Dennis S. Poe

Operative management of superior semicircular canal dehiscence.

Objective: To assess the outcomes of patients undergoing surgical management of superior semicircular canal dehiscence (SSCD).

Balloon Dilation of the Cartilaginous Eustachian Tube

Objectives. (1) To translate techniques developed in a previous cadaver study of balloon dilation of the cartilaginous eustachian tube (ET) into clinical treatment for refractory dilatory dysfunction and (2) to study the safety/efficacy of the technique in a pilot clinical trial. Study Design. Prospective with subjects as their own historical controls since June 2009. Setting. Regional academic center. Subjects and Methods. Eleven consecutive adult patients with longstanding otitis media with effusion (OME) who were unable to autoinsufflate their ET by Valsalva, swallow, or yawn and who had previous tympanostomies (average, 4.7). At the time of intervention, 5 of 11 had a tube; 2 of 11 had a tympanic membrane (TM) perforation. Four of 11 had intact TMs, 2 with OME and tympanogram type B and 2 with TM retraction and tympanogram types B and C. Balloon dilation of the cartilaginous ET was performed with sinus dilation instruments via transnasal endoscopic approach under general anesthesia in a day surgery setting. Inflation was to a maximum of 12 atm for 1 minute. Outcome measures: ability to Valsalva, rating of ET mucosal inflammation, tympanogram, and otomicroscopy findings. Results. All cases successfully dilated. Eleven of 11 could self-insufflate by Valsalva (P < .001); tympanograms were A (4/11), C (1/11), or open (6/11). All atelectases resolved. Procedures were well tolerated, without pain or complications related to dilation. Conclusion. Dilation of the cartilaginous ET appeared to be beneficial and without significant adverse effects in the treatment of ET dilatory dysfunction. Larger controlled trials with long-term results are now justified and needed.

Clinical Practice Guideline Otitis Media with Effusion (Update)

Objective This update of a 2004 guideline codeveloped by the American Academy of Otolaryngology—Head and Neck Surgery Foundation, the American Academy of Pediatrics, and the American Academy of Family Physicians, provides evidence-based recommendations to manage otitis media with effusion (OME), defined as the presence of fluid in the middle ear without signs or symptoms of acute ear infection. Changes from the prior guideline include consumer advocates added to the update group, evidence from 4 new clinical practice guidelines, 20 new systematic reviews, and 49 randomized control trials, enhanced emphasis on patient education and shared decision making, a new algorithm to clarify action statement relationships, and new and expanded recommendations for the diagnosis and management of OME. Purpose The purpose of this multidisciplinary guideline is to identify quality improvement opportunities in managing OME and to create explicit and actionable recommendations to implement these opportunities in clinical practice. Specifically, the goals are to improve diagnostic accuracy, identify children who are most susceptible to developmental sequelae from OME, and educate clinicians and patients regarding the favorable natural history of most OME and the clinical benefits for medical therapy (eg, steroids, antihistamines, decongestants). Additional goals relate to OME surveillance, hearing and language evaluation, and management of OME detected by newborn screening. The target patient for the guideline is a child aged 2 months through 12 years with OME, with or without developmental disabilities or underlying conditions that predispose to OME and its sequelae. The guideline is intended for all clinicians who are likely to diagnose and manage children with OME, and it applies to any setting in which OME would be identified, monitored, or managed. This guideline, however, does not apply to patients <2 months or >12 years old. Action Statements The update group made strong recommendations that clinicians (1) should document the presence of middle ear effusion with pneumatic otoscopy when diagnosing OME in a child; (2) should perform pneumatic otoscopy to assess for OME in a child with otalgia, hearing loss, or both; (3) should obtain tympanometry in children with suspected OME for whom the diagnosis is uncertain after performing (or attempting) pneumatic otoscopy; (4) should manage the child with OME who is not at risk with watchful waiting for 3 months from the date of effusion onset (if known) or 3 months from the date of diagnosis (if onset is unknown); (5) should recommend against using intranasal or systemic steroids for treating OME; (6) should recommend against using systemic antibiotics for treating OME; and (7) should recommend against using antihistamines, decongestants, or both for treating OME. The update group made recommendations that clinicians (1) should document in the medical record counseling of parents of infants with OME who fail a newborn screening regarding the importance of follow-up to ensure that hearing is normal when OME resolves and to exclude an underlying sensorineural hearing loss; (2) should determine if a child with OME is at increased risk for speech, language, or learning problems from middle ear effusion because of baseline sensory, physical, cognitive, or behavioral factors; (3) should evaluate at-risk children for OME at the time of diagnosis of an at-risk condition and at 12 to 18 months of age (if diagnosed as being at risk prior to this time); (4) should not routinely screen children for OME who are not at risk and do not have symptoms that may be attributable to OME, such as hearing difficulties, balance (vestibular) problems, poor school performance, behavioral problems, or ear discomfort; (5) should educate children with OME and their families regarding the natural history of OME, need for follow-up, and the possible sequelae; (6) should obtain an age-appropriate hearing test if OME persists for 3 months or longer OR for OME of any duration in an at-risk child; (7) should counsel families of children with bilateral OME and documented hearing loss about the potential impact on speech and language development; (8) should reevaluate, at 3- to 6-month intervals, children with chronic OME until the effusion is no longer present, significant hearing loss is identified, or structural abnormalities of the eardrum or middle ear are suspected; (9) should recommend tympanostomy tubes when surgery is performed for OME in a child <4 years old; adenoidectomy should not be performed unless a distinct indication exists (nasal obstruction, chronic adenoiditis); (10) should recommend tympanostomy tubes, adenoidectomy, or both when surgery is performed for OME in a child ≥4 years old; and (11) should document resolution of OME, improved hearing, or improved quality of life when managing a child with OME.

