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.

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.

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.

Invasive fungal rhinosinusitis associated with COVID-19: Course changes and prognosis predictors / Rinosinusitis fúngica invasiva asociada con COVID-19: cambios clínicos y predictores de pronóstico

Background This study aimed to analyze the behavior of acute invasive fungal rhinosinusitis (AIFRS) associated with COVID-19 infection as there has been an increase in the rate of AIFRS cases in the last two years, and many reports connected this rising with the COVID-19 infection. We studied most factors that may impact the prognosis as a trial to find the most affecting factors to improve the outcomes. Methods It was a retrospective observational study that included cases from four tertiary referral institutions between November 2020 to February 2022. We included sixty-six patients who suffered from AIFRS associated with confirmed COVID-19. We observed the prognosis of all included patients with a six-month follow-up. We correlated the prognosis with many factors, such as demographic data, medical conditions, blood investigations, the features of fungal infections, and management. Results Forty-two patients (64%) survived after the AIFRS associated with COVID-19, and twenty-two patients (36%) died. High doses of corticosteroids with prolonged use were the main factors that affected the behavior of the AIFRS associated with COVID-19. HbA1c was a good predictor of the prognosis; a level less than 9.35% may indicate survival with 87.5% sensitivity. Conclusions According to this multi-center study, the mortality of the AIFRS associated with COVID-19 was high. The behavior was affected by glycemic control, the type of fungal species, and the type of antifungal therapy. Early surgical debridement, a combination of Amphotericin B with Voriconazole, and anticoagulants helped improve the prognosis. (AU)

Antecedentes Durante el periodo de la pandemia de COVID19, ha habido un aumento en la tasa de casos de rinosinusitis fúngica invasiva aguda (RSFIA), siendo cada vez más evidente la asociación entre ambas entidades. EL objetivo de este estudio ha sido analizar la evolución de los pacientes con rinosinusitis fúngica invasiva aguda asociado con la infección por COVID-19, analizando los factores determinantes en la evolución y pronóstico de la enfermedad. Métodos Fue un estudio observacional retrospectivo que incluyó casos de cuatro instituciones de referencia de tercer nivel entre noviembre de 2020 y febrero de 2022. Se incluyeron sesenta y seis pacientes que padecían RSFIA asociado a COVID-19 confirmado. Observamos el pronóstico de todos los pacientes incluidos con un seguimiento de seis meses. Correlacionamos el pronóstico con muchos factores, como los datos demográficos, las condiciones médicas, las investigaciones de sangre, las características de las infecciones fúngicas y el manejo. Resultados Cuarenta y dos pacientes (64%) sobrevivieron después de la RSFIA asociada a COVID-19, y veintidós pacientes (36%) fallecieron. Las dosis altas de corticoides con uso prolongado fueron los principales factores que afectaron el comportamiento de la RSFIA asociada a la COVID-19. HbA1c fue un buen predictor del pronóstico; un nivel inferior al 9,35 % puede indicar supervivencia con una sensibilidad del 87.5%. Conclusiones Según este estudio multicéntrico, la mortalidad de la RSFIA asociada a la COVID-19 fue alta. El comportamiento se vio afectado por el control glucémico, el tipo de especie fúngica y el tipo de terapia antifúngica. El desbridamiento quirúrgico temprano, una combinación de Amphotericin B con Voriconazole y anticoagulantes ayudaron a mejorar el pronóstico. (AU)

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 novel traction-suturing technique in correction of caudal end deviation of the nasal septum.

BACKGROUND: Caudal end correction is one of the main challenges during septoplasty that needs extra steps and skills. This complex area affects the shape of the nose. Moreover, the caudal end represents the medial boundary of the internal nasal valve. Thus, any deviation may disturb this critical area causing nasal obstruction. This study aimed to evaluate the novel traction-suture technique to correct septal caudal end deviation and its postoperative impact. STUDY DESIGN: This prospective case-series study. SETTINGS: It was held in a tertiary referral university institute between January 2019 to February 2022. METHODS: We included 95 cases who suffered from nasal obstruction and a cosmetic problem because of mild or moderate caudal end deviation. Under general anesthesia, the caudal end was corrected by the novel traction-suturing technique (TST). To evaluate the surgical outcomes and patients' related quality of life, we used two validated questionnaires; the Nasal Obstruction Symptom Evaluation and the Rhinoplasty Outcome Evaluation before the surgery and 1 year after the surgery. RESULTS: NOSE and ROE questionnaires showed statistically significant improvements after the surgery (P value was < 0.001). Complications occurred in seven patients (7.3%), all of which were minor complications. CONCLUSIONS: Traction-suturing technique (TST) improved nasal breathing and patients' satisfaction with their nasal configuration. Traction-suturing is a simple short maneuver that junior doctors can easily learn without distinct complications or recurrence.

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.

Invasive fungal rhinosinusitis associated with COVID-19: Course changes and prognosis predictors.

BACKGROUND: This study aimed to analyze the behavior of acute invasive fungal rhinosinusitis (AIFRS) associated with COVID-19 infection as there has been an increase in the rate of AIFRS cases in the last two years, and many reports connected this rising with the COVID-19 infection. We studied most factors that may impact the prognosis as a trial to find the most affecting factors to improve the outcomes. METHODS: It was a retrospective observational study that included cases from four tertiary referral institutions between November 2020 to February 2022. We included sixty-six patients who suffered from AIFRS associated with confirmed COVID-19. We observed the prognosis of all included patients with a six-month follow-up. We correlated the prognosis with many factors, such as demographic data, medical conditions, blood investigations, the features of fungal infections, and management. RESULTS: Forty-two patients (64%) survived after the AIFRS associated with COVID-19, and twenty-two patients (36%) died. High doses of corticosteroids with prolonged use were the main factors that affected the behavior of the AIFRS associated with COVID-19. HbA1c was a good predictor of the prognosis; a level less than 9.35% may indicate survival with 87.5% sensitivity. CONCLUSIONS: According to this multi-center study, the mortality of the AIFRS associated with COVID-19 was high. The behavior was affected by glycemic control, the type of fungal species, and the type of antifungal therapy. Early surgical debridement, a combination of Amphotericin B with Voriconazole, and anticoagulants helped improve the prognosis.

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.