Delaying Cochlear Implantation Impacts Postoperative Speech Perception of Nontraditional Pediatric Candidates.

INTRODUCTION: As pediatric cochlear implant (CI) candidacy expands, children with greater degrees of residual hearing are receiving CIs. These nontraditional candidates have audiometric thresholds that meet adult manufacturer labeling but are better than current pediatric guidelines allow. The purpose of this study was to determine the impact of delayed cochlear implantation on speech perception in nontraditional pediatric CI recipients. METHODS: Pediatric CI recipients with a history of progressive hearing loss and a preoperative 4-frequency pure-tone average of ≤75 dB HL at the time of implantation were considered for this retrospective study. Preoperative serial audiograms and word recognition scores were reviewed, and a method was created to establish a date when each individual ear 1st met nontraditional candidacy. The length of time between the date of candidacy and implantation was calculated and defined as the "delay time." A multiple linear regression investigated delay time, age at surgery, surgery type (1st vs. 2nd side), and array type as predictive factors of maximum postoperative Consonant-Nucleus-Consonant (CNC) word scores. A one-way ANCOVA was performed comparing the postoperative CNC scores between subjects grouped by delay time. RESULTS: A significant regression was found (F(4, 38) = 5.167, p = 0.002, R2 = 0.353). Both age at implantation (p = 0.023) and delay time (p = 0.002) predicted CNC word scores. Longer delay time was associated with poorer word recognition scores, while older age at implantation correlated with higher CNC word scores in this progressive hearing loss group. A significant difference was noted between subjects implanted with <1 year of delay and those with 3 or more years of delay (p = 0.003). All ears implanted within a year of candidacy achieved word recognition abilities that are generally accepted as above average (M = 84.91). CONCLUSION: CI candidacy for adults has evolved to allow for greater degrees of residual hearing, while audiometric guidelines for children have not changed since 2000. Our findings suggest that delay of cochlear implantation, even for children with significant levels of residual hearing, leads to poorer outcomes. Modified candidacy guidelines for children should be established to expedite referral to multidisciplinary CI teams and minimize delays in this population.

Management of vestibular dysfunction and hearing loss in intralabyrinthine schwannomas.

PURPOSE: Intralabyrinthine schwannomas (ILS) are rare, benign, slow-growing tumors arising from schwann cells of the cochlear or vestibular nerves within the bony labyrinth. This study provides insight into the management of this rare tumor through a large case series. MATERIALS AND METHODS: After Institutional Review Board approval, a retrospective chart review was performed of all ILS patients treated at our institution between 2007 and 2019. RESULTS: 20 patients (9 male, 11 female) with ILS were managed at our institution. The right ear was affected in 9 patients (45%) and the left in 11 (55%). Subjective hearing loss was endorsed by all 20 patients. Average pure tone average at presentation was 72 dB nHL. Nine tumors (45%) were intravestibular, 6 (30%) were intracochlear, 4 (20%) were transmodiolar and 1 (5%) was intravestibulocochlear. Hearings aids were used in 3 patients (15%), BiCROS in 2 (10%), CI in 2 (10%), and bone conduction implant in 1 (5%). Vestibular rehabilitation was pursued in 5 patients. Surgical excision was performed for one patient (5%) via translabyrinthine approach due to intractable vertigo. No patients received radiotherapy or intratympanic gentamicin injections. CONCLUSION: ILS presents a diagnostic and management challenge given the similarity of symptoms with other disorders and limited treatment options. Hearing loss may be managed on a case-by-case basis according to patient symptoms while vestibular loss may be mitigated with vestibular therapy. Surgical excision may be considered in patients with intractable vertigo, severe hearing loss with concurrent CI placement, or in other case-by-case situations.

Absent pyramidal eminence and stapedial tendon associated with congenital stapes footplate fixation: Intraoperative and radiographic findings.

