Faculty Bibliography

OBJECTIVES/OBJECTIVE:(1) To determine the effect of hearing aid (HA) bandwidth on bimodal speech perception in a group of unilateral cochlear implant (CI) patients with diverse degrees and configurations of hearing loss in the nonimplanted ear, (2) to determine whether there are demographic and audiometric characteristics that would help to determine the appropriate HA bandwidth for a bimodal patient. DESIGN/METHODS:Participants were 33 experienced bimodal device users with postlingual hearing loss. Twenty three of them had better speech perception with the CI than the HA (CI>HA group) and 10 had better speech perception with the HA than the CI (HA>CI group). Word recognition in sentences (AzBio sentences at +10 dB signal to noise ratio presented at 0° azimuth) and in isolation [CNC (consonant-nucleus-consonant) words] was measured in unimodal conditions [CI alone or HAWB, which indicates HA alone in the wideband (WB) condition] and in bimodal conditions (BMWB, BM2k, BM1k, and BM500) as the bandwidth of an actual HA was reduced from WB to 2 kHz, 1 kHz, and 500 Hz. Linear mixed-effect modeling was used to quantify the relationship between speech recognition and listening condition and to assess how audiometric or demographic covariates might influence this relationship in each group. RESULTS:For the CI>HA group, AzBio scores were significantly higher (on average) in all bimodal conditions than in the best unimodal condition (CI alone) and were highest at the BMWB condition. For CNC scores, on the other hand, there was no significant improvement over the CI-alone condition in any of the bimodal conditions. The opposite pattern was observed in the HA>CI group. CNC word scores were significantly higher in the BM2k and BMWB conditions than in the best unimodal condition (HAWB), but none of the bimodal conditions were significantly better than the best unimodal condition for AzBio sentences (and some of the restricted bandwidth conditions were actually worse). Demographic covariates did not interact significantly with bimodal outcomes, but some of the audiometric variables did. For CI>HA participants with a flatter audiometric configuration and better mid-frequency hearing, bimodal AzBio scores were significantly higher than the CI-alone score with the WB setting (BMWB) but not with other bandwidths. In contrast, CI>HA participants with more steeply sloping hearing loss and poorer mid-frequency thresholds (≥82.5 dB) had significantly higher bimodal AzBio scores in all bimodal conditions, and the BMWB did not differ significantly from the restricted bandwidth conditions. HA>CI participants with mild low-frequency hearing loss showed the highest levels of bimodal improvement over the best unimodal condition on CNC words. They were also less affected by HA bandwidth reduction compared with HA>CI participants with poorer low-frequency thresholds. CONCLUSIONS:The pattern of bimodal performance as a function of the HA bandwidth was found to be consistent with the degree and configuration of hearing loss for both patients with CI>HA performance and for those with HA>CI performance. Our results support fitting the HA for all bimodal patients with the widest bandwidth consistent with effective audibility.

Pharyngeal lumen volume is prone to increase as a consequence of pharyngeal muscle atrophy in aging. Yet, the impact of this on swallowing mechanics and function is poorly understood. We examined the relationship between pharyngeal volume and pharyngeal swallowing mechanics and function in a sample of healthy community-dwelling seniors. Data were collected from 44 healthy seniors (21 male, mean age = 76.9, SD = 7.1). Each participant swallowed 9 boluses of barium (3 × 5 ml thin, 3 × 20 ml thin, 3 × 5 ml nectar). Pharyngeal shortening, pharyngeal constriction, pyriform sinus and vallecular residue were quantified from lateral view videofluorosopic swallowing studies. Pharyngeal lumen volume was captured during an oral breathing task with acoustic pharyngometry. In addition, within-participant measures of strength and anthropometrics were collected. Four linear mixed effects regression models were run to study the relationship between pharyngeal volume and pharyngeal constriction, pharyngeal shortening, pyriform sinus residue, and vallecular residue while controlling for bolus condition, age, sex, and posterior tongue strength. Increasing pharyngeal lumen volume was significantly related to worse constriction and vallecular residue. In general, larger and thicker boluses resulted in worse pharyngeal constriction and residue. Pharyngeal shortening was only significantly related to posterior tongue strength. Our work establishes the utility of acoustic pharyngometry to monitor pharyngeal lumen volume. Increasing pharyngeal lumen volume appears to impact both pharyngeal swallowing mechanics and function in a sample of healthy, functional seniors.

