Samuel A. Spear

Intratympanic steroids for sudden sensorineural hearing loss: a systematic review.

Objective. To determine the evidence for efficacy of intratympanic (IT) steroid treatment for the management of idiopathic sudden sensorineural hearing loss through a systematic review of the existing literature. Data Sources. Online databases consisting of PubMed, Medline, OVID, Google Scholar, Cochrane Review, and collected additional publications cited in bibliographies. Review Methods. Literature search by both authors with structured criteria to select studies evaluated for systematic review. Results. The authors identified 176 articles, of which 32 represented studies of initial or salvage intratympanic steroid injections for sudden hearing loss that included 6 randomized trials and only 2 randomized controlled trials. Despite the paucity of well-executed trials, the vast majority of studies of intratympanic steroids for salvage treatment in all tiers demonstrated a benefit of intratympanic steroid therapy. A limited meta-analysis of the higher quality studies revealed a mean difference in improvement of 13.3 dB (95% confidence interval [CI], 7.7-18.9; P < .0001). Although statistically significant, it is still unclear if this difference is clinically significant. Initial intratympanic therapy was equivalent to standard therapy in the existing literature of all qualities. Conclusion. Intratympanic steroid treatment as primary treatment for sudden sensorineural hearing loss appears equivalent to treatment with high-dose oral prednisone therapy. As salvage therapy, intratympanic steroids offer the potential for some degree of additional hearing recovery, although it remains uncertain if this improvement is clinically significant and what percentage of patients is likely to show benefit.

Gene Expression Analysis in Sinonasal Polyposis before and after Oral Corticosteroids: A Preliminary Investigation

OBJECTIVE: To characterize gene expression in sinonasal polyps and to gain insight into change in expression after oral corticosteroid treatment. STUDY DESIGN AND METHODS: Nasal polyps were obtained before and after oral corticosteroid treatment and gene expression was analyzed with a focused gene array technique. RESULTS: Pretreated sinonasal polyps demonstrated high gene expression for chemokine and leukotriene receptor genes (CCR2, CCR5, CX3CL1, and LTB4R) in all patients. After treatment, the global effects of corticosteroids were evident on gene expression. CONCLUSIONS: Gene array techniques hold promise as a research method in sinonasal polyposis. The potential benefits, as well as the potential challenges, in using these research methods will be discussed.

Subjective and objective findings in patients with true dehiscence versus thin bone over the superior semicircular canal.

Objective To compare subjective and objective findings between patients with true dehiscence versus thin bone over the superior semicircular canal (SSC). Study design Retrospective case series. Setting Tertiary referral center. Patients All patients from our institution with true dehiscence or thin bone over the SSC on computed tomography temporal bone (oblique view) from 2007 to 2013. Main outcome measures Subjective test: Dizziness Handicap Inventory (DHI). Objective tests: Infrared video eye recording with varying stimuli (Tulio, Fistula, and Vibration); vestibular evoked myogenic potential (VEMP); electrocochleography; videonystagmography; pure-tone audiometry (i.e., air-bone gap). Results Fifty-four patients (64 ears) were reviewed. Thirty-nine patients (47 ears) had true dehiscence of the SSC on temporal bone computed tomography. Fifteen patients (17 ears) had thin bone over the SSC. There was no statistical difference in DHI scores for patients with true dehiscence versus those with thin bone over the SSC. Only cervical VEMP and air-bone gap via pure-tone audiometry revealed a significant difference between the two groups. The remaining vestibular assessments did not demonstrate any difference. No significant correlations were revealed between DHI and objective test findings across and within the two groups. Conclusion Among the objective tests, cervical VEMP and pure-tone audiometry are the only tools to distinguish between true dehiscence and thin bone over the SSC. DHI does not differentiate between these two groups. Furthermore, no correlation exists between DHI and any objective finding. Further investigation is necessary to develop a validated subjective symptom index of patients with SSC syndrome.

