Vestibular Co-stimulation in Adults with a Cochlear Implant.

BACKGROUND: Vestibular co-stimulation is a side effect of cochlear implant stimulation. The electrical currents delivered by the cochlear implant can spread toward the vestibular system and thus stimulate it. The aim of the study is to evaluate whether it is feasible to functionally restore the balance by modifying the vestibular co-stimulation. METHODS: Four adult patients, who had received a commercially available cochlear implant previously, were enrolled. Counterbalanced biphasic pulses were presented as bursts or as an amplitude-modulated biphasic pulse train (modulation frequencies ranging from 1 to 500 Hz) at the participant's upper comfortable level for electrical stimulation. Subjective sensations and vestibular-mediated eye movements were used for evaluating the possible effects of vestibular co-stimulation. RESULTS: One participant experienced a cyclic tilting of his head in response to an amplitude-modulated biphasic pulse train with a modulation frequency of 2 and 400 Hz. However, during a follow-up visit, the sensation could not be replicated. CONCLUSION: Subjective vestibular sensations or vestibular-mediated eye movements could not be electrically evoked with a commercially available cochlear implant in 4 adult patients with almost normal vestibular function. Therefore, customized design of the hard-, firm-, and/or software of the commercially available cochlear implant might be necessary in order to electrically restore vestibular performance.

The reliability of the Dutch version of the vestibular activities avoidance instrument in persons with and without dizziness.

BACKGROUND: Avoidance of activities that trigger dizziness in persons with vestibular disorders may inhibit dynamic vestibular compensation mechanisms. OBJECTIVE: To determine the reliability of the Vestibular Activities Avoidance Instrument (VAAI) 81 and 9 item tool and to compare the VAAI scores in Dutch-speaking healthy adults and in patients with vestibular disorders. METHODS: A prospective cohort study was conducted including 151 healthy participants and 106 participants with dizziness. All participants completed the 81-item VAAI. Within 7 days, the VAAI was completed a second time by 102 healthy adults and 43 persons with dizziness. RESULTS: The average 81-item VAAI scores [54.8(47.1) vs. 228.1(78.3)] and 9-item VAAI scores [2.4(5.9) vs. 28.1(12)] were significantly different between healthy adults and participants with dizziness (p < 0.001). In participants with dizziness the ICC for the 81-item VAAI was 0.95 (95% CI: 0.91, 0.97) and for the 9-item VAAI was 0.92 (95% CI: 0.85, 0.95). Cronbach's alpha for the 81-item VAAI was 0.97 and 0.85 for the 9-item VAAI. The minimal detectable change was 47.8 for the 81-item VAAI and 8.9 for the 9-item VAAI. CONCLUSIONS: Persons with dizziness have a greater tendency to avoid movements. Both test-retest reliability and internal consistency of the Dutch version of the VAAI were excellent.

Comparison between 3D SPACE FLAIR and 3D TSE FLAIR in Menière's disease.

PURPOSE: Heavily T2-weighted 3D FLAIR (hT2w-3D-FLAIR) sequence with constant flip angle (CFA) has been reported as being more sensitive to low concentrations of gadolinium (Gd) enabling endolymphatic hydrops (EH) visualization. The purpose of this study was to compare signal-to-noise (SNR) ratio, detection rate of EH, and increased perilymphatic enhancement (PE) as well as diagnostic accuracy in diagnosing definite Menière's disease (MD), using 3D-SPACE FLAIR versus conventional 3D-TSE FLAIR. METHODS: This retrospective study included 29 definite MD patients who underwent a 4-h delayed intravenous (IV) Gd-enhanced 3D-TSE FLAIR and 3D-SPACE FLAIR MRI between February 2019 and February 2020. MR images were qualitatively and quantitatively analyzed twice by 2 experienced head and neck radiologists. Qualitative assessment included grading of cochlear and vestibular EH and visual comparison of PE. Quantitative assessment of PE was performed by placing a region of interest (ROI) and ratio calculation in the basal turn of the cochlea and the brainstem. RESULTS: The intra- and inter-reader reliability for grading of EH and PE was excellent (0.7 < kappa < 0.9) for 3D-SPACE FLAIR and exceeded the values for 3D-TSE FLAIR (0.5 < kappa < 0.9) The combination of EH and visual assessment of PE has the highest diagnostic accuracy in diagnosing definite MD on 3D-SPACE FLAIR with a sensitivity of 0.91 and a specificity of 0.98 resulting in a sensitivity raise of 6% compared to 3D-TSE FLAIR. CONCLUSION: Four-hour delayed IV Gd-enhanced 3D-SPACE FLAIR sequence has a higher sensitivity and reproducibility than 3D-TSE FLAIR for the visualization of EH and increased PE in definite MD patients.

