Impact of virtual reality training on mastoidectomy performance: a prospective randomised study.

PURPOSE: The opportunities for surgical training and practice in the operating room are in decline due to limited resources, increased efficiency demands, growing complexity of the cases, and concerns for patient safety. Virtual reality (VR) offers a novel opportunity to enhance surgical training and provide complementary three-dimensional experience that has been usually available in the operating room. Since VR allows viewing and manipulation of realistic 3D models, the VR environment could enhance anatomical and topographical knowledge, in particular. In this study, we explored whether incorporating VR anatomy training improves novices' performance during mastoidectomy over traditional methods. METHODS: Thirty medical students were randomized into two groups and taught mastoidectomy in a structured manner. One group utilized a VR temporal bone model during the training while the other group used more traditional materials such as anatomy books. After the training, all participants completed a mastoidectomy on a 3D-printed temporal bone model under expert supervision. Performance during the mastoidectomy was evaluated with multiple metrics and feedback regarding the two training methods was gathered from the participants. RESULTS: The VR training method was rated better by the participants, and they also needed less guidance during the mastoidectomy. There were no significant differences in operational time, the occurrence of injuries, self-assessment scores, and the surgical outcome between the two groups. CONCLUSION: Our results support the utilization of VR training in complete novices as it has higher trainee satisfaction and leads to at least as good results as the more traditional methods.

Spoken Language Skills in Children With Bilateral Hearing Aids or Bilateral Cochlear Implants at the Age of Three Years.

OBJECTIVES: Early hearing aid (HA) fitting and cochlear implants (CIs) aim to reduce the effects of hearing loss (HL) on spoken language development. The goals of this study were (1) to examine spoken language skills of children with bilateral HAs and children with bilateral CIs; (2) to compare their language skills to the age-norms of peers with normal hearing (NH); and (3) to investigate factors associated with spoken language outcomes. DESIGN: Spoken language results of 56 Finnish children with HL were obtained from a nationwide prospective multicenter study. Children with HL comprised two groups: children with mild-to-severe HL who used bilateral HAs (BiHA group, n = 28) and children with profound HL who used bilateral CIs (BiCI group, n = 28). Children's spoken language comprehension, expressive and receptive vocabulary, and phonological skills were compared with normative values of children with NH at the age of three years. Odds ratio (OR) was calculated to compare proportions of children below age-norms in BiHA and BiCI groups. Factors associated with spoken language outcomes were modeled with analysis of covariance. RESULTS: At the age of 3 years, 50%-96% of children with HL performed 1 SD or more below the mean of the normative sample of age-peers with NH in spoken language skills, depending on the language domain. Receptive vocabulary and phonological skills were the most vulnerable language domains. In receptive vocabulary, 82% of the children in the BiHA group and 50% of the children in the BiCI group scored 1 SD or more below the normative mean. The BiHA group was 4.4 times more likely to have poorer receptive vocabulary than the BiCI group. In phonological skills, 96% of children in the BiHA group and 60% of the children in the BiCI group scored 1 SD or more below the normative mean. The BiHA group was 18.0 times more likely to have poorer phonological skills than the BiCI group. The analysis of covariance models showed that unaided pure-tone average, PTA0.5-4 kHz, had a significant effect on spoken language comprehension in the BiHA group. For the BiCI group, age at HL diagnosis and age at CI activation had a significant effect on expressive vocabulary. High maternal level of education had a significant effect on language comprehension and expressive vocabulary and female gender on phonological skills. CONCLUSIONS: At the age of 3 years, especially receptive vocabulary and phonological skills caused difficulties for children with HL showing also considerable individual variation. Children with bilateral HAs seemed to be more likely to have poorer receptive vocabulary and phonological skills than children with bilateral CIs. A variety of factors was associated with outcomes in both groups. Close monitoring of spoken language skills of children with HL is important for ensuring similar opportunities for all children with HL and timely intervention, when needed.

Cochlear implantation under local anesthesia in 117 cases: patients' subjective experience and outcomes.