OBJECTIVE: Report an association between congenital stapes footplate fixation (CSFF) and radiological absence of the pyramidal eminence and stapedial tendon. PATIENTS: Children and adults with intraoperatively confirmed CSFF and an absent stapedial tendon. INTERVENTIONS: Computed tomography (CT); exploratory tympanotomy with stapedotomy. MAIN OUTCOME MEASURES: Absence of a pyramidal eminence and stapedial tendon aperture identified on preoperative CT that was confirmed intraoperatively. RESULTS: Eight patients with intraoperative confirmation of CSFF and absent stapedial tendon were retrospectively identified. The average preoperative bone conduction and air conduction pure tone averages were 19.6 dB (SD 15.6 dB) and 55.9 dB (SD 23.6 dB), respectively. The average air-bone gap was 36.3 dB (SD 17.9 dB) preoperatively. In the seven patients who underwent preoperative CT, all were consistently identified to have an absent or hypoplastic pyramidal eminence and absent stapedial tendon aperture at the pyramidal eminence. In six cases, the stapedial footplate appeared normal, while in one case the footplate appeared abnormal which correlated with severe facial nerve prolapse observed intraoperatively. All eight cases underwent exploratory tympanotomy and demonstrated intraoperative stapes footplate fixation, absent stapedial tendon and either absent or hypoplastic pyramidal eminence, which correlated with preoperative CT findings. CONCLUSIONS: This study identifies a clinically pragmatic association between an absent pyramidal eminence identified on high-resolution CT and the diagnosis of CSFF. In a condition that otherwise generally lacks distinctive radiological features, the absence of a pyramidal eminence on CT in a patient with nonprogressive, congenital conductive hearing loss may strengthen clinical suspicion for CSFF.

Outcomes with Management of Cholesteatoma.

This article provides an expert summary of the immense amount of outcomes research in cholesteatoma surgery. Specific topics discussed include canal wall-up versus canal wall-down surgery, ossicular chain reconstruction, endoscopic ear surgery, disease-specific quality-of-life outcomes, and congenital cholesteatoma.

High Prevalence of Cochlear Nerve Deficiency in Pediatric Patients With Cochlear Aperture Stenosis.

OBJECTIVE: Cochlear nerve deficiency (CND) is a common radiologic finding among unilateral sensorineural hearing loss (USNHL) patients. It is generally detected with magnetic resonance imaging (MRI), which is associated with higher cost, less availability, and possible need for sedation. Therefore, identifying computed tomography (CT) findings, such as cochlear aperture stenosis (CAS), that can reliably predict CND is valuable. Our study aimed to determine the prevalence of CND in pediatric patients with CT-diagnosed CAS. STUDY DESIGN: Retrospective study. SETTING: Tertiary care center. METHODS: We included pediatric patients diagnosed with CAS on temporal bone CT and with available temporal bone MRI. For each patient, an otolaryngologist and a pediatric neuroradiologist measured the cochlear aperture width on CT to confirm CAS (cochlear aperture < 1.4 mm) and assessed the status of the cochlear nerve on MRI. RESULTS: Fifty-five patients, representing 65 ears, had CAS on CT measurement. Median cochlear aperture width in CAS ears was 0.70 mm (interquartile range [IQR]: 0.40-1.05 mm) versus 2.00 mm in non-CAS ears (IQR: 1.80-2.30 mm, P < .001). CND was found in 98.5% (n = 64/65) of CAS ears, while a normal cochlear nerve was found in 1.5% (n = 1/65) of CAS ears. CONCLUSION: CND is highly prevalent among pediatric patients with CAS. This suggests that MRI may not be needed to assess for CND in USNHL patients with CAS, as initial CT may provide sufficient information to determine cochlear implant candidacy. We recommend thoughtful shared decision-making with parents of USNHL patients when determining whether to pursue MRI in the setting of a CAS diagnosis.

Comparison of Speech Recognition and Hearing Preservation Outcomes Between the Mid-Scala and Lateral Wall Electrode Arrays.

