Lumbar Drain Use during Middle Fossa Approaches for Nonneoplastic Pathology of the Skull Base.

Introduction The middle fossa craniotomy (MFCs) is commonly utilized for spontaneous cerebrospinal fluid (CSF) leaks, encephaloceles, and superior semicircular canal dehiscence (SSCD). This study compares postoperative outcomes of MFCs with and without LD use. Methods A retrospective cohort study of adults over the age of 18 years presenting for the repair of nonneoplastic CSF leak, encephalocele, or SSCD via MFC from 2009 to 2021 was conducted. The main exposure of interest was the placement of an LD. The primary outcome was the presence of postoperative complications (acute/delayed neurologic deficit, meningitis, intracranial hemorrhage, and stroke). Secondary outcomes included operating room (OR) time, length of stay, recurrence, and need for reoperation. Results In total, 172 patients were included, 96 of whom received an LD and 76 who did not. Patients not receiving an LD were more likely to receive intraoperative mannitol ( n = 24, 31.6% vs. n = 16, 16.7%, p = 0.02). On univariate logistic regression, LD placement did not influence overall postoperative complications (OR: 0.38, 95% confidence interval [CI]: 0.05-2.02, p = 0.28), CSF leak recurrence (OR: 0.75, 95% CI: 0.25-2.29, p = 0.61), or need for reoperation (OR: 1.47, 95% CI: 0.48-4.96, p = 0.51). While OR time was shorter for patients not receiving LD (349 ± 71 vs. 372 ± 85 minutes), this difference was not statistically significant ( p = 0.07). Conclusion No difference in postoperative outcomes was observed in patients who had an intraoperative LD placed compared to those without LD. Operative times were increased in the LD cohort, but this difference was not statistically significant. Given the similar outcomes, we conclude that LD is not necessary to facilitate safe MCF for nonneoplastic skull base pathologies.

Improved Postoperative Speech Recognition and Processor Use With Early Cochlear Implant Activation.

OBJECTIVE: To report speech recognition outcomes and processor use based on timing of cochlear implant (CI) activation. STUDY DESIGN: Retrospective cohort. SETTING: Tertiary referral center. PATIENTS: A total of 604 adult CI recipients from October 2011 to March 2022, stratified by timing of CI activation (group 1: ≤10 d, n = 47; group 2: >10 d, n = 557). MAIN OUTCOME MEASURES: Average daily processor use; Consonant-Nucleus-Consonant (CNC) and Arizona Biomedical (AzBio) in quiet at 1-, 3-, 6-, and 12-month visits; time to peak performance. RESULTS: The groups did not differ in sex ( p = 0.887), age at CI ( p = 0.109), preoperative CNC ( p = 0.070), or preoperative AzBio in quiet ( p = 0.113). Group 1 had higher median daily processor use than group 2 at the 1-month visit (12.3 versus 10.7 h/d, p = 0.017), with no significant differences at 3, 6, and 12 months. The early activation group had superior median CNC performance at 3 months (56% versus 46%, p = 0.007) and 12 months (60% versus 52%, p = 0.044). Similarly, the early activation group had superior median AzBio in quiet performance at 3 months (72% versus 59%, p = 0.008) and 12 months (75% versus 68%, p = 0.049). Both groups were equivalent in time to peak performance for CNC and AzBio. Earlier CI activation was significantly correlated with higher average daily processor use at all follow-up intervals. CONCLUSION: CI activation within 10 days of surgery is associated with increased early device usage and superior speech recognition at both early and late follow-up visits. Timing of activation and device usage are modifiable factors that can help optimize postoperative outcomes in the CI population.

Endoscopic Versus Microscopic Transcanal Resection of Glomus Tympanicum: A Retrospective Comparative Study.

OBJECTIVE: Comparison of outcomes of microscopic and endoscopic resection of glomus tympanicum (GT) tumors. STUDY DESIGN: Retrospective case review. SETTING: Single tertiary referral center. PATIENTS: All adult patients undergoing transcanal GT resection without mastoidectomy from 2007 to 2021. INTERVENTIONS: Surgical resection-endoscopic versus microscopic approach. MAIN OUTCOME MEASURES: Primary outcomes were tumor recurrence at 1 year and presence of residual tumor at conclusion of surgery. Secondary outcome measures included operative time, postoperative air-bone gap, postoperative symptom resolution, and surgical complications. RESULTS: Thirty-eight patients underwent resection of GT (74% female; mean age, 59 years). Twenty-nine cases were performed microscopically, and nine cases were performed endoscopically. Both endoscopic and microscopic approaches yielded high rates of complete tumor resection (27/29 microscopic cases, 7/9 endoscopic cases). There was no significant difference in mean operative time (2.3 hours for microscopic; 2.6 hours for endoscopic). On average, air-bone gaps (ABGs) decreased by 6.3 dB after endoscopic resection compared with 1.0 dB after microscopic resection ( p = 0.064). No patients were found to have tumor recurrence during an average follow-up interval of 21 months. CONCLUSIONS: These results suggest comparable outcomes with both endoscopic and microscopic approaches for GT resection, and decisions regarding preferred approach should be dictated by surgeon preference.

