Publications by authors named "Maura K Cosetti"

42 Publications

The Price of Otologic Procedures: Variation in Markup by Surgical Procedure and Geography in the United States.

Otol Neurotol 2021 Mar 26. Epub 2021 Mar 26.

Department of Otolaryngology, Icahn School of Medicine at Mount Sinai Department of Otolaryngology, New York Eye and Ear Infirmary of Mount Sinai, New York, New York.

Objective: To characterize and analyze variation in price markup of seven common otologic surgeries by procedure and geographic region.

Study Design: Retrospective Analysis of the Centers for Medicare and Medicaid Services database of 2017 Medicare Provider Utilization and Payment Public File.

Setting: Inpatient and outpatient centers delivering Medicare-reimbursed services.

Patients: Full sample of patients undergoing procedures with Medicare fee-for-service final action claims during 2017.

Interventions: Seven procedures (myringotomy, tympanoplasty, mastoidectomy, tympanomastoidectomy stapedotomy/stapedectomy, cochlear implant, bone-anchored hearing aid).

Main Outcome Measures: Markup ratio (MUR) is defined as the ratio of total charges to Medicare-allowable-costs; Variation in MUR was measured using coefficient of variation (CoV).

Results: Among all providers, the median MUR was 2.4 (interquartile range: 1.9-3.1). MUR varied significantly by procedure, from 2.3 for myringotomy to 8.7 for mastoidectomy (p < 0.01). MUR also varied significantly within procedure, with the least variation found in myringotomy (CoV = 0.46), and the greatest in cochlear implants (CoV = 0.92). Using the national average as baseline, MUR varied 71% between states, ranging from 1.75 to 6.24. Within the same state, significant variation was also noted, varying by 4% (CoV = 0.04) in Montana compared with 138% (CoV = 1.38) in Pennsylvania. MUR was not significantly correlated with patient comorbidity or Centers for Medicare and Medicaid Services risk scores.

Conclusions: There was significant variation in the price of otologic surgery across geographic regions and procedures. The MUR for otology is lower or comparable to that reported in other surgical fields.
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http://dx.doi.org/10.1097/MAO.0000000000003151DOI Listing
March 2021

In Response to The Challenges of Pharmacotherapy of SARS-CoV-2 Infection in Patients with Sudden Sensorineural Hearing Loss Due to COVID-19.

Laryngoscope 2021 Mar 17. Epub 2021 Mar 17.

Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, U.S.A.

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http://dx.doi.org/10.1002/lary.29517DOI Listing
March 2021

The utility of augmented reality in lateral skull base surgery: A preliminary report.

Am J Otolaryngol 2021 Jan 29;42(4):102942. Epub 2021 Jan 29.

Icahn School of Medicine at Mount Sinai, Department of Otolaryngology-Head and Neck Surgery, United States of America; New York Eye and Ear Infirmary of Mount Sinai, Department of Otolaryngology, United States of America.

Objective: To discuss the utility of augmented reality in lateral skull base surgery.

Patients: Those undergoing lateral skull base surgery at our institution.

Intervention(s): Cerebellopontine angle tumor resection using an augmented reality interface.

Main Outcome Measure(s): Ease of use, utility of, and future directions of augmented reality in lateral skull base surgery.

Results: Anecdotally we have found an augmented reality interface helpful in simulating cerebellopontine angle tumor resection as well as assisting in planning the incision and craniotomy.

Conclusions: Augmented reality has the potential to be a useful adjunct in lateral skull base surgery, but more study is needed with large series.
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http://dx.doi.org/10.1016/j.amjoto.2021.102942DOI Listing
January 2021

A Narrative Review of Pharmacologic Treatments for COVID-19: Safety Considerations and Ototoxicity.

Laryngoscope 2021 Jan 24. Epub 2021 Jan 24.

Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, U.S.A.

Objective/hypothesis: The purpose of this review is to summarize evidence-based data regarding the ototoxic effects of potential COVID-19 therapeutics to treat patients suffering from SARS-CoV-2.

Methods: Medications under investigation as novel therapeutics to treat COVID-19 were identified using the search term coronavirus therapeutics, COVID therapeutics, and SARS-CoV-2 therapeutics on ClinicalTrials.gov and the PubMed Database. A literature review was performed using the PubMed Database for each proposed COVID-19 therapeutic to identify relevant articles. Search criteria included Medical Subject Headings (MeSH) and key word search terms for ototoxicity, vestibulotoxicity, hearing disorders, and vertigo.

Results: Six proposed COVID-19 therapeutics were identified as possessing ototoxic side effects including chloroquine and hydroxychloroquine, azithromycin, lopinavir-ritonavir, interferon, ribavirin, and ivermectin.

Conclusions: Available evidence suggests that ototoxic effects may be improved or mitigated by stopping the offending agent. Recognition of hearing loss, tinnitus, or imbalance/vertigo is therefore crucial to facilitate early intervention and prevent long-term damage. Hospitals should consider the inclusion of audiologic monitoring protocols for patients receiving COVID-19 therapeutics with known ototoxicity, especially in high-risk patient groups such as the elderly and hearing impaired. Laryngoscope, 2021.
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http://dx.doi.org/10.1002/lary.29424DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8014300PMC
January 2021

Cochlear Implantation in Meniere's Disease: A Systematic Review and Meta-Analysis.

Laryngoscope 2021 Jan 19. Epub 2021 Jan 19.

Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, U.S.A.

