Publications by authors named "Vivian F Kaul"

21 Publications

  • Page 1 of 1

Cost-effectiveness of Canal Wall-Up vs Canal Wall-Down Mastoidectomy: A Modeling Study.

Otolaryngol Head Neck Surg 2022 Feb 8:1945998221076051. Epub 2022 Feb 8.

Department of Otolaryngology, Icahn School of Medicine at Mount Sinai, New York, New York, USA.

Objective: To assess the relative lifetime costs, benefits, and cost-effectiveness between the 2 approaches, canal wall-up (CWU) and canal wall-down (CWD) tympanomastoidectomy, used in the treatment of cholesteatomas.

Study Design: Markov state transition model.

Setting: Tertiary academic health system.

Methods: A Markov state transition model was used to simulate outcomes across the patient lifetime. Outcome and complication probabilities were obtained from the existing literature. Costs were calculated from the payer perspective, with procedure, hospital, clinic, and physician cost derived from Medicare reimbursement. Quality-adjusted life years (QALYs) were used to represent effectiveness and utility. One-way and probability sensitivity analyses (PSAs) were conducted.

Results: The base case analysis, assuming a 40-year-old patient, yielded a lifetime cost of $14,214 for a patient treated with the CWU approach assuming second-look surgery and $22,290 with a CWD approach. CWU and CWD generated a benefit of 17.11 and 17.30 QALYs, respectively. The incremental cost-effectiveness ratio for CWU was $43,237 per QALY. The Monte Carlo PSA validated the base case scenario. Using a standard $50,000 willingness-to-pay threshold, CWD was the more cost-effective approach and was selected 54.8% of the time by the simulation.

Conclusion: Both CWU and CWD were found to be cost-effective, with CWD being cost-effective 54.8% of the time at a WTP threshold of $50,000. The assumptions used in the analysis were validated by the results of 1-way and PSA.
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http://dx.doi.org/10.1177/01945998221076051DOI Listing
February 2022

Endoscopic Versus Microscopic Stapedotomy: A Single-Blinded Randomized Control Trial.

Otol Neurotol 2021 12;42(10):1460-1466

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

Objective: To demonstrate non-inferiority of endoscopic stapedotomy to microscopic stapedotomy for the treatment of otosclerosis.

Study Design: Single-blinded randomized control trial.

Setting: Tertiary, academic otology-neurotology practice.

Patients: Adult subjects with a diagnosis of otosclerosis and a preoperative air-bone gap (ABG) more than or equal to 20 dB undergoing primary stapedotomy.

Intervention: Endoscopic or microscopic stapedotomy.

Main Outcome Measures: Primary audiometric outcome was postoperative ABG. Secondary audiometric outcomes included speech reception threshold (SRT), word recognition score (WRS), bone- and air-conduction pure tone averages (PTA), change in ABG, and ABG closure rates to less than or equal to 10 dB and less than or equal to 20 dB.

Results: Twenty-two patients were recruited. Eleven patients underwent endoscopic stapedotomy and 11 underwent microscopic stapedotomy. The endoscopic group was non-inferior to the microscopic group in terms of postoperative audiometric outcomes (endoscope versus microscope, p-value): ABG (8.1 dB versus 8.1 dB, <0.001), SRT (27.7 dB versus 25.9 dB, <0.001), WRS (92% at 65 dB versus 98% at 62 dB, <0.001), air-conduction PTA (33.5 dB versus 30.8 dB, <0.01), and change in ABG (23.0 dB versus 20.7 dB, <0.0001). ABG closure rates to less than or equal to 10 dB (72.7% versus 81.2%, p = 1.0) and less than or equal to 20 dB (90.9% versus 100%, p = 1.0) were not significantly different. There was no significant difference in operative time, necessity of scutum curettage, or postoperative dysgeusia. No patients required chorda tympani sacrifice. Preoperative tinnitus resolved in three patients in each group postoperatively.

