Faculty Bibliography

OBJECTIVES:Pitch is poorly perceived by cochlear implant (CI) users. However, as it is not well understood how pitch is encoded with electric stimulation, improving pitch representation with a CI is challenging. Changes in place of stimulation along the cochlea have been described as changes in pitch and can be accurately ranked by CI users. However, it remains unknown if place-pitch can be used to encode musical intervals, which are a necessary attribute of pitch. The objective of these experiments is to determine if place-pitch coding can be used to represent musical intervals with a CI. DESIGN:In the first experiment, 10 CI users and 10 normal hearing (NH) controls were tested on their sensitivity to changes in the semitone spacing between each of the notes in the melody "Happy Birthday." The changes were implemented by uniformly expanding or compressing the frequency differences between each note in the melody. The participant's task was to scale how "out-of-tune" the melody was for various semitone spacing distortions. The notes were represented by pure-tones ≥440 Hz to minimize potential useful temporal information from the stimuli. A second experiment replicated the first experiment using single-sided deafened CI users allowing for a within-subject control. A third experiment verified that the CI users who participated in Experiment 1 were each able to determine pitch direction reliably. RESULTS:Unlike NH listeners, CI listeners often ranked all distortions of interval spacing similarly in both the first and second experiment, and no effect of interval spacing was detected across CI users. Some participants found distorted interval spacings to be less out-of-tune than the nominally correct interval spacings. However, these patterns were inconsistent across listeners. Although performance was better for the NH listeners, the third experiment demonstrated that the CI listeners were able to reliably identify changes in pitch direction from place-pitch coding. CONCLUSIONS:The data suggest that place-pitch intervals are not properly represented through a CI sound processor. Some limited support is found for place-pitch being useful for interval encoding as some participants demonstrated improved ratings for certain interval distortions. Presumably the interval representation for these participants could be improved by a change to the frequencies represented by each electrode. However, as these patterns vary across listeners, there is not a universal correction to frequency representation that will solve this issue. As results are similar for single-sided deafened CI users, the limitations in ratings are likely not limited by an eroded representation of the melody caused by an extended duration of deafness.

PURPOSE:To provide evidence-based recommendations to practicing physicians and other health care providers on the diagnosis and management of squamous cell carcinoma of unknown primary in the head and neck (SCCUP). METHODS:The American Society of Clinical Oncology convened an Expert Panel of medical oncology, surgery, radiation oncology, radiology, pathology, and advocacy experts to conduct a literature search, which included systematic reviews, meta-analyses, randomized controlled trials, and prospective and retrospective comparative observational studies published from 2008 through 2019. Outcomes of interest included survival, local and regional disease control, and quality of life. Expert Panel members used available evidence and informal consensus to develop evidence-based guideline recommendations. RESULTS:The literature search identified 100 relevant studies to inform the evidence base for this guideline. Four main clinical questions were addressed, which included subquestions on preoperative evaluations, surgical diagnostic and therapeutic procedures, appropriate pathology techniques, and adjuvant therapy. RECOMMENDATIONS:Evidence-based recommendations were developed to address preoperative evaluation for patients with a neck mass, surgical diagnostic and therapeutic procedures, appropriate treatment options in unilateral versus bilateral SCCUP.Additional information is available at www.asco.org/head-neck-cancer-guidelines.

OBJECTIVE:To determine factors associated with infection, management, and resultant outcomes following pediatric cochlear implantation. STUDY DESIGN/METHODS:Retrospective cohort study with nested case series. SETTING/METHODS:Tertiary academic medical center. PATIENTS/METHODS:Children who underwent either unilateral or bilateral cochlear implantation between June 2011 and September 2016 and were under the age of 18 at the time of surgery. INTERVENTION(S)/METHODS:Subjects were compared based on age, cochlea malformation, revision surgery, operative time, device manufacturer, and antibiotic use. Infections were compared based on location, time, bacteria, management, and resolution. MAIN OUTCOME MEASURE(S)/METHODS:Rate of infection, rate of device explantation. RESULTS:There were 16 infections among 246 surgeries, an infection rate of 6.5%. There was a significant age difference between infected and noninfected patients overall (n = 246, 1.4 versus 4.3 years, p = 0.005), but not within the cohort of patients five or younger (n = 172, 1.4 versus 1.8 years, p = 0.363). The most common infectious complication was skin infection, followed by device infection. No cases of meningitis were seen. The most common organism was S Aureus. The implant was salvaged in 9 of 16 patients (56.3%), with higher rates in patients treated with IV versus oral antibiotics (70 versus 40%). CONCLUSIONS:Postoperative infection is positively associated with younger age overall, but not in patients below the age of 5. With modern devices and surgical practices, risk of meningitis-though a concern-may be lower than cited in the literature. Prompt and aggressive therapy with IV antibiotics and operative intervention can allow for high rates of device salvage.

