Cochlear implantation through intracochlear fibrosis: A comparison of surgical techniques.

OBJECTIVE: While the implications of ossification on cochlear implantation (CI) have been extensively described, there is a paucity of data regarding the fibrotic stage. We examined the outcomes of different insertion techniques for managing intracochlear fibrosis. STUDY DESIGN: Retrospective review of case series with case-control comparison. SETTING: University-based tertiary-referral otology-neurotology practice. PATIENTS: Between 2009 to 2020, 384 patients underwent CI. Of those, 7 patients (8 ears) demonstrated intracochlear fibrosis. INTERVENTIONS: CI performed 1-4 months following meningitis/labyrinthitis and 12-24 months after idiopathic sudden SNHL. Fibrosis removal (38%) or dilation (63%) permitted implantation. A styleted-electrode was used in 63% due to dense fibrosis. MAIN OUTCOME MEASURES: Postoperative audiometry with CI in place, additional comparisons with audiometric outcomes in age-matched controls. RESULTS: Full insertion achieved in all except one ear with partial ossification. Mean ipsilateral pure tone average (PTA) improved to 29 ± 15 dB and speech discrimination to 72 ± 28%. Fibrosis removal vs. dilation resulted in no PTA differences (p = 0.76). Poorest outcomes occurred with the longest time to surgery. CONCLUSIONS: Good CI audiologic outcomes in the setting of cochlear fibrosis can be achieved and are independent of technique. Instead, they vary with time to implantation. Every attempt should be made to intervene as early as possible.

Conversations in Cochlear Implantation: The Inner Ear Therapy of Today.

As biomolecular approaches for hearing restoration in profound sensorineural hearing loss evolve, they will be applied in conjunction with or instead of cochlear implants. An understanding of the current state-of-the-art of this technology, including its advantages, disadvantages, and its potential for delivering and interacting with biomolecular hearing restoration approaches, is helpful for designing modern hearing-restoration strategies. Cochlear implants (CI) have evolved over the last four decades to restore hearing more effectively, in more people, with diverse indications. This evolution has been driven by advances in technology, surgery, and healthcare delivery. Here, we offer a practical treatise on the state of cochlear implantation directed towards developing the next generation of inner ear therapeutics. We aim to capture and distill conversations ongoing in CI research, development, and clinical management. In this review, we discuss successes and physiological constraints of hearing with an implant, common surgical approaches and electrode arrays, new indications and outcome measures for implantation, and barriers to CI utilization. Additionally, we compare cochlear implantation with biomolecular and pharmacological approaches, consider strategies to combine these approaches, and identify unmet medical needs with cochlear implants. The strengths and weaknesses of modern implantation highlighted here can mark opportunities for continued progress or improvement in the design and delivery of the next generation of inner ear therapeutics.

Post-traumatic temporal bone pneumatocele presenting after aggressive Valsalva.

We report a case of a temporal bone pneumatocele with full-thickness erosion of the cranium associated with aggressive nose blowing. This condition presented 9 years after traumatic fracture of the temporal bone. There are 17 reported cases of mastoid sinus hyperpneumatisation in the literature. Eleven of the 17 are associated with Valsalva manoeuvres or elevated middle ear pressure. However, no other cases of full-thickness erosion at the site of a former fracture have been reported. We propose that the fracture, in combination with elevated mastoid sinus pressure from aggressive nose blowing, led to escape and trapping of pressurised air in the epidural and subcutaneous spaces, which resulted in bone erosion.

Preoperative Differences in Intracranial Facial Versus Vestibular Schwannomas: A Four Nerve Assessment.

OBJECTIVES: Assesses whether preoperative functional testing can distinguish vestibular schwannomas from facial nerve schwannomas medial to the labyrinthine segment. STUDY DESIGN: Retrospective cohort. METHODS: Retrospectively review surgically managed intracranial facial and vestibular schwannomas between January 2015 and December 2019 at two tertiary care centers. Patients with neurofibromatosis 2 and surgery for recurrence were excluded. Preoperative functional testing to include House-Brackmann scores, electroneuronography (ENoG), cervical vestibular evoked myogenic potentials (cVEMP), caloric testing, acoustic brainstem responses (ABRs), acoustic reflexes, and audiograms was compared between the two groups of schwannomas. RESULTS: Twelve facial and 128 vestibular schwannomas met inclusion criteria. In only one case was a facial schwannoma diagnosed preoperatively from imaging. No statistically significant difference was found in preoperative House-Brackmann scores, ENoG, cVEMP, caloric testing, ABRs, or acoustic reflexes. Pure tone average was worse in the vestibular schwannoma group (63 dB [95% CI: 58-68 dB] vs. 46 dB [95% CI: 34-58 dB], P = .01), and the difference was more apparent in the lower frequencies. Word recognition score was better in the facial schwannoma group (66% [95% CI: 45-86%] vs. 41% [95% CI: 34-47%], P = .02). CONCLUSION: Specialized preoperative functional evaluation of the nerves of the internal auditory canal cannot reliably predict the presence of an intracranial facial schwannoma. Hearing is better in facial schwannomas, particularly in the lower frequencies. This should raise the index of suspicion for an intracranial facial schwannoma, especially in candidates for hearing preservation vestibular schwannoma surgery. LEVEL OF EVIDENCE: 3 Laryngoscope, 131:2098-2105, 2021.

