Ossicle Coupling Active Implantable Auditory Devices: Magnetic Driven System.

Active auditory implants, such as the Maxum, provide significantly improved hearing function compared to hearing aids in patients with moderate to severe hearing loss who are not reaching their cochlear hearing potential. The speech perception gap (SPG), defined as PB Max (phonetically balanced maximum) minus word recognition score with hearing aid, is a useful measure of inadequate hearing aid performance. The Maxum middle ear implant provides significantly improved performance over hearing aids in patients with significant SPG because of superior high frequency gain. Patients with PB Max 60% or greater with SPG are possible candidates for the implant.

Comparison of an Electromagnetic Middle Ear Implant and Hearing Aid Word Recognition Performance to Word Recognition Performance Obtained Under Earphones.

OBJECTIVE: To report the results of patients with the Maxum middle ear implant (MEI) and compare word recognition scores (WRS) and speech perception gap (SP Gap) of Maxum versus optimally fit hearing aids (HA). STUDY DESIGN: Case series with chart review. SETTING: Single, private otology clinic. PATIENTS: Eleven ears, in nine adult patients (two women; average age 62.7 yr). INTERVENTIONS: Twelve consecutive ears with moderate to severe sensorineural hearing loss (SNHL) underwent implantation of the Maxum system. One patient was not included due to inadequate preoperative testing. MAIN OUTCOME MEASURES: Primary outcome measures included word recognition score (WRS) and SP Gap (maximum word understanding [PB max] - WRSaided) improvement compared with HAs. RESULTS: The average Maxum WRS was 64.7% (range, 28-94%), a 41.6% improvement (range, 10-66%) over HAs (p < 0.001). The average Maxum SP Gap was 6.6% (range, -8 to 24%), a 41.6% improvement (range, 10-66%) over HAs (p < 0.001). CONCLUSION: These data demonstrate that the Maxum provides superior WRS than HAs for patients with significant aided SP Gaps. There is a significant, very strong correlation between Maxum WRS and PB max (r = 0.85, p = 0.001). This implies that PB max may reasonably predict WRS outcomes with Maxum before implantation, and the SP Gap can reasonably predict the degree of additional potential benefit with Maxum. In advising patients who may be candidates for both a CI and MEI, PB max and SP Gap measurements will provide useful predictive information to help clinicians counsel patients on their choice of hearing technology. LEVEL OF EVIDENCE: 4.

Stapedectomy Effects on Tinnitus: Relationship of Change in Loudness to Change in Severity.

OBJECTIVE: To relate poststapedectomy change in tinnitus loudness to change in tinnitus severity. STUDY DESIGN: Prospective, within-subjects. SETTING: A single otology and neurotology subspecialty referral practice. SUBJECTS AND METHODS: Forty-nine subjects undergoing stapedectomy completed the study between January 2012 and October 2013. Tinnitus instruments, audiometric data, and demographic information were collected prior to and 1 and 6 months after surgery. Tinnitus loudness was assessed using an 11-point (0 = none; 5 = conversation level; 10 = jet engine) visual analog scale, and severity was measured using the validated Tinnitus Functional Index. The relationship between change in tinnitus loudness and change in tinnitus severity was evaluated using linear regression and receiver operating characteristic (ROC) analyses. RESULTS: A linear regression model of change in tinnitus loudness averaged for both ears on a visual analog scale (ΔVASavg) versus change in Tinnitus Functional Index score (ΔTFI) showed a strong correlation (ΔTFI = 9.35 ×ΔVASavg; R = 0.64; P < .001). An ROC analysis identified ΔVASavg between 1.5 and 2.0 as the optimal threshold for predicting a clinically significant change in tinnitus severity (ΔTFI ≥ 13), with sensitivity and specificity of approximately 0.62 and a positive predictive value (PPV) of 0.64. CONCLUSION: For poststapedectomy patients, a VAS loudness change by 1.5 to 2.0 points averaged for both ears in bilateral tinnitus or ~3 points in unilateral tinnitus has a PPV ~0.64 for a clinically significant change in tinnitus severity.

Tinnitus modulation by stapedectomy.

