Acquired Stenosis of the External Ear Canal.

Acquired stenosis of the external ear canal (ASEEC) is a relatively uncommon condition. Stenosis or narrowing of the external ear canal (EEC) occurs lateral to the tympanic membrane resulting in a skin lined blind canal. Recurrent otorrhea, and conductive hearing loss are typical clinical features. Although ASEEC can be due to different etiologies, a common pathogenesis, namely an inflammatory cascade, has been implicated. Clinical evaluation, audiogram, and Computed tomography (CT scan) form the mainstay of diagnosis. Surgery is the primary modality for treatment. Restenosis is the most common postsurgical complication.

Hearing Rehabilitation in Vestibular Schwannoma.

The most common complaint among patients with vestibular schwannoma (VS) is hearing loss. This significantly affects the quality of life before, during, and after treatment for patients with VS. Untreated hearing loss in VS patients may even lead to depression and feelings of social isolation. A variety of devices are available for hearing rehabilitation for patients with vestibular schwannoma. These include contralateral routing of hearing signals (CROSs), bone-anchored hearing devices, auditory brainstem implants (ABI), and cochlear implants. In the United States, ABI is approved for patients 12 years of age and older with neurofibromatosis type 2. In the past few years, cochlear implantation has been offered simultaneously or sequentially with tumor resection or irradiation, or even to patients whose VS have been monitored with serial imaging. However, determining the functional integrity of the auditory nerve in patients with vestibular schwannoma is a challenge. This review article consists of (1) the pathophysiology of vestibular schwannoma (VS), (2) hearing loss in VS, (3) treatment of VS and associated hearing loss, (4) options for auditory rehabilitation in patients with VS with their individual benefits and limitations, and (5) challenges in hearing rehabilitation in this cohort of patients to determine auditory nerve functionality. (6) Future directions.

Histoplasmosis of the External Auditory Canal.

This report describes the diagnosis and treatment of a patient with a rare fungal infection of the external ear, as well as a review of the literature. A 76-year-old Caucasian gentleman from rural southern United States with diabetes and hypertension was referred to our clinic for intractable left otalgia, otorrhea, headaches, and an exophytic lesion in the left external ear since five months. There was no pertinent travel history. Biopsy by an outside otolaryngologist was inconclusive. Repeat biopsy under anesthesia revealed morphological characteristics consistent with histoplasmosis. Intravenous amphotericin B and later oral antifungal agent voriconazole led to improvement in symptoms. The clinical presentation resembled a malignancy. A high index of clinical suspicion, histologic confirmation with deep tissue biopsy, and culture are essential for diagnostic confirmation followed by treatment with systemic antifungals. A multidisciplinary team approach is necessary to manage this rare condition.

Helping Patients Understand Their Dizziness: Assessment of a Three-Dimensional Printed Vestibular Model.

To assess the improvement in patient understanding with use of a three-dimensional printed vestibular model as a teaching tool and to evaluate the effects of educational approach on dizziness-related disabilities. Single center randomized controlled trial set in the Otolaryngology ambulatory care clinic located at a tertiary care, teaching institution in Shreveport, Louisiana. Patients with a current or suspected diagnosis of benign paroxysmal positional vertigo who met inclusion criteria were randomized to either the three-dimensional model group or the control group. Each group received the same education session about dizziness, with the three-dimensional model being used as a visual aid in the experimental group. The control group received only verbal education. Outcome measures included patient understanding of benign paroxysmal positional vertigo etiology, comfort level with symptom prevention, anxiety related to vertigo symptoms, and how likely the patient was to recommend the teaching session to another individual suffering from vertigo. Pre-session and post-session surveys were administered to all patients to assess outcome measures. Eight patients were enrolled in the experimental group, and eight patients were enrolled in the control group. On post-survey data, the experimental group reported increased understanding of symptom etiology (p = 0.0289), increased comfort level with preventing symptoms (p = 0.2999), a larger decrease in symptom related anxiety (p = 0.0453) and were more likely to recommend the education session (p = 0.2807) compared to the control group. Three-dimensional printed vestibular model demonstrates promise for patient education and reducing related anxiety. Supplementary Information: The online version contains supplementary material available at 10.1007/s12070-022-03325-5.

