Audiological outcome after stapes surgery in relation to prosthesis type.

PURPOSE: Different techniques are used to fix crimp and CliP® Piston stapes prostheses to the long process of the incus (LPI). The CliP® Piston provides a stiff connection in contrast to the static bended loop of the crimp prosthesis, which imitates the physiological incudostapedial joint (ISJ) and thereby potentially leads to different hearing outcome. METHODS: In a retrospective single-center study of German-speaking one hundred and ninety patients who underwent stapes surgery CliP® Piston or crimp prostheses between the years of 2016 and 2019 by the same surgeon and in the same setting. Pre- and postoperative bone- (BC) and air-conduction (AC) pure-tone thresholds, pre- and postoperative air-bone gap (ABG) for 0.5, 1, 1.5, 2, 3, 4 kHz and the surgery time were examined. RESULTS: The postoperative bone conduction thresholds were significantly lower in the frequencies between 0.5 and 3 kHz and the mean ABG was < 10 dB in most cases independent of the prosthesis used. Crimp prosthesis showed a significantly better closure of the ABG at 0.5 kHz. CONCLUSIONS: The audiological outcome after stapes surgery is dependent on the type of prosthesis used, as reflected by the frequency-specific air-bone gap. The better ABG closure with the crimp prosthesis might be the result of the connection to the LPI imitating the physiological ISJ. The crimp prosthesis may be the better choice if use of hearing aids is expected postoperatively.

Intraoperative quantification of floating mass transducer coupling quality in active middle ear implants: a multicenter study.

PURPOSE: Evaluating the effectiveness of intraoperative auditory brainstem responses (ABRs) to stimulation by the Vibrant Soundbridge (VSB) active middle ear implant for quantifying the implant's floating mass transducer (FMT) coupling quality. METHODS: In a diagnostic multicentric study, patients (> 18 years) who received a VSB with different coupling modalities were included. Pre- and postoperative bone conduction thresholds, intraoperative VSB-evoked ABR thresholds (VSB-ABR) using a modified audio processor programmed to preoperative bone conduction thresholds, postoperative vibrogram thresholds, and postoperative VSB-ABR thresholds were measured. Coupling quality was calculated from the difference between the pure tone average at 1000, 2000, and 4000 Hz (3PTA) vibrogram and postoperative 3PTA bone conduction thresholds. RESULTS: Twenty-three patients (13 males, 10 females, mean age 56.6 (± 12.5) years) were included in the study. Intraoperative VSB-ABR response thresholds could be obtained in all except one patient where the threshold was > 30 dB nHL. Postoperatively, an insufficient coupling of 36.7 dB was confirmed in this patient. In a Bland-Altman analysis of the intraoperative VSB-ABRs and coupling quality, the limits of agreement exceeded ± 10 dB, i.e., the maximum allowed difference considered as not clinically important but the variation was within the general precision of auditory brainstem responses to predict behavioral thresholds. Five outliers were identified. In two patients, the postoperative VSB-ABR thresholds were in agreement with the coupling quality, indicating a change of coupling before the postoperative testing. CONCLUSION: The response thresholds recorded in this set-up have the potential to predict the VSB coupling quality and optimize postoperative audiological results.

Evaluation of a synthetic version of the digits-in-noise test and its characteristics in CI recipients.

OBJECTIVE: The goal of this study was the evaluation of a synthetic version of the Digits-in-Noise (DiN) in participants with normal hearing. Additionally, the basis characteristics of the DiN in CI recipients were investigated. DESIGN AND STUDY SAMPLE: Twenty participants with normal hearing and 21 CI recipients with a Nucleus®-System ran two to three adaptive and up to five fixed measurements. Afterwards the discrimination function was measured with fixed signal-to-noise ratios. RESULTS: All subjects were able to perform the DiN within three minutes per test run. The median speech reception threshold (SRT) for the NH was -8.1 dBSNR, with a median steepness of 23%/dBSNR. The median absolute test-retest difference in the NH group was 0.4 dB (range: 0 to 1.5 dB). In the CI group, the SRTs range from -6.6 to +12.4 dBSNR with a median test-retest difference of 0.4 dB (range: 0 to 6.1 dB). CONCLUSION: The synthetic DiN is a valuable complement of the audiometric test battery in CI recipients. The excellent applicability is also particularly helpful in poor performing CI recipients. With its small time exposure, it is a time- and cost-saving test, which could also be used at home via app to check the individual hearing success.

