Latest updates of endoscopic lateral skull base surgery

The start of neurotologic surgery using endoscope dates back to the 1960s, but there has been much debates as to whether or not to replace operative microscope. Therefore, endoscope has been mainly used for diagnostic purposes for a while. Recently, with the increasing interest in minimally invasive surgery, various surgical procedures have been tried in the field of neurotology and their success has been reported. In this review, cases of vestibular schwannoma, facial nerve decompression, glomus tumor, petrous apex cholesterol granuloma, venous malformations of the facial nerve, and perilymph fistula are summarized.ope

Which Patients With a Unilateral Hearing Aid for Symmetric Sensorineural Hearing Loss Have Auditory Deprivation?

Objectives: The aim of study is to find conditions that aggravate auditory deprivation in patients with symmetric hearing loss after unilateral digital, non-linear hearing aid (HA). Methods: In the retrospective case-comparison study, we assessed 47 patients with symmetric sensorineural hearing loss (SNHL), wearing unilateral conventional HAs. Audiological outcomes were assessed >1 year after HA fitting (mean duration, 31.0 months). Pure-tone audiometry in HA-aided and HA-unaided conditions was performed over time. Word recognition score (WRS) was evaluated at the most comfortable listening level. Results: The initial pure tone average of four frequency thresholds at 500, 1,000, 2,000, and 4,000 Hz (PTA4) did not show a difference of >5 dB HL between HA-aided and HA-unaided ears. WRS progressively decreased for both HA-aided and HA-unaided ears although the extent of decrease was significantly greater for HA-unaided (7.6%) than for HA-aided ears (5.1%, P<0.05). Notably, auditory deprivation in HA-unaided ears was significantly greater in patients with an initial PTA4 ≥53 dB HL (P<0.001). Conclusion: Bilateral HAs are strongly recommended, particularly for patients with moderate to severe SNHL to prevent auditory deprivation in the contralateral ear.ope

Externally Monitored Versus Conventional Buried Flaps in Laryngopharyngeal Reconstruction

Objectives: To compare the surgical outcomes of externally monitored and conventional buried flaps with the goal of determining the usefulness of external monitoring of buried flaps. Methods: In this case-control study with propensity score matching, 30 patients were evenly divided into externally monitored buried flap and conventional buried flap groups. The total operative time for free flap reconstruction, the flap survival rate, the length of hospital stay, the initial time of a reliable visual assessment, complications, the final diet achieved, and the duration until diet initiation were compared between the groups. Results: The mean operative time for reconstruction was 115 minutes (interquartile range, 85-150 minutes) and 142 minutes (interquartile range, 95-180 minutes) in the externally monitored and conventional groups, respectively (P= 0.245). The median length of hospital stay was 24 days (interquartile range, 18-30 days) and 27 days (interquartile range, 20-41 days) in the externally monitored and conventional groups, respectively (P=0.298). The median duration until diet initiation was 15 days (interquartile range, 15-21 days) and 18 days (interquartile range, 15-34 days) in the externally monitored and conventional groups, respectively (P=0.466). The final diet, initial time of a reliable visual assessment, and complications were comparable between the groups, but the external skin paddle provided an excellent visual assessment immediately postoperatively in all cases. Conclusion: The outcomes were comparable between the groups, indicating that externalization of the cutaneous component of a buried flap may be a straightforward and useful technique for monitoring a buried anterolateral thigh free flap in laryngopharyngeal reconstructions. The salvage and false-positive rates of compromised flaps should be compared in large subject groups in future studies to prove that the use of an external skin paddle improves flap monitoring.ope

Hearing Rehabilitation with Combined Electroacoustic Stimulation and Ossiculoplasty

We report a case of hearing rehabilitation following combined cochlear implantation and ossiculoplasty. A 71-year-old patient visited the clinic for right-sided mixed hearing loss. We targeted neural and conductive components, performing two different operations simultaneously. At two months post-operative, the patient showed satisfactory results with respect to hearing threshold and speech comprehension. Our experience suggests that careful evaluation of patients and consideration of the diverse array of available treatment strategies can be used to provide personalized rehabilitation with maximal effectiveness. To the best of our knowledge, this is the first report to take such an integrated approach to treat hearing impairment and is thus likely to have clinical importance for otologists.ope