Objectives/hypothesis: Meniere's disease (MD) is a debilitating condition characterized by hearing loss, vertigo, and tinnitus. The objective of this study was to systematically investigate outcomes in MD after cochlear implantation (CoI), with and without labyrinthectomy.

Study Design: Systematic review and meta-analysis.

Methods: A systematic review of articles in Medline and Embase was performed to identify all studies of patients with MD who underwent CoI. This analysis evaluates outcomes of speech recognition, pure tone audiometry, vertigo, tinnitus, and quality of life.

Results: Of 321 studies identified, 37 were included, involving 216 patients. Mean age at implantation was 61.4 years (range 27-85 years) with average length of follow-up at 1.7 years (range 0-9 years). Forty-four (20.4%) patients underwent labyrinthectomy. Meta-analysis demonstrated significant improvements in audiometric outcomes following CoI. There was a statistically significant improvement in Hearing in Noise Test performance, with a mean difference improvement of 44.7 (95% confidence interval [CI] [8.8, 80.6]) at 6 months and 60.1 (95% CI [35.3, 85.0]) at 12 months. The Freiburger Monosyllabic Test (FMT) and Consonant-Nucleus-Consonant (CNC) also improved significantly, with mean difference improvements of 46.2 (95% CI [30.0, 62.4]) for FMT and 19.3 (95% CI [8.1, 30.4]) for CNC. There was a statistically significant decrease in tinnitus, as measured by a mean difference reduction of 48.1 (95% CI [1.0, 95.2]) in the Tinnitus Handicap Index.

Conclusions: CoI with and without simultaneous labyrinthectomy is a viable treatment option for patients with MD, yielding high rates of tinnitus suppression and vertigo control. Post-CoI MD patients demonstrate similar postoperative speech perception outcomes to non-MD implant recipients. Laryngoscope, 2021.
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http://dx.doi.org/10.1002/lary.29393DOI Listing
January 2021

Endoscopic Myringoplasty and Type I Tympanoplasty.

Otolaryngol Clin North Am 2021 Feb 2;54(1):75-88. Epub 2020 Nov 2.

Icahn School of Medicine of Mount Sinai, Department of Otolaryngology-Head and Neck Surgery, 1 Gustave L. Levy Place, Box 1189, New York, NY 10029, USA.

Herein we provide a broad overview of the literature as it applies to endoscopic myringoplasty and type I tympanoplasty. Advantages and disadvantages of the endoscopic approach are reviewed for both the adult and pediatric populations and are compared with conventional microscopic techniques.
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http://dx.doi.org/10.1016/j.otc.2020.09.010DOI Listing
February 2021

Hearing From the COVID-19 Epicenter-A Neurotologist's Reflection From the Front Lines.

Authors:
Maura K Cosetti

JAMA Otolaryngol Head Neck Surg 2020 10;146(10):889-890

Department of Otolaryngology-Head and Neck Surgery, New York Eye and Ear Infirmary of Mount Sinai, New York, New York.

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http://dx.doi.org/10.1001/jamaoto.2020.2532DOI Listing
October 2020

The National Landscape of Acute Mastoiditis: Analysis of the Nationwide Readmissions Database.

Otol Neurotol 2020 09;41(8):1084-1093

Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai.

Objective: To determine risk factors for readmission, prolonged length of stay, and discharge to a rehabilitation facility in patients with acute mastoiditis. Trends in treatment and complication rates were also examined.

Study Design: Retrospective cohort study.

Setting: Nationwide Readmissions Database (2013, 2014).

Patients: Pediatric and adult patients in the Nationwide Readmissions Database with a primary diagnosis of acute mastoiditis.

Interventions: Medical treatment, surgical intervention.

Outcome Measures: Rates of and risk factors for readmission, prolonged length of stay, and discharge to a rehabilitation facility. Procedure and complication rates were also examined.

Results: Four thousand two hundred ninety-five pediatric and adult admissions for acute mastoiditis were analyzed. The overall rates of readmission, prolonged length of stay, and discharge to a rehabilitation facility were 17.0, 10.4, and 10.2%, respectively. Children 4 to 17 years of age had the highest rates of intracranial complications, and children ≤3 years were most likely to undergo operative intervention. Any procedure was performed in 31.2% of cases, and undergoing myringotomy or mastoidectomy was associated with lower rates of readmission but higher rates of prolonged length of stay. Those with intracranial complications and subperiosteal abscesses had the highest surgical intervention rates.

Conclusions: Readmission, prolonged length of stay, and discharge to a rehabilitation facility are common in patients with acute mastoiditis with various sociodemographic and disease-related risk factors. While once a primarily surgical disease, a minority of patients in our cohort underwent procedures. Undergoing a surgical procedure was protective against readmission but a risk factor for prolonged length of stay.
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http://dx.doi.org/10.1097/MAO.0000000000002745DOI Listing
September 2020

COVID-19 sampling from the middle ear and mastoid: A case report.

Am J Otolaryngol 2020 Sep - Oct;41(5):102577. Epub 2020 Jun 2.

Icahn School of Medicine at Mount Sinai, Department of Otolaryngology-Head and Neck Surgery, United States of America; New York Eye and Ear Infirmary of Mount Sinai, Department of Otolaryngology-Head and Neck Surgery, United States of America.

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http://dx.doi.org/10.1016/j.amjoto.2020.102577DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7264918PMC
September 2020

Temporal Bone Encephaloceles: Utility of Preoperative Imaging.

