Otology Neurotology 2020-10-01

Otology and Neurotology in a Post-COVID-19 World

Lustig, Lawrence R.

Publicatie 01-10-2020


No abstract available

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Tribute: David Andrew Moffat, 1947–2020

Ramsden, Richard T.

Publicatie 01-10-2020


No abstract available

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Book Review

Arriaga, Moisès A.

Publicatie 01-10-2020


No abstract available

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American Neurotology Society, American Otological Society, and American Academy of Otolaryngology – Head and Neck Foundation Guide to Enhance Otologic and Neurotologic Care During the COVID-19 Pandemic

Kozin, Elliott D.; Remenschneider, Aaron K.; Blevins, Nikolas H.; Jan, Taha A.; Quesnel, Alicia M.; Chari, Divya A.; Kesser, Bradley W.; Weinstein, Jaqueline E.; Ahsan, Syed F.; Telischi, Fred F.; Adunka, Oliver F.; Weber, Peter; Knoll, Renata M.; Coelho, Daniel H.; Anne, Samantha; Franck, Kevin H.; Marchioni, Daniele; Barker, Frederick G. II; Carter, Bob S.; Lustig, Lawrence R.; Bojrab, Dennis I.; Bhansali, Sanjay A.; Westerberg, Brian D.; Lundy, Larry; Jackler, Robert K.; Roland, J. Thomas Jr.; Chandrasekhar, Sujana S.; Antonelli, Patrick J.; Carey, John P.; Welling, D. Bradley; Slattery, William H. III; Lee, Daniel J.; members of the American Neurotology Society Council, members of the American Otological Society Council, and members of the American Academy of Otolar

Publicatie 01-10-2020


This combined American Neurotology Society, American Otological Society, and American Academy of Otolaryngology – Head and Neck Surgery Foundation document aims to provide guidance during the coronavirus disease of 2019 (COVID-19) on 1) “priority” of care for otologic and neurotologic patients in the office and operating room, and 2) optimal utilization of personal protective equipment. Given the paucity of evidence to inform otologic and neurotologic best practices during COVID-19, the recommendations herein are based on relevant peer-reviewed articles, the Centers for Disease Control and Prevention COVID-19 guidelines, United States and international hospital policies, and expert opinion. The suggestions presented here are not meant to be definitive, and best practices will undoubtedly change with increasing knowledge and high-quality data related to COVID-19. Interpretation of this guidance document is dependent on local factors including prevalence of COVID-19 in the surgeons’ local community. This is not intended to set a standard of care, and should not supersede the clinicians best judgement when managing specific clinical concerns and/or regional conditions.Access to otologic and neurotologic care during and after the COVID-19 pandemic is dependent upon adequate protection of physicians, audiologists, and ancillary support staff. Otolaryngologists and associated staff are at high risk for COVID-19 disease transmission based on close contact with mucosal surfaces of the upper aerodigestive tract during diagnostic evaluation and therapeutic procedures. While many otologic and neurotologic conditions are not imminently life threatening, they have a major impact on communication, daily functioning, and quality of life. In addition, progression of disease and delay in treatment can result in cranial nerve deficits, intracranial and life-threatening complications, and/or irreversible consequences. In this regard, many otologic and neurotologic conditions should rightfully be considered “urgent,” and almost all require timely attention to permit optimal outcomes. It is reasonable to proceed with otologic and neurotologic clinic visits and operative cases based on input from expert opinion of otologic care providers, clinic/hospital administration, infection prevention and control specialists, and local and state public health leaders. Significant regional variations in COVID-19 prevalence exist; therefore, physicians working with local municipalities are best suited to make determinations on the appropriateness and timing of otologic and neurotologic care.

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Covid-19 and Otologic/Neurotologic Practices: Suggestions to Improve the Safety of Surgery and Consultations

Ayache, Stephane; Schmerber, Sebastien

Publicatie 01-10-2020


Since the beginning of 2020, the world has been confronted by the Covid-19 pandemic. The lock-down aims to limit the circulation of the virus and thus avoid overwhelming healthcare systems. Healthcare workers have had to adapt by postponing consultation and surgical activities. Otolaryngologists are particularly exposed to infection from the upper airway where the virus is highly concentrated. Literature has previously reported other human coronaviruses in the middle ear and mastoid, suggesting a risk of infection to staff during ear surgery where aerosolizing procedures are usually used. The aim of this article is to propose a strategy for planning consultations and surgeries for ear and lateral skull base diseases, in the context of the current active evolution of the pandemic and of the future gradual recovery to normal practice.

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The Risks of Being Otologist, an Ergonomic and Occupational Hazard Review

Stern Shavit, Sagit; Golub, Justin S.; Lustig, Lawrence R.

Publicatie 01-10-2020


Objective: To review occupational ergonomic risks for the Otologist and Neurotologist.Data Sources: MEDLINE, OVID, PubMed, and Google Scholar.Study Selection: A search was conducted to identify all studies in the English language that involve ergonomic-related risks for surgeons.Results: Occupational hazards, particularly musculoskeletal disorders (MSDs), are common in the surgical community in general and among Otolaryngologists in particular. Very few studies have been conducted assessing MSDs specific to Otologists and Neurotologists. However, extrapolating from other surgical professions with similar ergonomic postures in the operation room and office, one can infer that cervical and lumbar pain are related to prolonged static sitting and neck flexion when working with a microscope and begins early in training. Early institution of correct ergonomic training is feasible and may be effective. Improved ergonomic habits include upright sitting, avoidance of neck flexion, initiating short breaks, and the use of chairs with arm and back support. Future technologies incorporated into otologic surgery should have improved ergonomic design.Conclusions: Otologists and Neurotologists are exposed to MSDs directly related to their work demands. Incorporating healthy ergonomics into surgical training as well adopting correct posture and the use equipment designed for back support may help mitigate the long-terms risks of MSD.

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Cochlear Implant Outcomes Following Vestibular Schwannoma Resection: Systematic Review

Wick, Cameron C.; Butler, Margaret J.; Yeager, Lauren H.; Kallogjeri, Dorina; Durakovic, Nedim; McJunkin, Jonathan L.; Shew, Matthew A.; Herzog, Jacques A.; Buchman, Craig A.

Publicatie 01-10-2020


Objective: Hearing loss remains a significant morbidity for patients with vestibular schwannomas (VS). A growing number of reports suggest audibility with cochlear implantation following VS resection; however, there is little consensus on preferred timing and cochlear implant (CI) performance.Data Sources: A systematic literature search of the Ovid Medline, Embase, Scopus, and clinicaltrails.gov databases was performed on 9/7/2018. PRISMA reporting guidelines were followed.Study Selection: Included studies reported CI outcomes in an ear that underwent a VS resection. Untreated VSs, radiated VSs, and CIs in the contralateral ear were excluded.Data Extraction: Primary outcomes were daily CI use and attainment of open-set speech. Baseline tumor and patient characteristics were recorded. Subjects were divided into two groups: simultaneous CI placement with VS resection (Group 1) versus delayed CI placement after VS resection (Group 2).Data Synthesis: Twenty-nine articles with 93 patients met inclusion criteria. Most studies were poor quality due to their small, retrospective design. Group 1 had 46 patients, of whom 80.4% used their CI on a daily basis and 50.0% achieved open-set speech. Group 2 had 47 patients, of whom 87.2% used their CI on a daily basis and 59.6% achieved open-set speech. Group 2 had more NF2 patients and larger tumors. CI timing did not significantly impact outcomes.Conclusions: Audibility with CI after VS resection is feasible. Timing of CI placement (simultaneous versus delayed) did not significantly affect performance. Overall, 83.9% used their CI on a daily basis and 54.8% achieved open-set speech.

