CyberKnife Stereotactic Radiosurgery for Growing Vestibular Schwannoma: Longitudinal Tumor Control, Hearing Outcomes, and Predicting Post-Treatment Hearing Status.

OBJECTIVES: (1) To determine tumor control rates for treating growing vestibular schwannoma (VS) with CyberKnife stereotactic radiosurgery (CK SRS); (2) to determine hearing outcomes after CK SRS; (3) to propose a set of variables that could be used to predict hearing outcomes for patients receiving CK SRS for VS. STUDY DESIGN: Retrospective case series review. METHODS: 127 patients who received CK SRS for radiographically documented growing VS were reviewed. Tumors were monitored for post-procedure growth radiographically with linear measurements and three-dimensional segmental volumetric analysis (3D-SVA). Hearing outcomes were reviewed for 109 patients. Cox proportional hazard modeling was used to identify variables correlated with hearing outcomes. RESULTS: Tumor control rate was 94.5% for treating VS with CK SRS. Hearing outcomes were categorized using the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) classification system. As of their last available audiogram, 33.3% of patients with pre-treatment class A and 26.9% of patients with class B retained their hearing in that class. 15.3% of patients starting with class A or B with extended follow-up (>60 months), maintained hearing within this same grouping. Our final model proposed to predict hearing outcomes included age, fundal cap distance (FCD), tumor volume, and maximum radiation dose to the cochlea; however, FCD was the only statistically significant variable. CONCLUSION: CK SRS is an effective treatment for control of VS. Hearing preservation by class was achieved in a third of patients. Finally, FCD was found to be protective against hearing loss. LEVEL OF EVIDENCE: 4 Laryngoscope, 134:S1-S12, 2024.

Comparison of Endoscopic Endonasal Approach and Lateral Microsurgical Infratemporal Fossa Approach to the Jugular Foramen: An Anatomical Study.

Objective The jugular foramen is one of the most challenging surgical regions in skull base surgery. With the development of endoscopic techniques, the endoscopic endonasal approach (EEA) has been undertaken to treat some lesions in this area independently or combined with open approaches. The purpose of the current study is to describe the anatomical steps and landmarks for the EEA to the jugular foramen and to compare it with the degree of exposure obtained with the lateral infratemporal fossa approach. Materials and Methods A total of 15 osseous structures related to the jugular foramen were measured in 33 adult dry skulls. Three silicone-injected adult cadaveric heads (six sides) were dissected for EEA and three heads (six sides) were used for a lateral infratemporal fossa approach (Fisch type A). The jugular foramen was exposed, relevant landmarks were demonstrated, and the distances between relevant landmarks and the jugular foramen were obtained. High-quality pictures were obtained. Results The jugular foramen was accessed in all dissections by using either approach. Important anatomical landmarks for EEA include internal carotid artery (ICA), petroclival fissure, inferior petrosal sinus, jugular tubercle, and hypoglossal canal. The EEA exposed the anterior and medial parts of the jugular foramen, while the lateral infratemporal fossa approach (Fisch type A) exposed the lateral and posterior parts of the jugular foramen. With EEA, dissection and transposition of the facial nerve was avoided, but the upper parapharyngeal and paraclival ICA may need to be mobilized to adequately expose the jugular foramen. Conclusion The EEA to the jugular foramen is anatomically feasible but requires mobilization of the ICA to provide access to the anterior and medial aspects of the jugular foramen. The lateral infratemporal approach requires facial nerve transposition to provide access to the lateral and posterior parts of the jugular foramen. A deep understanding of the complex anatomy of this region is paramount for safe and effective surgery of the jugular foramen. Both techniques may be complementary considering the different regions of the jugular foramen accessed with each approach.

Pain and Pain Control With Opioid and Nonopioid Medications After Otologic Surgery.