Diagnosis and management of paragangliomas of the skull base

In appropriately selected patients, glomus tumors of the head and neck are best treated surgically. Unresectability is not a factor in therapeutic planning for local disease control. Existing techniques and exposures for tumor removal can be reliably applied to these paragangliomas, with acceptable morbidity and mortality. A team approach to this problem is mandatory.

Diagnosis and Management of the Patulous Eustachian Tube

Objective: The patulous eustachian tube (ET) seems to be caused by a longitudinal concave defect in the mucosal valve at the superior aspect of its anterolateral wall and causes troublesome autophony of ones own voice and breathing sounds. Patulous ET reconstruction was evaluated to analyze whether submucosal graft implantation to fill in the concavity within the patulous tubal valve may produce lasting relief of symptoms. Study Design: Prospective trial. Setting: Tertiary referral center, ambulatory surgery. Patients: Fourteen ETs in 11 adults with 1 or more years of confirmed continuous patulous ET symptoms refractory to medical care. Intervention: Endoluminal patulous ET reconstruction was performed in 14 separate cases using a combined endoscopic transnasal and transoral approach under general anesthesia. A submucosal flap was raised along the anterolateral wall of the tubal lumen up to the valve and mobilized superiorly off of the basisphenoid. The pocket was filled with autologous cartilage graft or Alloderm implant, restoring the normal convexity and competence to the mucosal lumen valve. Main Outcome Measure: Autophony symptoms were scored as 1) complete relief; 2) significant improvement, satisfied; 3)significant improvement, dissatisfied; 4) unchanged; or 5)worse. Results: All 14 cases reported immediate complete relief of autophony. Results with an average follow-up of 15.8 months are as follows: 1 (7%) case had complete relief; 5 (36%) had significant improvement, satisfied; 7 (50%) had significant improvement, dissatisfied; and 1 (7%) was unchanged. There were no complications. Correlation between patulous ET and other conditions was strongest with previous tubal dysfunction. Autophony of voice, but not breathing sounds, was also found to be experienced by 17 (94%) of 18 patients with superior semicircular canal dehiscence syndrome and could be easily mistaken for patulous ET autophony. Conclusion: Patulous ET seems to be caused by a concave defect in the tubal valves anterolateral wall. Submucosal graft implantation to restore the normal convexity to the valve wall seems to provide lasting relief of symptoms. Long-term study is needed. It is important to differentiate between the autophony of semicircular canal dehiscence syndrome and patulous ET.

Analysis of the dysfunctional eustachian tube by video endoscopy.

Objective Human eustachian tubes with known pathologic conditions of the ear were inspected endoscopically, and video recordings were made for slow-motion analysis of the pathophysiologic changes. Setting Ambulatory office in a tertiary referral center. Subjects Forty-four adults with 64 ears having pathologic conditions. Interventions Transnasal endoscopic examination of the nasopharyngeal opening of the eustachian tube during rest, swallowing, and yawning to study the dilatory movements of the eustachian tube. Main Outcome Measures Slow-motion video analysis of the dilatory movements of the eustachian tube. Results Sixty-four ears and eustachian tubes with pathologic changes were studied. Tubal function was graded on (1) the extent of lateral excursion and progression of dilatory wave as estimates of tensor veli palatini and dilator tubae muscle function, reduced function being observed in 43 tubes; (2) the degree of mucosal disease, which was significant in 48 tubes; (3) obstructive mucosal changes, which were present in 15 tubes; (4) ease and frequency of tubal dilation with maneuvers—26 tubes opened moderately, 21 opened minimally, and 11 were unable to open; and (5) patulous tubes—all 6 clinically patulous tubes showed concavities in the superior third of the tube, which is convex in normal subjects. All tubes with active pathologic conditions of the ear (otitis media with effusion, tympanic membrane retraction, draining ear, cholesteatoma) had significant abnormalities. A correlation could not be made between the severity of middle ear disease and the severity of observed eustachian tube dysfunction. Conclusions Slow-motion endoscopic video analysis is a potentially useful technique in classifying types of pathologic changes in the eustachian tube. Additional studies of dysfunctional tubes are needed to predict outcomes in operative ear cases and to design intratubal therapy for chronically dysfunctional tubes.