Conclusions: This study is the first randomized control trial to demonstrate non-inferiority of endoscopic to microscopic stapedotomy.
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http://dx.doi.org/10.1097/MAO.0000000000003298DOI Listing
December 2021

Initial Experience With a Recently Developed Lateral Wall Electrode.

Laryngoscope 2021 12 23;131(12):2782-2788. Epub 2021 Jul 23.

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

Objective: To review our hearing preservation rates and speech recognition outcomes in patients undergoing cochlear implantation with a recently developed lateral wall electrode.

Study Design: Retrospective cohort study.

Methods: Retrospective case series of all patients, both pediatric and adult, undergoing cochlear implantation with the Advanced Bionics Hifocus™ SlimJ electrode between December 2017 and January 2020. Main outcomes included hearing preservation rates using several definitions, speech recognition testing primarily through Arizona Biosciences (AzBio) and Consonant-Nucleus-Consonant (CNC) testing, intra- and postoperative complications.

Results: Sixty-one ears underwent implantation with the new electrode. Hearing preservation rates were 13.0% to 36.0% depending on the definition used. Speech recognition testing showed significant increases from pre- to postoperative condition (Implant-only AzBio: 24.1 to 48.3, P = .004, binaural AzBio: 46.1 to 65.9, P = .002, Implant-only CNC: 9.7 to 35.1, P < .001, binaural CNC: 29.8 to 59.40, P < .001) with last speech recognition testing occurring an average of 8.8 months postoperatively. The elderly population had the worst hearing preservation rates across all definitions. Five explantations were required due to two infections and three device failures.

Conclusion: Hearing preservation rates varied significantly depending on the definition used, but users experienced a significant improvement in speech recognition testing after implantation. More work is needed in the community to standardize the definition of residual hearing and hearing preservation.

Level Of Evidence: 4 Laryngoscope, 131:2782-2788, 2021.
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http://dx.doi.org/10.1002/lary.29779DOI Listing
December 2021

Is There a Role for Intraoperative Navigation During Cochlear Implantation in Patients With Aural Atresia?

Otol Neurotol 2021 10;42(9):e1250-e1255

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

Objective: Concurrent bilateral congenital aural atresia (CAA) and profound sensorineural hearing loss are rare. While not a contraindication, temporal bone and cochleovestibular abnormalities are an important consideration for cochlear implantation (CI) candidacy. Intraoperative image-guided surgical navigation may play a role during CI surgery in patients with complex anatomy, such as CAA.

Patient: One patient with bilateral CAA, cochlear dysplasia, speech delay, and profound sensorineural hearing loss underwent candidacy evaluation for cochlear implantation.

Interventions: Cochlear implantation using intraoperative image-guided navigation.

Main Outcome Measures: (1) Registration accuracy, (2) surgical outcomes, (3) audiometry.

Results: A four-year-old girl with complete bilateral CAA and profound sensorineural hearing loss successfully underwent a right transmastoid approach for CI using intraoperative image-guided navigation with sticker fiducials. Bony landmarks included the mastoid tip, tympanomastoid suture line, helical root, zygomatic root, and lateral brow. A registration accuracy of 0.9 mm was achieved. There were no intraoperative or immediate postoperative complications. Postoperatively, Neural Response Imaging was confirmed on 9 electrodes and behavioral testing demonstrated Ling-6 access at 30 dB. On most recent follow-up, she has demonstrated gains in language development, vocalizations, and uses total communication in a hearing-impaired educational environment.

Conclusions: Children with CAA and profound sensorineural hearing loss may be candidates for cochlear implantation, with successful outcomes in the setting of complex anatomy. Surgical navigation may play a role corroborating intraoperative landmarks.
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http://dx.doi.org/10.1097/MAO.0000000000003283DOI Listing
October 2021

Cadaveric Feasibility Study of Exoscope-Assisted Transcanal Transpromontorial Approach to the Internal Auditory Canal.

