Tremor Assessment in Robot-Assisted Microlaryngeal Surgery Using Computer Vision-Based Tool Tracking.

OBJECTIVE: Use microscopic video-based tracking of laryngeal surgical instruments to investigate the effect of robot assistance on instrument tremor. STUDY DESIGN: Experimental trial. SETTING: Tertiary Academic Medical Center. METHODS: In this randomized cross-over trial, 36 videos were recorded from 6 surgeons performing left and right cordectomies on cadaveric pig larynges. These recordings captured 3 distinct conditions: without robotic assistance, with robot-assisted scissors, and with robot-assisted graspers. To assess tool tremor, we employed computer vision-based algorithms for tracking surgical tools. Absolute tremor bandpower and normalized path length were utilized as quantitative measures. Wilcoxon rank sum exact tests were employed for statistical analyses and comparisons between trials. Additionally, surveys were administered to assess the perceived ease of use of the robotic system. RESULTS: Absolute tremor bandpower showed a significant decrease when using robot-assisted instruments compared to freehand instruments (P = .012). Normalized path length significantly decreased with robot-assisted compared to freehand trials (P = .001). For the scissors, robot-assisted trials resulted in a significant decrease in absolute tremor bandpower (P = .002) and normalized path length (P < .001). For the graspers, there was no significant difference in absolute tremor bandpower (P = .4), but there was a significantly lower normalized path length in the robot-assisted trials (P = .03). CONCLUSION: This study demonstrated that computer-vision-based approaches can be used to assess tool motion in simulated microlaryngeal procedures. The results suggest that robot assistance is capable of reducing instrument tremor.

Increasing radiation therapy and lower survival for human papillomavirus-related oropharynx cancer associated with a shift to community cancer center care.

BACKGROUND: Studies have shown lower overall survival for patients with head and neck cancer treated at low-volume or community cancer centers. As the incidence of human papillomavirus (HPV)-related oropharyngeal squamous cell carcinoma steadily rises in the United States, we hypothesized that a greater proportion of patients with HPV-related oropharyngeal squamous cell carcinoma is being treated at community cancer centers, with a shift toward primary nonsurgical treatment. METHODS: This cohort study included patients from the US National Cancer Database who received a diagnosis of HPV-related oropharyngeal squamous cell carcinoma from 2010 to 2019 and underwent treatment at a community cancer center or academic cancer center. The proportion of patients with HPV-related oropharyngeal squamous cell carcinoma treated at community cancer centers and receiving primary nonsurgical treatment was analyzed over time. Four-year overall survival was compared between community cancer centers and academic cancer centers. RESULTS: The majority (67.4%) of 20 298 patients were treated at an academic cancer center, yet the proportion of patients treated at community cancer centers increased by 10% from 2010 to 2019 (P < .01 for trend). The proportion of patients undergoing primary nonsurgical treatment increased from 62.1% to 73.7% from 2010 to 2019 (P < .01 for trend), and patients were statistically significantly more likely to undergo nonsurgical treatment at community cancer centers than at academic cancer centers (adjusted odds ratio = 1.20, 95% confidence interval = 1.18 to 1.22). Treatment at community cancer centers was associated with worse survival overall (adjusted hazard ratio = 1.19, 95% confidence interval = 1.09 to 1.31), specifically for patients receiving primary nonsurgical treatment (adjusted hazard ratio = 1.22, 95% confidence interval = 1.11 to 1.34). CONCLUSIONS: Treatment of HPV-related oropharyngeal squamous cell carcinoma has recently shifted to community cancer centers, with an increase in the proportion of nonsurgical treatment and worse overall survival at these centers compared with academic cancer centers. Concentration of care for HPV-related oropharyngeal squamous cell carcinoma at academic cancer centers and dedicated head and neck cancer centers may increase access to all available treatment modalities and improve survival.

Study protocol: randomised controlled trial of conditioned open-label placebo (COLP) for perioperative pain management in patients with head and neck cancer.

