Otology & Neurotology - Published Ahead-of-Print

Standardized Active Middle-Ear Implant Coupling to the Short Incus Process. Introduction: Active middle-ear implants with floating-mass transducer (FMT) technology are used to treat mild-to-severe sensorineural hearing losses. The standard surgical approach for incus vibroplasty is a mastoidectomy and a posterior tympanotomy, crimping the FMT to the long incus process. An alternative fixation side with less surgical trauma might be the short incus process and incus body. The aim of this study was to develop and test a short incus process coupling device for its functional properties in temporal bone preparations and clinical practice. Materials and Methods: An extended antrotomy and a posterior tympanotomy were performed in 10 fresh human temporal bones. As a control for normal middle-ear function, the tympanic membrane was stimulated acoustically, and the vibration of the stapes footplate was measured using laser Doppler vibrometry. FMT-induced vibration responses of the stapes were then measured for standard attachment at the long process and for 2 types of couplers designed for attachment at the short process of the incus (SP1 and SP2 coupler). Additionally, the functional outcome in 2 patients provided with an SP2 coupler was assessed postoperatively at 2 weeks, 3 months, and then 11 months, using pure-tone audiometry, auditory thresholds for frequency-modulated (warble) tones, vibroplasty thresholds, and speech audiometry in quiet and noise. Results: For the SP2 coupler, velocity-amplitude responses in temporal-bone preparations showed generally similar mean amplitudes as compared with the standard coupling of the FMT to the long process but with clearly increased mean amplitudes between 0.7 and 1.5 kHz and with reduced interindividual variation between 0.5 and 3 kHz. The clinical data of 2 patients with mild-to-severe sensory hearing loss showed good vibroplasty thresholds and convincing results for speech audiometry in quiet (Freiburger monosyllables at 65 dB SPL, 23 +/- 31% unaided versus 83 +/- 4% aided) and noise (Hochmair-Schulz-Moser-test at 65 dB SPL at 10 dB SNR, 32 +/- 45% unaided and 42 +/- 29% aided). Conclusion: The attachment of the FMT to the short incus process with the SP2 coupler leads to good mechanical and functional coupling in an experimental setup and clinical practice. Copyright (C) 2015 by Otology & Neurotology, Inc. Image copyright (C) 2010 Wolters Kluwer Health/Anatomical Chart Company

GDP Matters: Cost-Effectiveness of Cochlear Implantation and Deaf Education in Sub-Saharan Africa. Hypothesis: Cochlear implantation and deaf education are cost effective in Sub-Saharan Africa. Background: Cost-effectiveness of pediatric cochlear implantation has been well established in developed countries but is unknown in low resource settings, where access to the technology has traditionally been limited. With incidence of severe-to-profound congenital sensorineural hearing loss 5 to 6 times higher in low/middle-income countries than the United States and Europe, developing cost effective management strategies in these settings is critical. Methods: Costs were obtained from experts in Nigeria, South Africa, Kenya, Rwanda, Uganda, and Malawi using known costs and published data, with estimation when necessary. A disability adjusted life years (DALY) model was applied using 3% discounting and 10-year length of analysis. Sensitivity analysis was performed to evaluate the effect of device cost, professional salaries, annual number of implants, and probability of device failure. Cost-effectiveness was determined using the WHO standard of cost-effectiveness ratio/gross domestic product per capita (CER/GDP) less than 3. Results: Cochlear implantation was cost effective in South Africa and Nigeria, with CER/GDP of 1.03 and 2.05, respectively. Deaf education was cost effective in all countries investigated, with CER/GDP ranging from 0.55 to 1.56. The most influential factor in the sensitivity analysis was device cost, with the cost effective threshold reached in all countries using discounted device costs that varied directly with GDP. Conclusion: Cochlear implantation and deaf education are equally cost effective in lower-middle and upper-middle income economies of Nigeria and South Africa. Device cost may have greater impact in the emerging economies of Kenya, Uganda, Rwanda, and Malawi. Copyright (C) 2015 by Otology & Neurotology, Inc. Image copyright (C) 2010 Wolters Kluwer Health/Anatomical Chart Company