OBJECTIVE: To prospectively analyze pain and pain medication use following otologic surgery. STUDY DESIGN: Prospective cohort study with patient reported pain logs and medication use logs. SETTING: Tertiary academic hospital.Patients: Sixty adults who underwent outpatient otologic surgeries. INTERVENTIONS: Surveys detailing postoperative pain levels, nonopioid analgesic (NOA) use, and opioid analgesic use. MAIN OUTCOME MEASURES: Self-reported pain scores, use of NOA, and use of opioid medications normalized as milligrams morphine equivalents (MME). RESULTS: Thirty-two patients had surgery via a transcanal (TC) approach, and 28 patients had surgery via a postauricular (PA) approach. TC surgery had significantly lower reported pain scores than PA surgery on both postoperative day (POD) 1 (median pain score 2.2, IQR 0-5 vs. median pain score 4.8, IQR 3.4-6.3, respectively; p = 0.0013) and at POD5 (median pain score 0, IQR 0-0 vs. median pain score 2.0, IQR 0-3, respectively; p = 0.0002). Patients also used significantly fewer opioid medications with TC approach than patients who underwent PA approach at POD1 (median total MME 0, IQR 0-5 vs. median total MME 5.0, IQR 0-15, respectively; p = 0.03) and at POD5 (median total MME 0, IQR 0-0 vs. median total MME 0, IQR 0-5, respectively; p = 0.0012). CONCLUSIONS: Surgery with a postauricular approach is associated with higher pain and opioid use following otologic surgery. Patient- and approach-specific opioid prescribing is feasible following otologic surgery.

Scoping review of cochlear implantation in Susac's syndrome.

OBJECTIVE: Scoping review of published literature to establish clinical characteristics and audiologic outcomes in patients diagnosed with Susac's Syndrome(SS) who have undergone cochlear implantation (CI). DATA SOURCES: All published studies of CI in SS and contribution of two of our own patients who have not been reported previously. METHODS: A comprehensive search of MEDLINE (via PubMed) was carried out in March 2020 using the following keywords and related entry terms: Susac's Syndrome, Cochlear Implantation. RESULTS: Our search identified a total of five case reports of CI in SS. With the addition of our two patients reported here, we analyzed characteristics and outcomes in seven patients. Mean age at implantation was 30 years old (range 19-46), with six women and one man implanted. Mean time from onset of hearing loss to implantation was 17 months (range three months to four years). Best reported postoperative speech understanding was reported via different metrics, with six of seven patients achieving open set speech scores of 90% or better, and one subject performing at 68%. Vestibular symptoms were present preoperatively in four of seven patients (57%), with vestibular testing reported in two patients, and showing vestibulopathy in one patient. No complications were reported following cochlear implantation. CONCLUSION: Cochlear implantation is a viable option for hearing rehabilitation in patients with SS, with levels of attainment of open set speech comparable to other populations of CI candidates.

Long term outcomes with linear accelerator stereotactic radiosurgery for treatment of jugulotympanic paragangliomas.

BACKGROUND: Data supporting linear accelerator (linac) stereotactic radiosurgery (SRS) for jugulotympanic paragangliomas (JTPs) come from small series with minimal follow-up. Herein, we report a large series of JTPs with extended follow-up after frameless linac-based SRS. METHODS: JTPs treated with linac-based SRS from 2002 to 2019 with 1+ follow-up image were reviewed for treatment failure (radiographic or clinical progression, or persistent symptoms after SRS requiring intervention) and late toxicities (CTCAE v5.0). RESULTS: Forty JTPs were identified; 30 were treated with a multifraction regimen. Median clinical and radiographic follow-up was 79.7 (interquartile range [IQR] 31.7-156.9) and 54.4 months (IQR 17.9-105.1), respectively, with a median 4.5 follow-up scans (IQR 2-9). Seven-year progression-free survival (PFS) was 97.0% (95% confidence interval 91.1%-100.0%). PFS was similar between single- and multifraction regimens (log rank P = .99). Toxicity was seen in 7.7% (no grade III). CONCLUSIONS: With extended clinical and radiographic follow-up, frameless linac-based SRS provides excellent local control with mild toxicity <8%.

Cochlear Implant Performance in Adult Patients with Absent Intraoperative Electrically Evoked Compound Action Potentials.