PURPOSE: To report the outcomes and the patients' subjective experience of cochlear implantation (CI) performed under local anesthesia (LA). To describe a new form of intraoperative cochlear monitoring based on the patients subjective sound perception during CI. METHODS: In this retrospective case-cohort study, 117 patients underwent CI under LA with (n = 58) or without conscious sedation (n = 59). Included were primarily elderly patients with elevated risks for general anesthesia and recently patients with residual hearing eligible for electro-acoustic stimulation (EAS) (n = 27), in whom hearing could be monitored during the electrode insertion. A 500 Hz test tone was presented and the patient reported  of subjective changes in loudness, leading to a modification of the insertion. A questionnaire was sent to all patients in which they assessed their subjective experience. RESULTS: All patients were successfully operated under LA without the need to intraoperatively convert to general anesthesia. 90% of the patients reported that the surgery was a positive experience. The vast majority, 90% of patients were satisfied with the overall treatment and with intraoperative pain management and 84% of the patients would opt for local anesthesia again. Cochlear monitoring by the patients' subjective sound perception enabled for atraumatic insertions as all EAS patients could hear the test tone up to the end of the surgery. CONCLUSIONS: CI under LA was well tolerated and recommended by the vast majority of patients. In addition, it offers the possibility to monitor the patients' hearing during the electrode insertion, which may help to prevent insertion trauma.

The effect of virtual reality on temporal bone anatomy evaluation and performance.

PURPOSE: There is only limited data on the application of virtual reality (VR) for the evaluation of temporal bone anatomy. The aim of the present study was to compare the VR environment to traditional cross-sectional viewing of computed tomography images in a simulated preoperative planning setting in novice and expert surgeons. METHODS: A novice (n = 5) and an expert group (n = 5), based on their otosurgery experience, were created. The participants were asked to identify 24 anatomical landmarks, perform 11 distance measurements between surgically relevant anatomical structures and 10 fiducial markers on five cadaver temporal bones in both VR environment and cross-sectional viewings in PACS interface. The data on performance time and user-experience (i.e., subjective validation) were collected. RESULTS: The novice group made significantly more errors (p < 0.001) and with significantly longer performance time (p = 0.001) in cross-sectional viewing than the expert group. In the VR environment, there was no significant differences (errors and time) between the groups. The performance of novices improved faster in the VR. The novices showed significantly faster task performance (p = 0.003) and a trend towards fewer errors (p = 0.054) in VR compared to cross-sectional viewing. No such difference between the methods were observed in the expert group. The mean overall scores of user-experience were significantly higher for VR than cross-sectional viewing in both groups (p < 0.001). CONCLUSION: In the VR environment, novices performed the anatomical evaluation of temporal bone faster and with fewer errors than in the traditional cross-sectional viewing, which supports its efficiency for the evaluation of complex anatomy.

Virtual reality improves the accuracy of simulated preoperative planning in temporal bones: a feasibility and validation study.

PURPOSE: Consumer-grade virtual reality (VR) has recently enabled various medical applications, but more evidence supporting their validity is needed. We investigated the accuracy of simulated surgical planning in a VR environment (VR) with temporal bones and compared it to conventional cross-sectional image viewing in picture archiving and communication system (PACS) interface. METHODS: Five experienced otologic surgeons measured significant anatomic structures and fiducials on five fresh-frozen cadaveric temporal bones in VR and cross-sectional viewing. Primary image data were acquired by computed tomography. In total, 275 anatomical landmark measurements and 250 measurements of the distance between fiducials were obtained with both methods. Distance measurements between the fiducials were confirmed by physical measurement obtained by Vernier caliper. The experts evaluated the subjective validity of both methods on a 5-point Likert scale qualitative survey. RESULTS: A strong correlation based on intraclass coefficient was found between the methods on both the anatomical (r > 0.900) and fiducial measurements (r > 0.916). Two-tailed paired t-test and Bland-Altman plots demonstrated high equivalences between the VR and cross-sectional viewing with mean differences of 1.9% (p = 0.396) and 0.472 mm (p = 0.065) for anatomical and fiducial measurements, respectively. Gross measurement errors due to the misidentification of fiducials occurred more frequently in the cross-sectional viewing. The mean face and content validity rating for VR were significantly better compared to cross-sectional viewing (total mean score 4.11 vs 3.39, p < 0.001). CONCLUSION: Our study supports good accuracy and reliability of VR environment for simulated surgical planning in temporal bones compared to conventional cross-sectional visualization.

An exploratory investigation of speech recognition thresholds in noise with auralisations of two reverberant rooms.

