Salivary gland carcinoma is a rare form of head and neck carcinoma, but it comprises a variety of subsites and histologic subtypes that each present with unique clinical courses and management challenges. Preoperative work-up generally consists of fine-needle aspiration cytology and MRI. However, because of the large variety of subtypes, there are often challenges obtaining a histologic diagnosis before surgery. Upfront surgery at the primary site leads to the greatest improvement in survival. Posttreatment surveillance of these patients is important. This article discusses some of the current controversies in the management of salivary gland carcinomas.

Objective Determine levels of catastrophizing in patients with vestibular disorders and prospectively evaluate their relationship with patient-reported outcome measures. Study Design Prospective cohort study. Setting Tertiary care neurotology vestibular disorders clinic. Patients Adult patients with various vestibular disorders. Interventions Patients were given the Dizziness Handicap Inventory (DHI) and the Dizziness Catastrophizing Scale (DCS) at a baseline visit and follow-up visit after treatment. Main outcome measures Correlation studies were used to determine the relationships between DHI and DCS. Multivariable linear regression was performed to determine the relationship between DCS and DHI change with treatment, accounting for demographic variables. Results Forty-six subjects completed both the DHI and the DCS before and after treatment. Patients with higher baseline DCS scores had higher baseline DHI scores ( p < 0.001). There was a significant improvement in both DHI score ( p < 0.001) and DCS ( p < 0.001) at follow-up. Patients who had reduction in DCS scores during were more likely to show reduction in DHI scores ( p < 0.001). A subset of patients had a mindfulness-based stress reduction program included in their treatment. These patients had a greater reduction in both DCS and DHI scores at follow-up compared with those who received other treatments. Conclusions Catastrophizing is associated with higher pretreatment DHI scores and worse treatment outcomes. Addressing dizziness catastrophizing may help improve vestibular outcomes.

Objective To compare hearing, tinnitus, balance, and quality-of-life treatment outcomes of petroclival meningioma and nonpetroclival cerebellopontine angle meningioma cohorts. Study Design A retrospective cohort study of 60 patients with posterior fossa meningiomas, 25 petroclival and 35 nonpetroclival, who were treated at a single tertiary care center between 2000 and 2020. Intervention A survey battery that included the Hearing Effort of the Tumor Ear, Speech and Spatial Qualities of Hearing, Tinnitus Functional Index, Dizziness Handicap Inventory (DHI), and Short Form Health Survey. Petroclival and nonpetroclival cohorts were matched for tumor size and demographic features. Main Outcome Measures Differences between groups in hearing, balance outcomes, and quality of life and patient factors that influence posttreatment quality of life. Results Petroclival meningioma patients reported poorer audiovestibular outcomes with a higher rate of deafness in the tumor ear (36.0% versus 8.6%, p = 0.032) and lower functional hearing by the Hearing Effort of the Tumor Ear, Speech and Spatial Qualities of Hearing (76.6 [6.1] versus 82.0 [4.4], p < 0.001). Current dizziness rate was higher (48.0% versus 23.5%, p = 0.05), with more severe dizziness by DHI (18.4 [4.8] versus 5.7 [2.2], p < 0.001). Both cohorts had similar high quality of life and low tinnitus severity indices. Quality-of-life Short Form Health Survey predictors were tumor size (p = 0.012) and DHI (p = 0.005) in multivariable analysis. Conclusions Hearing and dizziness treatment outcomes of petroclival meningioma are poorer relative to other posterior fossa meningiomas. Despite audiovestibular outcome distinctions, the overall posttreatment quality of life was high for both petroclival and nonpetroclival meningioma.

OBJECTIVES/HYPOTHESIS:To identify the imaging characteristics associated with better hearing outcomes found in cochleovestibular nerve (CVN) abnormalities treated with hearing aids and/or cochlear implantation (CI).STUDY DESIGN:Retrospective review.METHODS:A retrospective review was undertaken of 69 ears with CVN abnormalities seen on magnetic resonance imaging (MRI) treated at a tertiary referral academic center analyzing the clinical features, imaging characteristics, and hearing data. We searched for associations among the hearing and imaging data, hypothesizing that the imaging data was not a good indicator of hearing function.RESULTS:In univariable analysis of all those who underwent aided testing (hearing aid and CI), health status (P = .016), internal auditory canal (IAC) midpoint diameter (P < .001), and number of nerves in the IAC (P < .001) were predictors of positive hearing outcome. Modiolar abnormalities, cochlear aperture diameter, cochlear malformations, vestibular malformations, and nerves in the cerebellar cistern did not predict hearing outcome (P = .79, .18, .59, .09, .17, respectively). For patients who received CI, health status (P = .018), IAC midpoint (P = .024), and number of nerves in the IAC (P = .038) were significant. When controlling for health status, IAC midpoint diameter (P < .001) and number of nerves in the IAC (P < .001) remained significant. In our cohort, one out of the eight ears (13%) with Birman class 0 or 1 exhibited responses to sound compared to nine out of 13 ears (70%) with Birman class 2-4.CONCLUSIONS:Current imaging modalities cannot accurately depict the status of the cochleovestibular nerve or predict a child's benefit with a CI. Cochlear implantation should be considered in children with abnormal cochleovestibular nerves.LEVEL OF EVIDENCE:3 Laryngoscope, 132:S1-S15, 2022.

