Auditory and Vestibular Symptom Improvement With Surgery for Superior Canal Dehiscence Syndrome.

OBJECTIVE: (1) To measure the change in auditory and vestibular symptoms following superior canal dehiscence (SCD) surgery, and (2) to determine differences in clinical features and surgical outcomes between superior canal dehiscence syndrome (SCDS) patients with primarily auditory or vestibular complaints. STUDY DESIGN: Retrospective cohort study. SETTING: Single surgeon series at the tertiary academic medical center from 2002 to 2021. METHODS: Retrospective review of SCDS patients who underwent surgical repair. (1) Patients were administered a standardized symptom questionnaire at preoperative and follow-up visits, and results were compared with paired statistical testing. (2) Patients were divided into 2 cohorts based on either auditory or vestibular chief complaint and differences in demographic, clinical, and outcome variables were examined. RESULTS: Our study included 113 patients with 118 operated ears. Twenty-seven patients (24%) had radiographic bilateral dehiscence. 10/11 auditory symptoms (91%) and 5/8 vestibular symptoms (63%) solicited on the questionnaire improved significantly with surgery, except for nonpulsatile tinnitus, sense of imbalance, positional dizziness, and oscillopsia. Analyses stratified by chief complaint (auditory vs vestibular) revealed overall similar characteristics and surgical outcomes. Patients with chief vestibular complaints underwent surgery at an earlier age (45.5 vs 53.9 years, p < 0.05). CONCLUSION: SCD surgery alleviates a wide range of auditory and vestibular symptoms. Overall, we did not find significant differences between patients with chief auditory versus vestibular complaints, and both groups benefited from surgery. Symptoms are not directly linked to third-window physiology and certain vestibular symptoms may be more likely to persist. Bilateral dehiscence may play an important role in persistent symptoms as well.

Middle Fossa Decompression for Recurrent Facial Palsy: Prevalence and Surgical Outcomes.

OBJECTIVE: To investigate the surgical outcomes in patients treated for recurrent facial nerve palsy (RFP) at a quaternary facial nerve referral center. METHODS: A retrospective chart review was performed on 132 patients with RFP who presented to our institution's facial nerve clinic from 2001 to 2021. Records were analyzed for etiology of palsy, facial nerve function, and recurrence rates. Pre- and post-operative audiometric outcomes were also assessed in surgically managed patients. RESULTS: 6.8% of RFP patients underwent surgical decompression. For patients who did not undergo surgery, the House-Brackmann (HB) score was 2.9 ± 1.3 (SD) at the initial clinic visit, and 2.4 ± 1.3 (SD) at the last clinic visit. This difference was significantly different (p = 0.01, t-test). For surgical patients, the pre-operative HB score was 2.9 ± 0.9 (SD) and post-operative HB score was 1.8 ± 0.6 (SD), which were significantly different (p = 0.01, t-test). The number of facial palsy episodes also decreased pre- and post-operatively from 3.5 ± 0.8 (SD) to 0.2 ± 0.4 (SD) episodes, which were significantly different (p < 0,001, t-test). Audiometric outcomes were not significantly different pre- and post-surgery (p = 0.31, t-test for PTA; p = 0.34, t-test for WRS). CONCLUSION: Facial nerve decompression for RFP patients with incomplete functional recovery may be an effective treatment for decreasing the frequency and severity of facial palsy episodes. LEVEL OF EVIDENCE: 4 Laryngoscope, 133:1222-1227, 2023.

Roid Rage: Historical Perspective on the Emergence of Oral Steroids as a Treatment of Idiopathic Sudden Sensorineural Hearing Loss.

