Otology Neurotology

Otology Neurotology

Endoscopic Versus Microscopic Middle Ear Surgery: A Meta-analysis of Outcomes Following Tympanoplasty and Stapes Surgery

01-09-2019 – Manna, Sayan; Kaul, Vivian F.; Gray, Mingyang L.; Wanna, George B.

Journal Article

Objective: This meta-analysis compares the efficacy and safety of endoscopic and microscopic approaches to tympanoplasty and stapes surgery, two common middle ear procedures.
Data Sources: A comprehensive electronic search of PubMed/MEDLINE, Scopus, Web of Science, and Cochrane Library was conducted for studies published from the year 1960 through June 2018. Article selection and screening proceeded according to the strategies outlined in the standard Preferred Reporting Items for Systematic Reviews and Meta-analysis statement.
Methods: Studies were assessed for quality using the Newcastle-Ottawa Scale and the Jadad scale depending on the presence of randomization. Bias was analyzed using funnel plots. For each outcome measure, a forest plot was generated and a pooled relative risk or risk difference was calculated to assess significance.
Results: Twenty-one studies met the inclusion criteria, 16 tympanoplasty (1,323 ears) and 5 stapes surgery (283 ears). The nonrandomized studies scored moderately well but the randomized studies were of low quality with respect to the Newcastle-Ottawa Scale and the Jadad Scale, respectively. With respect to tympanoplasty, statistical analysis demonstrated that the endoscopic approach had significantly lower canalplasty rates, better cosmetic outcomes, and shorter operative times. Furthermore, endoscopic compared to microscopic methods were similar in terms of audiological outcome, graft success rate, and complication rate. Among stapes surgeries, the endoscopic approach demonstrated a significantly decreased incidence of postoperative pain and chorda tympani injury but was similar to the microscopic approach with respect to audiological outcome, postoperative dizziness, and operative time.
Conclusions: Though the merits of endoscopic techniques are becoming more well known, there are still concerns regarding their efficacy and safety. An analysis of the current literature suggests that audiological, functional, and safety outcomes are similar, if not superior, for the endoscopic approach to both tympanoplasty and stapes surgery compared to the microscopic approach. With respect to tympanoplasty, patients undergoing the endoscopic approach had lower canalplasty rates, better cosmetic outcomes, and shorter operative times. Among stapes surgeries, patients in the endoscopic group had a lower incidence of postoperative pain and injury to the chorda tympani. This meta-analysis of the current evidence supports the use of endoscopic techniques for tympanoplasty and stapes surgery.

The Influence of Metabolic Syndrome on the Prognosis of Idiopathic Sudden Sensorineural Hearing Loss

01-09-2019 – Zhang, Yanni; Jiang, Qian; Wu, Xuewen; Xie, Shaobing; Feng, Yong; Sun, Hong

Journal Article

Objectives: We aimed to verify the hypothesis that metabolic syndrome (Met
S) and its components affect the prognosis of idiopathic sudden sensorineural hearing loss (ISNNHL).
Study Design: A retrospective cohort study.
Setting: Tertiary otology referral center.
Patients: We divided patients who were diagnosed with ISSNHL between January 2015 and January 2018 into a Met
S group and a Non-Met
S group according to the diagnostic criteria of Met
S.
Interventions: We diagnosed ISSNHL patients by using pure-tone audiometry and treated them with oral steroids, blood flow promoting agents, and hyperbaric oxygen therapy.
Main Outcome Measures: We used multivariate logistic analysis to identify prognostic factors of ISSNHL.
Results: The Met
S group comprised 94 patients, and the Non-Met
S group comprised 162 subjects. Despite the rate of hypertension, diabetes mellitus, hyperlipidemia, and BMI, no significant difference was observed between the two groups (p > 0.05). The rates of complete recovery and partial recovery of the Met
S group were significantly lower than those of the Non-Met
S group (p < 0.05). According to the multivariate analysis, Met
S was significantly correlated with a poor prognosis (OR = 2.912, p = 0.008), and the OR increased with an increase in the number of Met
S components. Late onset of treatment, high initial hearing threshold, and presence of diabetes mellitus and hyperlipidemia were associated with a poor prognosis (p < 0.05).
Conclusions: The presence of Met
S may negatively affect the recovery of Chinese patients with ISSNHL, and the prognosis was poorer with an increase in the number of Met
S components. Early onset of treatment, low initial hearing threshold and absence of diabetes mellitus, and hyperlipidemia are associated with favorable hearing recovery.

Long-term Outcomes of Bone Conduction Hearing Implants in Patients With Bilateral Microtia-atresia

01-09-2019 – Fan, Xinmiao; Yang, Tengyu; Niu, Xiaomin; Wang, Yibei; Fan, Yue; Chen, Xiaowei

Journal Article

Objectives: To evaluate the long-term outcomes of three different types of bone conduction hearing implants (BCHI)—BAHA, Ponto, and Bonebridge—in Mandarin-speaking patients with bilateral microtia-atresia.
Methods: This cohort study enrolled 59 patients affected by bilateral microtia-atresia, with an upper bone conduction threshold limit of 30 d
B HL at frequencies of 0.5 to 4 k
Hz. All subjects underwent unilateral BCHI surgery, including 26 (18 males, 8 females, of mean age 8.7 ± 1.9 yr) implanted with BAHA devices; 10 (7 males, 3 females, of mean age 11.7 ± 2.8 yr) implanted with Ponto devices; and 23 (14 males, 9 females, of mean age 9.0 ± 1.8 yr) implanted with Bonebridge devices. The main outcome measures included long-term audiological benefits, patient satisfaction, and complications. Each subject acted as his or her own control.
Results: Two years after BCHI surgery, the mean hearing thresholds in the BAHA, Ponto, and Bonebridge groups had improved to 22.6 ± 1.6 d
B HL, 21.6 ± 1.2 d
B HL, and 22.5 ± 1.5 d
B HL, respectively. The mean percentages of subjects in these three groups recognizing speech at 65 d
B SPL under quiet conditions were 97.7 ± 4.2%, 96.3 ± 1.1%, and 94.4 ± 9.4%, respectively, whereas the mean percentages recognizing speech under noise conditions (signal:noise ratio +5) were 87.0 ± 1.8%, 89.3 ± 9.3%, and 85.3 ± 4.7%, respectively. Questionnaires revealed patients’ benefits and satisfaction with this surgery. Three (11.5%) of 26 patients in the BAHA group and 1 (10%) of 10 in the Ponto group experienced skin irritation, but all recovered after local treatment. Five (19.2%) patients in the BAHA group and two (20%) in the Ponto experienced abutment extrusion about 6 months postoperatively, with all achieving good results after revision surgery to replace the abutment. One (3.8%) patient in the BAHA group experienced local chronic inflammation and underwent surgery to replace the BAHA with a Bonebridge implant. One (4.3%) patient in the Bonebridge group developed a local infection 3 months postoperatively and underwent implant removal.
Conclusions: All three BCHIs were well tolerated after long-term follow-up, and all improved audiometric thresholds and the intelligibility of speech in the presence of both quiet and noise. These implants should be considered valid and safe options for the functional rehabilitation of patients with bilateral microtia-atresia.

Validating a New Tablet-based Tool in the Determination of Cochlear Implant Angular Insertion Depth

01-09-2019 – Canfarotta, Michael W.; Dillon, Margaret T.; Buss, Emily; Pillsbury, Harold C.; Brown, Kevin D.; O’Connell, Brendan P.