Meniere's Syndrome or Disease: Time Trends in Management and Quality of Evidence Over the Last Two Decades. Objective: To evaluate the evidence and trends in published literature on the treatment of Meniere's syndrome or disease (MS/D) by comparing studies published in the last two decades. Data Sources: A literature search was performed on AMED, EMBASE, HMIC, MEDLINE, PsycINFO, BNI, CINAHL, HEALTH BUSINESS ELITE, CENTRAL and Cochrane Ear, Nose and Throat disorders groups trials register using a combination of MeSH. The date of last search was October 2014. Study Selection and Data Extraction: Two hundred five studies (104 in decade I and 101 in decade II) were evaluated to report trends in the management of this condition, the differing levels of evidence published for each treatment modality, evaluate whether the guidelines published by the AAOHNS-Committee on Hearing and Equilibrium had been correctly employed, and whether the randomized controlled trials (RCTs) were compliant with the CONSORT guidelines. Results: The number of published RCTs almost tripled from decade I (1994-2003) to decade II (2004-2103). There was a significant decline in the use of surgical intervention (p = 0.013); however, the number of studies involving the use of intratympanic injection remained largely unchanged. There was a shift in the level of evidence in published studies; studies with level 1 evidence tripled from decade I to II (4.8 to 17.8%, respectively) (p = 0.03); however, compliance with the AAOHNS-CHE criteria for reporting treatment outcomes and the CONSORT checklist was still poor. Conclusion: Although the evidence base on published literature on MS/D has improved over the last decade with an increase in emphasis on RCTs and quality of life (QoL) studies, a significant number of studies failed to follow AAOHNS-CHE criteria for reporting treatment outcome and the CONSORT criteria for reporting RCTs. Copyright (C) 2015 by Otology & Neurotology, Inc. Image copyright (C) 2010 Wolters Kluwer Health/Anatomical Chart Company

Histopathologic Findings of an Aberrant Internal Carotid Artery in the Temporal Bone with Fatal Complication. No abstract available

Refractory Positional Vertigo with Apogeotropic Horizontal Nystagmus After Labyrinthitis: Surgical Treatment and Identification of Dysmorphic Ampullae. Objectives: To describe the rationale, intraoperative details, and histopathologic findings discovered when treating an unusual case of apogeotropic horizontal canal positional vertigo with a transmastoid labyrinthectomy. Patient: A single case report. Intervention: Therapeutic. Main Outcome Measures: Resolution of apogeotropic nystagmus and improvement of positional vertigo. Results: The apogeotropic variant of horizontal canal positional vertigo can be a difficult entity to treat. This report describes a patient who developed profound sensorineural hearing loss and vertigo after an acute left labyrinthitis. Ten months later, she developed vertigo with apogeotropic positional nystagmus involving the left horizontal semicircular canal. Particle repositioning maneuvers and vestibular physical therapy were unsuccessful. In addition, she developed intermittent positional vertigo affecting the ipsilateral vertical semicircular canals. Given the persistence of her vertigo, multiple canal involvement, and patient preference for definitive treatment, a transmastoid labyrinthectomy was performed. Intraoperatively, the ampulla of the horizontal canal as well as that of the other canals was grossly abnormal as later confirmed on histology. After surgery, her apogeotropic nystagmus and vertigo resolved, and her balance ability gradually improved to a highly functional level. Conclusion: This case illustrates a unique form of positional vertigo that developed and persisted after acute labyrinthitis. Conservative measures were unsuccessful and a transmastoid labyrinthectomy documented dense inflammatory tissue involving all three ampullae. We postulate that the post-labyrinthitic inflammatory changes resulted in mass loading of the membranous ampullae, causing abnormal nystagmus patterns and positional vertigo, which resolved after the labyrinthectomy. Copyright (C) 2015 by Otology & Neurotology, Inc. Image copyright (C) 2010 Wolters Kluwer Health/Anatomical Chart Company

CERVICAL SPINE DYSFUNCTIONS IN PATIENTS WITH CHRONIC SUBJECTIVE TINNITUS. No abstract available

Prevention of Postoperative Cerebrospinal Fluid Leaks After Translabyrinthine Tumor Resection with Resorbable Mesh Cranioplasty. Objectives: To evaluate the effectiveness of resorbable mesh cranioplasty at reducing postoperative cerebrospinal fluid (CSF) leak and pseudomeningocele formation after translabyrinthine tumor resection. Study Design: Case series with chart review. Setting: Tertiary academic referral center. Patients: Fifty-three consecutive cases using a resorbable mesh cranioplasty after translabyrinthine tumor resection were reviewed. Intervention: Temporal bone defects were repaired with a dural substitute, layered fat graft, and a resorbable mesh plate secured with screws. Main Outcome Measures: Primary outcome measures included the incidence of postoperative CSF wound leak or rhinorrhea, pseudomeningocele formation, and surgical site infection. Results: Fifty-three cases (average age, 54.0 yr; range, 19.3-75.1 yr) were analyzed. The average body mass index was 30.8 kg/m2 (range, 17.9-48.3 kg/m2), and the average tumor size was 18.8 mm (range, 8-38 mm). One patient (1.9%) experienced CSF rhinorrhea on postoperative Day 16, which resolved after transmastoid middle ear and eustachian tube packing. One patient (1.9%) experienced a surgical site infection requiring surgical debridement and mesh removal 4 months after surgery. Compared with 1,441 prior translabyrinthine surgeries analyzed from our institution using a traditional fat graft closure without mesh, the rate of postoperative CSF leak was significantly less using the resorbable mesh cranioplasty technique (p = 0.0483). Conclusion: Resorbable mesh cranioplasty is a safe and effectivemethod to reduce postoperative CSF leak and pseudomeningocele formation after translabyrinthine craniotomy for tumor excision. Copyright (C) 2015 by Otology & Neurotology, Inc. Image copyright (C) 2010 Wolters Kluwer Health/Anatomical Chart Company

