Deep Brain Stimulation in the Setting of Cochlear Implants: Case Report and Literature Review.

BACKGROUND/AIMS: As technology continues to advance for our aging population, an increasing number of deep brain stimulation (DBS) candidates will have preexisting implanted electrical devices. In this article, we discuss safe and successful DBS in a patient with Parkinson's disease (PD) and bilateral cochlear implants. METHODS: A 70-year-old male with PD and bilateral cochlear implants underwent successful microelectrode-guided DBS implantation into bilateral subthalamic nuclei (STN). The patient's cochlear implant magnets were removed and replaced in the outpatient clinic for preoperative MRI and stereotactic targeting. The cochlear implants were turned off intraoperatively for STN microelectrode recordings. RESULTS: Precise, MRI-guided stereotactic DBS implantation was possible. Intraoperative high-fidelity microelectrode recordings confirmed STN neurons with the cochlear implants turned off. These recordings were not possible with active cochlear implant devices. Our literature review describes the other approaches/techniques that have been used to manage DBS surgery in the setting of cochlear implants. CONCLUSIONS: Despite the risk of electrical interference between implanted medical devices, DBS and cochlear implants may be safe and compatible in the same patient if necessary precautions are taken.

BPPV Information on Google Versus AI (ChatGPT).

OBJECTIVE: To quantitatively compare online patient education materials found using traditional search engines (Google) versus conversational Artificial Intelligence (AI) models (ChatGPT) for benign paroxysmal positional vertigo (BPPV). STUDY DESIGN: The top 30 Google search results for "benign paroxysmal positional vertigo" were compared to the OpenAI conversational AI language model, ChatGPT, responses for 5 common patient questions posed about BPPV in February 2023. Metrics included readability, quality, understandability, and actionability. SETTING: Online information. METHODS: Validated online information metrics including Flesch-Kincaid Grade Level (FKGL), Flesch Reading Ease (FRE), DISCERN instrument score, and Patient Education Materials Assessment Tool for Printed Materials were analyzed and scored by reviewers. RESULTS: Mean readability scores, FKGL and FRE, for the Google webpages were 10.7 ± 2.6 and 46.5 ± 14.3, respectively. ChatGPT responses had a higher FKGL score of 13.9 ± 2.5 (P < .001) and a lower FRE score of 34.9 ± 11.2 (P = .005), both corresponding to lower readability. The Google webpages had a DISCERN part 2 score of 25.4 ± 7.5 compared to the individual ChatGPT responses with a score of 17.5 ± 3.9 (P = .001), and the combined ChatGPT responses with a score of 25.0 ± 0.9 (P = .928). The average scores of the reviewers for all ChatGPT responses for accuracy were 4.19 ± 0.82 and 4.31 ± 0.67 for currency. CONCLUSION: The results of this study suggest that the information on ChatGPT is more difficult to read, of lower quality, and more difficult to comprehend compared to information on Google searches.

Public Perception of Ménière's Disease: A Social Media Analysis.

OBJECTIVE: To analyze tweets associated with Ménière's disease (MD), including type of users who engage, change in usage patterns, and temporal associations, and to compare the perceptions of the general public with healthcare providers. METHODS: An R-program code, academictwitterR API, was used to query Twitter. All tweets mentioning MD from 2007 to 2021 were retrieved and analyzed. Valence Aware Dictionary and Sentiment Reasoning was used as a model to assess sentiment of tweets. Two reviewers assessed 1,007 tweets for qualitative analysis, identifying the source and the topic of the tweet. RESULTS: A total of 37,402 tweets were analyzed. The number of tweets per user ranged from 1 to 563 (M = 33.7, SD = 91.1). Quantitative analysis showed no temporal or seasonal association; however, tweeting increased when celebrities were diagnosed with MD. Of the 1007 representative tweets analyzed, 60.6% of tweets came from the general public and were largely of negative sentiment focusing on quality of life and support, whereas healthcare providers accounted for 23% of all tweets and focused on treatment/prevention. Tweets by news sources accounted for the remaining 13% of all tweets and were primarily positive in sentiment and focused on awareness. CONCLUSIONS: MD is commonly tweeted about by the general public, with limited input regarding the disease from healthcare providers. Healthcare providers must provide accurate information and awareness regarding MD, especially when awareness is highest, such as when celebrities are diagnosed. LEVEL OF EVIDENCE: Level IV.Indicate IRB or IACUCNot applicable.

