Otology Neurotology 2021-04-01

Predictive Ability of Direct Electrical Stimulation on Facial Nerve Function Following Vestibular Schwannoma Surgery: A Systematic Review and Meta-analysis

Quimby, Alexandra E.; Lui, Justin; Chen, Joseph

Publication date 01-04-2021


Objective: Facial nerve preservation is critical in vestibular schwannoma (VS) surgery. Direct electrical stimulation (DES) is a widely used method for intraoperative localization of the facial nerve and assessment of nerve integrity. We sought to assess the predictive ability of DES parameters on facial nerve function post-VS surgery.
Databases reviewed: A systematic literature search of English-language studies published from 1946 to 2019 was undertaken using EMBASE, Med Line/Pub Med, and the Cochrane Central Register of Controlled Trials.
Methods: Included studies involved patients undergoing VS surgery and assessed predictive ability of any DES parameter on postoperative facial function. Two authors independently reviewed studies and extracted data. Meta-analysis of diagnostic accuracy of DES parameters was used to calculate pooled sensitivities and specificities of common cutoffs. For DES parameters reported by less than four studies, outcomes were reported descriptively.
Results: A MST cutoff of 0.10 mA had sensitivity of 0.76 (95% CI 0.53–0.90) and specificity 0.68 (95% CI 0.42–0.87) for facial function in the long term, and MST 0.05 mA had sensitivity 0.73 (95% CI 0.58–0.84) and specificity 0.74 (95% CI 0.59–0.85). CMAP amplitude < 500 μV had sensitivity of 0.87 (95% CI 0.78–0.93) for poor short-term facial function.
Conclusions: A CMAP amplitude response < 500 μV is sensitive for poor short-term facial function, whereas MST values of 0.05 mA and 0.10 mA are both sensitive and specific in the long term. Other DES parameters may be able to accurately predict both short- and long-term postoperative facial function, but have been less studied.

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Otologic Manifestations of Eosinophilic Granulomatosis With Polyangiitis: A Systematic Review

Ashman, Peter E.; Chen, Tiffany; Barinsky, Gregory L.; Benson, Brian; Babu, Seilesh; Bojrab, Dennis I. II; Svider, Peter F.

Publication date 01-04-2021


Objective: To perform a systematic review of the diagnosis, treatment, and management of patients with otologic manifestations of eosinophilic granulomatosis with polyangiitis.
Databases Reviewed: Pub Med, Embase, Cochrane.
Methods: A systematic search for relevant published literature in Pub Med, Cochrane Library, and EMBASE databases was done. Data was collected on demographics, otologic manifestations, specific diagnostic criteria fulfilled, common clinical, and imaging findings as well as medical and surgical treatments received.
Results: Fifteen articles encompassing 219 patients met inclusion criteria including 8 case reports and 7 case series. The mean age was 52.8 (range of 24–70). The most common otologic presenting symptoms were hearing loss (76%), otitis media with effusion (44%), vertigo (22%), tinnitus (21%), and chronic otitis media (20%). The most common diagnostic criteria observed in these patients were paranasal sinus abnormalities (75%), asthma (66%), and eosinophilia >10% (44%). The most common treatment was systemic steroids (66%), followed by surgery (52%), with myringotomy with tube insertion (M&T) (32%) and endoscopic sinus surgery (21%) being the most prevalent. Thirty-four percent of patients received an immunosuppressive agent. Successful treatments included systemic steroids (23%), surgical modalities (13%) with M&T being the most common (7%), topical nasal steroids (12%), and cyclophosphamide (10%).
Conclusion: Hearing loss and a middle ear effusion are the most common presenting otologic manifestations of eosinophilic granulomatosis with polyangiitis. Sinonasal disease was more prevalent in patients with otologic manifestations. Primary treatment consists of systemic steroids and immunomodulation. M&T, endoscopic sinus surgery, and local steroid administration can be adjunctive measures to alleviate local disease.
Level of Evidence: Level 1

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Trends in Medicare Reimbursement for Otology Procedures From 2000 to 2020

Schartz, Derrek A.; McCool, Ryan R.

Publication date 01-04-2021


Objective: The purpose of this study is to investigate the Medicare reimbursement trends for otologic procedures from 2000 to 2020.
Study Design: Retrospective data analysis using the Physician Fee Schedule Look-Up tool from the Centers for Medicare and Medicaid services.
Setting: Facility performed procedures of the auditory system.
Patients: Medicare beneficiaries from 2000 to 2020.
Interventions: Selected otologic current procedural terminology codes and their respective year-to-year reimbursement data.
Main Outcome Measures: Assessment of trends in financial reimbursement.
Results: After adjusting for inflation, the total average reimbursement for all procedures saw an average decrease of –21.2% from 2000 to 2020. The average adjusted percent change per year was –1.3% indicating a slow decline in reimbursement over the study period. There was a difference between the adjusted and unadjusted percent change in reimbursement rate during the study period (–21% versus 20.4%, respectively; p < 0.001). Linear regression analysis of the adjusted average reimbursement across all procedures revealed an overall decline from 2000 to 2020 with an R-squared value of 0.85 indicating a decline in reimbursement over time.
Conclusions: After adjusting all data for inflation, there has been a reduction in the average Medicare reimbursement for otology procedures from 2000 to 2020. Compared with previous reimbursement studies on the whole field of otolaryngology, otology has a less severe decline in reimbursement. Knowledge of these reimbursement trends is critical for otologic surgeons and leaders within the field to develop more sustainable reimbursement plans.

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Performance With an Adhesive Bone Conduction Device in Active Transcutaneous Bone Conduction Implant Users

Dahm, Valerie; Traxler, Stefanie; Liepins, Rudolfs; Auinger, Alice B.; Sterrer, Elisabeth; Kaider, Alexandra; Riss, Dominik; Arnoldner, Christoph

Publication date 01-04-2021


Objectives: The aim of this study was to evaluate the performance and limits of an adhesive bone conduction hearing aid in patients implanted with an active transcutaneous bone conduction implant. Therefore, hearing performance and subjective benefit of patients with mixed and conductive hearing loss were assessed with both bone conduction devices.
Study Design and Patients: This cohort study was conducted at a tertiary care center. Fifteen subjects, who had been implanted with an active transcutaneous device previously, were included and used the adhesive hearing device for 3 weeks instead of the implant. Subjects underwent two sets of audiological tests as well as assessments of quality of life at the beginning and at the end of the testing period.
Results: Audiological results showed a significantly greater improvement in regards to functional hearing gain and word recognition scores with the transcutaneous bone conduction device than the nonimplantable adhesive device. Regression analysis showed a trend toward greater improvement with the transcutaneous device compared with the adhesive device in patients with an increasing bone conduction threshold. Hearing-specific and general quality-of-life questionnaires revealed no significant difference between the two devices.
Conclusion: Patients with mixed or conductive hearing loss experience hearing gain with both, the adhesive device and the active transcutaneous device. The adhesive device may be a valuable alternative to the active transcutaneous device, depending on the individual bone conduction threshold.

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Effects of Presentation Level on Spatial Hearing With and Without Bone-Conduction Amplification in Congenital Unilateral Aural Atresia

Canfarotta, Michael W.; Kane, Stacey L.G.; Buss, Emily

Publication date 01-04-2021


Objective: This study assessed the effect of ipsilateral bone-conduction amplification on spatial hearing abilities in subjects with congenital unilateral aural atresia (CUAA).
Patients: Twelve patients with unilateral conductive hearing loss secondary to CUAA and normal hearing in the contralateral ear were tested. Most (75%) had limited experience with a bone-conduction hearing aid (BCHA).
Intervention: Performance was evaluated with and without a BCHA fitted acutely on a softband.
Main Outcome Measures: Spatial hearing abilities were evaluated in two paradigms. Spatial release from masking was evaluated by comparing masked sentence recognition with a target and two speech maskers either colocated at 0 degree or with the maskers separated at +90 degrees and −90 degrees. Sound source localization was evaluated in a 180 degrees arc of loudspeakers on the horizontal plane. Performance was evaluated at 50 and 75 dB SPL, and results were compared for patients tested with and without a BCHA.
Results: Group level results indicate similar spatial release from masking in the aided and unaided conditions at both presentation levels. Localization at 50 dB SPL was similar aided and unaided, but at 75 dB SPL the root mean square error was lower unaided than aided (17.2 degrees vs 41.3 degrees; p = 0.010).
Conclusions: Use of a BCHA in patients with CUAA may interfere with auditory cues required for sound source localization when the signal level is intense enough to overcome the patients conductive hearing loss. These findings have potential clinical implications in fitting of BCHAs to support optimal spatial hearing in patients with CUAA.

