Online training for hearing implant surgery : A new approach to otological training.

OBJECTIVE: Education in microsurgery of the ear includes staged training to allow for mastering of the complex microsurgical procedures, particularly in the context of middle ear reconstruction and cochlear implantation. Traditional surgical training includes temporal bone preparations by cadaver dissection and supervised operating room practice. As these on-site trainings are limited, there is a need to broaden education facilities in an on-line format. Therefore, a first basic on-line training for otosurgery was developed. MATERIALS AND METHODS: The system consists of an artificial temporal bone model together with a set of basic surgical instruments and implant dummies. As an essential part of the training kit, a high-resolution camera set is included that allows for connection to a video streaming platform and enables remote supervision of the trainees' surgical steps by experienced otological surgeons. In addition, a pre-learning platform covering temporal bone anatomy and instrumentation and pre-recorded lectures and instructional videos has been developed to allow trainees to review and reinforce their understanding before hands-on practice. RESULTS: Over the three courses held to date, 28 participants with varying levels of prior surgical experience took part in this otological surgical training program. The immediate feedback of the participants was evaluated by means of a questionnaire. On this basis, the high value of the program became apparent and specific areas could by identified where further refinements could lead to an even more robust training experience. CONCLUSION: The presented program of an otosurgical online training allows for basal education in practical exercises on a remote system. In this way, trainees who have no direct access to on-site instruction facilities in ear surgery now have the chance to start their otosurgical training in an educational setting adapted to modern technologies.

[Online training for hearing implant surgery : A new approach to otological training. German version]. / Online-Training für Hörimplantatchirurgie : Ein neuer Ansatz in der otologischen Ausbildung.

OBJECTIVE: Education in microsurgery of the ear includes staged training to allow for mastering of the complex microsurgical procedures, particularly in the context of middle ear reconstruction and cochlear implantation. Traditional surgical training includes temporal bone preparations by cadaver dissection and supervised operating room practice. As these on-site trainings are limited, there is a need to broaden education facilities in an on-line format. Therefore, a first basic on-line training for otosurgery was developed. MATERIALS AND METHODS: The system consists of an artificial temporal bone model together with a set of basic surgical instruments and implant dummies. As an essential part of the training kit, a high-resolution camera set is included that allows for connection to a video streaming platform and enables remote supervision of the trainees' surgical steps by experienced otological surgeons. In addition, a pre-learning platform covering temporal bone anatomy and instrumentation and pre-recorded lectures and instructional videos has been developed to allow trainees to review and reinforce their understanding before hands-on practice. RESULTS: Over the three courses held to date, 28 participants with varying levels of prior surgical experience took part in this otological surgical training program. The immediate feedback of the participants was evaluated by means of a questionnaire. On this basis, the high value of the program became apparent and specific areas could by identified where further refinements could lead to an even more robust training experience. CONCLUSION: The presented program of an otosurgical online training allows for basal education in practical exercises on a remote system. In this way, trainees who have no direct access to on-site instruction facilities in ear surgery now have the chance to start their otosurgical training in an educational setting adapted to modern technologies.

[Increasing incidence of mastoidectomies in children : Result of reduced antibiotic therapy or late COVID-19 sequela?] / Steigende Inzidenzen bei Mastoidektomien im Kindesalter : Folge geringeren Antibiotikaeinsatzes oder eine COVID-19-Spätfolge?

BACKGROUND: An increasing number of pediatric patients with mastoiditis and a consequent increase in mastoidectomy rates was noted in 2022 and 2023. OBJECTIVE: This study aimed to analyze the increase in the number of children presenting with mastoiditis and subsequent mastoidectomy, to assess correlations with prior antibiotic treatment or COVID-19 infection, and to provide an overview of involved pathogens, treatment, and disease course. MATERIALS AND METHODS: A retrospective analysis of all patients with mastoidectomy since 2012 was conducted. Data collected comprised type and duration symptoms, prior antibiotic therapy, diagnostic tests and disease course, causal pathogens, length of hospitalization, and complications. RESULTS: A highly significant increase in mastoidectomies in children could be demonstrated from 2022. Neither the pathogens involved nor the course of disease or complications showed differences. An increase in the number of patients with prior outpatient antibiotic therapy could be shown. About a half of the patients becoming ill after fall 2022 had a positive history of COVID. Hyperplasia of adenoid tissue was a far less frequent causal mechanism than in the years before COVID. CONCLUSION: No clear correlation with reduced outpatient antibiotic therapy could be found. Whether there exists an association with prior COVID infection cannot be judged at this time, due to the high number of asymptomatic and therefore unknown COVID infections.