Congenital Aural Stenosis With Cholesteatoma.

OBJECTIVE: Compare surgical and audiological outcomes of patients with congenital aural stenosis (CAS) with cholesteatoma to patients with CAS without cholesteatoma and patients with complete congenital aural atresia (CCAA). STUDY DESIGN: Retrospective case series. SETTING: Tertiary care hospital. PATIENTS: Patients with CAS (with and without cholesteatoma) and CCAA. INTERVENTION: Surgery for CAS/CAA. MAIN OUTCOME MEASURES: Patients with CAS and CAA undergoing surgical repair from June 2004 to July 2020 were identified from an institutional database. Included patients were divided by presence of a canal cholesteatoma. Clinical history, pre- and postoperative audiometric data, and clinical outcomes were compared. RESULTS: Of the 283 patients (300 ears), 18 (19 ears) had a canal cholesteatoma. When compared to ears without cholesteatoma (CCAA ears plus CAS ears without cholesteatoma), ears with cholesteatoma were more likely to be younger (9.2 ±â€Š6.6 vs. 11.5 ±â€Š9.2; p = 0.015), female (66.7% vs. 38.1%; p = 0.02; OR 3.2, 95% CI 1.18-8.9), and have normal/Grade I microtia (47.4% vs. 9.6%; p < 0.0001; OR 0.12, 95% CI 0.044-0.32), but not a history of draining ear (5.3% vs. 0%; p = 0.05; OR 0.06, 95% CI 0.004-0.999). Preoperative audiometric data demonstrated a lower mean air-bone gap (45.8 dB vs. 52.3 dB; p = 0.009) and better speech reception threshold (48.7 dB vs. 57.4 dB; p = 0.0004) in cholesteatoma ears. Postoperatively, ears with cholesteatoma were more likely to close the ABG within 20 dB (p = 0.001; OR 0.19, 95% CI 0.072-0.52). No patient in the cholesteatoma group developed post-operative bony/soft-tissue stenosis (0% vs. 9.7%; p = 0.65; OR 1.61; 0.21-12.6) or required revision surgery (0% vs. 11%; p = 0.38; OR 2.46, 0.32-19). CONCLUSIONS: Patients with CAS and cholesteatoma have better audiometric outcomes and likely a more durable repair with a decreased need for revision possibly secondary to greater embryologic development of the meatus, ear canal, and middle ear space despite the cholesteatoma.

Audiometric Outcomes After Surgical Repair of Congenital Aural Atresia: Does Age Matter?

OBJECTIVE: To determine if there is an age-based difference in audiometric outcomes for patients undergoing primary congenital aural atresia (CAA) repair. STUDY DESIGN: Retrospective chart review. SETTING: Single academic, high-volume, tertiary care hospital. PATIENTS: Individuals undergoing primary CAA repair by a single surgeon between 2004 and 2020. INTERVENTIONS: CAA repair. MAIN OUTCOME MEASURES: Preoperative and postoperative four tone (500, 1,000, 2,000, 4,000 Hz) air-conduction pure-tone average (PTA), bone-conduction PTA, air-bone gap and speech reception threshold, and preoperative to postoperative change in values. RESULTS: We identified 247 patients (262 ears) who underwent repair. The mean and median ages were approximately 12 and 8.5 years, respectively, both of which served as cutoff ages to compare younger versus older patients. The average preoperative to postoperative improvement values in air-conduction PTA, air-bone gap, and speech reception threshold for individuals younger than 12 years were 26.6 ± 10.2, 23.8 ± 12.6, and 30.1 ± 12.1 dB hearing level (HL), respectively, and those for individuals 12 years or older were 25.9 ± 15.7, 26.2 ± 10.3, and 31.3 ± 12.8 dB HL, respectively. For individuals younger than 8.5 years, the values were 25.8 ± 9.5, 24.9 ± 9.4, and 30.0 ± 10.6 dB HL, respectively, and those for individuals 8.5 years or older were 27.1 ± 13.5, 25.7 ± 11.0, and 30.0 ± 14.6 dB HL, respectively. The improvement did not differ significantly between the younger and older groups, using both cutoff ages. There was no difference in revision surgery rates or complications between groups. CONCLUSION: An individual at any age can enjoy audiometric improvement from atresia repair.

