Are Opioids Necessary in Middle Ear Surgery? Comparing the Transcanal and Postauricular Approach.

OBJECTIVE: Understand opioid-prescribing patterns in otologic surgery and the difference in opioid use between transcanal and postauricular surgery. STUDY DESIGN: Prospective survey. SETTING: Multihospital network. PATIENTS: All patients undergoing otologic surgery from March 2017 to January 2019. INTERVENTION: Patients undergoing otologic surgery were surveyed regarding postoperative opioid use and their level of pain control. Patients were divided by surgical approach (transcanal vs. postauricular). Those who underwent mastoid drilling were excluded. Narcotic amounts were converted to milligram morphine equivalents (MME) for analysis. MAIN OUTCOME MEASURES: Amount of opioid was calculated and compared between the two groups. Mann-Whitney U test and Chi-square testing were used for analysis. RESULTS: Fifty-five patients were included in the analysis; of these 18 (33%) had a postauricular incision. There was no difference in age (p = 0.85) or gender (p = 0.5) between the two groups. The mean amount of opioid prescribed (MME) in the postauricular and transcanal groups was 206.4 and 143 (p = 0.038) while the mean amount used was 37.7 and 37.5 (p = 0.29) respectively. There was no difference in percentage of opioid used (p = 0.44) or in patient-reported level of pain control (p = 0.49) between the two groups. CONCLUSION: Patients in both the transcanal and postauricular groups used only a small portion of their prescribed opioid. There was no difference in the amount of opioid used or the patient's reported level of pain control based on the approach. Otologic surgeons should be aware of these factors to reduce narcotic diversion after ear surgery.

Acoustic Reflexes in Aural Atresia Patients: Evidence of an Intact Efferent System?

OBJECTIVE: To record crossed acoustic reflex thresholds (xART's) postoperatively from patients after surgical repair of unilateral congenital aural atresia (CAA). To seek explanations for when xARTs can and cannot be recorded. We hope to understand the implications for this central auditory reflex despite early afferent deprivation. METHODS: Patients who underwent surgery to correct unilateral CAA at a tertiary academic medical were prospectively enrolled to evaluate for the presence of xART. Preoperative ARTs in the normal (non-atretic) ear, and postoperative ipsilateral ARTs (stimulus in the normal ear) and contralateral ARTs (stimulus in the newly reconstructed atretic ear; record in the normal ear) were measured at 500, 1000, and 2000 Hz. RESULTS: Four of 11 patients with normal ipsilateral reflex thresholds preoperatively demonstrated crossed acoustic reflexes postoperatively (stimulus in reconstructed ear; record from normal ear). Four other patients demonstrated normal ipsilateral thresholds preoperatively but did not have crossed reflexes postoperatively. No reflexes (pre- or postoperatively) could be recorded in 3 patients. Crossed reflex threshold is significantly correlated with the postoperative audiometric threshold. There was no correlation between ipsilateral and contralateral reflex thresholds. CONCLUSION: Crossed acoustic reflexes can be recorded from some but not all postoperative atresia patients, and the thresholds for those reflexes correlate with the postoperative pure tone threshold. The presence of acoustic reflexes implies an intact CN VIII-to-opposite CN VII central reflex arc despite early unilateral sound deprivation.

Evaluation of opioid prescription patterns among patients undergoing thyroid surgery.

BACKGROUND: There is variability in opioid prescription patterns among surgeons performing thyroidectomy. Thus, the aim of this study is to evaluate opioid prescription rates and opioid use among hemithyroidectomy (HT) and total thyroidectomy (TT) patients. DESIGN/METHOD: An electronic postoperative survey was distributed to assess opiate use among patients undergoing HT/TT. Groups were compared using t-tests, chi-square tests, and analysis of variance. RESULTS: A total of 142 opiate naïve patients were included, of which 75 (52.8%) underwent HT and 67 (47.1%) underwent TT. The mean number of tablets prescribed was 21.3 (HT = 22.1, TT = 20.4; P = 0.3), with a mean of 14.1 tablets unused after surgery (HT = 13.2 tablets, TT = 15.0 tablets; P = 0.44). The mean morphine milligram equivalent (MME) prescribed was 150.1 mg (HT = 159.0 mg, TT = 140.2 mg; P = 0.3), with a mean of 98.2 MME unused after surgery (HT = 93.7 mg, TT = 103.2 mg; P = 0.6). CONCLUSIONS: Opioids are overprescribed after thyroid surgery. Avoidance of overprescribing is vital in mitigating the current opioid crisis.

Otology-Neurotology 2020 US Workforce Distribution.