Otol Neurotol 2021 10;42(9):e1408

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

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http://dx.doi.org/10.1097/MAO.0000000000003273DOI Listing
October 2021

Opioids Are Infrequently Required following Ambulatory Otologic Surgery.

Otol Neurotol 2021 10;42(9):1360-1365

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

Objective: To determine the frequency with which postoperative opioid prescriptions are required after ambulatory otologic surgery.

Study Design: Retrospective chart review.

Setting: Tertiary otology-neurotology practice.

Patients: Patients (n = 447) given over-the-counter acetaminophen and ibuprofen following ambulatory otologic surgery between July 1, 2018 and June 30, 2020.

Intervention: Opioid prescription upon request.

Main Outcome Measures: Patient, disease, and surgical variables such as age, sex, past medical history, chronic pain condition, surgical procedure, primary versus (vs.) revision surgery, and endoscopic vs. microscopic approach were examined for relationship to ad hoc opioid prescription rate.

Results: Of 370 adult patients (mean age 49.0 yrs, range 18.0-88.5 yrs), 75 (20.3%) were prescribed opioids for postoperative pain, most commonly oxycodone-acetaminophen 5/325 mg. Of 77 pediatric patients (mean age 8.8 yrs, range 0.7-17.9 yrs), 5 (6.5%) were prescribed postoperative opioid analgesia. In the adult population, chronic pain condition, pain medication use at baseline, canal wall up mastoidectomy, tympanoplasty, tympanomeatal flap, bone removal of the mastoid, postauricular incision, and intraoperative microscopy were independent predictors of opioid pain prescription. When controlling for all significant variables, only chronic pain condition remained significant (odds ratio = 3.94; p = 0.0007). In the pediatric population, atresiaplasty, meatoplasty, and conchal cartilage removal were independently associated with opioid prescription, but none remained significant when analyzed in a multivariate linear model.

Conclusions: Pain following ambulatory otologic surgery may be adequately managed with over-the-counter pain medications in the majority of cases. Opioids may be necessary in adults with preexisting pain conditions.
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http://dx.doi.org/10.1097/MAO.0000000000003264DOI Listing
October 2021

Single-stage long-segment tracheal transplantation.

Am J Transplant 2021 10 19;21(10):3421-3427. Epub 2021 Jul 19.

The Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA.

Tracheal transplantation has been envisioned as a viable option for reconstruction of long-segment tracheal defects. We report the first human single-stage long-segment tracheal transplantation. Narrow-band imaging and bronchoscopic biopsies demonstrate allograft vascularization and viable epithelial lining. The recipient was immunosuppressed with Tacrolimus, Mycophenolate mofetil, and corticosteroids. Six months after transplantation, the trachea is both functional and the patient is breathing without the need of a tracheostomy or stent.
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http://dx.doi.org/10.1111/ajt.16752DOI Listing
October 2021

3D Exoscope Navigation-Guided Approach to Middle Cranial Fossa.

Otol Neurotol 2021 09;42(8):1223-1227

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

Objective: To test the feasibility and efficacy of a 3D exoscope navigation-guided middle cranial fossa (MCF) approach to the internal auditory canal (IAC); to potentially obviate the need to use dissection landmarks and instead, use the navigation probe as a guide to find structures and drill down to the IAC.

Patients: Cadaveric dissection of six temporal bones.

Intervention: Computed tomography temporal bone was performed with fiducials on each specimen before the dissection to employ the navigation system. Using a 3D exoscope with navigation by Synaptive (Toronto, Ontario, Canada), the MCF approach was performed.

Main Outcome Measures: Navigation accuracy, ability to identify critical structures, and ability to drill out the IAC successfully.

Results: All six specimens had the IAC successfully drilled out using the 3D exoscope. All dissections were performed with navigation and did not require dissecting out the greater superficial petrosal nerve and superior semicircular canal. One specimen used landmark dissection to confirm the IAC after navigation had been used to locate the IAC first. Navigation accuracy mean was 1.86 mm (range, 1.56-2.05 mm).