Journal Article

Objective: The objective of this study is to determine the reliability of a new tablet-based software that utilizes postoperative computed tomography to determine angular insertion depth (AID), cochlear duct length (CDL), and the cochlear place frequency of individual electrodes in cochlear implant recipients.
Patients: Twenty adult cochlear implant recipients with lateral-wall electrode arrays of varying lengths were included in the study.
Intervention: Cochlear and electrode array measurements were made by 2 otolaryngologists using a tablet-based software. The user manually identifies the modiolus, round window, and each electrode contact to calculate AID. The user also manually identifies cochlear landmarks to calculate the CDL. The AID and CDL are applied to the Greenwood function to obtain an estimate of the cochlear place frequency for each electrode.
Main Outcome Measure(s): The primary outcome measure was the reliability of the instrument, as assessed with intra and interrater reliability of measured AID and CDL. The resultant differences in the estimated cochlear place frequency of the most apical electrode were also evaluated.
Results: A broad range of AIDs were observed (390°–659°). Intraclass correlation coefficients for intra (0.991) and interrater reliability (0.980) of AID of the most apical electrode contact were excellent. Intra (0.820) and interrater reliability (0.784) of CDL were also excellent. The estimated cochlear place frequency for the most apical electrode differed by an average of 6.7% (0–18.7%) across the 2 raters.
Conclusion: There is excellent agreement amongst clinicians in the determination of AID and CDL, resulting in small changes in estimated cochlear place frequency of the most apical electrode using this new software.

Clinical Applicability of a Preoperative Angular Insertion Depth Prediction Method for Cochlear Implantation

01-09-2019 – Rathgeb, Christoph; Demattè, Marco; Yacoub, Abraam; Anschuetz, Lukas; Wagner, Franca; Mantokoudis, Georgios; Caversaccio, Marco; Wimmer, Wilhelm

Journal Article

Objective: Evaluation of the accuracy and clinical applicability of a single measure cochlear implant angular insertion depth prediction method.
Background: Cochlear implantation outcomes still vary extensively between patients. One of the possible reasons could be variability in intracochlear electrode array placement. For this reason, single measure methods were suggested to preoperatively predict angular insertion depths. Based on a previously performed accuracy study in human temporal bones, we were interested in determining the extent to which the method could be applied in a clinical setting.
Methods: A retrospective analysis was performed on pre- and postoperative radiographic images of 50 cochlear implant recipients. Preoperatively predicted angular insertion depths were compared with angular insertion depths measured on postoperative ground truth. The theoretical prediction error was computed under the assumption that all achieved insertions were matching the preoperatively assumed linear insertion depth. More importantly, the clinical prediction error was assessed using two different software tools performed by three experienced surgeons.
Results: Using the proposed method we found a theoretical prediction error of 5 degrees (SD = 41 degrees). The clinical prediction error including the cases with extracochlear electrodes was 70 degrees (SD = 96 degrees).
Conclusions: The presented angular insertion depth prediction method is a first practical approach to support the preoperative selection of cochlear implant electrode arrays. However, the presented procedure is limited in that it is unable to predict the occurrence of insertion results with extracochlear electrodes and requires user training.

Speech Perception Growth Patterns in Prelingual Deaf Children With Bilateral Sequential Cochlear Implantation

01-09-2019 – Kim, Yehree; Lee, Jee Yeon; Lim, Won Seob; Kwak, Min Young; Seo, Ji Won; Park, Jun Woo; Lee, Je Yeon; Kang, Byung Chul; Kang, Woo Seok; Ahn, Joong Ho; Chung, Jong Woo; Park, Hong Ju

Journal Article

Objective: To evaluate speech perception following the first (CI-1) and second (CI-2) cochlear implantation (CI) in children with sequential bilateral CI.
Study Design: Retrospective.
Patients: Seventy children with follow-up for 60 months post CI-1 and 36 months post CI-2.
Main Outcome Measures: Word recognition score (WRS) was the main outcome. WRSs were compared by age at CI operation (group A ≤ 3.5 yr, B 3.6–8.6, for CI-1; group I ≤ 3.5 yr, II 3.6–7.0, III 7.1–13, IV > 13, for CI-2).
Results: For CI-1, the WRS of group A exceeded 80% at 24 months post procedure, earlier than group B (54 mo). Group A also had a shorter period of CI-1 use up to the WRS plateau than group B. CI-2 showed an initial burst of WRS growth much earlier than CI-1. This initial burst was most robust within 3 months in group II, but modest in group IV. The periods of CI-2 use (11–17 mo) up to the WRS plateau were much shorter than CI-1 (40–64 mo). Group I did not show the best WRS at 1 month post CI but later exceeded the other groups.
Conclusion: Children received an immediate benefit by a burst of WRS growth from CI-2 earlier than CI-1, even within 3 months, suggesting that CI-1 gets the auditory cortex ready to foster speech processing from CI-2. The CI-2 performance depends on age at CI-2 implantation and on CI-1 performance. Our current findings will be relevant for clinicians who are counselling parents on CI-2 surgery.

Cochlear Implant Outcomes in Large Vestibular Aqueduct Syndrome—Should We Provide Cochlear Implants Earlier?

01-09-2019 – Hall, Andrew C.; Kenway, Bruno; Sanli, Halit; Birman, Catherine S.

Journal Article

Objective: Examine postoperative speech perception outcomes in a large vestibular aqueduct syndrome (LVAS) patients at a major cochlear implantation center.
Study Design: Retrospective analysis of the Sydney Cochlear Implant Centre (SCIC) database and medical records from January 1994 to December 2015 was performed.
Setting: Tertiary referral center.
Patients: Patients with a diagnosis of LVAS who received a cochlear implant (CI). Only those with speech perception outcomes recorded at least 12 months post implant were included in our analysis.
Intervention(s): Therapeutic.
Main Outcome Measure(s): : Postoperative speech perception scores.
Results: Between 1994 and 2015, 176 adult and pediatric patients with a diagnosis of LVAS underwent cochlear implantation at SCIC. Postoperative Bamford-Kowal Bench (BKB) sentence test scores were obtained for 97 patients. The postoperative median BKB score was 93% with a lower quartile score of 85% and an upper quartile score of 98%. Smaller numbers were available for post-CI City University of New York (CUNY) and Consonant-Nucleus-Consonant (CNC) word scores yet similar excellent results were seen.
Conclusions: Our study results suggest the CI should be considered when BKB scores have dropped to 85%. We suggest that rather than LVAS cases representing a challenge to cochlear implantation, they are amongst the best candidates for surgery, and should receive a CI at an earlier stage in hearing loss, when they have better speech perception. This allows stable hearing to be established earlier along with excellent speech perception outcomes.

Density of Macrophages Immunostained With Anti-iba1 Antibody in the Vestibular Endorgans After Cochlear Implantation in the Human

01-09-2019 – Okayasu, Tadao; O’Malley, Jennifer T.; Nadol, Joseph B. Jr

Journal Article

Hypothesis: Cochlear implantation may result in an increase in the density of macrophages in vestibular endorgans in the human.
Background: Vestibular symptoms are a common complication of cochlear implantation. In a previous study, we demonstrated histological evidence of a foreign-body response caused by silicon and platinum in the human cochlea following cochlear implantation. The objective of the current study was to seek evidence of a possible immune response in vestibular endorgans after cochlear implantation.
Methods: The density of macrophages immunostained with anti-Iba1 antibody in the vestibular endorgans (lateral and posterior semicircular canals, utricle and saccule) in 10 human subjects who had undergone unilateral cochlear implantation was studied by light microscopy. The densities of macrophages in the neuroepithelium, subepithelial stroma, and among dendritic processes in the mid-stromal zone in four vestibular endorgans in the implanted and the opposite unimplanted ears were compared. The distributions of macrophage morphology (amoeboid, transitional and ramified) were also compared.
Results: The densities of macrophages in implanted ears in four vestibular endorgans were significantly greater than that in opposite unimplanted ears except in the subepithelial zone of the utricle and posterior semicircular canal. In contrast to the neuroepithelium, the subepithelial distribution of amoeboid macrophages in implanted ears was significantly less than in unimplanted ears.
Conclusion: An increase in the density of macrophages in four vestibular endorgans after implantation was demonstrated. The transition among phenotype of macrophages suggested possible migration of amoeboid macrophages from the subepithelial stroma into the neuroepithelium.

