Discrepancies Between Expected and Actual Cochlear Implant-Related Functional Outcomes.

OBJECTIVE: Previous research has demonstrated that realistic patient expectations are a critical factor in determining cochlear implant (CI) candidacy. The current study uses the validated Cochlear Implant Quality of Life-Expectations (CIQOL-Expectations) instrument to determine expectations of potential CI users and the degree to which their pre-CI expectations are met after implantation. STUDY DESIGN: Prospective cohort study. SETTING: Tertiary medical center. PATIENTS: Sixty adult CI patients. INTERVENTIONS/MAIN OUTCOME MEASURES: Pre-CI aided and post-CI consonant-nucleus-consonant word and AzBio sentence scores, pre-CI CIQOL-Expectations, and pre-CI and 3/6/12-month post-CI CIQOL-35 Profile scores. RESULTS: Mean pre-CI CIQOL-Expectations exceeded 12-month mean CIQOL-35 Profile scores for the global measure and the communication, environment, and listening effort domains ( d = 0.65-0.97). The communication and listening effort domain scores had the largest discrepancy between expected and actual post-CI improvement (actual scores, 15.1 and 16.3 points lower than expected [ d = 0.93-0.97], respectively). For 42% of patients, pre-CI global expectations exceeded 12-month post-CI CIQOL-35 Profile global scores, 49% met their expectations, and actual scores exceeded expectations for only 10% of patients. Similar patterns were seen for all CIQOL domains except emotional. CONCLUSIONS: Post-CI functional abilities seem to fall short of pre-CI expectations for a substantial percentage of CI users, which was most apparent for the communication and listening effort CIQOL domains. These results may help clinicians direct personalized counseling toward common misconceptions, which can aid shared decision making and potentially minimize the mismatch between expected and realized outcomes.Level of Evidence: III.IRB Pro00073019, approved December 20, 2017 (Medical University of South Carolina).

General Health Quality of Life Instruments Underestimate the Impact of Bilateral Cochlear Implantation.

OBJECTIVE: To determine the extent to which bilateral cochlear implantation increases patient-reported benefit as compared with unilateral implantation and no implantation. DATA SOURCES: PubMed, Scopus, CINAHL, and Cochrane databases searches were performed using the keywords ("Cochlear Implant" or "Cochlear Implantation") and ("bilateral"). STUDY SELECTION: Studies assessing hearing/CI-specific (CI) and general-health-related (HR) quality of life (QOL) in adult patients after bilateral cochlear implantation were included. DATA EXTRACTION: Of the 31 articles meeting criteria, usable QOL data were available for 16 articles (n = 355 bilateral CI recipients). DATA SYNTHESIS: Standardized mean difference (Δ) for each measure and weighted effects were determined. Meta-analysis was performed for all QOL measures and also independently for hearing/CI-specific QOL and HRQOL. CONCLUSION: When measured using hearing/CI-specific QOL instruments, patients reported very large improvements in QOL comparing before cochlear implantation to bilateral CI (Δ=2.07 [1.76-2.38]) and medium improvements comparing unilateral CI to bilateral CI (Δ=0.51 [0.32- 0.71]). Utilization of parallel versus crossover study design did not impact QOL outcomes (χ = 0.512, p = 0.47). No detectable improvements were observed in either CI transition when using HRQOL instruments (no CI to bilateral CI: Δ=0.40 [-0.02 to 0.81]; unilateral CI to bilateral CI: Δ=0.22 [-0.02 to 0.46]).The universal nature of HRQOL instruments may render them insensitive to the medium to large QOL improvements reported by patients using hearing/CI-specific QOL instruments. Given that HRQOL instruments are used to determine the economic benefit of health interventions, these measurement differences suggest that the health economic value of bilateral cochlear implantation has been underestimated.

Gland-preserving surgery for salivary stones and the utility of sialendoscopes.

BACKGROUND: Sialoendoscopy is the standard treatment for sialolithiasis; however, some patients may be unlikely to benefit from an endoscopic approach. This study assesses predictors of failure in the endoscopic management of sialoliths. METHODS: Patients treated for sialolithiasis from 2012 to 2017 at two centers were stratified into 3 groups: successful interventional sialendoscopy, incisional sialolithotomy, and gland excision. Patient, disease, and surgical factors were compared. RESULTS: Interventional sialendoscopy was attempted in 156 of 206 cases and successful for 42 (27%). Endoscopically retrieved calculi were smaller (4.96 mm) compared to incisional sialolithotomy (7.90 mm). Nonendoscopic approaches were required more often in submandibular cases 87% (P ≤ .005). Palpable stones were present in 74% of incisional sialolithotomies (P < .001). Submandibular location (OR 3.50, 1.53-7.98), palpability (OR 2.74, 1.21-6.18), CT localization (OR 3.05, 1.32-7.10, P = .010), and increased diameter (OR 1.25, 1.09-1.44) were predictive of incisional management. CONCLUSION: Stone size/location, CT-localization, and palpability were predictive of calculi that require an incisional approach. If these factors are recognized, the surgeon can consider proceeding directly to incisional sialolithotomy. LEVEL OF EVIDENCE: III.

