Incidence of Complete Insertion in Cochlear Implant Recipients of Long Lateral Wall Arrays.

OBJECTIVE: High rates of partial insertion have been reported for cochlear implant (CI) recipients of long lateral wall electrode arrays, presumably caused by resistance encountered during insertion due to cochlear morphology. With recent advances in long-electrode array design, we sought to investigate (1) the incidence of complete insertions among patients implanted with 31.5-mm flexible arrays and (2) whether complete insertion is limited by cochlear duct length (CDL). STUDY DESIGN: Retrospective review. SETTING: Tertiary referral center. METHODS: Fifty-one adult CI recipients implanted with 31.5-mm flexible lateral wall arrays underwent postoperative computed tomography to determine the rate of complete insertion, defined as all contacts being intracochlear. CDL and angular insertion depth (AID) were compared between complete and partial insertion cohorts. RESULTS: Most cases had a complete insertion (96.1%, n = 49). Among the complete insertion cohort, the median CDL was 33.6 mm (range, 30.3-37.9 mm), and median AID was 641° (range, 533-751°). Two cases of partial insertion had relatively short CDL (31.8 mm and 32.3 mm) and shallow AID (542° and 575°). Relatively shallow AID for the 2 cases of partial insertion fails to support the idea that CDL alone prevents a complete insertion. CONCLUSION: Complete insertion of a 31.5-mm flexible array is feasible in most cases and does not appear to be limited by the range of CDL observed in this cohort. Future studies are needed to estimate other variations in cochlear morphology that could predict resistance and failure to achieve complete insertion with long arrays.

Prevalence of and Associations With Distress and Professional Burnout Among Otolaryngologists: Part II, Attending Physicians.

OBJECTIVE: To ascertain the prevalence of and associations with distress and professional burnout among academic otolaryngology attending physicians. STUDY DESIGN: Cross-sectional survey. SETTING: Twelve US academic otolaryngology programs. METHODS: A questionnaire was administered that encompassed sociodemographic and professional features, the Expanded Physician Well-being Index for distress, the 2-item Maslach Burnout Inventory for professional burnout, the Patient Health Questionnaire-2 screen for major depressive disorder, and the Generalized Anxiety Disorder-2 screen for generalized anxiety disorder. RESULTS: The survey response rate was 56% and included 186 attending physicians. The average respondent age was 47 years; 72% were men; 93% were married or partnered; and 86% had children. Distress was present in 40%, professional burnout in 26%, positive depression screening in 8%, and positive anxiety screening in 11%. In a univariable setting, age, hours worked in a typical week, nights on call in a typical week, and years of practice were significantly associated with distress, although in a multivariable setting, only hours worked in a typical week remained significantly associated with a positive Expanded Physician Well-being Index screen (odds ratio for each 10-hour increase, 2.61; 95% CI, 1.73-3.93; P < .001). In a univariable setting, hours worked in a typical week was significantly associated with a positive Maslach Burnout Inventory screen. CONCLUSION: Distress or professional burnout occurs in more than a quarter of academic otolaryngology attending physicians, whereas the prevalence of depression or anxiety is approximately 10%. The number of hours worked per week had the strongest association with distress and burnout. These findings may be used to develop and implement programs to promote physician well-being and mitigate professional burnout.

Prevalence of and Associations With Distress and Professional Burnout Among Otolaryngologists: Part I, Trainees.

OBJECTIVE: To assess the prevalence of distress and burnout in otolaryngology trainees, including associations with relevant sociodemographic and professional factors, and to compare these results with those of attending otolaryngologists. STUDY DESIGN: A cross-sectional survey of trainees and attending physicians. SETTING: Twelve academic otolaryngology programs. METHODS: Distress and burnout were measured with the Expanded Physician Well-being Index and the 2-item Maslach Burnout Inventory. The Patient Health Questionnaire-2 and Generalized Anxiety Disorder-2 were used to screen for depressive disorders and anxiety disorders, respectively. Associations with sociodemographic and professional characteristics were assessed. RESULTS: Of the 613 surveys administered to trainees and attending physicians, 340 were completed (56%). Among 154 trainees, distress was present in 49%, professional burnout in 35%, positive depressive disorder screening in 5%, and positive anxiety disorder screening in 16%. In univariable analysis, female gender, hours worked in a typical week (HW), and nights on call in a typical week (NOC) were significantly associated with distress. In multivariable analysis, female gender (odds ratio, 3.91; P = .001) and HW (odds ratio for each 10 HW, 1.89; P = .003) remained significantly associated with distress. Female gender, HW, and NOC were significantly associated with burnout univariably, although only HW (odds ratio for each 10 HW, 1.92; P = .003) remained significantly associated with burnout in a multivariable setting. Attending physicians had less distress than trainees (P = .02) and felt less callous and less emotionally hardened than trainees (P < .001). CONCLUSION: Otolaryngology trainees experience significant work-place distress (49%) and burnout (35%). Gender, HW, and NOC had the strongest associations with distress and burnout.

