The Chronically Draining Ear: Why Current Management Fails and What We Should Be Doing
Michael B. Gluth, MD (Moderator); Peter Santa Maria, MBBS; Wade Chien, MD
Session Description: We discuss the underlying basis for why ears chronically drain in chronic suppurative otitis media and cholesteatoma. We discuss relevant biomechanics and acoustic principles, microbiology, immunology, biochemistry, and histopathology, including the reversible and irreversible changes that occur in the middle ear mucosa, the basis for cholesteatoma-related bone destruction, patterns of cholesteatoma spread, implications of fibrocystic sclerosis/tympanosclerosis in the middle ear on surgical decision making and to provide insight into some select situations such as tympanic membrane blunting and suppuration/inflammation in the cochlea. We review the failure and success of the various treatment options including topical and systemic therapies as well as surgical tips and pearls that may eradicate chronic ear discharge. We also present some potential future directions for therapeutics for addressing the chronically draining ear such as evolving antimicrobials and immunotargeted photodynamic therapy. The structure of the learning will be centered around real-life case examples.
Outcome Objectives: (1) Explain the mechanisms underlying why ears chronically drain. (2) Compare the advantages and disadvantages of the currently available treatment options. (3) Implement new treatment ideas into surgical practice to reduce treatment occurrence for chronic ear drainage.
Curing Genetic Hearing Loss: A Goal Within Reach
Margaret A. Kenna, MD, MPH (Moderator); Jeffrey Holt, PhD; Cynthia Morton, PhD; Karl Koehler, PhD
Session Description: Sensorineural hearing loss (SNHL) is the most common congenital sensory impairment (2/500 births) rising to >50% prevalence in patients older than 75 years. Genetic etiologies cause more than 50% of hearing loss in children and are a significant contributor to age-related hearing loss. Hearing aids, cochlear implants, and other assistive technology have greatly improved access to audition for many patients but often provide only incomplete access, and they do not prevent or cure the hearing loss. Therapy for genetic hearing loss, until now only hypothetical, is becoming a reality. Multiple preclinical studies for the hearing loss genes TMC1, Ush1g (sans), Ush1C (harmonin), Vglut3, Otof, Gjb2, Gjb6, Kcnq1, Msrb3, Clrn1, Whrn, and Lhfp15 have been completed or are under way. The first successful model of genetic hearing loss showing improvement with gene therapy was in 2012 and used adeno-associated virus viral delivery of vglut3 cDNA into mice. Subsequently, very successful mouse models of hearing loss due to TMC1, USH1C, or Clrn1, and nonhuman primate models of Usher 3, are leading to clinical trials in humans. This panel will address the emerging area of genetic hearing loss therapy. Topics include genes under study, modes of therapy, gene delivery (viruses, nanomaterials, liposomes, polymers), nonspecific gene therapy (eg, stem cells), nongenetic therapies (eg, small molecules), and nonanimal models of hearing loss and therapy (eg, organoids). Panelists include a pediatric otologist, a geneticist/cytopathologist, and 2 translational genetic hearing loss scientists.
Outcome Objectives: (1) Describe the genetic causes of hearing loss, which parts of the inner ear are involved, and which populations are affected. (2) Interpret the current genetic hearing loss basic science studies and relevance to human hearing. (3) Outline how current preclinical studies will translate into therapy for human hearing loss.
Dizziness: The Right Questions to Ask and the Right Tests to Order
Meredith E. Adams, MD (Moderator); Edward I. Cho, MD; Heather M. Weinreich, MD; Steven A Telian, MD
Session Description: How can we most effectively evaluate patients with dizziness within the confines of modern practice? During this panel, sponsored by the American Otological Society, experts in vestibular diagnosis will discuss how to integrate best evidence with clinical experience to efficiently formulate a differential diagnosis for any patient with dizziness. Using illustrative cases, we will present the key questions—focused on timing, triggers, and associated symptoms—that elicit the pertinent history and minimize vague reporting. We will review the merits of clinical questionnaires and the highest yield physical exam elements that warrant incorporation into daily practice. With this diagnostic framework established, we will guide clinicians in determining what tests to order, if any, by defining the specific questions that can and cannot be answered with the current array of audiovestibular tests, imaging, and other physiologic investigations. We aim to provide an approach that clinicians can readily implement to make correct diagnoses in a timely fashion, thus expediting initiation of therapy and improving patient outcomes.
Outcome Objectives: (1) Efficiently gather an informative case history from patients with dizziness. (2) Formulate a differential diagnosis for dizziness based on timing, triggers, and associated symptoms. (3) Select appropriate diagnostic tests that yield information necessary for patient management.
