Training in temporal bone drilling.

Acquiring surgical experience in the operating room is increasingly difficult. Simulation of temporal bone drilling is therefore essential, and more and more widely used. The aim of this review is to clarify the limitations of classical surgical training, and to describe the different types of simulation available for temporal bone drilling. Systematic Medline search used the terms: "temporal bone" and training and surgery; "temporal bone" and training and drilling. Seventy-one of the 467 articles identified were relevant for this review. Various temporal bone simulators have been created to get around the limitations (ethical, financial, cultural, working time) of temporal bone drilling. They can be classified as cadaver, animal, physical or virtual models. The main advantages of physical and virtual prototyping are their ease of access, the possibility of repeating gestures on a standardised model, and the absence of ethical issues. Validation is essential before these simulators can be included in the curriculum, to ensure efficacy and thus improve patient safety in the operating room.

Guidelines of the French Society of Otorhinolaryngology-Head and Neck Surgery (SFORL) and the French Society of Audiology (SFA) for Speech-in-Noise Testing in Adults.

OBJECTIVES: This document presents the fundamentals of speech audiometry in noise, general requirements for implementation and criteria for choice among the tests available in French according to the health-professional's needs. MATERIAL AND METHODS: The recommendations are based on a systematic analysis of the literature carried out by a multidisciplinary group of doctors, audiologists and audioprosthetists from all over France. They are graded A, B, C or expert opinion according to decreasing level of scientific evidence. RESULTS: Eight tests of speech audiometry in noise can be used in France. CONCLUSION: To be complete, evaluation of hearing status requires testing understanding of speech in noise. The examination must begin with a minimum of two measurements familiarizing the subject with the test procedure. For initial diagnosis, adaptive procedures establishing the 50% speech reception threshold (SRT50) in noise are to be preferred in order to obtain a rapid and standardized measurement of perception of speech in noise. When the aim is to measure real-life speech comprehension, tests based on sentences, cocktail-party noise and free-field stimulation are to be preferred. Prosthetic gain is evaluated exclusively in free field. This is the only way to evaluate the contribution of binaurality and to measure perception in noise in an environment as close as possible to real life. In order to avoid acoustic interference in free field, at least five loudspeakers should be used, in particular for evaluating the effectiveness of directional microphones, CROS devices enabling sounds picked up in the damaged ear to be rerouted to the functional ear, or bimodal fitting (i.e., when hearing is enabled by two modalities: for example, hearing aid for one ear, cochlear implant for the other).

Otosclerosis surgery under local anesthesia with sedation: Assessment of quality of life and stress.

OBJECTIVES: The main study endpoint was tolerance of stapedotomy under local anesthesia with sedation and under general anesthesia using stress and quality of life assessment questionnaires. Secondary endpoints comprised operative time and functional results. MATERIAL AND METHOD: In a consecutive series of stapedotomy patients operated on over a 12-month period, quality of life and perioperative stress were analysed by 3 questionnaires: the Glasgow Benefit Inventory, Cohen's perceived stress scale and the Post-traumatic stress disorder checklist scale. Questionnaire responses and audiometric data were compared between groups treated under local anesthesia with sedation and under general anesthesia. RESULTS: Twenty-two patients were included in the local anesthesia with sedation group and 6 in the general anesthesia group. There was no difference between the groups for quality of life, onset of post-traumatic stress, or perceived pre- and postoperative stress. There was also no difference in operative time. The audiometric data confirmed the reliability of stapedotomy. Stapedotomy under local anesthesia with sedation improved air conduction with≤10dB air-bone gap (ABG), comparable to results under general anesthesia. The rate of ABG≤10dB was 71.4%; no labyrinthisation was observed. CONCLUSION: Under local anesthesia with sedation, stapedotomy was well tolerated without increasing the stress associated with otosclerosis surgery. By correcting hearing loss, the procedure improves quality of life.

Vestibular evoked myogenic potentials.

