James H. Clark

Predictors of Vestibular Schwannoma Growth and Clinical Implications

Objective: Vestibular schwannomas exhibit variable and unpredictable patterns of growth. We evaluated the extent to which tumor growth influences the management of these benign tumors, and we explored symptom markers present at diagnosis that may be predictive of tumor growth. Study Design: Retrospective case review. Setting: Tertiary care hospital center. Patients: One hundred eighty patients with unilateral vestibular schwannomas diagnosed between 1997 and 2007 who were initially managed conservatively by serial observation. Intervention(s): Serial observation versus eventual microsurgical or radiosurgical treatment. Main Outcome Measure(s): Tumor growth, defined as a 1 mm/year or greater increase in tumor size. Results: We observed that tumor growth was the most important predictor of a change in treatment strategy from serial observation to microsurgical or radiosurgical treatment. We further noted in multivariate analyses that larger tumor size at diagnosis was associated with higher odds of tumor growth, such that each 1-mm increment in tumor size at presentation increased the odds of growth by 20%. We also found that the symptom marker of tinnitus at diagnosis significantly increased the odds of tumor growth nearly 3-fold. Conclusion: Tumor growth plays a significant role in guiding the management of vestibular schwannomas. Assessment of tumor size at diagnosis and for the presence of tinnitus may allow for risk stratification of patients with newly diagnosed vestibular schwannomas and for a more rational application of the conservative management approach.

Cochlear Implant Rehabilitation in Older Adults: Literature Review and Proposal of a Conceptual Framework

To review studies investigating cochlear implant (CI) outcomes in older adults, and to develop a conceptual framework demonstrating important interactions between characteristics of hearing disability, aging, and the CI intervention.

Transoral robotic thyroid surgery.

There is currently significant demand for minimally invasive thyroid surgery; however the majority of proposed surgical approaches necessitate a compromise between minimal tissue dissection with a visible cervical scar or extensive tissue dissection with a remote, hidden scar. The development of transoral endoscopic thyroid surgery however provides an approach which is truly minimally invasive, as it conceals the incision within the oral cavity without significantly increasing the amount of required dissection. The transoral endoscopic approach however presents multiple technical challenges, which could be overcome with the incorporation of a robotic operating system. This manuscript summarizes the literature on the feasibility and current clinical experience with transoral robotic thyroid surgery.

A novel role for otolaryngologists in the multidisciplinary difficult airway response team

The Difficult Airway Response Team (DART) was implemented in July 2008 to address emergent difficult airway situations. The main objective of this study was to highlight the unique role and skill set that otolaryngologists bring and their impact on patient outcomes.

Timing of Cochlear Implantation and Parents’ Global Ratings of Children’s Health and Development

Objective To assess children’s health-related quality of life (HRQL) and development after cochlear implant (CI) surgery and compare improvements between different age of implantation categories. Study Design Prospective, longitudinal study comparing outcomes of deaf children post-CI with hearing controls. Setting Six US CI centers. Patients Deaf children who received CI (n = 188) and hearing children of comparable ages (n = 97). Intervention CI before 5 years of age. Main Outcome Measure Parental ratings of global HRQL and development, as assessed over the first 4 years of follow-up using visual analog scales. Development scores assess parental views of children’s growth and development, motor skills, ability to express themselves and communicate with others, and learning abilities. Associations of baseline child and family characteristics with post-CI HRQL and development were investigated using multivariable analysis, controlling for factors that influence post-CI language learning. Results Baseline deficits of CI candidates relative to hearing controls were larger in development than HRQL. Development scores improved significantly by 4 years after CI, particularly in the youngest CI recipients. Developmental deficits of older CI recipients with early, extended hearing aid use were only partially remediated by CI. Overall, no significant health deficits were observed in CI children after 4 years. Cognition and speech recognition were positively associated with both HRQL and development. Conclusion Parental perspectives on quality of their child’s life and development provide practical insight into the optimal timing of interventions for early-onset deafness. Validity of parental global assessments is supported by clinical measures of speech perception and language learning and comparison with a well-validated health status instrument.

