Subjective and Objective Taste Change After Cochlear Implantation Systematic Review and Meta-Analysis.

INTRODUCTION: There is a paucity of data reporting the rate of chorda tympani nerve injury during cochlear implantation (CI) surgery. To better provide clarity to patients and surgeons regarding the risk of taste change, we performed a systematic review and meta-analysis of prospective studies examining taste change after CI. DATA SOURCES: PubMed, Embase, and Cochrane Library databases were queried. METHODS: Databases were queried according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Search terms included "(chorda tympani OR gustatory OR taste OR chemosensory OR dysgeusia OR nervus intermedius) AND (cochlea OR cochlear implant OR cochlear implantation)." Prospective studies were included and further divided into "objective" and "subjective" assessments of taste dysfunction. A systematic review was performed for all studies. A random-effects model was used to compare studies with similar methods and patient demographics. RESULTS: The initial database query yielded 2,437 articles, which were screened according to inclusion and exclusion criteria. Nine appropriate studies were identified, including 442 total patients-254 with subjective assessment and 271 with objective assessment of gustation. Seventeen of 144 patients (11.8%) reported short-term taste change (incidence = 0.09 [0.02-0.16], 95% confidence interval with pooled data). Twenty-six of 265 patients (9.8%) reported long-term taste change (incidence = 0.07 [0.01-0.13]). Objective results were heterogenous and therefore not amenable to pooled meta-analysis. CONCLUSIONS: Taste change from chorda tympani nerve injury is a likely underrecognized complication of CI and may be the most common adverse consequence of CI surgery. Surgeons should counsel prospective patients on this potential complication and that the risk of taste change may persist longer than the immediate postoperative period.

The impact of injury of the chorda tympani nerve during primary stapes surgery or cochlear implantation on taste function, quality of life and food preferences: A study protocol for a double-blind prospective prognostic association study.

BACKGROUND: The chorda tympani nerve (CTN) is a mixed nerve, which carries sensory and parasympathetic fibres. The sensory component supplies the taste sensation of the anterior two-thirds of the ipsilateral side of the tongue. During middle ear surgery the CTN is exposed and frequently stretched or sacrificed, because it lacks a bony covering as it passes through the middle ear. Injury may cause hypogeusia, ageusia or altered taste sensation of the ipsilateral side of the tongue. To date, there is no consensus regarding which type of CTN injury (sacrificing or stretching), during middle ear surgery, leads to the least burden for the patient. METHODS: A double-blind prospective prognostic association study was designed in a single medical centre in the Netherlands to determine the effect of CTN injury on postoperative taste disturbance and quality of life. 154 patients, who will undergo primary stapes surgery or cochlear implantation will be included. The taste sensation, food preferences and quality of life of these patients will be evaluated preoperatively and at one week, six weeks and six months postoperatively using the Taste Strip Test, Electrogustometry, supplementary questionnaire on taste disturbance, Macronutrient and Taste Preference Ranking Task, Appetite, Hunger and Sensory Perception questionnaire and Questionnaire of Olfactory Disorders to assess the association of these outcomes with CTN injury. Evaluation of olfactory function will only take place preoperatively and at one week postoperatively using the Sniffin' Sticks. The patient and outcome assessor are blinded to the presence or absence of CTN injury. DISCUSSION: This study is the first to validate and quantify the effect of chorda tympani nerve injury on taste function. The findings of this study may lead to evidence-based proof of the effect of chorda tympani injury on taste function with consequences for surgical strategies. TRIAL REGISTRATION: Netherlands Trial Register NL9791. Registered on 10 October 2021.

Taste Changes after Atresioplasty in Patients with Congenital Aural Atresia.

OBJECTIVE: We evaluated chorda tympani nerve (CTN) and postoperative taste dysfunction according to anomaly severity and intraoperative CTN status. STUDY DESIGN: Prospective observational study. SETTING: Tertiary referral center, Samsung medical center hospital. PATIENTS: Thirty-one patients who underwent atresioplasty by a single surgeon in a tertiary referral center were enrolled. INTERVENTIONS: Therapeutic surgery. MAIN OUTCOME MEASURES: Preoperative Schuknecht type and Jahrsdoerfer score and intraoperative CTN status were recorded, and a postoperative questionnaire was administered to evaluate taste function. RESULTS: A significant difference was found among intact, cut, and unidentified groups in terms of Schuknecht type ( p = 0.000) and Jahrsdoerfer score (9.28 ± 1.11, 8.80 ± 0.83, 8.10 ± 0.93, p = 0.028). CTN was observed in Schuknecht type B, and not in type C ( p = 0.000), and was more likely to be observed as Jahrsdoerfer score increased ( p = 0.012). Taste disturbance tended to last longer in adult patients than in children. A significant difference was observed in the incidence of taste change between cut and intact CTN groups ( p = 0.018). CONCLUSION: CTN was not identified during surgery in patients with Schuknecht type C anomalies, and there was no change in taste after surgery. Meanwhile, CTN was observed in all patients with Schuknecht type B anomalies, and CTN injury occurred in 41.67%. Therefore, CTN presence can be predicted by severity of anomaly, and patients with type B anomalies should be informed of the risk of CTN injury before surgery.