Comparison of Speech Recognition and Hearing Preservation Outcomes Between the Mid-Scala and Lateral Wall Electrode Arrays.

OBJECTIVE: To assess speech recognition and hearing preservation (HP) outcomes with the Advanced Bionics Mid-Scala and SlimJ electrodes. STUDY DESIGN: Retrospective cohort. SETTING: Tertiary referral center. PATIENTS: A total of 237 adult patients implanted between 2013 and 2020 (Mid-Scala, n = 136; SlimJ, n = 101). MAIN OUTCOME MEASURES: Consonant-nucleus-consonant (CNC) and AzBio (Arizona Biomedical) scores at 6 and 12 months; postoperative HP, defined as low-frequency pure-tone average ≤ 80 dB HL; scalar position. RESULTS: Mean CNC scores did not significantly differ between Mid-Scala and SlimJ recipients at 6 (45.8% versus 46.0%, p = 0.962) and 12 (51.9% versus 48.8%, p = 0.363) months. Similarly, mean AzBio in quiet scores were equivalent for both groups at 6 (55.1% versus 59.2%, p = 0.334) and 12 (60.6% versus 62.3%, p = 0.684) months. HP rates were significantly higher with the SlimJ (48.4%) than the Mid-Scala (30.8%; p = 0.033). Scalar translocations were 34.8 and 16.1% for the Mid-Scala and SlimJ groups, respectively ( p = 0.019). Ears with postoperative HP had significantly fewer scalar translocations (16.7% versus 37.2%, p = 0.048), and postoperative HP was associated with higher AzBio in noise scores at the most recent follow-up interval (38.7% versus 25.1%, p = 0.042). CNC, AzBio in quiet and noise, low-frequency pure-tone average shifts, and PTA at 6 and 12 months were not significantly different between patients with scala tympani insertions of the SlimJ versus the Mid-Scala ( p > 0.05). CONCLUSIONS: Compared with the Mid-Scala, the lateral wall electrode has superior HP rates and fewer scalar translocations, whereas speech recognition scores are equivalent between both electrode arrays. These findings can help providers with electrode selection and patient counseling.

Machine Learning Approach for Screening Cochlear Implant Candidates: Comparing With the 60/60 Guideline.

OBJECTIVE: To develop a machine learning-based referral guideline for patients undergoing cochlear implant candidacy evaluation (CICE) and to compare with the widely used 60/60 guideline. STUDY DESIGN: Retrospective cohort. SETTING: Tertiary referral center. PATIENTS: 772 adults undergoing CICE from 2015 to 2020. INTERVENTIONS: Variables included demographics, unaided thresholds, and word recognition score. A random forest classification model was trained on patients undergoing CICE, and bootstrap cross-validation was used to assess the modeling approach's performance. MAIN OUTCOME MEASURES: The machine learning-based referral tool was evaluated against the 60/60 guideline based on ability to identify CI candidates under traditional and expanded criteria. RESULTS: Of 587 patients with complete data, 563 (96%) met candidacy at our center, and the 60/60 guideline identified 512 (87%) patients. In the random forest model, word recognition score; thresholds at 3000, 2000, and 125; and age at CICE had the largest impact on candidacy (mean decrease in Gini coefficient, 2.83, 1.60, 1.20, 1.17, and 1.16, respectively). The 60/60 guideline had a sensitivity of 0.91, a specificity of 0.42, and an accuracy of 0.89 (95% confidence interval, 0.86-0.91). The random forest model obtained higher sensitivity (0.96), specificity (1.00), and accuracy (0.96; 95% confidence interval, 0.95-0.98). Across 1,000 bootstrapped iterations, the model yielded a median sensitivity of 0.92 (interquartile range [IQR], 0.85-0.98), specificity of 1.00 (IQR, 0.88-1.00), accuracy of 0.93 (IQR, 0.85-0.97), and area under the curve of 0.96 (IQR, 0.93-0.98). CONCLUSIONS: A novel machine learning-based screening model is highly sensitive, specific, and accurate in predicting CI candidacy. Bootstrapping confirmed that this approach is potentially generalizable with consistent results.