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Tinnitus Affects Speech in Noise Comprehension in Individuals With Hearing Loss

Oosterloo, Berthe C.; Homans, Nienke C.; Goedegebure, André

Publicatie 01-10-2020


Background: Tinnitus is a prevalent auditory disorder that frequently co-occurs with hearing loss. It is suggested that tinnitus might have negative impact on speech perception. However, studies thus far have not been able to disentangle tinnitus, hearing loss, and speech in noise intelligibility. We therefore investigated whether there is an association between tinnitus and speech understanding in noise, independent of hearing loss.Methods: Of 4,211 participants from the population-based Rotterdam Study (mean age 67.8 SD 8.9, 57.3% female) data was available on tinnitus, pure-tone audiometry, and digits in noise test. We compared the speech reception threshold in noise (SRTn) in participants with and without tinnitus for the whole population as well as for subgroups stratified for average hearing threshold in 10-dB strata. Additionally, we regressed tinnitus on SRTn with a multivariable regression model, adjusting for sex, age, highest achieved education, and cognitive function.Results: Participants with tinnitus (20.8%) had a higher SRTn (−3.6 dB SD 3.7 versus −4.6 dB SD 3.1). This difference remained only in the subgroups of participants with hearing loss, between 0.6 and 0.8 dB difference in the SRTn for the different subgroups. In the fully adjusted model tinnitus was associated with 0.2 dB (95% CI 0.00, 0.39) SRTn increase.Conclusion: We have shown that tinnitus is associated with speech intelligibility in noise, but it is a small effect, only found in people with co-occurring hearing loss.

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Endoscopic Stapedectomy: Collective Experience From a Large Australian Center

Vaughan, Casey; Fox, Richard; Jufas, Nicholas; Kong, Jonathan H. K.; Patel, Nirmal P.; Saxby, Alexander J.

Publicatie 01-10-2020


Introduction: Endoscopic stapes surgery is a technically demanding procedure that is increasing in popularity. Surgical outcomes and complication rates have been demonstrated to be comparable to traditional microscopic techniques. The surgical outcomes for patients undergoing stapes surgery performed by the Sydney Endoscopic Ear Surgery Research Group are presented.Study Design: Retrospective review from prospectively gathered database.Setting: Tertiary referral centers.Patients: A retrospective case review of patients undergoing endoscopic stapes surgery performed by four surgeons between February 2015 and July 2019 was carried out. Sixty nine patients were identified, and assessed for demographics, functional results, and postoperative complications.Intervention: Endoscopic stapedotomy.Main Outcome Measure: Postoperative hearing results.Results: Sixty eight of 69 patients (98.6%) achieved an air-bone gap (ABG) closure of less than 20 dB. Sixty of 69 patients (87%) achieved and ABG closure of less than 10 dB. The average improvement of the ABG over four frequencies achieved was 26.5 dB (range, 0–61). Postoperative complications were infrequent and self-limiting. Six patients experienced dysgeusia without obvious chorda tympani injury, four patients developed short lived vertigo, and two patients experienced tinnitus.Conclusions: Endoscopically assisted stapes surgery represents a safe alternative to traditional microscopic techniques, with similar morbidity and audiological outcomes.

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The Rise and Fall of Otosclerosis: A Population-based Study of Disease Incidence Spanning 70 Years

Marinelli, John P.; Totten, Douglas J.; Chauhan, Kiran K.; Lohse, Christine M.; Grossardt, Brandon R.; Vrabec, Jeffrey T.; Carlson, Matthew L.

Publicatie 01-10-2020


Objective: Although it is commonly held that otosclerosis has become increasingly uncommon over recent decades, no population-based data exist to characterize this trend. Moreover, because most large epidemiologic databases within the United States primarily include cancer data, even the modern incidence of otosclerosis is unknown. The chief objective of the current work was to characterize the trend in the incidence of otosclerosis over 70 years using the unique resources of the Rochester Epidemiology Project.Study Design: Population-based study.Patients: Residents of Olmsted County, Minnesota diagnosed with otosclerosis.Main Outcome Measure: Disease incidence from 1950 to 2017.Results: From 1950 to 2017, 614 incident cases of otosclerosis were identified. The incidence rose from 8.9 per 100,000 person-years in the 1950s to a peak of 18.5 from 1970 to 1974. From this peak, the incidence significantly declined to 6.2 per 100,000 person-years by the early-1990s and reached a nadir of 3.2 from 2015 to 2017 (p<0.001). From 1970 to 2017, age at diagnosis (p = 0.23) and the proportion of bilateral cases (p = 0.16) did not significantly change; pure-tone average at diagnosis did not clinically appreciably change over the study period (median difference <5 dB across decades, p = 0.034).Conclusions: The incidence of otosclerosis drastically declined since the early-1970s. Historically considered one of the most common causes of acquired hearing loss, the low modern incidence of otosclerosis renders it legally a “rare disease” within the United States. These trends require consideration when determining trainee case requirements and developing practice guidelines.

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Association of Speech Recognition Thresholds With Brain Volumes and White Matter Microstructure: The Rotterdam Study

Armstrong, Nicole M.; Croll, Pauline H.; Oosterloo, Berthe C.; Lin, Frank R.; Ikram, M. Arfan; Goedegebure, André; Vernooij, Meike W.

Publicatie 01-10-2020


Objectives: Brain volumetric declines may underlie the association between hearing loss and dementia. While much is known about the peripheral auditory function and brain volumetric declines, poorer central auditory speech processing may also be associated with decreases in brain volumes.Methods: Central auditory speech processing, measured by the speech recognition threshold (SRT) from the Digits-in-Noise task, and neuroimaging assessments (structural magnetic resonance imaging MRI and fractional anisotropy and mean diffusivity from diffusion tensor imaging), were assessed cross-sectionally in 2,368 Rotterdam Study participants aged 51.8 to 97.8 years. SRTs were defined continuously and categorically by degrees of auditory performance (normal, insufficient, and poor). Brain volumes from structural MRI were assessed on a global and lobar level, as well as for specific dementia-related structures (hippocampus, entorhinal cortex, parahippocampal gyrus). Multivariable linear regression models adjusted by age, age-squared, sex, educational level, alcohol consumption, intracranial volume (MRI only), cardiovascular risk factors (hypertension, diabetes, obesity, current smoking), and pure-tone average were used to determine associations between SRT and brain structure.Results: Poorer central auditory speech processing was associated with larger parietal lobe volume (difference in mL per dB increase= 0.24, 95% CI: 0.05, 0.42), but not with diffusion tensor imaging measures. Degrees of auditory performance were not associated with brain volumes and white matter microstructure.Conclusions: Central auditory speech processing in the presence of both vascular burden and pure-tone average may not be related to brain volumes and white matter microstructure. Longitudinal follow-up is needed to explore these relationships thoroughly.

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A Case of Incus Necrosis Following Oral and Intratympanic Steroid Administration for Sensorineural Hearing Loss

Kapoor, Elina; Sabetrasekh, Parisa; Monfared, Ashkan

Publicatie 01-10-2020


Objective: Intratympanic (IT) steroid injections are often used for the treatment of inner ear pathologies, including sudden sensorineural hearing loss. IT steroids are also commonly used in conjunction with or in case of systemic steroid therapy failure. They are viable options for patients who cannot endure side effects or are at high risk of complications from systemic therapy. The duration of treatment, strength, and type of steroid, and number of IT injections are important factors that impact possible treatment complications. Reported complications, though uncommon, include tympanic membrane perforation, otalgia, vertigo, otitis media, and acne. In this report, we explore a novel case of incus necrosis associated with oral and/or IT steroid administration.Study Design: Clinical Capsule Report.Setting: Tertiary Academic Center.Patient: We present a case of a 70-year-old male with sudden sensorineural hearing loss who developed incus necrosis and conductive hearing loss following treatment with oral and intratympanic steroids.Intervention: The patient underwent a left tympanoplasty with ossicular chain reconstruction to treat the conductive component of his hearing loss.Results: The left tympanoplasty almost fully-resolved the conductive component of his hearing loss. However, intraoperative and CT assessment of the temporal bone revealed resorption of the long process of the incus, with otherwise normal-appearing ossicles.Conclusion: We report the first case of possible steroid-induced necrosis of the long process of the incus. Owing to its tenuous blood supply, the incus may be predisposed to steroid-induced osteonecrosis similar to that of the femoral head.

