Caution in Transnasal Balloon Dilation of the Eustachian Tube: Middle Ear Penetration of Catheter Tip in a Cadaveric Model.

OBJECTIVE: To investigate the degree to which transnasal eustachian tube (ET) dilation balloon catheters are able to be passed through the ET in a cadaver model. PATIENTS AND INTERVENTIONS: A cadaveric study of 8 cadaver heads (16 ears), which underwent transnasal ET insertion with a 3 × 20-mm balloon catheter with transtympanic endoscopic visualization and grading. RESULTS: Catheter tip incursion into the protympanum or mesotympanum occurred in all ears. Radiological validation was obtained with correlation to published ET length data. CONCLUSION: Middle ear incursion of balloon catheter tips can be demonstrated in a cadaver model and highlights the ongoing need for both caution in novel surgical techniques and evolution in device design.

Cochlear Implantation in Far Advanced Otosclerosis: A Systematic Review and Meta-Analysis.

OBJECTIVE: To evaluate speech outcomes and facial nerve stimulation (FNS) rates in patients with far advanced otosclerosis (FAO) after cochlear implantation. METHODS: A systematic review was performed using standardized methodology of Medline, EMBASE, PubMed, Cochrane, and Web of Science databases. Studies were included if adults with FAO underwent cochlear implantation. Exclusion criteria included concurrent otologic history (e.g., Meniere's disease, superior canal dehiscence), non-English-speaking implant users, case reports, abstracts, and letters/commentaries. Bias was assessed using the Newcastle-Ottawa Scale for cohort studies and the National Institute of Health Scale for case series. The primary outcome measure was speech discrimination and the secondary outcomes were rates of partial insertion and FNS. RESULTS: Twenty-seven studies evaluated cochlear implantation in FAO. Due to the heterogeneity of testing methods, statistical pooling of speech discrimination was not feasible, but qualitative synthesis indicated a positive effect of implantation. Pooled rates of FNS were 18% (95% confidence interval, CI 12%-27%) and the rate of partial insertion was 10% (95% CI 7%-15%). CONCLUSION: Cochlear implantation in FAO demonstrates significant gains in speech discrimination scores with higher rates of FNS and partial insertion. Laryngoscope, 133:1288-1296, 2023.

Assessing the Quality of Patient Information for Vestibular Schwannoma on the Open Source Video Sharing Platform YouTube.

BACKGROUND: Patients frequently use the internet to gain information and make decisions about their health conditions. This work aims to assess the quality of information about Vestibular Schwannoma on a popular video sharing platform, YouTube (Alphabet Inc.). OBJECTIVES: To assess quality of the most popular vestibular schwannoma videos using recognized scoring systems and whether video quality metrics correlated with video popularity based on metadata analysis. SETTING: Public domain. STUDY DESIGN: Cross-sectional Study. METHODS: The YouTube website was systematically searched on separate days with a formal search strategy to identify videos relevant to vestibular schwannoma. Each video was viewed and scored by three independent assessors, using scores for quality and disease specific accuracy. Popularity metrics were analyzed and compared to video quality. Patient surveys were conducted to further assess their perspectives of the included videos. RESULTS: A total of 23 YouTube videos were included. In terms of Essential and Ideal Video Completeness Criteria, the mean scores ranged from 4.8 to 5.0 (out of 12), indicating moderate video quality. The average DISCERN score ranged from 30.0 to 36.7, indicating lower reliability. The mean JAMA scores ranged from 1.96 to 2.48, indicating average quality. Based on metrics including DISCERN and JAMA instruments, the information in the YouTube videos were of low to average quality and reliability. Rater scoring was reliable. Viewer engagement correlated poorly with video quality except for JAMA metrics. CONCLUSION: Video quality on YouTube with respect to Vestibular Schwannoma is of low to average quality. Viewer engagement and popularity correlated poorly with video quality. Clinicians should direct their patients to high quality videos and should consider uploading their own high-quality videos.

Endoscopic Stapedotomy: A Systematic Review.