Endoscope-Assisted Visualization of the Internal Auditory Canal Using the Middle Fossa Approach.

HYPOTHESIS: Angled endoscopes have been postulated to increase visualization of the internal auditory canal (IAC); however, few studies have quantified the extent of IAC visualization using endoscopes of varying angles. BACKGROUND: Preservation of the bony labyrinth in middle fossa (MF) vestibular schwannoma surgery may limit visualization of the lateral IAC. We sought to determine the extent to which IAC visualization is increased with endoscopes in these situations. METHODS: Computed tomography (CT) scans were acquired before and after two cadaveric MF bony drill-outs. An atlas-based method was used to localize the IAC in the preprocedure CT and then registered with the postprocedure CT using standard image registration methods. Virtual microscope and endoscope positions and angles of approach were determined in a 3D rendering environment. Using ray casting techniques, the percentage of IAC surface area visible (unobscured by bony structures) with the microscope and 0°, 30°, and 45° endoscopes was calculated. RESULTS: For cadaver 1, the microscope led to visible IAC surface areas of 72%, whereas 0°, 30°, and 45° endoscopes visualized 58%, 79%, and 84%, respectively. For cadaver 2, the microscope led to visible surface areas of 67%, whereas the same endoscopes visualized 66%, 84%, and 84%, respectively. CONCLUSIONS: Using a microscope yields similar proportions of visible IAC surface area to a 0° endoscope in MF bony drill-outs. Increased visualization of the IAC is possible with more angled endoscopes. Using angled endoscopes may facilitate improved tumor dissection in the lateral IAC with neural and vascular preservation in vestibular schwannoma surgery aimed at hearing preservation.

Presbycusis and Hearing Preservation in Observed Vestibular Schwannomas.

OBJECTIVE: We reviewed a cohort of patients with untreated sporadic vestibular schwannoma (VS) and examined the relationship between high-frequency hearing loss (HFHL) in the non-VS ear and long-term hearing outcomes in the VS-affected ear. We hypothesized that the progression of HFHL is associated with accelerated hearing decline in sporadic VS. STUDY DESIGN: Retrospective cohort study. SETTING: Tertiary center. PATIENTS: We studied 102 patients with sporadic VS diagnosed from 1999 to 2015 with ≥5 years of observation (median, 6.92; interquartile range, 5.85-9.29). Sixty-six patients had AAO-HNS class A/B hearing at presentation and were included in analysis. INTERVENTIONS: Audiometry, serial magnetic resonance imaging for observation of VS. MAIN OUTCOME MEASURES: Four-frequency pure tone average (PTA) and word recognition scores (WRS) in the VS-affected ear. Decline in high-frequency PTA (average of thresholds at 4000, 6000, and 8,000 Hz) was defined as ≥10 dB during the study period. Decline in WRS was defined as ≥10%. RESULTS: Compared with those without, patients with progressive HFHL in the non-VS ear were more likely to experience a decline in WRS in the VS ear (80% vs. 54%, p = 0.031). However, the same group showed no difference (52% vs. 41%, p = 0.40) in decline in PTA of the VS ear. CONCLUSIONS: Patients with observed VS who experience progressive HFHL in the non-VS ear are more likely to experience significant declines in speech understanding in the VS-affected ear over time. Patients with a history of presbycusis may have an increased risk of losing serviceable hearing because of sporadic VS.

Early Datalogging Predicts Cochlear Implant Performance: Building a Recommendation for Daily Device Usage.

OBJECTIVE: To quantify the effect of datalogging on speech recognition scores and time to achievement for a "benchmark" level of performance within the first year, and to provide a data-driven recommendation for minimum daily cochlear implant (CI) device usage to better guide patient counseling and future outcomes. STUDY DESIGN: Retrospective cohort. SETTING: Tertiary referral center. PATIENTS: Three hundred thirty-seven adult CI patients with data logging and speech recognition outcome data who were implanted between August 2015 and August 2020. MAIN OUTCOME MEASURES: Processor datalogging, speech recognition scores, achievement of "benchmark speech recognition performance" defined as 80% of the median score for speech recognition outcomes at our institution. RESULTS: The 1-month datalogging measure correlated positively with word and sentences scores at 1, 3, 6, and 12 months postactivation. Compared with age, sex, and preoperative performance, datalogging was the largest predictive factor of benchmark achievement on multivariate analysis. Each hour/day increase of device usage at 1 month resulted in a higher likelihood of achieving benchmark consonant-nucleus-consonant and AzBio scores within the first year (odds ratio = 1.21, p < 0.001) as well as earlier benchmark achievement. Receiver operating characteristic curve analysis identified the optimal data logging threshold at an average of 12 hours/day. CONCLUSIONS: Early CI device usage, as measured by 1-month datalogging, predicts benchmark speech recognition achievement in adults. Datalogging is an important predictor of CI performance within the first year postimplantation. These data support the recommended daily CI processor utilization of at least 12 hours/day to achieve optimal speech recognition performance for most patients.

