Harvard Otolaryngology Spring 2014

HARVARD

SPRING 2014

ISSUE 10

NEWS FROM THE DEPARTMENT OF OTOLARYNGOLOGY AT HARVARD MEDICAL SCHOOL

Otolaryngology New Hope for the ABI

Clinical trials explore auditory brainstem implant outcomes in a select population of deaf patients (page 14)

Otolaryngology

HARVARD Otolaryngology

News from the Department of Otolaryngology at Harvard Medical School Please send comments, requests for additional copies and other inquiries regarding this issue to: Suzanne Day Publications Manager Department of Otolaryngology Massachusetts Eye and Ear 243 Charles Street, Boston, MA 02114 Ph: 617-573-3897 | suzanne_day@meei.harvard.edu

Contributors Editors-in-Chief: D. Bradley Welling, M.D., Ph.D., FACS Joseph B. Nadol, Jr., M.D. Managing Editor: Suzanne Day Writer: Suzanne Day Design/Layout: Garyfallia Pagonis Principal Photography: Garyfallia Pagonis Contributing Photographers: Mary Leach, Jon Pack Contributing Writer: Mary Leach

Spring 2014

Issue 10

Contents 1 Meet Our New Chief and Chair D. Bradley Welling, M.D., Ph.D., FACS 2 Specialized Fellowship Program Will Advance Care for Patients With Dizziness and Imbalance 3 From Bench to Bedside: Clinical Research in the Pediatric Airway, Voice and Swallowing Center 4 Researchers Gain Insight into Clinical Vestibular Testing 6 Awake Steroid Injections May Effectively Treat and Prevent Recurrence of Idiopathic Subglottic Stenosis 10 Moving Forward with Research

One year later, reflections from Harvard Otolaryngology physicians on the Boston Marathon bombing 14 New Hope for the ABI

Clinical trials explore auditory brainstem implant outcomes in a select population of deaf patients

17 Research Highlights 20 News and Notes

On the Cover: Philip Frederick and his son, Alex, the youngest child to receive the ABI in the United States. Photo by Mary Leach.

Otolaryngologists from around the world gathered for the “Endoscopic Surgery of the Sinuses, Eustachian Tube and Ear� course held in the Joseph B. Nadol, Jr., M.D. Otolaryngology Surgical Training Laboratory.

Meet Our New Chief and Chair D. Bradley Welling, M.D., Ph.D., FACS, is the sixth Walter Augustus LeCompte Professor and Chair of Otology and Laryngology at Harvard Medical School and Chief of Otolaryngology at Massachusetts Eye and Ear and Massachusetts General Hospital. His appointment concluded a year-long, nationwide search that began when his predecessor, Joseph B. Nadol, Jr., M.D., announced that he planned to step down after 28 years to focus more on his research efforts.

“Without question, Dr. Welling is an exemplary leader and worthy successor to Dr. Nadol, who has ably led the Department through unprecedented growth for 28 years.

We are delighted that these two leaders will have time for a thoughtful and thorough transition,” said John Fernandez, President and CEO of Mass. Eye and Ear. Dr. Welling joined the Department after devoting much of his career to The Ohio State University, where he served in multiple capacities from 1989 to 2014, including nine years of service as Chair of Otolaryngology. He earned his bachelor of arts and his doctor of medicine at the University of Utah in Salt Lake City. He completed his residency in Otolaryngology–Head and Neck Surgery at the University of Iowa and a fellowship in Otology, Neurotology and Skull Base Surgery at the Ear Foundation in Nashville, Tenn.

Dr. Welling has a doctorate in Pathobiology from The Ohio State University.

“It is a tremendous honor for me to join this great department. I have been so impressed with the dedication, talent and passion to improve patients’ lives and to bring forward knowledge that will bless many more,” Dr. Welling said. “The commitment to educating the next generation is inspiring.

I consider myself most fortunate to be surrounded by such energy and ability.”

Among his many contributions to the otolaryngology community, Dr. Welling currently serves as a member of the Residency Review Committee for the Accreditation Council on Graduate Medical Education. He is a Director of the American Board of Otolaryngology and is the Presidentelect of the American Otologic Society. Dr. Welling’s research involves basic and translational studies on Neurofibromatosis type 2-associated tumors, for which he was awarded the Edmund Prince Fowler Award by the Triological Society.

Dr. Welling’s leadership formally began on March 1, 2014.

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Dr. Steven Rauch with David and Sharon Neskey.

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aculty from the Department of Otolaryngology at Harvard Medical School recently announced the establishment of the Neskey-Coghlan Fellowship in Balance and Vestibular Disorders, a one-year post-residency fellowship program based at Massachusetts Eye and Ear, to train qualified physicians in the diagnosis and management of patients with balance and vestibular disorders.

Specialized Fellowship Program Will Advance Care for Patients with Dizziness and Imbalance

Dizziness and imbalance are very common in the United States, with up to 40 percent of Americans visiting a doctor at some point in their lives with complaints of these symptoms. For seniors, dizziness and imbalance can lead to falls, which account for 50 percent of accidental deaths.

However, unearthing the cause and managing these symptoms can be challenging and often involves input from a diverse group of medical specialties. For this large population of patients, finding one specialist to take ownership of their care can be difficult.

“There is a real shortage of physicians, globally, who specialize in the evaluation and management of dizzy patients,” said Steven D. Rauch, M.D., who will serve as director of the fellowship program. “Patients who have balance problems suffer in our healthcare system, because our sense of balance involves information from the ears, from the eyes, from the muscles and joints sending signals up the spine…and there is no one specialty that owns all of that system.”

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With four clinicians who specialize in the evaluation and management of dizzy and off balance patients, two state-of-the-art vestibular diagnostic laboratories (one in Boston and another in Braintree), and a high volume of dizzy patients, Massachusetts Eye and Ear offers an ideal environment for training future specialists in balance disorders.

“We are fortunate in this department that we have a collection of otologists and neurologists who specialize in the management of balance and dizziness disorders,” Dr. Rauch said. “The way that we can really leverage our expertise and help people is to train more dizzy doctors and to send them out to populate clinics and departments all over the world.”

This specialized fellowship program was made possible through the generosity of Mr. David Neskey, his wife Sharon, and his friends Paul and Tina Coghlan. A long-time patient of Dr. Rauch, Mr. Neskey suffers from hearing loss and vestibular problems as a result of Meniere’s disease. He has also been a friend and trustee of Mass. Eye and Ear for many years.

The first fellow selected will start in July 2015.

The one-year post-residency fellowship will comprise a minimum of 75 percent time commitment to clinical training and patient care under the supervision of our faculty, with the remainder of the fellows’ time dedicated to clinical research, didactic and other scholarly career development. Candidates will be drawn from specialties in which physicians may have an interest in balance problems, including (but not limited to) otolaryngology and neurology. l

From Bench to Bedside Clinical Research in the Pediatric Airway, Voice and Swallowing Center

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he Pediatric Airway, Voice and Swallowing Center brings together pediatric otolaryngologists, pediatric pulmonologists, pediatric surgeons, pediatric gastroenterologists, pediatric psychiatrists, speechlanguage pathologists and other specialized health professionals from Massachusetts Eye and Ear and Massachusetts General Hospital for Children to provide multidisciplinary, comprehensive care for patients suffering from conditions affecting the upper airway.

Photos courtesy of Mary Leach

Christopher J. Hartnick, M.D., M.S. Epi, established the Center to improve communication between specialists and to address the logistical problems of having patients travel between two hospitals for treatment. Modeled after a similar airway center at the Cincinnati Children’s Hospital, where Dr. Hartnick obtained fellowship training in pediatric otolaryngology, the Center at Mass. Eye and Ear offers patients the convenience of being cared for by this group of specialists all under one roof.

“Before the Center was established, patients and their families were having to come to two different hospitals on different days, and they often had to have procedures done separately rather than simultaneously,” Dr. Hartnick said. “It was a complicated system.”

But in addition to the clinical and logistical advantages for physicians and their patients, the Center model has also engendered an ideal setting for clinical research.

Dr. Hartnick with a patient before surgery.

The Center is in the third year of a five-year clinical trial funded by the National Institutes of Health that investigates the benefits of voice therapy in children ages 6 through 10 with benign vocal nodules. The study is a collaborative effort between these physicians and specialists and the Mass. Eye and Ear Voice and Speech Laboratory.

Currently there is little standardization of treatment in voice therapy for hoarseness for the

pediatric population.

The goal of the study is to determine whether or not voice therapy improves quality of life for this particular subset of patients.

“We send these patients to a speech therapist for voice therapy to Dr. Christopher Hartnick teach them how to use their voices well, but we don’t know exactly what therapy is the best, or if it works at all,” said Dr. Hartnick.

