Predictors of Distant Metastasis and Survival in Adenoid Cystic Carcinoma of the External Auditory Canal Objective: To analyze the predictors of both distant metastasis and survival in patients with adenoid cystic carcinoma of the external auditory canal. Study Design: Retrospective patient review. Setting: A single university hospital. Patients: Eighty-two cases with adenoid cystic carcinoma of the external auditory canal were referred to our institution between 2004 and 2016. Main Outcome Measures: Distant metastasis was detected by lung computed tomography, proton emission tomography computed tomography, or histopathologic examination of tissue samples. Distant metastasis predictors were analyzed using Student's t tests and χ2 tests. The log-rank tests of Kaplan–Meier survival curves were used to evaluate survival differences. Results: During a median follow-up of 36 months (range, 6–162 mo), distant metastasis developed in 25 patients. The occurrence of distant metastasis was significantly associated with histopathologic subtype, T classification, and local recurrence (p < 0.05). The 1-, 10-, 20-, and 25-year cumulative survival rates in the patents with DM were 95.7, 95.7, 71.7, and 0%, respectively, and all survival rates were 100% for the 57 patients without distant metastasis (p = 0.115). Median survival time after occurrence of distant metastasis was 13 months (range, 1–120 mo). Prognosis was better with solely lung metastasis than with metastases to other visceral organs or bone (p < 0.05). Conclusions: Distant metastasis appeared to result in a poorer prognosis, occurrence of distant metastasis was significantly associated with local recurrence, extensive surgery is recommended to achieve local control and reduce distant metastasis risk. Routine follow-up investigations for detecting distant metastasis are warranted for patients with an increased risk for distant metastasis. Address correspondence and reprint requests to Chunfu Dai, M.D., Ph.D., 83 Fenyang Road, Shanghai, 200031, P.R. China; E-mail: cfdai66@126.com Y.Z. and H.L have contributed equally to this work. The authors disclose no conflicts of interest. Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

Reducing Postoperative Call Volume Through Verbal Preoperative Education Objective: To improve patient satisfaction and understanding of what to expect after chronic ear surgery and reduce call volume to an otology clinic at an academic tertiary referral center. Study Design: Quality improvement initiative. Setting: A single-academic tertiary referral center. Patients: One hundred and ten patients who underwent chronic ear surgery in March to May 2018. Intervention: Preoperative counseling over the phone 1 week before surgery. Main Outcome Measures: Patient call volume to the clinic within a 2-week postoperative window, patient understanding, and satisfaction of perioperative course. Results: There was a significant increase in patient satisfaction (10.1% increase, 9.8 intervention vs. 8.9 no intervention, p = 0.0032) and in patient understanding of what to expect after surgery (6.7% increase, 9.5 intervention vs. 8.9 no intervention, p = 0.0275). There was a significant decrease in mean number of calls per patient to the clinic (57.6% decrease, 0.31 intervention vs. 0.72 no intervention, p = 0.0105) and in percentage of patients who made any number of calls to the clinic (20% intervention vs. 46%, no intervention, p = 0.00438). Conclusions: Verbal preoperative counseling over the phone was effective in significantly reducing unnecessary call volume to the clinic and in improving patient satisfaction and overall understanding of what to expect after surgery. Address correspondence and reprint requests to Marc L. Bennett, M.D., Department of Otolaryngology-Head and Neck Surgery, The Vanderbilt Bill Wilkerson Center for Otolaryngology & Communication Sciences, 7209 Medical Center East, South Tower 1215 21st Avenue South, Nashville, TN 37232-8605; E-mail: marc.bennett@vanderbilt.edu; Alexander Chern, M.D., Department of Otolaryngology-Head and Neck Surgery, Columbia University Irving Medical Center, 180 Ft. Washington Ave, 8th Floor, New York, NY 10032; E-mail: alc9230@nyp.org Internal departmental funding was utilized without commercial sponsorship or support. Institutional review board approval: N/A (quality improvement study). 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