Conclusion: A 3D exoscope navigation-guided MCF approach to the IAC is feasible without landmark dissection.
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http://dx.doi.org/10.1097/MAO.0000000000003185DOI Listing
September 2021

Intraoperative navigation during atresiaplasty for congenital aural atresia.

Int J Pediatr Otorhinolaryngol 2021 Jul 11;146:110756. Epub 2021 May 11.

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

Objective: The purpose of this study was to evaluate the feasibility of intraoperative navigation (ION) using adhesive fiducials and high-resolution computed tomography (HRCT) of the temporal bone in pediatric patients undergoing atresiaplasty for congenital aural atresia (CAA).

Methods: From June 2018 to August 2019, a retrospective review was performed on pediatric patients with unilateral or bilateral CAA who underwent atresiaplasty with or without concurrent bone anchored implant (BAI) placement. Single stage atresiaplasty was performed at a tertiary referral center with ION linked to image-guidance compatible HRCT non-contrast temporal bone images. Up to six adhesive fiducials were placed for navigation. Patient demographics were collected including Schuknecht classification type and Jahrsdoerfer score. Main outcome measures included the number of useable adhesive fiducials for navigation, navigation system registration accuracy, operative time, intraoperative complications, and postoperative outcomes including facial nerve function, surgical site infection rate, restenosis rate, and audiometric data.

Results: Five patients (3 male, 1 AU atresia, 2 AS atresia, all Schuknecht type C) with an average age of 9.2 years (range 6.8-11.8 years) underwent single sided atresiaplasty with ION. Two patients underwent concurrent BAI placement. Average Jahrsdoerfer score was 8.6 (range 7-10). Preoperative audiogram demonstrated a mean air-bone gap (ABG) of 45 dB (range 35-54 dB). The navigation system registration accuracy ranged from 0.08 to 1.80 mm (mean 1.00 mm). Mean operative time was 268 min (range 217-307 min). There were no intraoperative complications. At an average follow up of 7.2 months (range 2-15 months), postoperative facial nerve function was normal in all patients and no patients developed postoperative stenosis or surgical site infections. Four patients underwent postoperative audiogram at an average of 4 months after surgery (range 2-5 months) and all demonstrated an ABG of less than 30 dB (mean 20 dB, range 15-26 dB) with an average improvement in ABG of 23 dB (range 11-39 dB). The one patient who did not undergo postoperative pure tone audiometry underwent AzBio speech perception testing and demonstrated an improvement from 81% to 89%.

Conclusions: The use of ION in otologic surgery is uncommon. Inherent aberrant temporal bone anatomy in CAA makes this a unique population to study the value of this technology. The use of adhesive fiducials is feasible, with navigation registration accuracy and surgical outcomes comparable to those in the literature. More data is necessary regarding the impact of ION on long-term surgical and audiometric outcomes.
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http://dx.doi.org/10.1016/j.ijporl.2021.110756DOI Listing
July 2021

Does Auditory Environment Predict Speech Perception Outcomes in Elderly Cochlear Implant Patients?

Audiol Neurootol 2021 5;26(5):378-386. Epub 2021 May 5.

Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine, Ear Institute, New York Eye and Ear Infirmary of Mount Sinai, New York, New York, USA.

Introduction: Cochlear implantation (CI) is a reliable and safe means by which sensorineural hearing loss can be ameliorated in the elderly population. However, a high degree of variation exists in postimplantation hearing outcomes for which some modifiable factors of the daily natural auditory environment may be contributory. In this study, we analyze the relationship between cochlear implant patient age, natural auditory environment, and postimplantation speech perception among older adults.

