Interactive live-stream surgery contributes to surgical education in the context of contact restrictions

BACKGROUND

Attendance teaching is the predominant teaching method at universities but needs to be questioned in the context of digital transformation. This study establishes and evaluates a method to accomplish electronic learning to supplement traditional attendance courses.

MATERIALS AND METHODS

Surgery was transmitted in real-time conditions via an online live stream from the surgical theater. Visualization was transferred from a fully digital surgical microscope, an endoscope or an environmental camera in high definition quality. Students were able to participate at home from their personal computer. After following the surgery, they participated in an online-evaluation.

RESULTS

A total of 65 students participated in the live stream. The majority of students (61.54%) indicated a significant subjective increase in knowledge after participation. The majority of students (53.85%) indicated that live surgeries should be offered as a permanent component in addition to classroom teaching. Likewise, a broader offer was desired by many students (63.08%).

CONCLUSIONS

Live streaming of surgery is a promising approach as an alternative or supplement to traditional attendance teaching. An expansion of digital teaching can be explicitly supported on the basis of this study.

Establishment and characterization of patient-derived head and neck cancer models from surgical specimens and endoscopic biopsies

Background

Head and neck squamous cell carcinoma (HNSCC) is heterogeneous in etiology, phenotype and biology. Patient-derived xenografts (PDX) maintain morphology and molecular profiling of the original tumors and have become a standard “Avatar” model for human cancer research. However, restricted availability of tumor samples hindered the widespread use of PDX. Most PDX-projects include only surgical specimens because reliable engraftment from biopsies is missing. Therefore, sample collection is limited and excludes recurrent and metastatic, non-resectable cancer from preclinical models as well as future personalized medicine.

Methods

This study compares the PDX-take rate, -growth, histopathology, and molecular characteristics of endoscopic specimens with surgical specimens. HNSCC samples (n = 55) were collected ad hoc, fresh frozen and implanted into NOD.Cg-Prkdc^scidIl2rg^tm1Wjl/SzJ mice.

Results

Engraftment was successful in both sample types. However, engraftment rate was lower (21 vs. 52%) and growth delayed (11.2 vs. 6.7 weeks) for endoscopic biopsies. Following engraftment, growth kinetic was similar. Comparisons of primary tumors and corresponding PDX models confirmed preservation of histomorphology (HE histology) and molecular profile (Illumina Cancer Hotspot Panel) of the patients’ tumors. Accompanying flow cytometry on primary tumor specimens revealed a heterogeneous tumor microenvironment among individual cases and identified M2-like macrophages as positive predictors for engraftment. Vice versa, a high PD-L1 expression (combined positive score on tumor/immune cells) predicted PDX rejection.

Conclusion

Including biopsy samples from locally advanced or metastatic lesions from patients with non-surgical treatment strategies, increases the availability of PDX for basic and translational research. This facilitates (pre-) clinical studies for individual response prediction based on immunological biomarkers.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13046-021-02047-w.

Long-Term, Multicenter Results With the First Transcutaneous Bone Conduction Implant

OBJECTIVE

Investigation of long-term safety and performance of an active, transcutaneous bone conduction implant in adults and children up to 36 months post-implantation.

STUDY DESIGN

Prospective, single-subject repeated-measures design.

SETTING

Otolaryngology departments of eight German and Austrian hospitals.∗†‡§||¶#∗∗†† Affiliations listed above that did not participate in the study.‡‡§§||||¶¶.

PATIENTS

Fifty seven German-speaking patients (49 adults and eight children) suffering from conductive or mixed hearing loss, with an upper bone conduction threshold limit of 45 dB HL at frequencies between 500 and 3000 Hz.

INTERVENTION

Implantation of the Bonebridge transcutaneous bone conduction hearing implant (tBCI).

MAIN OUTCOME MEASURES

Patients' audiometric pure tone averages (PTA4) (0.5, 1, 2, 4 kHz) thresholds (air conduction, bone conduction, and sound field) and speech perception (word recognition scores [WRS] and speech reception thresholds [SRT50%]) were tested preoperatively and up to 36 months postoperatively. Patients were also monitored for adverse events and administered quality-of-life questionnaires.

RESULTS

Speech perception (WRS: pre-op: 17.60%, initial activation [IA]: 74.23%, 3M: 83.65%, 12M: 83.46%, 24M: 84.23%, 36M: 84.42%; SRT50%: pre-op: 65.56 dB SPL, IA: 47.67 dB SPL, 3M: 42.61 dB SPL, 12M: 41.11 dB SPL, 24M: 41.74 dB SPL, 36M: 42.43 dB SPL) and sound field thresholds (pre-op: 57.66 dB HL, IA: 33.82 dB HL, 3M: 29.86 dB HL, 12M: 28.40 dB HL, 24M: 28.22 dB HL, 36M: 28.52 dB HL) improved significantly at all aided postoperative visits. Air and bone conduction thresholds showed no significant changes, confirming preservation of patients' residual unaided hearing. All adverse events were resolved by the end of the study.