Are children with unilateral hearing loss more tired?

OBJECTIVE: To determine whether children with unilateral sensorineural hearing loss (USNHL) and unilateral conductive hearing loss (UCHL) have higher levels of fatigue than literature reported normal hearing (LRNH) children. METHODS: This was a cross-sectional survey utilizing the PedsQL™ Multidimensional Fatigue Scale administered to children with unilateral hearing loss (UHL) and their parents at two tertiary care academic medical centers and a nationwide microtia/atresia conference. The PedsQL™ Multidimensional Fatigue Scale was used to compare child and parental proxy reports of fatigue among USNHL, UCHL, and LRNH children. ANOVA and post-hoc Tukey Honest Significant Difference testing were used for statistical analysis. RESULTS: Of 69 children included in the study, 42 had UCHL (61%) and 27 (39%) had USNHL. Children with USNHL reported more total fatigue (mean 69.1, SD 19.3) than LRNH children (mean 80.5, SD 13.3; difference -11.4; 95% CI: -19.98 to -2.84) and children with UCHL (mean 78.0, SD 14.5; difference -8.95; 95% CI: -17.86 to 0.04). Children with UCHL reported similar levels of fatigue compared to LRNH children (difference -2.5; 95% CI: -9.95 to 5.03). Parents of children with USNHL reported greater levels of fatigue (mean 67.6, SD 22.6) in their children than parents of LRNH children (mean 89.6, SD 11.4; difference -22.0; 95% CI: -29.8 to -14.3) and parents of children with UCHL (mean 76.2, SD 17.3; difference -8.6; 95% CI: -17.5 to 0.21). Parents of children with UCHL also report higher levels of fatigue than parents of LRNH children (difference -13.4; 95% CI: -19.98 to -6.84). CONCLUSIONS: Children with USNHL reported greater levels of fatigue than LRNH children and children with UCHL. Results implicate cognitive load as an important consideration in children with hearing loss. The measurement of fatigue may be a useful indicator to determine the benefit of intervention (e.g., amplification) for these children.

When to Say When-Reasons to Abort Surgery for Congenital Aural Atresia.

OBJECTIVE: To determine reasons for premature termination in surgery for congenital aural atresia (CAA). STUDY DESIGN: Retrospective chart review. SETTING: High-volume tertiary care center. PATIENTS: Patients undergoing primary surgical repair of CAA whose surgeries were aborted for various indications. INTERVENTION: Patients with CAA who underwent elective aural atresia surgery at the University of Virginia from July 2004 to January 2020 were identified from the medical record and an institutional database of patients with CAA. Patients undergoing revision surgery or surgery not for hearing correction were excluded. All included candidates were noted to be good surgical candidates for atresia repair based on preoperative Jahrsdoerfer score of 6 or greater. Reasons for terminating surgery prematurely were categorized by anatomical constraints (inability to identify middle ear space, position of the facial nerve, or other anatomic abnormality), stapes fixation, and middle ear and/or mastoid inflammatory disease. MAIN OUTCOME MEASURES: Reasons for premature termination in CAA surgery. RESULTS: Over the interval, 319 patients underwent primary surgery for CAA. Surgery was terminated prematurely without completing the primary objective in 14 patients (4.4%); surgery was terminated in 8 (57%) due to anatomic constraints, 4 (29%) due to stapes fixation, and 2 (14%) due to middle ear space and/or mastoid inflammatory disease. CONCLUSIONS: Premature termination in surgery for CAA is a rare occurrence with careful study of the preoperative high-resolution computed tomography of the temporal bone. Of the reasons for premature termination, anatomic constraints were the most common. Knowing limitations in surgery-both technical and anatomic-is critical to optimize outcomes and prevent complications.

