7-Tesla (T) magnetic resonance imaging may allow for higher resolution images but may produce greater acoustic noise than 1.5- and 3-T scanners. We sought to characterize the intensity of acoustic noise from 7- versus 3-T scanners. A-weighted sound pressure levels from 5 types of pulse sequences used for brain and inner ear imaging in 3- and 7-T scanners were measured. Time-averaged sound level and maximum sound levels generated for each sequence were compared. Time-averaged sound levels exceeded 95 dB and reached maximums above 105 dB on the majority of 3- and 7-T scans. The mean time-averaged sound level and maximum sound level across pulse sequences were greater in 7- than 3-T (105.6 vs 91.4, P = .01; 114.0 vs. 96.5 dB, P < .01). 7- and 3-T magnetic resonance imaging scanners produce high levels of acoustic noise that exceed acceptable safety limits, emphasizing the need for active and passive noise protection.

Natural gas toxicity is known to cause a variety of neurologic and pulmonary symptoms. To date, there are no documented cases of true vertigo caused by natural gas exposure alone. We describe the case of a 34-year-old who developed intractable vertigo and unilateral pulsatile tinnitus with complete resolution of symptoms after addressing a gas leak in his home. We hypothesize a mechanism for this clinical presentation as it relates to natural gas toxicity. This case report was considered not to be human subjects research by the Henry Ford Health Institutional Review Board. A healthy 34-year-old male presented to the otolaryngology clinic with intractable vertigo and pulsatile tinnitus that began days after firearm training, which was the initial suspected cause. He had a long history of occupational noise exposure from firearms and used hearing protection without any previous issues. He was treated by his primary care provider with a short course of low-dose prednisone and meclizine with initial improvement followed by symptom relapse. His vertigo symptoms were a room-spinning sensation, and the pulsatile tinnitus was entirely right-sided and synchronous with his heartbeat. The symptoms fluctuated in severity but never resolved. Due to symptom severity, he took leave from work and remained at home. Vital signs were within normal limits, and pulse oximetry at a visit with his primary care provider for these symptoms showed a saturation of 97%. His physical exam was normal, and audiometry showed normal hearing with type A tympanogram ruling out hearing loss as a precipitant of the tinnitus especially given his recent and chronic noise exposures. Comprehensive balance function testing was normal, ruling out vestibular organ disorders. Magnetic resonance imaging (MRI) showed mild prominence of the cerebrospinal fluid (CSF) spaces in the optic nerve sheaths bilaterally but no other abnormalities, ruling out lesions of the internal auditory canal or labyrinth. He was diagnosed with vestibular migraine, though his symptoms persisted for months and did not respond to abortive therapy. Later in his clinical course, his partner moved into his residence and developed similar symptoms. The patient surmised an environmental cause, carefully inspected his home, and noticed the faint odor of natural gas. He notified his utility company which identified and repaired two gas leaks in his home. Days later, the patient and his partner's symptoms completely resolved. Natural gas has many components, predominantly methane, and incomplete combustion can produce carbon monoxide.1 In excess, methane has been reported as toxic by means of pneumonitis and asphyxiation.2 Carbon monoxide exposure is also known to cause many symptoms including dizziness and hearing loss.3 Reports have described cases of dizziness and hearing loss attributed to carbon monoxide exposure after symptoms resolved following home repairs.4 However, pulsatile tinnitus as a dominant symptom of carbon monoxide exposure is not well-documented, and there are no reports of tinnitus or true vertigo associated with isolated natural gas exposure. Though the mechanism is unclear, we hypothesize that the pathophysiology of this patient's presentation is similar to that of carbon monoxide toxicity or could be from carbon monoxide itself. Hypoxemia from asphyxiation can stimulate vasodilation and increase cerebral blood flow, causing intracranial hypertension, a presumed cause of pulsatile tinnitus.5 Given the MRI findings of increased optic nerve sheath CSF prominence, we believe this patient's natural gas exposure caused hypoxemia, subsequent intracranial hypertension, and resultant intractable pulsatile tinnitus and vertigo. We acknowledge that any of the components in natural gas could have precipitated hypoxemia or other toxic effects, causing the patient's symptoms; however, carbon monoxide is the most likely culprit. Further testing such as ambulatory pulse oximetry or CO-oximetry was not pursued after symptoms resolved, so we cannot prove the exact culprit or pathophysiology. We recognize that our proposed mechanism cannot be ethically studied in vivo; nonetheless, this case illustrates the importance of considering toxic exposure in patients with intractable vertigo. A 34-year-old male experienced intractable vertigo and unilateral pulsatile tinnitus associated with exposure to a gas leak. His symptoms were likely due to natural gas toxicity, although the exact pathophysiology is unclear. The mechanism may be similar to carbon monoxide poisoning, and perhaps from carbon monoxide itself. We hypothesize that hypoxemia from the natural gas exposure caused cerebral vasodilation and subsequent intracranial hypertension, precipitating pulsatile tinnitus and vertigo. Kyle W. Leonard, chart review for data acquisition, analysis, and manuscript planning, drafting and revising the manuscript, final review and approval of the version to be published, agreement to be held accountable for the content of this manuscript; Ravi R. Shah, contributions: chart review for data acquisition, analysis, and manuscript planning, revising the manuscript, final review and approval of the version to be published, agreement to be held accountable for the content of this manuscript. None. None.

