Duration of Processor Use Per Day Is Significantly Correlated With Speech Recognition Abilities in Adults With Cochlear Implants Objective: Quantify the relationship between average hours of processor use per day and measures of speech recognition in post-lingually deafened adults with cochlear implants. Setting: Cochlear implant (CI) program at a tertiary medical center. Patients: Three hundred adult (mean age = 64, 130 women) CI users were included. Main Outcome Measures: Correlation analyses were completed for CI-aided speech recognition (Consonant-Nucleus-Consonant [CNC] monosyllables and AzBio sentences) at approximately 12 months post-implantation and average hours of processor use per day, which was extracted from the CI programming software. Results: Average processor use was 10.2 hours per day (range, 0.1–22.7), and average speech recognition scores were 49.9 and 61.7% for CNC and AzBio sentence recognition, respectively. We found a strong, significant correlation between hours of processor use per day and consonant-nucleus-consonant (CNC) word recognition (rs = 0.61, p < 0.0001) and AzBio sentence recognition (rs = 0.56, p < 0.0001). Conclusions: Results suggest that highest speech recognition outcomes are correlated with greater than 10 hours of CI use per day. Further research is needed to assess the causal link between daily CI use and speech recognition abilities. Address correspondence and reprint requests to Jourdan T. Holder, Au.D., Department of Hearing and Speech Sciences, 1215 21st Avenue South, Medical Center East, South Tower, #9302, Nashville, TN 37232-8605; E-mail: jourdan.t.holder@vumc.org Financial material & support: NIH R01 DC13117; PI: René H. Gifford, PhD. INSITUTIONAL REVIEW BOARD: IRB# 190958. R.G.: Advisory board for Advanced Bionics, Cochlear, and Frequency Therapeutics. Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

Anatomical and Functional Consequences of Microneedle Perforation of Round Window Membrane Hypothesis: Microneedles can create microperforations in the round window membrane (RWM) without causing anatomic or physiologic damage. Background: Reliable delivery of agents into the inner ear for therapeutic and diagnostic purposes remains a challenge. Our novel approach employs microneedles to facilitate intracochlear access via the RWM. This study investigates the anatomical and functional consequences of microneedle perforations in guinea pig RWMs in vivo. Methods: Single three-dimensional-printed, 100 μm diameter microneedles were used to perforate the guinea pig RWM via the postauricular sulcus. Hearing was assessed both before and after microneedle perforation using compound action potential and distortion product otoacoustic emissions. Confocal microscopy was used ex vivo to examine harvested RWMs, measuring the size, shape, and location of perforations and documenting healing at 0 hours (n = 7), 24 hours (n = 6), 48 hours (n = 6), and 1 week (n = 6). Results: Microneedles create precise and accurate perforations measuring 93.1 ± 29.0 μm by 34.5 ± 16.8 μm and produce a high-frequency threshold shift that disappears after 24 hours. Examination of perforations over time demonstrates healing progression over 24 to 48 hours and complete perforation closure by 1 week. Conclusion: Microneedles can create a temporary microperforation in the RWM without causing significant anatomic or physiologic dysfunction. Microneedles have the potential to mediate safe and effective intracochlear access for diagnosis and treatment of inner ear disease. Address correspondence and reprint requests to Anil K. Lalwani, M.D., Division of Otology, Neurotology, and Skull Base Surgery, Department of Otolaryngology—Head and Neck Surgery, Columbia University College of Physicians and Surgeons, 180 Fort Washington Avenue, Harkness Pavilion, 8th Floor, New York, NY 10032; E-mail: anil.lalwani@columbia.edu E.S.O., J.W.K., and A.K.L. are co-senior authors. Research was funded by the National Institutes of Health (NIH) National Institute on Deafness and Other Communication Disorders with award number R01DC014547. Dr. A.K.L. is on the Medical Advisory Board of Advanced Bionics. The authors disclose no other conflicts of interest. Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

