Auditory Characteristics in Patients With Mucopolysaccharidosis Objective: The purpose of the study was to evaluate audiologic findings according to mucopolysaccharidosis (MPS) subtypes and to estimate hearing changes as the disease progressed, as well as the therapeutic effect of enzyme replacement therapy on the hearing apparatus. Methods: A total of 124 patients who were diagnosed with MPS between September 1994 and December 2016 were retrospectively analyzed. Play audiometry or pure-tone audiometry was performed for hearing assessment, and auditory brainstem response was conducted in patients with poor compliance. Results: In total 124 patients were identified, ranging in age at diagnosis from 0 to 33 years. Fourteen of the patients had been diagnosed with type I, while 91 had type II, 2 had type III, 14 had type IV, and 3 had type VI. Mean bone conduction and air conduction for the better ear were 26.13±16.95 dB and 34.77 ± 20.00 dB in all patients, and 34.20±7.64 dB and 40.70±9.67 dB in patients with MPS II. The average auditory brainstem response threshold was 68.96 ±21.93 dB nHL. The most common type of hearing loss was pure sensorineural hearing loss in all subtypes, and the degree of hearing loss was variable mostly within the mild to severe range. The increase in the hearing threshold was also significantly correlated with the disease duration. However, the change in hearing level was not correlated with the duration of enzyme replacement therapy. Conclusions: Hearing impairment in MPS patients is common and is aggravated as the disease progresses. Thus, adequate intervention and hearing rehabilitation might play an important role in managing hearing disabilities in MPS patients. Address correspondence and reprint requests to Il Joon Moon, M.D., Ph.D., Department of Otorhinolaryngology—Head and Neck Surgery, Sungkyunkwan University School of Medicine, Samsung Medical Center, 81 Irwon-ro, Gangnam-gu, 06351 Seoul, Korea; E-mail: iljoon.moon@samsung.com; Dong-Kyu Jin, M.D., Ph.D., Department of Pediatrics, Sungkyunkwan University School of Medicine, Samsung Medical Center, 81 Irwon-ro, Gangnam-gu, 06351 Seoul, Korea; E-mail: jindk@skku.edu I.J.M. and D.-K.J contributed equally to this study. The authors disclose no conflicts of interest. Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

Benign Paroxysmal Positional Vertigo in the Elderly: A Single-center Experience Objectives: Dizziness and balance problems are common in the elderly, and benign paroxysmal positional vertigo (BPPV) is one of the most common causes of dizziness. The aim of this study is to investigate the subtype distribution of geriatric BPPV in a single tertiary referral center, and compare the treatment efficacy according to the subtype of BPPV. Study Design: Retrospective study. Setting: Tertiary referral academic center. Patients: The consecutive 316 elderly patients diagnosed with BPPV between March 2013 and March 2019 were included. Main Outcome Measures: Using a head-roll and Dix-Hallpike tests, subtype of BPPV was determined. Once the diagnosis of BPPV was made, patients were treated by its corresponding canalith repositioning maneuver (CRM). Results: Among 316 elderly patients with BPPV, 143 patients (45%) were diagnosed with posterior semicircular canal BPPV, 46 patients (15%) were diagnosed with lateral semicircular canal (LSCC) canalolithiasis, 126 patients (40%) were diagnosed with LSCC cupulolithiasis, and 1 patient (0%) was diagnosed with anterior semicircular canal BPPV. While 66 and 63% of the patients with posterior semicircular canal BPPV and LSCC canalolithiasis recovered after one session of CRM, only 32% of the patients with LSCC cupulolithiasis recovered after one session of CRM. Conclusion: The proportion of LSCC cupulolithiasis was higher in the elderly, and treatment efficacy by CRM is lower in LSCC cupulolithiasis than other subtypes of BPPV. High prevalence of LSCC cupulolithiasis may be explained by a delay between onset of BPPV and patient's presentation to the tertiary referral hospital or pathophysiology of ageotropic positional nystagmus other than otoconial attachment on the LSCC cupula in the elderly. Address correspondence and reprint requests to Chang-Hee Kim, M.D., Ph.D., Department of Otorhinolaryngology—Head and Neck Surgery, Konkuk University Medical Center, Konkuk University School of Medicine, 120-1 Neungdong-ro (Hwayang-dong), Gwangjin-gu, Seoul 143-729, Republic of Korea; E-mail: ryomachang@gmail.com This article was supported by Konkuk University in 2019. The authors disclose no conflicts of interest. Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