Tissue Preservation Techniques for Bone-Anchored Hearing Aid Surgery.

OBJECTIVE: Compare outcomes of surgical techniques in percutaneous bone-anchored hearing implant surgery. STUDY DESIGN: Matched retrospective cohort study. SETTING: Tertiary referral center. PATIENTS: Electronic review of adult and pediatric patients who underwent bone conduction device surgery by either the Minimally-invasive Ponto Surgery (MIPS) technique or the linear incision with no soft tissue removal (LnSTR) technique or between August 2015 and April 2018 at our facility. INTERVENTION: Patients in MIPS group underwent Minimally invasive Ponto Surgery (MIPS) technique, while those in LnSTR group underwent LnSTR technique. MAIN OUTCOME MEASURE: Major outcome was presence/severity of localized skin reaction. Secondary outcomes included cosmetic outcome, revision surgery, minor adverse events, device utilization, and postoperative aided speech recognition thresholds (SRTs) across 250 to 4000 Hertz (Hz). RESULTS: Fifty patients met inclusion criteria. There was a significantly lower rate of localized cutaneous reactions for the MIPS group (4.5%) compared with LnSTR group (33.3%; p = 0.026). Rate of revision surgery was significantly less for MIPS (13.6%) compared with LnSTR (20.8%; p = 0.008). Occurrence of poor cosmetic outcome was noted significantly less for the MIPS group (9.1%) compared with LnSTR patients (20.8%; p = 0.005). Minor adverse events and aided SRTs were comparable between groups. CONCLUSIONS: MIPS leads to a statistically significant decrease in localized cutaneous reaction compared with LnSTR. Both the LnSTR and MIPS techniques are safe and effective in the treatment of hearing loss, however MIPS may be superior in certain cases by offering improved healing, decreasing needs for wound care, and possibly decreasing need for frequent follow up.

Endoscopic Over Under Cartilage Tympanoplasty Is Not Inferior to Underlay Cartilage Tympanoplasty.

Objective: Evaluate whether elevating the tympanic membrane from the malleus during endoscopic tympanoplasty may negatively affect postoperative hearing outcomes or perforation rates by comparing 2 similar endoscopic tympanoplasty techniques. Study Design: Retrospective cohort. Setting: Tertiary care center. Patients: Endoscopic over-under cartilage tympanoplasties age and gender matched to endoscopic underlay cartilage tympanoplasties between January 2015 and January 2019. Exclusion criteria included preoperative or intraoperative cholesteatoma, performance of mastoidectomy or ossicular chain reconstruction, and lack of postoperative audiogram. Interventions: Endoscopic cartilage tympanoplasty via over-under or underlay technique. Main Outcome Measures: Pre- and postoperative pure-tone average and word recognition score, graft success. Results: A total of 52 patients were evaluated: 26 endoscopic over-under cartilage tympanoplasties were matched to endoscopic underlay cartilage tympanoplasties. Both groups demonstrated a statistically significant improvement in air conduction hearing (9 dB [P < 0.001] and 6 dB [P < 0.01], respectively), and bone pure-tone average did not worsen in either group (P < 0.001 and P < 0.05, respectively). Postoperative air conduction pure-tone average was statistically noninferior in the over-under group compared with the underlay group (P < 0.05). Reperforation was present in 3 patients (12%) in the underlay group and none in the over-under group, but this difference was not statistically significant (P = 0.24). Conclusions: Endoscopic over-under cartilage tympanoplasty effectively closes tympanic membrane perforations and improves hearing, without greater risk than underlay tympanoplasty. Elevating the tympanic membrane from the malleus does not confer worsen hearing outcomes.

Primary facial nerve paraganglioma: report and review of the literature.

