Yarah M. Haidar

Smartphone-Enabled Otoscopy in Neurotology/Otology

Objective A smartphone-enabled otoscope (SEO) can capture tympanic membrane (TM) images. We sought to compare a SEO to microscopic otoscopy in the detection and evaluation of TM pathology in an otology/neurotology practice. Study Design Prospective single-site study in adults presenting over a 3-month period. Setting Neurotology clinic within a tertiary care academic medical center. Subjects and Methods Following consent, 57 patients underwent a medical and microscopic ear examination. Afterward, clinicians photographed bilateral TMs using a SEO. A second “blinded” neurotologist received a SEO-acquired image of each TM and a brief patient history. Our primary end point was identification of TM pathology (or lack thereof) and the blinded neurotologists’ corresponding diagnosis. Secondary end points included patient-reported SEO comfort levels. Results A single SEO-acquired TM image and brief patient history resulted in correct diagnosis of 96% (23/24) of normal TMs and identification of 100% (33/33) of microscope-confirmed abnormal TMs. When pathology was identified by the “blinded” physician, the diagnosis was identical to that made by the primary treating physician 82% (27/33) of the time. On patient surveys, 93% (53/57) of patients felt “very comfortable” with SEO utilization, and 88% (50/57) reported viewing acquired images was “very useful” in understanding their condition. Conclusion A SEO is 96% specific in identifying normal TMs and 100% sensitive in identifying pathology. Its 97% positive predictive value and small false-positive rate makes it a useful screening tool. Furthermore, patients are receptive to this technology and felt comfortable with its utilization in a health care or possible telemedicine setting.

Management of mal de debarquement syndrome as vestibular migraines

Mal de debarquement syndrome (MdDS) is a balance disorder that typically starts after an extended exposure to passive motion, such as a boat or plane ride. Management is typically supportive (e.g. physical therapy), and symptoms that persist beyond 6 months have been described as unlikely to remit. This study was conducted to evaluate the response of patients with MdDS to management with migraine prophylaxis, including lifestyle changes and medical therapy.

Postoperative Complications and Readmission Rates Following Surgery for Cerebellopontine Angle Schwannomas

Objective: To investigate the 30-day postoperative complication, readmission, and reoperation rates following surgery for cerebellopontine angle (CPA) schwannomas. Study Design: Cross-sectional analysis. Setting: National surgical quality improvement program dataset (NSQIP) 2009 through 2013. Patients: All surgical cases with an International Classification of Diseases, 9th edition, Clinical Modification (ICD-9-CM) diagnosis code of 225.1, benign neoplasms of cranial nerves, and one of the following current procedural terminology (CPT) codes, were included: 61616, 61526, 61530, and 61520. Intervention(s): Surgical resection as indicated by the CPT codes above. Main Outcome Measure(s): Demographics, comorbidities, 30-day postoperative complications, readmission rate, and reoperation rate. Results: Overall, 404 cases were identified, of which 42.6% were men. The average age was 51 years. Comorbidities were present in 45.3%. NSQIP-tracked complications occurred in 9.7% of patients. Most common complications were wound infections including surgical-site infection and wound dehiscence (11 patients, 2.7%), sepsis (10 patients, 2.5%), blood loss (nine patients, 2.2%), and deep vein thrombosis (DVT; seven patients, 1.7%). Mortality occurred in four patients (1.0%). The complication rate was statistically higher in patients with comorbidities versus those without (10.2% versus 4.1%, p = 0.04). Patients with complications were more likely to undergo reoperation (2.5% with versus 4.1% without, p = 0.001). Unplanned readmissions occurred in 41 cases (10.1%) and reoperations occurred in 23 patients (5.7%). Conclusions: Most common NSQIP-tracked complications in excision of CPA neoplasms are infections, sepsis, blood loss, and deep vein thrombosis (DVT). Further, investigation of patients with unplanned readmission and reoperation are warranted. Neurotologists need to take an active role in the data to be gathered in the NSQIP database as it relates to vestibular schwannomas.

Migraine-Related Aural Fullness: A Potential Clinical Entity

In this case series, we set out to describe the clinical entity of isolated, prolonged aural fullness (AF) and its relationship with migraine. Patients with isolated, persistent AF for 6 months or more were included with all possible etiologies ruled out. Migraine dietary and lifestyle changes and medical migraine prophylactic therapy were prescribed to all. Eleven patients were included (mean age, 52 years). Six (54%) patients fulfilled International Headache Society criteria for migraine with or without aura. Changes in perceived sensation of AF using the visual analog scale and quality of life questionnaires resulted in a statically significant improvement (P < .001, 95% confidence interval [CI], 4.7 to 6.72, and P < .001, 95% CI, −5.3 to −2.7, respectively). As such, an improvement of isolated, prolonged AF with migraine lifestyle changes and prophylactic treatment may suggest an etiological association between migraine and prolonged aural fullness.

Antibiotic prophylaxis in clean-contaminated head and neck cases with microvascular free flap reconstruction: A systematic review and meta-analysis

Optimal antibiotic prophylaxis duration in head and neck clean‐contaminated free‐flap cases is unknown.

The Role of In-Office Ultrasound in the Diagnosis of Neck Masses:

To evaluate the efficacy of otolaryngologist-performed in-office ultrasound (US) in the clinical assessment of lateral neck masses, we performed a retrospective review of patients with lateral neck masses who had both a surgeon-performed US and US-guided fine-needle aspiration (USGFNA) at our tertiary academic center from 2012 to 2015. Fifty-nine patients were included. USGFNA results included 32 (54%) malignant lesions, 23 (39%) benign lesions, and 4 (6%) nondiagnostic lesions. USGFNA demonstrated 85% accuracy. In 22 (37%) patients, in-office US revealed additional findings that were not identified on physical examination (eg, nonpalpable lymph nodes or elucidated anatomical structures), which either assisted in surgical planning or altered treatment. In-office US and USGFNA on initial evaluation by the otolaryngologist augment physical examination and have potential value as the primary imaging and diagnostic modality in the workup of lateral neck masses.