Sensorineural Hearing Loss in the Nonimplanted Ear Following Cochlear Implantation in a Patient With Bilateral Enlarged Vestibular Aqueducts

01-09-2019 – Vaisbuch, Yona; Thai, Anthony; Pirko, Sarah L.; Santa Maria, Peter L.

Journal Article

Objective: To document the case of a patient with bilateral enlarged vestibular aqueducts who experienced sensorineural hearing loss in the nonimplanted ear following unilateral cochlear implantation complicated by perilymph gusher requiring lumbar drain insertion and to highlight the need to counsel regarding the risk of potential hearing loss to the contralateral ear when preparing for cochlear implants in the setting of inner ear malformations.
Patients: One patient with bilateral enlarged vestibular aqueducts in a tertiary referral center.
Intervention(s): Cochlear implantation complicated by perilymph gusher requiring lumbar drain insertion.
Main Outcome Measure(s): Bone conduction hearing thresholds, word recognition scores.
Results: The patient underwent unilateral cochlear implantation, which was complicated by a perilymphatic gusher and necessitated placement of an intraoperative lumbar drain. On postoperative day 1, the patient reported hearing loss in the opposite ear. The word recognition score in the contralateral ear dropped from 24% at preimplantation to 8% at 2-weeks postimplantation, and did not improve at 6 months postimplantation. Moreover, the bone conduction threshold at 1 k
Hz worsened from 20 d
B preoperatively to no response at 75 d
B (the limit of the testing equipment) at 2-weeks postoperatively and only partially improved to 40 d
B at 6 months postimplantation.
Conclusion: As patients with inner ear malformations potentially have direct high-pressure anatomical connections between the perilymphatic spaces and the cerebrospinal fluid, they are at risk of hearing loss in the nonimplanted ear during cochlear implantation. This case highlights the need for potential additional patient counseling regarding this risk in the nonimplanted ear.

Auditory Performances in Older and Younger Adult Cochlear Implant Recipients: Use of the HEARRING Registry

01-09-2019 – Hofkens-Van den Brandt, Anouk; Mertens, Griet; Gilles, Annick; Fransen, Erik; Lassaletta, Luis; Gavilan, Javier; Calvino, Miryam; Yanov, Yuri; Kuzovkov, Vladislav; Kliachko, Dmitrii; Zernotti, Mario; Gregorio, Dra Maria Fernanda Di; Van Rompaey, Vincent; Van de Heyning, Paul; Sugarova, Seraphima

Journal Article

Objective: To evaluate the hearing outcomes of cochlear implantation in different age groups by using data collected in the HEARRING registry.
Methods: A multicenter study. Data of 146 patients were collected in a HEARRING registry. Patients were divided into three different age groups; ≤ 55 years old (age group 1, n = 66), 56 to 69 years old (age group 2, n = 45), and ≥ 70 years old (age group 3, n = 35). Speech in quiet (SPIQ), speech in noise (SPIN), and hearing implant sound quality index (HISQUI19) scores were evaluated for the different age groups at different test moments (preoperatively, 3, 6, 12, and 24 mo after first fitting).
Results: A statistically significant difference (p < 0.01) was found between preoperative scores and the scores on all the follow-up moments across all age groups. For SPIQ and SPIN, none of the time points showed a statistically significant age effect (p = 0.88 and p = 0.89). For HISQUI19 scores, a statistically significant age effect was found at 12 months after first fitting. The oldest age group scored significantly lower on the HISQUI19 compared with the youngest age group.
Conclusion: Hearing outcomes of adult cochlear implant users of different age groups were evaluated. The SPIQ and SPIN tests showed no significant differences between the different age groups. Nevertheless, the youngest group scored significantly better on self -perceived benefit (HISQUI19) with a cochlear implant compared with the oldest age group.
Further research is needed to receive more insight into cochlear implantation in the elderly and its implications on rehabilitating and supporting this expanding older population.

Evaluation of the Effect of Diclofenac Sodium and 5-Fluourasil in a 3D Cholesteatoma Cell Culture Model

01-09-2019 – Kara, Ahmet; Duman, Busra Oncel; Yazir, Yusufhan; SinanYilmaz, Mahmut; Halbutogullari, Zehra Seda Unal; Demir, Deniz; Kara, Rabia Oztas; Bayraktar, Hakan; Guven, Mehmet

Journal Article

Introduction: Middle ear cholesteatoma is a benign disease with invasive and destructive clinical behaviors. It increases the rate of both chronic otitis media complications and revision surgeries. The most effective treatment of middle ear cholesteatoma is surgical excision, and there is no medical treatment for this disease. Exploring new medical treatment options may help to create treatment alternatives instead of surgery.
Materials and Methods: Required cholesteatoma tissues for cell culture were excised from 4 different participants who underwent surgery in our clinic and agreed to give tissue for the study. Cholesteatoma-derived keratinocytes and fibroblasts were cocultured in temperature-sensitive culture dishes to make a three-dimensional (3D) cholesteatoma model. Then, the effects of 1% and 2% diclofenac sodium on viability and cell proliferation rates were examined using WST-1 and annexin-V tests.
Results: Cell viability and proliferation rates were found to be lower and apoptosis rates were higher in the diclofenac sodium group versus the negative and positive control groups.
Conclusion: In this present study, we described a new 3D cholesteatoma cell culture model developed using cell sheet technology and demonstrated the efficacy of diclofenac sodium on cholesteatoma for the first time in the literature. It may be used in patients with chronic otitis media with cholesteatoma, but further studies investigating ototoxic and neurotoxic effects of this molecule are needed.

Audiologic Improvement Following MCF Approach for Spontaneous Cerebrospinal Fluid Leaks

01-09-2019 – Alwani, Mohamedkazim; Bandali, Elhaam; Van Buren, Lauren; Yates, Charles W.; Nelson, Rick F.

Journal Article

Objective: To determine the audiologic improvement after middle cranial fossa (MCF) approach to repair spontaneous cerebrospinal fluid (s
CSF) leaks.
Study Design: Retrospective cohort study.
Setting: Tertiary referral center.
Patients: Twenty-four consecutive patients (27 ears) with temporal bone s
CSF leak over a 4-year period. Patient age, sex, ethnicity, body mass index (BMI), location of CSF leak, recurrence of CSF leak, and presence of encephalocele(s) were recorded.
Intervention: Audiometric testing in patients undergoing MCF repair of temporal bone s
CSF leak.
Main Outcome Measures: Comparison of preoperative and postoperative pure-tone average (PTA), air-bone gap (ABG), and word recognition score (WRS) in the s
CSF leak ear.
Results: Out of 27 ears, 55% had multiple tegmen defects and 82% had more than or equal to 1 encephaloceles. There were no recurrent CSF leaks at a median follow up of 4 months. The mean (SD) preoperative PTA and ABG were 40.58 15.67 and 16.44 6.93 d
B, respectively. There was significant improvement in mean PTA (10.28 8.01 d
B; p < 0.001; Cohen d = 0.95) and ABG (9.31 7.16 d
B; p < 0.001; Cohen d = 0.88) after s
CSF repair. Mean WRS improved (by 3.07 6.11 %; p = 0.024; Cohen d = 0.46) from a mean preoperative WRS of 93.16 9.34% to a mean postoperative WRS of 96.26 6.49%.
Conclusions: MCF approach for repair of s
CSF leaks yields significant improvement in conductive hearing loss and is highly effective in management of the entire lateral skull base where multiple bony defects are often identified.