Methods: Data log from automatic environment classification enabled sound processors of postlingually deafened CI recipients ≥50 years old (n = 115) were obtained retrospectively and analyzed for time spent (hours per day) in listening environment and loudness (SPL dB). Speech perception testing was assessed in a subset of patients (n = 27) using open-set word recognition in quiet Consonant-Nucleus-Consonant in the short and intermediate postoperative period.

Results: The mean subject age was 70 years (range, 53-99 years). Average daily implant use was 10.8 h and was not significantly correlated with age (p = 0.23, Spearman's rho). Age was positively correlated with the percentage of hours spent at <40 and 40-50 dB and negatively correlated to proportional CI use at higher volume (60-70, 70-80, and >80 dB; rs = 0.21, 0.20, -0.20, -0.35, -0.43; p = 0.021, 0.036, 0.033, <0.001, <0.001, respectively). Age was positively correlated with CI use in the quiet scene (rs = 0.26, p = 0.006) and negatively correlated with scenes containing speech and noise (rs = -0.19, -0.25; p = 0.046, 0.007). Total hours of device use and time spent at <40, 40-50 dB, and quiet environments were significantly correlated with improved CNC word scores (rs = 0.48, 0.48, 0.51; p = 0.01, 0.01, <0.01, Spearman's rho). While all speech (speech in noise + speech) was not significantly correlated to improvements in speech perception, a medium effect size was observed (rs = 0.37, p = 0.057).

Discussion/conclusion: This study supports a relationship between auditory environment and age, with older CI recipients spending a greater proportion of time in quiet. Older CI users demonstrated greater improvements in speech perception with longer daily device use. Additional examination of the relationship between auditory environment and speech perception is necessary to conclusively guide future auditory rehabilitation efforts.
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http://dx.doi.org/10.1159/000513637DOI Listing
October 2021

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

Am J Otolaryngol 2021 Jul-Aug;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
November 2021

Microdrill in endoscopic stapes surgery: Is it safe?

Am J Otolaryngol 2020 Nov - Dec;41(6):102666. Epub 2020 Aug 12.

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

Purpose: To assess the safety of using a microdrill in endoscopic vs microscopic stapes surgery.

Materials And Methods: A retrospective review of 29 adult ears with otosclerosis who underwent either an endoscopic or microscopic approach to microdrill stapedotomy.

Primary Outcome: Determine if transcanal endoscopic stapes surgery with the microdrill is as safe as microscopic stapes surgery. Secondary outcome: Bone and air pure-tone averages, air-bone gap, speech discrimination, overall surgical cost, and operative time were measured and analyzed. Complications such as post-operative dysgeusia, vertigo, readmission, revision and hearing loss were noted.

Results: 29 patients with otosclerosis were retrospectively reviewed, in total 14 endoscopic and 15 microscopic approaches were included, all performed over one-year period. None of the endoscopic surgeries require conversion to the microscope. No statistically significant audiometric differences between the endoscopic vs microscopic approaches in air pure-tone averages and air-bone gap. There were 82.8% air-bone gap closure to <15 dB with no significant difference in the percent of such closures between the endoscopic (85.7%) and microscopic groups (80%, P = .68). Three prostheses were used: 4.25 mm (17.2%), 4.5 mm (58.6%) and the 4.75 mm (24.1%) smart/eclipse. Endoscopic median operative time was 51 min vs 42 min for microscopic approach (P =.004).

Conclusions: The endoscopic with microdrill approach is criticized to lack depth perception, especially when using a microdrill to perform in stapedotomies. Our study showcases that using the microdrill use produces minimal differences in outcomes, cost, and is a safe modality to stapes surgery in both approaches.
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http://dx.doi.org/10.1016/j.amjoto.2020.102666DOI Listing
December 2020

Nuances in transcanal endoscopic surgical technique for glomus tympanicum tumors.

Am J Otolaryngol 2020 Sep - Oct;41(5):102562. Epub 2020 May 27.

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

Objective: To describe the utility and nuances of transcanal endoscopic surgery (TCES) on glomus tympanicum tumors from a single surgeon's experience.

