Management of facial nerve trauma.

PURPOSE OF REVIEW: To present the current literature on management of facial nerve disorder secondary to trauma, with a focus on the utility of electrodiagnostic testing in this setting. RECENT FINDINGS: Patients with facial palsy related to temporal bone fractures should be started on high-dose corticosteroids as early as possible. Recent literature on the benefit of surgical intervention in the setting of temporal bone fracture is mixed. Some studies support early surgical decompression whereas others have found no benefit compared with conservative treatment. SUMMARY: The management of facial nerve trauma is based on location and extent of injury. Extratemporal trauma and transected nerve should be treated with surgical exploration and tension-free coaptation ideally within 72 h. There are no guidelines for intratemporal facial nerve trauma. Surgical decompression compared with medical management is debated in the literature without consensus and more large studies are needed.

Investigating Socioeconomic Barriers to Cochlear Implantation.

OBJECTIVE: To explore socioeconomic disparities in cochlear implant evaluation (CIE) referrals and cochlear implantation. STUDY DESIGN: Retrospective chart review. SETTING: Tertiary referral academic center. METHODS: Adult patients (n = 271) with an audiogram performed between 2015 and 2019 with a pure-tone average of at least 60 dB and word recognition score of 60% or less in the better-hearing ear or no word recognition score performed were included to determine if socioeconomic factors influenced the rate of referral to CIE and cochlear implantation. RESULTS: There were 122 insured patients referred to CIE where 84 were considered cochlear implant (CI) candidates and 73 were implanted. In multivariate regression analysis, non-English-speaking patients were referred to CIE at lower rates ( p < 0.01) than English-speaking patients. Patients who met the CI candidacy criteria with private insurance ( p = 0.03) or Medicare with private insurance supplement ( p = 0.03) had higher rates of cochlear implantation than those with Medicare or Medicaid. Of the uninsured patients (n = 22), 3 were referred to CIE and 2 were considered CI candidates. No uninsured patients received a CI. CONCLUSIONS: Primary language spoken was associated with a disparity in rates of CIE referral. Insurance type did influence rate of cochlear implantation once patients completed CIE and were considered CI candidates. Additional research is needed to implement strategies for more inclusive treatment.

[AUDITORY OUTCOMES OF COCHLEAR IMPLANTATION IN MENIERE'S DISEASE].

BACKGROUND: Cochlear implants are valuable in the auditory rehabilitation of patients with severe to profound hearing loss. However, there is limited data on the outcomes of cochlear implantation in patients with Meniere's disease (MD). OBJECTIVES: In this study, we aim to evaluate the auditory outcomes of cochlear implantation in patients with MD. METHODS: A retrospective case series of patients with MD and severe to profound sensorineural hearing loss (SNHL), who underwent cochlear implantation at a tertiary academic center between 2006-2017. Patient's clinical characteristics and audiometric data were reviewed. RESULTS: The study included 20 ears in 19 patients with MD who underwent cochlear implantation with available pre- and postoperative audiometric data. There were 10 males and 9 females with a mean age of 63 years and a mean follow-up duration of 70.8 months. Pre- and post-implant CNC word recognition scores were 18.31% and 66.89%, respectively (p<0.001). Pre- and post-implant AzBio and/or HINT sentence recognition scores were 12.25% and 68.28% in quiet, respectively (p<0.001), and 18.25% and 63.43% in noise, respectively (p<0.001). CONCLUSIONS: Cochlear implantation resulted in an improvement of word and sentence recognition scores in MD patients. These results support the role of cochlear implants in the auditory rehabilitation of MD. DISCUSSION: Dr. Samy received research support from Cochlear Corporation.

Hemopneumothorax detection through the process of artificial evolution - a feasibility study.

