Otology & Neurotology最新文献

Abstract: Over the past two decades, there has been increasing interest in the diagnosis and management of schwannomas of the inner ear including hearing rehabilitation with cochlear implants. However, tumor nomenclature and classification within the literature have been variable and oftentimes cumbersome. The term "intralabyrinthine schwannoma" is in common use when describing these tumors but is a potential source of confusion given that people often use the term "labyrinth" or "labyrinthine" to refer to the vestibular component of the inner ear only (i.e., labyrinthectomy or the translabyrinthine approach).During the Ninth Quadrennial Conference on Vestibular Schwannoma and Other Cerebellopontine Angle Lesions in Bergen, Norway, in May 2023, a multidisciplinary group of conference participants met and discussed issues pertaining to current terminology and classifications to enhance clarity and to reflect recent advances in tumor management and hearing rehabilitation.Although a variety of terms have been previously used to describe inner ear schwannomas, consensus was achieved on the term "inner ear schwannoma (IES)" to describe eighth nerve schwannomas of the cochlea, vestibule, or semicircular canals. Subgroups under this term comprise intravestibular, intracochlear, or intravestibulocochlear inner ear schwannomas (low complexity tumors), inner ear schwannomas with transfundal extension into the internal auditory canal but without modiolar involvement (intermediate complexity tumors), and inner ear schwannomas with transfundal extension with modiolar involvement (high complexity tumors).The details of the recommendations for an updated and simplified tumor nomenclature centered around tumor control and hearing rehabilitation with cochlear implantation are presented.

Background: To create and develop a delivery approach for clinical inner ear gene therapy, we conducted a study of trans-round window membrane (RWM) microinjection using a pipetting microneedle via transcanal endoscopic ear surgery (TEES).

Methods: The implementation of the trans-RWM microinjection surgery involved seven cadaveric specimens, and the surgical procedures and the pipetting microneedle were developed and optimized. The TEES procedures included tympanic cavity visualization, RWM exposure, stapes footplate perforation, and trans-RWM microinjection. The feasibility of different pipetting microneedles was evaluated during microinjection.

Results: Exposure of the RWM microinjection site could be easily achieved in TEES, and the soft-connected pipetting microneedle was most suitable for the trans-RWM microinjection. The fluid outflow from stapes perforation could be visibly observed during the microinjection, which indicated inner ear drug delivery was successful. This inner ear drug delivery approach was successfully applied in the clinical trial.

Conclusion: The trans-RWM microinjection via the soft-connected pipetting microneedle in TEES was proved to be a feasible delivery approach of the inner ear gene therapy.

Objective: To analyze cases of medial migration of vestibular schwannomas to propose an underlying mechanism.

Study design: Retrospective chart review.

Patients: Ten patients from one institution with sporadic vestibular schwannomas that demonstrated medial migration toward the cerebellopontine angle on serial imaging were reviewed.

Interventions: Among the 10 patients studied, 8 patients underwent stereotactic radiosurgery and 2 were managed with wait-and-scan. All serial imaging was analyzed throughout follow-up.

Main outcome measures: Volumetric and linear measurements were used to assess vestibular schwannoma growth. The fundal fluid cap length was measured from the most lateral end of the neoplasm within the internal auditory canal to the medial end of the cochlea. Pure tone averages of 0.5, 1, 2, and 3 kHz, word recognition scores, and AAO-HNS hearing class were used to assess levels of hearing loss per patient.

Results: Tumor growth exhibited a positive correlation with medial migration. Of the 10 patients studied, 9 exhibited tumor volume growth from initial to most recent imaging. Median changes in tumor volumes and fundal fluid cap lengths from initial diagnosis to the most recent imaging regardless of intervention were 130 mm 3 (range 1,400-2,970) and 2.8 mm (range 1.8-6.0), respectively. Migration was noted in 4 patients prior to any intervention, in 4 patients postradiosurgery, and in 2 patients before and after radiosurgery. Therefore, half of the tumors studied migrated before an intervention and half migrated postradiosurgery. No correlation of migration and hearing decline was observed.

