Bruce Black

Prognostic indicators in paediatric cochlear implant surgery: a systematic literature review

Abstract Background Paediatric cochlear implantation (PCI) requires complex case evaluation and counselling, surgical intervention, and habilitation. Outcomes vary and many cases have sub-optimal outcomes as a result of a broad spectrum of adverse influences. Objective To systematically review the literature to identify research papers that indicate a demonstrated outcome or prognostic factor in paediatric CI, the overall aim being to develop a prognostic index for clinical use. Methods Six main literature domains were assessed: medical/surgical; audiology; psychology; speech/language; education; and family. Search strategies were applied to appropriate databases and journals. A strict inclusion criterion was utilized. A critical appraisal tool was administered to evaluate the final eligible citations. Results The review identified 92 citations, of which 38 were eligible. Heterogeneity in study design prevented a quantitative meta-analysis of the data. Discussion While there are a large range of factors that impact PCI outcomes, well-constructed case control studies are limited in number and scope and relatively few demonstrated significant prognostic factors. Only four factors were identified as consistently influencing PCI outcomes: age at implantation, Connexin 26, inner ear malformations, and meningitis. Conclusion Evaluation of relevant adverse prognostic factors in paediatric CI remains a largely unreported field. Better identification of these factors is required for improving vital pre-operative counselling and resultant surgical expectations and outcomes.

Reporting results in ossiculoplasty.

Objective To review and modify past methods of reporting ossiculoplasty results, improve analysis, standardize presentation formats, and achieve greater veracity of the reported outcomes. Study Design A review of past and present evaluation methods. Background Past ossiculoplasty evaluation methods have been often poorly comparable, based on questionable methodology, and frequently failed to adequately verify the results described. Guidelines set by the American Academy in 1995 to improve matters appear unsatisfactory in several respects. Methods Past evaluation techniques and the Academy modifications are examined for areas that may be subject to modification and improvement, particularly the choice of audiologic frequencies, the calculation of the air-bone gap, and the description of the pathologic findings within the caseload itself. Findings Some audiologic measures and disease evaluations are potentially inaccurate or inadequate. The Academy frequency selections may be flawed. Insufficient emphasis is given to the evaluation of case pathologic findings, which is the major factor pertinent in series comparisons and preoperative case prognostication. Conclusions Further in-depth analysis of reporting methods is overdue. The matter is one of an international measure standard and should be subject to a global discussion, written and oral, to produce an adequately researched and formulated consensus. This in turn may provide the clinical and theoretical tools by which this troubled area can be more effectively analyzed.

Acquired cholesteatoma: Classification and outcomes

Objective: Reclassification of acquired cholesteatoma into the commonly observed presentations of this condition to provide a simple and clear grouping that indicates the pathology, management, and outcomes of the group cases. Patients: Virgin acquired cholesteatoma cases from a single center managed from 1986 to 2008 (515 cases). Interventions: Cases were managed by transcanal (20%) or intact canal wall techniques. Wall repairs successively used autograft cartilage (transcanal and early intact canal wall mastoidectomy cases), hydroxylapatite plates (1989-2007), or titanium sheeting (2007). Drum repairs used cartilage-perichondrial composite grafts. Assembly techniques were the preferred ossiculoplasty method. Results: Distribution: attic, 41%; pars tensa, 45%; and combined attic-pars tensa, 14%. Unclassifiable cases (n = 14) were excluded. Contralateral disease was present in 15% and effusions in 34% during or after surgery. Cell formation was most extensive in attic disease, least in combined patterns. Ossicular pathology was worse in the collapsed drum cases. Attic cases had the best hearing outcomes but risked recurrent disease, which required precise countermeasures. Overall, the combined pattern group carried the worst prognosis. Conclusion: Compared with previous methods, the clinical classification proved simple, descriptive, and comprehensive. It provides a readily discerned practical basis for clinical management and research purposes.

Paediatric cochlear implantation: Adverse prognostic factors and trends from a review of 174 cases

Abstract Objectives Identification and evaluation of prognostic factors that are associated with paediatric cochlear implantation (PCI) outcomes was the aim of this study. Methods A retrospective review of 174 charts was performed at the Royal Childrens Hospital and the Hear and Say Centre, Brisbane. This examined the possible influence of a number of variables (including age at implant, family, additional disabilities, surgical complications, gender, GJB2 mutations, meningitis, inner ear malformations, and prematurity) on outcome measures: receptive, expressive, and total language, receptive and expressive vocabulary, speech articulation and categories of auditory performance at 18–24 months post-implant. Multiple regression analysis was used to identify variables related to language and vocabulary outcomes. Results The findings suggest that inner ear malformations and family concern are negatively associated with receptive and expressive language and receptive vocabulary scores. There was marginal evidence to suggest that increasing age at implantation was associated with lower receptive and expressive language scores. Discussion Prognostic factors that have been adequately validated statistically include inner ear malformations, the influence of family and late age at implantation. However, this study identified a need to define better the impact of the various degrees of inner ear malformations, to particularly emphasize the role of family as a strong predictor of PCI outcomes, and to confine the study of ‘age at implantation’ to pre-lingually deafened children. Conclusion Evaluation of prognostic factors is a key element in PCI. This study confirmed several factors that are strongly associated with outcomes. For better research, there is a need for universal standardized outcome measures and development of a standardized framework for recording patient data.

Use of titanium in repair of external auditory canal defects.

