Brendan P. O'Connell

Electrode Location and Angular Insertion Depth Are Predictors of Audiologic Outcomes in Cochlear Implantation.

Objectives: 1) Investigate the impact of electrode type and surgical approach on scalar electrode location; and 2) examine the relation between electrode location and postoperative audiologic performance. Setting: Tertiary academic hospital. Patients: Two hundred twenty post-lingually deafened adults undergoing cochlear implant (CI). Main Outcome Measures: Primary outcome measures of interest were scalar electrode location and postoperative audiologic performance. Results: In 68% of implants, electrodes were observed to be located solely in the scala tympani (ST). Multivariate analysis demonstrated perimodiolar (PM) and mid-scala (MS) electrodes were 22.4 (95% CI: 6.3–80.0, p < 0.001) and 55.0 (95% CI: 9.7–312.8, p < 0.001) times more likely to have at least one electrode in the scala vestibuli (SV) compared with lateral wall (LW) electrodes, respectively. Compared with cochleostomy (C), round window (RW) and extended round window (ERW) approaches demonstrated 70% reduction in SV insertion (RW: OR 0.28, 95% CI: 0.1–0.8, p = 0.01; ERW: OR 0.28, 95% CI: 0.1–0.7, p = 0.005). Examining postoperative audiometric performance, consonant-nucleus-consonant (CNC) score increased 0.6% with every 10 degrees increase in angular insertion depth beyond the group minimum of 208 degrees (coefficient 0.0006, 95% CI: 0.0001–0.001, p = 0.03). SV insertion was associated with a 12% decrease in CNC score (coefficient −0.12, 95% CI: −0.22 to −0.02, p = 0.02). CNC score decreased 0.3% for every 1 year increase in age (coefficient −0.003, 95% CI: −0.006 to −0.0006, p = 0.02). Conclusions: Electrode design and surgical approach were predictors of scalar electrode location. Specifically, LW electrodes showed higher rates of ST insertion compared with PM or MS. RW and ERW approaches showed higher rates of ST insertion when compared with C. In regards to performance, ST insertion, younger age, and greater angular insertion depth were predictors of improved CNC scores.

Insertion depth impacts speech perception and hearing preservation for lateral wall electrodes

1) Examine angular insertion depths (AID) and scalar location of Med‐El (GmbH Innsbruck, Austria) electrodes; and 2) determine the relationship between AID and audiologic outcomes controlling for scalar position.

Current concepts in the management of idiopathic sudden sensorineural hearing loss.

Purpose of reviewThe purpose of this manuscript is to review the initial management strategies for idiopathic sudden sensorineural hearing loss, with an emphasis on the role that steroids play in treatment of this condition, and discuss options for auditory rehabilitation of persistent unilateral hearing loss. Recent findingsRecent data suggest that hearing improvement may be greater for patients initially treated with both systemic and intratympanic steroid when compared with those treated with systemic steroids alone. Salvage intratympanic steroids have been shown to confer hearing benefit if initial management fails. The ideal dosing regimen for intratympanic steroids has not been established, but evidence supports that higher dosing strategies are advantageous. Cochlear implantation has emerged as a strategy for auditory rehabilitation of persistent unilateral hearing loss. Recent studies have demonstrated high patient satisfaction, subjective improvement in tinnitus, and objective performance benefit after cochlear implantation for single-sided deafness. SummaryPatients can be offered steroid therapy in the initial management of idiopathic sudden sensorineural hearing loss, but should be counseled that the efficacy of steroids remains unclear. If patients fail to improve with initial management, salvage intratympanic steroid administration should be considered. If hearing loss persists long term, options for auditory rehabilitation should be discussed.

Single Institutional Experience With Observing 564 Vestibular Schwannomas: Factors Associated With Tumor Growth.

