Purpose of review

This review briefly covers the history of stapedectomy, discusses the indications and problems encountered with revision surgery, and provides case examples with solutions.

Recent findings

Revision surgery is challenging and successful outcome even in the most experienced specialists is 45-71%, which is far less than that of primary surgery.

Summary

Careful evaluation of the reasons for reoperation, anticipation of the common problems, and patient education on reasonable expectations are all very important for success.

Objective

AIED (autoimmune inner ear disease) is an autoimmune process that leads to the dysfunction of the inner ear, resulting in fluctuating, audiovestibular symptoms. Although the pathogenesis is likely heterogeneous, immune processes within the inner ear ultimately lead to histopathologic changes and sensorineural hearing loss. This review will discuss the latest evidence on treatment options.

Methods

A literature search on articles pertaining to the treatment of autoimmune inner ear disease was performed on PubMed.

Results

Corticosteroid treatment continues to remain as first line therapy for AIED but long-term responsiveness is poor. Cytotoxic chemotherapies can be effective alternatives for steroid nonresponsive patients, but significant side effects may limit their use. Intratympanic steroid injections are beneficial and although there is not enough evidence currently to supplant oral steroid trial they may be a useful adjunct if steroid toxicity is an issue. The efficacy of biologic agents has been variable. Compared to placebo, etanercept does not improve the hearing improvement already attained by steroids alone. However, open pilot studies of other biologic agents show hearing improvements, improvements in tinnitus/aural fullness/vertigo, ability to wean steroid dependency, or benefits in steroid-resistant AIED.

Conclusion

There is currently not enough evidence that alternative treatments supersede the use of initial steroid treatment. Biologic agents and intratympanic steroid injections are relatively well tolerated and should be considered as adjunctive therapy. More studies on the efficacy of various biologics and more studies on the treatment of steroid resistant disease especially after initial benefit are still needed. For those who eventually lose their hearing, cochlear implantation remains as a viable option.

Level of evidence

expert opinion.

Objectives/hypothesis

To better understand the obstacles facing residents and K-awardee faculty in choosing a clinician-scientist career in otolaryngology.

Study design

Anonymous survey.

Methods

An anonymous, online Qualtrics survey was sent to residents participating in T32 training grants and K-awardee junior faculty. The survey was sent to the residents with the permission of their program chair. The results of this survey were compiled and analyzed. A separate survey was sent to current K-awardees in U.S. academic programs. Both surveys were then compared to a survey published in 2008 to determine if the concerns and obstacles faced by aspiring clinician-scientists are still present.

Results

Residents felt that combining a research and clinical career presented many obstacles, including a lower salary, competition with PhDs for grant funding, and the lack of departmental support. Prolonging their training to include a fellowship was not a deterrent. Family/spousal issues which ranked as the primary concern previously were no longer given the same level of importance. The major concerns of K-awardees were the economic disparity of clinician-scientists with their clinical counterparts, the lack of mentors, and department support. Forty percent received their K-award after first try, 100% after two revisions, and one has received an R grant funding.

Conclusions

The obstacles facing clinician-scientists in otolaryngology are highlighted by this survey and require attention by our academic programs, National Institutes of Health, and specialty societies.

Level of evidence

NA Laryngoscope, 132:1555-1560, 2022.

Objective

Recent data regarding the incidence of sudden sensorineural hearing loss (SSNHL) in the United States is lacking. The objective of this study was to assess the current day incidence of SSNHL in the United States using data from a medical and pharmaceutical claims database containing information for more than 60 million unique patients.

Study design

Population-based cross-sectional analysis.

Setting

Inpatient and outpatient.

Patients

Patients in the database are reported to be representative of the national, commercially insured population on a variety of demographic measures including age, sex, health plan type, and geographic location.

Results

During 2006 and 2007, the annual incidence of SSNHL was 27 per 100,000 in the United States. The incidence increased with increasing age, ranging from 11 per 100,000 for patients younger than 18 years to 77 per 100,000 for patients 65 years and older. There was an overall slight male preponderance with a male-to-female ratio of 1.07:1. This was more pronounced in patients 65 years and older, with a ratio of 1.30:1.

Conclusion

More than 66,000 new cases of SSNHL are seen annually in the United States. The disorder is more common in men and the elderly.

Importance

Otosclerosis can be managed through surgical treatment, such as stapedectomy, or through hearing amplification with hearing aids. To our knowledge, there has been no cost-effectiveness analysis of these 2 treatment methods.

Objective

To determine the cost-effectiveness of stapedectomy vs hearing aid use for the treatment of otosclerosis.

Design and setting

In this cost-effectiveness analysis, a decision tree was built to model the treatment choices for otosclerosis. The tree was run as a Markov model of a case patient aged 30 years. The model spanned the patient's lifetime to determine total costs of management of otosclerosis with stapedectomy or hearing aids. Cost-effectiveness was measured using an incremental cost-effectiveness ratio, with a willingness to pay of $50 000 per quality-adjusted life-year (QALY) considered cost-effective. One-way sensitivity analyses were performed for all variables. A 2-way sensitivity analysis was performed for the cost of stapedectomy vs the cost of hearing aids. Probabilistic sensitivity analysis was performed to determine the likelihood that stapedectomy would be cost-effective across a range of model inputs.

Interventions

Stapedectomy vs hearing aid use.