OBJECTIVE: Speech-in-noise tests are widely used in hearing diagnostics but typically without reverberation, although reverberation is an inextricable part of everyday listening conditions. To support the development of more real-life-like test paradigms, the objective of this study was to explore how spatially reproduced reverberation affects speech recognition thresholds in normal-hearing and hearing-impaired listeners. DESIGN: Thresholds were measured with a Finnish speech-in-noise test without reverberation and with two test conditions with reverberation times of ∼0.9 and 1.8 s. Reverberant conditions were produced with a multichannel auralisation technique not used before in this context. STUDY SAMPLE: Thirty-four normal-hearing and 14 hearing-impaired listeners participated in this study. Five people were tested with and without hearing aids. RESULTS: No significant differences between test conditions were found for the normal-hearing listeners. Results for the hearing-impaired listeners indicated better performance for the 0.9 s reverberation time compared to the reference and the 1.8 s conditions. Benefit from hearing aid use varied between individuals; for one person, an advantage was observed only with reverberation. CONCLUSIONS: Auralisations may offer information on speech recognition performance that is not obtained with a test without reverberation. However, more complex stimuli and/or higher signal-to-noise ratios should be used in the future.

Preservation of residual hearing after cochlear implant surgery with slim modiolar electrode.

PURPOSE: To evaluate the insertion results and hearing preservation of a novel slim modiolar electrode (SME) in patients with residual hearing. METHODS: We retrospectively collected the data from the medical files of 17 patients (18 ears) implanted with a SME. All patients had functional low frequency hearing (PTA (0.125-0.5 kHz) ≤ 80 dB HL). The insertion results were re-examined from the postoperative cone-beam computed tomography scans. Postoperative thresholds were obtained at the time of switch-on of the sound processors (mean 43 days) and at latest follow-up (mean 582 days). The speech recognition in noise was measured with the Finnish matrix sentence test preoperatively and at follow-up. RESULTS: The mean insertion depth angle (IDA) was 395°. Neither scala dislocations nor tip fold over were detected. There were no total hearing losses. Functional low-frequency hearing was preserved in 15/18 (83%) ears at switch-on and in 14/17 (82%) ears at follow-up. According to HEARRING classification, 55% (10/18) had complete HP at switch-on and 41% (7/17) still at follow-up. Thirteen patients (14 ears) were initially fitted with electric-acoustic stimulation and seven patients (8 ears) continued to use it after follow-up. CONCLUSIONS: The preliminary hearing preservation results with the SME were more favorable than reported for other perimodiolar electrodes. The results show that the array may also be feasible for electro-acoustic stimulation; it is beneficial in that it provides adequate cochlear coverage for pure electrical stimulation in the event of postoperative or progressive hearing loss.

The long-term learning effect related to the repeated use of the Finnish matrix sentence test and the Finnish digit triplet test.

Objectives: To assess are there learning-related improvements in the speech reception thresholds (SRTs) for the Finnish matrix sentence test (FMST) and the Finnish digit triplet test (FDTT) in repeated use over 12 months.Design: Test sessions were scheduled at 0, 1, 3, 6 and 12 months, and each session included five FMST measurements and four FDTT measurements. The within-session and inter-session improvements in SRTs were analysed with a linear mixed model.Study sample: Fifteen young normal-hearing participants.Results: Statistically significant mean improvements of 2.0 dB SNR and 1.2 dB SNR were detected for the FMST and the FDTT, respectively, over the 12-month follow-up period. For the FMST, majority of the improvement occurred during the first two test sessions. For the FDTT, statistically significant differences were detected only in comparison to the first test session and to the first test measurement of every session over the 12-month follow-up.Conclusions: Repeated use of the FMST led to significant learning-related improvements, but the improvements appeared to plateau by the third test session. For the FDTT, the overall improvements were smaller, but a significant within-session difference between the first and consecutive FDTT measurements persisted throughout the test sessions.

The Finnish simplified matrix sentence test for the assessment of speech intelligibility in the elderly.

Objective: A simplified version of the Finnish matrix sentence test (FMST) was developed to improve the reliability of hearing diagnostic for children and for patients with limited working memory capacity and/or vocabulary.Design: Study 1 evaluated the word matrix of the Finnish simplified matrix sentence test (FINSIMAT) to rule out systematic differences between the new FINSIMAT test lists, and to provide reference values for normal-hearing (NH) young adults (YA). In Study 2, the FINSIMAT and the FMST were evaluated in elderly listeners with mild-to-moderate hearing impairment (HI).Study sample: Twenty NH YAs participated in Study 1, and 16 elderly HI adults participated in Study 2.Results: For NH YAs, the reference speech reception threshold (SRT50) estimate and the slope for the FINSIMAT were -11.2 ± 1.0 dB signal-to-noise ratio (SNR) and 19.4 ± 1.9%/dB SNR. For the elderly HI listeners, the mean SRT50 estimates for the FINSIMAT and FMST were -4.1 and -3.6 dB SNR, respectively. The correlation between the FMST and FINSIMAT results was strong (r2 = 0.78, p < 0.001).Conclusion: The FINSIMAT showed comparable characteristics to the FMST and proved feasible for measurements in elderly HI listeners.