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"Is Menières Disease a Contraindication to Stapedectomy?"

Sioshansi, Pedrom C.; Schettino, Amy E.; Bojrab, Dennis I.; Babu, Seilesh C.; Michaelides, Elias M.; Luryi, Alexander L.; Schutt, Christopher A.

Publication date 01-04-2021


Objective: Review surgical outcomes of stapedectomy for otosclerosis in patients with Menierès disease.
Study Design: Retrospective case review.
Setting: Tertiary referral center.
Patients: Patients with otosclerosis and Menières disease undergoing stapedectomy between 2010 and 2017.
Intervention: Stapedectomy.
Main Outcome Measures: Pre- and postoperative hearing and complications. Hearing was measured by air conduction (AC) and bone conduction (BC) pure-tone frequency, pure-tone averages (PTA), air-bone gap (ABG), and word recognition scores (WRS).
Results: Among 1,499 patients with otosclerosis, the incidence of concomitant Menières disease was 1.7%. Fifteen patients with otosclerosis and Menières disease underwent stapedectomy, 12 primary and three revisions. Mean AC PTA was 43 dB preoperatively, and 25 dB postoperatively (p = 0.0007), while the ABG improved on average from 20 to 5 dB (p = 0.0001). There was no significant difference in BC PTA or WRS postoperatively. Two patients experienced fluctuation of hearing in the postoperative period, one of which resolved with a course of steroids. The mean follow-up time was 41 months.
Conclusions: In patients with otosclerosis and Menières disease, stapedectomy provides excellent hearing outcomes in a majority of patients. As is characteristic of Menières disease, some patients will continue to experience fluctuating hearing postoperatively, which may progress to severe sensorineural hearing loss. Menières disease may not be an absolute contraindication to stapes surgery.

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A Novel COCH Mutation Affects the vWFA2 Domain and Leads to a Relatively Mild DFNA9 Phenotype

Smits, Jeroen J.; van Beelen, Eline; Weegerink, Nicole J. D.; Oostrik, Jaap; Huygen, Patrick L. M.; Beynon, Andy J.; Lanting, Cornelis P.; Kunst, Henricus P. M.; Schraders, Margit; Kremer, Hannie; de Vrieze, Erik; Pennings, Ronald J. E.

Publication date 01-04-2021


Objective: To study the genotype and phenotype of a Dutch family with autosomal dominantly inherited hearing loss.
Study Design: Genotype–phenotype correlation study. Genetic analysis consisted of linkage analysis, variable number of tandem repeats analysis, and Sanger sequencing. Audiovestibular function was examined. Regression analysis was performed on pure tone audiometry and speech recognition scores and correlated with the age and/or level of hearing loss.
Setting: Tertiary referral center.
Patients: A large Dutch family presenting with sensorineural hearing loss.
Main Outcome Measures: Identification of the underlying genetic defect of the hearing loss in this family. Results of pure tone and speech audiometry, onset age, progression of hearing loss and vestibular (dys)function.
Results: A novel mutation in COCH, c.1312C > T p.(Arg438Cys), cosegregates with hearing loss and a variable degree of vestibular (dys)function in this family. The reported mean age of onset of hearing loss is 33 years (range, 18–49 yr). Hearing loss primarily affects higher frequencies and its progression is relatively mild (0.8 dB/yr). Speech perception is remarkably well preserved in affected family members when compared with other DFNA9 families with different COCH mutations.
Conclusion: These findings expand the genotypic and phenotypic spectrum of DFNA9. The c.1312C > T mutation, which affects the vWFA2 domain, causes a relatively mild audiovestibular phenotype when compared with other COCH mutations.

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Low Thyroid-stimulating Hormone Levels Are Associated With Annoying Tinnitus in Adult Women: Korea National Health and Nutrition Examination Surveys

Kim, So Young; Min, Chanyang; Kim, Hyung-Jong; Choi, Hyo Geun

Publication date 01-04-2021


Objective: This study aimed to investigate the relationship between thyroid function and tinnitus.
Study Design: A cross-sectional study.
Setting: The Korean National Health and Nutrition Examination Survey from 2013 was used.
Patients and Interventions: A total of 1,165 participants ≥ 40 years old who were surveyed for the presence of tinnitus and underwent thyroid function tests were included. The presence of discomfort from tinnitus was defined as annoying tinnitus. The control group included participants with “no tinnitus” or “no discomfort from tinnitus.” The participants were divided into the annoying tinnitus group and the control group.
Main Outcome Measures: The associations of free thyroxine and thyroid-stimulating hormone (TSH) with annoying tinnitus were analyzed using logistic regression with complex sampling methods. Subgroup analyses were performed according to sex.
Results: The low TSH level group had 2.35-fold greater odds of annoying tinnitus than the control group (95% confidence interval  = 1.10–5.12, p = 0.027). Even in patients with a normal free thyroxine level, a low TSH level was related to 2.78-fold higher odds of annoying tinnitus (95% confidence interval  = 1.21–6.38, p = 0.016). In subgroup analyses, this association was apparent in the female subgroup. The male subgroup did not show a relationship between low TSH levels and annoying tinnitus.
Conclusions: Subclinical hyperthyroidism was related to an increased risk of annoying tinnitus. This relationship was apparent in the female subgroup.

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Comparison of Cochlear Implant Device Fixation—Well Drilling Versus Subperiosteal Pocket. A Cost Effectiveness, Case–Control Study

Stern Shavit, Sagit; Weinstein, Emery P.; Drusin, Madeleine A.; Elkin, Elena B.; Lustig, Lawrence R.; Alexiades, George

Publication date 01-04-2021


Objective: To compare surgical characteristics and complications between well drilling (WD) and subperiosteal pocket techniques (SPT) for receiver/stimulator (R/S) fixation of cochlear implant (CI), and conduct cost-effectiveness analysis.
Study Design: Retrospective clinical study, decision-analysis model.
Setting: Tertiary referral center.
Patients: Three-hundred and eighty-eight CI recipients with a minimum of 6-months follow-up.
Interventions: CI surgery using either WD or SPT for R/S fixation. A decision-analysis model was designed using data from a systematic literature review.
Main Outcome Measures: Surgical operation time, rates of major and minor long-term complications were compared. Incremental cost-effectiveness was also estimated, comparing the two methods of fixation.
Results: We compared 179 WD with 209 SPT. Surgery time was significantly shorter in SPT (148 versus 169 min, p = 0.001) and remained significant after adjustment for possible confounders. Higher rates of major complications requiring surgical intervention were found with SPT (10.5% versus 4.5%, p = 0.042), however, the difference was not significant after adjusting for follow-up time (47.8 versus 32.5 months for SPT, WD respectively; p < 0.001). The incremental cost-effectiveness ratio for WD (compared with SPT) was $48,795 per major complication avoided, which was higher than the willingness-to-pay threshold of $47,700 (average cost of 2 h revision surgery).
Conclusions: SPT was found to be faster but potentially risks more complications, particularly relating to device failure. Further long-term studies are required to validate these differences. Based on data from the current literature, neither of the methods is compellingly cost-effective over the other, and surgeons can base their choice on personal preference, comfort, and previous training.

