| Intraoperative Electrocochleography in Patients With Menière's Disease Undergoing Endolymphatic Sac Decompression and Shunt Surgery Hypothesis: Objective physiologic changes measured using electrocochleography at the round window (ECOGRW) are observable during endolymphatic sac decompression and shunt surgery (ELS). Background: Limited effective treatment options are available to patients with Menière's disease (MD) who have failed conservative management, experience persistent vertigo symptoms, and have substantial residual hearing. ELS is a feasible therapeutic option for these patients. However, the efficacy of this procedure has been questioned, and objective measures assessing inner ear physiologic alterations are lacking. Methods: ECOGRW was measured in patients with MD undergoing ELS. Stimuli consisted of tone bursts (250, 500, 1000, 2000, 4000 Hz) and 100 μs broadband clicks at various intensities (60–90 dB nHL). Cochlear microphonic (CM), summation potential (SP), compound action potential (AP), SP:AP ratio, and CM harmonic distortions were measured. Results: ECOGRW was completed in 18 patients. The mean SP magnitude at 500 Hz changed significantly from −7.1 μV before to −5.1 μV after ELS (p < 0.05). However, the mean SP:AP ratio in those tested (n = 13) did not significantly change after ELS. CM harmonic magnitudes remained unchanged from pre- to post-ELS (n = 12) across all frequencies. Conclusion: ECOGRW allows detection of acute electrophysiological changes in the cochlea. However, our results indicate only small objective changes in the low-frequency SP magnitude (500 Hz) immediately after ELS, but not in other frequencies or measures tested (CM, SP:AP, CM harmonic distortions). These results suggest minimal electrophysiological changes occur in the cochlea as a result of ELS. Address correspondence and reprint requests to Jameson K. Mattingly, M.D., Department of Otolaryngology – Head and Neck Surgery, The Ohio State University Wexner Medical Center, 915 Olentangy River Road, Suite 4000, Columbus, OH 43212; E-mail: jameson.mattingly@osumc.edu O.F.A. is consultant for MED-EL and Advanced Bionics Corporations and receives research support from Cochlear, MED-EL, and Advanced Bionics Corporations. O.F.A. is the president of Advanced Cochlear Diagnostics. A.C.M. received grant support through the American Otology Society Clinician-Scientist Award and the National Institutes of Health, National Institute on Deafness and Other Communication Disorders (NIDCD) Career Development Award 5K23DC015539-02 that are unrelated to this project. He also received research support from Cochlear Americas for an unrelated investigator-initiated project. No funding was provided for the work related to this manuscript. The authors disclose no conflicts of interest. Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company |
| Clinical and Radiological Characteristics of Malignant Tumors Located to the Cerebellopontine Angle and/or Internal Acoustic Meatus Objective: Metastatic lesions to the internal auditory meatus (IAM) and/or the cerebellopontine angle (CPA) are rare and may appear like a vestibular schwannoma (VS). We herein raise the issue of the diagnosis and treatment of nine malignant cases of the CPA and IAM among three referral centers in France and Japan. The aim of this study was 1) to report malignant lesions of the CPA, their diagnosis and treatment, 2) to review the literature, 3) to propose criteria of suspicion for malignant tumors of the CPA. Methods: Nine patients who had malignant lesions of the CPA and/or IAM for whom the final diagnosis was made by surgery, lumbar puncture, or PET scan were included. The main outcomes measured were: rapid onset of symptoms, association of cochlea-vestibular symptoms with facial palsy, and MRI analysis. Results: Among the nine patients with malignant tumor of the CPA, 8 of them (89%) had a facial palsy associated with cochlea-vestibular symptoms. Rapid growth of the tumor was observed in 77% (7/9) of the cases in a mean time interval of 4.6 months. The initial diagnosis evoked was VS in 44% of the cases (4/9). Atypical MRI aspect was seen in 67% of the cases (6/9) with bilateral tumors in 55% of cases (5/9). Conclusion: Although rare, malignant tumors of the CPA and/or IAM should be evoked in case of association of cochleovestibular symptoms and facial palsy, rapid onset and atypical MRI aspect. Address correspondence and reprint requests to Michael Eliezer, M.D., 2 rue Ambroise Paré, 75010 Paris, France; E-mail: mcheliezer@gmail.com The authors disclose no conflicts of interest. Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company |
