Reply to Hornibrook, J. Comment on "Tabet et al. Vestibular Migraine versus Méniere's Disease: Diagnostic Utility of Electrocochleography. Audiol. Res. 2023, 13, 12-22".

We appreciate the comments made by Hornibrook (2024) [...].

The Emerging Future of Mobile Audiometry: A Prospective Validation Study of the Mimi Hearing Test Application.

OBJECTIVE: The objective of this study is to assess the accuracy of the Mimi Hearing Test (MHT) mobile application in the detection of air conduction (AC) thresholds and in screening for moderate hearing loss. STUDY DESIGN: Prospective clinical study. SETTING: Tertiary care center. PATIENTS: Participants with or without a varying degree of hearing loss, aged 18 years and over, without cognitive impairment and without active otorrhea or earwax impaction at the time of the hearing assessment were included. INTERVENTION: Subjects with a ranging severity of hearing loss underwent a conventional in-booth audiogram as well as mobile-based screening with MHT in a quiet room (45.5 dB background noise) on the same day. Both regular over-the-ear and noise-canceling headphones were tested with MHT. MAIN OUTCOME MEASURES: Comparisons of AC thresholds between conventional audiometry and mobile-based audiometry at discrete frequencies and with pure-tone averages (PTA) were performed. RESULTS: A total of 75 adults (mean age: 56.2 yr, 54.7% male) were recruited and 63 used for analysis. Of the thresholds measured with MHT using regular headphones, 44.0% were within 10 dB of the conventional audiogram, compared to 39.3% using noise-canceling headphones. MHT demonstrated best accuracy at high frequencies (4-8 kHz). When screening for moderate hearing loss (PTA >40 dB HL), MHT demonstrated a sensitivity and specificity of 100.0% and 80.2%, respectively. CONCLUSIONS: MHT is reliable for identifying moderate hearing loss but lacks precision in detecting thresholds at low frequencies. Noise canceling headphones seem to improve its precision at 4,000 Hz only.

Endolymphatic duct blockage surgery vs. intratympanic steroids for treatment of refractory Ménière's disease.

PURPOSE: To compare the effectiveness of the Endolymphatic duct blockage (EDB) and intratympanic methylprednisolone(ITMP) injection to control refractory Ménière's disease(MD) symptoms and evaluate their impact on hearing level. STUDY DESIGN: Retrospective study in a tertiary care center. METHODS: 36 received ITMP injection and 52 EDB. Mean outcome measures at 24 months included vertigo control, tinnitus, aural fullness and hearing level: pure-tone average (PTA), bone conduction average(BCA) and speech discrimination score(SDS). RESULTS: At 24 months postoperatively, 90.4% of the EDB group had complete control of vertigo and 43.4% of the ITMP group (p = 0.001). There was no significant difference in tinnitus or aural fullness control (p = 0.34 and p 0.21 respectively). In each group, the drop in tinnitus and aural fullness frequency at 24 months were significant for EDB (p = 0.03; p < 0.001 respectively) and for ITMP group in tinnitus (p = 0.03) but not aural fullness (p = 0.063). At 24 months, PTA, BCA and SDS were significantly worst in the ITMP group when compared to preoperative levels (p = 0.038, p = 0.027, p = 0.016). PTA in the EDB group was stable with no difference compared to ITMP group (p = 0.48). BCA and SDS in the EDB group were stable and better than the ITMP group (p = 0.032; p = 0.036). In each group, vestibular paresis was not significantly different before (p = 0.06) and after treatment (p = 0.68). CONCLUSION: EDB is more effective than the ITMP for controlling the vertigo symptoms of Ménière's disease and in preserving hearing function. It is a novel surgical technique with promising results for a complete treatment of Ménière's disease. ITMP decreases the frequency and the severity of the symptoms but only control vertigo in 27.8% of cases.

Large Vestibular Aqueduct-Associated Symptoms: Endolymphatic Duct Blockage as a Surgical Treatment.