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Cochlear Implant Therapy Improves the Quality of Life in Older Patients—A Prospective Evaluation Study

Issing, Christian; Baumann, Uwe; Pantel, Johannes; Stöver, Timo

Publicatie 01-10-2020


Objective: To determine the effects of cochlear implant (CI) hearing rehabilitation on quality of life in older patients (≥65 yr).Study design: Prospective observational study.Setting: Department of Oto-Rhino-Laryngology, Medical University Frankfurt/Main.Patients: Patients aged between 65 and 86 years who received unilateral CI therapy for the first time.Intervention: Unilateral cochlear implantation.Main Outcome Measures: In addition to audiological parameters, the World Health Organization Quality-of-Life Scale – old (WHOQL-OLD) was used to assess quality of life prior to surgery, at the time of first fitting of the audio processor (approx. 1 mo after surgery) and 6 months afterward. Dementia and depression were excluded using dementia detection test (DemTect) and geriatric depression scale.Results: Speech recognition improved significantly during the study period. Furthermore, the total WHOQL-OLD score showed a significant improvement of quality of life comparing the preoperative and the 6 months data (60.0 ± 15.7 to 66.8 ± 12.2 points) (p = 0.001). Only 6 months after surgery, comparable quality of life values were achieved compared to the corresponding population average of the same age group (67.96 ± 14.74 points). No statistically significant difference remained between the study group and the age-adjusted population average (p = 0.37).Conclusion: To achieve auditory rehabilitation, CI treatment in older patients can be strongly recommended, not only hearing rehabilitation, but also to improve quality of life.

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Intraoperative Observational Real-time Electrocochleography as a Predictor of Hearing Loss After Cochlear Implantation: 3 and 12 Month Outcomes

O’Leary, Stephen; Briggs, Robert; Gerard, Jean-Marc; Iseli, Claire; Wei, Benjamin P.C.; Tari, Sylvia; Rousset, Alex; Bester, Christo

Publicatie 01-10-2020


Objective: A decrease in intracochlear electrocochleographic (ECochG) amplitude during cochlear implantation has been associated with poorer postoperative hearing preservation in several short-term studies. Here, we relate the stability of ECochG during surgery to hearing preservation at 3- and 12-months.Methods: Patients with hearing ≤80-dB HL at 500 Hz were implanted with a slim-straight electrode array. ECochG responses to short, high-intensity, 500-Hz pure tones of alternating polarity were recorded continuously from the apical-most electrode during implantation. No feedback was provided to the surgeon. ECochG amplitude was derived from the difference response, and implantations classified by the presence (“ECochG drop”) or absence (“no drop”) of a ≥30% reduction in ECochG amplitude during insertion. Residual hearing (relative and absolute) was reported against the ECochG class.Results: ECochG was recorded from 109 patients. Of these, interpretable ECochG signals were recorded from 95. Sixty-six of 95 patients had an ECochG drop during implantation. Patients with an ECochG drop had poorer preoperative hearing above 1000 Hz. Hearing preservation (in decibels, relative to preoperative levels and functionally) was significantly poorer at 250-, 500-, and 1000-Hz at 3 months in patients exhibiting an ECochG drop. Twelve-month outcomes were available from 85 patients, with significantly poorer functional hearing, and greater relative and absolute hearing loss from 250 to 1000 Hz, when an ECochG drop had been encountered.Conclusion: Patients exhibiting ECochG drops during implantation had significantly poorer hearing preservation 12 months later. These observational outcomes support the future development of surgical interventions responsive to real-time intracochlear ECochG. Early intervention to an ECochG drop could potentially lead to prolonged improvements in hearing preservation.

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Effect of Electrode to Modiolus Distance on Electrophysiological and Psychophysical Parameters in CI Patients With Perimodiolar and Lateral Electrode Arrays

Degen, Chantal Vanessa; Büchner, Andreas; Kludt, Eugen; Lenarz, Thomas

Publicatie 01-10-2020


Objectives: To investigate the intracochlear position of the latest Cochlear Nucleus 532 electrode array compared with the straight Nucleus 522 and the precurved 512 arrays and determine the effect of the electrode–modiolus distance on electrically evoked compound action potential, C-levels, electrically evoked stapedius reflex thresholds (ESRTs), and impedances.Methods: Postoperative high-resolution cone beam computational tomography images of 30 patients with Cochlear Nucleus 532, 522, and 512 implants were evaluated using the Comet (Cochlea Measurement Tool) program to determine the distance between the 22 individual electrode contacts and the medial wall. ESRTs were documented intraoperatively and electrophysiological as well as psychophysical parameters were measured at multiple time points including the first fitting after the initial activation.Results: The electrode–modiolus distance in perimodiolar arrays is uniformly small across the array, whereas in a straight electrode carrier it varies significantly along the length of the array. Electrically evoked compound action potential thresholds and C-levels are larger with increased distance to the modiolus. Impedances and stapedius reflex thresholds do not differ significantly between the arrays. Our results show that the electrode position has a significant effect on both electrophysiological and psychophysical parameters, while impedances and ESRTs are not impacted.Conclusion: Novel tools can be used in the evaluation of high resolution cone beam computational tomography images to determine individual electrode–modiolus distances after cochlear implantation. The results of this study suggest that the correlations between electrode–modiolus distance and electrophysiological and psychophysical parameters are not sufficiently strong to adjust CI-fitting based on imaging data.

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Ultrasound in Diagnosis of Magnet Dislocation of Cochlear Implants: A Retrospective Study in Patients With Surgical Magnet Repositioning and Preinterventional Ultrasound Examination

Rupp, Robin; Hornung, Joachim; Balk, Matthias; Hoppe, Ulrich; Iro, Heinrich; Gostian, Antoniu-Oreste

Publicatie 01-10-2020


Objective: To investigate whether ultrasound is a reliable diagnostic tool to identify magnet dislocation in patients with cochlear implant.Design: Retrospective analysis.Setting: A tertiary referral medical center.Patients: Patients with cochlear implant who presented with the suspicion of magnet dislocation between January 1, 2009 and July 31, 2019.Interventions: Preinterventional ultrasound with subsequent surgical magnet repositioning.Main Outcome Measures: Accuracy of ultrasound in detecting magnet dislocation; intraoperative extent of magnet dislocation.Results: Out of the 28 included patients (n = 28 magnets, 36% ♀; 51.6 years ±19.0 yr) the diagnosis by the preoperative ultrasound was confirmed intraoperatively in 25 patients (89%). In two cases (7%), tissue swelling impeded the determination of the magnet by the preoperative ultrasound. In one case, ultrasound misdiagnosed the magnet as not dislocated. During revision surgery, all 28 magnets were repositioned successfully revealing a predominant partial dislocation (86%) compared with complete magnet dislocation (14%).Conclusion: In CI-patients undergoing 1.5 Tesla MRI, partial magnet dislocation occurs much more frequently than complete magnet dislocation. The clinical suspicion of a dislocated cochlear implant magnet can be accurately confirmed by preoperative ultrasound. Thus, preoperative diagnostic ultrasound can be advocated as the diagnostic tool of first choice.

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Cochlear Implant Infections and Outcomes: Experience From a Single Large Center

Vijendren, Ananth; Ajith, Amritha; Borsetto, Daniele; Tysome, James R.; Axon, Patrick R.; Donnelly, Neil P.; Bance, Manohar L.

