Matthew D. Cox

TORP Ossiculoplasty Outcomes with and without a Stapes Footplate Prosthesis

Objective The titanium stapes footplate prosthesis (FPP) was designed to ensure a stable connection of a total ossicular replacement prosthesis (TORP) to the stapes footplate and maximize acoustic coupling by centering the footplate on the oval window. Our goal was to assess the impact of the FPP on TORP ossiculoplasty outcomes. Study Design Case series with chart review. Setting Tertiary care center. Subjects Adult patients undergoing TORP ossiculoplasty with (n = 53) or without (n = 108) a stapes FPP. Methods Rate of prosthesis displacement and audiologic outcomes were tabulated for statistical analysis. Results A lower rate of prosthesis displacement and statistically better audiologic outcomes were seen in FPP patients. The pure-tone average air-bone gap (PTA-ABG) was closed to <20 dB in 69.8% (37/53) of patients in the study arm and 44.4% (48/108) of patients in the control arm (P = .003). The PTA-ABG was decreased by a mean ± SD of 19.3 ± 11.7 dB and 12.6 ± 11.0 dB in the study and control groups, respectively (P = .0012). Conclusions Use of the titanium stapes FPP during TORP ossiculoplasty provides a statistically significant advantage in short-term PTA-ABG closure and a higher rate of successful rehabilitation of conductive hearing loss. Further studies are necessary to assess any long-term advantages a FPP may offer.

Long-Term Hearing Results After Ossiculoplasty

OBJECTIVES To determine if the OOPS index is predictive of long-term hearing results after ossiculoplasty. STUDY DESIGN Case series with retrospective chart review. SETTING Tertiary care otology practice. PATIENTS Adult and pediatric patients (3-88 years of age). INTERVENTIONS Ossiculoplasty with cartilage tympanoplasty, with or without mastoidectomy. OUTCOME MEASURES Primary outcome measures included short-term hearing results (pure-tone average air-bone gap [PTA-ABG] measured between 60 days and 1 year after surgery), long-term hearing results (PTA-ABG measured ≥5 years after surgery), and the rate of successful ABG closure to ≤20 dB. Secondary measures included the need for revision surgery, delayed tympanic membrane graft failure, worsening conductive hearing loss (after an initially satisfactory hearing result), and recurrence of cholesteatoma. RESULTS There was no significant difference between adults and children for short-term hearing results (average post-op PTA-ABG was 18.9 dB vs. 19.8 dB, respectively; p = 0.544), long-term hearing results (average final PTA-ABG was 19.3 dB vs. 19.4 dB, respectively; p = 0.922), or rate of ABG closure to less than 20 dB (63.1% vs. 58.0%, p = 0.282). Spearmans rank-order correlation (ρ) identified a strong positive correlation between OOPS index score and average post-operative PTA-ABG (ρ = 0.983; p < 0.001; 2-tailed), as well as average long-term PTA-ABG (ρ = 0.950, p < 0.001; 2-tailed). CONCLUSIONS The OOPS index makes it possible to accurately prognosticate hearing outcomes in adult and pediatric patients undergoing ossiculoplasty in both the short term and the long term.

The Impact of Smoking on Ossiculoplasty Outcomes

Objectives: To assess the impact of tobacco smoking on outcomes after ossiculoplasty. Study Design: Case series with chart review. Setting: Tertiary care center. Patients: Adult patients (16–88 yr of age) undergoing ossiculoplasty with cartilage tympanoplasty. Outcome Measures: Patients were classified as smokers (TOB+) or nonsmokers (TOBN). Comparisons were then made between these two groups with regard to early and late audiometric outcomes, rate of cure of conductive hearing loss, rate of successful graft healing, and incidence of complications after surgery. Results: There was no significant difference between the two groups with regard to postoperative &Dgr;PTA-ABG (change in pure-tone average air-bone gap) (−14.4 dB vs. −14.6 dB for TOBN vs. TOB+, respectively, p = 0.946) or final audiometric outcome (&Dgr;PTA-ABGfinal) (−13.6 dB vs. −11.7 dB for TOBN vs. TOB+, respectively, p = 0.315), cure of conductive hearing loss, defined as closure of the PTA-ABG to ⩽20 dB HL, at postoperative audiometry (75.0% [129/172] for the TOBN group vs. 69.3% [52/75] for the TOB+ group, p = 0.355), late audiometry (71.4% [105/147] for the TOBN group vs. 66.7% [44/66] for the TOB+ group, p = 0.483), or successful graft healing (99.4% in the TOBN group vs. 98.7% in the TOB+ group, p = 0.544). However, complications were observed significantly (p = 0.0003) more often in the TOB+ group (34.7% [26/75]) than the TOBN group (14.5% [25/172]). Conclusion: Smoking is not a significant risk factor for anatomic failure of cartilage tympanic membrane graft or worsened audiometric outcome after ossiculoplasty. However, complications were significantly more common in smokers, supporting the practice of primary tympanostomy tube placement at the time of ossiculoplasty.

Simultaneous versus sequential bilateral cochlear implants in adults: Cost analysis in a US setting

From a purely surgical efficiency point of view, simultaneous cochlear implantation (SimCI) is more cost‐effective than sequential cochlear implantation (SeqCI) when total direct costs are considered (implant and hospital costs). However, in a setting where only SeqCI is practiced and a proportion of initially unilaterally implanted patients do not progress to a second implant, this may not be the case, especially when audiological costs are factored in. We present a cost analysis of such a scenario as would occur in our institution.

