Gunesh P. Rajan

The role of preoperative, intratympanic glucocorticoids for hearing preservation in cochlear implantation: A prospective clinical study†‡§

Hearing Preservation is becoming increasingly important in cochlear implantation as there is growing evidence that preserving the residual hearing, especially in the low frequencies in combination with the electric stimulation can significantly improve hearing and speech outcomes in noise. Besides the ongoing development of atraumatic implant electrodes and insertion techniques, the implementation of pharmacologic hair cell protection is thought to increase hearing preservation. This study investigates the effects of preoperative intratympanic glucocorticoid application on hearing preservation rates in cochlear implantation.

Cochlear implantation for unilateral deafness with and without tinnitus: A case series

Objectives/Hypothesis To investigate cochlear implantation (CI) in patients with unilateral deafness with and without tinnitus. Study Design Prospective case series of patients undergoing cochlear implantation for unilateral deafness and tinnitus in a tertiary academic unit. Methods Nine postlingually deafened subjects with unilateral hearing loss, with and without tinnitus ipsilaterally, and functional hearing in the contralateral ear were implanted with a standard electrode. Speech perception in noise was tested using the Bamford-Kowal-Bench presented at 65 dB SPL. The Speech, Spatial, and Qualities (SSQ) of Hearing Scale was used to evaluate the subjective perception of hearing outcomes, and the Tinnitus Reaction Questionnaire assessed the effect on tinnitus. Results All patients were implanted with the Med-El Flex soft electrode, Innsbruck, Austria. They are regularly wearing the speech processor and find it beneficial in improving their ability to hear, particularly in noise. Decrease of tinnitus perception and an improvement of sound localization sounds were also reported by these patients. Conclusion In our case series, CI was successful for all nine patients, with improvement of speech recognition in noise, self-perceived improvement of hearing, and for tinnitus control. Several factors such as deafness duration, age of deafness onset, the presence of residual hearing, patient motivation, and the rehabilitation intensity need to be further investigated in order to understand their impact on performance after implantation. Level of Evidence 4.To investigate cochlear implantation (CI) in patients with unilateral deafness with and without tinnitus.

Preliminary outcomes of cholesteatoma screening in children using non-echo-planar diffusion-weighted magnetic resonance imaging

OBJECTIVE Diffusion-weighted (DW) MRI imaging is evolving into an alternative to second look surgery in detection of cholesteatoma recurrence. Insights into the DW MRI appearances of postoperative or inflammatory mucosal changes have recently described using non-echo-planar, turbo spin-echo (TSE) DW MRI which reliably distinguishes between postoperative changes and cholesteatoma. We investigated the use of TSE DW MRI in our pediatric population in order to validate a rapid and cost-effective MRI sequence that can be used to screen for cholesteatoma. METHODS Prospective comparative study with adult and pediatric patients at a tertiary referral centre. Patients in the study underwent TSE DW MRI prior to second look or revision surgery for cholesteatoma. A Siemens 1.5 T scanner was employed, using the HASTE sequence (EPI DW MRI) as well as standard echo-planar DWI, T1 and T2 sequences. The MRI findings were then correlated with the intraoperative findings at surgery 9-15 months after primary surgery, or of revision surgery in the cases that were referred from other centres. Detection and localisation of cholesteatoma on TSE DW MRI were compared with the findings at second surgery, long considered the gold standard for detection of residual or recurrent disease. Scanning time between the TSE sequence and the standard planar DW MR were also compared. RESULTS In a cohort of 92 patients, 21 pediatric patients were identified. 15 patients have had their 15 second look or revision procedures and DW MRI prior to their surgery. TSE DW MRI detected cholesteatoma and reliably identified the location of the cholesteatoma in 2 patients whom all had disease confirmed at surgery. The 13 cases with negative preoperative DW MRI for cholesteatoma were all confirmed to be disease free at surgery. Scanning time of the TSE sequence takes 100 s as opposed to 20 min using standard echo-planar DW MRI techniques without the requirement of a contrast agent and without the need for a general anaesthetic for any of the children. CONCLUSION TSE (HASTE) DW MRI is emerging as a cost effective, noninvasive alternative to second look surgery for detection and screening for cholesteatoma in pediatric patients.

