Otology & Neurotology最新文献

Objective: To characterize national practice patterns and geographic variations in intratympanic injections among Medicare providers.

Study design: Retrospective cross-sectional analysis of intratympanic injections performed in the Medicare fee-for-service population from 2013 to 2021.

Setting: Center for Medicare & Medicaid Services Physician and Other Practitioners database.

Participants: Providers performing outpatient intratympanic injections, documented by Current Procedural Terminology code 69801.

Interventions: Intratympanic injections.

Main outcome measures: The number of intratympanic injections performed by individual providers, states, and geographic regions, as well as reimbursements, was analyzed annually.

Results: A total of 159,236 in-office intratympanic injections were performed. The Center for Medicare & Medicaid Services reimbursed $25,407,086; out-of-pocket patient costs were $6,591,514. The mean Medicare reimbursement rate and out-of-pocket cost per injection were $159.56 and $41.38, respectively. From 2013 to 2021, the number of intratympanic injections increased from 13,117 to 20,711 injections, representing a 57.9% increase. On linear regression, an additional 989.9 injections were performed each year (95% CI 766.4-1,213.4, p < 0.001). The number of providers performing injections also increased from 1,828 to 2,834 from 2013 to 2021 ( b = 125.6 [95% CI 111.3-140.0], p < 0.001). The population-controlled annual mean number of injections varied substantially across the United States, ranging from 12.0 injections per 100,000 beneficiaries in Oklahoma to 255.2 injections per 100,000 beneficiaries in Alabama.

Conclusions: The number of intratympanic injections administered in the Medicare population has increased from 2013 to 2021. There is variability in practice patterns and utilization of intratympanic injections among otolaryngologists in the United States.

Objective: Estimate the prevalence of hearing loss and hearing assistance device use among older adults in the United States, and assess for associations with select social determinants of health (SDOH).

Study design: Cross-sectional US population-based study using National Health and Nutrition Examination Survey (NHANES) 2017-March 2020 (pre-pandemic) data.

Setting: Non-institutionalized civilian adult US population.

Methods: US adults aged ≥70 years who completed NHANES audiometry exams were included. Sample weights were applied to provide nationally representative prevalence estimates of hearing loss and hearing assistance device use. Logistic regression analyses assessed associations between SDOH and both hearing loss and hearing assistance device use.

Results: The overall prevalence of hearing loss was 73.7%. Among those with nonprofound hearing loss, the prevalence of hearing assistance device use was 31.3%. Older individuals (odds ratio [OR], 6.3 [3.668-10.694] comparing ages 80+ versus 70-74 yr) and with lower education (OR, 3.8 [1.455-9.766] comparing

Conclusion: The prevalence of hearing loss among older adults in the United States remains roughly stable compared with previous population-based estimates, whereas the prevalence of hearing assistance device use is slightly increased. Population-level disparities exist both in the prevalence of hearing loss and hearing assistance device use across SDOH.

Objective: To evaluate the long-term changes in sporadic vestibular schwannoma (VS) disease-specific quality-of-life (QOL) outcomes.

Study design: Prospective longitudinal study using the Penn Acoustic Neuroma Quality of Life (PANQOL) Scale.

Setting: National survey.

Patients: Patients with sporadic VS who completed a baseline survey before treatment and at least one follow-up survey recruited through the authors' center and through the Acoustic Neuroma Association.

Interventions: Observation, microsurgery, radiosurgery.

Main outcome measures: Changes in PANQOL scores from baseline to most recent survey.

Results: Among 445 eligible patients the mean duration of follow-up was 4.4 (SD, 2.3) years, including 122, 218, and 105 in the observation, microsurgery, and radiosurgery groups, respectively. Patients managed with observation ( p = 0.03) or microsurgery ( p < 0.001) demonstrated improvement in anxiety scores. Changes in facial function scores differed significantly by management group ( p = 0.01), with patients undergoing microsurgery demonstrating a mean decline of 10 points in facial function scores compared with mean declines of 3 for those managed with observation or radiosurgery. Hearing loss scores decreased similarly over time for all three groups ( p = 0.3). There were minimal changes in total PANQOL scores over time across all management groups ( p = 0.5).