OBJECTIVE: To assess speech recognition and hearing preservation (HP) outcomes with the Advanced Bionics Mid-Scala and SlimJ electrodes. STUDY DESIGN: Retrospective cohort. SETTING: Tertiary referral center. PATIENTS: A total of 237 adult patients implanted between 2013 and 2020 (Mid-Scala, n = 136; SlimJ, n = 101). MAIN OUTCOME MEASURES: Consonant-nucleus-consonant (CNC) and AzBio (Arizona Biomedical) scores at 6 and 12 months; postoperative HP, defined as low-frequency pure-tone average ≤ 80 dB HL; scalar position. RESULTS: Mean CNC scores did not significantly differ between Mid-Scala and SlimJ recipients at 6 (45.8% versus 46.0%, p = 0.962) and 12 (51.9% versus 48.8%, p = 0.363) months. Similarly, mean AzBio in quiet scores were equivalent for both groups at 6 (55.1% versus 59.2%, p = 0.334) and 12 (60.6% versus 62.3%, p = 0.684) months. HP rates were significantly higher with the SlimJ (48.4%) than the Mid-Scala (30.8%; p = 0.033). Scalar translocations were 34.8 and 16.1% for the Mid-Scala and SlimJ groups, respectively ( p = 0.019). Ears with postoperative HP had significantly fewer scalar translocations (16.7% versus 37.2%, p = 0.048), and postoperative HP was associated with higher AzBio in noise scores at the most recent follow-up interval (38.7% versus 25.1%, p = 0.042). CNC, AzBio in quiet and noise, low-frequency pure-tone average shifts, and PTA at 6 and 12 months were not significantly different between patients with scala tympani insertions of the SlimJ versus the Mid-Scala ( p > 0.05). CONCLUSIONS: Compared with the Mid-Scala, the lateral wall electrode has superior HP rates and fewer scalar translocations, whereas speech recognition scores are equivalent between both electrode arrays. These findings can help providers with electrode selection and patient counseling.

Evaluating calcium channel blockers and bisphosphonates as otoprotective agents in cochlear implantation hearing preservation candidates.

OBJECTIVES: Evaluate potential effects of calcium channel blockers (CCB) and bisphosphonates (BP) on residual hearing following cochlear implantation. METHODS: Medications of 303 adult hearing preservation (HP) candidates (low frequency pure tone average [LFPTA] of 125, 250, and 500 Hz ≤80 dB HL) were reviewed. Postimplantation LFPTA of patients taking CCBs and BPs were compared to controls matched by age and preimplantation LFPTA. RESULTS: Twenty-six HP candidates were taking a CCB (N = 14) or bisphosphonate (N = 12) at implantation. Median follow-up was 1.37 years (range 0.22-4.64y). Among subjects with initial HP, 29% (N = 2 of 7) CCB users compared to 50% (N = 2 of 4) controls subsequently lost residual hearing 3-6 months later (OR = 0.40, 95% CI = 0.04-4.32, p = 0.58). None of the four BP patients with initial HP experienced delayed loss compared to 50% (N = 2 of 4) controls with initial HP (OR = 0.00, 95% CI = 0.00-1.95, P = 0.43). Two CCB and one BP patients improved to a LFPTA <80 dB HL following initial unaided thresholds that suggested loss of residual hearing. DISCUSSION: There were no significant differences in the odds of delayed loss of residual hearing with CCBs or BPs. CONCLUSION: Further investigation into potential otoprotective adjuvants for maintaining residual hearing following initial successful hearing preservation is warranted, with larger cohorts and additional CCB/BP agents.

Improved Postoperative Speech Recognition and Processor Use With Early Cochlear Implant Activation.

OBJECTIVE: To report speech recognition outcomes and processor use based on timing of cochlear implant (CI) activation. STUDY DESIGN: Retrospective cohort. SETTING: Tertiary referral center. PATIENTS: A total of 604 adult CI recipients from October 2011 to March 2022, stratified by timing of CI activation (group 1: ≤10 d, n = 47; group 2: >10 d, n = 557). MAIN OUTCOME MEASURES: Average daily processor use; Consonant-Nucleus-Consonant (CNC) and Arizona Biomedical (AzBio) in quiet at 1-, 3-, 6-, and 12-month visits; time to peak performance. RESULTS: The groups did not differ in sex ( p = 0.887), age at CI ( p = 0.109), preoperative CNC ( p = 0.070), or preoperative AzBio in quiet ( p = 0.113). Group 1 had higher median daily processor use than group 2 at the 1-month visit (12.3 versus 10.7 h/d, p = 0.017), with no significant differences at 3, 6, and 12 months. The early activation group had superior median CNC performance at 3 months (56% versus 46%, p = 0.007) and 12 months (60% versus 52%, p = 0.044). Similarly, the early activation group had superior median AzBio in quiet performance at 3 months (72% versus 59%, p = 0.008) and 12 months (75% versus 68%, p = 0.049). Both groups were equivalent in time to peak performance for CNC and AzBio. Earlier CI activation was significantly correlated with higher average daily processor use at all follow-up intervals. CONCLUSION: CI activation within 10 days of surgery is associated with increased early device usage and superior speech recognition at both early and late follow-up visits. Timing of activation and device usage are modifiable factors that can help optimize postoperative outcomes in the CI population.

