Measuring the Acoustic Reflex through the Tympanic Membrane.

INTRODUCTION: The acoustic reflex is the active response of the middle ear to loud sounds, altering the mechanical transfer function of the acoustic energy into the inner ear. Our goal was to observe the effect of the acoustic reflex on the tympanic membrane by identifying a significant nonlinear increase in membrane oscillations. METHODS: By using interferometric spectrally encoded endoscopy, we record the membrane oscillations over time in response to a loud, 200-ms-long acoustic stimulus. RESULTS: A gradual reflex activation is measured between approximately 40 and 100 ms, manifested as a linear 42% increase in the umbo oscillation amplitude. CONCLUSION: The measured oscillations correlate well with those expected from a mechanical model of a damped harmonic oscillator, and the results of this work demonstrate the potential of interferometric spectrally encoded endoscopy to observe unique dynamical processes in the tympanic membrane and in the middle ear.

Intracranial complications of acute mastoiditis: Surgery not always necessary.

INTRODUCTION: Acute mastoiditis (AM) can rapidly become life-threatening with various intracranial complications. The standard care includes antibiotics, mastoidectomy, and drainage. Reports show varying preferences for conservative and surgical treatments, with a more conservative approach gaining popularity. In this study we aim to evaluate the presenting symptoms, management and outcomes of patients presenting with intracranial complications secondary to acute mastoiditis. METHODS: Retrospective review for all children admitted for acute mastoiditis for 12 years period (January 2010-December 2021). Children who had mastoiditis associated with intracranial complications were included in the study. STROBE guidelines were followed in this study. RESULTS: 23 patients were diagnosed with acute mastoiditis with intracranial complications. The mean age was 2.1 years. The most common presenting sign was fever, followed by otalgia. The most common pathogens were Fusobacterium necrophorum and Streptococcus pneumoniae. The most common intracranial complication was sinus vein thrombosis (SVT) affecting 13 patients. Eventually, 10 patients underwent cortical mastoidectomy during 1-6 days upon admission, with an average of 3.2 days. During the follow-up period patients were monitored for clinical progression. Patients who did not show clinical improvement such as persistent fever, worsening symptoms, or the presence of neurological symptoms were treated surgically. The length of stay was an average of 15.5 days overall, with no significantly longer hospital stay in patients who were treated surgically compared to patients who were treated conservatively (17.1 days vs. 14.2 days, P = .26). CONCLUSION: Intracranial complications of acute mastoiditis remain a significant challenge. Selected patients with intracranial complications can be treated conservatively with close monitoring, without increasing the risk of immediate or long-term complications. Initial antimicrobial treatment should cover anaerobic bacteria, as it correlates with severe complications.

Primary Tumor Staging for Oral Cancer and a Proposed Modification Incorporating Perineural Invasion: An International Multicenter Study.

The objective of this study is to determine if the incorporation of perineural invasion (PNI) into the T-classification would improve the prognostic performance of TNM-8. An international, multicenter study of 1049 patients with oral cavity squamous cell carcinoma that were treated from 1994 to 2018 is performed. Various classification models are developed within each T-category and evaluated using the Harrel-concordance index (C-index), Akaike-information criterion (AIC), and visual inspection. Stratification into distinct prognostic categories, with internal validation, is performed using bootstrapping analysis (SPSS and R-software). Through multivariate analysis, PNI is significantly associated with disease-specific survival (p < 0.001). PNI integration into the staging system results in a significantly improved model compared with the current T category alone (lower AIC, p < 0.001). The PNI-integrated model is superior in predicting differential outcomes between T3 and T4 patients. A new model for T-classification of oral cavity squamous cell carcinoma is proposed, which is based on incorporating PNI into the staging system. These data can be used for future evaluations of the TNM staging system.

The Impact of Surgical Expertise on the Cost-Effectiveness of Stapes Surgery.

