Otology Neurotology

Otology Neurotology

Validation of the Hearing Handicap Inventory for Adults Scale for Spanish-Speaking Patients

01-12-2019 – Carrillo, Alvaro; Medina, María del Mar; Polo, Ruben; Alonso, Daniel; Vaca, Miguel; Muriel, Alfonso; Fernandez, Borja; Rivera, Teresa; Cobeta, Ignacio

Journal Article

Objective: To perform translation, cross-cultural adaptation, and validation of the hearing handicap inventory for adults scale (HHIA) to the Spanish language.
Study Design: Prospective study.
Setting: Tertiary neurotologic referral center.
Patients: The study included 104 hearing impaired persons. Inclusion criteria were adults with untreated hearing loss, diagnosed in the past 12 months. A control group of 30 normal hearing subjects was also recruited.
Intervention: HHIA was translated and translated back, and a pretest trial was performed. Feasibility, internal consistency, test-retest reliability, construct validity, and ceiling and floor effects were assessed for the present study.
Main Outcome Measures: The mean overall score of the HHIA was 31.9 (0–100 scale, lowest to highest handicap). Cronbachs α was 0.95. Intraclass correlation coefficient was performed for each item, with an overall score of 0.95. The k coefficient scores ranged between moderate and almost perfect in all patients. The emotional score of the HHIA was correlated with the mental component of the SF-12.
Conclusions: Feasibility, internal consistency, reliability, and construct validity outcomes in the current study support the validity of the Spanish version of the HHIA.

Age-related Hearing Loss Is Strongly Associated With Cognitive Decline Regardless of the APOE4 Polymorphism

01-12-2019 – Morita, Yuka; Sasaki, Takanobu; Takahashi, Kuniyuki; Kitazawa, Meiko; Nonomura, Yoriko; Yagi, Chihiro; Yamagishi, Tatsuya; Ohshima, Shinsuke; Izumi, Shuji; Wakasugi, Minako; Yokoseki, Akio; Narita, Ichiei; Endo, Naoto; Horii, Arata

Journal Article

Objective: To examine the association between hearing impairment and cognitive decline and to identify possible risk factors for presbycusis.
Study Design: Cross-sectional survey in prospective cohort study.
Setting: University hospital.
Patients: A total of 322 participants aged >60 years, for whom all the below data were available, were enrolled in the study. There were 168 females and 154 males with a median age of 71 years (range: 60–89 yrs).
Interventions: PROST (Project in Sado for Total Health), a medical database in Sado island Japan, was analyzed.
Main Outcome Measures: Data on pure-tone audiometry, mini-mental state examination (MMSE), polymorphism of apolipoprotein E4 (Apo
E4), diabetes mellitus, hypertension, smoking, and alcohol consumption were extracted. Hearing impairment was defined as an average frequency between 0.25 and 8 k
Hz that exceeded 30 d
B. Multivariate analysis was used to identify which of the above factors could predict the hearing impairment. Hearing threshold of each Hz was compared between the Apo
E4 (+/+), (+/−), and (−/−) groups.
Results: Among various factors, only low MMSE scores (<24) showed significant association with hearing impairment. There were no differences in the hearing threshold of all frequencies between Apo
E status groups.
Conclusions: Hearing impairment was associated with low MMSE sores, regardless of the Apo
E4 status. If Apo
E4 status would be a common upstream predictor for both the hearing and cognitive impairment, hearing threshold would be related to Apo
E4 status. However, these results may suggest that hearing impairment may be causally related to the cognitive dysfunction, perhaps via the cognitive load mechanisms.

Auditory Characteristics in Patients With Mucopolysaccharidosis

01-12-2019 – Ahn, Jungmin; Lee, Jung Joo; Park, Song-I.; Cho, Sung-Yoon; Jin, Dong-Kyu; Cho, Yang-Sun; Chung, Won-Ho; Hong, Sung-Hwa; Moon, Il Joon

Journal Article

Objective: The purpose of the study was to evaluate audiologic findings according to mucopolysaccharidosis (MPS) subtypes and to estimate hearing changes as the disease progressed, as well as the therapeutic effect of enzyme replacement therapy on the hearing apparatus.
Methods: A total of 124 patients who were diagnosed with MPS between September 1994 and December 2016 were retrospectively analyzed. Play audiometry or pure-tone audiometry was performed for hearing assessment, and auditory brainstem response was conducted in patients with poor compliance.
Results: In total 124 patients were identified, ranging in age at diagnosis from 0 to 33 years. Fourteen of the patients had been diagnosed with type I, while 91 had type II, 2 had type III, 14 had type IV, and 3 had type VI. Mean bone conduction and air conduction for the better ear were 26.13±16.95 d
B and 34.77 ± 20.00 d
B in all patients, and 34.20±7.64 d
B and 40.70±9.67 d
B in patients with MPS II. The average auditory brainstem response threshold was 68.96 ±21.93 d
B n
HL. The most common type of hearing loss was pure sensorineural hearing loss in all subtypes, and the degree of hearing loss was variable mostly within the mild to severe range. The increase in the hearing threshold was also significantly correlated with the disease duration. However, the change in hearing level was not correlated with the duration of enzyme replacement therapy.
Conclusions: Hearing impairment in MPS patients is common and is aggravated as the disease progresses. Thus, adequate intervention and hearing rehabilitation might play an important role in managing hearing disabilities in MPS patients.

Triphasic Pulses in Cochlear Implant Patients With Facial Nerve Stimulation

01-12-2019 – Braun, Katharina; Walker, Kevin; Sürth, Werner; Löwenheim, Hubert; Tropitzsch, Anke

Journal Article

Objective: Evaluation of triphasic pulse stimulation in comparison to the traditional biphasic pulse stimulation in cochlear implant (CI) patients with unintended facial nerve costimulation.
Study Design: Retrospective case review.
Setting: Cochlear Implant Center of a University Department of Otolaryngology, Head and Neck Surgery.
Patients: Fifteen CI patients (MED-EL, Innsbruck, Austria) received a triphasic fitting map instead of a biphasic fitting map due to a previous diagnosis of facial nerve stimulation or stimulus induced pain during the years 2014 to 2017.
Intervention(s): Application of a triphasic stimulation strategy.
Main Outcome Measure(s): Reduction of facial nerve costimulation and speech understanding. Biphasic and triphasic fitting maps were compared to accurately assess the effects of the switch, and hearing tests (monosyllables and sentences in noise tests) were analyzed.
Results: Triphasic pulse stimulation showed a significant reduction of unintended side effects and resulted in an observed improved quality of life in most cases. Although there was no significant change in the understanding of speech with CI in all test situations, in many cases, improvement was observed.
Conclusions: Triphasic pulse stimulation had a beneficial effect for CI patients with severe, unintended costimulation and should be considered a valuable tool during CI fitting.