PURPOSE OF REVIEW:The purpose of this narrative review is to discuss current literature about vestibular migraine and other cochleovestibular symptoms related to migraine.RECENT FINDINGS:Vestibular migraine affects 2.7% of the US population. Misdiagnosis is common. The pathophysiology is currently unknown but new research shows that calcitonin gene-related peptide, which is implicated in migraine headaches, is expressed in the audiovestibular periphery. A recent large-scale placebo-controlled trial looking at metoprolol for vestibular migraine was terminated early due to poor recruitment; however, at study completion, no differences were seen between treatment arms. Many other audiovestibular symptoms have been shown to be associated with migraine, including tinnitus, hearing loss, aural fullness, otalgia, and sinus symptoms. Migraine is also associated with risk for developing numerous otologic conditions, including Meniere's disease, vestibular loss, Benign Paroxysmal Positional Vertigo, and sudden sensorineural hearing loss. There is now some evidence that patients may experience fluctuating hearing loss and aural fullness without vertigo in association with migraine, which is called cochlear migraine.SUMMARY:Migraine can cause a variety of audiologic and vestibular symptoms, and further research is required to understand how migraine affects the inner ear.

Purpose of Review To summarize and critically review recent literature on the relative cost-effectiveness of hearing augmentation versus stapes surgery for the treatment of otosclerosis. Recent Findings Otosclerosis leads to reduced patient quality of life, which can be ameliorated by either stapes surgery, or hearing aid usage. The success of stapes surgery is high, and the risks of serious postoperative complications are low. Hearing aids don’t have the complications of surgery but are associated with long-term costs. Cost-effectiveness models have shown that stapes surgery is a cost-effective method for treating otosclerosis. Summary Both stapes surgery and hearing aids can improve patient-reported quality of life in otosclerosis. Stapes surgery has larger upfront costs and surgical risks, but hearing aids are associated with longer lifetime costs. Stapes surgery is cost-effective for the treatment of otosclerosis.

To compare functional hearing and tinnitus outcomes in treated large (~ 3 cm) vestibular schwannoma (VS) and posterior fossa meningioma cohorts, and construct willingness-to-accept profiles for an experimental brain implant to treat unilateral hearing loss. A two-way MANOVA model with two independent variables (tumor type; time from treatment) and three dependent variables (hearing effort of tumor ear; abbreviated Speech, Spatial, and Qualities of Hearing scale (SSQ12); Tinnitus Functional Index (TFI)) was used to analyze data from VS ( N = 32) and meningioma ( N = 50) patients who were treated at a tertiary care center between 2010 and 2020. A query to probe acceptance of experimental treatment for hearing loss relative to expected benefit was used to construct willingness-to-accept profiles. Tumor type was statistically significant on the combined dependent variables analysis ( F [3, 76] = 19.172, p < .0005, Wilks' Λ = 0.569). Meningioma showed better outcome for hearing effort ( F [1, 76] = 14.632, p < .0005) and SSQ12 ( F [1, 76] = 16.164, p < .0005), but not for TFI ( F [1, 76] = 1.247, p = .268) on univariate two-way ANOVA analyses. Superior hearing effort and SSQ12 indices in the short-term (< 2 years) persisted in the long-term (> 2 years) ( p ≤ .017). At the 60% speech understanding level, 77% of respondents would accept an experimental brain implant. Hearing outcome is better for posterior fossa meningioma compared to VS. Most patients with hearing loss in the tumor ear would consider a brain implant if the benefit level would be comparable to a cochlear implant. 2