Otolaryngol Head Neck Surg 2020 09 28;163(3):577-581. Epub 2020 Apr 28.

Department of Otolaryngology and Head and Neck Surgery, New York Eye and Ear Infirmary of Mount Sinai, New York, New York, USA.

Objective: To determine the diagnostic efficacy and clinical value of preoperative computed tomography (CT) and magnetic resonance imaging (MRI) among patients with suspected temporal bone encephaloceles (TBE).

Study Design: Retrospective chart review from 2006 to 2018.

Setting: Tertiary referral center.

Subjects And Methods: The subjects underwent surgery for a clinically suspected TBE or cerebrospinal fluid (CSF) leak. Preoperative imaging test characteristics of CT and MRI, including sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV), were calculated for TBE scans and compared with intraoperative findings.

Results: Fifty-seven subjects with otorrhea, middle ear effusion, hearing loss, and/or meningitis with suspected TBE or CSF leak were identified. All had preoperative CT scans, and 61% (35/57) had preoperative MRI scans. Intraoperatively, 37 of 57 patients (65%) were found to have a TBE. CT scans (17% sensitivity, 100% specificity, 100% PPV, 46% NPV) were less sensitive than MRI (58% sensitivity, 100% specificity, 100% PPV, 24% NPV) for detecting TBEs. Furthermore, the time from initial scan to operative repair was significantly longer in those who had a CT followed by MRI scan compared with CT alone or a fused CT-MRI scan (mean = 68 vs 15 days, respectively; = .004).

Conclusion: CT and MRI provide complementary information that may aid surgical planning. However, imaging cannot always rule out TBE. In cases with high clinical suspicion, surgical confirmation is often required for definitive diagnosis and treatment. The cost of an additional preoperative study should be considered before its use.
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http://dx.doi.org/10.1177/0194599820918566DOI Listing
September 2020

Repair of a Temporal Bone Encephalocele With the Surgical Exoscope.

Otol Neurotol 2020 04;41(4):561

Department of Otolaryngology Head and Neck Surgery, New York Eye and Ear Infirmary of Mount Sinai.

Objective: We describe our experience using the extracorporeal video microscope, the "exoscope" for repair of a temporal bone encephalocele.

Method: The patient is a 69-year-old male with a right temporal lobe encephalocele herniating through a tegmen defect. He underwent definitive tegmen defect repair and bipolar cauterization of the encephalocele. The authors elected for a combined transmastoid and transtemporal approach in order to isolate the tegmen defect and provide watertight repair. The Synaptive robotic BrightMatter (Toronto, ON) drive video exoscope monitor system was used for the entirety of the case including both the transmastoid approach and transtemporal craniotomy.

Results: No intraoperative complications were encountered during either the transmastoid (mastoidectomy) or transtemporal craniotomy. The authors were able to complete the entire case without abandonment of the exoscope in favor of the traditional binocular microscope. Advantages of this technology in clinical practice includes high-resolution three-dimensional visualization, increased degrees of freedom for exoscope adjustment, and reduced surgeon fatigue in a fixed, unnatural posture. Limitations include decreased depth perception and increased operative time.

Conclusion: The exoscope system is a safe and effective alternative or adjunct to the existing binocular operating microscope for lateral skull based procedures. The exoscope provides the surgeon with a comfortable, high-resolution visualization without compromising surgical exposure and patient safety.SDC video link: http://links.lww.com/MAO/A837.
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http://dx.doi.org/10.1097/MAO.0000000000002433DOI Listing
April 2020

Use of IL-5 Inhibitor Benralizumab as a Novel Therapy for Eosinophilic Otitis Media: Clinical Capsule and Review of Literature.

Otol Neurotol 2020 02;41(2):e238-e240

Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York.

Objective: We report a case of recurrent eosinophilic otitis media (EOM) successfully treated with the novel monoclonal IL-5 inhibitor benralizumab. We also review literature relevant to EOM diagnosis and potential for biologic treatment.

Patient: A 24-year-old woman with bilateral otitis media with effusion unresponsive to standard treatment.

Intervention(s): Multidisciplinary treatment using subcutaneous benralizumab after diagnosis of EOM.

Main Outcome Measure(s): Behavioral audiometry, peripheral serology, otomicroscopy, and eosinophilic otitis media symptom severity.

Results: Recalcitrant otitis media with effusion (OME) in the setting of nasal polyposis and asthma prompted clinical suspicion for EOM, which was confirmed by pathologic examination of middle ear effusion and soft tissue biopsy. Treatment with benralizumab was initiated by pulmonology and well-tolerated. Within 2 months of treatment onset there was a cessation of EOM symptoms, a reduction of peripheral eosinophil levels, and an improvement in conductive hearing loss.

Conclusions: Monoclonal antibodies such as benralizumab may be an effective treatment option for EOM. A high level of clinical suspicion in patients with bronchial asthma, nasal polyposis, and recalcitrant OME may allow early diagnosis of EOM. Awareness of emerging biologic treatment options is important in the management of this challenging entity and may prevent long-term sequelae.
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http://dx.doi.org/10.1097/MAO.0000000000002493DOI Listing
February 2020

Gender Trends in Authorship of Original Otolaryngology Publications: A Fifteen-Year Perspective.

Laryngoscope 2020 09 4;130(9):2126-2132. Epub 2019 Dec 4.

Department of Otolaryngology, Mount Sinai Hospital, New York, New York, U.S.A.

