Time to Functional Recovery After Laser Tonsillotomy Performed Under Local Anesthesia vs Conventional Tonsillectomy With General Anesthesia Among Adults: A Randomized Clinical Trial.

Importance: Carbon dioxide laser tonsillotomy performed under local anesthesia may be an effective and less invasive alternative than dissection tonsillectomy for treatment of tonsil-related afflictions. Objective: To compare functional recovery and symptom relief among adults undergoing tonsillectomy or tonsillotomy. Design, Setting, and Participants: This randomized clinical trial was conducted at 5 secondary and tertiary hospitals in the Netherlands from January 2018 to December 2019. Participants were 199 adult patients with an indication for surgical tonsil removal randomly assigned to either the tonsillectomy or tonsillotomy group. Interventions: For tonsillotomy, the crypts of the palatine tonsil were evaporated using a carbon dioxide laser under local anesthesia, whereas tonsillectomy consisted of total tonsil removal performed under general anesthesia. Main Outcomes and Measures: The primary outcome was time to functional recovery measured within 2 weeks after surgery assessed for a modified intention-to-treat population. Secondary outcomes were time to return to work after surgery, resolution of primary symptoms, severity of remaining symptoms, surgical complications, postoperative pain and analgesics use, and overall patient satisfaction assessed for the intention-to-treat population. Results: Of 199 patients (139 [70%] female; mean [SD] age, 29 [9] years), 98 were randomly assigned to tonsillotomy and 101 were randomly assigned to tonsillectomy. Recovery within 2 weeks after surgery was significantly shorter after tonsillotomy than after tonsillectomy (hazard ratio for recovery after tonsillectomy vs tonsillotomy, 0.3; 95% CI, 0.2-0.5). Two weeks after surgery, 72 (77%) patients in the tonsillotomy group were fully recovered compared with 26 (57%) patients in the tonsillectomy group. Time until return to work within 2 weeks was also shorter after tonsillotomy (median [IQR], 4.5 [3.0-7.0] days vs 12.0 [9.0-14.0] days; hazard ratio for return after tonsillectomy vs tonsillotomy, 0.3; 95% CI, 0.2-0.4.). Postoperative hemorrhage occurred in 2 patients (2%) in the tonsillotomy group and 8 patients (12%) in the tonsillectomy group. At 6 months after surgery, fewer patients in the tonsillectomy group (25; 35%) than in the tonsillotomy group (54; 57%) experienced persistent symptoms (difference of 22%; 95% CI, 7%-37%). Most patients with persistent symptoms in both the tonsillotomy (32 of 54; 59%) and tonsillectomy (16 of 25; 64%) groups reported mild symptoms 6 months after surgery. Conclusions and Relevance: This randomized clinical trial found that compared with tonsillectomy performed under general anesthesia, laser tonsillotomy performed under local anesthesia had a significantly shorter and less painful recovery period. A higher percentage of patients had persistent symptoms after tonsillotomy, although the intensity of these symptoms was lower than before surgery. These results suggest that laser tonsillotomy performed under local anesthesia may be a feasible alternative to conventional tonsillectomy in this population. Trial Registration: Netherlands Trial Register Identifier: NL6866 (NTR7044).

A non-invasive, automated diagnosis of Menière's disease using radiomics and machine learning on conventional magnetic resonance imaging: A multicentric, case-controlled feasibility study.

PURPOSE: This study investigated the feasibility of a new image analysis technique (radiomics) on conventional MRI for the computer-aided diagnosis of Menière's disease. MATERIALS AND METHODS: A retrospective, multicentric diagnostic case-control study was performed. This study included 120 patients with unilateral or bilateral Menière's disease and 140 controls from four centers in the Netherlands and Belgium. Multiple radiomic features were extracted from conventional MRI scans and used to train a machine learning-based, multi-layer perceptron classification model to distinguish patients with Menière's disease from controls. The primary outcomes were accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of the classification model. RESULTS: The classification accuracy of the machine learning model on the test set was 82%, with a sensitivity of 83%, and a specificity of 82%. The positive and negative predictive values were 71%, and 90%, respectively. CONCLUSION: The multi-layer perceptron classification model yielded a precise, high-diagnostic performance in identifying patients with Menière's disease based on radiomic features extracted from conventional T2-weighted MRI scans. In the future, radiomics might serve as a fast and noninvasive decision support system, next to clinical evaluation in the diagnosis of Menière's disease.

Deep learning for the fully automated segmentation of the inner ear on MRI.