Investigating the Minimal Clinically Important Difference for AzBio and CNC Speech Recognition Scores.

OBJECTIVE: To assess the minimal clinically important difference (MCID) values for cochlear implant-related speech recognition scores, which have not been previously reported. STUDY DESIGN: Retrospective cohort. SETTING: Tertiary referral center. PATIENTS: Eight hundred sixty-three adult patients who underwent cochlear implantation between 2009 and 2022. MAIN OUTCOME MEASURES: MCID values for consonant-nucleus-consonant (CNC) word scores and AzBio sentences in quiet and noise scores using distribution-based methods (half-standard deviation, standard error of measurement, Cohen's d, and minimum detectable change). RESULTS: In this cohort, the mean preoperative CNC word score was 13.9% (SD, 15.6). The mean preoperative AzBio sentences in quiet score was 19.1% (SD, 22.1), and the mean preoperative AzBio sentences in noise score was 13.0% (SD, 12.0). The average MCID values of several distribution-based methods for CNC, AzBio in quiet, and AzBio in noise were 7.4%, 9.0%, and 4.9%, respectively. Anchor-based approaches with the Speech, Spatial, and Qualities of hearing patient-reported measure did not have strong classification accuracy across CNC or AzBio in quiet and noise scores (ROC areas under-the-curve ≤0.69), highlighting weak associations between improvements in speech recognition scores and subjective hearing-related abilities. CONCLUSIONS: Our estimation of MCID values for CNC and AzBio in quiet and noise allows for enhanced patient counseling and clinical interpretation of past, current, and future research studies assessing cochlear implant outcomes.

Correlation Between Quality of Life and Speech Recognition Outcomes Following Cochlear Implantation.

OBJECTIVE: To study the relationship between Cochlear Implant Quality of Life-10 Global (CIQOL-10) scores and speech recognition scores 6 and 12 months after cochlear implantation (CI) and to compare CIQOL-10 scores for patients who met the benchmark speech recognition scores with those who did not. STUDY DESIGN: Retrospective review. SETTING: Tertiary referral center. PATIENTS: One hundred twenty-four adults who underwent CI between 2018 and 2021 and completed a CIQOL-10 questionnaire at their 6- and/or 12-month postoperative visit. MAIN OUTCOME MEASURES: CIQOL-10, Consonant-Nucleus-Consonant (CNC) word, and AzBio in quiet and noise scores. RESULTS: At 6 months, weak positive correlations were found between CIQOL-10 and CNC (n = 78, r = 0.234, p = 0.039) and AzBio in quiet (n = 73, r = 0.293, p = 0.012) scores but not AzBio in noise scores (n = 39, r = 0.207, p = 0.206). At 12 months, weak positive correlations were found between CIQOL-10 and CNC (n = 98, r = 0.315, p = 0.002), AzBio in quiet (n = 88, r = 0.271, p = 0.011), and AzBio in noise (n = 48, r = 0.291, p = 0.045) scores. Patients who met the benchmark CNC scores had notably higher CIQOL-10 scores than those who did not at 6 months (52.0 vs 45.5, p = 0.008) and 12 months (52.0 vs 45.5, p = 0.003). A similar relationship was found for those who met the benchmark AzBio in quiet scores at both 6 months (52.0 vs 44.0, p = 0.006) and 12 months (52.0 vs 46.5, p = 0.011). CONCLUSION: CIQOL-10 scores have weak positive correlations with postoperative speech recognition outcomes at 6 and 12 months. This highlights the need for the continued use of quality-of-life measures, such as the CIQOL-10, in assessing CI outcomes to gain a more comprehensive understanding of patients' experiences.

Evaluating Risk of Noise-Induced Hearing Loss in Otologic Surgery.