Voice therapy is a very common medical intervention for patients with benign vocal nodules who are hoarse. However, many insurance companies do not cover the full cost of treatment, as it has not been proven to be effective in restoring voice in these patients. Patients and their families may be burdened by time away from school and work, while also having to cover the cost of multiple sessions out of pocket.

“It’s a common problem, and yet it’s a family problem,” Dr. Hartnick said. “There is a cost associated, and parents often have to take time off from work.”

The clinical trial follows 116 children ages 6-10 who have been diagnosed with hoarseness due to benign vocal nodules. Patients are randomly assigned to two different treatment pathways, with one group practicing vocal hygiene and the second group completing a regimen of standardized voice therapy. Dr. Hartnick and his team will then ask basic questions to determine whether these patients benefit from therapy.

Other clinical trials are in the nascent stages of development in the Center, including a study of treatments for paradoxical vocal fold motion, as well as a study on the application of optical biopsy to aid in the diagnosis of vocal nodules.

He hopes that the Center will continue to advance treatment for pediatric patients in this complex area where multiple specialties meet.

“Our Center is not just designed for clinical care,” Dr. Hartnick said. “We want to move our research from bench to bedside to try to implement new techniques and technologies to improve these kids’ lives. This is one of the best ways to move forward.” l

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Researchers Gain Insight into Clinical Vestibular Testing

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hen patients present with dizziness and imbalance, physicians often turn to clinical vestibular testing to assess vestibular function in the inner ear.

But modern clinical vestibular testing has its shortcomings.

Because the vestibular system in the inner ear is so complex, physicians must rely on a series of tests that yields almost 100 data points, as well as the analytical skills of whoever is interpreting the test results, to put together a diagnosis.

“The vestibular system in the inner ear is complicated and can be very hard to study,” said Dr. Richard Lewis, Medical Director of the Jenks Vestibular Diagnostics Laboratory at Mass. Eye and Ear. “None of the tests can give us a perfect answer, and that’s why we do a series of four tests. Even then, it’s not usually an easy ‘yes’ or ‘no’ answer.”

To overcome this, and in the interest of improving diagnoses for patients suffering from vestibular problems, Dr. Lewis and his colleagues from Mass. Eye and Ear/Harvard Medical School used machine learning to look at the reliability of each test in the clinical vestibular test battery. In this study, they determined that rotational testing is the most reliable in detecting unilateral vestibular loss.

“The rotational test will give you the right answer 80.2 percent of the time, so that test is much more sensitive.”

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Clinical vestibular testing at Mass. Eye and Ear includes four separate tests performed in one of two clinical vestibular testing laboratories—one located at the main campus in Boston and the other at the suburban site in Braintree. The full test battery includes rotational testing, visual-vestibular interaction testing, electronystagmagram (ENG) and computerized dynamic posturography. The two most salient results in determining vestibular loss are the asymmetry of caloric response, derived from the ENG, and the vestibuloocular reflex time constant, derived from the rotational test.

The research project began as an endeavor to develop an algorithm for sorting out the broad test results from the full battery of clinical vestibular testing. Dr. Lewis and his colleagues had noticed that in about 30 percent of patients who received a complete evaluation, the results from the caloric ENG and the rotational testing disagreed, making it very difficult to draw conclusions for those patients and their doctors.

“In these cases where those two results conflict, we couldn’t determine if there was a problem with the vestibular system or not,” Dr. Lewis said.

With help from a computer scientist, they reviewed more than 10,000 results from records dating back to the laboratory’s establishment in 1986 and applied machine learning to develop an algorithm to make a correct diagnosis. The best algorithm was 95.6 percent accurate in determining the presence or absence of vestibular loss.

“If we add the machine learning algorithm to help us interpret the data, we get the answer right more than 95 percent of the time,” Dr. Lewis said. “It does it in a way that can’t be done by a person, since the algorithm is trained to use complex patterns of data to converge on the correct answer.”

Once the machine learning technique was determined to be successful, Dr. Lewis and his team wanted to go further and test the validity of each individual test in the full clinical vestibular test battery.

“Once the machine learning algorithm had been determined, we then had a way of running the data through the algorithm to determine which test was more accurate,” Dr. Lewis said. “The machine learning gave us a tool to look at the utility of each test individually, and we found, surprisingly, that the test that’s recommended most for unilateral loss is not the most sensitive.”

They found that the rotational test was the most sensitive test in determining unilateral vestibular loss.

This finding challenges the current recommendation that caloric testing is the gold standard for assessing unilateral vestibular loss by the American Academy of Neurology.1

“If you look at the American Academy of Neurology statement, they recommend caloric testing as the gold standard for unilateral vestibular loss,” said Dr. Adrian Priesol, Dr. Lewis’ collaborator in this research and an otoneurologist at Mass.

Eye and Ear/Harvard Medical School. “Our results challenge that. They indicate that the most sensitive test for unilateral loss is also rotational testing.”

“If someone is abnormal, we’ve found that the caloric test will give you the right answer 59.3 percent of the time, which is just a little better than flipping a coin, meaning that you have a 40 percent chance of being misdiagnosed,” Dr. Lewis said. “The rotational test will give you the right answer 80.2 percent of the time, so that test is much more sensitive.”

Drs. Lewis and Priesol speculate that the caloric response may not be as accurate for a variety of reasons, perhaps because of the expertise needed to perform the test or because of the complex anatomy of the inner ear.

“It turns out that the caloric ENG is not a very good test, because there are so many variables that can compromise the results,” Dr. Lewis said.

“If somebody had scarring from childhood ear infections, there may be a false positive in caloric testing because the amount of insulation is different on one side because of the pathology,” Dr. Priesol added. “It’s also a technically difficult study. For example, the position of the the stimulating probe may be different on the two sides.”

Rotational testing is currently not as commonly done as the caloric ENG, because the equipment is expensive and requires experienced technicians to perform the test.

“Rotation testing involves a heavy chair that has to be very accurately turned, and the data must be carefully analyzed to avoid spurious results,” Dr. Priesol said.

“We have an engineer in our lab who keeps everything running, which is costly, but it’s worth it.”

Treatment decisions are often made based on the results of these tests, and sometimes these treatments involve surgery.

“As physicians, we are reliant on these tests to make accurate diagnoses and to decide the best course of treatment for our patients,” Dr. Lewis said. “False positives in caloric testing could lead to inappropriate treatment.” l

Dr. Richard Lewis, top photo inset and Dr. Adrian Priesol, bottom inset.

Reference: 1. Assessment: vestibular testing techniques in adults and children: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Fife TD, Tusa RJ, Furman JM, Zee DS, Frohman E, Baloh RW, Hain T, Goebel J, Demer J, Eviatar L. Neurology. 2000 Nov 28;55(10):143141. PMID: 11094095

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Awake Steroid Injections May Effectively Treat and Prevent Recurrence of

Idiopathic Subglottic Stenosis

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Dr. Ramon Franco measures air flow volume in a patient.

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ubglottic stenosis, or an abnormal narrowing of the airway, is a medical problem that afflicts children and adults. It can occur for a variety of reasons, from traumatic injury to cancer, but for some patients it occurs without a known cause.

This particular subset of patients, usually women between 40 and 60 years old, suffers from idiopathic subglottic stenosis. When the process for the disease is unknown, it can Dr. Ramon Franco be very difficult to decide on a treatment plan without knowing how to prevent the stenosis from recurring.

Standard treatment methods have been disappointing for a number of reasons.

Dr. Ramon Franco, Director of the Laryngology Division at Massachusetts Eye and Ear, has developed a new approach to treating idiopathic subglottic stenosis that is minimally invasive using awake steroid injections.

The treatment has shown to not only effectively open the airway but also to curb the scarring process and in some cases prevent recurrence of the disease.

More traditional methods for treating idiopathic subglottic stenosis often lead patients down a surgical pathway. The laryngologist can dilate the airway, either by inflating a balloon or with rigid dilators. However, “With the steroid injections, patients who opt for this treatment will need to have you’re changing the airway, their airways dilated once and what I like most about it every six months, and the is that you’re changing it airway will gradually become at a biochemical level. narrow again shortly after You are truly affecting the that initial dilation. disease and preventing “By the time you get close its recurrence.” to the 5- or 6-month mark before your next dilation, you’re already doing badly again,” Dr. Franco said. “And that’s no way for patients to live their lives — waiting for their next dilations to be able to breathe.”

A second method involves repeated surgeries to open the subglottis, by coring out a piece either with a laser or cold instruments. This method typically offers a few additional months of relief than the dilating method, but it still necessitates regular trips to the operating room.

The third and most invasive treatment option is cricotracheal resection surgery. Though intended to be a permanent solution for subglottic stenosis, cricotracheal resection has been known to fail in some patients with continued on page 8

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“The side effects are very difficult, and it’s incompatible with getting pregnant,” Dr. Franco said. “Although we were getting results with airways staying open longer, patients just couldn’t tolerate it.”