Publicatie 01-10-2020


Objective: To review our experience with cochlear implant infections over the past 5 years, the management strategy and to identify predictive factors that led to explantation.Study Design: Retrospective record-base case series of cochlear implant infections.Setting: Tertiary otology and implant center.Patients: All patients who had cochlear implantation over a period of 5 years.Intervention(s): None.Main Outcome Measure(s): To identify risk factors, rates and outcomes of cochlear implant infections, and to formulate strategies to develop clearer management protocols to prevent cochlear implant explantation.Results: Of 704 implanted patients, 22 suffered a postoperative soft tissue infection (3%). Fifty-nine percent of these infected patients resulted in explantation, giving an explantation rate of 1.8% over the whole study population. One hundred percent of the infected implants identified as having either Staph. Aureus or Pseudomonas spp. as the single causative organism resulted in explantation.Conclusions: There is a high rate of explantation when infection is detected. Currently there is no clear consensus on medical management, such as choice of antibiotics or length of antibiotic course. A registry of cochlear implants would facilitate standard reporting methods for severity and type of infection, to be able to pool data across centers and form a more robust management protocol for cochlear implant infections.

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Are There Real-world Benefits to Bimodal Listening?

Nyirjesy, Sarah; Rodman, Cole; Tamati, Terrin N.; Moberly, Aaron C.

Publicatie 01-10-2020


Objective: To assess the benefits of bimodal listening (i.e., addition of contralateral hearing aid) for cochlear implant (CI) users on real-world tasks involving high-talker variability speech materials, environmental sounds, and self-reported quality of life (quality of hearing) in listeners’ own best-aided conditions.Study Design: Cross-sectional study between groups.Setting: Outpatient hearing clinic.Patients: Fifty experienced adult CI users divided into groups based on normal daily listening conditions (i.e., best-aided conditions): unilateral CI (CI), unilateral CI with contralateral HA (bimodal listening; CIHA), or bilateral CI (CICI).Intervention: Task-specific measures of speech recognition with low (Harvard Standard Sentences) and high (Perceptually Robust English Sentence Test Open-set corpus) talker variability, environmental sound recognition (Familiar Environmental Sounds Test-Identification), and hearing-related quality of life (Nijmegen Cochlear Implant Questionnaire).Main Outcome Measures: Test group differences among CI, CIHA, and CICI conditions.Results: No group effect was observed for speech recognition with low or high-talker variability, or hearing-related quality of life. Bimodal listeners demonstrated a benefit in environmental sound recognition compared with unilateral CI listeners, with a trend of greater benefit than the bilateral CI group. There was also a visual trend for benefit on high-talker variability speech recognition.Conclusions: Findings provide evidence that bimodal listeners demonstrate stronger environmental sound recognition compared with unilateral CI listeners, and support the idea that there are additional advantages to bimodal listening after implantation other than speech recognition measures, which are at risk of being lost if considering bilateral implantation.

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Comparing Cochlear Duct Lengths Between CT and MR Images Using an Otological Surgical Planning Software

George-Jones, Nicholas A.; Tolisano, Anthony M.; Kutz, J. Walter Jr; Isaacson, Brandon; Hunter, Jacob B.

Publicatie 01-10-2020


Objective: We sought to examine the intra- and interobserver variability in measuring the cochlear duct length (CDL) from magnetic resonance imaging (MRI) images versus computed tomography (CT) images using an otological surgical planning software that uses measurements of the basal turn diameter and cochlear width to estimate the CDL.Patients: Twenty-one adult cochlear implant patients with preoperative MRI and CT images.Intervention: Three fellowship-trained neurotologists served as the raters in the study. One rater measured the CDL using preoperative CT scans to serve as the benchmark. Two of the raters measured the CDL on preoperative MRI scans. One rater also remeasured the scans using MRI images after a period of 1 week to assess intraobserver variability.Main Outcome Measure: Intraclass correlational coefficients were calculated to assess for intra- and interobserver agreement.Results: The mean CDL measured from the CT scans was 32.7 ± 2.0 mm (range 29.4 – 37.6 mm). The mean difference between the raters when measuring the CDL using MRI scans was −0.15 ± 2.1 mm (range −3.2 to 4.3 mm). The intraclass correlational coefficients for inter-rater reliability of CDL determination using MRI scans was judged as fair to excellent (0.68; 95% CI 0.41–0.84). The intrarater reliability of CDL determination using MRI scans was judged at fair to excellent (0.73; 95% CI 0.491–0.866).Conclusion: We demonstrate that a validated otological surgical planning software for estimating the CDL preoperatively had comparable performance using MRI scans versus the gold-standard CT scans.

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Demonstration and Mitigation of Aerosol and Particle Dispersion During Mastoidectomy Relevant to the COVID-19 Era

Chen, Jenny X.; Workman, Alan D.; Chari, Divya A.; Jung, David H.; Kozin, Elliott D.; Lee, Daniel J.; Welling, D. Bradley; Bleier, Benjamin S.; Quesnel, Alicia M.

Publicatie 01-10-2020


Background: COVID-19 has become a global pandemic with a dramatic impact on healthcare systems. Concern for viral transmission necessitates the investigation of otologic procedures that use high-speed drilling instruments, including mastoidectomy, which we hypothesized to be an aerosol-generating procedure.Methods: Mastoidectomy with a high-speed drill was simulated using fresh-frozen cadaveric heads with fluorescein solution injected into the mastoid air cells. Specimens were drilled for 1-minute durations in test conditions with and without a microscope. A barrier drape was fashioned from a commercially available drape (the OtoTent). Dispersed particulate matter was quantified in segments of an octagonal test grid measuring 60 cm in radius.Results: Drilling without a microscope dispersed fluorescent particles 360 degrees, with the areas of highest density in quadrants near the surgeon and close to the surgical site. Using a microscope or varying irrigation rates did not significantly reduce particle density or percent surface area with particulate. Using the OtoTent significantly reduced particle density and percent surface area with particulate across the segments of the test grid beyond 30 cm (which marked the boundary of the OtoTent) compared with the microscope only and no microscope test conditions (Kruskall–Wallis test, p = 0.0066).Conclusions: Mastoidectomy with a high-speed drill is an aerosol-generating procedure, a designation that connotes the potential high risk of viral transmission and need for higher levels of personal protective equipment. A simple barrier drape significantly reduced particulate dispersion in this study and could be an effective mitigation strategy in addition to appropriate personal protective equipment.

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Correlation of Radiologic Versus Endoscopic Visualization of the Middle Ear: Implications for Endoscopic Ear Surgery

Bonali, Marco; Fermi, Matteo; Alicandri-Ciufelli, Matteo; Mattioli, Francesco; Villari, Domenico; Presutti, Livio; Anschuetz, Lukas

Publicatie 01-10-2020


Objectives: To determine the limits of visualization during transcanal endoscopic ear surgery (EES) by correlating the relationship between radiologic and endoscopic anatomy using angled optics.Methods: Radiology and endoscopic visualization of tensor fold, protympanum, facial sinus (FS), sinus tympani (ST), subtympanic sinus (STS), hypotympanum, and aditus ad antrum were analyzed using a transcanal approach in 30 human temporal bones specimens with different angled endoscopes (0 degree, 45 degrees, 70 degrees) to check for the full visualization of these regions. High-resolution computed tomography (CT) was performed prior to dissection to classify retrotympanic anatomy. According to previously published descriptions, FS, ST, and STS were classified into types A, B, and C depending on their morphology relative to the mastoid segment of the facial nerve. These radiologic findings were compared to endoscopic visualization of these same structures using a Chi-squared test.Results: Visualization of the posterior wall of three different retrotympanic areas was significantly associated (FS p 70% with 45 degrees and 70 degrees).Conclusion: Complete visual access to the hidden recesses of the middle ear can be achieved using angled endoscopes (45 degrees and 70 degrees). We observed a statistically significant association of endoscopic visualization to radiologic description of the retrotympanum on CT and the optical angle used. The prediction of the endoscopic exposure of the retrotympanum from the preoperative CT is possible. Even with the use of 70 degrees lens, retrotympanum is not fully visualized on transcanal endoscopy if a type C retrotympanic recesses (posterior and medial to the facial nerve) is present. This represents a technical limit of exclusive transcanal EES.