OBJECTIVES: To evaluate risk for noise-induced hearing damage from otologic surgery-related noise exposure, given recent research indicating that noise levels previously believed to be safe and without long-term consequence may result in cochlear synaptopathy with subsequent degeneration of spiral ganglion neurons, degradation of neural transmission in response to suprathreshold acoustic stimuli, and difficulty understanding in background noise. METHODS: A prospective observational study of surgeon noise exposure during otologic and neurotologic procedures was performed in a tertiary care center. Surgeon noise exposure was recorded in A- and C-weighted decibel scales (dBA, dBC), including average equivalent (LAeq) and peak (LApeak, LCpeak) levels and noise dose. RESULTS: Sound measurements taken at the ear with continuous recording equipment during cadaveric otologic surgery demonstrated LAeq 80-83 dBA, LApeaks of 105 dBA, LCpeaks of 127 dBC, with noise doses of 0.9% to 6.7%. Sound level measurements during live surgery translabyrinthine approaches yielded lower LAeq of 72 to 74 dBA and lower noise doses compared with temporal bone lab measurements. Raw sound recordings during live surgery demonstrated narrow band, high frequency, high amplitude spikes between 4 and 12 kHz. CONCLUSION: Noise exposure to surgeons, staff, and patients in the operating room is acceptable per NIOSH recommendations. Temporal bone lab noise exposures are greater, possibly due to poorly maintained drill systems and lack of noise shielding from microscope bulk, yet are also within NIOSH recommended levels.

Cochlear Implantation in Very Young Children With Single-Sided Deafness.

OBJECTIVE: Cochlear implants (CIs) for single-sided deafness (SSD) have only been approved for patients 5 years and older despite data supporting that younger children can also benefit from implantation. This study describes our institution's experience with CI for SSD in children 5 years and younger. STUDY DESIGN: Case series with chart review. SETTING: Tertiary referral center. METHODS: A case series with chart review identified 19 patients up to age 5 years who underwent CI for SSD between 2014 and 2022. Baseline characteristics, perioperative complications, device usage, and speech outcomes were collected. RESULTS: The median age at CI was 2.8 (range, 1.0-5.4) years, with 15 (79%) patients being below age 5 at implantation. Etiologies of hearing loss were idiopathic (n = 8), cytomegalovirus (n = 4), enlarged vestibular aqueduct (n = 3), hypoplastic cochlear nerve (n = 3), and meningitis (n = 1). The median preoperative pure-tone average was 90 (range, 75-120) and 20 (range, 5-35) dB eHL in the poor and better hearing ears, respectively. No patients had postoperative complications. Twelve patients achieved consistent device use (average, 9 h/d). Three of the seven who were not consistent users had hypoplastic cochlear nerves and/or developmental delays. The three patients with available preoperative and postoperative speech testing showed significant benefits, and five patients with available postoperative testing demonstrated speech recognition in the implanted ear when isolated from the better ear. CONCLUSION: CI can safely be performed in younger children with SSD. Patients and families accept early implantation, as evidenced by consistent device use, and derive notable benefits in speech recognition. Candidacy can be broadened to include SSD patients under age five years, particularly individuals without hypoplastic cochlear nerves or developmental delay.

Facial Paralysis in Skull Base Osteomyelitis - Comparison of Surgical and Nonsurgical Management.

TITLE: Facial Paralysis in Skull Base Osteomyelitis - Comparison of Surgical and Nonsurgical Management. OBJECTIVE: To compare outcomes of surgical and nonsurgical management in cases of facial paresis secondary to skull base osteomyelitis. METHODS: A 14 patients presenting with skull base osteomyelitis complicated by facial nerve paresis at a single tertiary referral center from 2009 to 2019 were retrospectively reviewed. Patients were treated with medical therapy with or without surgical intervention, consisting of mastoidectomy and debridement with or without facial nerve decompression. House-Brackmann (HB) Grade was the main outcome measure. RESULTS: A 14 patients (average age 68 years, range 58-82 years, 71% male) were analyzed, with 5 undergoing facial nerve decompression (36%), 5 undergoing mastoidectomy without facial nerve decompression (36%), and 4 undergoing medical management alone (28%). Of the 4 patients who underwent medical therapy alone, none experienced significant improvement in facial function. Of the 5 patients who underwent facial nerve decompression, 3 patients experienced improved facial function. Of the 5 patients who underwent mastoidectomy without decompression, 4 experienced improved facial function. There was no clear link between the severity of infection and the severity of facial paresis. When comparing HB score changes before and after treatment across groups, there was no statistically significant difference seen (p = 0.47). CONCLUSIONS: Mastoidectomy and debridement with or without facial nerve decompression may improve facial nerve outcomes when compared to isolated medical management, although differences were not of statistical significance. The best facial nerve recoveries occurred in patients undergoing surgery within 14 days of the onset of paralysis. LEVEL OF EVIDENCE: 4 - Case Series Laryngoscope, 133:179-183, 2023.