Long-term Outcomes in Down Syndrome Children After Cochlear Implantation: Particular Issues and Considerations Objective: The aim of the study was to analyze the long-term outcomes after cochlear implantation in deaf children with Down syndrome (DS) regarding age at the first implantation and refer the results to preoperative radiological findings as well as postoperative auditory and speech performance. Additionally, the influence of the age at implantation and duration of CI use on postoperative hearing and language skills were closely analyzed in children with DS. Study Design: Retrospective analysis. Setting: Referral center (Cochlear Implant Center). Materials and Methods: Nine children with Down syndrome were compared with 220 pediatric patients without additional mental disorders or genetic mutations. Patients were divided into four categories depending on the age of the first implantation: CAT1 (0–3 yr), CAT2 (4–5 yr), CAT3 (6–7 yr), and CAT4 (8–17 yr). The auditory performance was assessed with the meaningful auditory integration scales (MAIS) and categories of auditory performance (CAP) scales. The speech and language development were further evaluated with meaningful use of speech scale (MUSS) and speech intelligibility rating (SIR). The postoperative speech skills were analyzed and compared between the study group and the reference group by using nonparametric statistical tests. Anatomic abnormalities of the inner ear were examined using magnetic resonance imaging (MRI) and high-resolution computed tomography of the temporal bones (HRCT). Results: The mean follow-up time was 14.9 years (range, 13.1–18.3 yr). Patients with DS received a multichannel implant at a mean age of 75.3 months (SD 27.9; ranging from 21 to 127 mo) and 220 non-syndromic children from reference group at a mean age of 51.4 months (SD 34.2; ranging from 9 to 167 mo). The intraoperative neural response was present in all cases. The auditory and speech performance improved in each DS child. The postoperative mean CAP and SIR scores were 4.4 (SD 0.8) and 3.2 (SD 0.6), respectively. The average of scores in MUSS and MAIS/IT-MAIS scales was 59.8% (SD 0.1) and 76.9% (SD 0.1), respectively. Gathered data indicates that children with DS implanted with CI at a younger age (<6 years of age) benefited from the CI more than children implanted later in life, similarly in a control group. There were additional anomalies of the temporal bone, external, middle, or inner ear observed in 90% of DS children, basing on MRI or HRCT. Conclusions: The early cochlear implantation in children with DS is a similarly useful method in treating severe to profound sensorineural hearing loss (SNHL) as in non-syndromic patients, although the development of speech skills present differently. Due to a higher prevalence of ear and temporal bone malformations, detailed diagnostic imaging should be taken into account before the CI qualification. Better postoperative outcomes may be achieved through comprehensive care from parents/guardians and speech therapists thanks to intensive and systematic rehabilitation. Address correspondence and reprint requests to Pedro Clarós, M.D., Ph.D., Clarós Clinic, c./Vergós 31, 08017 Barcelona, Spain; E-mail: clinica@clinicaclaros.com The authors report no potential conflict of interest. The authors report no financial and material support for the research and the work in the manuscript. The principal investigator of the research, Pedro Clarós (M.D. Ph.D.), states that he had full access to all data in the study and takes responsibility for the integrity of the data and accuracy of the data analysis. In their research three authors, i.e., Pedro Clarós (M.D. Ph.D.; Clarós Clinic, Cochlear Implant Center, Barcelona, Spain), Agnieszka Remjasz (M.D.; Clarós Clinic, Cochlear Implant Center, Barcelona, Spain; Department of Otorhinolaryngology at Stefan Zeromski Specialist Hospital, Cracow, Poland), and Andrzej Wiatrow (M.Sc.; Institute of Psychology Polish Academy of Sciences, Warsaw, Poland), conducted and were responsible for the data analysis. ORCID iD for P. Clarós: 0000-0002-7567-0370. ORCID iD for A. Clarós: 0000-0001-6084-3470. ORCID iD for A. Clarós-Pujol: 0000-0002-9288-8849. Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