| Non-contrast Magnetic Resonance Imaging for Diagnosis and Monitoring of Vestibular Schwannomas: A Systematic Review and Meta-analysis Objective: This study aimed to evaluate the diagnostic accuracy of high-resolution T2-weighted magnetic resonance imaging (T2wi) in terms of detecting vestibular schwannoma compared with gadolinium-enhanced T1-weighted MRI (GdT1wi). Data Sources: Five databases (PubMed, SCOPUS, Embase, the Web of Science, and the Cochrane database). Data Selection: Two authors independently searched five databases up to January 2019 on diagnosis of vestibular schwannomas via T2wi. Data Extraction: In the included studies, tumor diameters reported using T2wi were compared with those revealed by GdT1wi and correlation coefficients were calculated. Data on true-positives, true-negatives, false-positives, and false-negatives were extracted from the relevant articles. Methodological quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 tool. Inter-rater agreement among different observers and intra-rater agreement among different measurements made by a single observer was assessed. Data Synthesis: Outcomes subjected to analysis included diagnostic accuracy (the diagnostic odds ratio); summary receiver operating characteristic curve and area under the curve values. The summary intra-class correlation coefficient was used for various random-effects models. The quality of each study was analyzed using the Quality Assessment of Diagnostic Accuracy Studies 2 tool. Conclusions: T2wi performed without the use of a contrast agent is a highly accurate diagnostic and monitor tool compared with GdT1wi and also demonstrated high reliability. However, further studies are required to confirm the results of this study. Address correspondence and reprint requests to Se Hwan Hwang, M.D., Ph.D., Department of Otolaryngology–Head and Neck Surgery, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 327 Sosa-ro, Bucheon-si, Gyeonggi-do, 14647, Republic of Korea; E-mail: yellobird@catholic.ac.kr Sponsorships: None. Author contributions: D.H.K. study conception and design, acquisition of data, analysis and interpretation of data, drafting the article and revisions, final approval of article. S.L., study conception and design, analysis and interpretation of data, drafting the article and revisions, final approval of article. S.H.H., study conception and design, acquisition of data, analysis and interpretation of data, drafting the article and revisions, final approval of article. Funding: This research was supported by the Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Education (2017R1D1A1B03027903, 2018R1D1A1B07045421), the Bio & Medical Technology Development Program of the NRF funded by the Ministry of Science & ICT (2018M3A9E8020856), and the Institute of Clinical Medicine Research of Bucheon St. Mary's Hospital, Research Fund (2017, 2018). This research was also supported by a grant from the E.N.T. Fund of the Catholic University of Korea (program years 2017–2018). The authors disclose no conflicts of interest. Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company |
| Concurrent Treatment With Intratympanic Dexamethasone for Moderate-Severe Through Severe Bell's Palsy Objective: To determine whether early intervention with intratympanic steroid injection, known as concurrent intratympanic steroid therapy, is effective as a supplement to systemic steroid therapy for treating moderate-severe to severe Bell's palsy. Design: An open-label historical control trial. Setting: Tertiary referral center. Participants: A total of 35 Bell's palsy patients presenting with House–Brackmann grade IV or higher were treated with intratympanic steroid therapy concurrent with standard systemic treatment and compared with 108 patients treated with standard systemic therapy alone started within 7 days of onset. Interventions: In the concurrent intratympanic steroid therapy group, patients received both 410 mg of prednisolone (standard dose) and 1.65 mg of intratympanic dexamethasone for 10 consecutive days. Patients in the control group received the standard dose, or more, of systemic prednisolone. Both groups were additionally treated with valacyclovir. Main Outcomes and Measures: The primary outcome measure was restoration of a House–Brackmann