Evaluation of a new slim lateral wall electrode for cochlear implantation: an imaging study in human temporal bones.

PURPOSE: To evaluate the insertion characteristics and trauma of a new slim lateral wall electrode (SlimJ) in human temporal bones (TB). METHODS: Pre- and postoperative assessment was performed using cone beam computed tomography (CBCT) and image fusion in 11 human TB. The position of the array in each cochlea was analyzed and described using a vertical scaling factor, calculated by dividing the distance of the scala tympani floor to the centre of the electrode by the duct height. Insertion trauma was scaled according to the presumed localization of the basilar membrane, which was modeled from histologic sections of 20 TBs. The insertion trauma was described by the adaptation of the Eshragi trauma grading. RESULTS: A full electrode insertion, via the round window, was achieved in all TBs. Surgical handling was good, with a favorable compromise between high flexibility but sufficient stiffness to facilitate smooth insertions. The median angular insertion depth was 368° (range 330°-430°). Scala tympani placement was achieved in ten out of eleven TBs; in one TB a scala translocation was observed, occurring at approximately 180°. CONCLUSIONS: The SlimJ showed atraumatic insertion characteristics. The CBCT fusion technique provides an accurate and reliable assessment of the electrode position and allows for grading insertion trauma without histology. The SlimJ true potential for structure and hearing preservation needs to be further assessed in vivo.

Electrode migration after cochlear implant surgery: more common than expected?

The overall complication rate of cochlear implant surgery is low and so-called electrode failures (electrode migration, misplacement, etc.,) account for only a minority of all complications. The aim of this study was to explore the prevalence of electrode migration as the cause for increased impedance values and non-auditory stimulation in the basal channels. Within the scope of a quality control process, the cochlear implant database of the Kuopio University Hospital (Finland) was reviewed. Patients with gradual elevation of impedance values and/or non-auditory stimulation of the basal electrode channels were re-examined and cone-beam computed tomography was administered. There were 162 cochlear implant recipients and 201 implanted devices registered in the database. A total of 18 patients (18 devices) were identified having significantly increased impedance values or non-auditory stimulation of the basal electrodes. Cone-beam computed tomography revealed extra-cochlear electrodes in 12 of these patients due to the migration of the electrode array. All extruded electrodes were lateral wall electrodes, i.e., straight electrode arrays (Cochlear CI422 and Med-El devices). The most common feature of electrode migration was the gradual increase of the impedance values in the basal electrodes, even though telemetry could also be unsuspicious. Electrode migration after cochlear implant surgery may be more common than previously reported. At surgery, special attention should be paid to the reliable fixation of the electrode array. This study underlines the importance of postoperative imaging after cochlear implant surgery.

Insertion characteristics and placement of the Mid-Scala electrode array in human temporal bones using detailed cone beam computed tomography.

The aim of this study was to evaluate the insertion results and placement of the new Advanced Bionics HiFocus Mid-Scala (HFms) electrode array, inserted through the round window membrane, in eight fresh human temporal bones using cone beam computed tomography (CBCT). Pre- and post-insertion CBCT scans were registered to create a 3D reconstruction of the cochlea with the array inserted. With an image fusion technique both the bony edges of the cochlea and the electrode array in situ could accurately be determined, thus enabling to identify the exact position of the electrode array within the scala tympani. Vertical and horizontal scalar location was measured at four points along the cochlea base at an angular insertion depth of 90°, 180° and 270° and at electrode 16, the most basal electrode. Smooth insertion through the round window membrane was possible in all temporal bones. The imaging results showed that there were no dislocations from the scala tympani into the scala vestibule. The HFms electrode was positioned in the middle of the scala along the whole electrode array in three out of the eight bones and in 62 % of the individual locations measured along the base of the cochlea. In only one cochlea a close proximity of the electrode with the basilar membrane was observed, indicating possible contact with the basilar membrane. The results and assessments presented in this study appear to be highly accurate. Although a further validation including histopathology is needed, the image fusion technique described in this study represents currently the most accurate method for intracochlear electrode assessment obtainable with CBCT.