Prognostic Value of Trial Round Window Stimulation for Selection of Candidates for Cochlear Implantation as Treatment for Tinnitus.

Electrical stimulation with cochlear implants is able to significantly suppress the tinnitus sensations in 25-72% of implanted patients. Up to this point, no clear predictors for the effectiveness of tinnitus suppression with cochlear implants have been found and this substantially limits the possibility of the application of cochlear implants for this purpose. The objective of the study was to investigate if a trial electrical round window stimulation (RWS) could be used as a diagnostic tool for identifying candidates in whom electrical stimulation would be successful as treatment for tinnitus. Thirty-four patients with unilateral severe tinnitus and ipsilateral moderate to severe sensorineural hearing loss underwent a trial RWS under local anesthesia. Thirteen patients received a cochlear implant. All patients qualified for cochlear implantation on the basis of the trial RWS showed tinnitus suppression with the implant switched on. Complete or almost complete tinnitus suppression was obtained in 77% and partial in 23%. The mean tinnitus loudness reduction was 68% (VAS score reduction from 7.7 to 2.5). False negative results are estimated not to exceed 10-15%. We conclude that significant tinnitus suppression achieved during trial RWS under local anesthesia is a simple procedure allowing the efficient identification of candidates in whom electrical stimulation with a cochlear implant would be successful as treatment for intractable tinnitus.

Differences in Vestibular-Evoked Myogenic Potential Responses by Using Cochlear Implant and Otolith Organ Direct Stimulation.

Objective: Several studies have demonstrated the possibility to obtain vestibular potentials elicited with electrical stimulation from cochlear and vestibular implants. The objective of this study is to analyze the vestibular-evoked myogenic potentials (VEMPs) obtained from patients implanted with cochlear and vestibulo-cochlear implant. Material and Methods: We compared two groups: in the first group, four cochlear implant (CI) recipients with present acoustic cVEMPs before CI surgery were included. In the second group, three patients with bilaterally absent cVEMPs and bilateral vestibular dysfunction were selected. The latter group received a unilateral cochleo-vestibular implant. We analyze the electrically elicited cVEMPs in all patients after stimulation with cochlear and vestibular electrode array stimulation. Results: We present the results obtained post-operatively in both groups. All patients (100%) with direct electrical vestibular stimulation via the vestibular electrode array had present cVEMPs. The P1 and N1 latencies were 11.33-13.6 ms and 18.3-21 ms, respectively. In CI patients, electrical cVEMPs were present only in one of the four subjects (25%) with cochlear implant ("cross") stimulation, and P1 and N1 latencies were 9.67 and 16.33, respectively. In these patients, the responses present shorter latencies than those observed acoustically. Conclusions: Electrically evoked cVEMPs can be present after cochlear and vestibular stimulation and suggest stimulation of vestibular elements, although clinical effect must be further studied.

The MO-meatocanalplasty: long-term results in the narrow external auditory canal with recurrent otitis externa or the inability to wear a hearing aid.