Vestibular Evoked Myogenic Potentials (VEMP) are commonly recorded in patients experiencing vertigo or chronic instability. This test evaluates the patient's otolith function and is often combined with both Videonystagmography and Video Head Impulse Test. VEMP is a simple, reproducible test, in the absence of any pre-existing conductive hearing loss. Cervical VEMP explore both saccular function and the inferior vestibular nerve, whereas ocular VEMP assess utricular function and the superior vestibular nerve. In combination with previously described tests, VEMP allows characterization of vertigo and provides support for the diagnosis of superior semicircular canal dehiscence syndrome, Menière's disease, vestibular neuritis, vestibular schwannoma or idiopathic bilateral vestibulopathy. A good knowledge of these electrophysiological tests is essential in order to precisely assess the presence or absence of vestibular function impairment. We describe the test recording technique and the most common pitfalls in interpretation of the results. We then outline the results observed in various diseases impacting vestibular function.

Telemedicine in Audiology. Best practice recommendations from the French Society of Audiology (SFA) and the French Society of Otorhinolaryngology-Head and Neck Surgery (SFORL).

OBJECTIVES: Access to diagnosis and treatments for auditory disorders and related pathologies has regressed in France during the COVID-19 pandemic, posing a risk to the patient's chance of recovery. This best practice recommendations guide aims to list the existing technological solutions for the remote examination of a patient with hearing complaint, and to outline their benefits and, where applicable, their limitations. METHODS: The recommendations were developed both from the clinical experience of the medical experts who drafted the guide, and from an extensive review of the literature dealing with clinical practice recommendations for tele-audiology. Tele-audiometry solutions were identified on the basis of a search engine query carried out in April 2020, prior to verification of their availability on the European market. RESULTS: Video otoscopy solutions allow for the teletransmission of images compatible with a high-quality diagnosis, either by connecting via internet to a tele-health platform or using a smartphone or a tablet with an iOS or Android operating system. Using the same telecommunication methods, it is possible to remotely conduct a pure-tone audiometry test in accordance with standard practice, a speech-in-quiet or a speech-in-noise audiometry test, as well as objective measures of hearing. Clinical and paraclinical examinations can be accessed by the physician to be interpreted on a deferred basis (asynchronous tele-audiology). Examinations can also be conducted in real time in a patient, at any age of life, as long as a caregiver can be present during the installation of the transducers or the acoumetry. Tele-audiology solutions also find application in the remote training of future healthcare professionals involved in the management of deafness and hearing impairment. CONCLUSION: Under French law, tele-otoscopy is a medical procedure that is either a tele-expertise (asynchronous adive) or a teleconsultation act (synchronous advice). Subjective and objective evaluation of the patient's hearing functions can be done remotely provided that the listed precautions are respected.

Stapes surgery for otosclerosis under local anaesthesia with sedation.

The stapes surgery surgical technique has now been clearly standardized, ensuring a reliable and reproducible procedure with a satisfactory success rate. The possibility of performing this surgery under local anaesthesia with sedation requires very good collaboration between surgeons and anaesthetists. The patient is informed about the various steps of the operation to ensure that he or she is reassured both before and during the procedure. Local anaesthesia with sedation constitutes an alternative in patients afraid of general anaesthesia. Sudden onset of dizziness reported by the patient during the operation after piston placement may be due to an excessively long piston, which may need to be adjusted. We describe the technique used in our centre. In the literature, there is no difference in terms of audiometric performance and dizziness between patients operated under local anaesthesia with sedation or general anaesthesia.

Influence of surgical technique on residual cholesteatoma location and prevalence.