Characteristics and international comparability of the Finnish matrix sentence test in cochlear implant recipients.

OBJECTIVES: The first Finnish sentence-based speech test in noise--the Finnish matrix sentence test--was recently developed. The aim of this study was to determine the characteristics of the new test with respect to test-retest reliability, speech recognition curve, and international comparability in Finnish cochlear implant (CI) recipients. DESIGN: The speech reception thresholds (SRT) were measured by means of an adaptive test procedure and compared with the results of the traditional Finnish word test. Additional measurements for concurrent slope and SRT estimation were conducted to determine the speech recognition curve and to check the test-retest reliability. STUDY SAMPLE: The measurements were performed on 78 Finnish CI recipients. In a subset of 25 patients, additional measurements for test-retest reliability and slope determination were performed. RESULTS: The mean SRT was -3.5 ± 1.7 dB SNR, with only a weak correlation with the Finnish word test. Test-retest reliability was within ± 1 dB and the mean slope of the speech recognition curve was 14.6 ± 3.6 %/dB. The rehabilitation results were similar to the results published for the German matrix test. CONCLUSIONS: The Finnish matrix test was found to be suitable and efficient in CI recipients with similar characteristics as the German matrix test.

Insertion Results and Hearing Outcomes of a Slim Lateral Wall Electrode.

BACKGROUND: The clinical outcomes of cochlear implantation vary for several reasons. It is necessary to study the different electrodes and variables for further development. The aim of this study is to report the clinical outcomes of a new slim lateral wall electrode (SlimJ). METHODS: Data of 25 cochlear implantations in 23 patients with the SlimJ electrode were retrospectively collected. The insertion results were assessed by image fusion of the preoperative computed tomography (CT), magnetic resonance imaging (MRI), and postoperative cone-beam CT. The hearing outcomes were evaluated by the improvement of speech recognition in noise, measured preoperatively and at follow-up. Postoperative pure-tone thresholds were obtained in cases with preoperative functional low frequency hearing [PTA (0.125-0.5 kHz) ≤ 80 dB HL]. RESULTS: The preoperative mean speech reception threshold (SRT) was +0.6 dB signal-to-noise ratio (SNR) (SD ± 4.2 dB) and the postoperative -3.5 dB SNR (SD ± 2.3 dB). The improvements between the preoperative and postoperative SRT levels ranged from 0.0 to 15.1 dB, with a mean improvement of 4.2 dB (SD ± 3.6 dB). Residual hearing in low frequencies (mean PTA(125-500 Hz)) was preserved within 30 dB HL in 70% and within 15 dB HL in 40% of patients who had preoperatively functional low frequency hearing. Mean insertion depth angle (IDA) was 401° (SD ± 41°). We observed scalar translocations from scala tympani to scala vestibuli in 2 ears (9%). CONCLUSION: The relatively atraumatic insertion characteristics make the SlimJ array feasible for hearing preservation cochlear implantation. The hearing outcomes are comparable to those reported for other electrodes and devices.

Estimating Cognitive Workload Using Task-Related Pupillary Responses in Simulated Drilling in Cochlear Implantation.

OBJECTIVES: Training of temporal bone drilling requires more than mastering technical skills with the drill. Skills such as visual imagery, bimanual dexterity, and stress management need to be mastered along with precise knowledge of anatomy. In otorhinolaryngology, these psychomotor skills underlie performance in the drilling of the temporal bone for access to the inner ear in cochlear implant surgery. However, little is known about how psychomotor skills and workload management impact the practitioners' continuous and overall performance. METHODS: To understand how the practitioner's workload and performance unfolds over time, we examine task-evoked pupillary responses (TEPR) of 22 medical students who performed transmastoid-posterior tympanotomy (TMPT) and removal of the bony overhang of the round window niche in a 3D-printed model of the temporal bone. We investigate how students' TEPR metrics (Average Pupil Size [APS], Index of Pupil Activity [IPA], and Low/High Index of Pupillary Activity [LHIPA]) and time spent in drilling phases correspond to the performance in key drilling phases. RESULTS: All TEPR measures revealed significant differences between key drilling phases that corresponded to the anticipated workload. Enlarging the facial recess lasted significantly longer than other phases. IPA captured significant increase of workload in thinning of the posterior canal wall, while APS revealed increased workload during the drilling of the bony overhang. CONCLUSION: Our findings contribute to the contemporary competency-based medical residency programs where objective and continuous monitoring of participants' progress allows to track progress in expertise acquisition. Laryngoscope, 2024.