OBJECTIVE: The MO-meatocanalplasty is the oblique modification of the M-meatoplasty. The MO-meatocanalplasty was designed to address the superior quadrants of the meatus and the bony canal without the need for a retro-auricular incision. This retrospective analysis was performed to evaluate the long-term results of the MO-meatocanalplasty in patients with a narrow external auditory canal (EAC) with recurrent otitis externa or in patients unable to wear a hearing aid. METHODS: Twenty-two ears in twenty consecutive patients who received a MO-meatocanalplasty for a narrow EAC with recurrent otitis externa or the inability to wear a hearing aid were analysed retrospectively. There were no patients included with any type of previous or planned second stage tympanoplasty procedures. A follow-up period of 3 years was analysed for postoperative recurrent narrowing, the self-cleaning capacity of the EAC, the recurrence of otitis externa, the inability to wear a hearing aid, change in hearing level and for all types of aesthetical complaints. RESULTS: The MO-meatocanalplasty procedure was effective in 82% (n = 18). Postoperative recurrent narrowing was detected in 9% (n = 2). Insufficient self-cleaning capacity of the EAC was 9.1% (n = 2). The ability to wear a hearing aid was restored in all patients with the need for a hearing aid. No aesthetical complaints were reported. CONCLUSION: The MO-meatocanalplasty is an effective, safe and aesthetical accepted procedure to address the narrow meatus and external auditory canal. With this procedure, there is no need for a retro-auricular incision in order to create a well aerated, dry and self-cleaning EAC in patients with a narrow EAC with recurrent otitis externa or in patient with the inability to wear a hearing aid.

The relationship between cochleovestibular function tests and endolymphatic hydrops grading on MRI in patients with Menière's disease.

PURPOSE: In this retrospective study the relationship between cochleovestibular function and a magnetic resonance imaging (MRI-) based classification system of endolymphatic hydrops was investigated. METHODS: Seventy-eight patients with unilateral definite Menière's disease who underwent MRI were included. The parameters of Pure Tone Audiometry (PTA), caloric irrigation test, cervical vestibular evoked myogenic potentials, and video Head Impulse Test were compared between the grades of endolymphatic hydrops (EH) and perilymphatic enhancement (PE) on MRI. RESULTS: The low-frequency PTA was significantly different between cochlear EH grades I and II (p = 0.036; Grade I: mean (Standard Deviation, SD) = 51 decibel Hearing Level (dB HL) (18 dB HL); Grade II: mean (SD) = 60 dB HL (16 dB HL)), and vestibular EH grades 0 and III (p = 0.018; Grade 0: mean (SD) = 43 dB HL (21 dB HL); Grade III: mean = 60 dB HL (10 dB HL)). The ipsilateral caloric sum of ears with vestibular EH grade I (n = 6) was increased with regards to vestibular EH grades 0 (p = 0.001), II (p < 0.001), and III (p < 0.001) (Grade 0: mean (SD) = 24°/s (15°/s); Grade I: mean (SD) = 47°/s (11°/s); Grade II: mean (SD) = 21°/s (13°/s); Grade III: mean (SD) = 16°/s (8°/s)). CONCLUSION: According to these results we can conclude that only the highest grades of cochlear and vestibular EH seem to be associated with decreased cochleovestibular functioning.

Understanding and Managing Trauma-Induced Vestibular Deficits.

OBJECTIVES: Traumatic brain injury occurs frequently worldwide. Half of traumatic brain injuries are related to falls or motor vehicle accidents. The term "concussion" is often used to describe a minor form of traumatic brain injury. These often involve decelerative events to the head (e.g., flexion/extension injury) and can also cause damage to the vestibular system of the inner ear. MATERIALS AND METHODS: The European Society for Clinical Evaluation of Balance Disorders meets yearly and has proposed an investigation and analysis of the vestibular consequences of traumatic brain injury. This review paper outlines these discussions. RESULTS: The Society discussed all aspects of trauma-induced vestibular disorders along with diagnosis and management. They also assessed the diagnostic tests available to investigate these disorders. CONCLUSION: Trauma-induced vestibular disorders are difficult to manage, as our level of understanding of the pathology can be poor and anatomical localization can also be difficult. Accordingly, a definitive diagnosis cannot be pinpointed in many patients, but an extensive history taking is crucial to determine the nature and extent of vestibular involvement. Trauma can not only result in microtrauma to the central nervous system but can also significantly affect peripheral vestibular structures, particularly the otolith organs. The committee hopes that better understanding of trauma to the vestibular system, along with improvements in the field of radiology and vestibular assessments, will aid in more precise techniques of pinpointing pathology in order to develop an adapted treatment plan.