INTRODUCTION: Patients with head and neck cancer have a substantial risk of chronic opioid dependence following surgery due to pain and psychosocial consequences from both the disease process and its treatments. Conditioned open-label placebos (COLPs) have been effective for reducing the dose of active medication required for a clinical response across a wide range of medical conditions. We hypothesise that the addition of COLPs to standard multimodal analgesia will be associated with reduced baseline opioid consumption by 5 days after surgery in comparison to standard multimodal analgesia alone in patients with head and neck cancer. METHODS AND ANALYSIS: This randomised controlled trial will evaluate the use of COLP for adjunctive pain management in patients with head and neck cancer. Participants will be randomised with 1:1 allocation to either the treatment as usual or COLP group. All participants will receive standard multimodal analgesia, including opioids. The COLP group will additionally receive conditioning (ie, exposure to a clove oil scent) paired with active and placebo opioids for 5 days. Participants will complete surveys on pain, opioid consumption and depression symptoms through 6 months after surgery. Average change in baseline opioid consumption by postoperative day 5 and average pain levels and opioid consumption through 6 months will be compared between groups. ETHICS AND DISSEMINATION: There remains a demand for more effective and safer strategies for postoperative pain management in patients with head and neck cancer as chronic opioid dependence has been associated with decreased survival in this patient population. Results from this study may lay the groundwork for further investigation of COLPs as a strategy for adjunctive pain management in patients with head and neck cancer. This clinical trial has been approved by the Johns Hopkins University Institutional Review Board (IRB00276225) and is registered on the National Institutes of Health Clinical Trials Database. TRIAL REGISTRATION NUMBER: NCT04973748.

Peri-Operative Pain and Opioid Use in Opioid-Naïve Patients Following Inpatient Head and Neck Surgery.

Pain management is an important consideration for Head and Neck Cancer (HNC) patients as they are at an increased risk of developing chronic opioid use, which can negatively impact both quality of life and survival outcomes. This retrospective cohort study aimed to evaluate pain, opioid use and opioid prescriptions following HNC surgery. Participants included patients undergoing resection of a head and neck tumor from 2019-2020 at a single academic center with a length of admission (LOA) of at least 24 h. Exclusion criteria were a history of chronic pain, substance-use disorder, inability to tolerate multimodal analgesia or a significant post-operative complication. Subjects were compared by primary surgical site: Neck (neck dissection, thyroidectomy or parotidectomy), Mucosal (resection of tumor of upper aerodigestive tract, excluding oropharynx), Oropharyngeal (OP) and Free flap (FF). Average daily pain and total daily opioid consumption (as morphine milligram equivalents, MME) and quantity of opioids prescribed at discharge were compared. A total of 216 patients met criteria. Pain severity and daily opioid consumption were comparable across groups on post-operative day 1, but both metrics were significantly greater in the OP group on the day prior to discharge (DpDC) (5.6 (1.9-8.6), p < 0.05; 49 ± 44 MME/day, p < 0.01). The quantity of opioids prescribed at discharge was associated with opioid consumption on the DpDC only in the Mucosal and FF groups, which had longer LOA (6-7 days) than the Neck and OP groups (1 day, p < 0.001). Overall, 65% of patients required at least one dose of an opioid on the DpDC, yet 76% of patients received a prescription for an opioid medication at discharge. A longer LOA (aOR = 0.82, 95% CI: 0.63-0.98) and higher Charlson Comorbidity Index (aOR = 0.08, 95% CI: 0.01-0.48) were negatively associated with receiving an opioid prescription at the time of discharge despite no opioid use on the DpDC, respectively. HNC patients, particularly those with shorter LOA, may be prescribed opioids in excess of their post-operative needs, highlighting the need the for improved pain management algorithms in this patient population. Future work aims to use prospective surveys to better define post-operative and outpatient pain and opioid requirements following HNC surgery.

Intracochlear New Fibro-Ossification and Neuronal Degeneration Following Cochlear Implant Electrode Translocation: Long-Term Histopathological Findings in Humans.