OBJECTIVE: To describe cochlear implant performance outcomes in adult patients in whom no intraoperative electrically evoked compound action potential (ECAP) responses were able to be obtained despite intracochlear electrode placement. STUDY DESIGN: Retrospective case review. SETTING: Academic tertiary center. SUBJECTS AND METHODS: Patients 18 years of age and older undergoing cochlear implantation between May 2010 and September 2018 with absent ECAP measurements intraoperatively with intracochlear electrode positioning were identified. Patient performance on sentence recognition testing using the Hearing in Noise Test (HINT) and AzBio at 6 to 12 months postoperatively was compared to preimplantation scores. Additional collected data included patient demographics, etiology of hearing loss, and preoperative pure-tone average (PTA) and word recognition scores (WRSs). RESULTS: Intraoperative ECAP measurements were unable to be obtained in 15 cochlear implants performed on 14 patients out of 383 cochlear implant cases. Of the patients with absent ECAP measures, the mean ± SD age was 61.7 ± 15.7 years. Causes of hearing loss included congenital hearing loss, meningitis, autoimmune inner ear disease, otosclerosis, presbycusis, and Ménière's disease. The average preoperative PTA was 103.5 ± 17.0 dB. Twelve implanted ears had a WRS of 0% and 9 had a HINT score of 0% prior to surgery. The mean HINT score at 6 to 12 months postimplantation was 57.8% ± 37.8% and had improved by 42.6% ± 35.6% compared to the mean preimplantation HINT score (95% confidence interval, 22.0%-63.1%, P = .001, paired Student t test). CONCLUSION: There is a wide range of cochlear implant performance in patients with absent intraoperative ECAP measures ranging from sound awareness to HINT scores of 100%.

Metachronous Sudden Sensorineural Hearing Loss: Patient Characteristics and Treatment Outcomes.

OBJECTIVES: Idiopathic sudden sensorineural hearing loss (ISSNHL) is a distressing condition that can significantly affect quality of life. Unilateral ISSNHL, occurring first in 1 ear and then the contralateral ear at a separate and discrete time, is a rare presentation that we refer to as metachronous ISSNHL. Our objective was to characterize the presentation of metachronous ISSNHL and report on management and hearing outcomes. STUDY DESIGN: Retrospective case series. SETTING: Otology clinic at an academic tertiary referral center. SUBJECTS AND METHODS: Patients ≥18 years old presenting with metachronous ISSNHL between April 2008 to November 2017 were identified through review of the clinic electronic medical record. Metachronous ISSNHL was defined as unilateral ISSNHL occurring in temporally discrete episodes (>6 months apart) affecting both ears. Patients with identifiable causes for sudden hearing loss were excluded. Patient demographics, comorbidities, management, and audiologic outcomes were recorded. RESULTS: Eleven patients with metachronous ISSNHL were identified out of 558 patients with ISSNHL. In patients with metachronous ISSNHL, the mean ± standard deviation age at the time of ISSNHL in the second ear was 58.6 ± 15.2 years (range, 31-77 years). The mean interval between episodes was 9.6 ± 7.5 years (range, 1-22 years). Patients were treated with systemic and intratympanic steroids with variable hearing recovery; 5 patients with resultant bilateral severe to profound hearing loss underwent successful cochlear implantation. CONCLUSION: Metachronous ISSNHL is uncommon. Treatment is similar to ISSNHL, and cochlear implantation can successfully restore hearing in individuals who do not experience recovery.

Comparison of Spontaneous Temporal Bone Cerebrospinal Fluid Leaks From the Middle and Posterior Fossa.

OBJECTIVES: To compare patients surgically managed for spontaneous cerebrospinal fluid (CSF) leaks of the temporal bone arising from the middle cranial fossa (MCF) and posterior cranial fossa (PCF) and to describe the surgical management of posterior fossa CSF leaks. STUDY DESIGN: Retrospective case review. SETTING: Academic tertiary center. PATIENTS: Adult patients presenting with spontaneous temporal bone CSF leaks undergoing operative repair between January 2010 and August 2018. Patients with a history of trauma, previous mastoid surgery, and iatrogenic CSF leaks were excluded. INTERVENTION: Transmastoid or MCF CSF leak repair. MAIN OUTCOME MEASURES: Patient demographics, body mass index (BMI), comorbidities, presenting features, and lumbar puncture opening pressures were compared between groups and the management of the PCF CSF leaks described. RESULTS: Forty-six patients (26 women, 20 men) were included. The mean age at the time of repair was 58.0 ±â€Š12.9 years (±SD). The origin of the CSF leak was from the PCF in three patients and MCF in 43 patients. All three patients with PCF leaks presented with an acute history of meningitis compared with only seven (16%) in the MCF group. This difference was statistically significant (p = 0.01, Fisher's exact test). There were no statistically significant differences in age, sex, BMI, or lumbar puncture opening pressures. The PCF leaks were repaired using a transmastoid approach with multilayer closure of the bony defect and fat graft obliteration of the mastoid. CONCLUSIONS: Spontaneous CSF leaks arising from the PCF are rare and may present more commonly with meningitis. Identification requires careful review of imaging.