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Etiological Work-up in Referrals From Neonatal Hearing Screening: 20 Years of Experience

Boudewyns, An; van den Ende, Jenneke; Declau, Frank; Wuyts, Wim; Peeters, Nils; Brandt, Anouk Hofkens-Van den; Van Camp, Guy

Publicatie 01-10-2020


Background: Confirmation of permanent hearing loss in a newborn should be followed by a search for an underlying etiology because this may impact hearing loss management and counselling.Methods: Retrospective chart review of all newborns seen at a tertiary referral center after referral from newborn hearing screening over a 20-year period. The changes in the diagnostic protocol over the years are outlined and the most recent protocol includes targeted next-generation sequencing using a panel for known hearing loss causing genes, in all cases of bilateral sensorineural hearing loss (SNHL).Results: Permanent hearing loss was confirmed in 235 of 1,002 neonates. A complete etiological work-up was performed in 138 cases of SNHL (77 bilateral and 61 unilateral), with the underlying cause found in 77.9% and in 67.2% of patients respectively. Genetic causes explained 55 (58.4%) of bilateral cases and in 17 a genetic cause was identified by the gene panel. Pathogenic variants in GJB2 and MYO15A explained most cases of nonsyndromic SNHL. Waardenburg syndrome was the most frequent syndromic cause. Cochlear nerve deficiency and congenital cytomegalovirus infection accounted for the majority of unilateral SNHL.Other causes of congenital hearing loss were conductive hearing loss (n = 12) and auditory neuropathy/dyssynchrony (n = 9).Conclusion: Implementation of targeted next-generation sequencing in the etiological work-up improves the diagnostic yield in congenital SNHL, leaving only about 20% of bilateral and 30% of unilateral cases unsolved.

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Malformations Associated With Pediatric Congenital Cholesteatomas

Distinguin, Léa; Simon, François; Alvin, Fiona; Couloigner, Vincent; Leboulanger, Nicolas; Garabédian, Noel; Loundon, Natalie; Denoyelle, Françoise

Publicatie 01-10-2020


Objective: To describe malformations associated with pediatric congenital cholesteatomas of the middle ear.Study Design: Retrospective study.Setting: Tertiary referral center.Patients: One hundred and seventy-three cases of middle ear congenital cholesteatoma (CC) in 171 children operated between 2007 and 2017.Interventions: Demographic, clinical, and surgical data were collected from operative reports.Main Outcome Measures: We first described the type and rate of malformations associated with CC. Secondly, we compared cholesteatoma features in two subgroups: anterior superior (AS) versus posterior superior (PS) starting point. Third, we compared demographic, clinical, and surgical data between patients with and without malformation.Results: CC was associated with malformations in 17 cases (17/173; 9.8%). The main malformation was preauricular fistula (8/173; 4.6%). Other malformations were: one first branchial cleft, two labio palatine cleft, one nasal cyst, two preauricular fibrochondroma, and five other malformations. PS congenital cholesteatomas were diagnosed in older children (4.6 versus 8.6 years, p < 0.05) and had greater extension in middle ear than the AS cholesteatoma (39.7% versus 95.8%, p < 0.05). We did not find any significant difference between these two groups regarding the associated malformations. We did not find a difference in clinical presentation of CC between patients with and without associated malformation.Conclusions: We found various associated malformations in 9.8% of CC cases with no statistical difference in the malformation rate between AS and PS groups. All the malformations were located in the craniofacial region suggesting that genes implicated in craniofacial development may play a role in the pathophysiology of CC.

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Multicenter Clinical Investigation of a New Active Osseointegrated Steady-State Implant System

Mylanus, Emmanuel A. M.; Hua, Håkan; Wigren, Stina; Arndt, Susan; Skarzynski, Piotr Henryk; Telian, Steven A.; Briggs, Robert J. S.

Publicatie 01-10-2020


Objective: A new active transcutaneous bone conduction hearing implant system that uses piezoelectric technology has been developed: an active osseointegrated steady-state implant system (OSI). This was the first clinical investigation undertaken to demonstrate clinical performance, safety, and benefit of the new implant system.Study Design and Setting: A multicenter prospective within-subject clinical investigation was conducted.Patients: Fifty-one adult subjects with mixed and conductive hearing loss (MHL/CHL, n = 37) and single-sided sensorineural deafness (SSD, n = 14) were included.Main Outcome Measure: Audiological evaluations included audiometric thresholds, speech recognition in noise, and quiet. Hearing and health-related patient-reported outcomes (PROs; health utilities index HUI, abbreviated profile of hearing aid benefit APHAB, and speech, spatial of qualities of hearing scale SSQ), daily use, surgical and safety parameters were collected.Results: Intra- and postoperative complications were few. One implant was removed before activation due to post-surgical infection. Compared with the preoperative softband tests, a significant improvement in speech recognition-in-noise was observed in the MHL/CHL group (–7.3 dB, p ≤ 0.0001) and the SSD group (–8.1 dB, p = 0.0008). In quiet, word recognition improved in the MHL/CHL group, most markedly at lower intensity input of 50 dB SPL (26.7%, p ≤ 0.0001). The results of all PROs showed a significant improvement with the new device compared with preoperative softband in the MHL/CHL group. In the SSD group significant improvements were observed in the APHAB and SSQ questionnaires.Discussion: The results confirmed the clinical safety, performance, and benefit of this new treatment modality for subjects with CHL, MHL, and SSD.

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Clinical Balance Testing to Screen for Patients With Vestibular Disorders: A Retrospective Case-control Study

Salah, Mahadi; Van de Heyning, Paul; De Hertogh, Willem; Van Rompaey, Vincent; Vereeck, Luc

Publicatie 01-10-2020


Objective: Identify clinical screening tests to proficiently screen for patients with vestibular disorders.Study design: Retrospective case-control study.Setting: Tertiary referral center.Patients: 318 healthy individuals and 331 subjects with vestibular disorders.Interventions: All subjects performed Romberg and Jendrassic maneuver with eyes closed (ROMJec), standing on foam with eyes open (SOFeo) and eyes closed (SOFec), Tandem Romberg with eyes open (TReo) and eyes closed (TRec), single leg stance with eyes open (SLSeo) and eyes closed (SLSec), Tandem gait (TG) and Timed Up and Go (TUG).Main outcome measures: Significant differences in performance on the balance tests.Results: For the age-group 6 seconds (OR 102.4; p 7 seconds (OR 4.0; p = 0.0107) and TRec 60 the combination of TUG >8 seconds (OR 17.4; p < 0.0001) and SOFec <30 seconds (OR 10.4; p < 0.0001) was the most predictive (AUC 0.9 LR+ 6.3; LR− 0.2), with a PPV of 84.8%.Conclusions: Combinations of clinical tests are proposed to promptly screen for vestibular disorders in specific age groups. To interpret the results for the individual patient, the physician must take the history and the general examination into consideration.