Metastatic Salivary Ductal Carcinoma to the Mastoid Segment of the Facial Nerve.

OBJECTIVE: To describe salivary ductal carcinoma (SDC) presenting as an isolated lesion of the mastoid segment of the facial nerve PATIENTS:: A 70-year-old man presenting with weakness of his right lower lip that progressed to complete facial paralysis over a span of 2 weeks. MAIN OUTCOME MEASURES: Clinical case records, immunohistochemical analyses, and radiological analyses including magnetic resonance imaging and positron emission tomography-computed tomography. RESULTS: Nodular enhancement along the mastoid segment of the facial nerve was identified without any mass within the parotid on magnetic resonance imaging or regional/distant disease on positron emission tomography-computed tomography. Pathologic analysis of tissue obtained from a right parotidectomy, neck dissection, and transmastoid resection of the vertical segment of the facial nerve revealed a benign parotid gland with malignant glands identified intra- and perineurally within the central aspect of the gland. CONCLUSIONS: SDC is one of the most aggressive salivary malignancies and typically presents as a rapidly enlarging mass in the involved gland. Although SDC's clinical course is characterized by early metastasis, isolated neural invasion has not been reported in the absence of an identifiable primary tumor within the gland of origin. The present case illustrates the clinical history and treatment of the first case of a SDC presenting as an isolated facial nerve lesion from perineural spread.

Evaluation of Outcome Variability Associated With Lateral Wall, Mid-scalar, and Perimodiolar Electrode Arrays When Controlling for Preoperative Patient Characteristics.

OBJECTIVE: Determine the impact of electrode array selection on audiometric performance when controlling for baseline patient characteristics. STUDY DESIGN: Retrospective evaluation of a prospective cochlear implant (CI) database (January 1, 2012-May 31, 2017). SETTING: Tertiary Care University Hospital. PATIENTS: Three hundred twenty-eight adult CI recipients. INTERVENTIONS/MAIN OUTCOMES MEASURED: Hearing outcomes were measured through unaided/aided pure tone thresholds and speech recognition testing before and after cochlear implantation. All reported postoperative results were performed at least 6 months after CI activation. All device manufacturers were represented. RESULTS: Of the 328 patients, 234 received lateral wall (LW) arrays, 46 received perimodiolar (PM) arrays, and 48 received mid-scalar (MS) arrays. Patients receiving PM arrays had significantly poorer preoperative earphone and aided PTAs and SRTs, and aided Consonant-Nucleus-Consonant(CNC) word and AzBio +10 SNR scores compared with patients receiving LW arrays (all p ≤ 0.04), and poorer PTAs and AzBio +10 SNR scores compared with MS recipients (all p ≤ 0.02). No preoperative audiological variables were found to significantly differ between MS and LW patients. After controlling for preoperative residual hearing and speech recognition ability in a hierarchical multiple regression analysis, no statistically significant difference in audiological outcomes was detected (CNC words, AzBio quiet, or AzBio +10 SNR) among the three electrode array types (all p > 0.05). CONCLUSION: While previous studies have demonstrated superior postoperative speech recognition scores in LW electrode array recipients, these differences lose significance when controlling for baseline hearing and speech recognition ability. These data demonstrate the proclivity for implanting individuals with greater residual hearing with LW electrodes and its impact on postoperative results.

Earphone and Aided Word Recognition Differences in Cochlear Implant Candidates.

OBJECTIVE: Compare word recognition scores for adults undergoing cochlear implant evaluations (CIE) measured using earphones and hearing aids. STUDY DESIGN: Retrospective review of data obtained during adult CIEs. SETTING: Tertiary cochlear implant center. PATIENTS: Two hundred eight ears in 183 subjects with greater than 10% word recognition scores measured with earphones. INTERVENTIONS/MAIN OUTCOMES MEASURED: Preoperative pure-tone thresholds and word recognition scores measured with earphones and hearing aids. RESULTS: A review of audiological data obtained from 2012 to 2017 during adult CIEs was conducted. Overall, a weak positive correlation (r = 0.33, 95% confidence interval 0.17-0.40, p < 0.001) was observed between word recognition scores measured with earphones and hearing aids. Earphone to aided differences (EAD) ranged from -38 to +72% (mean 14.3 ±â€Š19.9%). Consistent with EADs, 108 ears (51.9%) had earphone scores that were significantly higher than aided word recognition scores (+EAD), as determined by 95% confidence intervals; for 14 ears (6.7%), earphone scores were significantly lower than aided scores (-EAD). Moreover, of the patients with earphone word recognition scores ≥50%, 82.6% were CI candidates based on aided AzBio+10 dB SNR scores. CONCLUSION: These results demonstrate the limited diagnostic value of word recognition scores measured under earphones for patients undergoing CIE. Nevertheless, aided word recognition is rarely measured before CIEs, which limits the information available to determine CI candidacy and referral for CIEs. Earlier and routine measurement of aided word recognition may help guide clinical decision making by determining the extent to which patients are achieving maximum benefit with their hearing aids or should consider cochlear implantation.