BACKGROUND: Tension pneumothorax is one of the leading causes of preventable death on the battlefield. Current prehospital diagnosis relies on a subjective clinical impression complemented by a manual thoracic and respiratory examination. These techniques are not fully applicable in field conditions and on the battlefield, where situational and environmental factors may impair clinical capabilities. We aimed to assemble a device able to sample, analyze, and classify the unique acoustic signatures of pneumothorax and hemothorax. METHODS: Acoustic data was obtained with simultaneous use of two sensitive digital stethoscopes from the chest wall of an ex-vivo porcine model. Twelve second samples of acoustic data were obtained from the in-house assembled digital stethoscope system during mechanical ventilation. The thoracic cavity was injected with increasing volumes of 200, 400, 600, 800, and 1000 ml of air or saline to simulate pneumothorax and hemothorax, respectively. The data was analyzed using a multi-objective genetic algorithm that was used to develop an optimal mathematical detector through the process of artificial evolution, a cutting-edge approach in the artificial intelligence discipline. RESULTS: The in-house assembled dual digital stethoscope system and developed genetic algorithm achieved an accuracy, sensitivity and specificity ranging from 64 to 100%, 63 to 100%, and 63 to 100%, respectively, in classifying acoustic signal as associated with pneumothorax or hemothorax at fluid injection levels of 400 ml or more, and regardless of background noise. CONCLUSIONS: We present a novel, objective device for rapid diagnosis of potentially lethal thoracic injuries. With further optimization, such a device could provide real-time detection and monitoring of pneumothorax and hemothorax in battlefield conditions.

Middle Cranial Fossa Approach to Vestibular Schwannoma Resection in the Older Patient Population.

OBJECTIVE: Compare outcomes of middle cranial fossa approach (MCF) to vestibular schwannoma (VS) resection in patients 60 years of age and older to patients under 60. STUDY DESIGN: Retrospective case series. SETTING: Tertiary referral center. PATIENTS: Charts of 216 consecutive VS patients over 18 years of age were reviewed to identify 67 patients who underwent MCF approach to VS resection between 2006 and 2017. INTERVENTION(S): Age at time of surgery. MAIN OUTCOME MEASURE(S): Measured outcomes included postoperative hearing results, facial nerve function, length of hospital stay, wound complications, cerebrospinal fluid leak, myocardial infarction, cerebrovascular accident, seizure, deep vein thrombosis, 30-day readmission, and return to operating room. RESULTS: Sixty-seven patients underwent VS resection via MCF approach including 16 patients > = 60 years (mean 64.4 SD 3.3) and 51 patients < 60 years (mean 45.7 SD 10.2). Between these two groups, there were no differences in sex, tumor laterality, tumor size (10.4 mm versus 9.8 mm, p = 0.6), or other demographic characteristics. Postoperatively, there were no differences between groups in complication rates. Rates of HB 1 or 2 facial nerve function were similar (93.8% versus 88.2%, p = 0.7) as were rates of maintenance of class A or B hearing (58.3% versus 44.4%, p = 0.7). CONCLUSIONS: Patients over 60 undergoing MCF for VS resection experienced similar rates of postoperative complications, facial nerve outcomes, and hearing preservation compared with younger patients. MCF for VS may be considered in the older population. Further research is warranted to evaluate appropriate limitations for this approach based on age.

Socioeconomic Disparities in Pediatric Single-Sided Deafness.

OBJECTIVE: To explore socioeconomic disparities in pediatric single-sided deafness (SSD) treatment. STUDY DESIGN: Retrospective chart review. SETTING: Tertiary referral academic center. METHODS: The charts of 190 pediatric patients with SSD were reviewed for demographic and clinical characteristics. Socioeconomic variables included race and insurance status. ZIP codes were used to obtain additional socioeconomic data from the American Community Survey, including mean and median income, percentage of families below the poverty level, and employment status. Socioeconomic status (SES) was classified by insurance status and income. Treatment outcomes were analyzed by socioeconomic variables. RESULTS: There were 105 males and 85 females with a mean follow-up of 55.2 months and a mean age at diagnosis of 4.4 years. Sixty-three percent of children received treatment at last follow-up. Thirty-five percent of children had public insurance and 65% had private insurance. Treatment rates were similar in the private and public insurance groups (60.6% vs 66.7%, P = .42), but device type was different between groups (P = .02). Consistent device use was associated with private insurance (47.5% vs 38.9%, P = .003) and high SES (94.4% vs 80%, P = .04) on univariate but not on multivariate analysis. Aided audiometry results were similar between SES groups. No association was found between sex, race, income level, poverty level, or employment status and treatment outcomes. CONCLUSION: Insurance type and SES were not associated with SSD treatment outcomes in children, although device use may be higher in children with private insurance and higher SES. Further research should focus on strategies to reduce barriers to treatment and improve adherence.