INTRODUCTION: Otosclerosis is the primary cause of conductive hearing loss with normal otoscopy. As the condition worsens, certain patients may develop a sensorineural component. Patients with successful surgeries may still need hearing aids, which creates a dilemma for health professionals as there are insufficient data to make informed decisions. This study investigated the influence of the surgeon's proficiency level, individual patient factors (e.g., age at the time of intervention and survival rates), and surgery costs on the cost-effectiveness of stapes surgery. METHODS: We performed a cost-effectiveness analysis using an adapted Markov model incorporating annual all-cause mortalities. In addition, we introduced sensitivity analyses to address the effects of surgical expertise on adults with bilateral conductive hearing loss due to otosclerosis. A model was developed based on a decision tree with treatment options and complication scenarios for otosclerosis patients undergoing stapes surgery or receiving hearing aids. Annual all-cause mortality was considered. A sensitivity analysis was performed assigned to different training levels ("experts" and "less experienced") to simulate the effects of surgical experience on the cost-effectiveness of surgical outcomes. Successful surgery was defined as closing of the air-bone gap to 10 dB or less. Based on published data, "experts" were simulated with a 93.7% success rate, and "less experienced" were manufactured with a 68.9% success rate. RESULTS: Stapes surgery provides improved quality of life (QoL) compared to hearing aids with lower cumulative costs up to 87 years of age in the case of "expert" surgeons and up to 78 years of age, when performed by "less experienced" surgeons. CONCLUSIONS: Primary stapes surgery is highly cost-effective and delivers improved QoL compared to hearing aids with lower cumulative costs. Additionally, undergoing stapes surgical training remains highly cost-effective.

In vivo optical mapping of the tympanic membrane impulse response.

The wide frequency range of the human hearing could be narrowed by various pathologies in the middle ear and in the tympanic membrane that lead to conductive hearing loss. Diagnosing such hearing problems is challenging, however, often relying on subjective hearing tests supported by functional tympanometry. Here we present a method for in vivo 2D mapping of the impulse response of the tympanic membrane, and demonstrate its potential on a healthy human volunteer. The imaging technique is based on interferometric spectrally encoded endoscopy, with a handheld probe designed to scan the human tympanic membrane within less than a second. The system obtains high-resolution 2D maps of key functional parameters including peak response, rise and decay times, oscillation bandwidth and resonance frequency. We also show that the system can identify abnormal regions in the membrane by detecting differences in the local mechanical parameters of the tissue. We believe that by offering a full 2D mapping of broad-bandwidth dynamics of the tympanic membrane, the presented imaging modality would be useful for effective diagnosis of conductive hearing loss in patients.

No difference in wound complications with or without a post-operative pressure dressing: Our experience in 135 children undergoing mastoidectomy.

OBJECTIVES: To assess the efficacy of avoiding mastoid pressure dressing (MPD) on children as a means of preventing discomfort and post-operative pain. DESIGN: A retrospective controlled study. SETTING: All operations were carried out by experienced surgeons using standard techniques, whose custom, not the gravity of any individual case, dictated the use of MPD. PARTICIPANTS: Children who underwent mastoidectomy for inflammatory middle ear diseases at a tertiary centre from 2010 to 2021. MAIN OUTCOME MEASURES: Wound-related complications and Visual Analogue Scale (VAS) pain scores at discharge were compared between children who had an MPD applied following surgery and those who did not. RESULTS: One hundred thirty-five cases were included. The demographic characteristics of the patients and surgical techniques employed were similar for both groups. There were 91 patients in the MPD group and 44 in the non-mastoid dressing (NMPD) group. In the MPD group, five patients developed minor wound dehiscence, eight experienced surgical site infections (SSI), and one patient developed a keloid. In the NMPD group, one patient had an SSI, one patient suffered from a keloid scar, wound dehiscence was observed in one patient, and another one had a local hematoma. Therefore, there were no differences between the groups in relation to post-operative complications (p = .32). Despite these similitudes, the NMPD patients suffered less post-operative pain, as measured by the VAS (p = .02). CONCLUSION: This study shows that no significant benefit is derived from using an MPD after mastoidectomy in children. Surgeons should adhere to principles of appropriate haemostasis and wound closure to prevent post-operative wound complications. Our study supports the abandonment of routine MPD in children following mastoidectomy.