Optimization of Intraoperative Imaging Protocol to Confirm Placement of Cochlear Implant Electrodes.

OBJECTIVES: The need to intraoperatively confirm correct placement of the active electrode of a cochlear implant may occur in various clinical settings. These include a malformed cochlea, difficulty with insertion, or suboptimal or abnormal electrical responses (impedance or evoked action potentials) obtained during intraoperative testing. Frustration with inconsistent images using portable x-ray machines prompted this study to determine the technique needed to reliably image the electrode within the cochlea. Our objective was to establish a radiology protocol that would be reproducible and reliable across institutions. METHODS: Prospective cadaveric imaging study. Access to the round window via the facial recess was established using cadaver heads. Electrodes provided by three cochlear implant manufacturers were inserted into the cochlea. The position of the head, angle of the x-ray tube, and beam settings were varied. A compendium of electrode images was obtained and analyzed by neurotologists and a head and neck radiologist to reach a consensus on an optimal imaging protocol. RESULTS: The optimal position for intraoperative x-ray confirmation of cochlear implant electrode placement is obtained by turning the head 45 degrees toward the contralateral ear. The portable digital x-ray machine and central ray was angled 15 degrees (aiming cephalic) from vertical with exposure settings of 32 mAs at 70 kVp and the digital radiography image receptor was positioned under the mattress of the operating table. CONCLUSION: A protocol for patient and beam source positioning and exposure using a portable digital x-ray unit can provide reliable imaging for intraoperative confirmation of cochlear implant electrode positioning.

Evaluation of 3D Printed Temporal Bone Models in Preparation for Middle Cranial Fossa Surgery.

HYPOTHESIS: Patient-specific 3D printed models are useful presurgical planning tools because they accurately represent the anatomy and drilling characteristics of the middle cranial fossa (MCF) approach to the internal auditory canal (IAC). BACKGROUND: The MCF approach to the IAC can be challenging due to variability of the bony architecture along the floor of the middle fossa. Patient-specific 3D printed models may enhance surgeon knowledge of a given patient's anatomy when preparing for MCF surgery. METHODS: Six temporal bone models were printed from photoacrylic resin based on CT data obtained from cadaveric specimens using a desktop stereolithography 3D printer. Critical structures to avoid injuring, the facial nerve and membranous labyrinth, were modeled as hollow cavities and filled with indicator paint. Two neurotologists each drilled three 3D printed models and the corresponding cadaveric specimens, and then completed a 41-item visual analog scale questionnaire (score range of each item: 0-10) to assess the model's accuracy, utility, and potential as a training tool. RESULTS: Drilling the model was favorably rated (median score 9.2; range 7.3-9.6) for its ability to provide surgeons with an accurate mental image of the corresponding cadaveric anatomy. Overall similarity of feel of drilling the model in comparison to human bone was moderate (median 7.6; range 6.6-9.0). Surgeons would use this model to prepare for future cases (median 9.4; range 5.1-9.9) and felt it had excellent utility for training purposes (median 9.3; range 8.4-9.9). CONCLUSIONS: Patient-specific 3D printed models provide an anatomically accurate and favorable tool for preparing for MCF surgery.

Patient Positioning During In-Office Otologic Procedures Impacts Physician Ergonomics.