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Evidence of Large Vestibulo-Ocular Reflex Reduction in Patients With Menière Attacks

Yacovino, Dario A.; Schubert, Michael C.; Zanotti, Estefania

Publicatie 01-10-2020


Objective: To examine the high frequency horizontal vestibular ocular-reflex (hVOR) during acute attacks of vertigo in Menières disease (MD).Study Design: Retrospective case series and literature review.Setting: Tertiary academic medical center.Patients: Patients with clinical diagnosis of unilateral “definite MD.”Intervention: Review of medical records.Main Outcome Measures: Spontaneous nystagmus and the dynamic hVOR gain change at different stages of an acute episode of MD attack.Results: We studied 10 vertigo attacks during the unique stages of the episode. During the acme stage of the attack, lower hVOR gain was recorded on the affected side (mean 0.48 ± 0.23), which was associated with a paralytic nystagmus (beating away from the affected ear). Additionally, the mean hVOR gain remained significantly (p < 0.05) reduced during each of the other stages of the attack as compared with the unaffected side and a control group. After the attack, mean hVOR gains normalized in the affected ear. Mean hVOR gain of the unaffected ear remained normal during all stages.Conclusion: Vestibular function during an attack of MD is a dynamic process associated with fluctuation of the dynamic (hVOR gain) and static (spontaneous nystagmus) processes, which exist in parallel with the perception of vertigo. Our data support vHIT monitoring during an episode to provide objective and accurate evidence of the ear with active disease. This would be particularly useful for those patients with MD presentations of unreliable hearing or assisting to identify the ear to be treated in the case of bilateral MD.

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Laterality of Audiovestibular Symptoms Predicts Laterality of Endolymphatic Hydrops in Hydropic Ear Disease (Menière)

Gürkov, Robert; Todt, Ingo; Jadeed, Rawad; Sudhoff, Holger; Gehl, Hans-Björn

Publicatie 01-10-2020


Background: For clinical confirmation of the diagnosis of hydropic ear disease (HED) (Menière) by MR imaging, two routes of contrast enhancement of the perilymphatic space are currently being used: intratympanic and intravenous. While unilateral intratympanic contrast application generally enables a higher perilymph signal intensity and image quality, the intravenous route allows for imaging of both inner ears simultaneously. It is conceivable that intratympanic contrast application to one ear would result in a failure to detect endolymphatic hydrops in a given patient if the hydrops is present only in the other ear. Therefore, in this study we examined the question whether the ear with the greater degree of endolymphatic hydrops may be predicted based on clinical features.Methods: Retrospective study of 50 patients with HED confirmed on MR imaging. Three tesla MR imaging with 3D fluid attenuated inversion recovery 4 hours after intravenous gadolinium contrast application was used to detect endolymphatic hydrops. The index ear was defined by auditory symptoms during attacks, low frequency hearing loss, and caloric canal paresis.Results: In all patients the ear with more severe symptoms corresponded with the ear showing the more severe hydrops on MR imaging.Conclusion: In summary, in this study population the degree of low-frequency hearing loss (250 Hz–1 kHz) in combination with auditory symptoms during attacks identified the ear with the greater extent of endolymphatic hydrops in all patients. In conclusion, intratympanic contrast application to the index ear seems to be sufficient to confirm the diagnosis of HED (Menière) on MR imaging.

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Simultaneous Vestibular Schwannoma Resection and Cochlear Implantation Using Electrically Evoked Auditory Brainstem Response Audiometry for Decision-making

Dahm, Valerie; Auinger, Alice B.; Honeder, Clemens; Riss, Dominik; Landegger, Lukas D.; Moser, Gerhard; Matula, Christian; Arnoldner, Christoph

Publicatie 01-10-2020


Objective: The aim of the study was to evaluate the predictive value regarding postoperative hearing benefit of electrically evoked auditory brainstem response audiometry in sporadic vestibular schwannoma patients undergoing simultaneous tumor resection and cochlear implantation.Design: Patients were included in a prospective study conducted between October 2016 and January 2019.Setting: The study was conducted at a tertiary care center.Participants: Subjects with unilateral sporadic vestibular schwannoma were screened for study participation. Patients underwent translabyrinthine vestibular schwannoma resection and cochlear implantation simultaneously.Intervention: Electrically evoked brainstem response audiometry was performed during surgery before and after tumor removal using an intracochlear test electrode to objectively evaluate nerve conduction.Main Outcome Measure: Electrically evoked brainstem response audiometry results were correlated with postoperative sound field audiometry, word recognition tests, and speech reception thresholds. Quality of life was assessed before and 12 months after translabyrinthine tumor removal and cochlear implantation.Results: Five patients, three male and two female, were included in the study and followed for at least 1 year after implantation. Three of the five patients are daily cochlear implant users with open set speech recognition. Two individuals with negative intraoperative electrically evoked auditory brainstem response results showed no auditory perception with cochlear implant.Conclusions: Simultaneous translabyrinthine vestibular schwannoma resection and cochlear implantation with intraoperative electrically evoked auditory brainstem response measurements is a feasible and promising option for sporadic vestibular schwannoma patients. Preservation of electrically evoked auditory brainstem responses seems to predict good subsequent hearing outcomes.

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Inner Ear Enhancement With Delayed 3D-FLAIR MRI Imaging in Vestibular Schwannoma

Bowen, Andrew J.; Carlson, Matthew L.; Lane, John I.

Publicatie 01-10-2020


Objectives: To evaluate blood–labyrinth barrier permeability using delayed gadolinium enhanced three-dimensional fluid-attenuated inversion recovery (3D-FLAIR) in patients with untreated sporadic vestibular schwannoma (VS) to interrogate the etiopathogenesis of progressive sensorineural hearing loss.Design: Prospective case series.Setting: Single institution tertiary care center.Participants: Patients with previously untreated small to medium-sized unilateral VS undergoing 3D-FLAIR imaging 10 minutes (immediate) and 5 to 8 hours (delayed) after administration of intravenous gadolinium.Main Outcome Measures: Comparison of cochlear and vestibular signal intensity ratios (SIRs) across immediate and delayed images and across the tumor and nontumor ear.Results: Six of eight (75%) patients demonstrated asymmetric enhancement of inner ear structures on delayed contrast-enhanced imaging. Delayed mean cochlea and vestibule SIRs were significantly greater than immediate SIRs (cochlea: 1.91 versus 1.21 p = 0.02; vestibule 1.74 versus 1.15 p = 0.02). A higher vestibule SIR was statistically significantly associated with poorer pure-tone average and word recognition scores (p = 0.001).Conclusion: Ears with VS exhibited increased enhancement on delayed 3D FLAIR imaging. These findings suggest that alterations in blood–labyrinth barrier permeability may explain progressive sensorineural hearing loss in a subset of patients with untreated VS.

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Effect of Vestibular Schwannoma Size and Nerve of Origin on Posterior External Auditory Canal Sensation: A Prospective Observational Study

Mehta, Gautam U.; Lekovic, Gregory P.; Maxwell, Anne K.; Brackmann, Derald E.; Slattery, William H.

Publicatie 01-10-2020


Objective: Posterior external auditory canal (EAC) hypesthesia (Hitselbergers sign) has been previously described to occur in all vestibular schwannomas (1966) but has not been studied since. We hypothesized that sensory loss may be related to tumor size and sought to determine if this clinical sign could predict preoperative characteristics of vestibular schwannomas, intraoperative findings, and/or surgical outcomes.Study Design: Prospective observational study.Setting: Tertiary referral center.Patients: Twenty-five consecutive patients who underwent surgery for vestibular schwannoma.Intervention: Patients were tested for the presence of EAC hypesthesia or anesthesia.Main Outcome Measures: Preoperative, intraoperative, and postoperative findings were recorded, including facial nerve function, hearing function, tumor size, tumor nerve of origin, and extent of resection.Results: Twelve patients (48%) demonstrated either posterior EAC hypesthesia (11 patients) or anesthesia (1 patient). Sensory loss was a significant predictor of size (tumor maximal diameter) (p = 0.004). Median tumor diameter was 1.7 cm in the cohort with intact sensation versus 2.9 cm in the cohort with sensory loss. Patients with sensory loss were also significantly more likely to be associated with a superior vestibular nerve origin tumor (p = 0.01). Preoperative sensory loss did not significantly predict postoperative facial outcome (p = 0.10).Conclusion: Neurological exam findings may be overlooked in the workup of brain tumors. Posterior EAC hypesthesia is a predictor of tumor size and superior vestibular nerve origin. These findings may have implications for patient selection, particularly with the middle cranial fossa approach. Furthermore, given this relationship with tumor size, this clinical biomarker should be studied as a potential predictor of tumor growth.

