Long-term quality of life in patients with vestibular schwannoma managed with microsurgery.

OBJECTIVE: Little is known about the long term (greater than 10 years) quality of life in patients with vestibular schwannoma. This study aimed to evaluate long-term outcomes in patients with vestibular schwannoma. METHOD: A retrospective cohort study was performed across 2 academic institutions, with patients followed at least 10 years after vestibular schwannoma surgery (2000 to 2007). Telephone interviews were used to assess quality of life using the Glasgow Benefit Inventory and short form 12 item (version 2) health survey. RESULTS: A total of 99 out of 110 patients were included. Increasing age and symptom burden were associated with poorer quality of life (p = 0.01 and 0.02, respectively). The presence of imbalance, headache and facial nerve dysfunction were all associated with poorer quality of life scores (p = 0.01, 0.04 and 0.02, respectively). CONCLUSION: Identifying and managing post-operative symptoms may improve quality of life in vestibular schwannoma patients and can guide clinical decision making.

A population-based study of the association between dysglycaemia and hearing loss in middle age.

AIMS: To investigate the independent associations between hearing loss and dysglycaemia in a sample of middle-aged adults, including separate analysis of those aged < 60 years. METHODS: The first 2023 participants in the cross-sectional Busselton Health Ageing Survey were assessed for hearing loss ≥ 26 dB (better ear) for four-frequency average (4FA) of pure-tone thresholds at 500, 1000, 2000 and 4000 Hz, and high-frequency average (HFA) of pure-tone thresholds at 4000 and 8000 Hz. RESULTS: Valid data from 1864 participants in the Busselton Health Ageing Survey [92.1%; mean ± sd age 56.2 ± 5.5 years, 46.0% men, 120 (7.0%) with diabetes, 274 (14.7%) with prediabetes] were analysed, of whom 103 (5.5%) had four-frequency average hearing loss and 561 (30.1%) had high-frequency average hearing loss. In multivariable analyses, glycaemic status was not independently associated with four-frequency or high-frequency average hearing loss. In the 1286 participants aged < 60 years, there was no relationship between dysglycaemia and high-frequency average hearing loss, but the prevalence of four-frequency average hearing loss increased from 2.3% (95% CI 1.5-3.4) in participants with normoglycaemia to 5.7% (95% CI 3.0-10.6) in those with prediabetes and 10.2% (4.2-21.5) in those with diabetes (trend P = 0.003). In multivariable analysis with normoglycaemia as reference, the odds ratios for four-frequency average hearing loss were 2.84 (95% CI 1.29-6.27) for prediabetes and 5.93 (95% CI 1.67-21.05) for diabetes (P ≤ 0.01) in the < 60 year age group. CONCLUSIONS: There was progressively increasing mid-range hearing loss with worsening glucose tolerance in younger individuals, suggesting dysglycaemia-associated early-onset presbycusis.

Protective benefit of predominant breastfeeding against otitis media may be limited to early childhood: results from a prospective birth cohort study.

OBJECTIVES: To examine the long-term effects of predominant breastfeeding on incidence of otitis media. DESIGN: Prospective birth cohort study. SETTING: The West Australian Pregnancy Cohort (Raine) Study recruited 2900 mothers through antenatal clinics at the major tertiary obstetric hospital in Perth, Western Australia, between 1989 and 1992. PARTICIPANTS: In total, 2237 children participated in a 6-year cohort follow-up, and a subset of 1344 were given ear and hearing assessments. MAIN OUTCOME MEASURES: OM diagnosis at 6 years of age (diagnosed by low-compliance tympanograms, 0-0.1 mmho). This was compared to OM diagnosed at the 3-year cohort follow-up using parent-report measures. Main exposure measures were duration of predominant breastfeeding (defined as the age other milk was introduced) and duration of partial (any) breastfeeding (defined as the age breastfeeding was stopped). RESULTS: There was a significant, independent association between predominant breastfeeding (OR = 1.33 [1.04, 1.69]; P = 0.02) and OM, and breastfeeding duration (OR = 1.35 [1.08, 1.68]; P = 0.01) with OM at 3 years of age. However, at 6 years of age, this relationship was no longer statistically significant (predominant breastfeeding OR = 0.78 [0.48, 1.06]; P = 0.09; duration of breastfeeding, OR = 1.34 [0.81, 2.23]; P = 0.25). CONCLUSIONS: Our findings are in line with a number of epidemiological studies which show a positive association between breastfeeding and OM in early childhood. However, the long-term follow-up of these children revealed that by 6 years of age, there was no significant influence of breastfeeding on presence of OM. These results suggest that the protective effect of predominant breastfeeding for at least 6 months does not extend to school-age children, where other social and environmental factors may be stronger predictors of OM.

