Comparison of passive versus active transcutaneous bone anchored hearing devices in the pediatric population.

OBJECTIVE: Transcutaneous bone anchored hearing devices (BAHDs) were introduced in an effort to avoid potential complications associated with the abutment of percutaneous BAHDs. Transcutaneous BAHDs can be active or passive. While studies have demonstrated good outcomes with both, a direct comparison of audiological and clinical outcomes of these devices in the pediatric population has not yet been studied. STUDY DESIGN: Retrospective, multicenter study. SETTING: Two tertiary academic centers. METHODS: Between 2015 and 2019, all patients who received an active transcutaneous BAHD (Bonebridge, BB) at one center, and patients that received a passive transcutaneous BAHD (Attract, AT) at another center, were included in this study. Exclusion criteria included age > 18 years, and mixed hearing loss or single-sided deafness. Study outcomes included patient demographics, indications, complications and preoperative and one-year postoperative audiometric data. RESULTS: Eighteen BB and eight AT patients met the inclusion criteria. The age range was 5-16 years. There were no significant differences in complication outcomes. Both devices demonstrated similar mean improvements in hearing thresholds at frequencies of 250 Hz (38 dB Active vs. 38 dB Passive), 500 Hz (34 dB vs. 42 dB), 1000 Hz (34 dB vs. 40 dB) and 2000 Hz (31 dB vs. 22 dB). The BB was significantly more effective at frequencies of 4000 Hz (28 dB vs. 7 dB) and 8000 Hz (29 dB vs. 6 dB) (p < 0.05). CONCLUSION: This is the first study comparing audiological outcomes between an active and a passive transcutaneous BAHD in the pediatric population. While both devices improved audiometric outcomes in the low and mid frequencies, the active BAHD demonstrated significantly better outcomes in the higher frequencies.

Robotics and cochlear implant surgery: goals and developments.

PURPOSE OF REVIEW: Cochlear implantation (CI) is a viable option for patients with severe sensorineural hearing loss. Advances in CI have focused on minimizing cochlear trauma to improve hearing preservation outcomes, and in doing so expanding candidacy to patients with useful cochlear reserve. Robotics holds promise as a potential tool to minimize intracochlear trauma with electrode insertion, improve surgical efficiency, and reduce surgical complications. The purpose of this review is to summarize efforts and advances in the field of robotic-assisted CI. RECENT FINDINGS: Work on robotics and CI over the past few decades has explored distinct surgical aspects, including image-based surgical planning and intraoperative guidance, minimally invasive robotic-assisted approaches mainly through percutaneous keyhole direct cochlear access, robotic electrode insertion systems, robotic manipulators, and drilling feedback control through end effector sensors. Feasibility and safety have been established and many devices are undergoing clinical trials for clinical adoption, with some having already achieved approval of national licensing bodies. SUMMARY: Significant work has been done over the past two decades that has shown robotic-assisted CI to be feasible and safe. Wider clinical adoption can potentially result in improved hearing preservation and quality of life outcomes to more CI candidates.

Long-Term Audiometric Outcomes of a Self-Crimping Stapes Prosthesis With CO 2 Laser Stapedotomy.

OBJECTIVE: To evaluate our experience with a self-crimping stapes prosthesis. STUDY DESIGN: Retrospective case review. SETTING: Tertiary referral center. PATIENTS: All patients diagnosed with otosclerosis who underwent surgery between June 2013 and June 2020. Inclusion criteria were 18 years or older, isolated stapes ankylosis, and at least 1 year of postoperative audiologic data. INTERVENTIONS: CO 2 laser stapedotomy undertaken by the same surgeon using the same CO 2 laser stapedotomy technique and the same prosthesis. MAIN OUTCOME MEASURES: Preoperative and postoperative audiologic data including air-bone gap (ABG) measurements, average speech discrimination score and pure-tone averages (PTAs). Postoperative hearing assessments were performed at 3 weeks, 3 months, 6 months, 1 year, and annually thereafter. RESULTS: Two hundred fourteen patients were included in the study, of whom 17 had bilateral sequential surgery for a total of 231 ears. Mean preoperative air conduction-PTA was 58.8 dB and mean preoperative bone conduction-PTA 24.2 dB, a preoperative ABG of 34.6 dB. One year postoperatively, mean air conduction-PTA improved to 31.2 dB ( p < 0.0001). ABG showed a significant improvement from 34.6 to 5.5 dB ( p < 0.0001). Closure of the ABG to within 10 dB was achieved in 87% ears at 3 months, in 91% at 6 months, and in 93% at 1 year. There was no significant difference in preoperative and postoperative average speech discrimination score. CONCLUSION: The current study demonstrates favorable audiologic outcomes in a large cohort of patients using a self-crimping stapes prosthesis. These results were stable for up to 7 years on follow-up.