Neural representations of the external world are constructed and updated in a manner that depends on behavioral context. For neocortical networks, this contextual information is relayed by a diverse range of neuromodulatory systems, which govern attention and signal the value of internal state variables such as arousal, motivation, and stress. Neuromodulators enable cortical circuits to differentially process specific stimuli and modify synaptic strengths in order to maintain short- or long-term memory traces of significant perceptual events and behavioral episodes. One of the most important subcortical neuromodulatory systems for attention and arousal is the noradrenergic locus coeruleus. Here we report that the noradrenergic system can enhance behavior in rats performing a self-initiated auditory recognition task, and optogenetic stimulation of noradrenergic locus coeruleus neurons accelerated the rate at which trained rats began correctly responding to a change in reward contingency. Animals successively progressed through distinct behavioral epochs, including periods of perseverance and exploration that occurred much more rapidly when animals received locus coeruleus stimulation. In parallel, we made recordings from primary auditory cortex and found that pairing tones with locus coeruleus stimulation led to a similar set of changes to cortical tuning profiles. Thus both behavioral and neural responses go through phases of adjustment for exploring and exploiting environmental reward contingencies. Furthermore, behavioral engagement does not necessarily recruit optimal locus coeruleus activity.

Previous studies have shown that tumor necrosis factor alpha (TNFα) is significantly increased in complete Freund's adjuvant (CFA)-treated temporomandibular joint (TMJ) tissues. However, it is unclear whether TNFα in the trigeminal nociceptive system contributes to the development of TMJ pain. In the present study, we investigated the role of TNFα in trigeminal ganglia (TG) and spinal trigeminal nucleus caudalis (Sp5C) in CFA-induced inflammatory TMJ pain. Intra-TMJ injection of CFA (10 μl, 5 mg/ml) induced inflammatory pain in the trigeminal nerve V2- and V3-innervated skin areas of WT mice, which was present on day 1 after CFA and persisted for at least 10 days. TNFα in both TG and Sp5C of WT mice was upregulated after CFA injection. The CFA-induced TMJ pain was significantly inhibited in TNFα KO mice. The immunofluorescence staining showed that intra-TMJ CFA injection not only enhanced co-localization of TNFα with Iba1 (a marker for microglia) in both TG and Sp5C but also markedly increased the expression of TNFα in the Sp5C neurons. By the methylated DNA immunoprecipitation assay, we also found that DNA methylation at the TNF gene promoter region in the TG was dramatically diminished after CFA injection, indicating that epigenetic regulation may be involved in the CFA-enhanced TNFα expression in our model. Our results suggest that TNFα in the trigeminal nociceptive system plays a critical role in CFA-induced inflammatory TMJ pain.

OBJECTIVE:Given that financial considerations play an increasingly prominent role in clinical decision-making, we sought (1) to determine the cost-effectiveness of in-office biopsy for the patient, the provider, and the health-care system, and (2) to determine the diagnostic accuracy of in-office biopsy. STUDY DESIGN/METHODS:Retrospective, financial analyses were performed. METHODS:Patients who underwent in-office (Current Procedural Terminology Code 31576) or operative biopsy (CPT Code 31535) for laryngopharyngeal lesions were included. Two financial analyses were performed: (1) the average cost of operating room (OR) versus in-office biopsy was calculated, and (2) a break-even analysis was calculated to determine the cost-effectiveness of in-office biopsy for the provider. In addition, the diagnostic accuracy of in-office biopsies and need for additional biopsies or procedures was recorded. RESULTS:Of the 48 patients included in the current study, 28 underwent in-office biopsy. A pathologic sample was obtained in 26 of 28 (92.9%) biopsies performed in the office. Of these patients, 16 avoided subsequent OR procedures. The average per patient cost was $7000 and $11,000 for in-office and OR biopsy, respectively. Break-even analysis demonstrated that the provider could achieve a profit 2 years after purchase of the necessary equipment. CONCLUSION/CONCLUSIONS:In-office laryngopharyngeal biopsies are accurate and, overall, more cost-effective than OR biopsies. Purchase of the channeled, distal chip laryngoscope and biopsy forceps to perform in-office biopsies can be profitable for a provider with a videolaryngoscopy tower. In-office biopsy should be considered the initial diagnostic tool for suspected laryngopharyngeal malignancies noted on videolaryngoscopy.

GOALS:To compare the adenoma detection rate (ADR) during colonoscopy in patients with melanosis coli against matched controls without melanosis. BACKGROUND:Melanosis coli is a colonoscopic finding in which the colon wall appears darkly pigmented, most often due to extended laxative use, and is considered benign. The pigmentation spares adenomas, which should therefore be more readily detectable in melanosis coli. STUDY:We identified all patients with melanosis on colonoscopy at our institution over a 5-year period. We matched each patient with 2 controls by age, gender, and endoscopist. We compared the prevalence of adenomas between groups, and used multivariable analysis, adjusting for procedure indication and bowel preparation quality, to determine the independent association of melanosis with adenoma detection. RESULTS:At least 1 adenoma was detected in 34.7% of melanosis patients and 26.5% of controls [odds ratio (OR)=1.52; 95% confidence interval (CI), 1.04-2.24; P=0.03]. On multivariable analysis, the presence of melanosis remained associated with increased adenoma detection (OR=1.56; 95% CI, 1.05-2.33; P=0.03). Melanosis patients were more likely to have an adenoma ≤5 mm (OR=1.62; 95% CI, 1.04-2.51; P=0.03), but not adenomas 6 to 9 mm or ≥10 mm. CONCLUSIONS:Melanosis coli is associated with a significant increase in ADR during colonoscopy compared with controls. The increased visibility of adenomas given their contrast with the pigmented background is a likely explanation. Future efforts to identify bowel preparation agents that can induce a similar effect could improve ADRs during colonoscopy.