OBJECTIVE: We aim to assess the histopathology of human temporal bones (TBs) with evidence of cochlear implantation (CI) electrode scalar translocation. STUDY DESIGN: Otopathology study. SETTING: Otopathology laboratory. PATIENTS: TBs from patients who had a history of CI and histopathological evidence of interscalar translocation. Specimens with electrode placed entirely within the ST served as controls. INTERVENTION: Histopathological assessment of human TBs. MAIN OUTCOME MEASURES: TBs from each patient were harvested postmortem and histologically analyzed for intracochlear changes in the context of CI electrode translocation and compared to controls. Intracochlear new fibro-ossification, and spiral ganglion neuron (SGN) counts were assessed. Postoperative word recognition scores (WRS) were also compared. RESULTS: Nineteen human TBs with electrode translocation and eight controls were identified. The most common site of translocation was the ascending limb of the basal turn (n = 14 TBs). The average angle of insertion at the point of translocation was 159°â€Š±â€Š79°. Eighteen translocated cases presented moderate fibroosseous changes in the basal region of the cochlea, extending to the translocation point and/or throughout the electrode track in 42%. Lower SGN counts were more pronounced in translocated cases compared to controls, with a significant difference for segment II (p = 0.019). Although final postoperative hearing outcomes were similar between groups, translocated cases had slower rate of improvement in WRS (p = 0.021). CONCLUSIONS: Cochlear implant electrode translocation was associated with greater fibroosseous formation and lower SGN population. Our findings suggest that scalar translocations may slow the rate of improvement in WRS overtime as compared to atraumatic electrode insertions.Level of evidence: IV.

Otopathologic Analysis of Patterns of Postmeningitis Labyrinthitis Ossificans.

OBJECTIVE: Labyrinthitis ossificans (LO) may occur following meningitis and, in cases where cochlear implantation is indicated, complicate electrode insertion. LO is critical to identify for successful cochlear implantation, and histopathology is more sensitive than imaging for identification of LO. Herein we utilize otopathologic techniques to study the timing and location of intracochlear tissue formation following meningitic labyrinthitis (ML). STUDY DESIGN: Retrospective review. SETTING: Academic institution. METHODS: Temporal bone specimens with a history of bacterial ML were histologically evaluated. The location and extent of intracochlear tissue formation within the scala tympani (ST) and scala vestibuli (SV) were graded, and spiral ganglion neurons were counted. RESULTS: Fifty-one temporal bones were identified: 32 with no intracochlear tissue formation, 9 with fibrosis alone, and 10 with LO. Fibrosis was identified as early as 1.5 weeks after ML, while ossification was found only in specimens that survived multiple years after ML. All LO cases showed ossification of the ST at the round window membrane (RWM) with continuous extension throughout the basal turn. Extent of SV ossification correlated with that in the ST but showed frequent isolated distal involvement of the cochlea. Spiral ganglion neuron counts were lower than those in age-matched controls. CONCLUSION: In this human temporal bone study, we found that postmeningitic LO results in ossification at the RWM with continuous extension into the ST of the basal turn and variable involvement of the SV. Identification of a patent basal turn beyond RWM ossification of the ST should permit full electrode insertion. LEVEL OF EVIDENCE: Retrospective review.

A Systematic Review of Nonautologous Graft Materials Used in Human Tympanoplasty.