CONCLUSIONS

Safety and performance of the tBCI was demonstrated in children and adults 36 months postoperatively.

[Mastoid cavity obliteration with allogenic and autologous material]

INTRODUCTION

Surgical obliteration is the treatment of choice for symptomatic mastoid cavities. Various methods and materials are available. Allogeneic material is easily available but can lead to wound infections due to rejection, granulation and inflammatory reactions. Consequently, autologous material is often preferred due to its good biocompatibility. The aim of this study was to compare the long-term outcomes of patients after mastoid cavity obliteration with allogeneic and autologous material with regard to the occurrence of recurrent cholesteatoma, the number of revision surgeries and the impact of surgery on the health-related quality of life.

METHODS

Patients who underwent mastoid cavity obliteration with an allogeneic material (hydroxyapatite matrix [HMM]) were retrospectively included in the study. In a prospective part, patients who underwent mastoid cavity obliteration with autologous reconstruction material (AutoM) were included. In addition to a detailed chart review, all patients underwent pure tone audiometry and completed the Zurich Chronic Middle Ear Inventory (ZCMEI-21) at the postoperative examination to assess health-related disease-specific quality of life.

RESULTS

A total of 22 patients with a mean age of 56.9 (SD 18.7 years) receiving HMM (mean follow-up interval: 88.3 months [SD 21.9 months]) and 25 patients with a mean age of 52.4 years (SD 13.7 years) receiving AutoM (mean follow-up interval: 13.5 months [SD 9.5 months]) were included in the study. The revision-free rate for audiological indication after one year was 100% for HMM and 85% for AutoM. The recurrence-free rate at one year was 95% for HMM and 100% for AutoM. 55% of the patients with alloplastic material and 8% of the patients with autologous material required revision surgery due to ear discharge or recurrent cholesteatoma. The groups did not differ in terms of postoperative hearing outcome or postoperative quality of life.

DISCUSSION

Obliteration of mastoid cavities is a surgical challenge. There was no relevant difference between the materials used in terms of recurrence rate, hearing and health-related quality of life within the 13.5-month observation period of both groups. The lack of subjective symptoms together with the high rate of recurrent cholesteatoma and revision indications emphasises the need for regular clinical follow-up including ear microscopy in chronic middle ear disease and strongly suggests regular follow-up examinations.

History of otorhinolaryngology in Germany before 1921

In 2021, the German Society of Otorhinolaryngology, Head and Neck Surgery is celebrating the 100th anniversary of its foundation. The aim of this article is to present the main inventions and progress made in Germany before 1921, the date the society was founded. Three chronological periods are discernible: the history of otorhinolaryngology (ORL) in Germany until the beginning of the 19th century, focusing mainly on the development of scattered knowledge; the birth of the sub-specialties otology, laryngology (pharyngo-laryngology and endoscopy), and rhinology in the 19th century, combining advances in knowledge and implementation of academic structures; and the creation of the ORL specialty at the turn of the 20th century, mainly concentrating on academic organization and expansion. This period was crucial and allowed for the foundation of the German Society of Otorhinolaryngology, Head and Neck Surgery on solid ground. Germany played an important role in the development and progress of ORL internationally in the 19th century with such great contributors as Anton von Tröltsch, Hermann Schwartze, Otto Körner, Rudolf Voltolini, and Gustav Killian to mention a few.

Two-phase survey on the frequency of use and safety of MRI for hearing implant recipients

PURPOSE

Magnetic resonance imaging (MRI) is often used to visualize and diagnose soft tissues. Hearing implant (HI) recipients are likely to require at least one MRI scan during their lifetime. However, the MRI scanner can interact with the implant magnet, resulting in complications for the HI recipient. This survey, which was conducted in two phases, aimed to evaluate the safety and performance of MRI scans for individuals with a HI manufactured by MED-EL (MED-EL GmbH, Innsbruck, Austria).

METHODS

A survey was developed and distributed in two phases to HEARRING clinics to obtain information about the use of MRI for recipients of MED-EL devices. Phase 1 focused on how often MRI is used in diagnostic imaging of the head region of the cochlear implant (CI) recipients. Phase 2 collected safety information about MRI scans performed on HI recipients.