Assessing Cochlear Implant Insertion Angle From an Intraoperative X-ray Using a Rotating 3D Helical Scala Tympani Model.

BACKGROUND: Angular insertion depth (AID) of the electrode array provides valuable information regarding intracochlear positioning, which can be used to predict outcomes and optimize performance. While computed tomography (CT) offers high-resolution imaging, there is a need to develop technology to accurately determine AID from intraoperative x-rays acquired at unknown angles. METHODS: An algorithm was developed using a three-dimensional model of the scala tympani to estimate AID from an x-ray acquired at an unknown angle. The model is manipulated over the x-ray until the projection angle is inferred and the location of the round window and individual electrode contacts are identified. Validation of the algorithm involved 1) assessing accuracy with deviation from cochlear view by comparing AID determined with simulated x-rays to those determined with CT in a temporal bone model, and 2) assessing reproducibility in the clinical setting, by comparing intra- and inter-rater reliability with intraoperative x-ray in cochlear implant (CI) recipients, which were subsequently compared to AID determined with postoperative CT. RESULTS: Estimates of AID from x-rays were generally within 10 degrees of CT regardless of deviation from cochlear view. Excluding two outliers with poor imaging quality, the intraclass correlation coefficients for intra- and inter-rater reliability were excellent (0.991 and 0.980, respectively). CONCLUSION: With intraoperative x-rays of sufficient quality, the helical scala tympani model can be used to accurately and reliably determine AID without the need to specify a preferred image angle. The application can therefore be used in most CI recipients when a postoperative CT is not available.

Outcomes of Revision Cochlear Implantation.

OBJECTIVES/HYPOTHESIS: This study aims to 1) report revision cochlear implantation (CI) rates at a high-volume CI center, 2) describe classifications for revision CI, 3) analyze audiologic and surgical outcomes in patients who undergo revision CI, and 4) describe a new subcategory of soft failures, named presumed soft failures. STUDY DESIGN: Retrospective case series. SETTING: Tertiary care otologic center. PATIENTS: Adults and children undergoing revision CI from 2005 to 2015. MAIN OUTCOME MEASURE: Type and etiology of CI failure, preoperative, and postoperative outcomes (audiologic, surgical). RESULTS: During the study period, 1,469 CI surgeries were performed with a total of 81 (5.51%) revision cochlear implantations, 64 of these meeting inclusion criteria with adequate follow up and clear indications for revision surgery. The most common indication for revision surgery was hard failure (53.1%), followed by soft failure (29.7%), and medical/surgical failure (17.2%). 78.1% (50/64) of revision CI patients showed improvement postoperatively (defined as 15% improvement of speech perceptions scores or improvement of aversive symptoms, according to the 2005 consensus statement guidelines). Hard failures showed improvement in 85.3% (29/34) of cases, medical and surgical failures showed improvement in 72.7% (8/11) of cases, and soft failures showed improvement in 68.4% (13/19) of cases. There was a statistically significant difference in percentage of adult versus pediatric patients by failure subtype, with 84.2% of soft failure patients classified as adults (18 or older) at the time of revision surgery compared with 50% and 36.3% for hard failure and medical/surgical failure patients, respectively (p = 0.02). Similarly, there was a trend, though not statistically significant, towards older age in the soft failure group compared with hard and medical/surgical failure groups (median 43 yr versus 18 and 16, respectively). Within the soft failure group there was a subset of patients that failed to show improvement in audiologic performance or experienced continued aversive symptoms referred to as "presumed soft failures." These patients, by definition, experienced worse outcomes after revision surgery (p < 0.05) and trended towards older age (43 versus 31 yr) and longer time from initial to revision surgery (27.3 versus 24.7 mo) when compared with true soft failures. CONCLUSIONS: The majority of patients improved after revision CI surgery; patients with hard failure demonstrated the highest percentage with improvement, while those with soft failures had worse outcomes. The presumed soft failure group may represent a unique etiology for CI failure that warrants further investigation given worse outcomes after revision surgery.

Subjective Benefits of Bimodal Listening in Cochlear Implant Recipients with Asymmetric Hearing Loss.