Patients/intervention: Twelve patients, eight female and four males, diagnosed pre-operatively with glomus tympanicum tumors. They all underwent endoscopic resection by a single surgeon.

Main Outcome Measures: Feasibility of endoscopic resection of glomus tympanicum tumors without conversion to a microscopic approach. Secondary outcomes include tumor stage, pre and post-operative audiometry, vertigo, sensorineural hearing loss (SNHL) and integrity of the facial nerve, ossicles, chorda tympani and tympanic membrane.

Results: Twelve patients underwent TCES, eight patient's pathology results were glomus tympanicum, ranging from Glasscock-Jackson grade I-III. Due to loss in follow up, 6/8 patients had complete audiometric data, which were analyzed. Average pre-operative air-bone-gap (ABG) was 5.41 compared to post-operative ABG of 5.08 (p > 0.89). No patients resulted in any, post-operative vertigo, tinnitus, SNHL, facial nerve injury or chorda tympani nerve injury. Two patients had intentional tympanic membrane perforations secondary to tumor adherence to the membrane. They were repaired with tragal perichondrium graft. No patients have had any recurrences.

Conclusions: Endoscopic resection of glomus tympanicum tumors is a feasible and effective, alternative visualization modality for the neurotologist. Surgical pearls are described herein.
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http://dx.doi.org/10.1016/j.amjoto.2020.102562DOI Listing
November 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

Surgery of the Palatomaxillary Structure.

Semin Plast Surg 2020 May 6;34(2):71-76. Epub 2020 May 6.

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

The palatomaxillary structure plays critical roles in both form and function of the midface. Surgical defects of the palate and maxilla can be associated with significant morbidity and deformity. Various defect classification systems have been used to assist in reconstruction and rehabilitation. Reconstructive options include prosthetic rehabilitation, local flaps, and free tissue transfer. Here, we review the functional and surgical anatomy of the palatomaxillary complex, defect classification systems, and provide an overview of reconstructive options.
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http://dx.doi.org/10.1055/s-0040-1709430DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7202911PMC
May 2020

Amyloidosis Presenting as a Mass Abutting the Tympanic Membrane.

Ear Nose Throat J 2021 Jun 30;100(5):337-339. Epub 2019 Sep 30.

Department of Otolaryngology-Head and Neck Surgery, 5925Icahn School of Medicine at Mount Sinai, New York, NY, USA.

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http://dx.doi.org/10.1177/0145561319868453DOI Listing
June 2021

Endoscopic Versus Microscopic Middle Ear Surgery: A Meta-analysis of Outcomes Following Tympanoplasty and Stapes Surgery.

Otol Neurotol 2019 09;40(8):983-993

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

Objective: This meta-analysis compares the efficacy and safety of endoscopic and microscopic approaches to tympanoplasty and stapes surgery, two common middle ear procedures.

Data Sources: A comprehensive electronic search of PubMed/MEDLINE, Scopus, Web of Science, and Cochrane Library was conducted for studies published from the year 1960 through June 2018. Article selection and screening proceeded according to the strategies outlined in the standard Preferred Reporting Items for Systematic Reviews and Meta-analysis statement.

Methods: Studies were assessed for quality using the Newcastle-Ottawa Scale and the Jadad scale depending on the presence of randomization. Bias was analyzed using funnel plots. For each outcome measure, a forest plot was generated and a pooled relative risk or risk difference was calculated to assess significance.

Results: Twenty-one studies met the inclusion criteria, 16 tympanoplasty (1,323 ears) and 5 stapes surgery (283 ears). The nonrandomized studies scored moderately well but the randomized studies were of low quality with respect to the Newcastle-Ottawa Scale and the Jadad Scale, respectively. With respect to tympanoplasty, statistical analysis demonstrated that the endoscopic approach had significantly lower canalplasty rates, better cosmetic outcomes, and shorter operative times. Furthermore, endoscopic compared to microscopic methods were similar in terms of audiological outcome, graft success rate, and complication rate. Among stapes surgeries, the endoscopic approach demonstrated a significantly decreased incidence of postoperative pain and chorda tympani injury but was similar to the microscopic approach with respect to audiological outcome, postoperative dizziness, and operative time.