Shared Surgical Decision Making in the Era of COVID-19: Lessons From Hurricane Katrina.

The COVID-19 pandemic has challenged every surgical discipline. Lessons learned from Hurricane Katrina have informed our department's management of the current crisis. That experience impressed upon us a profound appreciation for shared decision making in the face of scarce resources, an evolving clinical context, and potential harm to patients and health care workers. To that end, we have formed a Resource Utilization Committee to prospectively review all nonemergent surgical cases during the current crisis. This has allowed "state-of-the-pandemic" otolaryngologic care in a real-time, collaborative, and high-information setting. In addition, to protect our patients and health care workers, it has influenced our institution's thoughtful application of COVID testing and the use of personal protective equipment.

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

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

Can Dizziness Handicap Inventory and Activities-Specific Balance Confidence Scores Assess Vestibular Loss After Vestibular Schwannoma Excision?

OBJECTIVE: Evaluate and compare the Dizziness Handicap Inventory with Activities-specific Balance Confidence scores shortly after vestibular schwannoma excision. STUDY DESIGN: Retrospective database review. SETTING: Tertiary care center. PATIENTS: Adults undergoing vestibular schwannoma excision between January 2015 and December 2019. INTERVENTION: Diagnostic, therapeutic, and rehabilitative. MAIN OUTCOME MEASURES: Postoperative change in Dizziness Handicap Inventory scores and Activities-specific Balance Confidence scores 2 to 3 weeks after surgical intervention in relation to preoperative vestibular testing. RESULTS: A total of 49 patients met inclusion criteria. The average change in the Dizziness Handicap Inventory was 6 (p = 0.07, 95% CI 0-13). This was weakly correlated to preoperative caloric testing values (r = -0.31, p = 0.03), but not cervical vestibular evoked myogenic potentials (cVEMP) values (r = -0.17, p = 0.23). The average change in Activities-specific Balance Confidence was -10% (p = 0.007, 95% CI -3 to -17%). This change was moderately correlated with preoperative caloric values (r = 0.42, p = 0.006), but it was not correlated with cVEMP (r = 0.07, p = 0.66). CONCLUSIONS: In vestibular schwannoma patients, factors other than preoperative vestibular function likely affect postoperative Dizziness Handicap Inventory and Activities-specific Balance Confidence scores. The change in Activities-specific Balance Confidence was slightly more consistent with expected physiological vestibular loss, and it represents another tool in a multidisciplinary vestibular evaluation of the postoperative patient.

Next-Day Loading of a Bone-Anchored Hearing System: Preliminary Results.

OBJECTIVES: To demonstrate the feasibility and efficacy for next-day loading of a percutaneous bone-anchored hearing device. STUDY DESIGN: Multicenter prospective cohort study. SETTING: Tertiary neurotologic referral centers. SUBJECT AND METHODS: In this multicenter prospective study, a 4.5-mm laser-etched bone-anchored hearing device was implanted in adult subjects who had conductive/mixed hearing loss or single-sided deafness. One day following implantation, the surgical site was assessed for soft tissue reaction per the Holgers Scale, and implant stability was evaluated by manual palpation and resonance frequency analysis. On the same day, subjects were fitted with the processor. Follow-up evaluations were at 1 week, 4 weeks, 3 months, 6 months, and 12 months. The Glasgow Benefit Inventory and Abbreviated Profile of Hearing Aid Benefit questionnaires were completed postoperatively. RESULTS: Fourteen devices were implanted in 12 subjects. Two subjects underwent bilateral implantation. Implant stability was rated as firm at every interval for all ears, and the Implant Stability Quotient values at 3 months were stable or increased as compared with day 1 measurements. Skin irritation was limited to Holgers grade 0 and 1, with the majority having no skin irritation. The mean Glasgow Benefit Inventory global score was +43.8, and the mean Abbreviated Profile of Hearing Aid Benefit global benefit score was 60.2%. All 14 implants have remained firmly anchored. CONCLUSIONS: Next-day loading of this 4.5-mm-diameter percutaneous bone-anchored hearing device appears to be a feasible alternative to the original 3-month delayed loading. Although this is a preliminary study, the results support continued investigation of a next-day loading strategy.