[Endoscopic ear surgery in Germany : Survey on the current situation and an international comparison]. / Endoskopische Ohrchirurgie in Deutschland : Umfrage zur aktuellen Situation im internationalen Vergleich.

BACKGROUND: Endoscopic ear surgery (EES) has become firmly established internationally. In Germany this technology is controversially discussed and used very differently. Therefore, a survey was carried out on the availability, indications, contraindications, and future significance of EES. METHODS: A questionnaire with 20 questions was sent to 141 German university and central departments of otorhinolaryngology, head and neck surgery. The results are discussed on the basis of current literature retrieved in a search of PubMed and Google Scholar. RESULTS: The response rate was 32% (45 clinics). Of these respondents, 27 clinics (60%) stated that EES was usually carried out as an accompanying measure. Only one clinic performed ear surgery endoscopically alone. In cases of intraoperative bleeding, mastoid drilling, or if bimanual work was required, the surgeons switched to microscopic ear surgery (MES). The most common indications for EES were tympanoscopy, cholesteatoma, retraction pockets, and interventions on the tympanic membrane and external auditory canal. The necessary resources for EES were estimated to be higher than for MES in 49-50% of the responding clinics. Tragus cartilage dominated as the graft material for reconstruction in EES clinics, at 78%. Only 4 of 45 responding clinics rated the future significance of ESS in Germany as high. CONCLUSION: Although EES is used in Germany, only few ENT clinics use it extensively. Reservations relate to one-handed working, drilling, management of bleeding, and the expected high resource demand. Thus, EES in Germany is often performed as an accompanying procedure, with switching between EES and MES.

[Results of Speech Audiometry Testing in Case of Transcranial CROS Depend on Duration of Deafness]. / Audiologische Ergebnisse bei transkranieller CROS-Versorgung in Abhängigkeit von der Ertaubungsdauer.

In single sided deafness, treatment with transcranial CROS makes pseudo stereophonic listening possible. This leads to improved speech understanding in noise. However, several reports show large variations between the individual results of the benefit by speech audiometry in noise. One possible factor is the duration and changes in the auditory pathway between the onset of deafness to CROS supply. 18 patients with single sided deafness have tested a transcranial CROS supply. The speech intelligibility thresholds were evaluated in 2 spatial hearing situations each with CROS and unaided. When speech was arriving at 45° from the deaf ear and noise at 45° from the hearing ear, a significant improvement of speech reception threshold for 50% intelligibility was detected by CROS supply compared the medians. Patients with longer duration of deafness showed higher benefit by an average of -4.0 dB, in contrast to patients with short duration of deafness. In the reversed situation, that speech on the hearing ear and noise on the deaf ear was a significant deterioration observed, an average of 3.1 dB at longer deafened patients. In addition, a highly significant correlation was found with the individual changes in the speech recognition threshold between the two situations. The duration of deafness is an essential factor in the individual benefit estimate for treatment with transcranial CROS supply. The time frame for audimetrically proven changes in the auditory pathway as a result of unilateral auditory deprivation can be estimated to about 1-3 years. Patients with short duration of deafness have low or no benefit from transcranial CROS supply.

Intraoperative findings on ECAP-measurement: normal or special case?

OBJECTIVE: This study aimed to investigate the measurability and threshold level of electrically evoked compound action potentials (ECAPs) in order to provide a baseline for the development of diagnostic references to support aftercare procedures. DESIGN: In this retrospective study, cochlear implant patients were grouped according to the electrode array type and preoperative diagnostic findings from radiological imaging. ECAP measurements were performed intraoperatively on 22 electrodes for each patient resulting in two comparisons: (1) normal vs. pathological findings based on imaging with same electrode array, (2) perimodiolar electrode vs. straight electrode array within the normal group. STUDY SAMPLE: The study sample consisted of 218 ears with a Nucleus(®) implant. RESULTS: In the group with normal radiological imaging, the percentage of measurable ECAPs was higher than in the pathological group. The ECAP thresholds on 21 electrodes were significantly different between the two groups. Furthermore the thresholds were significantly lower for basal electrodes mainly for the two different electrode types. CONCLUSION: The pathological changes in the inner ear, the type of electrode array, and the electrode position affect the ECAP threshold. Further consideration suggests that a receiver operating characteristic curve can be derived from the results.

Intraoperatives Tip-Foldover-Screening mittels Spread of Excitation Messungen.

