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Craniomaxillofacial vascular anomalies encompass a diverse and complex set of pathologies that may have a profound impact on pediatric patients. They are subdivided into vascular tumors and vascular malformations depending on biological properties, clinical course, and distribution patterns. Given the complexity and potential for leading to significant functional morbidity and esthetic concerns, a multidisciplinary approach is generally necessary to optimize patient outcomes. This article reviews the etiology, clinical course, diagnosis, and current management practices related to vascular anomalies in the head and neck.

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Objective: The primary aim of this study was to define characteristics of transgender women seeking gender-affirming voice modification at our voice center. The secondary aim was to evaluate outcome measures, comparing (a) behavioral voice training alone, (b) surgery alone, and (c) combination of behavioral voice training+surgery. Methods: Patients seen in a 30-month period, who sought care for gender-affirming voice modification, were included if they were assigned male at birth and identified as female. Patient demographic information, patient quality of life index scores, Trans Woman Voice Questionnaire (TWVQ), and acoustic data were collected before and after intervention. Results: Sixteen patients met inclusion criteria. The majority of patients were (a) undergoing hormone replacement therapy at initiation of treatment, (b) were presenting in public for over 2 years as female, and (c) had a history of psychological disorders (i.e., gender dysphoria, anxiety, depression, and attention deficit hyperactivity disorder [ADHD]). Increased f0 and decreased TWVQ scores were evident and statistically significant within behavioral voice training cohort and behavioral voice training+surgery cohort. Treatment groups appear similar with respect to average changes; pre- and post-data were not available for surgery only patients. Greater change in f0 was directly correlated with increased number of voice training sessions. Conclusion: There is variability in treatment course for patients seeking gender-affirming voice modification; however, treatment type may not impact outcomes. Increased patient quality of life and increased speaking fundamental frequency were found in this patient cohort.

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OBJECTIVES: To evaluate clinical characteristics and outcomes of patients diagnosed with anterior (ASB) or lateral skull base (LSB) spontaneous cerebrospinal fluid (sCSF) leak. METHODS: Single center retrospective review of patients diagnosed with sCSF leaks of ASB or LSB between 1/1/2009 and 11/1/2019 (n = 69). Body mass index (BMI), gender, age at diagnosis, origin of CSF leak (ASB vs LSB), surgical approach, lumbar drain use, recurrence, pre-operative diagnosis of diabetes mellitus (DM), and obstructive sleep apnea (OSA) were collected. RESULTS: 69 patients included in this study met criteria for sCSF leak without a traumatic or iatrogenic cause (Female: 51 (74%); average BMI: 37.0 ± 7.9). Forty-eight (70.0%) presented with sCSF leaks of the lateral skull base. All ASB leaks were treated with an endoscopic transnasal approach. Eleven (22.9%) LSB leak patients were treated using transmastoid approaches and 35 (72.9%) patients with a middle cranial fossa approach. Eleven patients (15.9%) reported sCSF leak recurrence. Two patients (9.5%) with anterior skull base and 9 patients (18.8%) with lateral skull base leaks had recurrence. LSB sCSF leaks had a relative risk of 2.192 of recurrence compared to ASB leaks (95% CI: 0.431-11.157, P = .483). A 5.017 times increased risk (95% CI: 1.285-19.583, P = .020) was reported for patients with OSA, while the risks for DM and BMI were 1.351 (95% CI: 0.67-9.105, P = .177) and 1.026 (95% CI: 0.963-1.094, P = .426) respectively. Patients with sCSF leak recurrence had significantly lower lumbar drain use (33.3%) than those without recurrence (72.7%) (P = .049). CONCLUSION: Spontaneous CSF leak recurrence is complex and multifactorial, and while patients with both DM and OSA had the higher risk of recurrence, OSA is likely an independent clinical risk factor for sCSF leak recurrence in this patient population.

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OBJECTIVE: The clinical evaluation and management of an adult with head and neck rhabdomyosarcoma is explored to delineate the diagnostic challenge posed by soft-tissue sarcomas bordering scar tissue. CASE REPORT: A 59 year old female presents with persistent, evolving paresthesia and burning in the right posterior neck, which was found to be in close proximity to a well-healed rhytidectomy scar. Serial biopsies were non-diagnostic. Six months after initial presentation, rhabdomyosarcoma was diagnosed subsequent to histopathological and immunohistochemistry analysis. A wide local excision with posterolateral neck dissection was performed. CONCLUSION: A high index of suspicion for soft-tissue sarcoma should be maintained for patients with persistent soft-tissue lesions, especially in areas of scarred tissue, who present with new-onset neurological symptoms in the context of nondiagnostic biopsies.