Self-reported cochlear implant management skills: development and validation of the self-administered Cochlear Implant Management Skills (CIMS-self) survey.

OBJECTIVE: A self-administered device management survey was developed and validated to investigate the ability of cochlear implant recipients to self-report physical handling and care for their hearing implant device(s) and to identify factors that may influence self-reported management skills. DESIGN: Survey development and validation. A prospective convenience cohort design study. SETTING: Specialist hearing implant clinic. PARTICIPANTS: Forty-nine post-lingually hearing impaired, adult cochlear implant recipients, at least 12 months postoperative. MAIN OUTCOME MEASURES: Survey test-retest reliability, responsiveness, criterion validity and sensitivity and specificity compared to clinician evaluation of device management skills. Correlations between self-reported management skills and participant demographic, audiometric, cognitive function, clinical outcomes and device factors. RESULTS: The self-administered Cochlear Implant Management Skills survey was developed, demonstrating high test-retest reliability (ICC = 0.884, P < 0.001; CI 95%: 0.721-0.952), responsiveness to intervention (management skills training) [t(20) = -3.245, P = 0.004], criterion validity (ICC = 0.765, P < 0.001; CI 95%: 0.584-0.868) and sensitivity (0.89). No associations were found between self-reported management skills and participant factors. CONCLUSIONS: This study demonstrated that a self-report survey is an effective method for the evaluation of skills required for cochlear implant device management.

The role of subtotal petrosectomy in cochlear implantation.

BACKGROUND: Subtotal petrosectomy combined with cochlear implantation is a procedure required in specific situations. METHODS: A retrospective review of all cases of subtotal petrosectomy in cochlear implant surgery over a five-year period was performed. The indications, complications and outcomes for this procedure are outlined. RESULTS: Sixteen patients underwent cochlear implantation in combination with subtotal petrosectomy and blind sac closure of the external auditory meatus from 2008 to 2013. Seventy-five per cent of these were completed as a two-stage procedure and 25 per cent as a single-stage procedure. The most common indications for the procedure were chronic otitis media, previous radical cavity, and for surgical access in challenging anatomy or in drill-out procedures. Mastoids were obliterated with fat or musculoperiosteal flaps. The complication rate relating to blind sac closure was 6 per cent. Cochlear implants were successfully placed in all cases and there was no incidence of device failure. CONCLUSION: For patients with chronic suppurative otitis media or existing mastoid cavities, subtotal petrosectomy with blind sac closure of the external auditory canal, closure of the eustachian tube, and cavity obliteration is an effective technique to facilitate safe cochlear implantation.

Simultaneous cochlear implantation and labyrinthectomy for advanced Ménière's disease.

BACKGROUND: Patients with Ménière's disease can develop unaidable sensorineural hearing loss. Cochlear implantation has recently been utilised in this group with favourable results. A more challenging group are those with intractable vertigo, and they have traditionally posed a significant management dilemma. CASE REPORT: Two female patients with unaidable hearing and recurrent incapacitating vertigo attacks despite conservative management underwent simultaneous labyrinthectomy and cochlear implantation. There was complete resolution of vertigo in both patients. Speech perception in quiet conditions and the ability to hear in background noise improved considerably. CONCLUSION: Surgical labyrinthectomy is effective for the elimination of vertigo in Ménière's disease patients. The major disadvantage in the past was loss of residual hearing. Cochlear implantation is now an option in these patients. The benefits of simultaneous labyrinthectomy with cochlear implantation include the prevention of implantation of a fibrosed or ossified cochlea, a decrease in the duration of deafness, and a single operative procedure.

A prospective study evaluating cochlear implant management skills: development and validation of the Cochlear Implant Management Skills survey.

