Unilateral Cochlear Implants for Severe, Profound, or Moderate Sloping to Profound Bilateral Sensorineural Hearing Loss: A Systematic Review and Consensus Statements.

Importance: Cochlear implants are a treatment option for individuals with severe, profound, or moderate sloping to profound bilateral sensorineural hearing loss (SNHL) who receive little or no benefit from hearing aids; however, cochlear implantation in adults is still not routine. Objective: To develop consensus statements regarding the use of unilateral cochlear implants in adults with severe, profound, or moderate sloping to profound bilateral SNHL. Design, Setting, and Participants: This study was a modified Delphi consensus process that was informed by a systematic review of the literature and clinical expertise. Searches were conducted in the following databases: (1) MEDLINE In-Process & Other Non-Indexed Citations and Ovid MEDLINE, (2) Embase, and (3) the Cochrane Library. Consensus statements on cochlear implantation were developed using the evidence identified. This consensus process was relevant for the use of unilateral cochlear implantation in adults with severe, profound, or moderate sloping to profound bilateral SNHL. The literature searches were conducted on July 18, 2018, and the 3-step Delphi consensus method took place over the subsequent 9-month period up to March 30, 2019. Main Outcomes and Measures: A Delphi consensus panel of 30 international specialists voted on consensus statements about cochlear implantation, informed by an SR of the literature and clinical expertise. This vote resulted in 20 evidence-based consensus statements that are in line with clinical experience. A modified 3-step Delphi consensus method was used to vote on and refine the consensus statements. This method consisted of 2 rounds of email questionnaires and a face-to-face meeting of panel members at the final round. All consensus statements were reviewed, discussed, and finalized at the face-to-face meeting. Results: In total, 6492 articles were identified in the searches of the electronic databases. After removal of duplicate articles, 74 articles fulfilled all of the inclusion criteria and were used to create the 20 evidence-based consensus statements. These 20 consensus statements on the use of unilateral cochlear implantation in adults with SNHL were relevant to the following 7 key areas of interest: level of awareness of cochlear implantation (1 consensus statement); best practice clinical pathway from diagnosis to surgery (3 consensus statements); best practice guidelines for surgery (2 consensus statements); clinical effectiveness of cochlear implantation (4 consensus statements); factors associated with postimplantation outcomes (4 consensus statements); association between hearing loss and depression, cognition, and dementia (5 consensus statements); and cost implications of cochlear implantation (1 consensus statement). Conclusions and Relevance: These consensus statements represent the first step toward the development of international guidelines on best practices for cochlear implantation in adults with SNHL. Further research to develop consensus statements for unilateral cochlear implantation in children, bilateral cochlear implantation, combined electric-acoustic stimulation, unilateral cochlear implantation for single-sided deafness, and asymmetrical hearing loss in children and adults may be beneficial for optimizing hearing and quality of life for these patients.

Bone conduction hearing: device auditory capability to aid in device selection.

OBJECTIVE: To obtain identical laboratory measures of 8 (surgical and nonsurgical) bone conduction devices and relate them to clinical function. STUDY DESIGN: Each device was measured with a single laboratory system and characterized with descriptive statistics. SETTING: Laboratory. SUBJECTS AND METHODS: Seven surgical devices (Intenso, BP110, BP100, and Cordelle [Cochlear, Denver, Colorado]; Ponto Pro and Ponto Pro Power [Oticon Medical, Somerset, New Jersey]; and Alpha 2 [Sophono, Inc, Boulder, Colorado]) and 1 nonsurgical dental device (SoundBite; Sonitus Medical, Inc, San Mateo, California) constituted the independent variables. Measured maximum output and gain parameters were the dependent variables. RESULTS: Maximum output varied across devices in the pure-tone average (PTA; 500-3000 Hz) frequency range (mean, 109.7 dB re 1 µN; range, 98.8-119.2 dB) and in the above-PTA (4000-8000 Hz) frequency range (mean, 102.6 dB re 1 µN; range, 88.99-119.6 dB). Maximum gain varied in the PTA frequency range (mean, 40 dB; range, 29.1-49.1 dB) and was higher in the frequency range above the PTA (mean, 32.0 dB; range, 20.8-46.0 dB). CONCLUSION: All devices have sufficient maximum output and gain for the PTA frequency range for single-sided deafness (SSD). The devices differed in maximum output and gain for the frequency range above the PTA, a consideration for accommodating presbycusis and optimizing auditory function for SSD. The surgical devices have less maximum output and gain in the above-PTA range than in the PTA range. The nonsurgical dental device had the highest output (up to 30 dB higher) and gain (up to 26 dB higher) in the above-PTA range.

