Benjamin J. Wycherly

Computed Tomography and Otosclerosis: A Practical Method to Correlate the Sites Affected to Hearing Loss

Objectives: We present a practical method for correlating computed tomography (CT) scans with hearing loss in otosclerosis. Methods: We reviewed the CT scans of 18 patients (34 ears) with clinical otosclerosis who were seen between 2007 and 2008. The scans were reviewed by an otologist in a clinical office setting, followed by a blinded radiologist working at an imaging workstation. The 5 most commonly affected sites in otosclerosis were evaluated for evidence of otospongiosis and then correlated with the degree of air-bone gap and sensorineural hearing loss. Results: Positive CT findings were noted in 70.5% of ears, with a 94% concordance between readings. The sites affected included the ante fenestram (21 ears), round window niche (12), cochlear promontory (4), cochlear apex (3), and posterior fenestram (2). The average air-bone gap increased with each additional site of involvement within an otic capsule (p = 0.004). The bone conduction threshold also increased, on average, with each additional affected site (p = 0.047). Conclusions: Most patients with clinical evidence of otosclerosis have evidence of otosclerosis on CT that is readily detected in the office setting. Ears with more affected sites have a significantly greater degree of air-bone gap and sensorineural hearing loss.

Complications of Bone-Anchored Hearing Devices

Complications of bone-anchored hearing devices occur with both soft tissue and bone. Soft tissue complications are much more common and most often involve irritation of the skin surrounding the implant. Other complications include: skin flap necrosis, wound dehiscence, bleeding or hematoma formation, and persistent pain. Bone complications are classified as either early or late. Early complications are due to failure of osseointegration, while late complications are usually the result of either chronic infection or trauma. Pediatric patients are a unique group of implant patients and are more likely to have complications of both soft tissue and bone. Most complications can be managed in the office with topical therapy and wound care, although revision surgery may be required in extensive skin overgrowth cases. Proper patient selection, meticulous surgical technique, and patient hygiene around the implant are the most critical aspects in minimizing complications in patients with osseointegrated implants.

Induction of tracheal stenosis in a rabbit model—endoscopic versus open technique†‡§

To evaluate and compare open versus endoscopic methods of inducing tracheal stenosis in the New Zealand white rabbit model.

Three week loading for the Baha BI-300® implant system.

PURPOSE The timing of loading of titanium craniofacial implants is dependent upon implant characteristics, host factors, and the bonding of titanium oxide and bone referred to as osseointegration. The purpose of this feasibility study seeks to determine the safety of early loading of the Baha BI-300 implant system (Cochlear Limited, Englewood, CO), which has been modified with novel surface texture and geometric design. SUBJECTS AND METHODS This prospective study measures implant stability as determined by clinical evaluation and resonance frequency analysis at implantation and at 1, 3, 6, 12, 24 and 52weeks post-op in 20 patients who underwent single-stage implantation and exteriorization of the BI-300. The processor was loaded at 3weeks post-operatively. A modified Holgers classification system was used to evaluate skin reactions. RESULTS There was a positive linear trend in mean implant stability scores from implantation to 52weeks. Only one subject (5%) had a mild local soft tissue Holgers grade 1 score at 24weeks. No implant loss or postoperative complications were encountered as a result of the 3-week loading. CONCLUSION Three-week loading of the BI-300 implant did not result in any implant loss or failure of osseointegration. Earlier activation of the external processor with earlier hearing rehabilitation resulted in improved patient satisfaction. Further studies are needed to confirm these results for more universal adoption of early loading in adults.

Early Posttreatment Audiometry Underestimates Hearing Recovery after Intratympanic Steroid Treatment of Sudden Sensorineural Hearing Loss

Objective. To review our experience with intratympanic steroids (ITSs) for the treatment of idiopathic sudden sensorineural hearing loss (ISSNHL), emphasizing the ideal time to perform follow-up audiograms. Methods. Retrospective case review of patients diagnosed with ISSNHL treated with intratympanic methylprednisolone. Injections were repeated weekly with a total of 3 injections. Improvement was defined as an improved pure-tone average ≥20 dB or speech-discrimination score ≥20%. Results. Forty patients met the inclusion criteria with a recovery rate of 45% (18/40). A significantly increased response rate was found in patients having an audiogram >5 weeks after the first dose of ITS (9/13) over those tested ≤5 weeks after the first dose of ITS (9/27) (P = 0.03). Conclusions. Recovery from ISSNHL after ITS injections occurs more frequently >5 weeks after initiating ITS. This may be due to the natural history of sudden hearing loss or the prolonged effect of steroid in the inner ear.