Hearing Improvement Following Middle Cranial Fossa Floor Defect Repair Utilizing a Modified Middle Fossa Approach and Reconstructive Techniques

01-09-2019 – Alwan, Mostafa; Ibbett, Imogen; Pullar, Michael; Lai, Leon T.; Gordon, Michael

Journal Article

Background: Few studies report hearing preservation following middle cranial fossa (MCF) floor defect repair.
Objective: To investigate audiological outcomes following MCF floor defect repair using a modified MCF suprapetrous approach.
Study Design: Retrospective cohort.
Setting: Tertiary referral center.
Patients: Eleven patients, with MCF floor defects.
Interventions: MCF floor defect surgical repairs with either fascia or fascia and bone graft.
Main Outcome Measured: Hearing outcomes.
Results: Eleven patients (two men) aged 34 to 82 years (median, 62 yrs) were identified. All patients were operated on by the same two senior surgeons (M.
P. and M.
G.). One patient with conductive hearing loss (based on tuning fork test) was excluded from the analysis due to missing preoperative audiogram data. All patients had middle fossa plate defects leading to cerebrospinal fluid (CSF) otorrhoea, rhinorrhoea, or meningitis. Nine patients had retrieval of herniated contents from the defect. Five patients had repair with temporalis fascia and split calvarial bone graft, and six patients had repair with fascia only. Follow up audiogram was performed at a mean 7.5 months (range, 0.5–24 mo). There was no recurrent CSF leak during the follow up period. The 10 patients (90.9%, 95% confidence interval CI 60.1–100.6) who had complete audiologic data sets demonstrated a mean improvement of 18.86 d
B (range, –7.5 to 33.75 d
B) in hearing postoperatively. One of these patients acquired a 7.5 d
B reduction in postoperative hearing due to post-procedural middle ear effusion which subsequently resolved. Hearing improvement following fascial graft alone versus fascial graft with bone was 12.5 and 26.5 d
B, respectively (p < 0.01).
Conclusion: Middle fossa craniotomy with or without retrieval of herniated contents and floor reconstruction with fascia and bone is associated with improved hearing. Clinical efficacy of this technique, however, can be only fully established when a statistically meaningful number of cases have been performed.

Differentiation Between Eosinophilic Otitis Media and Otitis Media Associated With Eosinophilic Granulomatosis With Polyangiitis

01-09-2019 – Fukuda, Atsushi; Morita, Shinya; Nakamaru, Yuji; Hoshino, Kimiko; Fujiwara, Keishi; Homma, Akihiro

Journal Article

Objective: To perform comparisons and clarify differences in clinical manifestations between eosinophilic otitis media (EOM) and otitis media associated with eosinophilic granulomatosis with polyangiitis (EGPA).
Study Design: Retrospective case review.
Setting: Tertiary referral center.
Patients: Twenty-two ears of 11 patients exhibiting EOM (EOM group) and 20 ears of 12 patients exhibiting otitis media associated with EGPA (EGPA group).
Main Outcome Measures: Otological manifestations, nasal and paranasal manifestations, incidence of asthma, positivity for serum antineutrophil cytoplasmic antibodies (ANCA), total serum immunoglobulin (Ig) E level, peripheral blood eosinophil fraction, and hearing outcomes.
Results: The incidence and age of onset of asthma and chronic rhinosinusitis were comparable between the EOM and EGPA groups. Moreover, otological findings and hearing outcomes at the initial visit were similar in both groups. Computed tomography images of the paranasal sinus showed predominant opacification of the ethmoid sinus in both groups. Although the total serum Ig
E level was not significantly different, the peripheral blood eosinophil fraction was significantly larger in the EGPA group than in the EOM group (p = 0.0035). Furthermore, the rate of myeloperoxidase–antineutrophil cytoplasmic antibodies (ANCA) positivity was significantly higher in the EGPA group than in the EOM group (p = 0.019).
Conclusions: The findings of the present study suggest that the phenotypic characteristics of EOM closely resemble those of otitis media associated with EGPA in early stages before the appearance of vasculitis. Therefore, it is challenging to differentiate the two conditions purely on the basis of otorhinological examinations.

Partial Epithelial–Mesenchymal Transition Was Observed Under p63 Expression in Acquired Middle Ear Cholesteatoma and Congenital Cholesteatoma

01-09-2019 – Takahashi, Masahiro; Yamamoto-Fukuda, Tomomi; Akiyama, Naotaro; Motegi, Masaomi; Yamamoto, Kazuhisa; Tanaka, Yasuhiro; Yamamoto, Yutaka; Kojima, Hiromi

Journal Article

Introduction: Partial epithelial–mesenchymal transition (p-EMT) is a process by which epithelial cells partially lose their intercellular adhesion and change to obtain migration ability. The transcription factor p63 regulates the expression of cadherin family and induces epithelial cell proliferation. In this study, we hypothesized that p-EMT under p63 expression may be a key factor in epithelial cell growth in middle ear cholesteatoma.
Methods: Specimens were surgically excised from patients with congenital cholesteatoma (CC) (n = 48), acquired middle ear cholesteatoma (AC) (n = 120), and normal skin tissue (n = 34). We analyzed immunohistochemically for the EMT marker (N-cadherin), adherence junction marker (E-cadherin), and tight junction marker (claudin-1, claudin-4, occludin). We also examined the labeling index (LI) of p63 and Proliferating cell nuclear antigen (PCNA) (late S phase marker), and Snail expression as a mobility marker.
Results: The expression of p63 (CC 51.0 ± 7.4%, AC 50.0 ± 5.9%) was significantly higher in the thickened epithelium of CC and AC compared with normal skin tissue (p < 0.0001). The loss of E-cadherin was observed (CC 50.0%, AC 55.8%) but the expression patterns in the tight junction were almost normal. N-cadherin was partially detected in the basal and upper layer of epithelium in CC and AC. In contrast to that of normal skin tissue, the LI of PCNA was significantly higher in AC (p < 0.0001). The positive rate of Snail was significantly higher in CC (p < 0.0001).
Conclusion: This study indicates that p-EMT via the p63 signaling pathway might plays an essential role in epithelial growth in AC and CC formation, although tight junction formation and terminal differentiation were not affected in those processes.

Osteonecrosis of the External Auditory Canal Associated With Oral Sorafenib Therapy: Sorafenib and Temporal Bone Osteonecrosis

01-09-2019 – Canzano, Federica; Di Lella, Filippo; Manuguerra, Roberta; Vincenti, Vincenzo

Journal Article

Objective: To present the first case of osteonecrosis of the external auditory canal associated with sorafenib treatment. Patient: 58-year-old patient with right-sided otorrhea and otalgia was treated for otitis externa for 1 month without improvement. Otoscopic examination revealed a large defect in the inferior wall of the tympanic bone filled with skin debris and bony fragments. Previous medical history included treatment with sorafenib for metastatic renal cell cancer; he had never been exposed to radiotherapy. Computed tomography of the temporal bone showed a large right external auditory canal bony erosion with involvement of the tympanic bone and bony sequestra extending to the mastoid cells and temporomandibular joint. Histologic examination revealed necrotic bone and inflammatory changes with no signs of malignancy. A diagnosis of osteonecrosis of external auditory canal was made.
Intervention: Right subtotal petrosectomy with obliteration of surgical cavity with abdominal fat was performed.
Results: Final histological report revealed avascular necrosis of the bone with perivascular lymphocitic infiltration of the soft tissues. Diagnosis of medication-related external auditory canal osteonecrosis was confirmed.
Conclusion: Medication-related osteonecrosis of the temporal bone is not a well-known entity among otolaryngologists and could therefore be misclassified as another diagnosis. In patients with othorrea and earache following sorafenib treatment, temporal bone osteonecrosis should be suspected.

Mycotic Pseudoaneurysm of Internal Carotid Artery Induced by Skull Base Osteomyelitis

01-09-2019 – Budhiraja, Shilpi; Sagar, Prem; Kumar, Rajeev; Sharma, Suresh C.