Complications after the Surgical Treatment of Malignant Thyroid Disease

OBJECTIVES Our objectives were to document the complication rates after total thyroidectomy or lobectomy for malignant thyroid disease and to compare these rates with previously documented complication rates after operations for benign thyroid disease. METHODS This is a retrospective chart review of patients diagnosed with thyroid carcinoma at a tertiary military medical center from 1996 to 2000. RESULTS Eighty-two patients were identified with thyroid carcinoma, of which 81 underwent surgical treatment. Nine patients had complications related to their treatment, four were permanent. This included two cases of permanent postoperative hypoparathyroidism, one case of phrenic nerve injury, and one case of unilateral vocal cord paralysis. There is a statistically significant higher overall complication rate of this series (10%) in comparison to a similar series of patients surgically treated for benign thyroid disease (2%) when comparing only recurrent laryngeal nerve injury and hypoparathyroidism (p = 0.02). There is also a higher overall complication rate (11% vs. 4.9%); however, this does not reach statistical significance (p = 0.16). CONCLUSION Recurrent laryngeal nerve injury and hypoparathyroidism complication rates after operations for malignant thyroid disease are statistically higher in this series than complication rates after operations for benign thyroid disease. Overall complication rates are also higher for malignant thyroid disease as compared to benign thyroid disease. Before surgical treatment for malignant thyroid disease, patients should be counseled accordingly.

Is MRI Equal to CT in the Evaluation of Thin and Dehiscent Superior Semicircular Canals

Objective: Can magnetic resonance imaging (MRI) diagnose abnormally thin and dehiscent superior semicircular canals (SSCs) that traditionally rely on evaluation by computed tomography (CT) imaging? Study Design: Retrospective clinical study. Setting: Tertiary referral center. Patients: Adults who underwent both MRI and CT of the temporal bones over the past 3 years. Interventions: CT and MR images of SSCs were separately reviewed, in a blinded fashion by three neuroradiologists at our institution. CT diagnosis of abnormally thin or dehiscent SSC was used as the “gold” standard. Main Outcome Measures: 1) Dehiscent SSC. 2) Abnormally thin SSC. 3) Normal SSC. Results: One hundred temporal bones with evaluable superior semicircular canals from 51 patients were eligible for review on CT and MR imaging. There were 26 patients of thin SSC and 17 patients of SSC dehiscence on CT imaging, of which 13 and 15 respectively were also found on MRI. There were nine false-positive dehiscent SSC patients and four thin SSC patients observed on MR imaging while not observed on CT. For thin SSCs, MRI sensitivity was 61.9% and specificity of 94.3% with a positive predictive value of 81.3% and a negative predictive value of 86.2%. For dehiscent SSCs, sensitivity was 88.2% and specificity of 89.2% with a positive predictive value of 62.5% and a negative predictive value of 97.4%. Conclusion: In this series, MRI in the axial and coronal plane had a high negative predicative value for thin SSC (86%) and dehiscent SSC (97%). However, MRI cannot conclusively diagnose thin or dehiscent SSCs.

Magnetic Resonance Imaging versus Computed Tomography in Temporal Bone Carcinoma: Radiological and Pathological Correlation

Objectives: Correlate the findings of preoperative magnetic resonance imaging (MRI) and computed tomography (CT) in temporal bone carcinoma with histopathological findings following lateral temporal bone resection. Methods: In this retrospective review, 11 cases of temporal bone carcinoma over the past 3 years were reviewed at our institution. Preoperative CT and MRI scans were systematically reviewed for tumor involvement in 10 anatomic areas involving and surrounding the temporal bone. These were compared with results found on final histopathology. Results: Among the 11 cases, 30 anatomic areas of tumor involvement identified on CT imaging were also found on MRI and confirmed on final histopathology. Two areas suggestive on tumor involvement on CT and MRI (parotid gland and regional lymph nodes) and 2 areas on MRI alone (mastoid antrum and middle ear) were negative on final histopathology. MRI did not change the preoperative clinical staging in any of the 11 cases, however, examination of the MRI in 1 case suggested temporal lobe involvement that was not seen on CT images and subsequently changed the management of the patient. Conclusions: The addition of MRI in the preoperative evaluation of these patients confirmed the extent of tumor involvement seen on CT and did not identify additional tumor or facial nerve involvement in most cases except for one advanced case. In this case, the addition of the MRI findings changed the treatment plan. While CT remains the imaging gold-standard for preoperative evaluation and staging, MRI should be obtained in evaluating advanced temporal bone tumors.

Hydrophilic Hydroxyapatite Cement Cranioplasty: Preventing Cerebrospinal Fluid Leaks and Wound Complications in Translabyrinthine Acoustic Neuroma Surgery

Objectives: (1) Examine the efficacy of quick-setting, hydrophilic formulation of hydroxyapatite cement (HAC) used in cranioplasty for the prevention of cerebrospinal fluid (CSF) leaks and long-term wound complications following translabyrinthine acoustic neuroma (TLAN) surgery. (2) Review evolution of HAC cranioplasty. Methods: Retrospective case review from 2006 to 2013 in atertiary referral center. Consecutive patients undergoing translabyrinthine approach for acoustic neuroma tumors were operated on by the senior author. Intervention: Therapeutic: Cranioplasty combining a medial abdominal fat graft with hydrophilic hydroxyapatite cement filling the mastoid. Main outcome measures: Incidence of cerebrospinal fluid (CSF) leaks and any wound complications. Results: Forty-four patients met inclusion criteria. There were no CSF leaks or other wound complications in this series. Conclusions: Hydrophilic HAC appears to be safe and efficacious for cranioplasty following translabyrinthine acoustic neuroma surgery.