OBJECTIVE: To investigate the influence of cochlear implant (CI) use on subjective benefits in quality of life in cases of asymmetric hearing loss (AHL). STUDY DESIGN: Prospective clinical trial. SETTING: Tertiary academic center. SUBJECTS AND METHODS: Subjects included CI recipients with AHL (n = 20), defined as moderate-to-profound hearing loss in the affected ear and mild-to-moderate hearing loss in the contralateral ear. Quality of life was assessed with the Speech, Spatial, and Qualities of Hearing Scale (SSQ) pragmatic subscales, which assess binaural benefits. Subjective benefit on the pragmatic subscales was compared to word recognition in quiet and spatial hearing abilities (ie, masked sentence recognition and localization). RESULTS: Subjects demonstrated an early, significant improvement (P < .01) in abilities with the CI as compared to preoperative abilities on the SSQ pragmatic subscales by the 1-month interval. Perceived abilities were either maintained or continued to improve over the study period. There were no significant correlations between results on the Speech in Quiet subscale and word recognition in quiet, the Speech in Speech Contexts subscale and masked sentence recognition, or the Localization subscale and sound field localization. CONCLUSIONS: CI recipients with AHL report a significant improvement in quality of life as measured by the SSQ pragmatic subscales over preoperative abilities. Reported improvements are observed as early as 1 month postactivation, which likely reflect the binaural benefits of listening with bimodal stimulation (CI and contralateral hearing aid). The SSQ pragmatic subscales may provide a more in-depth insight into CI recipient experience as compared to behavioral sound field measures alone.

Influence of Age at Cochlear Implantation and Frequency-to-Place Mismatch on Early Speech Recognition in Adults.

OBJECTIVE: Default frequency filters of cochlear implant (CI) devices assign frequency information irrespective of intracochlear position, resulting in varying degrees of frequency-to-place mismatch. Substantial mismatch negatively influences speech recognition in postlingually deafened CI recipients, and acclimatization may be particularly challenging for older adults due to effects of aging on the auditory pathway. The present report investigated the influence of mismatch and age at implantation on speech recognition within the initial 6 months of CI use. STUDY DESIGN: Retrospective review. SETTING: Tertiary referral center. SUBJECTS AND METHODS: Forty-eight postlingually deafened adult CI recipients of lateral wall electrode arrays underwent postoperative computed tomography to determine angular insertion depth of each electrode contact. Frequency-to-place mismatch was determined by comparing spiral ganglion place frequencies to default frequency filters. Consonant-nucleus-consonant (CNC) scores in the CI-alone condition at 1, 3, and 6 months postactivation were compared to the degree of mismatch at 1500 Hz and age at implantation. RESULTS: Younger adult CI recipients experienced more rapid growth in speech recognition during the initial 6 months postactivation. Greater degrees of frequency-to-place mismatch were associated with poorer performance, yet older listeners were not particularly susceptible to this effect. CONCLUSIONS: While older adults are not necessarily more sensitive to detrimental effects of frequency-to-place mismatch, other factors appear to limit early benefit with a CI in this population. These results suggest that minimizing mismatch could optimize outcomes in adult CI recipients across the life span, which may be particularly beneficial in the elderly considering auditory processing deficits associated with advanced age.

Low-Frequency Hearing Preservation With Long Electrode Arrays: Inclusion of Unaided Hearing Threshold Assessment in the Postoperative Test Battery.

Purpose The goal of this work was to evaluate the low-frequency hearing preservation of long electrode array cochlear implant (CI) recipients. Method Twenty-five participants presented with an unaided hearing threshold of ≤ 80 dB HL at 125 Hz pre-operatively in the ear to be implanted. Participants were implanted with a long (31.5-mm) electrode array. The unaided hearing threshold at 125 Hz was compared between the preoperative and postoperative intervals (i.e., initial CI activation, and 1, 3, 6, 9, and 12 months after activation). Results Eight participants maintained an unaided hearing threshold of ≤ 80 dB HL at 125 Hz postoperatively. The majority (n = 5) demonstrated aidable low-frequency hearing at initial activation, whereas 3 other participants experienced an improvement in unaided low-frequency hearing thresholds at subsequent intervals. Conclusions CI recipients can retain residual hearing sensitivity with fully inserted long electrode arrays, and low-frequency hearing thresholds may improve during the postoperative period. Therefore, unaided hearing thresholds obtained within the initial weeks after surgery may not reflect later hearing sensitivity. Routine measurement of postoperative unaided hearing thresholds-even for patients who did not demonstrate aidable hearing thresholds initially after cochlear implantation-will identify CI recipients who may benefit from electric-acoustic stimulation. Supplemental Material https://doi.org/10.23641/asha.11356637.

Rate of Initial Hearing Loss During Early Observation Predicts Time to Non-Serviceable Hearing in Patients With Conservatively Managed Sporadic Vestibular Schwannoma.

