Cochlear Implant Outcomes in Large Vestibular Aqueduct Syndrome-Should We Provide Cochlear Implants Earlier?

OBJECTIVE: Examine postoperative speech perception outcomes in a large vestibular aqueduct syndrome (LVAS) patients at a major cochlear implantation center. STUDY DESIGN: Retrospective analysis of the Sydney Cochlear Implant Centre (SCIC) database and medical records from January 1994 to December 2015 was performed. SETTING: Tertiary referral center. PATIENTS: Patients with a diagnosis of LVAS who received a cochlear implant (CI). Only those with speech perception outcomes recorded at least 12 months post implant were included in our analysis. INTERVENTION(S): Therapeutic. MAIN OUTCOME MEASURE(S): Postoperative speech perception scores. RESULTS: Between 1994 and 2015, 176 adult and pediatric patients with a diagnosis of LVAS underwent cochlear implantation at SCIC. Postoperative Bamford-Kowal Bench (BKB) sentence test scores were obtained for 97 patients. The postoperative median BKB score was 93% with a lower quartile score of 85% and an upper quartile score of 98%. Smaller numbers were available for post-CI City University of New York (CUNY) and Consonant-Nucleus-Consonant (CNC) word scores yet similar excellent results were seen. CONCLUSIONS: Our study results suggest the CI should be considered when BKB scores have dropped to 85%. We suggest that rather than LVAS cases representing a challenge to cochlear implantation, they are amongst the best candidates for surgery, and should receive a CI at an earlier stage in hearing loss, when they have better speech perception. This allows stable hearing to be established earlier along with excellent speech perception outcomes.

Effects of prolonged microscopic work on neck and back strain amongst male ENT clinicians and the benefits of a prototype postural support chair.

Musculoskeletal pain is a common occupational hazard experienced by surgeons. Ear, nose and throat (ENT) surgeons are predisposed to neck and back pain due to regular prolonged microscopic work. We conducted a prospective pilot study to investigate the effects of sustained microscopic work on the neck and back, its correlation to surgical experience and to assess the benefits of a prototype postural support chair (PSC) amongst 10 male, ENT clinicians. We used a subjective measure of time to fatigue and pain for the neck and back as well as objective readings from a surface electromyogram (sEMG). We found that an increase in surgical experience correlated with the time taken to experience fatigue and pain in the neck and back. This was corroborated by our sEMG findings. The PSC significantly delayed the sensations in the neck and also eliminated the difference seen amongst the varying seniority of clinicians.

Clinicians' perception of the preventability of inpatient mortality.

Purpose The purpose of this paper is to assess whether clinicians have an accurate perception of the preventability of their patients' mortality. Case note review estimates that approximately 5 percent of inpatient deaths are preventable. Design/methodology/approach The design involved in the study is a prospective audit of inpatient mortality in a single NHS hospital trust. The case study includes 979 inpatient mortalities. A number of outcome measures were recorded, including a Likert scale of the preventability of death- and NCEPOD-based grading of care quality. Findings Clinicians assessed only 1.4 percent of deaths as likely to be preventable. This is significantly lower than previously published values ( p<0.0001). Clinicians were also more likely to rate the quality of care as "good," and less likely to identify areas of substandard clinical or organizational management. Research limitations/implications The implications of objective assessment of the preventability of mortality are essential to drive quality improvement in this area. Practical implications There is a wide disparity between independent case note review and clinicians assessing the care of their own patients. This may be due to a "knowledge gap" between reviewers and treating clinicians, or an "objectivity gap" meaning clinicians may not recognize preventability of death of patients under their care. Social implications This study gives some insight into deficiencies in clinical governance processes. Originality/value No similar study has been performed. This has significant implications for the idea of the preventability of mortality.

Are routine preoperative CT scans necessary in adult cochlear implantation? Implications for the allocation of resources in cochlear implant programs.

Our aim was to critically assess the influence of preoperative computed tomography (CT) scans on implantation decisions for adult cochlear implant candidates. The working hypothesis was that these routine scans might not provide critical additional information in most adult cochlear implant candidates. The charts of 175 adults with unilateral cochlear implantation were reviewed. Preoperative CT scan reports were audited, and scans with reported pathology were examined by an Otologist/ENT Surgeon. Clinic notes and multidisciplinary team meeting summaries were also analyzed to assess whether the results of the radiology report had influenced the decision to implant or the laterality of implantation. Twenty-five of the 175 scans (14.3%) showed an abnormality. Five of those 25 scans showed evidence of previous surgeries already known to the clinicians. Of the remaining 20 scans, 17 showed abnormalities, including wide vestibular aqueducts, Mondini deformities, and varying degrees of otospongiosis, the identification of which can be considered preoperatively helpful. Of the 175 scans, 3 (1.7%) demonstrated abnormalities that influenced the side of implantation or the decision to implant and, therefore, had an impact on treatment. We conclude that a preoperative CT scan seems to have an impact on treatment in only a small percentage of adult cochlear implantees. Hence, it may only need to be performed in patients with a history or clinical suspicion of meningitis or otosclerosis, if the individual was born deaf or became deaf before the age of 16, or if there are other clinical reasons to scan (e.g., otoscopic appearance). The related resources can be allocated to other facets of cochlear implant programs.