OBJECTIVES: Stapes surgery has evolved from its origins in 1956. Microscopic assisted stapedotomy remains the most common technique but the introduction of endoscopic ear surgery has led to some units using this new approach. The endoscope delivers a wide angled, contextual view of the stapes, and associated pathology. This systematic review provides a critical analysis of the current published endoscopic data, allowing comparison to the established microscopic technique. DATA SOURCES: Six databases (PubMed, Medline, Cochrane database, AMED, EMBASE, and CINAHL) were searched for studies within the last 10 years. STUDY SELECTION AND DATA EXTRACTION: English language articles including 5 or more cases were included. Primary outcomes included audiological results and reported complications. Data was extracted according to PRISMA guidelines. RESULTS: Thirteen papers were identified comprising 361 endoscopic stapes surgeries. Postoperative temporary facial nerve weakness was reported in 3 patients (0.8%) which all resolved within 4 weeks. Chorda tympani injury occurred in 21 cases (5.8%) and vertigo in 61 (16.9%). The audiometric outcomes of endoscopic stapes surgery were available for 259 patients and showed air bone gap closure rates of 71.4% (0-10 dB), 25.9% (11-20 dB), 2.3% (21-30 dB), and 0.4% (>30 dB). CONCLUSIONS: Endoscopic stapes surgery has similar audiometric outcomes compared to the traditional microscopic approach with air bone gap closure values of <20 dB in 97.3% of cases. However, the complication rates of chorda tympani damage, postoperative dysguesia, and tympanic membrane perforation for endoscopic stapes surgery are high. Caution should therefore be taken before undertaking stapes surgery with the endoscopic technique. Further studies are required to prove superiority over well established existing microsurgical methods.

Endoscopic Management of Early Stage Middle Ear Paragangliomas - An Australian Case Series.

OBJECTIVE: To analyze the outcomes of the endoscopic transcanal approach for removal of early stage middle ear paraganglioma tumors (MEPT). STUDY DESIGN: Cases series with chart review. SETTING: Two tertiary Australian Otology centers. PATIENTS: Adult patients with middle ear paraganglioma tumors treated with transcanal endoscopic approach from 2/2016 to 12/2019. Tumor staging was described using the Modified Fisch-Mattox (MFM). Inclusion criteria included patients with an MFM Class A or B. Exclusion criteria included higher staged or syndromic disease. INTERVENTION: All tumors were managed with transcanal endoscopic approach. MAIN OUTCOME MEASURES: Primary outcome measures included disease clearance and hearing measured according to the AAO-HNS guidelines. Secondary outcomes included complications, duration of surgery, and length of stay. RESULTS: Ten patients underwent totally endoscopic transcanal resection of MEPT (9 female, mean age of 45.5 years, 70% were left sided). Mean tumor size was 6.1 mm (SD 3.4 mm). Five cases (50%) were classified using the MFM system as class A1, two cases were class A2, and three cases were class B1. Three cases required canalplasty for access but were completed entirely endoscopically. Nine of the 10 cases had complete audiometric data. Pre- and postoperative mean air conduction remained stable with a decrease in mean air-bone gap of 2.84 dB. Postoperative complications include one pinhole perforation. There were no facial nerve complications. Mean follow-up period was 10 months (range 4-25 mo) with all cases having resolution of pulsatile tinnitus and no tumor recurrence. CONCLUSION: The transcanal endoscopic approach for early stage MEPT offers excellent visualization and permits safe and effective removal of disease with the advantages of a minimally invasive technique for patient recovery.

Intracanalicular Vestibular Schwannoma: A Systematic Review and Meta-analysis of Therapeutics Outcomes.

OBJECTIVE: To perform a systematic review and meta-analysis summarizing the current evidence on the management of intracanalicular vestibular schwannoma. DATA SOURCES: Embase (1947-), Medline (1946-), Cochrane library (1947-), Scopus (2010-), and CINAHL (1961-) were searched from 1969 to October 5, 2019 (50 years). STUDY SELECTION: A search strategy was performed to identify patients with vestibular schwannoma confined to the internal auditory canal without extension to the cerebellopontine angle. Studies with patients aged less than 18, Neurofibromatosis type 2, revision cases, and non-English language were excluded. DATA EXTRACTION: A standardized collection sheet was used for the extracted data and a quality assessment was performed using the Newcastle-Ottawa Scale with the comparability criterion omitted. DATA SYNTHESIS: Seventy-one studies were included with 24 on observation, 14 on radiotherapy, and 34 on surgery. The primary outcome was serviceable hearing preservation. Secondary outcomes were preservation of facial nerve function, growth, involution, and dizziness. Sub-analysis on the type of surgery and type of radiotherapy were performed. Excel 2016 with MIX 2.0 Pro add-on package was used to analyze the data and create forest plots. Data were presented in proportion with a 95% confidence interval. CONCLUSIONS: Serviceable hearing was observed in 31% of patients after observation, 56% after radiotherapy, and 51% after surgical treatment with mean follow-up time of 4.04 years, 4.92 years, and 2.23 years, respectively. Facial nerve function was found to be best preserved in both observation and radiotherapy groups. Vestibular schwannoma growth occurred in 33% of patients under observation. Involution occurred in 2% of patients under observation and in 38% after radiotherapy.

Novel Radiologic Approaches for Cholesteatoma Detection: Implications for Endoscopic Ear Surgery.

