Nader Nassif

Favorable outcome of cochlear implant in VIIIth nerve deficiency.

Objective: To report on the outcomes of cochlear implantation (CI) in a child with cochleovestibular nerves (CVN) hypoplasia. Study Design: Retrospective case review. Setting: Tertiary referral center, University hospital. Patients: An 18-month-old child with profound bilateral congenital hearing loss and bilateral hypoplasia of the CVN at imaging. Intervention: Left CI at age 29 months with a Nucleus Contour device (Cochlear Ltd., Lane Cove, New South Wales, Australia) after unsatisfactory results of hearing aid use for 10 months. Main Outcome Measures: Speech perception tests, behavioral observation, electrophysiologic tests, and cognitive evaluation. Results: Although the child scores poorly in every perceptive category with the CI alone, the device greatly enhances his speech understanding with the hearing aid in the opposite ear. In the bimodal condition, his words and sentences identification, recognition, and comprehension far exceed the monaural figures. The Meaningful Auditory Integration Scale (MAIS) tests reaches a score of 26/40, and the MacArthurs questionnaires confirm the improvement of language production and comprehension. These results became noticeable after 5 to 6 months and continued to improve up to the 10th month. The childs cognitive scores and overall performance competences greatly benefit from the CI, with the mental age overcoming the chronological age. Conclusion: We can confirm the chance of achieving satisfactory results by CI even when the imaging of CVN is doubtful and the electrophysiological tests are disappointing. In our experience, a CI in Type IIb dysplasia of the CVN is a feasible option, provided that the candidate shows some responses at aided audiogram and at least minimal signs of language development. Adequate counseling is necessary for these children because the expected outcome is somewhat lower than that of their deaf peers with normal appearance of the nerves.

Tympanic membrane perforation in children: Endoscopic type I tympanoplasty, a newly technique, is it worthwhile?

OBJECTIVES To evaluate the results of a newly introduced technique to our Department of endoscopic assisted transcanal myringoplasty applied in tympanic membrane perforation in children of any age and compare them to that of the previously standard microscopic assisted myringoplasty technique. METHODS A retrospective study of myringoplasties performed between January 2005 and June 2014 in children suffering from chronic otitis media with perforation. In microscope-assisted cases, a transcanal approach was applied when the anterior tympanic annulus was completely visible through the ear speculum, and a postauricular approach was used in all other cases. A transcanal approach was used in all endoscopic-assisted cases. RESULTS Between January 2005 and December 2010 and January 2011 and June 2014, 23 and 22 myringoplasties were performed by means of an operative microscope and an endoscope, respectively. Patient age varied from 5 to 16 years. Median duration of microscopic and endoscopic approaches was 90 min and 80 min (P=0.3), respectively. Hospital stay after surgery was significantly longer in the microscope group than the endoscope group (P<0.001). The intact graft success rate was 82.6% in microscopic and 90.9% in endoscopic approaches. Median postoperative air-bone gap of microscopic and endoscopic approaches was 6.2 dB and 6.6 dB, respectively (P=0.9). Neither intra- nor postoperative complications were observed. CONCLUSION Endoscopic transcanal myringoplasty is an alternative surgical approach to traditional technique. This surgery is more conservative than microscopic approach and can be performed in all pediatric cases independently from age. Moreover, it offers comparable anatomical and functional results to the traditional surgery, and grants better comfort for the child.

Surgical repair of bone defects of the ear canal wall with flexible hydroxylapatite sheets: a pilot study.