A novel imaging scoring method for identifying facial canal dehiscence: an ultra-high-resolution CT study.

OBJECTIVES: Facial canal dehiscence (FCD), typically found in the tympanic segment, is a risk factor for facial nerve injury. An imaging scoring method was proposed to identify FCD based on ultra-high-resolution CT. METHODS: Forty patients (21 females and 19 males, mean age 44.3 ± 17.4 years), whose tympanic facial canal (FC) was examined during otological surgery, were divided into the FCD group (n = 29) and the control group (n = 11) based on surgical findings. Imaging appearance of tympanic FC was scored 0-3: 0 = no evident bony covering, 1 = discontinuous bony covering with linear deficiency, 2 = discontinuous bony covering with dotted deficiency, and 3 = continuous bony covering. Both lateral and inferior walls were assigned a score as LFCD and IFCD, respectively. An FCD score was calculated as LFCD + IFCD. The diagnostic value of the FCD score was tested using the ROC curve. RESULTS: The inter-observer agreement was moderate for the lateral wall (Cohen's κ coefficient 0.416, 95% CI 0.193-0.639), and good for the inferior wall (Cohen's κ coefficient 0.702, 95% CI 0.516-0.888). In the FCD group, the most common appearance for both walls was discontinuous bony covering with linear deficiency (LFCD = 1, 22/29, 75.9%; IFCD = 1, 15/29, 51.7%). An FCD score of less than 4 was associated with high sensitivity (0.82) and specificity (0.93) for identifying FCD, with an AUC of 0.928. CONCLUSIONS: Using the proposed scoring method, FCD score < 4 could identify FCD of the tympanic segment with high concordance with surgical findings. KEY POINTS: • Imaging appearance of the tympanic facial canal (FC) is divided into four types based on ultra-high-resolution CT images. • The most common appearance of FC with facial canal dehiscence (FCD) is discontinuous bony covering with linear deficiency. • An FCD score, consisting of scores of the lateral and inferior walls, less than 4 is highly indicative of FCD.

PROPELLER diffusion weighted imaging for diagnosis of cholesteatoma in comparison with surgical and histopathological results: emphasis on false positivity and false negativity.

PURPOSE: To investigate the role of non-echo planar diffusion weighted imaging (DWI) using "periodically rotated overlapping parallel lines with enhanced reconstruction" (PROPELLER) sequence for the diagnosis of cholesteatoma compared to surgical and histopathological results in an attempt to determine the factors causing false negative and false positive diagnoses. METHODS: Patients who had PROPELLER DWI before ear surgery were retrospectively reviewed. The presence of a lesion with diffusion restriction on PROPELLER DWI was accepted as positive for cholesteatoma, and the results were compared to the intraoperative and histopathological findings. RESULTS: A total of 112 ears in 109 patients were reviewed. On PROPELLER DWI, a lesion with diffusion restriction was found in 101 (90.2%) ears, while in 11 (9.8%) of the patients, no diffusion restriction was found. Surgery and histopathological analysis revealed a cholesteatoma in 100 (89.3%) ears, while in 12 (10.7%) ears, no cholesteatoma was found surgically. There were 96 (85.7%) true positives, 7 (6.2%) true negatives, 5 (4.5%) false positives and 4 (3.6%) false negatives. The accuracy, sensitivity, specificity, positive predictive and negative predictive values of non-echo planar DWI were calculated to be 91.96%, 96%, 58.33%, 95.05%, and 63.64%, respectively. CONCLUSION: Non-echo planar DWI using PROPELLER sequence has high accuracy, sensitivity and positive predictive value and can be used for the detection of cholesteatoma. The external auditory canal, postoperative ears and small lesions should be evaluated with caution to avoid false results.

[Revision surgery after stapedectomy]. / Revisionsoperationen nach Stapesplastik.