Long-term Outcomes in Down Syndrome Children After Cochlear Implantation: Particular Issues and Considerations

01-12-2019 – Clarós, Pedro; Remjasz, Agnieszka; Clarós-Pujol, Astrid; Pujol, Carmen; Clarós, Andrés; Wiatrow, Andrzej

Journal Article

Objective: The aim of the study was to analyze the long-term outcomes after cochlear implantation in deaf children with Down syndrome (DS) regarding age at the first implantation and refer the results to preoperative radiological findings as well as postoperative auditory and speech performance. Additionally, the influence of the age at implantation and duration of CI use on postoperative hearing and language skills were closely analyzed in children with DS.
Study Design: Retrospective analysis.
Setting: Referral center (Cochlear Implant Center).
Materials and Methods: Nine children with Down syndrome were compared with 220 pediatric patients without additional mental disorders or genetic mutations. Patients were divided into four categories depending on the age of the first implantation: CAT1 (0–3 yr), CAT2 (4–5 yr), CAT3 (6–7 yr), and CAT4 (8–17 yr). The auditory performance was assessed with the meaningful auditory integration scales (MAIS) and categories of auditory performance (CAP) scales. The speech and language development were further evaluated with meaningful use of speech scale (MUSS) and speech intelligibility rating (SIR). The postoperative speech skills were analyzed and compared between the study group and the reference group by using nonparametric statistical tests. Anatomic abnormalities of the inner ear were examined using magnetic resonance imaging (MRI) and high-resolution computed tomography of the temporal bones (HRCT).
Results: The mean follow-up time was 14.9 years (range, 13.1–18.3 yr). Patients with DS received a multichannel implant at a mean age of 75.3 months (SD 27.9; ranging from 21 to 127 mo) and 220 non-syndromic children from reference group at a mean age of 51.4 months (SD 34.2; ranging from 9 to 167 mo). The intraoperative neural response was present in all cases. The auditory and speech performance improved in each DS child. The postoperative mean CAP and SIR scores were 4.4 (SD 0.8) and 3.2 (SD 0.6), respectively. The average of scores in MUSS and MAIS/IT-MAIS scales was 59.8% (SD 0.1) and 76.9% (SD 0.1), respectively. Gathered data indicates that children with DS implanted with CI at a younger age (<6 years of age) benefited from the CI more than children implanted later in life, similarly in a control group. There were additional anomalies of the temporal bone, external, middle, or inner ear observed in 90% of DS children, basing on MRI or HRCT.
Conclusions: The early cochlear implantation in children with DS is a similarly useful method in treating severe to profound sensorineural hearing loss (SNHL) as in non-syndromic patients, although the development of speech skills present differently. Due to a higher prevalence of ear and temporal bone malformations, detailed diagnostic imaging should be taken into account before the CI qualification. Better postoperative outcomes may be achieved through comprehensive care from parents/guardians and speech therapists thanks to intensive and systematic rehabilitation.

Multi-frequency Electrocochleography Measurements can be Used to Monitor and Optimize Electrode Placement During Cochlear Implant Surgery

01-12-2019 – Saoji, Aniket A.; Patel, Neil S.; Carlson, Matthew L.; Neff, Brian A.; Koka, Kanthaiah; Tarigoppula, Venkata S. Aditya; Driscoll, Colin L. W.

Journal Article

Objective: To report the use of multi-frequency intra-cochlear electrocochleography (ECOG) in monitoring and optimizing electrode placement during cochlear implant surgery. An acoustic pure tone complex comprising of 250, 500, 1000, and 2000 Hz was used to elicit ECOG, or more specifically cochlear microphonics (CMs), responses from various locations in the cochlea. The most apical cochlear implant electrode was used as the recording electrode.
Study Design: Clinical capsule report.
Setting: Tertiary academic referral center.
Results: ECOG measurements were performed during cochlear implant surgery in an adult patient with significant residual acoustic hearing. The 500, 1000, and 2000 Hz CM tracings from the most apical electrode showed an amplitude peak at three different instances during the early phase of cochlear implant electrode insertion. These results are consistent with the tonotopic organization of the cochlea. During final electrode placement a slight advancement of the electrode array resulted in a correlated decrease in 250, 500, and/or 1000 Hz CM amplitude. The electrode array was retracted and repositioned which resulted in a recovery of CM amplitude. Intraoperative CM thresholds revealed a correlation of r = 0.87 with preoperative audiometric thresholds.
Conclusion: We present a report on simultaneous multi-frequency ECOG monitoring during cochlear implant surgery. Multi-frequency ECOG can be used to differentiate between electrode trauma and the advancement of the apical electrode beyond the CM source in the cochlea.

Musical Ear Syndrome and Cochlear Explantation: Case Report and Proposal for a Theoretical Framework

01-12-2019 – Kompis, Martin; Mantokoudis, Georgios; von Gunten, Benjamin; Schmid, Christoph; Blaser, Daniela; Caversaccio, Marco

Journal Article

Objective: To report an unusual case of musical ear syndrome, and to present a theoretical framework for this condition, merging information from the presented case and from former case reports.
Patient: A 67-year-old semi-professional musician, who underwent bilateral cochlear implantation and experienced musical ear syndrome, i.e., hearing music, where none was present.
Interventions: Cochlear implantation with a bilateral cochlear implant, and cochlear explantation 17 months later.
Main Outcome Measure: Report of presence or absence of musical ear syndrome by the patient.
Results: Musical ear syndrome started 1 day after implantation. It ceased immediately after cochlear explantation, but reappeared 3 months later.
Conclusions: Several types of factors seem to determine whether a musical ear syndrome is present or not. We propose to differentiate between triggers, modifiers, and conditions, which determine a base vulnerability. Vulnerability seems to be increased by auditory deprivation and by habitual retrieval of music from memory. Cochlear implantation or explantation seems to act as triggers. The proposed framework may help to stimulate reporting of more potentially relevant factors in future case reports on musical ear syndrome, and ultimately to help to understand this condition better.

Assessment of a Novel 3T MRI Compatible Cochlear Implant Magnet: Torque, Forces, Demagnetization, and Imaging

01-12-2019 – Tysome, James Russell; Tam, Yu Chuen; Patterson, Ilse; Graves, Martin John; Gazibegovic, Dzemal

Journal Article

Hypothesis: A novel cochlea implant (CI) device magnet providing alignment to the static field of a magnetic resonance imaging (MRI) will lead to reduced torque, longitudinal forces, and demagnetization effects. The image void and distortion will be comparable to those obtained with standard CI magnets.
Background: MRI investigations of CI users pose several challenges such as magnet dislocation, demagnetization, and may cause pain. The presence of a CI magnet within MRI field causes image distortions and may diminish the diagnostic value of an MRI procedure. Objective of this work is to evaluate magnetic forces and imaging properties of the novel CI magnet within 1.5 and 3T MRI.
Methods: Forces and torque of the novel CI magnet were measured in both 1.5 and 3T MRI and compared with the standard magnet in 1.5T. One cadaver head was implanted with the CI devices containing the novel and standard magnets in different configurations reflecting clinical scenarios and imaging properties were assessed and compared.
Results: In particular the torque has been reduced with the novel CI magnet in comparison to the standard one. Both CI magnets have not shown any signs of demagnetization. The image void and distortion was comparable between the two magnets for the main MRI clinical scanning protocols in 1.5T MRI.
Conclusions: The novel CI magnet is safe to use for MRI investigations of CI users in 3T MRI without a need for bandaging and has acceptable level of image artefacts.

Communication Mode and Speech and Language Outcomes of Young Cochlear Implant Recipients: A Comparison of Auditory-Verbal, Oral Communication, and Total Communication

01-12-2019 – Thomas, Ellen S.; Zwolan, Teresa A.

Journal Article

Objective: To evaluate the effect of communication mode on the spoken language outcomes of children who received a cochlear implant.
Study Design: Retrospective analysis of postoperative speech and language and reading scores for children who received a cochlear implant and used three different modes of communication: auditory-verbal (AV) (n = 39), oral communication (OC) (n = 107), and total communication (TC) (n = 57).
Setting: A single tertiary cochlear implant clinic.
Patients: All children received their cochlear implant before the age of 5 years, had no known cochlear anomaly or cognitive delay that would affect their outcome with the CI, and had established consistent use of their respective communication methodology.
Intervention: Rehabilitation varied depending on the selected communication methodology. Data were collected during routine postoperative speech and language evaluations.
Main Outcome Measures: Receptive and expressive language, reading comprehension, and speech intelligibility scores obtained up to 7 years post-activation of a cochlear implant.
Results: All groups showed improvements over time. Linear mixed model analyses indicated scores obtained by children in the AV group were significantly higher than mean scores obtained by children in the other groups on most test measures at most post-implant intervals. Significantly greater numbers of children in the AV group obtained standard scores within normal limits than children in the OC and TC groups.
Conclusions: These findings support the use of the auditory-verbal communication approach to facilitate development of age-appropriate speech and language and literacy skills in profoundly deaf children.