OBJECTIVE: To date, prediction models for estimating risk of acquiring non-serviceable hearing in subjects with observed vestibular schwannoma (VS) have evaluated outcomes primarily based on features at initial diagnosis. Herein, we evaluate the association of rate of hearing decline during the initial period of observation with time to non-serviceable hearing. If significant, rate of hearing decline may inform decision making after an introductory period of observation. SETTING: Two tertiary care centers. PATIENTS: VS patients with serviceable hearing who underwent at least three audiograms and two magnetic resonance imaging (MRI) studies before intervention or being lost to follow-up. The rate of change in pure-tone average (PTA) and word recognition score (WRS) was calculated as the score from the second audiogram minus the score from the first audiogram, divided by the duration in months between the two. MAIN OUTCOME MEASURE(S): Serviceable hearing, defined as PTA ≤50 dB HL and WRS ≥50%. RESULTS: Among 266 patients meeting inclusion criteria, 52 developed non-serviceable hearing at last follow-up. Kaplan-Meier estimated rates of maintaining serviceable hearing (95% CI; number still at risk) at 1, 3, 5, 7, and 10 years were 97% (95-100; 206), 78% (72-85; 98), 68% (60-77; 39), 60% (50-73; 17), and 44% (29-67; 2), respectively. In a univariable setting, each 1 dB increase per month in the rate of initial PTA change was associated with a 96% increased likelihood of acquiring non-serviceable hearing (hazard ratio [HR] 1.96; 95% CI 1.44-2.68; p < 0.001). Each 1% increase per month in the rate of initial WRS change was associated with a decreased likelihood of acquiring non-serviceable hearing (hazard ratio [HR] 0.79; 95% confidence interval [CI] 0.66-0.94; p = 0.009). After multivariable adjustment, both rate of PTA change (HR 2.42; 95% CI 1.72-3.41; p < 0.001) and rate of WRS change (HR 0.81; 95% CI 0.67-0.99; p = 0.043) remained statistically significantly associated with time to non-serviceable hearing. CONCLUSION: Rate of early PTA and WRS decline during the initial period of observation are significantly associated with time to development of non-serviceable hearing. This information may facilitate accurate patient counseling and inform decision-making regarding prospective disease management.

Hearing Outcomes Following Type 3 Tympanoplasty With Stapes Columella Grafting in Canal Wall Down Mastoidectomy.

OBJECTIVES: To analyze hearing outcomes following Type 3 tympanoplasty with stapes columella grafting after canal wall down mastoidectomy and determine disease recurrence rates in patients undergoing this procedure. METHODS: This retrospective cohort analysis examines patients undergoing Type 3 tympanoplasty with stapes columella grafting following canal wall down mastoidectomy for cholesteatoma at a tertiary care center from 2005 to 2015. Patient charts were reviewed for demographic data, diagnosis, and operative details. Patients were included in statistical analysis if they were found to have undergone the aforementioned procedure. Evaluation of hearing improvement was made by comparing preoperative air-bone gap (ABG) and ABG at follow-up at 6 months and 1 year postoperatively. RESULTS: Nineteen patients met criteria for this study. Erosion of the otic capsule, posterior fossa plate, or tegmen was noted in 37% of cases, highlighting disease severity. Eighteen (95%) had undergone prior otologic surgery. Mean time to short-term follow-up was 6 ± 3 months. The average short-term ABG was 26 ± 11 dB HL; 26% achieved an ABG <20 dB, and 58% achieved an ABG <30 dB. Fifteen had follow-up at least 1 year postoperatively (mean = 33 ± 16 months). At longer-term follow-up, mean ABG was 25 ± 10 dB HL; 33% achieved an ABG <20 dB, while 66% achieved an ABG <30 dB. Hearing remained stable over time (P = .52). At date of last clinical follow-up, only 1 (5%) patient had undergone revision for recurrent disease. CONCLUSION: In some patients undergoing canal wall down mastoidectomy for advanced or recurrent cholesteatoma, Type 3 tympanoplasty with stapes columella grafting yields marginal hearing benefit. This type of reconstruction is a viable option in this challenging patient cohort, particularly as it is associated with low rates of revision surgery.

Translabyrinthine Excision of Vestibular Schwannoma with Concurrent Cochlear Implantation: Systematic Review.