Objective: Determine the geographic and per capita distribution of otology-neurotology physician-surgeons within the United States. Study Design: National database review. Setting: United States. Methods: The American Neurotology Society and ENThealth.org membership databases were queried to identify otology-neurotology physician-surgeons within the United States. Physician-surgeons were divided by regional national census areas, state, and by largest population statistical area based on 2019 US Census population estimates. The number of otology-neurotology physician-surgeons per 1 million persons was calculated for each population designation. Results: Four-hundred eighty-two physician-surgeons were identified, representing 49 states and the District of Columbia. The New England division (Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island) was the most concentrated region (1.89), whereas the West-South-Central (Texas, Oklahoma, Arkansas, Louisiana) was the least concentrated region (1.23) per million persons. The highest concentration of physician-surgeons by state is within the District of Columbia (4.25), Vermont (3.21), North Dakota (2.62), Massachusetts (2.61), and New York (2.21) (per million), whereas Mississippi (0.67), Georgia (0.66), Idaho (0.56), New Mexico (0.48), and Wyoming (0.0) were the least concentrated per million persons. Increasing number of physician-surgeons was significantly correlated by state (r2 = 0.9; P < 0.0001), largest statistical area (r2 = 0.88; P < 0.0001), and census region (r2 = 0.95; P < 0.0005). Conclusions: Otology-neurotology physician-surgeons are evenly distributed across the United States; however, certain areas are likely underrepresented. Variability in clinical practice may account for under or overrepresentation not captured in this analysis.

Increasing Frailty, Not Increasing Age, Results in Increased Length of Stay Following Vestibular Schwannoma Surgery.

OBJECTIVE: Understand the frailty of vestibular schwannoma surgical patients and how frailty impacts clinical course. STUDY DESIGN: Retrospective Cohort. SETTING: Single-tertiary academic hospital. PATIENTS: All patients undergoing vestibular schwannoma surgery. INTERVENTION: The modified frailty index (mFI) was calculated for all patients undergoing surgery for vestibular schwannoma between 2011 and 2018. Patient demographics and medical history, perioperative course, and postoperative complications were obtained from the medical record. MAIN OUTCOME MEASURES: The primary endpoint was hospital length of stay (LOS). Secondary endpoint was postoperative complications. Basic statistical analysis was performed including multivariate linear regressions to determine independent predictors of LOS. RESULTS: There were 218 patients included and the mean age was 48.1 ±â€Š0.9 (range 12-77). One-hundred ten patients were male (50.5%). The mean ICU LOS was 1.6 ±â€Š0.1 days while mean total hospital LOS was 4.3 ±â€Š0.2. There were 145 patients (66.5%) who were robust (nonfrail) with an mFI of 0, while 73 (33.5%) had an mFI of ≥1. Frailty (mFI≥2) was associated with longer hospital LOS compared with the prefrail (p = 0.0014) and robust (p = 0.0004) groups, but was not associated with increased complications (OR = 1.3; 95% CI: 0.5-3.7; p = 0.5925) or ICU LOS (p > 0.05). In multivariate analysis, increased mFI, and NOT increased age, was an independent risk factor for increased hospital LOS (p = 0.027). CONCLUSION: Increasing frailty, and not increasing age, is an independent risk factor for longer hospital LOS, but not for increased postoperative complications. Patients' frailty status may be useful preoperatively in counselling patients about postoperative expectations and frail vestibular schwannoma patients may require increased health spending costs given their increased hospital LOS.

Aspiration in the otherwise healthy Infant-Is there a natural course for improvement?

OBJECTIVES/HYPOTHESIS: Timing and indication for surgical intervention is a major challenge in managing pediatric oropharyngeal dysphagia. No study has evaluated a natural course of swallowing dysfunction in otherwise healthy infants. Our objective was to review the outcomes and time to resolution of abnormal swallow in infants with aspiration. STUDY DESIGN: Retrospective case series at a tertiary children's hospital. METHODS: Fifty patients under 1 year old with aspiration on a modified barium swallow study were included. Patients born <34 weeks, with medical or genetic comorbidities, or who underwent surgical intervention for aspiration were excluded. Patients were followed until aspiration resolved on a swallow study. Kaplan-Meier survival analysis was performed. RESULTS: Forty patients (25 patients [50%] by 6 months, 10 [20%] by 1 year, three [6%] by 2 years, and two [4%] at the end of the follow-up interval) were recommended a normal diet, and 10 patients (20%) were still aspirating by the end of the follow-up interval. Median time to resolution was 202 ± 7 days (range, 19-842 days), probability 48% (95% confidence interval [CI]: 0.34-0.62). The probability of resolution at 6 months was 46% (95% CI: 0.4-0.68), at 1 year was 64% (95% CI: 0.51-0.77), at 2 years was 76% (95% CI: 0.64-0.88), and at the end of the follow-up interval 81.3% (95% CI: 0.7-0.92). CONCLUSIONS: The majority of infants with aspiration and without any other major comorbidities improved within 1 year. Future research should be directed toward better understanding swallowing dysfunction in neurologically normal infants. LEVEL OF EVIDENCE: 4 Laryngoscope, 130:514-520, 2020.