Objective: To characterize the risk and predictors of growth during observation of vestibular schwannomas (VS). Study Design: Retrospective case series. Setting: Single academic, tertiary care center. Patients: Five hundred sixty-four consecutive VS patients who underwent at least two magnetic resonance imaging (MRI) studies before intervention. Intervention(s): Serial MRI studies. Main Outcome Measure(s): Tumor growth, defined as a ≥2 mm increase in the maximum tumor diameter between consecutive MRI studies, or between the first and last study. Results: A total of 1296 patients (1995–2015) with VS were identified. Of those, 564 patients (median age 59.2 years; 53.5% female) were initially observed and underwent multiple MRI studies (median follow-up 22.9 months, interquartile range [IQR] 11.7–42.7). The median maximum tumor diameter at presentation was 1.00 cm (IQR 0.6–1.51 cm). In all, 40.8% of tumors demonstrated growth and 32.1% underwent intervention (21.5% microsurgery, 10.5% radiation) during the surveillance period. Multivariable Cox regression analysis showed that for each tumor, the risk of growth or intervention was significantly increased for larger initial VS diameters (HR = 2.22; 95% CI: 1.90–2.61) and when disequilibrium was a presenting symptom (HR = 1.70; 95% CI: 1.30–2.23). Patient age, sex, aspirin use, and presenting symptoms of asymmetric hearing loss, tinnitus, and vertigo were not associated with tumor growth. Conclusion: To date, this is the largest series of observed VS reported in the literature. Risk of VS growth is significantly increased among patients who present with larger tumors and who have concomitant disequilibrium. IRB: 151481. Define Professional Practice Gap and Educational Need: No cohort with this sample size has assessed vestibular schwannoma growth rates in conjunction with this number of variables. Learning Objective: To characterize vestibular schwannoma growth rates and predictors of growth.

Intra- and Postoperative Electrocochleography May Be Predictive of Final Electrode Position and Postoperative Hearing Preservation

Introduction: The objectives of the current study were to (1) determine the relationship between electrocochleography (ECochG), measured from the cochlear implant (CI) electrode array during and after implantation, and postoperative audiometric thresholds, (2) determine the relationship between ECochG amplitude and electrode scalar location determined by computerized tomography (CT); and (3) determine whether changes in cochlear microphonic (CM) amplitude during electrode insertion were associated with postoperative hearing. Materials and Methods: Eighteen subjects undergoing CI with an Advanced Bionics Mid-Scala device were prospectively studied. ECochG responses were recorded using the implant coupled to a custom signal recording unit. ECochG amplitude collected intraoperatively concurrent with CI insertion and at activation was compared with audiometric thresholds postoperatively. Sixteen patients also underwent postoperative CT to determine scalar location and the relationship to ECochG measures and residual hearing. Results: Mean low-frequency pure tone average (LFPTA) increased following surgery by an average of 28 dB (range 8–50). Threshold elevation was significantly greater for electrodes with scalar dislocation. No correlation was found between intraoperative ECochG and postoperative behavioral thresholds collapsed across frequency; however, mean differences in thresholds measured by intraoperative ECochG and postoperative audiometry were significantly smaller for electrodes inserted completely within scala tympani (ST) vs. those translocating from ST to scala vestibuli. A significant correlation was observed between postoperative ECochG thresholds and behavioral thresholds obtained at activation. Discussion: Postoperative audiometry currently serves as a marker for intracochlear trauma though thresholds are not obtained until device activation or later. When measured at the same time-point postoperatively, low-frequency ECochG thresholds correlated with behavioral thresholds. Intraoperative ECochG thresholds, however, did not correlate significantly with postoperative behavioral thresholds suggesting that changes in cochlear physiology occur between electrode insertion and activation. ECochG may hold clinical utility providing surgeons with feedback regarding insertion trauma due to scalar translocation, which may be predictive of postoperative hearing preservation. Conclusion: CI insertion trauma is generally not evident until postoperative audiometry when loss of residual hearing is confirmed. ECochG has potential to provide estimates of trauma during insertion as well as reliable information regarding degree of hearing preservation.