NF2-Related Intravestibular Schwannomas: Long-Term Outcomes of Cochlear Implantation Objective: Intravestibular schwannomas (IVS) are uncommon tumors in Neurofibromatosis type 2 (NF2) and are mainly associated with multiple internal auditory meatus (IAM) and cerebellopontine angle (CPA) tumors. They usually induce profound hearing loss which can be rehabilitated by cochlear implantation (CI). The aim of this study was to analyze the long-term outcomes of CI during the unpredictable evolution of NF2 disease. Study Design: Retrospective case review. Setting: Tertiary referral center. Patients: Three adults with neurofibromatosis type 2 and intravestibular schwannomas, and who were cochlear implant recipients. Interventions: Periodic radiologic follow-up, tumor resection, and hearing rehabilitation. Main Outcome Measures: Audiological evolution, tumor evolution, surgical outcome, cochlear implant outcome. Results: Three NF2 patients (mean age at diagnosis, 26.3 ± 3.2 yr) were identified with IVS in the period between 2000 and 2017. IVS were first observed by serial MRI and profound hearing loss occurred in this ear after 4 ± 1.5 years of follow-up. IVS were removed via a translabyrinthine approach, and ipsilateral cochlear implantations were simultaneously performed. In two patients, large contralateral CPA tumors had previously been removed without hearing preservation, whereas in the third patient, a small, growing contralateral VS was excised via a retrosigmoid approach 6 months after IVS removal/cochlear implantation with serviceable hearing preservation. In all cases, CI provided good hearing outcomes. In two cases, hearing outcomes were even better for more than 5 years when ipsilateral intracanalicular vestibular schwannomas were removed in either the same or subsequent procedures. Conclusions: Rehabilitation of hearing with CI provides a favorable long-term outcome in patients with NF2-related IVS which could be altered by the occurrence of other intracanalicular and/or CPA NF2-related tumors. Address correspondence and reprint requests to Olivier Sterkers, M.D., Ph.D., GH Pitié-Salpêtrière, Service d’Otologie, Implants Auditifs et Chirurgie de la base du Crâne, Bâtiment Castaigne, 47-83 Boulevard de l’Hôpital, 75651 Paris cedex 13, France; E-mail: olivier.sterkers@aphp.fr; Hao Wu, M.D., Ph.D., Department of Otolaryngology–Head and Neck Surgery, Shanghai Ninth People's Hospital, No 639 Zhizaoju Road, Shanghai 200011, China; E-mail: wuhao622@sina.cn The authors from China were supported by the projects of the National Natural Science Foundation of China (81200742) and the Shanghai Scientific and Technological Innovation Action Plan (17441903600) in this study. The authors disclose no conflicts of interest. Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

Recidivism After Endoscopic Treatment of Cholesteatoma Objective: To investigate the recidivism rate of cholesteatoma treated via endoscopic ear surgery (EES), either via transcanal endoscopic ear surgery or endoscopic assisted tympanomastoidectomy compared with a microscopic postauricular approach. Study Design: Retrospective chart review. Setting: Academic otology practice. Patients: Adult patients (18 years and older) with at least 11 months of surgical follow-up who were treated for cholesteatoma via endoscopic techniques or microscopic postauricular approach. Intervention: Use of the endoscope for cholesteatoma dissection. Main Outcome Measure: Residual or recurrent cholesteatoma identified at second look surgery or postoperative diffusion-weighted magnetic resonance imaging. Results: Fifty-nine patients treated for cholesteatoma via endoscopic techniques and 35 patients treated via microscopic postauricular approach were analyzed. The endoscopic group required significantly fewer mastoid procedures (28% versus 80%, p-value 0.001). Postoperative changes in median ABG (5 dB versus 3.75 dB, p = 0.9519), median PTA (6.875 dB versus 1.25 dB, p = 0.3864), and median word recognition score (0% versus 0%, p = 0.3302) were not significantly different between the EES and microscopic surgery groups. Median operative times were not significantly different between the two groups (182 min endoscopic versus 174 min microscopic, p-value 0.66). The rate of residual disease (17% EES versus 17% microscopic, p = 0.959) or