The Antwerp Vestibular Compensation Index (AVeCI): an index for vestibular compensation estimation, based on functional balance performance.

PURPOSE: To create an index that is a measure of the amount of vestibular compensation and for which only functional balance performance is needed. METHODS: The medical charts of 62 eligible peripheral vestibular dysfunction (PVD) patients were analyzed retrospectively. To be included, the following vestibulo-ocular reflex (VOR) and balance performance data had to be available: (1) caloric and sinusoidal harmonic acceleration test (SHA) and (2) standing balance sum-eyes closed (SBS-EC), Timed Up and Go Test and Dynamic Gait Index. Patients were divided into three groups: normal caloric- and SHA test (group 1), abnormal caloric- and normal SHA test (group 2, PVD compensated) and abnormal caloric- and SHA test (group 3, PVD uncompensated). Next to the use of non-parametric tests to study the VOR and balance variables, logistic regression was used to identify the balance measures that predict whether PVD patients were compensated or uncompensated. This resulted also in the construction of a continuous measure representing the degree of compensation. RESULTS: Logistic regression identified SBS-EC and age to classify uncompensated from compensated patients with sensitivity of 83.9% and specificity of 72.4%. Then an index was created, called the Antwerp Vestibular Compensation Index, AVeCI = - 50 + age × 0.486 + SBS-EC × 0.421. A patient belongs to the uncompensated group when AVeCI < 0 and to the compensated group when AVeCI > 0, with respective group means of - 5 and 5. CONCLUSION: AVeCI stages the degree of compensation of PVD patients and can serve to evaluate rehabilitation effects.

The bony obliteration tympanoplasty in cholesteatoma: safety, hygiene and hearing outcome: allograft versus autograft tympanic membrane reconstruction.

OBJECTIVE: To evaluate early results on hygiene, safety and functional outcome in a population undergoing a canal wall up technique with bony obliteration of the mastoid and epitympanic space (CWU-BOT) for extensive cholesteatoma, performed by a single surgeon. This study compares different techniques of tympanic membrane reconstruction, viz. allografts and autografts. PATIENTS: A consecutive series of 61 ears with acquired cholesteatoma treated with primary or revision CWU-BOT surgery from 2009 to 2014. INTERVENTION: Obliteration was performed by the use of cortical bone-chips and bone pâté. Patients were followed up with micro-otoscopy and MRI with diffusion-weighted imaging. Ossicular reconstruction was performed using a remodelled autologous or allogenic incus or malleus. MAIN OUTCOME MEASURES: Residual and recurrence rate and short- and mid-term hearing outcome prior to any revision tympanoplasty were analysed, the effect of type of tympanic membrane reconstruction was considered. RESULTS: 44 Ears were primary cholesteatoma cases, 17 cases were referred for revision surgery. Mean postoperative follow up was 45 months (SD 18.08) and mean follow-up until the last non-EP DW MRI 42 months (SD 17.72). Recurrent disease was present in 3%, no residual disease was present. An AC gain was seen in 75% of all ears undergoing ossicular reconstruction. CONCLUSION: Reproducible safety, hygiene and hearing results with limited recurrence and residual disease can be obtained by younger otologic surgeons performing the BOT-CWU for extensive cholesteatoma while using a variety of grafts for tympano-ossicular reconstruction. The tympano-ossicular allograft nevertheless shows superior hearing results when a mobile intact stapes is present. LEVEL OF EVIDENCE: Level 4.

Vestibular Infant Screening (VIS)-Flanders: results after 1.5 years of vestibular screening in hearing-impaired children.

Due to the close anatomical relationship between the auditory and vestibular end organs, hearing-impaired children have a higher risk for vestibular dysfunction, which can affect their (motor) development. Unfortunately, vestibular dysfunction often goes unnoticed, as vestibular assessment in these children is not standard of care nowadays. To timely detect vestibular dysfunction, the Vestibular Infant Screening-Flanders (VIS-Flanders) project has implemented a basic vestibular screening test for hearing-impaired infants in Flanders (Belgium) with a participation rate of 86.7% during the first year and a half. The cervical Vestibular Evoked Myogenic Potentials (cVEMP) test was applied as vestibular screening tool to map the occurrence of vestibular (mainly saccular) dysfunction in this population. At the age of 6 months, 184 infants were screened. No refers on vestibular screening were observed in infants with permanent conductive hearing loss. In infants with permanent sensorineural hearing loss, a cVEMP refer rate of 9.5% was observed. Failure was significantly more common in infants with severe-profound compared to those with mild-moderate sensorineural hearing loss (risk ratio = 9.8). Since this is the first regional study with a large sample size and successful participation rate, the VIS-Flanders project aims to set an example for other regions worldwide.