Conclusion: Medial migration of vestibular schwannoma is associated with an increase in tumor volume, supporting a "tumor squeeze" mechanism within a conical internal auditory canal toward the wider porus acusticus and cerebellopontine angle.

Objective: To report the feasibility and potential utility of monitoring acoustic hearing on awake patients using intraoperative behavioral responses to threshold and suprathreshold stimuli while undergoing cochlear implantation (CI) under local anesthesia, without any form of sedation.

Study design: Retrospective review of the first five cases performed by one surgeon.

Setting: Tertiary care academic medical center.

Patients: Adult patients with residual acoustic hearing undergoing CI.

Interventions: CI under local anesthesia, without any form of sedation.

Main outcome measures: Procedural tolerance, reliability of intraoperative pure tone threshold and suprathreshold audiometry, and correlation of intraoperative findings with early postoperative residual hearing.

Results: Five ears in four patients underwent CI, including three males and one female, with a median age of 61 years. Intraoperatively, patients reported reliable behavioral responses to pure tone threshold and suprathreshold stimuli and provided real-time feedback on perceived stimulus change to the surgeon just prior to, during, and immediately following electrode insertion. All patients were able to complete the operation under local anesthesia. During electrode insertion, three cases reported no change and two cases reported diminished stimulus perception that reversed with limited electrode pull back near terminal insertion. Immediate postoperative audiograms demonstrated preservation of bone conduction thresholds within 10 dB of their preoperative baseline for all cases, suggesting hearing preservation. Three-month postoperative AzBio in quiet scores were available for two patients, measuring 45% and 94%, respectively.

Conclusions: This report describes the feasibility of intraoperative behavioral audiometry during CI under local anesthesia, using patient feedback during electrode insertion to optimize hearing preservation surgery. Akin to other surgical subspecialties that use real-time patient feedback where objective intraoperative measures of neurofunction are imperfect, we demonstrate feasibility and potential utility of live acoustic monitoring during CI.

Objective: To assess the factors that drive a patient's selection of cochlear implant (CI) manufacturer.

Study design: Prospective survey study.

Setting: Tertiary referral center.

Patients: One hundred twenty-eight adult patients undergoing primary CI.

Interventions: Survey administered in the preoperative area.

Main outcome measures: Sources of information regarding CI manufacturer offerings, factors that were most important in deciding on a manufacturer, and manufacturer ultimately selected.

Results: One hundred twenty-eight patients were included (average age, 63.7 years; 97% White). The most cited source of information that patients used to choose a device was his/her audiologist (80.5% of patients). When asked his/her number 1 reason for choosing their CI manufacturer, the most commonly cited reason was technology (e.g., battery life, device pairing), regardless of manufacturer. When asked about specific technology offerings, hearing aid pairing was rated as the most important. The numbers 2 and 3 reasons for choosing a manufacturer were cosmetics/structure of the wearable portion of the device and audiologist recommendation of that manufacturer, respectively. The relative weight given to each of the top 3 reasons differed significantly across the three manufacturers ( p = 0.017).

Conclusions: Audiologists are by far the leading source of information used by patients choosing a CI manufacturer. Patients prioritize technology most when choosing an implant manufacturer, but audiologist recommendation and the cosmetics and structure of the wearable device are also important. CI manufacturers should be mindful of patient priorities when designing and marketing their devices.

Objectives: Balloon dilation eustachian tuboplasty (BDET) has gained popularity as a treatment modality for chronic eustachian tube dysfunction (ETD) in both adults and children. Although its safety and efficacy in the adult population have been well described, very few large-sample studies assessing its safety profile have been performed in the pediatric population. This study serves as a follow-up to a previously published analysis assessing the safety of BDET in the pediatric population.

Methods: Retrospective chart review of 71 pediatric patients (139 ears) aged 11 ± 7 years who underwent BDET from 2019 to 2023. Medical records were reviewed from the extended postoperative period. A standardized grading scale that assesses severity of surgical complications was used.