Conclusions: Long-term changes in total QOL among VS management groups are not significantly different. Microsurgery may continue to confer an advantage regarding improvement in anxiety postoperatively, but with a greater decline in facial function when compared to observation or radiosurgery. Long-term declines in hearing loss scores were not statistically significantly different among groups.

Objective: To analyze the outcomes of exoscopic versus microscopic ossicular chain reconstruction (OCR).

Study design: Retrospective chart review.

Setting: Tertiary care otology-neurotology practice.

Patients: Adult subjects with a diagnosis of ossicular discontinuity from 2018 to 2022.

Interventions: Exoscopic or microscopic primary OCR (without mastoidectomy) with a partial ossicular replacement prosthesis (PORP) or total ossicular replacement prosthesis (TORP).

Main outcome measures: Audiometric outcomes at 3 months and 1 year postoperatively including bone and air pure tone averages (PTA), air-bone gap (ABG), change in ABG, speech reception threshold (SRT), and word recognition score (WRS). Secondary outcomes included operative time and complication rates of primary and delayed graft failure, tympanic membrane lateralization, prosthesis extrusion, cerebrospinal fluid leak, facial nerve injury, profound hearing loss, persistent tinnitus, and persistent vertigo.

Results: Sixty ears underwent primary OCR and were subdivided based on prosthesis type (PORP and TORP) and surgical approach (exoscope vs microscope). Exoscopic OCR was performed on 30 ears (21 PORP, 9 TORP), and microscopic OCR was performed on 30 ears (19 PORP, 11 TORP). In the overall group (PORP + TORP) and in the PORP and TORP subgroups, there were no significant differences in 1) demographics, 2) intraoperative findings, and 3) audiometric outcomes of bone and air PTA, ABG, change in ABG, SRT, and WRS at 1 year postoperatively. Operative time was 64.7 and 59.6 minutes for the exoscopic and microscopic group, respectively ( p = 0.4, 95% CI [-16.4, 6.1], Cohen's D = 0.2).

Conclusions: Audiometric and surgical outcomes after exoscopic and microscopic OCR are comparable.

Objective: Lateral skull base defects (LSBD) pose a diagnostic challenge; however, early recognition and treatment are important to avoid sequelae. This study examines the impact of health care disparities associated with time to diagnosis and treatment for patients with LSBD.

Study design, setting, patients, intervention, outcome measures: Multi-institutional retrospective cohort study at four U.S. tertiary centers from 2000 to 2022. Adult patients with a primary diagnosis of CSF leak or encephalocele were included. Multivariate regressions used to analyze how age, sex, race/ethnicity, insurance, language, zip code, distance to medical center, referral patterns, diagnostic workup, and clinical course affected time to diagnosis and treatment.

Results: In 127 patients with LSBD, mean time to treatment of CSF leak or encephalocele was 13.9 months. On average, patients waited 10.6 months from initial assessment to diagnosis and saw 2 providers prior to diagnosis. Approximately 91% (115) of patients had a CT scan, and 75% (95) had an MRI. Imaging did not influence time to treatment. Older age, public insurance, and number of providers seen were associated with delays. Non-English speakers (5% of 127) encountered treatment delays, although this was not statistically significant. Fifty-eight (46%) people had private insurance. The average traveled distance for care was 62.6 miles. Clinical presentation, race, zip code, imaging, myringotomy, beta-2 transferrin, and ED workup were not found to be associated with delays to care.

Conclusion: There are significant delays in diagnosis and management of LSBD. Referral patterns did influence care. Health care disparities did not impact care; however, disparities and language barriers need to be studied further to determine contributions to delays in care.

Objective: This study assesses the electrically evoked stapedius reflex threshold (eSRT) as an objective method for generating auditory maps in individuals with pulse-width-modulation cochlear implants (CIs). It investigates the impact of both single- and multiple-electrode stimulations on eSRT detection rates and their association with patients' comfort loudness levels (C-levels). Despite eSRT exploration by several CI brands incorporating pulse-amplitude-modulation stimulation technology, there is a lack of information on systems using pulse-width modulation.

Approach: The eSRT was measured in 19 ears ipsilaterally and contralaterally in response to stimulations in groups of 1, 3, and 5 electrodes across five distinct cochlear regions, spanning from apical to basal. For each group, the eSRT detection rate and its correlation with the C-levels were analyzed both regionally and overall.