OBJECTIVE: To assess change in tinnitus severity after stapedectomy using the validated Tinnitus Functional Index (TFI) at 1 and 6 months in 2 cohorts of subjects with otosclerosis with different preoperative (TFIpre) distress levels. STUDY DESIGN: Prospective within-subjects repeated measures. MATERIALS AND METHODS: Twenty-six subjects completed the study between January 2012 and April 2013. Demographic information, preoperative and postoperative audiometric data at 1 month, and TFI scores measured preoperatively within 1 month of stapedectomy and postoperatively at 1 and 6 months were captured and analyzed. RESULTS: Stapedectomy has its largest effect on tinnitus severity reduction within the first month of surgery. Cohort A (TFIpre > 15, n = 16) ΔTFI mean and median values were ∼20 for the intervals preoperatively to 1 month and preoperatively to 6 months (p values < 0.01) and dropped to ∼0 for the interval between 1 and 6 months postoperatively. Cohort B (TFIpre < 15, n = 10) ΔTFI mean and median values were ∼0 for all time intervals (all pairwise comparison p values > 0.05). CONCLUSION: Stapedectomy in patients with otosclerosis with more than a small problem with tinnitus (TFIpre > 15) will reduce severity by at least 1 clinical category in ∼85% of cases within 6 months of surgery. The majority of patients will experience stable tinnitus suppression within the first postoperative month. In patients with no tinnitus or less than a small problem with tinnitus (TFIpre < 15), stapedectomy carries a 10% risk of transient worsening of tinnitus at 1 month, which resolves by the sixth postoperative month.

Ossicular chain reconstruction using titanium versus hydroxyapatite implants.

OBJECTIVES: Compare the efficacy of total and partial ossicular chain reconstruction using hydroxyapatite (HA) implants versus titanium (Ti) implants. DESIGN: Case series with chart review. SETTING: Academic tertiary referral center and private practice. SUBJECTS AND METHODS: 404 patients underwent ossiculoplasty using either Ti or HA implants from June 1996 to September 2008. Patient data were collected retrospectively from the senior author's electronic database of surgical cases. RESULTS: The change in air-bone gap (ΔABG) (defined as the difference between the means of preoperative and postoperative ABG) was 9.9 dB for the HA group that received partial ossicular reconstruction prosthesis (PORP), 9.5 dB for the Ti PORP group, 12.3 dB for the Ti group that received total ossicular reconstruction prosthesis (TORP), and 10.0 dB for the HA TORP group. There was no statistically significant difference between the HA and Ti groups. There was no significant difference in hearing results between canal wall up (CWU) and canal wall down (CWD) cases in which mastoidectomy was performed. Four confounding factors (preoperative otorrhea, preoperative perforation, cholesteatoma, mastoidectomy performed) were analyzed using regression analysis. In the Ti PORP group, the presence of cholesteatoma was found to have a significant negative bias for hearing results. CONCLUSION: No statistically significant differences in hearing results were found between the HA and the Ti partial and total ossiculoplasty prostheses. No outcome difference was found between CWU versus CWD mastoidectomy groups for any type of implant used. A randomized, prospective study is necessary for a more definitive comparison of efficacy between HA and Ti OCR implants.

Dermoid cyst in the facial nerve--a unique diagnosis.

Facial nerve paralysis in children may occur as a complication of infections, trauma, or rarely from benign or malignant tumors of the facial nerve. We present the first reported case of a dermoid tumor in the facial nerve causing facial paralysis in a child. Case report at a tertiary Children's Hospital. A 9-month-old was referred to our institution for evaluation of persistent, complete right sided facial paralysis three months after receiving a diagnosis of Bell's palsy. A workup at our institution including MRI and CT revealed marked widening of the facial canal in the mastoid segment consistent with facial nerve schwannoma or hemangioma. Surgical exploration via mastoidectomy and facial nerve decompression revealed keratinous material containing hair that had fully eroded the facial nerve, disrupting it completely. The entire tumor was removed along with the involved segment of facial nerve, and the missing facial nerve segment was cable grafted. Histological examination of the tumor confirmed a ruptured dermoid cyst in the facial nerve. Facial nerve tumors are rare causes of facial paralysis in children, accounting for fewer than 10% of cases of facial paralysis in the pediatric population. Dermoid cyst can occur throughout the head and neck region in children, but a dermoid tumor in the facial nerve has not been described in the literature prior to this report. This represents a new and uncommon diagnostic entity in the evaluation of facial nerve paralysis in children. Appropriate imaging studies and pathology slides will be reviewed.

Efficacy of tympanoplasty without mastoidectomy for chronic suppurative otitis media.

OBJECTIVE: To compare the efficacy of tympanoplasty without mastoidectomy in patients with chronic suppurative otitis media (CSOM) vs efficacy in those with dry tympanic membrane (TM) perforations. DESIGN: Retrospective controlled study based on a prospective database. SETTING: Academic tertiary referral center. PATIENTS: A total of 150 consecutive patients without cholesteatoma with CSOM or dry perforations alone who underwent tympanoplasty without mastoidectomy from January 2000 through December 2005. INTERVENTION: Tympanoplasty without mastoidectomy. MAIN OUTCOME MEASURE: Perforation recurrence. Independent variables were age, surgical approach, perforation size, and revision surgery. RESULTS: The TM graft failure rate was not significantly worse in the CSOM group compared with the dry perforation group (P = .48). The independent variables studied were not statistically related to the success of tympanoplasty except that revision surgery was associated with a slightly reduced success rate (P = .03). CONCLUSIONS: The success rate of tympanoplasty without mastoidectomy is at least as good for patients with CSOM as it is for patients with perforation without prior otorrhea. Age (P = .28), perforation size (P = .11), and surgical approach (P = .82) were not significantly related to success rate. Revision surgery was associated with a slightly lower success rate.