Differential Biases and Variabilities of Deep Learning-Based Artificial Intelligence and Human Experts in Clinical Diagnosis: Retrospective Cohort and Survey Study

Background: Deep learning (DL)-based artificial intelligence may have different diagnostic characteristics than human experts in medical diagnosis. As a data-driven knowledge system, heterogeneous population incidence in the clinical world is considered to cause more bias to DL than clinicians. Conversely, by experiencing limited numbers of cases, human experts may exhibit large interindividual variability. Thus, understanding how the 2 groups classify given data differently is an essential step for the cooperative usage of DL in clinical application. Objective: This study aimed to evaluate and compare the differential effects of clinical experience in otoendoscopic image diagnosis in both computers and physicians exemplified by the class imbalance problem and guide clinicians when utilizing decision support systems. Methods: We used digital otoendoscopic images of patients who visited the outpatient clinic in the Department of Otorhinolaryngology at Severance Hospital, Seoul, South Korea, from January 2013 to June 2019, for a total of 22,707 otoendoscopic images. We excluded similar images, and 7500 otoendoscopic images were selected for labeling. We built a DL-based image classification model to classify the given image into 6 disease categories. Two test sets of 300 images were populated: balanced and imbalanced test sets. We included 14 clinicians (otolaryngologists and nonotolaryngology specialists including general practitioners) and 13 DL-based models. We used accuracy (overall and per-class) and kappa statistics to compare the results of individual physicians and the ML models. Results: Our ML models had consistently high accuracies (balanced test set: mean 77.14%, SD 1.83%; imbalanced test set: mean 82.03%, SD 3.06%), equivalent to those of otolaryngologists (balanced: mean 71.17%, SD 3.37%; imbalanced: mean 72.84%, SD 6.41%) and far better than those of nonotolaryngologists (balanced: mean 45.63%, SD 7.89%; imbalanced: mean 44.08%, SD 15.83%). However, ML models suffered from class imbalance problems (balanced test set: mean 77.14%, SD 1.83%; imbalanced test set: mean 82.03%, SD 3.06%). This was mitigated by data augmentation, particularly for low incidence classes, but rare disease classes still had low per-class accuracies. Human physicians, despite being less affected by prevalence, showed high interphysician variability (ML models: kappa=0.83, SD 0.02; otolaryngologists: kappa=0.60, SD 0.07). Conclusions: Even though ML models deliver excellent performance in classifying ear disease, physicians and ML models have their own strengths. ML models have consistent and high accuracy while considering only the given image and show bias toward prevalence, whereas human physicians have varying performance but do not show bias toward prevalence and may also consider extra information that is not images. To deliver the best patient care in the shortage of otolaryngologists, our ML model can serve a cooperative role for clinicians with diverse expertise, as long as it is kept in mind that models consider only images and could be biased toward prevalent diseases even after data augmentation.ope

Feasibility of Asynchronous and Automated Telemedicine in Otolaryngology: Prospective Cross-Sectional Study

Background: COVID-19 often causes respiratory symptoms, making otolaryngology offices one of the most susceptible places for community transmission of the virus. Thus, telemedicine may benefit both patients and physicians. Objective: This study aims to explore the feasibility of telemedicine for the diagnosis of all otologic disease types. Methods: A total of 177 patients were prospectively enrolled, and the patient's clinical manifestations with otoendoscopic images were written in the electrical medical records. Asynchronous diagnoses were made for each patient to assess Top-1 and Top-2 accuracy, and we selected 20 cases to conduct a survey among four different otolaryngologists to assess the accuracy, interrater agreement, and diagnostic speed. We also constructed an experimental automated diagnosis system and assessed Top-1 accuracy and diagnostic speed. Results: Asynchronous diagnosis showed Top-1 and Top-2 accuracies of 77.40% and 86.44%, respectively. In the selected 20 cases, the Top-2 accuracy of the four otolaryngologists was on average 91.25% (SD 7.50%), with an almost perfect agreement between them (Cohen kappa=0.91). The automated diagnostic model system showed 69.50% Top-1 accuracy. Otolaryngologists could diagnose an average of 1.55 (SD 0.48) patients per minute, while the machine learning model was capable of diagnosing on average 667.90 (SD 8.3) patients per minute. Conclusions: Asynchronous telemedicine in otology is feasible owing to the reasonable Top-2 accuracy when assessed by experienced otolaryngologists. Moreover, enhanced diagnostic speed while sustaining the accuracy shows the possibility of optimizing medical resources to provide expertise in areas short of physicians.ope