Being born in autumn or winter is associated with asthma and allergic rhinitis in Finland.

BACKGROUND: Our population-based study has previously shown that being born in winter or spring was associated with adult-onset asthma. The aim was to study if season of birth (SOB) is associated with airway allergy and related diseases: NSAID exacerbated respiratory disease (N-ERD), asthma, allergic rhinitis (AR), nonallergic rhinitis (NAR), chronic rhinosinusitis with nasal polyps (CRSwNP) and CRS without nasal polyps (CRSsNP) in Finland. METHODS: A randomly sampled retrospective registry-based follow-up data (n = 74,868) of patients visiting Hospital District of Helsinki and Uusimaa (HUS) in Finland was used. The birth date, sex, visit date and comorbidities were collected from electronic health record data during visits from 2005 to 2019. RESULTS: The mean (SD, range) age of the sample was 34.53 (25.47, 0-102) years, with 48.7 % being men. We divided the whole population in four groups based on the season they were born (SOB-groups). When observing these four SOB-groups, the proportion of those having asthma was 43.1%, 42.1%, 41.1%, 42.7%, in winter, spring, summer, and autumn SOB-groups, respectively. The proportion of those having AR was 12.6%, 12.0%, 10.7%, 12.1%, respectively. When having summer as a reference, being born in any other time of year was significantly associated with AR and, being born in autumn or winter was associated with asthma. No significant association was observed in CRS or N-ERD or NAR groups in adjusted models. CONCLUSIONS: The study suggests that early life immunological events may have a role a role in pathogenesis of asthma and AR. As no association was observed between SOB and CRSsNP, CRSwNP, N-ERD or NAR, further studies on this are warranted.

Comorbidities of chronic rhinosinusitis in children and adults.

BACKGROUND: Chronic rhinosinusitis (CRS) is a chronic inflammatory disease of the nose and paranasal sinuses lasting ≥12 weeks. CRS may exist with (CRSwNP) or without (CRSsNP) nasal polyps. The aim was to evaluate conditions associated with CRS in a randomized hospital cohort. We hypothesized that comorbidities and surgical procedures differ between pediatric and adult patients. METHODS: This study consisted of hospital registry data of a random sample of rhinosinusitis patients (age range 0-89 years) with the diagnosis of J32 or J33, correspondingly, registered during outpatient visits from 2005 to 2019 (n = 1461). The covariates of interest were collected from electronic health records based on ICD-10 codes and keyword searches. RESULTS: Among pediatric patients (n = 104), the relative proportions of CRSsNP and CRSwNP were 86% and 14% respectively. The relative proportions of adult patients (n = 1357) with CRSsNP and CRSwNP were 60% and 40%, respectively. The following comorbidities significantly differed (p < 0.05) between pediatric and adult populations: allergy, chronic otitis media, and tonsillar diseases. In total, 41 % of the children and 46% of the adults underwent baseline endoscopic sinus surgery (ESS). Additional surgeries of the ear, nose and pharynx were significantly more common among children compared with adults. Risk of revision after baseline ESS was associated (p < 0.05) with allergy, asthma, eosinophilia, CRSwNP, immunodeficiency or its suspicion, non-steroidal anti-inflammatory drug exacerbated respiratory disease, and number of any diseases ≥2. CONCLUSIONS: Our study showed that comorbidities differ between pediatric and adult rhinosinusitis patients, as allergy, asthma and allergy, chronic otitis media, mental health disorders, and tonsils disease were significantly more prevalent among pediatric patients. Children and adults were equally treated with ESS. Notably, children underwent additional surgery on adenoids and tonsils more frequently. The effectiveness of ESS in multimorbid adults should be assessed at an individual level.

Extracting the Cochlea from a Human Temporal Bone: A Cadaveric Protocol.