Main outcomes and measures

The primary objective of this study was to determine the cost-effectiveness of stapedectomy vs hearing aids in the treatment of otosclerosis. The secondary objectives were to determine which factors are associated with the cost-effectiveness of the interventions.

Results

Stapedectomy had an estimated lifetime cost of $19 417.95, while hearing aids had an average lifetime cost of $16 439.94. Stapedectomy also had a benefit of 16.58 QALYs, and hearing aids had a benefit of 15.82 QALYs. Stapedectomy increases lifetime costs by $2978.01, with a benefit of 0.76 QALYs compared with hearing aids. The incremental cost-effectiveness ratio for stapedectomy is $3918.43 per QALY. The model was sensitive to the cost of stapedectomy and the cost of stapedectomy revision surgery. Probabilistic sensitivity analysis showed that stapedectomy was cost-effective compared with hearing aids 99.98% of the time.

Conclusions and relevance

Stapedectomy appears to be a cost-effective option for treating otosclerosis compared with hearing aid use, from the patient perspective.

Tophaceous gout of the middle ear is a rare occurrence that presents as a granular white-colored mass. It is frequently misdiagnosed as cholesteatoma or tympanosclerosis in patients who otherwise may not manifest any clinical or biochemical signs of gout. While uncommon, it can lead to clinically significant disease such as conductive hearing loss. The present report describes 2 cases of middle ear gouty tophi initially mistaken for another entity. Both patients underwent surgery, and the diagnosis of gout was revealed after final histopathological analysis. A review of the literature is also presented.

Purpose of review

Systemic corticosteroids have been the mainstay of treatment of idiopathic sudden sensorineural hearing loss (ISSNHL) for over 30 years. Recently, intratympanic steroids have risen in popularity; however, there is no consensus regarding the details of their application. The purpose of this article is to review the current literature and share our opinion that intratympanic dexamethasone (alone or with systemic steroids) should be offered as primary treatment of ISSNHL.

Recent findings

Intratympanic steroids have been shown to result in higher inner ear concentrations than systemic steroids in animal and human studies. Primary treatment of ISSNHL with intratympanic steroids in combination with systemic steroids has been demonstrated to result in better hearing outcomes than systemic steroids alone. Recent evidence has revealed these hearing outcomes to be dependent on the dose of intratympanic steroid. Dexamethasone may be better absorbed than methylprednisolone, and potentially offer a greater benefit. Furthermore, intratympanic steroids provide an effective alternative for patients who cannot tolerate systemic steroids.

Summary

Intratympanic dexamethasone alone, or in combination with systemic steroids, provides effective treatment of ISSNHL and should be utilized as primary treatment. Further investigation is required to determine the optimal choice, concentration, and administration schedule of intratympanic steroids.

Objective

Otogenic brain abscess is a well-recognized clinical condition that describes brain abscess secondary to an ear infection or mastoiditis. Current evidence remains limited on risk factors associated with mortality as most data are from case series. We aimed to 1) report the mortality rate among patients who did and did not receive mastoidectomy 2) identify factors associated with inpatient mortality.

Study design

Retrospective cohort study.

Setting

Multi-institutional.

Patients

We identified a cohort of patients for years 2008 to 2014 who in their inpatient hospitalization carried the diagnoses of both brain abscess and infectious ear disease.

Interventions

Inpatient neurotology and neurosurgical procedures.

Main outcome measures

A multivariable logistics regression model was built to identify the factors associated with inpatient mortality.

Results

The final analysis included 252 patients, of which 84 (33.3%) underwent mastoidectomy. The rate of inpatient morbidity and mortality were 17.5% and 4.0%, respectively. The rate of mortality in patients without mastoidectomy versus those with mastoidectomy was 4.2% versus 3.6%, respectively (p > 0.99). The odds of inpatient mortality were significantly increased for every 10-year increase in age (odds ratio [OR] 2.73, 95% confidence interval [CI]: 1.39-7.01, p = 0.011) and for Black compared to White patients (OR: 45.81, 95% CI: 4.56-890.92, p = 0.003).

Conclusion

Older age and Black race were associated with increased odds of inpatient mortality and there were no significant differences in mortality between mastoidectomy cohorts. This research serves to generate further hypotheses for larger observational studies to investigate the association between sociodemographic factors and surgical variables with outcomes among this surgical population.

Objective

We describe three rare cases of spontaneous intracranial hypotension (SIH) presenting with symptoms of endolymphatic hydrops (EH) and perform a literature review to bring attention to a rare link between SIH and EH.

Patient

A 59-year-old female presented with postural headache, aural fullness, vertigo, hearing loss, and abnormal electrocochleography after being diagnosed with SIH by magnetic resonance imaging. The site of cerebrospinal fluid leak was identified in this individual. Two additional patients with vertigo, hearing loss, and SIH were identified by retrospective chart review.

Intervention

All patients underwent blood patches. One patient also had diuretic treatment while another had fibrin glue injection.

Main outcome measures

The outcomes of interest were resolution of headache, vertigo, aural fullness, and hearing loss.

Results

All patients eventually improved with time. Literature review suggests that overall outcome is excellent.

Conclusions

SIH may be an under-recognized cause of EH. We support the theory that negative intracranial pressure transmitted through the cochlear aqueduct and perilymph leads to EH. Despite the variations in treatments, the overall prognosis is excellent.