Technological advancement in computed tomography (CT) and MRI has improved cholesteatoma detection rates considerably in the past decade. Accurately predicting disease location and extension is essential for staging, planning, and preoperative counseling, in particular in the newer approach of endoscopic ear surgery. Improved sensitivity and specificity of these radiological methods may allow the surgeon to confidently monitor patients, therefore avoiding unnecessary surgery. This article outlines recent advances in CT and MRI technology and advantages and disadvantages of the newer techniques. Emphasis on improving the feedback loop between the radiologist and surgeon will increase the accuracy of these new technologies.

Endoscopic Stapedectomy: Collective Experience From a Large Australian Center.

INTRODUCTION: Endoscopic stapes surgery is a technically demanding procedure that is increasing in popularity. Surgical outcomes and complication rates have been demonstrated to be comparable to traditional microscopic techniques. The surgical outcomes for patients undergoing stapes surgery performed by the Sydney Endoscopic Ear Surgery Research Group are presented. STUDY DESIGN: Retrospective review from prospectively gathered database. SETTING: Tertiary referral centers. PATIENTS: A retrospective case review of patients undergoing endoscopic stapes surgery performed by four surgeons between February 2015 and July 2019 was carried out. Sixty nine patients were identified, and assessed for demographics, functional results, and postoperative complications. INTERVENTION: Endoscopic stapedotomy. MAIN OUTCOME MEASURE: Postoperative hearing results. RESULTS: Sixty eight of 69 patients (98.6%) achieved an air-bone gap (ABG) closure of less than 20 dB. Sixty of 69 patients (87%) achieved and ABG closure of less than 10 dB. The average improvement of the ABG over four frequencies achieved was 26.5 dB (range, 0-61). Postoperative complications were infrequent and self-limiting. Six patients experienced dysgeusia without obvious chorda tympani injury, four patients developed short lived vertigo, and two patients experienced tinnitus. CONCLUSIONS: Endoscopically assisted stapes surgery represents a safe alternative to traditional microscopic techniques, with similar morbidity and audiological outcomes.

Endoscopic Management of Pediatric Cholesteatoma.

Pediatric cholesteatoma occurs in one of two forms: congenital cholesteatoma, developing from embryonic epidermal cell rests or acquired cholesteatoma, associated with a focal defect in the tympanic membrane. This disease has been traditionally managed with the operating microscope, often requiring mastoidectomy for adequate visualization of and access to the middle ear and mastoid cavities. Recently, advances in endoscopic equipment have enabled otologists to manage most cases of pediatric cholesteatoma via a minimally-invasive, transcanal endoscopic approach. This review discusses the current literature relating to the etiopathogenesis, assessment and endoscopic management of pediatric cholesteatoma. Early outcomes of endoscopic treatment, emerging trends and technologies are also reviewed.

The Endoscopic Relationship of the Stapedius Muscle to the Facial Nerve: Implications for Retrotympanic Surgery.

OBJECTIVES: The stapedius muscle, tendon, and pyramidal eminence are structures within the retrotympanum. In cholesteatoma surgery, the retrotympanum is a common site of residual disease. The removal of the pyramidal eminence during surgery is sometimes necessary to obtain better visualization of the superior retrotympanum during surgery. Understanding the relational anatomy of structures in the region to the facial nerve allows the surgeon to safely access regional disease. This study aims to better understand the anatomical relationship between the mastoid portion of the facial nerve, the pyramidal eminence, and the stapedius muscle. A secondary aim is to demonstrate that removal of the stapedius muscle in the cadaver model, can increase exposure to the retrotympanic space. STUDY DESIGN: Anatomical cadaveric observation study. METHODS: Endoscopic dissection of cadaveric heads was undertaken. Classification of the superior and inferior retrotympanic area was performed. The anatomy of the stapedius muscle was described including relationships, depth, course, and angle with respect to the facial nerve. The pyramidal eminence and stapedius muscle were removed in all specimens and the exposure of the retrotympanum re-evaluated to determine if exposure of the region was increased. RESULTS: In all cases (11 ears), the stapedius muscle was located medial and anterior to the mastoid portion of the facial nerve, with the second genu superior. The mean antero-posterior distance from the apex of the pyramidal eminence, which the stapedius tendon enters, to the stapes itself was 4.10 mm (range, 2.92-5.73 mm; standard deviation [SD] 0.90 mm). In all cases, irrespective of sinus tympani conformation, removal of the pyramidal eminence and stapedial bony crest in proximity to the facial nerve allowed exposure of the whole retrotympanic region, using a 0-degree endoscope. CONCLUSIONS: The pyramidal eminence and stapedius muscle have a relatively constant relationship to the facial nerve. Removal of the stapedius muscle in the human cadaver model increases the exposure of the sinus tympani and subpyramidal space. Increased visualization in this region, may reduce risk of residual cholesteatoma in patients.