OBJECTIVES: Nonautologous graft materials may solve several dilemmas in tympanoplasty by obviating the need for graft harvest, facilitating consistent wound healing, and permitting graft placement in the clinical setting. Prior studies of nonautologous grafts in humans have shown variable outcomes. In this systematic review, we aim to 1) summarize clinical outcomes and 2) discuss limitations in the literature regarding nonautologous grafts for tympanoplasty in humans. METHODS: A literature review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations. The study size, etiology and duration of perforation, type of nonautologous graft, and postoperative closure rate were assessed. RESULTS: The PRISMA approach yielded 61 articles, including 3,247 ears that met inclusion criteria. Studies evaluated nonautologous grafts including paper patch, gelatin sponge, growth factors, porcine small-intestinal submucosa, among others. Traumatic perforations (62.3%) were most commonly studied, whereas postinfectious perforations (31.9%) and other etiologies (5.8%) comprised a minority of cases. Acute perforations of <8 weeks duration constituted just over half of all treated ears. Overall closure rate was 82.1%, with significantly higher closure rates in acute (89.9%) versus chronic perforations (64.9%, P < .01), regardless of material. A median postoperative air-bone gap of 5.6 dB was found in the 23% of studies reporting this metric. CONCLUSIONS: The majority of publications reviewing nonautologous materials in tympanoplasty evaluate acute or traumatic perforations, and few rigorously report hearing outcomes. Given available data, porcine submucosa and basic fibroblast growth factor may hold promise for chronic perforation closure. Future studies should report closure rates and hearing outcomes in perforations >8 weeks duration. Laryngoscope, 131:392-400, 2021.

Do high-frequency air-bone gaps persist after ossiculoplasty?

OBJECTIVES: Conventional reporting of postoperative hearing outcomes utilizes a pure-tone averaged air-bone gap (ABG) that is biased toward low frequencies. Consequently, a high-frequency ABG after otologic surgery may go unnoticed. In this study, we evaluate changes in low- and high-frequency ABG following ossiculoplasty. STUDY DESIGN: Retrospective review. SUBJECTS AND SETTING: Consecutive series of patients who underwent ossiculoplasty at a single tertiary care center. Patients with pre- and postoperative audiograms were included. METHODS: Low-frequency ABG was calculated as the mean ABG at 250, 500, and 1000 Hz. High-frequency ABG was calculated at 4 kHz. Pre- and postoperative ABGs were compared. RESULTS: Thirty-seven consecutive patients were included. Mean age at surgery was 38 years (range, 7-77 years). Reconstruction materials included: cartilage (N = 4), hydroxyapatite cement (N = 5), and partial or total ossicular replacement prostheses (N = 20 and N = 8, respectively). Postoperatively, the mean low-frequency ABG improved by 11.9 ± 15.1 dB (P < .0001) and the mean high-frequency ABG improved by 5.9 ± 16.0 dB (P = .030). Low-frequency ABG closure was significantly larger than high-frequency ABG closure (P = .007). Mean postoperative persistent high-frequency ABG was 22.0 ± 13.8 dB. CONCLUSION: In this series, ossiculoplasty improved ABG across all frequencies, but greater improvements were observed at low frequencies when compared to high frequency. Current reporting standards may not identify persistent high-frequency ABG. Additional study of the mechanisms of high-frequency sound conduction in reconstructed middle ears is needed to improve high-frequency hearing outcomes in ossiculoplasty. LEVEL OF EVIDENCE: Level 4.

Long-term cochlear implantation outcomes in patients following head injury.

OBJECTIVE: In cases of a severe to profound sensorineural hearing loss following head injury, the cochlear implant (CI) is the primary option for auditory rehabilitation. Few studies, however, have investigated long-term CI outcomes in patients following head trauma, including those without temporal bone fracture (TBF). Herein, the aim of this study is to examine CI outcomes following cases of head injury with and without TBF. METHODS: Audiometric outcomes of patients who received a CI due to a head injury resulting in severe to profound hearing loss at two tertiary care hospitals were analyzed. Patients were divided into those who received a CI in a fractured temporal bone (group A, n = 11 patients corresponding to 15 ears) and those who received a CI in a non-fractured temporal bone (group B, n = 8 patients corresponding to nine ears). Primary outcomes included duration of deafness prior to CI and postoperative consonant-nucleus-constant whole word (CNC) scores. RESULTS: Nineteen patients (84% male), corresponding to 24 CIs, were identified. Fifteen CI were performed on ears with TBF (group A), and nine CI were performed on ears without TBF (group B). No patients had an enlarged vestibular aqueduct (EVA). The mean duration of deafness was 5.7 and 11.3 years in group A and group B, respectively. The mean duration of CI follow-up (CI experience) was 6.5 years in group A and 2.1 years in group B. The overall mean postoperative CNC score for all subjects was 68.6% (±21.2%, n = 19 with CNC testing). There was no difference in CNC score between group A and group B (69.8% and 66% respectively, P = .639). CONCLUSION: The study is among the largest series examining long-term outcomes of CI after head injury. CI is an effective method for auditory rehabilitation in patients after head injury. LEVEL OF EVIDENCE: IV.