Objective: To examine trends in female author representation within original otolaryngology research between 2000 and 2015.

Methods: Original research articles published in 11 otolaryngology journals were analyzed for 2000, 2003, 2006, 2009, 2012, and 2015. The genders of the first and last authors for each article were recorded. Overall female authorship was calculated by summing the numbers of the first, last, and both first and last female-authored articles. Student t test and Cochran-Armitage trend test were utilized to determine significance between years and groups.

Results: Of the 9,623 research articles published during 5 representative years, 223 were excluded due to one or more gender-indeterminate authors. Female first authorship exhibited a significant upward trend from 2000 to 2015 (P < 0.0001), as did the proportion of literature with female first and last authors (P < 0.0001). Although female senior authorship in literature with an impact factor (IF) greater than 2 did not increase significantly (10.0% in 2000 to 10.1% in 2015; P = 0.738), this metric did increase significantly just within journals with an IF between 1 and 2 (9.7%-12.3%, P = 0.036). The proportion of articles with a female author in the first, last, or both positions increased from 28% to 39% (P < 0.0001).

Conclusion: Increasing female representation in otolaryngology literature may reflect the rising proportion of women within otolaryngology as well as greater mentorship availability. Despite these auspicious strides, female-authored articles nonetheless represent a smaller proportion of the literature, and female senior authors remain a stark minority. Future studies should identify the barriers to female access and advancement within the field.

Level Of Evidence: III Laryngoscope, 130:2126-2132, 2020.
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http://dx.doi.org/10.1002/lary.28372DOI Listing
September 2020

Sex-based Differences in Hearing Loss: Perspectives From Non-clinical Research to Clinical Outcomess.

Otol Neurotol 2020 03;41(3):290-298

Department of Otolaryngology-Head & Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.

Introduction: It is estimated over 466 million people worldwide have disabling hearing loss, and untreated hearing loss is associated with poorer health outcomes. The influence of sex as a biological variable on hearing loss is not well understood, especially for differences in underlying mechanisms which are typically elucidated through non-clinical research. Although the inclusion of sex as a biological variable in clinical studies has been required since 1993, sex reporting has only been recently mandated in National Institutes of Health funded non-clinical studies.

Objective: This article reviews the literature on recent non-clinical and clinical research concerning sex-based differences in hearing loss primarily since 1993, and discusses implications for knowledge gaps in the translation from non-clinical to clinical realms.

Conclusions: The disparity between sex-based requirements for non-clinical versus clinical research may inhibit a comprehensive understanding of sex-based mechanistic differences. Such disparities may play a role in understanding and explaining clinically significant sex differences and are likely necessary for developing robust clinical treatment options.
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http://dx.doi.org/10.1097/MAO.0000000000002507DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7012726PMC
March 2020

Thirty-Day Readmission and Prolonged Length of Stay in Malignant Otitis Externa.

Laryngoscope 2020 09 22;130(9):2220-2228. Epub 2019 Nov 22.

Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, U.S.A.

Objectives: To determine independent risk factors for 30-day readmission, prolonged length of stay (PLOS), and discharge to a rehabilitation facility for those with malignant otitis externa.

Methods: Retrospective cohort study of patients hospitalized with malignant otitis externa (International Classification of Diseases, 9th edition, code 380.14) in the Nationwide Readmissions Database (2013-2014). Overall and disease-specific complication and mortality data were analyzed using chi-squared and multivariate analysis.

Results: There were 1267 cases of malignant otitis externa extracted. A PLOS of ≥8 days (90th percentile) was found in 14.2% (n = 180) of patients, and 13.7% (n = 174) were discharged to a facility. Patients were readmitted within 30 days at a rate of 12.5% (n = 159). The overall rates of uncomplicated and complicated diabetes were found to be 42.1% and 17.8%, respectively. Factors independently associated with PLOS included undergoing a surgical procedure (odds ratio [OR] 2.08, P < .001), and having central nervous system complications (OR 3.21, P < .001). Independent risk factors for disposition to a facility included nutritional deficiency (OR 1.91, P = .029), PLOS (OR 4.61, P < .001), and age 65-79 years (OR 6.57, P = .001). Readmission was independently linked to PLOS (OR 3.14, P < .001). Diabetes was not an independent risk factor for any outcome.

Conclusions: Thirty-day readmission, PLOS, and ultimate discharge to a rehabilitation facility were common and closely intertwined. Despite the classic association between diabetes and malignant otitis externa, diabetes was not an independent risk factor for any of our outcomes.

Level Of Evidence: 4 Laryngoscope, 130:2220-2228, 2020.
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http://dx.doi.org/10.1002/lary.28409DOI Listing
September 2020

Atypical Schwannoma: A 10-year experience.

Am J Otolaryngol 2020 Jan - Feb;41(1):102309. Epub 2019 Oct 17.

Department of Otolaryngology, New York University School of Medicine, New York, NY, USA; Department of Neurosurgery, New York University School of Medicine, New York, NY, USA.

Objective: The goal of this study was to describe the clinical presentation associated with atypical schwannoma of the cerebellopontine angle, characterize the pathologic findings and describe the long-term outcome.

Materials And Methods: The study design was retrospective case review of patients with the histopathologic diagnosis of atypical and benign schwannoma of the cerebellopontine angle diagnosed at the study institution over a 10-year period.

Setting: Tertiary referral center.