Teleaudiology.

Teleaudiology has become a more viable approach to delivering care. Asynchronous and synchronous delivery can be used to deliver Teleaudiology. Hybrid delivery involves using both synchronous and asynchronous modes of delivery. Teleaudiology has been used for otoscopy, audiometry, immitance, cochlear implant programming and newborn screening. Teleaudiology is a viable technology, although reimbursement remains unclear.

Word recognition following implantation of conventional and 10-mm hybrid electrodes.

We compared the effectiveness of 2 surgical interventions for improving word recognition ability in a quiet environment among patients who presented with: (1) bilateral, precipitously sloping, high-frequency hearing loss; (2) relatively good auditory thresholds at and below 500 Hz, and (3) poor speech recognition. In 1 intervention (n = 25), a conventional electrode array was inserted into 1 cochlea. As a consequence, hearing was lost in the implanted ear. In the other intervention (n = 22), a Nucleus Hybrid short-electrode array was inserted 10 mm into 1 cochlea with the aim of preserving hearing in that ear. Both groups of patients had similar low-frequency hearing and speech understanding in the ear contralateral to the implant. Following surgery, both groups had significantly higher word recognition scores than before surgery. Between-group comparisons indicated that the conventional electrode array group had higher word recognition scores than the 10-mm group when stimulation was presented to the operated ear and when stimulation was presented to both ears.

Safety of magnetic resonance imaging of stapes prostheses.

OBJECTIVE: Assess the safety of performing magnetic resonance imaging (MRI) on patients with stapes prostheses. STUDY DESIGN: Survey and animal model. METHODS: A survey regarding implant usage, MRI procedures, and adverse outcomes after MRI in patients previously undergoing stapes procedures. Guinea pigs implanted with ferromagnetic 17 to 4 stainless steel, 316L nonferromagnetic stainless steel, titanium, and fluoroplastic stapes prostheses underwent a MRI in a 4.7 Tesla MR system. RESULTS: : Three adverse outcomes were reported on the clinical survey. One adverse event occurred during an MRI performed on a recalled ferromagnetic prosthesis. The other two adverse events were probably not secondary to MRI exposure. No damage or inflammation was observed in the region of the oval window or vestibule of implanted guinea pigs exposed to a 4.7 Tesla MR system. CONCLUSIONS: The combination of prior studies, the clinical survey, and the absence of histopathologic evidence of damage in the guinea pigs is compelling evidence that MRI for patients with stapes prostheses is safe. Implanting physicians should feel comfortable clearing a patient for a MRI in a 1.5 Tesla or 3.0 Tesla MRI. It is imperative for the physician to qualify the field strength when clearing a patient to undergo a MRI.

Oral carcinoma associated with betel nut chewing in the Pacific: an impending crisis?

In Western populations, tobacco and alcohol use are the major etiologic factors associated with oral cavity cancers. In developing countries of Asia and the South Pacific, however, oral cancer is increasingly associated with the chewing of betel nut. As the population of Asia and the South Pacific immigrates, Head and Neck surgeons in North America are likely to see more patients with oral carcinoma induced by betel nut chewing. Tumor Registry records from 1977-2003 from a tertiary care, referral medical center were reviewed. All patient charts (27) demonstrating betel quid use of greater than 20 years and carcinoma of the upper aerodigestive tract were entered into the study. Five-year disease-free rates by stage were as follows: Stage 1: 100% (2/2); Stage 11: 50% (2/4); Stage III: 36% (4/9): Stage IV: 25% (3/12). Despite the prevalent misperception in the Pacific region that betel nut chewing is a harmless habit, betel nut-induced oral carcinomas are aggressive malignancies requiring aggressive treatment and long-term follow-up.