Efficacy of steroid injection on idiopathic sudden sensorineural hearing loss.

OBJECTIVE: To evaluate the effectiveness of transtympanic steroid injection on patients with idiopathic sudden sensorineural hearing loss (ISSNHL) compared with patients who receive oral steroids alone. STUDY DESIGN: Retrospective chart review. METHODS: Patients with a history of ISSNHL and failed oral steroid therapy were included. Audiograms were performed and patients were included if SNHL of more than 20 dB occurred over less than 72 hours. Patients who received transtympanic steroid injection were compared with those who received oral steroids alone. RESULTS: Sixty-one patients met inclusion criteria and were included in the study. The number of patients with improvement in pure tone average in the injection group was 9 (30%) compared with 5 (17%) in the oral group. Twelve (38.7%) of the injected patients did have improvement in speech discrimination scores of greater than 15% compared with only 3 (10%) in the oral steroid group. CONCLUSION: Our study revealed that patients with ISSNHL who have failed oral steroid therapy obtain better hearing results with transtympanic steroids in comparison to oral steroids. EBM RATING: B-3b.

Ossicular chain dislocation with normal hearing.

We report a unique case of an ossicular chain injury in a young man. Despite the fact that the patient's incus was dislocated into the external auditory canal while remaining attached to the stapes, his hearing was not affected and remained nearly normal. We discuss the patient's presenting features and our diagnostic and management strategy in this case.

Pressed scar tissue for tympanic membrane grafting in revision tympanoplasty.

OBJECTIVE: Compare the efficacy of pressed scar tissue grafts to standard fascia and areolar tissue grafts for use in tympanoplasty. STUDY DESIGN: A retrospective review of a prospective computerized database of tympanoplasty and mastoid surgeries at an academic, tertiary care practice was performed. Search parameters were set to find all patients who underwent tympanoplasty with or without mastoidectomy with use of various grafting materials for repair of tympanic membrane perforation from 1996 to 2002. All ages were included. Patients with cholesteatoma at the time of surgery were excluded. The short-term graft take rate was evaluated at 30 to 90 days to identify any differences in results using the standard fascia and areolar grafts vs. pressed scar tissue grafts. Other parameters that may have an influence on outcome were analyzed including mastoidectomy, infection, perforation size, perforation location, age of patient, primary vs. revision surgery, number of previous surgeries, postauricular vs. transcanal approaches, and medial vs. lateral grafting techniques. Hearing results were analyzed to see whether the use of scar tissue grafts resulted in equivalent outcomes compared to standard graft materials. RESULTS: There were no statistically significant differences in short-term tympanic membrane closure rates in subjects undergoing surgery using standard fascia/areolar tissue grafts and pressed scar tissue grafts. Hearing results were also statistically equivalent regardless of graft material used. The only parameter that was somewhat associated with successful closure of tympanic perforation was use of the postauricular approach compared to the transcanal approach. CONCLUSIONS: Pressed scar tissue grafts are as efficacious as standard fascia and areolar tissue grafts when used to repair tympanic membrane perforations. Pressed scar tissue graft can be used successfully in cases such as revision tympanoplasty when standard tissue grafts are not available or difficult to obtain. EBM RATING: B-3.

Risk factors for hearing loss in neonates: a prospective study.

OBJECTIVES: To identify potential risk factors for neonatal hearing loss that are not included in the current variables recognized by the Joint Committee on Infant Hearing (JCIH). METHODS: A series of consecutively born neonates with risk factors for hearing loss based on the 1994 JCIH registry were screened prospectively. There were 110 subjects with hearing loss and 636 subjects without hearing loss. Data collected as potential risk factors for infant hearing loss included not only those on the JCIH list but also others that we believed to be possibly significant. The infant hearing screening was performed on each subject using auditory brain stem testing. Statistical analysis of data was performed using the chi-square test. RESULTS: In addition to the variables listed by the JCIH, we identified 11 additional risk factors that were associated with hearing loss in our neonatal population. These are: length of stay in the intensive care unit, respiratory distress syndrome, retrolental fibroplasia, asphyxia, meconium aspiration, neurodegenerative disorders, chromosomal abnormalities, drug and alcohol abuse by the mother, maternal diabetes, multiple births, and lack of prenatal care. CONCLUSION: This study identifies 11 risk factors in addition to those currently on the high-risk registry published by the JCIH for neonatal hearing loss. The inclusion of these additional risk factors in neonatal screening programs may improve the detection rate of neonates with hearing loss. Further study will be needed to determine whether inclusion of these additional risk factors in a hearing screening program can provide an efficacious alternative to the use of universal infant screening.