OBJECTIVE: The purpose of this study was to evaluate the impact of patient positioning on physician ergonomics during in-office otologic procedures. A previous simulation study suggested that placing patients supine during in-office otology procedures is ergonomically favorable. This study aims to substantiate these findings during the routine care of patients in an otolaryngology practice setting. STUDY DESIGN: Observational study. SETTING: Outpatient otology clinic within tertiary care facility. STUDY SUBJECTS: Two neurotology attending physicians. INTERVENTIONS: Physicians performed cerumen removal procedures in the office with patients either in the seated position (n = 24) or supine position (n = 24). MAIN OUTCOME MEASURES: The rapid upper limb assessment (RULA), a validated instrument that measures body positioning with a focus on the upper arm, was used to measure ergonomic positioning. RULA scores correlate occupational body positioning with a numeric representation of musculoskeletal injury risk ranging from 1 (minimal risk) to 7 (very high risk). RESULTS: Overall median RULA scores were 4.5 (medium risk) with patients in the seated position, and 2 (low risk) with patients in the supine position (p < 0.0001). Similarly, RULA scores were significantly lower with patients in the supine position when each physician was evaluated independently (p < 0.0001, for both). CONCLUSIONS: Placing patients in a supine position for cerumen removal results in more favorable ergonomic positioning for the physician, thus reducing risk for work-related musculoskeletal disorders. This suggests that physicians should consider placing patients in the supine position for in-office otologic procedures. Further study is needed to investigate optimal ergonomic positioning for other common otolaryngology procedures.

Imaging in the Diagnosis and Management of Necrotizing Otitis Externa: A Survey of Practice Patterns.

OBJECTIVE: To survey neurotologists and head and neck radiologists regarding use of imaging in the diagnosis and management of necrotizing otitis externa (NOE). STUDY DESIGN: Cross-sectional survey study. SETTING: Online survey distributed through email to specialty society membership lists. PARTICIPANTS: Neurotologists and head and neck radiologists with membership in either the American Neurotology Society or The American Society of Head and Neck Radiology. MAIN OUTCOME MEASURES: Responses to survey consisting of two demographic and seven clinically oriented questions related to the use of imaging in the diagnosis and management of NOE. RESULTS: One hundred thirty-six participants responded to the survey. The imaging modality of choice in establishing the diagnosis of NOE selected by the respondents was computed tomography (CT) (37.5%) followed by technetium scintigraphy (21.3%). Magnetic resonance imaging (MRI) was the preferred investigation by 41.9% of participants for determining extent of disease. Gallium scanning was the imaging modality preferred by 32.4% of respondents for determining when to cease medical therapy. Ninety-five percent of participants responded that CT scans were always or frequently used in the diagnosis and management of NOE compared with 72.8% for MRI, 34.5% for gallium scans, and 34.2% for technetium scans. CONCLUSIONS: There is considerable heterogeneity in the preferred imaging modalities used in the diagnosis and management of NOE. CT and MRI are the preferred contemporary modalities used by many physicians, demonstrating a shift away from the historic use of nuclear medicine scans.

Hearing Preservation: Does Electrode Choice Matter?

Objective Evaluate if electrode design affects hearing preservation (HP) following cochlear implantation (CI) with full-length electrodes. Study Design Case series with chart review. Setting Tertiary referral academic center. Subjects and Methods Forty-five adults with low-frequency hearing (≤85 dB at 250 and 500 Hz) who underwent unilateral CI with full-length electrode arrays made by 1 manufacturer were included. HP was calculated with (1) mean low-frequency pure-tone average (LFPTA) at 250 and 500 Hz (MEAN method), (2) a percentile method across the audiometric frequency spectrum generating an S-value (HEARRING method), and (3) functional if hearing remained ≤85 dB at 250 and 500 Hz. Audiometric testing was performed approximately 1 month and 1 year postoperatively, yielding short-term and long-term results, respectively. Results Of 45 patients who underwent CI, 46.7% received lateral wall (LW) and 53.3% received perimodiolar (PM) electrodes. At short-term follow-up, LW electrodes were associated with significantly better HP than PM (LFPTA method: 27.7 vs 39.3 dB, P < .05; S-value method: 48.2 vs 21.8%, P < .05). In multivariate regression of short-term outcomes, LW electrode use was a significant predictor of better HP ( P < .05). At long-term follow-up, electrode type was not associated with HP. Younger patient age was the only significant predictor of long-term HP on multivariate analysis ( P < .05). Conclusion The LW electrode is associated with short-term HP, suggesting its design is favorable for limiting trauma to the cochlea during and directly following CI. Other factors, including age, are relevant for maintaining HP over the long term. The data support further investigation into what modifiable factors may promote long-term HP.