Endoscopic Ear Surgery in Clinical Practice
Michael S. Cohen, MD (Moderator); Daniel J. Lee, MD; Sharon L. Cushing, MD; Alicia M. Quesnel, MD
Session Description: This session will introduce otolaryngologists to the principles of endoscopic ear surgery (EES). Our target audience includes surgeons-in-training as well as established surgeons who wish to augment their existing surgical armamentarium with endoscopic techniques. Topics will include essential equipment, operating room layout, ergonomics, patient selection, safety, surgical techniques, pediatric and adult EES outcomes, common pitfalls, and barriers to entry. Extensive use of case videos will demonstrate how endoscopic techniques can augment, and in some cases replace, traditional microscopic approaches. Participants should leave this session with a greater understanding of how EES can be incorporated into an otologic surgical practice.
Outcome Objectives: (1) Outline the equipment, ergonomics, and patient selection necessary for getting started with endoscopic ear surgery. (2) Select cases and techniques for endoscopic ear surgery with an eye toward optimizing outcomes and minimizing complications. (3) Summarize outcomes following transcanal EES both in pediatric and adult patients.
Endoscopic Ear Surgery: Tips and Pearls
Joao-Flavio Nogueira, MD (Moderator); Daniel J. Lee, MD; Muaaz Tarabichi, MD; Daniele Marchioni, MD
Session Description: Endoscopic ear surgery (EES) is becoming very popular worldwide. Transcanal endoscopic-assisted procedures and combined endoscopic and microscopic surgeries have proven to be safe and effective to manage ear diseases in a minimally invasive way, preserving important anatomic structures, allowing functional approaches to well-known conditions. Moreover, endoscopes have provided a better view and understanding of traditional middle ear anatomy and physiology, allowing new landmarks, novel concepts of tissue preservation, ventilation routes, and management of other conditions within the middle ear and beyond. In this session we will present the latest trends on EES, discussing advantages, disadvantages, indications, results, and possible complications.
Outcome Objectives: (1) Review the endoscopic anatomy of the middle ear, discussing the important endoscopic anatomic landmarks. (2) Identify the actual indications and limitations of this minimally invasive approach, discussing the instruments and equipment needed. (3) Describe and demonstrate stepwise endoscopic middle ear approaches for several diseases of this area.
Expanding Criteria for Cochlear Implantation Part 2: Adult Candidates
Matthew L. Bush, MD, PhD (Moderator); Matthew L. Carlson, MD; Sandra Prentiss, PhD; René Gifford, PhD
Session Description: This is the second presentation of a 2-part panel on expanding cochlear implantation (CI) candidacy. The incidence of global hearing loss among adults continues to rise. CI has been a standard treatment for adults with severe hearing loss for decades, and ongoing refinements in surgical technique and electrode design have improved patient outcomes over time. Regardless of these advancements and the trends in hearing loss incidence, access to and utilization of CI among adults remain alarmingly low. Poor utilization of CI may be due, in part, to a lack of understanding among health care providers of standard CI candidacy criteria as well as a lack of consensus on preoperative CI candidacy audiological assessment protocols. Significant regulatory changes and research findings have also influenced this field. In 2019, the Food and Drug Administration expanded CI indications to include patients with single-sided deafness; furthermore, there is a growing body of evidence to support expanding indications and candidacy criteria of CI for adults with bilateral hearing loss. There is a pressing need to increase the awareness and understanding of providers in our field regarding expanding CI criteria. This panel, supported by the American Academy of Otolaryngology–Head and Neck Surgery Foundation Hearing Committee and Implantable Device Committee, will review standard indications for CI and candidacy evaluation strategies, discuss research and regulatory updates regarding expanding CI indications, and describe challenges and controversies facing patients who may benefit from CI. Learning will be enhanced by case scenarios and discussion with expert panelists from the field of adult CI.
Outcome Objectives: (1) Summarize the standard indications and assessment strategies for CI. (2) Discuss the expansion of CI candidacy criteria based on research evidence and regulatory changes. (3) Recognize the challenges and complexities in CI candidacy through clinical scenarios.
Hearing and Cognition: What’s the Connection and What Can We Do About It?
Richard K. Gurgel, MD (Moderator); Carrie L. Nieman, MD, MPH; Justin S. Golub, MD, MS; Aaron C. Moberly, MD
Session Description: As the largest potentially modifiable risk factor for dementia, hearing loss has recently grown to be a major national public health concern. This is in part because of its extremely high prevalence and low treatment levels. Dementia is also highly prevalent in older adults and carries an enormous societal toll. The economic cost of dementia is estimated at more than $220 billion per year in the United States. Our understanding of the potential relationship between hearing and cognition has grown considerably in the past decade. This presentation will review what is known regarding the association between hearing loss and cognitive impairment, including the latest research on potential mechanisms, risk factors, and the impact of treatment. We will discuss when the link between hearing loss and cognition begins and when it makes sense to recommend treating age-related hearing loss. This will include when we should start hearing aids and the role of upcoming over-the-counter devices. We will also cover current understanding of the role cognition plays in otologic outcomes, specifically older cochlear implant users. Finally, the presentation will review the impact of hearing loss on the health and well-being of older adults who are already experiencing cognitive impairment. This session will be a tour of the cutting-edge research on hearing and cognition and equip the audience with key take-aways on how the current evidence translates to clinical practice.
