Importance: Neural recordings from cochlear implant users provide a valuable, noninvasive measure of auditory nerve function. However, inconsistent methods for acquiring and analyzing these recordings limit their clinical application.
Objective: To develop and validate an automated method for standardizing the analysis of electrically evoked compound action potentials in cochlear implant users, and to characterize longitudinal changes in auditory nerve function across the largest cohort studied to date.
Design, settings, and participants: This multicenter cohort study used nonlinear curve-fitting models to analyze electrically evoked compound action potentials acquired during clinical programming and follow-up at multiple US centers from July 28, 2002, to August 13, 2017. Data were analyzed from October 8, 2024 to May 6, 2025.
Main outcomes and measures: Model fit success rates; variation in auditory nerve response parameters with age, sex, electrode location, and duration of implant use; and identification of age-related periods of peripheral neural plasticity.
Results: The analysis included 1 145 323 electrically evoked compound action potential recordings comprising 169 159 growth functions from 10 111 cochlear implants in 7416 patients (3560 [48%] female and 3856 [52%] male individuals). Both models successfully fit approximately 80% of auditory-nerve growth functions. Thresholds increased from apex to base along the cochlear array, paralleled by a decline in response slope and plateau. Latencies remained stable across electrode locations. Age at implantation significantly predicted nerve response slope, with younger recipients showing steeper slopes that declined with increasing age, particularly after adolescence. In infants and toddlers, slopes continued to increase over 5 years of implant use, suggesting peripheral neural plasticity early in life. Older recipients showed minimal slope change over time. Although thresholds rose modestly with prolonged device use, slope and plateau stabilized after age 30 years, indicating that age at implantation, rather than stimulation duration, was the primary determinant of auditory nerve responsiveness.
Conclusions and relevance: This cohort study introduces a robust and scalable framework for in vivo assessment of auditory nerve function and monitoring of peripheral plasticity across the lifespan. The findings highlight the critical importance of early cochlear implantation for preserving neural health and optimizing long-term outcomes.
Importance: Excessive bleeding during endoscopic sinus surgery (ESS) impairs visualization and increases complications. Controlled hypotension is widely used; however, comparative effectiveness of available pharmacological agents remains uncertain.
Objective: To compare the effectiveness and safety of hypotensive drugs for reduced bleeding in ESS.
Data sources: PubMed, Scopus, Web of Science, and Cochrane databases were searched from inception to December 2024, and updated to include studies up to May 2025.
Study selection: Randomized clinical trials of patients undergoing ESS and receiving dexmedetomidine, clonidine, esmolol, labetalol, bisoprolol, metoprolol, diltiazem, nifedipine, or verapamil vs placebo. A total of 1258 records were screened.
Data extraction and synthesis: Data were extracted and assessed using the Cochrane risk of bias tool. Certainty was rated using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) framework. A random-effects meta-analysis was conducted in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement guidelines.
Main outcomes and measures: Surgical bleeding score, intraoperative mean arterial pressure (MAP), and mean intraoperative heart rate. Secondary outcomes included blood loss, surgery duration, and emergence time.
Results: The analysis included 52 randomized clinical trials involving 3526 participants; of these, 43 studies contributed to the network analysis. Several agents were associated with reduced bleeding vs placebo: diltiazem (mean difference [MD], -1.25; 95% CI, -2.13 to -0.37), esmolol (MD, -1.16; 95% CI, -1.80 to -0.51), dexmedetomidine (MD, -1.09; 95% CI, -1.48 to -0.70), labetalol (MD, -1.00; 95% CI, -1.58 to -0.42), and clonidine (MD, -0.69; 95% CI, -1.23 to -0.16). Dexmedetomidine was associated with the most reduced MAP (MD, -30.30 mm Hg; 95% CI, -47.91 to -12.69), followed by clonidine (MD, -28.61; 95% CI, -53.11 to -4.11), esmolol (MD, -27.62; 95% CI, -49.73 to -5.51), and labetalol (MD, -26.54; 95% CI, -47.20 to -5.87). At 60 minutes, bisoprolol (MD, -58.30; 95% CI, -67.50 to -49.10 beats per minute [bpm]), verapamil (MD, -49.90; 95% CI, -58.98 to -40.82 bpm), and labetalol (MD, -43.89; 95% CI, -54.59 to -33.18 bpm) produced the largest heart rate reductions. Esmolol (MD, -3.67; 95% CI, -4.21 to -3.13 minutes) and labetalol (MD, -3.64; 95% CI, -4.79 to -2.49 minutes) shortened emergence time.
Conclusions and relevance: In this systematic review and network meta-analysis, controlled hypotension improved surgical field quality in ESS with comparable safety. Diltiazem, esmolol, dexmedetomidine, labetalol, and clonidine were effective; dexmedetomidine was associated with reduced MAP the most, and esmolol favored recovery.
Importance: Balloon sinus dilation (BSD) is a tool for treating patients with chronic rhinosinusitis or recurrent acute rhinosinusitis. The use of BSD has increased exponentially since its introduction, with concerns for potential misuse. Expert consensus reports that most patients who are candidates for BSD do not need to have all 6 sinuses dilated (bilateral frontal, maxillary, and sphenoid).
Objective: To determine the percentage of patients who are undergoing 6-sinus BSD, evaluate factors associated with this practice, and explore outlier practice patterns when performing 6-sinus BSD.
Design, setting, and participants: This cross-sectional, retrospective review of a Medicare claims database from January 2022 to December 2023 included otolaryngologists (US Centers for Medicare & Medicaid Services code 04) who performed at least 11 BSDs during the study period, who were defined as high-volume BSD clinicians (>10 BSDs per year). Data were analyzed in July 2024.
Main outcomes and measures: The primary outcome defined before data collection as the percentage of patients billed for 6-sinus BSD. Physician variables were explored for potential association with 6-sinus BSD.
Results: Of the 522 otolaryngologists (mean [SD] age, 52 [9.3] years), most physicians were male (489 [94%]), practiced in a group setting (428 [82%]), and were in an urban environment (474 [91%]). A total of 21 290 unique BSD procedures were performed, and 12 799 procedures (60%) involved all 6 sinuses. Of the 522 otolaryngologists, 40 (8%) performed 6-sinus BSD in 100% of their BSD procedures, while 54 (10%) performed no 6-sinus BSDs. Practice patterns varied substantially, with 8 physicians (2%) responsible for 10% of 6-sinus BSDs (n = 2152).
Conclusions and relevance: The results of this cross-sectional study suggest that the high volume of 6-sinus BSD suggests the potential for overuse of BSD. Substantial variations in care emphasize the need for clear guidelines and indications for multisinus BSD to optimize the utilization and value of BSD.
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