Objective Evaluation of suitability of flexible composite sheets (hydroxylapatite and polymer) for outer ear canal (OEC) wall reconstruction in tympanoplasty. Study Design Prospective, open label pilot study. Setting University and regional hospital. Patients Forty-two randomly selected patients with chronic otitis media (n = 20) and cholesteatoma (n = 22) among 356 patients admitted between 1996 and 1997. Interventions Eradication of disease through a partial or total canal wall down mastoidectomy; immediate reconstruction of canal wall with flexible composite sheet (hydroxylapatite and polymer) and connective tissue graft. Outcome Measures Anatomic integrity of the OEC and neotympanum, extrusion rate, complications. Results At minimum follow-up of 24 months: recurrent cholesteatoma (n = 0), residual cholesteatoma (n = 3/22) (13.6%) in the mesotympanum (none behind the hydroxylapatite sheet or in the attic or antrum). The neotympanum was intact in 38 ears (90.4%), reperforated in 2, and severely retracted and lateralized in 1, respectively. Anatomic integrity of the OEC was obtained in 37 (88%) of 42 patients; stenosis or membranous synechiae were observed in 5 ears and treated in the office. Extrusion of the hydroxylapatite sheet occurred in 7 patients (16.6%) because of purulent otorrhea and granulation tissue formation. Surgical revision achieved complete epithelialization of the rebuilt canal wall in 33 ears (78.6%). Conclusions A dry, disease-free ear and normal anatomy may be expected 2 years postoperatively in more than three-fourths of the patients treated using the described surgical technique. Complete protection with a connective tissue graft is essential to avoid extrusion of the implant. The failure rate is significantly higher if otorrhea is present at the time of the operation.

Simultaneous translabyrinthine removal of acoustic neuroma and cochlear implantation.

OBJECTIVES To report of a 65-year-old woman with bilateral Menieres disease was referred for cochlear implantation (CI) due to severe/profound sensorineural hearing loss. METHODS During the assessment workup, a vestibular schwannoma in the right ear was found by MR imaging. She underwent a translabyrinthine removal of the acoustic neuroma (AN) with sparing of the cochlear nerve and concurrent ipsilateral CI with a Nucleus Freedom device (Cochlear Ltd., Lane Cove, New South Wales, Australia). RESULTS Complete removal of the AN was achieved without complications. Neural Response Telemetry (NRT) measurements, which showed poor morphology at the intraoperative tests, rapidly improved after activation, similarly to electrically evoked auditory brainstem responses (E-ABR). The patient reached 100% speech perception performances within 2 months from implantation, in the monaural condition. She was relieved from vertigo spell up to 14 months after the operation. CONCLUSION Cochlear implantation at the time of acoustic neuroma removal with VIII nerve sparing can be a safe and effective hearing restoration procedure.

Factors affecting residual hearing preservation in cochlear implantation.

SUMMARY The likelihood of residual hearing preservation in cochlear implantation (CI) is related to surgical factors such as type of cochleostomy (trans-fenestral vs. promontorial), use of lubricants and protective drugs, and device-related factors such as shape, length and flexibility of the array. We investigated the impact of these factors on the hearing preservation rate in adults and children with conventional audiological indications to CI. Eighty-two children aged 1-9 years and 73 adults (16-79 years) received a CI in the right (59%) or left ear (41%). An anterior-inferior promontorial cochleostomy was performed in 143 ears (92%); a trans-fenestral approach was used in 12 (8%). A perimodiolar electrode was implanted in 144 ears (93%), and a straight electrode in the remaining 11 (7%). Overall, some post-operative hearing was retained in 39% of ears. The rate of preservation was higher at the low than at the high frequencies. When correlated with age, side of implant, implant model and type of cochleostomy, the mean threshold variations did not reach statistical significance for any of these variables. A slight trend in favour of better residual hearing preservation in children vs. adults was seen, especially at lower frequencies.

Endoscopic ventilation tube placement in the pediatric age

Dear Editor, The development of oto-endoscopic techniques in the last years has opened new alternatives to traditional oto-microscopic surgical approaches to the middle ear. Endoscopic VT placement was started at our Pediatric ENT Department by the first author to manage children with stenotic and curved canals. As this procedure was easily handled, gradually other colleagues shifted from microscope to endoscope approach owing to its easy and straightforward procedure. The authors have reviewed personal experience in termsof feasibility andadvantagesof the endoscopic technique for ventilation tubes (VTs) placement by comparisonwith the conventional oto-microscopic approach in children.