Main Outcomes Measure: Demographic data of the cohort were recorded. Findings on pathology were evaluated. Initial treatment and post-operative course was recorded. Main outcome measures were clinical presentation, including cranial nerve deficits at the time of presentation, complication and recurrence rates.

Results: At presentation, a somewhat accelerated course of cranial nerve deficit was noted among patients with atypical schwannoma as compared to benign schwannoma. In the immediate post-operative period, there were no differences noted in the complication rate. Atypical schwannomas appear to have higher recurrence rate compared to benign schwannomas.

Conclusions: Atypical schwannoma is an intermediate disease process with an accelerated clinical course and higher recurrence rate as compared to vestibular schwannoma. Traditional operative approaches may be employed without increased concern for post-operative complications. Thorough counseling and close follow-up should be offered to these patients given the higher recurrence rate. Larger studies are required to determine if these patients need more frequent MRIs for long-term surveillance.
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http://dx.doi.org/10.1016/j.amjoto.2019.102309DOI Listing
April 2020

Amyloidosis Presenting as a Mass Abutting the Tympanic Membrane.

Ear Nose Throat J 2019 Sep 30:145561319868453. Epub 2019 Sep 30.

Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA.

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http://dx.doi.org/10.1177/0145561319868453DOI Listing
September 2019

Accuracy of a Modern Intraoperative Navigation System for Temporal Bone Surgery in a Cadaveric Model.

Otolaryngol Head Neck Surg 2019 11 24;161(5):842-845. Epub 2019 Sep 24.

Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA.

Objectives: To determine the accuracy of a modern navigation system in temporal bone surgery. While routine in other specialties, navigation has had limited use in the temporal bone due to issues of accuracy, perceived impracticality, and value.

Study Design: Prospective observational study.

Setting: Temporal bone laboratory.

Subjects And Methods: Eighteen cadaveric specimens were dissected after rigid fiducials were implanted and computed tomography scans were obtained. Target registration and target localization errors were then measured at various points.

Results: The mean overall target registration error was 0.48 ± 0.29 mm. The mean target localization error was 0.54 mm at the sinodural angle, 0.48 mm at the lateral semicircular canal, 0.55 mm at the round window, 0.39 mm at the oval window, and 0.52 mm at the second genu of the facial nerve.

Conclusion: A modern navigation system demonstrated submillimeter accuracy for all points of interest. Its use in clinical as well as training settings has yet to be fully elucidated.
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http://dx.doi.org/10.1177/0194599819864292DOI Listing
November 2019

National 30-day readmission and prolonged length of stay after vestibular schwannoma surgery: Analysis of the Nationwide Readmissions Database.

Am J Otolaryngol 2019 Nov - Dec;40(6):102290. Epub 2019 Sep 10.

Icahn School of Medicine at Mount Sinai, Department of Otolaryngology-Head and Neck Surgery, United States of America; New York Eye and Ear Infirmary of Mount Sinai, Department of Otolaryngology, United States of America; Audiology, Hearing, and Balance Center, Mount Sinai Health System, United States of America; Ear Institute, Mount Sinai Health System, United States of America. Electronic address:

Purpose: To determine the risk factors for unanticipated readmission, prolonged index admission, and discharge to a facility after vestibular schwannoma surgery.

Materials And Methods: Retrospective cohort study of those undergoing surgery for vestibular schwannoma in the Nationwide Readmissions Database (2013-2014). Main outcome measures included readmission rate, length of stay, discharge destination.

Results: There were 4585 cases identified. The overall unanticipated readmission rate was 8.1%, and 9.1% had a prolonged length of stay (PLOS) of ≥7 days. Mean and median LOS were 4.63 and 4.00 days, respectively, and >90% of patients were discharged after 7 days. Disposition to a facility occurred in 6.7% of cases. Teaching hospitals were protective against unintended readmission (odds ratio [OR] 0.44, p < .001). Major functional loss was associated with PLOS (OR 12.55, p < .001). High volume centers were associated with decreased risk of PLOS (OR 0.46, p < .001) and facility discharge (OR 0.68, p < .001). The most common readmission diagnoses included "other nervous system complications" (n = 128), cerebrospinal fluid leak (n = 71), "other postoperative infection" (n = 61), and meningitis (n = 59).

Conclusions: Unanticipated readmission and prolonged LOS following vestibular schwannoma surgery are common, with varied sociodemographic, hospital, and patient factors independently associated with each. Further studies are needed to investigate targeted interventions aimed at minimizing readmission and prolonged LOS using the factors outlined above.
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http://dx.doi.org/10.1016/j.amjoto.2019.102290DOI Listing
April 2020

The utility of intraoperative navigation of the temporal bone for otolaryngology resident training.

Laryngoscope 2020 05 5;130(5):E368-E371. Epub 2019 Aug 5.

Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, New York, U.S.A.

Objectives: To determine whether image guidance improves dissection quality among residents in the temporal bone lab and to gauge their reactions to its use.

Methods: Prospective cohort study of nine otolaryngology residents who dissected cadaveric temporal bones with and without image guidance in the temporal bone laboratory. Quality of dissection was measured with the Welling scale. A survey was administered assessing their interactions with the navigation system.

Results: There was no significant difference in quality of dissection for the majority of structures or number of major errors with use of image guidance. Dissection quality of the tegmen (4.67 vs. 5.67, P = .034) and sinodural angle (0.83 vs. 1.56, P = .005) was superior in the non-navigation specimens. The majority of residents reported increased confidence with locating several critical anatomic structures and found the system intuitive to use. Nearly all thought it would be helpful in revision cases or for aural atresia.