Automated Whole Cochlear T2 Signal Demonstrates Weak Correlation with Hearing Loss in Observed Vestibular Schwannoma.

INTRODUCTION: We sought to evaluate the correlation between whole cochlear T2 signal changes obtained with a novel automated segmentation method and hearing levels, both at diagnosis and over time, in patients with observed vestibular schwannoma. METHODS: This retrospective correlation study within an academic medical center neurotology practice evaluated 127 patients with vestibular schwannoma observed over time, each with ≥2 MRI scans (367 total) and ≥2 audiograms (472 total). 86 patients had T2-weighted sequences with sufficient resolution for cochlear signal analysis, yielding 348 unique timepoint intervals. The main outcome measure was correlation of the ipsilateral-to-contralateral ratio of whole cochlear T2 signal with hearing outcomes as measured by pure tone average (PTA) and word recognition score (WRS). RESULTS: Whole cochlear T2 signal ratios did not show a correlation with hearing levels at diagnosis. Change in signal ratio over time showed weak correlation with changes in PTA, but not WRS, over time. Cochlear signal ratio did not precede changes in hearing but did follow changes in both PTA and WRS. CONCLUSION: Whole cochlear T2 signal ratios were weakly correlated with changes in hearing in patients with observed vestibular schwannoma. The technology of automated segmentation and signal processing holds promise for future evaluation of clinical entities causing cochlear signal changes.

The Impact of Daily Processor Use on Adult Cochlear Implant Outcomes: Reexamining the Roles of Duration of Deafness and Age at Implantation.

OBJECTIVE: To quantify the roles and relationships between age at implantation, duration of deafness (DoD), and daily processor use via data logging on speech recognition outcomes for postlingually deafened adults with cochlear implants. STUDY DESIGN: Retrospective case review. SETTING: Cochlear implant (CI) program at a tertiary medical center. PATIENTS: Six-hundred fourteen postlingually deafened adult ears with CIs (mean age, 63 yr; 44% female) were included. MAIN OUTCOME MEASURES: A stepwise multiple regression analysis was completed to investigate the combined effects of age, DoD, and daily processor use on CI-aided speech recognition (Consonant-Nucleus-Consonant monosyllables and AzBio sentences). RESULTS: Results indicated that only daily processor use was significantly related to Consonant-Nucleus-Consonant word scores ( R2 = 0.194, p < 0.001) and AzBio in quiet scores ( R2 = 0.198, p < 0.001), whereas neither age nor DoD was significantly related. In addition, there was no significant relationship between daily processor use, age at implantation, or DoD and AzBio sentences in noise ( R2 = 0.026, p = 0.005). CONCLUSIONS: Considering the clinical factors of age at implantation, DoD, and daily processor use, only daily processor use significantly predicted the ~20% of variance in postoperative outcomes (CI-aided speech recognition) accounted for by these clinical factors.

Monopolar Electrosurgery With Cochlear Implants.

OBJECTIVE: To evaluate safety of monopolar electrosurgery (MES) in patients with cochlear implants (CIs) by reporting outcomes of a series of patients who underwent MES after CI. STUDY DESIGN: Retrospective case series. SETTING: Tertiary referral center. PATIENTS: Patients with indwelling CI subsequently undergoing surgery with operative note specifically detailing MES use. MAIN OUTCOME MEASURES: Adverse outcomes in post-operative audiology/otolaryngology documentation; speech recognition scores. RESULTS: Thirty-five patients (10 with bilateral CI) experienced 63 unique MES exposure events, 85.7% below and 14.3% above the clavicle. No adverse events or decreased performance due to MES use were reported for any patient. Pre- and immediate postoperative speech recognition scores were not significantly different for patients using either consonant-nucleus-consonant (CNC; n = 23, 68%-66%, p = 0.80) or AzBio (n = 15, 82%-88%, p = 0.60). For individual CNC performance, 21 (91%) patients demonstrated stability, 1 improved >15%, and 1 declined >15%, although this patient had become a non-user due to magnet issues and, after resolution of these issues, exceeded baseline pre-operative score. For individual AzBio performance, 12 (80%) patients demonstrated stability, 3 improved >15%, and none declined >15%. CONCLUSIONS: No adverse events resulted from MES use in CI patients. Given the increased prevalence and expansion of indications for CIs, and widespread utility of MES, we suggest clarification and improved guidance from device manufacturers regarding safety and use of MES for patients with these devices. We hope that data regarding electrosurgery exposure events will better inform clinician decision-making with regards to relative benefits and risks for MES use for CI patients. LEVEL OF EVIDENCE: 4 Laryngoscope, 133:933-937, 2023.