Hemifacial Spasm as a Rare Clinical Presentation of Idiopathic Intracranial Hypertension: Case Report and Literature Review.

OBJECTIVES: To report a rare case of idiopathic intracranial hypertension (IIH) presenting with hemifacial spasm (HFS) and review the current literature. METHODS: Case report and literature review. The patient's medical record was reviewed for demographic and clinical data. For literature review, all case reports or other publications published in English literature were identified using PUBMED. RESULTS: A 43-year-old obese female presented with a 2-year history of left HFS.Electroencephalography and head computed tomography were unremarkable. Magnetic resonance imaging demonstrated bilateral anterior inferior cerebellar artery vascular loops involving the internal auditory canals as well as IIH-associated findings. A lumbar puncture was performed and revealed an elevated opening pressure of 26 cm H20 cerebrospinal fluid. Acetazolamide treatment was then initiated, resulting in complete resolution of the HFS. CONCLUSION: HFS may be a rare presenting manifestation of IIH, and treatment of IIH may result in improvement of HFS symptoms. This is the first report of IIH presenting with HFS in the absence of headache or visual change. As a result, this is the first report of HFS as a presenting manifestation of IIH in Otolaryngology literature.

Visual Speech Recognition: Improving Speech Perception in Noise through Artificial Intelligence.

OBJECTIVES: To compare speech perception (SP) in noise for normal-hearing (NH) individuals and individuals with hearing loss (IWHL) and to demonstrate improvements in SP with use of a visual speech recognition program (VSRP). STUDY DESIGN: Single-institution prospective study. SETTING: Tertiary referral center. SUBJECTS AND METHODS: Eleven NH and 9 IWHL participants in a sound-isolated booth facing a speaker through a window. In non-VSRP conditions, SP was evaluated on 40 Bamford-Kowal-Bench speech-in-noise test (BKB-SIN) sentences presented by the speaker at 50 A-weighted decibels (dBA) with multiperson babble noise presented from 50 to 75 dBA. SP was defined as the percentage of words correctly identified. In VSRP conditions, an infrared camera was used to track 35 points around the speaker's lips during speech in real time. Lip movement data were translated into speech-text via an in-house developed neural network-based VSRP. SP was evaluated similarly in the non-VSRP condition on 42 BKB-SIN sentences, with the addition of the VSRP output presented on a screen to the listener. RESULTS: In high-noise conditions (70-75 dBA) without VSRP, NH listeners achieved significantly higher speech perception than IWHL listeners (38.7% vs 25.0%, P = .02). NH listeners were significantly more accurate with VSRP than without VSRP (75.5% vs 38.7%, P < .0001), as were IWHL listeners (70.4% vs 25.0% P < .0001). With VSRP, no significant difference in SP was observed between NH and IWHL listeners (75.5% vs 70.4%, P = .15). CONCLUSIONS: The VSRP significantly increased speech perception in high-noise conditions for NH and IWHL participants and eliminated the difference in SP accuracy between NH and IWHL listeners.

Imaging findings in pediatric single-sided deafness and asymmetric hearing loss.

OBJECTIVE: To examine the imaging findings on computer tomography (CT) and magnetic resonance imaging (MRI) in pediatric single-sided deafness (SSD) and asymmetric hearing loss (ASH). METHODS: The medical records of 189 pediatric patients with SSD and ASH were retrospectively reviewed, and imaging findings were compared. SSD was defined as unilateral profound hearing loss and contralateral normal hearing ear. In the ASH group, ASHw was defined as the worse hearing ear with profound hearing loss, while ASHb was defined as the better hearing ear with mild-moderate hearing loss. RESULTS: There were 170 patients with SSD and 19 patients with ASH. In the SSD group, 83 patients (48.8%) had imaging findings associated with hearing loss. In the ASH group, such imaging findings were found in six (31.6%) of the ASHw and in five (26.3%) of the ASHb ears. The most common finding in the SSD group was cochlear nerve deficiency (50.6%), followed by cochlear dysplasia (39.8%) and enlarged vestibular aqueduct (26.5%). In the ASH groups, cochlear dysplasia was seen in three (50%) of ASHw ears and in two (40%) of the ASHb ears, and enlarged vestibular aqueduct was seen in three (50%) of ASHw ears and in two (40%) of the ASHb ears. CONCLUSION: Imaging studies identified the etiology in half of the cases of SSD and in one-third of ASH patients. Our findings strongly support the use of imaging studies in the evaluation of pediatric SSD and ASH. LEVEL OF EVIDENCE: 4 Laryngoscope, 130:1007-1010, 2020.