OBJECTIVE: This study aimed to evaluate the effectiveness of endolymphatic duct blockage (EDB) on dizziness control in patients with a large vestibular aqueduct (LVA) and to evaluate its effect on hearing. STUDY DESIGN: This is a prospective nonrandomized study. SETTING: Five adults and one child with dizziness and five children with progressive hearing loss were referred to our tertiary centers. METHODS: The dizziness handicap inventory (DHI) and DHI-PC (dizziness handicap inventory-patient caregiver) questionnaires were used before and after surgery. All patients underwent a preoperative temporal bone HRCT scan and pure tone audiometry one day before surgery, then four and twelve months after surgery and at the last follow-up. The mean follow-up time was 5.6 years. Student's t-test was used to compare DHI/-PC results. RESULTS: The DHI scores were 44, 24, 84, 59 and 56 before surgery, respectively, for Patients 1 to 5. The DHI scores at four months was significantly different, i.e., 4, 6, 0, 7 and 18 (p = 0.001). No differences were found between 4 and 12 months. Patient 6 (child) had Trisomy 21; their DHI-PC score dropped from 38 (preoperative score) to 8 (postoperative score), showing no activity limitations; clinical evaluation showed the complete resolution of symptoms. We found no significant differences between hearing loss before the surgery and at 1 and 12 months post operation for four adult patients. Our fifth adult patient's hearing changed from severe to profound SNHL. For 5 out of 6 pediatric patients, preoperative PTA and mean ABG were 63 dB and 20 dB, respectively; postoperatively, they improved to 42 dB and 16 dB, respectively. The hearing loss level for the sixth pediatric patient dropped from moderate (PTA = 42 dB) to severe (PTA = 85 dB) due to an opening of the endolymphatic sac and a sudden leak of the endolymph. CONCLUSIONS: EDB, using two titanium clips, seems to be helpful for controlling vestibular symptoms and for stabilizing hearing or even to improve hearing in 82% of cases. Nevertheless, there is a risk of hearing worsening.

Click SP/AP Area Ratio Vesrus Tone Burst SP Amplitude to Diagnose Ménière's Disease Using Electrocochleography.

OBJECTIVES: To evaluate the sensitivity and the specificity of summating potential (SP)/action potential (AP) area under the curve (AUC) ratio by a transtympanic electrode and a click stimulus (TT-CS), SP/AP AUC ratio by an extratympanic electrode and a click stimulus (ET-CS) and SP amplitude value by a transtympanic electrode and tone burst stimulus (TT-TBS) in regard of Ménière's disease (MD) diagnosis. This is the first study that compares SP amplitude value performed by a TT-TBS and the SP/AP AUC ratio performed by a TT-CS. STUDY DESIGN: Retrospective comparative study. SETTINGS: Ninety-five patients met the inclusion criteria for electrocochleography (ECochG) testing in a tertiary care center. METHODS: The sensitivity and specificity of our different ECochG protocols were calculated in regard of the diagnosis of MD. RESULTS: The patients' mean age was 54 years old (female predominance). The sensitivity and the specificity of SP/AP area ratio by a TT-CS were 88.5% and 70.0%, respectively. On the other hand, the sensitivity and specificity for the SP amplitude value by a TT-TBS were 60.0% and 55.6%, respectively. SP/AP area ratio by TT-CS was statistically better than SP amplitude value by TT-TBS to detect MD disease (P = .016). However, no difference was identified between SP/AP area ratio by ET-CS and SP amplitude value by a TT-TBS (P = .573). CONCLUSION: SP/AP area ratio by click stimulation has higher sensitivity and specificity to detect MD compared to SP amplitude value by tone burst stimulation. ECochG would be extremely useful in the diagnosis of MD if we use the SP/AP area ratio (sensitivity: 88.5%); therefore, it changes the bad reputation of ECochG sensitivity using SP/AP amplitude ratio (sensitivity: 51.7%) for the diagnosis of MD.

Suspicion and Treatment of Perilymphatic Fistula: A Prospective Clinical Study.