Telehealth: voice therapy using telecommunications technology.

Telehealth offers the potential to meet the needs of underserved populations in remote regions. The purpose of this study was a proof-of-concept to determine whether voice therapy can be delivered effectively remotely. Treatment outcomes were evaluated for a vocal rehabilitation protocol delivered under 2 conditions: with the patient and clinician interacting within the same room (conventional group) and with the patient and clinician in separate rooms, interacting in real time via a hard-wired video camera and monitor (video teleconference group). Seventy-two patients with voice disorders served as participants. Based on evaluation by otolaryngologists, 31 participants were diagnosed with vocal nodules, 29 were diagnosed with edema, 9 were diagnosed with unilateral vocal fold paralysis, and 3 presented with vocal hyperfunction with no laryngeal pathology. Fifty-one participants (71%) completed the vocal rehabilitation protocol. Outcome measures included perceptual judgments of voice quality, acoustic analyses of voice, patient satisfaction ratings, and fiber-optic laryngoscopy. There were no differences in outcome measures between the conventional group and the remote video teleconference group. Participants in both groups showed positive changes on all outcome measures after completing the vocal rehabilitation protocol. Reasons for participants discontinuing therapy prematurely provided support for the telehealth model of service delivery.

Management of cholesteatoma: status of the canal wall.

OBJECTIVE/HYPOTHESIS: Management of chronic otitis media with cholesteatoma remains controversial. The purpose of the study is to examine factors associated with the surgical approach to manage cholesteatoma. STUDY DESIGN: A retrospective review. METHODS: A retrospective review was made of all primary cases of mastoid surgery for cholesteatoma performed at an otological center between 1995 and 2000. During the study period, 486 ears underwent surgery for cholesteatoma. Data included procedures performed, location and extent of the disease, residual and recurrent disease, complications, reasons for staging the surgery, and duration of follow-up. RESULTS: The canal wall remained intact in 68.5% of ears. The majority of the remainder of the patients underwent a canal wall down technique with mastoid obliteration. Residual cholesteatoma was found in 26.9% of second procedures and in 2.7% of third procedures. CONCLUSIONS: The majority of patients with cholesteatoma can be adequately managed with a canal intact tympanomastoidectomy with staging. Otolaryngologists should consider a two-staged procedure as a viable management approach for chronic otitis media with cholesteatoma.

Telemedicine: teleproctored endoscopic sinus surgery.

OBJECTIVE/HYPOTHESIS: Teleproctored surgery projects a surgeon's expertise to remote locations. The objective of the present study was to evaluate the safety and feasibility of this technique as compared with the current standard of care. STUDY DESIGN: Prospective. METHODS: A study was conducted in a residency training program comparing conventionally proctored endoscopic sinus surgery cases with teleproctored cases, with the faculty surgeon supervising through audiovisual teleconferencing (VTC) in a control room 15 seconds from the operating room. RESULTS: Forty-two control patients (83 sides) and 45 teleproctored patients (83 sides) were evaluated. There were no internal differences between groups regarding extent of polypoid disease, revision status, procedures per case, degree of difficulty, general or local anesthesia, or microdebrider use. There were no cases of visual disturbance, orbital ecchymosis or hematoma, or cerebrospinal fluid leak. Orbital fat herniation and blood loss were equal between groups. Three teleproctored cases required faculty intervention: two for surgical difficulty, one for VTC problems. Teleproctored cases took 3.87 minutes longer per side (28.54 vs. 24.67 min, P <.024), a 16% increase. This was thought to be a result of nuances of VTC proctoring. Residents had a positive learning experience, with nearly full control of the operating suite combined with remote supervision through telepresence. Faculty thought such supervision was safe but had concerns regarding personal skills maintenance. CONCLUSIONS: Teleproctored endoscopic sinus surgery can be safely performed on selected cases with an acceptable increase in time. Teleproctored surgery with remote sites may continue to be safely investigated. Incorporating remote supervision through telepresence into the curriculum of surgical residency training requires further study.