More than 3 years ago, Dr. Franco began using awake steroid injections to reverse the disease course and to allow these patients to breathe. This technique takes advantage of the natural anti-inflammatory and antiscarring properties of steroids, with patients seen every three weeks over a course of 4-6 injections.

“We know that if we inject the skin with steroids, it will become thinner, and it changes the properties of anything that has collagen in it,” Dr. Franco said.

The procedure takes merely five minutes and is performed in an office setting. The physician first numbs the area with an injection of lidocaine, which causes the patient to cough, spreading the anesthetic through the trachea and the voice box. Using a scope to visualize the

idiopathic subglottic stenosis, as the disease process may return and narrow the airway again after surgery.

“The problem is that with idiopathic subglottic stenosis, when we have no idea what’s causing the narrowing, we see some patients who will fail after surgery,” Dr. Franco said. “So we do this big procedure on them, with a sizeable incision in the neck, and then for whatever reason the stenosis returns.”

Because none of these treatments can definitively offer stable long-term results for a disease process that is poorly understood, Dr. Franco and other laryngologists have spent a considerable amount of time searching for a better way to treat these patients.

For Dr. Franco, the first step was a shift in approach, and he encourages other physicians to see idiopathic subglottic stenosis as a chronic disease that may benefit more from medical management than from surgical repair.

“We’ve been taking these cases of idiopathic subglottic stenosis down the surgical pathway, thinking that this is a surgical disease, when it’s really not,” Dr. Franco said. “It’s a medical disease that we happen to treat every once in a while with surgery.”

With this in mind, Dr. Franco began to look into medical therapies for idiopathic subglottic stenosis.

Methotrexate, a chemotherapeutic agent that slows down the scarring process, is sometimes used to treat subglottic stenosis. However, for women in their 40s and 50s, the drug can take a toll on quality of life.

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Outcomes for a patient treated with steroid injections for idiopathic subglottic stenosis: BEFORE

AFTER

The above photographs show a patient’s subglottic region before and after treatment with steroid injection.

The first graph is a flow-volume loop recorded when a patient was asked to breathe into a portable spirometry machine. These tests are used to keep track of how much air the patient is able to get through the larynx, especially through the area of stenosis. The upper part of the graph represents breathing out. The lines do not reach the normal areas shaded in blue, which indicates that the patient’s maximum flow is under 5 liters per second, causing breathing difficulty. The patient’s peak expiratory flow is 55% of predicted (80% or higher is considered normal).

“We’ve been taking these cases of idiopathic subglottic stenosis down the surgical pathway, thinking that this a surgical disease, when it’s really not.

It’s a medical disease that we happen to treat every once in a while with surgery.” affected area, the physician then injects the steroid into the scarred area.

Dr. Franco’s clinical data has shown treatment equivalence with dilations alone (p=0.99) and with surgery plus steroid injection at the time of surgery (p=0.9). The steroid injections are equivalent to the more traditional, more invasive and inconvenient forms of treatment.

Moreover, the data shows that the steroid injections have long-term effects on some patients, cumulatively melting away the scarred area.

“There are some patients who will never require another treatment it seems,” Dr. Franco said. “Some people are very steroid responsive.”

These long-term results suggest that the steroid injections are gradually improving the airway, as opposed to surgery or the dilation methods, which open the airway quickly but don’t do anything to prevent recurrence.

“With the steroid injections, you’re changing the airway, and what I like most about it is that you’re changing it at a biochemical level,” Dr. Franco said.

“You are truly affecting the disease and preventing its recurrence.” l

The second graph shows the patient’s results after the steroid injections were stopped over one year previously. The lines now extend well into the normal areas shaded in blue. Importantly, the peak in the top part of the graph (breathing out) can be appreciated, representing the ability to rapidly exhale air. The patient’s peak expiratory flow is 94% of predicted.

This patient no longer suffers from respiratory problems from subglottic stenosis.

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Moving Forward with Research

One year later, reflections from Harvard Otolaryngology physicians on the Boston Marathon bombing 10

Photo by Jon Pack

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everal hours after the explosions at the finish line of the 2013 Boston Marathon, Dr. Aaron Remenschneider had seen more patients with acoustic trauma in the Mass. Eye and Ear and Mass General emergency departments in one day than in his entire career.

As the chief otolaryngology resident on call on April 15, 2013, Dr. Remenschneider treated patients with blast-related eardrum perforations, as well as hearing loss, tinnitus and vestibular complaints, deep into the night. The volume of patients was so unusual that he began to keep track of patients by drawing the eardrums he saw in a notebook.

“I saw so many patients that the only way I could keep track was to draw pictures of what I saw,” he said.

The experience of the event led Dr. Remenschneider and the attending neurotologist on call that evening, Dr. Alicia Quesnel, to initiate a multi-institutional study to follow patients who suffered otologic injuries as a result of the Boston Marathon bombing.

They are joined in these efforts by Harvard Otolaryngology colleagues Drs. Daniel Lee from

Mass. Eye and Ear and Brigham and Women’s Hospital, Selena Heman-Ackah from Beth Israel Deaconess Medical Center and Jacob Brodsky from Boston Children’s Hospital. The study also includes data from other participating institutions in Boston—Harvard Vanguard Medical Center, Boston Medical Center and Tufts Medical Center—to provide a complete picture of patients seen with ear injuries caused by the blasts.

Though military literature has provided some understanding of blast-related ear injuries, few studies have explored otologic outcomes following an explosion in a civilian population.

“We’ve collected a significant amount of prospective data on these patients,” Dr. Quesnel said. “In addition to obtaining audiograms and physician records, we’ve asked them to fill out surveys that attempt to quantify their hearing, tinnitus and dizziness handicaps related to the explosions.” continued on page 12

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Courtesy of Beth Israel Deaconess Medical Center

Though military literature has provided some understanding of blast-related ear injuries, few studies have explored otologic outcomes following an explosion in a civilian population.

“The patient population is somewhat different because civilians are not wearing armor or ear protection,” Dr. Remenschneider said. “We also saw pediatric and elderly patients who were affected. While most military patients are in their 20s, the patients in this study span a complete range of ages.”

For a period of three years, the study will follow the 94 patients who were seen for acoustic trauma at the collaborating institutions, with the largest number (78) seen at Mass.

Eye and Ear. Through this research, investigators are trying to understand the range and scope of these injuries and how the quality of victims’ lives has been affected.

“In patients who suffered from sensorineural hearing loss or tinnitus that we suspect is related to the blast, we’re looking at whether or not that improved over time,” Dr. Quesnel said. “We’re also looking at how patients who underwent tympanoplasty for ear drum perforations— did they heal at the same rate as patients who have this surgery for another cause?”

Many of the victims who suffered acoustic trauma were not seen until the following day or week after the blasts, as they first needed to be stabilized from life- or limb-threatening injuries. This was especially true at Beth Israel Deaconess Medical Center, where 18 out of 20 patients seen by Dr. Heman-Ackah suffered from eardrum perforations that required surgical repair.

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“For the most part, the patients that I consulted with were seen a day or two after they had undergone multiple orthopedic procedures,” Dr. Heman-Ackah said. “I saw a lot of pretty substantial perforations, and some of them were total perforations.”

The experience challenged Dr. Heman-Ackah in other ways.

“We’re also looking at how patients who underwent tympanoplasty for ear drum perforations— did they heal at the same rate as patients who have this surgery for another cause?”

Dr. Alicia Quesnel

“The otology part was easy,” she said. “Seeing people who were my age or younger in this situation when they were out doing great things, raising money for a cause and supporting their community—that was the hardest part.”

At Boston Children’s Hospital, Dr. Brodsky similarly began to see victims with ear injuries as they became evident in the days following the event. As the attending neurotologist on call, he saw most patients directly in the ICU. “It was especially challenging because a lot of earrelated symptoms are very hard for children to articulate,” Dr. Brodsky said. “Especially after a traumatic incident like this, younger children are very challenging sometimes to examine, and especially to examine their ears.”

For Dr. Brodsky, participating in the research study has helped him to heal by contributing to the literature and adding to what is known about pediatric otologic injuries in relation to a bombing.

“The entire week was very diffi“The otology part was easy. cult for everyone on our team,” Dr. Seeing people who were my age or Brodsky said. “For me personally, this younger in this situation when they were study has given me the opportunity out doing great things, raising money to process what went on and to try to move forward.” for a cause and supporting their Similarly, the large number of community—that was the hardest part.” victims who have participated in the Dr. Selena Heman-Ackah study shows their resilience.

“We both wanted to live out the philosophy and mission of the marathon, which is to persevere and to bring people together.

It’s a huge celebration for the city and a day for people to look forward to.”