Effect of cochlear implantation on hearing fluctuation in patients with biallelic SLC26A4 variants

Objectives: To investigate whether cochlear implantation has a protective or deleterious effect on hearing fluctuation in patients with biallelic SLC26A4 variants. Design: Patients with biallelic SLC26A4 variants (N = 16; age = 10.24±9.20 years) who had unilateral cochlear implantation and consecutive post-surgical, bilateral pure-tone audiograms more than 3 times were selected. The authors retrospectively reviewed the patients’ medical records from 2008 to 2019 obtained from a tertiary medical center and used the auditory threshold change between tests of each ear as a marker of hearing fluctuation. They then compared the auditory threshold changes of the implanted and contralateral ears using logistic regression with a generalized estimating equation and a linear mixed model. In total, 178 audiograms were included. Results: The odds of fluctuating hearing frequency were 11.185-fold higher in the unimplanted ear compared to the implanted ear (p = 0.001). At both 250 Hz and 500 Hz, the extent of fluctuation was significantly increased lower in the unimplanted ear compared to the unimplanted ear after adjusting for every other effect (p= 0.003, p<0.001, respectively). Also, the higher the residual hearing was, the lesser the fluctuation frequency and the extent of the fluctuation at 500 Hz. Age at the operation affected the fluctuation frequency and the extent of the fluctuation at 250Hz. Genotype, sex did not affect the magnitude of fluctuations. Conclusions: In patients with biallelic SLC26A4 variants, cochlear implantation may reduce the frequency and magnitude of hearing fluctuations. SLC26A4 변이로 인한 유전성 난청 환자에서 반복되는 급성 청력의 악화와 호전은 고유한 임상적 특징 중 하나이다. 본 저자는 이중대립유전자성 SLC26A4 변이를 지닌 환자에서 인공 와우 수술이 급성 청력변동에 미치는 영향에 대해 연구하였다. 2008년부터 2019년까지 연세대학교 세브란스 병원 이비인후과에 내원한 이중대립유전자성 SLC26A4 변이 환자의 의무 기록을 후향적으로 검토하여 일측 인공 와우 수술을 받았거나, 시간적 거리를 두고 양측 인공 와우 수술을 받았던 환자에서 양측의 순음 청력검사를 3회 이상 측정한 16명이 선택되었다. 평균연령은 10.24 ± 9.20 세였으며, 이중 10명이 남성이었다. 시간경과에 따른 청각 역치의 변화를 shift 로 정의하여 청력 변동의 지표로 사용하였다. 총 178개의 shift를 계산하여 수술한 귀와 수술하지 않은 귀에서의 청력변동의 빈도와 250, 500Hz에서 각각 청력변동의 크기를 비교하기 위해 일반화 추정방정식과 선형 혼합 모델을 이용한 로지스틱 회귀분석을 이용해 분석하였다. 인공 와우 수술을 받은 귀에 비해 받지 않은 귀에서 11.185배의 청력변동이 더 많았다 (p=0.001). 또한 250과 500Hz 모두에서 수술받지 않은 귀에서 수술받았던 귀에 비해 청력 변동의 크기가 유의하게 증가하였다 (p=0.003, p<0.001). 잔존 청력이 높을수록 청력 변동의 빈도가 적게 나타났으며 (p=0.001), 500Hz에서 청력 변동의 크기가 적게 나타났다 (p<0.001). 수술시 나이가 많을수록 청력 변동의 빈도가 적게 나타났고 (p<0.001), 250Hz에서 청력 변동의 크기가 적게 나타났다 (p=0.046). 유전형이나 성별은 청력 변동에 영향을 미치지 않았다. 따라서 이중 대립형 SLC26A4 변이 환자에서 인공 와우 이식은 청력 변동의 빈도와 크기를 모두 감소시키는 효과가 있다는 결론에 도달하였다.open석

Assessment of radiation-induced otitis media in patients with parotid gland malignancy