OBJECTIVES: To review the historical circumstances that led to the emergence of corticosteroid therapy for idiopathic sudden sensorineural hearing loss (ISSNHL) and to discuss how this history has influenced current perspectives on the condition. METHODS: PubMed and Google scholar were used to identify articles of ISSNHL and oral corticoid steroid use. Historical articles accessed through our institutional medical library were also reviewed. RESULTS: The use oral corticosteroids as a treatment for ISSNHL was seemingly influenced by three key historical circumstances that, together, provided the substrate for the treatment's use in ISSNHL. First, ISSNHL was a frustrating condition with uncertainty regarding its etiology and few reliable treatment options. Second, the discovery of corticosteroids was awarded the Nobel Prize in 1950, which led to widespread application of this therapy. Third historical circumstance was the evolution and emergence of more rigorous methodological study designs in clinical research. In 1980, these events culminated in a double-blind study evaluating the effectiveness of oral steroids for treatment of ISSNHL. Interestingly, this study is often misrepresented as a randomized controlled trial, which ultimately contributed to adoption of a new standard for treatment in ISSNHL. Research subsequent to these historical events has challenged the notion of corticosteroids as a gold standard but has not altered the historically established paradigm of corticosteroid treatment. CONCLUSIONS: The use of steroids as a treatment for ISSNHL evolved from our specialty's need to address a complex condition, a novel therapeutic discovery, and a landmark study that met emerging methodological standards. Despite these strong historical foundations, ISSNHL remains a condition with an unknown etiology and the therapeutic value of corticosteroids remains unpredictable despite their gold standard label.

Development of a Predictive Model for Individualized Hearing Aid Benefit.

OBJECTIVES: To develop a model to predict individualized hearing aid benefit. To provide interpretations of model predictions on global and individual levels. METHODS: We compiled a data set of patients with hearing loss who trialed hearing aids and completed the Client Oriented Scale of Improvement (COSI) questionnaire, a validated patient-reported outcome measure of hearing aid benefit. Features included demographic, medical, and audiological measures. The outcome was the COSI score for change in listening ability with hearing aids, scaled from 1 to 5. Model development was performed using fivefold cross-validation repeated three times with hyperparameter tuning. Model performance was assessed using the root mean squared error (RMSE) of the COSI scores. Model interpretation was performed using Shapley Additive Explanations. RESULTS: The data set comprised 1,286 patients across 3,523 listening situations. The best performing model was random forest with an RMSE of 0.80, found to be significantly better than the next best model (eXtreme gradient boosting with RMSE of 0.85, p < 0.01). The most important features in predicting hearing aid benefit were shorter duration of hearing aid use, higher pure-tone average in the better hearing ear, and younger age. CONCLUSION: We have developed a predictive model for hearing aid benefit that can also provide individualized explanations of model predictions. Predictive modeling could be a useful tool in assessing a patient's candidacy and predicted benefit from hearing aids.

MRI Correlates of Ototoxicity in the Auditory Pathway in Children Treated for Medulloblastoma.

OBJECTIVE: To assess diffusion and perfusion changes of the auditory pathway in pediatric medulloblastoma patients exposed to ototoxic therapies. STUDY DESIGN: Retrospective cohort study. SETTING: A single academic tertiary children's hospital. PATIENTS: Twenty pediatric medulloblastoma patients (13 men; mean age 12.0 ±â€Š4.8 yr) treated with platinum-based chemotherapy with or without radiation and 18 age-and-sex matched controls were included. Ototoxicity scores were determined using Chang Ototoxicity Grading Scale. INTERVENTIONS: Three Tesla magnetic resonance was used for diffusion tensor and arterial spin labeling perfusion imaging. MAIN OUTCOME MEASURES: Quantitative diffusion tensor metrics were extracted from the Heschl's gyrus, auditory radiation, and inferior colliculus. Arterial spin labeling perfusion of the Heschl's gyrus was also examined. RESULTS: Nine patients had clinically significant hearing loss, or Chang grades more than or equal to 2a; 11 patients had mild/no hearing loss, or Chang grades less than 2a. The clinically significant hearing loss group showed reduced mean diffusivity in the Heschl's gyrus (p = 0.018) and auditory radiation (p = 0.037), and decreased perfusion in the Heschl's gyrus (p = 0.001). Mild/no hearing loss group showed reduced mean diffusivity (p = 0.036) in Heschl's gyrus only, with a decrease in perfusion (p = 0.008). There were no differences between groups in the inferior colliculus. There was no difference in fractional anisotropy between patients exposed to ototoxic therapies and controls. CONCLUSIONS: Patients exposed to ototoxic therapies demonstrated microstructural and physiological alteration of the auditory pathway. The present study shows proof-of-concept use of diffusion tensor imaging to gauge ototoxicity along the auditory pathway. Future larger cohort studies are needed to assess significance of changes in diffusion tensor imaging longitudinally, and the relationship between these changes and hearing loss severity and longitudinal changes of the developing auditory white matter.