High-Frequency Conductive Hearing following Total Drum Replacement Tympanoplasty.

OBJECTIVES: Conventional reporting of posttympanoplasty hearing outcomes use a pure-tone averaged air-bone gap (ABG) largely representing a low-frequency sound conduction. Few studies report high-frequency conductive hearing outcomes. Herein, we evaluate high-frequency ABG in patients following temporalis fascia total drum replacement. STUDY DESIGN: Case series with chart review. SETTING: Tertiary care center. SUBJECTS AND METHODS: All patients who underwent type 1 tympanoplasty using a lateral graft total drum replacement technique between August 2016 and February 2019 were identified. Patients with pre- and postoperative audiograms were included. Low-frequency ABG was calculated as the mean ABG at 250, 500, and 1000 Hz. High-frequency ABG was calculated at 4 KHz. Pre- and postoperative ABGs were compared. RESULTS: Twenty-three patients were included, and the mean age at surgery was 44 years (range, 9-68 years). Perforation etiology was from trauma (n = 14) or chronic otitis media (n = 9). Preoperative mean low-frequency ABG was 27.8 ± 12.6 dB and mean high-frequency ABG was 21.5 ± 15.1 dB (P = .044). Postoperatively, the mean low-frequency ABG was significantly reduced by 15.5 ± 13.3 dB (P < .001) while the mean high-frequency ABG insignificantly changed (reduced by 2.6 ± 16.2 dB, P = .450). CONCLUSION: In a series of patients undergoing temporalis fascia total drum replacement, low-frequency ABG improved; however, high-frequency conductive hearing loss persists. Conventional methods of reporting ABG may not identify persistent high-frequency ABG. These results merit further study across a range of tympanoplasty graft materials and surgical techniques.

Oea Signaling Pathways and the Metabolic Benefits of Vertical Sleeve Gastrectomy.

OBJECTIVE: The aim of this study was to determine whether downstream [peroxisome proliferator-activated-receptor alpha (PPARα) and the G-protein coupled receptor, GPR119] and upstream (a fatty acid translocase, CD36) signaling targets of N-oleoylethanolamide (OEA) were necessary for weight loss, metabolic improvements, and diet preference following vertical sleeve gastrectomy (VSG). SUMMARY BACKGROUND DATA: OEA is an anorectic N-acylethanolamine produced from dietary fats within the intestinal lumen that can modulate lipid metabolism, insulin secretion, and energy expenditure by activating targets such as PPARα and GPR119. METHODS: Diet-induced obese mice, including wild-type or whole body knockout (KO) of PPARα, GPR119, and CD36, were stratified to either VSG or sham surgery before body weight, body composition, diet preference, and glucose and lipid metabolic endpoints were assessed. RESULTS: We found increased duodenal production of OEA and expression of both GPR119 and CD36 were upregulated in wild-type mice after VSG. However, weight loss and glucose tolerance were improved in response to VSG in PPARαKO, GPR119KO, and CD36KO mice. In fact, VSG corrected hepatic triglyceride dysregulation in CD36KO mice, and circulating triglyceride and cholesterol levels in PPARαKO mice. Lastly, we found PPARα-mediated signaling contributes to macronutrient preference independent of VSG, while removal of CD36 signaling blunts the VSG-induced shift toward carbohydrate preference. CONCLUSIONS: In the search for more effective and less invasive therapies to help reverse the global acceleration of obesity and obesity-related disease OEA is a promising candidate; however, our data indicate that it is not an underlying mechanism of the effectiveness of VSG.