Acellular Human Dermal Allograft in Canal WallDown Mastoidectomy and Considerations of GraftThickness

Acellular Human Dermal Allograft in Canal Wall Down Mastoidectomy and Considerations of Graft Thickness Objectives/Hypothesis: Describe our method and results to observe the optimal thickness of AlloDerm used in canal-wall-down mastoidectomy defects. Study Design: Retrospective consecutive case series. Methods: AlloDerm with an average thickness of 0.33 to 0.76 mm was used; selecting the portions of tissue with a thickness closest to 0.5 mm to line mastoid cavity defects. Failures occurred when AlloDerm’s thickness was beyond the average of 0.76mm. We report time to healing as well as long term results including need for revision surgery and skin breakdown.

The Efficacy of Ear Canal Irrigations with Isopropyl Alcohol

Objective: To assess the efficacy and safety of 70% isopropyl alcohol (IPA) as a weekly irrigant to reduce cerumen accumulation, using a unique closed tip irrigator bottle. Method: Prospective crossover study. Forty ears randomly divided into 2 groups. Group 1 instilled IPA weekly for 2 months, followed by 2 months of no cleaning. Group 2 did the opposite. Cerumen occlusion graded 0 to 4 (0%, 25%, 50%, 75%, 100%) followed by cerumenectomy at 0, 2, and 4 months. Results: The mean grade at the initial evaluation in Group 1 was 3.1 (range, 2-4) and in Group 2 was 3.3 (range, 3-4) (P = .33). After the first 2 months, there was a significant difference between those who used the IPA (Group 1) vs those who did not (Group 2) (P < .0002). There was also a significant difference within both groups between using the IPA for 2 months and not cleaning for 2 months (P < .02 Group 1, P < .01 Group 2). All subjects tolerated IPA with no complaints or side effects, and there were no cases of canal irritation. Conclusion: Weekly irrigation with 70% IPA is safe and reduces the accumulation of cerumen in the external auditory canal. Routine use of IPA may decrease the number of patient visits for cerumen related issues.

Three-Week Loading for Baha BI-300 Implant System

Objective: Loading of titanium craniofacial implants is dependent upon osseointegration, the bonding of titanium oxide and bone. The purpose of this study seeks to determine the safety of early loading of the Baha BI-300 implant system (Cochlear Limited, Englewood, Colorado), which has been modified with novel surface texture and geometric design. Method: This prospective multi-institutional study follows implant stability as determined by clinical evaluation and resonance frequency analysis (RFA) at implantation, 1, 3, 6, 12, and 24 weeks postopative, in 20 patients who underwent single-stage implantation and exteriorization of the BI-300. The processor was loaded at 3 weeks postoperative. Results: Implant stability and the incidence of implant loss was compared with patients loaded at 6 weeks and the traditional 12 weeks postoperative. Our preliminary results confirm implant stability at 3 weeks postoperative. No increase in implant loss or postoperative complications were encountered as a result of the early loading. Conclusion: Three-week loading of the BI-300 implant did not result in any failure of osseointegration. Earlier activation of the external processor with earlier hearing rehabilitation resulted in improved patient satisfaction.

CT Findings and Conductive Hearing Loss in Otosclerosis

OBJECTIVES: 1) Model the cost-effectiveness of expanded criteria for cochlear implantation that entail the preservation of low-frequency hearing with the Hybrid device; 2) Similarly assess conventional cochlear implants and hearing aids alone. METHODS: Current FDA-approved labeling for cochlear implantation restricts its recipients to those with severe hearing loss. We compared two conditions: 1) narrow criteria reflecting FDA-approved labeling for traditional cochlear implants in which a cochlear implant or hearing aids are used; and 2) expanded criteria as utilized in current hybrid implant trials where access is expanded to include those with better hearing; thereby decreasing the proportion of patients with hearing aides alone. Patient outcomes were obtained from monosyllabic word tests from unpublished clinical trial data. Utility data for hybrid implants was obtained by regression mapping the relationship between changes in utility and monosyllabic word scores for traditional implants. National direct costs included the implant, complications, and follow-up care. RESULTS: The use of broad criteria, including Hybrid cochlear implants, was found to be a cost-effective strategy with an incremental cost-effectiveness ratio of

R453 – Cryoballoon Dilation of Tracheal Stenosis

4,176/QALY. Results were sensitive to utility values and the proportion of patients within each set of criteria for each type of cochlear implant or hearing aid alone. Tornado analysis revealed that utility variables accounted for 70.6% of model variability, while the proportions of patients within each set of criteria accounted for 28.9%. CONCLUSIONS: Our analysis demonstrates substantial costeffectiveness for Hybrid devices and traditional cochlear implants relative to the use of amplification alone. Broader eligibility criteria that include Hybrid devices offer a solution that represents effective expenditure of health care dollars.