BACKGROUND: In rare cases, a cochlear implantation can lead to a so-called tip fold-over during insertion of the electrode array. In order to detect or exclude such a misalignment a radiological check of the cochlear implant (CI) electrode array is carried out intra- or often post-operatively (gold standard), thereby exposing the patient to additional radiation. Alternatively, successful electrode insertion can be verified by measuring the spread of excitation (SOE). However, interpretation of the test results requires considerable expertise, and standardized measurement protocols and reference values are also essential. Therefore, the aim of the study is to evaluate an automated screening procedure in order to obtain a reliable statement about the normal tonotopic position of the implanted CI electrode array intraoperatively and with as little effort as possible. METHODS: For CI surgery with Cochlear™ Nucleus® implants, an intraoperative tip-fold-over (TFO) screening was performed in a bi-centric study in over 100 adult patients: Firstly, threshold measurements for electrically evoked compound action potential (ECAP) using AutoNRT™ were recorded. Subsequently, SOE measurements were carried out on electrodes 13 and 22. The automated evaluation of the SOE data sets then made it possible to make a dichotomous decision about a normal or abnormal test result. The position of the electrode array was checked intra- or post-operatively using conventional transorbital X-ray (reference method). RESULTS: The intraoperative TFO screening procedure is applicable in around 80% of cases. The accuracy of the screening for measurements via the active stimulation electrodes 13 / 22 is 63.9% / 95.4%. The classification error is 36.1% / 4.6% and the phi coefficient is 0.27 / 0.69. All radiologically proven tip-fold-overs were reliably identified with the intraoperative screening (sensitivity = 100%). A higher specificity (>95%) can be achieved only with measurements via electrode 22. CONCLUSIONS: The TFO Screening via measurement at electrode 22 can successfully distinguish between a correct and incorrect position of the electrode array due to a tip-fold-over, and the remaining cases would require further imaging.

Active Middle Ear Implant Evoked Auditory Brainstem Response Intensity-Latency Characteristics.

OBJECTIVE: To analyze intensity-latency functions of intraoperative auditory evoked brainstem responses (ABRs) to stimulation by the Vibrant Soundbridge (VSB) active middle ear implant with respect to coupling efficiency, VSB evoked ABR thresholds, and coupling modality [oval window (OW) placement vs. Incus placement and vs. round window (RW) placement]. STUDY DESIGN: Exploratory study. SETTING: Bi-centric study at tertiary referral centers. PATIENTS: Twenty-four patients (10 female, 14 male, mean age: 58 years) who received a VSB. OUTCOME MEASURES: Wave-V intensity-latency functions of intraoperative VSB evoked ABRs using a modified audio processor programmed to preoperative bone conduction thresholds for stimulation. Threshold level correction to coupling efficiency and ABR thresholds. Individual plots and exponential function fits. RESULTS: After ABR threshold level correction, the latency functions could be aligned. A large variance of latencies was observed at individual threshold level. Wave-V latency was longest in the Incus placement subgroup (9.73 ms, SD: 1.04) as compared to OW placement subgroup (9.47 ms, SD: 1.05), with the shortest latency in the RW placement subgroup (8.99 ms, SD: 0.68). For increasing stimulation levels, the variance decreased with intensity-latency function slopes converging toward a steady-state (saturation) latency caused by saturation of audio processor (stimulation) gain. Latency saturation was reached at a stimulation level of 50 dB nHL for the OW placement subgroup, 35 dB nHL for the Incus placement subgroup, and 30 dB nHL for the RW placement subgroup. The latency and saturation results indicated decreased dynamic range for RW placement, i.e., reverse stimulation. CONCLUSIONS: VSB evoked ABR wave-V intensity-latency function slopes were similar to acoustic stimulation at high stimulation levels with a shift toward longer latencies caused by audio processor signal delay. Saturation of latencies occurred for higher stimulation levels due to saturation of audio processor gain. Thus, the analysis of VSB evoked intensity-latency functions appears to allow for the objective assessment of a patient's individual dynamic range. This can further improve diagnostics as well as intraoperative and postoperative quality control.

Intraoperative Recording of Auditory Brainstem Responses for Monitoring of Floating Mass Transducer Coupling Efficacy During Revision Surgery-Proof of Concept.