Long-term Complications and Surgical Failures After Ossiculoplasty

OBJECTIVE To study long-term complications after ossiculoplasty. STUDY DESIGN Case series with chart review. SETTING Tertiary care referral center otology practice. PATIENTS One hundred ninety-five patients (18-88 yr of age) undergoing ossiculoplasty with tympanoplasty or tympanomastoidectomy using cartilage tympanic membrane grafts, retrograde mastoidectomy with canal wall reconstruction, or mastoid obliteration techniques between July 1998 and July 2012. The studied patients all had at least 3 years of clinical follow-up. OUTCOME MEASURES Incidence of long-term complications, including need for revision surgery, need for secondary ventilation tube placement, recurrence of conductive hearing loss (and related etiologies), recurrent cholesteatoma, and delayed graft failure (recurrent tympanic membrane perforation). RESULTS Long-term complications were observed in 10.3% (20/195) of patients. 8.2% (16/195) required revision surgery, 10.2% (17/195) required secondary ventilation tube placement, 3.6% (7/195) experienced recurrence of conductive hearing loss, 4.1% (8/195) had delayed failure of tympanic membrane graft, and 1.5% (3/195) had recurrence of cholesteatoma. Recurrence of conductive hearing loss was caused by the displacement of prosthesis in 3 of 7 patients and extensive scar tissue formation without prosthesis displacement in 4 of 7 patients. Seventy-two percent obtained a postoperative pure-tone average - air-bone gap  < 20 dB. Forty-eight percent (93/195) obtained a hearing result worse than expected based on the ossiculoplasty outcome parameter staging index. CONCLUSION Long-term complications are a significant consideration in all the patients undergoing ossiculoplasty. Our data suggest that tobacco smoking, Eustachian tube dysfunction, and an unexpectedly poor hearing result on the first postoperative audiogram are all important risk factors for the development of significant complications.

Long-term Outcomes After Secondary Mastoid Obliteration.

Objectives: To assess long-term outcomes after secondary mastoid obliteration. Study Design: Case series with chart review. Setting: Tertiary care center. Patients: Adult patients (20–80 yr of age) undergoing secondary mastoid obliteration. Outcome Measures: Hearing results (improvement in pure-tone average air-bone gap [PTA-ABG] from baseline) at the time of postoperative audiometry and at least 5 years after surgery, anatomic outcomes (rate of successful tympanic membrane graft healing), and the incidences of observed complications. Results: An average improvement in PTA-ABG by 16.9 dB (p = 1.8 × 10−9) was noted. Postoperatively, the PTA-ABG was successfully closed to ⩽20 dB in 39.5% (17/43) of patients. The average final PTA-ABG (obtained at least 5 years after surgery) was 25.3 dB, which was also a significant improvement over the preoperative baseline PTA-ABG (p <<< 0.01). Significant complications were observed in 14.0% (6/43) of patients, with 9.3% (4/43) requiring a subsequent surgery. Although 69.8% (30/43) of patients experienced otorrhea preoperatively, otorrhea was only observed in 4.7% (2/43) at any point in time postoperatively. Conclusion: Secondary mastoid obliteration with reconstruction of a more natural posterior canal wall, cartilage tympanoplasty, and ossicular chain reconstruction is a hybrid technique that allows for creation of a safe, dry ear with significant, long-term improvement in hearing and functional outcomes in patients with unstable mastoid cavities.

Does cochlear implant brand influence patient satisfaction? A survey of 102 cochlear implant users

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The Influence of Intraoperative Testing on Surgical Decision-making During Cochlear Implantation

OBJECTIVE To review our use of intraoperative testing during cochlear implantation (CI) and determine its impact on surgical decision-making. STUDY DESIGN Retrospective chart review. SETTING Tertiary referral center. PATIENTS A total of 197 children and adults who underwent a total of 266 primary and/or revision CI by a single surgeon from 2010 to 2015. INTERVENTION Intraoperative electrophysiologic monitoring including evoked compound action potentials and electrical impedances. MAIN OUTCOME MEASURES Whether surgical management was changed based on intraoperative testing. RESULTS In only 2 of 266 patients (0.8%), the back-up device was used due to findings on intraoperative testing. In three patients (1.1%), X-ray was performed intraoperatively to confirm intracochlear electrode placement, which was found to be normal in all patients. CONCLUSION Our data suggest that with respect to CI in children and adults in straightforward cases (e.g., normal anatomy, nondifficult insertion, etc.), routine intraoperative evoked compound action potentials, impedances, and imaging rarely influence surgical decision-making in our clinic and may have limited usefulness in these patients. The implications of this are discussed and a review of the literature is presented.

Influence of Behavior on Complications of Osseointegrated Bone Conduction Devices in Children

OBJECTIVE Compare incidences of complications following implantation of osseointegrated bone conduction devices (OBCD) between children with and without behavioral disorders. STUDY DESIGN Case series with chart review. SETTING Tertiary referral center otology and neurotology practice. PATIENTS Pediatric patients who underwent implantation of OBCD between May 2009 and July 2014 at Arkansas Childrens Hospital. INTERVENTIONS Implantation with Cochlear BAHA 200 series, Cochlear BAHA BI300, or Oticon OBCD. MAIN OUTCOME MEASURES Osseointegration failure (OIF) with resulting loss of flange-fixture and/or skin and soft tissue reactions. RESULTS The total rate of complications was 66.2%, with the majority being minor complications (39.4%). There was no difference in the total rate of complication (p = 0.461), minor complications (p = 0.443), major complications (p = 0.777), and minor and major complications (p = 0.762) between the control group and children with behavioral disorders. CONCLUSION Behavior was not observed to influence the incidence of OIF or skin/soft tissue reactions after implantation of OBCD in pediatric patients.