Peripheral Vestibular Organ Degeneration After Temporal Bone Fracture: A Human Otopathology Study.

OBJECTIVES/HYPOTHESIS: Vestibular symptoms are a common sequela of temporal bone fractures (TBFs). The mechanisms of injury to the peripheral vestibular system following TBF, however, are not well described. Herein, we aimed to investigate the histopathology of the peripheral vestibular system in patients who sustained TBFs. STUDY DESIGN: Retrospective human specimen analysis. METHODS: Specimens from the National Temporal Bone Pathology Registry with (cases) and without (controls) TBFs were evaluated. Specimens were analyzed by light microscopy for vestibular hair cell and/or dendritic degeneration, presence of endolymphatic hydrops, blockage of the endolymphatic duct, and number of Scarpa ganglion cells (ScGCs) in the superior and inferior vestibular nerves. RESULTS: Seven temporal bones (TBs) from five individuals with TBFs, and seven TBs from six age-matched individuals without a history of head injury met inclusion and exclusion criteria. All fractures involved the otic capsule. Severe degeneration of the cristae was identified in the semicircular canals in all TBF cases. The utricular and saccular maculae showed mild to severe degeneration in the TBF cases. Vestibular hydrops (n = 2 TBs) and blockage of the endolymphatic duct (n = 3 TBs) were also present in the TBF cases. There was a decrease of 52.6% in the mean total ScGC count in the TBF cases (n = 3 TBs) compared to age-matched controls (n = 7 TBs, P = .015). There was a mean loss of 53% of the ScGCs in the superior vestibular nerve and a mean loss of 52.3% of the ScGCs in the inferior vestibular nerve compared to age-matched controls (P = .033 and P = .021, respectively). CONCLUSIONS: In a cohort of patients with TBFs, there were distinct peripheral vestibular changes including reduction of ScGCs. LEVEL OF EVIDENCE: NA Laryngoscope, 130:752-760, 2020.

Human Otopathology of Cochlear Implant Drill-out Procedures.

OBJECTIVE: Human otopathology following drill-out procedures for cochlear implantation (CI) in cases with labyrinthitis ossificans (LO) has not been previously described. This study uses the high sensitivity of histopathology to (1) evaluate surgical drill-out technique with associated intracochlear findings and (2) quantify spiral ganglion neuron populations in a series of patients with LO who underwent CI. STUDY DESIGN: Retrospective otopathology study. SETTING: Otopathology laboratory. SUBJECTS AND METHODS: Temporal bone (TB) specimens from cases with evidence of preoperative intracochlear fibroossification that required a drill-out procedure for CI electrode array insertion were included. All cases were histopathologically evaluated and 3-dimensional reconstructions of the cochleae were performed to interpret drilling paths and electrode trajectories. RESULTS: Five TB specimens were identified, of which 4 underwent drill-out of the basal turn of the cochlea and 1 underwent a radical cochlear drill-out. In multiple TBs, drilling was imprecise with resultant damage to essential structures. Two TBs showed injury to the modiolus, which was associated with substantially decreased or even absent neuronal populations within these areas. In addition, 2 cases with inadequate drill-out or extensive LO of the basal turn resulted in extracochlear placement of electrode arrays into the vestibule due to persistent obstruction within the basal turn. CONCLUSION: Otopathology highlights the challenges of drill-out procedures in cases of LO. Imprecise drilling paths, due to distortion of normal cochlear anatomy, risk injury to the modiolus and adjacent neurons as well as extracochlear placement of electrode arrays, both of which may contribute to poorer hearing outcomes.

Peripheral Vestibular System Histopathologic Changes following Head Injury without Temporal Bone Fracture.