Objectives Hearing rehabilitation is an important management aspect of patients undergoing excision of vestibular schwannomas. Studies have shown cochlear implantation (CI) is possible at the time of tumor excision via a translabyrinthine approach. Primary objectives of this report are (1) to review prospective studies pertaining to outcomes of concurrent CI and translabyrinthine tumor removal in detail and (2) perform an aggregate analysis of outcomes for case reports and series. Design Systematic review based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Setting Review of literature using PubMed and Cochrane databases. Participants Eligibility included patients undergoing translabyrinthine excision of vestibular schwannoma with concurrent CI. Main Outcome Measures Open-set speech discrimination scores, sound localization, patient-reported outcome measures. Results Forty-one subjects were identified. Two prospective studies have been performed, which showed improvement in speech localization and patient-reported outcome measures. While the majority of patients achieved open set speech recognition, data pertaining to improvement in speech perception were variable. Approximately 85% of subjects had audibility with their CI. Of those that achieved open-set speech discrimination, 75% could be classified as either intermediate or high performers. The majority of low performers in open-set speech either endorsed subjective benefit or demonstrated improvement compared to preoperative measures. There was a high risk of selection and reporting bias. Conclusions The majority of patients undergoing translabyrinthine excision of vestibular schwannoma with concurrent CI achieve open set speech perception, with 75% of these patients meeting criteria for being intermediate to high performers. Additional benefits include improved subjective hearing measures, decreased tinnitus, and improved sound localization.

Long-Term Hearing Outcomes following Total Ossicular Reconstruction with Titanium Prostheses.

OBJECTIVE: (1) Characterize a large cohort of patients undergoing total ossicular chain reconstruction with titanium prosthesis. (2) Analyze long-term hearing outcomes of the same cohort. STUDY DESIGN: Case series with chart review. SETTING: Tertiary care center. SUBJECT AND METHODS: This study reviews patients who underwent total ossicular chain reconstruction (OCR) with titanium prostheses (TORPs) at a single tertiary care center from 2005 to 2015. Patient charts were reviewed for demographic data, diagnosis, and operative details. Patients were included in statistical analysis if length of follow-up was 2 years or more. Evaluation of hearing improvement was made by comparing preoperative air-bone gap (ABG) and ABG at follow-up at 2 years. RESULTS: In total, 153 patients were identified who met inclusion criteria. The mean age of included patients was 40 years (range, 6-89 years). Sixty patients (39%) had a history of OCR, and 120 patients (78%) had a diagnosis of cholesteatoma at the time of OCR. Preoperatively, the mean ABG was 36 ± 12, whereas the mean ABG at 2-year follow-up improved to 26 ± 13. This was statistically significant (P < .0001) using a Wilcoxon matched-pairs signed rank test. Twelve patients (8%) required revision OCR. Two revisions were performed due to prosthesis extrusion (<1%). CONCLUSION: Titanium prostheses lead to significant improvement in hearing over long periods. The results are sustained as far out as 5 years following surgery. In addition, rates of revision surgery with titanium TORPs are low. Based on this series, there are no readily identifiable predictors for outcomes following total OCR.

Evaluation of Social Media Presence of Otolaryngology Residency Programs in the United States.

Importance: Over two-thirds of the adult population in the United States use Facebook. Despite the high interest in and use of social media by the general public, the presence and accessibility of health care organizations on social media has not yet been fully evaluated. Objective: To determine the use and popularity of social media among otolaryngology residency programs in the United States. Design, Setting, and Participants: A cross-sectional study of the presence of accredited otolaryngology residency programs in the United States in an internet data repository was conducted. Programs were stratified by Doximity Residency Navigator reputation rankings (dividing programs into quartiles) and US News & World Report (comparing programs affiliated with hospitals ranked in the top 50 vs programs affiliated with unranked hospitals). Social media sites and activity for each program were assessed using internet searches. The study was conducted in April 2017. Results: Among 101 otolaryngology residency programs, 30 were found to have social media sites (29.7%). Facebook and Twitter were the most commonly used services, with 25 (24.8%) and 14 (13.9%) accounts, respectively. Based on Doximity Residency Navigator rankings, programs in the first quartile were more likely to have Facebook profiles than programs in the fourth quartile (42.3% vs 12.0%; absolute difference, 30%; 95% CI, 2.9% to 52.6%). First- and second-quartile programs showed increased Facebook activity. There was greater Twitter presence in first- vs fourth-quartile programs (19.2% vs 8.0%; absolute difference, 11.2%; 95% CI, -11.6% to 33.0%). Higher-quartile programs were more active on Twitter and exhibited increased numbers of likes and followers. Analysis of US News & World Report rankings revealed that ranked programs had higher rates of presence, activity, and popularity on both Facebook and Twitter. However, these were smaller differences than seen when comparing Doximity Residency Navigator rankings. Correlation between the 2 ranking systems was indicated (Spearman ρ = 0.59; 95% CI, 0.34 to 0.76). Conclusions and Relevance: This study suggests that otolaryngology residency programs with higher Doximity Residency Navigator reputation rankings have a stronger presence on social media. Smaller trends were observed for programs in the top 50 US News & World Report rankings. Overall, social media use among otolaryngology programs seems relatively low, and this may present an opportunity to increase communication with the public via these technologies.