OBJECTIVES:Our objectives were (1) to use in situ simulation to assess the clinical environment and identify latent safety threats (LSTs) related to the management of pediatric tracheostomy patients and (2) to analyze the effects of systems interventions and team factors on LSTs and simulation performance. METHODS:A multicenter, prospective study to assess LSTs related to pediatric tracheostomy care management was conducted in emergency departments (EDs) and intensive care units (ICUs). LSTs were identified through equipment checklists and in situ simulations via structured debriefs and blinded ratings of team performance. The research team and unit champions developed action plans with interventions to address each LST. Reassessment by equipment checklists and in situ simulations was repeated after 6 to 9 months. RESULTS:Forty-one LSTs were identified over 21 simulations, 24 in the preintervention group and 17 in the postintervention group. These included LSTs in access to equipment (ie, availability of suction catheters, lack of awareness of the location of tracheostomy tubes) and clinical knowledge gaps. Mean equipment checklist scores improved from 76% to 87%. Twenty-one unique teams (65 participants) participated in the simulations. The average simulation score was 6.19 out of 16 points. DISCUSSION:In situ simulation is feasible and effective as an assessment tool to identify latent safety threats and thus measure the system-level performance of a clinical care environment. IMPLICATIONS FOR PRACTICE:In situ simulation can be used to identify and reassess latent safety threats related to pediatric tracheostomy management and thereby support quality improvement and educational initiatives.

BACKGROUND:For early-stage oral squamous cell carcinoma (OSCC), there is no existing risk-stratification modality beyond conventional TNM staging system to identify patients at high risk for cancer-specific mortality. METHODS:A total of 568 early-stage OSCC patients who had surgery only and also with available 5-year clinical outcomes data were identified. Signature microRNAs (miRNAs) were discovered using deep sequencing analysis and validated by qRT-PCR. The final 5-plex prognostic marker panel was utilized to generate a cancer-specific mortality risk score using the multivariate Cox regression analyses. The prognostic markers were validated in the internal and external validation cohorts. RESULTS:The risk score from the 5-plex marker panel consisting of miRNAs-127-3p, 4736, 655-3p, TNM stage and histologic grading stratified patients into four risk categories. Compared to the low-risk group, the high-risk group had 23-fold increased mortality risk (hazard ratio 23, 95% confidence interval 13-42), with a median time-to-recurrence of 6 months and time-to-death of 11 months (vs >60 months for each among low-risk patient; p < .001). CONCLUSION/CONCLUSIONS:The miRNA-based 5-plex marker panel driven mortality risk score formula provides clinically practical and reliable measures to assess the prognosis of patients assigned to an early-stage OSCC.

The COVID-19 pandemic has created uncertainty regarding the safety and appropriate utilization of minimally invasive surgery (MIS) during this current outbreak. Surgical governing bodies such as Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and the Royal Colleges of Surgery of Great Britain and Ireland have made statements regarding the possibility of COVID-19 release into CO2 insufflant during MIS. The basis for this concern is prior evidence in the literature of other viral pathogen release during laparoscopic surgery. The recommendations are correctly based on caution given the lack of understanding of how COVID-19 compares to other viruses with regard to transmission and presence in CO2 during MIS. In this review we have investigated the available literature on COVID-19 transmission during MIS, address the implications of current and previously published recommendations and discuss steps to mitigate COVID-19 transmission during MIS for staff and patient safety.

OBJECTIVE:To review outcomes of stapes surgery in patients with concurrent otosclerosis and superior semicircular canal dehiscence. STUDY DESIGN/METHODS:Retrospective case series. SETTING:/UNASSIGNED:Tertiary referral center. PATIENTS/METHODS:Patients with concurrent otosclerosis and superior canal dehiscence, confirmed by computed tomography (CT) imaging. INTERVENTION(S)/METHODS:Stapes surgery for conductive hearing loss. MAIN OUTCOME MEASURE(S):/UNASSIGNED:Postoperative air-bone gap (ABG), as well as the number of patients in whom surgery was deemed successful (postoperative ABG <10 dB HL). RESULTS:Five patients with superior canal dehiscence and concomitant otosclerosis who underwent surgical repair were identified. Mean preoperative ABG was 29.0 ± 6.4 dB HL. Mean postoperative ABG was 13.0 ± 13 dB HL. Three patients (60%) had a successful outcome, defined as postoperative ABG less than 10. One patient experienced unmasking of superior canal dehiscence vestibular symptoms. CONCLUSIONS:Patients with concurrent otosclerosis and superior canal dehiscence appear to have a lower likelihood of successful hearing restoration following stapes surgery. Patients should be counseled accordingly. Routine preoperative CT imaging before stapes surgery may be helpful to identify patients at risk for poor outcomes.

BACKGROUND:Prior studies have shown an advantage for electro-acoustic stimulation (EAS) in cochlear implant (CI) patients with residual hearing, but the degree of benefit can vary. The objective was to explore which factors relate to performance with and acceptance of EAS for CI users with conventional-length electrodes. METHODS:A retrospective chart review was conducted for adults with an average threshold of 75 dB hearing loss or better across 250 and 500 Hz preoperatively (n = 83). All patients underwent cochlear implantation with a conventional-length electrode. Low-frequency audiometric thresholds were measured at initial activation as well as 3 and 12 months postoperatively to determine who met the criteria for EAS. Speech perception for CNC words and AzBio sentences in quiet and +10 dB SNR noise was evaluated 3 and 12 months after activation. RESULTS:Speech perception in quiet and noise was similar regardless of whether or not the patient was eligible for EAS. Less than half of the patients who met the EAS criteria chose to use it, citing reasons such as physical discomfort or lack of perceived benefit. EAS users performed better on CNC words but not sentence recognition than EAS nonusers. CONCLUSIONS:EAS use is dependent on audiologic and nonaudiologic issues. Hearing preservation is possible with conventional electrodes, but hearing preservation alone does not guarantee superior speech perception.