Detection of endolymphatic hydrops using traditional MR imaging sequences.

PURPOSE: The purpose of this study was to determine whether Meniere's disease (MD) produces endolymphatic cavity size changes that are detectable using unenhanced high-resolution T2-weighted MRI. MATERIALS & METHODS: This retrospective case-control study included patients with documented MD who had a high-resolution T2-weighted or steady-state free procession MRI of the temporal bones within one month of diagnosis, between 2002 and 2015. Patients were compared to age- and sex- matched controls. Cross sectional area, length, and width of the vestibule and utricle were measured in both ears along with the width of the basal turn of the cochlea and its endolymphatic space. Absolute measurements and ratios of endolymph to perilymph were compared between affected, contralateral, and control ears using analysis of variance and post-hoc pairwise comparisons. RESULTS: Eighty-five case-control pairs were enrolled. Mean utricle areas for affected, contralateral, and control ears were 0.038cm2, 0.037cm2, and 0.033cm2. Mean area ratios for affected, contralateral, and control ears were 0.32, 0.32, and 0.29. There was a statistically significant difference between groups for these two variables; post-hoc comparisons revealed no difference between affected and contralateral ears in Meniere's patients, while ears in control patients were different from the ears of patients with MD. All other measurements failed to show significant differences. CONCLUSIONS: Enlargement of the endolymphatic cavity can be detected using non-contrast T2-weighted MRI. MRI, using existing protocols, can be a useful diagnostic tool for the evaluation of MD, and intratympanic or delayed intravenous contrast may be unnecessary for this diagnosis.

Radiographic Mastoid and Middle Ear Effusions in Intensive Care Unit Subjects.

BACKGROUND: This study was conducted to determine the incidence of and risk factors associated with the development of radiographic mastoid and middle ear effusions (ME/MEE) in ICU patients. METHODS: Head computed tomography or magnetic resonance images of 300 subjects admitted to the University of Pittsburgh Medical Center neurologic ICU from April 2013 through April 2014 were retrospectively reviewed. Images were reviewed for absent, partial, or complete opacification of the mastoid air cells and middle ear space. Exclusion criteria were temporal bone or facial fractures, transmastoid surgery, prior sinus or skull base surgery, history of sinonasal malignancy, ICU admission < 3 days or inadequate imaging. RESULTS: At the time of admission, 3.7% of subjects had radiographic evidence of ME/MEE; 10.3% (n = 31) of subjects subsequently developed new or worsening ME/MEE during their ICU stay. ME/MEE was a late finding and was found to be most prevalent in subjects with a prolonged stay (P < .001). Variables associated with ME/MEE included younger age, the use of antibiotics, and development of radiographic sinus opacification. The proportion of subjects with ME/MEE was significantly higher in the presence of an endotracheal tube (22.7% vs 0.6%, P < .001) or a nasogastric tube (21.4% vs 0.6%, P < .001). CONCLUSIONS: Radiographic ME/MEE was identified in 10.3% of ICU subjects and should be considered especially in patients with prolonged stay, presence of an endotracheal tube or nasogastric tube, and concomitant sinusitis. ME/MEE is a potential source of fever and sensory impairment that may contribute to delirium and perceived depressed consciousness in ICU patients.

Palatal botulinum toxin as a novel therapy for objective tinnitus in forced eyelid closure syndrome.

Objective tinnitus associated with eyelid closure is a rare clinical entity with only a few reported cases. This association previously was identified as forced eyelid closure syndrome (FECS) and involves an aberrant neural reflex between cranial nerve VII (activating the orbicularis oculi muscle) and cranial nerve V (activating the tensor tympani muscle). We present a 52-year-old Caucasian female with a 2-month history of FECS who was successfully treated with intrapalatal botulinum toxin, with full resolution of her objective tinnitus symptoms. This is the first reported use of botulinum toxin in FECS. Laryngoscope, 127:1199-1201, 2017.

Optimizing Positioning for In-Office Otology Procedures.