Machine Learning Approach for Screening Cochlear Implant Candidates: Comparing With the 60/60 Guideline.

OBJECTIVE: To develop a machine learning-based referral guideline for patients undergoing cochlear implant candidacy evaluation (CICE) and to compare with the widely used 60/60 guideline. STUDY DESIGN: Retrospective cohort. SETTING: Tertiary referral center. PATIENTS: 772 adults undergoing CICE from 2015 to 2020. INTERVENTIONS: Variables included demographics, unaided thresholds, and word recognition score. A random forest classification model was trained on patients undergoing CICE, and bootstrap cross-validation was used to assess the modeling approach's performance. MAIN OUTCOME MEASURES: The machine learning-based referral tool was evaluated against the 60/60 guideline based on ability to identify CI candidates under traditional and expanded criteria. RESULTS: Of 587 patients with complete data, 563 (96%) met candidacy at our center, and the 60/60 guideline identified 512 (87%) patients. In the random forest model, word recognition score; thresholds at 3000, 2000, and 125; and age at CICE had the largest impact on candidacy (mean decrease in Gini coefficient, 2.83, 1.60, 1.20, 1.17, and 1.16, respectively). The 60/60 guideline had a sensitivity of 0.91, a specificity of 0.42, and an accuracy of 0.89 (95% confidence interval, 0.86-0.91). The random forest model obtained higher sensitivity (0.96), specificity (1.00), and accuracy (0.96; 95% confidence interval, 0.95-0.98). Across 1,000 bootstrapped iterations, the model yielded a median sensitivity of 0.92 (interquartile range [IQR], 0.85-0.98), specificity of 1.00 (IQR, 0.88-1.00), accuracy of 0.93 (IQR, 0.85-0.97), and area under the curve of 0.96 (IQR, 0.93-0.98). CONCLUSIONS: A novel machine learning-based screening model is highly sensitive, specific, and accurate in predicting CI candidacy. Bootstrapping confirmed that this approach is potentially generalizable with consistent results.

Early Datalogging Predicts Cochlear Implant Performance: Building a Recommendation for Daily Device Usage.

OBJECTIVE: To quantify the effect of datalogging on speech recognition scores and time to achievement for a "benchmark" level of performance within the first year, and to provide a data-driven recommendation for minimum daily cochlear implant (CI) device usage to better guide patient counseling and future outcomes. STUDY DESIGN: Retrospective cohort. SETTING: Tertiary referral center. PATIENTS: Three hundred thirty-seven adult CI patients with data logging and speech recognition outcome data who were implanted between August 2015 and August 2020. MAIN OUTCOME MEASURES: Processor datalogging, speech recognition scores, achievement of "benchmark speech recognition performance" defined as 80% of the median score for speech recognition outcomes at our institution. RESULTS: The 1-month datalogging measure correlated positively with word and sentences scores at 1, 3, 6, and 12 months postactivation. Compared with age, sex, and preoperative performance, datalogging was the largest predictive factor of benchmark achievement on multivariate analysis. Each hour/day increase of device usage at 1 month resulted in a higher likelihood of achieving benchmark consonant-nucleus-consonant and AzBio scores within the first year (odds ratio = 1.21, p < 0.001) as well as earlier benchmark achievement. Receiver operating characteristic curve analysis identified the optimal data logging threshold at an average of 12 hours/day. CONCLUSIONS: Early CI device usage, as measured by 1-month datalogging, predicts benchmark speech recognition achievement in adults. Datalogging is an important predictor of CI performance within the first year postimplantation. These data support the recommended daily CI processor utilization of at least 12 hours/day to achieve optimal speech recognition performance for most patients.

Association of Postoperative Sigmoid Sinus Occlusion and Cerebrospinal Fluid Leak in Translabyrinthine Surgery.