Main results: In both contralateral and ipsilateral sides, higher electrically evoked stapedius reflex (eSR) detection rates were obtained for multielectrode (67%, 47%) than for single-electrode (41%, 23%) stimulation. Invoking eSR in the apical and basal regions was easier than in the middle region. The multiple stimulation just increased slightly the correlation coefficients between eSRT and C-levels from 0.73 to 0.77 and from 0.77 to 0.85 (p < 0.05) for the contralateral and ipsilateral ears, respectively.

Significance: Our research indicates that using a multielectrode stimulation approach enhances the detection rate of eSRT and slightly improves the correlation coefficient between eSRT and C-levels. It is found preferable to obtain measurements from the contralateral side due to its higher detection rate, although the ipsilateral side yields a marginally higher correlation coefficient. The findings suggest that eSRTs obtained from pulse width modulation implants could aid audiologists in programming the device.

Objective: To compare cochlear implant (CI) speech perception outcomes in patients with sporadic vestibular schwannoma (VS) managed with observation, radiosurgery, or microsurgery.

Study design: Retrospective review.

Setting: Eleven tertiary academic medical centers.

Patients: One hundred patients with sporadic VS who received an ipsilateral CI.

Interventions: Ipsilateral cochlear implantation.

Main outcome measures: Pure-tone thresholds, monosyllabic speech perception testing scores, and rates of open-set speech acquisition.

Results: Of the 100 patients studied, 54 underwent microsurgery, 26 underwent radiosurgery, 19 continued observation, and 1 underwent multimodal therapy. Among all patients, the median post-implantation pure-tone average was 31 dB (interquartile range [IQR] 25-39 dB) and the median monosyllabic speech perception score was 30% (IQR 0-60%) at a median of 12 months (IQR 5-25 months) post-implantation. Patients who were managed with microsurgery (median speech perception score 11%, IQR 0-52%) exhibited poorer implant outcomes overall compared with those managed with observation (median speech perception score 52%, IQR 40-72%) or radiosurgery (median speech perception score 30%, IQR 16-60%). Open-set speech perception was achieved in 61% of patients managed with microsurgery, 100% with observation, and 80% with radiosurgery. In a multivariable setting, those managed with observation (p = 0.02) or who underwent radiosurgery (p = 0.04) were significantly more likely to achieve open-set speech perception compared with patients who underwent microsurgery.

Conclusions: Cochlear implants offer benefit in selected patients with sporadic VS. Although achieved in over half of people after microsurgery, open-set speech perception is more reliably attained in patients who are treated with observation or radiosurgery compared with microsurgical resection. These data may inform patient counseling and VS tumor management in people who may benefit from implantation.

Objectives: Describe a single institution's cochlear implant outcomes for patients with inner ear schwannomas (IES) in the setting of various tumor management strategies (observation, surgical resection, or stereotactic radiosurgery [SRS]).

Study design: Single-institution retrospective review.

Patients: Patients diagnosed with isolated, sporadic IES who underwent cochlear implantation (CI).

Interventions: CI with or without IES treatment.

Main outcome measures: Speech perception outcomes, tumor status.

Results: Twelve patients with IES underwent CI with a median audiologic and radiologic follow-up of 12 months. Six patients underwent complete resection of the tumor at the time of CI, four underwent tumor observation, and two underwent SRS before CI. At 1 year after CI for all patients, the median consonant-nucleus-consonant (CNC) word score was 55% (interquartile range, 44-73%), and the median AzBio sentence in quiet score was 77% (interquartile range, 68-93%). Overall, those with surgical resection performed similarly to those with tumor observation (CNC 58 versus 61%; AzBio in quiet 74 versus 91%, respectively). Patients who underwent tumor resection before implantation had a wider range of speech performance outcomes compared with patients who underwent tumor observation. Two patients had SRS treatment before CI (10 months previous and same-day as CI) with CNC word scores of 6 and 40%, respectively.

Conclusions: Patients with IES who underwent CI demonstrated similar speech performance outcomes (CNC 56% and AzBio 82%), when compared with the general cochlear implant population. Patients who underwent either tumor observation or surgical resection performed well after CI.