Objective Surgeons often report musculoskeletal discomfort in relation to their practice, but few understand optimal ergonomic positioning. This study aims to determine which patient position-sitting versus supine-is ergonomically optimal for performing otologic procedures. Study Design Observational study. Setting Outpatient otolaryngology clinic setting in a tertiary care facility. Subjects and Methods We observed 3 neurotologists performing a standardized simulated cerumen debridement procedure on volunteers in 2 positions: sitting and supine. The Rapid Upper Limb Assessment (RULA)-a validated tool that calculates stress placed on the upper limb during a task-was used to evaluate ergonomic positioning. Scores on this instrument range from 1 to 7, with a score of 1 to 2 indicating negligible risk of developing posture-related injury. The risk of musculoskeletal disorders increases as the RULA score increases. Results In nearly every trial, RULA scores were lower when the simulated patient was placed in the supine position. When examined as a group, the median RULA scores were 5 with the patient sitting and 3 with the patient in the supine position ( P < .0001). When the RULA scores of the 3 neurotologists were examined individually, each had a statistically significant decrease in score with the patient in the supine position. Conclusion This study indicates that patient position may contribute to ergonomic stress placed on the otolaryngologist's upper limb during in-office otologic procedures. Otolaryngologists should consider performing otologic procedures with the patient in the supine position to decrease their own risk of developing upper-limb musculoskeletal disorders.

Longitudinal evaluation of corticospinal tract in patients with resected brainstem cavernous malformations using high-definition fiber tractography and diffusion connectometry analysis: preliminary experience.

OBJECT: Brainstem cavernous malformations (CMs) are challenging due to a higher symptomatic hemorrhage rate and potential morbidity associated with their resection. The authors aimed to preoperatively define the relationship of CMs to the perilesional corticospinal tracts (CSTs) by obtaining qualitative and quantitative data using high-definition fiber tractography. These data were examined postoperatively by using longitudinal scans and in relation to patients' symptomatology. The extent of involvement of the CST was further evaluated longitudinally using the automated "diffusion connectometry" analysis. METHODS: Fiber tractography was performed with DSI Studio using a quantitative anisotropy (QA)-based generalized deterministic tracking algorithm. Qualitatively, CST was classified as being "disrupted" and/or "displaced." Quantitative analysis involved obtaining mean QA values for the CST and its perilesional and nonperilesional segments. The contralateral CST was used for comparison. Diffusion connectometry analysis included comparison of patients' data with a template from 90 normal subjects. RESULTS: Three patients (mean age 22 years) with symptomatic pontomesencephalic hemorrhagic CMs and varying degrees of hemiparesis were identified. The mean follow-up period was 37.3 months. Qualitatively, CST was partially disrupted and displaced in all. Direction of the displacement was different in each case and progressively improved corresponding with the patient's neurological status. No patient experienced neurological decline related to the resection. The perilesional mean QA percentage decreases supported tract disruption and decreased further over the follow-up period (Case 1, 26%-49%; Case 2, 35%-66%; and Case 3, 63%-78%). Diffusion connectometry demonstrated rostrocaudal involvement of the CST consistent with the quantitative data. CONCLUSIONS: Hemorrhagic brainstem CMs can disrupt and displace perilesional white matter tracts with the latter occurring in unpredictable directions. This requires the use of tractography to accurately define their orientation to optimize surgical entry point, minimize morbidity, and enhance neurological outcomes. Observed anisotropy decreases in the perilesional segments are consistent with neural injury following hemorrhagic insults. A model using these values in different CST segments can be used to longitudinally monitor its craniocaudal integrity. Diffusion connectometry is a complementary approach providing longitudinal information on the rostrocaudal involvement of the CST.

Robot assisted stapedotomy ex vivo with an active handheld instrument.

Micron is a fully handheld active micromanipulator that helps to improve position accuracy and precision in microsurgery by cancelling hand tremor. This work describes adaptation, tuning, and testing of the Micron system for stapedotomy, a microsurgical procedure performed in the middle ear to restore hearing that requires accurate manipulation in narrow spaces. Two end-effectors, a handle, and a brace (or rest) were designed and prototyped. The control system was adapted for the new hardware. The system was tested ex vivo in stapedotomy procedure comparing manually-performed and Micron-assisted surgical tasks. Tremor amplitude was found to be reduced significantly. Further testing is needed in order to obtain statistically significant results regarding other parameters dealing with regularity of the fenestra shape.