The Role of Sex on Early Cochlear Implant Outcomes

01-12-2019 – Raymond, Mallory J.; Ballestas, Samir A.; Wise, Justin C.; Vivas, Esther X.

Journal Article

Objective: To determine the presence of sex differences in cochlear implant outcomes.
Study Design: Retrospective chart review.
Setting: Tertiary referral center.
Patients: Adult patients having undergone cochlear implantation from 2009 to 2017.
Intervention(s): Standard electrode length cochlear implantation.
Main Outcome Measure(s): Az
Bio scores in quiet of the implanted ear at the 1 to 3 months and 6 to 9 months postoperative time points.
Results: Of 55 patients with complete demographic and speech recognition testing, 36.4% (n = 20) were men. The mean age at time of surgery was 59.81 ± 16.54 years and the mean duration of hearing loss was 26.33 ± 18.54 years; there was no significant difference between men and women. The mean preoperative Az
Bio score was 11 ± 15.86% and there was no difference between men and women. Through 2 (sex) × 3 (time point) analysis of covariance (ANCOVA), there was no main effect of sex (F1, 48 = 0.74, p = 0.39, η2 = 0.02) on postoperative Az
Bio scores, but there was a significant sex by time point interaction, (F1.77, 85.03 = 4.23, p = 0.02, η2 = 0.08). At the 1 to 3 months postoperative time point, women exhibited higher relative improvement in Az
Bio scores than men (67 ± 27% versus 55 ± 31%). Further, this relative improvement increased and remained significant at the 6 to 9 months postoperative time point (women: 71 ± 22% versus 58 ± 30%).
Conclusions: Sex may play a role in early speech recognition outcomes after adult cochlear implantation.

Clinical Presentation, Management, and Outcomes of Idiopathic Pain in Percutaneous Bone-anchored Hearing Implants

01-12-2019 – Caspers, Coosje Jacoba Isabella; Nelissen, Rik Chrétien; Verhamme, Luc Martijn; Meijer, Frederick Jan Anton; Mylanus, Emmanuel Antonius Maria; Hol, Myrthe Karianne Sophie

Journal Article

Objective: To identify clinical features and investigate treatment outcomes of patients with idiopathic pain related to a percutaneous bone-anchored hearing implant (BAHI) and to propose management recommendations.
Study Design: Retrospective chart analysis.
Setting: Tertiary referral center.
Patients: The clinical data of 14 patients who were treated for idiopathic pain around their percutaneous BAHI between May 2007 and February 2018 at our tertiary referral center were reviewed.
Main Outcome Measures: Pain after treatment and implant loss.
Results: All 14 patients received treatment with oral antibiotics. Nine patients received oral antibiotic combination therapy for 4 weeks, whereafter pain resolved in 4. Out of the five other patients, receiving either antibiotic monotherapy or shortened antibiotic combination therapy, pain resolved in two. In case of persistent pain (57.1%) after initial treatment, other pain management therapies were attempted, however all with only limited effect. Six patients (42.8%) underwent elective removal of the implant. In two patients spontaneous implant loss occurred. In two of the four patients who underwent reimplantation, pain relapsed. In one of these, pain resolved after the removal of the new implant. In the other patient, pain persisted, despite abutment removal. With exception of this latter patient, all other 13 patients were pain free at the latest follow-up. Cone beam computed tomography did not offer additional information regarding diagnosis or treatment.
Conclusion: Idiopathic pain in BAHI is a rare but bothersome symptom which can result in implant removal. After oral antibiotic combination treatment, symptoms resolved in approximately 40% of patients. Therefore, we think conservative treatment with these antibiotics before implant removal surgery, is worth considering.

Transcanal Endoscopic Ear Surgery for Congenital Middle Ear Anomalies

01-12-2019 – Ito, Tsukasa; Kubota, Toshinori; Furukawa, Takatoshi; Matsui, Hirooki; Futai, Kazunori; Kakehata, Seiji

Journal Article

Objective: To demonstrate the efficacy of transcanal endoscopic ear surgery (TEES) for congenital middle ear anomalies.
Study Design: Retrospective case review.
Setting: Tertiary referral center.
Patients: Twenty-one patients ranging in age from 4 to 62 years old (median: 15 yr) who underwent TEES between 2011 and 2017 were compared with 19 patients ranging in age from 3 to 49 years old (median: 11 yr) who underwent microscopic ear surgery (MES) between 2000 and 2011.
Intervention: Ossiculoplasty or stapes surgeries were performed with TEES or MES. TEES was performed using a rigid endoscope with an outer diameter of 2.7-mm coupled with a full high-definition video system. MES was performed via a transcanal approach with a retroauricular incision.
Main Outcome Measure: Middle ear anomaly classification, operating time, and hearing outcomes based on the American Academy of Otolaryngology and Head and Neck Surgery criteria were evaluated and compared between the TEES and MES groups.
Results: For Teunissen and Cremers class III anomalies, defined as ossicular chain malformations with a mobile stapes footplate, postoperative air-bone gap closure to 10 d
B or less was achieved in 50% of the TEES group and 47% of the MES group. Postoperative air-bone gap closure to 20 d
B or less was achieved in 86% of the TEES group and 100% of the MES group. No significant difference was found in the operating time between the two groups. All MES procedures required a retroauricular incision.
Conclusion: Our results indicate that TEES has similar auditory outcomes compared with MES while avoiding a retroauricular incision.

Combined Endoscopic and Microscopic Surgery for Perilabyrinthine Lesions: Feasibility and Technique

01-12-2019 – Wei, Xingmei; Gao, Zhiqiang; Tian, Xu; Zhao, Yang; Feng, Guodong

Journal Article

Objectives: To determine the feasibility of endoscopic-assisted surgery for lesions involving the perilabyrinthine recesses, and develop and validate a technique for this kind of lesions that increases the possibility of preserving the labyrinth and cochlea.
Study Design: Observational study.
Setting: Referral center.
Cases: Five patients who underwent endoscopy-assisted surgery for lateral skull base pathology involving the perilabyrinthine recesses between July 2010 and March 2016 were reviewed.
Interventions: Clinical data of the five patients were collected.
Main Outcomes Measures: Hearing level and recurrence.
Results: Three of the five patients (three women, two men) had petrous bone cholesteatomas, one a facial neurofibroma, and one a petrous bone cholesterol granuloma. Complete excision with labyrinth and cochlea preservation was achieved using an endoscopic-assisted technique in all patients. Four had preoperative conductive hearing loss and one was totally deaf. In one patient, the postoperative air-bone gap was 30 d
B lower than preoperatively levels, one stayed the same, and one was 30 d
B because of closing of the external ear canal. After an average follow-up of 62.9 months, no patient had recurrence.
Conclusions: Endoscope-assisted surgery is feasible for lesions involving the perilabyrinthine recesses and increases the likelihood to preserve the structure and function of labyrinth/cochlea, which may provide chances for artificial hearing devices implantation.