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BACKGROUND AND OBJECTIVES: Performing an effective maxillary antrostomy is critical to improving chronic maxillary sinusitis symptomatology. Incomplete dissection of the uncinate process and failure to incorporate the natural drainage pathway may lead to recirculation and need for revision surgery. The purpose of this study is to determine if 70° endoscopes provide added value in determining incomplete dissection or residual disease. METHODS: Prospective study of 35 sinuses from 18 patients undergoing FESS for Chronic Rhinosinusitis (CRS) between 11/1/2020 and 4/30/2021. Two fellowship trained Rhinologists initially performed maxillary antrostomies exclusively using a 0° endoscope, then transitioned to a 70° endoscope. Surgeons completed a survey to assess completion of the antrostomy prior to use of 70° endoscope, sino-nasal anatomy, and difficulty of the operation. Intraoperative photographs before and after using a 70° endoscope were evaluated by a third party. Pre-operative CT scans were used to evaluate the sphenoid keel-caudal septum-nasolacrimal duct (SK-CS-NL) angle. RESULTS: Of 35 sinuses from 18 patients all 35 sinuses had CRS with 48.5% having nasal polyposis and 42.9% having active infection. There was residual inflammatory tissue in the anterior maxillary sinus, including polypoid tissue and uncinate process prior to using the 70° endoscope in 82.9% of sinuses. The natural drainage pathway was not incorporated into the dissection in 28.6% of sinuses before converting to 70° endoscope. Incomplete dissection with 0° endoscope was not associated with nasal polyposis (P = .086) or uncinate position (0.741). Narrow SK-CS-NL angles were associated with incomplete dissection of the anterior maxillary sinus with 0° endoscope (16.0° ± 3.0° vs 20.6° ± 3.2°; P = .013). CONCLUSION: Use of 70° endoscope in maxillary antrostomy may be beneficial in identifying and resecting disease within the anterior maxillary sinus that may otherwise be difficult to find using a 0° endoscope. This is especially true in patients with narrow nasolacrimal duct positioning.

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OBJECTIVES: To reveal hearing loss patterns in patients with enlarged vestibular aqueduct (EVA) syndrome according to demographic and clinical characteristics. METHODS: A retrospective, longitudinal study design was utilized to identify patients with EVA. Ears of patients were categorized into one of four cohorts: progressive fluctuating, progressive non-fluctuating, stable fluctuating, and stable non-fluctuating patterns. Pairwise and group comparisons were performed with non-parametric tests to assess vestibular aqueduct (VA) morphology, clinical, and demographic variables between hearing loss pattern cohorts. Rates of hearing loss in the subgroups were determined utilizing a mixed linear effects model. RESULTS: 44 patients (25 female, 19 male, median diagnosis age: 8.06 years) met inclusion criteria. 16 individuals demonstrated unilateral EVA and 29 had bilateral EVA, resulting in 74 total ears with EVA. Amongst the four cohorts, differences in operculum widths amongst groups were statistically significant (p = 0.049) while VA midpoint widths were not (p = 0.522). Progressive hearing loss ears without fluctuations demonstrated a 3.20 dB per year (p < 0.001) progression while progressive hearing loss ears with fluctuations reported a rate of 3.52 dB loss per year (p < 0.001). CONCLUSION: Hearing fluctuations occur similarly in EVA patients with stable and progressive hearing loss. With the exception of increased rates of hearing loss progression for fluctuating progressive hearing loss patients, vestibular aqueduct morphology, demographic, and clinical characteristics commonly reported are likely not strong predictors for whether patients will or will not experience fluctuating patterns of hearing loss.

