Daniel M. Zeitler

Speech perception benefits of sequential bilateral cochlear implantation in children and adults: a retrospective analysis.

Objective: To examine speech perception outcomes and determine the impact of length of deafness and time between implants on performance in the sequentially bilateral implanted population. Study Design: Retrospective review. Setting: Tertiary academic referral center. Patients: Forty-three children (age, <18 yr) and 22 adults underwent sequential bilateral implantation with at least 6 months between surgeries. The mean age at the time of the second implant in children was 7.83 years, and mean time between implants was 5.16 years. Five children received the first side implant (C1) below 12 months of age; 16, at 12 to 23 months; 9, between the ages of 24 and 35 months; and 11, at 36 to 59 months; 2 were implanted above the age of 5 years. In adults, mean age at second implant was 46.6 years, and mean time between implants was 5.6 years. Intervention: Sequential implantation with 6 months or more between implantations. Main Outcome Measures: Speech perception tests were performed preoperatively before the second implantation and at 3 months postoperatively. Results: Results revealed significant improvement in the second implanted ear and in the bilateral condition, despite time between implantations or length of deafness; however, age of first-side implantation was a contributing factor to second ear outcome in the pediatric population. Conclusion: Sequential bilateral implantation leads to significantly better speech understanding. On average, patients improved, despite length of deafness, time between implants, or age at implantation.

Preoperative embolization in carotid body tumor surgery: is it required?

Objectives We compared estimated blood loss (EBL) in patients who underwent surgical excision of carotid body tumors (CBTs) after preoperative superselective angiography with embolization (PSE) with that in patients who underwent excision of CBTs without PSE. Methods We performed a retrospective chart review of a consecutive case series in a single surgeons practice within an academic tertiary care medical center. Twenty-five patients underwent surgical resection of a CBT from 1989 to 2009. From 1989 to 1996, 10 consecutive patients had PSE of the CBT, whereas the subsequent 15 patients (1996 to 2009) had no PSE. Demographic data including age, sex, and tumor size were collected. The EBL was obtained from intraoperative records and operative notes dictated at the time of surgery. Tumor size was based on preoperative radiographic measurements by a senior radiologist and the surgeon. Results In the 10 patients with PSE, the mean age was 41 years (range, 22 to 72 years) and the mean tumor size was 4.8 cm (range, 2.9 to 8.3 cm). The mean EBL was 305 mL (range, 50 to 1,000 mL); 2 patients had an EBL of more than 400 mL. In the 15 patients without PSE, the mean age was 43.7 years (range, 20 to 75 years) and the mean tumor size was 4.4 cm (range, 2.8 to 7.9 cm). The mean EBL was 265.6 mL (range, 40 to 900 mL); 2 patients had an EBL of more than 400 mL. There were no significant differences between the 2 groups with regard to age, tumor size, or EBL. Conclusions Preoperative superselective angiography with embolization of a CBT does not lead to a significant reduction in intraoperative EBL.

Revision cochlear implantation.

Purpose of reviewCochlear implantation is a well tolerated and effective procedure in the rehabilitation of profoundly and severely hearing-impaired individuals. Cochlear reimplantation may be necessary for a variety of reasons. The recent literature regarding the indications, surgical considerations, and outcomes in revision cochlear implant (RCI) surgery is reviewed here. Recent findingsA small but significant percentage (3–8%) of all cochlear implant procedures requires RCI surgery. The most common indication for RCI is hard failure (40–80%), but other common indications include soft failures, wound complications, infection, improper initial placement, and electrode extrusions. There is a high rate of surgical success in RCI with preservation or improvement of preoperative performance in the majority of patients, in addition to the alleviation of prereimplantation symptoms. Both children and adults benefit from RCI when indicated and experience similar auditory successes following RCI. SummaryThe need for RCI is uncommon, but the potential for restoration or improvement in speech perception and alleviation of symptoms exists. Regardless of indication, RCI surgery is well tolerated, and, with thoughtful preparation, individualized patient counseling, and proper surgical technique, most patients can expect successful outcomes.

Evaluation of the short hybrid electrode in human temporal bones.

Hypothesis: The current hybrid electrode can be inserted without trauma to the temporal bone and, after insertion, assumes a position within the scala tympani near the outer cochlear wall just beneath the basilar membrane. Background: Conservation of residual hearing after cochlear implant electrode insertion requires a special insertion technique and an atraumatic short electrode. This allows electroacoustic stimulation in ears with significant residual hearing. Methods: Human cadaveric temporal bones were implanted with soft surgical technique under fluoroscopic observation. Dehydrated and resin-impregnated bones are dissected. Real-time electrode insertion behavior and electrode position were evaluated. The bones are examined for evidence of insertion-related trauma. Results: No gross trauma was observed in the implanted bones, and the electrode dynamics evaluation revealed smooth scala tympani insertions. Conclusion: Atraumatic insertion of the 10-mm hybrid electrode can be accomplished using an appropriate cochleostomy and insertion technique.