Background: Since the discovery of the perilymphatic fistula (PLF), the diagnosis and treatment remain controversial. If successfully recognized, the PLF is surgically repairable with an obliteration of the fistula site. Successful treatment has a major impact on patient's quality of life with an improvement in their audiological and vestibular symptoms. Objective: To prospectively investigate patients' clinical and audiological evolution with PLF suspicion after middle ear exploration and obliteration of the round and oval window. Study Design: Prospective comparative study. Setting: Tertiary care center. Methods: Patients were divided into two groups: Group I consisted of patients where no PLF had been identified intraoperatively at the oval and/or at the round window, and Group II consisted of patients where a fistula had been visualized. Patient assessment was a combination of past medical history, the presence of any risk factors, cochlear and vestibular symptoms, a physical examination, temporal bone imaging, audiograms, and a videonystagmogram (VNG). Results: A total of 98 patients were divided into two groups: 62 in Group I and 36 in Group II. A statistically significant difference regarding gender was observed in Group II (83.3% of males vs. 16.7% of females, p = 0.008). A total of 14 cases (4 and 10 in Groups I and II, respectively) were operated for a recurrent PLF. Fat graft material was used in the majority of their previous surgery; however, no difference was found when comparing fat to other materials. In addition, no statistically significant difference was noted between Groups I and II concerning predisposing factors, imaging, VNG, symptom evolution, or a physical exam before the surgery and at 12 months post-operative. However, both groups showed statistically significant hearing and vestibular improvement. On the other hand, the air conduction (AC) and bone conduction (BC) at each frequency were not statistically different between the two groups before surgery but showed statistically significant improvement at 12 months post-operatively, especially for the BC at the frequencies 250 (p = 0.02), 500 (p = 0.0008), and 1000 Hz (p = 0.04). Conclusions: Whenever you suspect a perilymphatic fistula, do not hesitate to explore middle ear and do window obliterations using a tragal perichondrium material. Our data showed that cochlear and vestibular symptoms improved whether a fistula had been identified or not.

Hearing Outcomes Following Endolymphatic Duct Blockage Surgery and Factors Associated with Improved Audition at Two Years Follow-Up.

Objective: To evaluate hearing outcomes at 2 years post endolymphatic duct blockage (EDB) surgery, with an analysis of factors that may predict hearing improvement. Study Design: Retrospective comparative study. Setting: Tertiary care center. Subjects: Definite Ménière's Disease (MD) patients undergoing EDB for refractory disease. Methods: Chart review was conducted to assign cases to one of the three hearing outcome groups (deteriorated, stable, and improved). All cases that met our inclusion criteria were selected. Preoperative data collected were audiograms, bithermal caloric tests, preoperative vertigo episodes, history of previous ear surgery for Ménière, intratympanic steroid injections (ITS) and intraoperative endolymphatic sac (ELS) tear or opening. Postoperative data collected at 24 months were audiograms, vertigo episodes and bithermal caloric testing. Results: Preoperative vertigo episodes, caloric paresis and history of surgery, ITS injections or ELS integrity, as well as postoperative vertigo class distribution and caloric paresis changes were not different between our groups. Preoperative word recognition score (WRS) was lowest in the improved hearing group (p = 0.032). The persistence of tinnitus at 2 years postoperatively was associated with deteriorated hearing (p = 0.033). Conclusions: There are no strong predictors of hearing improvement on presentation pre-EDB, but low preoperative WRS may be the best estimator available. Therefore, ablative interventions should be considered very carefully in patients presenting with low WRS, as they may benefit more from EDB; there is a fair chance of a good hearing outcome with EDB surgery. Persistence of tinnitus can reflect deteriorating audition. Vertigo control and hearing preservation are independent outcomes of EDB surgery, making it desirable as an early intervention for refractory MD cases.

Endolymphatic Duct Blockage as a Surgical Treatment Option for Ménière's Disease.

Endolymphatic duct blockage is a relatively new treatment option for Ménière's disease, aiming to reduce vertigo attacks while sparing hearing and equilibrium. After a regular mastoidectomy, the posterior semicircular canal is identified, and Donaldson's line is determined. This is a line through the horizontal semicircular canal, crossing the posterior semicircular canal. The endolymphatic sac is usually found at this site under the posterior semicircular canal. The bone of the endolymphatic sac and the dura are thinned until the sac is skeletonized, after which the endolymphatic duct is identified. The duct is then blocked with a titanium clip. Using a computerized tomography (CT) scan, the position is confirmed. Follow-up visits take place 1 week, 6 weeks and 1 year after surgery. To this day, only one prospective trial assessing this method has been conducted, comparing this new method to endolymphatic sac decompression. Results of the duct blockage are promising, with 96.5% of the patients free of vertigo after 2 years. However, further research is required.

Manual neuronavigation for superior semicircular canal dehiscence surgery.