OBJECTIVE: Compared to canal wall up (CWU) tympanoplasty, canal wall reconstruction (CWR) allows better visualization of cholesteatoma extension. The canal wall up approach provides good functional outcomes, but with higher rates of residual cholesteatoma. The aim of this study was to compare residual cholesteatoma prevalence and location between the two approaches. METHOD: Subjects were adult patients with residual cholesteatoma following CWU or CWR surgery between January 1, 2010 and December 31, 2015. During this period, 94 patients underwent CWU and 71 CWR; 22 presented with residual cholesteatoma: 16 after CWU (R-CWU group) and 6 after CWR (R-CWR group). RESULTS: There was no significant inter-group difference in residual cholesteatoma prevalence: 17% after CWU, 8.4% after CWR. Locations comprised: 13 (81%) in the attic, 9 (56%) in the tympanic cavity and 4 (25%) in the mastoid in the R-CWU group, and 6 (100%) in the attic in the R-CWR group. There were significantly fewer tympanic cavity locations after CWR compared to CWU (P=0.046). CONCLUSION: Residual cholesteatoma prevalence did not significantly differ between the CWU and CWR approaches. The most frequent location was the attic; significantly more locations were in the tympanic cavity with the CWU approach. These findings are important for surgeons and neuro-radiologists during follow-up.

Otosclerosis surgery: Assessment of patient comfort.

OBJECTIVES: To evaluate operative comfort and stress in patients undergoing stapedotomy for otosclerosis under local versus general anesthesia. MATERIAL AND METHODS: Consecutive otosclerosis patients managed over a 9-month period responded to 3 validated questionnaires to assess peri- and post-operative comfort: Glasgow Benefit Inventory, Cohen's Perceived Stress Scale and the Posttraumatic Stress Disorder Checklist Scale. These results and audiometric data were compared between local and general anesthesia groups. RESULTS: Twenty-one patients were included in the local anesthesia group and 7 in the general anesthesia group, after exclusion of patients with history of otosclerosis surgery. There was no significant inter-group difference on Glasgow Benefit Inventory (P=0.38) or Posttraumatic Stress Disorder Checklist Scale (P=0.86). Perceived Stress Scale scores were higher in the general anesthesia group (P=0.038). In total, 67% of patients reported no discomfort under local anesthesia, and 86% were ready to undergo the procedure under local anesthesia again. There were no significant differences in postoperative symptoms, or in air-bone gap≤10dB (local anesthesia 81%, general anesthesia 71%; P=0.156). CONCLUSIONS: Local anesthesia in otosclerosis surgery did not increase stress or postoperative symptoms compared to general anesthesia. Audiometric results were not affected by type of anesthesia.

Total and partial ossiculoplasty in children: Audiological results and predictive factors.

OBJECTIVE: To assess ossiculoplasty results in children and screen for predictive factors of efficacy. PATIENTS AND METHODS: Seventy five children undergoing ossiculoplasty between 2001 and 2014 in a pediatric ENT department were included. The following data were collected and analyzed: demographic data, surgical indication, history of tympanoplasty, contralateral ear status (healthy, affected), preoperative hearing thresholds, surgical technique, intraoperative findings, and ossicular chain status at eardrum opening. Audiological results were reported according to American Academy of Otolaryngology-Head and Neck Surgery guidelines. RESULTS: Forty eight patients were included in the total ossicular reconstruction prosthesis (TORP) group. Mean age at surgery was 9.9years. Mean follow up was 2.7years. Mean air-bone gap (ABG) closure to within 20dB was achieved in 40% of cases at medium term (12 to 18 months after surgery). Air conduction (AC) threshold ≤30dB was achieved in 68% of cases. AC threshold improved by 14.6dB and 8.7dB at medium and long-term follow-up, respectively. A significant correlation was found between success rate and absence of history of tympanoplasty. The success rate was higher for primary than for revision procedures. Twenty seven children were included in the partial ossicular reconstruction prosthesis (PORP) group. Mean age was 9.5years, and mean follow-up 2.6years. Mean air-bone gap (ABG) closure to within 20dB was achieved in 75% of cases at medium term. AC threshold ≤30dB was achieved in 75% of cases AC threshold improved by 9.3dB and 5dB at medium and long-term follow-up, respectively. No predictive factors for success were found in the PORP group. CONCLUSION: The present study suggested that total ossiculoplasty leads to better results when performed in first-line. It also confirmed that functional outcome is better in partial than total ossicular reconstruction prosthesis.