Journal Article

Background: Skull base osteomyelitis (SBO) is predominantly seen in immunocompromised patients, with diabetes mellitus being the most common underlying comorbidity. Microbial aetiology is commonly bacterial, although fungal SBO is encountered in a small fraction of patients. Treatment consists of prolonged antimicrobial therapy, control of underlying comorbidity, and surgical debridement in selected cases. Involvement of cranial nerves is a common complication and is considered a poor prognostic factor. Pseudoaneurysm of internal carotid artery caused by skull base osteomyelitis is a very rare complication, limited to few case reports only.
Case: We report the case of a 55-year-old diabetic patient with bacterial SBO who developed pseudoaneurysm of cervical–petrous part of internal carotid artery during the course of treatment.
Conclusion: New onset symptoms or persistent symptoms in SBO suggest progressive disease and necessitate re-evaluation of the microbial aetiology and antimicrobial treatment. Skull base osteomyelitis induced aneurysm is rare but can be life threatening, if not identified and managed immediately.

Treatment of Auricular Hematomas by OK-432: How and Why It Works

01-09-2019 – Ohta, Nobuo; Fukase, Shigeru; Kusano, Yusuke; Saito, Yutaro; Tateda, Yutaka; Ishida, Yusuke; Ikeda, Ryoukichi; Yamazaki, Muneharu; Ono, Junya; Izuhara, Kenji

Journal Article

Objectives: The aim of this article was to investigate the effectiveness and underlying mechanisms of OK-432 therapy in patients with auricular hematomas.
Study Design and Setting: Case series with planned data collection.
Subjects and Methods: We tried this therapy in 47 patients with auricular hematoma between April 2008 and August 2018. We aspirated as much of the fluid content of each lesion as possible with a 21-gage needle. We injected OK-432 solution into the lesion with the same needle that we used for aspiration. We performed this treatment at an outpatient basis without hospitalization.
Results: Disappearance and marked reduction of the lesion were observed in all patients who had this therapy, and local scarring and deformity of the auricle did not occur in any patients. As adverse effects, local pain at the injection site and fever (37–38.5°C) were observed in some cases of the patients who had this therapy. The concentrations of various cytokines in each aspirate before and after OK-432 therapy were investigated. The production of tumor necrosis factor-α, interleukin-6, interleukin-8, interferon gamma, vascular endothelial growth factor, and periostin was significantly elevated in the aspirate fluid after OK-432 therapy.
Conclusion: OK-432 therapy is simple, easy, safe, effective, and can be used as a substitute for surgery in the treatment of auricular hematoma.

Management of Traumatic Injury and Osseointegration Failure in Children With Percutaneous Bone Conduction Implants

01-09-2019 – Purcell, Patricia L.; Ziai, Hedyeh; Xu, Josie; Gordon, Karen A.; Papsin, Blake C.; Cushing, Sharon L.

Journal Article

Objective: This study examines the incidence and management of traumatic loss or osseointegration failure of percutaneous bone conduction implants in children.
Study Design: Case series.
Setting: Pediatric tertiary care institution.
Patients: Children who underwent percutaneous osseointegrated implant placement from 1996 to 2016.
Interventions: Clinical evaluation and revision surgery after implant loss.
Main Outcome Measures: This study compares the characteristics of children who experienced traumatic loss of implant to those who did not to calculate odds ratios (ORs) describing the risk of injury and investigate device utilization after implant failure.
Results: One hundred forty-seven children received percutaneous bone conduction devices; 129 were followed for at least 1 year. Trauma occurred in 19 of 129 cases (15%). Among children with traumatic injury, mean age at initial surgery was 5 years (SD = ±3.3), and 42% had a developmental delay. Among children without traumatic injury, mean age at initial surgery was 6.5 years (SD = ±4.4), and 28% had a developmental delay. Multivariate logistic regression found no significant differences in age, sex, or developmental delay associated with implant loss. In five of 19 traumatic cases (26%), the implant remained in situ due to either skull fracture or abutment loss. In the remaining 14 of 19 cases (74%), there was osseointegration failure with extrusion of the implant. Seventeen children underwent revision surgery utilizing previously placed “sleeper,” or backup, osseointegrated implant, and 14 (82%) of these continued to use their device. Two patients with extruded implants did not undergo revision surgery.
Conclusion: Traumatic injury or osseointegration failure leads to loss of percutaneous bone conduction implants in approximately 15% of children. Revision surgery is often successful.

Characteristics and Outcomes of Pediatric Vestibular Schwannomas

01-09-2019 – Janz, Tyler A.; Camilon, Philip Ryan; Cheung, Anthony Y.; Nguyen, Shaun A.; Meyer, Ted A.; McRackan, Theodore R.; Lambert, Paul R.

Journal Article

Objective: To review the demographics, treatment modalities, and survival of children with vestibular schwannomas.
Study Design: Analysis using the Surveillance, Epidemiology, and End Results (SEER) database.
Subjects and Methods: Pediatric patients from birth to 18 years in the SEER database were included from 2004 to 2014 based on a diagnosis of vestibular schwannoma using the primary site International Classification of Diseases (ICD) O-3 code of C72.4: acoustic nerve and the ICD O-3 histology codes of 9540/1: neurofibromatosis, Not Otherwise Specified (NOS); 9560/0: neurilemoma, NOS; or 9570/0: neuroma, NOS.
Results: One hundred forty-eight pediatric vestibular schwannomas (VSs) cases were identified. The mean age at diagnosis was 13.9 years (range, 4.0–18.0). Eighty-five (57.4%) patients were women. Seventy-seven (52.0%) patients had isolated unilateral VSs while 71 (48.0%) patients had either bilateral VSs or unilateral VSs with other brain, spinal cord, or cranial nerve tumors. Eighty two (55.4%) patients received surgical resection only, 45 (30.4%) received no treatment, 6 (4.1%) received radiation only, and 12 (8.1%) received surgery and radiation. The median tumor size for patients who received no treatment was 9.5 mm (interquartile range IQR: 8.0) compared with 33.5 mm (IQR: 23.0) for patients who received surgical care and 41.0 mm (IQR: 1.5) for patients who received both surgery and radiation (p < 0.001). The 5-year overall survival rate was 97%.
Conclusion: Pediatric VSs tend to be diagnosed in adolescence. No men or women predominance was appreciated. Treatment varied according to tumor size. Survival rates for children with vestibular schwannomas are excellent. These data may assist healthcare providers when counseling children with vestibular schwannomas and their families.

Outcomes of Primary Pediatric Stapedotomy

01-09-2019 – Page, Joshua Cody; Gau, Victoria L.; Allsopp, Tristan; King, DeAnne; Jervis-Bardy, Joshua; Dornhoffer, John L.

Journal Article

Objective: To review a single institution experience with pediatric stapedotomy for juvenile otosclerosis (JO), congenital stapes footplate fixation (CSFF), or tympanosclerosis.
Study Design: Retrospective chart review.
Setting: Tertiary referral center.
Patients: Pediatric patients undergoing surgery for stapes fixation from 2001 to 2017.
Main Outcome Measures: Hearing result based on preoperative, first postoperative, and final postoperative pure-tone average air-bone gap (PTA-ABG). Age, sex, diagnosis, procedure performed, prosthesis, and ossicular anomalies were considered.
Results: A total of 59 children (4–16 years of age) underwent surgery for stapes fixation (67 ears), with an average postoperative audiogram out to 2.88 years. Final postoperative ABG for tympanosclerosis (30.4 d
B ± 10.9 d
B) showed some improvement but the outcome was significantly worse than in CSFF (21.0 d
B ± 11.4 d
B) (p = 0.020) and JO (22.8 d
B ± 14.9 d
B).
Conclusion: Our data suggest, that in our clinic, surgery for stapes fixation is safe to perform in children. While we achieved desirable results for JO and CSFF, patients with tympanosclerosis showed a statistically worse hearing outcome. Tympanosclerosis deserves special consideration and may be better served with a malleovestibulopexy, total ossicular replacement prosthesis (TORP), or amplification in lieu of traditional stapes surgery.