Background: Otitis media with effusion (OME) is a known side effect of radiation therapy in patients with head and neck cancer. Aims/objectives: To investigate the incidence rate and clinical course of radiation-induced OME, we have reported on the long-term characteristics of OME in patients with parotid gland malignancy. Material and methods: This cohort study assessed 200 patients who underwent post-parotidectomy radiation therapy from January 2010 to December 2019 in a tertiary referral center. Postoperative radiation therapy was performed at 6 weeks post-surgery. Serial magnetic resonance images were collected to detect otitis media. Two blinded otologists individually assessed data from radiation therapy initiation to 36 months of post-radiation therapy. Results: A total of 121 patients were enrolled (male, 61 [50.4%]; mean age, 46.98 ± 15.69 years), of which 14 developed otitis media (11.6%) within 6 months after radiation therapy. Spontaneous remission occurred without intervention within 1 year, excluding one patient who sustained otitis media for 2 years. Conclusions and significance: Radiation-induced OME occurred in 11.6% of patients and it remitted within 1 year without intervention. Therefore, cooperation between otolaryngologists and radiation oncologists is required and invasive intervention should be considered with careful risk-benefit evaluation.restrictio

Is an Ultrasonic and Bipolar Integrated Energy Device More Useful Than a Conventional Electric Device in Head and Neck Free Flap Reconstruction? A Prospective Comparison

Purpose: Thunderbeat (TB) is an integrated energy device incorporating ultrasonic and bipolar technology that provides rapid cut and precision dissection and reliable vessel sealing compared with conventional electrosurgery (ES). The present study compared the surgical outcomes of TB and ES for harvesting the anterolateral thigh free flap (ALTFF). Patients and Methods: The present prospective cohort study compared TB and ES in patients who had undergone head and neck reconstruction using ALTFFs. The baseline characteristics, including age, gender, body mass index, primary tumor site (recipient site), and T stage, were measured. Patients who had undergone reconstruction after previous unsuccessful head and neck cancer treatment using radiation were included in the salvage surgery group. The primary outcome variables were the harvesting time, blood loss, and flap failure. The interval until the start of an oral diet and the percutaneous endoscopic gastrostomy (PEG) insertion rate were analyzed to compare the functional outcomes. After identifying the confounding variables, multivariate approaches were used to adjust for the confounding variables. Results: No significant differences were found in the demographics and disease-related factors such as age, gender, body mass index, anatomic distribution, and T stage of the primary disease, between the 2 groups. The operation time and bleeding volume were reduced by 32.4 and 33.1%, respectively, in the TB group compared with those in the control group. The postoperative drainage volume, duration, flap failure rate, and intensive care unit and total hospital stays were nearly identical between the 2 groups. No statistically significant differences were found in the functional outcomes (PEG insertion and oral diet start day) between the 2 groups. Conclusions: The results of the present study have shown that TB is a useful supportive tool for head and neck reconstruction surgery because it decreases the operation time with surgical outcomes comparable to those with conventional ES. (C) 2020 American Association of Oral and Maxillofacial Surgeonsrestrictio

Effect of Cochlear Implantation on Hearing Fluctuation in Patients with Biallelic SLC26A4 Variants

Introduction: Fluctuating hearing loss is a distinctive feature caused by SLC26A4 variants. We investigated whether cochlear implantation had protective or deleterious effect on hearing fluctuation in patients with biallelic SLC26A4 variants. Methods: Patients with biallelic SLC26A4 variants (N = 16; age = 10.24 ± 9.20 years) who had unilateral cochlear implantation and consecutive postsurgical, bilateral pure-tone audiograms more than 3 times were selected. We retrospectively reviewed the patients' medical records from 2008 to 2019 obtained from a tertiary medical center and used the auditory threshold change (Shift) over time as a marker of hearing fluctuation. Fluctuation events were counted, and the Shift of the implanted and contralateral ears was compared using logistic regression with a generalized estimating equation and linear mixed model. A total of 178 values were included. Results: The odds of fluctuating hearing frequency were 11.185-fold higher in the unimplanted ears than in the implanted ears postoperatively (p = 0.001). The extent of fluctuation at 250 and 500 Hz was also significantly lower in the implanted ears than in the unimplanted ears after adjusting for every other effect (p = 0.003 and p < 0.001, respectively). Notably, higher residual hearing was rather associated with lesser fluctuation in frequency and the extent of fluctuation at 500 Hz, indicating residual hearing function is not the positive predictor for hearing fluctuation. Conclusion: In patients with biallelic SLC26A4 variants, cochlear implantation may reduce the frequency and extent of hearing fluctuations.restrictio