Results: A total of five minor complications (7%) were noted. These included transient postoperative tinnitus, hyperacusis, otalgia, nausea, and epistaxis. There were no major complications requiring repeat intervention or need for imaging or hospital admission. In all cases, these symptoms had resolved in the postoperative time frame, with majority of them demonstrating complete resolution before the first postoperative visit.When combining these findings with the previously published paper by the same institution, the overall complication rate is 6.1% with 114 total patients. All complications between both papers are considered minor with no long-term effects.

Conclusions: In this retrospective analysis, BDET is shown to be a relatively safe procedure when performed in the pediatric population. Upon review of the literature, this is the largest safety analysis of exclusively pediatric patients who underwent BDET.

Level of evidence: 4.

Objective: The objectives were to determine the interrater agreement of the Skull AP X-ray in measuring angular insertion depth (AID), to provide descriptive information about the insertion depths of different electrodes used in inner ear malformations (IEMs), to investigate the effect of cochlear size and electrode length on AID, and to guide clinicians in electrode selection in IEMs.

Study design: Retrospective case review.

Setting: Tertiary referral center.

Patients: A total of 198 IEMs (n = 169 patients) and 60 cochleae with normal anatomy (n = 60 patients) were selected from patients with severe mixed or sensorineural hearing loss who presented to our clinic and underwent cochlear implantation (CI) between January 2010 and December 2022.

Interventions: Three neurotologists independently measured AID on Skull AP X-rays. Basal turn length of the cochlea was measured in axial and coronal oblique reformatted sections on HRCT images.

Main outcome measures: Interrater reliability (ICC) of the AID measurements on Skull AP X-ray, determining the impact of cochlea size and electrode length on AID measurements.

Results: The interrater reliability (ICC) test showed a high level of consistency in measuring AID in the Skull AP X-ray ( R = 0.906, p < 0.001). In the control group, a negative correlation was observed between the AID and the basal turn length of the cochlea, while a positive correlation was found between electrode length and AID ( R = 0.947, p < 0.001).

Conclusions: The Skull AP X-ray appears to be a dependable tool for measuring AID. In cases of IEMs, it is important to select an electrode of appropriate length, considering the dimensions of the cochlea.

Objective: To evaluate the difference in overall, hospital, and out-of-hospital cost difference of day-case stapes surgery, compared with inpatient stapes surgery, while maintaining equal hearing outcomes and quality of life (QoL).

Study design: A single-center, nonblinded, randomized controlled trial in a tertiary referral center.

Methods: A total of 112 adult patients planned for primary or revision stapes surgery for clinically suspected otosclerosis were randomly assigned to either the day-case or inpatient treatment group. An evaluation was performed of the difference in total health care-related costs (hospital and out-of-hospital costs) from a hospital and patient perspective over the course of 1 year. Audiometric measurements included pure-tone audiometric measurements and speech audiometry measured at 2 months and 1 year postoperatively. QoL was assessed at 3 months and 1 year postoperatively, using the EQ-5D and HUI3 questionnaires.

Results: A total of 109 cases (100 patients) were analyzed due to three dropouts. The total health care-related costs were €16,586 in the inpatient group (n = 54) and €16,904 in the day-case group (n = 55). The mean postoperative hospital stay was 0.9 days (mean costs of €854) in the inpatient group and 0.5 days (mean costs of €561) in the day-case group (both mean differences statistically significant), with a crossover rate from day-case to the inpatient group of 36% (n = 20) and a crossover rate from inpatient to the day-case group of 11% (n = 6). There were no differences in postoperative complications and objective hearing outcomes. Besides an increased number (0.2) of postoperative telephone consultations in the day-case group, there were no statistically significant differences in postoperative hospital and out-of-hospital costs or visits. The QoL showed no statistically significant differences.

Conclusion: A day-case approach in primary or revision stapes surgery does not result in a statistically significant reduction of health care-related hospital and out-of-hospital costs compared with an inpatient approach. It also does not affect the surgical outcome (objective audiometric measurements and complication rate), QoL, and postoperative course (number of postoperative hospital and out-of-hospital visits).Level of evidence: 1.