Conclusion: Image guidance did not improve quality of temporal bone dissection or number of major errors in this cohort of residents, but the majority found it intuitive and increased confidence in finding several structures. Navigation systems may play an important adjunctive role in resident education and further work is required to determine its optimal use.

Level Of Evidence: NA Laryngoscope, 130:E368-E371, 2020.
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http://dx.doi.org/10.1002/lary.28219DOI Listing
May 2020

Standardization of the Punch Technique for the Implantation of Bone Anchored Auditory Devices: Evaluation of the MIPS Surgical Set.

Otol Neurotol 2019 07;40(6):e631-e635

Texas Ear Center, Houston, Texas.

Objective: To describe and assess intraoperative and postoperative outcomes in the insertion of osseointegrated auditory implants with a newly designed surgical instrumentation set through a punch type technique.

Study Design: Retrospective case series.

Methods: Patients who underwent bone anchored auditory implant surgery using the Minimally Invasive Ponto Surgery (Oticon Medical, Somerset, NJ) surgical set through a punch technique at nine neurotology tertiary referral based practices were identified. Demographic data, skin thickness at implant site, implant used, duration of surgery, adverse intraoperative events, and postoperative outcomes were recorded.

Results: Seventy-five patients comprised the study cohort (32 males, 43 females). Most patients (57. 3%) were aged 51 to 75 years while 30.7% of the cohort comprised those aged 18 to 50 years and 12% were over 75 years. All but two patients received 4 mm fixtured implants and 68% received the Oticon Medical BioHelix implant. Two patients received 3 mm fixture implants and 32% received the Oticon Medical Wide Ponto implant. Mean surgical time was 12.2 minutes (6-45 min, standard deviation of 6.88 min). In three instances, surgery was converted to a linear incision to control brisk bleeding. Skin condition was Holgers 0 to 1 in 91.8%, while 5.5% had Holgers 2, and 2.7% had Holgers 3 at the first postoperative visit. At second postoperative visit, 94.3% had Holgers 0 to 1, 4.3% had Holgers 2, and 1.4% had Holgers 3. All instances of adverse skin reactions were treated with topical or systemic antibiotics and/or local debridement. There were no instances of implant loss. One patient had his implant traumatically displaced to a 45-degree angle necessitating implant replacement at a second site.

Conclusion: Punch technique placement of osseointegrated auditory implants using the Minimally Invasive Ponto Surgery surgical set represents a safe technique that further simplifies a progressively minimally invasive surgery.
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http://dx.doi.org/10.1097/MAO.0000000000002291DOI Listing
July 2019

The Use of the Exoscope in Lateral Skull Base Surgery: Advantages and Limitations.

Otol Neurotol 2019 02;40(2):236-240

Department of Otolaryngology Head and Neck Surgery, New York Eye and Ear Infirmary of Mount Sinai.

Objective: We describe our experience using the extracorporeal video microscope, the "exoscope" for various applications within the field of lateral skull base surgery.

Study Design: A retrospective case series was performed investigating patient demographics, indications for surgery, procedure type, operative time, approach to the skull base, complications, adequacy of visualization, and surgeon comfortability.

Patients: Six cases were performed with a three dimensional surgical exoscope, obviating the use of a traditional binocular microscope.

Setting: Academic, tertiary referral center.

Main Outcome Measures: Type of surgical approach, operative time, patient demographics, surgical complications, and surgeon comfortability.

Results: The following procedures were performed; four vestibular schwannoma resections via suboccipital craniotomy and two combined transmastoid and transtemporal approaches for temporal lobe encephalocele repairs. The average operative time was 227 and 577 minutes for temporal lobe encephalocele repairs and vestibular schwannoma cases, respectively. No intraoperative complications were encountered during these cases. None of the procedures required abandonment of the exoscope in favor of the microscope during the procedure. Advantages include high-resolution three-dimensional visualization, increased degrees of freedom for exoscope adjustment, and reduced surgeon fatigue in a fixed, unnatural posture. Limitations include decreased depth perception and increased operative time.

Conclusion: The exoscope system is a safe and effective alternative or adjunct to the existing binocular operating microscope for lateral skull based procedures. The exoscope provides the surgeon with a comfortable, high-resolution visualization without compromising surgical exposure and patient safety.

Level Of Evidence: 4.
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http://dx.doi.org/10.1097/MAO.0000000000002095DOI Listing
February 2019

Management of Vestibular Schwannoma (Including NF2): Facial Nerve Considerations.

Otolaryngol Clin North Am 2018 Dec;51(6):1193-1212

Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York Eye and Ear of Mount Sinai, Floor 6, 310 East 14th Street, New York, NY 10003, USA. Electronic address:

Current consensus on optimal treatment of vestibular schwannoma remains poorly established; treatment options include observation, stereotactic radiosurgery, microsurgical resection, medical therapy, or a combination of these. Treatment should be individualized and incorporate the multitude of patient- and tumor-specific characteristics known to affect outcome. Treatment paradigms for sporadic and neurofibromatosis type 2-related tumors are distinct and decision-making in neurofibromatosis type 2 is uniquely challenging. In all cases, treatment should maximize tumor control and minimize functional deficit.
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http://dx.doi.org/10.1016/j.otc.2018.07.015DOI Listing
December 2018

Neurocognitive testing and cochlear implantation: insights into performance in older adults.

Clin Interv Aging 2016 12;11:603-13. Epub 2016 May 12.