This report describes the diagnosis and treatment of a patient with a rare primary facial nerve paraganglioma as well as a review of the current literature. A 60-year-old male patient presented to our clinic with a 4-month history of left-sided progressive facial paralysis House-Brackmann V. Biopsy taken during facial nerve (FN) decompression confirmed the diagnosis of paraganglioma. The left FN was sacrificed during resection of the mass and a 12-7 jump graft, using the left greater auricular nerve, was performed with acceptable outcomes. The rarity of these tumours does not discount their clinical importance or the necessity to include them in the differential when presented with unilateral FN paralysis. Investigation should begin with CT and MRI imaging to identify and localise the potential mass. Histologic confirmation requires tissue. While surveillance imaging is occasionally an option, often complete surgical resection of the mass and sacrifice of the nerve is necessary.

Additional Benefits of Facial Nerve Monitoring during Otologic Surgery.

OBJECTIVE: This study assesses the role of facial nerve monitoring (FNM) for intraoperative decision making during otologic surgery and possible benefits beyond protecting facial nerve integrity. STUDY DESIGN: This prospective study examines intraoperative FNM data and structured interviews collected during 52 otologic procedures. SETTING: Tertiary referral center. SUBJECTS AND METHODS: Subjects include adults and children undergoing middle ear or mastoid surgery. Data include intraoperative neuromonitoring activity and structured interviews conducted with the operating surgeon immediately following surgery. RESULTS: Facial nerve stimulation was used to confirm the position of the nerve in 42 of 52 surgical procedures. In 26.9% of cases, the patient became "light" and moved under anesthesia, which was predicted by neuromonitoring 71.4% of the time. Through structured interviews, the operating surgeons reported the following. (1) The facial nerve took an unexpected anatomic course in 7.8% of patients and was difficult to identify in 39.2%. (2) The nerve was at increased risk of injury in 66.7% of cases due to chronic disease or previous surgery. (3) Among these high-risk cases, the monitor helped reduce the risk of nerve damage 100% of the time. (4) Neuromonitoring allowed the surgeon to operate faster 86.5% of the time, and (5) FNM allowed the resident to perform more of the operation 68.9% of the time. No patients experienced postoperative facial weakness. CONCLUSIONS: Beyond potentially protecting facial nerve integrity, this study identified additional benefits of FNM, including warning of patient movement during anesthesia, confirming facial nerve anatomic location, reducing operative time, and enhancing resident surgical experience.

Cochlear Enhancement May Precede Cochlear Obliteration After Vestibular Schwannoma Excision.

OBJECTIVE: Cochlear obliteration after vestibular schwannoma excision has been noted, with implications on cochlear implantation. Early postoperative cochlear enhancement with gadolinium on magnetic resonance imaging (MRI) has also been observed. Timing of enhancement and association with obliteration is described here. STUDY DESIGN: Retrospective case review. SETTING: Tertiary referral center, ambulatory. PATIENTS: Patients receiving vestibular schwannoma excision surgery by the senior author performed at one institution between January 2015 and July 2017 with postoperative MRIs INTERVENTION:: Diagnostic. MAIN OUTCOME MEASURE(S): The imaging characteristics on postoperative MRIs examined were loss of fluid signal on postoperative T2 images and cochlear enhancement on gadolinium enhanced T1 images. In the patients receiving labyrinthine sparing procedures, presence of postoperative hearing was evaluated. RESULTS: Of the 42 patients evaluated, 24 received the translabyrinthine approach and 18 received a labyrinth sparing surgery. Twenty-nine had evidence of cochlear enhancement on T1 with gadolinium contrast, and 27 had evidence of cochlear obliteration on T2 images. The odds ratio of patients with cochlear enhancement having obliteration was 30.0:1 (p < 0.0001). Intense cochlear enhancement (n = 21) appeared a median of 163 days after surgery, and complete or near complete obliteration (n = 18) appeared a median of 480 days after surgery, a statistically significant difference (p < 0.001). Within the labyrinth sparing group, there was no statistically significant association between hearing loss and cochlear obliteration or enhancement. CONCLUSIONS: Cochlear enhancement is correlated with cochlear obliteration and may precede it.