Acoustic Reflexes in Aural Atresia Patients: Evidence of an Intact Efferent System?

OBJECTIVE: To record crossed acoustic reflex thresholds (xART's) postoperatively from patients after surgical repair of unilateral congenital aural atresia (CAA). To seek explanations for when xARTs can and cannot be recorded. We hope to understand the implications for this central auditory reflex despite early afferent deprivation. METHODS: Patients who underwent surgery to correct unilateral CAA at a tertiary academic medical were prospectively enrolled to evaluate for the presence of xART. Preoperative ARTs in the normal (non-atretic) ear, and postoperative ipsilateral ARTs (stimulus in the normal ear) and contralateral ARTs (stimulus in the newly reconstructed atretic ear; record in the normal ear) were measured at 500, 1000, and 2000 Hz. RESULTS: Four of 11 patients with normal ipsilateral reflex thresholds preoperatively demonstrated crossed acoustic reflexes postoperatively (stimulus in reconstructed ear; record from normal ear). Four other patients demonstrated normal ipsilateral thresholds preoperatively but did not have crossed reflexes postoperatively. No reflexes (pre- or postoperatively) could be recorded in 3 patients. Crossed reflex threshold is significantly correlated with the postoperative audiometric threshold. There was no correlation between ipsilateral and contralateral reflex thresholds. CONCLUSION: Crossed acoustic reflexes can be recorded from some but not all postoperative atresia patients, and the thresholds for those reflexes correlate with the postoperative pure tone threshold. The presence of acoustic reflexes implies an intact CN VIII-to-opposite CN VII central reflex arc despite early unilateral sound deprivation.

Otology-Neurotology 2020 US Workforce Distribution.

Objective: Determine the geographic and per capita distribution of otology-neurotology physician-surgeons within the United States. Study Design: National database review. Setting: United States. Methods: The American Neurotology Society and ENThealth.org membership databases were queried to identify otology-neurotology physician-surgeons within the United States. Physician-surgeons were divided by regional national census areas, state, and by largest population statistical area based on 2019 US Census population estimates. The number of otology-neurotology physician-surgeons per 1 million persons was calculated for each population designation. Results: Four-hundred eighty-two physician-surgeons were identified, representing 49 states and the District of Columbia. The New England division (Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island) was the most concentrated region (1.89), whereas the West-South-Central (Texas, Oklahoma, Arkansas, Louisiana) was the least concentrated region (1.23) per million persons. The highest concentration of physician-surgeons by state is within the District of Columbia (4.25), Vermont (3.21), North Dakota (2.62), Massachusetts (2.61), and New York (2.21) (per million), whereas Mississippi (0.67), Georgia (0.66), Idaho (0.56), New Mexico (0.48), and Wyoming (0.0) were the least concentrated per million persons. Increasing number of physician-surgeons was significantly correlated by state (r2 = 0.9; P < 0.0001), largest statistical area (r2 = 0.88; P < 0.0001), and census region (r2 = 0.95; P < 0.0005). Conclusions: Otology-neurotology physician-surgeons are evenly distributed across the United States; however, certain areas are likely underrepresented. Variability in clinical practice may account for under or overrepresentation not captured in this analysis.

Correlation between hearing loss and middle ear volume in patients with a tympanic membrane perforation.