Additional Benefits of Facial Nerve Monitoring during Otologic Surgery.

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

Cochlear Enhancement May Precede Cochlear Obliteration After Vestibular Schwannoma Excision.

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

Structured inhibitory activity dynamics in new virtual environments.

Inhibition plays a powerful role in regulating network excitation and plasticity; however, the activity of defined interneuron types during spatial exploration remain poorly understood. Using two-photon calcium imaging, we recorded hippocampal CA1 somatostatin- and parvalbumin-expressing interneurons as mice performed a goal-directed spatial navigation task in new visual virtual reality (VR) contexts. Activity in both interneuron classes was strongly suppressed but recovered as animals learned to adapt the previously learned task to the new spatial context. Surprisingly, although there was a range of activity suppression across the population, individual somatostatin-expressing interneurons showed consistent levels of activity modulation across exposure to multiple novel environments, suggesting context-independent, stable network roles during spatial exploration. This work reveals population-level temporally dynamic interneuron activity in new environments, within which each interneuron shows stable and consistent activity modulation.

Malignant Hyperthermia During Translabyrinthine Acoustic Neuroma Surgery After Previous Uneventful Surgery.

OBJECTIVE: Review current literature and guidelines for malignant hyperthermia in the context of neurotologic surgery. PATIENT: A case of malignant hyperthermia during vestibular schwannoma surgery, in a patient previously exposed to anesthesia. INTERVENTIONS: Excision of vestibular schwannoma, acute management of malignant hyperthermia. MAIN OUTCOME MEASURES: Knowledge of the basic pathophysiology, clinical manifestations, and treatment protocols for malignant hyperthermia. RESULTS: Rapid termination of the procedure and appropriate modifications in surgical technique permitted expeditious treatment of malignant hyperthermia and prevented its lethality. CONCLUSIONS: Malignant hyperthermia is a rare and lethal condition that may arise in neurotologic surgery, even in patients who have previously received general anesthesia. The neurotologic surgeon has a role in early recognition and expeditious termination of surgery to help reduce its mortality.

Endoscopic Inside-Out Mastoidectomy with the Ultrasonic Bone Aspirator.

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

Facial Nerve Translocation for Low Tension Neurorrhaphy to Masseteric Nerve.

INTRODUCTION: The techniques of facial reanimation are continually evolving in search of the ideal method for rehabilitating the paralyzed face. In the past, alternative cranial nerve motor nuclei have been used to power facial musculature. The trigeminal nerve is gaining popularity as a promising nerve to drive facial motion, particularly in the lower face. OBJECTIVES: This article describes a low-tension technique of using the transposed facial nerve to the trigeminal nerve (masseteric branch) for facial reanimation. METHODS: Six patients over 2.5 years were treated with facial nerve translocation with division at the geniculate and direct neurorrhaphy to the motor branch of the masseter. Patients were evaluated by physical examination, measurement of oral commissure excursion using MEEI FACE-gram software, video assessment, Sunnybrook Facial Grading System, Facial Disability Index, and Facial Clinimetric Evaluation Scale (FaCE). RESULTS: Patients demonstrated early motion within 4 months postoperatively and were placed into facial physical therapy. All demonstrated improvements in oral competence, strong oral commissure excursion with good symmetry, speech improvements, and variable results in facial tone. Synkinesis to the smile antagonists in the lower face was noted and treated with chemodenervation in three of six. No upper division synkinesis was noted. CONCLUSION: The motor branch of the trigeminal nerve is an effective option for facial reanimation via facial nerve translocation and end-to-end neurorrhaphy. Variable results in facial tone were noted with excellent oral commissure excursion. This procedure is safe in the reoperated mastoid.

Cochlear implantation via middle fossa approach - a case report.

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

Balloon Dilation of the Eustachian Tube: 12-Month Follow-up of the Randomized Controlled Trial Treatment Group.

OBJECTIVE: Obstructive eustachian tube dysfunction (OETD) affects up to 5% of adults; however, available treatment strategies have limitations. It was previously reported that balloon dilation of the eustachian tube (BDET) with the eustachian tube balloon catheter + medical management (MM) results in a significantly higher proportion of subjects with normalized tympanograms versus MM alone at 6- and 24-week follow-up. The current analysis extends these initial findings by investigating the durability of BDET + MM treatment outcomes through 52 weeks. STUDY DESIGN: Prospective cohort follow-up study from the treatment group in a previously reported multicenter randomized controlled trial. SETTING: Twenty-one investigational sites across the United States. SUBJECTS AND METHODS: Here we report on secondary and exploratory endpoints for patients with OETD who previously failed MM and were randomized to the BDET + MM cohort. Analyses of tympanogram outcomes are reported by ear, unless specified otherwise, as a more accurate measure of durability of the procedure over time. RESULTS: Among subjects randomized to BDET + MM, the overall number with normalized tympanograms and ETDQ-7 scores (Eustachian Tube Dysfunction Questionnaire-7) remained comparable to those reported at 6- versus 52-week follow-up: tympanograms, 73 of 143 (51.0%) versus 71 of 128 (55.5%); ETDQ-7, 79 of 142 (55.6%) versus 71 of 124 (57.3%). The overall number of ears with normalized tympanograms also remained comparable, with 117 of 204 (57%) versus 119 of 187 (63.6%). CONCLUSIONS: The present study suggests that the beneficial effects of BDET + MM on tympanogram normalization and symptoms of subjects with refractory OETD demonstrate significant durability that is clinically relevant through 52 weeks.