Pregnancy Does Not Increase the Risk of Bell's Palsy: A National Cohort Study Objectives: The objective of this study was to compare the incidence of Bell's palsy between women during pregnancy or postpartum periods and non-pregnant/non-postpartum women (controls). Methods: Using the national cohort from the Korean Health Insurance Review and Assessment Service, pregnant/postpartum participants (63,264) and control participants (126,528) were matched in a 1:2 ratio based on age, income, region of residence, and medical history. The incidence of Bell's palsy in both groups was measured from pregnancy to 1 year postpartum. Results: Among the 63,264 pregnant/postpartum participants, 20 were diagnosed with or treated for Bell's palsy during pregnancy, and 38 during postpartum periods. The annual incidence of Bell's palsy per 100,000 women during pregnancy was 43.4 in the patient group and 80.2 in the control group (p < 0.05), and that during postpartum periods was 60.1 the patient group and 50.6 in the control group (p > 0.05). Conclusion: The annual incidence of Bell's palsy was not increased in pregnant women relative to that in the control. Address correspondence and reprint requests to Jiwon Chang, M.D., Ph.D., Department of Otolaryngology–Head & Neck Surgery, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, 948-1 Daerim 1-dong, Yeongdeungpo-gu, Zip: 150-950, Seoul, Republic of Korea; E-mail: brune77@naver.com This work was supported in part by a research grant (NRF-2015-R1D1A1A01060860, NRF- 2015R1C1A1A01054397) from the National Research Foundation of Korea. Financial Disclosures: None. The authors disclose no conflicts of interest. Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

Current Volumetric Models Overestimate Vestibular Schwannoma Size Following Stereotactic Radiosurgery Objective: Accurate volume assessment is essential for the management of vestibular schwannoma after stereotactic radiosurgery (SRS). A cuboidal approximation for volume is the standard surveillance method; however, this may overestimate tumor volume. We sought to evaluate several volumetric models and their suitability for post-SRS surveillance. Study Design: Retrospective cohort study. Setting: Tertiary referral center. Patients: We evaluated 54 patients with vestibular schwannoma before and after SRS. Intervention(s): Gold-standard volumes were obtained by a radiation oncologist using contouring software. Volume was also calculated by cuboidal, ellipsoidal, and spherical formulae using tumor diameters obtained by a neuroradiologist. Main Outcome Measure(s): Percent error (PE) and absolute percent error (APE) were calculated. Paired t test evaluated bias, and the Bland–Altman method evaluated reproducibility. Linear regression evaluated predictors of model error. Results: All models overestimated volume compared with the gold standard. The cuboidal model was not reproducible before SRS (p < 0.001), and no model was reproducible after SRS (cuboidal p < 0.001; ellipsoidal p = 0.02; spherical p = 0.02). Significant bias was present before SRS for the cuboidal model (p < 0.001), and post-SRS for all models [cuboidal (p < 0.001), ellipsoidal (p < 0.02), and spherical (p = 0.005)]. Model error was negatively associated with pretreatment volume for the cuboidal (PE p = 0.03; APE p = 0.03), ellipsoidal (PE p = 0.03; APE p = 0.04), and spherical (PE p = 0.02; APE p = 0.03) methods and lost linearity post-SRS. Conclusions: The standard cuboidal practice for following vestibular schwannoma tumor volume after SRS overestimates size. Ellipsoidal and spherical estimations have improved performance but also overestimate volume and lack reliability post-SRS. The development of other volumetric models or application of contouring software should be investigated. Address correspondence and reprint requests to Anthony J. Cmelak, M.D., Professor, Senior Medical Director of Radiation Oncology Satellites, Department of Radiation Oncology, Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, 2220 Pierce Avenue, Preston Research Building, Rm B-1003, Nashville, TN 37232-5671; E-mail: anthony.cmelak@vumc.org All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent was waived by the IRB due to minimal risk. Mohamed H. Khattab receives research funding from Varian Medical Systems and Brainlab. Alejandro Rivas is a consultant for Advanced Bionics, Med-El, Cochlear Corporation, Cook Medical, Grace Medical, and Stryker. Albert Attia receives funding from Brainlab, AstraZeneca, and Novocure. The remaining authors have no conflicts of interest to disclose. Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