OBJECTIVE: To investigate a possible correlation between the degree of conductive hearing loss (CHL) caused by an isolated tympanic membrane (TM) perforation and mastoid-middle ear volume. STUDY DESIGN: Retrospective chart, audiometry, and computed tomography (CT) imaging review. METHODS: Adult patients with a diagnosis of isolated TM perforation between 2010 and 2018 were identified and their audiometric data collected. Mastoid-middle ear volume (MMEV) was then calculated based on segmentation analysis from the patient's head or temporal bone CT. Calculated MMEV was compared to MMEV derived by tympanometry. A Student's t-test was performed to determine a correlation between the calculated MMEV on CT imaging and the degree of conductive hearing loss as measured by the air bone gap on standard audiometry. RESULTS: There was a statistically significant difference between MMEV as determined by segmentation analysis compared to that determined by tympanometry (absolute average percent difference = 33.8%; range -49.5% to +155.2%; P = .03). Greater MMEV determined by segmentation analysis correlated with smaller air bone gap; this trend approached but did not reach statistical significance (P = .09). CONCLUSIONS: Calculated MMEV by segmentation analysis on CT imaging may be a more accurate estimate of MMEV than tympanometry. MMEV may be correlated to the degree of conductive hearing loss in the setting of isolated TM perforation where greater volume was associated with better hearing. LEVEL OF EVIDENCE: 4 Laryngoscope, 130:E228-E232, 2020.

Long-term Audiometric Outcomes After Atresiaplasty for Congenital Aural Atresia.

OBJECTIVE: Describe long-term trends and stability of hearing outcomes for patients undergoing primary congenital aural atresia (CAA) repair. STUDY DESIGN: Retrospective chart review. SETTING: Single academic, tertiary referral center. PATIENTS: Children and adults who underwent primary CAA repair between 1980 and 2017. INTERVENTION: CAA repair. MAIN OUTCOME MEASURES: Long-term (> 1 yr) postoperative three-tone (500, 1000, 2000 Hz) air conduction pure-tone average (AC PTA) compared with the immediate (within 90 d of surgery) postoperative audiogram. RESULTS: The mean preoperative AC PTA was 59.6 dB HL. CAA repair improved hearing an average of 30.5 dB, but hearing declined by 8.2 dB over the long-term follow-up period (mean 4.4 yr; range 1-15.7 yr), leaving a final mean improvement of 22.2 dB (final mean AC PTA 37.3 dB HL). Two-thirds (92 of 138 ears) had an AC PTA ≤ 30 dB HL recorded in the first year after surgery. At the last follow-up test, 64% had "stable" hearing defined as no more than a 10 dB decline in AC PTA compared with the immediate postoperative audiogram; 21% had a 10 to 20 dB decline, 8% a 20 to 30 dB decline, and 7% declined > 30 dB. CONCLUSIONS: All patients enjoyed improvement in AC PTA after surgery (preoperative minus the best postoperative PTA, mean = 34 dB, range = 3.3-52 dB). Hearing declined by an average 8.2 dB over the long-term leaving a final average AC PTA of 37.4 dB HL. Sixty-four percent of patients exhibited stable (< 10 dB loss) hearing over time; 36% lost 10 dB or more over the long-term follow-up period. Hearing results typically stabilize over time with most of the change occurring in the first 3 years after CAA repair. Bone conduction thresholds remained stable over the study period.

American Neurotology Society, American Otological Society, and American Academy of Otolaryngology - Head and Neck Foundation Guide to Enhance Otologic and Neurotologic Care During the COVID-19 Pandemic.