Conclusions: Though the merits of endoscopic techniques are becoming more well known, there are still concerns regarding their efficacy and safety. An analysis of the current literature suggests that audiological, functional, and safety outcomes are similar, if not superior, for the endoscopic approach to both tympanoplasty and stapes surgery compared to the microscopic approach. With respect to tympanoplasty, patients undergoing the endoscopic approach had lower canalplasty rates, better cosmetic outcomes, and shorter operative times. Among stapes surgeries, patients in the endoscopic group had a lower incidence of postoperative pain and injury to the chorda tympani. This meta-analysis of the current evidence supports the use of endoscopic techniques for tympanoplasty and stapes surgery.
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http://dx.doi.org/10.1097/MAO.0000000000002353DOI Listing
September 2019

An unusual case of sudden sensorineural hearing loss after cycling class.

Am J Otolaryngol 2019 Jul - Aug;40(4):605-608. Epub 2019 Apr 25.

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

In this case report, our patient developed sudden sensorineural hearing loss (SSNHL) after loud noise exposure during a popular cardiovascular group exercise cycling class. To increase awareness among all healthcare professionals of the effects of these modern-day group fitness classes on hearing loss, we describe this case and review the current literature on SSNHL and its management. A 35-year old man developed SSNHL in the setting of loud noise exposure during a high intensity aerobic exercise class. After a short course of oral steroids with no improvement, intratympanic steroids were administered weekly for three weeks. The patient showed minimal improvement; thus, hyperbaric oxygen therapy was conducted. Serial audiograms continued to show severe to profound mixed hearing loss in the right ear. In conclusion, individuals who participate in loud, high-intensity aerobic group-exercise classes should be careful of the potential for noise-induced hearing loss. Aerobic exercise may make these individuals more susceptible to noise-induced hearing loss. Early intervention is critical for any chance of recovery.
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http://dx.doi.org/10.1016/j.amjoto.2019.04.016DOI Listing
December 2019

Phosphodiesterase-5 (PDE-5) Inhibitors and Ototoxicity: A Systematic Review.

Otol Neurotol 2019 03;40(3):276-283

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

Objective: This study explores the current literature regarding associations between phosphodiesterase-5 (PDE-5) inhibitors and ototoxicity and provides a detailed summary and discussion of the findings.

Data Sources: A comprehensive electronic search of PubMed/MEDLINE, Scopus, and Cochrane Library for studies published from database inception through March 21, 2018.

Study Selection: Basic science articles, epidemiological studies, randomized controlled trials, cohort studies, case reports, reviews, meta-analyses, press releases, and newsletters were included. The PRISMA search strategy was used to select papers. Search terms are included in the appendix (http://links.lww.com/MAO/A733).

Results: Twenty-two articles met the inclusion criteria. Among case reports, there were a total of nine patients, all male, with an average age of 57.4 years (37-79 years, SD = 13.87 years). Of the cases of hearing loss, 25% (2/8 cases) were bilateral and 75% (6/8) were unilateral; 22% (2/9) were associated with tinnitus; and 33% (3/9) had accompanying vestibular symptoms (including vertigo and dizziness). Among multipatient studies, all prospective studies failed to find a significant association between ototoxicity and PDE-5 inhibitor use. Results of the retrospective studies were also heterogeneous. Many key molecules in the PDE-5 inhibition pathway have been demonstrated to exist in the cochlea. However, mirroring the clinical studies, the basic science mechanisms have suggested both ototoxic and otoprotective effects.

