Evaluation of the Patient with Facial Palsy: A Multidisciplinary Approach.

This article aims to provide an overview of the management of facial palsy within a multidisciplinary team setting and discusses considerations used to develop patient-specific management plans. The national landscape of facial function services is also discussed including suggestions on what may enable a more equitable and sustainable service for the future.

Migration and other electrode complications following cochlear implantation.

OBJECTIVES: To investigate migration and other electrode-related complications in cochlear implant surgery. METHODS: Retrospective review of all patients (adult and paediatric) undergoing cochlear implantation at a tertiary referral centre in England, between April 2019 and December 2021. Split arrays and patients who did not have post-op imaging were excluded. RESULTS: Two hundred and ninety-nine cochlear implants were performed including 90% primary and 10% revision surgeries. Two hundred and forty-eight (86%) of electrodes implanted were straight arrays.Twenty-seven (9%) demonstrated suboptimal position on post-operative imaging. Three (11%) were true migration, 4 (15%) possible migration, 15 (56%) had two or less extra-cochlear electrodes, 3 (11%) expected partial insertion and 2 (7%) demonstrated tip fold-overs. Twenty (74%) of arrays within the suboptimal insertion group were in primary surgeries. Six patients required re-implantation. The most common reason for re-implantation was migration. DISCUSSION: Electrode migration after cochlear implantation may be more common than previously thought. We demonstrate rates of migration congruous with current literature; this is despite robust and varied fixation techniques. Notable in our series is that all true captured migrations were seen exclusively in straight arrays. The majority of patients in the possible and confirmed migration group had normal inner ear anatomy. CONCLUSION: Suboptimal electrode position following cochlear implant surgery is a recognized complication and can affect implant performance. Reporting may increase with more widespread use of sophisticated post-operative imaging. Use of a pre-curved electrode and routine use of appropriate fixation techniques may reduce migration rates.

Recurrent Swelling in Pediatric Cochlear Implant Patients.

OBJECTIVE: To determine the prevalence, characteristics, and outcomes of pediatric patients with recurrent swelling over their cochlear implant receiver package. STUDY DESIGN: Retrospective case review. SETTING: Tertiary referral center. PATIENTS: A total of 332 bilateral cochlear implant patients under the age of 18 years were reviewed. Twelve patients with more than one episode of swelling around their cochlear implant receiver package were isolated. Patients with clinical evidence of infection were excluded from the study. The etiology of hearing loss was heterogeneous. INTERVENTION: Three patients underwent ultrasound, and three patients underwent bedside aspiration. Most patients were treated with 7 days of oral broad-spectrum antibiotics. MAIN OUTCOME MEASURE: Incidence, frequency, and course of recurrent swelling around cochlear implant receiver packages. RESULTS: The first swelling appeared between 0.86 and 9.95 years after surgery (mean, 3.38), and the occurrence of the last episode ranged from 0.06 to 3.42 years from the current date (mean, 1.04). The total number of episodes ranged from 2 to 18 (mean, 6). Seven patients had unilateral swellings, and five had bilateral swellings. Swellings were associated with upper respiratory tract infection or minor trauma, or had no identifiable cause. Aspiration in three cases showed evidence of altered blood. CONCLUSIONS: Recurrent otherwise asymptomatic swelling over cochlear implant receiver packages in children is more common than initially thought. Possible causes include hematoma and seroma secondary to upper respiratory tract infection. The incidence and the timing of swelling are variable. There were no swelling-related device failures or reimplantations so patients and parents can be reassured about the long-term outcome.

Systematic review of the diagnosis and management of necrotising otitis externa: Highlighting the need for high-quality research.

OBJECTIVES: To present a systematic review and critical analysis of clinical studies for necrotising otitis externa (NOE), with the aim of informing best practice for diagnosis and management. DESIGN: Medline, Embase, Cochrane Library and Web of Science were searched from database inception until 30 April 2021 for all clinical articles on NOE. The review was registered on PROSPERO (ID: CRD42020128957) and conducted in accordance with PRISMA guidelines. RESULTS: Seventy articles, including 2274 patients were included in the final synthesis. Seventy-three percent were retrospective case series; the remainder were of low methodological quality. Case definitions varied widely. Median patient age was 69.2 years; 68% were male, 84% had diabetes and 10% had no reported immunosuppressive risk factor. Otalgia was almost universal (96%), with granulation (69%) and oedema (76%) the commonest signs reported. Pseudomonas aeruginosa was isolated in 62%, but a range of bacterial and fungal pathogens were reported and 14% grew no organism. Optimal imaging modality for diagnosis or follow-up was unclear. Median antimicrobial therapy duration was 7.2 weeks, with no definitive evidence for optimal regimens. Twenty-one percent had surgery with widely variable timing, indication, or procedure. One-year disease-specific mortality was 2%; treatment failure and relapse rates were 22% and 7%, respectively. CONCLUSION: There is a lack of robust, high-quality data to support best practice for diagnosis and management for this neglected condition. A minimum set of reporting requirements is proposed for future studies. A consensus case definition is urgently needed to facilitate high-quality research.