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OBJECTIVE: To observe trends in practice consolidation within otolaryngology by analyzing changes in size and geographic distribution of practices within the United States from 2014 to 2021. STUDY DESIGN: Retrospective analysis based on the Physician Compare National Database from the US Centers for Medicare and Medicaid Services. SETTING: United States. METHODS: Annual files from the Physician Compare National Database between 2014 and 2021 were filtered for all providers that listed "otolaryngology" as their primary specialty. Organization affiliations were sorted by size of practice and categorized into quantiles (1 or 2 providers, 3-9, 10-24, 25-49, and ≥50). Both the number of practices and the number of surgeons within a practice were collected annually for each quantile. Providers were also stratified geographically within the 9 US Census Bureau divisions. Chi-square analysis was conducted to test significance for the change in surgeon and practice distributions between 2014 and 2021. RESULTS: Over the study period, the number of active otolaryngology providers increased from 7763 to 9150, while the number of practices fell from 3584 to 3152 in that time span. Practices with just 1 or 2 otolaryngology providers accounted for 80.2% of all practices in 2014 and fell to 73.1% in 2021. Similar trends were observed at the individual provider level. Regional analysis revealed that New England had the largest percentage decrease in otolaryngologists employed by practices of 1 or 2 active providers at 45.7% and the Mountain region had the lowest percentage decrease at 17.4%. CONCLUSION: The otolaryngology practice marketplace has demonstrated a global trend toward practice consolidation.

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OBJECTIVES/HYPOTHESIS: To investigate patient-specific characteristics that independently predict for progressive hearing loss in patients with enlarged vestibular aqueduct (EVA). Utilize multivariable predictive models to identify subgroups of patients with significantly different progression risks. STUDY DESIGN: Retrospective analysis of patients evaluated at an academic tertiary care center. Cohort included 74 ears of patients with a diagnosis of EVA as defined by the Cincinnati criteria. METHODS: Hearing trajectories were characterized, and a Kaplan-Meier estimator was utilized to determine progressive phenotype probabilities across the first 10 years after diagnosis. Cox proportional hazard regression was used to identify patient characteristics that independently altered this probability. Stratified risk groups were delineated from generated nomogram scores. RESULTS: Male gender was associated with a 4.53 hazard ratio for progressive hearing loss (95% confidence interval [CI], 2.53 to 12.59). Each millimeter increase in operculum size was independently associated with an 80.40% increase in expected hazard (95% CI, 40.18 to 120.62). Each dB increase in air pure tone average at time of diagnosis decreased expected hazard by 1.59% (95% CI, -3.02 to -0.17). The presence of incomplete partition type II was associated with a 2.44 hazard ratio (95% CI, 1.04 to 5.72). Risk groups stratified by median nomogram score evidenced the discriminative ability of our model with the progression probability in the high-risk group being six times higher at 1 year, nearly five times greater at 3 years, and three times greater at 9 years. CONCLUSIONS: EVA patient characteristics can be used to predict hearing loss probability with a high degree of accuracy (C-index of 0.79). This can help clinicians make more proactive management decisions by identifying patients at high risk for hearing loss. LEVEL OF EVIDENCE: 4 Laryngoscope, 132:1439-1445, 2022.

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OBJECTIVE: This paper presents a case of a bronchial Dieulafoy's lesion in a pediatric patient with recurrent hemoptysis. CASE REPORT: A 11-year old female presented multiple times with dry cough and hemoptysis to an outside hospital, each time leading to a diagnosis of epistaxis and subsequent discharge. When she arrived to our tertiary center with heavy hemoptysis and no evidence of epistaxis, the patient was urgently taken to the operating room by both the otolaryngology and pediatric pulmonology services. Active bleeding from a Dieulafoy's lesion on the right lower bronchus was found and selective embolization of two tortuous arteries was subsequently performed. The patient was discharged in stable condition without recurrence of hemoptysis over the last two months. CONCLUSION: While rare, especially in pediatric patients, bronchial Dieulafoy's lesions may cause severe hemoptysis and should be considered in the differential diagnosis when the etiology for hemoptysis is unclear.