Recidivism After Endoscopic Treatment of Cholesteatoma

01-12-2019 – Killeen, Daniel E.; Tolisano, Anthony M.; Kou, Yann Fuu; Kutz, Joe Walter Jr; Isaacson, Brandon

Journal Article

Objective: To investigate the recidivism rate of cholesteatoma treated via endoscopic ear surgery (EES), either via transcanal endoscopic ear surgery or endoscopic assisted tympanomastoidectomy compared with a microscopic postauricular approach.
Study Design: Retrospective chart review.
Setting: Academic otology practice.
Patients: Adult patients (18 years and older) with at least 11 months of surgical follow-up who were treated for cholesteatoma via endoscopic techniques or microscopic postauricular approach.
Intervention: Use of the endoscope for cholesteatoma dissection.
Main Outcome Measure: Residual or recurrent cholesteatoma identified at second look surgery or postoperative diffusion-weighted magnetic resonance imaging.
Results: Fifty-nine patients treated for cholesteatoma via endoscopic techniques and 35 patients treated via microscopic postauricular approach were analyzed. The endoscopic group required significantly fewer mastoid procedures (28% versus 80%, p-value 0.001). Postoperative changes in median ABG (5 d
B versus 3.75 d
B, p = 0.9519), median PTA (6.875 d
B versus 1.25 d
B, p = 0.3864), and median word recognition score (0% versus 0%, p = 0.3302) were not significantly different between the EES and microscopic surgery groups. Median operative times were not significantly different between the two groups (182 min endoscopic versus 174 min microscopic, p-value 0.66). The rate of residual disease (17% EES versus 17% microscopic, p = 0.959) or disease recurrence (18% endoscopic versus 20% microscopic, p = 0.816) were not significantly different between the two groups.
Conclusions: EES is an effective option for cholesteatoma management with similar rates of recurrent or residual disease as compared with the more traditional microscopic postauricular approach in these samples.

Long-term Outcomes of Balloon Dilation for Persistent Eustachian Tube Dysfunction

01-12-2019 – Cutler, Jeffrey L.; Meyer, Ted A.; Nguyen, Shaun A.; O’Malley, Ellen M.; Thackeray, Lisa; Slater, Patrick W.

Journal Article

Objective: To gather long-term follow-up data on the efficacy of balloon dilation for treating patients with persistent Eustachian tube dysfunction (ETD).
Study Design: Extended follow-up study of the treatment arm of a prospective, multicenter, randomized controlled trial.
Setting: Tertiary care academic center and private practice.
Patients: Patients diagnosed with medically refractory persistent ETD.
Interventions: Balloon dilation of the Eustachian tube.
Main Outcome Measures: The endpoints were the mean change from baseline in the 7-item Eustachian Tube Dysfunction Questionnaire (ETDQ-7) score, revision dilation rate, changes in assessments of middle ear function, and patient satisfaction.
Results: A total of 47 participants enrolled in the extended follow-up study. Mean follow-up was 29.4 months (range, 18–42 mo). There was a statistically significant mean (SD) change from baseline in the overall ETDQ-7 score (–2.5 ± 1.2; p < 0.0001). A reduction of one or more in their overall ETDQ-7 score was observed by 93.6% (44/47) participants. The revision dilation rate was 2.1% (1/47). Among participants with abnormal baseline middle ear assessments, 76.0% had normalized tympanic membrane position (p < 0.0001), 62.5% had normalization of tympanogram type (p < 0.001), and 66.7% had positive Valsalva maneuvers (p < 0.0001). Participant satisfaction was 83.0% at long-term follow-up.
Conclusions: Balloon dilation results in durable improvements in symptoms and middle ear assessments for patients with persistent Eustachian tube dysfunction at mean follow-up of longer than 2 years.

Outcomes Following Transcanal Endoscopic Lateral Graft Tympanoplasty

01-12-2019 – Creighton, Francis X. Jr; Kozin, Elliot; Rong, Anni; Cohen, Michael; Lee, Daniel

Journal Article

Outcome Objectives: Demonstrate feasibility of performing endoscopic transcanal lateral graft tympanoplasty.
Compare audiometric and clinical outcomes of transcanal endoscopic lateral graft with previously reported outcomes of microscopic post-auricular lateral graft tympanoplasty.
Methods: A retrospective review of sequential pediatric and adult endoscopic transcanal lateral graft tympanoplasties (type I) performed between May 2014 and August 2015 at a single institution by two experienced otologists. Rate of perforation closure and audiometric outcomes (pure-tone average PTA and word recognition scores WRS) were obtained and compared with previous published outcomes of post-auricular microscopic lateral grafts.
Results: Twenty patients, five right and 15 left ears, met criteria. Ninety percent of patients had successful closure of their perforation. One patient had a residual central perforation; active acute otitis media was noted intraoperatively in this case. One patient had graft lateralization. Mean follow up was 10.5 months (standard deviation SD = 141 d). Mean operative time was 160 (SD = 26.1) minutes. Mean improvement in PTA was 18 d
B (SD = 10.3). Two patients had worsening of audiometric outcomes with <15 d
B decreases in PTA and unchanged WRS; all other patients showed improvement or no change in audiometric outcomes. These results are similar to previously published outcomes for post-auricular microscopic approaches.
Conclusion: Transcanal endoscopic lateral graft tympanoplasty is a novel technique for closure of anterior and subtotal perforations that avoids a postauricular incision. Outcomes in this cohort were similar to historical results for post-auricular microscopic approaches. Prospective studies with larger cohorts will be crucial to understanding the advantages and limitations of this new surgical approach.

Role of Autophagy in Acquired Cholesteatoma

01-12-2019 – Li, Quancheng; Ao, Yinjie; Yu, Qi; Zhou, Shuihong

Journal Article

Hypothesis: Autophagy and its enhancement may have a role in the pathogenesis of acquired cholesteatoma.
Background: The etiopathogenesis of acquired cholesteatoma remains unclear. Some clinical features of cholesteatoma are similar to those of cancer. The study of autophagy in cancer has indicated that enhanced autophagy enables tumor cell survival and growth.
Methods: Cholesteatoma epithelium and normal external auditory canal (EAC) epithelium were obtained from patients with acquired cholesteatoma, and marginal epithelium of the tympanic membrane perforation was obtained from patients with chronic otitis media (COM). Immunohistochemistry (IHC) was performed to detect the expression of light chain 3 (LC3) in cholesteatoma and EAC epithelium. Western blotting (WB) was performed to detect the expression of LC3, Beclin-1, or the PI3K/AKT pathway in cholesteatoma, EAC, and COM epithelium.
Results: LC3 staining of IHC was stronger in cholesteatoma epithelium compared with normal EAC epithelium. The ratios of LC3-II/I and Beclin-1 expression on WB were significantly higher in cholesteatoma epithelium compared with EAC epithelium or COM epithelium, and there was a significantly higher ratio of p-PI3K/PI3K and p-AKT/AKT in cholesteatoma epithelium compared with EAC epithelium.
Conclusions: Enhanced autophagy might play a role in the pathogenesis of acquired cholesteatoma. PI3Ks might have different regulatory functions on autophagy in the cholesteatoma epithelium.

Novel Minimal Access Bone Anchored Hearing Implant Surgery and a New Surface Modified Titanium Implant, the Birmingham Experience

01-12-2019 – Limbrick, Jack; Muzaffar, Jameel; Kumar, Raghu; Mulvihill, Daniel; Gaskell, Peter; Addison, Owen; Monksfield, Peter; Banga, Rupan

Journal Article

Background: Bone anchored hearing implants (BAHI) are widely used and highly successful, accompanied with a high level of patient satisfaction across most techniques. A large UK teaching hospital switched from the previously used wide diameter titanium fixture and drilling system to the novel minimally invasive technique and laser ablated titanium implant. Before this change the rates of fixture failure and skin problems necessitating abutment change were 1% each.
Methods: Retrospective case note review of consecutive BAHI patients drawn from an electronic database between January 2015 and October 2016.
Results: Data from a total of 118 procedures were reviewed, with different combinations of surgical techniques and implant types. Sixty procedures were performed via the novel minimally invasive technique with 21 failures (35%). Fourty-eight modified minimally invasive technique procedures were performed with seven failures. In 64 of the procedures, laser ablated titanium fixtures were placed with 21 failures (32.8%). In 54 procedures wide diameter titanium fixtures were placed with eight failures (5%).
Conclusion: Initial experience with the novel minimally invasive technique and laser ablated titanium fixture showed significantly higher failure rates than expected. This prompted a change to an open technique and subsequent abandonment of the laser ablated titanium fixture and custom drilling solution in our institution.

“Is Early Progression to Bilateral Involvement in Menières Disease a Poor Prognostic Indicator?”