Conclusions: Currently, the literature is inconclusive regarding the interaction between PDE-5 inhibitor use and ototoxicity. Future study such as a double-blinded placebo controlled randomized trial with audiometric assessment would provide more sound evidence. Similarly, a unified molecular model is necessary.
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http://dx.doi.org/10.1097/MAO.0000000000002148DOI Listing
March 2019

An Evaluation of the Program-Specific Paragraph in the Otolaryngology Residency Application.

Laryngoscope 2018 11 24;128(11):2508-2513. Epub 2018 Sep 24.

Department of Otolaryngology, Icahn School of Medicine at Mount Sinai, New York, New York.

Objectives/hypothesis: The recent addition of mandatory program-specific paragraphs within the personal statement during the otolaryngology match process has been controversial. It is unclear whether applicants customize these paragraphs for programs, or if they are largely uniform across applications. The objective of our study was to assess the degree of variability among program-specific paragraphs.

Study Design: Retrospective cohort analysis.

Methods: An analysis of deidentified program-specific paragraphs of 2016 otolaryngology residency applicants at two institutions was performed. Applicants who applied to both and had program-specific paragraphs were included. Paragraphs were assessed for 24 parameters, including quantitative content analysis. Subjective and objective similarity scores were assigned to each pair, using a five-point scale and Levenshtein distance function respectively. Differences between institutions were calculated using χ and two-sided t tests.

Results: Two hundred eight-five applications were reviewed, and 181 applied to both programs and had program-specific paragraphs. The median subjective similarity score among all paragraphs was "mildly similar" (2/5). The mean objective similarity score was 0.59. There were statistical differences between institutions in 13 parameters. One institution garnered more applicants who mentioned interest in research or global surgery (71.3% vs. 57.5%, P = .006; 17.7% vs. 4.4%, P < .0001, respectively), whereas the other attracted mention of clinical aspects and geographical ties (80.0% vs. 45.3%, P < .0001; 72.4% vs. 45.3%, P < .0001, respectively).

Conclusions: Our study suggests that applicants tailor program-specific paragraphs to the individual residency programs. These findings may aid programs and students in understanding the role of this new element of the application.

Level Of Evidence: 4 Laryngoscope, 2508-2513, 2018.
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November 2018

Endoscopic Lateral Cartilage Graft Tympanoplasty.

Otolaryngol Head Neck Surg 2017 10 6;157(4):683-689. Epub 2017 Jun 6.

1 Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA.

Objective To describe a novel technique for lateral graft tympanoplasty. Study Design Case series with chart review. Setting Tertiary care university hospital. Subjects and Methods Pediatric and adult patients with tympanic membrane perforations deemed unfavorable for a medial graft technique due to the perforation characteristics or myringitis. Results Between 2014 and 2016, 34 ears from 31 patients underwent a transcanal endoscopic lateral cartilage graft tympanoplasty. The mean age was 24.4 years (range, 6-71 years), and 22 patients (65%) were younger than 18 years. All patients had tympanic membrane perforations. Eighteen patients (53%) had total or near-total perforations, leaving a minimal anterior remnant, and 16 patients (47%) had extensive myringitis. A bisected tragal cartilage-perichondrium shield graft was used in 33 patients (97%). The mean (SD) follow-up length was 9.8 (5.7) months. Initial perforation closure rate was 88.2% (30/34). Three of the persistent perforations underwent a revision endoscopic medial graft tympanoplasty with successful closure, leaving a final closure rate of 97.1% (33/34). Five patients (15%) required topical therapy for postoperative myringitis. Mean (SD) pure-tone average and air-bone gap significantly improved by 11.5 (10.7) dB ( P < .001) and 11.4 (10.6) dB ( P < .001), respectively. Twenty-seven patients (79%) closed their air-bone gap within 20 dB. Conclusion Transcanal endoscopic lateral cartilage graft tympanoplasty is feasible, and initial data support favorable outcomes. Further data are necessary for evaluation of long-term results and efficacy comparisons.
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October 2017
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