Localization of the Vertical Part of the Facial Nerve in the High-Resolution Computed Tomography During Pediatric Cochlear Implantation.

BACKGROUND: This study proposed a classification of the vertical portion of the facial nerve (VPFN) location, incorporating the previous classifications regarding the posterior-to-anterior and medial-to-lateral dimensions. We also evaluated the implication of this proposed classification on the round window visibility during pediatric cochlear implantation (CI). METHODS: It was a retrospective multicenter observational cohort study. This study included 334 cases that underwent CI between 2015 and 2022 at multiple referral institutes. Two physicians evaluated the preoperative computed tomography images of 334 patients and determined the radiological type of the VPFN. These types were matched with intraoperative round window accessibility. RESULTS: The Spearman's correlation coefficient showed a strong correlation between the proposed VPFN type and the intraoperative round window visibility, as the P-value was <.001. CONCLUSION: This classification could provide the surgeon preoperatively with the precise location of the VPFN in the lateral-to-medial and posterior-to-anterior dimensions. Furthermore, this location classification of the VPFN was significantly correlated with intraoperative round window accessibility, with an accuracy of 90.42%. Therefore, types C and D were expected to have difficult accessibility into the round window, and more surgical interventions were needed to modify the posterior tympanotomy or use other approaches.

The novel retro-conchal approach for middle ear surgeries: Our experience in 196 patients / El nuevo abordaje retro-conchal para cirugías del oído medio: nuestra experiencia en 196 pacientes

Background This study aimed to describe a new proposed retro-conchal approach for middle ear surgery and to evaluate its advantages and postoperative impact. Methodology A retrospective case-series study was held at a tertiary university hospital from March 2008 to April 2022. We included 196 adult patients who were candidates for middle ear surgery because of chronic otitis media. The retro-conchal approach entailed a skin incision on the medial conchal surface 1 cm anterior to the auricular sulcus. It allowed the harvesting of the required size of conchal cartilage and temporalis fascia through the same incision with access into the middle ear and complete exposure to the mastoid process. In addition, we evaluated the use of this approach in tympanoplasty, including cholesteatoma surgeries with at least one-year postoperative follow-up. Result The long-term follow-up (22.9 ± 6.37 months) revealed that most operated cases (89%) did not develop postoperative sequelae related to this approach. On the other hand, 22 patients (11%) developed adverse outcomes, with a statistically significant difference regarding adverse outcomes as the P-value <0.001. Conclusion According to our experience with a relatively large number of patients, the retro-conchal technique was practical for various middle ear surgeries. It allowed optimal access to different middle ear areas and obtaining large-sized conchal cartilage and temporalis fascia (if needed) through the same incision without needing extra surgical steps. In addition, it was a safe maneuver without significant adverse outcomes in the long-term follow-up. (AU)

Antecedentes Este estudio tuvo como objetivo describir una nueva propuesta de abordaje retroconchal para la cirugía del oído medio y evaluar sus ventajas e impacto postoperatorio. Metodología Se realizó un estudio retrospectivo de serie de casos en un hospital universitario de tercer nivel desde marzo de 2008 hasta abril de 2022. Se incluyeron 196 pacientes adultos candidatos a cirugía de oído medio por otitis media crónica. El abordaje retroconchal implicó una incisión cutánea en la superficie medial de la concha 1 cm anterior al surco auricular. Permitió la recolección del tamaño requerido de cartílago de la concha y fascia temporal a través de la misma incisión con acceso al oído medio y exposición completa al proceso mastoideo. Evaluamos el uso de este abordaje en la timpanoplastia, incluidas las cirugías de colesteatoma con un seguimiento postoperatorio de al menos un año. Resultado El seguimiento a largo plazo (22,9 ± 6,37 meses) reveló que la mayoría de los casos operados (89%) no desarrollaron secuelas postoperatorias relacionadas con este abordaje. Por otro lado, 22 pacientes (11%) desarrollaron secuelas menores, con diferencia estadísticamente significativa en cuanto a la ocurrencia de secuelas como el valor P < 0,001. Conclusión De acuerdo con nuestra experiencia con un número relativamente grande de pacientes, la técnica retroconchal fue práctica para varias cirugías del oído medio. Permitió un acceso óptimo a diferentes áreas del oído medio y obtener cartílago de la concha y fascia temporal (si es necesario) de gran tamaño a través de la misma incisión sin necesidad de pasos quirúrgicos adicionales. Fue una maniobra segura y sin complicaciones significativas en el seguimiento a largo plazo. (AU)

Radioclinical Assessment of Posterior Tympanotomy Difficulties during Ordinary Cochlear Implantation: A Prospective Case-Series Study.