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BACKGROUND: Vertigo and dizziness are extremely common conditions in the adult population and therefore place a significant social and economic burden on both patients and the healthcare system. However, limited information is available for the economic burden of vertigo and dizziness across various health care settings. OBJECTIVE: Estimate the economic burden of vertigo and dizziness, controlling for demographic, socioeconomic, and clinical comorbidities. METHODS: A retrospective analysis of data from the Medical Expenditures Panel Survey (2007-2015) was performed to analyze individuals with vertigo or dizziness from a nationally representative sample of the United States. Participants were included via self-reported data and International Classification of Diseases, 9th Revision Clinical Modification codes. A cross-validated 2-component generalized linear model was utilized to assess vertigo and dizziness expenditures across demographic, socioeconomic and clinical characteristics while controlling for covariates. Costs and utilization across various health care service sectors, including inpatient, outpatient, emergency department, home health, and prescription medications were evaluated. RESULTS: Of 221,273 patients over 18 years, 5,275 (66% female, 34% male) reported either vertigo or dizziness during 2007-2015. More patients with vertigo or dizziness were female, older, non-Hispanic Caucasian, publicly insured, and had significant clinical comorbidities compared to patients without either condition. Furthermore, each of these demographic, socioeconomic, and clinical characteristics lead to significantly elevated costs due to having these conditions for patients. Significantly higher medical expenditures and utilization across various healthcare sectors were associated with vertigo or dizziness (p < 0.001). The mean incremental annual healthcare expenditure directly associated with vertigo or dizziness was $2,658.73 (95% CI: 1868.79, 3385.66) after controlling for socioeconomic and demographic characteristics. Total annual medical expenditures for patients with dizziness or vertigo was $48.1 billion. CONCLUSION: Vertigo and dizziness lead to substantial expenses for patients across various healthcare settings. Determining how to limit costs and improve the delivery of care for these patients is of the utmost importance given the severe morbidity, disruption to daily living, and major socioeconomic burden associated with these conditions.

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BACKGROUND: The magnitude and time course of the COVID-19 epidemic in the United States depends on early interventions to reduce the basic reproductive number to below 1. It is imperative, then, to develop methods to actively assess where quarantine measures such as social distancing may be deficient and suppress those potential resurgence nodes as early as possible. OBJECTIVE: We ask if social media is an early indicator of public social distancing measures in the United States by investigating its correlation with the time-varying reproduction number (Rt) as compared to social mobility estimates reported from Google and Apple Maps. METHODS: In this observational study, the estimated Rt was obtained for the period between March 5 and April 5, 2020, using the EpiEstim package. Social media activity was assessed using queries of "social distancing" or "#socialdistancing" on Google Trends, Instagram, and Twitter, with social mobility assessed using Apple and Google Maps data. Cross-correlations were performed between Rt and social media activity or mobility for the United States. We used Pearson correlations and the coefficient of determination (ρ) with significance set to P<.05. RESULTS: Negative correlations were found between Google search interest for "social distancing" and Rt in the United States (P<.001), and between search interest and state-specific Rt for 9 states with the highest COVID-19 cases (P<.001); most states experienced a delay varying between 3-8 days before reaching significance. A negative correlation was seen at a 4-day delay from the start of the Instagram hashtag "#socialdistancing" and at 6 days for Twitter (P<.001). Significant correlations between Rt and social media manifest earlier in time compared to social mobility measures from Google and Apple Maps, with peaks at -6 and -4 days. Meanwhile, changes in social mobility correlated best with Rt at -2 days and +1 day for workplace and grocery/pharmacy, respectively. CONCLUSIONS: Our study demonstrates the potential use of Google Trends, Instagram, and Twitter as epidemiological tools in the assessment of social distancing measures in the United States during the early course of the COVID-19 pandemic. Their correlation and earlier rise and peak in correlative strength with Rt when compared to social mobility may provide proactive insight into whether social distancing efforts are sufficiently enacted. Whether this proves valuable in the creation of more accurate assessments of the early epidemic course is uncertain due to limitations. These limitations include the use of a biased sample that is internet literate with internet access, which may covary with socioeconomic status, education, geography, and age, and the use of subtotal social media mentions of social distancing. Future studies should focus on investigating how social media reactions change during the course of the epidemic, as well as the conversion of social media behavior to actual physical behavior.