Background: Intraoperative identification of a superior semicircular canal (SSC) dehiscence via the middle cranial fossa approach (MCFA) remains a difficult endeavor without a neuronavigation system. To address these challenges, we propose a technique to localize the SSC dehiscence intraoperatively using certain anatomical landmarks. Method: Three anatomical landmarks should be identified on preoperative radiological images: the distance from the squamous part of the temporal bone to the dehiscent SSC, the lower limit of the craniotomy, and the exact location of the craniotomy in relation to the bony external auditory canal. The use of these landmarks intraoperatively can allow the surgeon to correctly identify the position of the SSC. Two instructional videos explaining this technique are presented. Conclusion: The proposed manual neuronavigation technique seems to be an accurate, safe, and cost-effective alternative technique for use in SSC dehiscence surgery.

Proprioceptive Cervicogenic Dizziness Care Trajectories in Patient Subpopulations: A Scoping Review.

Proprioceptive cervicogenic dizziness (PCGD) is the most prevalent subcategory of cervicogenic dizziness. There is considerable confusion regarding this clinical syndrome's differential diagnosis, evaluation, and treatment strategy. Our objectives were to conduct a systematic search to map out characteristics of the literature and of potential subpopulations of PCGD, and to classify accordingly the knowledge contained in the literature regarding interventions, outcomes and diagnosis. A Joanna Briggs Institute methodology-informed scoping review of the French, English, Spanish, Portuguese and Italian literature from January 2000 to June 2021 was undertaken on PsycInfo, Medline (Ovid), Embase (Ovid), All EBM Reviews (Ovid), CINAHL (Ebsco), Web of Science and Scopus databases. All pertinent randomized control trials, case studies, literature reviews, meta-analyses, and observational studies were retrieved. Evidence-charting methods were executed by two independent researchers at each stage of the scoping review. The search yielded 156 articles. Based on the potential etiology of the clinical syndrome, the analysis identified four main subpopulations of PCGD: chronic cervicalgia, traumatic, degenerative cervical disease, and occupational. The three most commonly occurring differential diagnosis categories are central causes, benign paroxysmal positional vertigo and otologic pathologies. The four most cited measures of change were the dizziness handicap inventory, visual analog scale for neck pain, cervical range of motion, and posturography. Across subpopulations, exercise therapy and manual therapy are the most commonly encountered interventions in the literature. PCGD patients have heterogeneous etiologies which can impact their care trajectory. Adapted care trajectories should be used for the different subpopulations by optimizing differential diagnosis, treatment, and evaluation of outcomes.

Video Head Impulse Test Demonstrates a Residual Function after Plugging of Dehiscent Superior Semicircular Canal.

OBJECTIVE: Plugging a symptomatic dehiscent superior semicircular canal (SSCC) often leads to a nonfunctional postoperative canal. However, in some instances, a residual function has been described. This study attempts to describe what factors may lead to such residual function. STUDY DESIGN: Retrospective study. SETTING: Tertiary referral center. PATIENTS: Thirty-five patients with confirmed SSCC dehiscence. INTERVENTION: Video head impulse test was conducted pre- and postoperatively to assess any difference in the function of the SSCC. MAIN OUTCOME MEASURES: Mean gain and pathological saccades were recorded according to well-established thresholds along with dehiscence length and location to evaluate any associations to residual canal function. RESULTS: When comparing preoperative to postoperative SSCC abnormal gains, a significant increase was observed after plugging ( p = 0.023). This also held true when abnormal gain and pathologic saccades were taken together ( p < 0.001). Interestingly, 55.3% of patients were observed to remain with a residual SSCC function 4 months postoperatively even with a clinical improvement. Of these, 47.6% had normal gain with pathologic saccades, 38.1% had an abnormal gain without pathologic saccades, and 14.3% had normal gain without pathologic saccades (normal function). Preoperatively, SSCC abnormal gain was associated with a larger dehiscence length mean ( p = 0.002). Anterosuperior located dehiscences were also associated with a larger dehiscence length mean ( p = 0.037). A residual SSCC function after plugging was associated with a shorter dehiscence length regardless of location ( p = 0.058). CONCLUSION: Dehiscence length and location may be useful in predicting disease symptomatology preoperatively and canals function recovery after plugging. These factors could be used as indicators for preoperative counseling and long-term management.

Reliability of Monothermal Caloric Test as Screening Test of Vestibular System.