Maxillofacial brown tumours: Series of 5 cases.

OBJECTIVES: Brown tumours are benign bone tumours secondary to hyperparathyroidism. The authors describe the various clinical features, diagnostic methods and treatment modalities for maxillofacial brown tumours. MATERIAL AND METHODS: This multicentre retrospective study comprised 5 patients (four women and one man, between the ages of 29 and 70 years) with one or several maxillofacial brown tumours observed over a 16-year period from January 2000 to December 2016. RESULTS: Four patients presented secondary hyperparathyroidism in a context of chronic renal failure, one patient presented primary hyperparathyroidism due to parathyroid adenoma. Three patients presented a mandibular brown tumour, and two patients presented a maxillary brown tumour. The diagnosis was based on histological examination and laboratory tests. Brown tumours were treated either surgically or conservatively. A favourable outcome was observed in all cases. CONCLUSION: Brown tumours are rare lesions. This diagnosis must be considered in a context of giant cell tumour associated with hyperparathyroidism. Brown tumours should be treated conservatively.

Hearing aids in patients with vestibular schwannoma: Interest of the auditory brainstem responses.

OBJECTIVE: Hearing loss subsequent to a unilateral vestibular schwannoma (VS) has an impact on the social life of non-operated patients. We investigated the utility of auditory brainstem responses (ABRs) for predicting the results of auditory rehabilitation in such patients. DESIGN: Prospective study. SETTING: University tertiary medical centre. PARTICIPANTS: We collected the demographic, audiometric, ABR and imaging data of non-operated patients with unilateral VS. A hearing aid trial was performed over 1 month. We assessed auditory performance following the auditory rehabilitation according to the ABR results. Patients with distinct waves (I, III and V) were included in the "distinct ABR" group and patients with no ABR were included in the "desynchronised ABR" group. MAIN OUTCOME MEASURES: Following the trial, audiometric performance and quality of life were evaluated with the Glasgow Benefit Inventory (GBI). SUBJECTS AND METHOD: We collected the demographic, audiometric, ABR and imaging data of non-operated patients with unilateral VS. A hearing aid trial was performed over 1 month. Following the trial, audiometric performance and quality of life were evaluated with the Glasgow Benefit Inventory (GBI). We assessed auditory performance following the auditory rehabilitation according to the ABR results. Patients with distinct waves (I, III and V) were included in the "distinct ABR" group and patients with no ABR were included in the "desynchronised ABR" group. RESULTS: In total, 25 patients were included in this prospective study; 15 in the "distinct ABR" group and 10 in the "desynchronised ABR" group. The speech recognition threshold (SRT, P < .0001; W = -120) and speech discrimination score (P = .0005; W = 78) were significantly improved in the aided vs unaided conditions. These improvements were not observed in the "desynchronised ABR" group for the SRT (P = .48; W = -10) and word recognition score (P = .06; W = 15). Ninety-three per cent of the patients in the "distinct ABR" group kept significantly (P = .04) the hearing aids following the trial compared to 20% in the "desynchronised ABR" group. CONCLUSIONS: Auditory brainstem responses can help to predict the auditory performance following auditory rehabilitation in unilateral non-operated VS patients.

Tympanometry and isolated fracture of the stapes.

INTRODUCTION: Temporal bone fractures are frequently associated with ossicular dislocations or fractures, most commonly involving the incus. To our knowledge, isolated fracture of the posterior crus of the stapes has not been previously reported. CASE REPORT: A 20-year-old man consulted for persistent left hypoacusis several months after a head injury. Initial computed tomography of the temporal bone showed a simple temporal bone fracture with no other associated abnormalities. The diagnosis of stapes fracture was suggested by increased compliance on tympanometry, leading to a second thin-section temporal bone computed tomography, which suggested a fracture of the posterior crus of the stapes. Endaural surgical exploration confirmed the diagnosis and allowed placement of ionomer cement in the posterior crus. DISCUSSION: The possibility of ossicular dislocation or fracture must be considered in patients with persistent conductive hearing loss associated with increased compliance on tympanometry, even when computed tomography of the temporal bone does not show dislocation of the ossicular chain or ossicular fracture. Hearing rehabilitation can be performed by hearing aid or surgical reconstruction of the ossicles.