Segmentation of anatomical structures is valuable in a variety of tasks, including 3D visualization, surgical planning, and quantitative image analysis. Manual segmentation is time-consuming and deals with intra and inter-observer variability. To develop a deep-learning approach for the fully automated segmentation of the inner ear in MRI, a 3D U-net was trained on 944 MRI scans with manually segmented inner ears as reference standard. The model was validated on an independent, multicentric dataset consisting of 177 MRI scans from three different centers. The model was also evaluated on a clinical validation set containing eight MRI scans with severe changes in the morphology of the labyrinth. The 3D U-net model showed precise Dice Similarity Coefficient scores (mean DSC-0.8790) with a high True Positive Rate (91.5%) and low False Discovery Rate and False Negative Rates (14.8% and 8.49% respectively) across images from three different centers. The model proved to perform well with a DSC of 0.8768 on the clinical validation dataset. The proposed auto-segmentation model is equivalent to human readers and is a reliable, consistent, and efficient method for inner ear segmentation, which can be used in a variety of clinical applications such as surgical planning and quantitative image analysis.

Chronic otorrhea caused by myospherulosis in the middle ear after tympanoplasty.

OBJECTIVES: Myospherulosis is a foreign body reaction induced by the application of oil-based ointments. Myospherulosis in the ear is extremely rare. Only 4 cases have been described, all of which occurred after (repeated) mastoid surgery. METHODS: We present a case of persistent otorrhea and conductive hearing loss caused by myospherulosis in the middle ear following tympanoplasty. RESULTS: The patient underwent revision middle ear surgery with removal of abnormally thick, pale tissue in the middle ear. Histology showed a foreign body reaction with signs of myospherulosis. CONCLUSIONS: Myospherulosis is a very rare complication of the use of oil-based ointments. Surgeons should be aware that these products might cause a foreign body reaction leading to myospherulosis. In patients who have chronic otorrhea after previous mastoid or middle ear surgery, myospherulosis should be considered in the differential diagnosis.

Stapedius muscle fibre characterization in the noise exposed and auditory deprived rat.

In skeletal muscle, interventions that unload the muscle cause slow-to-fast myosin heavy chain (MHC) conversions, whereas fast-to-slow conversions are seen when the muscles are engaged in resistance training and endurance exercise. The stapedius muscle (SM) is reported to prevent cochlear damage by noise. This theory may be supported by showing comparable changes of muscle fibre composition when ears are exposed to longstanding noise (SM training). Comparable changes after sound deprivation (SM unloading) would suggest that the SM needs a certain degree of daily activity evoked by environmental sound to sustain its normal composition. We investigated the difference in myosin composition of SM fibres from rats exposed to noise, from auditory deprived rats and from rats exposed to low level ambient noise (control group). Consecutive complete SM cross-sections were processed by enzymehistochemistry to determine acid/alkali lability of myofibrillar adenosine triphosphatase (mATPase) and by immunohistochemistry using MHC antibodies. Fibres were assigned to mATPase type I, IIA, IIX or 'Miscellaneous' categories. Per mATPase category, the fibres were attributed to groups with specific MHC isoform compositions. Auditory deprivation lasting nine weeks was accomplished by closure of the external meatus at the age of three weeks. A slow-to-fast shift was seen in these rats when compared to the control group. The noise exposed group was exposed to 65-90dB sound pressure level during a period lasting nine weeks from the age of three weeks onwards. A shift from an overwhelming presence of type mATPase IIX, as seen in the control group, to type mATPase IIA occurred in the noise exposed group. Also, more MHC IIA/IIX hybrid fibres were found in the mATPase IIX category. An adaptive response to the acoustic environment in the characteristics of the fibres of the SM, comparable to the response in skeletal muscles on unloading and training activity, can be ascertained. This supports the theory that the SM plays an active role in modulating external acoustic energy on entry to the cochlea. Our results are also in favour of another postulated function of the SM, the unmasking of high-frequency signals in low-frequency background noise.

Stapedius muscle fiber characterization during postnatal development in the rat.

The stapedius muscle (SM) is reported to prevent cochlear damage by noise. Functional demands are then the ability of fast contraction with long endurance. At the end of the third postnatal week, the middle ear of the rat is completely pneumatized and according to electrophysiological data, the auditory function starts to match the adult. We investigated the developmental changes in myosin composition of SM fibres using consecutive complete SM cross-sections (taken from rats on post natal day (PND) 7, 14, 16, 21, 28, 42 and 84) which were processed by enzymehistochemistry to determine acid/alkali lability of myofibrillar adenosine triphosphatase (mATPase) and by immunohistochemistry using myosin heavy chain (MHC) antibodies (mAb). Fibres were assigned to mATPase type I, IIA, IIB, IIX or 'Miscellaneous' categories. Per mATPase category, the fibres were attributed to groups with specific MHC isoform compositions. Neonatal MHC expression could not be documented with the mAb used. However, embryonal (Emb) MHC was expressed at PND 7, very little at PND 14; at later PND fibres did not show Emb MHC. In general, the mATPase-based classification did not show large alterations after PND 21. Expression of MHC IIB, which was present in almost 50% of the fibres at PND 7 and 14, diminished to 3% at PND 84. A decrease in number of fibres expressing more than one MHC isoform was found. These results show that the SM is a precociously developing muscle compared to limb muscles and even to the diaphragm. Moreover, it is shown that the expression of the adult MHC isoform phenotype coincides with the onset of auditory function in the third postnatal week.