Incidental Effect of Long-Term Tacrolimus Treatment on Sporadic Vestibular Schwannoma Volume Shrinkage and Clinical Improvement Objective: We describe the effect of long-term tacrolimus delivery on sporadic vestibular schwannoma (VS). Patient: A 48-year-old woman who was diagnosed a right VS. Intervention: Long-term tacrolimus delivery following liver transplant. Main Outcome Measures: Clinical examination, audiometric test, and gadolinium-contrasted magnetic resonance imaging. Results: During the reported follow-up period, the patient felt hearing improvement especially in noisy environment. This was consistent with a clear audiometric improvement. Over a 26 months follow-up period, we noticed a 50% volume regression and a 40% decrease in the intensity of enhancement of the tumor after gadolinium injection. Conclusion: Tacrolimus, an immunosuppressant used to prevent rejection in organ transplant, could lead to VS volume shrinkage and hearing improvement. Tacrolimus could be an interesting new therapeutic weapon, especially for VS in Neurofibromatosis type 2. Address correspondence and reprint requests to Marion Montava, M.D., Ph.D., Department of Otorhinolaryngology–Head and Neck Surgery, Conception Hospital, Aix-Marseille University, 147 Boulevard Baille, 13005 Marseille, France; E-mail: marion.montava@ap-hm.fr The authors do not have any conflicts of interest or financial disclosure to declare. Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

Functional Head Impulse Test With and Without Optokinetic Stimulation in Subjects With Persistent Postural Perceptual Dizziness (PPPD): Preliminary Report Objective: Persistent postural perceptual dizziness (PPPD) is a clinical condition characterized by unsteadiness present on most days for a period of at least 3 months. The aim of our work was to assess vestibular function, the role of anxiety, and possible interactions between visual and vestibular systems in patients with PPPD. Study Design: Cross-sectional prospective study. Setting: Tertiary referral center. Patients: Twenty-five PPPD patients. Interventions: Clinical history was collected before examination; vestibular function was assessed through bedside examination, video and functional head impulse test (video-HIT, f-HIT). The latter test was based on having the patient identify an optotype displayed on a computer screen during passive head rotations. The test was repeated while optokinetic stimulation (OKS) was given on the screen. Results were compared with those of 25 controls. State and trait anxiety levels were measured with the State-Trait Anxiety Inventory (STAI) questionnaire. Anxiety before and after vestibular examination was assessed using a VAS scale. Main Outcome Measure: Results of video and functional HIT with and without OKS. Results: Video-HIT and f-HIT showed normal values in all subjects. f-HIT with OKS provoked more reading errors in patients than in controls. The interaction of group per time detected different decreasing trends between the two groups (p = 0.0002). Patients presented a reduction in anxiety levels after examination. Nine patients fulfilled diagnostic criteria for vestibular migraine, eight of whom presented nystagmus either to positional tests or vibration test. Only anxiety levels before testing were predictive of worsening of f-HIT with optokinetic stimulation (p = 0.0007). Conclusions: Our data support the hypothesis that increased anxiety may play a role in visuo-vestibular interactions; moreover, they are not inconsistent with the hypothesis that OKS might provoke a “threatening effect,” leading to gaze bias during examination. Address correspondence and reprint requests to Roberto Teggi, M.D., San Raffaele Hospital, via Olgettina 60, 20132 Milan, Italy; E-mail: teggi.roberto@hsr.it The authors disclose no conflicts of interest. Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