Opioid Prescribing and Use in Ambulatory Otolaryngology.

OBJECTIVES: The objective of this study was to evaluate surgeon-prescribing patterns and opioid use for patients undergoing common otolaryngology surgeries. We hypothesized that there was little consistency across surgeons in prescribing patterns and that surgeons prescribed significantly more opioids than consumed by patients. METHODS: E-mail-based surveys were sent to all postoperative patients across a 23-hospital system. The survey assessed quantity of opioids consumed postoperatively, patient-reported pain control, and methods of opioid disposal. We compared patient-reported opioid consumption to opioids prescribed based on data in the electronic data warehouse. RESULTS: There was wide variation in prescribing between providers both in the quantity and type of opioids prescribed. Patients used significantly less opioids than they were prescribed (10 vs. 30 tablets, P < 0.001) for both opioid-exposed and opioid-naïve patients. More than 75% of patients had excess opioids remaining. CONCLUSION: Opioids are consistently overprescribed following ambulatory head and neck surgery. Otolaryngologists have an important role in the setting of the national opioid epidemic and should be involved in efforts to reduce excess opioids in their community. LEVEL OF EVIDENCE: 4 Laryngoscope, 130: 1913-1921, 2020.

Prescription patterns and opioid usage in sinonasal surgery.

BACKGROUND: Excess opioid use after surgery contributes to opiate misuse and diversion. Understanding opioid prescribing and utilization patterns after sinonasal surgery is critical in designing effective practice protocols. In this study we aim to identify factors associated with variable opioid usage and further delineate optimal prescription patterns for sinonasal surgery. METHODS: All patients undergoing sinonasal surgery within a single health-care system from March 2017 to August 2018 were sent electronic postoperative surveys. Data were collected on the amount of opioid required, pain control, presurgical opiate use, and narcotic disposal. Additional data collected from the electronic medical record included demographics, type of surgery performed, and total amount of opioid prescribed, including refills. RESULTS: Three-hundred sixty four patients were included. A mean number of 25.3 tablets were prescribed per patient, yet the mean taken was just 11.8 tablets. Excess opioids were prescribed 84.9% of the time with a mean excess narcotic in oral morphine equivalents of 152.5. Among patients, 11.8% reported using no opioids, whereas 52.1% used <50% and 36.1% used >50% of their narcotic prescription. Patients used 9.3% of their full prescription and only 2.6% required a refill. The amount used was not associated with complexity of endoscopic sinus surgery, type of opiate prescribed, gender, distance living from hospital, or current opioid usage before surgery (p > 0.05). The addition of septoplasty and/or turbinoplasty was associated with variation in opioid usage (p < 0.001). A total of 76.1% of patients incorrectly discarded/stored excess opiates. CONCLUSION: Opioids are overprescribed after sinonasal surgery. The amount of postoperative opiate prescribed should be greatly reduced and may be based on the specific procedures performed. Improved patient education regarding disposal of excess narcotics may help to curtail future opioid diversion.

Variations in Stapes Surgery Cost within a Multihospital Network.

OBJECTIVE: To identify costs and operative times for stapedotomy and evaluate factors influencing cost variation. STUDY DESIGN: Case series with cost analysis. SETTING: Multihospital network. SUBJECTS AND METHODS: A multihospital network's standardized activity-based accounting system was used to determine costs and operative times of all patients undergoing stapedotomy from 2013 to 2017. Subjects with additional procedures were excluded. Correlations between variable factors and cost were calculated by Spearman correlation coefficients. Audiometric and cost data were compared with a Mann-Whitney U test. RESULTS: The study cohort included 176 stapedotomies performed by 23 surgeons at 10 hospitals. Mean ± SD patient age was 44.3 ± 17.4 years. Mean cut-to-close time was 61.1 ± 23.55 minutes. Mean total encounter cost was $3542.14 ± $1258.78 (US dollars). Significant factors correlating with increased total encounter cost were surgical supply cost (r = 0.74, P < .0001) and cut-to-close time (r = 0.66, P < .0001). Laser utilization ($563.37 ± $407.41) was the highest-cost surgical supply, with the carbon dioxide laser being significantly more costly than the potassium titanyl phosphate (KTP; $852.60 vs $230.55, P < .001). Additionally, the carbon dioxide laser was associated with a significantly higher mean total encounter cost than the KTP laser ($4645.43 vs $2903.00, P < .001) and cases where no laser was used ($4645.43 vs $2932.47, P < .001). There was no difference in mean total encounter cost between the KTP laser and cases of no laser use ($2903.00 vs $2932.47, P = .75). CONCLUSIONS: Significant cost variation exists in stapes surgery. Surgical supply cost, specifically laser use, may be associated with significantly increased costs. Reducing variation in costs while maintaining outcomes may improve health care value.