The Utility of In-Office Ultrasound in the Diagnosis of Parotid Lesions.

Objective To determine whether the use of in-office ultrasound (US) by a head and neck surgeon is a useful adjunct to clinical assessment of parotid lesions and decrease the need of additional imaging, such as magnetic resonance imaging (MRI) or computed tomography (CT). Study Design Case series with chart review. Setting Tertiary care academic center. Subjects Seventy patients presenting with a parotid lesion who obtained an in-office US and ultrasound-guided fine-needle aspiration (USGFNA) from a head and neck surgeon from 2006 to 2015. Methods US images were retrospectively reviewed for 70 patients and characterized by a radiologist and a head and neck surgeon. Results Of the 70 patients, 6 had US characteristics that demonstrated a statistically significant association with a benign/malignant diagnosis: depth from surface; irregular borders; presence of calcifications, which included either micro- or macro-calcifications; posterior echogenicity enhancement; irregular shape; and homogeneous/heterogeneous echotexture. Imaging was performed prior to referral in 25 cases (35.7%); of those, 17 (68%) were for superficial, small (<2 cm) tumors where prereferral imaging studies did not provide additional information to that obtained with US. Of the 55 patients without MRI or CT performed prior to referral, MRI or positron emission tomography–CT scan was obtained in only 4 patients (7.3%) in cases involving recurrent parotid lesions, large tumors, or workup of a malignant neoplasm. Conclusions Several US characteristics individually assist in lesion characterization. In-office US and USGFNA are an appropriate first-line modality in the assessment of parotid lesions, can allow for immediate parotid lesion assessment, and can decrease the need for additional imaging.

Price variation in the most commonly prescribed ear drops in Southern California

To evaluate the variability and discrepancies among the most commonly prescribed ear drops sold at pharmacies in southern California.

Association Between Electronic Medical Record Implementation and Otolaryngologist Productivity in the Ambulatory Setting

Importance In the current health care era, many medical practices are transitioning to a new electronic health record system. Until now, there has been little information published on the association between electronic medical record (EMR) use and otolaryngologist productivity in the ambulatory setting. Objective To examine the association between transitioning to an EMR system and physician productivity in otolaryngology. Design, Setting, and Participants Observational study at a tertiary care academic ambulatory center. Participants were 5 full-time otolaryngologists in practice, among whom a retrospective analysis of physician productivity was performed from May 5, 2013, through April 30, 2015. Main Outcomes and Measures We examined 5 practicing otolaryngologists for 24 months (12 months before and 12 months after transitioning to a new EMR system). Physician productivity was measured using the mean work relative value units (wRVUs) and the mean number of clinic visits. Each practitioner, with his wRVUs and clinic visit volume, was compared before and after implementation of the EMR system. The overall change in wRVUs and clinic visit volume was measured. The mean time spent after a full clinic day editing documentation before and after implementation of the EMR system for each practitioner was also recorded. Results Among all 5 practitioners (age range, 38-51 years), the monthly wRVUs decreased from a mean of 334 before EMR implementation to a mean of 284 after EMR implementation, with an absolute difference of 50 (95% CI, 6-85). The monthly clinic visit volume decreased from a mean of 132 to 121, with an absolute difference of 11 (95% CI, 0-18). When examined individually, only 1 physician had a significant decrease in wRVUs. The remainder of the physicians did not demonstrate a significant change in wRVUs or clinic visit volume. On average, the physicians spent 2.1 hours after clinic reviewing and editing documentation before the transition to the EMR system and 1.9 hours after the transition. Conclusions and Relevance Transitioning to an EMR system in an ambulatory otolaryngology tertiary care setting slightly decreased physician productivity as measured by wRVUs and clinic visit volume in the 12-month period after implementation in an incentivized compensation system.

Customized Versus Noncustomized Sound Therapy for Treatment of Tinnitus: A Randomized Crossover Clinical Trial

Objectives: To determine the effectiveness of a customized sound therapy and compare its effectiveness to that of masking with broadband noise. Methods: Subjects were randomized to receive either customized sound therapy or broadband noise for 2 hours per day for 3 months and then switched to the other treatment after a washout period. The outcome variables were tinnitus loudness (scored 0-10), Tinnitus Handicap Inventory (THI), Beck Anxiety Inventory (BAI), minimum masking levels (MML), and residual inhibition (RI). Results: Eighteen subjects completed the study. Mean age was 53 ± 11 years, and mean tinnitus duration was 118 ± 99 months. With customized sound therapy, mean loudness decreased from 6.4 ± 2.0 to 4.9 ± 1.9 (P = .001), mean THI decreased from 42.8 ± 21.6 to 31.5 ± 20.3 (P < .001), mean BAI decreased from 10.6 ± 10.9 to 8.3 ± 9.9 (P = .01), and MML decreased from 22.3 ± 11.6 dB SL to 17.2 ± 10.6 dB SL (P = .005). After 3 months of broadband noise therapy, only BAI and, to a lesser degree, MML decreased (P = .003 and .04, respectively). Conclusions: Customized sound therapy can decrease the loudness and THI scores of tinnitus patients, and the results may be superior to broadband noise.