Brian J. McKinnon

Challenges and Opportunities in Presbycusis

The population aged 65 years and older is increasing at a faster rate than the total population, with predictions that by 2030, 20% of the population will be 65 years or older. In 2006, between 35% and 50% of those aged 65 years or older reportedly had presbycusis, a sensory impairment that contributes to social isolation and loss of autonomy and is associated with anxiety, depression, and cognitive decline. To address these concerns, the Geriatric Committee of the American Academy of Otolaryngology, in conjunction with the Hearing Committee, focused on 3 challenges and opportunities in the management of presbycusis: (1) the financial burden of caring for patients with presbycusis in the face of increasing costs and declining reimbursements; (2) future treatment options arising from improved understanding of the molecular mechanisms underlying presbycusis, and (3) recognition of central presbycusis as a condition commonly superimposed on peripheral age-related hearing loss whose diagnosis and management can improve outcomes.

Congenital auricular atresia: update on options for intervention and timing of repair

Although the surgical correction of congenital atresia is difficult, it has the potential to achieve a level of patient and physician satisfaction unparalleled in other types of ear surgery.

Cochlear Implantation Using Thin-Film Array Electrodes:

Objective. Current limitations in language perception may stem from an inability to provide high-resolution sound input. Thin-film array technology allows for a greater density of stimulating sites within the limited diameter of the scala tympani. This study examines the use of a flexible carrier to achieve adequate depth of insertion. Study Design. A prospective human cadaveric temporal bone insertion analysis. Setting. Academic otolaryngology department and school of electrical and computer engineering collaboration. Methods. A prototype thin-film array electrode coupled with an insertion test device (ITD) was manufactured and inserted into 10 human cadaveric temporal bones. As controls, 2 additional temporal bones were implanted with the ITD only and 2 were unimplanted. Radiologic and histologic data were collected. Results. Ten thin-film array electrodes were successfully implanted into 10 individual temporal bones via round window (5) and cochleostomy (5) approaches. Seventeen millimeters of insertion was noted for each device, with an average angular insertion depth of 292° by radiographic measurements and 392° by histologic sectioning. Electrode distance to the modiolus averaged 0.88 mm by computed tomography and 0.67 mm by histologic measurements. Average percentage trauma was 26% for the ITD-backed arrays compared with 15% and 29% for ITD only and unimplanted temporal bones, respectively. Conclusion. Thin-film array electrodes coupled with an ITD were successfully inserted into the human cochlea with limited trauma. With continued development and testing of this electrode design, the thin-film array may improve the language perception achieved through cochlear implantation.

Cochlear implant programs: Balancing clinical and financial sustainability†‡§

In 2006, a tertiary academic medical centers adult and pediatric cochlear implant program was closed due to financial losses. Using business practices known as supply chain and revenue management, the objective was to establish a new cochlear implant program that was financially viable.

Cost effectiveness of cochlear implants.

Purpose of reviewHealth professionals would be well served to have as good an understanding of cost effectiveness as clinical effectiveness, as both are critical to their patients having access to better health care and achieving better health outcomes. Cost-effectiveness evaluations allow decision makers a means of comparing different interventions when deciding resource allocation. It is a powerful tool, but like any analysis, not understanding the processes and assumptions involved leads to misinterpretation. Recent findingsCost effectiveness is an economic evaluation of cost and benefit. The threshold at which an intervention is considered cost effective is reflected by the payers “willingness to pay”, which can vary considerably from country to country. These evaluations are complex and can involve the use of incomplete financial data, and subjective impressions of benefit, while excluding broader social and economic benefits. SummaryPediatric unilateral and simultaneous bilateral cochlear implantation, and adult unilateral cochlear implantation are felt to be cost effective in the United States. Pediatric sequential cochlear implantation, adult bilateral cochlear implantation, implantation in the aged and the long deaf are not. However, cost-effectiveness economic evaluations are only part of broader assessment of social and economic benefit when determining resource allocation.

Chondroid tenosynovial giant cell tumor of the temporal bone.

Tenosynovial giant cell tumors (TGCTs) are rare, benign proliferative disorders of the synovium. TGCT usually occur in the extremities, most commonly in the hands. Occurrence in the region of the head and neck is unusual. Although a benign neoplastic process, TGCT may be locally aggressive and has the potential to recur locally. Histologically, TGCT consists of proliferating synovial-like cells with many multinucleated giant cells, inflammatory cells, and xanthoma cells (1). Chondroid tenosynovial giant cell tumors are a rare, recently described subset of synovial tumors that have a predilection for the temporomandibular joint (TMJ). Only a few cases have been reported in the literature. In this report, we present a rare location of a TGCT involving the ossicular chain within the left temporal bone and its surgical treatment.

