Patient-Reported Outcomes in Middle Ear and Active Transcutaneous Bone Conduction Hearing Implants.

OBJECTIVE: This study used questionnaires to examine the patient-reported satisfaction with 2 hearing implant devices to determine the level of overall satisfaction with the devices, which, if any, factors predicted good or poor perceived outcomes, or whether there were any specific aspects of the devices where dissatisfaction was apparent. METHODS: A post-treatment questionnaire survey of 39 adult patients who had received a Vibrant Soundbridge (VSB) or Bonebridge (BB) hearing implant, with at least 3 months of follow-up, was conducted using the Glasgow Benefit Inventory (GBI) and Hearing Device Satisfaction Scale (HDSS). Satisfaction scores were compared to pre- and post-operative audiologic outcomes. The correlation between GBI and HDSS scores was also examined. RESULTS: A total of 28 of the 39 patients (72%) responded: 13 with a BB and 15 with a VSB at a mean of 13 months after implantation. The overall mean total GBI score was 30, with no significant differences across the groups. The responders generally reported that they were "satisfied" across most domains of the HDSS. In the study, 25 of the 28 responders were largely satisfied with their devices but 3 respondents were not. Two were known non-users, while one used the device but did not gain the benefit expected. It is instructive to note that all of these dissatisfied recipients were close to the manufacturer recommended limits for implantation of their respective devices at the time of surgery. Certain themes were identified within the patients' responses, indicating common aspects where satisfaction was poorer. CONCLUSION: This series of 28 implant recipients demonstrates high levels of satisfaction with implantable hearing devices across 2 different validated questionnaires. Implant teams could exercise caution and manage patient expectations if the patients are close to the recommended limits of a particular device.

Self-Evaluated Quality of Life and Functional Outcomes After Microsurgery, Stereotactic Radiation or Observation-Only for Vestibular Schwannoma of the Adult Patient: A Systematic Review.

OBJECTIVE: To evaluate the impact of different management options on health-related quality of life (HRQoL) in vestibular schwannoma patients. DATA SOURCES: A systematic search of the Cochrane Database, Database of Abstracts of Reviews of Effectiveness, and the Ovid Medline & EMBASE was performed. English and German language studies published between 1980 and 2015 were considered. STUDY SELECTION: This is a systematic review of HRQoL of patients managed for vestibular schwannoma. Studies in which HRQoL after one management option were evaluated or compared with other managements or with control populations using validated or reliable questionnaires, were included. DATA EXTRACTION: The included studies were independently evaluated by two reviewers. The quality of studies was assessed and graded as per Oxford Centre of Evidence Based Medicine System. RESULTS: Ten prospective and 29 retrospective studies were identified: microsurgery initially exerted a negative effect on HRQoL but this tended to improve with follow up. Radiotherapy had a less negative effect but with minimal change over follow up. A significant limitation was that studies did not present results stratified by tumor size. Many patients will need active treatment despite the potential for negative effects on their QoL. The concept of a minimal clinically important difference has been introduced into this field and was compared with five studies. CONCLUSION: A number of prospective studies are available but none yet with a disease-specific questionnaire. Heterogeneity and the methodological weaknesses of the included studies constitute the principle limitation of this review. The introduction of the minimal clinically important difference should improve the relevance of studies and allow a sensitive comparison of treatments.

Assessing the threshold for vestibular schwannoma resection and the behavior of residual tumor.

OBJECTIVES: In vestibular schwannoma surgery postoperative facial nerve function is generally described as being related to tumor size, with 20 mm extrameatal diameter suggested as the threshold at which facial nerve function deteriorates. Near-total resection is accepted if the risk to nerve function becomes unacceptably high. We sought to review outcomes of vestibular schwannoma resection and follow residual tumor fragments. Second, we pooled data to quantify the risk of regrowth and need for subsequent intervention. METHODS: Prospectively collected data on all patients undergoing microsurgical removal of vestibular schwannoma by the senior author over the past 15 years. RESULTS: Approximately 247 patients were identified, the spread of tumors was 74 intracanalicular, 120 15 mm or lesser, 57 between 16 and 30 mm, and 6 greater than 30 mm. Overall, 91.5% recovered to House-Brackmann Grade 1 or 2, with no difference between the groups with 15 mm or lesser and greater than 15 mm (p > 0.05); 26 had incomplete resection, and 3 showed regrowth. Pooled data: 193 near total resections with 12% regrowing; 181 subtotal resections with 30% regrowing. Of 108 growing fragments, 78% had intervention. CONCLUSION: The present series suggests that the threshold for preservation of good facial nerve function may be moved to a tumor of 30-mm extrameatal diameter. Although historically tumor fragments were felt to have a low growth potential, the cumulative data would suggest that a significant proportion of fragments do grow and may need intervention.

Do high-speed drills generate high-frequency noise in mastoid surgery?