Revision stapes surgery is considered to be significantly more demanding than primary stapes surgery, both in terms of the indication and the surgical approach. This article reviews common indications for revision after stapedectomy as well as the surgical approaches and intraoperative findings. A distinction is made between revision surgeries, which are usually carried out because of conductive hearing loss a long time after stapes surgery, and acute or subacute revisions that become necessary in the immediate postoperative course. With the shortening of postoperative observation times under inpatient conditions as a result of increasing economization and the associated shift of the immediate postoperative phase to the outpatient setting, the recognition of postoperative irregularities is also becoming increasingly important for otorhinolaryngologists in private practice, even if they do not perform these highly specialized interventions themselves.

Audiological characteristics and effect of endoscopic surgery for simple congenital malformation of ossicular chain.

OBJECTIVE: To analyze the audiological characteristics and surgical results in patients undergoing surgery for simple congenital ossicular chain malformation, and the effect of endoscopic surgery. METHODS: A retrospective review was performed on 86 patients who underwent surgery for the congenital malformation of the ossicular chain. Clinical characteristics and audiometric data were analyzed. Fifty-eight patients had detailed postoperative data, and the preoperative and postoperative audiometric results were compared. The subjects were further divided into endoscopic and microscopic groups, and their surgical effects were examined. RESULTS: The preoperative audiometry results in the low-frequency group were worse than those in the high-frequency group (P < 0.05). A postoperative air-bone gap closure to 20 dB or less was achieved in 73.33% of the 60 ears of patients postoperatively. The postoperative air conduction and air-bone gap were significantly better than the preoperative ones (P < 0.05), and the improvement effect was the best in class III patients (P < 0.05). Postoperative hearing had no significant differences between the endoscopic and microscopic groups. However, endoscopic surgery also was more advantageous in terms of operating time (P < 0.05). CONCLUSIONS: Preoperative pure tone audiometric results showed moderate or moderate-severe hearing loss, especially in the low-frequency area. The reconstruction of the auditory ossicle chain can achieve satisfactory results, especially in class III patients. Endoscopic and microscopic surgery in the treatment of simple congenital ossicular chain malformations can effectively improve postoperative hearing.

Validation of the novel Deep Reality Viewer (DRV) 3D digital stereo viewer in otology surgery.

PURPOSE: Magnification with accurate optic reproduction of the surgical field is essential in otology surgery, but current technologies are subject to specific disadvantages. This study aims to evaluate a novel 3D digital stereo viewer, the Deep Reality Viewer (DRV), in otology surgery, in comparison to both a 2D monitor and the gold standard of microscopy. METHODS: In this prospective clinical research study, ENT consultants and trainees evaluated visual and practical applications of the DRV. In visual assessment, participants (n = 11) viewed pre-recorded in vivo mastoid exploration displayed on a 2D monitor and the DRV screen. In practical assessment, participants (n = 9) performed otology surgical tasks on a cadaveric human head using both the microscope and DRV. Face, task-specific (TSV) and global content (GCV) outcomes were assessed using 5-point Likert scale questionnaires. Construct validity was assessed separately. RESULTS: The DRV achieved the pre-determined validation threshold of 4 for all validation parameters in both visual and practical assessment. The DRV significantly outperformed the 2D monitor in fourteen of 16 parameters. In comparison to microscopy, there was no significant difference in 13 of 16 parameters, with the DRV significantly outperforming in the remaining 3: defining anatomy (GCV), assessing middle ear anatomy (TSV) and overall TSV. Construct validity was not demonstrated for either technology. CONCLUSION: The DRV achieved the validation threshold for all parameters, and outperformed the 2D monitor and microscopy in several parameters. This validates the DRV for performing otological procedures, and suggests that it would be a useful alternative to the gold standard of microscopy in otology surgery. LEVEL OF EVIDENCE: N/A.

[Low-grade (polymorphous) adenocarcinoma of the middle ear mimicking a jugulotympanic paraganglioma. German version]. / (Polymorphes) Low-Grade-Adenokarzinom des Mittelohrs als Imitator eines jugulotympanalen Paraganglioms.