The Sensitivity of the cVEMP Test in Detecting A Superior Semicircular Canal Dehiscence and the Influence of a Coexisting Incudal Lysis: A Case Report.

In this case report, the air-conducted cervical vestibular evoked myogenic potentials (AC cVEMP) test was only sensitive for the left superior semicircular canal dehiscence (SCD), even though the contralateral SCD was of equal length (2.5 mm). Furthermore, a lysis of the processus lenticularis incudis caused a real conductive hearing loss in the left ear. A diminished left AC cVEMP was thus expected, but the opposite was shown (increased corrected amplitude, lowered detection threshold). The patient only experienced hearing loss, so middle ear surgery was performed to repair the lysis. The postoperative AC cVEMP showed a further "uncovering" of the SCD with increased corrected amplitude on the left but no vestibular symptoms. The significance of an SCD should be interpreted with caution, even when the AC cVEMP and the imaging are significant. Furthermore, AC cVEMPs should not be considered as evidence for the absence or presence of conductive hearing loss.

Electrical Vestibular Stimulation in Humans: A Narrative Review.

BACKGROUND: In patients with bilateral vestibulopathy, the regular treatment options, such as medication, surgery, and/or vestibular rehabilitation, do not always suffice. Therefore, the focus in this field of vestibular research shifted to electrical vestibular stimulation (EVS) and the development of a system capable of artificially restoring the vestibular function. Key Message: Currently, three approaches are being investigated: vestibular co-stimulation with a cochlear implant (CI), EVS with a vestibular implant (VI), and galvanic vestibular stimulation (GVS). All three applications show promising results but due to conceptual differences and the experimental state, a consensus on which application is the most ideal for which type of patient is still missing. SUMMARY: Vestibular co-stimulation with a CI is based on "spread of excitation," which is a phenomenon that occurs when the currents from the CI spread to the surrounding structures and stimulate them. It has been shown that CI activation can indeed result in stimulation of the vestibular structures. Therefore, the question was raised whether vestibular co-stimulation can be functionally used in patients with bilateral vestibulopathy. A more direct vestibular stimulation method can be accomplished by implantation and activation of a VI. The concept of the VI is based on the technology and principles of the CI. Different VI prototypes are currently being evaluated regarding feasibility and functionality. So far, all of them were capable of activating different types of vestibular reflexes. A third stimulation method is GVS, which requires the use of surface electrodes instead of an implanted electrode array. However, as the currents are sent through the skull from one mastoid to the other, GVS is rather unspecific. It should be mentioned though, that the reported spread of excitation in both CI and VI use also seems to induce a more unspecific stimulation. Although all three applications of EVS were shown to be effective, it has yet to be defined which option is more desirable based on applicability and efficiency. It is possible and even likely that there is a place for all three approaches, given the diversity of the patient population who serves to gain from such technologies.

Health Related Quality of Life after the Bony Obliteration Tympanoplasty for COM with Cholesteatoma using the COMQ12 - A Disease Specific PROM.