Efficacy of Vestibular Rehabilitation Following Acute Vestibular Neuritis: A Randomized Controlled Trial Objective: To investigate whether a vestibular rehabilitation program started early after diagnosis of vestibular neuritis combined with standard care reduces dizziness and improves functions of daily life more effectively than standard care alone in patients with acute vestibular neuritis. Study Design: Non-blinded, randomized controlled trial with 2 parallel groups. Setting: Specialist centers in 2 university hospitals. Patients: Patients, 18–70 years, with acute vestibular neuritis confirmed by videonystagmography. Intervention: Standard care was 10 days of prednisolone, general information, and counseling given to all patients. In addition to standard care, the intervention group received supervised exercise therapy (vestibular rehabilitation). Vestibular rehabilitation was given in a group format, individually tailored, and supported by home exercises. Main Outcome Measure: Perceived dizziness during head motion. Secondary outcomes were walking speed, standing balance, Hospital Anxiety and Depression Scale (HADS), Vertigo Symptom Scale, Visual Analog Scales (VASs), Dizziness Handicap Inventory (DHI), The University of California Los Angeles Dizziness Questionnaire. Results: Sixty-five patients were included, 27 participated in the vestibular rehabilitation group. There was a statistically significant difference in favor of the vestibular rehabilitation group in overall perceived dizziness at 3 (p = 0.007) and 12 months (p = 0.001). No statistically significant differences were found in standing balance and walking speed. Results from self-report measures showed a statistically significant difference at 12 months in HADS (p = 0.039), DHI (p = 0.049) and VAS-C (p = 0.012). Conclusion: A vestibular rehabilitation program started early after confirmed vestibular neuritis diagnosis in addition to standard care reduces the perception of dizziness and improves functions of daily life more effectively than standard care alone. Address correspondence and reprint requests to Guri Tokle, Clinic of Clinical Service, St. Olavs Hospital/Trondheim University Hospital, Postboks 3250 Torgarden, N-7006 Trondheim, Norway; E-mail: Guri.Tokle@stolav.no Part of the work was funded by The Norwegian Fund for Postgraduate Training in Physiotherapy and Unimed Innovations AS. The authors disclose no conflicts of interest. Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

Usefulness of High Resolution T2-Weighted Images in the Evaluation and Surveillance of Vestibular Schwannomas? Is Gadolinium Needed? Objectives: First aim of study was to compare the diagnostic accuracy of high resolution T2-WI (HRT2-WI) and gadolinium-enhanced T1-weighted image (Gd T1-WI) sequences in quantitative evaluation of vestibular schwannomas (VS). The second one was to determine through qualitative evaluation when Gd-injection should be recommended. Methods: Two observers in consensus retrospectively reviewed 137 magnetic resonance imaging (MRI) scans of patients with histological diagnosis of VS (33 women, 26 men), 116 with both HRT2-WI and Gd T1-WI. The examinations were subdivided in: surveillance (10), pretreatment (30), posttreatment (43), and posttreatment follow-up (33) studies. Quantitative evaluation was based on size measurement of the lesion. Structural details of the lesion, facial nerve course, and involvement of the fundus of the internal auditory canal were assessed for the qualitative evaluation in both sequences. Results: No statistically significant changes were demonstrated between size measurement in the HRT2-WI and Gd T1-WI (p = 0.329). Sensitivity, specificity, and accuracy of HRT2-WI in the detection of lesional size were 90.4, 98.9, 92.5%, respectively. HRT2-WI was worse for characterization of structural details in pretreatment, posttreatment, and posttreatment follow-up examinations. HRT2-WI showed better or equal capability for all the groups in the demonstration of the facial nerve course. In the evaluation of the involvement of the fundus of the internal auditory canal, HRT2-WI showed worse results or had a complementary role for the posttreatment and posttreatment follow-up groups, while in the other groups was considered mainly equal or complementary. Only in the surveillance group, HRT2-WI was never worse for all the criteria. Conclusion: Results for quantitative evaluation were similar in both the sequences. Gadolinium injection can be avoided only in surveillance studies. Address correspondence and reprint requests to Francesco Fiorino, M.D., Otolaryngology, Department of Surgery, “Mater Salutis” Hospital, via Gianella 1, 37045 Legnago, Verona, Italy; E-mail: francesco.fiorino@aulss9.veneto.it The authors disclose no conflicts of interest. Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