Endoscopic Inside-Out Mastoidectomy with the Ultrasonic Bone Aspirator.

We report our experience using the ultrasonic bone aspirator (UBA) for transcanal endoscopic "inside out" mastoidectomy. The UBA has irrigation, suction, and nonrotatory ultrasonic bone-removing technology in 1 handpiece, which makes it appropriate for bone removal during this procedure. The results of our study show that this technique is safe and effective for patients with cholesteatoma in a small sclerotic mastoid. We also discuss the nuances associated with using the UBA during endoscopic ear surgery.

Cochlear implantation via middle fossa approach - a case report.

Objective: Cochlear implantation is routinely performed all over the world via the post-auricular, facial recess approach. Our case study describes the middle fossa approach for the management of bilateral profound sensorineural hearing loss in a female child with multiple external, middle and inner ear malformations. The middle fossa approach has been reported sporadically and has been used inconsistently in patients with chronic otitis media and inner ear malformations. Case study: A 3-year-old female child presented with bilateral profound sensorineural hearing loss, bilateral anotia, right cochlear nerve agenesis, right facial paralysis, bilateral mild inner ear dysplasia and an aberrant left facial nerve covering the left round window. Further tests indicated that she was a suitable candidate for cochlear implantation and was medically cleared for surgery. In view of the multiple malformations and high risk of injury to her only functioning left facial nerve on the side with a cochlear nerve, cochlear implantation via a middle fossa approach was performed. Conclusion: Middle fossa approach to cochlear implantation is challenging but can be safely performed even in children and offers an option in patients when a routine mastoidectomy, facial recess and round window approach cannot be undertaken.

Our experience with split electrode array implant for obliterated cochlea.

UNLABELLED: To study the outcomes of split electrode array cochlear implantation in ossified cochlea using the CAP scoring system. Retrospective case study. Tertiary referral center. Six cochleae in three adult and three pediatric patients with ossification. INTERVENTION(S): All Patients underwent cochlear implantation with a split electrode array system. Major outcome parameter(s): Number of electrodes inserted during surgery, number of functioning electrodes on follow-up and auditory performance evaluation using the CAP score-Category of Auditory Perception [TSC Revised Version, based on Nottingham CI Program, 1995]. Six patients (three children and three adults) had insertion of split electrode array system. The mean number of electrodes inserted were 18.3 (range 15-21) and functioning electrodes at follow-up were mean of 14.3 (range 7-21). Auditory performance was measured using CAP score at 1 year post implant follow up, mean score in children was six and that in adult was eight. One pt had facial nerve twitching which was corrected by switching off the concerned electrode. No complications in sort of facial palsy or vestibular disorder were observed. Patients of ossified cochlea having profound deafness do well with split electrode array cochlear implantation as evaluated with CAP scoring system. The split electrode array results in more number of electrodes within the cochlear lumen. Retro graded apical array insertion has less chances of facial nerve stimulation as it is placed away from the nerve.

Cochlear stenting: how I do it.

Post-meningitis cases with profound sensorineural hearing loss are known to have progressive labyrinthine ossification; such cases need to be implanted early. In our region, often a substantial amount of time is spent procuring the necessary finances for a cochlear implant; therefore, here we describe our technique of maintaining cochlear lumen patency in post-meningitis cases with early ossification, for a complete functional electrode insertion at a later date. This is a descriptive case study of a patient having post-meningitis profound deafness, with imaging studies showing early cochlear ossification, who was rehabilitated with a cochlear implant. At a tertiary referral centre, a 1-year-old child with post-meningitis bilateral profound sensorineural hearing loss was rehabilitated with cochlear implantation. The left cochlea with early ossification was stented with a customised sterile electrode to prevent scalar occlusion; 3 months later the stent was replaced with a commercial Nucleus Contour Advance implant. A complete insertion of the functional electrode array replaced the stent. Categories of auditory performance (CAP) were used to assess the outcome in our case. The pre-operative CAP score was 1 (detects environmental sounds) and the score at 15 months post implant was 6 (understands some spoken words). In post-meningitis cases with progressive cochlear ossification, stenting the cochlear lumen prevents scalar occlusion and ensures a complete insertion of a functional electrode at a later date.