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Radiological and Audiological Outcomes of the LISTENT LCI-20PI Cochlear Implant Device

Tan, Haoyue; Yao, Junji; Li, Yun; Zhang, Zhihua; Chen, Ying; Huang, Meiping; Sterkers, Olivier; Jia, Huan; Wu, Hao

Publication date 01-04-2021


Objective: To study the surgical results, intracochlear position of the electrode array (EA) and auditory performance of the LISTENT LCI-20PI cochlear implant device, and daily use status at 3 years.
Study Design: A retrospective study.
Setting: A single-tertiary referral center.
Patients: Between January and December 2016, 20 patients underwent cochlear implantation using the LISTENT LCI-20PI (lateral wall EA).
Intervention: Cochlear implantation.
Main Outcome Measures: Measurement of cochlear size, extent of posterior tympanotomy, and insertion depth. Scalar position of the EA evaluated by 3D reconstruction. Auditory outcomes 1 year after implantation and daily use status at 3 years.
Results: EAs were completely inserted in all cases with an insertion depth of 288 ± 36.8 degrees. One year later, the average sentence recognition score (SRS) was 90 ± 21.7%. EA scalar location was analyzed in 18 patients. Thirteen EAs (72.2%) were fully inserted into the scala tympani (ST) and 5 (27.8%) had shifted from the ST to the scala vestibuli (SV). There was no statistically significant difference in cochlear size, extent of posterior tympanotomy, or insertion depth between these two groups. EAs inserted by cochleostomy had a higher chance of scalar shift than those inserted via the round window (60% vs 15.4%, p = 0.099). SRS at 1 year with full ST insertion was significantly better than in those with scalar shift (99 ± 1.3% vs 83 ± 16.5%, p = 0.002). Three years after implantation, 92% of patients were daily users and 46% were telephone users.
Conclusions: The LISTENT LCI-20PI provided accredited hearing rehabilitation with a short insertion depth. Full insertion into the ST was associated with better cochlear implantation outcomes.

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Comparative Performance of Lateral Wall and Perimodiolar Cochlear Implant Arrays

Sturm, Joshua J.; Patel, Vir; Dibelius, Greg; Kuhlmey, Megan; Kim, Ana H.

Publication date 01-04-2021


Objective: The physical shape of cochlear implant (CI) arrays may impact hearing outcomes. The goal of this study was to compare post-operative speech and melody perception between patients with lateral wall (LW) and perimodiolar (PM) electrode arrays across a range of lengths and manufacturers.
Study Design: Retrospective chart review.
Setting: Tertiary Care Hospital.
Patients: 119 adult patients with post-lingual hearing loss who underwent cochlear implantation.
Main Outcome Measures: A total of seven different electrodes were evaluated including 5 different LW electrodes (CI422 Cochlear American, 1J Advanced Bionics, Medium Med El, Standard Med El, Flex28 Med El) and 2 PM electrodes (Contour Cochlear American, Mid Scala Advanced Bionics). Speech perception outcomes (n = 119 patients) were measured by Consonant-Nucleus-Consonant (CNC) scores collected 3, 6, 12 and 24 months after implantation. Melody perception outcomes (n = 35 CI patients and n = 6 normal hearing patients) were measured by Melodic Contour Identification (MCI).
Results: CNC scores increased over time after implantation across all array designs. PM designs exhibited higher CNC scores compared to LW electrodes, particularly 6-months after implantation. Pre-operative pure tone averages did not correlate with post-operative CNC scores. PM arrays outperformed LW electrodes in terms of MCI scores.
Conclusions: The physical shape of cochlear implant electrode arrays may impact hearing performance. Compared to LW designs, PM arrays appear to offer superior speech perception during the first 6 months after implantation, with performance equalizing between groups by 24 months. Compared to LW designs, PM arrays also appear to afford superior melody perception.

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Cochlear Implant Outcomes in Neurofibromatosis Type 2: Implications for Management

Deep, Nicholas L.; Patel, Evan J.; Shapiro, William H.; Waltzman, Susan B.; Jethanamest, Daniel; McMenomey, Sean O.; Roland, John Thomas Jr; Friedmann, David R.

Publication date 01-04-2021


Objective: To describe our institutional experience with cochlear implantation (CI) for rehabilitation of hearing loss in Neurofibromatosis type 2 (NF2) patients.
Study Design: Retrospective review between 1989 and 2019.
Setting: Tertiary-care center.
Patients: Twenty-four patients (67% female, mean age 45.6years) with NF2. Management of their ipsilateral vestibular schwannoma included microsurgery (n=12), stereotactic radiation (n=5), and observation (n=7).
Interventions: Cochlear implantation.
Main Outcome Measures: Ability to obtain open-set speech, daily device usage and long-term device benefit.
Results: All patients achieved some degree of sound awareness with CI. Nineteen patients (79%) achieved open-set speech understanding with a mean word-recognition score of 43% (range 0-88%). Patients with tumors 1.5 cm or less demonstrated the better speech understanding, without significant differences among treatment modalities. For tumors greater than 1.5 cm, patients who underwent microsurgery had a lower rate of open-set speech understanding compared to those treated with radiation or observation. Regular daily device use in 83% of patients was found. Long-term use (>10years) was observed in several patients, though some ultimately required reimplantation with an auditory brainstem implant due to progressive tumor growth. Mean follow-up duration was 4.1 years (range 0.4-15).
Conclusions: Cochlear implantation can be an effective treatment for hearing loss in NF2 patients provided the cochlear nerve is intact, regardless of prior management for the ipsilateral tumor. The degree of benefit varies and is influenced by tumor size. Management strategies that preserve the cochlear nerve maximize the interval during which a CI could be of benefit to NF2 patients.

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Cochlear Implantation in the Active Duty Military Population: A Survey Assessing Military Readiness and Satisfaction

Sommerfeldt, John M.; Fischer, Jakob L.; Morrison, Danielle A.; Pillion, Elicia; Bernstein, Joshua; Tolisano, Anthony M.

Publication date 01-04-2021


Objective: Evaluate the impact of cochlear implantation (CI) on retention for United States active duty (AD) service members.
Study Design: Retrospective observational study.
Setting: Tertiary military CI centers.
Patients: AD service members who underwent CI and completed a telephonic survey.
Main Outcome Measures: The ability for military personnel to maintain AD status following CI as determined by the nonvolitional hearing-related AD separation rate and whether subjects would recommend CI to other qualified candidates.
Results: Twenty AD service members who underwent CI between 2004 and 2020 completed a telephonic survey. Fifteen (75%) were single-sided deafness (SSD) and five were traditional CI candidates. The mean age was 40.3 years (range 27.5–64.3), 19 (95%) were male, and 12 (80%) were Caucasian. Ten (50%) were officers and 14 (70%) were noncombat support personnel. Idiopathic sudden sensorineural hearing loss was the most common cause of hearing loss (8, 40%) followed by occupational noise exposure (4, 20%). Sixteen (80%) maintained AD status yielding 46.15 person-years of AD service following CI. For SSD, 14 (93%) maintained AD status yielding 40.54 person-years of AD service. The nonvolitional hearing-related patient separation rate for CI recipients with bilateral hearing loss was 35.65 cases per 100 AD person-years and 0 cases per 100 person-years for SSD candidates. Nineteen (95%) stated they would recommend CI to other AD CI candidates.
Conclusions: The vast majority of AD CI recipients, and particularly those with SSD, are able to remain on AD after surgery and report a high degree of satisfaction with their implant.

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Assessment of Inter- and Intra-Rater Reliability of Tablet-Based Software to Measure Cochlear Duct Length

Cooperman, Shayna P.; Aaron, Ksenia A.; Fouad, Ayman; Tran, Emma; Blevins, Nikolas H.; Fitzgerald, Matthew B.