Pharyngeal involvement of antrochoanal polyp

A 5-year-old boy presented with a 9-month history of right nasal obstruction and foreign body sensation in the throat. Intraoral examination revealed a large, soft, translucid mass sited behind the uvula (figure 1) and hanging from the rhinopharynx. Nasal endoscopy showed a polyp into the middle meatus that extended posteriorly through the right choana into the …

Long-term Results and Prognostic Factors of Underlay Myringoplasty in Pars Tensa Atelectasis in Children

IMPORTANCE Pars tensa retraction is a frequent condition in chronic otitis media, and there is a large diversity of opinions regarding its management. OBJECTIVE To report the long-term results and prognostic factors of myringoplasty in pediatric patients with grade 5 pars tensa atelectasis. DESIGN, SETTING, AND PARTICIPANTS This was an observational, retrospective case review, conducted at a referral university hospital, of children undergoing surgical intervention for dry tympanic disruption after a clinical history of tensa retraction with a transcanal or postauricular approach under general anesthesia. INTERVENTIONS Underlay myringoplasty with temporalis fascia or tragal perichondrium by transcanal or postauricular approach under general anesthesia. MAIN OUTCOMES AND MEASURES Anatomical results are reported with a minimum follow-up of 5 years analyzing perforation or retraction of the neotympanum. Age; sex; side, position, and size of the eardrum disruption; surgical approach; graft material; and presence of contralateral disease were correlated with anatomical failure. RESULTS The population included 33 girls and 28 boys undergoing 65 interventions; the age varied from 4 to 16 years (mean [SD], 10 [3.2] years). An intact tympanic membrane was obtained in 58 cases (89.2%) with a follow-up varying from 5 to 14 years (mean follow-up, 9 years). None of the variables analyzed significantly predisposed patients to tympanic perforation after surgical repair. There were no new progressive retractions. CONCLUSIONS AND RELEVANCE Tensa retraction resulting in a tympanic disruption can be cured by underlay myringoplasty with perichondrium or temporalis fascia with results similar to those of simple tympanic perforations without recurrent retraction even in the long-term period.

Video HIT in adults with cochlear implants

Abstract Objective: To evaluate the high-frequency function of bilateral lateral, posterior and anterior semicircular canals by video head impulse testing (vHIT) in adult patients with profound sensorineural hearing loss subjected to cochlear implant. Methods: A group of 19 adult bearers of monolateral cochlear implants for more than one year was assessed by vHIT on both sides with CI-ON modality and CI-OFF modality. The average of the VOR gains in each of the six semicircular canals was assessed. The Mann–Whitney U-test was used to compare VOR of implanted and non-implanted side semicircular canals (independent samples) and the Wilcoxon test was used to compare VOR with CI-ON modality and CI-OFF modality (related samples). Results: From a clinical point of view, no vestibular symptoms were observed although the median of VOR gain to vHIT was lower than normal values in most cases. Comparing the VOR in semicircular canals in the implanted side with that in the non-implanted side and each canal in the OFF modality compared to the ON modality, we observed no significant difference in VOR gain values, except in the lateral semicircular canal of the opposite side, in which the median of VOR gain was 0.80 (0.68–0.95) in OFF modality and 0.84 in ON modality (0.76–1.06) (p = .04). Conclusion: Even though cochlear implant has no negative impact on clinical vestibular function VOR gain in vHIT recordings is frequently reduced.

Minimally invasive approach to suppurated cervical lymphadenitis in children: Our experience on 60 patients

The majority of cases of acute cervical lymphadenitis have good outcomes with intravenous antibiotic therapy.1 Involvement of pyogenic microorganisms may progress to suppuration resulting in the development of acute suppurated cervical lymphadenitis.1 When suppurated cervical lymphadenitis non-responding to antibiotic therapy is observed, incision and drainage is still indicated.1 A less invasive approach, namely needle aspiration, can be an alternative method in the management of suppurated cervical lymphadenitis in children, providing material to perform bacterial culture and being curative in association with medical therapy.2 This study aimed to support the usefulness of needle aspiration instead of open surgical drainage in the diagnostic and therapeutic approach to acute suppurated cervical lymphadenitis in children. This article is protected by copyright. All rights reserved.