This retrospective study completed at a tertiary care center aimed to assess the monothermal caloric test (MCT) as a screening test, using the bithermal caloric test (BCT) as a reference. Additionally, it attempts to measure the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of a fixed inter-auricular difference (IAD) value for both cold and warm stimuli using water irrigation. Medical records of 259 patients referred for vestibular symptoms who underwent BCT with water irrigation were reviewed. Patients with bilateral vestibular weakness and caloric tests using air irrigation were excluded. BCT showed 40.9% unilateral weakness. Two formulas were used to determine the monothermal caloric asymmetry (MCA-1 and MCA-2). The measurement of agreement Kappa between the two formulas in comparison with BCT revealed moderate agreement at 0.54 and 0.53 for hot and cold stimulation, respectively. The monothermal warm stimulating test (MWST) using MCA-2 showed better results, with a sensitivity of 80%, specificity of 91%, PPV of 83.1%, and NPV of 89.2%. Thirty-four patients had horizontal spontaneous nystagmus (HSN) with a mean velocity of 2.25°/s. These patients showed better sensitivity but lower specificity after adjustment of HSN using the MCA-2 formula at warm temperatures. Therefore, they should complete the caloric test with cold irrigation to perform the BCT. MCT is efficient as a screening test if the warm stimulus is used with the MCA-2 formula fixed at 25%. If present, HSNs should be adjusted. Negative IAD (normal) in the absence or presence of adjusted HSN or slow-phase eye velocity ≤ 6°/s at each right and left warm stimulation should be accomplished by the BCT.

Postoperative Recurrences in Patients Operated for Pheochromocytomas and Paragangliomas: New Data Supporting Lifelong Surveillance.

At least 10% of pheochromocytomas (PHEOs) and paragangliomas (PGLs) (PPGLs) may recur after the initial surgery. Guidelines recommend annual screening for recurrence in non-metastatic tumors for at least 10 years after the initial surgical resection and lifelong screening in high-risk patients. However, recent data suggest that a shorter follow-up might be appropriate. We performed a retrospective analysis on patients with PPGLs who had local and/or metastatic recurrences between 1995 and 2020 in our center. Data were available for 39 cases of recurrence (69.2% female) including 20 PHEOs (51.3%) and 19 PGLs (48.7%) (13 head and neck (HNPGL) and 6 thoracoabdominal (TAPGL)). The overall average delay of recurrence was 116.6 months (14-584 months) or 9.7 years and the median was 71 months or 5.9 years. One-third of the cohort had a recurrence more than 10 years after the initial surgery (10-48.7 years). The average tumor size at initial diagnosis was 8.2 cm for PHEOs, 2.7 cm for HNPGLs, and 9.6 cm for TAPGLs. Interestingly, 17.6% of PHEOs were under 5 cm at the initial diagnosis. Metastatic recurrence was identified in 75% of PHEOs, 15.4% of HNPGLs, and 66.7% of TAPGLs. Finally, 12/23 (52.2%) patients with recurrence who underwent genetic testing carried a germline mutation. Overall, the safest option remains a lifelong follow-up.

Analysis of the Acoustic Transcranial Bone Conduction.

OBJECTIVES: (1) To analyze the preferential pathways of sound transmission and sound waves travelling properties in the skull and (2) to identify the location(s) on the skull where bone conduction to the cochlea is optimal. STUDY DESIGN: Basic research Methods: Nine cadaveric heads were placed in an anechoic chamber and equipped with six Bone Anchored Hearing Aids (BAHA™) implants (Cochlear™, Sydney, NSW, Australia) and fifteen accelerometers. A laser velocimeter was used to measure cochlear response by placing a reflector on the round window. Different frequency sweeps were applied to each implant, and measurements were recorded simultaneously by the laser velocimeter and accelerometers. RESULTS: Low-frequency sound waves mostly travel the frontal transmission pathways, and there is no clear predominant pattern for the high frequencies. The mean inter-aural time lag is 0.1 ms. Optimal sound transmission to the cochlea occurs between 1000 and 2500 Hz with a contralateral 5 to 10 dB attenuation. The implant location does not influence mean transmission to the cochlea. CONCLUSION: There is a pattern of transmission for low frequencies through a frontal pathway but none for high frequencies. We were also able to demonstrate that the localization of the BAHA™ implant on the skull had no significant impact on the sound transmission, either ipsi or contralaterally.