Features and management of a schwannoma of the chorda tympani and review of the literature.

Intrinsic facial nerve tumors are rare lesions. Among the different histology types, schwannomas is the most frequently reported in literature. Other histological types of facial nerve tumors are hemangiomas, meningiomas, and neurofibromas. Chorda tympani schwannomas (CTSs) are extremely rare entities and are considered as an independent subgroup of facial nerve schwannomas because of their clinical characteristics. The aim of this report is to present the clinical and radiological features and the management of a CTS in a 27-year-old male presenting with conductive hearing loss.

Chorda tympani injury during endoscopic versus microscopic stapes surgery: a randomized controlled clinical trial.

OBJECTIVES: The aim of this study was to compare the incidence of chorda tympani nerve (CTN) injury between endoscopic and microscopic stapes surgery. METHODS: This randomized controlled clinical trial included 88 patients who were randomly divided into two groups: endoscopic stapedotomy group (n = 44) and microscopic stapedotomy group (n = 44). The incidence of chorda tympani nerve (CTN) injury after surgery was determined by both subjective taste testing and chemical taste tests, before and after surgery. The results were compared between the two groups. RESULTS: The total number of patients who were identified as having CTN affection (based on the chemical testing) was 16 out of 88 (18.2%). The incidence was significantly lower in the endoscopic group (n = 2) than the microscopic group (n = 14) (p = 0.019). CONCLUSION: Altered taste as a result of iatrogenic CTN injury can affect the patients' quality of life. Endoscopic ear surgery offers better visualization, less need for extensive manipulation of the chorda tympani, and consequently decreased incidence of CTN injury.

Gustatory Function of Patients With and Without Cholesteatoma Undergoing Middle Ear Surgery.

OBJECTIVE: To compare measured and perceived taste function before and after surgery of patients with chronic otitis media with cholesteatoma (OMCC) to patients without cholesteatoma (patients with chronic suppurative otitis media [CSOM] and patients with lateral skull base lesions [LSB]). METHODS: This prospective cohort study included 29 patients undergoing surgery for unilateral OMCC. The chorda tympani nerve (CTN) was resected in 8 of these patients. Fourteen patients undergoing surgery for unilateral CSOM and 5 patients undergoing surgery for unilateral LSB (with CTN resection) served as the comparison group. Taste function was measured using taste strips on both sides of the tongue before surgery, 2 weeks postoperatively and 3 months postoperatively. The affected side of the tongue was compared to the unaffected side. A questionnaire on taste perception was completed at each visit. RESULTS: Preoperatively, cholesteatoma patients showed higher taste strip scores than non-cholesteatoma patients, indicating a larger difference between the healthy and affected sides of the tongue. Despite this difference in measured taste function few cholesteatoma patients reported taste alteration before surgery (3/29 [10.3%]). Postoperatively, patients with CTN resection (OMCC patients with CTN resection and LSB patients) showed a decreased measured taste function. Subjectively, only approximately 20% of these patients reported taste alteration 3 months postoperatively. CONCLUSIONS: Before surgery, cholesteatoma patients displayed an impaired measured taste function compared to patients without cholesteatoma (CSOM, LSB). Subjectively this was often unnoticed. After surgery, despite removal of the CTN and consequent reduction of measured taste function, few patients reported taste alteration and subjective taste perception was seen to be improving. In regards to middle ear surgery, perceived taste function does not seem to reflect measured gustatory function.

Validation of the radiological detection of the chorda-facial angle: impact on the round window accessibility during pediatric cochlear implantation.