Pulmonary Embolism and Sigmoid Sinus Thrombosis After Translabyrinthine Vestibular Schwannoma Resection: A Retrospective Case Series.

OBJECTIVE: To describe the presentation and treatment of patients developing pulmonary embolism following translabyrinthine approach for vestibular schwannoma resection. METHODS: This was a retrospective case series of patients at 2 academic tertiary medical centers who developed symptomatic pulmonary embolism post-operatively following translabyrinthine approach for vestibular schwannoma resection and were found to have evidence of sigmoid sinus thrombosis. RESULTS: Three patients were identified to have post-operative pulmonary emboli after translabyrinthine approach for vestibular schwannoma resection with sigmoid sinus or internal jugular vein clots in the absence of lower extremity deep vein thrombosis. Caprini scores for these patients were 5 or lower. All patients underwent CT pulmonary angiography and were confirmed to have pulmonary emboli. Two were promptly anticoagulated with heparin drips and transitioned to long-term oral anticoagulation therapy and 1 had delayed anticoagulation. None of these patients suffered from intracranial hemorrhage post-operatively. CONCLUSIONS: Patients undergoing translabyrinthine approach for vestibular schwannoma can develop pulmonary embolism from sigmoid sinus entry or thrombosis. No clear guidelines exist for the management of this complication in the setting of recent craniotomy and the risk of intracranial hemorrhage must be considered prior to initiating anticoagulation.

Effect of Immersive Virtual Reality-Based Bilateral Arm Training in Patients with Chronic Stroke.

Virtual reality (VR)-based therapies are widely used in stroke rehabilitation. Although various studies have used VR techniques for bilateral upper limb training, most have been only semi-immersive and have only been performed in an artificial environment. This study developed VR content and protocols based on activities of daily living to provide immersive VR-based bilateral arm training (VRBAT) for upper limb rehabilitation in stroke patients. Twelve patients with chronic stroke were randomized to a VRBAT group or a normal bilateral arm training (NBAT) group and attended 30-min training sessions five times a week for four weeks. At the end of the training, there was a significant difference in upper limb function in both groups (p < 0.05) and in the upper limb function sensory test for proprioception in the NBAT group (p < 0.05). There was no significant between-group difference in upper limb muscle activity after training. The relative alpha and beta power values for electroencephalographic measurements were significantly improved in both groups. These findings indicate that both VRBAT and NBAT are effective interventions for improving upper limb function and electroencephalographic activity in patients with chronic stroke.

Postoperative Venous Thromboembolism after Neurotologic Surgery.

