Faculty Bibliography

BACKGROUND/UNASSIGNED:Mal de débarquement syndrome (MdDS) is a chronic vestibular disorder of non-spinning vertigo, with various somatic, cognitive, and affective symptoms. The manifestation of MdDS is often only subjective, and different symptoms are variably emphasized when patients appraise the severity of their illness. The etiology of MdDS remains unclear but may lie in improperly sustained neuroplasticity in the velocity storage mechanism of the central vestibular system. Two broad approaches targeting velocity storage-one focusing on correcting velocity storage's maladapted behavior and the other on attenuating its contribution to higher-order processing-have yielded varying degrees of treatment success. METHODS/UNASSIGNED:We conducted a secondary analysis of data from our recent study contrasting the outcomes of the above two approaches. We examined the variations in individual emphases of separate symptoms by correlating the subjective ratings of overall MdDS severity with those of specific symptoms across time points for each subject. We also explored the possibility that variations in symptom presentation influence the responsiveness to the two approaches of treatment. RESULTS/UNASSIGNED:Many symptoms correlated with the overall severity rating, but even those that showed strong correlation among many subjects, such as dizziness, fatigue, and brain fog, were endorsed variably across subjects. A moderate unfavorable dependence on visual sensitivity was found for the responsiveness to the velocity storage attenuation treatment, which distinguished the two treatment approaches. CONCLUSION/UNASSIGNED:Results provide a glimpse into the complexity of MdDS manifestations. Individual variations in what contributes to their perceived overall symptom severity may aid the choice of treatment approach.

BACKGROUND:Preclinical evidence suggests statins enhance antitumor immunity. This study evaluates whether concurrent statin use during immune checkpoint inhibitor (ICI) therapy is associated with overall survival (OS) in mucosal head and neck squamous cell carcinoma (HNSCC). METHODS:This retrospective study uses Epic COSMOS, a multi-health system electronic health record dataset. Adults with mucosal HNSCC receiving PD-1 inhibitors were included. Concurrent statin use required ≥ 2 statin orders from -365 to +180 days relative to ICI initiation. The primary outcome was OS from ICI initiation to death or last encounter. RESULTS:Among 21 456 patients, 5719 (26.7%) met concurrent statin criteria. In the fully adjusted model, statin use was associated with increased mortality (HR 1.08; 95% CI 1.04-1.13). In drug-specific analysis, rosuvastatin was associated with reduced mortality (HR 0.87; 0.80-0.96). CONCLUSIONS:Class-level statin use was not associated with improved survival, likely reflecting confounding by cardiovascular comorbidity. Rosuvastatin-specific findings warrant prospective investigation.

OBJECTIVES/HYPOTHESIS/OBJECTIVE:Concurrent chemoradiotherapy (CCRT) is an effective treatment for various head and neck cancers; however, CCRT can result in significant swallowing impairment, presumably due largely to dysfunction of the muscles of swallowing, which are within the field of radiation. This translational study examines the mechanisms underlying CCRT-induced muscle dysfunction using (1) a rat model of CCRT and (2) analysis of archival human specimens. METHODS:131 Sprague Dawley rats were divided into experimental and control groups. Experimental rats received cisplatin and 5-fluorouracil intravenously, followed by 7 Gray radiation daily for 5 days. Rats were further split into three time points: acute (2 weeks), intermediate (5 months), and long-term (10 months), at which time tissue was harvested for analysis. Human samples included preexisting CCRT-treated and age- and sex-matched control muscle samples from head and neck cancer patients. Quantitative analyses of Paired Box Homeotic Gene 7-positive cells (Pax7 in rats; PAX7 in humans), fibrosis, muscle fiber size, and neuromuscular junctions were conducted and compared between groups in both rats and humans. RESULTS:Analysis demonstrated a significant decline in the percent of Pax7/PAX7-positive cells (a marker of muscle stem cells) after CCRT in both rats and humans, increased collagen percent, and decreased muscle percent in rats at 10 months. CCRT was associated with significantly reduced muscle fiber size in human specimens. Neuromuscular junction presence and morphology in rats were not affected. CONCLUSION/CONCLUSIONS:This translational study demonstrates significant alterations in head and neck muscles in both a rat model and human specimens from subjects exposed to CCRT. LEVEL OF EVIDENCE/METHODS:NA.

BACKGROUND/UNASSIGNED:Advances in endoscopic endonasal approaches in ventral skull base surgery have led to increasingly complex resections and reconstructions. This study investigates differences in postoperative outcomes, including postoperative cerebrospinal fluid (CSF) leak and infection, following anterior skull base surgery and reconstruction, as a function of the type of nasal packing (absorbable vs. nonabsorbable) used to bolster the skull base reconstruction. METHODS/UNASSIGNED:A retrospective chart review was performed at a single tertiary care institution. Patients who underwent ventral skull base surgery with placement of nasal packing between January 1, 2020, and December 1, 2023, were included. We included only patients of a single rhinologist (S.L.) involved. Outcome measures included postoperative CSF leaks and postoperative infection. RESULTS/UNASSIGNED: = 0.309) between these two cohorts of patients. CONCLUSION/UNASSIGNED:While no significant differences were found in the rate of postoperative CSF leak or infection, additional patient factors should be taken into consideration when choosing between absorbable and nonabsorbable nasal packing for ventral skull base reconstruction. LEVEL OF EVIDENCE/UNASSIGNED:4.