Is Longer Surgery More Dangerous? Operative Duration Not Associated With Complications After Vestibular Schwannoma Resection.

OBJECTIVE: To examine the association between operative duration and complications after vestibular schwannoma (VS) surgery. STUDY DESIGN: Retrospective chart review. SETTING: Tertiary referral center. PATIENTS: One hundred forty-eight patients undergoing vestibular schwannoma resection in a single institution. INTERVENTION: Vestibular schwannoma resection. MAIN OUTCOME MEASURES: Operative duration, surgical approach, tumor size, and postoperative complications. RESULTS: Forty-one patients underwent middle cranial fossa (MCF) approach, 46 underwent translabyrinthine (TL) approach, and 61 underwent retrosigmoid (RS) approach. The mean operative duration overall was 407 minutes (MCF-339 min, TL-450 min, RS 420 min). When controlling for tumor size, there was no difference in procedure duration by approach (OR 0.92, CI 0.82-1.02, p=0.11).When controlling for approach, there was a significant increase in procedure duration by tumor size (OR 1.36, CI 1.23-1.50, p < 0.0001). Increased procedure duration was not associated with 30-day readmission (p = 0.82), cerebrospinal fluid leak (CSF) (p = 0.84), return to the operating room (p = 0.75), postoperative deep vein thrombosis (p = 1.0), postoperative stroke (p = 0.23), or postoperative wound complications (p = 0.70). Longer operative time was associated with increased hospital length of stay (p = 0.04). However, when controlling for tumor size and surgical approach, hospital length of stay was no longer associated with increased procedure duration (OR 1.15, CI 0.98-1.33, p = 0.3). CONCLUSION: Increased operative duration was associated with larger tumor size; however contrary to previous reports, increased operative duration was not associated with postoperative complications.

Central Effects of Cranial Nerve Stimulation.

The current literature on peripheral cranial nerve stimulation for the purpose of achieving therapeutic effects via altering brain activity is reviewed. Vagus nerve stimulation, which is approved for use in refractory epilepsy, is the most extensively studied cranial nerve stimulator that has direct impact on the central nervous system. Despite the recognized central effects of peripheral cranial nerve stimulation, the mechanism of action for all indications remains incompletely understood. Further research on both mechanisms and indications of central effects of cranial nerve stimulation has the potential to alleviate burden of disease in a large array of conditions.

Obesity Is Not Associated With Postoperative Complications After Vestibular Schwannoma Surgery in a Large Single Institution Series.

OBJECTIVE: Determine whether elevated body mass index (BMI) is associated with postoperative complications after vestibular schwannoma (VS) surgery. STUDY DESIGN: Retrospective case series. SETTING: Tertiary referral center. PATIENTS: Two hundred six patients undergoing surgery for VS between 2010 and 2017, grouped into obese and nonobese patients. INTERVENTION: Surgery for VS resection. MAIN OUTCOME MEASURES: Postoperative facial nerve outcomes, length of hospital stay, presence of postoperative cerebrospinal fluid leak, 30-day readmission, return to the operating room, wound complications, cardiovascular and thromboembolic complications. RESULTS: After excluding 1 patient for missing BMI, our cohort included 205 patients. Seventy-nine patients (38.5%) were obese (mean BMI 36.2 kg/m, range 30-55.1) and the remaining 126 (61.5%) were nonobese (mean BMI 25.0, range 18.8-29.8 kg/m). Compared with nonobese patients, obesity was not associated with postoperative cerebrospinal fluid leak (OR 1.1, 95% CI 0.93-1.1), length of hospital stay (OR 0.98, 95% CI 0.65-1.47), 30-day readmission rates (1.04, 95% CI 0.95-1.14), return to operating room (OR 1.05, 95% CI 0.98-1.11), or other wound-related complications (OR 0.99, 95% CI 0.94-1.04). CONCLUSION: In this cohort, elevated BMI was not associated with an increased risk for postoperative complications after VS surgery. Our findings may mitigate concerns associated with surgical management of VS in obese patients.