Vestibular Migraine versus Méniere's Disease: Diagnostic Utility of Electrocochleography.

Objectives: The diagnostic criteria for vestibular migraine (VM) and Méniere's disease (MD) present an important overlap, which leads to a difficult diagnosis in patients presenting with headache, vertigo, hearing loss, ear fullness, and tinnitus. The objective of our study is to determine whether the area-under-the-curve ratio of the summating potentials (SP) and action potentials (AP) curves on electrocochleography (ECoG) helps differentiate VM from MD with or without the use of the well-established clinical criteria. Method: A retrospective review of patients filling either VM or MD criteria was undertaken between September 2015 and December 2018. All patients underwent ECoG before the introduction of anti-migraine therapy. The prediction of symptom improvement between the clinical criteria and ECoG results was compared by using the Vertigo Symptom Scale. Results: In total, 119 patients were included. An overlap of 36% exists between patients filling VM and MD criteria. Clinical criteria alone did not demonstrate a significant prediction of symptom response to anti-migraine therapy (VM 83%, MD 51%; p = 0.10). However, ECoG results alone did demonstrate adequate prediction (VM 94%, MD 32%; p < 0.001). A negative ECoG result combined with the clinical criteria of VM (100% symptom improvement) was shown to be more predictive of treatment response when compared to clinical criteria alone (83% symptom improvement) (p = 0.017). Finally, when used in patients filling both the VM and MD criteria (VMMD), ECoG was able to predict symptom improvement, thus better differentiating both diseases (normal ECoG: 95%, abnormal ECoG 29%; p < 0.001). Conclusion: Combining VM criteria with normal ECoG using the AUC ratio seems superior in predicting adequate symptom improvement than VM criteria alone.

Investigating Performance of cVEMP and oVEMP in the Identification of Superior Canal Dehiscence in Relation to Dehiscence Location and Size.

Compare the sensitivity and specificity of cVEMP (500 Hz), oVEMP (500 Hz and 4 kHz) in the identification of SSCD. A secondary objective was to identify the influence of dehiscence size and location on cVEMP and oVEMP responses. Methods: Individuals with unilateral (n = 16) and bilateral (n = 10) scan confirmed SSCD were assessed using air-conducted cVEMP and oVEMP Results: For cVEMP, an amplitude cutoff of 286.9 µV or a threshold cutoff of 67.5 dBnHL revealed, respectively, a sensitivity of 75% and 70.6% and a specificity of 69.4% and 100%. For oVEMP (500 Hz), an amplitude cutoff of 10.8 µV or a threshold cutoff of 77.5 dBnHL revealed a sensitivity of 83.33% and a specificity of 87.5% and 80%, respectively. oVEMP (4 kHz), an amplitude cutoff of 3.1 µV, revealed a high specificity of 100% but a low sensitivity of 47.2%. A positive correlation was noted between the length of the SSCD and the cVEMP and oVEMP (500 Hz) thresholds and cVEMP amplitude. Conclusions: Our results support the use of oVEMP in the identification of SSCD. The presence of oVEMP (500 Hz) with an amplitude higher or equal to 10.8 µV, a threshold lower or equal to 77.5 dBnHL or oVEMP (4 kHz) amplitude of 3.1 µV represents the most useful to identify SSCD.

Subannular ventilation tubes in the pediatric population: Clinical outcomes of over 1000 insertions.

OBJECTIVES: Long-term transtympanic tube insertions for chronic middle ear disease are associated with high rates of complications. The objective of this study was to examine the clinical outcomes achieved with an alternate technique, the subannular tube insertion, by determining mean tube lifespan, cumulative incidence of post-operative events and complications, audiometric changes and risk factors associated with earlier tube extrusion in the pediatric population. METHODS: A retrospective chart review of all patients operated for subannular tube insertion between January 2007 and 2013 was conducted in a single pediatric tertiary care center. Exploratory Cox regression analysis was performed to identify potential risk factors. RESULTS: A total of 1014 tubes from 459 patients were included in the study. Mean subannular tube lifespan was 41.3 months with median time of 35.0 months. Cumulative incidence of post-operative events in decreasing frequency were otorrhea (21.7%), tube blockage (16.0%), tympanic membrane retraction (12.5%), otitis media with effusion (10.0%), acute otitis media (6.4%), perforation (4.6%) and cholesteatoma formation (1.1%). For patients with available pre- and post-operative audiograms, mean air-bone gap improved from 19.5 dB to 7.0 dB after subannular tube insertion (p < 0.01). Increasing age and previous subannular tube insertion carried hazard ratios of 1.029 (p < 0.01) and 1.749 (p < 0.01) for tube extrusion respectively, while craniofacial anomalies and concomitant tympanoplasty at the time of tube insertion had hazard ratios of 0.795 (p < 0.01) and 0.680 (p = 0.03). CONCLUSIONS: Subannular tube insertion appears to be a safe and effective alternate technique for middle ear ventilation in cases of intractable disease.