01-12-2019 – Lee, Hyun Jin; Lee, Jeon Mi; Shim, Dae Bo; Jung, Jinsei; Kwak, Sang Hyun; Kim, Sung Huhn

Journal Article

Objective: To investigate differences in the clinical features of bilateral Menières disease (BMD) with early and late bilateral involvement.
Study Design: A retrospective case-comparison study.
Setting: Tertiary referral center.
Patients: In total, 25 patients with definite BMD were enrolled. Patients with bilateral involvement with a transition interval shorter than 1 month were considered to have synchronous BMD, whereas the others had metachronous BMD.
Interventions: We investigated differences in prognosis as defined by changes in the number of vertigo attacks after treatment, demographics, comorbidities, and inner ear function according to the transition interval from unilateral to bilateral involvement.
Main Outcome Measure: We investigated other appropriate cut-off values in the interval from first- to second-ear involvement to predict poor prognosis.
Results: Receiver operating characteristic curve analysis revealed that a cut-off value of  0.05). None of the patients exhibited systemic autoimmune disease.
Conclusion: BMD with early bilateral progression exhibited poorer prognosis compared with late bilateral progression.

Is Asymmetric Hearing Loss a Risk Factor for Vestibular Dysfunction? Lesson From Big Data Analysis Based on the Korean National Health and Nutrition Survey

01-12-2019 – Suh, Michelle Jee Young; Yi, Hee Jun; Kim, Hyun Jung; Kim, Sung Huhn

Journal Article

Objective: The purpose of this study was to investigate whether asymmetric hearing loss affects vestibular function.
Study Design: Retrospective cross-sectional study.
Patients: Data from the 2010 Korean National Health and Nutrition Survey for adults aged 40 years or more were used.
Interventions: The modified Romberg test and pure-tone audiometry were performed. Data were analyzed using a complex sample χ2 test of independence and complex sample logistic regression analysis.
Main Outcome Measures: Vestibular dysfunction and hearing thresholds.
Results: The overall prevalence of vestibular dysfunction was 3.3% (95% confidence interval CI, 2.5–4.3%). In adults more than 40 years of age, multivariate linear regression analyses showed that the odds ratio (OR) of vestibular dysfunction was 3.067 times higher than the reference for a 30-d
B difference in hearing thresholds between both ears (CI, 1.481–6.351; p = 0.007) after adjusting for factors associated with vestibular dysfunction. Among these individuals, the risk of equilibrium disturbance was higher in the presence of low-frequency asymmetric hearing loss (OR, 2.148; CI, 1.216–3.793; p = 0.009); on the other hand, high-frequency asymmetry did not lead to a higher risk.
Conclusions: As low-frequency asymmetric hearing thresholds tend to coexist with vestibular dysfunction in adults, those with asymmetric hearing loss should be closely monitored.

“Predicting Development of Bilateral Menières Disease Based on cVEMP Threshold and Tuning”

01-12-2019 – Noij, Kimberley S.; Herrmann, Barbara S.; Guinan, John J. Jr.; Rauch, Steven D.

Journal Article

Objective: To investigate if the cervical vestibular evoked myogenic potential (cVEMP) is predictive for developing bilateral Menières disease (MD).
Study Design: Retrospective cohort study.
Setting: Tertiary care center.
Patients: Records of 71 patients previously diagnosed with unilateral MD at our institution who underwent cVEMP testing between 2002 and 2011 were screened.
Intervention: Patients were contacted to answer a questionnaire to identify which patients had developed bilateral disease. Based on questionnaires and medical charts, 49 patients with a follow-up time of at least 5 years were included. The 49 originally asymptomatic ears are referred to as “study ears.” Previously reported cVEMP criteria (original criteria) applied to study-ear cVEMPs separated them into Menière-like and normal-like groups.
Main Outcome Measure: The main purpose was to determine if previously obtained cVEMP thresholds and tuning ratios of unilateral MD patients could predict who develops bilateral disease.
Results: From the 49 included patients, 12 developed bilateral disease (24.5%). The study ears characterized by original cVEMP criteria as Menière-like were significantly more likely to develop bilateral disease compared with the normal-like study ears. The original criteria predicted development of bilateral disease with a positive predictive value (PPV) and negative predictive value (NPV) of 58.3% and 86.5% respectively. ROC curves were used to revise cVEMP criteria for predicting the progression to bilateral disease. A revised criterion combining three cVEMP metrics, reached a PPV and NPV of 85.7% and 93.7%.
Conclusion: cVEMP threshold and tuning in unilateral MD patients are predictive of which patients will develop bilateral disease.

Validating the Utility of High Frequency Ocular Vestibular Evoked Myogenic Potential Testing in the Diagnosis of Superior Semicircular Canal Dehiscence

01-12-2019 – Lin, Kenny; Lahey, Ryan; Beckley, Rachel; Bojrab, Dennis II; Wilkerson, Brent; Johnson, Emily; Babu, Seilesh; Hong, Robert S.

Journal Article

Introduction: Ocular vestibular evoked myogenic potential (oVEMP) is a diagnostic test employed in the evaluation of superior semicircular canal dehiscence (SSCD) syndrome. Previous work showed that the presence of the n10 component of oVEMP at 4000 Hz was diagnostic of SSCD with perfect sensitivity and specificity of 1.0 in a series of 22 patients. This study sought to validate the diagnostic accuracy of high-frequency oVEMP with comparison to 500 Hz oVEMP and cervical vestibular evoked myogenic potential (cVEMP) in a larger series of patients.
Methods: Retrospective chart review of 171 patients with clinical symptoms consistent with SSCD who underwent oVEMP and cVEMP testing. Dehiscence of the superior semicircular canal (SCC) on high-resolution computed tomography (CT) imaging of the temporal bone was used to identify cases of likely SSCD. The presence or absence of 4000 Hz oVEMP n10 responses, increased amplitude of 500 Hz oVEMP responses, and reduced threshold of 500 Hz cVEMP responses were identified for each patient.
Results: SCC dehiscence was identified by CT imaging in 48 of 171 patients with symptoms consistent with SSCD. High-frequency oVEMP testing at 4000 Hz elicited a n10 response in 40 of 48 (83.3%) of patients and was present in 48 of 171 (28.1%) patients overall. The corresponding sensitivity was 0.83, specificity was 0.93, positive predictive value was 0.83, and negative predictive value was 0.93. oVEMP and cVEMP testing at 500 Hz was less accurate with sensitivity of 0.62 and 0.64, respectively, and specificity of 0.73 and 0.73, respectively.
Conclusion: The presence of a 4000 Hz oVEMP n10 response was predictive of SSC dehiscence on CT imaging among patients with symptoms consistent with SSCD with sensitivity of 0.83, specificity of 0.93, positive predictive value of 0.83, and negative predictive value of 0.93. A negative finding strongly rules out SSCD. High-frequency oVEMP was more accurate than 500 Hz oVEMP or cVEMP.

Benign Paroxysmal Positional Vertigo in the Elderly: A Single-center Experience

01-12-2019 – Nahm, HyunJoo; Han, Kyujin; Shin, Jung Eun; Kim, Chang-Hee

Journal Article

Objectives: Dizziness and balance problems are common in the elderly, and benign paroxysmal positional vertigo (BPPV) is one of the most common causes of dizziness. The aim of this study is to investigate the subtype distribution of geriatric BPPV in a single tertiary referral center, and compare the treatment efficacy according to the subtype of BPPV.
Study Design: Retrospective study.
Setting: Tertiary referral academic center.
Patients: The consecutive 316 elderly patients diagnosed with BPPV between March 2013 and March 2019 were included.
Main Outcome Measures: Using a head-roll and Dix-Hallpike tests, subtype of BPPV was determined. Once the diagnosis of BPPV was made, patients were treated by its corresponding canalith repositioning maneuver (CRM).
Results: Among 316 elderly patients with BPPV, 143 patients (45%) were diagnosed with posterior semicircular canal BPPV, 46 patients (15%) were diagnosed with lateral semicircular canal (LSCC) canalolithiasis, 126 patients (40%) were diagnosed with LSCC cupulolithiasis, and 1 patient (0%) was diagnosed with anterior semicircular canal BPPV. While 66 and 63% of the patients with posterior semicircular canal BPPV and LSCC canalolithiasis recovered after one session of CRM, only 32% of the patients with LSCC cupulolithiasis recovered after one session of CRM.
Conclusion: The proportion of LSCC cupulolithiasis was higher in the elderly, and treatment efficacy by CRM is lower in LSCC cupulolithiasis than other subtypes of BPPV. High prevalence of LSCC cupulolithiasis may be explained by a delay between onset of BPPV and patients presentation to the tertiary referral hospital or pathophysiology of ageotropic positional nystagmus other than otoconial attachment on the LSCC cupula in the elderly.