Comparison of Opioid Prescription Patterns and Consumption Following Otologic Surgery Objective: To examine opioid prescribing patterns and consumption among patients undergoing common otologic surgeries. Study Design: Retrospective cohort study with chart review and telephone survey. Setting: Tertiary academic medical center. Methods: Retrospective chart review and telephone survey of those undergoing tympanoplasty, tympanomastoidectomy, stapedectomy, and cochlear implantation in 2018. The survey consisted of questions regarding the details of the number of pills taken, duration of opioid use, subjective pain control, the use of over-the-counter pain medications, opioid disposal, and their history of substance abuse. Results: Sixty-one patients were able to be contacted and agreed to participate in the study. Fifty-nine (96.7%) stated that their pain was controlled, and 10 (16.4%) did not take any opioids postoperatively despite their prescription. The mean morphine milligram equivalent (MME) prescribed was 99.9 (44.3) and MME taken was 45.2 (SD 46.3) (p < 0.001). Similarly, the mean number of pills prescribed was 17.8 (SD 8.6) and mean taken was 7.9 (SD 8.3) (p < 0.001). Comparison between males and females regarding MME and pills prescribed and taken were not statistically significantly different (p > 0.05). Analysis of the MME and pills prescribed and taken among the different surgeries (tympanoplasty, stapes surgery, tympanomastoidectomy, and cochlear implantation) revealed no statistically significant interactions (p > 0.05). Pain control was achieved for 50% of patients with 5 pills (MME = 25 mg), for 75% with 12 pills (MME = 60 mg), and for 90% with 24 pills (MME = 135 mg). Conclusion: The opioid epidemic continues to be an ongoing issue in the United States, and prescription opioid abuse is a large contributor. There is increasing literature to suggest a practice of overprescribing in multiple surgical specialties. This same finding appears to be present in common otologic surgeries, where on average patients took less than half of the prescribed MME/pills, and 75% of patients had their pain controlled with 12 pills or fewer. Otolaryngologists performing otologic surgery should strongly consider adjusting their postoperative regimens to reflect these findings. Level of Evidence: 2b Address correspondence and reprint requests to Jameson K. Mattingly, M.D., Department of Otolaryngology—Head and Neck Surgery, The Ohio State University Wexner Medical Center, 915 Olentangy River Road, STE 4000, Columbus, OH 43212; E-mail: jameson.mattingly@osumc.edu A.C.M. received grant support from Cochlear Americas for an unrelated investigator-initiated project. O.F.A. is a consultant for MED-EL and Advanced Bionics Corporations and receives research support from Cochlear, MED-EL, and Advanced Bionics Corporations. O.F.A. is the president of Advanced Cochlear Diagnostics. The authors disclose no conflicts of interest. Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

A Case Series of Patients With Concurrent Otosclerosis and Superior Semicircular Canal Dehiscence Objective: To describe the presentations and treatment results for patients with concurrent otosclerosis and superior semicircular canal dehiscence (SCD). Study Design: Retrospective case series and literature review. Setting: Tertiary academic medical center. Patients: Patients with concurrent diagnoses of otosclerosis (radiographically and/or surgically confirmed) and SCD (radiographically confirmed) in the same ear. Intervention(s): Review of medical records. Main Outcome Measure(s): Clinical presentations, outcomes following stapedotomy. Results: Eight patients with 10 affected ears were identified. All patients presented with slowly progressive conductive hearing loss, normal otoscopy, absent acoustic reflexes, and without other symptoms of SCD syndrome. Seven patients were treated with stapedotomy and 1 with hearing aids. Of those treated with stapedotomy, a persistent conductive hearing loss was the most common hearing result. One patient had near-complete closure of their air bone gap. None had a profound sensorineural hearing loss. Four patients had unmasking of SCD symptoms. Conclusions: The clinical and audiometric presentations of patients with concurrent otosclerosis and SCD are often indistinguishable from those of patients with only otosclerosis. Computed tomography of the temporal bone is the only way to identify concurrent SCD. Stapedotomy in these patients typically results in a persistent conductive hearing loss, though 14 to 33% of patients experience near-complete closure of their air bone gap. SCD symptoms are unmasked in 57 to 63% of patients who undergo stapedotomy. Further work is needed to delineate the utility of routine preoperative computed tomography scan in otosclerosis patients, and to identify prognostic factors for patients with concurrent otosclerosis and SCD who wish to undergo stapedotomy. Address correspondence and reprint requests to Nicholas A. Dewyer, M.D., 1501 N. Campbell Ave, Suite 5401, Tucson, AZ 85724; E-mail: dewyer@oto.arizona.edu The authors disclose no conflicts of interest. Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