Cerebrospinal Fluid Leak Rate after Vestibular Schwannoma Surgery via Middle Cranial Fossa Approach.

Objective Evaluate the cerebrospinal fluid (CSF) leak rate after the middle cranial fossa (MCF) approach to vestibular schwannoma (VS) resection. Design Retrospective case series. Setting Quaternary referral academic center. Participants Of 161 patients undergoing the MCF approach for a variety of skull base pathologies, 66 patients underwent this approach for VS resection between 2007 and 2017. Main Outcome Measure Postoperative CSF leak rate. Results There were two instances of postoperative CSF leak (3.0%). Age, gender, and BMI were not significantly associated with CSF leak. In the two cases with CSF leakage, tumors were isolated to the internal auditory canal (IAC) and both underwent gross total resection. Both CSF leaks were successfully treated with lumbar drain diversion. For the 64 cases that did not have a CSF leak, 51 were isolated to the IAC, 1 was located only in the cerebellopontine angle (CPA), and 12 were located in both the IAC and CPA. 62 patients underwent gross total resection and 2 underwent near-total resection. Mean maximal tumor diameter in the CSF leak group was 4.5 mm (range: 3-6 mm) versus 10.2 mm (range: 3-19 mm) in patients with no CSF leak ( p = 0.03). Conclusions The MCF approach for VS resection is a valuable technique that allows for hearing preservation and total tumor resection and can be performed with a low CSF leakage rate. This rate of CSF leak is less than the reported rates in the literature in regard to both translabyrinthine and retrosigmoid approaches.

Utility of Magnetic Resonance Imaging in Differentiating Cerebrospinal Fluid Leak from Middle Ear Effusion.

OBJECTIVE: To demonstrate the clinical utility, sensitivity, and specificity of standard magnetic resonance imaging (MRI) sequences in differentiating temporal bone cerebrospinal fluid leaks from all other middle ear effusions. STUDY DESIGN: Retrospective imaging review. SETTING: Academic medical center. SUBJECTS: Patients with cerebrospinal fluid leaks or other middle ear effusions who also underwent MRI. METHODS: Patients were assigned to cerebrospinal fluid leak and other effusion cohorts based on clinical course, findings at surgery/myringotomy, and beta-2 transferrin fluid analysis. Reviewers blinded to the clinical outcome examined T1-weighted, T2-weighted, diffusion-weighted, fluid-attenuated inversion recovery (FLAIR), and 3-dimensional (3D) acquired T2-weighted MRI sequences. For each sequence, fluid imaged in the temporal bone was graded as either similar or dissimilar in signal intensity to cerebrospinal fluid in the adjacent subarachnoid space. Signal similarity was interpreted as being diagnostic of a leak. Test characteristics in predicting the presence of a leak were calculated for each series. RESULTS: Eighty patients met criteria (41 leaks, 39 other effusions). The 3D T2 series was 76% sensitive and 100% specific in diagnosing a leak, and FLAIR was 44% sensitive and 100% specific. The T1-weighted (73% sensitive, 69% specific), T2-weighted (98% sensitive, 5.1% specific), and diffusion-weighted (63% sensitive, 66% specific) series were less useful. CONCLUSIONS: MRI, with attention to 3D T2 and FLAIR series, is a noninvasive and highly specific test for diagnosing cerebrospinal fluid leak in the setting of an indeterminate middle ear effusion.

Impact of Motor-Evoked Potential Monitoring on Facial Nerve Outcomes after Vestibular Schwannoma Resection.