OBJECTIVES: The facial recess, an essential landmark for the posterior tympanotomy approach, is limited by the facial nerve and the chorda tympani, with a complicated relationship. This study tried to find the most appropriate radiological method to evaluate the chorda-facial angle (CFA). We also checked the effect of this angle on the round window accessibility during cochlear implantation. METHODS: It was a retrospective study that included cochlear implant surgeries of 237 pediatric patients, from September 2016 to April 2021. Two physicians evaluated the CFA in the para-sagittal cut of the preoperative HRCT. The round window accessibility was assessed in the unedited surgery videos. RESULTS: The CFA ranged from 21° to 35° with a mean of 27.14 ± 3.5°. It was detected in all cases with a high agreement between the two CT reviewers' measurements. The CFA differed significantly between the accessible group and the group with difficult accessibility (p value < 0.001). Spearman's correlation coefficient revealed a strong correlation between the CFA and the intraoperative round accessibility. 25.5° was the best cutoff point; below this angle, difficult accessibility into the RW was expected, with high sensitivity, specificity, and accuracy CONCLUSIONS: Our study on a relatively large number of cases provided a precise, valid, reliable, and applicable method to evaluate the CFA in the HRCT scan. We found a significant-close relation between the CFA and the round window accessibility; the difficulty increased with a need for posterior tympanotomy modification when the angle decreased. KEY POINTS: • Radiological detection of the chorda-facial angle was always problematic, without a previous straightforward method in the literature. • We used the para-sagittal cut of the high-resolution CT scans to evaluate the CFA. This cut was beneficial to seeing the chorda tympani nerve in every examined case. There was a high agreement between the two CT reviewers' measurements. • Preoperative evaluation of the CFA in the HRCT accurately predicted the round window accessibility. Patients with CFA less than 25.5° were expected to have difficult accessibility into the round window during cochlear implantation.

Radiological Evaluation of Tympanic Segment of Chorda Tympani Nerve in Normal Ears: An Ultra-High-Resolution Computed Tomography Study.

BACKGROUND: To visualize the course of the tympanic segment of chorda tympani nerve (CTN) using ultra-high-resolution computed tomography. METHODS: A hundred and fourteen ears with no evident otologic pathologies were included. The tympanic segment of CTN was divided into 4 portions as follows: periannular, posteromalleal, malleal, and anteromalleal. The length of the periannular portion running along the tympanic annulus was recorded. Four points of interest (the beginning and end of the posteromalleal and anteromalleal portions) were selected to perform distance measurements relative to the tip of the malleus manubrium. Differences in lengths and distances were compared in terms of ear sides and sexes. RESULTS: The length of the periannular portion was 2.49 ± 1.16 mm. The beginning of the posteromalleal portion was located more laterally on the right side than on the left side (mean: 4.09 mm vs. 3.92 mm;, P = 0.016). The end of the posteromalleal portion was located more inferiorly on the right (mean: 2.11 mm vs. 2.26 mm; P = 0.018). The beginning of the anteromalleal portion on the right was located more laterally than that on the left (mean: 2.60 mm vs. 2.45 mm; P = 0.027). The start and end of the anteromalleal portion were more posteriorly located in women than in men (both Ps < 0.001). CONCLUSIONS: The course of the tympanic segment of normal CTN was comprehensively visualized by ultra-high-resolution computed tomography. Preoperative evaluation of the tympanic segment of CTN might be helpful in avoiding iatrogenic injury during middle ear surgery.

Early postoperative gustatory dysfunction after middle ear surgery / Korai posztoperatív ízérzészavar középfülsebészeti beavatkozásokat követoen

Introduction: Preserving maximal quality of life is an important factor in middle ear surgery according to current standards. Taste disturbance is a common postoperative complication, which can be explained with the risk of injury due to the localisation of chorda tympani. The knowledge about this complication is mandatory for optimal surgical decision-making and for patient education as well. Objective: Investigation of early postoperative taste disturbances, to clarify the differences between the impact of different surgical interventions, and the impact of nerve manipulation. Methods: 15 stapes surgeries and 28 tympanoplasties were investigated. Patients answered subjective questionnaires before surgery and on the first postoperative day. Visual analogue scale (VAS) was used to measure the degree of disturbances (0-10). Degree of nerve manipulation was classified into 5 groups. Results: No significant differences between the impact of stapes surgeries and tympanoplasties could be found (9, 9.1; p = 0.861). In groups '0', '1' and '2', the VAS scores were 10, 9.26, and 8.5. Between the groups no manipulation (0) and significant manipulation without macroscopic injury (2), the difference was significant (10, 8.5; p = 0.039). In the stapes surgery group, no severe taste disturbance (VAS<5) was found. Discussion: In the case of adequate microscopic surgical technique, the rate of postoperative taste disturbances is relatively low. Conclusions: The rate of postoperative taste disturbance could be kept at a low level while the continuity of the chorda tympani could be preserved in the majority of cases. The postoperative morbidity rate is primarily influenced by the degree of nerve manipulation and not by the type of surgery.

