Development of a feline model for preclinical research of a new translabyrinthine auditory nerve implant.

Cochlear implants are among the most successful neural prosthetic devices to date but exhibit poor frequency selectivity and the inability to consistently activate apical (low frequency) spiral ganglion neurons. These issues can limit hearing performance in many cochlear implant patients, especially for understanding speech in noisy environments and in perceiving or appreciating more complex inputs such as music and multiple talkers. For cochlear implants, electrical current must pass through the bony wall of the cochlea, leading to widespread activation of auditory nerve fibers. Cochlear implants also cannot be implanted in some individuals with an obstruction or severe malformations of the cochlea. Alternatively, intraneural stimulation delivered via an auditory nerve implant could provide direct contact with neural fibers and thus reduce unwanted current spread. More confined current during stimulation can increase selectivity of frequency fiber activation. Furthermore, devices such as the Utah Slanted Electrode Array can provide access to the full cross section of the auditory nerve, including low frequency fibers that are difficult to reach using a cochlear implant. However, further scientific and preclinical research of these Utah Slanted Electrode Array devices is limited by the lack of a chronic large animal model for the auditory nerve implant, especially one that leverages an appropriate surgical approach relevant for human translation. This paper presents a newly developed transbullar translabyrinthine surgical approach for implanting the auditory nerve implant into the cat auditory nerve. In our first of a series of studies, we demonstrate a surgical approach in non-recovery experiments that enables implantation of the auditory nerve implant into the auditory nerve, without damaging the device and enabling effective activation of the auditory nerve fibers, as measured by electrode impedances and electrically evoked auditory brainstem responses. These positive results motivate performing future chronic cat studies to assess the long-term stability and function of these auditory nerve implant devices, as well as development of novel stimulation strategies that can be translated to human patients.

Nationwide Utilization of Computerized Dynamic Posturography in an Era of Deimplementation.

Computerized dynamic posturography (CDP) provides multisensory assessment of balance. Consensus is lacking regarding CDP utility and coverage determinations vary. To inform best practices and policy, this cross-sectional study quantifies provider use of CDP among Medicare beneficiaries over time (2012-2017), by geographic region (hospital referral region [HRR]), and specialty. We observed 195,267 beneficiaries underwent 212,847 CDP tests totaling $15,780,001 in payments. Number of CDPs billed per 100,000 beneficiaries varied 534-fold across HRRs. Over 6 years, CDP use grew by 84% despite stagnant reimbursement. More utilization was attributable to primary care clinicians than specialties focused on care for dizziness and balance disorders. The observed growth and variation illustrate the potential for policy and provider preferences to drive unexpected practice patterns and underscore the need to engage a broad network of providers to develop optimal guidelines for use. CDP may offer a use case for deimplementation of low-value diagnostic services.

Efficient Use of Vestibular Testing.

While the majority of vestibular disorders may be diagnosed solely on clinical grounds, a variety of clinical scenarios exist in which objective functional assessment of the vestibular system provides data that facilitate diagnosis and treatment decisions. There exists a veritable armamentarium of sophisticated vestibular test modalities, including videonystagmography, rotary chair testing, video head impulse testing, and vestibular-evoked myogenic potentials. This article aims to help clinicians apply an accessible decision-making rubric to identify the clinical scenarios that may and may not benefit from data derived from specific vestibular function tests.

Variation in Canalith Repositioning Procedure Use Among Medicare Beneficiaries: Understanding the Role of Geographic Region and Provider Specialty.