OBJECTIVES:: Assess the utility of intraoperative transcranial facial motor-evoked potential (FMEP) monitoring in predicting and improving facial function after vestibular schwannoma (VS) resection. STUDY DESIGN:: Retrospective chart review. METHODS:: Data were obtained from 82 consecutive VS resections meeting inclusion criteria. Sixty-two cases were performed without FMEP and 20 with FMEP. Degradation of FMEP response was defined as a final-to-baseline amplitude ratio of 0.5 or less. House-Brackmann (HB) grade was assessed preoperatively, postoperatively, at follow-up assessments, and it was compared between pre- and post-FMEP cohorts. Positive predictive value (PPV) and negative predictive value (NPV), sensitivity, and specificity of FMEP degradation in predicting facial weakness were calculated. RESULTS:: In the pre-FMEP group, at length of follow-up (LOF) ⩾9 months, 83.9% (52/62) of patients exhibited HB 1-2 outcome. In the post-FMEP cohort, 75.0% (15/20) exhibited HB 1-2 function at LOF ⩾9 months. There was no difference in rates of HB 1-2 outcomes between groups in the immediate postoperative period ( P = .35) or at long-term follow-up ( P = 1.0). With respect to predicting immediate postoperative facial function, FMEP demonstrated high specificity (88.9%) and moderate sensitivity (54.5%). The PPV and NPV for immediate postoperative facial function were 85.7% and 61.5%, respectively. With respect to long-term (⩾9 months LOF) facial function, intraoperative FMEP was moderately sensitive (71.4%) and highly specific (84.6%); PPV was moderate (71.4%), and NPV was high (84.6%). CONCLUSIONS:: Intraoperative FMEP is highly specific and moderately sensitive in predicting postoperative facial function for patients undergoing VS resection, but its use may not be associated with improved facial nerve outcomes. LEVEL OF EVIDENCE:: 4.

Application of Ultrasonic Bone Aspirator for Decompression of the Internal Auditory Canal via the Middle Cranial Fossa Approach.

OBJECTIVE: Evaluate the safety and efficacy of the ultrasonic bone aspirator (UBA) during middle cranial fossa (MCF) approach to vestibular schwannoma (VS). STUDY DESIGN: Retrospective case series. SETTING: Tertiary referral center. PATIENTS: Charts of 192 consecutive VS patients over 18 years of age were reviewed to identify 65 patients who underwent MCF approach to VS resection between 2006 and 2017. A combination of UBA and high-speed drill (HSD) was used to decompress the internal auditory canal (IAC) in 25 patients and HSD alone was used in the other 40 patients. INTERVENTION(S): Use of UBA during vestibular schwannoma surgery via MCF approach for decompression of the IAC. MAIN OUTCOME MEASURE(S): Postoperative facial nerve outcomes assessed by the House-Brackmann (HB) facial nerve grading scale. Rates of gross total resection (GTR) and cerebrospinal fluid (CSF) leak. RESULTS: There were no significant differences in postoperative facial nerve function, in rate of GTR of tumor, or in rate of CSF leak. In the UBA group 24/25 (96%) had postoperative HB grade I-II compared with 36/40 (90%) in the HSD group (p-value = 0.66). GTR was achieved in 25/25 (100%) in the UBA group compared with 38/40 (95%) in the HSD group (p-value = 1). In the UBA group, there were 0/25 (0%) cases of CSF leak compared with 1/40 (2.5%) in the HSD group (p-value = 1). CONCLUSIONS: UBA use is a safe and effective alternative or adjunct to HSD during MCF approach to expose the IAC contents. This surgical tool allows for bone removal with low risk of injury to adjacent structures.

Adolescent Obesity Is an Independent Risk Factor for Sensorineural Hearing Loss: Results From the National Health and Nutrition Examination Survey 2005 to 2010.

OBJECTIVE: We investigated the hypothesis that childhood obesity is a risk factor for sensorineural hearing loss (SNHL) independent of other metabolic risk factors. STUDY DESIGN: A complex, multistage, stratified geographic area design for collecting representative data from noninstitutionalized US population. METHODS: A total of 5,638 adolescents between age 12 and 19 from the NHANES database (2005-2010) were studied. Subjects with body mass index >= 95th percentile were classified as obese. SNHL was defined as average pure-tone greater than 15 dB HL for 0.5, 1, and 2 kHz or 3, 4, 6, and 8 kHz in at least 1 ear. Multivariable logistic regression models assessed incident hearing loss odds across obese patients in comparison with normal weight individuals (5th-85th percentile). Multivariable models included age, sex, socioeconomic status, race, smoke exposure, high density lipoprotein level, triglyceride level, elevated blood pressure measurement, hemoglobin A1C level, and C-reactive protein level. RESULTS: The rate of SNHL was 21.5% in obese and 13.44% in normal weight adolescents (p < 0.0001). In multivariable analyses, obesity was associated with 1.73-fold increase in the odds of SNHL (95% CI: 1.25-2.40, p value = 0.006). Potentially confounding and mediating factors had minimal effect on the odds of SNHL in obese study participants (OR range of 1.69-1.75, all p values <= 0.01). CONCLUSIONS: Obesity is associated with higher prevalence of SNHL in adolescents independent of other potential risk factors. Future longitudinal investigations and mechanistic studies are warranted.