The pre-chorda and post-chorda tympani approach in endoscopic stapes surgery based on the chorda tympani nerve classification.

PURPOSE: In most stapes surgeries, the posterior ear canal is enlarged and a piston is inserted posterior to the chorda tympani nerve (post-chorda tympani approach; Post C). Although reports vary, some indicate that more than 60% of the patients experience lingual symptoms following surgery. Endoscopic surgery may permit an anterior approach to the nerve (pre-chorda tympani approach; Pre C). Herein, we propose a suitable approach for endoscopic stapes surgery based on the classification of the chorda tympani nerve. METHODS: We retrospectively reviewed the medical records of 23 patients who underwent endoscopic stapes surgery at our institution between 2019 and 2021. The nerve classification previously reported, the modified nerve classification (attached long type is divided into Category 1: lenticular process is visible with 0° endoscope and Category 2: not visible), selected approach (Pre C or Post C), use of a 30° endoscope, and manipulation of the nerve (number of contacts and traction, with or without suction, with or without malposition or extension and amputation, and damage score) were evaluated. RESULTS: The damage score was significantly lower in the Pre C group (p < 0.05); however, using this approach for all cases is not desirable owing to the high risk of damage to the nerve during posterior malpositioning. CONCLUSION: The Post C should be used for the detached and attached long 1 types, while the Pre C with a 30° endoscope should be used for the attached long 2, attached short, ultrashort, and external auditory canal types.

The Impact of the Location of Chorda Tymapni Nerve Origin on the Round Window Accessibility During Pediatric Cochlear Implantation: A Radioclinical Assessment.

OBJECTIVES: This study assessed the impact of the location of the chorda tympani nerve (CTN) origin on the round window (RW) accessibility during pediatric cochlear implantation (CI). We also tried to validate the radiologic method to measure the length between the origin of the CTN from the facial nerve to the stylomastoid foramen (CF-SM). STUDY DESIGN: It was a prospective observational case-series study. SETTINGS: The included CI surgeries were performed at tertiary referral institutions from November 2018 to August 2021. SUBJECTS: We included 146 pediatric patients who were candidates for CI. INTERVENTION: We measured the CF-SM length in the parasagittal cut of the preoperative high-resolution computed tomography. We also classified the intraoperative RW according to the accessibility through the ordinary posterior tympanotomy approach into accessible or inaccessible. MAIN OUTCOME MEASURE: We correlated the preoperative radiologic CF-SM length with the intraoperative RW accessibility. RESULTS: The radiologic CF-SM length ranged from 2.9 to 7.4 mm with a mean of 4.9 ± 1.03 mm. The RW was accessible in 107 patients and inaccessible in 39 patients. Spearman's correlation coefficient revealed a significant relationship between the location of CTN origin and the RW accessibility as the p value was less than 0.0001. CONCLUSIONS: We found a precise method to measure the CF-SM length in the parasagittal cut of the high-resolution computed tomography. We also found a significant impact of the location of the CTN origin on intraoperative RW accessibility. The radiologic CF-SM length of more than 5.4 mm had a powerful prediction capability of the RW inaccessibility.

Sacrifice of the chorda tympani nerve during middle-ear surgery can lead to resolution of dysgeusia.

BACKGROUND: Cholesteatoma often presents with persistent otorrhoea, conductive hearing loss or vestibular dysfunction. Rarely, cholesteatoma can cause dysgeusia if the lesion invades into the chorda tympani nerve. This paper presents an individual with cholesteatoma whose dysgeusia resolved following a mastoidectomy in which the chorda tympani was sacrificed. The current literature was reviewed for explanations behind this phenomenon. CASE REPORT: A previously fit 57-year-old man presented with a 3-month history of persistent otorrhoea and the complaint of a metallic taste in the mouth, and was diagnosed with cholesteatoma. The patient underwent radical mastoidectomy and the chorda tympani nerve was sacrificed. On post-operative review, he reported complete resolution of dysgeusia. CONCLUSION: The sense of taste is mediated by a complex neural network. It is possible that once the diseased chorda tympani is transected, compensation arises from other parts of the network. Sectioning of the chorda tympani could lead to a beneficial outcome in selected patients.

The posterior ligament of the incus ("white dot"): A reliable surgical landmark for the facial recess.