Computed tomographic analysis of outer calvarial thickness for osseointegrated bone-anchored hearing system insertion.

INTRODUCTION: Osseointegrated bone-anchored hearing systems (BAHSs) are a useful tool in auditory rehabilitation for single-sided deafness and conductive/mixed hearing loss. They rely on adequate osseointegration of titanium implants, which can be limited by calvarial thickness. This study examines adult computed tomographic (CT) temporal bone normative data for calvarial thickness in the areas commonly recommended for BAHS insertion and identifies hazards that may compromise the osseointegration process. METHODS: Prospective analysis of 100 consecutive adult helical CT scans. Calvarial thickness was measured in axial and coronal planes 5.5 cm posterior to the superior external auditory canal at 6 vertical points (EAC, +1 cm, +2 cm, +3 cm, +4 cm, and +5 cm). Other parameters measured include temporal bone pneumatization and the presence of suture lines, bone marrow, and vascular structures. RESULTS: A total of 195 temporal bones were examined in 100 patients. Mean patient age was 60.9 years, of whom 54.4% were men and 45.6% were women. Mean calvarial thickness was greatest at +1 cm above the EAC level (6.3 mm) and thinnest at +4 cm (5.1 mm). Of temporal bones, 55% had at least 1 site thinner than 4 mm and 21% had at least 1 site thinner than 3 mm. Air cells and suture lines were more likely to be encountered within 2 cm above the EAC level, and marrow space is more likely to be encountered 3 to 4 cm above the EAC level. DISCUSSION: Selecting a position 3 to 4 cm above the level of the EAC is more likely to result in dural exposure for a 3-mm BAHS abutment, especially in men. Selecting a position near the level of the EAC provides thicker bone, but the surgeon is more likely to encounter suture line or enter mastoid air cells. Preoperative CT imaging may be a useful tool in evaluating calvarial thickness and hazards when planning BAHS insertion in the adult population.

The radiologic diagnosis of endolymphatic sac tumors.

OBJECTIVE: To identify and classify radiologic criteria for the diagnosis of endolymphatic sac tumors. STUDY DESIGN: Retrospective case review. Tertiary referral center. METHODS: 31 adult patients (32 tumors) with imaging (computed tomography [CT], magnetic resonance imaging [MRI], and/or angiography) and histopathologic diagnoses of lesions that involved the posterior temporal bone from July 1995 to August 2004 were included in the study. Interventions were diagnostic. Main outcome measures were CT, MRI (T1, T1 with gadolinium enhancement and T2-weighted), and angiographic features of seven patients (eight temporal bones) with endolymphatic sac tumors were examined and compared to the radiologic findings of the 24 historical control patients with various lesions involving the posterior temporal bone. RESULTS: CT findings of endolymphatic sac tumors revealed lesions centered over the endolymphatic sac, retrolabyrinthine, and presigmoid regions of the temporal bone. Central calcific spiculation and posterior rim calcification was present in all lesions (100%) on CT examination. T1-weighted MRI scans showed hyperintense foci in seven of eight lesions (88%). T1-weighted post-gadolinium scans showed heterogeneous enhancement in all cases (100%). T2-weighted images showed heterogeneous signals in all lesions (100%). Angiography (traditional or magnetic resonance angiography [MRA]) identified exclusive external carotid supply for lesions less than 3 cm. Tumors greater than 3 cm were supplied by external carotid, internal carotid, and posterior fossa circulation arteries. CONCLUSIONS: Reliable radiologic criteria to preoperatively identify endolymphatic sac tumors exist. Preoperative diagnosis of posterior temporal bone lesions enables appropriate surgical planning and treatment of the pathology.

Biological therapy for the inner ear.

Biological therapy for the inner ear has the potential to revolutionise the treatment of sensorineural hearing loss, the most common form of deafness. Progress in the molecular understanding of hearing and hearing loss, combined with advances in the fields of both gene and cellular therapy for the inner ear, is providing a robust foundation from which clinical translation is plausible. Potential areas of interest in gene therapy and its preclinical application to deafness are reviewed, and experimental progress that has occurred in cellular therapy for the inner ear is examined.

Molecular pathogenesis of skull base tumors.

OBJECTIVE: To review contemporary molecular biological literature related to skull base tumor biology and tumorigenesis. DATA SOURCES: PUBMED and Ovid literature searches were performed using keyword search. Only English language articles published between 1965 and December 4, 2003 were chosen. STUDY SELECTION AND DATA EXTRACTION: All relevant articles from the past 8 years, as well as landmark articles in years before 1995, were retrieved and reviewed. CONCLUSION: Consistent progress is being made toward the molecular genetic and biological basis of the most common skull base tumors. An understanding of these mechanisms will aid the neurotologist in future diagnosis and management of the lesions.