RESULTS

106 of the 126 MRI scans reported in this survey were performed at a field strength of 1.5 T, on HI recipients who wore the SYNCHRONY CI or SYNCHRONY ABI. The head and spine were the most frequently imaged regions. 123 of the 126 scans were performed without any complications; two HI recipients experienced discomfort/pain. One recipient required reimplantation after an MRI was performed using a scanner that had not been approved for that implant. There was only one case that required surgical removal of the implant to reduce the imaging artefact.

CONCLUSION

Individuals with either a SYNCHRONY CI or SYNCHRONY ABI from MED-EL can safely undergo a 1.5 T MRI when it is performed according to the manufacturer's safety policies and procedures.

Mapping Cochlear Duct Length to Electrically Evoked Compound Action Potentials in Cochlear Implantation

OBJECTIVE

Objective measurements may assist in indicating cochlear implants and in predicting outcomes of cochlear implantation surgery. Using electrically evoked compound action potentials (ECAP), information about the function of the auditory nerve can be obtained by analyzing responses to electrical stimulation transmitted and derived by the recording electrode. The aim of this study was to determine whether ECAP characteristics differ depending on the stimulated intracochlear region and the size of the cochlea.

STUDY DESIGN

Retrospective cohort study.

SETTING

University Medical center, tertiary academic referral center.

PATIENTS

Patients undergoing cochlear implant surgery between 2015 and 2018.

INTERVENTION

Cochlear implantation with FLEXsoft electrode arrays (length 31.5 mm, 12 stimulating channels).

MAIN OUTCOME MEASURES

The cochlear duct length (CDL) and the cochlear coverage (CC) were measured using a new computed tomography-based software and correlated to the postoperative speech performance. Additionally, ECAP were measured and associated to the CDL.

RESULTS

A total of 59 ears of 53 cochlear implant users with a mean age of 63.6 (SD 14.9) years were included. The mean estimated CDL was 35.0 (SD 2.2) mm. The mean CC was 90.3% (SD 5.5%). A total of 4,873 ECAP were measured. A statistically significant, moderate, negative correlation between the ECAP slope and the site of stimulation was found (r = -0.29, 95% confidence interval: -0.32 to -0.27, p < 0.0001). No correlation between the CC and the speech performance was found (r = -0.08, 95% confidence interval: -0.33 to 0.18 p = 0.52).

CONCLUSION

ECAP slopes seem to be a reliable tool to identify the electrode's position inside the cochlea and also showed correlations to the anatomy of the patient. A combination of objective measurements such as anatomical parameters and ECAPs are helpful to assist the postoperative fitting and are promising tools to improve patient care.

[Laser Doppler vibrometric measurements on human temporal bones]

Laser Doppler vibrometric (LDV) measurements on human temporal bones represent the standard method for predicting the performance of active middle ear implants (AMEI) and are used as preclinical tests in the development, approval process, and indication expansion of AMEI. The quality of the coupling of the floating mass transducer to the mobile structures of the middle ear is decisive for the performance of the implant and patients' hearing perception. The cochlea can be stimulated via the oval window (forward stimulation) or the round window (reverse stimulation). For forward stimulation, the ASTM standard F2504-05 defines a method to ensure physiologically normal properties of the temporal bones used in the experiments. For reverse stimulation, which depends even more critically on the quality of the temporal bone, a comparable standard method is lacking. Appropriate preparation and storage of the human petrous bone as well as suitable LDV test setups with respect to calibration and reproducibility of measuring positions and angles provide results that allow a comparison of different types of coupling and also correlate well with clinical data.

[Effects of the SARS-CoV‑2 pandemic on the otolaryngology university hospitals in the field of research, student teaching and specialist training]

Hintergrund

Ab Frühjahr 2020 kam es zur weltweiten Verbreitung von SARS-CoV‑2 mit der heute als erste Welle der Pandemie bezeichneten Phase ab März 2020. Diese resultierte an vielen Kliniken in Umstrukturierungen und Ressourcenverschiebungen. Ziel unserer Arbeit war die Erfassung der Auswirkungen der Pandemie auf die universitäre Hals-Nasen-Ohren(HNO)-Heilkunde für die Forschung, Lehre und Weiterbildung.

Material und Methoden

Die Direktorinnen und Direktoren der 39 Universitäts-HNO-Kliniken in Deutschland wurden mithilfe einer strukturierten Online-Befragung zu den Auswirkungen der Pandemie im Zeitraum von März bis April 2020 auf die Forschung, Lehre und die Weiterbildung befragt.