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OBJECTIVE: Barriers to surgical treatment for sleep apnea remain understudied. In this study, we sought to evaluate whether specific demographic and socioeconomic characteristics are associated with whether or not patients receive surgery for sleep apnea management. METHODS: The National Inpatient Sample (NIS) database was analyzed for 2007-2014. Patients aged 18 or older with primary or secondary diagnoses of sleep apnea were selected. Patients were sub-categorized by whether they received related soft-tissue removal or skeletal modifying procedures. Age, race, gender, region, insurance, comorbidities, procedure type, and procedure setting were analyzed between surgical and nonsurgical groups. RESULTS: A total of 449,705 patients with a primary or secondary diagnosis of sleep apnea were identified, with 27,841 (5.8%) receiving surgical intervention. Compared with the non-surgical group, patients in the surgical cohort were more likely to be younger, male (74.4% vs. 59.0%), Hispanic (10.2% vs. 6.2%), Asian (3.6% vs. 1.0%) (p < 0.001), and have less clinical comorbidities. Those receiving surgery were more likely to be in the highest income bracket (36.1% versus 25.1%) and utilize private insurance (76.3% vs. 50.8%). Soft-tissue surgeries comprised 88.5% of total procedures while skeletal modifying procedures constituted 11.5% (p < 0.001). CONCLUSIONS: This study identified multiple demographic, socioeconomic, and clinical discrepancies in the utilization of surgical versus nonsurgical management of sleep apnea in the United States. Future studies should examine the causes for these health disparities in the ultimate effort to provide more equitable healthcare in the United States.

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OBJECTIVE: Given high COVID-19 viral load and aerosolization in the head and neck, otolaryngologists are subject to uniquely elevated viral exposure in most of their inpatient and outpatient procedures and interventions. While elective activity has halted across the board nationally, the slow plateau of COVID-19 case rates prompts the question of timing of resumption of clinical activity. We sought to prospectively predict geographical "hot zones" for otolaryngological exposure to COVID-19 based on procedural volumes data from 2013 to 2017. METHODS: Otolaryngologic CPT codes were stratified based on risk-level, according to recently published specialty-specific guidelines. Using the Medicare POSPUF database, aerosol-generating procedures (AGPs) were mapped based on hospital referral regions, against up-to-date COVID-19 case distribution data, as of April 24, 2020. RESULTS: The most common AGPs were diagnostic flexible laryngoscopy, diagnostic nasal endoscopy, and flexible laryngoscopy with stroboscopy. The regions with the most AGPs per otolaryngologist were Iowa City, IA, Detroit, MI, and Burlington, VT, while the states with the most COVID-19 cases as of April 24th are New York, New Jersey, and Massachusetts. CONCLUSIONS: Our study provides a model for predicting possible "hot zones" for otolaryngologic exposure based on both COVID-19 case density and AGP-density. As the focus shifts to resuming elective procedures, these potential "hot zones" need to be evaluated for appropriate risk-based decision-making, such as "reopening strategies" and allocation of resources.

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During the coronavirus 2019 pandemic, there has been a surge in production of remote learning materials for continued otolaryngology resident education. Medical students traditionally rely on elective and away subinternship experiences for exposure to the specialty. Delays and cancellation of clinical rotations have forced medical students to pursue opportunities outside of the traditional learning paradigm. In this commentary, we discuss the multi-institutional development of a robust syllabus for medical students using a multimodal collection of resources. Medical students collaborated with faculty and residents from 2 major academic centers to identify essential otolaryngology topics. High-quality, publicly available, and open-access content from multiple sources were incorporated into a curriculum that appeals to a variety of learners. Multimodal remote education strategies can be used as a foundation for further innovation aimed at developing tomorrow's otolaryngologists.

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OBJECTIVE: The 2019 novel coronavirus (COVID-19) is disproportionately impacting older individuals and healthcare workers. Otolaryngologists are especially susceptible with the elevated risk of aerosolization and corresponding high viral loads. This study utilizes a geospatial analysis to illustrate the comparative risks of older otolaryngologists across the United States during the COVID-19 pandemic. METHODS AND MATERIALS: Demographic and state population data were extracted from the State Physician Workforce Reports published by the AAMC for the year 2018. A geospatial heat map of the United States was then constructed to illustrate the location of COVID-19 confirmed case counts and the distributions of ENTs over 60 years for each state. RESULTS: In 2018, out of a total of 9578 practicing U.S. ENT surgeons, 3081 were older than 60 years (32.2%). The states with the highest proportion of ENTs over 60 were Maine, Delaware, Hawaii, and Louisiana. The states with the highest ratios of confirmed COVID-19 cases to the number of total ENTs over 60 were New York, New Jersey, Massachusetts, and Michigan. CONCLUSIONS: Based on our models, New York, New Jersey, Massachusetts, and Michigan represent states where older ENTs may be the most susceptible to developing severe complications from nosocomial transmission of COVID-19 due to a combination of high COVID-19 case volumes and a high proportion of ENTs over 60 years.