A 64-year-old female patient presented with otalgia and hearing loss in the right ear. On otoscopy, the right tympanic membrane was highly vascularized and bulged into the anteroinferior quadrant. High-resolution computed tomography revealed an osteolytic lesion with occupation of the hypotympanum extending into the petrous apex and right parapharyngeal space as well as infiltration of the wall of the right internal carotid artery. MRI strengthened the suspicion of a jugulotympanic paraganglioma. The biopsy material obtained through exploratory tympanotomy was assessed as a low-grade polymorphic adenocarcinoma. The tumor was treated with definitive chemoradiotherapy. Posttherapeutic imaging after 4 months did not show any evidence of tumor progression.

Introducing the High-definition 3D exoscope in ear surgery: preliminary analysis of advantages and limits compared with operative microscope.

PURPOSE: The aim of this study was to evaluate the potential of 3D exoscope (EX) in selected ear procedures assessing if this new technology could be an improvement in the field of ear surgery. METHODS: A case series of consecutive patients surgically treated with a post-auricular approach using EX was retrospectively compared with a similar previous series treated with operating microscope (OM). Patient demographics, indications for surgery, procedure type, complications, operating room setting time (ORst), operative time, adequacy of visualization, image quality, ergonomics aspects, instrument usability, and technique as a teaching tool were investigated. Thirteen patients were included in each group. Surgical procedures in EX group were nine tympanoplasties with mastoidectomy, 1 mastoidectomy for acute complicated mastoiditis, 1 revision miringoplasty, and 2 cochlear implants. Same types of procedures were enrolled in OM group. RESULTS: No statistically significant difference was found between the two groups concerning ORst and operative time. In EX group, one complication occurred--a middle cranial fossa cerebrospinal fluid leak. Advantages of EX were lightness, maneuverability and compactness, less need of endoscopy during surgery, and teaching potential. Limits were a need of a large surgical corridor and the bright structures rendering in high magnification. CONCLUSION: EX resulted safe and efficient in treating diseases of the middle ear in post-auricular approaches. To date, EX advantages are not enough to abandon the OM, and it can be considered as an additional, innovative tool to be added to ear surgical equipment.

Low-grade (polymorphous) adenocarcinoma of the middle ear mimicking a jugulotympanic paraganglioma.

A 64-year-old female patient presented with otalgia and hearing loss in the right ear. On otoscopy, the right tympanic membrane was highly vascularized and bulged into the anteroinferior quadrant. High-resolution computed tomography revealed an osteolytic lesion with occupation of the hypotympanum extending into the petrous apex and right parapharyngeal space as well as infiltration of the wall of the right internal carotid artery. MRI strengthened the suspicion of a jugulotympanic paraganglioma. The biopsy material obtained through exploratory tympanotomy was assessed as a low-grade polymorphic adenocarcinoma. The tumor was treated with definitive chemoradiotherapy. Posttherapeutic imaging after 4 months did not show any evidence of tumor progression.

[Surgical strategy of minimally invasive cochlear implantation].

Cochlear implantation is currently the most effective treatment for patients with severe-to-profound sensorineural hearing loss. How to achieve minimally invasive treatment, preserve the residual hearing, and further improve curative effect and reduce surgical complications is the goal of cochlear implantation practice. This article introduces the minimally invasive cochlear implantation technique in terms of the idea of minimally invasive operation, the advantages of electric acoustic stimulation, the key points of electrode implantation technique, the design of surgical incision, and the precise processing of perioperative period. This technique not only has the merits of less operative damage and better hearing and speech rehabilitation after surgery, but also reserves favorable structures and function for the future application of gene therapy and hair cell regeneration technique. Therefore, it is strongly recommended for further promotion in clinical practice.

Preparing the surgical area for non-shaved ear surgery: a clinical assessment.

OBJECTIVE: To review the clinical experience for non-shaved middle ear/mastoid surgery and evaluate the proper method of preparing the postauricular surgical field. METHODS: This retrospective study reviewed medical records of cases where the non-shaved surgical procedure was carried out for middle ear/mastoid diseases. In all cases, middle ear and mastoid surgery was performed by one otologic surgeon without hair shaving to treat chronic perforation of tympanic membrane, as well as chronic suppurative otitis media, with or without mastoiditis during two years. The prevalence of surgical site infection (SSI) and bacterial culture of the surgical field was assessed just before the skin incision. RESULTS: In this review of 106 cases, the SSI rate was 1.6% for the non-shaved ear surgery. Bacterial colonisation was found on the prepared surgical field in 8.5% of cases and these bacteria was different from true pathogens. SSI of the skin incision occurred in two cases, although no bacterial colonisation of the non-shaved surgical field was found. The surgical exposure of postauricular area was enough to do tympanoplasty or tympanomastoidectomy, even though in cases where a hairline was close to postauricular sulcus. CONCLUSION: This study showed that when preparing the non-shaved ear surgery, the surgeons should not have to worry about skin contamination by hair. We suggest that the non-shaved ear surgery would appear to be preferable for the postauricular approach.