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Natural History of Growing Sporadic Vestibular Schwannomas: An Argument for Continued Observation Despite Documented Growth in Select Cases

Marinelli, John P.; Lees, Katherine A.; Lohse, Christine M.; Driscoll, Colin L.W.; Neff, Brian A.; Link, Michael J.; Van Gompel, Jamie J.; Carlson, Matthew L.

Publicatie 01-10-2020


Objective: Definitive treatment of sporadic vestibular schwannoma (VS) following documented growth is common practice at most centers in the United States. However, as a natural extension of this paradigm, very little evidence exists surrounding the natural history of growing tumors. The primary objective of the current work was to describe the natural history of sporadic VS following documentation of initial tumor growth.Study Design: Retrospective cohort study.Setting: Tertiary referral center.Patients: Patients diagnosed with sporadic VS between January 1, 2001 and December 31, 2015 who elected continued observation despite having volumetric growth ≥20% of original tumor volume on interval magnetic resonance imaging (MRI).Main Outcome Measure: Survival free of subsequent volumetric growth.Results: Of 361 patients undergoing observation with serial imaging during the study period, 85 patients met inclusion criteria at a median age of 66 years (interquartile ranges IQR 55–71). Within this cohort, 40 patients demonstrated subsequent volumetric growth at a median of 1.7 years (IQR 1.0–2.6) from the date of initial MRI that documented growth. The median volumetric growth was 43% (IQR 28–57), and the median growth rate was 0.026 cm3 per year (IQR 0.009–0.107). Survival free of subsequent volumetric growth rates (95% CI; number still at risk) at 1, 2, 3, 4, and 5 years were 93% (87–99; 75), 67% (58–79; 45), 54% (43–67; 29), 44% (33–59; 19), and 41% (30–56; 12), respectively.Conclusions: In a cohort exclusively comprised of sporadic VS with documented growth, over 40% of tumors demonstrated no subsequent volumetric growth after 5 years of continued MRI surveillance. These data challenge the supposition that once growth occurs, all tumors will exhibit sustained growth. Continued observation after documented growth of sporadic VS is a reasonable consideration in appropriately selected cases.

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Early Experience With Telemedicine in Patients Undergoing Otologic/Neurotologic Procedures

Shapiro, Scott B.; Lipschitz, Noga; Kemper, Nathan; Zuccarello, Mario; Breen, Joseph T.; Pensak, Myles L.; Samy, Ravi N.

Publicatie 01-10-2020


Objective: Compare outcomes for patients who were seen via telemedicine visits after otology/neurotology surgical procedures with those who were seen in traditional office visits.Study Design: Retrospective case review.Setting: Tertiary care academic medical center.Patients: Inclusion criteria were patients who underwent otologic/neurotologic surgery and were seen in at least one telemedicine visit for postoperative care.Intervention (s): Telemedicine visit for postoperative care.Main Outcome Measure (s): Comparison of the number of patient calls, unplanned visits, and delayed complications between telemedicine patients and controls matched for age, procedure, and American Society of Anesthesiologists (ASA) status.Results: Eighteen patients were seen in telemedicine visits postoperatively after the following otologic/neurotologic surgical procedures: cochlear implant surgery (10), vestibular schwannoma resection (4), combined middle fossa and transmastoid cerebrospinal fluid (CSF) leak repair (2), middle fossa repair of superior canal dehiscence (1), and stapedectomy (1). All telehealth visits were for the second postoperative visit. The mean number of patient calls after surgery was 2.3 for the telemedicine group and 1.9 for matched controls which was not a statistically significant difference (p = 0.466). Both groups each had two patients who went to the emergency room, with one in each group being admitted. There was one delayed complication in the control group.Conclusion: Our preliminary experience suggests telemedicine may be used safely in caring for patients after otologic/neurotologic surgery, though it may be associated with more patient phone calls. Further study and experience, including assessing patient satisfaction, will clarify the future role of telemedicine in otology and neurotology.

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Validation and Precision of Mixed Reality Technology in Baha Attract Implant Surgery

Tian, Xu; Gao, Zhi-qiang; Zhang, Zhu-hua; Chen, Yu; Zhao, Yang; Feng, Guo-dong

Publicatie 01-10-2020


Objective: To test the feasibility of image-guided Baha Attract implant surgery with mixed reality (MR) in the form of the HoloLens to visualize critical structures and facilitate precise Baha implant placement.Methods: A cadaveric case study of bilateral Baha Attract implant approaches was conducted using Star Atlas MR three-dimensional (3D) medical interaction system guidance at the Otolaryngology Department of PUMCH, Beijing, China. The accuracy of visual surface registration was determined by the target registration error (TRE) between the predefined points on the preoperative 3D holographic Baha Attract implant model and the postoperatively reconstructed 3D model.Results: Bilateral Baha Attract implantation was completed successfully for all four cadaveric heads using the Star Atlas MR 3D medical interaction system with the HoloLens. The preoperative 3D digital model characteristics (including bone quality and thickness and avoidance of cranial vessels, air cells, and cranial sutures) corresponded well with the 3D model of the actual implantation reconstructed postoperatively. The median TRE of our system was 2.97 mm (ranging from 1.98 to 4.58 mm) in terms of distance and 2.76 degrees (ranging from 0.59 to 6.4 degrees) in terms of angle.Conclusions: Applying MR technology in the form of the HoloLens in Baha Attract implant surgery is feasible and could improve the accuracy of the surgery. The described MR system for Baha Attract implantation has the potential to improve the surgeons confidence, as well as the surgical safety, efficiency, and precision.

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Immune Response of Macrophage Population to Cochlear Implantation: Cochlea Immune Cells

Noonan, Kathryn Y.; Lopez, Ivan A.; Ishiyama, Gail; Ishiyama, Akira

Publicatie 01-10-2020


Hypothesis: The presence and distribution of ionized calcium binding adaptor 1 and CD68 macrophages in the human cochlea is altered in cochlear implantation (CI) compared with the normative or nonimplanted cochlea.Background: It has been hypothesized that CI induces an immunological response in macrophages leading to implant failure or reduced hearing. Macrophages are resident immune cells in human cochlea and have been shown to phagocytize implant material. In animal models, macrophage populations increase with surgical stress and with the introduction of a foreign body. However, the function and response of inner ear macrophages to CI are only beginning to be understood. This study seeks to investigate the inflammatory response to CI by comparing cochlear macrophages in implanted and nonimplanted human temporal bones.Methods: Nineteen temporal bones from nine implanted ears, seven contralateral controls, and three normal control ears were evaluated for the presence and distribution of CD68 and Iba1 expressing positive macrophages.Results: Three types of macrophage populations were detected 1) CD68 positive macrophages, 2) Iba1 positive macrophages, and 3) CD68 and Iba1 colocalizing macrophages. Macrophage distribution was ubiquitous: the stria vascularis, Rosenthal canal, and the mid-modiolus intermingled in the spiral ganglia. Iba1 and CD68 macrophages were found in the CI and non-CI contralateral and normal human cochlea. Most ionized calcium binding adaptor 1 expressing macrophages were ramified/amoeboid cells, while CD68 expressing macrophages were round shaped with foamy appearance in some areas. In the CI cochlea, both types of macrophages were detected in the fibrous sheath surrounding the CI path and within fibrotic areas within the scala tympani and the scala vestibuli in the case of CI translocation. In four cases, the density of macrophages was unchanged in the CI compared with the contralateral nonimplanted side, and in three cases, there was an increased number of macrophages in the implanted CI side compared with the nonimplanted side.Conclusion: Multiple populations of macrophages exist within the cochlea which are present at baseline and in response to trauma from CI. These results further support evidence for a macrophage response to cochlear implantation. Further studies are indicated to evaluate whether these macrophages have a beneficial, detrimental, or a mixed effect in CI patients.