OBJECTIVE: Vestibular symptoms such as dizziness and vertigo are common after head injury and may be due to trauma to the peripheral vestibular system. The pathophysiology of peripheral vestibular symptoms following head injury without temporal bone (TB) fracture, however, is not well understood. Herein, we investigate the histopathology of the peripheral vestibular system of patients who sustained head injury without a TB fracture. STUDY DESIGN: Otopathology study. SETTING: Otopathology laboratory. SUBJECTS AND METHODS: TB of subjects with a history of head injury without TB fractures were included and evaluated by light microscopy. Specimens were assessed for qualitative and quantitative characteristics, such as number of Scarpa's ganglion cells in the superior and inferior vestibular nerves, vestibular hair cell and/or dendrite degeneration in vestibular end organs, presence of vestibular hydrops, and obstruction of the endolymphatic duct. RESULTS: Five cases (n = 5 TBs) had evidence of vestibular pathology. There was a decrease of 48.6% (range, 40%-59%) in the mean count of Scarpa's ganglion cells as compared with that of normative historical age-matched controls. Moderate to severe degeneration of the vestibular membranous labyrinth was identified in the posterior, superior, and lateral canals in several cases (50%, n = 4 TBs). The maculae utriculi and sacculi showed mild to severe degeneration in 2 cases. Additional findings include vestibular hydrops (25%, n = 2 TBs) and blockage of the endolymphatic duct (n = 1 TB). CONCLUSIONS: Otopathologic analysis of patients with a history of head injury without TB fracture demonstrated peripheral vestibular otopathology. Future studies are necessary to determine if otopathology findings are directly attributable to head injury.

Otopathology of Unilateral Cochlear Implantation in Patients With Bilateral Temporal Bone Fracture.

OBJECTIVE: Audiometric outcomes following cochlear implantation (CI) in patients with temporal bone fracture (TBF) are variable and the pathophysiology is not well understood. Herein, we describe otopathologic findings in two such cases to provide insight into pathophysiology and outcomes. PATIENTS: Two patients had a history of head trauma resulting in bilateral TBF and sudden, profound, sensorineural hearing loss. INTERVENTION: Both cases underwent unilateral CI following head trauma. MAIN OUTCOME MEASURES: Both TBs from each patient were harvested postmortem and histologically analyzed to determine fracture lines, intralabyrinthine fibroosseous changes, and spiral ganglion neuron (SGN) counts. Clinical histories and audiometric outcomes were also reviewed. RESULTS: In both cases, the implanted TB showed extensive intracochlear ossification, which was greater when fracture involved the cochlea. In contrast, the nonimplanted cochleae were patent with small osseous deposits at the round window membrane. Interaural SGN counts were lower on the implanted side and hearing results were moderate to poor. CONCLUSIONS: Otopathologic analyses of patients with a CI after bilateral TBF are rare. Based on otopathology of two patients with bilateral TBF and subsequent CI, implanted TBs show extensive intracochlear fibroosseous changes greater than the nonimplanted side. Findings have implications for auditory rehabilitation after TBF.

Transcanal endoscopic infracochlear vestibular neurectomy: A pilot cadaveric study.

PURPOSE: Effective operative approaches for the treatment of refractory vertigo in Meniere's disease are invasive. Vestibular neurectomy can preserve hearing and has been shown to be effective; however, current approaches require an extensive craniotomy. Transcanal endoscopic approaches to the internal auditory canal (IAC) with cochlear preservation have been recently described and may offer a minimally invasive approach to selectively sectioning the distal vestibular nerves while preserving residual hearing. MATERIALS AND METHODS: Three cadaveric human heads were imaged using high resolution computed tomography (CT). Anatomic analysis of preoperative CT scans showed adequate diameters (>3 mm) of the infracochlear surgical corridor for access to the IAC. A transcanal endoscopic approach was attempted to section the vestibular nerve. Post-operative CT scans were assessed to define the operative tract, determine cochlear preservation and assess cochlear and facial nerve preservation. RESULTS: Transcanal endoscopic approach was successfully performed (n = 3) using 3 mm-diameter, 14 cm-length 0°, 30°, and 45° endoscopes and microsurgical drills. In all cases the tympanomeatal flap and ossicular chain remained intact. Internal auditory canalotomy was performed using angled instruments and confirmed in real time via lateral skull base navigation. The vestibular nerves were readily identified and sectioned with preservation of the facial and cochlear nerves. Post-procedure CT showed no violation of the cochlea. CONCLUSION: A transcanal, infracochlear approach to the IAC may permit a minimally invasive approach to distal vestibular neurectomy in cadavers with appropriate anatomy.