disease recurrence (18% endoscopic versus 20% microscopic, p = 0.816) were not significantly different between the two groups. Conclusions: EES is an effective option for cholesteatoma management with similar rates of recurrent or residual disease as compared with the more traditional microscopic postauricular approach in these samples. Address correspondence and reprint requests to Brandon Isaacson, M.D., F.A.C.S., Department of Otolaryngology–Head and Neck Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-9035; E-mail: Brandon.Isaacson@utsouthwestern.edu IRB: This project was approved and in compliance with University of Texas Southwestern Medical Center IRB STU 012013-017. Authorship participation: Study design: D.E.K., A.M.T., B.I., Y.F.K. Data acquisition: D.E.K., A.M.T. Data Analysis: D.E.K., A.M.T., B.I. Manuscript drafting: D.E.K., A.M.T., B.I. Critical Revisions: D.E.K., A.M.T., B.I., J.W.K. Funding: None. The authors have no conflicts of interest to disclose. Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

Mortality and Cause of Death in Hearing Loss Participants: A Longitudinal Follow-up Study Using a National Sample Cohort Objective: The purpose of the present study was to estimate the risk of mortality in hearing loss subjects in accordance with the cause of death. Study Design: A longitudinal follow up study. Setting: Data from the Korean National Health Insurance Service-National Sample Cohort were collected from a period between 2002 and 2013. Patients and Intervention: The 4,606 severe and 1,007 profound hearing loss participants with 40 or more years old were 1:4 matched with control participants, respectively, for age, sex, income, and region of residence. The causes of death were grouped into 12 classifications. Main Outcome Measures: The ratio of mortality was compared between the hearing loss and control group using a χ2 test or Fisher's exact test. In a Cox-proportional hazard model, age, sex, income, region of residence, and past medical histories were considered confounders. Results: The severe and profound hearing loss groups showed 4.07 (95% CI = 3.71–4.46, p < 0.001) and 4.22 times (95% CI = 3.52–5.05, p < 0.001) higher mortality ratios in the adjusted models, respectively. Both the severe and profound hearing loss groups showed higher mortality by infection, neoplasm, trauma, and metabolic, mental, circulatory, respiratory, and digestive diseases than control groups (p < 0.05). Among various causes of death, death by trauma revealed the highest odds ratios in both the severe and profound hearing loss groups. Conclusion: Hearing loss was associated with a significant increase in mortality. Address correspondence and reprint requests to Hyo Geun Choi, M.D., Department of Otorhinolaryngology–Head & Neck Surgery, Hallym University Sacred Heart Hospital, 22, Gwanpyeong-ro 170beon-gil, Dongan-gu, Anyang-si, Gyeonggi-do, 14068, Republic of Korea; E-mail: pupen@naver.com This work was supported in part by a research grant (NRF-2016M3A9E8941669 and NRF-2018-R1D1A1A02085328) from the National Research Foundation (NRF) of Korea. The authors disclose no conflicts of interest. Supplemental digital content is available in the text. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (http://journals.lww.com/otology-neurotology). Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

Rate of Initial Hearing Loss During Early Observation Predicts Time to Non-Serviceable Hearing in Patients With Conservatively Managed Sporadic Vestibular Schwannoma Objective: To date, prediction models for estimating risk of acquiring non-serviceable hearing in subjects with observed vestibular schwannoma (VS) have evaluated outcomes primarily based on features at initial diagnosis. Herein, we evaluate the association of rate of hearing decline during the initial period of observation with time to non-serviceable hearing. If significant, rate of hearing decline may inform decision making after an introductory period of observation. Setting: Two tertiary care centers. Patients: VS patients with serviceable hearing who underwent at least three audiograms and two magnetic resonance imaging (MRI) studies before intervention or being lost to follow-up. The rate of change in pure-tone average (PTA) and word recognition score (WRS) was calculated as the score from the second audiogram minus the score from the first audiogram, divided by the duration