Radiographic Sigmoid Sinus Wall Abnormalities and Pulsatile Tinnitus: A Case-Control Study.

OBJECTIVE: Compare incidence of sigmoid sinus wall abnormalities (SSWAs) and other radiographic abnormalities in patients with pulsatile tinnitus (PT) versus controls. STUDY DESIGN: Retrospective case-control. SETTING: Tertiary referral center. PATIENTS: Adults with PT and high-resolution computed tomography imaging were compared with adults undergoing cochlear implant workup including high-resolution computed tomography imaging. MAIN OUTCOME MEASURES: Incidence of SSWA in PT cohort (n = 141) compared with control (n = 149, n = 298 ears). Secondary outcome measures included differences in demographics and in other radiographic abnormalities between cohorts. RESULTS: Patients with PT had a higher incidence of SSWA (34% versus 9%, p < 0.001) and superior canal dehiscence (23% versus 12%, p = 0.017) than controls. Spearman product component correlations demonstrated that ipsilateral PT was weakly associated with SSWA ( r = 0.354, p < 0.001). When SSWA was present in the PT cohort (n = 48 patients, n = 59 ears), in 31 cases (64.6%), the SSWA correlated with PT laterality (e.g., left SSWA, left PT); in 12 (25.0%), SSWA partially correlated with PT laterality (e.g., bilateral SSWA, right PT); and in 5 (10.4%), the SSWA did not correlate with PT laterality (e.g., right SSWA, left PT). CONCLUSIONS: For our patients with both PT and SSWA, the SSWA is likely a contributing factor in approximately 65% of cases. For a third of patients with PT and concomitant SSWA, the association between the two is either not causative or not solely causative. Surgeons counseling patients with PT and SSWA may be optimistic overall regarding sigmoid resurfacing procedures but must appreciate the possibility of treatment failure, likely because of untreated comorbid conditions.

Cochlear Implants for Single-Sided Deafness: Quality of Life, Daily Usage, and Duration of Deafness.

OBJECTIVE: To report our experience for adults undergoing cochlear implantation (CI) for single-sided deafness (SSD). METHODS: This is a retrospective case series for adults with SSD who underwent CI between January 2013 and May 2021 at our institution. CNC and AzBio speech recognition scores, Tinnitus Handicap Inventory (THI), Speech, Spatial, and Qualities of Hearing Scale (SSQ12), datalogging, and the Cochlear Implant Quality of Life (CIQOL)-10 Global measure were utilized. RESULTS: Sixty-six adults underwent CI for SSD (median 51.3 years, range 20.0-74.3 years), and 57 (86.4%) remained device users at last follow-up. Compared to pre-operative performance, device users demonstrated significant improvement in speech recognition scores and achieved peak performance at six months post-activation for CNC (8.0% increased to 45.6%, p < 0.0001) and AzBio in quiet (12.2% increased to 59.5%, p < 0.0001). THI was decreased at 6 months post-implantation (58.1-14.6, p < 0.0001), with 77% of patients reporting improved or resolved tinnitus. Patients demonstrated improved SSQ12 scores as well as the disease-specific CIQOL-10 Global questionnaire. Duration of deafness was not associated with significant differences in speech recognition performance. Average daily wear time was positively associated with CNC and AzBio scores as well as post-operative CIQOL-10 scores. CONCLUSIONS: Herein we present the largest cohort of adult CI recipients with SSD with data on speech recognition scores, tinnitus measures, and SSQ12. Novel insights regarding the correlation of datalogging, duration of deafness, and CI-specific quality of life (CIQOL-10) metrics are discussed. Data continue to support CI as an efficacious treatment option for SSD. LEVEL OF EVIDENCE: 4 Laryngoscope, 133:2362-2370, 2023.

Speech Recognition Performance Differences Between Precurved and Straight Electrode Arrays From a Single Manufacturer.