Ergebnisse

Alle 39 Direktorinnen und Direktoren beteiligten sich an der Umfrage. Hiervon gaben 74,4 % (29/39) an, dass es zu einer Verschlechterung ihrer Forschungstätigkeit infolge der Pandemie gekommen sei. Von 61,5 % (24/39) wurde berichtet, dass pandemiebezogene Forschungsaspekte aufgegriffen wurden. Von allen Kliniken wurde eine Einschränkung der Präsenzlehre berichtet und 97,5 % (38/39) führten neue digitale Lehrformate ein. Im Beobachtungszeitraum sahen 74,4 % der Klinikdirektoren die Weiterbildung der Assistenten nicht gefährdet.

Schlussfolgerung

Die Ergebnisse geben einen Einblick in die heterogenen Auswirkungen der Pandemie. Die kurzfristige Bearbeitung pandemiebezogener Forschungsthemen und die Einführung innovativer digitaler Konzepte für die studentische Lehre belegt eindrücklich das große innovative Potenzial und die schnelle Reaktionsfähigkeit der HNO-Universitätskliniken, um auch während der Pandemie ihre Aufgaben in der Forschung, Lehre und Weiterbildung bestmöglich zu erfüllen.

HPV DNA/RNA detection in various oral and oropharyngeal biomaterials identifies active HPV infections also in non-neoplastic tonsils

Previous studies describe a correlation between HPV-positivity and non-smoking in TSCC; p16^INK4A-expression as surrogate-marker for HPV-DNA/RNA-positivity is discussed controversially. In the present study, these parameters are assessed prospectively. HPV-status of sputum and tonsillar-swabs was analyzed to determine their validity as surrogate-marker for tissue-HPV-status. TSCC- (n = 52) and non-neoplastic tonsillar tissue (n = 163) were analyzed. HPV-DNA- and HPV-RNA-status of total sputum, cellular fraction and supernatants, tonsillar-swabs and -tissue was determined by (RT)-PCR. Immunohistochemistry determined p16^INK4A-expression. 23/163 (14.2%) non-neoplastic tonsils were HPV-DNA-positive; five patients (3 HPV16, 2 HPV11) had active HPV-infections (HPV-RNA-positive), in all biomaterials. 140/163 (85.9%) patients were either HPV-DNA-positive or HPV-DNA-negative in all samples. 21/52 (40.4%) TSCC-tonsils were HPV-DNA-positive; 17 patients were HPV-RNA-positive (14 HPV16; 4 HPV18). 40/52 (76.9%) TSCC-patients were congruent in all biomaterials. p16^INK4A-expression alone would have misclassified the HPV-status of 14/52 (26.2%) TSCC-patients. This prospective study confirms the discrepancy between HPV-status and p16^INK4A-expression and the significant correlation between non-smoking and HPV-DNA-positivity. HPV-sputum- and/or swab-results do not consistently match tissue-results, possibly having (detrimental) consequences if those were used to assess tissue-HPV-status. In the 5 patients with active HPV infection in the non-neoplasitic tonsils, tonsillectomy likely prevented subsequent development of TSCC.

Characteristics of health-related quality of life in different types of chronic middle ear disease

PURPOSE

Different types of chronic middle ear disease (CMED) present with differing severity of single symptoms, such as discharge, vertigo or hearing loss, which impair health-related quality of life (HRQoL). Here, we aimed to (i) investigate characteristics of HRQoL and (ii) evaluate the association between HRQoL and hearing among different types of CMED.

METHODS

In this prospective longitudinal cohort study, we included adult patients undergoing surgical treatment for CMED. Primary outcomes included HRQoL assessed by the Zurich Chronic Middle Ear Inventory (ZCMEI-21) and hearing assessed by pure-tone audiometry.

RESULTS

In the included 108 patients (51% females), CMED were chronic otitis media (COM) with (n = 46) or without (n = 22) cholesteatoma, persistent mastoid cavity (with [n = 15] or without [n = 10] recurrent cholesteatoma), revision ossiculoplasty for hearing restoration (n = 14), and postinflammatory meatal fibrosis (n = 1). Preoperatively, the mean ZCMEI-21 score showed statistically significant differences among different types of CMED (p = 0.007) with persistent mastoid cavity without cholesteatoma exhibiting the highest score (34.1, SD 7.7) indicating poor HRQoL. At a mean follow-up period of 183 days, no statistically significant differences in the ZCMEI-21 scores among different types of CMED were observed (p = 0.67).

CONCLUSION

This study objectifies differences in HRQoL among different types of CMED. In patients with indication for functional surgery only, e.g., persistent mastoid cavity without cholesteatoma, the worst HRQoL was observed. Yet, in these types of CMED, HRQoL guides decision for treatment. Moreover, differences in HRQoL among different types of CMED were not closely associated with hearing, but largely depended on other symptoms, such as discharge or vertigo.