A Transcutaneous Active Middle Ear Implant (AMEI) in Children and Adolescents: Long-term, Multicenter Results

01-09-2019 – Hempel, John-Martin; Sprinzl, Georg; Riechelmann, Herbert; Streitberger, Christian; Giarbini, Nadia; Stark, Thomas; Zorowka, Patrick; Koci, Viktor; Magele, Astrid; Strenger, Tobias; Müller, Joachim; Wollenberg, Barbara; Frenzel, Henning

Journal Article

Objective: Evaluation of the long-term safety and performance of an active middle ear implant (AMEI) in the treatment of hearing loss in children and adolescents with a primary focus on improvement in speech discrimination.
Study Design: Prospective, multicentric, single-subject repeated-measures design in which each subject serves as his or her own control.
Subjects: Thirty-one pediatric subjects aged 5 to 17 years.
Intervention: Implantation of an active middle ear implant.
Methods: Improvement in word recognition scores, speech reception thresholds (SRT) in quiet and noise, in addition to air conduction, bone conduction, and sound field thresholds were evaluated in two age groups.
Results: Residual hearing did not change over time and speech intelligibility significantly improved and remained stable after 36 months. Children aged 5 to 9 improved in WRS from 21.92 to 95.38% and in SRT in quiet and in noise respectively from 62.45 d
B SPL (sound pressure level) and +1.14 d
B SNR to 42.07 d
B SPL and −4.45 d
B SNR. Adolescents aged 10 to 17 improved in WRS from 12.78 to 84.71% and in SRT in quiet and in noise respectively from 63.96 d
B SPL and +3.32 d
B SNR to 35.31 d
B SPL and −4.55 d
B SNR.
Conclusions: The AMEI, under investigation, is a safe treatment for children and adolescents, and significantly improved audiological performance that remains stable on the long-term scale (up to 36 mo postimplantation). In general, all adult-related issues and questions regarding safety and performance can also be applied to the pediatric population, as no apparent specific issues developed.

Speech Perception Outcomes in Transcutaneous Versus Percutaneous Bone Conduction Stimulation in Individuals With Single-sided Deafness

01-09-2019 – Snapp, Hillary A.; Morgenstein, Kari E.; Kuzbyt, Brianna

Journal Article

Objective(s): To investigate the differences in percutaneous versus passive transcutaneous bone-conduction stimulation in individuals with single-sided deafness.
Study Design: Prospective, single-subject.
Setting: Tertiary academic referral center.
Patients: Adult bone-anchored implant listeners with single-sided deafness using a percutaneous implant system.
Interventions: Experienced percutaneous bone anchored implant recipients were tested in the percutaneous and transcutaneous conditions using a BAHA 5 (Cochlear Corp., Cochlear Bone-Anchored Solutions, Mölnlycke, Sweden) sound processor on the patients own abutment and on a softband.
Main Outcome Measures: Phoneme recognition was assessed using Consonant-Nucleus-Consonant (CNC) words for soft (47 d
B SPL) and average (62 d
B SPL) speech inputs. Speech perception in noise performance was also assessed for soft (47 d
B SPL) and average (62 d
B SPL) speech inputs using sentences presented in multi-talker babble. Aided free-field thresholds were obtained in both conditions using warble tone stimuli.
Results: Compared with percutaneous bone-conduction stimulation, transcutaneous stimulation demonstrated reduced effective gain for high frequency stimulation. Transcutaneous stimulation required higher signal to noise ratios to achieve comparable performance to the percutaneous condition. Phoneme recognition was poorer in transcutaneous versus percutaneous stimulation with the most significant impact observed for soft speech inputs.
Conclusion: A significant performance gap in speech recognition is observed between percutaneous and transcutaneous bone-conduction stimulation in individuals with single-sided deafness at the same signal to noise ratios. Compared with percutaneous bone-conduction stimulation, transcutaneous stimulation demonstrated reduced effective gain, decreased phoneme recognition, word recognition, and performance in noise, with the most significant impact observed for soft speech inputs.

Incidence and Risk of Various Disorders of the External Ear in Patients With Hearing Aids Treated in ENT Practices in Germany

01-09-2019 – Seidel, David Ulrich; Park, Jonas Jae-Hyun; Sesterhenn, Andreas M.; Kostev, Karel

Journal Article

Objective: The aim of the study was to investigate the relationship between the presence of a hearing aid (HA) and the occurrence of various disorders of the external ear, using data from ear, nose, and throat (ENT) practices in Germany from a nationwide, representative practice database.
Methods: In the period between 2012 and 2016, the incidences of disorders of the external ear (ICD-10 groups H60 and H61) in patients with HA prescriptions were compared retrospectively with a control group without HA prescriptions (1:1 matching).
Results: A total of 20,127 patients with HA prescriptions were compared with 20,127 controls. The highest 12-month incidences (HA vs. controls) were determined for “Impacted cerumen” (H61.2) (16.5% vs. 4.2%), “Unspecified otitis externa” (H60.9) (2.6% vs. 1.2%) and “Acute noninfective otitis externa” (H60.5) (2.3% vs. 0.7%). The most significant risk increases for HA wearers were found for “Abscess of external ear” (H60.0, OR 10.03), “Other otitis externa” (H60.8, OR 6.00), and “Impacted cerumen” (H61.2, OR 4.55). A smaller risk increase was found for “Cholesteatoma of external ear” (H60.4, OR 2.26), among others.
Conclusion: In HA wearers, the risk of developing almost all of the diagnoses reviewed is significantly increased, especially for external auditory canal (EAC) furuncle, chronic otitis externa, and impacted cerumen. This study provides the first epidemiological evidence for HA as a risk factor for the rare EAC cholesteatoma.

Physical and Emotional Burden of the Epley Maneuver in the Elderly

01-09-2019 – Maas, Britta D. P .J.; Bruintjes, Tjasse D.; van der Zaag-Loonen, Hester J.; Winters, Stephanie M.; Masius-Olthof, Sylvia; Colijn, Carla; Benthem, Peter Paul G. van; van Leeuwen, Roeland B.

Journal Article

Objective: To analyze and compare experiences of anxiety and discomfort caused by the Epley maneuver and the willingness for a potential retreatment between younger (≤70 yr) and older (>70 yr) patients.
Study Design: Prospective, observational cohort study.
Setting: Tertiary referral center.
Methods: Dutch adults, diagnosed with posterior canal benign paroxysmal positional vertigo, were included. Patients with dementia or subjected to an Epley maneuver ≤4 months before the hospital visit were excluded. Patients were asked about their experiences with the Epley maneuver directly after the maneuver, after 2 weeks and after 2 months. Differences in experiences between the age groups were tested with the Fishers exact test and subgroup analyses were performed using multivariable logistic regression.
Results: Out of 179 included patients, 115 (64%) were aged ≤70 and 134 (75%) were female. In both groups, 25% reported anxiety directly after the Epley maneuver. Two weeks later, 19 and 27%, respectively (p = 0.26) reported anxiety. In the young group, 30% expressed discomfort directly after treatment compared with 45% in the elderly (OR 1.98, 95% CI 1.05–3.75, p = 0.04). Two weeks later, this was 36 and 38%, respectively (p = 0.87). This decreased to 24 and 33%, respectively (p = 0.37), after 2 months. There was no significant difference in willingness for potential retreatment between both groups after 2 weeks (93 and 95%, respectively, p = 0.75) nor after 2 months (97 and 92%, respectively, p = 0.13).
Conclusion: The Epley maneuver results in little anxiety and discomfort both in young and in elderly patients. Most patients show willingness for potential retreatment in case symptoms recur.