Carotid Artery-Cochlear Dehiscence No abstract available

Novel Minimal Access Bone Anchored Hearing Implant Surgery and a New Surface Modified Titanium Implant, the Birmingham Experience Background: Bone anchored hearing implants (BAHI) are widely used and highly successful, accompanied with a high level of patient satisfaction across most techniques. A large UK teaching hospital switched from the previously used wide diameter titanium fixture and drilling system to the novel minimally invasive technique and laser ablated titanium implant. Before this change the rates of fixture failure and skin problems necessitating abutment change were 1% each. Methods: Retrospective case note review of consecutive BAHI patients drawn from an electronic database between January 2015 and October 2016. Results: Data from a total of 118 procedures were reviewed, with different combinations of surgical techniques and implant types. Sixty procedures were performed via the novel minimally invasive technique with 21 failures (35%). Fourty-eight modified minimally invasive technique procedures were performed with seven failures. In 64 of the procedures, laser ablated titanium fixtures were placed with 21 failures (32.8%). In 54 procedures wide diameter titanium fixtures were placed with eight failures (5%). Conclusion: Initial experience with the novel minimally invasive technique and laser ablated titanium fixture showed significantly higher failure rates than expected. This prompted a change to an open technique and subsequent abandonment of the laser ablated titanium fixture and custom drilling solution in our institution. Address correspondence and reprint requests to Jack Limbrick, M.B.B.S., B.Sc., M.R.C.S. (ENT), ENT Department, Queen's Hospital, Belvedere Road, Burton-on Trent, DE13 0RB, UK; E-mail: jack.limbrick@nhs.net No financial support was received for this study; however, travel grants to present the results at the OSSEO 2017 meeting were provided by Oticon Medical. The authors disclose no conflicts of interest. Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

Completion of an Individualized Learning Plan for Otology-Related Milestone Subcompetencies Leads to Improved Otology Section Otolaryngology Training Exam Scores Objective: To examine the relationships among self-assessment of knowledge in otology via an individualized learning plan (ILP), otology milestone achievement rate, and otolaryngology training exam (OTE) otology scores. Study Design: Prospective study. Setting: One otolaryngology residency covering a tertiary care facility, trauma and hospital center, outpatient ambulatory surgery center, and outpatient clinics. Participants: Twenty otolaryngology residents, four from each class. Methods: Residents identified four milestones from otology-related sub-competencies to achieve in a 3-month rotation via an ILP. During the same rotation, the residents sat for the OTE, and their overall and otology scores were analyzed. Main Outcome Measures: Completion of an ILP before and at the end of the rotation, self-reported achievement of otology milestones, and OTE score components including total percent correct, scaled score, group stanine, national stanine, and residency group weighted scores. Results: Group stanine OTE otology scores were higher for those residents who completed pre- and post-rotation ILPs compared with those who did not, 4.0 (±0.348) versus 2.75 (±0.453), respectively (p = 0.04). Residents who self-reported achieving all four otology milestones had significantly higher otology group stanine scores than the residents who achieved less, 4.1 (±0.348) versus 2.9 ± 0.433, respectively (p = 0.045). Residents who performed well in their PGY program cohort on the otology OTE 1 year were less inclined to complete an ILP for otology in the subsequent year (Pearson correlation –0.528, p = 0.035). Conclusion: In the otology subspecialty, residents who completed ILPs scored better on OTE examinations independent of resident class. Consequently, programs may find ILPs useful in other otolaryngology subspecialties and across residencies. Address correspondence and reprint requests to Maja Svrakic, M.D., M.S.Ed., 430 Lakeville Road, New Hyde Park, NY 11040; E-mail: MSvrakic@northwell.edu This study was funded through department funds. There are no conflicts of interest to disclose. Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