OBJECTIVES:To compare treatment outcomes for sinogenic subdural empyema (SE) between those managed with initial endoscopic sinus surgery (ESS) alone versus those treated with a combination of ESS and craniotomy over the last decade at our institution. To better characterize subdural empyema with regard to presentation, causative pathogens, and treatment course.METHODS:Retrospective single-center chart review to identify and evaluate pediatric SE patients between 2009 and 2019. Patients meeting inclusion criteria were classified in one of two groups: those who initially underwent ESS or frontal trephination without concurrent neurosurgical procedure and those who underwent craniotomy or burr hole in addition to a sinus procedure. Presenting characteristics and treatment outcomes were compared between the two groups.RESULTS:Eighteen patients met inclusion criteria. The ESS alone and the ESS + craniotomy subgroups each had 9 patients with similar baseline characteristics. The ESS + craniotomy group was more likely to present with neurological symptoms (p = 0.039) and have multiple intracranial fluid collections (p = 0.046). 74.1% of patients presented to the Emergency Department (ED) or to their primary medical doctor and were treated with outpatient management prior to hospitalization with definitive surgical management. The most common presenting symptoms were fever, headache and nausea/vomiting. There were no differences between treatment groups in rate of return to the operating room (OR) (p = 1.00), length of stay (LOS) (p = 0.553), or adverse neurological outcomes (p = 0.456). 44.4% of patients in the ESS alone group eventually required neurosurgical intervention.CONCLUSIONS:Surgical SE patients often present to medical professionals in the primary care setting or ED and are managed with outpatient treatment before admission with definitive treatment. In this small retrospective cohort patients who underwent sinus intervention alone had similar rates of return to OR, LOS and adverse neurological outcomes use as those who underwent a sinus procedure in coordination with a neurosurgical intervention. There may be a group of patients with SE who may be managed with endoscopic procedures alone and further studies should seek to determine the characteristics of this population.

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.

OBJECTIVES:There are significant variations across centers on how to acquire and interpret imaging of children with congenital sensorineural hearing loss and cochleovestibular abnormalities. This study assesses the quality of imaging, sequences included, and accuracy of official radiology reports, to determine if these children are being assessed appropriately. METHODS:This study is retrospective review of CTs and MRIs from 40 pediatric patients diagnosed with profound sensorineural hearing loss and cochleovestibular structure/nerve abnormalities presenting to a tertiary referral academic center. Images were reviewed by two experienced neuroradiologists and a neurotologist. Findings were compared to official reports, when available. RESULTS:Twelve (30%) patients had an MRI only, while 28 (70%) had both an MRI and a CT. There were 3 (10.7%) CTs and 7 (17.5%) MRIs noted to be of poor quality. Children received an average of 6.8 (±2.7) CT acquisitions and 10.9 (±5.7) MRI acquisitions. There was non-concordance between the official report and expert review for 27 (71.1%) ears on CT and 27 (56.3%) ears on MRI. CONCLUSIONS:These data demonstrate high variability in protocols and quality of medical imaging of children with sensorineural hearing loss. Interpretation of images is highly discordant between official reports and tertiary review. Given these results, we recommend that these children be imaged and evaluated at centers with neuroradiologists who are experienced in interpreting congenital abnormalities of the cochleovestibular system.

Introduction: The utilization of advance directives in individuals with Parkinson's disease (PD) and atypical parkinsonian disorders (APD) and their caregivers requires further investigation. This study determined the utilization rates of four forms of advance directives: living will, durable power of attorney, durable power of attorney for healthcare, and medical orders in these individuals. We hypothesized that having a neurodegenerative parkinsonian disorder or exposure to these disorders would increase the likelihood of having advance directives. Methods: 50 PD participants, 49 APD participants, 50 caregivers and 50 non-caregiver controls were surveyed regarding advance directives. Results: The median number of advance directives was 1 in controls, 2 in caregivers and PD participants and 3 in APD participants. Patients with PD were 4.08 times more likely to have durable power of attorney (p < 0.001) and 2.08 times more likely to have durable power of attorney for healthcare (p = 0.011) than controls. Patients with APD were 1.66 times more likely to have a living will (p = 0.006), 4.81 times more likely to have a durable power of attorney (p < 0.001) and 2.47 times more likely to have a durable power of attorney for healthcare (p = 0.003) than controls. Caregivers were1.58 times more likely to have a living will (p = 0.012) and 2.21 times more likely to have a durable power of attorney for healthcare than controls. Conclusion: Having or being exposed to parkinsonian disorders significantly increases the likelihood of utilizing advance directives. Additionally, exposure to a parkinsonian disorder as a caregiver increases advance directive use.