Effect of Vestibular Exercises Associated With Repositioning Maneuvers in Patients With Benign Paroxysmal Positional Vertigo: A Randomized Controlled Clinical Trial

01-09-2019 – Rodrigues, Daniele Leite; Ledesma, Alleluia Lima Losno; Pires de Oliveira, Carlos Augusto; Bahmad, Fayez Jr.

Journal Article

In addition to positional vertigo, it is quite common for patients with benign paroxysmal positional vertigo (BPPV) to present complaints associated with balance problems and a feeling of dizziness even after repositioning maneuvers.
Objective: It was to evaluate the additional effects of vestibular rehabilitation exercises as a therapeutic resource in the treatment of BPPV, to improve symptoms and reduce recurrence.
Study Design: This was an experimental, prospective, randomized, controlled study.
Setting: Instituto Brasiliense de Otorrinolaringologia (IBORL) from August 2016 to September 2017.
Patients: Thirty-two individuals, both men and women, over 18 years of age with BPPV.
Intervention: They were randomly assigned to two groups: the control group (n = 15) performing only the maneuver technique as treatment and the experimental group (n = 17) performing the maneuvers and vestibular rehabilitation exercises. Patients underwent treatment and responded to the dizziness handicap inventory (DHI) and visual analog scale (VAS) questionnaires for comparison between groups. Participants were followed up for 6 months to observe recurrence of symptoms.
Main Outcome Measures: To investigate the additional effects of vestibular exercises in the treatment of BPPV.
Results: The experimental group had a lower level of dizziness in the posttreatment period (p < 0.05) and a lower incidence of recurrences (p = 0.038) than the control group.
Conclusions: Vestibular exercises performed after repositioning treatments for BPPV increased the overall efficacy of treatment by improving symptoms with a lower rate of recurrence.

An Educational Intervention for Acute Dizziness Care: A Randomized, Vignette-based Study

01-09-2019 – Meurer, William J.; Johnson, Patricia; Brown, Devin; Tsodikov, Alexander; Rowell, Brigid; Fagerlin, Angela; Telian, Steven A.; Damschroder, Laura; An, Lawrence C.; Morgenstern, Lewis B.; Kerber, Kevin A.

Journal Article

Importance: Benign paroxysmal positional vertigo (BPPV) is a common cause of acute dizziness. Strong evidence exists for diagnosing BPPV using the Dix-Hallpike Test (DHT) and treating it with the canalith repositioning maneuver (CRM). Despite this, both are infrequently used in the emergency department (ED).
Objective: As an early method to evaluate a BPPV-focused educational intervention, we evaluated whether an educational intervention improved ED provider performance on hypothetical stroke and BPPV cases delivered by vignette.
Design: A randomized, controlled, educational intervention study in ED physicians. The intervention aimed to promote the appropriate use of the DHT and CRM. A BPPV vignette, a stroke-dizziness (safety) vignette, and vignette scoring schemes (higher scores indicating more optimal care) used previously established vignette methodology.
Setting: We recruited participants at the exhibitor hall of an emergency medicine annual meeting.
Participants: We recruited 48 emergency physicians. All were board certified or residency trained and board eligible. All were engaged in the active practice of emergency medicine. None were trainees.
Interventions: Intervention group: a narrated, educational presentation by computer followed by the clinical vignettes. Control group: Received no educational intervention and completed the clinical vignettes—intended to mirror current clinician practice.
Main Outcome Measure: Primary endpoint: total score (out of 200 points) on a vignette-based scoring instrument assessing the performance of history, physical, and diagnostic testing on hypothetical stroke and BPPV cases.
Results: The efficacy threshold was crossed at the interim analysis. The intervention group had higher performance scores compared with controls (113.2 versus 68.6, p < 0.00001). BPPV and safety subscores were both significantly higher in the intervention group. Sixty-two percent of the intervention group planned to use the DHT versus 29% of controls. After the vignette described characteristic BPPV nystagmus, 100% of the intervention group planned to use the CRM versus 17% of controls.
Conclusions and Relevance: The educational intervention increased provider performance in dizziness vignettes, including more frequent appropriate use of the DHT/CRM. These findings indicate the intervention positively influenced planned behavior. Future work is needed to implement and evaluate this intervention in clinical practice.

Vestibular Schwannoma Tumor Size Is Associated With Acute Vestibular Symptoms After Gamma Knife Therapy

01-09-2019 – Lee, Daniel Y.; Lerner, David K.; Naples, James G.; Brant, Jason A.; Bigelow, Douglas C.; Lee, John Y. K.; Alonso-Basanta, Michelle; Ruckenstein, Michael J.

Journal Article

Objective: To assess how pretreatment vestibular schwannoma (VS) tumor characteristics are associated with vestibular symptoms after gamma knife (GK) surgery.
Study Design: Retrospective chart review of patients undergoing GK treatment for VS at our institution from 2005 to 2018.
Setting: Academic tertiary referral center.
Patients: Patients receiving primary GK surgery for vestibular schwannomas with at least 6 months of follow up. Patients with neurofibromatosis 2 or previous surgery were excluded.
Main Outcome Measures: The presence of posttreatment vestibular symptoms within 6 months after GK. Clinical records were assessed for pretreatment tumor, patient, and treatment characteristics that impacted posttreatment symptoms.
Results: All patients received radiation doses between 12 and 13 Gy. Of 115 patients, the average age was 60. Thirty-seven (32%) patients developed vestibular symptoms within 6 months post-GK, and 18 patients were referred for vestibular rehabilitation. Ten of 13 patients undergoing vestibular rehabilitation reported improvement. Overall, 112 patients had tumor measurements. Pretreatment tumors were significantly smaller for patients with acute vestibular symptoms (mean 1.43 cm versus 1.71 cm, p = 0.007). On multivariate analysis, smaller tumor size (p = 0.009, odds ratio OR = 0.29, 95% confidence interval CI 0.12–0.73) was significantly associated with vestibular symptoms within 6 months of GK. Patients with tumors less than 1.6 cm were more likely to receive referrals for vestibular rehabilitation within 6 months posttreatment (25% versus 9.4%, p = 0.026, OR = 3.22, 95% CI 1.00, 11.32).
Conclusions: Smaller vestibular schwannomas were significantly associated with higher rates of post-GK vestibular symptoms. Pretreatment tumor size may be used to counsel patients on the likelihood of post-GK vestibular symptoms and vestibular rehabilitation.

Hearing and Quality of Life Over Time in Vestibular Schwannoma Patients: Observation Compared to Stereotactic Radiosurgery

01-09-2019 – Miller, Lauren E.; Brant, Jason A.; Chen, Jinbo; Kaufman, Adam C.; Ruckenstein, Michael J.

Journal Article

Objective: To examine quality of life changes for patients with vestibular schwannoma (VS) undergoing observation or stereotactic radiosurgery (SRS).
Study Design: Retrospective review.
Setting: Academic medical center.
Patients: Patients with VS who underwent observation or SRS and had at least two audiograms and Penn Acoustic Neuroma Quality of Life (PANQOL) surveys, a quality of life survey for patients with VS.
Interventions: SRS or observation.
Main Outcome Measures: Pure-tone average (PTA), speech discrimination score (SDS), PANQOL score; controlling for tumor size, baseline hearing, and other factors.
Results: One hundred twenty-three patients met inclusion criteria: 89 underwent observation and 34 SRS. There was no significant difference in the rate of decline measured by PTA (PTA worsened at a rate of 0.25 d
B/yr more in the observation group compared with the SRS group, p = 0.77) and SDS (SDS worsened at a rate of 2.1%/yr more in the SRS group compared with the observation group, p = 0.82). Kaplan–Meier analysis demonstrated the SRS group had a higher probability to progress to class D hearing over observation (hazard ratio 7.1, p = 0.005). The rate of change of the SRS PANQOL scores was significantly improved in the total (p = 0.005) and hearing (p = 0.04) domain score compared with observation. However, both groups regress to a similar PANQOL total and hearing domain score over time.
Conclusion: PANQOL scores were higher at baseline in the observation group than in the SRS group. However, over time, PANQOL scores in the observation group decreased while PANQOL scores in the SRS group increased, resulting in PANQOL scores that were equivalent by the end of follow-up.