Pitch Discrimination: An Independent Factor in Cochlear Implant Performance Outcomes.

OBJECTIVE: To assess differences in pitch-ranking ability across a range of speech understanding performance levels and as a function of electrode position. STUDY DESIGN: An observational study of a cross-section of cochlear implantees. SETTING: Tertiary referral center for cochlear implantation. PATIENTS: A total of 22 patients were recruited. All three manufacturers' devices were included (MED-EL, Innsbruck, Austria, n = 10; Advanced Bionics, California, USA, n = 8; and Cochlear, Sydney, Australia, n = 4) and all patients were long-term users (more than 18 months). Twelve of these were poor performers (scores on BKB sentence lists <60%) and 10 were excellent performers (BKB >90%). INTERVENTION: After measurement of threshold and comfort levels, and loudness balancing across the array, all patients underwent thorough pitch-ranking assessments at 80% of comfort levels. MAIN OUTCOME MEASURE: Ability to discriminate pitch across the electrode array, measured by consistency in discrimination of adjacent pairs of electrodes, as well as an assessment of the pitch order across the array using the midpoint comparison task. RESULTS: Within the poor performing group there was wide variability in ability to pitch rank, from no errors, to a complete inability to reliably and consistently differentiate pitch change across the electrode array. Good performers were overall significantly more accurate at pitch ranking (p = 0.026). Consistent pitch ranking was found to be a significant independent predictor of BKB score, even after adjusting for age. Users of the MED-EL implant experienced significantly more pitch confusions at the apex than at more basal parts of the electrode array. CONCLUSIONS: Many cochlear implant users struggle to discriminate pitch effectively. Accurate pitch ranking appears to be an independent predictor of overall outcome. Future work will concentrate on manipulating maps based upon pitch discrimination findings in an attempt to improve speech understanding.

The effect of early division of the chorda tympani on gustatory function.

This study was undertaken to assess dysgeusia in patients who have undergone middle ear surgery for chronic suppurative otitis media (CSOM) when the surgeon's practice was to cleanly divide the chorda tympani without prior manipulation, if it in any way hindered operative access or the aims of surgery. We wanted to determine whether lower rates of taste disturbance might be obtained by early, clean division of the nerve. We followed 110 patients prospectively and asked them to complete a postoperative dysgeusia questionnaire 1 year after surgery. The "cut nerve" group included 81 patients, and the "uncut nerve" group included 29 patients. In the uncut group, the nerve was untouched or underwent minimal handling. In the cut nerve group, 68% of patients had no taste disturbance after surgery; 4% of patients in this group had ongoing symptoms at 1 year postoperatively. In the uncut nerve group, 67% were asymptomatic, while 11% had ongoing taste disturbance at 1 year. Statistical analysis of symptoms beyond 1 year showed a mean difference of 7%, but this is not statistically significant (p = 0.38). These results suggest that early division of the chorda tympani without prior manipulation in patients with chronic suppurative otitis media does not result in higher rates of taste disturbance than in patients with uncut nerves. Indeed rates of taste disturbance in our cut group were lower than in the uncut group, and lower than or comparable to those seen in other studies.

Developmental changes in cochlear orientation--implications for cochlear implantation.

OBJECTIVES: To investigate changes in cochlear orientation with age and discuss the implications of any change with respect to cochlear implantation. STUDY DESIGN: Cross-sectional study of computed tomographic scans of the temporal bones in patients with no congenital abnormalities. PATIENTS: One hundred fifty-nine patients were included in the study, making a total of 318 ears. The age range was 9 months to 85 years. INTERVENTION: Axial computed tomographic scans showing the basal turn of the cochlea were identified. The angle of the basal turn of the cochlea was measured by drawing a line through the long axis of the basal turn and measuring its angle with a line drawn through the midsagittal plane. The patients were grouped according to age, and a 1-way analysis of variance was used to identify any statistically significant change in basal turn angulation. Interobserver and intraobserver errors were calculated and presented as repeatability coefficients. The basal turn angles of 3 difficult cases of cochlear implantation were related to the findings. RESULTS: The mean basal turn angle was 54.6 degrees (range, 46.8-63.8 degrees; standard deviation, 3.5). There was a statistically significant reduction in the angulation of the basal turn with increasing age (F = 10.1; p = 0.002). The majority of the change occurs between the ages of 11 and 15 years. The interobserver reliability coefficient was 4.8. The intraobserver reliability coefficient was 2.0. The 3 difficult cases had basal turn angles that were at the upper limit of the reference range. CONCLUSION: There is a statistically significant reduction in basal turn angulation relative to the midsagittal plane with increasing age. However, care should be taken in interpreting these results in light of the inherent error in the measuring technique, although the intraobserver repeatability coefficient was only 2.0. The more obtuse angulation of the basal turn in children may have implications for cochlear implantation.