Introduction: Canal wall defect repairs commonly result from cholesteatoma, surgery for chronic ear disease, or exostosis and also from congenital deformities. Reconstructions of these defects are often difficult and unstable. This article reports the use of titanium sheeting to repair external auditory canal wall defects. Methods: Titanium sheeting was used to repair a variety of wall defects. The sheeting was used as a support material, lying deep to the wall defect, which was sealed with an autograft cartilage layer that was fitted to fill the defect. Middle temporal or temporalis fascia vascular flaps were used to cover large-defect repairs to promote rapid healing. The sheeting was used in 56 external auditory canal defect cases, including 35 deep canal defects, 4 lateral bony wall repairs, 12 open-cavity reconstructions, and 5 anterior wall repairs. Results: There were no evident biomaterial complications, and infection was absent from the series. The sheeting was simpler touse than ceramics, being easily shaped and bent to fit the individual case. Second-look cavity reinspections were simpler than when ceramics or autografts had been used for reconstructions. Discussion & Conclusion: Titanium sheeting has been proven an effective method of canal wall repair when combined with the supplementary techniques used with biomaterials in this role (cartilage cover and vascular flaps). Its ease of use, versatility, and reliability are superior to previous organic or ceramic methods.

Keyhole cochlear implantation: current status.

Introduction Past cochlear implantation (CI) techniques have included a variety of soft tissue and bony trauma to place and stabilize the implant body. Despite minimalist approaches, the surgery invites further refinement. Materials and Methods A restricted access “keyhole” CI technique was developed through a series of 547 cases undertaken from 1997. The surgery used a 20-mm-diameter mini C-incision on the rear of the auricle and avoided the use of a bony retention well or suture fixation. Initial body migration rates were successfully countered using small titanium mesh “bridges.” The series was free from other problems specific to the technique. Discussion The study demonstrates that CI can be performed with only restricted exposure, disposing of well and suture fixation methods, and without a wound that may be adjacent to the implant body or electrode arrays. Conclusion The keyhole approach proved atraumatic and brief. It is particularly suited to simultaneous bilateral implantation in the infant and proved adaptable to all ages.

The Prevention of Recurrent Cholesteatoma in CWU Surgery: The Use of Titanium Sheeting

OBJECTIVE Assessment of the outcomes of a technique of prevention of recurrent cholesteatoma in canal wall up (CWU) mastoidectomy, using titanium sheeting to repair the external auditory canal wall. PATIENTS Sixty four cholesteatoma cases were managed during a period from 2007 to 2015. The cases were unselected; the surgery was performed by the senior author. Cholesteatoma Patterns Were: Forty two attic, nine pars tensa, seven combined attic-pars tensa, three congenital, and three other. Primary surgery was undertaken in 33 cases. INTERVENTIONS All cases underwent CWU surgery that employed canal wall repair using fine titanium sheeting combined with overlying organic material to repair canal wall defects. Drum repairs employed cymba conchae cartilage-perichondrium composite grafts. Chain reconstruction used Spanner struts or Grace Alto PORPs or TORPS. RESULTS Two cases suffered mesotympanic residual disease, and three, mesotympanic recurrence one of which extended into the attic. Two other cases incurred atticomastoid residues. Transient myringitis occurred in three cases. CONCLUSION The surgery was judged on its ability to avoid atticomastoid recurrence, and was regarded as highly successful. The titanium sheeting offers a relatively simple but effective technique. The mesotympanic complications are those also commonly found in both CWD and other CWU methods. As in other CWU procedures, the problems of the open cavity were avoided.

Reconstruction of the canal wall in tympanoplasty for cholesteatoma with titanium sheeting

In Reply: Thank you for your request to respond to the accompanying letter with respect to possible conflict between the use of titanium repairs had a need for magnetic resonance imaging (MRI) follow-up of cholesteatoma cases. Although during the earlier phase of this study, MRI scans were unsubstantiated in this role, it has been the experience in this center that at 12 months approximately 25% of such ‘‘pearls’’ have been less than 2 mm in size, rendering their detection by scanning uncertain. In addition, early recurrent sacs may also go undetected. For these reasons we are uncertain as yet re the reliability of the scans and prefer staged surgery as a routine. From a wealth of past studies it is evident that residual disease rates are inevitable in closed surgery. If small pearls are common then the alternative to staged surgery is either delayed or repeated scanning; this would likely incur the loss of follow-up in a proportion of cases. Because of the above policy, we have only limited experience using MRI. For the purpose of this response, several available cases were reviewed, that have undergone scans. The films have shown very limited artefactual response, probably due to the 0.12 thickness and limited size of the sheeting used. We wish to note, that for intact canal wall surgery, the titanium sheet technique is designed to facilitate the re-inspection process, especially when examining the critical anterior attic. The thin sheeting provides optimal access for inspection; any fibrosis is easily cleared to check for disease residue/recurrence. The combination of precise and versatile wall repair, retaining ready reinspection is perhaps without equal in other techniques.

POSTERIOR GENICULATE ARTERY: A SURGEON??S GUIDE TO THE FACIAL NERVE

Locating the facial nerve is an essential step in most mastoid procedures. A constantly occurring, easily identifiable, arterial bleeding point has been identified arising on the posterosuperior-lateral eminence of the posterior genu of the nerve, passing posterosuperiorly. The vessel permits exact sitting of the genu before the nerve is seen, and provides a timely warning of the nerves presence.