Single-Center Experience Evaluating Clinical Outcomes of a Novel-Guided Drill System for Percutaneous Bone-Anchored Hearing Implant.

OBJECTIVE: Evaluate intraoperative and postoperative outcomes of a novel guided drill system for percutaneous bone-anchored hearing implants. METHODS: Between January 2016 and February 2021, patients age ≥18 years deemed potential candidates for a bone-anchored hearing device, were formally assessed for candidacy and counseling. Those that qualified and opted to proceed were added to a prospectively maintained database, including demographic, clinical, and audiologic data. Intraoperative findings were reported, as were clinical outcomes at 7 days, 4 weeks, 3 months and 6 months postoperatively. The Holgers index was used to grade soft tissue reactions. RESULTS: One hundred patients underwent the procedure. There were 56 women, and mean age was 54 years (18-84 yr). Ninety-six were done under local anesthetic. Mean surgical time was 13 minutes (9-27 min). No significant intraoperative events were noted. There were nine cases of implant loss, all in the first 50 cases. Mean duration of implant loss was 3.6 weeks (range, 2-5 wk). At the first postoperative visit, 82 had Holgers 0, 16 Holgers 1, 2 Holgers 2, and none Holgers 3. At the second postoperative visit, excluding the 9 with implant loss, 83 (91%) had Holgers 0, 6 (7%) Holgers 1, and 2 (2%) Holgers 2. None were Holgers 3. CONCLUSIONS: The current study represents, to our knowledge, the largest series on the novel guided drill technique. Results show it is safe and efficient with low soft tissue complication rates. Drill bit design and technical modifications may have helped lower implant loss rate in this series over time.

Treatment of patients with glomus jugulare tumours (GJT) and its subjective effect on quality of life (QoL) measures.

Cerebellopontine angle (CPA) tumours account for 6-10% of intracranial tumours. The most common CPA tumours are vestibular schwannomas (VS), also known as acoustic neuromas, benign tumours of the vestibulocochlear nerve. Less common but symptomatic skull base lesions are glomus jugulare tumours (GJT), of which approximately 40% are identified as CPA tumours. Initial symptoms for GJT may include hearing loss and tinnitus and progress to various cranial nerve dysfunctions. Three well-accepted treatment modalities for such tumours include surgical resection, radiotherapy and/or conservative management employing serial MR or CT imaging. Patients' quality of life may be impacted by different treatment methods, so treatment decisions should be client centered.

Clinical and audiometric outcomes of palisade cartilage myringoplasty under local anesthetic in an office setting.

OBJECTIVE: Assess clinical and functional outcomes of a modified palisade cartilage-perichondrium graft myringoplasty under local in an office setting. STUDY DESIGN: Retrospective case series. SETTING: Tertiary care facility. PATIENTS: Patients with a tympanic membrane perforation presenting between March 2013 and October 2017. Inclusion criteria included age ≥ 7 years, entire perforation margin visualized through a transcanal view, and the ability to lie supine for up to 45 min. Exclusion criteria included a conductive hearing loss larger than expected, and presence of active infection. INTERVENTION: In-office modified myringoplasty technique under local anesthesia without sedation. MAIN OUTCOME MEASURES: Complete perforation closure rate and audiometric outcomes. RESULTS: 250 patients underwent the procedure, of whom 13 had bilateral sequential procedures (total 263 ears). Of those, 197 were primary and 66 revision. Average age was 46.3 years. Perforation sizes were categorized as small (32), moderate (109), large (78), and subtotal (44). Complete perforation closure was evident in 219 of the 250 cases (88%). Preoperative mean air pure tone average (PTA) was 56.7 dB and mean bone PTA was 27.5 dB (pre-operative ABG 29.2 dB). AC-PTA significantly improved to 35.0 dB (p < 0.0001), and ABG to 9.6 dB (p < 0.0001). Only subtotal perforations showed a statistically significant negative relationship with outcome (p = 0.04). CONCLUSION: The modified palisade cartilage-perichondrium graft myringoplasty under local anesthetic is a highly successful procedure well tolerated by adult and pediatric patients with variable perforation sizes. This may have significant potential patient benefits, as well as cost savings to the health care system.