Dr. Aaron Remenschneider and his wife Emily

Photo courtesy of Mary Leach

“I’ve been so impressed by how these individuals have been willing to participate in the study,” Dr. Remenschneider said. “I think it helps them to feel as though they are a part of something that’s bigger than just being a victim.”

As it has been one year since the study was initiated, preliminary data is currently being tabulated and evaluated. Dr. Sharon Kujawa, director of the Mass.

Eye and Ear audiology department, has been especially instrumental in determining the best way to analyze the audiologic data. Early findings were presented at the Combined Otolaryngology Society Meetings (COSM) in May 2014.

Dr. Remenschneider ran the 2014 Boston Marathon with his wife, Emily, on behalf of Mass. Eye and Ear to support research on blast-related injuries to the ears.

“We both wanted to live out the philosophy and mission of the marathon, which is to persevere and to bring people together,” he said. “It’s a huge celebration for the city and a day for people to look forward to. We celebrated all of the good things about Boston and our city’s resilience.” l

Photo by Ian Howard. Permission granted by Creative Commons license.

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New Hope for the ABI Clinical trials explore auditory brainstem implant outcomes in a select population of deaf patients

Daniel J. Lee, M.D., FACS, and a team of surgeons, audiologists and nurses from Mass. Eye and Ear and Mass General Hospital for Children (MGHfC), recently made history by performing an auditory brainstem implant (ABI) on the youngest child to date in the United States.

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Dr. Daniel Lee with the Frederick family before surgery.

“The clinical data from Europe has really helped to reenergize the field of auditory brainstem implantation.”

Dr. Daniel Lee

not have NF2 and do not qualify for cochlear implant based upon anatomy.

Inspired by this encouraging work, Dr. Daniel Lee is exploring auditory brainstem implant outcomes in a select population of deaf patients, and has successfully performed the procedure on an infant.

Making Pediatric Auditory Brainstem Implant History Dr. Lee and his team enrolled and performed ABI surgery on their first patient in the pediatric clinical trial, a 17-month old child named Alex Frederick from Michigan, in October 2013. The patient was the youngest child to date to receive the auditory brainstem implant in the United States. In March 2014, the team successfully placed an ABI in a 12-month old infant.

Physicians are hopeful that the ABI may support oral language development, especially in children who are

Photo courtesy of Mary Leach

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or patients who are profoundly deaf but unable to receive the cochlear implant, the auditory brainstem implant (ABI) has been shown to restore some degree of hearing sensation. Unlike a hearing aid or cochlear implant, the ABI bypasses the outer, middle and inner ears and the auditory nerve to directly stimulate the cochlear nucleus, a special center in the brainstem that normally receives inputs from the cochlea and auditory nerve and transmits these inputs to the pathways of hearing in the brain.

In the U.S., the ABI is approved by the FDA in patients with Neurofibromatosis type 2 (NF2) age 12 and older. But recent clinical outcomes from Europe suggest that the ABI may improve quality of life for other deaf populations, specifically in patients who are deaf but do

Dr. Lee, Director of the Helene and Grant Wilson Pediatric and Adult Auditory Brainstem Implant Program, is leading two FDA-approved clinical trials of auditory brainstem implants—one for adults and another for pediatric patients. The goal of the studies is to collect and evaluate short- and long-term outcomes data in pediatric and adult patients who are deaf, do not qualify for cochlear implant and do not suffer from NF2.

Studies from Europe have also shown that these nonNF2 patients experience improved speech perception over those with NF2.

“The clinical data from Europe has really helped to reenergize the field of auditory brainstem implantation,” Dr. Lee said. “It gives us new hope that an implant that bypasses the cochlea and auditory nerve can provide meaningful sound sensations that go beyond just the ability to enhance lip reading.”

The clinical trials follow infants, children and adults who do not have NF2 but have deafness from conditions that do not allow for successful cochlear implant surgery.

This may include severe congenital malformation of the inner ear, scarring of the inner ears due to infection or injury to the auditory or cochlear nerves.

For pediatric ABI candidates, neuropsychological evaluations are critical to determine the developmental age of the child and to establish expectations for the families involved. Dr. Margaret Pulsifer of MGHfC has provided evaluations for candidates enrolled in the clinical trial.

continued on page 16

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Photos courtesy of Mary Leach

Colletti, whose work on auditory brainstem implants in Italy has led the way for the clinical trials based at Mass. Eye and Ear. Chairman of Otolaryngology at the University of Verona, Dr. Colletti was the first surgeon in the world to implant the ABI in an infant and has the most experience with the device, having performed more than 100 of these operations. Drs. Colletti and Lee have developed a formal collaboration that will allow for the exchange of research fellows, surgical training and analysis of ABI outcomes in this unique patient population.

“Professor Colletti has been a vital member of our team,” Dr. Lee said. “He has been a part of our surgeries and has given us valuable insight in ensuring that we provide safe and successful surgery for pediatric candidates, specifically.”

Dr. Daniel Lee performing ABI surgery.

normal neurologically and are implanted at a young age.

“We are optimistic that this approach can take advantage of the extraordinary capacity of the brains of young children to learn and adapt to their environments,” said Dr. Ann-Christine Duhaime, Director of Pediatric Neurosurgery at Massachusetts General Hospital for Children. “Their plasticity is a real advantage at this age and we are very happy to be able to explore this option to restore hearing for these children.”

The surgical team included Dr. Lee, Dr. Duhaime and Dr. Frederick Barker (Chief of Skull Base Neurosurgery at MGH), as well as a special guest, Professor Vittorio

Dr. Lee with Professor Vittorio Colletti, Chairman of Otolaryngology at the University of Verona.

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What’s next?

For all patients, not just those involved in the clinical trials, a lot of hard work is needed to achieve success with the ABI. “Continuous interactions with audiology and speech therapy are essential,” Dr. Lee said. “You have to make sure that continuous tracking of their hearing progress is made, as well as understanding how the hearing programming can be improved in order to enhance the hearing in that particular patient. We are grateful to Dr. Barbara Herrmann, who has overseen the programming of these children after surgery, and to Cheryl Bakey for ensuring that the language needs of the candidate are met before and after surgery.”

Following these patients for five years after surgery, the team will assess the long-term safety and efficacy of the ABI in these subjects by measuring audiologic performance with the ABI, recording stimulation thresholds for each electrode and evaluating any complications that may arise.

The studies may help provide future patients with ABI technology.

“We hope that, in fact, we can use an implant to safely and reliably stimulate an area beyond the cochlea and actually provide sound sensations that go beyond the ability to give improved lip reading abilities and give these patients back some of their hearing.” l

RESEARCH HIGHLIGHTS

The following are select research advances from the HMS Department of Otolaryngology.

Excerpted from press releases written by Mary Leach, Director of Public Affairs at Mass. Eye and Ear. For more information, please visit www.MassEyeAndEar.org/news.

Basic Science Researchers Gain Insight into “Lazy Ear” Daniel B. Polley, Ph.D. and colleagues of the EatonPeabody Laboratories have identified two critical periods occurring shortly after hearing onset that regulate how sounds from each ear are fused into a coherent representation in the brain. Their research appeared in the online journal, Nature Communications, in September 2013.

Degraded sensory experience during critical periods of childhood development can have detrimental effects on the brain and behavior.

In this study, researchers set out to determine how temporary disruption of hearing at precise times in development affect the ability for the brain to hear once hearing is restored.

If sensory experience is degraded during these critical periods in early life, as would occur with conductive hearing loss that can accompany an ear infection, the brain’s representation of the sensory world can be distorted in a specific and enduring way, even after the physical deficit in the ear has been corrected.

In this study, researchers found that creating a temporary hearing loss one day after hearing has begun disrupted the basic alignment of sound frequency selectivity in the mouse cortex, whereas the same manipulation initiated just a few days later interfered with the neural computation of loudness differences between the ears.

“These findings demonstrate that brief bouts of asymmetric hearing loss during very specific points in postnatal development can have a lasting effect on brain circuits that compare and integrate the sound waves that enter each ear,” Dr. Polley said. “Though our study was conducted in an animal

model, these data support a growing body of work that underscores the importance of minimizing hearing loss or excessive environmental noise for healthy infant brain development.”

New Findings in Protective Mechanisms for Hearing Loss Mingqian Huang, Ph.D., Albena Kantardzhieva, Ph.D., M. Charles Liberman, Ph.D., Zheng-Yi Chen, Ph.D. and colleagues in the Eaton-Peabody Laboratories, have created a new mouse model in which, by expressing a gene in the inner ear hair cells, protects the mice from age-related hearing loss (ARHL) and noiseinduced hearing loss (NIHL).

Researchers Regenerate Hair Cells in the Ears of Mice Albert Edge, Ph.D. and colleagues have found that supporting cells in the inner ear can turn into hair cells in newborn mice. If the findings can be applied to older animals, they may lead to ways to help stimulate cell replacements in adults and to the design of new treatment strategies for patients suffering from deafness due to hair cell loss. This research appeared in the online journal, Stem Cell Reports, in February 2014.