Hemodynamic Changes in the Sigmoid Sinus of Patients With Pulsatile Tinnitus Induced by Sigmoid Sinus Wall Anomalies Objective: This study is to investigate the hemodynamic changes of pulsatile tinnitus (PT) patients induced by sigmoid sinus wall anomalies (SSWA). Study Design: Prospective study. Setting: Tertiary referral university hospital. Patients: Fifteen unilateral PT patients with SSWA identified on computed tomography images and surgery and 15 age-, sex-, and body mass index-matched healthy volunteers underwent velocity-encoded, cine magnetic resonance imaging. Intervention: Hemodynamic data in sigmoid sinus were obtained from velocity-encoded, cine magnetic resonance imaging, and compared between PT patients and controls. Main Outcome Measures: Heart rate was recorded. Cross-sectional area (CSA), peak positive velocity (PPV), average positive flow volume per beat (APFV/beat), average flow volume per beat (AFV/beat), peak negative velocity (PNV), and average negative flow volume per beat (ANFV/beat) were measured. Average flow volume per minute (AFV/min), average positive flow volume per minute (APFV/min), average negative flow volume per minute (ANFV/min), average positive velocity (APV), average negative velocity (ANV), and regurgitation fraction (RF) were calculated. Results: APV at PT side of patients was 13.4 ± 3.3 cm/s, which was significantly slower than that at corresponding side of controls (15.8 ± 2.6 cm/s). PNV and RF at PT side of patients were 21.0 ± 15.4 cm/s and 2.4% respectively, which were significantly higher than those values at corresponding side of controls (both of them were 0). HR, CSA, PPV, APFV/beat, APFV/min, AFV/beat, AFV/min, ANV, ANFV/beat, and ANFV/min were 69.8 ± 9.4 beat/min, 48.4 ± 17 mm2, 31.4 ± 5.9 cm/s, 5.4 ± 1.8 ml/beat, 373.9 ± 117.7 ml/min, 5.1 ± 2.0 ml/beat, 352.0 ± 134.6 ml/min, 2 (0–4.9) cm/s, 1 (0–2.7) ml/beat, and 4.1 (0–141.3) ml/min at PT side of patients, and 67.4 ± 7.8 beat/min, 38.2 ± 18 mm2, 29.9 ± 3.9 cm/s, 5.3 ± 2.0 ml/beat, 350.3 ± 125.3 ml/min, 5.1 ± 1.9 ml/beat, 340.5 ± 117.9 ml/min, 0 (0–2.1) cm/s, 0 (0–0.8) ml/beat, and 0 (0–55.4) ml/min at corresponding side of controls. These hemodynamics were not significantly different between groups. Conclusion: APV, PNV, and RF changes take place in SSWA patients, which may be associated with the occurrence of PT and have the potential value to improve accurate etiological diagnosis and predict treatment success. Address correspondence and reprint requests to Zhaohui Liu, M.D., Department of Radiology, Capital Medical University, Beijing Tongren Hospital, No 1 Dong Jiao Min Street, Dongcheng District, Beijing 100730, China; E-mail: lzhtrhos@163.com X.H., R.D., G.W., S.G., Z.W. are co-authors. This work was supported by the grant (81371545) from the National Natural Science Foundation of China, the grant (Z161100004916041) from Beijing Nova Program Interdisciplinary Studies Cooperative Projects, and the grant (2015-3-016) from Beijing Health System High-level Health Technical Personnel Training Program. The authors disclose no conflicts of interest. Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

