Faculty Bibliography

Management of head and neck squamous cell carcinoma necessitates a multimodal approach. The neck dissection has evolved over many years but is well established as the key surgical intervention for management of nodal disease in the neck. The open neck dissection has many varieties based on location and degree of disease but is the gold standard surgical technique. Robot-assisted neck dissections have emerged in recent years as an alternative. More research is required to establish long-term oncologic outcomes achieved with robot-assisted surgery and to assess whether cost and operative times decrease with experience.

OBJECTIVE:To address variance in clinical care surrounding sporadic vestibular schwannoma, a modified Delphi study was performed to establish a general framework to approach vestibular schwannoma care. A multidisciplinary panel of experts was established with deliberate representation from key stakeholder societies. External validity of the final statements was assessed through an online survey of registered attendees of the 8th Quadrennial International Conference on Vestibular Schwannoma. STUDY DESIGN/METHODS:Modified Delphi method. METHODS:The panel consisted of 16 vestibular schwannoma experts (8 neurotology and 8 neurosurgery) and included delegates representing the AAOHNSF, AANS/CNS tumor section, ISRS, and NASBS. The modified Delphi method encompassed a four-step process, comprised of one prevoting round to establish a list of focus areas and three subsequent voting rounds to successively refine individual statements and establish levels of consensus. Thresholds for achieving moderate consensus, at ≥67% agreement, and strong consensus, at ≥80% agreement, were determined a priori. All voting was performed anonymously via the Qualtrics online survey tool and full participation from all panel members was required before procession to the next voting round. RESULTS:Through the Delphi process, 103 items were developed encompassing hearing preservation (N = 49), tumor control and imaging surveillance (N = 20), preferred treatment (N = 24), operative considerations (N = 4), and complications (N = 6). As a result of item refinement, moderate (4%) or strong (96%) consensus was achieved in all 103 final statements. Seventy-nine conference registrants participated in the online survey to assess external validity. Among these survey respondents, moderate (N = 21, 20%) or strong (N = 73, 71%) consensus was achieved in 94 of 103 (91%) statements, and no consensus was reached in 9 (9%). Of the four items with moderate consensus by the expert panel, one had moderate consensus by the conference participants and three had no consensus. CONCLUSION/CONCLUSIONS:This modified Delphi study on sporadic vestibular schwannoma codifies 100% consensus within a multidisciplinary expert panel and is further supported by 91% consensus among an external group of clinicians who regularly provide care for patients with vestibular schwannoma. These final 103 statements address clinically pragmatic items that have direct application to everyday patient care. This document is not intended to define standard of care or drive insurance reimbursement, but rather to provide a general framework to approach vestibular schwannoma care for providers and patients.

Although the majority of attention to the health care impact of COVID-19 has focused on adult first responders and critical care providers, the pandemic has had a profound effect on the entire health care industry, including the pediatric otolaryngology community. This article highlights the unique ramifications of COVID-19 on pediatric otolaryngology, with a focus on the immediate and potential long-term shifts in practice. Specifically, the article is divided into 3 sections (care for the patient, care for the practitioner, and care for the practice) and details the unique effects of the pandemic on the pediatric otolaryngology specialty.

Two notes sounded sequentially elicit melodic intervals and contours that form the basis of melody. Many previous studies have characterized pitch perception in cochlear implant (CI) users to be poor which may be due to the limited spectro-temporal resolution and/or spectral warping with electric hearing compared to acoustic hearing (AH). Poor pitch perception in CIs has been shown to distort melodic interval perception. To characterize this interval distortion, we recruited CI users with either normal (single sided deafness, SSD) or limited (bimodal) AH in the non-implanted ear. The contralateral AH allowed for a stable reference with which to compare melodic interval perception in the CI ear, within the same listener. Melodic interval perception was compared across acoustic and electric hearing in 9 CI listeners (4 bimodal and 5 SSD). Participants were asked to rank the size of a probe interval presented to the CI ear to a reference interval presented to the contralateral AH ear using a method of constant stimuli. Ipsilateral interval ranking was also measured within the AH ear to ensure that listeners understood the task and that interval ranking was stable and accurate within AH. Stimuli were delivered to the AH ear via headphones and to the CI ear via direct audio input (DAI) to participants' clinical processors. During testing, a reference and probe interval was presented and participants indicated which was larger. Ten comparisons for each reference-probe combination were presented. Psychometric functions were fit to the data to determine the probe interval size that matched the reference interval. Across all AH reference intervals, the mean matched CI interval was 1.74 times larger than the AH reference. However, there was great inter-subject variability. For some participants, CI interval distortion varied across different reference AH intervals; for others, CI interval distortion was constant. Within the AH ear, ipsilateral interval ranking was accurate, ensuring that participants understood the task. No significant differences in the patterns of results were observed between bimodal and SSD CI users. The present data show that much larger intervals were needed with the CI to match contralateral AH reference intervals. As such, input melodic patterns are likely to be perceived as frequency compressed and/or warped with electric hearing, with less variation among notes in the pattern. The high inter-subject variability in CI interval distortion suggests that CI signal processing should be optimized for individual CI users.