Comprehensive review of the extended middle cranial fossa approach.

PURPOSE OF REVIEW: To review the current literature on the extended middle cranial fossa (xMCF) approach and to provide a comprehensive description of the relevant anatomy, indications, surgical technique, results, and complications. RECENT FINDINGS: The xMCF approach expands the surgical exposure provided by the sMCF approach, allowing access to the internal auditory canal, cerebellopontine angle, prepontine cistern, anterior petrous apex, petrous carotid artery, Meckel's cave, cavernous sinus, mid and upper clivus, and posterior lesions approaching the jugular foramen. Preservation of serviceable hearing is possible with success rates approximating 50% in vestibular schwannoma and meningioma resection, and facial nerve outcome is excellent. SUMMARY: The xMCF is an important approach for difficult to access lesions that additionally offers the possibility of hearing preservation. This approach is also useful for vascular lesions, auditory brainstem implantation, and lesions of mid-brainstem.

The development and validation of the speech quality instrument.

OBJECTIVE: Although speech perception tests are available to evaluate hearing, there is no standardized validated tool to quantify speech quality. The objective of this study is to develop a validated tool to measure quality of speech heard. STUDY DESIGN: Prospective instrument validation study of 35 normal hearing adults recruited at a tertiary referral center. METHODS: Participants listened to 44 speech clips of male/female voices reciting the Rainbow Passage. Speech clips included original and manipulated excerpts capturing goal qualities such as mechanical and garbled. Listeners rated clips on a 10-point visual analog scale (VAS) of 18 characteristics (e.g. cartoonish, garbled). RESULTS: Skewed distribution analysis identified mean ratings in the upper and lower 2-point limits of the VAS (ratings of 8-10, 0-2, respectively); items with inconsistent responses were eliminated. The test was pruned to a final instrument of nine speech clips that clearly define qualities of interest: speech-like, male/female, cartoonish, echo-y, garbled, tinny, mechanical, rough, breathy, soothing, hoarse, like, pleasant, natural. Mean ratings were highest for original female clips (8.8) and lowest for not-speech manipulation (2.1). Factor analysis identified two subsets of characteristics: internal consistency demonstrated Cronbach's alpha of 0.95 and 0.82 per subset. Test-retest reliability of total scores was high, with an intraclass correlation coefficient of 0.76. CONCLUSION: The Speech Quality Instrument (SQI) is a concise, valid tool for assessing speech quality as an indicator for hearing performance. SQI may be a valuable outcome measure for cochlear implant recipients who, despite achieving excellent speech perception, often experience poor speech quality. LEVEL OF EVIDENCE: 2b. Laryngoscope, 128:1622-1627, 2018.

Early and Late Recurrent Epistaxis Admissions: Patterns of Incidence and Risk Factors.

Objective Epistaxis is a common complaint, yet few studies have focused on the incidence and risk factors of recurrent epistaxis. Our objective was to determine the patterns of incidence and risk factors for recurrent epistaxis admission (REA). Study Design Case series with chart review. Settings Single academic center. Subjects and Methods The medical records of patients admitted for epistaxis between 1999 and 2015 were reviewed. The follow-up period was defined as 3 years following initial admission. REAs were categorized as early (30 days) and late (31 days to 3 years) following initial admission. Logistic regression was used to identify potential predictors of REAs. Results A total of 653 patients were included. Eighty-six patients (14%) had REAs: 48 (7.5%) early and 38 (6.5%) late. Nonlinear incidence curve was demonstrated for both early and late REAs. Based on logistic regression, prior nasal surgery and anemia were independent risk factors for early REAs. According to multivariate analysis, thrombocytopenia was significantly associated with late REAs. Conclusion Early and late REAs demonstrate different risk predictors. Knowledge of such risk factors may help in risk stratification for this selected group of patients. All patients at risk should be advised on possible preventive measures. Patients at risk for early REA may benefit from a more proactive approach.