Intra-Cochlear Electrocochleography During Cochear Implant Electrode Insertion Is Predictive of Final Scalar Location.

HYPOTHESIS: Electrocochleography (ECochG) patterns observed during cochlear implant (CI) electrode insertion may provide information about scalar location of the electrode array. BACKGROUND: Conventional CI surgery is performed without actively monitoring auditory function and potential damage to intracochlear structures. The central hypothesis of this study was that ECochG obtained directly through the CI may be used to estimate intracochlear electrode position and, ultimately, residual hearing preservation. METHODS: Intracochlear ECochG was performed on 32 patients across 3 different implant centers. During electrode insertion, a 50-ms tone burst stimulus (500 Hz) was delivered at 110 dB SPL. The ECochG response was monitored from the apical-most electrode. The amplitude and phase changes of the first harmonic were imported into an algorithm in an attempt to predict the intracochlear electrode location (scala tympani [ST], translocation from ST to scala vestibuli [SV], or interaction with basilar membrane). Anatomic electrode position was verified using postoperative computed tomography (CT) with image processing. RESULTS: CT analysis confirmed 25 electrodes with ST position and 7 electrode arrays translocating from ST into SV. The ECochG algorithm correctly estimated electrode position in 26 (82%) of 32 subjects while 6 (18%) electrodes were wrongly identified as translocated (sensitivity = 100%, specificity = 77%, positive predictive value = 54%, and a negative predictive value = 100%). Greater hearing loss was observed postoperatively in participants with translocated electrode arrays (36 ±â€Š15 dB) when compared with isolated ST insertions (28 ±â€Š20 dB HL). This result, however, was not significant (p = 0.789). CONCLUSION: Intracochlear ECochG may provide information about CI electrode location and hearing preservation.

Adenomatous Neuroendocrine Tumors of the Middle Ear: A Multi-institutional Investigation of 32 Cases and Development of a Staging System.

OBJECTIVE: To date, less than 150 cases of middle ear adenomatous neuroendocrine tumors (MEANTs) have been reported in the English literature. The objective of this study was to provide a contemporary analysis of these rare lesions and develop a consensus-driven staging system. STUDY DESIGN: Multi-institutional retrospective histopathologic, radiologic, and clinical review. SETTING: Six tertiary referral centers. PATIENTS: Thirty-two patients with pathologically confirmed MEANT. INTERVENTION: Surgical resection, adjuvant therapy. MAIN OUTCOME MEASURES: Clinical manifestations, outcomes, staging system. RESULTS: Patients commonly presented with progressive conductive or mixed hearing loss (90%), aural fullness (50%), and tonal tinnitus (46%). Pulsatile tinnitus (16%), carcinoid syndrome (4%), and facial nerve paresis (4%) were less commonly observed. MEANTs frequently mimicked temporal bone paraganglioma (31%) and cholesteatoma (15%) at presentation. According to a novel T/N/M/S staging system (S = secretory tumor) proposed herein, there were 6 (19%) T1, 19 (59%) T2, and 7 (22%) T3 MEANTs. T3 tumors were significantly more likely to undergo subtotal or near total resection compared with lower staged tumors secondary to adherence to critical neurovascular structures such as the petrous internal carotid artery and facial nerve (p = 0.027). Patients with T3 MEANTs were more likely to experience multiple recurrences, require adjuvant therapy with a somatostatin analogue, or develop permanent facial nerve paresis compared with lower staged tumors. At last follow up, no patients with T1 MEANTs had developed recurrence, whereas 37% (7/19) of patients with T2 MEANT and 57% (4/7) of patients with T3 MEANT experienced either disease recurrence after gross total resection (GTR) or regrowth of known residual tumor requiring additional surgery at a median duration of 72 months (95% CI, 24-84). CONCLUSIONS: Patients with MEANTs can present with nonspecific symptomatology that overlaps with more commonly encountered middle ear lesions. MEANT exhibits a proclivity for recurrence according to T-stage and long-term clinical follow up is necessary, particularly for advanced stage tumors.

Hearing Outcomes in Conservatively Managed Vestibular Schwannoma Patients With Serviceable Hearing.