OBJECTIVES: This study aimed to investigate the effect of canal wall up with bony obliteration tympanoplasty (CWU-BOT) on the health-related quality of life (HRQOL) in patients with chronic otitis media with cholesteatoma by using the chronic otitis media questionnaire 12 (COMQ-12). MATERIALS AND METHODS: This study is a retrospective analysis of the COMQ-12 of 26 patients who completed the COMQ-12 before and after a CWU-BOT with eradication of cholesteatoma followed by obliteration of the mastoid and paratympanic space with bone chips and bone pâté and reconstruction of the tympanic membrane and ossicular chain. RESULTS: All patients were operated upon in our institute between 2014 and 2017. The median score of the 12 questions was preoperatively and postoperatively calculated, and then compared. A large effect was observed in the total score and the questions about running ear, discharge, and visits to the general practitioner. A medium positive size effect was observed in the questions about hearing in noisy surroundings, discomfort, dizziness, tinnitus, medication use, and the mental aspect of the patient. In the questions about the hearing at home and quality of life and impact on work, we noted a small positive size effect. In 50% of patients, the HRQOL became normal; the remaining 50% improved to a level very close to normal. CONCLUSION: Canal wall up with bony obliteration tympanoplasty (CWU-BOT) showed a clear decrease in the severity of the symptoms, life and work impact, and health care after surgery.

Cochlear Erosion due to a Facial Nerve Schwannoma.

Facial nerve schwannomas are rare benign neoplasms. We report a case of a 60-year-old woman who initially presented with vestibular complaints. Magnetic resonance imaging (MRI) revealed a facial nerve schwannoma centered on the right geniculate ganglion extending in the labyrinthine segment. The patient consulted again after 2 months because she developed a sudden and severe right-sided sensorineural hearing loss. MRI showed no progression or pathological enhancement in the membranous labyrinth. A cone beam computed tomography (CT) of the temporal bone was performed and revealed a large erosion at the region of the geniculate ganglion in open communication with the middle turn of the cochlea. This case report demonstrates the importance of CT in facial nerve schwannomas for evaluating the impact on the surrounding structures.

Validity and Test-Retest Reliability of the Dutch Version of the Chronic Otitis Media Benefit Inventory.

OBJECTIVES: We aimed to test the validity and test-retest reliability of the Dutch translation of the Chronic Otitis Media Benefit Inventory (COMBI) questionnaire. MATERIALS AND METHODS: In total, 30 chronic otitis media (COM) patients with a previous ear surgery completed the questionnaire; 30 patients with a negative medical history of COM complaints and with previous non-otologic surgery as the control group completed the questionnaire. For estimating the test-retest reliability, patients of the COM group completed the questionnaire twice; the scores were compared to those of the control group to test the validity. RESULTS: The overall COMBI score ranged as 32-60 in the patient test group, 32-60 in the patient retest group, and 35-40 in the control group. A mean (standard deviation) score of 43.87 (6.81) in the patient test group, 44.4 (6.83) in the patient retest group, and 36.7 (1.29) in the control group was noted. Post-intervention, the COM patients had a significantly higher absolute COMBI score compared to the control group. The diagnostic accuracy was investigated, and a cut-off score of 38.5 was found to have a high sensitivity and specificity in distinguishing a significant positive change from an insignificant change after the intervention. The average-measures intra-class correlation coefficient for absolute agreement (ICCAA) was 0.985 (95% confidence interval: 0.969-0.993), indicating an excellent test-retest reliability in the control group. CONCLUSION: The Dutch version of the COMBI questionnaire has a good validity, diagnostic accuracy, and test-retest reliability.

The value of four stage vestibular hydrops grading and asymmetric perilymphatic enhancement in the diagnosis of Menière's disease on MRI.

PURPOSE: There is still a clinical-radiologic discrepancy in patients with Menière's disease (MD). Therefore, the purpose of this study was to investigate the reliability of current MRI endolymphatic hydrops (EH) criteria according to Baráth in a larger study population and the clinical utility of new imaging signs such as a supplementary fourth low-grade vestibular EH and the degree of perilymphatic enhancement (PE) in patients with Menière's disease (MD). METHODS: This retrospective study included 148 patients with probable or definite MD according to the 2015 American Academy of Otolaryngology, Head and Neck Surgery criteria who underwent a 4-h delayed intravenous Gd-enhanced 3D-FLAIR MRI between January 2015 and December 2016. Vestibular EH, vestibular PE, cochlear EH, and cochlear PE were reviewed twice by three experienced readers. Cohen's Kappa and multivariate logistic regression were used for analysis. RESULTS: The intra- and inter-reader reliability for the grading of vestibular-cochlear EH and PE was excellent (0.7 < kappa < 0.9). The two most distinctive characteristics to identify MD are cochlear PE and vestibular EH which combined gave a sensitivity and specificity of 79.5 and 93.6%. By addition of a lower grade vestibular EH, the sensitivity improved to 84.6% without losing specificity (92.3%). Cochlear EH nor vestibular PE showed added-value. CONCLUSIONS: MRI using vestibular-cochlear EH and PE grading system is a reliable technique. A four-stage vestibular EH grading system in combination with cochlear PE assessment gives the best diagnostic accuracy to detect MD.