Pulmonary Embolism and Infarct After Bilateral Cochlear Implantation in a Patient with Newly Diagnosed Sickle/[beta]+ Thalassemia. Objective: To heighten awareness of increased postoperative thromboembolic complications in patients with [beta]-hemoglobinopathies. Patient: A 42-year-old African American woman with previously undiagnosed [beta]-hemoglobinopathies suffers from sensorineural hearing loss caused by bacterial meningitis and undergoes bilateral cochlear implantation. Intervention(s): Diagnostic: hemoglobin electrophoresis. Therapeutic: cochlear implantation, anticoagulation. Main Outcome Measure(s): Risk of thromboembolic event. Results: Five days after surgery, the patient developed pulmonary embolism and infarct in the right lower lobe, which was treated with a 4-month course of anticoagulation. Hemoglobin electrophoresis showed that the patient had a previously undiagnosed rare [beta]-hemoglobinopathy known as sickle/[beta]+ thalassemia. Conclusion: [beta]-Hemoglobinopathies are associated with a higher incidence of thromboembolism; thus, they should be managed aggressively to prevent or treat perioperative thrombosis. Copyright (C) 2015 by Otology & Neurotology, Inc. Image copyright (C) 2010 Wolters Kluwer Health/Anatomical Chart Company

Unresectable Recurrent Squamous Cell Carcinoma of the Temporal Bone Treated by Induction Chemotherapy Followed by Concurrent Chemo-Reirradiation: A Case Report and Review of the Literature. Objective: To report a rare case of recurrent temporal bone carcinoma encasing the carotid artery. Patient: A 54-year-old man underwent mastoidectomy combined with adjuvant chemoradiotherapy of squamous cell carcinoma of the temporal bone. He developed metastatic disease and received parotidectomy and lymph node dissection. Three months later, the magnetic resonance imaging scan showed that the tumor had relapsed and invaded the carotid artery. Intervention: The patient completed TPF-C induction chemotherapy (docetaxel, cisplatin, 5-fluorouracil, cetuximab), followed by concurrent chemotherapy with reirradiation. Results: Magnetic resonance imaging revealed a complete response of tumor 1 month after treatment. The patient had no detectable recurrence after 53 months of follow-up. Conclusion: Concurrent chemotherapy with reirradiation is a potential curative treatment option for patients who have unresectable recurrent squamous cell carcinoma of the temporal bone. Copyright (C) 2015 by Otology & Neurotology, Inc. Image copyright (C) 2010 Wolters Kluwer Health/Anatomical Chart Company

Temporal Cortical Plasticity in Single-Sided Deafness: A Functional Imaging Study. Hypothesis: To refine and extend the knowledge on cortical plasticity in single-sided deafness (SSD) by assessing magnetoencephalographic imaging in a well-defined group of subjects. Background: SSD causes difficulties with directional hearing, signal extraction in noise, and multispeaker identification and separation. In SSD, the ipsilateral auditory cortex is never powerfully driven by sound, which may lead to plastic change and contribute to higher-order psychoacoustic dysfunction beyond loss of a peripheral sound sensor. Study Design: A cross-sectional study on 12 subjects with long-term, adult-onset, nontraumatic SSD and 12 normal-hearing controls was conducted using magnetoencephalographic imaging, magnetic resonance imaging, and validated hearing instruments. Pure-tone stimuli at five frequencies were presented to each hearing ear individually. M100 activation peak times of the ipsilateral and contralateral auditory cortices were analyzed. Results: Controls showed an M100 interhemispheric mean latency difference of 6.6 milliseconds. In contrast, subjects with SSD exhibited a mean of 1.7 milliseconds. This loss of interhemispheric latency difference was statistically significant (p < 0.05, analysis of variance with repeated measures). SSD subjects confirmed degraded hearing function on both Hearing Handicap Inventory for Adults (p < 0.001) and Speech, Spatial, and Qualities of Hearing Scale instruments (p < 0.001). Conclusion: SSD disrupts M100 latency difference between the two hemispheres to sound stimulation. This finding may represent maladaptive temporal cortical plasticity because of loss of a peripheral sensor. Based on this premise, a new generation of neurophysiologically inspired auditory treatments to correct or mitigate central consequences of SSD may be considered to optimize hearing in individuals with only one functional ear. Copyright (C) 2015 by Otology & Neurotology, Inc. Image copyright (C) 2010 Wolters Kluwer Health/Anatomical Chart Company