Sickness behaviors are common in cancer-associated cachexia and affect up to half of lung cancer patients. We demonstrate that among the most common cancer mutations, loss of liver kinase B1 (Lkb1) promotes the development of cachexia in preclinical models of lung cancer. In an effort to improve caloric intake with an obesogenic high-fat diet, we paradoxically observed worsened cachexia-associated sickness. We found that local production of prostaglandin E2 (PGE₂), rather than circulating factors, promotes sickness and that genetic, dietary, and pharmacological inhibition of tumor-derived PGE₂ suppresses sickness and cachexia. Notably, we demonstrate that lung sensory neuron abrogation prevents PGE₂-dependent cachexia. Our study establishes localized tumor-derived signals to sensory neurons, rather than circulating factors, as drivers of cachexia and highlights a previously unknown role of the peripheral nervous system in cancer cachexia.

BACKGROUND:Robot-assisted microsurgery with the Symani surgical system has emerged as a potential adjunct in complex reconstructive procedures. Its application in head and neck reconstruction remains early and incompletely characterized. We performed a systematic review to evaluate indications, technical utilization, and reported clinical outcomes of Symani-assisted microsurgery in head and neck reconstruction. METHODS:A systematic review was conducted in accordance with PRISMA guidelines. PubMed (MEDLINE), Embase, Scopus, and the Cochrane Library were searched for studies reporting Symani-assisted microsurgery in head and neck reconstruction. Primary outcomes were flap success and anastomotic complications. Secondary outcomes included operative time, conversion to conventional technique, ischemia time, reported learning curve metrics, and risk of bias. RESULTS: = 0%). Anastomotic complication rates were reported to be low with conversion to conventional technique occurring in one case due to technical malfunction. Anastomosis times were poorly reported across studies. CONCLUSIONS:Early clinical experience suggests that robot-assisted microsurgery with the Symani surgical system in head and neck reconstruction is technically feasible with acceptable short-term outcomes in selected cases. However, evidence remains limited to small, heterogeneous series. Prospective comparative studies are required to determine whether robotic assistance confers meaningful clinical or efficiency advantages over conventional microsurgery and determine optimal operative indications.

OBJECTIVES/OBJECTIVE:Prior research has shown that, among normal hearing college students, Hispanic-identifying participants experience higher levels of environmental noise and lower signal to noise ratios as compared with White non-Hispanic participants. The primary objective of this study was to examine whether these differences extend to cochlear implant (CI) users by using CI datalogging to quantify characteristics of the listeners' auditory environments. The authors further examined whether differences in auditory environments between groups persisted after controlling for demographic and socioeconomic factors. The primary socioeconomic variable of interest was population density, as it strongly correlates with other socioeconomic factors (e.g., education and income) and is more likely to directly influence auditory environments. DESIGN/METHODS:A retrospective chart review of CI patients at a tertiary medical center in New York City identified 80 adults (38 Hispanic, 42 White non-Hispanic) for further review. Demographic variables were compiled, and home addresses were used to obtain population-based socioeconomic data via the U.S. Census. Datalogging information extracted from the CI speech processor included hours of total use and time spent in different auditory environments, classified by the CI software into sound levels (in dBA) and sound scenes ("noise," "quiet," "speech in noise," "speech in quiet," "music," and "other"). RESULTS:Despite similar levels of device usage, there was a statistically significant group difference in the percentage of time spent in each scene: Hispanic-identifying participants spent more time in "speech in noise," "music," and "noise"; White non-Hispanics spent more time in "quiet" and "other." The Hispanic participants lived in census tracts with higher population density, which correlated with higher sound levels (>70 dBA) in the environment. Group differences in auditory environments remained statistically significant after controlling for age, CI experience, and population density (median daily level difference ~2.4 dB). CONCLUSIONS:Even after accounting for demographic and socioeconomic factors, the two groups showed distinct auditory environments, indicating a possible cultural contribution to these differences. Audiologists counseling CI patients regarding auditory environments should be conscious of their patients' cultural background and may consider the impact of listening preferences when advising on which environments to seek out or avoid.