OBJECTIVES: This study proposes a preoperative radiologic scoring system for predicting posterior tympanotomy (PT) and mastoidectomy-associated difficulties during cochlear implantation (CI). STUDY DESIGN: It was a prospective case-series study. SETTINGS: The included CI surgeries were performed at tertiary referral institutions from October 2022 to April 2023. SUBJECTS: We included 73 CI candidates performed via the PT approach. INTERVENTION: The proposed radiologic score, composed of 13 items, was fulfilled and evaluated before each CI surgery. MAIN OUTCOME MEASURE: We correlated this score with the intraoperative difficulty and surgical duration. RESULTS: The operation was straightforward in 42 patients with a score of 3.87 ± 1.72 and challenging in 31 patients with a score of 10.66 ± 1.73. The radiologic score was strongly correlated with the surgical difficulty and duration (p < 0.0001). CONCLUSIONS: Our proposed radiologic score was a valid, reliable, and precise tool to predict intraoperative difficulty during cochlear implantation. Chorda-facial angle was the strongest predictor, significantly affecting the difficulty, surgical duration, and preoperative radiologic score. A score equal to or more than 7.5 was expected to be associated with surgical difficulty.

Implantable hearing devices in clinical practice. Systematic review and consensus statements.

Objective: Implantable hearing devices represent a modern and innovative solution for hearing restoration. Over the years, these high-tech devices have increasingly evolved but their use in clinical practice is not universally agreed in the scientific literature. Congresses, meetings, conferences, and consensus statements to achieve international agreement have been made. This work follows this line and aims to answer unsolved questions regarding examinations, selection criteria and surgery for implantable hearing devices. Materials and methods: A Consensus Working Group was established by the Italian Society of Otorhinolaryngology. A method group performed a systematic review for each single question to identify the current best evidence on the topic and to guide a multidisciplinary panel in developing the statements. Results: Twenty-nine consensus statements were approved by the Italian Society of Otorhinolaryngology. These were associated with 4 key area subtopics regarding pre-operative tests, otological, audiological and surgical indications. Conclusions: This consensus can be considered a further step forward to establish realistic guidelines on the debated topic of implantable hearing devices.

The novel retro-conchal approach for middle ear surgeries: Our experience in 196 patients.

BACKGROUND: This study aimed to describe a new proposed retro-conchal approach for middle ear surgery and to evaluate its advantages and postoperative impact. METHODOLOGY: A retrospective case-series study was held at a tertiary university hospital from March 2008 to April 2022. We included 196 adult patients who were candidates for middle ear surgery because of chronic otitis media. The retro-conchal approach entailed a skin incision on the medial conchal surface 1 cm anterior to the auricular sulcus. It allowed the harvesting of the required size of conchal cartilage and temporalis fascia through the same incision with access into the middle ear and complete exposure to the mastoid process. In addition, we evaluated the use of this approach in tympanoplasty, including cholesteatoma surgeries with at least one-year postoperative follow-up. RESULT: The long-term follow-up (22.9 ±â€¯6.37 months) revealed that most operated cases (89%) did not develop postoperative sequelae related to this approach. On the other hand, 22 patients (11%) developed adverse outcomes, with a statistically significant difference regarding adverse outcomes as the P-value <0.001. CONCLUSION: According to our experience with a relatively large number of patients, the retro-conchal technique was practical for various middle ear surgeries. It allowed optimal access to different middle ear areas and obtaining large-sized conchal cartilage and temporalis fascia (if needed) through the same incision without needing extra surgical steps. In addition, it was a safe maneuver without significant adverse outcomes in the long-term follow-up.

Current trends on subtotal petrosectomy with cochlear implantation in recalcitrant chronic middle ear disorders.