score of grade I. Results: The rate of recovery to House–Brackmann Grade I was higher for the concurrent intratympanic steroid therapy group than for the control group (94% vs 73%, p = 0.008). The adjusted odds ratio was 5.47 (95% confidence interval: 1.18–25.21, p = 0.029). Conclusions: The recovery rate was higher for concurrent intratympanic steroid therapy treatment than for standard-of-care control treatment, regardless of whether steroid with lower or equivalent glucocorticoid action was administered. This result suggests that concurrent treatment with intratympanic steroid therapy is a potentially beneficial supplement to systemic steroid administration. Address correspondence and reprint requests to Akira Inagaki, M.D., Ph.D., 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya City, Aichi 467-8601, Japan; E-mail: ainagaki@med.nagoya-cu.ac.jp Akira Inagaki: ORCID ID: 0000-0001-5560-9321. Disclosure of funding received: Japan Society for the Promotion for Science (Nos. 15H04990, 16K15724 to A.I. and 16K11188 to S.M.). The authors disclose no conflicts of interest. Supplemental digital content is available in the text. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (www.jcraniofacialsurgery.com). Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company |
| MRI Evidence of Vestibular Atelectasis in Bilateral Vestibulopathy and Tullio Phenomenon No abstract available |
| Microbiome Analysis of Cholesteatoma by Gene Sequencing Objective: To compare the microbial flora of cholesteatoma and normal middle ears using gene-based sequencing analysis. Study Design: Controlled ex vivo human study. Setting: Academic, tertiary medical center. Subjects and Methods: Brush, swab, and tissue samples were each taken from cholesteatoma matrix and uninvolved tissue in patients with previously untreated, acquired cholesteatoma (n = 19) or middle ear mucosa from patients undergoing cochlear implantation with no history of cholesteatoma or previous middle ear surgery (control; n = 12). DNA was isolated from specimens then 16S rRNA gene sequencing was performed. Results: There was no difference in microbial yield between the sampling methods. Cholesteatoma specimens had lower relative abundance of 14 bacterial species compared with controls including Acidovorax sp., Bacillus sp., Masillia sp., Moraxella osloensis, Phenylobacterium conjunctum, Sphingomonas sp., and Staphylococcus epidermidis (all p < 0.05). Alternaria sp. were present on nearly all the specimens. Alternaria sp. and Cladosporium herbarum (both p ≤ 0.05) were lower in the cholesteatoma compared with control group. There was no difference in the relative abundance of any bacteria or fungi between the cholesteatoma matrix and uninvolved middle ear mucosa. Conclusions: Microbiome of cholesteatoma matrix is largely similar to adjacent mucosa. This differs from healthy ears. Further study is needed to understand if middle ear microbiome may impact cholesteatoma pathogenesis or treatment. Address correspondence and reprint requests to Carolyn O. Dirain, Ph.D., Department of Otolaryngology, University of Florida, Box 100264, 1345 Center Drive MSB M2-228, Gainesville, FL 32610-0264; E-mail: ojanoc@ent.ufl.edu Source of Funding: This study was supported by a grant from Medtronic Xomed, Jacksonville, FL. The study sponsor had no role in the conduct of the study or data analysis and was not involved in the preparation of the manuscript. P.J.A. discloses research support from Alcon Laboratories, Edison Pharmaceuticals, Otonomy, Next Science, and Medtronic ENT; service on Otonomy and Metarmor advisory boards; and speaker sponsorship by Alkem Laboratories and Vindico Medical Education. C.O.D. discloses research support from Next Science and Medtronic ENT. J.P.W. has no relevant conflicts to disclose. Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company |