The study of co-morbid conditions in adults with allergic rhinitis, from Mumbai, Maharashtra, India and their comparison with children.

Allergic rhinitis (AR) is an allergen-induced inflammation of the nasal mucosa. Several studies have shown a link not only between AR and asthma but also with other co-morbid conditions. It is important to recognize the onset and existence of these co-morbid conditions, for adequate treatment, prevention of the development of new allergen sensitizations and air-way hypersensitivities. This is a prospective study of co-morbid conditions in adults with AR, from Mumbai, Maharashtra, India and compares them with those in children 23 consecutive children below 6 years (Group 1), 42 children between age of 6 years and 14 years in Group 2 and 57 adults in Group 3 were selected for the symptoms of AR (sneezing, watering and blocked nose), which were currently sufficiently troublesome to require medication. A high association of co-morbid conditions with AR was found. More than 80% suffered from one to three co-morbid conditions each. The most common co-morbid condition was asthma in all the groups. Often asthma and sinusitis was asymptomatic and a high degree of suspicion was needed for diagnosis. Adults had the highest prevalence of sinusitis and allergic conjunctivitis. Prevalence of urticaria was similar in children as well as adults. Studies with larger data samples are needed to confirm these associations.

The mini-rhino-conjunctivitis quality of life (qol) questionnaire (mrqlq) - self administered.

OBJECTIVE: Our aim was to administer the MRQLQ Questionnaire in Indian adults with allergic rhino-conjunctivitis (ARc). CRITERIA FOR INCLUSION IN THE STUDY: Adults with chronic ARc, with sufficiently troublesome current symptoms, attending The Allergy Clinic of The Hinduja Hospital, Mumbai, during March-August 2006 were selected. RESULTS: The five highest PS were seen with sneezing 290, irritation 238, running nose 228, stuffy nose 220, anxiety 203 and interrupted working 203. The 5 lowest PS were seen with disturbed sleep 83, dry throat 98, affected walking for 1/2 kilometre 98, do not sleep deeply 103 and phlegm 105. DISCUSSION: The five highest PS were due to symptoms of rhinitis, general irritation, anxiety & interruption of work. Thus rhinitis itself affects QOL. The 5 least PS were mainly sleep-related. CONCLUSION: We have applied the MRQLQ on Indian patients with ARc. We could obtain a product score for every item in it, on the basis of which we could classify the degree of its effect on his QOL. PS was highest in rhinitis-related symptoms. 2 Emotions related and 1 Role limitation item gave moderate PS, while all PS in eye related, Physical functioning, Social functioning, Sleep-related & Other Symptoms items were in the mild range. Larger data sample is needed to validate and show its discriminatory power.

The study of co-morbid conditions in children with allergic rhinitis, from Mumbai, Maharashtra, India.

Allergic rhinitis (AR), an allergen-induced inflammation of the nasal mucosa, is frequently associated with co-morbid conditions. It is important to recognize the onset and existence of these co-morbid conditions, for adequate treatment and prevention of the development of new allergen sensitizations and air-way hypersensitivities. The aim of our study was to determine the prevalence of co-morbid conditions associated with AR, in Indian children. We selected 65 consecutive children below the age of 18 years, who attended the Allergy and Asthma Clinic of our hospital, between March 1, 2005 to November 30, 2006 and compared them with the available literature. The most common co-morbid condition with AR was asthma (75.4%), followed by urticaria (33.9%), conjunctivitis (29.2%) and sinusitis (23.1%) in that order. Two patients (3.1%) each, had adenoid hypertrophy and nasal polyps. Psoriasis was seen in 4/65 (6.2%). Four patients (6.2%) were free from any co-morbid conditions as opposed to 61/65 (93.8%), who suffered from one to three co-morbid conditions each. Co-morbid conditions are a rule rather than an exception, the most common association being asthma. Asthma often is asymptomatic and routine PFT testing is valuable. The association of psoriasis is interesting.