Objective: To establish the safety and effectiveness of subtotal petrosectomy with cochlear implantation in patients affected by chronic middle ear disorders to refractory to previous surgical treatments. Methods: A multicentre, retrospective study was conducted on patients affected by recalcitrant chronic middle ear disorders who underwent cochlear implantation in combination with subtotal petrosectomy. Patients' details were collected from databases of 11 Italian tertiary referral centres. Additionally, a review of the most updated literature was carried out. Results: 55 patients were included with a mean follow-up time of 44 months. Cholesteatoma was the most common middle ear recurrent pathology and 50.9% of patients had an open cavity. 80% of patients underwent a single stage surgery. One case of explantation for device failure was reported among the 7 patients with post-operative complications. Conclusions: Subtotal petrosectomy with cochlear implantation is a benchmark for management of patients with recalcitrant chronic middle ear disorders. A single stage procedure is the most recommended strategy. Optimal follow-up is still debated. Further studies are required to investigate the role of this surgery in paediatric patients.

Introducing Telemedicine in Italy: Citizens' Awareness of a New Healthcare Resource.

In recent years, especially during the COVID-19 pandemic, new technologies have emerged as useful resources in healthcare. Telemedicine services may decrease opportunities for contagion by limiting direct medical contacts; they can lead to greater access to and better quality of care, especially for the elderly and chronically ill patients. However, there are still some difficulties in their widespread use, such as lack of knowledge about the effectiveness and safety of telemedicine; lack of awareness of its existence; privacy issues; and lack of computer literacy. The aim of this study is to assess the awareness of and attitude toward telemedicine in the Italian adult population, considering sociodemographic characteristics and territorial differences in telemedicine service implementation. A questionnaire was administered to Italian citizens from October 2022 to February 2023 using communication and social media in order to collect sociodemographic and health characteristics and data on awareness and use of telemedicine services. Less than half of the respondents (n = 1002) were aware of telemedicine services in their region; most of them did not use the available services due to a preference for in-person visits or lack of need. More than 90% of participants who used these services were satisfied with them. A negative attitude toward telemedicine was found in a higher proportion of older adults. This study demonstrated that, although telemedicine services are active in Italy, a large part of the population ignores its availability. Therefore, further efforts should be made to increase citizens' awareness and the use of telemedicine in our country.

The role of cochlear implantation in alleviating Tumarkin drop attacks of Meniere's disease; a case report.

Ménière's disease (MD) patients may suffer episodes of sudden falls, named Tumarkin drop attacks (DAs). This fall occurs abruptly and without warning or loss of consciousness. DAs usually aggravate the clinical picture of MD and are challenging to manage. The present report describes a case treated by cochlear implantation (CI) due to concomitant deafness and offers some clinical considerations for this condition. A male patient aged 48 years with a 10-year history of definite bilateral MD had profound SNHL on the right and severe SNHL on the left side. He suffered from intermittent attacks of vertigo, ear fullness, and tinnitus and, in the last year, had developed DAs and experienced 14 episodes in the previous six months. The preoperative category of acoustic performance was 3. The Dizziness Handicap Inventory (DHI) questionnaire showed a total score of 46, which indicated a moderate degree of disability. A CI was planned for the right side. The patient did not report any further DAs episode for two years since then. The postoperative category of acoustic performance became 11, and the postoperative DHI questionnaire showed a decrease in the total score (from 46 to 19), which indicated a mild disability. Unilateral CI effectively alleviated the DAs associated with bilateral MD. Our report proposes a new modality for managing vertiginous symptoms in cases of MD with hearing loss without the need for more aggressive surgical interventions with the need for clinical trials to confirm our results.

The impact of labyrinthine magnetic resonance signal alterations on the treatment of sudden sensory-neural hearing loss.