Malignant solitary fibrous tumor of the nasal cavity.

Solitary fibrous tumors (SFTs) are unusual mesenchymal tumors that were first described as primary spindle-cell neoplasms of the pleura. These tumors have been described in many other locations, including the urogenital system, orbit, mediastinum, and upper respiratory tract. Twenty-two cases of an SFT of the paranasal sinuses and nasal cavity have been reported, but none described a malignant SFT extending through the anterior skull base. A 70-year-old man had a 6-month history of unilateral left-sided epiphora and nasal obstruction. Computed tomography and magnetic resonance imaging showed a large left-sided nasal cavity mass with extension into the left extraconal orbit and intracranial extension through the left cribriform plate and ethmoid roof. The patient underwent preoperative embolization of the internal maxillary artery and a subsequent anterior craniofacial resection via a midfacial degloving approach and a left anterior craniotomy. Histopathological analysis of the specimen was consistent with a malignant SFT.

The effects of cochlear implant electrode deactivation on speech perception and in predicting device failure.

Objective: To examine speech perception outcomes as related to a reduction in the number of functional electrodes postimplantation and to determine the effect of electrode reduction on subsequent device failure. Study Design: Retrospective review. Setting: Tertiary academic referral center. Patients: Of 1,520 children and adults with full insertions of the Advanced Bionics, Med El, and Nucleus devices, 15 (1%) were patients. Patients were included in the study if all electrodes were functional at initial stimulation, but the number of electrodes in use was subsequently reduced at follow-up programming sessions. Exclusion criteria included partial and split-array electrode insertions. Intervention(s): Patients with bilateral severe to profound sensorineural hearing loss underwent either unilateral or bilateral cochlear implantation. Main Outcome Measure(s): Postimplantation speech perception tests obtained with a full complement of functional electrodes were performed and the results compared to those obtained with 1 or more electrodes removed from the user program. Electrode deactivation was also correlated with device failure. Results and Conclusion: The results of this study indicate that deactivation of cochlear implant electrodes is relatively uncommon, and although the deactivation does not have a direct influence on speech performance outcomes, the loss of 5 or more electrodes can suggest impending device failure. Additionally, those patients with electrode deactivation coupled with a decline in speech perception scores should also be considered at risk for device failure.

Tongue Necrosis: A Rare Complication of Oral Intubation

OBJECTIVES (1) Present a unique case of partial necrosis of the dorsal tongue caused by an endotracheal tube; (2) highlight the importance of verifying proper endotracheal tube positioning during cases requiring prolonged intubation. METHODS Case report and literature review. RESULTS A 50 year-old man underwent total thyroidectomy and bilateral lymphadenectomies for papillary thyroid carcinoma. A nerve monitoring endotracheal tube was used during the case. Postoperatively, the patient reported tongue pain and examination revealed partial necrosis of his dorsal tongue. On follow up, the patient had improved tongue pain and well-healing dorsal tongue. DISCUSSION We present the a case of tongue ischemia and partial necrosis due to oral endotracheal intubation, specifically with a nerve monitoring endotracheal tube, which has not previously been reported in the English literature. Tongue necrosis due to compression by an endotracheal tube during prolonged intubation is unusual, however surgeons, anesthesiologists and those involved in the care of intubated patients should consider the potential for this complication when orienting and securing endotracheal tubes. CONCLUSIONS This unique case of tongue necrosis underscores the importance of proper endotracheal tube positioning during prolonged intubation.

Unsedated Flexible Fiberoptic Bronchoscopy in the Resident Clinic: Technique and Patient Satisfaction†