Outcome Objectives: (1) Review the potential mechanisms underlying the association between hearing loss and cognitive impairment. (2) Discuss current evidence of the impact of hearing treatment on cognition and the role of cognition in treatment outcomes. (3) Describe how hearing loss affects older patients with cognitive impairment.
Medical Workup of Pediatric Sensorineural Hearing Loss: Case Presentation
Oliver F. Adunka, MD (Moderator); Daniel Choo, MD; Craig A. Buchman, MD; Margaret A. Kenna, MD, MPH
Session Description: The management of pediatric sensorineural hearing loss requires a coordinated team approach between a diverse group of professionals. These include audiologists, speech and language pathologists, early intervention specialists, physicians, educators, and many others. Although the approaches and the details of the clinical algorithm vary dramatically across the country, the managing physician often plays a central role. The session aims at detailing the physician’s perspective of the team approach by discussing various common clinical scenarios applying evidence-based guidelines. This seems especially pertinent given the diverse clinical population served by hearing loss professionals. The panelists also plan to detail imaging, surgical aspects in the management of pediatric hearing loss, established and new trends in cochlear implantation, and alternative technology.
Outcome Objectives: (1) Summarize general principles involved in the medical and audiological workup of pediatric hearing loss. (2) Discuss various clinical scenarios commonly encountered in the management of pediatric sensorineural hearing loss. (3) Review genetic, audiometric, and radiologic aspects of pediatric hearing loss.
Single-Sided Deafness: Data-Driven Treatment Options for Children and Adults
Ravi N. Samy, MD (Moderator); Daniel M. Zeitler, MD; Oliver F. Adunka, MD
Session Description: Single-sided deafness (SSD) is a common otologic diagnosis in the United States and around the world but remains a complex problem to manage because of the numerous potential etiologies and possibilities for treatment. The focus of this presentation will be to review the various management options currently available both for pediatric and adult patients with SSD. We will briefly review the key elements in the workup of patients with SSD, but the primary emphasis of this presentation will be on the specific audiological habilitative options (surgical and nonsurgical) available for the treatment of SSD, as well as to compare the objective outcomes for each of these options as they relate to all listening conditions in patients of all ages. We will also review the data for cochlear implantation (CI) for the treatment of SSD in terms of traditional objective outcome measures as well as more subjective data focusing on the sound quality of CI for SSD.
Outcome Objectives: (1) Demonstrate an understanding of the various SSD treatment options available for children and adults. (2) Discuss differences in treatment outcomes between children and adults with SSD and report subjective sound quality of a CI. (3) Implement a streamlined algorithm for the treatment of SSD.
Temporal Bone Radiology, Part II: Advanced
Ashkan Monfared, MD (Moderator); Howard W. Francis, MD; Brandon Isaacson, MD; Andrea Vambutas, MD
Session Description: Through this interactive presentation, the audience is exposed to challenging temporal bone radiology cases and offered strategies to improve interpretation. The first hour will focus on fundamentals of temporal bone imaging and the second hour on advance-case presentation. The emphasis is placed on subtle but pertinent findings on computed tomography and magnetic resonance imaging examinations and their importance in creating and narrowing a differential diagnosis. We will present guidelines to aid in the efficient acquisition and interpretation of imaging for patients with common otologic conditions such as chronic ear disease, vertigo, and pulsatile tinnitus as well as rare and more challenging disorders such as skull-base, jugular foramen, and facial nerve tumors.
Outcome Objectives: (1) Review the fundamentals of temporal bone imaging. (2) List the order of appropriate radiographic tests and understand the strengths and limitations of different imaging modalities. (3) Interpret key radiographic findings for common pathologic conditions of the temporal bone.
Vestibular Migraines: 2020 Management Update
Soha N. Ghossaini, MD (Moderator); Ilka C. Naumann, MD; Courtney C.J. Voelker, MD, PhD; Jeffrey D. Sharon, MD
Session Description: Vestibular migraine is a common presenting cause of dizziness that remains fairly underdiagnosed. Otolaryngologists end up playing a major role not only in diagnosing but also in managing those patients because of limited access to other specialists. This panel presentation will review the clinical presentation, diagnostic techniques, treatment strategies of vestibular migraine and its relationship to other common balance entities.
Outcome Objectives: (1) Discuss the clinical presentation and the differential diagnosis of vestibular migraine. (2) Describe new techniques used to diagnose vestibular migraine. (3) Analyze novel treatment modalities for vestibular migraine and describe its relationship to other common balance disorders.