BACKGROUND: Sudden sensory-neural hearing loss (SSNHL), with positive findings on magnetic resonance imaging (MRI), possibly related to labyrinthine hemorrhage, is a rare condition and difficult to be diagnosed. OBJECTIVES: We evaluated the role of MRI in detecting labyrinthine signal changes and the impact of these changes on the prognosis of SSNHL after the intratympanic corticosteroid injection. METHODS: A prospective study was held between January and June 2022. We included patients who complained of SSNHL, either idiopathic (30 patients) or labyrinthine signal alterations (14 patients), as diagnosed by MRI performed 15 days after the SSNHL onset. In addition, all patients underwent a course of intratympanic prednisolone injections. RESULTS: 83.3% of the idiopathic group showed a complete or marked improvement after the intratympanic injection. Conversely, most cases of positive MR signal alterations (92.8%) had slight or poor improvement after the therapeutic course. CONCLUSIONS: Our study revealed that MRI imaging is essential for assessing any SSNHL case. It can diagnose labyrinthine hemorrhage, whose course and prognosis differ significantly from idiopathic SSNHL. SIGNIFICANCE: Intratympanic prednisolone injection was effective in managing idiopathic SSNHL. On the other hand, this therapeutic modality was ineffective in improving SSNHL associated with labyrinthine hemorrhage.

Assessment of the ability of the radiological incudo-stapedial angle to predict the stapedotomy technique type: a prospective case-series study.

PURPOSE: This study aimed to propose a radiological classification of the incudo-stapedial angle by preoperative high-resolution computed tomography (HRCT) images and to highlight its importance for predicting the use of reversal-steps stapedotomy (RSS) rather than the traditional non-reversal technique. METHODS: We included 83 candidates for stapedotomy operation. Two physicians measured the radiological incudo-stapedial joint angle in the preoperative HRCT. According to this measurement, the radiological incudo-stapedial joint was classified into three types: obtuse, right, and acute. In addition, this radiological classification was correlated with the intraoperative use of the stapedotomy technique, either reversal or non-reversal. RESULTS: The RSS technique was used in forty-two (97.7%) cases with an obtuse angle and twenty-six (89.7%) with a right angle. At the same time, the traditional non-reversal technique was used in all patients with an acute angle. The three groups differed significantly regarding the method used for stapedotomy (P value < 0.001). Moreover, Spearman's correlation coefficient revealed a significant correlation between the used technique and the radiological type of the incudo-stapedial angle (P value < 0.001). CONCLUSIONS: This prospective study proposed a preoperative radiological classification of the incudo-stapedial angle. This classification was significantly correlated with the type of stapedotomy technique. The RSS technique was feasible in most cases with an obtuse and right radiological incudo-stapedial angle. In contrast, the non-reversal method was used in all patients with an acute radiological incudo-stapedial angle. This radiological classification could predict the choice for the stapedotomy technique with an accuracy of 95.18%, a sensitivity of 73.33%, and a specificity of 100%.

Augmented Virtual Reality in Vestibular Assessment: A Dynamic Gait Application.

INTRODUCTION: Dizziness is a common complaint affecting up to 23% of the world population. Diagnosis is of utmost importance and routinely involves several tests to be performed in specialized centers. The advent of a new generation of technical devices would make envision their use for a valid objective vestibular assessment. Microsoft HoloLens 2 (HL2) mixed reality headset has the potential to be a valuable wearable technology that provides interactive digital stimuli and inertial measurement units (IMUs) to objectively quantify the movements of the user in response to various exercises. The aim of this study was to validate the integration of HoloLens with traditional methods used to analyze the vestibular function in order to obtain precise diagnostic values. METHODS: Twenty-six healthy adults completed the Dynamic Gait Index tests both with a traditional evaluation and while wearing HL2 headset, thus allowing to collect kinematic data of the patients' head and eyes. The subjects had to perform 8 different tasks, and the scores were independently assigned by two otolaryngology specialists. RESULTS: The maximum of the mean position of the walking axis of the subjects was found in the second task (-0.14 ± 0.23 m), while the maximum value of the standard deviation of the walking axis was found in the fifth task (-0.12 ± 0.27 m). Overall, positive results were obtained in regard to the validity of the HL2 use to analyze kinematic features. CONCLUSION: The accurate quantification of gait, movement along the walking axis, and deviation from the normality using HL2 provide an initial evidence for its useful adoption as a valuable tool in gait and mobility assessment.

The impact of fusion imaging technique on middle ear cholesteatoma surgery: a prospective comparative study.