OBJECTIVE: To investigate the ability of cochlear implant (CI) recipients to physically handle and care for their hearing implant device(s) and to identify factors that may influence skills. To assess device management skills, a clinical survey was developed and validated on a clinical cohort of CI recipients. DESIGN: Survey development and validation. A prospective convenience cohort design study. SETTING: Specialist hearing implant clinic. PARTICIPANTS: Forty-nine post-lingually deafened, adult CI recipients, at least 12 months postoperative. MAIN OUTCOME MEASURES: Survey test-retest reliability, interobserver reliability and responsiveness. Correlations between management skills and participant demographic, audiometric, clinical outcomes and device factors. RESULTS: The Cochlear Implant Management Skills survey was developed, demonstrating high test-retest reliability (0.878), interobserver reliability (0.972) and responsiveness to intervention (skills training) [t(20) = -3.913, P = 0.001]. Cochlear Implant Management Skills survey scores range from 54.69% to 100% (mean: 83.45%, sd: 12.47). No associations were found between handling skills and participant factors. CONCLUSIONS: This is the first study to demonstrate a range in cochlear implant device handling skills in CI recipients and offers clinicians and researchers a tool to systematically and objectively identify shortcomings in CI recipients' device handling skills.

Unique microbiology of chronically unstable canal wall down tympanomastoid cavities: considerations for surgical revision.

OBJECTIVE: To review the microbiology of open tympanomastoid cavities in patients who underwent revision surgery due to chronic instability. METHODS: This paper describes a retrospective chart review of surgical revision cases of chronically unstable open mastoid cavities. Patient records from 2000 to 2010 were reviewed for the type of organism cultured, antimicrobial resistance and the presence of cholesteatoma. RESULTS: In total, 121 revision surgical procedures were performed on 101 patients. Seventy-nine procedures involved culture specimen processing, 37 of which were positive. The most commonly cultured organism was Staphylococcus aureus, which was more than twice as common as any other pathogen. The presence of cholesteatoma had no impact on the likelihood of a positive culture or polymicrobial culture. Antimicrobial-resistant pathogens were uncommon. CONCLUSION: A positive culture was not an overwhelmingly common characteristic of unstable tympanomastoid cavities. Furthermore, antimicrobial resistance did not appear to play an essential role in leading patients towards revision open mastoid surgery.

Utilising silk fibroin membranes as scaffolds for the growth of tympanic membrane keratinocytes, and application to myringoplasty surgery.

BACKGROUND: Chronic tympanic membrane perforations can cause significant morbidity. The term myringoplasty describes the operation used to close such perforations. A variety of graft materials are available for use in myringoplasty, but all have limitations and few studies report post-operative hearing outcomes. Recently, the biomedical applications of silk fibroin protein have been studied. This material's biocompatibility, biodegradability and ability to act as a scaffold to support cell growth prompted an investigation of its interaction with human tympanic membrane keratinocytes. METHODS AND MATERIALS: Silk fibroin membranes were prepared and human tympanic membrane keratinocytes cultured. Keratinocytes were seeded onto the membranes and immunostained for a number of relevant protein markers relating to cell proliferation, adhesion and specific epithelial differentiation. RESULTS: The silk fibroin scaffolds successfully supported the growth and adhesion of keratinocytes, whilst also maintaining their cell lineage. CONCLUSION: The properties of silk fibroin make it an attractive option for further research, as a potential alternative graft in myringoplasty.

Surgical anatomy of the anterior supralabyrinthine air cell tract.

INTRODUCTION: In order to safely explore the medial wall of the attic, a working knowledge of the anatomy of the anterior supralabyrinthine air cell tract is required. AIM: To clarify the surgically relevant anatomical relationships that comprise the anterior supralabyrinthine air cell tract. MATERIALS AND METHODS: Surgical dissection of 10 fresh cadaveric temporal bones was undertaken, including measurement of distances between the key anterior supralabyrinthine anatomical landmarks. RESULTS: The following mean distances were calculated: the labyrinthine segment between the geniculate ganglion and the ampullated end of the superior semicircular canal, 2.33 mm (range 1.75-2.75); the tympanic segment between the anterior margin of the oval window niche and the geniculate ganglion, 3.58 mm (range 3.25-4); and from the tympanic segment adjacent to the anterior margin of the oval window niche to the labyrinthine segment adjacent to the superior semicircular canal, 3.48 mm (range 3-4.25). CONCLUSION: The key anatomical landmarks of the anterior supralabyrinthine air cell tract define a distinct triangular segment of bone, knowledge of which is helpful in surgical dissection.

Patient's quality of life and hearing outcomes after stapes surgery.