OBJECTIVE: Clinical practice guidelines recommend canalith repositioning procedures (CRPs) for the management of benign paroxysmal positional vertigo (BPPV). As only 10 to 20% of affected individuals receive CRPs, there is concern for guideline adherence and knowledge dissemination to relevant medical specialties. This study aimed to characterize patterns of CRP utilization over time, across all United States regions, and by provider specialty. STUDY DESIGN: Cross-sectional analysis with time trends of CRP claims in the Centers for Medicare and Medicaid Service Provider Utilization and Payment database, 2012 to 2017. SETTING: National administrative claims data. PATIENTS: Fee-for-service Medicare beneficiaries. INTERVENTIONS: Canalith repositioning procedures. MAIN OUTCOME MEASURES: CRP utilization was analyzed by year, hospital referral region (HRR), and provider specialty. RESULTS: From 2012 to 2017, 253,894 CRPs were performed on 146,139 Medicare beneficiaries and CRP utilization increased 80%. CRP use varied widely by geographic region. In 2017, CRP use per 100,000 beneficiaries varied 113-fold across HRRs (range, 6.0-701.8, interquartile range, 68.4, extremal ratio, 116.9). Most CRPs were performed by otolaryngologists (50.9%) and physical therapists (34.3%) with few by primary care providers (1.3%). CONCLUSIONS: CRP utilization increased substantially suggesting improved dissemination and implementation of BPPV management guidelines. Nevertheless, wide geographic and provider-level variation remained, signifying non-uniform provider practices and access to care. Care for BPPV may thus be improved through education and incentivization of a broader range of providers.

Long-term outcomes of cartilage-buttressed T-tube tympanoplasty for prolonged middle ear ventilation.

OBJECTIVES/HYPOTHESIS: To report on the safety and efficacy of cartilage-buttressed T-tube tympanoplasty for long-term middle ear ventilation, specifically by examining duration of tube survival, as well as adverse events associated with prolonged middle ear intubation, including persistent tympanic membrane perforation. STUDY DESIGN: Retrospective case series of patients undergoing cartilage-buttressed T-tube tympanoplasty between January 2005 and December 2016 in a tertiary-care neurotology private practice. METHODS: Patients who underwent cartilage T-tube tympanoplasty with complete pre- and postoperative audiometric data and a minimum follow-up duration of 12 months were analyzed. T-tube survival and adverse events including persistent tympanic membrane perforation were recorded and compared to published data for other long-term middle ear ventilation techniques. RESULTS: The study cohort included 72 cartilage-buttressed T-tube tympanoplasties in 68 patients. Median tube survival was 34 months (range, 2-131 months). Incidence of persistent tympanic membrane perforation (n = 1) was 1.4% CONCLUSIONS: Cartilage-buttressed T-tube tympanoplasty is a safe and effective means of accomplishing long-term middle ear ventilation with a considerably lower rate of persistent tympanic membrane perforation as compared to alternative methods of prolonged middle ear ventilation. LEVEL OF EVIDENCE: 4 Laryngoscope, 129:203-208, 2019.

Improved swallow outcomes after injection laryngoplasty in unilateral vocal fold immobility.

While the impact of injection laryngoplasty on voice outcomes in unilateral vocal fold immobility has been well characterized, there is a relative paucity of literature investigating its influence on swallow function and outcomes. We performed a retrospective chart review of patients presenting to an academic cancer center between January 2014 and January 2016 to evaluate the clinical impact of percutaneous injection laryngoplasty on reduction of aspiration risk, patient perception of swallowing, and recommended safe diet in patients with vocal fold immobility after head and neck and thoracic surgery. A consecutive sample of patients diagnosed with unilateral vocal fold immobility with patient- or clinician-identified abnormal swallow function who underwent bedside or in-office vocal fold injection was included in the study. Fiberoptic endoscopic evaluation of swallowing, Eating Assessment Tool-10 scores, Functional Oral Intake Scale scores, and patient perceptual assessment of swallow were evaluated pre- and postinjection. Twenty-one patients with new-onset unilateral vocal fold immobility who underwent injection laryngoplasty were evaluated. Median Eating Assessment Tool-10 and Functional Oral Intake Scale scores postinjection were significantly improved from preinjection. Patients who initially required restricted oral diets, or were nil per os, were able to advance their diet after injection laryngoplasty. Injection laryngoplasty is a safe and effective intervention for improvement of dysphagia in patients with unilateral vocal fold immobility. A single treatment may markedly reduce or eliminate risk of aspiration and potential sequelae.

Utility of Eating Assessment Tool-10 in Predicting Aspiration in Patients with Unilateral Vocal Fold Paralysis.