BACKGROUND: The fusion of computed tomography images with non-echo planner diffusion-weighted magnetic resonance images may overcome the limitations of each individual modality. OBJECTIVES: This study aimed to assess the ability of the 'fusion' technique to predict the location of middle ear cholesteatoma by evaluating Its impact on preoperative surgical planning and postoperative results. METHODOLOGY: Eighty-three adults with cholesteatoma underwent preoperative CT scans and non-EPI-DW-MRI with or without the 'fusion' technique. We evaluated cholesteatoma localization in both groups, selecting the most appropriate surgical technique, and correlating it with the intraoperative findings. Both groups were compared in terms of residual/recurrent cholesteatoma at one, six and twelve months after surgery. RESULTS: The 'fusion' technique's sensitivity, specificity, and accuracy in predicting the location of cholesteatoma were 97.5. 97.4, and 97.5%, respectively, versus 97.59, 57.69, and 73.21% of CT alone. There was a total operators agreement after the evaluation of the 'fusion' images with the adopted surgical technique. A statistically significant decrease in residual and recurrence cholesteatoma rates was found in group A. CONCLUSIONS: The 'fusion' technique provides the surgeon with the precise cholesteatoma location, guiding him in making the correct surgical decision, contributing to the decrease in postoperative residual and recurrence rates.

On the battery life of a totally implantable active middle ear device: a retrospective study in a single implanting center.

BACKGROUND: Totally-implantable active middle ear devices (AMED) rely on a non-rechargeable battery encased with the implantable sound processor that needs to be replaced with a minor surgical procedure after its depletion. OBJECTIVES: This study aimed to investigate the most significant factors affecting the implant's battery life. MATERIALS AND METHODS: The implanted subjects (29 patients) were divided into three groups; group A with 17 patients who underwent one battery change surgery; group B with ten patients who underwent two battery changes; and group C with two patients and three surgeries. The battery life was put in correlation with several variables, including daily use and the auditory threshold. RESULTS: The battery life ranged from 26 to 67 months, with a mean of 48.93 ± 13.47. Pearson's correlation coefficient revealed that the battery life was statistically correlated only with the mean post-implantation bone conduction thresholds (p-value <.0001). CONCLUSIONS: Although the non-rechargeable battery system of the AMED under study overcomes the drawbacks of daily charging, it needs to be surgically changed after its depletion. The different rates of battery life were shown to mainly depend on the post-implantation BC thresholds, which in some cases showed a deterioration concerning the pre-implanting values.

The impact of adding platelet-rich plasma during fat graft myringoplasty for managing medium-sized tympanic membrane perforations: A prospective randomized case-control study.

PURPOSE: This study aimed to evaluate the effect of adding platelet-rich plasma (PRP) during FGM to close medium-sized TM perforations. METHODS: This prospective randomized case-control study was conducted from February 2017 to March 2022. We included 320 patients with a medium-sized TM perforation with inactive mucosal otitis media. Transcanal FGM managed all patients under general or local anesthesia according to the patient preference. According to PRP, patients were divided into two groups: the first with PRP (170 patients) and the other without PRP (150 patients). We evaluated the closure rate of both groups one month, six months, and one year after the surgery. Also, we assessed the audiological performance before and one year after the operation for the patients with a successful closure. RESULTS: The closure rate was 87.6 % in the first group and 72.7 % in the second group, with a statistically significant difference between both groups as the P-value, was 0.001. Successful closure of the ABG to <10 dB occurred in 95.3 % of group A and 90.8 % of group B without a statistically significant difference between both groups (P-value = 0.163). CONCLUSIONS: This prospective comparative study on a relatively large number of patients revealed that FGM effectively closed medium-sized TM perforations. It also significantly improved postoperative audiological performance in both groups. Adding PRP during the FGM enhanced the closure success and the healing process without recorded complications. We recommend using the PRP in the routine FGM for closing medium-sized TM perforations.

Validation of the radiological detection of the chorda-facial angle: impact on the round window accessibility during pediatric cochlear implantation.