Usefulness of temporal bone prototype for drilling training: A prospective study.

OBJECTIVES: Dissection of cadaveric temporal bones (TBs) is considered the gold standard for surgical training in otology. For many reasons, access to the anatomical laboratory and cadaveric TBs is difficult for some facilities. The aim of this prospective and comparative study was to evaluate the usefulness of a physical TB prototype for drilling training in residency. DESIGN: Prospective study. SETTING: Tertiary referral centre. PARTICIPANTS: Thirty-four residents were included. Seventeen residents (mean age 26.7±1.6) drilled on only cadaveric TBs ("traditional" group), in the traditional training method, while seventeen residents (mean age 26.5±1.7) drilled first on a prototype and then on a cadaveric TB ("prototype" group). MAIN OUTCOME MEASURES: Drilling performance was assessed using a validated scale. Residents completed a mastoid image before and after each drilling to enable evaluation of mental representations of the mastoidectomy. RESULTS: No differences were observed between the groups with respect to age, drilling experience and level of residency. Regarding drilling performance, we found a significant difference across the groups, with a better score in the prototype group (P=.0007). For mental representation, the score was statistically improved (P=.0003) after drilling in both groups, suggesting that TB drilling improves the mental representation of the mastoidectomy whether prototype or cadaveric TB is used. CONCLUSION: The TB prototype improves the drilling performance and mental representation of the mastoidectomy in the young resident population. A drilling simulation with virtual or physical systems seems to be a beneficial tool to improve TB drilling.

The effect of the transducers on paediatric thresholds estimated with auditory steady-state responses.

The objective of this study was to investigate the usefulness of auditory steady-state responses (ASSRs) for estimating hearing thresholds in young children, compared with behavioural thresholds. The second objective was to investigate ASSR thresholds obtained with insert earphones versus supra-aural headphones to determine which transducer produces ASSR thresholds most similar to behavioural thresholds measured with supra-aural headphones. This retrospective study included 29 participants (58 ears): 12 children (24 ears) in the insert group and 17 children (34 ears) in the supra-aural group. No general anaesthesia was used. For both groups, there was a strong correlation between behavioural and ASSR thresholds, with a stronger correlation for the insert group. When behavioural thresholds are difficult to obtain, ASSR may be a useful objective measure that can be combined with other audiometric procedures to estimate hearing thresholds and to determine appropriate auditory rehabilitation approaches.

Local anaesthesia and conscious sedation for cochlear implantation: experience with 20 patients.

OBJECTIVE: Cochlear implantation is mostly performed under general anaesthesia. This study aimed to evaluate cochlear implantation performed under local anaesthesia and sedation. METHOD: Twenty patients had a cochlear implant fitted under combined local anaesthesia (local anaesthesia group) and 41 patients had one fitted under general anaesthesia (general anaesthesia group) for bilateral profound hearing loss, from 2011 to 2014. Surgical duration, period of post-operative hospitalisation and early post-operative symptoms were compared. In the local anaesthesia group, operative symptoms reported during the surgery and by questionnaire were analysed. RESULTS: Mean surgical duration was significantly shorter in the local anaesthesia group: 87 versus 122 minutes (p < 0.001). No significant difference was observed between the local anaesthesia and general anaesthesia groups regarding mean post-operative hospitalisation and early post-operative symptoms. Under local anaesthesia, patients had no particular symptoms in 60 per cent of cases. The remaining patients in this group experienced vertigo (10 per cent), pain (20 per cent) and pain-related movement (10 per cent) during the intervention. These symptoms can be controlled with symptomatic treatment. CONCLUSION: Combined local anaesthesia for cochlear implantation is a good alternative to general anaesthesia for co-operating patients.