Durability of Hearing Preservation Following Microsurgical Resection of Vestibular Schwannoma

01-12-2019 – Dowling, Eric M.; Patel, Neil S.; Lohse, Christine M.; Driscoll, Colin L. W.; Neff, Brian A.; Van Gompel, Jamie J.; Link, Michael J.; Carlson, Matthew L.

Journal Article

Objective: To ascertain long-term hearing outcomes in patients with serviceable hearing following microsurgical resection of sporadic vestibular schwannoma (VS).
Study Design: Retrospective cohort.
Setting: Tertiary academic referral center.
Patients: Forty-three adult subjects with unilateral sporadic VS who had serviceable hearing (American Academy of Otolaryngology–Head and Neck Surgery AAO-HNS class A or B) on initial postoperative audiogram following microsurgical resection between 2003 and 2016 with a minimum of two postoperative audiograms available for review.
Intervention: Surgical treatment with a retrosigmoid or middle cranial fossa approach.
Main Outcome Measure: Rate of maintaining serviceable hearing, as estimated using the Kaplan–Meier method, in accordance with the 1995 and 2012 AAO-HNS guidelines on reporting hearing outcomes.
Results: The median immediate postoperative pure-tone average (PTA) and word recognition score (WRS) were 31 d
B and 95%, respectively. At last follow-up, the median PTA was 38 d
B with a median change of 5 d
B from initial postoperative audiogram, and the median WRS was 90% with a median change of 0% from initial postoperative audiogram. Eight patients developed non-serviceable hearing at a median of 4.1 years following microsurgical resection (interquartile range, 2.9–7.0). The median duration of hearing follow-up for the 35 patients who maintained serviceable hearing was 3.1 years (interquartile range, 2.2–7.5). Tumor control was achieved in 41 (95%) patients. The rate of maintaining serviceable hearing at 5 years was 81%.
Conclusion: Microsurgical resection provides excellent tumor control and durable long-term hearing in those with AAO-HNS class A or B hearing postoperatively. The paradigm of proactive microsurgical resection—when the tumor is small and hearing is good—hinges on the surgeons ability to preserve residual hearing in a very high percentage of cases at or near preoperative hearing levels to maintain an advantage over conservative observation with regard to long-term hearing preservation.

Obesity Is Not Associated With Postoperative Complications After Vestibular Schwannoma Surgery in a Large Single Institution Series

01-12-2019 – Lipschitz, Noga; Kohlberg, Gavriel D.; Walters, Zoe A.; Tawfik, Kareem O.; Samy, Ravi N.; Pensak, Myles L.; Zuccarello, Mario; Andaluz, Norberto; Dinapoli, Vincent A.; Breen, Joseph T.

Journal Article

Objective: Determine whether elevated body mass index (BMI) is associated with postoperative complications after vestibular schwannoma (VS) surgery.
Study Design: Retrospective case series.
Setting: Tertiary referral center.
Patients: Two hundred six patients undergoing surgery for VS between 2010 and 2017, grouped into obese and nonobese patients.
Intervention: Surgery for VS resection.
Main Outcome Measures: Postoperative facial nerve outcomes, length of hospital stay, presence of postoperative cerebrospinal fluid leak, 30-day readmission, return to the operating room, wound complications, cardiovascular and thromboembolic complications.
Results: After excluding 1 patient for missing BMI, our cohort included 205 patients. Seventy-nine patients (38.5%) were obese (mean BMI 36.2 kg/m2, range 30–55.1) and the remaining 126 (61.5%) were nonobese (mean BMI 25.0, range 18.8–29.8 kg/m2). Compared with nonobese patients, obesity was not associated with postoperative cerebrospinal fluid leak (OR 1.1, 95% CI 0.93–1.1), length of hospital stay (OR 0.98, 95% CI 0.65–1.47), 30-day readmission rates (1.04, 95% CI 0.95–1.14), return to operating room (OR 1.05, 95% CI 0.98–1.11), or other wound-related complications (OR 0.99, 95% CI 0.94–1.04).
Conclusion: In this cohort, elevated BMI was not associated with an increased risk for postoperative complications after VS surgery. Our findings may mitigate concerns associated with surgical management of VS in obese patients.

Cochlear MRI Signal Change Following Vestibular Schwannoma Resection Depends on Surgical Approach

01-12-2019 – West, Niels; Sass, Hjalte Christian Reeberg; Møller, Martin Nue; Cayé-Thomasen, Per

Journal Article

Objective: Information on cochlear MRI signal change following vestibular schwannoma (VS) surgery by the retrolabyrinthine approach (RLA) is nonexisting, and information using the translabyrinthine approach (TLA) is scarce. We aimed to evaluate cochlear MRI fluid signal in patients with a unilateral VS, before and after surgery by the RLA or the TLA, that can have clinical importance for subsequent cochlear implantation feasibility.
Study Design: Retrospective cohort study.
Setting: University hospital.
Patients: One hundred one patients with a unilateral VS.
Intervention: VS resection by the TLA or the RLA. Pre- and postoperative T2-weighted MRI.
Main Outcome Measure: Cochlear signal change using a semiquantitative system for grading cochlear asymmetry, with grades ranging from 1 (normal fluid signal both sides) to 4 (no fluid signal one side).
Results: Seventy-four patients were operated by the TLA and 27 by the RLA. The number of cochleas with grade 3 and 4 asymmetries postoperative was significantly higher than preoperative. The postoperative proportions of grade 1 (TLA 20%, RLA 56%) and grade 2–4 asymmetry (TLA 80%, RLA 44%) were significantly different between the two groups. In the TLA group, 46 patients (62%) demonstrated an increased asymmetry postoperatively, as compared with three patients (11%) in the RLA group.
Conclusions: Postoperative decrease of cochlear MRI fluid signal is more likely to occur after translabyrinthine surgery (occurring in 62%), as compared with retrolabyrinthine surgery (occurring in 11%). The decrease of cochlear signal may be due to compromised vascularity or fibrosis.

Predictors of Distant Metastasis and Survival in Adenoid Cystic Carcinoma of the External Auditory Canal

01-12-2019 – Zhang, Yibo; Liu, Hongyan; Wu, Qianru; Wang, Shuyi; Dai, Chunfu

Journal Article

Objective: To analyze the predictors of both distant metastasis and survival in patients with adenoid cystic carcinoma of the external auditory canal.
Study Design: Retrospective patient review.
Setting: A single university hospital.
Patients: Eighty-two cases with adenoid cystic carcinoma of the external auditory canal were referred to our institution between 2004 and 2016.
Main Outcome Measures: Distant metastasis was detected by lung computed tomography, proton emission tomography computed tomography, or histopathologic examination of tissue samples. Distant metastasis predictors were analyzed using Students t tests and χ2 tests. The log-rank tests of Kaplan–Meier survival curves were used to evaluate survival differences.
Results: During a median follow-up of 36 months (range, 6–162 mo), distant metastasis developed in 25 patients. The occurrence of distant metastasis was significantly associated with histopathologic subtype, T classification, and local recurrence (p < 0.05). The 1-, 10-, 20-, and 25-year cumulative survival rates in the patents with DM were 95.7, 95.7, 71.7, and 0%, respectively, and all survival rates were 100% for the 57 patients without distant metastasis (p = 0.115). Median survival time after occurrence of distant metastasis was 13 months (range, 1–120 mo). Prognosis was better with solely lung metastasis than with metastases to other visceral organs or bone (p < 0.05).
Conclusions: Distant metastasis appeared to result in a poorer prognosis, occurrence of distant metastasis was significantly associated with local recurrence, extensive surgery is recommended to achieve local control and reduce distant metastasis risk. Routine follow-up investigations for detecting distant metastasis are warranted for patients with an increased risk for distant metastasis.