Longitudinal Comparison of Quality-of-Life Outcomes in Vestibular Schwannoma Patients

Objectives: 1) Compare long-term quality of life (QOL) outcomes in vestibular schwannoma (VS) patients managed conservatively, with microsurgery, or with stereotactic radiation; 2) Evaluate factors contributing to their QOL. Methods: The Penn Acoustic Neuroma Quality of Life (PANQOL) survey was administered to 645 patients treated for VS at a tertiary care center over 24 years. Patients in each treatment group were sub-divided by years since diagnosis (0-5, 6-10, and >10). Composite QOL (cQOL) scores and sub-scores in hearing, balance, facial symptoms, pain, anxiety, and energy were compared by ANOVA at each time interval. Regression analysis correlated QOL with tumor size, speech recognition threshold, and reported symptoms. Results: Survey return rate was 49%. Mean follow-up was 7.6 years. The only significant difference in cQOL was at 1-5 years, where stereotactic radiation was best and conservative treatment was worst (P = .009). No significant differences in cQOL were detected at 6-10 or >10 years. Significant differences between sub-scores were found in hearing, balance, and facial symptoms. Overall tumor size was inversely proportional to QOL (R = .54; P < .001); this correlation decreased with time (1-5 R = .61, P < .001 / 6-10 R = .40, P < .001 / >10 R = .16, P = .02). Conclusions: 1) We found no significant difference in long-term QOL outcomes between treatment groups; however, patients treated by stereotactic radiation may experience better overall QOL up to 5 years post-treatment. 2) Tumor size at presentation is a good prognostic tool in VS patients but may be limited in predicting long-term QOL outcomes.

Comparison of Nitinol Stapes Pistons with Conventional Stapes Pistons: A Cadaver Study

Objective. To visually compare the Nitinol “smart” stapes prosthesis to conventional manual crimping stapes pistons in temporal bone cadaver specimens. Main Outcome Measures. 10 otolaryngologists were given a photograph of the randomly ordered stapes pistons and asked to use the pictures to answer questions about each stapes piston. The answers to the survey were then recorded for analysis. Results. 8 of 9 Nitinol pistons were described as circular, and 3 of 9 manual crimped pistons were described as circular (P < .05). 6 of 9 Nitinol pistons were considered to be in contact with >66% of the incus and 3 of 9 to be in contact with 34–66% of the incus. 3 of 9 manually crimped pistons were considered to be in contact with >66% of the incus, 3 with 34–66% contact and 3 with less than 34% contact. Conclusions. The Nitinol “smart” stapes pistons were considered to provide a more circular and circumferential crimping and to have greater contact with the long process of the incus than conventional stapes pistons.

P106: Smart Crimp vs. Traditional Crimp of Stapes Prosthesis

OBJECTIVES: A minimally invasive myringoplasty using fibrin glue through the external auditory canal is commonly performed in Japan. This study investigated the relationship between the perforation size of the tympanic membrane (TM) and the postoperative closure rate or hearing result after minimally invasive myringoplasty. METHODS: The team evaluated 133 ears with a postoperative follow-up of 2 years or more. Six had traumatic perforations, 13 had residual perforations after insertion of the tympanic drain tube, and 114 had chronic otitis media in the treated ear. Classification of the perforation size of TM was grade I (lesions localized in 1 of the quadrants) in 42 ears, grade II (2 of the quadrants) in 61 ears, grade III (3 of the quadrants) in 15 ears and grade IV (total perforation of TM) in 15 ears. RESULTS: The overall postoperative closure rate was 88% at 6 months and 77% at 12 months after surgery, which was slightly lower than the results previously reported. There were no significant differences in the closure rate based on perforation size of TM (Kruskal-Wallis test). Postoperative hearing improvements (Air-bone gap was reduced to 15 dB or less) were achieved in 124 ears (93%). In cases showing recurrent perforation, there was no enlargement of the perforation size or worsening of hearing level compared to those in the preoperative state. CONCLUSIONS: It is concluded that this minimal invasive myringoplasty may be safe and useful regardless of the perforation size if the postoperative closure rate could be improved using some re-closure techniques.