No association between HPV-status in tonsillar tissue and sexual behavior of the patients in a northern German population - Critical view of the link between HPV natural history and HPV-driven carcinogenesis

HPV-infection in patients with HNSCC is reportedly correlated with sexual behavior, age, and tobacco/alcohol-consumption. HPV-infections of the oral cavity are regarded as sexually transmitted. Comparable data of patient populations outside the U.S. are sparse or missing.

Questionnaires regarding sexual behavior, education tobacco- and alcohol-consumption, were given to 28 patients with tonsillar hyperplasia (H) and 128 patients with tonsillar carcinomas (CA), all with tissue-typed HPV-DNA-status performing PCR. Answers were correlated among groups and HPV-status.

106 questionnaires were analyzed. Comparisons between H- (n = 25) and CA- (n = 81) patients showed that CA-patients were older (61.1yrs ± 9.3) than H-patients (45.2yrs ± 11.9; p < 0.0001; Student's t-test); had a lower educational level (p = 0.0095); and lower number of sexual partners (p = 0.0222; Fisher's exact test). All groups showed a significant correlation between smoking and lack of HPV-DNA-positivity (p = 0.001). Further Fisher's exact tests and logistic regression analysis revealed in all 106 patients no significant correlations between tissue-HPV-status and the analyzed parameters.

Despite the limited sample size, we were able to confirm the established correlation between smoking and tissue-HPV-status. The correlation between sexual behavior and HPV-infection was not confirmed. No consensus exists in the literature about the latter. Our data does not support the strict classification of oral HPV-infections and HPV-driven HNSCCs as STDs.

•

Questionnaires from 81 TSCC and 25 tonsillar hyperplasia (H) patients were analyzed.

•

No correlation between HPV positivity and sexual behavior was found.

•

HPV positive H had both less sexual partners and oral sex than HPV negatives (trend).

•

In TSCC sexual partners and oral sex were similar irrespective of HPV status.

•

Incongruent data about sexual behavior, HPV transmission and cancer transgression.

Intraoperative quantification of floating mass transducer coupling quality in active middle ear implants: a multicenter study

Purpose

Evaluating the effectiveness of intraoperative auditory brainstem responses (ABRs) to stimulation by the Vibrant Soundbridge (VSB) active middle ear implant for quantifying the implant’s floating mass transducer (FMT) coupling quality.

Methods

In a diagnostic multicentric study, patients (> 18 years) who received a VSB with different coupling modalities were included. Pre- and postoperative bone conduction thresholds, intraoperative VSB-evoked ABR thresholds (VSB-ABR) using a modified audio processor programmed to preoperative bone conduction thresholds, postoperative vibrogram thresholds, and postoperative VSB-ABR thresholds were measured. Coupling quality was calculated from the difference between the pure tone average at 1000, 2000, and 4000 Hz (3PTA) vibrogram and postoperative 3PTA bone conduction thresholds.

Results

Twenty-three patients (13 males, 10 females, mean age 56.6 (± 12.5) years) were included in the study. Intraoperative VSB-ABR response thresholds could be obtained in all except one patient where the threshold was > 30 dB nHL. Postoperatively, an insufficient coupling of 36.7 dB was confirmed in this patient. In a Bland–Altman analysis of the intraoperative VSB-ABRs and coupling quality, the limits of agreement exceeded ± 10 dB, i.e., the maximum allowed difference considered as not clinically important but the variation was within the general precision of auditory brainstem responses to predict behavioral thresholds. Five outliers were identified. In two patients, the postoperative VSB-ABR thresholds were in agreement with the coupling quality, indicating a change of coupling before the postoperative testing.

Conclusion

The response thresholds recorded in this set-up have the potential to predict the VSB coupling quality and optimize postoperative audiological results.

Chronic otitis media following infection by non-O1/non-O139 Vibrio cholerae: A case report and review of the literature

We report a case of a chronic mesotympanic otitis media with a smelly purulent secretion from both ears and recurrent otalgia over the last five years in a six-year-old girl after swimming in the German Baltic Sea. Besides Staphylococcus aureus a non-O1/non-O139 Vibrio cholerae strain could be isolated from patient samples. An antibiotic therapy with ciprofloxacin and ceftriaxone was administered followed by atticotomy combined with tympanoplasty. We conclude that V. cholerae should not be overlooked as a differential diagnosis to otitis infections, especially when patients present with extra-intestinal infections after contact with brackish- or saltwater aquatic environments.