Office-Based Stapes Surgery.

OBJECTIVE: The objective of this study was to provide a proof of concept and to assess the success and safety of stapes surgery for otosclerosis under local anesthesia in an office-based setting (OBS) as compared with a hospital operating room setting (ORS). STUDY DESIGN: Retrospective cohort study. SETTING: We reviewed all patients who underwent stapes surgery by the same surgeon from October 2014 to January 2017 at our tertiary care center (ORS, n = 36, 52%) and in an OBS (n = 33, 48%). SUBJECTS AND METHODS: The surgical technique was identical in both groups. All patients had a temporal bone computed tomography scan and audiogram within the 6 months prior to surgery. Air-bone gaps (ABGs), bone conduction, and air conduction pure tone average values were calculated. Preoperative results for pure tone average, bone conduction, ABG, and word recognition scores were compared with early (4 months) and late (12 months) follow-up audiograms. Intra- and postoperative complications were compared. RESULTS: Both groups were comparable in terms of demographic characteristics and severity of disease. The mean 1-year postoperative ABG was 5.66 dB (95% CI = 4.42-6.90) in the ORS group and 6.30 dB (95% CI = 4.50-8.10) in the OBS group (P = .55). ABG improved by 24.27 dB (95% CI = 21.40-27.13) in the ORS group and 23.15 dB (95% CI = 18.45-27.85) in the OBS group (P = .68). Complication rates did not differ, although this study remains underpowered. CONCLUSIONS: In this small group of patients, the success of stapes surgery performed in an OBS and its complications were comparable to those of an ORS, thus providing an alternative to patients on long operating room waiting lists.

Cholesterol Granulomas: A Comparative Meta-Analysis of Endonasal Endoscopic versus Open Approaches to the Petrous Apex.

Petrous apex cholesterol granulomas (PACG) are rare disorders that can lead to patient morbidity and must, occasionally, be drained by either endoscopic endonasal (EN) or open procedures (OP). The objective of our study was to complete a review of the literature to compare the EN and OP approaches on multiple levels, notably on safety and effectiveness. Ovid MEDLINE and Embase were used to perform a thorough literature review of all cases of PACG treated by either EN or OP dating from January 1948 to August 2017. In total, 49 articles were selected including 23 for EN (n=76) and 26 for OP (n=210). Differences were found in the incidence of preoperative hearing loss (HL) (EN 18.4%, OP 57.3%; p<0.001), headache (EN 48.7%, OP 31.2%; p=0.007), and disequilibrium (EN: 14.5%, OP 26.1%; p=0.04). Differences in lesion proximity to the sphenoid sinus (EN 23.6%, OP: 1.0%; p<0.001), clivus (EN 11.8%, OP 4.7%; p=0.03), otic capsule (EN 0.0%, OP 5.2%; p=0.03), internal auditory canal (EN 2.6%, OP 10.9%; p=0.01), and internal carotid artery (ICA) (EN 9.2%, OP 2.8%; p=0.02) were found on preoperative imaging. The EN procedure had better hearing improvement rates (EN 85.7%, OP 23.4%; p<0.001), lower complication rates (EN 7.9%, OP 17.6%; p=0.04), shorter median follow-up (EN:13.5 months, OP:37.2 months; p<0.001), and shorter time to recurrence (EN 3 months, OP 22.6 months; p=0.002) than the known OP. No differences were found in age, preoperative size, recurrence rate, operative time, stent placement, or improvement of other symptoms. Endoscopic nasal approaches, when feasible, should be favored to open procedures for PACG drainage given their better hearing improvement and less complication rates.