The team’s previous research revealed that inhibition of the Notch signaling pathway increases hair cell differentiation and can help restore hearing to mice with noiseinduced deafness. In their latest work, the investigators found that blocking the Notch pathway increases the formation of new hair cells not from remaining hair cells but from certain nearby supporting cells that express a protein called Lgr5.

“By using an inhibitor of Notch signaling, we could push even more cells to differentiate into hair cells,” Dr. Edge said.

“It was surprising that the Lgr5-expressing cells were the only supporting cells that differentiated under these conditions.”

Combining this new knowledge about Lgr5expressing cells with the previous finding that Notch inhibition can regenerate hair cells will allow the scientists to design new hair cell regeneration strategies to treat hearing loss and deafness.

Adapted from a press release courtesy of Cell Press.

Their research, described in the Sept. 18, 2013 issue of the Journal of Neuroscience, provides new insight into protective mechanisms for hearing loss and suggests the potential for future molecular approaches, which may include gene therapy or medicine, to treat ARHL and NIHL. Mass. Eye and Ear researchers set out to understand if both age-related (ARHL) and noise-induced (NIHL) hearing loss share a common underlying mechanism by studying certain inbred strain of mice. They investigated whether overexpression of Isl1, an inner ear progenitor gene with roles in development and differentiation, could be effective in protecting the inner ear.

The team found that Isl1 expression protected hair cells from degeneration in aging and promoted hair cell survival after exposure to loud noise. As a result, the hearing in aged mice or in mice exposed to intense noise was significantly better than their siblings without the gene. continued on page 18

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RESEARCH HIGHLIGHTS

“The Isl1 gene further preserved the connections between hair cells and neurons, which is necessary for hearing,” senior author Dr. Chen said.

Future research can evaluate if Isl1 is protective from ARHL and NIHL in other mouse strains. The investigators hope to eventually study if such protection can be extended to the human condition.

Researchers Identify Key Components of the Mechanotransduction Channel Jeffrey Holt, Ph.D., and Gwenaelle Géléoc, Ph.D., and colleagues present compelling evidence that TMC1 and TMC2 are components of the mechanotransduction complex in sensory hair cells and may be subunits of the elusive transduction channel. The strongest evidence is based on an amino acid point mutation in TMC1 that alters core ion channel properties in hair cells of Beethoven mice, a model for dominant progressive hearing loss in humans (DFNA36).

They propose that gradients in TMC1 and TMC2 may contribute to frequency selectivity in the human auditory organ. Their research was published in Neuron.

For more information, please visit ChildrensHospital.org/news-and-events

Researchers Show that Efferent Feedback Slows Cochlear Aging Stéphane Maison, Ph.D., M. Charles Liberman, Ph.D., and colleagues of the Eaton-Peabody Laboratories have shown that the Olivocochlear (OC) efferent reflex dramatically slows agerelated hearing loss. Their findings were published in the March 26, 2014 issue of the Journal of Neuroscience.

The team surgically lesioned the OC efferent reflex and tracked hearing changes in mice exposed only to quiet ambient noise. After a year, mice with normal

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OC systems did not show significant hearing loss, while those with a lesioned efferent reflex presented damages to hair cells and auditory-nerve synapses. The lack of OC efferent reflex had turned middle-age ears into senescent ears.

These results support a protective effect of the OC system from the accumulated effects of daily ambient noise exposure. Without OC feedback, damage to hair cells and nerve synapses increases, causing respectively higher hearing thresholds and likely problems hearing in a noisy environment.

These impairments are the two classic signs of age-related hearing loss in humans.

Since MOC reflex strength varies among individuals and can be assessed noninvasively in humans, these findings suggest that a test of efferent reflex strength might identify those most at risk for acquiring significant age-related hearing impairment.

Decoding Sounds’ Source Mitchell Day, Ph.D., and Bertrand Delgutte, Ph.D., of the Eaton-Peabody Laboratories, gained new insight into how localized hearing works in the brain. Their research was published in the Oct. 2, 2013 issue of the Journal of Neuroscience.

In the experiment, researchers recorded the electrical activity of individual neurons in an essential lower-level auditory brain area called the inferior colliculus (IC), while an animal listened to sounds coming from different directions. They found that the location of a sound source could be accurately predicted from the pattern of activation across a population of less than 100 IC neurons – i.e., a particular pattern of IC activation indicated a particular location in space. Researchers further found that the pattern of IC activation could correctly distinguish whether there was a single sound source present or two sources coming from different directions – i.e., the pattern of IC activation could segregate concurrent sources.

“Our results show that higher levels of the brain may be able to accurately segregate and localize sound sources based on the

detection of patterns in a relatively small population of IC neurons,” Dr. Day said. “We hope to learn more so that someday we can design devices that work better in noisy environments.”

Clinical Practice The Supraclavicular Artery Flap for Head and Neck Daniel G. Deschler, M.D., FACS was lead author on a study conducted on 45 patients with defects related to malignant and nonmalignant disease undergoing reconstructive surgery. The team demonstrated the versatility of the supraclavicular artery (SCA) flap in head and neck reconstruction and offered technical highlights to improve the efficiency of flap harvest. The SCA flap is said to be a versatile and reliable reconstructive option for head and neck defects. This research was published in JAMA Facial Plastic Surgery.

Preoperative Laryngeal Exam Prior to Thyroid Surgery Combined with RLN Monitoring Provides Valuable Outcomes Gregory W. Randolph, M.D., FACS and colleagues conducted a retrospective study of all consecutive neck surgeries with nerve monitoring performed by Dr. Randolph at Mass. Eye and Ear/Harvard Medical School between December 1995 and January 2007. Their research was published in Otolaryngology– Head and Neck Surgery.

Of the 1,138 surgeries performed, 25 patients had preoperative vocal cord dysfunction. In patients with preoperative vocal cord dysfunction, recognizable RLN electrophysiologic activity was preserved in more than 50 percent of the cases.

Malignant invasion of the RLN was found in 22 patients. Neural invasion of the RLN was associated with preoperative vocal cord paralysis in only 50 percent of these patients.

In nerves invaded by malignancy, 60 percent maintained recognizable electrophysiologic activity, which was more commonly present

RESEARCH HIGHLIGHTS

and robust when vocal cord function was preserved, the authors wrote.

“Knowledge of electrophysiologic intraoperative neural monitoring provides additional functional information and, along with information about the preoperative condition of the vocal cord function, helps to construct decision algorithms regarding intraoperative management of the RLN, predicting postoperative outcomes, and counseling patients on expectations after surgery,” Dr. Randolph said.

Professionalism Jo Shaprio, M.D., FACS was lead author on a paper published in the April 2014 issue of The Joint Commission Journal on Quality and Patient Safety that describes the establishment of the Center for Professionalism and Peer Support (CPPS) at Brigham and Women’s Hospital. Dr. Shapiro serves as Director of CPPS, which was created in 2008 to educate the hospital community on professionalism and to manage unprofessional behavior.

For more information, please visit BrighamAndWomens.org

Aspirin Intake May Halt Growth of Vestibular Schwannomas Konstantina Stankovic, M.D., Ph.D., led a study that demonstrated, for the first time, that aspirin intake correlates with halted growth of vestibular schwannomas, a sometimes lethal intracranial tumor that typically causes hearing loss and tinnitus.

Motivated by experiments in the Molecular Neurotology Laboratory at Mass. Eye and Ear involving human tumor specimens, researchers performed a retrospective analysis of over 600 people diagnosed with vestibular schwannoma at Mass. Eye and Ear. Their research suggests the potential therapeutic role of aspirin in inhibiting tumor growth and motivates a clinical prospective study to assess efficacy of this well-tolerated anti-inflammatory medication in preventing growth of these intracranial tumors.

“Currently, there are no FDA-approved drug therapies to treat these tumors, which are the most common tumors of the cerebellopontine angle and the fourth most common intracranial tumors,” Dr. Stankovic said. “Current options for management of growing vestibular schwannomas include surgery (via craniotomy) or radiation therapy, both of which are associated with potentially serious complications.”

The findings, published in the journal, Otology & Neurotology, were based on a retrospective series of 689 people, 347 of whom were followed with multiple magnetic resonance imaging MRI scans (50.3 percent). The main outcome measures were patient use of aspirin and rate of vestibular schwannoma growth measured by changes in the largest tumor dimension as noted on serial MRIs. A significant inverse association was found among aspirin users and vestibular schwannoma growth (odds ratio: 0.50, 95 percent confidence interval: 0.29-0.85), which was not confounded by age or gender.