Rate of Initial Hearing Loss During Early Observation Predicts Time to Non-Serviceable Hearing in Patients With Conservatively Managed Sporadic Vestibular Schwannoma

01-12-2019 – Carlson, Matthew L.; Dowling, Eric M.; Lohse, Christine M.; O’Connell, Brendan P.; Driscoll, Colin L. W.; Haynes, David S.; Link, Michael J.; Hunter, Jacob B.

Journal Article

Objective: To date, prediction models for estimating risk of acquiring non-serviceable hearing in subjects with observed vestibular schwannoma (VS) have evaluated outcomes primarily based on features at initial diagnosis. Herein, we evaluate the association of rate of hearing decline during the initial period of observation with time to non-serviceable hearing. If significant, rate of hearing decline may inform decision making after an introductory period of observation.
Setting: Two tertiary care centers.
Patients: VS patients with serviceable hearing who underwent at least three audiograms and two magnetic resonance imaging (MRI) studies before intervention or being lost to follow-up. The rate of change in pure-tone average (PTA) and word recognition score (WRS) was calculated as the score from the second audiogram minus the score from the first audiogram, divided by the duration in months between the two.
Main Outcome Measure(s): Serviceable hearing, defined as PTA ≤50 d
B HL and WRS ≥50%.
Results: Among 266 patients meeting inclusion criteria, 52 developed non-serviceable hearing at last follow-up. Kaplan–Meier estimated rates of maintaining serviceable hearing (95% CI; number still at risk) at 1, 3, 5, 7, and 10 years were 97% (95–100; 206), 78% (72–85; 98), 68% (60–77; 39), 60% (50–73; 17), and 44% (29–67; 2), respectively. In a univariable setting, each 1 d
B increase per month in the rate of initial PTA change was associated with a 96% increased likelihood of acquiring non-serviceable hearing (hazard ratio HR 1.96; 95% CI 1.44–2.68; p < 0.001). Each 1% increase per month in the rate of initial WRS change was associated with a decreased likelihood of acquiring non-serviceable hearing (hazard ratio HR 0.79; 95% confidence interval CI 0.66–0.94; p = 0.009). After multivariable adjustment, both rate of PTA change (HR 2.42; 95% CI 1.72–3.41; p < 0.001) and rate of WRS change (HR 0.81; 95% CI 0.67–0.99; p = 0.043) remained statistically significantly associated with time to non-serviceable hearing.
Conclusion: Rate of early PTA and WRS decline during the initial period of observation are significantly associated with time to development of non-serviceable hearing. This information may facilitate accurate patient counseling and inform decision-making regarding prospective disease management.

High Altitude Alternobaric Facial Palsy: Case Series and Systematic Review of the Literature

01-12-2019 – Cumming, Benjamin; Matchett, Ian; Meller, Catherine; Saxby, Alexander

Journal Article

Background: Alternobaric facial palsy (AFP) is a rare phenomenon which occurs in patients with Eustachian tube dysfunction, a dehiscent facial canal, and subsequent compression induced ischemic neuropraxia of the facial nerve upon exposure to atmospheric pressure changes. There are few documented cases of AFP and most relate to underwater diving. There is limited understanding in the literature of AFP in the setting of high altitude, leading to a potential for misdiagnosis and inappropriate management.
Objective: We present two cases of transient, recurrent, unilateral facial palsy at high altitude and perform a systematic review of the available literature.
Data Sources: Full-text articles indexed to Medline, EMBase, and PubMed, and associated reference lists.
Data Extraction: Data was extracted into standardized data extraction forms.
Data Synthesis: Binomial proportions and Fischers exact test were used to analyze sex distribution and relationship between sex and side of palsy, and number of episodes experienced.
Methods: Systematic review using PRISMA guidelines with meta-analysis.
Results: We identified 19 cases in the literature relating to AFP in patients at high altitude and present two new cases.
Conclusion: AFP is an uncommon but important diagnosis. We present two cases and systematically review the literature to discuss the diagnosis and management of AFP.

“Concurrent Treatment With Intratympanic Dexamethasone for Moderate-Severe Through Severe Bells Palsy”

01-12-2019 – Inagaki, Akira; Minakata, Toshiya; Katsumi, Sachiyo; Murakami, Shingo

Journal Article

Objective: To determine whether early intervention with intratympanic steroid injection, known as concurrent intratympanic steroid therapy, is effective as a supplement to systemic steroid therapy for treating moderate-severe to severe Bells palsy.
Design: An open-label historical control trial.
Setting: Tertiary referral center.
Participants: A total of 35 Bells palsy patients presenting with House–Brackmann grade IV or higher were treated with intratympanic steroid therapy concurrent with standard systemic treatment and compared with 108 patients treated with standard systemic therapy alone started within 7 days of onset.
Interventions: In the concurrent intratympanic steroid therapy group, patients received both 410 mg of prednisolone (standard dose) and 1.65 mg of intratympanic dexamethasone for 10 consecutive days. Patients in the control group received the standard dose, or more, of systemic prednisolone. Both groups were additionally treated with valacyclovir.
Main Outcomes and Measures: The primary outcome measure was restoration of a House–Brackmann score of grade I.
Results: The rate of recovery to House–Brackmann Grade I was higher for the concurrent intratympanic steroid therapy group than for the control group (94% vs 73%, p = 0.008). The adjusted odds ratio was 5.47 (95% confidence interval: 1.18–25.21, p = 0.029).
Conclusions: The recovery rate was higher for concurrent intratympanic steroid therapy treatment than for standard-of-care control treatment, regardless of whether steroid with lower or equivalent glucocorticoid action was administered. This result suggests that concurrent treatment with intratympanic steroid therapy is a potentially beneficial supplement to systemic steroid administration.

Lack of Evidence to Support the Beneficial Role of Intratympanic Dexamethasone Injection in Acute Peripheral Facial Palsy

01-12-2019 – Kim, Su Jin; Lee, Jun; Lee, Ho Yun

Journal Article

Objectives: Adjunctive intratympanic dexamethasone injection (IT-DEX) has been used for the treatment of acute peripheral facial palsy (APFP). However, there are controversies regarding the validity of this treatment. In this study, we aimed to verify the feasibility of IT-DEX treatment for APFP.
Study Design: Retrospective cohort study.
Setting: Local university hospital.
Patients and Methods: Data of patients treated for APFP between 2015 and 2018, and whose follow-up records for more than 3 months were available, were collected and analyzed based on whether adjuvant IT-DEX was administered.
Main Outcome Measures: House–Brackmann grading at the initial visit, and at 2, 6, and 10 to 16 weeks after discharge. Patients with House–Brackmann I at any time point were regarded as having complete recovery (CR).
Results: A total of 108 patients 57 men, 51 women; mean age, 48 ± 15.67 yr (range: 18–85 yr) were enrolled in the study. Adjunctive IT-DEX was administered to 41.7% (n = 45) of patients during hospitalization. CR was observed in 71.7% of IT-DEX-treated patients; however, it was not significantly different from the conventional treatment group (79.4%) (p > 0.05). Multiple regression analysis revealed that better facial grade at week 2 EXP(B) = 7.407, 95% CI = 1.828–30.303, p = 0.005 was significantly associated with CR. However, the number of IT-DEX treatment sessions was not a significant prognostic factor for predicting CR.
Conclusion: Additional beneficial treatment effect was not observed with adjuvant IT-DEX. Thus, the use of IT-DEX for APFP should be reconsidered until scientific evidence for the basis of its use is established.