OBJECTIVE: To characterize the incidence of sigmoid sinus occlusion (SSO) following translabyrinthine (TL) surgery for posterior fossa tumor resection and determine the association with cerebrospinal fluid (CSF) leak. STUDY DESIGN: Retrospective case series. SETTING: Tertiary referral center. METHODS: Patients undergoing TL surgery for vestibular schwannoma from 2012 to 2020 were included. Demographic data, medical history, preoperative tumor length and volume, and postoperative complications including CSF leak were recorded. Neuroradiology review of postoperative magnetic resonance imaging was used to determine the presence or absence of flow through the sigmoid sinus. RESULTS: Of 205 patients undergoing TL, 21 (10.2%) experienced CSF leak postoperatively. Overall 56 (27%) demonstrated SSO on immediate postoperative magnetic resonance imaging. CSF leaks were more likely in those with SSO (19.6%) than those without SSO (6.7%; odds ratio, 3.54 [95% CI, 1.25-10.17]). Tumor volume and body mass index were not significantly associated with CSF leak. In total, 105 (51%) patients had some degree of sigmoid sinus thrombosis, but nonocclusive thrombosis was not associated with CSF leak. CONCLUSION: SSO after TL approaches is common and appears to be significantly associated with postoperative CSF leak development. Minimizing manipulation of the sigmoid sinus during TL surgery and compression after surgery may have a role in preventing CSF leak.

Cochlear Implants for Single-Sided Deafness: Quality of Life, Daily Usage, and Duration of Deafness.

OBJECTIVE: To report our experience for adults undergoing cochlear implantation (CI) for single-sided deafness (SSD). METHODS: This is a retrospective case series for adults with SSD who underwent CI between January 2013 and May 2021 at our institution. CNC and AzBio speech recognition scores, Tinnitus Handicap Inventory (THI), Speech, Spatial, and Qualities of Hearing Scale (SSQ12), datalogging, and the Cochlear Implant Quality of Life (CIQOL)-10 Global measure were utilized. RESULTS: Sixty-six adults underwent CI for SSD (median 51.3 years, range 20.0-74.3 years), and 57 (86.4%) remained device users at last follow-up. Compared to pre-operative performance, device users demonstrated significant improvement in speech recognition scores and achieved peak performance at six months post-activation for CNC (8.0% increased to 45.6%, p < 0.0001) and AzBio in quiet (12.2% increased to 59.5%, p < 0.0001). THI was decreased at 6 months post-implantation (58.1-14.6, p < 0.0001), with 77% of patients reporting improved or resolved tinnitus. Patients demonstrated improved SSQ12 scores as well as the disease-specific CIQOL-10 Global questionnaire. Duration of deafness was not associated with significant differences in speech recognition performance. Average daily wear time was positively associated with CNC and AzBio scores as well as post-operative CIQOL-10 scores. CONCLUSIONS: Herein we present the largest cohort of adult CI recipients with SSD with data on speech recognition scores, tinnitus measures, and SSQ12. Novel insights regarding the correlation of datalogging, duration of deafness, and CI-specific quality of life (CIQOL-10) metrics are discussed. Data continue to support CI as an efficacious treatment option for SSD. LEVEL OF EVIDENCE: 4 Laryngoscope, 133:2362-2370, 2023.

Radiographic Sigmoid Sinus Wall Abnormalities and Pulsatile Tinnitus: A Case-Control Study.

OBJECTIVE: Compare incidence of sigmoid sinus wall abnormalities (SSWAs) and other radiographic abnormalities in patients with pulsatile tinnitus (PT) versus controls. STUDY DESIGN: Retrospective case-control. SETTING: Tertiary referral center. PATIENTS: Adults with PT and high-resolution computed tomography imaging were compared with adults undergoing cochlear implant workup including high-resolution computed tomography imaging. MAIN OUTCOME MEASURES: Incidence of SSWA in PT cohort (n = 141) compared with control (n = 149, n = 298 ears). Secondary outcome measures included differences in demographics and in other radiographic abnormalities between cohorts. RESULTS: Patients with PT had a higher incidence of SSWA (34% versus 9%, p < 0.001) and superior canal dehiscence (23% versus 12%, p = 0.017) than controls. Spearman product component correlations demonstrated that ipsilateral PT was weakly associated with SSWA ( r = 0.354, p < 0.001). When SSWA was present in the PT cohort (n = 48 patients, n = 59 ears), in 31 cases (64.6%), the SSWA correlated with PT laterality (e.g., left SSWA, left PT); in 12 (25.0%), SSWA partially correlated with PT laterality (e.g., bilateral SSWA, right PT); and in 5 (10.4%), the SSWA did not correlate with PT laterality (e.g., right SSWA, left PT). CONCLUSIONS: For our patients with both PT and SSWA, the SSWA is likely a contributing factor in approximately 65% of cases. For a third of patients with PT and concomitant SSWA, the association between the two is either not causative or not solely causative. Surgeons counseling patients with PT and SSWA may be optimistic overall regarding sigmoid resurfacing procedures but must appreciate the possibility of treatment failure, likely because of untreated comorbid conditions.