OBJECTIVE: To characterize the risk of progression to nonserviceable hearing in patients with sporadic vestibular schwannomas (VS) who elect initial observation. STUDY DESIGN: Retrospective case series. SETTING: Two tertiary care centers. PATIENTS: VS patients with serviceable hearing who underwent at least two audiograms and two MRI studies before intervention or loss to follow-up. MAIN OUTCOME MEASURE(S): Serviceable hearing, defined as the pure tone average ≤ 50 dB HL and word recognition score ≥ 50%. RESULTS: Four-hundred sixty-six patients (median age of 57 yr and median tumor diameter of 7.3 mm) had serviceable hearing at presentation and were followed for a median of 2.3 years (IQR 1.0 - 4.0). Kaplan-Meier estimated rates of maintaining serviceable hearing (95% CI; number still at risk) at 1, 3, 5, 7, and 10 years following diagnosis were 94% (91-96; 357), 77% (73-82; 172), 66% (60-73; 81), 56% (49-65; 31), and 44% (33-59; 10), respectively. Each 10-dB increase in pure-tone averages at diagnosis was associated with a 2-fold increased likelihood of developing nonserviceable hearing (hazard ratio 2.07; p < 0.001). Each 10% decrease in word recognition score was associated with a 1.5-fold increased likelihood of developing nonserviceable hearing (hazard ratio 1.48; p < 0.001). CONCLUSIONS: Among patients with sporadic VS, good baseline word recognition score and low pure-tone average are jointly associated with maintenance of serviceable hearing. These data may be used to guide patient counseling and optimize management.

Endoscopic Ear Surgery Skills Training Improves Medical Student Performance.

OBJECTIVE: Analyze medical student performance using an endoscopic ear surgery (EES) skills trainer over time. DESIGN: Simulation experience. SETTING: Surgical skills lab. PARTICIPANTS: Five medical students and 1 expert surgeon completed 3 training sessions using an EES trainer to practice specific tasks designed to improve instrument control. During each session, participants performed 3 tasks, such as placing beads onto wires, 5 times per session for a total of 15 trials per task. Exercises were scored based on completion time. Results were compared before and after training. Pre- and post-task surveys were administered. RESULTS: Prior to skills training, 0% of medical students reported feeling comfortable holding an endoscope or ear instruments. For students, overall mean completion times decreased significantly for each exercise by the conclusion of the training experience: placing beads on wires improved from 152 to 44 seconds (p < 0.001), placing simulated prostheses from 264 to 93 seconds (p < 0.001), and navigating a pattern from 193 to 66 seconds (p = 0.002). Individual analysis showed varying learning curves among participants and between exercises, with some students exhibiting rapid improvement. At the conclusion of training, 80% of students felt comfortable holding the endoscope and using otologic instruments, and 100% were satisfied with the experience. CONCLUSIONS: Novice surgeons can exhibit significant skill improvement with repetitive practice on an EES trainer. Variable baseline skill and improvement rates highlight the individual characteristics of skill acquisition, which may be important factors during otolaryngology and endoscopic ear surgery training.

Tympanic Membrane Perforation Repair Using Porcine Small Intestinal Submucosal Grafting.

OBJECTIVE: To evaluate the use of porcine small intestinal submucosal grafts for tympanic membrane repair. PATIENTS: Adult and pediatric patients with tympanic membrane perforations with and without chronic otitits media, and perforations after removal of cholesteatoma. INTERVENTION: Endoscopic or microscopic tympanic membrane repair using porcine small intestinal submucosal grafts (Biodesign). MAIN OUTCOME MEASURE(S): Perforation closure, bone and air pure-tone averages (PTA), air-bone gap (ABG), and word recognition scores (WRS) were recorded as outcome measures. RESULTS: Thirty-seven patients were included with a mean age of 25.4 years (range, 6-75), 57% men. Twenty-six cases (70%) were performed endoscopically and 34 (92%) had concomitant cartilage grafting. Three patients (8%) had postoperative pinpoint (<1% surface area) perforation, and two patients (5%) had postoperative perforation, with an overall success rate of 86.5%. The mean improvement in air-bone gap was 7.6 dB and (p = 0.006). There were no statistically significant differences in closure rates when comparing primary versus revision cases, endoscopic versus microscopic cases, size of perforation, cholesteatoma, concomitant mastoidectomy, age, tobacco exposure, or comorbid diabetes mellitus. Patients with concomitant cartilage graft were more likely to be successful when compared with those without cartilage graft (p = 0.04). CONCLUSIONS: Porcine small intestinal submucosal grafts are effective in the repair of the tympanic membrane. These grafts are an excellent choice in total endoscopic cases as it avoids incisions necessary for allograft harvest.

Survey of the American Neurotology Society on Cochlear Implantation: Part 2, Surgical and Device-Related Practice Patterns.