The effect of ventilation tube insertion on quality of life in children with persistent otitis media with effusion.

OBJECTIVES: To determine the effect of ventilation tube (VT) surgery on quality of life (QoL) in children with persistent otitis media with effusion (OME). DESIGN: Secondary analysis of trial data (oral steroids versus placebo for persistent OME), comparing QoL by history of VT surgery performed between 5 weeks and 12 months post-randomisation. Multilevel regression models were used to identify the association between VT surgery and QoL scores at 12 months, controlling for pre-exposure risk factors associated with surgery, including pre-surgery hearing level. SETTING: Ear, nose and throat (ENT), paediatric audiology and audiovestibular medicine (AVM) departments in Wales and England. PARTICIPANTS: A total of 327 children aged 2-8 years with OME symptoms for at least three months and audiometry-proven bilateral hearing loss with VT surgery status. MAIN OUTCOME MEASURES: Otitis Media questionnaire (OM8-30) and Paediatric Quality of Life Inventory (PedsQL) total and subscale scores, and the Health Utilities Index Mark 3 (HUI3) at 12 months post-randomisation. RESULTS: Participants who had VT surgery had no significant difference in OM8-30, PedsQL or HUI total scores. OM8-30 hearing difficulty (HD) subscale scores at 12 months were better in those who had VT surgery (adjusted mean difference (aMD) = -0.46 (95% confidence interval: -0.69 to -0.23), P < .001), and this varied by when the surgery occurred (aMD for surgery between 5 weeks and 6 months = -0.4 [-0.67 to -0.13], P = .004 and between 6 and 12 months = -0.54, [-0.87 to -0.22], P = .001). CONCLUSION: Ventilation tube surgery was associated with an improvement in HD-related functional health status but no change in overall QoL.

Implantation of a new active bone conduction hearing device with optimized geometry.

Here, we describe the surgical technique for implanting a new, active, transcutaneous bone conduction hearing aid. The implant technology is based on a system that has been in use reliably since 2012. The geometry of the new implant has been adapted based on experience with previously introduced implants. The surgery was feasible, standardized, and safe. Due to the optimized geometric design that improved the bone fit, it is not necessary to use specialized, detailed preoperative planning, except in challenging anatomical conditions; e.g., in young children, malformations, poor pneumatization, or after a canal wall down mastoidectomy.

[Implantation of a new active bone conduction hearing device with optimized geometry. German version]. / Implantation eines neuen, aktiven, knochenverankerten elektronischen Hörimplantats mit verkleinerter Geometrie.

Here, we describe the surgical technique for implanting a new, active, transcutaneous bone conduction hearing aid. The implant technology is based on a system that has been in use reliably since 2012. The geometry of the new implant has been adapted based on experience with previously introduced implants. The surgery was feasible, standardized, and safe. Due to the optimized geometric design that improved the bone fit, it is not necessary to use specialized, detailed preoperative planning, except in challenging anatomical conditions; e.g., in young children, malformations, poor pneumatization, or after a canal wall down mastoidectomy.

[Global surgery from an otorhinolaryngological perspective]. / "Global surgery" aus otorhinolaryngologischer Sicht.

Since the middle of this century, the United Nations (UN) has paid increasing attention to the surgical care of the worldwide population, with the aim of global access to basic surgical procedures ("global surgery") in the future. The current article describes models for training and continuing education of "global surgeons," with a focus on activities in the field of otolaryngology. The diagnostic inventory in which the global surgeon should be educated is presented. Lists of indications and operative procedures the global surgeon should master are suggested, as are the limits of his/her actions. The surgical instruments required by the global surgeon are summarized in a table, whereby their description is oriented toward the different individual anatomic regions relevant to the otorhinolaryngologist. The paper concludes with an outlook devoted particularly to the idealized vision of availability of global surgery in the future.