Contemporary Neuroradiographic Assessment of the Cochleo-Carotid Partition.

PURPOSE: The cochleo-carotid partition (CCP) describes the intimate anatomic relationship between the petrous carotid artery and the cochlear basal turn. This partition bears significant surgical and unique clinical relevance. The purpose of this paper is to radiographically assess the CCP and discuss its clinical implications. METHODS: A total of 155 consecutive fine-cut temporal bone CT scans were retrospectively reviewed, and study scans were digitally analyzed in both axial and coronal views. The shortest distance between the petrous carotid canal and the cochlear basal turn was measured. RESULTS: In all, 310 temporal bones were studied, with a mean CCP of 1.9 mm (range 0.2-8.5, SD 1.1). The following CCP measurements were obtained: ≤1.0 mm [n = 46 (14.8%)]; 1.1-2.0 mm [n = 161 (51.9%)]; 2.1-3.0 mm [n = 29 (9.4%)], and ≥4.0 mm [n = 12 (4.2%)]. One temporal bone (0.3%) had complete CCP dehiscence. There was a positive correlation between each patient's right and left CCP measures (p < 0.005) and a significant negative correlation between CCP grade and age (p = 0.027). CONCLUSIONS: The CCP is a narrow anatomic confinement measuring ≤2 mm in 66.7% of patients. Potential implications of the CCP include iatrogenic risks, its possible function as a third inner ear window in patients with audiovestibular symptoms, and pathophysiology of new-onset tinnitus following cochlear implantation.

Radiographic Assessment and Surgical Implications of Arcuate Eminence Pneumatization.

BACKGROUND: The middle cranial fossa (MCF) approach is a valuable yet technically challenging technique. Identification of the superior semicircular canal (SCC) using the arcuate eminence (AE) was proposed as a surface landmark. However, the AE is sometimes absent, with inconsistent relationship to the SCC. Air cells in the AE area facilitate safer identification of the SCC. The aim of this study is to determine the radiographic prevalence of AE pneumatization. METHODS: Two hundred consecutive fine-cut temporal bone CT scans were retrospectively reviewed. The region of the petrosal bone at and above the level of the SCC dome was assessed for the presence of air cells, and graded 0 (no pneumatization) to 2 (well pneumatized). RESULTS: Four hundred temporal bones were studied. The average age was 49 years (range 18-89). Of all AE assessments, 47 (12%) were nonpneumatized, 62 (15%) partially pneumatized, and 291 (73%) well pneumatized. There was no significant correlation between patient age and pneumatization grade (p = 0.72). CONCLUSION: The SCC is a valuable landmark in MCF surgery as it holds consistent relationships to adjacent critical structures. Surrounding air cells should facilitate safer initial identification of the SCC, as the AE region is well pneumatized in 73% of patients.

Intravascular papillary endothelial hyperplasia of the internal auditory canal.

Intravascular papillary endothelial hyperplasia (IPEH), also known as Masson's tumor, is a rare vascular lesion characterized by intravascular proliferation of endothelial-lined papillae and a propensity for manifestation in the head and neck. Signs and symptoms associated with IPEH generally occur due to compressive effects of the lesion on adjacent structures. A rare instance of IPEH occurring in the internal auditory canal is presented herein. Clinical presentation, radiographic and pathologic findings, and management strategies are discussed.

Contemporary angiographic assessment and clinical implications of the vein of labbé in neurotologic surgery.