OBJECTIVE: The objective of the study was to measure auditory brainstem responses elicited by stimulation via a semi-implantable active middle ear implant with an electromagnetically driven floating mass transducer to quantify the coupling efficacy (=vibroplasty in situ thresholds - bone conduction thresholds) in a patient during a revision surgery. PATIENTS: One patient, reimplanted with an active middle ear implant in a revision surgery. INTERVENTION(S): Diagnostic. MAIN OUTCOME MEASURE(S): Intraoperative auditory brainstem responses evoked by stimulation via an active middle ear implant in a calibrated set-up directly indicating the coupling efficacy magnitude (auditory brainstem response threshold = coupling efficacy), as well as pre- and postoperative bone conduction and vibroplasty in situ thresholds. RESULTS: The intraoperative auditory brainstem response threshold was detected at 0 dB nHL, i.e., the magnitude of coupling efficacy was determined intraoperatively to be 0 dB. The actual postoperative coupling efficacy (=postoperative vibroplasty in situ - postoperative bone conduction thresholds) was -2.5 dB. CONCLUSIONS: The coupling efficacy determined intraoperatively was consistent with the postoperative coupling efficacy. The described method seems to be a promising tool to objectively quantify the magnitude of coupling efficacy in active middle ear implant surgeries.

Influence of Floating-Mass Transducer Coupling Efficiency for Active Middle-Ear Implants on Speech Recognition.

OBJECTIVE: The efficiency of vibroplasty (coupler-floating mass transducer [FMT] assembly) can be monitored by direct stimulation of the inner ear through the active middle-ear implant system and comparison of the vibroplasty in vivo threshold and the postoperative bone-conduction pure-tone threshold. The aim of this study was to compare the vibroplasty in vivo threshold with the postoperative speech recognition in patients with a high preoperative maximum word recognition score. STUDY DESIGN: Retrospective cohort study of German-speaking patients implanted with a vibrating ossicular prosthesis (VORP) 502 or VORP 503 and high preoperative maximum word recognition score between the years of 2011 and 2015. SETTING: Multicenter study of four German centers. PATIENTS: Twenty-three active middle-ear implant users. INTERVENTION: Rehabilitative. MAIN OUTCOME MEASURES: Bone-conduction pure-tone and vibroplasty thresholds, postoperative aided word recognition score (WRS) at 65 dB SPL (sound pressure level) and preoperative maximum WRS with Freiburg monosyllabic words. RESULTS: The mean postoperative aided WRS at 65 dB SPL was 82%. An increasing difference between vibroplasty thresholds and bone-conduction thresholds was associated with a higher discrepancy between the unaided maximum WRS and the postoperative aided WRS. Only if this difference was less than 20 dB, an articulation index of 0.5 (WRS = 75%) or more was achieved. CONCLUSIONS: Audiological outcome after vibroplasty depends on the coupling efficiency reflected by the vibroplasty threshold.

Mature teratoma of the temporal bone in 3.5-month-old baby girl.

Mature teratoma is a benign germ cell tumor rarely located in the temporal bone. We are reporting a case of a mature teratoma of the temporal bone in a healthy borne 3.5-month-old baby girl with a 2-day suggestive history of otitis media and polypoidal mass expulsing from the external auditory canal of the left ear. A definitive diagnosis is made after complete excision and histological examination of the tissue. Total surgical excision of the tumor is the treatment of choice.

[Origin of shoulder pain after "neck dissection". Importance of the cervical plexus]. / Entstehung von Schulterschmerzen nach "neck dissection". Wertigkeit des Plexus cervicalis.

BACKGROUND: The role of sensitive parts of the cervical plexus for the development of neuropathic pain is not yet clear. Our study investigated the correlation between shoulder pain and cervical plexus damage after different types of neck dissection (ND). MATERIAL AND METHODS: The sensitivity for warm/cold and sharp/blunt was tested in the dermatomes of C2, C3, C4, and the minor occipital nerve. Shoulder pain was measured semiquantitatively by a rating scale. RESULTS: Motion-dependent shoulder pain was observed 6 months postoperatively in 50% after resection and in 29.2% after preservation of these structures. Pain occurred more frequently following radical ND than after modified radical types 1 and 3 ND. DISCUSSION: Our investigations showed that the superficial cervical plexus function is assessable by cutaneous sensitivity tests. The minor occipital nerve seemed to be less affected. Fewer pain symptoms in cases with preserved cervical plexus could be demonstrated. We can conclude that preservation of the superficial cervical plexus is important to diminish postoperative shoulder pain.