The effect of light intensity on image quality in endoscopic ear surgery.

OBJECTIVES: Endoscopic ear surgery is a rapidly developing field with many advantages. But endoscopes can reach temperatures of over 110°C at the tip, raising safety concerns. Reducing the intensity of the light source reduces temperatures produced. However, quality of images at lower light intensities has not yet been studied. We set out to study the effect of light intensity on image quality in EES. DESIGN: Prospective study of patients undergoing EES from April to October 2016. Consecutive images of the same operative field at 10%, 30%, 50% and 100% light intensities were taken. Eight international experts were asked to each evaluate 100 anonymised, randomised images. SETTING: District General Hospital. PARTICIPANTS: Twenty patients. MAIN OUTCOME MEASURES: Images were evaluated on a 5-point Likert scale (1 = significantly worse than average; 5 = significantly better than average) for detail of anatomy; colour contrast; overall quality; and suitability for operating. RESULTS: Mean scores for photographs at 10%, 30%, 50% and 100% light intensity were 3.22 (SD 0.93), 3.15 (SD 0.84), 3.08 (SD 0.88) and 3.10 (SD 0.86), respectively. In ANOVA models for the scores on each of the scales (anatomy, colour contrast, overall quality and suitability for operating), the effects of rater and patient were highly significant (P < .0005) but light intensity was non-significant (P = .34, .32, .21, .15, respectively). CONCLUSION: Images taken during surgery by our endoscope and operative camera have no loss of quality when taken at lower light intensities. We recommend the surgeon considers use of lower light intensities in endoscopic ear surgery.

Systematic radiographic evaluation of three potential implantation sites for a semi-implantable bone conduction device in 52 patients after previous mastoid surgery.

The aim of this study was the evaluation of three localizations for the implantation of a semi-implantable transcutaneous bone conduction device after previous mastoid surgery. This is a retrospective review of electronic datasets of cranial computed tomography studies. The study setting is one tertiary referral center and included 52 consecutive adult patients (60 temporal bones) with a history of mastoid surgery. The intervention was virtual placement of the device with a planning software within the remaining mastoid as well as dorsal of the sigmoid sinus and caudal of the transverse sinus (retrosigmoidal localization) and dorsocranial of the parietomastoid suture and cranial of the transverse sinus (parietal localization). The main outcome measure included dimensions of the bone for the reception of implant and screws, relative localization of dura mater or sinus sigmoideus, distance to the cochlea, thickness of the epicranium and classification of implantation as possible or impossible. Implantation within the remaining mastoid was deemed possible in 35 mastoid bones (58.3%). The best-suited alternative localization was retrosigmoidal in 22 (42.3%) and parietal in 29 patients (55.8%). The mean distance from the implantation site to the cochlea was lowest with on average 41.2 ± 3.1 mm from within the remaining mastoid. The differences in distance from the cochlea to the alternative localizations were each statistically significant (p < 0.01, ANOVA/Bonferroni t test). The retrosigmoidal and parietal localizations are suitable alternative implantation sites. The application of spacers may prevent contact to the sinuses or dura. Preoperative CT-based planning is recommended in cases of previous mastoid surgery. LEVEL OF EVIDENCE: 4 (case series).

[Biological therapies in otology. German version]. / Biologische Therapien in der Otologie.

Millions of people worldwide suffer from hearing loss. Current treatment for patients with severe to profound hearing loss consists of cochlear implants. Providing the cochlear nerve is intact, patients generally benefit enormously from this intervention, frequently achieving significant improvements in speech comprehension. There are, however, some cases where current technology does not provide patients with adequate benefit. New therapeutic concepts based on cell transplantation and gene therapy are developing rapidly, at least in the research sector. Compared to the wealth of basic research available in this area, translation of these new experimental approaches into clinical application is presently at a very early stage. The current review focuses on translatable treatment concepts and discusses the barriers that need to be overcome in order to translate basic scientific research into clinical reality. Furthermore, the first examples of clinical application of biological therapies in severe hearing loss are presented, particularly in connection with cochlear implants.