Bone-Anchored Devices in Single-Sided Deafness

Single sided deafness (SSD) implies sensorineural hearing loss in one ear with normal contralateral hearing function. Traditionally, SSD patients have been overlooked due to a belief that the preserved functioning of the contralateral ear compensates for the nonhearing side. SSD patients however experience multiple audiological difficulties, particularly when the sound source is situated on the non-hearing side or in the presence of competing sounds. Through reviewing current literature, we describe the role of bone-anchored devices (Baha) in the management of SSD patients. Recent publications for Baha in SSD have demonstrated consistent objective and subjective improvement in audiologic metrics when compared to unaided conditions. There is also evidence of benefit provided by Baha by the Abbreviated Profile of Hearing Aid Benefit, in global measures of ease of communication, reverberation, and background noise, but not typically in aversiveness to sounds. Interestingly, despite some patients gaining minimal objective or subjective benefits, the majority of these patients still report improved quality of life and would recommend the procedure. Despite increasing evidence for the role of Baha in the management of SSD in the literature, much of these data are based on older technology. Further reports should specify the processor type used and the etiology of the hearing loss to ensure accuracy of future data.

Transoral thyroidectomy and parathyroidectomy – A North American series of robotic and endoscopic transoral approaches to the central neck

OBJECTIVE Most thyroid surgery in North America is completed via a cervical incision, which leaves a permanent scar. Approaches without cutaneous incisions offer aesthetic advantages. This series represents the largest series of transoral vestibular approaches to the central neck in North America, and the first published reports of robotic transoral vestibular thyroidectomy for thyroid carcinoma. MATERIALS AND METHODS Data was prospectively collected for patients that underwent transoral vestibular approach thyroidectomy and/or parathyroidectomy between April 2016 and February 2017. RESULTS Fifteen patients underwent the procedure for removal of the thyroid (n=12), parathyroid (n=2) or both thyroid and parathyroid glands (n=1). The first case was converted to an open procedure. Fourteen were completed through these remote access incisions, including patients with a body mass index as high as 44. There were no permanent complications. The postoperative median Dermatology Life Quality Index score was 3, which indicates a small effect on quality of life. CONCLUSION The transoral vestibular approach to the central neck is a promising technique for patients who desire to optimize aesthetics.

Traumatic facial nerve neuroma with facial palsy presenting in infancy.

Objective: To describe the management of traumatic neuroma of the facial nerve in a child and literature review. Patient: Sixteen-month-old male subject. Intervention: Radiological imaging and surgery. Main Outcome Measures: Facial nerve function. Results: The patient presented at 16 months with a right facial palsy and was found to have a right facial nerve traumatic neuroma. A transmastoid, middle fossa resection of the right facial nerve lesion was undertaken with a successful facial nerve-to-hypoglossal nerve anastomosis. The facial palsy improved postoperatively. Conclusion: A traumatic neuroma should be considered in an infant who presents with facial palsy, even in the absence of an obvious history of trauma. The treatment of such lesion is complex in any age group but especially in young children. Symptoms, age, lesion size, growth rate, and facial nerve function determine the appropriate management.

Malignant otitis externa caused by Aspergillus fumigatus: a case report.

Malignant otitis externa (MOE) is a life threatening pathology that may affect the external ear and skull base. Despite the nomenclature it is an infective disease process caused by Pseudomonas aeruginosa in up to 98 percent of cases (1). However when appropriate antibiotics fail, other infective organisms such as Aspergillus fumigatus should be considered, especially in the immunecompromised patient.

The Role of Obliteration in the Achievement of a Dry Mastoid Bowl.

Objective: To evaluate the impact of mastoid obliteration on the achievement of a dry mastoid bowl and frequency of maintenance care. Study Design: Retrospective chart review. Setting: Academic medical center. Patients: There were 63 canal-wall-down mastoidectomies for chronic otitis media with or without cholesteatoma between 2007 and 2014 with follow-up of at least 6 months. Eighteen mastoids were nonobliterated and 45 were obliterated. Thirteen underwent secondary obliteration of existing mastoid bowls with chronic drainage, whereas 32 underwent primary obliteration at the original canal-wall-down procedure. Intervention: Mastoid obliteration. Main Outcome Measures: Achievement of a dry healed mastoid cavity and frequency of outpatient visits. Results: In more than 80% of the cases, a dry ear was achieved, with no significant difference between the obliterated and nonobliterated cases (p = 0.786). Eleven of the 13 secondary cases experienced cessation of otorrhea, achieving dry ears at rates similar to that of the primary and nonobliterated cases. The secondary obliteration population was also significantly younger than the primary group (22.1 versus 43.5 years, p = 0.002). Multivariable-mixed effects analysis demonstrated a reduction in 0.1 visits per 6-month period following surgery overtime (p < 0.001). Conclusions: Mastoid obliteration may be valuable in the management of the well-developed and chronically wet mastoid cavity, particularly when the drainage emanates from mucosal disease or cell tracts in a deep sinodural angle. Younger patients may require secondary obliteration because of continued craniofacial maturation several years following canal-wall-down surgery.