Objective This study aimed to determine the incidence of postoperative venous thromboembolism (VTE) in adults undergoing neurotologic surgery at a single center. Methods The records of adults undergoing neurotologic surgery from August 2009 to December 2016 at a tertiary care hospital were reviewed for VTE within 30 postoperative days. Particular attention was focused on postoperative diagnosis codes, imaging, and a keyword search of postoperative notes. Caprini risk scores were calculated. Results Among 387 patients, 5 experienced postoperative VTE including 3 cases of pulmonary embolism (PE) and 2 cases of isolated deep vein thrombosis (DVT). All patients were given sequential compression devices perioperatively, and none received preoperative chemoprophylaxis. Patients with Caprini score > 8 had a significantly higher rate of VTE compared with those < 8 (12.5 vs. 1%, p = 0.004). Receiver operating characteristic analysis revealed the Caprini risk assessment model to be a fair predictor of VTE, with a C-statistic of 0.70 (95% confidence interval [CI]: 0.49-0.92). Conclusion While no specific validated VTE risk stratification scheme has been widely accepted for patients undergoing neurotologic surgery, the Caprini score appears to be a useful predictor of risk. The benefits of chemoprophylaxis should be balanced with the risks of intraoperative bleeding, as well as the potential for postoperative intracranial hemorrhage.

Dissociating antibacterial from ototoxic effects of gentamicin C-subtypes.

Gentamicin is a potent broad-spectrum aminoglycoside antibiotic whose use is hampered by ototoxic side-effects. Hospital gentamicin is a mixture of five gentamicin C-subtypes and several impurities of various ranges of nonexact concentrations. We developed a purification strategy enabling assaying of individual C-subtypes and impurities for ototoxicity and antimicrobial activity. We found that C-subtypes displayed broad and potent in vitro antimicrobial activities comparable to the hospital gentamicin mixture. In contrast, they showed different degrees of ototoxicity in cochlear explants, with gentamicin C2b being the least and gentamicin C2 the most ototoxic. Structure-activity relationships identified sites in the C4'-C6' region on ring I that reduced ototoxicity while preserving antimicrobial activity, thus identifying targets for future drug design and mechanisms for hair cell toxicity. Structure-activity relationship data suggested and electrophysiological data showed that the C-subtypes both bind and permeate the hair cell mechanotransducer channel, with the stronger the binding the less ototoxic the compound. Finally, both individual and reformulated mixtures of C-subtypes demonstrated decreased ototoxicity while maintaining antimicrobial activity, thereby serving as a proof-of-concept of drug reformulation to minimizing ototoxicity of gentamicin in patients.

Trends in Age of Cochlear Implant Recipients, and the Impact on Perioperative Complication Rates.

OBJECTIVE: The aim of the study is to examine trends in the age of patients receiving cochlear implants and to determine the effect of age on the rate of perioperative complications. STUDY DESIGN: Retrospective analysis of deidentified administrative claims data from a US commercial insurance database (Optum). PATIENTS: Individuals undergoing cochlear implantation between 2003 and 2016. SETTING: US hospital and outpatient facilities serving commercially insured patients. INTERVENTION: Cochlear implantation. MAIN OUTCOME MEASURES: Age at implantation, incidence of perioperative complications within 30 days identified by ICD9/10 codes including device problems, myocardial infarction, stroke, venous thromboembolism, local infection, meningitis, stroke, cerebrospinal fluid leak, and facial weakness. RESULTS: Between 2003 and 2016, 3420 patients underwent a total of 4154 cochlear implants. The number of implants per year increased annually from 171 in 2003 to 531 in 2016, with the greatest growth demonstrated in those aged 60 and older.The age of patients undergoing implantation increased annually from an average of 26.6-57.2 years (p < 0.001). The implantation rates from 2003 to 2016, per 100,000 enrollees, increased from 1.64 to 6.82 for patients 60-79 years of age, and 0 to 11.57 for patients greater than 80 years of age (p < 0.001). No significant differences in 30-day complication rates were found between patients when grouped by age in decades, except for device related problems, which was significantly higher in younger patients (<18 years). CONCLUSION: Over the past decade and a half, cochlear implantation is more frequently being performed, and in an increasingly aging population. This trend does not seem to alter the risk of perioperative complications.

Postoperative Venous Thromboembolism after Extracranial Otologic Surgery.