The Effects of Insertion Speed on Inner Ear Function during Cochlear Implantation: A Comparison Study

Objective: To investigate the insertion speed and its impact on electrode insertion characteristics, hearing preservation and clinical vestibular function in a prospective cohort study with a retrospective control group at a tertiary otology/neurotology centre. Interventions: Hearing-preserving cochlear implantation using systemic and topical steroids in conjunction with a round-window approach, a complete cochlear coverage electrode and two different electrode insertion speeds [60 mm/min (n = 18) vs. 15 mm/min (n = 22)] was performed. Results: The insertion speed had a significant impact on various insertion characteristics as well as hearing preservation and vestibular function. In conclusion, a slow electrode insertion speed appears to facilitate full electrode insertion, reduce the occurrence of insertion resistance as well as promote preservation of residual hearing and vestibular function after cochlear implantation.

Impact of floating mass transducer coupling and positioning in round window vibroplasty.

Objective: The round window application of the Vibrant Sound bridge, the so-called round window vibroplasty, is gaining increasing popularity for hearing rehabilitation of patients with mixed hearing loss or conductive hearing loss. In these patients, conventional hearing amplification and/or surgical restoration is either not possible or has failed because of chronic ear disease, extensive otosclerosis, or malformations. The exact mechanisms of direct cochlear stimulation via the round window membrane are not yet completely understood. It is unclear what kind and what degree of contact is required between the floating mass transducer (FMT) and the round window membrane (RWM) to elicit a functional hearing perception with the implant. We investigated the coupling efficiency between the FMT and the RWM and how the efficiency is altered by the FMT position, the degree of FMT-RWM contact, and the use of a soft tissue coupler. Study Design: Prospective cohort study. Setting: Tertiary referral center in Western Australia. Patients: Patients undergoing round window vibroplasty for a mixed or conductive hearing loss otherwise not aidable. Intervention: Patients underwent round window vibroplasty and received audiological and coupling analysis in the follow-up. These data were then correlated with FMT positioning and the extent of FMT-RWM interface as determined by postoperative high-resolution temporal bone computed tomography. Main Outcome Measures: Coupling and hearing levels in relation to FMT positioning and degree of FMT-RWM contact. Results: Of 10 patients, 8 were available for vibroplasty behavioral threshold testing. In 2 patients, testing could not be done because of wound breakdown requiring device explantation in 1 case, and in the other case, the bone conduction thresholds dropped 2 months after implantation, thus falling out of the performance range of the device. Postoperative FMT migration occurred in 50% of the patients (3/6) with recurrent chronic ear disease and status after multiple previous ear operations. All patients, including the 3 patients requiring surgical repositioning of the FMT, attained significantly improved speech in quiet and speech in noise when compared with the preoperatively best aided performance. All patients showed significantly improved average Abbreviated Profile of Hearing Benefit scores with the use of the FMT. Direct (partial or complete) contact with the RWM resulted in good coupling efficiency; soft tissue coupling resulted in a reduced coupling efficiency.

The impact of cochlear implantation on speech understanding, subjective hearing performance, and tinnitus perception in patients with unilateral severe to profound hearing loss.

Objectives This study aimed to determine the impact of cochlear implantation on speech understanding in noise, subjective perception of hearing, and tinnitus perception of adult patients with unilateral severe to profound hearing loss and to investigate whether duration of deafness and age at implantation would influence the outcomes. In addition, this article describes the auditory training protocol used for unilaterally deaf patients. Design This is a prospective study of subjects undergoing cochlear implantation for unilateral deafness with or without associated tinnitus. Methods Speech perception in noise was tested using the Bamford-Kowal-Bench speech-in-noise test presented at 65 dB SPL. The Speech, Spatial, and Qualities of Hearing Scale and the Abbreviated Profile of Hearing Aid Benefit were used to evaluate the subjective perception of hearing with a cochlear implant and quality of life. Tinnitus disturbance was measured using the Tinnitus Reaction Questionnaire. Data were collected before cochlear implantation and 3, 6, 12, and 24 months after implantation. Results Twenty-eight postlingual unilaterally deaf adults with or without tinnitus were implanted. There was a significant improvement in speech perception in noise across time in all spatial configurations. There was an overall significant improvement on the subjective perception of hearing and quality of life. Tinnitus disturbance reduced significantly across time. Age at implantation and duration of deafness did not influence the outcomes significantly. Conclusion Cochlear implantation provided significant improvement in speech understanding in challenging situations, subjective perception of hearing performance, and quality of life. Cochlear implantation also resulted in reduced tinnitus disturbance. Age at implantation and duration of deafness did not seem to influence the outcomes.