[Effects of the SARS-CoV-2 pandemic on the otorhinolaryngology university hospitals in the field of medical care]

INTRODUCTION

Since December 2019, the SARS-CoV-2 virus has been rapidly spreading worldwide. In Germany, an exponential increase in the number of infections was registered at the beginning of March 2020 and led to a call of the Ministry of Health to create more capacity for intensive medical treatment in hospitals. The aim of the present study was to determine the effects of the SARS-CoV-2 pandemic on Oto-Rhino-Laryngology (ORL) university hospitals regarding patient care.

MATERIALS AND METHODS

An online survey was sent out to all chairmen of the 39 ORL university hospitals in Germany. The answers to the questions referred to the defined period from March 15^th to April 15^th 2020 and were carried out using the online survey tool "SurveyMonkey". 87 questions focused on general information, health care, and structural effects in the respective institution.

RESULTS

All chairmen of the 39 university hospitals in Germany participated in the survey. The collected data prove the considerable impact on organizational, structural and medical aspects of patient care. For example, the surveyed clinics reported a decrease in outpatient cases by 73.8 % to 26.2 ± 14.2 % and in surgical treatments by 65.9 % to 34.1 ± 13.9 %. In contrast, emergency treatment remained unchanged or even increased in 80 % of the facilities and surgical treatment of emergency patients remained unchanged or even increased in more than 90 %. Emergency outpatient and surgical treatment of patients was provided throughout the pandemic in all facilities. In total, about 35 000 outpatients and about 12 000 surgical cases were postponed. As a result of the acute structural changes, the potential danger of falling below current treatment standards was seen in individual areas of patient care.

DISCUSSION

The assessment of the impact of the SARS-CoV-2 pandemic is heterogeneous. The majority of the chairmen are critically aware of the risk of falling below current medical treatment standards or guidelines. In the phase of an exponential increase in the number of infections, significant changes in treatment processes had to be accepted for understandable reasons. However, with the currently significantly reduced number of infections, falling below treatment standards and guidelines should not be allowed to remain constant and tolerated.

SUMMARY

This study shows a differentiated picture with regard to the effects of the SARS-CoV-2 pandemic on outpatient, inpatient and operative patient care at the ORL university hospitals in Germany and illustrates the importance of these institutions for ensuring patient care during this critical phase.

Automated detection of electrically evoked stapedius reflexes (eSR) during cochlear implantation

Introduction

In cochlear implantation, objective fitting methods are needed to optimize audiological results in small children or patients with poor compliance. Intraoperatively measured electrically evoked stapedius reflexes (eSR) can be used as a marker for the patient’s discomfort level. The aim of this study was to develop and evaluate an automated detection method for eSR and to compare it to the detection rate of the surgeon and independent observers.

Methods

Cochlear implantation using a fully digital surgical microscope was performed. Movements of the stapedius tendon were recorded and analyzed by means of computer vision technique. Differences in eSR elicited by stimulating electrodes at different cochlear locations (basal, middle and apical) were analyzed. The eSR detection rate of the image processing algorithm was compared to the surgeon’s detection rate and to those of two less experienced observers.

Results

A total of 387 electrically impulses were applied. The stimulation of middle turn electrodes showed significantly higher detection rates (50.4%) compared to the basal (40.0%; p = 0.001) and apical (43.6%; p = 0.03) turn. The software identified significantly more of the applied stimuli (58.4%) compared to the surgeon (46.3%; p = 0.0007), the intermediate observer (37.7%; p < 0.0001) and the unexperienced observer (41.3%; p < 0.0001).

Conclusion

The feasibility of an automated intraoperative software-based detection of eSR is demonstrated. By improving the eSR detection methods and their clinical applicability, their utility in objective cochlear implant fitting may be substantially increased.

Evaluating hearing outcome, recidivism and complications in cholesteatoma surgery using the ChOLE classification system

Purpose

To establish a standardized reporting system of cholesteatoma, the ChOLE classification has recently been introduced. We here aimed to systematically investigate the association between the ChOLE classification and (i) hearing, (ii) recidivism rate, and (iii) postoperative complications. These data may increase the utility of the ChOLE classification in clinical practice and research by stratifying patients according to expected outcomes or risks for complications.

Methods

In this prospective multicentric study, we included adult patients undergoing tympanomastoid surgery due to cholesteatoma. Main outcome measures included the association of the ChOLE classification system with (i) audiometric data including air conduction (AC) and bone conduction (BC) pure-tone average (PTA), and the air–bone gap (ABG), (ii) recidivism and complication.