The role of voice rest after micro-laryngeal surgery for benign vocal fold lesions.

PURPOSE: To compare post-operative vocal outcomes of a voice rest regimen versus no voice restrictions following micro-laryngeal surgery for benign glottic lesions. METHODS: This was a combined prospective and retrospective cohort study on 167 patients who underwent micro-laryngeal surgery for benign focal fold lesion removal. Participants were divided into two regimens: standard voice rest (n = 92) or no voice restriction (n = 75). The primary outcome was post-operative vocal improvement, evaluated using voice handicap index questionnaire (VHI-10), GRBAS scale, and computerised acoustic analysis (shimmer, jitter, and the harmonic-to-noise ratio). The secondary outcome was emergence of vocal fold mucosal abnormalities in the immediate post-operative period. Parameters were collected at baseline and at the last clinical visit. RESULTS: There was no statistically significant difference between the voice rest and no-voice rest groups regarding baseline parameters of age, gender, laryngeal pathology, and voice use. Improvement in GRBAS scale values and VHI-10 scores between pre- and post-operative periods between groups did not demonstrate any statistically significant differences (P = 0.5303 and P = 0.1457, respectively). Similarly, the results of computerized voice analysis also showed no differences between groups in terms of shimmer (P = 0.9590), jitter (P = 0.5692), and harmonic-to-noise ratio (P = 0.1871). No correlation was found between the post-operative vocal fold's mucosal abnormalities and the type of voice rest regimen. CONCLUSION: Voice quality and wound healing were similar regardless of the type of voice rest regimen applied. No voice rest at all was as good as voice rest after micro-laryngeal surgery.

Long-Term Quality of Life after Endoscopic Pituitary Adenoma Surgery with Nasoseptal Flap Reconstruction.

INTRODUCTION: Endoscopic endonasal transsphenoidal surgery (EETS) on the pituitary gland is considered safe and efficacious. The nasoseptal flap (NSF) is sometimes used to prevent or repair postoperative cerebrospinal fluid (CSF) leaks. Few investigators have quantified long-term quality-of-life (QOL) outcomes regarding sinonasal measures after EETS, with or without involvement of the NSF. This study assesses whether the septal flap affects sinonasal QOL outcomes for patients receiving EETS for pituitary adenoma. METHODS AND MATERIALS: This is a retrospective study of patients who underwent EETS between 2013 and 2018. A total of 62 adults completed the Sinonasal Outcome Test-22 (SNOT-22) at least one year after the surgery. Outcome measures were compared between patients who underwent EETS with and without septal flap reconstruction. RESULTS: For the entire cohort, there were 14 patients (22.6%) who had septal flap reconstruction and 48 patients (77.4%) who did not. Patient demographics, tumor characteristics, surgical outcomes, and duration between surgery and completion of the questionnaire were similar for both groups. The mean SNOT-22 scores in the no reconstruction (NR) group and the nasoseptal flap reconstruction (NSFR) group were similar (P=0.9). In terms of SNOT-22 subdomains (rhinologic symptoms, extranasal rhinologic symptoms, ear/facial symptoms, psychological dysfunction, and sleep dysfunction), no significant differences were found when comparing the groups. CONCLUSION: As compared with no reconstructive involvement, NSF utilization does not affect the QOL and nasal symptoms of patients undergoing EETS.

Inlay triple- "C" tympanoplasty: a comparative study for its use in large, marginal perforations.