OBJECTIVE: To examine surgical and device-related cochlear implant practice patterns across centers in the United States. METHODS: Cross-sectional survey of the American Neurotology Society (ANS). RESULTS: A total of 81 surveys were returned from ANS members who report regular involvement in cochlear implant care. Overall there was a broad distribution in age and clinical experience, with most respondents reporting Accreditation Council for Graduate Medical Education (ACGME) accreditation in neurotology and employment at an academic center. The annual volume of cochlear implant surgeries varied considerably across centers. Eighty percent of respondents report to offer all three Food and Drug Administration (FDA) approved device brands at their center.In cases where hearing preservation is not a goal, 56% of respondents prefer a perimodiolar electrode design, while 44% prefer a lateral wall electrode. With regard to insertion technique for scala tympani access, 64% prefer inserting through the round window (RW) membrane, 26% prefer an extended round window (ERW) approach, while only 10% prefer a cochleostomy. In cases where hearing preservation is a goal of surgery, 86% of respondents prefer a lateral wall electrode design, while only 14% prefer a perimodiolar electrode design. With regard to insertion technique, 86% prefer RW insertion, while only 9% prefer an ERW approach, and only 5% prefer a cochleostomy. Respondents who prefer RW electrode insertion more commonly use a lateral wall electrode, whereas those who prefer an ERW or cochleostomy approach more commonly use a periomodiolar electrode (p < 0.001). There was a statistically significant greater number of surgeons that prefer lateral wall electrodes (p < 0.001) and RW insertion (p < 0.001) for hearing preservation cases compared with non-hearing preservation cases. For implantation of a hypothetical patient with significant residual hearing, within the range of hybrid device candidacy, the great majority of surgeons prefer a conventional length electrode and only 29% prefer to implant a hybrid device.In cases where hearing preservation is a goal, the overwhelming majority of respondents (96%, n = 74) reported using at least one form of steroid application. Ninety-two percent (n = 71) used intraoperative intravenous steroids, 55% (n = 42) prescribed postoperative oral steroids, 44% (n = 34) bathed the middle ear with steroids during surgery, and 30% (n = 23) prescribed preoperative oral steroids.Together, 65% of respondents use a variation of the tight subperiosteal pocket technique for internal device fixation, 19% prefer a bony well and trough with tie-downs, 10% prefer a bony well and trough without tie-downs, and 5% prefer a screw fixation system. Of the 50 who prefer utilizing a subperiosteal pocket, 31 (62%) incorporate a bony trough and 19 (38%) perform a subperiosteal pocket alone without a bony trough. CONCLUSION: The results of this survey reflect the evolution in surgical and device-related preferences for cochlear implantation in the United States. An increasing number of surgeons prefer the RW approach for electrode insertion. When hearing preservation is not a goal, there is a near even preference for lateral wall and perimodiolar electrode designs; however, the great majority of surgeons prefer a lateral wall design when attempting to preserve residual acoustic hearing. Even in cases where substantial residual hearing exists, many surgeons prefer conventional length electrodes to hybrid designs. These changes reflect the prioritization of atraumatic surgery and parallel the development of thinner and more atraumatic electrodes.

Tumor Progression Following Petroclival Meningioma Subtotal Resection: A Volumetric Study.

BACKGROUND: One study has investigated postoperative growth rates following subtotal resection of petroclival meningiomas utilizing linear measurements, which are insensitive to the multidimensional complex growth of meningiomas, to estimate tumor volume. OBJECTIVE: To describe petroclival meningioma growth patterns following less-than-complete resection utilizing volumetric analysis and to identify variables associated with tumor progression. METHODS: Patients with surgically resected WHO grade I petroclival meningiomas were retrospectively reviewed (1999-2015). Image analysis software was utilized to perform volumetric analyses of tumor size and growth on serial MRI studies. The impact of preoperative and postoperative variables on tumor growth after subtotal resection was analyzed. An increase in tumor volume of at least 20% was defined as "tumor growth." RESULTS: Twenty-three patients had immediate preoperative and serial postoperative MRI studies available for review. The mean preoperative tumor volume was 20.9 cm3 (range 0.4-54.6). The mean extent of resection was 75.5% (range 31.5%-100.0%). At a mean follow-up of 24.8 mo, 12 tumors (66.7%) exhibited radiological tumor growth, while 6 tumors did not change in size. The median annual volumetric growth rate was 2.82 cm3/yr (range -0.34 to 10.1). Extent of resection and immediate postoperative tumor volume were significantly correlated with the annual volumetric growth rate following resection. At last follow-up, 3 (13%) patients required further intervention. CONCLUSION: The majority of petroclival meningiomas exhibit growth following subtotal resection. Extent of resection is strongly associated with risk for disease progression following surgery.