Numerous eponymous instruments are regularly used in the otology surgical suite. This manuscript uses a tympanoplasty to highlight 10 frequently used instruments and the remarkable surgeons behind their creation. Many of these names will be familiar, but we hope our readers will gain an appreciation of these landmark figures that have transformed the practice of otology.

ObjectiveTo understand the effect of age on health‐related quality of life (HRQoL) in patients with hearing loss and determine how primary language mediates this relationship.Study DesignCross‐sectional study.SettingGeneral otolaryngology clinic in Los Angeles.MethodsDemographics, medical records, and HRQoL data of adult patients presenting with otology symptoms were reviewed. HRQoL was measured using the Short‐Form 6‐Dimension utility index. All patients underwent audiological testing. A path analysis was performed to generate a moderated path analysis with HRQoL as the primary outcome.ResultsThis study included 255 patients (mean age = 54 years; 55% female; 27.8% did not speak English as a primary language). Age had a positive direct association with HRQoL (p < .001). However, the direction of this association was reversed by hearing loss. Older patients exhibited significantly worse hearing (p < .001), which was negatively associated with HRQoL (p < .05). Primary language moderated the relationship between age and hearing loss. Specifically, patients who did not speak English as a primary language had significantly worse hearing (p < .001) and therefore worse HRQoL (p < .01) than patients who spoke English as a primary language with hearing loss. Increasing age was associated with bilateral hearing loss compared to unilateral hearing loss (p < .001) and subsequently lower HRQoL (p < .001). Polypharmacy (p < .01) and female gender (p < .01) were significantly associated with lower HRQoL.ConclusionAmong otolaryngology patients with otology symptoms, older age and not speaking English as a primary language were associated with worse hearing and subsequently lower HRQoL.

ObjectivesTo describe the inside out surgical anatomy of the superior laryngeal artery and to resolve the ambiguities in the nomenclature of its main branches.Study DesignEndoscopic dissection of the superior laryngeal artery in the paraglottic space of larynges of fresh frozen cadavers and a review of the literature.SettingA center for anatomy encompassing facilities for latex injection into the cervical arteries of human donor bodies and a laryngeal dissection station equipped with a video‐guided endoscope and a 3‐dimensional camera.MethodsVideo‐guided endoscopic dissection of 12 hemilarynges in fresh frozen cadavers whose cervical arteries were injected with red latex. Description of the inside‐out surgical anatomy of the superior laryngeal artery and its main branches. Review of the previous reports describing the anatomy of the superior laryngeal artery.ResultsFrom inside the larynx, the artery was exposed upon its entry through the thyrohyoid membrane or through the foramen thyroideum. It was traced ventrocaudally in the paraglottic space exposing its branches to the epiglottis, the arytenoid, and the laryngeal muscles and mucosa. Its terminal branch was followed until it left the larynx through the cricothyroid membrane. Branches of the artery, previously described under different names, appeared to supply the same anatomical domains.ConclusionMastering the inside out anatomy of the superior laryngeal artery is mandatory to control any intraoperative or postoperative hemorrhage during transoral laryngeal microsurgery or during transoral robotic surgery. Naming the artery's main branches according to their domain of supply would resolve the ambiguities resulting from various nomenclatures.