Primary Petrous Apex Epidermoids With Skull Base Erosion.

OBJECTIVE: To describe the clinical course and treatment outcomes for patients with petrous apex epidermoid with skull base erosion. STUDY DESIGN: Retrospective case series. SETTING: Tertiary-care academic center. PATIENTS: Patients surgically managed for petrous apex epidermoids at a single-tertiary care institution from 2001 to 2017. INTERVENTIONS: Surgical management of primary petrous apex epidermoids. MAIN OUTCOME MEASURES: The presenting symptoms, imaging, pre- and postoperative clinical course, and complications were reviewed. RESULTS: Seven patients were identified. The most common presenting symptoms included: sudden sensorineural hearing loss (n = 3), headaches (n = 1), vertigo (n = 2), and facial paralysis/paresis (n = 2). An epidermoid was discovered in two patients as an incidental finding after a head trauma and one patient after admission for altered mental status and meningitis. Two patients presented with complete facial paralysis (House-Brackmann 6/6). Preoperative normal hearing (pure-tone average < 25 db) was identified in three patients and serviceable hearing (pure-tone average 25-60 dB) in one patient. Three patients with nonserviceable hearing underwent a transcochlear or transotic approach. The remaining four patients underwent an attempted hearing preservation approach. Postoperatively, one patient developed delayed facial paralysis, improving within 3 months. Hearing was preserved in three patients. Two patients developed recurrence of disease within 4 and 7 years respectively. CONCLUSIONS: Surgical management of aggressive petrous apex epidermoid is effective to preserve facial function and prevent recurrence. In our series different surgical approaches were used with variable outcomes.

Hearing Outcomes Reporting in Lateral Skull Base Surgery.

Hearing outcomes reporting has evolved significantly and new standards for reporting now enable a more precise and comprehensive representation of hearing outcomes. Hearing is one of the critical sensory domains contained within the lateral skull base and temporal bone. For those patients with serviceable hearing, hearing preservation is a key treatment goal. Pre- and postoperative hearing assessment is fundamental to the diagnostic evaluation of patients preparing to undergo lateral skull base surgery. Standardization in reporting these hearing outcomes is critical to compare the efficacy of different treatment options for lateral skull base lesions. Over the time, reporting of hearing outcomes has evolved from broadly categorizing patients into large groups to comparing individual patients which requires more specific datasets to compare pre- and posttreatment hearing outcomes. Future research in lateral skull base surgery will benefit from precise, accurate, and easily understood reporting outcomes, all of which will allow for more efficient comparability between studies and pooling of data for meta-analysis.

Coexistent Vestibular Schwannoma and Creutzfeldt-Jakob Disease: Recognition and Infection Control.

OBJECTIVES: We describe the first known case of coexistent vestibular schwannoma (VS) and Creutzfeldt-Jakob disease (CJD). Our objectives are to use this case as a general lesson for the subspecialist otolaryngologist to remain vigilant to alternative diagnoses, and to specifically improve understanding of the diagnosis and management of CJD as relevant to the practice of otolaryngology and skull base surgery. METHODS: Retrospective case review performed in June 2016 at an academic, tertiary, referral center. RESULTS: A 55-year-old man presents with one month of worsening disequilibrium and short-term memory loss. Magnetic resonance imaging (MRI) (T1, T2) identified a 4 mm left VS which was then surgically resected. Postoperatively, his neurological status decline continued, and subsequent MRI identified patterns of FLAIR hyperintensity and diffusion restriction consistent with CJD. While CSF analysis (tau and 14-3-3) and EEG was inconclusive, serial imaging and the clinical course were highly suggestive of CJD. A probable diagnosis was made, surgical instruments quarantined, and infection control involved to minimize transmission risk. The patient died 6 months after symptom onset. CONCLUSIONS: Patients with CJD may initially present with otolaryngologic symptoms. MRI signal abnormality in the basal ganglia on diffusion weighted imaging and FLAIR sequences in conjunction with physical findings and clinical course may help make a probable diagnosis CJD. Prions are resistant to traditional sterilization and additional measures must be taken to prevent iatrogenic transmission. LEVEL OF EVIDENCE: Level 4-Case series.