OBJECTIVE: There is a void in the literature describing reliable surgical landmarks that aid in the dissection of the facial recess in the absence of skeletonizing the mastoid segment of the facial nerve. The posterior ligament of the incus is a readily distinguishable "white dot" along the incus buttress that has been used to guide dissection in a safe and efficient manner. The goal of our study is to describe a surgical approach that utilizes this surgical landmark to drill the facial recess and to take anatomical measurements demonstrating the safety and reliability of this approach. MATERIALS AND METHODS: After cortical mastoidectomies were performed in 10 cadaveric temporal bones, the white dot was identified at the junction of short process of the incus and the incus buttress. Using the white dot for anatomical reference, a 2 mm diamond drill bit was used to open the facial recess without first identifying the facial nerve or chorda tympani nerve. After photographs were taken, the facial and chorda tympani nerves were definitively identified and skeletonized to delineate the confines of the facial recess. Photographs were once again acquired in a consistent manner for comparison. Finally, calibrated anatomic measurements were acquired from the 10 distinct image sets. RESULTS: The facial recess was successfully drilled in 10 temporal bones using the posterior ligament as a surgical landmark without injury to the chorda tympani or facial nerve. The median angle taken from the axis of the short process of the incus to the facial nerve - chorda tympani junction was 139.2° (IQR 136.8-141). At the widest point in the facial recess, median distances anterior and posterior to an imaginary line connecting the white dot to the facial nerve - chorda tympani junction were 1.6 mm (IQR 1.5-1.7) and 1.6 mm (IQR 1.6-1.7; p = 0.57), indicating at this point, the white dot reference reliably bisects the facial recess width. Similarly, at the level of the round window niche, median anterior and posterior distances from an imaginary line connecting the white dot to the facial nerve - chorda tympani junction were 1.1 mm (IQR 1.1-1.3) and 1.3 mm (IQR 1.1-1.7; p = 0.07), respectively, once again demonstrating the white dot reliably bisecting the facial recess. CONCLUSIONS: The white dot, representing the posterior ligament of the incus, is a reliable surgical landmark that aids in safe and efficient drilling of the facial recess without first skeletonizing the facial nerve.

Taste impairment after endoscopic stapes surgery: Do anatomic variability of chorda tympani and surgical technique matter? : Post-operative dysgeusia after EStS.

PURPOSE: To investigate how the anatomical configuration of the oval window region (OWR) influences the management of the chorda tympani (ChT) and the curetting of adjacent bony structures, in a setting of patients undergoing endoscopic stapes surgery (EStS); to assess the incidence of early and late post-operative dysgeusia and to identify anatomical and surgical factors influencing taste function after EStS. METHODS: Surgical video recordings of 48 patients undergoing EStS for otosclerosis between January 2019 and July 2020 were retrospectively revised, to classify the anatomical variability of selected middle ear structures and the management strategies for the ChT. Clinical records of included patients were reviewed for subjective early and late post-operative taste impairment using a 5-point Likert-scale. RESULTS: The most common configuration of the OWR was type III. The extension of the bony curettage resulted inversely proportional to the exposure of the OWR. The long-term rate of preserved post-operative taste function was 85%. Displacement of the ChT was necessary in 43/48 cases (90%), mostly medially (36/48, 75%). CONCLUSION: Bone curetting during EStS does not correlate with post-operative taste impairment. Despite 100% ChT preservation rate, dysgeusia may occur in a minority of patients, with no apparent relationship to anatomical variability or intraoperative management of the ChT. The use of CO2 laser could have a role in increasing the risk of post-operative dysgeusia after EStS.

A New Case of Endoscopic Resection of a Chorda Tympani Schwannoma.

Chorda tympani schwannoma is a very rare tumor, with only 12 reported cases in the English literature. There are few reports on the diagnosis of chorda tympani schwannoma, and it is easily misdiagnosed. At present, surgery is recognized as a treatment for chorda tympani schwannoma. We describe the clinical course of a patient presenting with a chorda tympani schwannoma treated with surgical resection using a transcanal endoscopic approach, and the results after this treatment were satisfactory. Therefore, we accordingly advocate the minimally invasive method of transcanal endoscopic resection to maximize intraoperative visualization and reduce postoperative morbidity for middle ear tumors.

Subtotal Petrosectomy With Preservation of Chorda Tympani for Petrous Bone Cholesteatoma: Case Report.

A petrous bone cholesteatoma (PBC) is a rare epidermoid cyst of the petrous portion of the temporal bone. The main treatment is subtotal petrosectomy (SP), which generally involves sacrificing the chorda tympani. We report a case of extensive supralabyrinthine PBC in an elderly patient undergoing hemodialysis that was treated by SP with anatomical preservation of the chorda tympani. To the best of our knowledge, preservation of the chorda tympani during SP has not been previously reported. For maintenance of postoperative taste and appetite, preservation of the chorda tympani is a meaningful maneuver whenever possible.