Petroclival Chondrosarcoma: A Multicenter Review of 55 Cases and New Staging System

Objective: To analyze clinical outcomes after treatment of petroclival chondrosarcoma and to propose a novel staging system. Study Design: Retrospective case review, 1995 to 2015. Setting: Multicenter study. Patients: Consecutive patients with histopathologically proven petroclival chondrosarcoma. Intervention(s): Microsurgery, endoscopic endonasal surgery, radiation therapy, observation. Main Outcome Measures: Disease- and treatment-associated morbidity, recurrence, mortality. Results: Fifty-five patients (mean age 42 years; 56% women) presenting with primary or recurrent petroclival chondrosarcoma were analyzed. The mean duration of follow-up was 74 months. Among 47 primary cases, the most common presenting symptoms were headache (55%) and diplopia (49%) and the mean tumor size at diagnosis was 3.3 cm. Subtotal resection was performed in 33 (73%) patients and gross total resection in 12 (27%). Adjuvant postoperative radiation was administered in 30 (64%) cases. Preoperative cranial neuropathy improved in 13 (29%), worsened in 11 (24%), and remained stable in 21 (47%) patients; notably, 11 preoperative sixth nerve palsies resolved after treatment. Nine recurrences occurred at a mean of 42 months. The 1-, 3-, 5- and 10-year recurrence-free survival rate for all 45 patients who underwent primary microsurgery with or without adjuvant radiation therapy was 97%, 89%, 70%, and 56%, respectively. Higher tumor stage, larger categorical size (<4 versus ≥4 cm), lack of adjuvant radiation, and longer duration of follow-up were associated with greater risk of recurrence. The overall mortality rate was 2% for patients presenting with primary disease. Analyzing the cohort of 17 cases with 20 recurrences, 3 received salvage surgery alone, 5 radiation therapy alone, 11 multimodality treatment, and one patient has been observed. Tumor control was ultimately achieved in 15 of 17 patients with recurrent disease. One patient (6%) with grade 3 petroclival chondrosarcoma died as a result of rapidly progressive disease within 6 months of salvage treatment. The overall mortality rate was 6% for patients with recurrent disease. Conclusion: Gross total or subtotal resection with adjuvant radiation provides durable tumor control with minimal morbidity in most patients. Surgery may improve preoperative cranial nerve dysfunction, particularly in the case of cranial nerve 6 paralysis.

Predictive factors for short‐ and long‐term hearing preservation in cochlear implantation with conventional‐length electrodes

The aims of this study were to investigate short‐ and long‐term rates of hearing preservation after cochlear implantation and identify factors that impact hearing preservation.

Impact of resident involvement in outpatient otolaryngology procedures: An analysis of 17,647 cases

This study examines the impact of resident physician participation on postoperative outcomes in outpatient otolaryngologic surgery.

The importance of electrode location in cochlear implantation

As indications for cochlear implantation have expanded to include patients with more residual hearing, increasing emphasis has been placed on minimally traumatic electrode insertion. Histopathologic evaluation remains the gold standard for evaluation of cochlear trauma, but advances in imaging techniques have allowed clinicians to determine scalar electrode location in vivo. This review will examine the relationship between scalar location of electrode arrays and audiologic outcomes. In addition, the impact that surgical approach, electrode design, and insertion depth have on scalar location will be evaluated.

Audiometric Outcomes Following Endoscopic Ossicular Chain Reconstruction

OBJECTIVE To evaluate the audiometric outcomes following endoscopic ossicular chain reconstruction (OCR). STUDY DESIGN Retrospective case series. SETTING Two tertiary referral centers. PATIENTS Sixty two ears with ossicular discontinuity. INTERVENTION(S) Endoscopic and microscopic OCR in patients with ossicular discontinuity. MAIN OUTCOME MEASURES Bone and air pure-tone averages (PTA), air-bone gap (ABG), and word recognition scores (WRS). RESULTS Sixty two ears were included for analysis. Patients that underwent ossiculoplasty were subdivided based on prosthesis type (total ossicular replacement prosthesis [TORP] and partial ossicular replacement prosthesis [PORP], primary and staged ossiculoplasties, and surgical approach [microscopic and total endoscopic]). Forty two ears required PORP reconstructions, while 20 ears required TORP reconstructions. The microscope was used to reconstruct the ossicular chain in 31 cases, while an exclusive endoscopic approach was used in the remaining 31 patients. Controlling for the prosthesis, there were no significant postoperative differences in bone PTA, air PTA, and ABG between primary and staged ossiculoplasties, or surgical approach. CONCLUSIONS Controlling for the type of prosthesis, there were no significant differences in hearing outcomes with respect to staged ossicular chain reconstruction or whether the endoscope or microscope was used for visualization. Thus, in this series, endoscopic OCR yields similar audiometric outcomes when compared with microscopic OCR.