: This combined American Neurotology Society, American Otological Society, and American Academy of Otolaryngology - Head and Neck Surgery Foundation document aims to provide guidance during the coronavirus disease of 2019 (COVID-19) on 1) "priority" of care for otologic and neurotologic patients in the office and operating room, and 2) optimal utilization of personal protective equipment. Given the paucity of evidence to inform otologic and neurotologic best practices during COVID-19, the recommendations herein are based on relevant peer-reviewed articles, the Centers for Disease Control and Prevention COVID-19 guidelines, United States and international hospital policies, and expert opinion. The suggestions presented here are not meant to be definitive, and best practices will undoubtedly change with increasing knowledge and high-quality data related to COVID-19. Interpretation of this guidance document is dependent on local factors including prevalence of COVID-19 in the surgeons' local community. This is not intended to set a standard of care, and should not supersede the clinician's best judgement when managing specific clinical concerns and/or regional conditions.Access to otologic and neurotologic care during and after the COVID-19 pandemic is dependent upon adequate protection of physicians, audiologists, and ancillary support staff. Otolaryngologists and associated staff are at high risk for COVID-19 disease transmission based on close contact with mucosal surfaces of the upper aerodigestive tract during diagnostic evaluation and therapeutic procedures. While many otologic and neurotologic conditions are not imminently life threatening, they have a major impact on communication, daily functioning, and quality of life. In addition, progression of disease and delay in treatment can result in cranial nerve deficits, intracranial and life-threatening complications, and/or irreversible consequences. In this regard, many otologic and neurotologic conditions should rightfully be considered "urgent," and almost all require timely attention to permit optimal outcomes. It is reasonable to proceed with otologic and neurotologic clinic visits and operative cases based on input from expert opinion of otologic care providers, clinic/hospital administration, infection prevention and control specialists, and local and state public health leaders. Significant regional variations in COVID-19 prevalence exist; therefore, physicians working with local municipalities are best suited to make determinations on the appropriateness and timing of otologic and neurotologic care.

Relationship Between Middle Ear Volume and Long-term Audiological Outcomes in Congenital Aural Atresia Repair.

OBJECTIVE: To assess the association of middle ear volume with long-term hearing outcomes in congenital aural atresia (CAA) repair. STUDY DESIGN: Retrospective chart and radiological review. SETTING: Single academic tertiary referral center. PATIENTS: Children and adults who underwent CAA repair between 1995 and 2016. Patients were divided into "best" and "worst" audiometric groups, based on stability of postoperative air conduction pure-tone average (AC PTA) results. Ten patients were included for study in the "best" group, and 12 in the "worst" group. INTERVENTION(S): CAA repair. MAIN OUTCOME MEASURE(S): Long-term (> 1 yr) postoperative three-tone (500, 1000, 2000 Hz) AC PTA, speech reception threshold (SRT), air bone gap, and semiautomated calculated middle ear volume from preoperative computed tomography (CT) scans. RESULTS: Statistically significant differences were noted between "best" and "worst" groups in AC PTA, SRT, and air bone gap (p < 0.001). Mean middle ear volume in the "best" group was 434.6 mm (range 326.3-602.1 mm) and 339.5 mm (range 199.4-502.1 mm) in the "worst" group (p = 0.02). The majority in both groups were right ears (p = 0.38), and males outnumbered females in the "best" group (9 out of 10; p = 0.018). Preoperative Jahrsdoerfer grading scores were similar between groups (p = 0.31). Mean follow-up for the "best" and "worst" groups was approximately 3.5 and 4.5 yr, respectively. CONCLUSIONS: For patients undergoing CAA repair, larger middle ear volume is associated with stable and better long-term audiometric outcomes.

International Consensus Recommendations on Microtia, Aural Atresia and Functional Ear Reconstruction.

The aim of this report is to provide international recommendations for functional ear reconstruction in patients with microtia and aural atresia. All patients with microtia and external auditory atresia should be seen in the setting of a multidisciplinary team and agreed treatment outcomes should be measured, so that techniques, approaches, and results can be compared. The methods are expert opinion from the members of the International Microtia and Atresia Workgroup (IMAW). The consensus recommendations reported herein take into account the variability in practice patterns present among experts in the field; the degree of consensus was quantified by presenting the percentage of above authors who agree or partially agree with each statement. Recommendations include the definition and classification of microtia/atresia, treatment of microtia, treatment of congenital aural atresia, flowchart of functional ear reconstruction, and future research directions. Patients with microtia and aural atresia can be guided by the consensus recommendations provided herein.

Gene transfer in human vestibular epithelia and the prospects for inner ear gene therapy.