Publication date 01-04-2021


Objective: The objective of this study is to build upon previous work validating a tablet-based software to measure cochlear duct length (CDL). Here, we do so by greatly expanding the number of cochleae (n = 166) analyzed, and examined whether computed tomography (CT) slice thickness influences reliability of CDL measurements.
Study Design: Retrospective chart review study.
Setting: Tertiary referral center.
Patients: Eighty-three adult cochlear implant recipients were included in the study. Both cochleae were measured for each patient (n = 166).
Interventions: Three raters analyzed the scans of 166 cochleae at 2 different time points. Each rater individually identified anatomical landmarks that delineated the basal turn diameter and width. These coordinates were applied to the elliptic approximation method (ECA) to estimate CDL. The effect of CT scan slice thickness on the measurements was explored.
Main Outcome Measures: The primary outcome measure is the strength of the inter- and intra-rater reliability.
Results: The mean CDL measured was 32.84 ± 2.03 mm, with a range of 29.03 to 38.07 mm. We observed no significant relationship between slice thickness and CDL measurement (F1,164 = 3.04; p = 0.08). The mean absolute difference in CDL estimations between raters was 1.76 ± 1.24 mm and within raters was 0.263 ± 0.200 mm. The intra-class correlation coefficient (ICC) between raters was 0.54 and ranged from 0.63 to 0.83 within raters.
Conclusions: This software produces reliable measurements of CDL between and within raters, regardless of CT scan thickness.

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Objective Vestibular Test Battery and Patient Reported Outcomes in Cochlear Implant Recipients

West, Niels; Tian, Luchen; Vang Petersen, Laura Katrine; Bille, Michael; Klokker, Mads; Cayé-Thomasen, Per

Publication date 01-04-2021


Objective: Cochlear implantation (CI) may have undesired effects on the vestibular apparatus. However, the literature holds no consensus on vestibular affection and the testing tools applied to test for vestibular dysfunction after cochlear implantation are inconsistent. We aimed to investigate the impact of CI on vestibular function by an extensive test battery including patient-reported outcomes.
Study Design: Prospective observational study.
Setting: University hospital.
Patients: Forty adult unilateral first-time CI recipients.
Intervention: Vestibular function was evaluated pre- and post-implantation with the video head impulse test (VHIT), the caloric test and cervical vestibular evoked myogenic potentials (cVEMPs), and the patient-reported dizziness handicap inventory (DHI).
Results: Mean VHIT gain decreased from preoperative 0.92 to 0.84 postoperative (p = 0.018); mean caloric unilateral weakness increased from 20.5% preoperative to 42.9% postoperative (p < 0.0001); cVEMP responses were present on 10 operated ears preoperative and five ears postoperative, and compared with non-implanted ears, cVEMP responses on implanted ears were impaired (p = 0.023). 50% of patients reported early postoperative dizziness, but the mean DHI score remained unchanged (p = 0.94). The DHI scores correlated poorly with the objective outcomes (rs = 0.19 and rs = –0.22).
Conclusion: Vestibular function is significantly affected after cochlear implantation, but vestibular hypofunction varies with the test used. Although early dizziness after implantation is common, later DHI scores are not significantly higher than before the implantation, indicating that central compensation plays a major role for these patients.

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Cochlear Implantation in Sporadic Vestibular Schwannoma and Other Retrocochlear Pathology: A Case Series

Patel, Evan J.; Deep, Nicholas L.; Friedmann, David R.; Jethanamest, Daniel; McMenomey, Sean O.; Roland, John Thomas Jr

Publication date 01-04-2021


Objective: To describe outcomes with cochlear implantation (CI) for rehabilitation of hearing loss in patients with sporadic vestibular schwannomas (VS) and other retrocochlear pathologies.
Study Design: Retrospective review.
Setting: Tertiary-care center.
Patients: Twenty three cases in 19 patients (53% men, mean age 55.8 yr) with non-neurofibromatosis type 2 related retrocochlear pathology.
Interventions: Unilateral or bilateral CI.
Main Outcome Measures: Word recognition score, device usage.
Results: Etiology of deafness included sporadic VS (n = 9, 39%), radiation after head and neck or central nervous system (CNS) malignancy (n = 8, 35%), superficial siderosis (n = 3, 13%), neurosarcoidosis (n = 2, 9%), and pontine stroke (n = 1, 4%). Mean follow-up duration was 2.3 years (standard deviation SD 3.0; range, 0.2–9.4). Auditory perception was achieved in 20 out of 22 patients (91%) who have been activated. Mean WRS in patients with sporadic VS was 18% (SD 20; range, 0–44). Mean WRS in patients with non-VS retrocochlear pathology was 55% (SD 30; range, 0–94). Data logs showed 7.0 h/d of average use (SD 4.3; range, 0–13).
Conclusions: Appropriately selected patients with retrocochlear pathology may benefit from CI so long as the patient has a cochlear fluid signal and an intact cochlear nerve. Patients with sporadic VS patients and normal contralateral hearing exhibited guarded outcomes with CI, whereas most patients with non-VS retrocochlear pathologies demonstrated open-set speech understanding scores comparable to or slightly worse than conventional CI candidates. Since variable performance benefit is observed with CI in patients with retrocochlear pathology, counseling is imperative to align patient expectations with realistic outcomes.

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Electrocochleography Observations in a Series of Cochlear Implant Electrode Tip Fold-Overs

Trecca, Eleonora M. C.; Adunka, Oliver F.; Mattingly, Jameson K.; Hiss, Meghan M.; Cassano, Michele; Malhotra, Prashant S.; Riggs, William J.

Publication date 01-04-2021


Objective: Tip fold-over is a rare but serious complication of cochlear implant (CI) surgery. The purpose of this study was to present intraoperative electrocochleography (ECochG) observations in a series of CI electrode tip fold-overs.
Patients: Five pediatric subjects undergoing CI surgery through a round window (RW) approach with a perimodiolar electrode array, who were diagnosed with either auditory neuropathy spectrum disorder or enlarged vestibular aqueduct.
Interventions: Intraoperative RW ECochG during CI surgery: tone burst stimuli were presented from 95 to 110 dB SPL.
Main Outcome Measure(s): Magnitude and phase characteristics of ECochG responses obtained intraoperatively before and immediately after electrode insertion were examined for patients with and without tip fold-over.
Results: Three subjects presented with tip fold-over and two formed the control group. Among fold-over cases, one participant exhibited an inversion in the starting phase of the cochlear microphonic response and a decrease in spectral magnitude from pre- to postinsertion. Both subjects who did not exhibit a change in phase had an increase in the ECochG-total response (ECochG-TR) magnitude. No case in the control group exhibited a change in starting phase. In regard to the ECochG-TR, all controls showed a decrease in the magnitude.
Conclusions: Despite the small number of patients, heterogeneous ECochG response patterns were observed within the fold-over group. Though these results are not conclusive, they can serve as a framework to begin to understand ECoch Gs utility in detecting intraoperative tip fold-over.

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Robot-assisted Cochlear Implant Electrode Array Insertion in Adults: A Comparative Study With Manual Insertion

Daoudi, Hannah; Lahlou, Ghizlene; Torres, Renato; Sterkers, Olivier; Lefeuvre, Vincent; Ferrary, Evelyne; Mosnier, Isabelle; Nguyen, Yann

Publication date 01-04-2021


Objective: To describe the first cochlear array insertions using a robot-assisted technique, with different types of straight or precurved electrode arrays, compared with arrays manually inserted into the cochlea.
Study Design: Retrospective review.
Setting: Tertiary otologic center.
Patients: Twenty cochlear implantations in the robot-assisted group and 40 in the manually inserted group.
Interventions: Cochlear implantations using a robot-assisted technique (Rob Otol) with straight (eight Cochlear CI522/622, and eight Advanced Bionics Hifocus Slim J) or precurved (four Advanced Bionics Hifocus Mid-Scala) matched to manual cochlear implantations. Three-dimensional reconstruction images of the basilar membrane and the electrode array were obtained from pre- and postimplantation computed tomography.
Main Outcome Measures: Rate and localization of scalar translocations.
Results: For straight electrode arrays, scalar translocations occurred in 19% (3/16) of the robot-assisted group and 31% (10/32) of the manually inserted group. Considering the number of translocated electrodes, this was lower in the robot-assisted group (7%) than in the manually inserted group (16%) (p < 0.0001, χ2 test). For precurved electrode arrays, scalar translocations occurred in 50% (2/4) of the robot-assisted group and 38% (3/8) of the manually inserted group.
Conclusion: This study showed a safe and reliable insertion of different electrode array types with a robot-assisted technique, with a less traumatic robotic insertion of straight electrode arrays when compared with manual insertion.