| Triphasic Pulses in Cochlear Implant Patients With Facial Nerve Stimulation Objective: Evaluation of triphasic pulse stimulation in comparison to the traditional biphasic pulse stimulation in cochlear implant (CI) patients with unintended facial nerve costimulation. Study Design: Retrospective case review. Setting: Cochlear Implant Center of a University Department of Otolaryngology, Head and Neck Surgery. Patients: Fifteen CI patients (MED-EL, Innsbruck, Austria) received a triphasic fitting map instead of a biphasic fitting map due to a previous diagnosis of facial nerve stimulation or stimulus induced pain during the years 2014 to 2017. Intervention(s): Application of a triphasic stimulation strategy. Main Outcome Measure(s): Reduction of facial nerve costimulation and speech understanding. Biphasic and triphasic fitting maps were compared to accurately assess the effects of the switch, and hearing tests (monosyllables and sentences in noise tests) were analyzed. Results: Triphasic pulse stimulation showed a significant reduction of unintended side effects and resulted in an observed improved quality of life in most cases. Although there was no significant change in the understanding of speech with CI in all test situations, in many cases, improvement was observed. Conclusions: Triphasic pulse stimulation had a beneficial effect for CI patients with severe, unintended costimulation and should be considered a valuable tool during CI fitting. Address correspondence and reprint requests to Katharina Braun, M.D./Dr. med., University Department of Otolaryngology, Head and Neck Surgery, Elfriede-Aulhorn-Straße 5, 72076 Tübingen, Germany; E-mail: Katharina.Braun@med.uni-tuebingen.de The authors disclose no conflicts of interest. Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company |
| The Component Structure of the Dizziness Handicap Inventory (DHI): A Reappraisal Objective.: The Dizziness Handicap Inventory (DHI) is a 25-item self-report questionnaire developed to measure the disabling and handicapping impact of dizziness. The present investigation was conducted in an effort to re-assess the factor structure of the DHI. Study Design.: Retrospective study. Setting.: Tertiary care center. Patients.: Subjects were 1,991 patients who were evaluated in the Mayo Clinic-Rochester Vestibular and Balance Laboratory. Main Outcome Measures.: Exploratory factor analysis: an exploratory bifactor analysis (EFA) with bifactor rotation was used to analyze a random sample of 999 patients. Analyses were used to determine the dominance of the general factor (i.e., total score) relative to the group factor (i.e., subscales). Confirmatory factor analysis: a confirmatory bifactor graded response model was fit with appropriate item-to-group relationships that was discovered by our exploratory analyses. To validate the bifactor model that was identified with the exploratory analyses, a bifactor model with three grouping factors (i.e., Physical manifestations, Catastrophic impact of dizziness, and the Emotional impact of dizziness) were fit to a different random sample of 992 patients using the new item-to-group factor specifications. Results.: In the confirmatory analyses, all items had a positive factor loading on the general factor. There were 14 items that loaded on the general factor only. The rest of the items (n = 11) loaded on both the general factor and one of three group factors. Conclusions.: Conclusions of the study revealed several findings: 1) reporting the result as a total score (i.e., a single general factor) is warranted, and, 2) there is statistical support for the existence of three subscales representing: the Physical manifestations, Catastrophic impact, and Emotional impact of dizziness and vertigo. Address correspondence and reprint requests to Devin L. McCaslin, Ph.D., Department of Otolaryngology, Mayo Clinic, Gonda 12-400 AUD, 200 1st Street SW, Rochester, MN; E-mail: mccaslin.devin@mayo.edu The authors disclose no conflicts of interest. Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company |
| Delayed Tumor Growth in Vestibular Schwannoma: An Argument for Lifelong Surveillance Objective: Previous research has shown that tumor growth during observation of small-to-medium sized sporadic vestibular schwannomas (VSs) occurs almost exclusively within 3 to 5 years following diagnosis. This has led some to consider ending surveillance after this interval. This study seeks to characterize a cohort of patients with tumors that exhibited late growth. Study Design: Retrospective cohort study. Setting: Tertiary referral center. Patients: Adults with sporadic VSs who initially elected observation with serial magnetic resonance imaging (MRI) surveillance. Intervention(s): None. Main Outcome Measure(s): Linear tumor growth was measured in accordance with AAO-HNS reporting guidelines. Delayed growth was defined as growth ≥2 mm in linear diameter that was first detected 5 years or more from the initial MRI. Results: From a total of 361 patients, 172 experienced tumor growth during the interval of observation. Fourteen