The Management of Tympanic Membrane Perforation With Endoscopic Type I Tympanoplasty Objective: The objective of this study is to describe what we consider to be the state-of-the-art procedure for the treatment of tympanic membrane perforations, and to present the results attained in our institution. Study Design: A retrospective cohort study, using data of Verona University Hospital, Italy. This medical record includes the data of 98 patients who underwent 100 transcanal endoscopic type I tympanoplasties from November 2014 to October 2017. Setting: Tertiary referral center University Hospital of Verona, Italy. Patients: Were enrolled 109 patients, that underwent endoscopic type I tympanoplasty in the period considered. Out of the selected patients, 11 (10.1%) were lost to long-term follow-up, and were therefore excluded from our study. Other exclusion criteria were surgical approaches that included other procedures. Patients whose follow-up was shorter than 6 months were excluded from this study. Intervention: The technique is based on an endoscopic placement of underlay graft of temporal fascia or tragal cartilage. We consider the data of four surgeons from Verona University ENT department. Main Outcome Measure: In the study we considered the reduction of the Air Bone Gap as functional outcome and the integrity of the reconstruction as anatomical outcome of success. Results: No major intraoperative complications were observed. The closure rate was 86%. The mean surgery time was 48.6 minutes. The air bone gap was improved within 20 DB HL in 89% of patient. Only 8% of patients needed revision surgery, and none needed a third surgical evaluation. Conclusion: Endoscopic ear surgery is by now a reality that has replaced in many cases exclusive microscopic ear surgery. Transcanal endoscopic type I tympanoplasty can be considered nowadays as an alternative technique for tympanic membrane perforations. Address correspondence and reprint requests to Dr Flavia Di Maro, M.D., Otolaryngology—Head and Neck Surgery Department, University Hospital of Verona, Piazzale Aristide Stefani, 1 37126 Verona, Italy; E-mail: fldm22@gmail.com All of the authors have participated in the planning writing or revising the manuscript. The authors disclose no conflicts of interest. Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

A Simple, Objective, and Mathematical Grading Scale for the Assessment of Facial Nerve Palsy Objectives: It is imperative to acquire a simple, objective, and mathematical method for the assessment of facial nerve palsy which can be universally accepted and implemented. A grading scale which is convenient, continuous and economical was attempted for the first time for global and region-specific assessment of facial nerve palsy. Study Design: Hospital-based observational study. Setting: Medical college hospital. Patients: Ten normal subjects and 51 patients with facial paralysis. Interventions: Patients with facial nerve palsy were graded according to the revised version of House–Brackmann grading system (HBGS-2) and a newly proposed grading system. Main Outcome Measures: The results of the present study were compared with the HBGS-2. Data were analyzed using SPSS-17 (IBM Corporation, New York) for descriptive statistics, normality test, Wilcoxon signed-rank test, and Mann–Whitney U test. Results: The mean time spent on recording measurements was 288 seconds. For the new method and HBGS-2, the modes were graded 3 and 4, corresponding to incomplete facial paralysis. The Kolmogorov–Smirnov normality and Wilcoxon signed rank tests were found significant. In Mann–Whitney U test, probability value indicated that grades of new scale were similar to grades of HBGS-2. Conclusion: The proposed simple, objective and mathematical (SOM) method of grading facial nerve palsy is convenient and provides global and regional continuous percentage that can monitor the progress and classify the patients with facial paralysis into six-point grades based on severity. This system was having substantial compatibility with HBGS-2 grading. For further validity, multi-center study with a larger sample of patients would be required. Address correspondence and reprint requests to Mohan Bansal, M.S., Ph.D., F.I.C.S., F.A.C.S., GPO Road, Near Old ST Stand, Anand, Gujarat, 388001, India; E-mail: mohanbansal@yahoo.com There are no financial interests, relationship, and affiliations relevant to the subject of the manuscript including employment, consultancies, honoraria, stock ownership, etc. No financial or personal relationships with other people or organizations that could inappropriately influence (bias) the authors’ actions. 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