OBJECTIVE AND INTERVENTION: To compare the efficacy of the inlay, composite chondroperichondrial clip (triple-C) tympanoplasty with conventional underlay cartilage island tympanoplasty, and to evaluate its efficacy in treating large, marginal perforations. STUDY DESIGN: The study involved 183 patients that were selected from a retrospective chart review of tympanoplasties performed at our center from March 2016 to June 2018. SETTING: A tertiary referral center hospital. PATIENTS: 65 patients underwent inlay, triple-C cartilage tympanoplasty (inlay group) and 118 underwent underlay cartilage island tympanoplasty (underlay group). MAIN OUTCOME MEASURES: Postoperative anatomical success rate, surgical time, hearing outcomes, and complications were analyzed. Focused analysis was performed on large or marginal perforations. RESULTS: Both groups exhibited similar characteristics in demographic distribution, general health status, preoperative anatomical and hearing disabilities. Excellent results were achieved in both groups. Re-perforation occurred for 9.2% of the inlay group and 7.6% of the underlay group (p = 0.71). Hearing improvement was significant in both groups. Within the separate groups, 36% of underlay patients and 60% of inlay patients improved to achieve closure of the air-bone gap (ABG) to less than 10 dB (p = 0.1). In large or marginal perforations, both groups performed similarly. No significant complications were seen in this cohort. Nevertheless, a significant reduction in surgical time was observed in the inlay group (38 min. vs 58 min.; p = 0.0004). CONCLUSION: Inlay triple-C tympanoplasty is comparable to conventional underlay cartilage island tympanoplasty in both anatomical and audiological success rates, even for large, marginal perforations. Due to its shorter operation time, inlay triple-C tympanoplasty should be considered a good surgical option for all tympanic membrane perforations.

Rapid imaging of tympanic membrane vibrations in humans.

Functional imaging of the human ear is an extremely challenging task because of its minute anatomic structures and nanometer-scale motion in response to sound. Here, we demonstrate noninvasive in vivo functional imaging of the human tympanic membrane under various acoustic excitations, and identify unique vibration patterns that vary between human subjects. By combining spectrally encoded imaging with phase-sensitive spectral-domain interferometry, our system attains high-resolution functional imaging of the two-dimensional membrane surface, within a fraction of a second, through a handheld imaging probe. The detailed physiological data acquired by the system would allow measuring a wide range of clinically relevant parameters for patient diagnosis, and provide a powerful new tool for studying middle and inner ear physiology.

Cold versus hot adenoidectomy: A prospective, randomized controlled trial.

OBJECTIVE: Adenoidectomy can be performed using the cold method (mainly adenoid curettes) or the hot method (suction diathermy). Both techniques have similar intra and postoperative outcomes. However, the long-term clinical outcome of improving sleep disorder symptoms has not been well established. The objective of this study was to compare outcomes of hot method and cold method adenoidectomy one year following the surgery. STUDY DESIGN: A prospective, randomized, single-blinded study of children under age 16 years who underwent adenoidectomy during the years 2014-2017. Patients were randomized to hot or cold adenoidectomy techniques. SETTING: A tertiary health care referral center. SUBJECTS AND METHODS: The final analysis included 58 children, mean age 5.9 years (range 1.2-15). The primary outcome was change in the Pediatric Sleep Questionnaire (PSQ) scores one month and one year after surgery. The secondary outcome was complication rate. RESULTS: Clinical and demographic parameters were similar between the patients in the hot method group (n = 30) and the cold method group (n = 28). Adenoid size and estimated bleeding were similar between the groups. At one month after surgery, PSQ score was improved by a mean + 0.31 in the hot method group compared to +0.32 in the cold method group (p = 0.54). Improvement in PSQ scores was greater following hot than cold adenoidectomy at one year after surgery (+0.31 points vs. +0.22 points, p = 0.009). CONCLUSION: Hot adenoidectomy is associated with better outcome than the cold technique, as reflected by PSQ scores one year after the surgery.