OBJECTIVE: To determine the incidence of postoperative venous thromboembolism (VTE) in adults undergoing otologic surgery. STUDY DESIGN: Cross-sectional retrospective study. SETTING: Single tertiary academic center. SUBJECTS AND METHODS: Adults undergoing nononcologic, extracranial otologic surgery from August 2009 to December 2016. Patients with postoperative diagnosis VTE codes were identified. Imaging and clinical documents were searched for VTE evidence within the first 30 postoperative days. Methods of thromboprophylaxis were documented, and Caprini risk scores were calculated. RESULTS: In total, 1213 otologic surgeries were evaluated. No postoperative VTE events were identified (0/1268). Mean age was 51.0 ± 17.3 years (range, 18.1-93.4 years). Average length of surgery was 136.0 ± 79.0 minutes (range, 5-768 minutes). The average Caprini score in all patients was 4.0 ± 1.7 (range, 1-15). Eighty-five percent of patients had a Caprini score ≥3, the threshold at which chemoprophylaxis has been recommended in general surgery patients by the American College of Chest Physicians 2012 guidelines. Six patients had documented preoperative chemoprophylaxis and a Caprini score of 4.8 ± 1.7. This was not significantly different from that of patients who did not receive preoperative chemoprophylaxis (t test, P = .3). The literature would estimate a rate of 3.7% VTE in adults with similar Caprini scores undergoing general surgery procedures with no VTE prophylaxis. CONCLUSION: The Caprini risk assessment model may overestimate VTE risk in patients undergoing extracranial otologic surgery. Postoperative VTE following otologic surgery is rare, even in patients traditionally considered moderate or high risk. Chemoprophylaxis guidelines in this group should be balanced against the potential risk of increased intraoperative bleeding and its associated effects on surgical visualization and morbidity.

Prevalence of Radiographic Cochlear-Facial Nerve Dehiscence.

OBJECTIVE: To determine the prevalence of radiographic cochlear-facial nerve dehiscence (CFD). STUDY DESIGN: Retrospective radiological study. SETTING: Two tertiary-referral centers. PATIENTS: Two hundred six temporal-bone computed tomography (CT) scans (405 total ears) of otology/neurotology patients from two academic institutions between the years 2014 and 2017. INTERVENTION: Diagnostic. MAIN OUTCOME MEASURES: The cochlear-facial nerve partition width (CFPW) was measured on coronal CT sections and defined as the shortest distance between the cochlear basal turn and facial nerve (FN) labyrinthine segment. We used logistics regression analyses to determine positive predictors for radiographic evidence of CFD. RESULTS: The overall prevalence of radiographic CFD was 5.4% (22/406 ears). 9.2% of patients (19/206) had CFD. Of these 19 patients, only one patient had mixed hearing loss that could not be explained by any other vestibular or auditory etiology. Three out of 206 patients had dehiscence in both ears (1.4%). The average CFPW was 0.6 ±â€Š0.2 mm, and fallopian canal width was 1.1 ±â€Š0.02 mm (n = 405). Older age, use of traditional CT scans, and thinner CT slice thickness were significant predictors for radiographic CFD. CONCLUSIONS: The radiographic prevalence of CFD is higher than what is reported in histologic studies, and may over-estimate the true prevalence of CFD. The clinician should keep this in mind when considering this as potential cause for third-window symptoms.

Temporal Bone CT Scan for Malleal Ligaments Assessment.