Commercial Quinolone Ear Drops Cause Perforations in Intact Rat Tympanic Membranes

01-12-2019 – Dirain, Carolyn O.; Karnani, David N.; Antonelli, Patrick J.

Journal Article

Hypothesis: Commercial quinolone ear drops may promote the development of perforations (TMPs) in intact tympanic membrane (TMs).
Background: Quinolone ear drops have been associated with TMPs after myringotomy +/- tube placement in a drug-specific manner and potentiation by steroids.
Methods: Rats were randomized to six groups (10/group), with one ear receiving otic instillation of dexamethasone, ofloxacin, ciprofloxacin, ofloxacin + dexamethasone, ciprofloxacin + dexamethasone, or neomycin + polymyxin + hydrocortisone—all commercial formulations and at standard clinical concentrations—and the contralateral ear receiving saline, twice daily for 10 days. TMs were assessed over 42 days.
Results: No TMPs were seen in ears treated with saline, dexamethasone, or neomycin. At day 10, TMPs were seen in one of 10 ofloxacin- and three of 10 ciprofloxacin + dexamethasone-treated ears (p = 0.038). At day 14, the ofloxacin TMP healed. In contrast, the three ciprofloxacin + dexamethasone TMPs remained and one new TMP developed in this group. A ciprofloxacin and an ofloxacin + dexamethasone-treated ears also had TMPs (p = 0.023). By day 21, the ofloxacin + dexamethasone TMP and two of four of the ciprofloxacin + dexamethasone TMPs healed but two new TMPs were seen in ciprofloxacin + dexamethasone ears (p = 0.0006). At day 28, 1 of 10 ciprofloxacin and 4 of 10 ciprofloxacin + dexamethasone-treated ears had TMPs (p = 0.0006). By day 35, only one ciprofloxacin + dexamethasone had TMP (p = 0.42). All TMPS were healed at day 42.
Conclusions: Application of commercial quinolone ear drops can cause TMPs in intact TMs. This effect appears to be drug-specific and potentiated by steroids.

The Feasibility to Isolate and Expand Tympanic Membrane Squamous Epithelium Stem Cells From Scarred Perforation Margins

01-12-2019 – Sagiv, Doron; Harari-Steinberg, Orit; Wolf, Michael; Dekel, Benjamin; Omer, Dorit

Journal Article

Hypothesis: The scarred rim of chronic tympanic membrane (TM) perforation contains keratinocytes with potential for regeneration while maintaining their morphological and genetic characteristics.
Background: The squamous epithelium of the TM has a good regeneration capacity. Successful isolation and expansion of human TM keratinocytes (h
TMKR) was reported from a full, en-bloc, healthy TM.
Methods: Trimmed margins of the TM perforation (harvested during tympanoplasty) underwent enzymatic digestion (collagenase or trypsin) and were seeded either with serum-containing medium (SCM) or keratinocyte serum-free medium (KSFM) and progenitor cell growth medium (PR) (KSFM:PR, 1:1). Gene expression analysis by real-time q
RT-PCR was used to compare between human TM cells derived from scarred perforation margins (h
TMKR), normal human skin keratinocytes (Nh
SKR), and human fibroblasts.
Results: Twelve patients were included in the study. In 9 of 12 cases (75%) single-cell isolation with fibroblastic or epithelial cell morphology (or both) was achieved. Cells seeded with KSFM:PR yielded epithelial morphology (h
TMKR) while SCM culturing resulted in a fibroblastic morphology (h
TMFib). Gene expression analysis revealed significant higher expression of VCAN (p = 0.002) and FOXC2 (p = 0.015) at the m
RNA levels (normal h
TMKR markers) in h
TMKR compared to Nh
SKR. In addition, a comparison of gene expression between h
TMKR and h
TMFib revealed significantly higher levels of both VCAN (p = 0.045) and SLC6A14 (p = 0.036) among h
Conclusion: For the first time, we developed a protocol to isolate h
TMKR from scarred TM perforation margins. Furthermore, we succeeded in achieving tissue expansion that preserved the characteristic of healthy TM cells. This study bridges “regenerative medicine” approach with clinical and surgical objectives.

Surgically-Relevant Anatomy of the External Auditory Canal Bulge and Scutum

01-12-2019 – Kennel, Christopher E.; Puricelli, Michael D.; Rivera, Arnaldo L.

Journal Article

Hypothesis: Anatomic study of the external auditory canals (EAC) anterior bulge, scutum, and ossicular chain will generate knowledge applicable to safe ear surgery and instrument design.
Background: The EAC contains two structures that obscure view of the middle ear: the anterior bulge and the scutum. The dimensions of these structures and their relationships to the ossicular chain have not been previously described.
Methods: Cadaveric temporal bones underwent computed tomography scanning, and three-dimensional reconstructions were created. Dimensions and angles of the EAC, its anterior bulge and scutum were measured. Distances to ossicular landmarks and the facial nerve were examined.
Results: The anterior EAC had a swan-neck shape. The thinnest portion was located medially and correlated with the canal thickness at the anterior bulge. However the thickness of the anterior bulge was not correlated with its angulation. The scutum averaged 3.8 mm long with a base thickness of 2.3 mm and a mean tip angle of 33 degrees. The short process of the incus was significantly closer to the scutum than other ossicular landmarks.
Conclusion: Prominent anterior canal bulges are formed by posterior temporomandibular joints, not thicker bone. The scutum has asymmetric distances to various portions of the ossicles with the incus short process sometimes as close as 0.2 mm, placing it at risk of injury.

Completion of an Individualized Learning Plan for Otology-Related Milestone Subcompetencies Leads to Improved Otology Section Otolaryngology Training Exam Scores

01-12-2019 – Pennock, Michael; Svrakic, Maja; Bent, John P. III

Journal Article

Objective: To examine the relationships among self-assessment of knowledge in otology via an individualized learning plan (ILP), otology milestone achievement rate, and otolaryngology training exam (OTE) otology scores.
Study Design: Prospective study.
Setting: One otolaryngology residency covering a tertiary care facility, trauma and hospital center, outpatient ambulatory surgery center, and outpatient clinics.
Participants: Twenty otolaryngology residents, four from each class.
Methods: Residents identified four milestones from otology-related sub-competencies to achieve in a 3-month rotation via an ILP. During the same rotation, the residents sat for the OTE, and their overall and otology scores were analyzed.
Main Outcome Measures: Completion of an ILP before and at the end of the rotation, self-reported achievement of otology milestones, and OTE score components including total percent correct, scaled score, group stanine, national stanine, and residency group weighted scores.
Results: Group stanine OTE otology scores were higher for those residents who completed pre- and post-rotation ILPs compared with those who did not, 4.0 (±0.348) versus 2.75 (±0.453), respectively (p = 0.04). Residents who self-reported achieving all four otology milestones had significantly higher otology group stanine scores than the residents who achieved less, 4.1 (±0.348) versus 2.9 ± 0.433, respectively (p = 0.045). Residents who performed well in their PGY program cohort on the otology OTE 1 year were less inclined to complete an ILP for otology in the subsequent year (Pearson correlation –0.528, p = 0.035).
Conclusion: In the otology subspecialty, residents who completed ILPs scored better on OTE examinations independent of resident class. Consequently, programs may find ILPs useful in other otolaryngology subspecialties and across residencies.

First MRI With New Cochlear Implant With Rotatable Internal Magnet System and Proposal for Standardization of Reporting Magnet-Related Artifact Size: Erratum

01-12-2019 –

Journal Article

No abstract available