Intraoperative neural monitoring during head and neck surgery in patients with concern for cervical spine instability.

Cervical and craniocervical instability are associated with catastrophic procedural outcomes. We discuss three individuals who required otolaryngologic surgical intervention: two with symptomatic spinal instability and one in whom spinal stability was unable to be assessed. Two cases were managed with procedural positioning precautions and evoked potential monitoring, and the other with procedural positioning precautions alone. Methods of monitoring and triggers for repositioning are discussed. This series is intended to discuss the approach and potential added value of evoked potential monitoring for risk mitigation in pediatric patients with concern for cervical spine instability.

Idiopathic cervical tracheal stenosis in an 11-year-old male.

Idiopathic laryngotracheal stenosis is a fibroinflammatory stenosis in persons without alternative explanation such as trauma, intubation, or autoimmune disease. Patients are usually females of child-bearing age. We report on an 11-year-old male who developed progressive dyspnea and stridor. Bronchoscopy revealed 90% stenosis of the cervical trachea. He underwent serial balloon dilation with steroid injection; stenosis decreased to 20%. He had no history of intubation or trauma. Histologic and laboratory workup for autoimmune disease was negative. This report highlights occurrence of a well-known disease in an uncommon population, and alerts providers to consider this when seeing new pediatric patients with symptoms of progressive airway restriction.

Silicone-coated thin film array cochlear implantation in a feline model.

OBJECTIVES: Some limitations of cochlear implants can be attributed to a restricted spectral representation of sound provided by contemporary electrode arrays. Microfabricated high-density thin film array (TFA) technology enables a greater density of stimulating sites and, thus, a more complete spectral representation. Previous pilot cadaveric studies have documented insertion characteristics, although not electrical characteristics. STUDY DESIGN: Electrode evoked auditory brainstem response (ABR) testing in a feline model. METHODS: Six healthy, normal hearing cats were unilaterally deafened and implanted with a silicone coated TFA, measuring 27.8 × 0.4 × 80µm (L × W × H). Monopolar stimulation of single electrodes was used to evoke a triple peaked ABR. Thresholds to evoke a minimal ABR were determined. RESULTS: All 6 cats underwent successful full insertion and activation. Thresholds to evoke minimal ABR's varied among implants ranging from 75 to 450 µA. Over the basal portion of the array, thresholds were either larger or unable to evoke an ABR. CONCLUSION: Two-thirds of the implants showed ABR's along the entire array, whereas the others evoked ABR's at the apical end and less robustly more basally. This may reflect increased distance of the electrodes from the modiolus, as the basal half of the array is narrower relative to the width of the scala. A tapered design to ensure array distance to modiolus is minimized may enable the basal half of the arrays to stimulate more consistently.

Cochlear implantation in children with anomalous cochleovestibular anatomy: a systematic review.

OBJECTIVE: To determine the influence of inner ear dysplasia on both surgical and audiologic outcomes following pediatric cochlear implant (CI) surgery. DATA SOURCES: MEDLINE (1982-2009) and data from Massachusetts Eye and Ear Infirmary. REVIEW METHODS: A systematic review of the literature was performed. Variables assessed included age at implantation, duration of CI use, radiologic and operative findings, and speech perception outcome data. RESULTS: The initial search yielded 1326 articles. Including data from our own study, twenty-two fulfilled criteria for inclusion, representing 311 patients. Data for bilateral implants were recorded only for the first implant. Data on simultaneous bilateral implants were not recorded. The most common anomaly seen was large vestibular aqueduct (89/311 or 29%). When comparing patients with mild-moderate or severe dysplasia, rates of cerebrospinal fluid gusher were 31% versus 35% (odds ratio [OR] = 0.50), anomalous facial nerve anatomy was seen in 11% versus 51% (OR = 0.15), and postoperative speech perception abilities were found in 84% versus 54% (OR = 1.93), respectively. A large heterogeneity was found among studies regarding all outcome measures. CONCLUSION: Although we found that severe inner ear dysplasia was associated with increased surgical difficulty and lower speech perception, the lack of uniformity in published clinical data limited the strength of these results. Standardization of surgical and radiologic reporting as well as more consistent speech perception testing is needed to better determine the association between anomalous cochleovestibular anatomy and clinical outcomes.

Cochlear implantation in children with anomalous cochleovestibular anatomy.

Our aim was to determine the influence of inner-ear anomalies on surgical difficulty and postoperative audiologic outcomes among pediatric cochlear implant (CI) recipients at our institution. We reviewed medical and audiologic records from 78 consecutive pediatric CI cases between 1985 and June 2009. Thirty patients had high-resolution temporal bone computed tomography imaging available for retrospective interpretation. Seven of these 30 patients (23%) had cochleovestibular dysplasia. Fifty percent of patients with severe dysplasia had a cerebrospinal fluid gusher intraoperatively, compared with 13% of patients with no dysplasia. Of patients with available audiologic outcome data, 17 of 26 patients with normal/mild/moderate dysplasia were able to complete CNC testing, whereas neither of the 2 patients with severe dysplasia could complete the open set test. Our experience suggests that surgical difficulty and audiologic outcomes in pediatric CI recipients may be affected by the presence and severity of a cochleovestibular anomaly.