OBJECTIVE: Precurved cochlear implant (CI) electrode arrays have demonstrated superior audiometric outcomes compared with straight electrodes in a handful of studies. However, previous comparisons have often failed to account for preoperative hearing and age. This study compares hearing outcomes for precurved and straight electrodes by a single manufacturer while controlling for these and other factors in a large cohort. STUDY DESIGN: Retrospective cohort study. SETTING: Tertiary academic medical center. PATIENTS: Two hundred thirty-one adult CI recipients between 2015 and 2021 with cochlear (Sydney, Australia) 522/622 (straight) or 532/632 (precurved) electrode arrays. INTERVENTIONS: Postactivation speech recognition and audiometric testing. MAIN OUTCOME MEASURES: Speech recognition testing (consonant-nucleus-consonant word [CNCw] and AzBio) was collected at 6 and 12 months postactivation. Hearing preservation was characterized by a low-frequency pure-tone average shift, or the change between preoperative and postoperative low-frequency pure-tone average. RESULTS: Two hundred thirty-one patients (253 ears) with 6-month and/or 12-month CNCw or AzBio testing were included. One hundred forty-nine (59%) and 104 (41%) ears were implanted with straight and precurved electrode arrays, respectively. Average age at implantation was 70 years (interquartile range [IQR], 58-77 y). There was no significant difference in mean age between groups. CNCw scores were significantly different ( p = 0.001) between straight (51%; IQR, 36-67%) and precurved arrays (64%; IQR, 48-72%). AzBio scores were not significantly different ( p = 0.081) between straight (72%; IQR, 51-87%) and precurved arrays (81%; IQR, 57-90%). Controlling for age, race, sex, preoperative hearing, and follow-up time, precurved electrode arrays performed significantly better on CNCw (b = 10.0; 95% confidence interval, 4.2-16.0; p < 0.001) and AzBio (b = 8.9; 95% confidence interval, 1.8-16.0;, p = 0.014) testing. Hearing preservation was not different between electrodes on adjusted models. CONCLUSION: During the study period, patients undergoing placement of precurved electrode arrays had significantly higher CNC and AzBio scores than patients receiving straight electrodes, even after controlling for age, preoperative hearing, and follow-up time. PROFESSIONAL PRACTICE GAP AND EDUCATIONAL NEED: Understanding the difference in audiometric outcomes between precurved and straight electrode arrays will help to guide electrode selection. LEARNING OBJECTIVE: To understand differences in speech recognition scores postoperatively by electrode array type (precurved versus straight). DESIRED RESULT: To demonstrate a difference in hearing performance postoperatively by electrode type. LEVEL OF EVIDENCE: III. INDICATE IRB OR IACUC: Approved by the Institutional IRB (090155).

A Five-Year Update on the Profile of Adults Undergoing Cochlear Implant Evaluation and Surgery-Are We Doing Better?

OBJECTIVE: To characterize the influence of expanding indications on the profile of adults undergoing cochlear implantation (CI) at a high-volume CI center. STUDY DESIGN: Retrospective review. SETTING: Tertiary referral center. PATIENTS: 774 adults undergoing CI evaluation from August 2015 to August 2020. MAIN OUTCOME MEASURES: Demographics; audiometry; speech recognition; speech, spatial, and qualities of hearing scale (SSQ-12). RESULTS: Of 745 (96.3%) patients qualifying for implantation, 642 (86.6%) pursued surgery. Median age at evaluation was 69 years; 56.3% were men; 88.2% were Caucasian. Median distance to our center was 95 miles. The majority (51.8%) had public insurance (Medicare, Medicaid), followed by private (47.8%) and military (0.4%). Mean PTA, CNC, and AzBio in quiet and noise for the ear to be implanted were 85.2 dB HL, 15.0%, and 19.2% and 3.5%, respectively. Hybrid/EAS criteria were met by 138 (18.5%) CI candidates, and 436 (77.0%) unilateral CI recipients had aidable contralateral hearing for bimodal hearing configurations. Younger age (odds ratio [OR], 0.96; 95% confidence interval, 0.93-0.99) and non-Caucasian race (OR, 6.95; 95% confidence interval, 3.22-14.98) predicted candidacy. Likelihood of surgery increased for Caucasian (OR, 8.08; 95% confidence interval, 4.85-13.47) and married (OR, 2.28; 95% confidence interval, 1.50-3.47) patients and decreased for those with public insurance (OR, 0.45; 95% confidence interval, 0.29-0.69). A lower SSQ-12 score predicted both candidacy and surgery. CONCLUSION: Despite expansions in criteria, speech understanding remained extremely low at CI evaluation. Younger age and non-Caucasian race predicted candidacy, and Caucasian, married patients with private insurance and lower SSQ scores were more likely to pursue surgery.