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Inflammation at the Tissue-Electrode Interface in a Case of Rapid Deterioration in Hearing Performance Leading to Explant After Cochlear Implantation

Hough, Kate; Sanderson, Alan; Grasmeder, Mary; Mitchell, Tim; Verschuur, Carl A.; Newman, Tracey A.

Publication date 01-04-2021


Objective: The reasons for soft failure after cochlear implantation require investigation. This study proposes a method to study and characterize the tissue response to the array in a case of soft failure in a person undergoing reimplantation.
Case: The woman in her 50s, with an underlying autoimmune condition, received a cochlear implant using hearing preservation technique after developing profound hearing loss more than 2 k Hz with a moderate loss of less than 500 Hz over a 10-year period. The case was identified as a soft failure due to deteriorating performance, discomfort, and migration over the 10 months after implantation. Impedance telemetry, speech perception measures, and audiometric thresholds are described. At explantation there was evidence of fibrosis.
Intervention(s): To use histology and immunohistochemistry to determine the cellular response of the tissue associated with the electrode array at time of explantation.
Main Outcome Measure(s): Identification of the cell types, regional variations, and inflammatory marker expression in the fibrotic tissue associated with the array.
Results: Neutrophils and eosinophils were identified, along with a variable pattern of collagen deposition. CD68 and CD163-positive macrophages and T cells were variably distributed through the tissue and interleukin-1 beta and vascular endothelial growth factor receptor-2 expression was identified.
Conclusions: The expression profile is evidence of active inflammation in the tissue despite the time since implantation. This study is the first to characterize the tissue response to the array in a person undergoing reimplantation, and who can be followed to determine the individual response to arrays. It establishes that the investigation of explanted devices after soft-failure is feasible.

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Utilization of SEMAC-VAT MRI for Improved Visualization of Posterior Fossa Structures in Patients With Cochlear Implants

Amin, Nikul; Pai, Irumee; Touska, Philip; Connor, Steve E. J.

Publication date 01-04-2021


Objective: The number of cochlear implant (CI) users is ever increasing worldwide, as is the utilization of magnetic resonance imaging (MRI) as a key diagnostic modality for pathology of the brain and surrounding structures. Despite advances in MRI compatibility with CI, metal artefact remains a significant issue that needs to be addressed. We test our hypothesis that the slice encoding for metal artefact correction and view angle tilting (SEMAC-VAT) metal artefact reduction technique improves demonstration of posterior fossa structures on MRI in CI recipients.
Study Design: A retrospective case review.
Setting: A tertiary referral hearing implant and skull base center.
Intervention(s): Dedicated MRI of the posterior fossa using T1 spin echo post-gadolinium sequences with and without the application of SEMAC-VAT in CI recipients.
Main Outcome Measure(s): Extent and severity of the artefact and visualization of surrounding anatomic structures with and without the application of SEMAC-VAT, allowing for direct comparison.
Results: Eight CI recipients with nine CI devices were analyzed. We noted a significant reduction in signal void and improved visibility of the ipsilateral hemisphere in every case. Penumbra size increased although there was improved visibility through the penumbra. There was improved visualization of key intracranial structures, such as the ipsilateral internal auditory canal, cerebellopontine angle, cerebellar hemisphere, and brainstem.
Conclusions: Application of SEMAC-VAT produces a significant reduction in signal void and improved visualization of key structures within the temporal bone and posterior cranial fossa in patients with CIs without the need for removal of the internal magnet.

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Balloon Dilation for Obstructive Eustachian Tube Dysfunction in Children

Toivonen, Joonas; Kawai, Kosuke; Gurberg, Joshua; Poe, Dennis

Publication date 01-04-2021


Objective: Determine the safety and efficacy of balloon dilation of the Eustachian tube (ET) in pediatric patients.
Study Design: Retrospective matched cohort study.
Setting: Tertiary medical center.
Patients: Pediatric patients (1.5 yr) chronic Eustachian tube dysfunction (ETD) with previous tympanostomy tube (TT) insertion versus matched controls.
Intervention(s): Balloon dilation of the cartilaginous ET (BDET) was performed using concomitant myringotomy with/without tube placement and adjunctive procedures if indicated versus controls (TT).
Main Outcome Measure(s): Otitis media with effusion (OME)/retraction with need for additional tube, tympanogram, audiogram, otomicroscopy, ET mucosal inflammation/opening score, and Valsalva maneuver.
Results: Forty six ETs (26 patients), ages 7 to 17 years (mean 12.5) underwent BDET. Mean follow-up was 2.3 years (standard deviation SD, 1.1; range, 6 mo–5 yr). Significant improvements were observed for all measures. Tympanic membranes were healthy in 9% preoperatively, 38% at 6 months, 55% at 12 months, and 93% at 36 months postoperatively. Tympanograms improved to type A in 50% at 6 months, 59% at 12 months, and 85% at 36 months. Mean scores of mucosal inflammation declined from 3.2 (±0.6) preoperatively to 2.5 (±0.7) at 6 months and 1.7 (±0.6) at 36 months postoperatively. BDET had lower risk of failure versus TT insertion (adjusted hazard ratio HR 0.26; 95% confidence interval CI: 0.10, 0.70; p = 0.007). Probability of being failure free at 2 years was 87% (95% CI: 70, 94%) after BDET and 56% (95% CI: 40, 70%) after TT insertions.
Conclusions: BDET is a safe and possibly effective procedure in selected pediatric patients with chronic ETD.

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Postoperative Recurrent Cholesteatoma in Rural Versus Urban Populations

Kennedy, Kenneth L.; Connolly, Kevin M.; Albert, Christy L.; Goldman, Julie L.; Cash, Elizabeth D.; Severtson, Mark Allen

Publication date 01-04-2021


Objective: Chronic ear disease presents a unique challenge to otolaryngologists in both rural and urban settings. Cholesteatoma remains a difficult disease to treat in rural populations due to limited healthcare access and high risk of recurrence. The purpose of this study was to determine if there are differences in surgical outcomes among patients with acquired cholesteatoma residing in rural versus urban settings.
Study Design: Single-surgeon retrospective case series with chart review.
Setting: Tertiary care private otolaryngology practice.
Patients: One hundred twenty-two patients presenting to the Kentuckiana ENT otology and neurotology practice from January 2011 to May 2017.
Main Outcome Measures: Surgical outcomes including recurrence, air-bone gap improvement, ossicular integrity, and complications were reviewed and compared between the rural and urban cohorts.
Results: Presence of postoperative residual cholesteatoma (OR = 8.667, 95% CI = 2.022–37.141, p = 0.008) and number of surgeries per patient (OR = 5.185, 95% CI = 1.086–24.763, p = 0.024) were significantly increased among patients in rural nonmetropolitan areas. No significant differences were found when comparing risk of recurrence, size of cholesteatoma, presence of complications, air-bone gap improvement, and ossicular chain integrity. There were significantly more second-look surgeries performed in privately insured patients (OR = 8.582, 95% CI = 1.937–38.017, p = 0.001).
Conclusions: Patients in rural communities have an increased number of surgeries and postoperative risk for residual cholesteatoma compared to patients residing in urban settings. This study provides the basis for larger, multicenter, prospective examinations of outcomes among urban versus rural patients, which would enable a better understanding of difference in surgical outcomes between rural and urban cohorts.
Level of Evidence: IV

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The Feasibility of Magnetic Resonance Imaging for the Differentiation of Cerebrospinal Fluid Leak From Middle Ear Effusion: A Quantitative Analysis

Raghavan, Arun M.; Breen, Joseph T.