Do Filling Defects of the Vestibule Represent a Neuroradiological Marker for Congenital Cytomegalovirus? A Retrospective Case Series.

INTRODUCTION: The aim of this study was to investigate whether radiological marker(s) of the inner ear can be detected in congenital cytomegalovirus (cCMV) patients with severe-profound sensorineural hearing loss. METHODS: A retrospective imaging review of confirmed cCMV paediatric patients that had undergone consecutive cochlear implantation was performed at a tertiary hospital. Available pre- and postoperative imaging was examined, and abnormalities of the labyrinth were catalogued by a consultant neuroradiologist in the study group and control group. RESULTS: Twenty-eight paediatric patients with cCMV having undergone cochlear implantation were identified between the ages of 1-15 years (mean 4.7 years) at the time of implantation. Increased density of the vestibule on computed tomography (CT) or filling defects of the vestibule on magnetic resonance imaging (MRI) were identified in 11 and 4 patients, respectively, of the 24 in the case series. No filling defects were identified in any of the 48 CT and MRI control group. CONCLUSION: This study demonstrates a potential novel radiological finding of the inner ear of patients with cCMV. With more research, greater onus placed on MRI and CT for inner ear assessment may facilitate early detection and treatment for patients at risk of significant hearing loss. Further prospective studies in this area will help to validate radiological markers in order to establish a comprehensive inner ear classification system for neuroradiological features in cCMV.

Cochlear implant outcomes in patients with Meniere's disease: a large case series.

OBJECTIVE: To perform a matched cohort study to assess whether patients with Meniere's Disease (MD) require more intensive auditory rehabilitation following cochlear implantation (CI) and identify factors that may affect outcomes in patients with MD. METHODS: A retrospective case review was performed. MD and control patients were matched for age, biological sex, implant manufacturer and electrode design. Outcomes measured were speech scores, number of visits to audiology department following switch-on, and post-operative active MD. RESULTS: Forty consecutive implanted MD patients were identified between May 1993 and May 2019. Patients with active MD following CI required significantly more visits to the audiology department compared to controls (P < 0.01) and patients who had inactive MD post-operatively (P < 0.01). However, in MD patients, active MD was less likely following CI (P = 0.03). In patients who continued to experience active MD post-operatively, further medical and surgical ablative intervention was required to control ongoing Meniere's attacks. CONCLUSION: We present the largest case series of performance outcomes in CI patients with MD. Although speech outcomes in MD patients are comparable to controls, patients with active MD pre-operatively are more likely to experience variation in CI performance requiring a prolonged period of auditory rehabilitation compared to inactive preoperative MD.

Endoscopic ear surgery: A case series and first United Kingdom experience.

AIM: To present the United Kingdom's first case series of 70 otological cases of endoscopic and non-endoscopic ear surgeries. METHODS: Prospective case series incorporating a range of endoscopic procedures performed using a 4 mm, 18 cm rigid endoscope, performed by a single surgeon at a single centre. Primary outcome measures included mean average pre and post-operative air-bone gap hearing thresholds and duration of surgery. RESULTS: Thirty-eight patients underwent endoscopic assisted ear surgery and 32 underwent non-endoscopic assisted ear surgery. In both surgical groups, there was a significant difference between pre and post-operative mean air-bone gaps (P = 0.02). Mean operating time was comparable between both groups. Eight patients developed post-operative complications. CONCLUSION: Endoscopic ear surgery can be performed safely in a range of otological procedures. This has the potential to become a well-established surgical option for middle ear surgery in the near future. Advantages and limitations are discussed.

A rare stapes abnormality.

The aim of this study is to increase awareness of rare presentations, diagnostic difficulties alongside management of conductive hearing loss and ossicular abnormalities. We report the case of a 13-year-old female reporting progressive left-sided hearing loss and high resolution computed tomography was initially reported as normal. Exploratory tympanotomy revealed an absent stapedius tendon and lack of connection between the stapes superstructure and footplate. The footplate was fixed. Stapedotomy and stapes prosthesis insertion resulted in closure of the air-bone gap by 50 dB. A review of world literature was performed using MedLine. Middle ear ossicular discontinuity can result in significant conductive hearing loss. This can be managed effectively with surgery to help restore hearing. However, some patients may not be suitable or decline surgical intervention and can be managed safely conservatively.

Stump appendicitis: a review.

Acute appendicitis is perhaps the commonest cause of acute abdomen and surgical intervention in the form of open or laparoscopic appendicectomy. Stump appendicitis is an uncommon late complication of appendicectomy; where inflammation occurs in the remaining appendicular stump. Delayed diagnosis of this condition may result in serious complications. This literature review has looked into the clinical presentation, diagnosis and treatment of Stump appendicitis.

Lesson of the month (1). Homonymous left hemianopia secondary to traumatic extracranial vertebral artery dissection.

This lesson reports the case of a 32-year-old female presenting with left-sided homonymous hemianopia after a road traffic accident. A diagnosis of vertebral artery dissection (VAD) was missed at presentation after an initial computed tomography head scan was normal. Later, VAD was confirmed on neck magnetic resonance imaging. VAD is an uncommon cause of stroke in the young and, to date, there are no current emergency guidelines available for the management of patients with the condition.