Bioengineering Prototype Chip Makes Possible Fully Implantable Cochlear Implant Researchers from Massachusetts Eye and Ear, Harvard Medical School, and Massachusetts Institute of Technology (MIT) have designed a protype system-on-chip (SoC) that could make possible a fully implanted cochlear implant.

They presented their findings on Feb. 11,

2014 at the IEEE International Solid State Circuits Conference in San Francisco.

Conventional cochlear implants are made up of an external unit with a microphone and sound processer to pick up and encode sound, and an internal unit that is seated in the skull and connected to an electrode array inserted into the cochlea. The external unit raises concerns in some individuals with social stigma and has limited use in the shower or during water sports.

“In addition to the cosmetic aspect of an invisible cochlear implant, a potential major functional benefit is that it can facilitate sound localization. Our system relies on a sound sensor located in the middle ear so that the user can benefit from directional cues provided by the auricle and ear canal.

Conventional cochlear implants detect sound by a microphone located outside of the ear so that important directional cues are lost,” said Konstantina Stankovic, M.D., Ph.D., Mass. Eye and Ear otologist who coled the study with Anantha Chandrakasan, Ph.D., MIT head of Electrical Engineering and Computer Science. “Our long-term goal is to develop a fully implantable cochlear implant. To facilitate that development, we have developed the SoC and tested it in ears of human cadavers.”

In addition, the SoC was designed to require lower power sound processing and auditory nerve stimulation to enable operation from an implantable battery that is wirelessly recharged once daily.

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& NOTES

New Physicians

NEWS

John M. Dobrowski, M.D., FACS, was

recently recruited as an Instructor of Otology and Laryngology at Harvard Medical School, bringing more than 30 years of expertise in Sleep Medicine to the General Otolaryngology Division at Mass. Eye and Ear. Dr. Dobrowski earned his medical degree from St. Louis University School of Medicine and completed his residency training in Otolaryngology–Head and Neck Surgery at the Walter Reed Army Medical Center in Washington, D.C. He holds two board certifications from the American Board of Otolaryngology, one in Otolaryngology– Head and Neck Surgery and the other in Sleep Medicine. Dr. Dobrowski has joined the department after more than 25 years with Cleveland Clinic.

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Linda N. Lee, M.D.,

joined the Facial Plastic and Reconstructive Surgery Division at Mass. Eye and Ear as an Instructor of Otology and Laryngology at Harvard Medical School. Dr. Lee was recruited to the Division to provide a new service, hair restoration surgery, which she studied extensively in her fellowship training in Facial Plastic and Reconstructive Surgery at Johns Hopkins University School of Medicine. Dr. Lee earned her medical degree from Baylor College of Medicine and her residency training in Otolaryngology at Harvard Medical School.

D. Bradley Welling, M.D., Ph.D., FACS, recently

joined the Otology and Neurotology Division at Mass. Eye and Ear as the Walter Augustus LeCompte Professor and Chair of

Otology and Laryngology at Harvard Medical School. For more information on Dr. Welling, please see, “Meet Our New Chief and Chair,” on page 1.

Molly Yancovitz, M.D.,

was recruited to the Facial Plastic and Reconstructive Surgery Division at Mass. Eye and Ear as an Instructor of Otology and Laryngology at Harvard Medical School. Dr. Yancovitz earned her medical degree from the University of California at San Francisco School of Medicine and completed her residency in Dermatology at the New York University School of Medicine. She went on to complete a Mohs surgery fellowship with David S. Becker, M.D., P.C. in New York City. Dr. Yancovitz’ clinical and research interests focus on Mohs surgery, dermatologic surgery and skin cancer (melanoma, specifically).

EPL Seminar Series

The Harvard Medical School Department of Otolaryngology recently launched an online calendar to provide a central resource for the community to share information about our upcoming events.

Thursdays, 4 p.m., Meltzer Auditorium, Mass. Eye and Ear The Eaton-Peabody Laboratories sponsor a seminar series featuring talks relevant to research in hearing and deafness.

Vestibular Seminar Series Mondays, 4 p.m., Sloane Teaching Room, Mass. Eye and Ear The Jenks Vestibular Physiology Laboratory at Mass. Eye and Ear sponsors a seminar series to discuss research on all aspects of the vestibular system.

Visiting Professor Lecture Series Meltzer Auditorium, Mass. Eye and Ear

Harvard Otolaryngology Grand Rounds Thursdays, 7 a.m., Meltzer Auditorium, Mass. Eye and Ear

Regular Otolaryngology Conferences The Department hosts a variety of regular teaching conferences at Mass. Eye and Ear and at Boston Children’s Hospital. For additional information regarding a regular conference, please visit the online calendar.

• ENT Pathology Conference • Facial Nerve Conference • Head and Neck Case Review • Issues in Research • Otology Conferences, including a Journal Club, Special Problems in Otology, and the Otopathology Conference • Pediatric Hearing Loss Case Conference • Rhinology Conferences, including a Journal Club and Special Problems in Rhinology • Thyroid and Parathyroid Surgery Conference

Mandibular reconstruction: What’s new and on the horizon?

Mark K. Wax, M.D., FACS, FRCS Professor of Oral and Maxillofacial Surgery Oregon Health Sciences University May 1, 2014, 7-9 a.m.

Harvard CME Courses Update on Pediatric Airway, Voice and Swallowing Disorders Meltzer Auditorium, Mass. Eye and Ear Directed by Dr. Christopher Hartnick September 13-14, 2014 Surgery of the Thyroid and Parathyroid Glands Boston Marriott Long Wharf Directed by Drs. Gregory Randolph, Richard Hodin, and Randall Gaz December 6-8, 2014

International Symposium on Usher Syndrome

NEWS

MassEyeAndEar.org/ENTCalendar

& NOTES

Upcoming Events

July 10-11, 2014 (Scientific Symposium) July 12, 2014 (Family Conference) Joseph B. Martin Conference Center, Harvard Medical School Organized by Harvard Otolaryngology faculty members at Boston Children’s Hospital, Gwenaelle Geleoc, Ph.D., and Margaret Kenna, M.D., the International Symposium on Usher Syndrome will bring together researchers, clinicians, geneticists and specialists on July 10-11, 2014 to present the latest research on Usher Syndrome. The meeting will promote a multidisciplinary exchange of ideas and knowledge related to Usher Syndrome. Following the scientific symposium, there will be an event for both professionals and those affected by Usher Syndrome held on July 12, 2014, the Usher Syndrome Family Conference.

This unprecedented combination of events is expected to engage the largest number of constituents in the history of the Usher Syndrome community.

For more information, please contact Krista Vasi at k.vasi@usher-syndrome.org.

HMS Department of Otolaryngology 2nd Annual Meeting and Resident and Fellow Graduation Meltzer Auditorium, Mass. Eye and Ear June 26-27, 2014 For more upcoming event information, please visit MassEyeAndEar.org/ENTCalendar.

Children’s Otolaryngology Residents’ Emergency Skills (CORES) Course Boston Children’s Hospital July 19, 2014 Using hands-on simulation and experiential learning techniques, this course teaches skills such as intubation, use of the operating microscope, control of epistaxis and direct laryngoscopy and bronchoscopy.

Required for PGY-2 residents.

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& NOTES

Members of the Department of Otolaryngology at Harvard Medical School joined colleagues across the country for the 2013 annual meeting of the American Academy of Otolaryngology–Head and Neck Surgery in Vancouver, Canada. Their participation is outlined below.

NEWS

American Academy of Otolaryngology–Head and Neck Surgery Annual Meeting Sept. 2013. Vancouver, BC