Publication date 01-04-2021


Objective: Assess quantitatively whether magnetic resonance imaging (MRI) signal intensity can be used to distinguish cerebrospinal fluid (CSF) leaks in the temporal bone from middle ear effusions.
Study Design: Retrospective case review.
Setting: Tertiary referral center.
Patients: Forty-nine patients, 18 with middle ear effusions (MEE), 30 with CSF leaks, and 1 with an MEE on one side and a CSF leak on the other, were evaluated in the study. Primary inclusion criteria for CSF leak patients were operative management of CSF leak with confirmatory diagnosis in follow-up. Primary inclusion criteria for MEE patients were electronic medical record documentation of an effusion with subsequent resolution on follow-up. For all patients, inclusion criteria included MRI imaging with 3D-T2 weighted sequences (3DT2) and fluid-attenuated inversion recovery (FLAIR) sequences performed within 1 year of diagnosis code entry.
Intervention: Computational analysis of signal intensity of fluid collections in MRI imaging.
Main Outcome Measures: Sensitivity and specificity of 3DT2 and FLAIR signal intensity in the detection of CSF leak.
Results: For 3DT2 sequences with a chosen normalized signal intensity threshold (CSF leak if ≥ 0.5), sensitivity was 100% (95% CI: 86.3–100) and specificity was 83.3% (95% CI: 51.6–97.9). For FLAIR sequences with a threshold of 1.0 (CSF leak if < 1.0), sensitivity was 77.4% (95% CI: 58.9–90.4) and specificity was 85.7% (95% CI: 63.6–97.0). For a combined test in which a fluid collection was considered CSF if both 3DT2 ≥ 0.5 and FLAIR < 1.0, sensitivity was 76% (95% CI: 54.9–90.6) and specificity was 100% (95% CI: 73.5–100).

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Prevalence of Depression and Anxiety in Adolescents With Hearing Loss

Cejas, Ivette; Coto, Jennifer; Sanchez, Chrisanda; Holcomb, Meredith; Lorenzo, Nicole E.

Publication date 01-04-2021


Objective: To develop and implement a universal screening protocol for depression and anxiety in adolescents serviced in an otology and audiology practice and to estimate the prevalence of depression and anxiety in adolescents with hearing loss, while also comparing rates by degree of hearing loss and type of hearing device used.
Study Design: Cross-sectional.
Setting: University tertiary medical center.
Patients: One hundred four adolescents 12- to 18-years-old who attended an otology clinic in a large metropolitan hospital in the southeastern United States.
Main Outcome Measure: (s): Depression (PHQ-8), anxiety (GAD-7), degree of hearing loss, type of hearing loss, and type of hearing device utilized.
Results: Twenty-five percent of adolescents scored above the clinical cutoff on at least one of the depression and/or anxiety measures, with 10% scoring in the elevated range on both measures. Specifically, 17% scored above the cutoff on the PHQ-8 and 16% scored in the clinically significant range for the GAD-7. An additional 30 and 21% scored in the at-risk range for depression and anxiety, respectively. Older adolescents were more likely to score within the elevated range for depression (r = 0.232, p = 0.026). Also, adolescents with severe to profound hearing loss had higher rates of depression and anxiety.
Conclusions: Integration of mental health screening is needed in otology and audiology practices both to identify those who require psychological support and to provide appropriate treatment to reduce long-term impact of hearing loss on quality of life and mental health functioning in adolescents.

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When to Say When—Reasons to Abort Surgery for Congenital Aural Atresia

Casazza, Geoffrey C.; Kesser, Bradley W.

Publication date 01-04-2021


Objective: To determine reasons for premature termination in surgery for congenital aural atresia (CAA).
Study Design: Retrospective chart review.
Setting: High-volume tertiary care center.
Patients: Patients undergoing primary surgical repair of CAA whose surgeries were aborted for various indications.
Intervention: Patients with CAA who underwent elective aural atresia surgery at the University of Virginia from July 2004 to January 2020 were identified from the medical record and an institutional database of patients with CAA. Patients undergoing revision surgery or surgery not for hearing correction were excluded. All included candidates were noted to be good surgical candidates for atresia repair based on preoperative Jahrsdoerfer score of 6 or greater. Reasons for terminating surgery prematurely were categorized by anatomical constraints (inability to identify middle ear space, position of the facial nerve, or other anatomic abnormality), stapes fixation, and middle ear and/or mastoid inflammatory disease.
Main Outcome Measures: Reasons for premature termination in CAA surgery.
Results: Over the interval, 319 patients underwent primary surgery for CAA. Surgery was terminated prematurely without completing the primary objective in 14 patients (4.4%); surgery was terminated in 8 (57%) due to anatomic constraints, 4 (29%) due to stapes fixation, and 2 (14%) due to middle ear space and/or mastoid inflammatory disease.
Conclusions: Premature termination in surgery for CAA is a rare occurrence with careful study of the preoperative high-resolution computed tomography of the temporal bone. Of the reasons for premature termination, anatomic constraints were the most common. Knowing limitations in surgery—both technical and anatomic—is critical to optimize outcomes and prevent complications.

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Which Inner Ear Disorders Lie Behind a Selective Posterior Semicircular Canal Hypofunction on Video Head Impulse Test?

Castellucci, Andrea; Piras, Gianluca; Del Vecchio, Valeria; Ferri, Gian Gaetano; Ghidini, Angelo; Brandolini, Cristina

Publication date 01-04-2021


Objective: To assess all different patterns of associated abnormalities on audiometry, bithermal caloric test (BCT) and cervical/ocular vestibular-evoked myogenic potentials (VEMPs) to air/bone-conduction in patients with selective posterior semicircular canal (PSC) hypofunction and to correlate them with underlying disorders.
Study Design: Retrospective review.
Setting: Tertiary referral center.
Patients: 51 patients (23 men, 28 women, mean age 57.5 yr) with isolated PSC deficit (one bilateral).
Interventions: Correlation with instrumental data and underlying diagnoses.
Main Outcome Measures: Video-oculographic findings, objective measurements on audiometry, BCT, VEMPs and video-head impulse test (vHIT).
Results: Ongoing or previous acute vestibular loss (AVL) was diagnosed in 13 patients (25.5%, 3 inferior vestibular neuritis, 10 AVL with sudden sensorineural hearing loss SSNHL), Menieres disease (MD) in 12 (23.5%), cerebellopontine angle (CPA) lesion in 9 (17.6%), various causes in 7 (13.7%), benign paroxysmal positional vertigo (BPPV) involving the non-ampullary arm of PSC in 5 cases (9.8%) whereas unknown pathology in 5 (9.8%). Involvement of at least one additional receptor besides PSC was seen in 89.8% of cases. Cochlear involvement was diagnosed in 74.5% with pure-tone average significantly greater in patients with AVL+SSNHL (p < 0.05). Overall involvement of labyrinthine receptors or afferents was highest in patients with AVL+SSNHL (p < 0.01), MD and CPA lesions (p < 0.05).
Conclusions: Isolated loss of PSC function on vHIT is mostly accompanied by additional labyrinthine deficits that could only be identified through an accurate instrumental evaluation. Assessment of all receptors and afferents should be always pursued to identify the lesion site and better understand the underlying pathophysiological mechanisms.