in months between the two. Main Outcome Measure(s): Serviceable hearing, defined as PTA ≤50 dB HL and WRS ≥50%. Results: Among 266 patients meeting inclusion criteria, 52 developed non-serviceable hearing at last follow-up. Kaplan–Meier estimated rates of maintaining serviceable hearing (95% CI; number still at risk) at 1, 3, 5, 7, and 10 years were 97% (95–100; 206), 78% (72–85; 98), 68% (60–77; 39), 60% (50–73; 17), and 44% (29–67; 2), respectively. In a univariable setting, each 1 dB increase per month in the rate of initial PTA change was associated with a 96% increased likelihood of acquiring non-serviceable hearing (hazard ratio [HR] 1.96; 95% CI 1.44–2.68; p < 0.001). Each 1% increase per month in the rate of initial WRS change was associated with a decreased likelihood of acquiring non-serviceable hearing (hazard ratio [HR] 0.79; 95% confidence interval [CI] 0.66–0.94; p = 0.009). After multivariable adjustment, both rate of PTA change (HR 2.42; 95% CI 1.72–3.41; p < 0.001) and rate of WRS change (HR 0.81; 95% CI 0.67–0.99; p = 0.043) remained statistically significantly associated with time to non-serviceable hearing. Conclusion: Rate of early PTA and WRS decline during the initial period of observation are significantly associated with time to development of non-serviceable hearing. This information may facilitate accurate patient counseling and inform decision-making regarding prospective disease management. Address correspondence and reprint requests to Matthew L. Carlson, M.D., Department of Otolaryngology–Head and Neck Surgery, Mayo Clinic, 200 1st St SW, Rochester, MN 55905; E-mail: carlson.matthew@mayo.edu Presented at: American Neurotology Society, 54th Annual Spring Meeting, 2018 Combined Triological Spring Meeting (COSM); May 4th, Austin, Texas. Internal departmental funding was used without commercial sponsorship or support. Colin L. Driscoll is a consultant for Advanced Bionics, Cochlear Corporation and Envoy Medical. Institutional review board approval: 151481 and 15-008224 Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

Obesity Is Not Associated With Postoperative Complications After Vestibular Schwannoma Surgery in a Large Single Institution Series Objective: Determine whether elevated body mass index (BMI) is associated with postoperative complications after vestibular schwannoma (VS) surgery. Study Design: Retrospective case series. Setting: Tertiary referral center. Patients: Two hundred six patients undergoing surgery for VS between 2010 and 2017, grouped into obese and nonobese patients. Intervention: Surgery for VS resection. Main Outcome Measures: Postoperative facial nerve outcomes, length of hospital stay, presence of postoperative cerebrospinal fluid leak, 30-day readmission, return to the operating room, wound complications, cardiovascular and thromboembolic complications. Results: After excluding 1 patient for missing BMI, our cohort included 205 patients. Seventy-nine patients (38.5%) were obese (mean BMI 36.2 kg/m2, range 30–55.1) and the remaining 126 (61.5%) were nonobese (mean BMI 25.0, range 18.8–29.8 kg/m2). Compared with nonobese patients, obesity was not associated with postoperative cerebrospinal fluid leak (OR 1.1, 95% CI 0.93–1.1), length of hospital stay (OR 0.98, 95% CI 0.65–1.47), 30-day readmission rates (1.04, 95% CI 0.95–1.14), return to operating room (OR 1.05, 95% CI 0.98–1.11), or other wound-related complications (OR 0.99, 95% CI 0.94–1.04). Conclusion: In this cohort, elevated BMI was not associated with an increased risk for postoperative complications after VS surgery. Our findings may mitigate concerns associated with surgical management of VS in obese patients. Address correspondence and reprint requests to Noga Lipschitz, M.D., Department of Otolaryngology – Head and Neck Surgery, University of Cincinnati College of Medicine, 213 Albert Sabin Way, MSB 6315, Cincinnati, OH 45267-0528; E-mail: lipschna@ucmail.uc.edu Dr R.N.S. received research support and honoraria from Cochlear Corporation. The authors disclose no conflicts of interest. Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