Department of Otolaryngology, New York University School of Medicine, New York, NY, USA.

Objective: The aim of this case series was to assess the impact of auditory rehabilitation with cochlear implantation on the cognitive function of elderly patients over time.

Design: This is a longitudinal case series of prospective data assessing neurocognitive function and speech perception in an elderly cohort pre- and post-implantation.

Setting: University cochlear implant center.

Participants: The patients were post-lingually deafened elderly female (mean, 73.6 years; SD, 5.82; range, 67-81 years) cochlear implant recipients (n=7).

Measurements: A neurocognitive battery of 20 tests assessing intellectual function, learning, short- and long-term memory, verbal fluency, attention, mental flexibility, and processing speed was performed prior to and 2-4.1 years (mean, 3.7) after cochlear implant (CI). Speech perception testing using Consonant-Nucleus-Consonant words was performed prior to implantation and at regular intervals postoperatively. Individual and aggregate differences in cognitive function pre- and post-CI were estimated. Logistic regression with cluster adjustment was used to estimate the association (%improvement or %decline) between speech understanding and years from implantation at 1 year, 2 years, and 3 years post-CI.

Results: Improvements after CI were observed in 14 (70%) of all subtests administered. Declines occurred in five (25%) subtests. In 55 individual tests (43%), post-CI performance improved compared to a patient's own performance before implantation. Of these, nine (45%) showed moderate or pronounced improvement. Overall, improvements were largest in the verbal and memory domains. Logistic regression demonstrated a significant relationship between speech perception and cognitive function over time. Five neurocognitive tests were predictive of improved speech perception following implantation.

Conclusion: Comprehensive neurocognitive testing of elderly women demonstrated areas of improvement in cognitive function and auditory perception following cochlear implantation. Multiple neurocognitive tests were strongly associated with current speech perception measures. While these data shed light on the complex relationship between hearing and cognition by showing that CI may slow the expected age-related cognitive decline, further research is needed to examine the impact of hearing rehabilitation on cognitive decline.
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http://dx.doi.org/10.2147/CIA.S100255DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4869653PMC
February 2017

Anatomical Factors Influencing Selective Vestibular Neurectomy: A Comparison of Posterior Fossa Approaches.

J Neurol Surg B Skull Base 2016 Feb 3;77(1):19-23. Epub 2015 Aug 3.

Departments of Otolaryngology-Head and Neck Surgery and Neurosurgery, Louisiana State University Health Sciences Center Shreveport, Shreveport, Louisiana, United States.

Objectives To identify measurable anatomical factors that may guide the surgical approach for posterior fossa selective vestibular neurectomy (SVN) and predict identification of the vestibulocochlear cleavage (VCC) plane. Study Design Dissection of fixed cadaveric heads through retrolabyrinthine and retrosigmoid-internal auditory canal (RSG-IAC) approaches with measurement of landmarks. Setting Cadaveric dissection model. Main Outcome Measures Area of the Trautmann triangle (TT) and the distance from the posterior semicircular canal to the anterior border of the sigmoid along the posterior Donaldson line (pDL). VCC planes from each approach were calculated and compared. Results Overall mean pDL was 8.53 mm (range: 5-11.5 mm); mean TT area was 124 mm(2) (range: 95-237 mm(2)). The VCC was identified in 63% of ears through the retrolabyrinthine (RVN) approach alone, whereas 37% of ears required the RSG-IAC approach. In ears requiring IAC dissection, the VCC was found within 1 to 2 mm distal to the porus. The pDL (p < 0.05) and area of TT (p < 0.05) were significantly larger in the RVN group compared with the RSG-IAC group. Conclusion Ears amenable to the RVN approach had a greater pDL and TT area. These anatomical measurements may have a role in surgical planning and the choice of approach for SVN.
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http://dx.doi.org/10.1055/s-0035-1556876DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4777624PMC
February 2016

Surgical techniques and outcomes of cochlear implantation in patients with radiographic findings consistent with X-linked deafness.

Int J Pediatr Otorhinolaryngol 2015 Oct 28;79(10):1689-93. Epub 2015 Jul 28.

Department of Otolaryngology-Head and Neck Surgery, New York University School of Medicine, New York, NY, USA.

Objectives: X-linked deafness is a potential etiology of sensorineural hearing loss characterized by bulbous dilatation of the fundus of the internal auditory canal (IAC) and the absence of the bony plates separating the basal turn of the cochlea and IAC. These malformations predispose patients to IAC insertion during cochlear implantation (CI). Our objective is to describe the surgical technique, audiometric and speech performance outcomes in a group of patients with this unique cochlear malformation.

Methods: A retrospective chart review was performed of all patients at a tertiary care facility who underwent CI between January 2006 and July 2011.

Results: A total of five patients were identified with radiographic findings characteristic of X-linked deafness, specifically a deficient modiolous, absent lamina cribrosa and bulbous IAC. A modified cochleostomy was utilized to ensure electrode insertion within the scala tympani avoiding the IAC. In each case, fluoroscopy was utilized to visual electrode progression during insertion and complete insertion was accomplished. All patients demonstrated improved speech performance following implantation.

Conclusions: Utilizing the techniques described, patients with these unique radiographic findings consistent with X-linked deafness may successfully undergo CI with excellent potential for auditory rehabilitation.
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http://dx.doi.org/10.1016/j.ijporl.2015.07.027DOI Listing
October 2015

Quality of Life (QoL) Assessment in Patients with Neurofibromatosis Type 2 (NF2).