OBJECTIVES/HYPOTHESIS:Over the past decade, thoracic slide tracheoplasty (TST) has become the principal operation in the management of congenital tracheal stenosis. The purpose of this report was to describe our experience with revision TST following unsuccessful prior tracheal reconstruction. STUDY DESIGN:Retrospective analysis at an academic children's hospital. METHODS:Patients undergoing TST on cardiopulmonary bypass between January 2005 and May 2014 were reviewed. Patients with a history of prior airway surgery were extracted for further analysis. Preoperative patient variables and postoperative outcomes were evaluated and compared between patients undergoing revision slide tracheoplasty (RTST) and a control group of 26 matched patients undergoing primary surgery TST. RESULTS:Twenty-six revision patients (25 referrals, one primary patient) of 162 patients reviewed over the study period met inclusion criteria. Twenty-three patients had a history of complete tracheal rings, and three patients had cartilaginous deficiency. A total of 41 airway reconstruction procedures had been performed prior to RTST. When compared to primary TST, patients undergoing RTST required fewer cardiac procedures intraoperatively, and fewer mean ventilator hours (P = .01) postoperatively. There was no significant difference in the median length of stay, requirement of >48 hours ventilation, or postoperative complications between groups. There was one nonsurgical postoperative mortality following RTST. CONCLUSIONS:Despite some differences in the postoperative management when compared to nonrevision cases, revision TST can be successfully performed after prior tracheal reconstruction with good postoperative outcomes. LEVEL OF EVIDENCE:4. Laryngoscope, 128:2181-2186, 2018.

Due to the rapid increase in the availability of patient data, there is significant interest in precision medicine that could facilitate the development of a personalized treatment plan for each patient on an individual basis. Radiation oncology is particularly suited for predictive machine learning (ML) models due to the enormous amount of diagnostic data used as input and therapeutic data generated as output. An emerging field in precision radiation oncology that can take advantage of ML approaches is radiogenomics, which is the study of the impact of genomic variations on the sensitivity of normal and tumor tissue to radiation. Currently, patients undergoing radiotherapy are treated using uniform dose constraints specific to the tumor and surrounding normal tissues. This is suboptimal in many ways. First, the dose that can be delivered to the target volume may be insufficient for control but is constrained by the surrounding normal tissue, as dose escalation can lead to significant morbidity and rare. Second, two patients with nearly identical dose distributions can have substantially different acute and late toxicities, resulting in lengthy treatment breaks and suboptimal control, or chronic morbidities leading to poor quality of life. Despite significant advances in radiogenomics, the magnitude of the genetic contribution to radiation response far exceeds our current understanding of individual risk variants. In the field of genomics, ML methods are being used to extract harder-to-detect knowledge, but these methods have yet to fully penetrate radiogenomics. Hence, the goal of this publication is to provide an overview of ML as it applies to radiogenomics. We begin with a brief history of radiogenomics and its relationship to precision medicine. We then introduce ML and compare it to statistical hypothesis testing to reflect on shared lessons and to avoid common pitfalls. Current ML approaches to genome-wide association studies are examined. The application of ML specifically to radiogenomics is next presented. We end with important lessons for the proper integration of ML into radiogenomics.

OBJECTIVE:Analysis of the efficacy of sphenopalatine artery (SPA) and internal maxillary artery (IMAX) ligation within the pterygopalatine fossa to control posterior epistaxis. METHODS:Demographic and clinical data were collected in sixty-two consecutive patients who had SPA/IMAX ligation surgery. Clinical outcomes such as re-bleed rates and complications were acquired. RESULTS:A total of 62 patients were studied. Thirty-eight percent of patients had previously undergone silver nitrate nasal cautery for epistaxis. Nine patients had undergone previous attempt of SPA procedure or embolization in other services. Two patients returned to the operating room for anterior ethmoid ligation. There was one mortality within 30 days of surgery. Follow up ranged from 3 months to 56 months (median= 28 months). CONCLUSIONS:Dual SPA and IMAX ligation is effective in the control of difficult epistaxis cases, even in those patients with prior surgical intervention.