BACKGROUND: To better understand the drainage patterns of the 3 largest superficial anastomotic veins (SAVs), namely, vein of Labbé (VL), the vein of Trolard (VT), and the superficial sylvian vein (SSV). To assess the dominance of the VL in the superficial cortical venous system, because this vein may be encountered in neurotologic surgery and its interruption may result in a venous infarct of the temporal lobe. METHODS: The database of the radiology department at the University of Cincinnati was used to identify all patients who underwent a diagnostic angiographic study between September 1, 2009, and January 1, 2010. Studies were excluded if there were intracranial masses or vascular lesions. Angiograms were assessed for the presence of the VL, VT, and SSV, as well as vessel dominance, determined by their relative calibers. RESULTS: A total of 101 patients (81%) underwent bilateral and 48 unilateral angiography, for a total of 250 studies. Mean age was 55 years (range, 16-83 yr). Seventy-seven patients (53%) were females. The most common pattern observed was the presence of all 3 SAVs (78%). The VL was absent or poorly developed in 34 studies (14%) and was the dominant superficial vein in 51 (20%), of which 28 (55%) occurred on the right. CONCLUSION: Considerable variability is demonstrated in the drainage patterns of the SAVs. Care should be taken in neurotologic surgery to avoid injuring the VL because this may represent the single dominant drainage pathway of the lateral surface of the temporal lobe in a large number of patients.

Analysis of carotid artery injury in patients with basilar skull fractures.

OBJECTIVES: Determine the prevalence of carotid artery injury (CAI) in patients with basilar skull fractures and describe significant demographic and radiographic risk factors for CAI. STUDY DESIGN: From January 2004 to December 2008, medical records of 1,279 consecutive adult patients treated for basilar skull fractures at a tertiary care academic hospital were retrospectively reviewed. Diagnostic angiography was performed in 112 patients because of concern for CAI. Computed tomographic studies of the head and cranial base were reviewed for evidence of pneumocephalus, petrous carotid canal fractures, and sphenoid bone fractures. RESULTS: Mean age of patients undergoing angiography was 38.7 years, and 85 patients (75.9%) were male subjects. Thirty-five (50%) of 70 discrete cerebrovascular injuries on angiography involved the carotid canal. The prevalence of CAI in patients with basilar skull trauma was 2.0%. CAI was associated with female sex (p = 0.001), whereas lower Glasgow Coma Scale score approached statistical significance (p = 0.07). Sensitivity and specificity of the 3 computed tomographic findings individually were 44% to 68% and 41% to 67%, respectively. With all 3 findings concurrently, 85% specificity and 80% negative predictive value for CAI were obtained, although sensitivity declined. CONCLUSION: The frequency of CAI in patients with basilar skull fractures was higher than that in those without basilar skull involvement. Female sex was strongly associated with CAI. The intimate anatomic relationship between the carotid artery and the cranial base posit substantial diagnostic and therapeutic challenges for the contemporary cranial base surgeon, and thus, understanding the epidemiology and risk factors for CAI is of paramount importance.

Do contemporary temporal bone fracture classification systems reflect concurrent intracranial and cervical spine injuries?

OBJECTIVES/HYPOTHESIS: Temporal bone fractures (TBFs) are a frequent manifestation of head trauma. We investigated the prevalence of concurrent intracranial injuries (ICIs) and cervical spine injuries (CSIs) in a series of patients with TBFs and attempted to identify significant associations between current TBF classification systems and either ICI or CSI. STUDY DESIGN: Retrospective case series with chart review. METHODS: The records of all patients ≥18 years of age diagnosed with a basilar skull fracture, including TBF, at a level I trauma center from 2004 to 2009 were reviewed. Patient demographics, mechanism of injury, and Glasgow Coma Scale (GCS) scores were collected. Imaging studies were reviewed to classify TBF using the traditional longitudinal-transverse-mixed and otic capsule-sparing versus -involving systems and identify concurrent ICI and CSI. RESULTS: Of 1,279 patients, 202 (15.8%) met inclusion criteria. There were 160 (79.2%) males. Sixteen (7.9%) patients had bilateral TBFs. Falls (n = 66, 32.7%) represented the most common mechanism for TBF. Longitudinal (n = 96, 44.0%) and otic capsule-sparing (n = 209, 95.9%) fractures were the most prevalent subtypes. There were 184 (91.1%) patients who sustained ICI and 18 (8.9%) who demonstrated CSI. Longitudinal, transverse, mixed, otic capsule-sparing, or otic capsule-involving TBF subtypes had no statistically significant associations with mechanism of injury, GCS score, or concomitant ICI or CSI. CONCLUSIONS: More than 90% of patients sustaining TBF presented with concomitant ICI, and 9% sustained CSI. Current TBF classification systems do not correlate with these outcomes. A more sophisticated, multidisciplinary classification system encompassing radiographic and clinical findings may better predict neurologic, neuro-otologic, and skull base complications.