Minimally invasive access to the posterior cranial fossa: An anatomical study comparing a retrosigmoidal endoscopic approach to a microscopic approach

OBJECTIVES The central location and complex neurovascular structures of the posterior cranial fossa make tumor resection in this region challenging. The traditional surgical approach is a suboccipital craniotomy using a microscope for visualization. This approach necessitates a large surgical window and cerebellar retraction, which can result in patient morbidity. With the advances in endoscopic technology, minimally invasive access to the cerebellopontine angle can be achieved with minimal manipulation of uninvolved structures, reducing the complications associated with the suboccipital approach. METHODS An endoscopic and microscopic approach was completed on anatomic specimens. To access the central structures of the posterior cranial fossa, a retrosigmoidal approach was undertaken. A keyhole craniotomy was made in the occipital bone posterior to the junction of the transverse and sigmoid sinuses. The endoscope was advanced and photographs were obtained for review. The exposure was compared with that obtained with a microscope. RESULTS The endoscopic retrosigmoidal approach to the posterior cranial fossa provided increased exposure to the midline structures while minimizing the surgical window. The relevant anatomy was identified without difficulty. CONCLUSION An endoscopic retrosigmoidal approach to the midline structures of the posterior cranial fossa is anatomically feasible. The morbidity associated with retraction of the cerebellum could possibly be avoided, improving patient outcomes. Retrosigmoidal endoscopy provides access to anatomical structures that is not possible using a microscope in a suboccipital approach. Further understanding of the endoscopic anatomy of the posterior fossa can allow for advances in cranial base surgery with improved safety and efficacy.

Transcanal surgical excision of an intracochlear schwannoma

An intracochlear schwannoma is a rare cause of sensorineural hearing loss, which is little discussed in the literature. This case report details the presentation of a patient with a sensorineural hearing loss due to an intracochlear schwannoma. The patient was initially managed conservatively; however, as her symptoms and serial imaging indicated progression, the lesion was surgically resected via a transcanal/transotic approach. Diagnosis and management of this unusual schwannoma are reviewed.

Craniofacial Injuries Due to Golf Cart Trauma

Objective. To characterize craniofacial injuries due to golf cart trauma. Study Design. Case series with chart review. Setting. Level 1 trauma center. Subjects and Methods. A tertiary academic medical center’s trauma database was queried for golf cart–related trauma from 2000 to 2009 and returned 68 patients. Data were obtained from the trauma database and by individually reviewing patient charts. Results. Of the 68 patients identified, 55% were male, with a median age of 13.4 years. Sixty-nine percent had head injuries, with 32% sustaining skull or facial fracture and 20.6% intracranial hemorrhage. The highest Abbreviated Injury Scale (AIS) by region was the head and neck. The average Glasgow Coma Scale score was 14.2, Injury Severity Score (ISS) 9.0, hospital stay 4.5 days, and intensive care unit (ICU) stay 2.8 days; 36.8% were admitted to the ICU. Ejection and rollover were the most common mechanisms of injury, with ejection having a significantly higher head and neck AIS compared with rollover and hitting a stationary object (P = .0055). Alcohol was detected in 59.2% of patients older than 16 years; the average blood alcohol concentration was 182.6 mg/dL. Children were involved 60.3% of the time, with an average age of 9.2 years, and children were passengers in the golf cart 69.2% of the time. Conclusions. Golf cart trauma can cause significant craniofacial injuries, particularly in the pediatric population and in adults who consume alcohol.

Etiologies of pediatric craniofacial injuries: A comparison of injuries involving all-terrain vehicles and golf carts

OBJECTIVE To determine incidence and etiologies of craniofacial injuries in the pediatric population through comparison of injuries caused by all-terrain vehicles and golf cart trauma. STUDY DESIGN Case series with chart review. SETTING Level 1 trauma center. SUBJECTS AND METHODS Retrospective review of pediatric traumas at a tertiary academic medical center from 2003 to 2012 identified 196 patients whose injuries resulted from accidents involving either all-terrain vehicles or golf carts. Data was collected and variables such as age, gender, driver vs. passenger, location of accident, Glasgow coma scale, Injury severity scale, Abbreviated injury scale, and presence or absence of helmet use were examined. RESULTS 196 pediatric patients were identified: 68 patients had injuries resulting from golf cart accidents, and 128 patients from ATV accidents. 66.4% of ATV-related traumas were male, compared to 52.9% of golf cart-related traumas. Ages of injured patients were similar between the two modalities with average age of ATV traumas 10.8 (±4.0) years and golf cart traumas 10.0 (±4.6) years. Caucasians were most commonly involved in both ATV (79.7%) and golf cart traumas (85.3%). 58.6% of all ATV related trauma and 69.1% of all golf cart trauma resulted in craniofacial injuries. The most common craniofacial injury was a closed head injury with brief loss of consciousness, occurring in 46.1% of the ATV traumas and 54.4% of the golf cart traumas. Temporal bone fractures were the second most common type of craniofacial injury, occurring in 5.5% of ATV accidents and 7.4% of the golf cart traumas. Length of hospital stay and, cases requiring surgery and severity scores were similar between both populations. Intensive care admissions and injury severity scores approached but not reach statistical significance (0.096 and 0.083, respectively). The only statistically significant differences between the two modalities were helmet use (P=0.00018%) and days requiring ventilator assistance (P=0.025). CONCLUSIONS ATVs and golf carts are often exempt from the safety features and regulations required of motor vehicles, and ATV and golf cart accidents represent a significant portion of pediatric traumas. This study found that ATV and golf cart accidents contribute significantly to craniofacial trauma requiring hospitalization, with resultant morbidity and mortality. Further investigation of these injuries and their prevention in the pediatric population is needed before efforts to promote effective safety regulations for such vehicles in the future can be addressed.