OBJECTIVES/UNASSIGNED:To develop and study a novel means of imaging auditory brainstem implant (ABI) paddle placement utilizing postoperative MRI images to determine correlation between ABI performance and ideal paddle placement properties. DESIGN/UNASSIGNED:Single-center retrospective review and image analysis. SETTING/UNASSIGNED:Tertiary referral center. PARTICIPANTS/UNASSIGNED:Patients >18 years old who received an ABI from 2009 to 2023 and had subsequent MRI and auditory performance testing completed. MAIN OUTCOME MEASURES/UNASSIGNED:ABI paddle angulation and insertion depth measure, in addition to categories of auditory performance (CAP) score. RESULTS/UNASSIGNED: = 0.049) once patients with large tumor burden were excluded. Insertion depth and axial angulation showed a negative correlation, in which higher insertion depth was associated with a decrease in axial angulation value, although not statistically significant. CONCLUSION/UNASSIGNED:We present a novel means of measuring ABI paddle placement utilizing MRI to improve the objectivity of paddle placements assessments. Multicenter collaboration to increase the number of patients studied with this new measurement scheme will be required before stronger measurement associations can be determined.

OBJECTIVES/OBJECTIVE:There is increased recognition of the importance of hearing ability in social connectedness and healthy aging. Hearing loss is common among Veterans, and hearing rehabilitation is prioritized within the Veterans Administration (VA). Despite the attention to hearing care in the VA, limited data on cochlear implant (CI) utilization raises concern about whether this transformative and accessible treatment is reaching Veterans who could be helped with communication to improve their quality of life. The overall hypothesis is that Veterans with severe hearing loss, despite having unique rehabilitative needs, are not consistently treated as a distinct population. In this article, we identify patterns associated with specific management strategies for Veterans with severe hearing loss and describe the utilization of CIs in the VA as an evidence-based strategy when hearing aids provide limited benefit. DESIGN/METHODS:We investigated rehabilitation strategies used for Veterans with severe hearing loss. We defined a population-based cohort of 213,285 United States Veterans with newly diagnosed bilateral severe or worse hearing loss from January 1, 2006, to December 31, 2023. Severe hearing loss was defined as having a 4-frequency pure tone average (0.5, 1, 2, and 4 kHz) ≥70 dB HL in both ears. Speech perception abilities were also collected. We related hearing rehabilitation treatment of Veterans to factors hypothesized to impact care, including audiologic results, sociodemographic characteristics, comorbidities, and geography. Main outcomes included the receipt of CI and the cumulative incidence of CI. We used a competing risks framework to determine the factors associated with CI receipt. RESULTS:Of the 213,285 Veterans with bilateral severe or poorer hearing loss (mean age [SD], 80.3 [9.7]), 202,949 (95.2%) were fit with hearing aids, 5335 (2.5%) had a CI procedure, and 5001 (2.3%) had no evidence of receiving hearing rehabilitation. The 5- and 10-yr cumulative incidence (95% confidence interval) of receipt of CI was 1.9% (1.8 to 2.0%) and 2.9% (2.8 to 3.0%), respectively (death treated as a competing risk). In competing risks regression, age, race and ethnicity, VA priority group, word recognition score (WRS), hearing loss severity, the year hearing loss was first identified, and a greater number of comorbidities were all significantly associated with the receipt of CI. Patient age, word recognition score, and hearing loss severity were found to be the most important predictors of CI receipt based on concordance loss. CONCLUSIONS:Most Veterans with severe hearing loss and poor speech understanding, who are likely to be audiologic candidates for CIs, are treated with hearing aids, whereas relatively few receive CIs. The treatment approach may be driven by several different factors specific to the Veteran, site of care, and VA policies. A multifaceted strategy and care delivery may be required to improve evidence-based care for those with severe hearing loss.

OBJECTIVE:Pediatric tracheostomy emergencies are high-acuity events requiring rapid, coordinated team-based care. This study assessed objective team performance and used in situ simulation to identify systems factors, including latent safety threats (LSTs) and resilience supports, that influence pediatric tracheostomy emergency readiness across diverse clinical settings. METHODS:In situ simulations of pediatric tracheostomy emergencies (obstructed or partially dislodged tubes) were conducted across inpatient floors, critical care units, and emergency departments at 11 pediatric hospitals. Time to completion of critical actions was recorded using the NeoCHART+™ for PEAK-II mobile application. Structured debriefs identified LSTs and resilience supports at unit and hospital levels. Multivariable Cox proportional hazards models assessed predictors of time-critical actions (tube replacement, suction, first effective ventilation) and the percentage of critical actions completed. RESULTS:Sixty-seven baseline simulations were conducted across 11 institutions. Seventy-seven percent of teams replaced an identical tracheostomy tube within 5 minutes (median 188.4 seconds, [IQR 165.3, 204.6]). Teams reported a median of 3.2 LSTs per simulation (IQR 3.0, 4.0). Common LSTs included attempted ventilation through occluded tracheostomy tubes, unclear leadership, ambiguous role definitions, and non-standardized equipment locations. Teams with a RT and at institutions with a dedicated tracheostomy team performed time-critical actions faster. DISCUSSION/CONCLUSIONS:In situ simulation revealed LSTs, resilience supports, and performance variability that may influence effective pediatric tracheostomy emergency response at the systems level. IMPLICATIONS FOR PRACTICE/CONCLUSIONS:Variability identified in systems factors and team performance can guide targeted interventions to improve pediatric tracheostomy emergency preparedness.