Human Otopathologic Findings in Cases of Folded Cochlear Implant Electrodes.

HYPOTHESIS: We hypothesize that human cases of cochlear implantation (CI) with folding of the electrode array will demonstrate greater degrees of intracochlear ossification, lower spiral ganglion neuron (SGN) counts, and poorer audiometric outcomes. BACKGROUND: CI electrode array folding, such folding of the proximal array, is a relatively common surgical complication that can occur with forceful electrode insertion and may be an important and avoidable factor affecting implant outcomes. However, otopathologic findings and audiologic outcomes of human cases where folding of the implant electrode array is observed remain undefined. METHODS: Specimens from a human temporal bone repository having undergone CI during life were evaluated. Specimens with folding of the electrode array on histological analysis constituted study cases. Electrode-matched specimens without array folding constituted controls. All specimens were examined by light microscopy and histopathologically described. Intracochlear fibrosis and osseous tissue, and SGN counts were measured. Pre- and postoperative word recognition scores were also compared. RESULTS: Cases with folded electrodes showed greater volumes of intracochlear osseous tissue than controls, which was most prominent in areas adjacent to array folding. Both cases and controls demonstrated similar amounts of fibrous tissue. Folded cases showed decreased SGNs when compared with the contralateral ear, whereas controls showed stable SGN populations between ears. In this small cohort, postoperative hearing outcomes were similar between groups. CONCLUSION: Atypical fibro-osseous changes and lower SGN counts are observed in cases of CI electrode folding. Future studies are necessary to determine if recognition and correction of folding can prevent long-term intracochlear changes.

Otopathologic evaluation of temporalis fascia grafts following successful tympanoplasty in humans.

OBJECTIVE: Temporalis fascia is a commonly used graft material in tympanoplasty; however, little is known about how the histological structure of fascia remodels postimplantation. Herein, we aim to quantify the pre- and postoperative microstructure of temporalis fascia and compare histological findings to the native tympanic membrane (TM). METHODS: Temporal bone specimens having undergone successful subtotal or total drum replacement using temporalis fascia were identified (n = 3). Surgically prepared preimplantation temporalis fascia (PreTF, n = 4) and normal TMs (n = 5) were used as controls. Multiple measurements of thickness of PreTF and of normal and fascia reconstructed TMs at the mesotympanum and hypotympanum were obtained. Collagen fiber patterns of normal and reconstructed TMs were histologically described. RESULTS: In cases of fascia tympanoplasty, the mean time of surgery to death was 16 years (range 8-28 years). All cases contained an aerated middle ear without residual perforation. There was no significant difference between the thickness of PreTF and fascia of reconstructed TMs (234.9 ± 144.9 µm vs. 162.9 ± 71.9 µm, P = 0.1). The lamina propria and total thicknesses of controls (59.8 ± 39.3 µm and 83.7 ± 42.4 µm, respectively) were thinner than the PreTF and fascia-reconstructed TMs, respectively, in all cases (P ≤ 0.001, P ≤ 0.001). Reconstructed TMs contained a thick, longitudinal fiber structure that was qualitatively similar to PreTF. CONCLUSION: Based on human temporal bone specimens, temporalis fascia does not significantly remodel, change thickness, or change fibrous structure following successful tympanoplasty. Results have implications for selection and surgical preparation of graft materials in TM reconstruction. LEVEL OF EVIDENCE: 4. Laryngoscope, 128:E351-E358, 2018.