Approach to Cochlear Implantation in Patients With Ventriculoperitoneal Shunts.

OBJECTIVE: To evaluate the safety and outcomes of cochlear implantation (CI) in patients with ventriculoperitoneal (VP) shunts to inform clinical practice. STUDY DESIGN: Historical cohort study. SETTING: Tertiary referral centers. METHODS: A multi-institutional historical cohort of patients with VP shunts and CI was identified and analyzed. RESULTS: A total of 46 patients (median age 8 years [interquratile range, IQR: 2-46]) with VP shunts and CI were identified. Of these, 41 (89%) patients had a VP shunt prior to CI. Based on institutional preference and individual patient factors, CI was performed contralateral to a pre-existing VP shunt in 24 of these 41 cases (59%) and ipsilateral in 17 (41%). Furthermore, pre-CI relocation of the VP shunt was performed in 3 cases (7%), and 2 patients (5%) underwent planned revision of their VP shunt concurrent with CI. In total, 2 of 27 pediatric patients (7%) required unanticipated revision shunt surgery, both contralateral to CI device placement, given VP shunt malfunction. One of 19 adult patients (5%) required shunt revision during CI due to shunt damage noted intraoperatively. Among 43 patients with available follow-up, 38 (88%) are regular CI users, with a median consonant-nucleus vowel-consonant word: score of 58% (IQR: 28-72). CONCLUSION: CI can be performed at low risk, either contralateral or ipsilateral, to a VP shunt, and does not mandate shunt revision in most cases. Additional considerations regarding CI receiver-stimulator placement are necessary with programmable shunts to mitigate device interaction. Preoperative planning, including coordination of care with neurosurgery, is important to achieving optimal outcomes.

Same-Day Patient Consultation and Cochlear Implantation: Patient Experiences and Barriers to Implementation.

OBJECTIVE: This study aimed to assess the efficacy of same-day cochlear implant (SDCI) evaluation and surgery in improving patient experience. PATIENTS: Adult CI candidates participated in this study. INTERVENTIONS: Education materials and communication with providers were offered via telephone, e-mail, and/or telemedicine. Patients then arrived for in-person consultation, imaging studies, and outpatient CI surgery in one visit and received a 3-month postoperative survey. MAIN OUTCOME MEASURES: Preoperative hearing, referral-to-surgery time, travel burden, and patient satisfaction were included as outcome measures. RESULTS: Of 35 patients who qualified, 14 were successfully contacted regarding the same-day program: 9 underwent CI, 1 enrolled but did not ultimately meet candidacy criteria, and 4 declined because of coronavirus and/or active medical conditions and did not pursue a CI. For the nine patients who underwent SDCI, mean age was 78 years, and mean preoperative consonant-nucleus-consonant score was 16% in the implanted ear. Mean referral-to-surgery time was 103 days and, after accounting for cancellations because of coronavirus, was 52 days. Mean travel distance to institution was 234 miles. Of the seven patients who completed the follow-up survey, none felt rushed for surgery, and mean program experience was rated 8.6 out of 10. Net promoter score was positive (+72), supporting high experience favorability among patients. Barriers to program expansion included patient recruitment and education, surgery scheduling, and the coronavirus pandemic. CONCLUSIONS: No patients declined the SDCI program to pursue traditional CI evaluation, and all patients were satisfied with their experience. The SDCI program is a feasible and successful model that overcomes barriers to implantation, including travel burden, and improves access to care.