INTRODUCTION Prior to the introduction of the flexible bronchoscope by Ikeda in 1968,1 otolaryngologists relied on rigid endoscopy under general anesthesia to evaluate patients presenting with complaints referable to the tracheobronchial tree such as chronic cough, possible foreign body aspiration, hemoptysis, shortness of breath, and stridor or wheezing. Although once considered the gold standard, rigid bronchoscopy carries with it certain major risks associated with general anesthesia,2,3 as well as the possibility of iatrogenic injuries to the upper aerodigestive tract or tracheobronchial tree. The advent of flexible fiberoptic bronchoscopy (FFB) has largely eliminated the need for general anesthesia, instead relying on conscious sedation and topical anesthesia. Only recently has the pulmonology literature supported FFB without sedation. Patient cooperation and comfort are usually not enhanced with sedation,4 which carries its own small risks of major complications.3 At the same time, shifting trends in medical economics and the aging population have popularized alternative officebased procedures, which may avoid trips to the operating room, among both endoscopists and patients.1 Many patients with suspected upper airway pathology will be referred to a pulmonologist. If an interventional procedure such as biopsy or bronchoalveolar lavage is planned, sedation may be justified. However, a subset of patients requiring diagnostic bronchoscopy for suspected tracheal or bronchial pathology present to an otolaryngologist, rather than a pulmonologist.5 Many of these patients presenting to an otolaryngologist have vague respiratory complaints with a long list of differential diagnoses, and diagnostic bronchoscopy may be valuable in ruling out tracheobronchial disease, identifying pathology needing further workup, or in directing treatment by either the otolaryngologist or another specialist. Additionally, many patients with head and neck squamous cell carcinoma may require either staging or surveillance bronchoscopy. Indeed, these patients may represent a subset who are more likely to be appropriate for awake FFB. Whereas interventional bronchoscopic procedures may justify sedation and monitoring, diagnostic bronchoscopy alone is both safe and comfortable without sedation in most patients.3–5 In many cases, this procedure can be accomplished in the otolaryngology clinic, without specialized instrumentation. We report a simple technique for unsedated FFB in the clinic, where this procedure has been safely performed by junior residents, with attending supervision, and well tolerated by patients.

Flat-panel computed tomography versus multislice computed tomography to evaluate cochlear implant positioning

Abstract Objective To evaluate and compare image quality between flat-panel volumetric computed tomography (fpVCT) and multislice CT (msCT) in temporal bones with cochlear implants (CIs), and to evaluate fpVCT imaging for accuracy in determining CI electrode positioning. Methods Six cadaveric temporal bones were imaged prior to CI using fpVCT. Each bone was implanted with an electrode array and rescanned in order to create radial reformatted images through each electrode contact. Electrode–modiolar interval (EMI) distances were measured. The bones were fixed and cut in order to grossly evaluate for CI intrascalar positioning and insertional trauma. Main outcome measure To compare image quality between fpVCT and msCT in temporal bones with CI, and to evaluate the utility of fpVCT in post-implantation temporal bone analysis. Results The mean EMI distances did not differ significantly between fpVCT and msCT images, while the image quality was significantly better for fpVCT. Furthermore, information about intracochlear trauma and intrascalar electrode array positioning can be ascertained using this radiographic technique. Conclusion fpVCT and msCT do not differ significantly in the evaluation of EMI distances in implanted temporal bones, but the image quality is significantly better using fpVCT. Additionally, useful information regarding intracochlear trauma, electrode depth of insertion, and intrascalar positioning can be gained from fpVCT imaging. Given the ease of use, superior image quality, improved convenience, reduced levels of radiation, and agreement with histology, fpVCT is a valuable option for post-implantation temporal bone imaging.

Cochlear Implantation in Prelingually Deafened Adolescents

OBJECTIVES To determine the efficacy of cochlear implantation (CI) in prelingually deafened adolescent children and to evaluate predictive variables for successful outcomes. DESIGN Retrospective medical record review. PARTICIPANTS Children aged 10 to 17 years with prelingual hearing loss (mean length of deafness, 11.5 years) who received a unilateral CI (mean age at CI, 12.9 years). INTERVENTION Unilateral CI. MAIN OUTCOME MEASURES Standard speech perception testing (Consonant-Nucleus-Consonant [CNC] monosyllabic word test and Hearing in Noise [HINT] sentence test) was performed preoperatively, 1 year postoperatively (year 1), and at the last follow-up/end of the study (EOS). RESULTS There was a highly significant improvement in speech perception scores for both HINT sentence and CNC word testing from the preoperative testing to year 1 (mean change score, 51.10% and 32.23%, respectively; P < .001) and from the preoperative testing to EOS (mean change score, 60.02% and 38.73%, respectively; P < .001), with a significantly greater increase during the first year (P < .001). In addition, there was a highly significant correlation between improvements in performance scores on the CNC word and HINT sentence speech perception tests and both age at CI and length of deafness at the year 1 testing (P ≤.009) but not from the year 1 testing to EOS testing. Adolescents with progressive deafness and those using oral communication before CI performed significantly better than age-matched peers. CONCLUSIONS Adolescents with prelingual deafness undergoing unilateral CI show significant improvement in objective hearing outcome measures. Patients with shorter lengths of deafness and earlier age at CI tend to outperform their peers. In addition, patients with progressive deafness and those using oral communication have significantly better objective outcomes than their peers.