OBJECTIVE: To determine the feasibility of using temporal bone computed tomography (CT) scans to identify malleal ligaments and the prevalence of calcification in malleal ligaments. STUDY DESIGN: Retrospective case review. CT scans were blindly and retrospectively reviewed by two physicians (a radiologist and a nonradiologist). Scans differed by slice thickness, and included both conventional CT and cone beam CT (CBCT). SETTING: Ambulatory tertiary referral center. PATIENTS: One hundred fifty-one temporal bone CT scans, obtained between the years 2014 and 2017, were initially screened, which included 302 ears. Patients with previous tympanomastoid surgery or middle ear opacification were excluded, leaving 187 ears in the study. INTERVENTION: Diagnostic. MAIN OUTCOME MEASURE: Percentage of visible normal and calcified malleal ligaments. RESULTS: Scans with submillimeter slice thickness were more likely to demonstrate all three malleal ligaments than those with 1 ml and larger slices (83.7% versus 50.0% for nonradiologist, p < 0.0001; 59.6 versus 34.8% for radiologist, p < 0.0001). Calcification was seen in 11.8% of ears reviewed. The ability to detect malleal ligaments with cone beam CT was 86.2%, while the rate with conventional CT was 71.1%, a difference that persisted when controlling for slice thickness. Interobserver agreement for the detection of malleal ligaments was 65% with a Cohen's kappa coefficient of κ = 0.27. CONCLUSION: Visualization of the malleal ligaments using CT scans is feasible in a majority of aerated ears. Detection of malleal ligaments improves with thinner slice thickness and cone-beam technique. Low interobserver agreement suggests the importance of experience and a need for standardized review.

Retrograde Parotidectomy and facial nerve outcomes: A case series of 44 patients.

PURPOSE: The most common surgical method to remove benign parotid tumors remains the prograde approach. We examined if a retrograde surgical technique offers better outcomes than historical prograde controls. MATERIALS AND METHODS: A retrospective chart review at Stanford Hospital was conducted to identify retrograde parotidectomies between February 2012 and October 2014 that were staffed by the senior author (DS) with resident involvement. Facial nerve (FN) outcomes and other post-surgical parameters were recorded. RESULTS: We identified 44 consecutive cases and found that 18.2% (n=8) of patients experienced temporary paresis and 2.3% (n=1) experienced minor (HB 2) permanent paresis limited to one branch. The average hospital length of stay was 0.64 days and complication rate was 6.8%. CONCLUSION: The retrograde technique has complication rates comparable to historical rates for the prograde technique and is amenable to minimally invasive outpatient superficial parotidectomy.

Synthesis of upconversion nanoparticles conjugated with graphene oxide quantum dots and their use against cancer cell imaging and photodynamic therapy.

Multifunctional nanocomposite has a huge potential for cell imaging, drug delivery, and improving therapeutic effect with less side effects. To date, diverse approaches have been demonstrated to endow a single nanostructure with multifunctionality. Herein, we report the synthesis and application of core-shell nanoparticles composed with upconversion nanoparticle (UCNP) as a core and a graphene oxide quantum dot (GOQD) as a shell. The UCNP was prepared and applied for imaging-guided analyses of upconversion luminescence. GOQD was prepared and employed as promising drug delivery vehicles to improve anti-tumor therapy effect in this study. Unique properties of UCNPs and GOQDs were incorporated into a single nanostructure to provide desirable functions for cell imaging and drug delivery. In addition, hypocrellin A (HA) was loaded on GOQDs for photo-dynamic therapy (PDT). HA, a commonly used chemotherapy drug and a photo-sensitizer, was conjugated with GOQD by π-π interaction and loaded on PEGylated UCNP without complicated synthetic process, which can break structure of HA. Applying these core-shell nanoparticles to MTT assay, we demonstrated that the UCNPs with GOQD shell loaded with HA could be excellent candidates as multifunctional agents for cell imaging, drug delivery and cell therapy.

Osteoconductivity of Binary Titanium Alloys with Different Micro/Nanoporous Surfaces.