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Clinical Implications of Horizontal Beating Nystagmus Induced by Dix-Hallpike Test in the Diagnosis of Horizontal Canal Benign Paroxysmal Positional Vertigo

Kong, Tae Hoon; Song, Mee Hyun; Shim, Dae Bo

Publication date 01-04-2021


Objectives: The purpose of this study was to identify the diverse patterns of nystagmus during the Dix-Hallpike test (DHT) and analyze their clinical significance in horizontal canal benign paroxysmal positional vertigo (HC-BPPV).
Study Design: Retrospective medical records review.
Patients: Two hundred ninety-five patients diagnosed with HC-BPPV.
Methods: Various nystagmus patterns identified during the DHT in patients with HC-BPPV were analyzed. The correlation between the affected side of HC-BPPV and the direction of the horizontal beating nystagmus (HBN) during the DHT was also analyzed.
Results: The nystagmus pattern during the DHT in 128 patients with geotropic HC-BPPV demonstrated, direction-changing positional nystagmus on both sides in 48 (37.5%) patients, HBN toward one side in 25 (19.6%) patients, and no nystagmus in 55 (42.9%) patients. In 144 patients with apogeotropic HC-BPPV, 54 (37.5%) patients presented with direction-changing positional nystagmus on both sides, 27 (18.8%) patients presented with HBN toward one side, and 63 (43.7%) patients did not show nystagmus during the DHT. The direction of HBN provoked by the DHT was significantly correlated with the affected side in each subtype of HC-BPPV (geotropic type, p = 0.049; apogeotropic type, p = 0.040; respectively).
Conclusion: More than half of the patients with HC-BPPV (56.6%) showed HBN during the DHT. When HBN was present during the DHT, it may provide a clue for determining the subtype and affected side in diagnosis of HC-BPPV before performing the supine roll test.

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Usefulness of the Video Head Impulse Test for the Evaluation of Vestibular Function in Patients With Otitis Media With Antineutrophil Cytoplasmic Antibody-Associated Vasculitis

Fujiwara, Keishi; Morita, Shinya; Fukuda, Atsushi; Yanagi, Hiroko; Hoshino, Kimiko; Nakamaru, Yuji; Homma, Akihiro

Publication date 01-04-2021


Objectives: To investigate usefulness of the video Head Impulse Test (vHIT) as a method for evaluating semicircular canal function in patients with otitis media with antineutrophil cytoplasmic antibody-associated vasculitis (OMAAV).
Study Design: Retrospective case review.
Setting: Tertiary referral center.
Patients: Fourteen patients with OMAAV underwent vestibular examination.
Main Outcome Measures: The gain in vestibulo-ocular reflex (VOR) and the presence of catch-up saccade were examined for each semicircular canal.
Results: Seven (50.0%) of the 14 patients felt subjective symptoms of disequilibrium. Dysfunction in at least one semicircular canal was detected in all ears of the OMAAV patients evaluated by vHIT. Dysfunction in posterior semicircular canal was detected more frequently than that in the anterior or horizontal canal. There were no significant correlations between the gain in VOR and hearing loss.
Conclusions: vHIT is thought to be the most suitable method for evaluating semicircular canal function in patients with OMAAV as vHIT is not influenced by middle ear pathology and was able to evaluate vertical canal function including the posterior canal.

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Treatment Analysis and Overall Survival Outcomes of Patients With Bilateral Vestibular Schwannoma

Goshtasbi, Khodayar; Abouzari, Mehdi; Yasaka, Tyler M.; Soltanzadeh-Zarandi, Sina; Sarna, Brooke; Lin, Harrison W.; Djalilian, Hamid R.

Publication date 01-04-2021


Objectives: To investigate the clinical presentation, treatment breakdown, and overall survival (OS) outcomes of patients with neurofibromatosis type 2 (NF2)-associated bilateral vestibular schwannoma (NVS).
Methods: The 2004 to 2016 National Cancer Database was queried for patients with a diagnosis of VS. The “Laterality” code was used to stratify patients into sporadic unilateral vestibular schwannoma (UVS) and NVS.
Results: Of the 33,839 patients with VS, 155 (0.46%) were coded for NVS with an average age and tumor size of 37.4 ± 20.5 years and 23.5 ± 18.2 mm. Patients underwent observation (45.3%), surgery (29.3%), and radiotherapy (20.0%), and had a 5.8% 5-year mortality rate. Compared with UVS, NVS was negatively associated with receiving surgery (40.2% versus 29.3%, p = 0.02) while watchful observation was more prevalent (30.1% versus 45.3%, p = 0.001). In NVS, undergoing surgery was associated with larger tumor size (34.5 ± 21.2 versus 17.8 ± 13.3 mm, p = 0.001) and shorter diagnosis-to-treatment time (49.1 ± 60.6 versus 87.0 ± 78.5 d, p = 0.02), radiotherapy was associated with older age (44.4 ± 18.9 versus 35.2 ± 20.6 yr, p = 0.02) and longer diagnosis-to-treatment time (85.9 ± 77.9 versus 53.9 ± 65.5 d, p = 0.04), and observation was associated with smaller tumor size (17.8 ± 15.9 versus 28.0 ± 19.2 mm, p = 0.01). Kaplan–Meier log-rank analysis demonstrated similar 10-year OS between NVS and UVS patients (p = 0.58) without factoring the earlier age of presentation. Furthermore, there were no temporal changes in presentation/management of NVS, and OS was not dependent on the received treatment (p = 0.30).
Conclusions: With younger age, larger tumors, and more conservative management, NVSs OS was not treatment-dependent and was similar to sporadic UVS, though the latter should not be interpreted as similar life expectancies due to the much earlier presentation.

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Increased Radiosurgery Toxicity Associated With Treatment of Vestibular Schwannoma in Multiple Sclerosis

Wallerius, Katherine; Collins, Sean; Forsthoefel, Matthew; Kim, Hung Jeffrey

Publication date 01-04-2021


Objective: Explore the risk of radiation-induced neurotoxicity in patients with multiple sclerosis (MS) treated with stereotactic radiosurgery (SRS) and better understand the pathophysiology of radiation-induced injury in the central nervous system (CNS).
Patients/Intervention: We present the clinical course and magnetic resonance imaging (MRI) findings of a 52-year-old woman with a history of relapsing remitting MS, who developed radiation-induced neurotoxicity following Cyber Knife SRS (25 Gy in five fractions) for a left-sided vestibular schwannoma (VS).
Main Outcome Measure: Risk of radiation-induced damage following SRS to the CNS, including radiation type and dose, toxicity, and time to symptom onset, in patients with MS.
Results: Our patient developed increased imbalance (grade 2 toxicity) 3 months following Cyber Knife SRS. Brain MRI showed new fluid-attenuated inversion recovery (FLAIR) hyperintensity in the pons and cerebellum. Neurotoxicity from SRS is rare. However, our literature review showed that 19 patients with MS who underwent intracranial radiation therapy sustained radiation-induced toxicity. The potential mechanisms for increased toxicity in MS could be due to a combination of demyelination, inflammatory, and/or vascular changes. Efficacy of treatments including steroids, bevacizumab, and hyperbaric oxygen therapy is currently unknown.
Conclusion: Treatment options of SRS and surgery for VS should be carefully considered as patients with known MS may be at increased risk for radiation-induced damage following SRS to the CNS. Thoughtful radiosurgical planning and dosing accounting for this inherent risk is essential for managing patients with MS and VS.

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Postural Sway Predicts Growth in Untreated Vestibular Schwannoma: A Retrospective Volumetric Study

Nilsen, Kathrin Skorpa; Dhayalan, Dhanushan; Lund-Johansen, Morten; Goplen, Frederik Kragerud

Publication date 01-04-2021


Background: One in three vestibular schwannomas (VS) will grow within 3 years after diagnosis, but no reliable baseline parameter has been found to predict such growth.
Objective: To determine if postural sway is associated with growth of untreated VS.
Methods: Patients with newly diagnosed sporadic VS assigned to a wait-and-scan protocol were identified from a prospectively maintained database. Postural sway was measured by posturography at baseline and patients were classified as steady or unsteady. Observer-blinded volumetric tumor measurements were performed on the diagnostic MRI and a 3-year control MRI. Tumor growth quantified as relative growth (%) and volume-doubling time (VDT and VDT−1) were investigated as dependent variables against baseline parameters.
Results: Out of 204 VS patients, 53 (26%) were classified as unsteady on the platform at baseline. Median tumor volume was 0.32 cm3 (range 0.02–4.79), and 51% demonstrated significant growth within 3 years. Unsteady patients had significantly faster-growing tumors, with a mean relative growth of 172.5% compared to 79.5% in steady patients (p 20% volume increase, compared to 42% in steady patients (p < 0.001). Mean VDT−1 was 0.65 doublings per year for unsteady patients, and 0.22 for steady patients (p < 0.001). Multivariate regression analysis including demographic and clinical parameters showed an OR of 5.6 (95% CI 2.6, 11.8) for growth in unsteady patients.
Conclusions: This is the first demonstrated association between a measurable parameter and future growth in untreated VS. Our findings may help clinicians identify patients with a higher risk for tumor growth and provide closer monitoring or early treatment.