ObjectiveTo quantify the changes in prevalence and impact of dizziness and balance disorders in adults from 2008 to 2016.Study DesignEpidemiological survey analysis.SettingUnited States.MethodsThe balance modules of the adult 2008 and 2016 National Health Interview Surveys were examined, and persons reporting dizziness or balance problems identified. The prevalence of balance problems was determined and compared over time, adjusting for age and sex. Among those with balance problems, associated symptoms and self‐reported functional limitations were quantified and compared over time.ResultsIn 2016, 36.8 ± 1.0 million (15.5% ± 0.3%) adults reported a balance problem in the past year, versus 24.2 ± 0.7 million (11.% ± 0.3%) in 2008 (p < .001). After adjustment for age and sex, this percentage increase remained significant (odds ratio 1.435 [1.332‐1.546], p < .001). Among those with balance problems, significantly more patients reported specific issues with feeling: off‐balance (69.4% vs. 65.4%; p = .005), faint (48.5% vs. 40.3%; p < .001), or vertiginous (45.9% vs. 39.3%; p < .001) in 2016 than 2008. More adults experienced anxiety (29.4% vs. 19.4%; p < .001) and depression (16.3% vs. 12.9%; p = .002) with their balance problems in 2016 than in 2008. In 2016, adults with balance problems were limited in ability to drive motor vehicles (13.0%), exercise (14.4%), or walk downstairs (12.8%). These rates were not significantly different from 2008 (all p > .05).ConclusionIn this nationally representative analysis, we found a significantly increasing prevalence of balance problems and associated psychiatric symptom burden. This merits attention with respect to present and future health care resource allocation.

Discrepancies in medical coding can negatively impact institutional revenue and result in accusations of medical fraud. The objective of the present study was to prospectively assess the utility of a dynamic feedback system for otolaryngology providers in improving the coding/billing accuracy of outpatient clinic encounters. A billing audit of outpatient clinic visits was performed. Dynamic billing/coding feedback, consisting of a virtual lecture and targeted e-mails, was provided at distinct intervals by the institutional billing and coding department. χ 2 was used for categorical data, and the Wilcoxon test was used to compare changes in accuracy over time. A total of 176 clinic encounters were reviewed. Prior to feedback, 60% of encounters were inaccurately billed by otolaryngology providers, requiring upcoding and representing a potential 35% work relative value unit (wRVU) loss of E/M generated productivity. After 1 year of feedback, providers significantly increased the accuracy of their billing from 40% to 70% (odds ratio [OR]: 3.55, p < .001, 95% confidence interval [CI]: 1.69, 7.29), with a corresponding decrease in potential wRVU loss from 35% to 10% (OR: 4.87, p < .001, 95% CI: 0.81, 10.51). Dynamic billing feedback significantly improved outpatient E/M coding among otolaryngology healthcare providers in this study. This study demonstrates that educating providers on appropriate medical coding and billing policies, while providing dynamic, intermittent feedback, may improve billing accuracy, translating into appropriate charges and reimbursements for services provided.

ObjectiveTo determine whether intracapsular tonsillectomy, using plasma ablation, results in differences in postoperative patient outcomes to total tonsillectomy.Data SourcesA systematic review of two databases (Embase and PubMed) was conducted in March 2022 to identify published English‐language randomized controlled trials and observational studies which provided a comparison between intracapsular tonsillectomy, using plasma ablation, and total tonsillectomy.Review MethodsQualitative synthesis and meta‐analysis were used to compare outcomes between techniques.ResultsSeventeen studies were identified for inclusion. Across these, 1996 and 4565 patients underwent intracapsular and total tonsillectomy, respectively. Studies included 8 randomized controlled trials, 1 prospective cohort study, and 8 retrospective cohort studies. Time to pain free, time on analgesia, time to normal diet, and time to normal activity were significantly shorter with intracapsular tonsillectomy by on average 4.2 (95% confidence interval [CI] 1.5‐5.9; p < .0001), 4.1 (95% CI 2.7‐5.4; p < .0001), 3.5 (95% CI 1.7‐5.4; p = .0002) and 2.8 (95% CI 1.6‐4; p < .0001) days, respectively. Risk of posttonsillectomy hemorrhage was significantly lower following intracapsular tonsillectomy (relative risk [RR] 0.36; 95% CI 0.16‐0.81; p = .0131); risk of posttonsillectomy hemorrhage requiring surgical management was lower but failed to reach significance (RR 0.52; 95% CI 0.19‐1.39; p = .19).ConclusionIntracapsular tonsillectomy using plasma ablation has similar efficacy in managing indications for tonsil surgery to total tonsillectomy while significantly reducing the postoperative morbidity and likelihood of posttonsillectomy hemorrhage experienced by patients, allowing them to return to their normal life faster.