Miniseminars “The New Cancer Patient: Young, Non-smoker, HPV+: Evaluation,” Daniel G. Deschler, M.D., FACS (moderator), Robert L. Ferris, M.D., Ph.D., Marilene B. Wang, M.D., Samir S. Khariwala, M.D., Jeremy D. Richmon, M.D. “Globus: The Perennial Complaint,” Melin Tan, M.D. (moderator), Natasha Mirza, M.D. (moderator), Ramon A. Franco, M.D., FACS, Philip A. Weissbrod, M.D. “Avenues to Leadership: Opportunities at Every Level,” Stacey Gray, M.D., FACS. “Innovative Immunomodulatory Therapies in Chronic Sinusitis,” Eric Holbrook, M.D. “Pediatric Laryngology: Innovations and Updates,” Scott M. Rickert, M.D., Melissa M. Statham, M.D., Alessandro de Alarcon, Karen B. Zur, M.D., Christopher J. Hartnick, M.D., M.S. “Reconstruction of Moh’s Defects,” John Lazor, M.D. “Parotidectomy Defect: To Reconstruct or Not,” Oleg N. Militsakh, M.D. (moderator), Douglas A. Girod, M.D., Matthew M. Hanasono, M.D., Derrick T. Lin, M.D., FACS “Hot Topics for the General Otolaryngologists,” J. Pablo Stolovitzky, M.D., David W. Kennedy, M.D., Dennis S. Poe, M.D., Ph.D., Michael Friedman, M.D. “Balloon Dilation of the Cartilaginous Portion of the Eustachian Tube,” Juha T. Silvola, M.D., Ph.D. (presenter), Ilkka Kivekas, M.D., Dennis S. Poe, M.D., Ph.D. “Global Health 2013: Academy around the World,” Gregory W. Randolph, M.D., FACS, FACE (moderator), Chung-Hwan Baek, M.D., Ph.D., Abdel-Hamid Benghalem, M.D., Cheerasook Chongkolwatana, M.D., Thana H. Nassir, M.D., Ph.D., Mohan Kameswaran, M.S., FRCS “Scary Cases 2013,” Michael P. Platt, M.D. (moderator), Gavin Setzen, M.D., Gregory A. Grillone, M.D., Elie E. Rebeiz, M.D., Phillip Song, M.D., Cathy D. Chong, M.D., David E. Tunkel, M.D. “Clinical Pearls in Pediatric Otolaryngology: A Video Forum,” Sanjay R. Parikh, M.D. (moderator), Soham Roy, M.D. (moderator), Craig S. Derkay, M.D., Christopher J. Hartnick, M.D., M.S., David R. White, M.D., Ken Kazahaya, M.D., M.B.A., Michael J. Rutter, M.D., Steven L. Goudy, M.D., Carlton Zdanski, M.D. “Practical Guide to MOC: Who, What, When, Why, and How,” Marita S. Teng, M.D. (moderator), Sonya Malekzadeh, M.D., Robert H. Miller, M.D., Sukgi S. Choi, M.D., Derrick T. Lin, M.D., FACS, Randal S. Weber, M.D., Shane Smith, M.D. “Thyroid Surgical Care 2013: The Impact of Molecular Testing,” Robert L. Witt, M.D. (moderator), Robert L. Ferris, M.D., Edmund A.

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Pribitkin, M.D., Gregory W. Randolph, M.D., FACS, FACE, David L. Steward, M.D. “Head and Neck Skin Cancer: When Mohs is Not Enough,” Christine G. Gourin, M.D., M.P.H., Derrick T. Lin, M.D., Cecelia E. Schmalbach, M.D., Carol R. Bradford, M.D., Randal S. Weber, M.D.

Oral Presentations “The Correlation between Hearing Loss and Obesity in Adolescents,” “Sameer Ahmed, M.D., Nina L. Shapiro, M.D., Neil Bhattacharyya, M.D. “Long-term Outcomes in Sinus Surgery Using New Tools for Measuring Health Related Quality of Life” with Laura D’Amico, Jamie Litvack, M.D., Aaron Remenschneider, M.D. (presenter), Eric Holbrook, M.D., and Ralph Metson, M.D.

Aaron K. Remenschneider, M.D., Matthew Naunheim, M.D., Margaret Carter, M.D., Josh Meier, M.D., Paul Vanderlaan, Robert A. Frankenthaler, M.D. “Preapproval of Sinus Computed Tomography for Evaluation of Chronic Rhinosinusitis Does not Save Healthcare Costs,” Ahmad R. Sedaghat, M.D. (presenter), Stacey Gray, M.D., FACS, David A. Kieff, M.D. “Motion of the Human Tympanic Membrane and Stapes Velocity after Placement of TORP with Cartilage Cover,” Cagatay H. Ulku, M.D., Jeffrey T. Cheng, Ph.D., Saumil N. Merchant, M.D., John J. Rosowski, Ph.D.

Instructional Courses

“Antibiotics and Ibuprofen Do Not Affect PostTonsillectomy Bleeding Risk,” Cassandra Bannos, Alexann Kirby, Jessica Leslie, Gi Soo Lee, M.D., David Roberson, M.D., FACS.

“Fundamentals of Videostroboscopy” Ramon Franco, M.D., FACS, Phillip Song, M.D.

“Nasal Anatomy Abnormalities and Objective Sleep-Disordered Breathing Severity,” Keith Leitzen, M.D. (presenter), Robin W. Lindsay, M.D., Scott E. Brietzke, M.D., M.P.H.

“Stertor, Stridor and Babies that Squeak: A Practical Approach” Christopher Hartnick, M.D., M.S., Matthew Brigger, M.D., and Seth Pransky, M.D.

“Does Residual Spiral Ganglion Cell Count Predict Performance in Patients with Bilateral Multichannel Cochlear Implants,” Mohammad Seyyedi (presenter), Joseph B. Nadol, Jr., M.D. “Errors in Otolaryngology Revisited”, Rahul Shah, Emily Boss, M.D., Jean Brereton, M.B.A., and David Roberson, M.D., FACS “Surgical Variation in Tonsillectomy and Adenoidectomy Procedures,” Rosh Sethi, Jessica Leslie, Cassandra Bannos, David Roberson, M.D., FACS and Gi Soo Lee, M.D. “Using LDV and ECR Measurements in the Differential Diagnosis of Patial and Complete Ossicular Discontinuity,” Cagatay H. Ulku, M.D. (presenter), Christof Roosli, M.D., Gabrielle R. Merchant, Christopher F. Halpin, Ph.D., John J. Rosowski, Ph.D., Saumil N. Merchant, M.D., Hideko H. Nakajima, M.D., Ph.D.

Poster Presentations “Microvascular Reconstruction in the Setting of Difficult Vascular Anatomy: The Reverse Arterial Flow Technique,” Daniel G. Deschler, M.D., FACS (presenter), Alice Lin, M.D. “The Increase of Global Health-Related Research in Otolaryngology,” Kyle J. Chambers, M.D. (presenter), Pete Creighton, M.D, Dunia AbdulAziz, M.D., Gregory W. Randolph, M.D., FACS, FACE. “Mammary Analog Secretory Carcinoma of the Paratotid Gland,” Elliot D. Kozin, M.D. (presenter),

“Steroids in ORL: Indications, Efficacy, and Safety” Stacey Gray, M.D., FACS, Eric Holbrook, M.D.

“Pediatric Hearing Loss: What Causes it and What to do?” Margaret Kenna, M.D., MPH, FACS, FAAP, John Greinwald, M.D., FAAP and Daniel Choo, M.D. “The HPV Epidemic and Oropharyngeal Cancer” Derrick Lin, M.D., FACS, James Rocco, M.D., Ph.D. “Surgical Management of Eustachian Tube Disorder” Ralph Metson, M.D., Dennis Poe, M.D., Ph.D. Five New Landmarks to Make You a Better Sinus Surgeon” Ralph Metson, M.D. “Surgical Management of Eustachian Tube Disorder” Dennis Poe, M.D., Ph. D., Ralph Metson, M.D. “RLN 2013: Continuous Vagal and SLN Monitoring” Gregory W. Randolph, M.D., FACS, FACE “Preoperative Decision Making in Thyroid Surgery” Gregory W. Randolph, M.D., FACS, FACE, David L. Steward, M.D., FACE “Parathyroid Surgery: What Head and Neck Surgeons Should Know” Gregory W. Randolph, M.D., FACS, FACE, David James Terris, M.D. “A Practical Approach to Assessment of Dizzy Patients” Steven Rauch, M.D. “The HPV Epidemic and Oropharyngeal Cancer” James Rocco, M.D., Ph.D., Derrick Lin, M.D., FACS “Fundamentals of Videostroboscopy” Phillip Song, M.D., Ramon Franco, M.D., FACS “Recognizing Neurlogical Voice Problems” Phillip Song, M.D.

& NOTES

Awards and Honors

Margaret Carter, M.D., (PGY4 resident) was awarded second place for her presentation, “Facial Transplantation,” at the New England Otolaryngology Society meeting in December 2013. Donald J. Annino, Jr., M.D., DMD, served as faculty advisor for the presentation.

Sunshine Dwojak, M.D., Ph.D., (PGY4 resident) and Neil Bhattacharyya, M.D., received the Richard J. Belluci, M.D. Research Award from the Triological Society in 2014 for their work on “Incremental and Comparative Health Care Expenditures for Head and Neck Cancer in the United States.”

Gregory W. Randolph, M.D., FACS, FACE, was nominated for the Massachusetts General Hospital Brian A. McGovern Award for Clinical Excellence.

Aaron Remenschneider, M.D., Chief Resident, won a first responder award from United Way for delivering compassionate care to victims of the 2013 Boston Marathon bombing.

Konstantina Stankovic, M.D., Ph.D., was awarded the HST Thomas A. McMahon Mentoring Award, which is designed to acknowledge a faculty member for outstanding mentorship of HST students.

GRANTS Mitchell Day, Ph.D., was awarded an R03 grant from the NIDCD for his project titled “Neural coding of sound location under normal and impaired hearing conditions.”