Results

A total of 160 patients suffering from cholesteatoma were included. ChOLE stage distribution was stage I in 23 (14%), stage II in 128 (80%), and stage III in 9 (6%) patients. The ChOLE stage was associated with the postoperative AC PTA (p = 0.05) and the postoperative BC PTA (p = 0.02). Further, the status of the ossicular chain after surgery (ChOLE subdivision “O”) was associated with both the postoperative ABG (p = 0.0001) and the postoperative AC PTA (p = 0.003). Moreover, we found an association between complications (ChOLE subdivision “L) and both the postoperative BC PTA (p = 0.04) and the postoperative ABG (p = 0.04). No association between the ChOLE stage was found to both cholesteatoma recidivism and surgical complications.

Conclusion

The ChOLE classification is a new system to classify cholesteatomas. We provide evidence that hearing outcomes vary among different ChOLE stages. In particular, hearing outcomes are associated with the ChOLE subdivision “O” and “L”. Thus, the ChOLE classification system has a predictive value regarding hearing outcomes.

Evaluating the didactic value of 3D visualization in otosurgery

Introduction

Improvements of surgical visualization add value to the quality of clinical routine and offer the opportunity to improve surgical education of medical staff. The aim of this study was to determine whether otorhinolaryngology trainees gain additional comprehension of the anatomical structures and the surgical site when 3D visualization is used.

Methods

Data were collected from ENT trainees of microsurgical courses of the middle ear, inner ear and lateral skull base at four university ENT departments (Charité (Berlin), Martin Luther University Halle-Wittenberg (Halle/Saale), Ludwig Maximilian University (Munich) and Rostock University Medical Center). Participants were asked to complete a questionnaire assessing the subjective value of identical surgical field visualization in 3D for surgeon and observer.

Results

A total of 112 participants completed the questionnaire. The majority of participants stated a high additional value of 3D visualization compared to 2D visualization, with 75% fully agreeing to the statement that 3D visualization of the surgical field is superior to perceive the anatomical topography and structures compared to 2D representation. Participants encouraged the storage of data in online learning platforms.

Conclusion

The results show that 3D visualization with identical imaging for surgeon and observer is a useful tool in teaching of microsurgery. It addresses perception of anatomical topography and structures as well as conception of the surgical workflow.

Electronic supplementary material

The online version of this article (10.1007/s00405-020-06171-9) contains supplementary material, which is available to authorized users.

A retrospective European multicenter analysis of the functional outcomes after active middle ear implant surgery using the third generation vibroplasty couplers

Purpose

To evaluate the safety and performance of three novel vibroplasty couplers that allow attachment of the floating mass transducer of a transcutaneous active middle ear implant (AMEI) to the round window (RW) membrane, the long process (LP), or the incus body and the short process (SP) of the incus.

Methods

Retrospective multicenter cohort study of 25 AMEI users with sensorineural or mixed hearing loss that were among the first implanted with an AMEI vibrating ossicular prosthesis in combination with the third generation of vibroplasty couplers between 2014 and 2016. Main Outcome Measures were bone-conduction pure-tone and vibroplasty thresholds, postoperative aided sound field thresholds and postoperative aided word recognition score (WRS).

Results

Bone conduction threshold changes of more than 10 dB in 4PTA_BC were observed in two subjects. A mean improvement of 57.8% in speech recognition was observed with a mean WRS at 65 dB SPL improving from 14.8% (SD 21.9%) preoperatively to a mean aided score of 72.6% (SD 18.6%). Sound field thresholds improved from an average 4PTA_SF of 64.1 dB HL (SD 9.8 dB HL) to 37.0 dB HL (SD 8.9 dB HL), resulting in a mean functional gain of 27.1 dB. There was no significant difference in WRS or functional gain between the coupler types.

Conclusion

Initial experience shows that all three third generation vibroplasty couplers represent safe and efficient attachment options for the FMT allowing the surgeon to choose the coupling type based on the present pathology.

Mapping the ChOLE classification to hearing outcomes and disease-specific health-related quality of life

Objectives

To investigate the association between the “ChOLE” classification, hearing outcomes and disease-specific health-related quality of life (HRQoL).

Methods

In two tertiary referral centers, patients requiring primary or revision surgery for cholesteatoma were assessed for eligibility. Audiometric assessment was performed pre- and postoperatively. The ChOLE classification was determined intraoperatively and via the preoperative CT scan. HRQoL was assessed pre- and postoperatively using the Zurich Chronic Middle Ear Inventory (ZCMEI-21).