Further Evidence for Individual Ear Consideration in Cochlear Implant Candidacy Evaluation.

OBJECTIVE: To report speech outcomes after cochlear implantation (CI) for asymmetric hearing loss (AHL) and assess the influence of contralateral hearing. STUDY DESIGN: Retrospective review. SETTING: Tertiary referral center. PATIENTS: One hundred eighty-eight adults (mean age, 70 yr) undergoing CI for AHL from 2015 to 2020. Candidacy included pure-tone average (PTA) at least 70 dB hearing level and AzBio in quiet 60% or less in the implanted ear and AzBio in quiet greater than 40% in the contralateral ear. MAIN OUTCOME MEASURES: PTA; Consonant-Nucleus-Consonant (CNC) word, AzBio sentences scores; Speech, Spatial, and Qualities of Hearing Scale (SSQ). RESULTS: Mean preoperative PTA and AzBio in the implanted and contralateral ears were 85.2 and 68.1 dB hearing level and 24.7% and 69.2%, respectively. Mean CNC in the implanted ear increased from 18.3% preoperatively to 44.4% ( p < 0.0001) at 6 months and 49.3% ( p < 0.0001) at 12 months. Mean AzBio in the implanted ear improved from 24.7% preoperatively to 60.3% ( p < 0.0001) at 6 months and 64.3% ( p < 0.0001) at 12 months. Patients demonstrated significant improvement in all SSQ domains at 6 and 12 months. When comparing patients with preoperative contralateral AzBio greater than 60% versus 41% to 60%, no significant differences existed in postoperative CNC scores (6-mo: 47% versus 41%, p = 0.276; 12-mo: 51% versus 47%, p = 0.543). There were no significant differences in 6-month ( p = 0.936) or 12-month ( p = 0.792) CNC scores between patients with AHL (contralateral ear AzBio >40%) and 169 unilateral CI patients meeting the traditional Medicare criteria (contralateral ear AzBio ≤40%). CONCLUSION: CI recipients with AHL derive significant speech improvements, supporting individual ear consideration for CI candidacy and patient benefit outside of current Medicare criteria.

Machine Learning for Automated Calculation of Vestibular Schwannoma Volumes.

HYPOTHESIS: Machine learning-derived algorithms are capable of automated calculation of vestibular schwannoma tumor volumes without operator input. BACKGROUND: Volumetric measurements are most sensitive for detection of vestibular schwannoma growth and important for patient counseling and management decisions. Yet, manually measuring volume is logistically challenging and time-consuming. METHODS: We developed a deep learning framework fusing transformers and convolutional neural networks to calculate vestibular schwannoma volumes without operator input. The algorithm was trained, validated, and tested on an external, publicly available data set consisting of magnetic resonance imaging images of medium and large tumors (178-9,598 mm 3 ) with uniform acquisition protocols. The algorithm was then trained, validated, and tested on an internal data set of variable size tumors (5-6,126 mm 3 ) with variable acquisition protocols. RESULTS: The externally trained algorithm yielded 87% voxel overlap (Dice score) with manually segmented tumors on the external data set. The same algorithm failed to translate to accurate tumor detection when tested on the internal data set, with Dice score of 36%. Retraining on the internal data set yielded Dice score of 82% when compared with manually segmented images, and 85% when only considering tumors of similar size as the external data set (>178 mm 3 ). Manual segmentation by two experts demonstrated high intraclass correlation coefficient (0.999). CONCLUSION: Sophisticated machine learning algorithms delineate vestibular schwannomas with an accuracy exceeding established norms of up to 20% error for repeated manual volumetric measurements-87% accuracy on a homogeneous data set, and 82% to 85% accuracy on a more varied data set mirroring real world neurotology practice. This technology has promise for clinical applicability and time savings.

HiRes Ultra Series Recall: Failure Rates and Revision Speech Recognition Outcomes.