The surface characteristics and osteoconductivity were evaluated for the micro/nanoporous surfaces of titanium (Ti) alloys prepared by micro-arc oxidation (MAO) and hydrothermal treatment (HT) of binary Ti-5 wt% A alloys (A = Au, Mn, Nb, and Pd). Surface properties were analyzed using X-ray diffractometry, scanning electron microscopy, and energy dispersive X-ray spectroscopy. The osteoconductivity was evaluated by measuring the total protein, ALPase activity, and osteocalcin production. The surface morphologies of MAO/HT specimens mainly affected on their osteoconductivity. Total proteins on Ti alloys (MAO/HT) were slightly lower than that on commercially pure Ti (MAO/HT) after incubation of MG-63 osteoblast-like cells for 14 days. However, better ALPase activity and osteocalcin production were observed on MAO/HT-treated Ti­5Mn, Ti­5Nb, and Ti­5Pd than that on cp-Ti (MAO/HT) after 14 days. Especially, Ti­5Mn (MAO/HT) showed a significant increase of ALPase activity due to its well grown micro/nano structure. Meanwhile, very small nanorods on Ti­5Au (MAO/HT) affected negatively to ALPase activity and osteocalcin production.

Consultation via telemedicine and access to operative care for patients with head and neck cancer in a Veterans Health Administration population.

BACKGROUND: The purpose of this study was to evaluate a telemedicine model that utilizes an audiovisual teleconference as a preoperative visit. METHODS: Veterans Health Administration (VHA) patients with head and neck cancer at 2 remote locations were provided access to the Palo Alto Veterans Affairs (PAVA) Health Care System otolaryngology department via the telemedicine protocol: tissue diagnosis and imaging at the patient site; data review at PAVA; and a preoperative teleconference connecting the patient to PAVA. Operative care occurred at PAVA. Follow-up care was provided remotely via teleconference. RESULTS: Fifteen patients were evaluated. Eleven underwent surgery, 4 with high-grade neoplasms (carcinoma). Average time from referral to operation was 28 days (range, 17-36 days) and 72 (range, 31-108 days), respectively, for high-grade and low-grade groups. The average patient was spared 28 hours traveling time and $900/patient was saved on travel-related costs. CONCLUSION: A telemedicine model enables timely access to surgical care and permits considerable savings among select VHA patients with head and neck cancer. © 2016 Wiley Periodicals, Inc. Head Neck 38: 925-929, 2016.

Faster Triage of Veterans With Head and Neck Cancer.

High-risk patients with a growing mass require proper assessment, including a thorough history, physical examination, and fine-needle aspiration for diagnosis.

Surface Characterization and Osteoconductivity Evaluation of Micro/Nano Surface Formed on Titanium Using Anodic Oxidation Combined with H2O2 Etching and Hydrothermal Treatment.

In this study, surface characteristics and osteoconductivity were investigated for the micro/nanostructured oxide layers fabricated on titanium using anodic oxidation (ANO), chemical etching (Et), and hydrothermal treatment (HT). Commercially pure titanium (CP-Ti) disks were anodic-oxidized using DC-type power supply in 1 M phosphoric acid electrolyte (P-ANO group). These specimens were further chemically etched using 30% H2O2 solution at 60 °C for 10 min (P-ANO-Et group). The P-ANO-Et-HT group was fabricated by hydrothermally treating the P-ANO-Et specimens in phosphorus-containing alkaline solution at 190 °C for 8 hrs. The P-ANO group showed a porous surface that was evenly covered with micro- and sub-micro pores. The size of these pores was decreased in the P-ANO-Et group. The P-ANO-Et-HT group showed a porous surface that was covered with nano-sized crystallites. Anatase TiO2 structure was observed in P-ANO-Et-HT group. The results of XPS demonstrated that the P-ANO-Et-HT group had a well-crystallized TiC2 structure, while the P-ANO and P-ANO-Et groups had an amorphous and phosphate-containing structure. Hydrophilicity of the P-ANO-Et-HT group was the highest. After MG63 osteoblast-like cells were cultured on the specimens for 3 hrs, SEM images of the cells cultured on P-ANO-Et-HT group specimens showed low initial adhesion. However, the osteoconductivity of these specimens increased more rapidly compared to that of the micro-structured surfaces. These results could be applied to fabricate titanium implants with an optimum micro/nano-surface for enhancing their osteoconductivity.