Evaluation of Cochlear Duct Length Measurements From a 3D Analytical Cochlear Model Using Synchrotron Radiation Phase-Contrast Imaging Hypothesis: Evaluating the accuracy of cochlear duct length (CDL) measurements from a published three-dimensional (3D) analytical cochlear model using Synchrotron Radiation Phase–Contrast Imaging (SR-PCI) data will help determine its clinical applicability and allow for model adjustments to increase accuracy. Background: Accurate CDL determination can aid in cochlear implant sizing for full coverage and frequency map programming, which has the potential to improve hearing outcomes in patients. To overcome problems with the currently available techniques for CDL determination, a novel 3D analytical cochlear model, dependent on four basal turn distances, was proposed in the literature. Methods: SR-PCI data from 11 cadaveric human cochleae were used to obtain reference measurements. CDL values generated by the analytical cochlear model were evaluated in two conditions: when the number of cochlear turns (NCT) were automatically predicted based on the four input distances, and when the NCT were manually specified based on SR-PCI data. Results: When the analytical cochlear model automatically predicted the NCT, the mean absolute error was 2.6 ± 1.6 mm, with only 27% (3/11) of the samples having an error in the clinically acceptable range of ±1.5 mm. When the NCT were manually specified based on SR-PCI data, the mean absolute error was reduced to 1.0 ± 0.6 mm, with 73% (8/11) of the samples having a clinically acceptable error. Conclusion: The 3D analytical cochlear model introduced in the literature is effective at modeling the 3D geometry of individual cochleae, however tuning in the NCT estimation is required. Address correspondence and reprint requests to Luke W. Helpard, B.E.Sc., School of Biomedical Engineering, Western University, 1151 Richmond St, London, ON N6A 5B7, Canada; E-mail: lhelpard@uwo.ca This work was supported by a Natural Sciences and Engineering Research Council of Canada (NSERC), Canada Graduate Scholarship-Masters, and a NSERC Discovery grant. Part of the research described in this paper was performed at the Canadian Light Source, which is supported by the Canada Foundation for Innovation, NSERC, the University of Saskatchewan, the Government of Saskatchewan, Western Economic Diversification Canada, the National Research Council Canada, and the Canadian Institutes of Health Research. The authors disclose no conflicts of interest. Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

Horizontal Vestibulo-Ocular Reflex Gain Measures During Convergence Using a Monocular Video Technique Hypothesis: Vestibulo-ocular reflex (VOR) response measures during convergence, which are clinically important to measure peripheral vestibular organ function during rotational and translational rapid head movements, can be implemented using existing clinically available monocular video-oculography (VOG) systems. Background: We have developed and validated a monocular VOG technique that allows for accurate measurement of the convergence angle immediately before a rapid translational or rotational head movement. Methods: We recorded binocular eye movements while subjects performed active or passive horizontal head impulses while viewing near and far targets. We calculated the convergence angles and VOR gains using monocular and binocular methods and compared them with a geometric model. Results: The monocular VOG technique resulted in convergence angle and VOR gain (eye velocity/head velocity) calculations that differed by ∼10% compared with values calculated using the binocular data. Conclusions: The monocular VOG technique can be clinically implemented using any unmodified, commercially available, monocular VOG system, provided its camera can be positioned to track either eye. Many vestibular clinics already have access to such systems. This method makes possible reliable measurement of the near-viewing horizontal angular VOR during the head impulse test, the translational VOR during the head heave test in patients, and the clinical measurement of convergence insufficiency. Address correspondence and reprint requests to Americo A. Migliaccio, Ph.D., Balance and Vision Laboratory, Neuroscience Research Australia, Cnr Barker Street & Easy Street Randwick 2031, Australia; E-mail: a.migliaccio@neura.edu.au A.A.M. was supported by The Garnett Passe and Rodney Williams Memorial Foundation Senior/Principal Research Fellowship in Otorhinolaryngology. M.C.S. was supported by Department of Defence Grant W81XWH-18-2-0075. The authors disclose no conflicts of interest. Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company