Canal wall reconstruction in cholesteatoma surgeries: rate of residual.

To evaluate the rates of residual and recurrent cholesteatoma following canal wall reconstruction (CWR) tympano-mastoidectomy with mastoid obliteration, for the treatment of chronic otitis with cholesteatoma. Consecutive cohort study. We included patients following surgical cholesteatoma removal by CWR tympano-mastoidectomy with hydroxyapatite mastoid obliteration from 2008 to 2012. We analyzed audiometric and postoperative radiologic data. We determined the rates of residual disease and recurrence, and evaluated postoperative complications. Thirty-six ears were included in this study. The mean follow-up after surgery was 24 months (range 12.3-51.4 months). The recurrence rate was 3.1% (one case) and the rate of residual disease was 6.2% (two cases including one of iatrogenic cholesteatoma). No canal-wall-down tympanoplasty was required. Local infection was detected in 33% of cases and was successfully treated with appropriate antibiotics. Postoperative audiometry showed no impairment of the cochlear reserve. No postoperative facial palsy or deafness was observed. CWR permits well exposure of the lesion, making complete excision of the cholesteatoma possible. This study showed a decreasing of the rate of residual cholesteatoma and must be confirmed with further studies. CWR makes it possible to use hearing aids for auditory rehabilitation.

Oropharyngeal teratomas in newborns: management and outcome.

OBJECTIVES: Congenital teratomas of the oropharyngeal cavity are extremely rare and are associated with a high neonatal mortality rate due to severe airway obstruction. Management has been improved with progress in antenatal diagnosis. The authors describe this progress in the light of a series of 4 cases and a review of the literature. METHODS: The medical charts of four neonates treated in the department since 1995 were reviewed. The following criteria were studied: age at diagnosis, clinical and radiological features of the tumour, management at birth and outcome. RESULTS: All four cases occurred in female neonates with an antenatal diagnosis in two cases, allowing preparation for endoscopy in the delivery room in one case and an EXIT procedure in the other case. Three neonates had to be intubated in the delivery room. Imaging showed invasion of the infratemporal fossa in 3 of the 4 cases. Surgical resection via various approaches to the infratemporal fossa was complete in every case. Adjuvant chemotherapy was administered in one case. CONCLUSION: Surgery for these mostly benign tumours is very challenging and requires a multidisciplinary team. Perinatal planning allows appropriate management at birth, decreasing the risk of airway obstruction. Surgery is the mainstay of treatment of teratomas.

Cancer of the external auditory canal.

INTRODUCTION: Cancer of the external auditory canal is a rare tumour with an annual incidence of one per one million inhabitants. The objective of this study was to evaluate the 5-year overall survival and disease-free survival rates in a series of patients with carcinoma of the external auditory canal and to compare our results concerning the clinical presentation, management and survival with those of the literature. PATIENTS AND METHOD: Ten patients were included in this retrospective, single-centre study over a 20-year period. Data concerning age, symptoms, imaging, TNM stage according to the Pittsburgh classification, histology, management, sequelae, recurrences and survival were recorded. RESULTS: The mean age of the patients of this series was 60.7 years. Seven patients had a squamous cell carcinoma. The other histological types were undifferentiated carcinoma, adenoid cystic carcinoma and neuroendocrine carcinoma. Staging was based on the Pittsburgh classification with one stage I, one stage III and eight stage IV tumours. Five-year overall survival rates were 100%, 50% and 0%, respectively. The mean 5-year overall survival rate was 35% and the mean 5-year disease-free survival rate was 24%. CONCLUSION: Carcinoma of the external auditory canal is a difficult diagnosis when the tumour does not present as a fungating mass protruding from the external auditory canal. The Pittsburgh classification was used for TNM staging of these tumours, allowing comparison of our results with those of the literature. The clinical findings and survival rates observed in this study are comparable to those reported in the literature. These tumours are associated with a poor prognosis on the basis of our results and published data.