Otolaryngol Head Neck Surg 2015 Oct 16;153(4):599-605. Epub 2015 Mar 16.

Department of Neurosurgery, New York University, New York, New York, USA Department of Otolaryngology, New York University, New York, New York, USA.

Objective: The aim of this study was to develop a multidimensional metric for assessing quality of life (QoL) in patients with neurofibromatosis type 2 (NF2).

Study Design: Electronically distributed questionnaire.

Setting: University tertiary care hospital, NF2 support groups.

Subjects And Methods: Structured interviews with NF2 providers and patients identified relevant domains. Items in each domain were extracted from validated QoL modules, then combined with items unique to NF2 and pretested on NF2 providers and patients. The final 61-item questionnaire was administered electronically to patients with NF2 (N = 118). The form assessed overall QoL and 11 additional domains, including hearing, balance, facial function, vision, oral intake, future uncertainty, psychosocial, cognition, sexual activity, pain, and vocal communication. Responses were compared with reference values for the general population, patients with head and neck cancer, and patients with brain cancer.

Results: Overall, QoL in patients with NF2 was lower than that of the general population (P < .01) and similar to that of patients with cancer. Patients with more facial weakness, hearing loss, and imbalance reported significantly lower QoL. However, domains most predictive of overall QoL were psychosocial, future uncertainty, and pain. Compared with patients with head and neck and brain cancer, patients with NF2 demonstrated significantly higher levels of psychosocial stressors, including disease-related anxiety, personal and financial stress, and lack of social support (P < .01).

Conclusion: Psychosocial stress and pain significantly affect QoL in NF2, indicating that mental health, pain management, and financial counseling could have an important impact on QoL in this population.
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http://dx.doi.org/10.1177/0194599815573002DOI Listing
October 2015

Is cochlear implantation safe and effective in the elderly?

Laryngoscope 2015 Jun 25;125(6):1279-81. Epub 2014 Nov 25.

Department of Otolaryngology-Head and Neck Surgery, Columbia University College of Physicians and Surgeons, New York, New York, U.S.A.

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http://dx.doi.org/10.1002/lary.25055DOI Listing
June 2015

Intraoperative Transcranial Motor-Evoked Potential Monitoring of the Facial Nerve during Cerebellopontine Angle Tumor Resection.

J Neurol Surg B Skull Base 2012 Oct;73(5):308-15

Departments of Otolaryngology, New York University School of Medicine, New York, New York, United States.

Objective To determine whether transcranial motor-evoked potential (TCMEP) monitoring of the facial nerve (FN) during cerebellopontine angle (CPA) tumor resection can predict both immediate and long-term postoperative FN function. Design Retrospective review. Setting Tertiary referral center. Main Outcome Measures DeltaTCMEP (final-initial) and immediate and long-term facial nerve function using House Brackmann (HB) rating scale. Results Intraoperative TCMEP data and immediate and follow-up FN outcome are reported for 52 patients undergoing CPA tumor resection. Patients with unsatisfactory facial outcome (HB >2) at follow-up had an average deltaTCMEP of 57 V, whereas those with HB I or II had a mean deltaTCMEP of 0.04 V (t = -2.6, p < 0.05.) Intraoperative deltaTCMEP did not differ significantly between groups with satisfactory (HB I, II) and unsatisfactory (HB > 2) facial function in the immediate postoperative period. Conclusion Intraoperative TCMEP of the facial nerve can be a valuable adjunct to conventional facial nerve electromyography during resection of tumors at the CPA. Intraoperative deltaTCMEP >57 V may be worrisome for long-term recovery of satisfactory facial nerve function.
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http://dx.doi.org/10.1055/s-0032-1321507DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3578638PMC
October 2012

The effects of residual hearing in traditional cochlear implant candidates after implantation with a conventional electrode.

Otol Neurotol 2013 Apr;34(3):516-21

Department of Otolaryngology, New York University School of Medicine, New York, NY 10016, USA.

Objective: To analyze the effects of residual hearing on postoperative speech performance in traditional cochlear implant (CI) patients implanted with a conventional electrode.

Study Design: Retrospective review.

Setting: Academic tertiary referral center.

Patients: A total of 129 adults implanted by a single surgeon at a tertiary care facility between June 2005 and November 2010 with measurable preoperative pure tone thresholds at any frequency were included.

Intervention: Cochlear implantation with a conventional electrode via an anterior inferior cochleostomy.

Main Outcome Measure: Speech perception using monosyllabic word scores in quiet and sentences in quiet and noise in the electric (CI-only) condition of the implanted ear. Preservation of hearing was defined as complete for postoperative thresholds within 10 dB of preimplant values and partial if greater than 11 dB. Pure tone audiometry and speech perception testing were performed preoperatively and at regular intervals postoperatively, with the 1-year evaluation being the final outcome period.

Results: Preservation at any frequency or level was not a factor in speech perception outcome, although preservation was more common in low frequencies. Hearing preservation was correlated with younger age at implantation, but was not related to length of hearing loss, cause of deafness, device type, sex, preoperative speech performance, or low-frequency pure-tone average.

Conclusion: Hearing can be preserved in traditional CI patients implanted with a conventional electrode. Although preservation of hearing may have implications for future technology, it is not currently correlated with speech performance in the CI-only condition.
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http://dx.doi.org/10.1097/MAO.0b013e3182785210DOI Listing
April 2013