“High-dose Corticosteroids for Adult Bells Palsy: Systematic Review and Meta-analysis”

01-09-2019 – Fujiwara, Takashi; Namekawa, Motoki; Kuriyama, Akira; Tamaki, Hisanobu

Journal Article

Objectives: To compare the efficacy and safety of high-dose corticosteroids (initial prednisolone PSL of 100 mg or more daily) and standard-dose corticosteroids (initial PSL of 50–60 mg) in patients with Bells palsy.
Study Design: A systematic review and meta-analysis.
Data Sources: Medline, Embase, Cochrane Central Register of Controlled Trials, Ichushi-Web, Web of Science, and CINAHL, combined with data from Clinical
Trials.gov.
Study Selection: Published and unpublished cohort studies comparing high- and standard-dose corticosteroids in adult patients with Bells palsy were included.
Data Extraction: Study characteristics (study design, patients number), patient characteristics (sex, age, disease severity, prescription of antivirals), and outcomes (nonrecovery, any adverse effects).
Data Synthesis: From the 1,974 identified articles, 8 studies were met eligible criteria. Of the included studies, the initial dose in high-dose corticosteroids regimens varied from 120 mg to 200 mg PSL daily. Compared with standard-dose corticosteroids, high-dose corticosteroids were associated with a significantly decreased nonrecovery at 6 months after disease onset (odds ratio 0.42, 95% confidence interval 0.22–0.80; very low quality) in patients with Bells palsy. No severe adverse effects were observed in patients receiving high- or standard-dose corticosteroids.
Conclusion: High-dose corticosteroids reduce nonrecovery in patients with Bells palsy. The dose of high-dose corticosteroids was varied and further prospective study is needed to identify an adequate dose of corticosteroids in these patients.

Meta-analysis of Delayed Facial Palsy Following Middle Ear Surgery

01-09-2019 – Bae, Seong Hoon; Kwak, Sang Hyun; Nam, Gi-Sung; Jung, Jinsei

Journal Article

Objective: Delayed facial palsy has been reported following various types of otologic surgery. However, the exact characteristics of this disease have not been fully elucidated because of its low incidence. This study analyzed case series studies on delayed facial palsy to increase the sample size and outline credible disease characteristics.
Data Sources: PubMed, Embase, and Cochrane Library databases were searched on October 10, 2018.
Study Selection: Delayed facial palsy case series covered in English in which the intervention was typical tympanoplasty, mastoidectomy, stapedectomy, or cochlear implantation including a statement of sample size.
Data Extraction: Evaluated according to the Joanna Briggs Institute Critical Appraisal Checklist for Case Series.
Data Synthesis: Fourteen case series studies were included. Incidence rate, onset time, prognosis were evaluated with meta-analysis. Etiology and treatment were discussed with systematic review.
Conclusions: The overall incidence rate of delayed facial palsy after middle ear surgery was 0.65%; however, it differed depending on the type of surgery. The mean onset time of facial palsy was 8.47 ± 3.98 days after surgery, and 95.3% of the patients completely recovered. The disease seems to have multiple etiologies. Facial palsy occurring 2 to 20 days after surgery is suggested to be considered delayed facial palsy.

Preclinical Validation of a Novel Device Designed to Reduce Biofilms on Percutaneous Osseointegrated Abutments

01-09-2019 – Sammons, Rachel; East, Matthew; Grant, Melissa; Proops, David

Journal Article

Aim: To assess the efficacy of a prototype cleaning device in removing biofilm from skin-penetrating abutments.
Background: Adverse skin reactions around percutaneous osseointegrated implants have been linked to poor hygiene and infection. A cleaning device made from open-cell polyfoam has been developed to facilitate manual cleaning of abutments by the patient.
Methods: Serratia biofilm was grown on clean and sterile conical bone-anchored hearing system abutments including both pre-2007 (straight sided) and post-2007 (conical-sided) designs. Eighteen were photographed and then subjected to cleaning using a toothbrush or the cleaning device soaked in water or a proprietary mouthwash. Biofilm on a further group of 10 conical abutments was recorded using a scanning electron microscope before and after cleaning with the test device soaked in water. Quantitative analysis of the efficiency of the cleaning was made using image analysis.
Results: Removal of biofilm using a dry or wet toothbrush was not as effective as cleaning with the device. In 10 cases subjected to image analysis, approximately 90% of the biofilm was removed from the top third of the abutments, 85% from the middle third, and 48% from the basal third.
Conclusion: The cleaning device is effective in removing most biofilm from the test abutments and represents a significant improvement in comparison with traditional methods such as a toothbrush.

Histopathology of Inner Ear Malformations: Potential Pitfalls for Cochlear Implantation

01-09-2019 – Monsanto, Rafael da Costa; Sennaroglu, Levent; Uchiyama, Mio; Sancak, Irem Gul; Paparella, Michael Mauro; Cureoglu, Sebahattin

Journal Article

Hypothesis: The presence of bony inner ear malformations may associate with a number of anatomical abnormalities affecting the middle ear structures. Those malformations may create pitfalls and complications for cochlear implantation.
Background: Inner ear malformations associate with varying degrees of hearing loss, and frequently require cochlear implantation for hearing rehabilitation. Therefore, the abnormalities affecting the middle- and inner-ear structures may increase the risk of surgical complications.
Methods: We examined 38 human temporal bones from donors with bony inner ear malformations. Using light microscopy, we analyzed the presence of abnormalities in the structures of the middle- and inner-ear.
Results: Our collection comprises of 38 specimens with inner-ear malformations (cochlear aplasia, n = 3; cochlear hypoplasia, n = 30; incomplete partition, n = 3; isolated vestibular malformation, n = 2). The anatomy of the middle ear was abnormal in most temporal bones with cochlear aplasia, cochlear hypoplasia, and incomplete partition type I (40%–100%). Some of those abnormalities (hypoplastic or obliterated mastoid, 55.2%; aplastic or obliterated round window, 71.0%; aberrant course of the facial nerve, 36.8%) may hinder the access to the round window using the conventional facial recess approach for cochlear implantation. The cochlear nerve and associated bony structures (internal auditory canal and bony canal for cochlear nerve) were normal in 71.0% of all temporal bones with inner ear malformations.
Conclusion: Each different type of malformation may create specific surgical challenges to surgeons. Comprehensive preoperative imaging is fundamental toward the surgical success of cochlear implants in patients with malformations. Alternatives to circumvent those middle- and inner-ear abnormalities and potential complications are further discussed.

Onyx Embolization Material Extrusion in the Middle Ear

01-09-2019 – Wang, Weitao; Lin, Edward; Zhang, Dongwei; Crane, Benjamin

Journal Article

No abstract available

Silver Nitrate: A Potential Mistaken Foreign Body

01-09-2019 – Godse, Neal R.; Branstetter, Barton F. IV; Hobson, Candace E.

Journal Article

No abstract available

Abnormal Enhancement of the Internal Auditory Canal and Petrous Apex: Possible Implication of Polysorbate 80 and Immunoglobulin-related Hypertrophic Pachymeningitis

01-09-2019 – Imbery, Terence E.; Kesser, Bradley W.

Journal Article

No abstract available

Quantitative Assessment of Inner Ear Histopathologic Findings in Partial Trisomy of 13

01-09-2019 – Monsanto, Rafael da Costa; Uchiyama, Mio; Paparella, Michael Mauro; Cureoglu, Sebahattin

Journal Article

No abstract available

Generic Quality of Life in Persons With Hearing Loss: A Review of the Recent Literature: Retraction

01-09-2019 –

Journal Article, Retraction of Publication

No abstract available