of these 172 patients (8.1%) experienced late growth occurring at 5 years or beyond. Among patients with delayed growth, the fastest growth rate after extended quiescence was 1.33 mm/yr, and the longest delay before tumor growth detection was 11.1 years. Additional treatment was recommended for six (42.9%) of the patients with delayed growth. Of 68 tumors that remained in the IAC, 11 (16.2%) demonstrated delayed growth. Of 66 tumors that presented in the CPA, 2 (3.0%) demonstrated delayed growth. Initial size was larger for tumors demonstrating early growth compared with those with delayed growth. For tumors within the IAC, those with early growth had a significantly higher median growth rate than those with delayed growth (1.40 vs. 0.45 mm/yr, p < 0.001). Conclusions: Delayed growth encompassed 8.1% of growing VSs and 3.9% of all observed tumors. Patients with delayed growth exhibited slower growth rates compared with those who were diagnosed with growth early in their observation course. These findings support the need for lifelong surveillance of untreated VSs given the possibility of clinically significant delayed growth. Increasing the time interval between MRI studies after 5 years is a reasonable concession to balance practicalities of cost and convenience with risk of delayed of tumor growth. Address correspondence and reprint requests to Matthew L. Carlson, M.D., Department of Otolaryngology – Head and Neck Surgery, Mayo Clinic, 200 1st St SW, Rochester, MN 55905; E-mail: carlson.matthew@mayo.edu Internal departmental funding was used without commercial sponsorship or support. The authors disclose no conflicts of interest. Supplemental digital content is available in the text. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (http://journals.lww.com/otology-neurotology). Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company |
| Involvement of the Cochlear Aqueduct by Jugular Paraganglioma Is Associated With Sensorineural Hearing Loss Objective: The etiology of sensorineural hearing loss (SNHL) in patients with jugular paraganglioma (JP) whose tumors lack inner ear fistulae or vestibulocochlear nerve involvement is unknown. Recent literature has proposed that occlusion of the inferior cochlear vein may be causative. Herein, we assess the association between radiologic involvement of the cochlear aqueduct (CA) and the development of SNHL. Study Design: Blinded, retrospective review of imaging and audiometry. Setting: Tertiary center. Patients: Adults with JP. Intervention(s): None. Main Outcome Measures: Asymmetric SNHL was assessed continuously as the difference in bone conduction pure-tone average (BCPTA) between ears and as a categorical variable (≥15 dB difference at two consecutive frequencies, or a difference in speech discrimination score of ≥15%). Involvement of the CA was considered present if there was evidence of medial T2 fluid signal loss, contrast enhancement, or bony erosion/expansion. Results: Of 30 patients meeting inclusion criteria, 15 (50%) had asymmetric SNHL. CA involvement was observed in 87% of patients with asymmetric SNHL compared with 13% in those with symmetric hearing (p = 0.0001). Univariate analysis demonstrated that age, sex, and tumor volume were not associated with asymmetric SNHL. The median difference in BCPTA between ears in patients with CA involvement was 21.3 dB HL compared to 1.2 dB HL in those without CA involvement (p < 0.0001). Regression analysis demonstrates that enhancement within the CA is associated with a BCPTA difference of 19.4 dB HL (p = 0.0006). Conclusions: Cochlear aqueduct involvement by JP is associated with SNHL in the absence of inner ear fistula, vestibulocochlear nerve involvement, or brainstem compression. Correlation with operative findings or histopathologic evidence of tumor involvement may validate this intriguing imaging finding. Address correspondence and reprint requests to Matthew L. Carlson, M.D., Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, 200 1st St SW, Rochester, MN 55905; E-mail: carlson.matthew@mayo.edu Internal departmental funding was utilized without commercial sponsorship or support. C.L.W.D. is a consultant for Advanced Bionics Corp., Cochlear Corp., and MED-EL GmbH. Institutional review board approval: Mayo Clinic IRB Approval 16-002291. The authors disclose no conflicts of interest. Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company |
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