The extraction of the cochlea from a cadaver human temporal bone may be required for different studies of the inner ear. For histological evaluations, the inner ear must be extracted from the temporal bone to facilitate histologic processing; likewise, some micro-computed tomography devices are too small to accommodate the complete temporal bones; additionally, the image quality can be enhanced when the cochlea is isolated. The inner ear is located within the petrous part of the temporal bone. The inner ear can be divided into the osseous labyrinth or otic capsule and the membranous labyrinth inside the otic capsule. Furthermore, the inner ear can be divided into the vestibular system (the semicircular canals and the vestibule) and the cochlea. The appreciation of the location and orientation of the cochlea within the temporal bone is difficult, as it is embedded within bony structures and thus cannot be directly visualized. Nevertheless, there are distinct anatomical structures that can help guide the process to allow a reliable drill-out of the cochlea. The landmarks in the posterior parts of the cochlea are the facial nerve, semicircular canals, and the vestibule. In the middle, the inferior borders of the cochlea are identified by the round window and the basal turn of the cochlea. In the anterior border, one encounters the carotid artery; the landmark for the superior border is the genicular ganglion (GG) of the facial nerve. The medial structures are determined by the locations of the internal auditory canal, the superior semicircular canal, and the canal of the internal carotid artery. In this article, we present a method for extracting the cochlea reliably out of the temporal bone by drill-out while following several anatomical landmarks.

The Feasibility of the Three-Dimensional Footswitch-Operated Robotic Arm Exoscope for Cochlear Implant Surgery.

OBJECTIVE: To compare the three-dimensional (3D) footswitch-operated robotic arm exoscope with the operating microscope (OM) in cochlear implant surgery. STUDY DESIGN: Matched case-control study. PATIENTS: Cochlear implantation was performed with the exoscope on unselected patients with normal temporal anatomy. The control group that underwent cochlear implantation with the OM was case matched with respect to age, anatomy, surgical technique, and type of anesthesia. INTERVENTIONS: Cochlear implantation performed with the 3D exoscope. MAIN OUTCOME MEASURES: Surgical time, occupation of the operation theater, surgical results, and user experience evaluated by a questionnaire. RESULTS: Eleven patients (13 ears) were successfully operated on with the exoscope. In the exoscope group, we observed one minor intraoperative complication, where the middle dura was exposed during mastoidectomy. Although no clear preference was evident for either device in the overall rating, the subdomain rating revealed that the exoscope's image quality was deemed inferior, especially at higher magnifications where pixelation became noticeable. The exoscope received higher scores for usability, particularly excelling in terms of surgeon's ergonomic and comfortability. There was a statistically significant difference in mean surgical time, 146 and 129 min for the exoscope and OM group, respectively. CONCLUSIONS: Cochlear implant surgery was found to be feasible with a 3D exoscope. However, there is a learning curve to overcome regarding handling and the different quality of the image. The exoscope provides better ergonomics for the surgeon.

A State-of-the-Art Method for Preserving Residual Hearing During Cochlear Implant Surgery.

The developments in surgical techniques and cochlear implant (CI) electrode design have expanded the indications for CI treatment. Currently, patients with high-frequency hearing loss may benefit from CIs when low-frequency residual hearing can be preserved, as this enables combined electric-acoustic stimulation (EAS). The possible benefits of EAS include, for example, improved sound quality, music perception, and speech intelligibility in noise. The risks of inner ear trauma and a deterioration or even complete loss of residual hearing vary according to the surgical technique and the type of electrode array used. Short, lateral-wall electrodes with shallower angular insertion depths have demonstrated higher rates of hearing preservation than longer electrodes. The very slow insertion of the electrode array through the round window of the cochlea contributes to insertion atraumaticity and, thus, may lead to favorable hearing preservation results. However, residual hearing can be lost even after an atraumatic insertion. Electrocochleography (ECochG) can be used to monitor inner ear hair cell function during the insertion of the electrode. Several investigators have demonstrated that the ECochG responses during surgery may predict postoperative hearing preservation results. In a recent study, we correlated the patients' subjective hearing perception with simultaneously recorded intracochlear ECochG responses during the insertion. This is the first report evaluating the association between intraoperative ECochG responses and hearing perception in a subject undergoing cochlear implantation under local anesthesia without sedation. The combination of intraoperative ECochG responses with the patient's real-time feedback to sound stimuli has excellent sensitivity for the intraoperative monitoring of cochlear function. This paper presents a state-of-the-art method for the preservation of residual hearing during CI surgery. We describe this treatment procedure with the special consideration of performing the surgery under local anesthesia, which makes it feasible for monitoring the patient's hearing during the insertion of the electrode array.