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The Effect of Soft Tissue Stimulation on Skull Vibrations and Hearing Thresholds in Humans

Chordekar, Shai; Perez, Ronen; Adelman, Cahtia; Sohmer, Haim; Kishon-Rabin, Liat

Publication date 01-04-2021


Hypothesis: Hearing via soft tissue stimulation involves an osseous pathway.
Background: A recent study that measured both hearing thresholds and skull vibrations found that vibratory stimulation of soft tissue led to hearing sensation that correlated with skull vibrations, supporting the hypothesis of an osseous pathway. It is possible, however, that a lower application force of the vibrator on the stimulated soft tissue would not be sufficient to elicit skull vibration suggesting hearing via a nonosseous pathway. The purpose of the present study was to confirm the osseous pathway by measuring skull vibrations and behavioral thresholds using a low application force on a layer of ultrasound gel. Gel was used to mimic soft tissue because of its similar acoustic impedance and to control for variability between participants.
Methods: Hearing thresholds and the skull vibrations of five patients who were implanted with bone-anchored implants were assessed in two conditions when the bone vibrator was applied on the forehead: 1) direct application with 5N force; 2) through a layer of ultrasound gel with minimal application force. Skull vibrations were measured in both conditions by a laser Doppler vibrometer focused on the bone-anchored implant.
Results: Skull vibrations were present even when minimal application force was applied on soft tissue. The difference in skull vibrations when the vibrator was directly on the forehead compared with the gel condition was consistent with the variability in hearing thresholds between the two conditions.
Conclusion: These results reinforce the hypothesis that skull vibrations are involved in hearing when sound is transmitted via either soft tissue or bone.

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Effect of Personal Protection Equipment (PPE) and the Distance From the Eye Piece of Surgical Microscope on the Field of Vision; An Experimental Study

Iyer, Arunachalam; Tikka, Theofano; Calder, Nicholas; Qamar, Sabih Nadeem; Chin, Andy

Publication date 01-04-2021


Background: During the Covid-19 pandemic, otolaryngologists are at risk due to aerosol-generating procedures such as mastoidectomy and need enhanced personal protective equipment (PPE). Eye protection can interfere with the use of a microscope due to a reduction in the field of vision. We aimed to study the effect of PPE on the microsurgical field.
Methods: Five surgeons measured the visual field using digital calipers at different power settings. They were done with no PPE, a surgical mask, FFP3 mask (N99), and with the addition of small goggles, large vistamax goggles, vistamax plus a face shield, and only a face shield. The measurements were repeated with rings of 5 mm increments. We also measured the “eye relief” of the microscope which is the ideal distance for maximum field of view.
Results: There was no major reduction of the field with the surgical or FFP3 mask. But even simple goggles reduced the field up to 31.6% and there were progressive reductions of up to 75.7% with large goggles, 76.8% when a face shield was added, and 61.9% when only face shield was used. The distance rings more than 5 mm also affected the field of view.
The eye relief of our eyepiece was found to be 15 mm.
Conclusion: The current PPE eye protection is not compatible with the use of a microscope. There is scope for research into better eye protection. Mitigation strategies including barrier drapes and alternative techniques such as endoscopic surgery or use of exoscopes should also be considered.

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Droplet and Aerosol Generation With Mastoidectomy During the COVID-19 Pandemic: Assessment of Baseline Risk and Mitigation Measures With a High-performance Cascade Impactor

Freiser, Monika E.; Dharmarajan, Harish; Sri Kavya Boorgu, Devi Sai; Sim, Edward S.; Corcoran, Timothy E.; Jabbour, Noel; Chi, David H.

Publication date 01-04-2021


Hypothesis: Aerosols are generated during mastoidectomy and mitigation strategies may effectively reduce aerosol spread.
Background: An objective understanding of aerosol generation and the effectiveness of mitigation strategies can inform interventions to reduce aerosol risk from mastoidectomy and other open surgeries involving drilling.
Methods: Cadaveric and fluorescent three-dimensional printed temporal bone models were drilled under variable conditions and mitigation methods. Aerosol production was measured with a cascade impactor set to detect particle sizes under 14.1 μm. Field contamination was determined with examination under UV light.
Results: Drilling of cadaveric bones and three-dimensional models resulted in strongly positive aerosol production, measuring positive in all eight impactor stages for the cadaver trials. This occurred regardless of using coarse or cutting burs, irrigation, a handheld suction, or an additional parked suction. The only mitigation factor that led to a completely negative aerosol result in all eight stages was placing an additional microscope drape to surround the field. Bone dust was scattered in all directions from the drill, including on the microscope, the surgeon, and visually suspended in the air for all but the drape trial.
Conclusions: Aerosols are generated with drilling the mastoid. Using an additional microscope drape to cover the surgical field was an effective mitigation strategy to prevent fine aerosol dispersion while drilling.

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Fluorescent Detection of Vestibular Schwannoma Using Intravenous Sodium Fluorescein In Vivo

Szczupak, Mikhaylo; Peña, Stefanie A.; Bracho, Olena; Mei, Christine; Bas, Esperanza; Fernandez-Valle, Cristina; Liu, Xue-Zhong; Telischi, Fred F.; Ivan, Michael; Dinh, Christine T.

Publication date 01-04-2021


Background: Vestibular schwannoma (VS) are intracranial tumors caused by merlin deficiency. Sodium fluorescein (SF) is a fluorescent compound that accumulates in various intracranial tumors, causing tumors to emit green fluorescence after blue light excitation.
Hypothesis: Intravenous SF preferentially deposits in VS, helping surgeons differentiate tumor from surrounding tissue.
Methods: Merlin-deficient Schwann cells were grafted onto cochleovestibular nerves of immunodeficient rats. Rats were randomized to receive SF (7.5 mg/kg; n = 5) or saline (n = 3). Tissues were harvested at 1 hour and photographed in white and blue light. Sixteen surgeons identified and marked the tumor-tissue interfaces on images. Fluorescence was measured on tissue specimens using the IVIS imaging system and on tissue cross-sections obtained with confocal microscopy. Western blot was performed to measure levels of organic anion transporting polypeptide (OATP), a drug transporter specific for SF.
Results: Under blue light, tumors from SF rats demonstrated bright green fluorescence under direct visualization, higher fluorescence measurements on tissue specimens (p < 0.001), and more SF deposition on tissue cross-sections (p < 0.001), when compared with surrounding tissues and placebo rats. Surgeons were better able to distinguish the tumor-tissue interfaces in SF rats. Furthermore, the expression level of OATP1C1 was significantly higher in tumors than in surrounding tissues (p < 0.0001).
Conclusion: In a xenograft model of VS, intravenous SF preferentially deposits in tumors, compared with normal surrounding tissue. Under blue light, tumors emit an intense green fluorescence that can help surgeons differentiate tumor from critical structures nearby, which may improve clinical outcomes in complicated VS surgery.

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Ruptured Vertebral Aneurysm With Progressive Deafness and Bruns Nystagmus

Harayama, Yukihisa; Morino, Tsunetaro; Ohto, Hiroto; Takahashi, Masahiro; Komori, Manabu; Yamamoto, Kazuhisa; Kojima, Hiromi

Publication date 01-04-2021


No abstract available

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American Otological Society: 154th Annual Spring Meeting

Publication date 01-04-2021


No abstract available

Pubmed PDF Web

American Neurotology Society: 56th Annual Spring Meeting

Publication date 01-04-2021


No abstract available

Pubmed PDF Web

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