The Value of Diffusion-Weighted MRI in the Long-term follow-up After Subtotal Petrosectomy for Extensive Cholesteatoma and Chronic Suppurative Otitis Media.

OBJECTIVE: To report the long-term follow-up with diffusion-weighted magnetic resonance imaging (DW MRI) after subtotal petrosectomy (SP) with blind sac closure of the external auditory canal for extensive cholesteatoma and chronic suppurative otitis media. STUDY DESIGN: Retrospective clinical record study. SETTING: Tertiary referral center. PATIENTS: Thirty-one patients (31 ears) with extensive cholesteatoma and 17 patients (19 ears) with chronic suppurative otitis media without cholesteatoma who underwent SP between July 1995 and December 2015. INTERVENTIONS: All 48 patients were followed clinically and with DW MRI to rule out residual cholesteatoma. MAIN OUTCOME MEASURE: Residual cholesteatoma, indicated by a marked hyperintensity on non-echoplanar (non-EP) DW MRI. RESULTS: In the cholesteatoma group the mean interval between surgery and the latest DW MRI was 3.9 years. Seven patients presented with a residual cholesteatoma pearl. The mean interval between surgery and detection of residual disease was 3.7 years. In the chronic suppurative otitis media group the mean interval between surgery and the latest DW MRI was 5.3 years. Residual cholesteatoma was found in three patients. Mean interval between surgery and the detection of disease was 4.5 years. CONCLUSIONS: This study shows the importance of DW MRI in the follow-up after SP for cholesteatoma and chronic suppurative otitis media. A little higher residual cholesteatoma rate was found compared with earlier studies, where patients were followed only clinically. One may wonder whether reintervention is always needed or whether in selected cases with small pearls, one may still observe these by a watchful waiting policy with DW MRI.

The Bony Obliteration Tympanoplasty in Pediatric Cholesteatoma: Long-term Hearing Results.

OBJECTIVE: To present the hearing results of a 5-year longitudinal study in a pediatric population undergoing surgery for extensive cholesteatoma using a canal wall up (CWU) approach with bony obliteration of the mastoid and epitympanic space, with a standard residual rate of 5.8%, a recurrence rate of 2.9%, and all ears waterproof, free of otorrhea and all external ear canals patent and self-cleaning. STUDY DESIGN: Retrospective consecutive study. PATIENTS: Thirty-three children (≤18 yr) undergoing surgery for cholesteatoma (34 ears) between 1997 and 2009. INTERVENTIONS: Therapeutic. SETTING: Tertiary referral center. MAIN OUTCOME MEASURES: Hearing and gain in hearing at 1- and 5-year postsurgery: (1) pure-tone average (PTA), (2) pure-tone average high frequency, (3) pure-tone average including 3 kHz, (4) bone conduction at corresponding frequency averages, (5) gain at corresponding air conduction and bone conduction (gain at corresponding air conduction) frequency averages. (6) The Amsterdam Hearing Evaluation Plots were used to study the individual cases. RESULTS: The Amsterdam Hearing Evaluation Plots at 5-year showed in 58.8% of patients a positive gain air conduction. In 23.5% a successful functional result was achieved, defined as an air-bone gap closure to 20 dBHL or less. In 6 patients (17.6%) a limited bone conduction deterioration was shown all limited to maximum 20 dBHL. CONCLUSION: The CWU bony obliteration tympanoplasty in a consecutive series of pediatric extensive cholesteatoma shows a similar to slightly improved hearing outcome as compared with CWU surgery without BOT. Although the series shows a clearly reduced reoperation rate and a significantly improved safety and hygienic outcome as compared with CWU without BOT, better hearing outcomes remain desirable in this group of children.