OBJECTIVE: To report Advanced Bionics (AB) Ultra (V1) and Ultra 3D (V1) cochlear implant (CI) electrode failures and revision speech recognition outcomes for patients at a large CI program. STUDY DESIGN: Retrospective case series. SETTING: Tertiary referral center. PATIENTS: Patients receiving Ultra (V1) or Ultra 3D (V1) devices as of September 21, 2021. MAIN OUTCOME MEASURES: Failure rate, revision surgery, speech recognition scores. RESULTS: To data, 65 (21.1%) of the 308 implanted devices are known failures, with 63 (20.5%) associated with the recent voluntary field corrective action (FCA). Average time to failure was 2.2 ± 1.1 years. Fifty-two patients (82.5%) elected for revision surgery. Among adults, immediate prerevision scores demonstrated a significant decrease from best-achieved scores with the faulty implant, with mean difference of -15.2% (p = 0.0115) for consonant-nucleus-consonant (CNC) and -27.3% (p < 0.0001) for AzBio in quiet. By 3 months postactivation of the revised device, CNC (p = 0.9766) and AzBio in quiet (p = 0.9501) scores were not significantly different than best prerevision scores. Overall, 15 of 19 patients regained or improved their best prerevision CNC score. The current trajectory for FCA device failures is approximately 6% per year. CONCLUSION: Compared to manufacturer reporting, a high number of patients experienced hard failures of the Ultra (V1) and Ultra 3D (V1) devices. Early identification of failures is possibly because of the diligent use of electrical field imaging testing. Most patients affected by the FCA regain or exceed their prefailure speech recognition score as soon as 3 months after revision surgery.

Labyrinthitis With Negative MRI As a Precursor to Rapidly Developing Primary CNS Lymphoma of the Cerebellopontine Angle.

Background: Few case reports have described primary central nervous system lymphoma (PCNSL) presenting as a cerebellopontine angle (CPA) lesion in HIV-positive patients. We describe a rare presentation of rapidly progressing PCNSL of the CPA/internal auditory canal (IAC) as labyrinthitis with initial negative MRI in an HIV-positive patient. Case: A 58-year-old male with well-controlled HIV presented with sudden left sensorineural hearing loss, tinnitus, and imbalance. Vestibular testing suggested an uncompensated left peripheral vestibular weakness. MRI demonstrated facial and cochleovestibular nerve enhancement within the CPA and IAC. The presumptive diagnosis of labyrinthitis was made. Two months later, he presented to his infectious disease provider with left facial weakness and disequilibrium and was treated for presumed Bell's palsy. One month later, he presented with left corneal reflex dysfunction, decreased visual acuity, diplopia, and worsening ataxia. Repeat MRI demonstrated a new 3.6 cm lesion of the left CPA/IAC with vasogenic edema. Despite location, the mass lacked the brainstem compression characteristic of other extra-axial CPA masses such as vestibular schwannoma. Flow cytometry and cytology from cerebrospinal fluid was consistent with primary central nervous system large B-cell lymphoma. Conclusions: We present a unique case of rapidly progressing PCNSL of the CPA/IAC in an HIV-positive patient, presenting initially as labyrinthitis with negative MRI followed by development of multiple cranial neuropathies and 3-month repeat MRI demonstrating a large CPA mass. In HIV-positive patients with a similar initial presentation, PCNSL should considered early in the diagnostic evaluation with close clinical monitoring and a low threshold for repeat imaging.

Temporal Bone Osteoradionecrosis: An 18-year, Single-Institution Experience.

OBJECTIVES/HYPOTHESIS: To report the largest single-institution review of temporal bone osteoradionecrosis (TBORN), and characterize the disease's natural history, prognostic factors, management, and outcomes. STUDY DESIGN: Retrospective chart review. METHODS: Retrospective review was conducted to identify patients with TBORN. Pertinent data were extracted. Descriptive statistics were used to summarize patient, tumor, and treatment characteristics. Multivariable analyses were conducted to explore associations between these characteristics and time to TBORN diagnosis and risk of developing diffuse disease. RESULTS: TBORN was identified in 145 temporal bones from 128 patients. Mean age at diagnosis was 62 years, and mean time to diagnosis after radiotherapy was 10 years. Age greater than 50 years was associated with earlier diagnosis. According to the Ramsden criteria, 76% of TBs had localized and 24% had diffuse disease at initial diagnosis; 37% had diffuse disease at last follow-up. On multivariable analysis, diabetes, three-dimensional conformal radiotherapy (3D-CRT), and periauricular skin malignancy were significant risk factors for developing diffuse disease. Localized disease was successfully managed with conservative measures, whereas surgery was often necessary for diffuse disease. When TBORN spread outside the mastoid or infratemporal fossa, conservative measures were always unsuccessful. CONCLUSIONS: TBORN occurs earlier in older patients. While diffuse disease is less common than localized disease, it occurs more frequently in patients with diabetes, history of 3D-CRT, and periauricular skin malignancies. Conservative management is appropriate for localized disease, while surgery is often necessary for diffuse disease. The prognostic factors identified helped propose a TBORN staging system and treatment guidelines which may improve patient risk stratification and disease management. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:2578-2585, 2021.