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Consequences of Mastoidectomy on Bone Conducted Sound Based on Simulations in a Whole Human Head

Prodanovic, Srdjan; Stenfelt, Stefan

Publicatie 01-10-2020


Hypothesis: The aim of this study is to investigate how a mastoidectomy surgery affects bone conduction (BC) sound transmission using a whole head finite element model.Background: Air conduction (AC) and BC hearing thresholds are normally used to evaluate the effect of an ear surgery. It is then assumed that the BC hearing thresholds are unaffected by the surgery. Moreover, BC hearing aids are used in cases of unilateral or conductive hearing loss in heads that have undergone a mastoidectomy surgery. Given the invasiveness of the surgery, the BC hearing sensitivity may be altered by the surgery itself.Methods: Two types of mastoid surgery, canal wall up and canal wall down, with and without obliteration, were simulated in a whole head finite element model for BC stimulation, the LiUHead. The evaluations were conducted for two different methods of applying the BC sound, at the skin surface (B71 transducer) and directly at the bone (BC hearing aid).Results: The results showed that a mastoidectomy surgery increased the cochlear vibration responses with BC stimulation. The increase was less than 5 dB, except for a canal wall down surgery which gave an increase of up to 8 dB at frequencies close to 10 kHz. The increase was greater at the ipsilateral cochlea compared with the contralateral cochlea.Conclusion: A mastoidectomy surgery increases the vibration at both cochleae for BC stimulation and the increase generally improved with frequency. Obliteration of the surgical cavity does not influence BC sound transmission.

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"Cochlear Implantation in Patients With Menières Disease: Does Disease Activity Affect the Outcome?"

Kocharyan, Armine; Mark, Michelle E.; Ascha, Mustafa S.; Murray, Gail S.; Manzoor, Nauman F.; Megerian, Cliff; Mowry, Sarah E.; Semaan, Maroun T.

Publicatie 01-10-2020


Objective: Menières disease (MD) is characterized by episodes of vertigo, tinnitus, and sensorineural hearing loss. In the setting of bilateral deafness due to MD alone or contralateral pathology, cochlear implantation (CI) improves hearing. Active MD is characterized by fluctuating auditory symptoms and vertigo; whereas remittance of vertiginous symptoms and severe, permanent sensorineural hearing loss characterizes the inactive disease state. This study evaluates outcomes for MD patients compared with the general CI population and assesses if disease activity affects implant outcomes.Study Design: Retrospective chart review.Setting: Tertiary referral center.Patients: Twenty-four patients with MD that received CI (7 active, 16 inactive, and 1 Probable Menières), and 24 age-matched controls.Interventions: Cochlear implantation.Main Outcome Measures: Word Recognition Score, Sentence Recognition Score (SRS), and Speech Reception Threshold.Results: Best-aided preoperative and postoperative audiometric data were compared per ear between MD patients and controls and stratified by disease status using descriptive statistics with mixed-effects modeling. Patients with MD derived significantly more benefit from CI than controls when comparing differences between preoperative and postoperative levels for Word Recognition Score (12.2%, p = 0.0236), SRS (12.8%, p = 0.0375), and Speech Reception Threshold (−14.4 dB, p = 0.0188). Active disease status does not negatively impact CI outcomes and patients with active MD may benefit from greater gains in SRS (23.5%, p = 0.0107).Conclusions: CI provides greater gains in functional hearing for patients with MD compared with age-matched controls. Patients with active MD seem to perform better with respect to SRS following CI than patients with inactive status.

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Fluctuations in Subjective Tinnitus Ratings Over Time: Implications for Clinical Research

Chen, Jenny X.; Whitton, Jonathon P.; Parthasarathy, Aravindakshan; Hancock, Kenneth E.; Polley, Daniel B.

Publicatie 01-10-2020


Objective: Patients with chronic, subjective tinnitus are often administered a battery of audiometric tests to characterize their tinnitus percept. Even a comprehensive battery, if applied just once, cannot capture fluctuations in tinnitus strength or quality over time. Moreover, subjects experience a learning curve when reporting the detailed characteristics of their tinnitus percept, such that a single assessment will reflect a lack of familiarity with test requirements. We addressed these challenges by programming an automated software platform for at-home tinnitus characterization over a 2-week period.Study Design: Prospective case series.Setting: Tertiary referral center, patients’ homes.Interventions: Following an initial clinic visit, 25 subjects with chronic subjective tinnitus returned home with a tablet computer and calibrated headphones to complete questionnaires, hearing tests, and tinnitus psychoacoustic testing. We repeatedly characterized loudness discomfort levels and tinnitus matching over a 2-week period.Main Outcome Measures: Primary outcomes included intrasubject variability in loudness discomfort levels, tinnitus intensity, and tinnitus acoustic matching over the course of testing.Results: Within-subject variability for all outcome measures could be reduced by approximately 25 to 50% by excluding initial measurements and by focusing only on tinnitus matching attempts where subjects report high confidence in the accuracy of their ratings.Conclusions: Tinnitus self-report is inherently variable but can converge on reliable values with extended testing. Repeated, self-directed tinnitus assessments may have implications for identifying malingerers. Further, these findings suggest that extending the baseline phase of tinnitus characterizations will increase the statistical power for future studies focused on tinnitus interventions.

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Beethoven: His Hearing Loss and His Hearing Aids

Perciaccante, Antonio; Coralli, Alessia; Bauman, Neil G.

Publicatie 01-10-2020


To celebrate the 250th anniversary of the birth of the great classical composer, Ludwig van Beethoven (1770–1827), we point out how his hearing loss affected him and how the primitive hearing aids at that time helped mitigate his hearing loss. From the age of 26, Beethoven began to suffer from a fluctuating, progressive hearing loss (“my hearing grew worse and worse”), This started in his left ear (“in my left ear, with which this illness of my ears had started”), where he had difficulty hearing higher pitched tones (“I don’t hear the high notes of the instruments and voices”) and words (“Sometimes, I cannot hear people who speak quietly, I can hear the sounds, but not the words”) and associated with tinnitus (“my ears, they still keep buzzing and humming day and night”) and loudness recruitment (“if someone yells, it is unbearable to me”).However, in spite of his hearing loss, Beethoven never lost his love for music and continued composing music, at times using some of the acoustic hearing aids that were just being developed. We analyze and describe the ear trumpets, and the resonant plate that engineer Johan Nepomuk Maelzel and piano-maker Conrad Graf, respectively, constructed to try to improve Beethovens hearing. Moreover, we discuss the possible use of a wooden drumstick Beethoven might have used to improve his perception of the pianos sound.

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Visualizing Affected Nerve Bundles of Cranial Nerves VII and VIII in Herpes Zoster Oticus

Lee, Yen-Hui; Young, Yi-Ho; Lin, Yi-Tsen

Publicatie 01-10-2020


No abstract available

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A Novel Surgical Technique for the Management of Cerebrospinal Fluid Gusher Encountered During Cochlear Implantation

Tolisano, Anthony M.; Wick, Cameron C.; Kutz, Joe Walter Jr

Publicatie 01-10-2020


Cerebrospinal fluid (CSF) gusher encountered during cochlear implantation are most commonly encountered in the setting of an inner ear abnormality. Repair of the gusher is essential to prevent CSF egress postoperatively and to decrease the risk of meningitis. Various methods to repair a CSF gusher have been described, including tight packing of the cochleostomy with fascia, lumbar drainage, and Eustachian tube packing with ear canal overclosure. We describe a novel and simple technique using a fascia ring placed around the cochlear implantation electrode (Cochlear Corporation, CI522) as a means to treat CSF gusher. The fascia is slid down the electrode after insertion, allowing circumferential coverage of the defect. The following video will provide an overview of patients at risk for CSF gusher and demonstrate the technique described above.SDC video link: http://links.lww.com/MAO/B52.

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