A case of giant ecchordosis physaliphora: a case report and literature review.

Objective: To report a case of a giant ecchordosis physaliphora causing local bone remodelling. Patients: A 45 year old man, who presented with sudden sensorineural hearing loss. Intervention: Transpetrosal approach to resect a midline prepontine mass. Main Outcome Measures: Radiological and histological findings. Conclusion: The distinction between giant ecchordosis physaliphora and intradural chordoma is questioned and exemplified by our case. It is possible they represent the same entity of disease, which must be distinguished from classical malignant osseous (extradural) chordoma.

Eliminating the limitations of manual crimping in stapes surgery: Mid-term results of 90 patients in the nitinol stapes piston multicenter trial

Objective: To present our mid‐term results of our multicenter study using the Nitinol self‐crimping stapes piston, focusing on the interindividual variations of postoperative air‐bone gap closures (ABGC), postoperative hearing results, and postoperative recurrences of conductive hearing loss and to compare these findings with our pilot group of patients.

Impact of the SMAS on Frey's syndrome after parotid surgery: a prospective, long-term study.

Background: Clinical observations indicate that creation of the superficial musculoaponeurotic system (SMAS) flap during parotid surgery decreases postoperative gustatory sweating (Freys syndrome) and improves cosmesis after surgery. Methods: On the basis of their previous study with 23 patients where no SMAS flap was used, the authors performed a prospective, long-term study of 6½ years in 25 patients, using the SMAS flap, and compared these results with the postoperative results of their initial study. Twenty-two patients of the SMAS flap group were available for reassessment of gustatory sweating and symptoms. The Minor starch test was used to document the extent and intensity of postoperative sweating. Satisfaction with postoperative cosmetic results was assessed through a semiquantitative questionnaire as used in the previous study. Results: The incidence of symptomatic Freys syndrome was significantly higher in the no–SMAS flap group after 23 months (43 percent versus 0 percent; p = 0.003). The surface extent of Freys syndrome after 23 months was significantly reduced in the SMAS flap group (p = 0.006). At final follow-up, the incidence and extent of symptomatic Freys syndrome showed no significant differences between the two groups (41 percent versus 56 percent; p = 0.42). The rate of satisfactory cosmetic results was significantly higher in the SMAS flap group (96 percent versus 35 percent; p < 0.05). Conclusions: Creation of the SMAS flap in parotid surgery for benign lesions delays the onset and reduces the intensity and extent, but does not prevent the occurrence, of Freys syndrome. It reliably improves the cosmetic results by reducing the retromandibular depression after parotid surgery.

Successful outcomes of cochlear implantation in long-term unilateral deafness: brain plasticity?

To investigate the implications of duration of deafness in the rehabilitation of unilateral deafness utilizing cochlear implantation. From the ongoing prospective cochlear implantation in unilateral deafness study, we looked at five adults who received a cochlear implant for long-term unilateral deafness. Speech perception in noise and subjective evaluation of the benefits of cochlear implantation were measured at 3, 6, and 12 months after implantation. The results were analyzed and compared with published data from normal hearing individuals and adults using cochlear implants bilaterally. Analysis of speech perception in noise showed significant improvement for three spatial configurations: speech and noise from the front (S0/N0; P=0.003), speech from the front and noise from the normal hearing ear (S0/NHE; P=0.001), speech from the implanted ear, and noise from the normal hearing ear (SCI/NHE; P<0.001). The scores obtained at 12 months after surgery improved to values similar to those obtained by individuals with normal hearing. The results of subjective measures showed significant improvement in hearing over time to the scores obtained by individuals with a bilateral cochlear implants and those with normal hearing. In this study, older adults with more than 25 years of unilateral deafness obtained scores in speech perception testing and in subjective evaluation that are similar to those attained by individuals with normal hearing and/or those with bilateral cochlear implants. Therefore, patients with postlingual unilateral deafness should not be excluded as cochlear implant candidates on the basis of a long duration of deafness.