Electronic Health Record Use Among American Neurotology Society Members.

OBJECTIVE: To describe the use of electronic health records (EHR) among members of the American Neurotology Society (ANS). STUDY DESIGN: Cross-sectional. SETTING: Active ANS members in November 2017. INTERVENTION: Internet-based survey. MAIN OUTCOME MEASURE: Survey that assessed the use of EHR in practice, types of EHR programs, different elements of EHR employed, and respondents' satisfaction and efficiency with EHR. RESULTS: One hundred twenty-seven ANS members responded to the survey with 67 (52.8%) respondents working in academic practice and 60 (47.2%) respondents working in private practice. Epic was the most commonly used EHR with 89 (70.1%) respondents using this system. Among all respondents, 84 (66.1%) respondents reported their efficiency was reduced by EHR use, and there was an even split between respondents who reported they were satisfied versus dissatisfied with their EHR (∼40% each). We found that younger members were more likely to feel EHR increased their efficiency compared with the older members (p = 0.04). In all other analyses, we found no significant difference in efficiency and satisfaction between age groups, practice settings, presence of residents or fellows, or specific EHR used. The main challenges reported by ANS members related to the EHR were increased time burden, poor user interface, lack of customizability, and the focus away from patients. CONCLUSIONS: The majority of ANS members felt their efficiency decreased as a result of EHR. These findings provide specific changes to the EHR that would improve efficiency and satisfaction among neurotologists.

The Stapes Prosthesis: Past, Present, and Future.

Since the original carved Teflon stapes over vein graft, stapedectomy prostheses have undergone evolution. Prostheses shapes, materials, and surgical techniques for placement have reflected advances in biomaterials and surgical tools. The variability in prostheses has reflected alternative techniques of stapedectomy and stapedotomy and differing strategies for attachment to the incus. Although many iterations of stapes prostheses have been proposed, excellent results can be achieved with various prostheses designed to rest on tissue grafts in stapedectomy techniques or pass through the footplate in stapedotomy techniques when used by surgeons experienced with technique details specific to the selected prosthesis.

Balloon dilation of the eustachian tube for dilatory dysfunction: A randomized controlled trial.

OBJECTIVES/HYPOTHESIS: To assess balloon dilation of the Eustachian tube with Eustachian tube balloon catheter in conjunction with medical management as treatment for Eustachian tube dilatory dysfunction. STUDY DESIGN: In this prospective, multicenter, randomized, controlled trial, we assigned, in a 2:1 ratio, patients age 22 years and older with Eustachian tube dilatory dysfunction refractory to medical therapy to undergo balloon dilation of the Eustachian tube with balloon catheter in conjunction with medical management or medical management alone. METHODS: The primary endpoint was normalization of tympanogram at 6 weeks. Additional endpoints were normalization of Eustachian Tube Dysfunction Questionaire-7 symptom scores, positive Valsalva maneuver, mucosal inflammation, and safety. RESULTS: Primary efficacy results demonstrated superiority of balloon dilation of the Eustachian tube with balloon catheter + medical management compared to medical management alone. Tympanogram normalization at 6-week follow-up was observed in 51.8% (72/139) of investigational patients versus 13.9% (10/72) of controls (P < .0001). Tympanogram normalization in the treatment group was 62.2% after 24 weeks. Normalization of Eustachian Tube Dysfunction Questionaire-7 Symptom scores at 6-week follow-up was observed in 56.2% (77/137) of investigational patients versus 8.5% (6/71) controls (P < .001). The investigational group also demonstrated substantial improvement in both mucosal inflammation and Valsalva maneuver at 6-week follow-up compared to controls. No device- or procedure-related serious adverse events were reported for those who underwent balloon dilation of the Eustachian tube. CONCLUSIONS: This study demonstrated superiority of balloon dilation of the Eustachian tube with balloon catheter + medical management compared to medical management alone to treat Eustachian tube dilatory dysfunction in adults. LEVEL OF EVIDENCE: 1b. Laryngoscope, 128:1200-1206, 2018.