Results

A total of 87 patients (mean age 45.2 years, SD 16.2) were included in this study. ChOLE stage I cholesteatoma was found in 8 (9%), stage II cholesteatoma was found in 65 (75%), and stage III cholesteatoma was found in 14 (16%) patients. Postoperatively, the mean air–bone gap (0.5, 1, 2, 3 kHz) was significantly smaller than before surgery (14.3 dB vs. 23.0 dB; p = 0.0007). The mean ZCMEI-21 total score significantly decreased after surgery (26.8 vs. 20.7, p = 0.004). No correlation between the ZCMEI-21 total score and both the ChOLE stage and the extent of the cholesteatoma (ChOLE subdivision “Ch”) was found. A trend towards worse HRQoL associated with a poorer status of the ossicular chain (ChOLE subdivision “O”) was observed. The audiometric outcomes were not associated with the extent of the cholesteatoma. The ChOLE subdivision describing the ossicular status showed a strong association with the pre- and postoperative air conduction (AC) thresholds. Further, the ZCMEI-21 total score and its hearing subscore correlated with the AC thresholds.

Conclusion

The ChOLE classification does not show a clear association with HRQoL measured by the ZCMEI-21. The HRQoL neither seems to be associated with the extent of the disease nor with the ossicular chain status. Yet, surgical therapy significantly improved HRQoL by means of reduced ZCMEI-21 total scores, which were strongly associated with the AC thresholds. Intraoperative assessment of a cholesteatoma using the ChOLE classification and HRQoL complement each other and provide useful information.

Evaluating Common Cavity Cochlear Deformities Using CT Images and 3D Reconstruction

OBJECTIVES

The aim of this study is to compare the common cavity (CC) with the normal anatomy inner ear in order to evaluate whether the cavity is representing both the cochlear and the vestibular parts of the inner ear and to revisit CC deformity from a three-dimensional (3D) perspective.

METHODS

High-resolution computed tomography image datasets of 17 temporal bones initially identified as CC were evaluated with 3D reconstruction and multiplanar image analysis using a free available software for 3D segmentation of the inner ear. All 3D images of CC were compared to a normal inner ear. Maximum and minimum diameter of the CC were correlated with the circumference of the CC in an axial plane.

RESULTS

In 13 cases (76%), CC represented only the vestibular part of the inner ear and did not represent CC as defined here and by Sennaroglu, Kontorinis, and Khan. True CC was correctly diagnosed in only one case (6%). In three cases (18%), a rudimentary part of the cochlear portion could be identified. The axes' length of the elliptical cavity showed a strong positive linear relation to the circumference of the cavity (long axis: r = 0.94; P < .0001; short axis: r = 0.68; P = .0029).

CONCLUSION

This study supports the assumption that many reported CC cases only represent the vestibular part of the inner ear and are therefore cases of cochlear aplasia. 3D segmentation and systematic analysis of CT-imaging add clinical value to the comprehension of the morphology of the anatomical structures of the inner ear.

LEVEL OF EVIDENCE

2C Laryngoscope, 131:386-391, 2021.

Mastoid cavity obliteration leads to a clinically significant improvement in health-related quality of life

Objective

To assess the change in health-related quality of life (HRQoL) in patients undergoing mastoid cavity obliteration.

Methods

Patients who had undergone canal wall-down mastoidectomy for chronic otitis media with creation of a persistent mastoid cavity and underwent revision tympanomastoid surgery including mastoid cavity obliteration using autologous material were included. Audiological measurements including air conduction (AC) and bone conduction (BC) pure-tone averages (PTA) and the air–bone gap (ABG) were assessed. Health-related Quality of Life (HRQoL) was assessed by the Zurich Chronic Middle Ear Inventory (ZCMEI-21) pre- and postoperatively.

Results

A total of 25 patients (16 females and 9 males; mean age 51.6 years, 14 right and 11 left ears) were included. Patients were reexamined after a mean follow-up period of 9.2 months (SD = 6.5) after obliteration of the mastoid cavity. Compared to the preoperative visit, patients showed a significantly reduced AC PTA at the postoperative visit (mean difference: − 4.1; SD = 10.4, p = 0.045). The mean ZCMEI-21 score changed from 31.7 (SD = 14.5) preoperatively to 17.4 (SD = 15.1) postoperatively (mean difference: − 14.3; SD = 19.1; p = 0.0002). The mean ZCMEI-21 score changes were neither correlated to the AC PTA shift (p = 0.60) nor to the ABG shift (p = 0.66).

Conclusions

This is the first study reporting a highly significant and clinically important improvement in HRQoL after mastoid cavity obliteration in a prospective setting. The improvement in HRQoL was not correlated to the hearing improvement. As a clinical implication, we provide evidence for a substantial subjective benefit of the surgical obliteration of a symptomatic mastoid cavity and, therefore, encourage this surgical procedure.