OBJECTIVES: To determine the quality of life (QOL) after stapes surgery and whether audiological parameters for hearing correlate with specific QOL factors. DESIGN: A retrospective cross-sectional study. SETTING: A tertiary referral centre. PARTICIPANTS: A series of 35 patients who underwent stapes surgery of which three were excluded because they were <18 years of age, chronically or mentally ill, or in a dependant relationship. Response rate was 93% (30/32). Nine were further excluded because they had revision or bilateral surgery, or missing data. Twenty-one patients were included in this study. MAIN OUTCOME MEASURES: The Glasgow Benefit Inventory (GBI) was used to evaluate general QOL and the Hearing Disability and Handicap Scale (HDHS) was used as a disease-specific measure. The Belfast Rule of Thumb and Glasgow Benefit Plot assessed hearing outcomes. RESULTS: Operative success was 86% using the Belfast Rule of Thumb and 95% had closure of the air-bone gap to within 20 dB. 81.8% of patients reported a better overall QOL as surgery. Glasgow Benefit Inventory Social and GBI Physical scores correlated positively with the HDHS speech component (P < 0.05). The duration of hearing loss correlated inversely with the average HDHS score (P < 0.05). CONCLUSION: The majority of patients report a better QOL as undergoing stapes surgery. Speech impacts on people's physical and social QOL of patients. Quality of life tools, in addition to objective audiologic measurements can provide clinicians with patients' subjective perspective that helps guide clinical decision-making and counselling.

Utilization of fresh human tympanic membranes for structural analysis and cytokeratin immunocytochemistry implementing resin techniques.

CONCLUSIONS: The results of this study have demonstrated for the first time that tympanic membrane (TM) structure is preserved following removal of fresh, normal tissue from patients undergoing surgery. Greater clarity has been demonstrated using resin sections than in previous studies on paraffin sections. Of particular note, cytokeratin (CK) immunocytochemistry was successfully performed on resin sections, which has not been previously reported. This may have potential applications for future work involving tissues that express CKs. OBJECTIVES: To analyse the structure of normal, fresh human TM specimens after surgical removal and to evaluate their CK immunocytochemistry using resin techniques, neither of which have been demonstrated previously. MATERIAL AND METHODS: Seven TM specimens were removed during surgery and then preserved in a modified Karnovsky's fixative. Semi-thin and thin sections were examined by means of light and electron microscopy, respectively. For comparison purposes, paraffin block-embedded specimens were also sectioned. CK immunocytochemistry was performed on semi-thin sections using standard immunoperoxidase techniques, with expression being demonstrated using light microscopy. RESULTS: The three-layer architecture of the TM was preserved. The morphology of the TM was vastly superior in the semi-thin resin sections than in the thicker paraffin sections. The outer, middle and inner layers were clearly demonstrated. The integrity of the outer epithelial layer was maintained, with an outer keratinizing stratum corneum and underlying stratum granulosum, stratum spinosum and stratum basale layers resting on the basal lamina. The thin inner mucosal layer was also viable, consisting of simple squamous or cuboidal cells. Preservation of the middle lamina propria was achieved, with demonstration of the outer radial and inner circular fibres. CK immunocytochemistry utilizing resin techniques provided excellent staining of CK 7 and 8 in the inner layer, with positive staining of CK 5 and 10 in the outer layer.

Superior canal dehiscence: review of a new condition.

A new cause of sound and pressure induced vertigo, superior canal dehisence, is described. Auditory manifestations include hyperacusis to bone-conducted sounds and conductive hearing loss with normal acoustic reflexes. The diagnosis is reached by a directed history, documentation of upward and torsional nystagmus evoked by sound and pressure, and radiology. Acoustic reflexes and VEMP (vestibular evoked myogenic potentials) aid in the identification of patients with an apparent conductive loss with normal acoustic reflexes or have an asymptomatic dehiscense on radiology. Treatment involves avoidance of the precipitating stimuli. Surgical treatment, by resurfacing the dehiscence, is considered in patients with more severe symptoms.

Sterile abscess mimicking recurrent tumour in the cerebellopontine angle.

Vestibular schwannomas are the most common tumours encountered in the cerebellopontine angle (CPA) region, accounting for 90 per cent of all lesions. Early pyogenic abscess following surgery and delayed abscesses due to retained foreign bodies have been reported. We describe a case of sterile abscess of unknown aetiology in the CPA region, occurring 13 years after surgical excision of a vestibular schwannoma. The clinical and radiological features were suggestive of recurrent vestibular schwannoma or malignant transformation. We believe this is the first reported case of delayed occurrence of sterile abscess in the CPA region. Further the diagnostic difficulties of such rare lesions occurring in the CPA after vestibular schwannoma surgery are discussed.

Evaluating the role of magnetic resonance imaging scans in the surgical management of acoustic neuromas.