Bertrand Delgutte, Ph.D., was recently awarded a new grant from the NIDCD for his project titled “Bilateral cochlear implants: physiology and psychophysics.”

Faisal Karmali, Ph.D., received an award from the National Space Biomedical Research Institute for his project, “Countermeasures to reduce sensorimotor impairment.”

Richard F. Lewis, M.D., received a new R01 award from the NIDCD for his project titled “Vestibular contributions to estimated head motion and orientation.”

Daniel Merfeld, Ph.D., received a new fellowship award from the National Space

Biomedical Research Institute for his project, “Predicting sensorimotor adaptation.”

power of ‘standard’ audiometry and indicate a new approach to hearing aids.”

Hideko Heidi Nakajima, M.D., received an R01 grant from the NIDCD for her project titled, “Mechanics of human middle and inner ear: basic science and clinical application.”

Daniel Merfeld, Ph.D., was named an Associate Editor at the Journal of Neurophysiology.

James W. Rocco, M.D., Ph.D., received funding from the NIDCD in collaboration with the Broad Institute to use next generation exome sequencing to look at intra-tumor heterogeneity as a biomarker of clinical outcome in head and neck squamous cell carcinoma.

John Rosowski, Ph.D., successfully renewed an R01 grant from the NIDCD for his project, “Structure and function relations in the middle-ears.”

Christopher Shera, Ph.D., successfully renewed an R01 grant from the NIDCD for his project, “Understanding otoacoustic emissions.”

Konstantina Stankovic, M.D., Ph.D., began a project funded by the Department of Defense titled, “Preclinical validation of anti-nuclear factor kappa B therapy against vestibular schwannoma and neurofibromatosis type II.”

HONORS Mack L. Cheney, M.D., FACS, Director of the Office of Global Surgery and Health at Mass.

Eye and Ear, was appointed Visiting Professor in the Department of Ear, Nose and Throat in the Faculty of Medicine at the Mbarara University of Science and Technology.

Tessa A. Hadlock, M.D., was appointed to the Admissions Committee of the Harvard-MIT Division of Health Sciences and Technology.

Dr. Hadlock also served as Keynote Speaker at the American Academy of Ophthalmology Annual Meeting in New Orleans in November 2013, where she discussed approaches to facial paralysis.

Christopher Halpin, Ph.D., delivered the keynote address at the Audiologic Society of Germany Annual Meeting in March 2014 titled, “Human temporal bones reveal the

NEWS

AWARDS

Joseph B. Nadol, Jr., M.D., served as the William Wilson Lecturer for the Department of Surgery at George Washington University in April 2014, during which he presented on the subject of “Histopathology of the human temporal bone after cochlear implantation.”

Gregory W. Randolph, M.D., FACS, FACE served as Visiting Professor of Endocrinology at Johns Hopkins and delivered the William Lees Distinguished Lecture in February 2014, which focused on nerve monitoring in thyroid and parathyroid surgery.

Steven D. Rauch, M.D., served as invited faculty in Salzburg, Austria in December 2013, teaching temporal bone surgery to doctors from Eastern European and other transitional countries in one of the Salzburg Seminars of the Open Medical Institute sponsored by the American Austria Foundation (AAF) and Cornell Weill Medical School.

James W. Rocco, M.D., Ph.D., was appointed to the American College of Pathologists expert panel and task force on HPV testing in oropharyngeal cancer.

Konstantina Stankovic, M.D., Ph.D., served as a keynote speaker at the annual meeting of the Harvard Program in Speech and Hearing Bioscience and Technology.

Dr. Stankovic also served as Visiting Professor of Otolaryngology at the Feinberg School of Medicine at Northwestern University in Chicago, where she discussed translational neurotology.

At the American Audiologic Society meeting in March 2014 in Scottsdale, Ariz., Dr. Stankovic served as President-Elect and Program Chair.

She was joined by Sharon Kujawa, Ph.D., who was a Keynote Speaker in Translational Research on the subject of cochlear neurodegeneration in noise and aging. Michael J. McKenna, M.D., gave a presentation titled “Progress in the Development of Methodologies for Direct Inner Ear Drug Delivery in Humans.”

HARVARD Otolaryngology

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& NOTES

Alumni News

2012

NEWS

Harrison Lin, M.D., a graduate of the Harvard Otolaryngology Residency Program, will finish his neurotology fellowship at UC San Diego in June 2014 (with fellow Harvard Otolaryngology alumnus, Dr. Jeffrey P. Harris). Following that, he will be starting as an assistant professor in the otolaryngology department at the University of California at Irvine.

2007

Jose Sanclement, M.D., a fellow in the Head and Neck Surgical Oncology Division at Mass. Eye and Ear from 2006 to 2007, was awarded the Steven E. Moore Chair of Head and Neck Cancer at the University of Oklahoma Health Science Center, where he is an Assistant Professor of Otolaryngology, in February 2014.

2005

Adele Evans, M.D., FAAP, a graduate of the Harvard Otolaryngology Residency Program, currently serves as Associate Professor of Pediatric Otolaryngology at Wake Forest School of Medicine. She received a federal grant through the North Carolina Emergency Medicine Society this year to design a tracheotomy training program for nurses, advanced practitioners, paramedic/EMTs, and family members. The program is now running monthly patient simulations.

2005

Andrew Scott, M.D., a graduate of the Harvard Otolaryngology Residency Program, was inducted as a member of the Triological Society in May 2014. His thesis, titled “Regional variations in the presentation and manage-ment of Pierre Robin sequence,” won the 2014 honorable mention clinical research thesis award. Dr. Scott currently serves as medical co-director of the Cleft Lip and Palate Clinic at Tufts Medical Center.

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HARVARD Otolaryngology

His service recently received full accreditation from the American Cleft Palate and Craniofacial Association and remains the only otolaryngology-run multidisciplinary cleft and craniofacial team on the east coast.

1996

Pa-Chun Wang, M.D., a research fellow at Mass.

Eye and Ear from 1995 to 1996, established the Harvey ENT Basic Research Laboratory in the Cathay General Hospital in Taipei, Taiwan in December 2011 (pictured below).

The laboratory is designed to provide otolaryngology surgeons a means for perfecting surgical skills and to conduct basic science research, aiming to improve patient care. The laboratory won the 2013 Symbol of National Quality from Taiwan’s Institute of Biotechnology and Medicine Industry.

1981

Roland D. Eavey, M.D., S.M., a graduate of the Harvard Otolaryngology Residency Program, recently received a Presidential award from the American Academy of Otolaryngology–Head and Neck Surgery at its 2013 annual meeting.

He recently spoke at West Point on leadership in medicine in March 2014. Dr. Eavey is the Executive Medical Director of Otolaryngology and the Guy M. Maness Professor and Chair of the Vanderbilt Department of Otolaryngology and the Director of the Vanderbilt Bill Wilkerson Center for Otolaryngology and Communications Sciences.

1979

Jeffrey P. Harris, M.D., Ph.D., FACS, a graduate of the Harvard Otolaryngology Residency Program, has been invited to be the 2014 Graduation Day Guest of Honor at the University of Colorado in June. He also served as a guest speaker at the 3rd Annual Minimally Invasive Office ENT Course in Sarasota, Florida

with the EAR Foundation and the Silverstein Institute. Otonomy, Inc, which Dr. Harris co-founded, has made progress in developing a sustained release cipro gel which is being tested in a phase III clinical trial. Additionally, they have initiated a phase 2 clinical trial of a sustained release dexamethasone gel for the treatment of Meniere’s disease. Dr. Harris is a Distinguished Professor of Otolaryngology and Neurological Surgery and Chief of Otolaryngology–Head and Neck Surgery at University of California at San Diego.

1979

John H. Krouse, M.D., Ph.D., a graduate of the Harvard Otolaryngology Residency Program, was selected to be the next Editor-in-Chief of Otolaryngology-Head and Neck Surgery, the official journal of the American Academy of Otolaryngology-Head and Neck Surgery, effective October 1, 2014. Dr. Krouse is Professor and Chairman of Otolaryngology– Head and Neck Surgery and Associate Dean of Graduate Medical Education at Temple University.

1975

Robert Sofferman, M.D., a graduate of the Harvard Otolaryngology Residency Program, received a Presidential Citation from James Netterville, M.D. at the American Academy of Otolaryngology–Head and Neck Surgery 2013 annual meeting.

Dr. Sofferman and fellow Harvard Otolaryngology alumus, Charles Cummings, M.D., have co-authored a book of photography and poetry titled, The Natural World: Images and Imagination. All proceeds from the book will benefit Conservation International, an organization that strives to protect and preserve natural wonders. For more information, visit www.thenaturalworld.info.

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HARVARD Otolaryngology

News from the Department of Otolaryngology at Harvard Medical School 243 Charles Street, Boston MA 02114

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