Laser eustachian tuboplasty: two-year results.

Objective/Hypothesis: Laser eustachian tuboplasty (LETP) combined with appropriate medical management will eliminate the chronic presence of middle ear effusions in selected patients.

Surgical excision of acoustic neuroma: patient outcome and provider caseload.

Objectives/Hypothesis For many complex surgical procedures, larger hospital or surgeon caseload is associated with better patient outcome. We examined the volume–outcome relationship for surgical excision of acoustic neuromas.

Cochlear Implantation in Adults: A Systematic Review and Meta-analysis

IMPORTANCE Sensorineural hearing loss is the third leading cause of years lived with disability worldwide. Cochlear implants may provide a viable alternative to hearing aids for this type of hearing loss. The Coverage and Analysis Group at the Centers for Medicare & Medicaid Services was interested in an evaluation of recently published literature on this topic. In addition, this meta-analysis is to our knowledge the first to evaluate quality-of-life (QOL) outcomes in adults with cochlear implants. OBJECTIVE To evaluate the communication-related outcomes and health-related QOL outcomes after unilateral or bilateral cochlear implantation in adults with sensorineural hearing loss. DATA SOURCES MEDLINE, Cochrane Central Register of Controlled Trials, Scopus, and previous reports from January 1, 2004, through May 31, 2012. STUDY SELECTION Published studies of adult patients undergoing unilateral or bilateral procedures with multichannel cochlear implants and assessments using open-set sentence tests, multisyllable word tests, or QOL measures. DATA EXTRACTION Five researchers extracted information on population characteristics, outcomes of interest, and study design and assessed the studies for risk of bias. Discrepancies were resolved by consensus. RESULTS A total of 42 studies met the inclusion criteria. Most unilateral implant studies showed a statistically significant improvement in mean speech scores as measured by open-set sentence or multisyllable word tests; meta-analysis revealed a significant improvement in QOL after unilateral implantation. Results from studies assessing bilateral implantation showed improvement in communication-related outcomes compared with unilateral implantation and additional improvements in sound localization compared with unilateral device use or implantation only. Based on a few studies, the QOL outcomes varied across tests after bilateral implantation. CONCLUSIONS AND RELEVANCE Unilateral cochlear implants provide improved hearing and significantly improve QOL, and improvements in sound localization are noted for bilateral implantation. Future studies of longer duration, higher-quality reporting, and large databases or registries of patients with long-term follow-up data are needed to yield stronger evidence.

Laser eustachian tuboplasty.

Objectives Surgery on the eustachian tube for chronic eustachian tube dysfunction has been previously directed toward the bony isthmus and failed to produce lasting results. Dynamic video analysis demonstrates pathophysiology in the tubal cartilaginous portion. This study investigated a new endoluminal procedure that focused on the cartilaginous eustachian tube. Study Design Prospective surgical trial. Setting Tertiary care private practice and outpatient surgical center. Patients One hundred eight eustachian tubes with intractable eustachian tube dysfunction (middle ear atelectasis or effusion) in 56 patients underwent laser eustachian tuboplasty by the first author (O. B. K.) since 1997. Intervention Dynamic video analyses of eustachian tube function were performed perioperatively. Laser eustachian tuboplasties were performed unilaterally or bilaterally under general anesthesia through a combined endoscopic nasal and transoral approach to the eustachian tube nasopharyngeal orifice. Carbon dioxide or 980-nm diode laser vaporization of mucosa and cartilage from the luminal posterior wall was accomplished until adequately dilation was achieved and the tube was packed. A laser myringotomy for temporary middle ear aeration while the eustachian tube was packed was also performed during surgery. Main Outcome Measures There were two outcome measures: 1) the presence or absence of middle ear effusion or tympanic membrane atelectasis and 2) impedance tympanometry. In addition, dynamic videos were examined to rate the degree of visible opening of the tubal valve and effects on mucosal edema and muscular movements. Results Seventy-four (68.51%) ears achieved normal middle ear aeration at 1 year, 70 (71.42%) at 2 years, and 60 (65.21%) at greater than or equal to 3 years. There were no intraoperative complications. Postoperative complications were limited to minimal peritubal synechia in nine (8.33%) tubes and epistaxis in one (0.9%) tubes. Seven (6.48%) ears failed treatment and required tympanostomy tubes. Conclusion Laser eustachian tuboplasty is a new procedure that has demonstrated early promise in correcting intractable eustachian tube dysfunction with few complications. Further studies will be necessary to reproduce the results and establish the role of laser eustachian tuboplasty in the management of chronic intractable eustachian tube dysfunction.