OBJECTIVE: To assess the reliability of magnetic resonance imaging (MRI) in predicting the size and position of an acoustic neuroma, with particular reference to the intracanalicular portion. STUDY DESIGN: Prospective study comparing the position of the tumor in the internal auditory canal on fast spin-echo MRI with the actual position measured intraoperatively. METHODS: The study was performed in a tertiary referral neurotology center, encompassing both the public and private health care systems. Fifteen consecutive patients admitted for acoustic neuroma removal via the translabyrinthine approach were studied. The main outcome measure was tumor position in the internal auditory canal expressed in millimeters, accurate to the nearest 0.5 mm. RESULTS: The fast spin-echo MRI was accurate within an error of 1 mm in predicting the lateral extent of the tumor in the internal auditory canal. CONCLUSION: Fast spin-echo MRI can accurately predict the lateral extent of an acoustic neuroma and allow accurate planning of the surgical approach.

Pneumocephalus after acoustic neuroma surgery.

OBJECTIVE: The study was conducted to describe the diagnosis and management of pneumocephalus after acoustic tumor resection. STUDY DESIGN: The study design was a retrospective chart review. SETTING: The study was conducted as a tertiary otologic referral to the senior authors' practices (PAF, MDA). PARTICIPANTS: Three patients operated on for acoustic tumor in St. Vincent's General Hospital and the Scottish Hospital, Sydney, Australia, were studied. INTERVENTION: Observation in both cases and surgery in a case in which tension pneumocephalus was progressive were performed. MAIN OUTCOME MEASURE: Recovery will follow either spontaneously or after intervention. RESULTS: All patients had an uneventful recovery. CONCLUSION: In most cases, spontaneous resolution occurs. However, if surgical re-exploration is indicated, it is best performed via the blind sac subtotal petrosectomy of Fisch.

Meniere's disease: evidence of an immune process.

OBJECTIVE: This study aimed to present further evidence of specific antibodies reactive against bovine inner ear proteins found in patients with Meniere's disease. BACKGROUND: There are a growing number of experimental and clinical features of Meniere's disease that indicate an immune association. Circulating antibodies directed against inner ear proteins have been detected in patients with bilateral progressive hearing loss and Meniere's disease. METHODS: A total of 36 patients with classical Meniere's disease were studied noting the presence of active or inactive, bilateral or unilateral disease. Bovine membranous labyrinth was used as inner ear extract and separated to molecular weights using sodium dodecyl sulfate-polyacrylamide gel electrophoresis. Western blotting included the addition of serum buffer (casein, Tween, and bovine serum albumins) and the use of alkaline phosphatase labeled anti-human immunoglobulin antibodies. RESULTS: The findings represent strong evidence of antibodies reactive to inner ear proteins. The incidence of these antibodies was correlated significantly with disease activity. CONCLUSIONS: The findings are further evidence of an immune process that is involved in Meniere's disease.

The cerebellopontine angle: does the translabyrinthine approach give adequate access?

A long-standing but unfounded criticism of the translabyrinthine approach is the misperception that this approach does not give adequate access to the cerebellopontine angle. Because of what is perceived as limited visualization and operating space within the cerebellopontine angle, some surgeons still believe that the translabyrinthine approach is inappropriate for large acoustic tumors. In this study, the surgical access to the cerebellopontine angle by virtue of the translabyrinthine approach is measured and analyzed. The parameters are compared with those measured for the retrosigmoid approach. This series objectively confirms that the translabyrinthine approach offers the neurotologic surgeon a shorter operative depth to the tumor, via a similar-sized craniotomy. This permits superior visualization by virtue of a wider angle of surgical access. Such access is achieved with the merit of minimal cerebellar retraction.

Imaging destructive lesions of the petrous apex.

Cholesterol granuloma and cholesteatoma are the two most common destructive lesions of the petrous apex. Arachnoid cyst is less common. These three expansile lesions are often indistinguishable on clinical grounds. Cholesterol granulomas can be treated effectively through internal drainage into the mastoid cavity or middle ear. Cholesteatomas, however, are managed by more aggressive and complicated removal, which often mandates the sacrifice of hearing. Symptomatic arachnoid cysts are amenable to simple surgical drainage. Therefore, accurate preoperative recognition on computed tomography (CT) and magnetic resonance imaging (MRI) is important in planning proper treatment. Thirteen cases of destructive lesions of the petrous apex are analyzed. The authors' experience illustrates that the "typical" CT and MRI radiographic features are diagnostic in some cases, but not in all. In this study the pathologic findings have been correlated with the radiologic features on both MRI and CT.