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Objectives: The extent of medical knowledge increases yearly, but the time available for students to learn is limited, leading to administrative pressures to revise and reconfigure medical school curricula. The goal of the present study is to determine whether the mixed reality platform HoloAnatomy represents an effective and time-efficient modality to learn anatomy when compared to traditional cadaveric dissection.Methods: This was a prospective, longitudinal study of medical students completing a musculoskeletal anatomy course at Case Western Reserve University School of Medicine. Participants were divided into two groups based on learning platform (HoloAnatomy versus traditional cadaveric dissection) and content area (upper limb versus lower limb anatomy). Time spent in lab and end of course practical exam scores were compared between groups.Results: The average study time of 48 medical students who completed study requirements was 4.564 h using HoloAnatomy and 7.318 h in the cadaver lab (p = 0.001). No significant difference was found between exam scores for HoloAnatomy and cadaver learners (p = 0.185).Conclusions: Our results indicate that HoloAnatomy may decrease the time necessary for anatomy didactics without sacrificing student understanding of the material.

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OBJECTIVE: To demonstrate whether race, education, income, or insurance status influences where patients seek medical care and the cost of care for a broad range of otolaryngologic diseases in the United States. STUDY DESIGN: Retrospective cohort study using data from the Medical Expenditure Panel Survey, from 2007 to 2015. SETTING: Nationally representative database. SUBJECTS AND METHODS: Patients with 14 common otolaryngologic conditions were identified using self-reported data and International Classification of Diseases, 9th Revision Clinical Modification diagnosis codes. To analyze disparities in the utilization and cost of otolaryngologic care, a multivariate logistic regression model was used to compare outpatient and emergency department visit rates and costs for African American, Hispanic, and Caucasian patients, controlling for sociodemographic characteristics. RESULTS: Of 78,864 respondents with self-reported otolaryngologic conditions, African American and Hispanic patients were significantly less likely to visit outpatient otolaryngologists than Caucasians (African American: adjusted odds ratio [aOR], 0.57; 95% CI, 0.5-0.65; Hispanic: aOR, 0.64; 95% CI, 0.56-0.73) and reported lower average costs per emergency department visit than Caucasians (African American: $4013.67; Hispanic: $3906.21; Caucasian: $7606.46; P < .001). In addition, uninsured, low-income patients without higher education were significantly less likely to receive outpatient otolaryngologic care than privately insured, higher-income, and more educated individuals (uninsured: aOR, 0.38; 95% CI, 0.29-0.51; poor: aOR, 0.75; 95% CI, 0.64-0.87; no degree: aOR, 0.67; 95% CI, 0.54-0.82). CONCLUSION: In this study, significant racial and socioeconomic discrepancies exist in the utilization and cost of health care for otolaryngologic conditions in the United States.

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OBJECTIVE: Enlargement of the vestibular aqueduct (EVA) is one of the most common congenital malformations in pediatric patients presenting with sensorineural or mixed hearing loss. The relationship between vestibular aqueduct (VA) morphology and hearing loss across sex is not well characterized. This study assesses VA morphology and frequency-specific hearing thresholds with sex as the primary predictor of interest. MATERIALS AND METHODS: A retrospective, longitudinal, and repeated-measures study was used. 47 patients at an academic tertiary care center with hearing loss and a record of CT scan of the internal auditory canal were candidates, and included upon meeting EVA criteria after confirmatory measurements of vestibular aqueduct midpoint and operculum widths. Audiometric measures included pure-tone average and frequency-specific thresholds. RESULTS: Of the 47 patients (23 female and 24 male), 79 total ears were affected by EVA; the median age at diagnosis was 6.60 years. After comparing morphological measurements between sexes, ears from female patients were observed to have a greater average operculum width (3.25 vs. 2.70 mm for males, p = 0.006) and a greater average VA midpoint width (2.80 vs. 1.90 mm for males, p = 0.004). After adjusting for morphology, male patients' ears had pure-tone average thresholds 17.6 dB greater than female patients' ears (95% CI, 3.8 to 31.3 dB). CONCLUSIONS: Though females seem to have greater enlargement of the vestibular aqueduct, this difference does not extend to hearing loss. Therefore, our results indicate that criteria for EVA diagnoses may benefit from re-evaluation. Further exploration into morphological and audiometric discrepancies across sex may help inform both clinician and patient expectations.

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