OBJECTIVES: The facial recess, an essential landmark for the posterior tympanotomy approach, is limited by the facial nerve and the chorda tympani, with a complicated relationship. This study tried to find the most appropriate radiological method to evaluate the chorda-facial angle (CFA). We also checked the effect of this angle on the round window accessibility during cochlear implantation. METHODS: It was a retrospective study that included cochlear implant surgeries of 237 pediatric patients, from September 2016 to April 2021. Two physicians evaluated the CFA in the para-sagittal cut of the preoperative HRCT. The round window accessibility was assessed in the unedited surgery videos. RESULTS: The CFA ranged from 21° to 35° with a mean of 27.14 ± 3.5°. It was detected in all cases with a high agreement between the two CT reviewers' measurements. The CFA differed significantly between the accessible group and the group with difficult accessibility (p value < 0.001). Spearman's correlation coefficient revealed a strong correlation between the CFA and the intraoperative round accessibility. 25.5° was the best cutoff point; below this angle, difficult accessibility into the RW was expected, with high sensitivity, specificity, and accuracy CONCLUSIONS: Our study on a relatively large number of cases provided a precise, valid, reliable, and applicable method to evaluate the CFA in the HRCT scan. We found a significant-close relation between the CFA and the round window accessibility; the difficulty increased with a need for posterior tympanotomy modification when the angle decreased. KEY POINTS: • Radiological detection of the chorda-facial angle was always problematic, without a previous straightforward method in the literature. • We used the para-sagittal cut of the high-resolution CT scans to evaluate the CFA. This cut was beneficial to seeing the chorda tympani nerve in every examined case. There was a high agreement between the two CT reviewers' measurements. • Preoperative evaluation of the CFA in the HRCT accurately predicted the round window accessibility. Patients with CFA less than 25.5° were expected to have difficult accessibility into the round window during cochlear implantation.

Evaluation of prednisolone and prednisolone sodium succinate concentrations in human plasma and inner ear perilymph during cochlear implantation 24 h after intratympanic injection.

BACKGROUND: The use of intratympanic (IT) steroids has drastically increased over the past 10-15 years to manage many otological pathologies. OBJECTIVES: This study aimed to compare the concentrations of prednisolone and prednisolone sodium succinate (SS) in the plasma and inner ear perilymph of participants who underwent cochlear implantation 24 h after IT injection. MATERIALS AND METHODS: It was a prospective comparative randomized study. Twenty participants received an IT injection of prednisolone SS ∼24 h before the cochlear implantation. The other five participants received an IT saline injection and represented the control group. Perilymph and blood were sampled during the cochlear implantation surgery. RESULTS: Both prednisolone and prednisolone SS were still present in perilymph ∼24 h after the IT administration. Only prednisolone was present in the blood plasma of seven participants (35%). CONCLUSION: IT injection of prednisolone SS resulted in high perilymph concentrations of prednisolone and prednisolone SS, which could stay in the perilymph for at least 24 h. Using a mini-endoscope during the IT injection may effectively detect barriers infront of the round window membrane, increasing the drug concentration in the inner ear. SIGNIFICANCE: IT injection is an effective method for delivering prednisolone to the inner ear.

The Use of Nanoparticles in Otoprotection.

The inner ear can be insulted by various noxious stimuli, including drugs (cisplatin and aminoglycosides) and over-acoustic stimulation. These stimuli damage the hair cells giving rise to progressive hearing loss. Systemic drugs have attempted protection from ototoxicity. Most of these drugs poorly reach the inner ear with consequent ineffective action on hearing. The reason for these failures resides in the poor inner ear blood supply, the presence of the blood-labyrinthine barrier, and the low permeability of the round window membrane (RWM). This article presents a review of the use of nanoparticles (NPs) in otoprotection. NPs were recently used in many fields of medicine because of their ability to deliver drugs to the target organs or cells. The studies included in the review regarded the biocompatibility of the used NPs by in vitro and in vivo experiments. In most studies, NPs proved safe without a significant decrease in cell viability or signs of ototoxicity. Many nano-techniques were used to improve the drugs' kinetics and efficiency. These techniques included encapsulation, polymerization, surface functionalization, and enhanced drug release. In such a way, it improved drug transmission through the RWM with increased and prolonged intra-cochlear drug concentrations. In all studies, the fabricated drug-NPs effectively preserved the hair cells and the functioning hearing from exposure to different ototoxic stimuli, simulating the actual clinical circumstances. Most of these studies regarded cisplatin ototoxicity due to the wide use of this drug in clinical oncology. Dexamethasone (DEX) and antioxidants represent the most used drugs in most studies. These drugs effectively prevented apoptosis and reactive oxygen species (ROS) production caused by ototoxic stimuli. These various successful experiments confirmed the biocompatibility of different NPs and made it successfully to human clinical trials.