Feasibility of Pediatric Robotic Cochlear Implantation in Phantoms Objective: To demonstrate the feasibility of robotic cochlear implant surgery in subject specific pediatric phantoms. Study Design: Pilot study. Materials and Methods: Computed tomographic preoperative encrypted data of 10 pediatric subjects (total of 20 sides) between 8 months and 48 months old, who underwent cochlear implant surgery were studied. Four datasets (n = 8 sides) were selected for investigation of the complete robotic procedure including middle and inner ear access and electrode insertion. Results: The planning of the safe trajectory for the robotic approach was possible in 17 of the cases. In three sides, planning the trajectory was not possible due to the small size of the facial recess. Bone thickness study demonstrated average sufficient bone thickness at the site of screw implantation in general. The complete robotic procure including the drilling and insertion was successfully carried out on all the created phantoms. Conclusion: With this work we have demonstrated the feasibility of planning and performing a robotic middle and inner ear access and cochlear implantation (CI) in phantom models of pediatric subjects. To develop and validate the proposed procedure for use in children, next stage optimization of the current surgical workflow and adaptation of the surgical material to pediatric population is necessary. Address correspondence and reprint requests to Gabriela O’Toole Bom Braga, M.D., Ph.D., University of Bern, Bern, Switzerland; E-mail: gabriela.braga@artorg.unibe.ch The authors disclose no conflicts of interest. Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

Effects of Age at Auditory Brainstem Implantation: Impact on Auditory Perception, Language Development, Speech Intelligibility Objective: To study the effect of age at auditory brainstem implant (ABI) surgery on auditory perception, language, and speech intelligibility. Study Design: Retrospective single cohort design. Setting: Tertiary referral center. Patients: In this study, 30 pediatric ABI users with no significant developmental issues were included. Participants were divided into two groups, according to age at surgery (Early Group: < 3 yr old [n = 15], Late Group: ≥ 3 yr old [n = 15]). Groups were matched by duration of ABI use and participants were evaluated after 5 years (±1 yr) experience with their device. The mean age at ABI surgery was 22.27 (ranged ± 6.5) months in the early group, 45.53 (ranged ± 7.9) months in the late group. Intervention(s): Retrosigmoid craniotomy and ABI placement. Main Outcome Measure(s): Auditory perception skills were evaluated using the Meaningful Auditory Integration Scale and Categories of Auditory Performance from the Children's Auditory Perception Test Battery. We used a closed-set pattern perception subtest, a closed-set word identification subtest, and an open-set sentence recognition subtest. Language performance was assessed with the Test of Early Language Development and Speech Intelligibility Rating, which was administered in a quiet room. Results: In this study, the results demonstrated that the Early Group's auditory perception performance was better than the Late Group after 5 years of ABI use, when children had no additional needs (U = 12, p < 0.001). Speech intelligibility was the most challenging skill to develop, in both groups. Due to multiple regression analysis, we found that auditory perception categories can be estimated with speech intelligibility scores, pattern perception scores, receptive language scores, and age at ABI surgery variables in ABI users with no additional handicaps. Conclusions: ABI is a viable option to provide auditory sensations for children with cochlear anomalies. ABI surgery under age 3 is associated with improved auditory perception and language development compared with older users. Address correspondence and reprint requests to Filiz Aslan, Ph.D., Department of Audiology, Faculty of Health Sciences, Hacettepe University, Ankara 16100, Turkey; E-mail: filizasl@gmail.com The authors disclose no conflicts of interest. Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company