OBJECTIVES/OBJECTIVE:This prospective study evaluates the effectiveness and safety of venous sinus stenting for patients with isolated pulsatile tinnitus and lateral sinus stenosis. METHODS:Patients with isolated pulsatile tinnitus and lateral sinus stenosis with a minimum trans stenotic gradient of 4 mm Hg were treated with stenting. Pulsatile tinnitus before and after treatment was assessed with the Tinnitus Handicap Inventory (THI). Periprocedural adverse events, neurological complications, clinical and radiographic follow-up were also recorded. RESULTS:A total of 42 patients (41 females and 1 male) were included in the study (median age of 37.5 years). Thirty patients had post-stenotic fusiform and 12 had post-stenotic saccular venous sinus aneurysm. In addition to stenting, coils were used to treat the patients with saccular venous aneurysms. The median follow-up was 5 months (range 1 to 34 months). Most patients had complete (39/42) or near-complete (2/42) resolution of their pulsatile tinnitus post-procedure. There were no serious adverse events. CONCLUSION/CONCLUSIONS:Stenting of the lateral venous sinus is a safe and effective treatment for patients with isolated pulsatile tinnitus due to venous sinus stenosis.

In this study, we investigate the feasibility of using dynamic contrast enhanced magnetic resonance imaging (DCE-MRI), diffusion weighted imaging (DWI), and dynamic positron emission tomography (PET) for detection of metastatic lymph nodes in head and neck squamous cell carcinoma (HNSCC) cases. Twenty HNSCC patients scheduled for lymph node dissection underwent DCE-MRI, dynamic PET, and DWI using a PET-MR scanner within one week prior to their planned surgery. During surgery, resected nodes were labeled to identify their nodal levels and sent for routine clinical pathology evaluation. Quantitative parameters of metastatic and normal nodes were calculated from DCE-MRI (v_e, v_p, PS, F_p, K^trans), DWI (ADC) and PET (K_i, K₁, k₂, k₃) to assess if an individual or a combination of parameters can classify normal and metastatic lymph nodes accurately. There were 38 normal and 11 metastatic nodes covered by all three imaging methods and confirmed by pathology. 34% of all normal nodes had volumes greater than or equal to the smallest metastatic node while 4 normal nodes had SUV > 4.5. Among the MRI parameters, the median v_p, F_p, PS, and K^trans values of the metastatic lymph nodes were significantly lower (p = <0.05) than those of normal nodes. v_e and ADC did not show any statistical significance. For the dynamic PET parameters, the metastatic nodes had significantly higher k₃ (p value = 8.8 × 10^-8) and K_i (p value = 5.3 × 10^-8) than normal nodes. K₁ and k₂ did not show any statistically significant difference. K_i had the best separation with accuracy = 0.96 (sensitivity = 1, specificity = 0.95) using a cutoff of K_i = 5.3 × 10^-3 mL/cm³/min, while k₃ and volume had accuracy of 0.94 (sensitivity = 0.82, specificity = 0.97) and 0.90 (sensitivity = 0.64, specificity = 0.97) respectively. 100% accuracy can be achieved using a multivariate logistic regression model of MRI parameters after thresholding the data with K_i < 5.3 × 10^-3 mL/cm³/min. The results of this preliminary study suggest that quantitative MRI may provide additional value in distinguishing metastatic nodes, particularly among small nodes, when used together with FDG-PET.

Similar to the hypertrophic scar and keloids, the efficacy of glucorticoids (GC) for vocal fold injury is highly variable. We previously reported dexamethasone enhanced the pro-fibrotic effects of transforming growth factor (TGF)-β as a potential mechanism for inconsistent clinical outcomes. In the current study, we sought to determine the mechanism(s) whereby GCs influence the fibrotic response and mechanisms underlying these effects with an emphasis on TGF-β and nuclear receptor subfamily 4 group A member 1 (NR4A1) signaling. Human VF fibroblasts (HVOX) were treated with three commonly-employed GCs+ /-TGF-β1. Phosphorylation of the glucocorticoid receptor (GR:NR3C1) and activation of NR4A1 was analyzed by western blotting. Genes involved in the fibrotic response, including ACTA2, TGFBR1, and TGFBR2 were analyzed by qPCR. RNA-seq was performed to identify global changes in gene expression induced by dexamethasone. GCs enhanced phosphorylation of GR at Ser211 and TGF-β-induced ACTA2 expression. Dexamethasone upregulated TGFBR1, and TGFBR2 in the presence of TGF-β1 and increased active NR4A1. RNA-seq results confirmed numerous pathways, including TGF-β signaling, affected by dexamethasone. Synergistic pro-fibrotic effects of TGF-β were observed across GCs and appeared to be mediated, at least partially, via upregulation of TGF-β receptors. Dexamethasone exhibited diverse regulation of gene expression including NR4A1 upregulation consistent with the anti-fibrotic potential of GCs.

The goal of this study was to evaluate the effects of ovarian hormones on female rat ultrasonic vocalizations (USVs). Twenty (10 control and 10 ovariectomized) 3-month-old female rats were recorded in 3 recording conditions (elicitation, dyad, and isolation) over a full estrous cycle or time-matched duration. There were differences in USV acoustics (frequency and complexity parameters) across recording conditions but no differences in USV acoustics between control and ovariectomized groups. USVs produced in isolation had lower frequency and complexity parameters than elicited USVs for both control and ovariectomized rats. Additionally, for control rats, USV parameters of frequency, complexity, duration, and intensity changed depending on the estrous state. Therefore, although fluctuating hormone levels may influence USV acoustics, this variation can be controlled for by ovariectomizing female rats.