BACKGROUND: The introduction of increasingly high speed drills for mastoid surgery has heightened the concern that cochlea damage may occur in both the operated and nonoperated ear. It has been observed clinically that this damage could be associated with frequencies above 8,000 Hz and that, to observe these changes, high-frequency audiometry should be performed. Previous studies have investigated noise transmission to the cochlea at frequencies below 4,000 Hz only. There having been, until recently, limitations to the equipment available to measure higher frequencies. OBJECTIVE: To define the characteristics of noise transmitted to the cochlea during drilling of temporal bone, specifically in the higher frequency ranges up to 20,000 Hz. METHODS: Cleaned temporal bones were fitted with 3 mutually perpendicular accelerometers, capable of measuring frequencies in the range 500 to 20,000 Hz. The system was calibrated using a Kamplex Audio Traveller AA220 pure tone audiometer, and accelerometer outputs were recorded on a personal computer at a sampling frequency of 102.4 kHz per channel. The magnitude of the noise transmitted to the cochlea was determined for a range of burrs. RESULTS: Maximum transmission of sound was 108 dBA at 4,000 Hz using a 6.5-mm burr on the cortical mastoid bone. The average results showed that the sound transmission tailed off at the higher frequencies dropping to 84 dBA at 8,000 Hz and 40 dBA at 16,000 Hz. CONCLUSION: The high-frequency hearing reduction noted in patients after mastoid surgery was shown not to be due to excessive high-frequency noise generated by drilling.

15-Year review of laryngeal and oral dysplasias and progression to invasive carcinoma.

The objective of this study is to identify a management or follow-up strategy for patients with laryngeal and oral dysplasia. A chart review of all patients with laryngeal and oral dysplasia over a 15-year period was performed. All patients were followed for a minimum period of 5 years from initial diagnosis of oropharyngeal or laryngeal dysplasia. If invasive carcinoma was demonstrated on subsequent biopsies, the exact time of this was recorded and Kaplan-Meier survival curves were plotted. In the laryngeal cohort, 45 patients were identified, 15 (33%) developed carcinoma, 7 of 30 patients (23%) with mild or moderate dysplasia, compared with 8 of 15 (53%) with severe dysplasia or CIS (P = 0.01). Thirteen of the carcinomas (87%) developed within 36 months of original biopsy. In the oral cohort, 32 patients were identified, 17 (53%) developed carcinoma, 1 of 9 patients (11%) with mild dysplasia, compared with 8 of 12 (67%) with severe dysplasia and 8 of 10 (80%) with CIS (P < 0.001). Fifteen of the 17 patients (88%) developed carcinoma within 36 months of original biopsy. In conclusion, although numbers are small, our results show that mild and moderate laryngeal dysplasia behaves differently to severe dysplasia and CIS. Mild oral dysplasia also behaves differently to severe dysplasia or CIS. In general, progress to malignancy happens within a 3-year period. Severe dysplasia or CIS should be managed aggressively.

Surgical techniques for the treatment of nasal valve collapse: a systematic review.

OBJECTIVES/HYPOTHESIS: To critically evaluate the surgical treatment strategies for nasal valve collapse. METHODS: A systematic review of studies to treat nasal valve collapse, using surgical methods, from 1970 to 2008. A search of EBM reviews, MEDLINE, and EMBASE was performed using the following search terms: "nasal valve collapse" AND "alar collapse," "nasal valve insufficiency," "alar insufficiency," and "functional rhinoplasty." The following outcome measures were sought: subjective symptom relief, cosmetic outcome, and objective measurements of nasal airway patency. The following were inclusion criteria: at least 10 patients in each study, stated aim to improve airway obstruction, and a minimum of 1 month follow-up for every patient. RESULTS: Our search identified 98 papers, which were then retrieved and analyzed. Of these, 43 met the inclusion criteria. No randomized controlled trials exist; one trial presented level IIIb evidence, but all other studies were classed as level IV. Seven authors present objective measurements of nasal airflow or cross-sectional area, and four authors present validated outcome measures. CONCLUSIONS: A variety of focussed surgical techniques are described to deal with nasal valve collapse. We could find no randomized controlled trials on nasal valve surgery. Research in nasal valve surgery is frequently driven by technical description of surgical technique rather than the establishment of evidence of long-term patient benefit. Although our understanding of the role of the nasal valve in the pathophysiology of nasal obstruction has improved vastly, the myriad of surgical techniques described perhaps reflects our uncertainty in choice of technique and in degree of patient benefit.

Juvenile nasopharyngeal angiofibroma: spontaneous resolution.

Juvenile nasopharyngeal angiofibroma is a rare, benign tumor that occurs most often in adolescent males. Common practice is to excise the tumor with open or endoscopic surgery. We report the case of a 17-year-old male who presented in 1995 with a mass filling the left posterior nasal cavity. A diagnosis of juvenile nasopharyngeal angiofibroma was obtained with computed tomography and magnetic resonance imaging. The patient elected to have no treatment. On annual scans, the lesion changed little until 1998, when it began to gradually decrease in size. Although it is not well proven, the natural history of these tumors seems to be regression over time. This case supports the argument that a policy of watchful waiting with regular imaging studies may postpone or eliminate the need for surgery and its attendant risks.

Spinal infarction following coronary artery bypass grafting.

Spinal infarction is an extremely rare complication of coronary artery bypass grafting (CABG), almost invariably associated with use of the intra-aortic balloon pump (IABP). We present the case of a 63-year-old lady who developed paraplegia, secondary to spinal infarction, following CABG in whom the IABP was not used and no other predisposing factors were present.