Transfer of exogenous genetic material into the mammalian inner ear using viral vectors has been characterized over the last decade. A number of different viral vectors have been shown to transfect the varying cell types of the nonprimate mammalian inner ear. Several routes of delivery have been identified for introduction of vectors into the inner ear while minimizing injury to existing structures and at the same time ensuring widespread distribution of the agent throughout the cochlea and the rest of the inner ear. These studies raise the possibility that gene transfer may be developed as a potential strategy for treating inner ear dysfunction in humans. Furthermore, a recent report showing successful transfection of excised human vestibular epithelia offers proof of principle that viral gene transfer is a viable strategy for introduction and expression of exogenous genetic material to restore function to the inner ear. Human vestibular epithelia were harvested from patients undergoing labyrinthectomy, either for intractable Ménière's disease or vestibular schwannoma resection, and cultured for as long as 5 days. In those experiments, recombinant, multiply-deleted, replication-deficient adenoviral vectors were used to transfect and express a reporter gene as well as the functionally relevant gene, wild-type KCNQ4, a potassium channel gene that when mutated causes the autosomal dominant HL DFNA2.Here, we review the current state of viral-mediated gene transfer in the inner ear and discuss different viral vectors, routes of delivery, and potential applications of gene therapy. Emphasis is placed on experiments demonstrating viral transfection of human inner ear tissue and implications of these findings and for the future of gene therapy in the human inner ear.

Congenital absence of the oval window: diagnosis, surgery, and audiometric outcomes.

OBJECTIVE: To review the surgical management and outcomes of patients with congenital absence of the oval window (CAOW) undergoing the oval window drill-out (OWD) procedure. STUDY DESIGN AND SETTING: A retrospective chart review of patients with CAOW seen in a tertiary care otologic practice between 1991 and 2006. PATIENTS/INTERVENTION: Patients with CAOW undergoing OWD procedure. MAIN OUTCOME MEASURES: Findings at surgery and preoperative and postoperative audiometric outcomes (air and bone conduction thresholds; speech reception threshold). RESULTS: Seventeen ears underwent OWD for CAOW. Four cases were aborted. For the 13 subject ears, average 1-month postoperative 4-tone air conduction and speech reception thresholds were significantly lower than preoperative thresholds. Long-term follow-up (average, 20 months) air conduction and speech reception thresholds were also significantly lower but showed a slight worsening of thresholds compared with the 1-month postoperative results. Speech discrimination scores and bone conduction thresholds remained stable. CONCLUSION: OWD may be a viable operation for patients with CAOW, although longer follow-up is needed. Given the mixed hearing results in the current patient series, we have tempered our enthusiasm for this operation. Technically challenging, this procedure nevertheless can improve patients' hearing with minimal morbidity. Revision surgery did not result in improved outcome.

Malignant otitis externa.

Malignant otitis externa is an invasive, potentially life-threatening infection of the external ear and skull base that requires urgent diagnosis and treatment. It affects immunocompromised individuals, particularly those who have diabetes. The most common causative agent remains Pseudomonas aeruginosa. Definitive diagnosis is frequently elusive, requiring a high index of suspicion, various laboratory and imaging modalities, and histologic exclusion of malignancy. Long-term oral antipseudomonal agents have proven effective; however, pseudomonal antibiotic resistance patterns have emerged and therefore other bacterial and fungal causative agents must be considered. Adjunctive therapies, such as aggressive debridement and hyperbaric oxygen therapy, are reserved for extensive or unresponsive cases.

Atresiaplasty in Congenital Aural Atresia: What the Facial Plastic Surgeon Needs to Know.

Patients with microtia and congenital aural atresia should have a comprehensive hearing assessment early in life. Options for hearing habilitation should be presented, and children with bilateral aural atresia should be fitted with a bone conducting hearing device to support normal speech and language development. If atresia surgery is pursued, the microtia surgeon must be aware of certain principles. This article presents recommendations on options for potentially improving hearing in children with congenital aural atresia: assessing surgical candidacy; chronology and timing of surgeries; functional importance of certain ear structures; and understanding the possible locations of an aberrant facial nerve to avoid injury in these patients.