Objective Examine the incidence of penetration/aspiration in patients with unilateral vocal fold immobility and investigate the relationship with self-reported perception of dysphagia. Study Design Case series with chart review. Setting Academic cancer center. Subjects and Methods Adult patients with unilateral vocal fold immobility diagnosed between 2014 and 2016 were reviewed. Patients were stratified into an aspiration group and a nonaspiration group using objective findings on flexible endoscopic evaluation of swallowing, as scored using Rosenbek's Penetration Aspiration Scale. Objective findings were compared to patient perception of dysphagia. Bivariate linear correlation analysis was performed to evaluate correlation between Eating Assessment Tool-10 scores and presence of aspiration. Tests of diagnostic accuracy were calculated to investigate the predictive value of Eating Assessment Tool-10 scores >9 on aspiration risk. Results Of the 35 patients with new-onset unilateral vocal fold immobility were evaluated, 25.7% (9/35) demonstrated tracheal aspiration. Mean ± SD Eating Assessment Tool-10 scores were 19.2 ± 13.7 for aspirators and 7.0 ± 7.8 for nonaspirators ( P = .016). A statistically significant correlation was demonstrated between increasing Eating Assessment Tool-10 scores and Penetration Aspiration Scale scores ( r = 0.511, P = .002). Diagnostic accuracy analysis for aspiration risk in patients with an Eating Assessment Tool-10 score >9 revealed a sensitivity of 77.8% and a specificity of 73.1%. Conclusion Patient perception of swallowing difficulty may have utility in predicting aspiration risk. An EAT-10 of >9 in patients with unilateral vocal fold immobility may portend up to a 5 times greater risk of aspiration. Routine swallow testing to assess for penetration/aspiration may be indicated in patients with unilateral vocal fold immobility.

Effect of rural and urban geography on larynx cancer incidence and survival.

OBJECTIVES/HYPOTHESIS: Investigate the impact of rural geography on larynx cancer incidence and survival. STUDY DESIGN: Surveillance, Epidemiology, and End Results (SEER) database study. METHODS: Incidence and survival rates by Rural-Urban Continuum codes for larynx squamous cell carcinoma patients diagnosed from 2004 to 2012 were evaluated using SEER statistical software and Cox proportional hazards survival analysis. RESULTS: The lowest age-adjusted incidence rates for larynx cancer were seen in densely populated urban regions, with mean rates of 2.8 per 100,000 person years (95% confidence interval [CI]: 2.7-2.8); the highest were in the most rural areas, with mean rates of 5.3 per 100,000 person years (95% CI: 4.7-5.9). Nevertheless, of 23,659 larynx cancer patients diagnosed over this period, 19,556 (82.7%) arose in urban residents, compared with 1,428 or 6% from rural areas. Urban larynx cancer patients more likely lived in counties with an American College of Surgeons-approved cancer center and/or a fourfold greater otolaryngology physician supply. Nevertheless, frequency of advanced stage at initial presentation was similar. Cause-specific and overall survival were no different, both on univariable and multivariable analyses. CONCLUSIONS: Compared with urban populations, Rural populations are at greater risk of developing larynx cancer, but initial stage and survival after diagnosis are comparable. Priority should be given to prevention strategies to decrease incidence rates. LEVEL OF EVIDENCE: 4 Laryngoscope, 1874-1880, 2018.

Inpatient injection laryngoplasty for vocal fold immobility: When is it really necessary?

PURPOSE: To compare pulmonary and swallow outcomes of injection laryngoplasty when performed in the acute versus subacute setting in head & neck and thoracic cancer patients presenting with new onset unilateral vocal fold immobility. MATERIALS AND METHODS: Case series with chart review at an academic cancer center over a 2year period. Based on swallow evaluation, patients diagnosed with vocal fold immobility were grouped into an unsafe swallow group, injected as inpatients, and a safe swallow group, for whom injection laryngoplasty was delayed to the outpatient setting or not performed. Rates of pneumonia, diet recommendations, and swallow outcomes were compared between groups. RESULTS: 24 patients with new-onset vocal fold immobility were evaluated. 7 underwent injection in the inpatient setting, 12 in the outpatient setting, and 5 did not undergo injection. There was no perceived difference in speech and swallow outcomes between the inpatient and outpatient injection groups. CONCLUSIONS: Injection laryngoplasty shows promise as an effective intervention for reducing aspiration risk and improving diet normalcy in patients with dysphagia as a result of unilateral vocal fold immobility. In patients determined to have a safe swallow, delay of injection laryngoplasty is not detrimental to swallow outcomes.