Clinical Utility of the Standardized Word Recognition Score

OBJECTIVES

An unexpectedly low word recognition (WR) score may be taken as evidence of increased risk for retrocochlear tumor. We sought to develop evidence for or against using a standardized WR (sWR) score in detecting retrocochlear tumors. The sWR is a z score expressing the difference between an observed WR score and a Speech Intelligibility Index-based predicted WR score. We retrospectively compared the sensitivity and specificity of pure-tone asymmetry-based logistic regression models that incorporated either the sWR or the raw WR scores in detecting tumor cases. Two pure-tone asymmetry calculations were used: the 4-frequency pure-tone asymmetry (AAO) calculation of the American Academy of Otolaryngology-Head and Neck Surgery and a 6-frequency pure-tone asymmetry (6-FPTA) calculation previously optimized to detect retrocochlear tumors. We hypothesized that a regression model incorporating the 6-FPTA calculation and the sWR would more accurately detect retrocochlear tumors.

DESIGN

Retrospective data from all patients seen in the audiology clinic at Mayo Clinic in Florida in 2016 were reviewed. Cases with retrocochlear tumors were compared with a reference group with noise- or age-related hearing loss or idiopathic sensorineural hearing loss. Two pure-tone-based logistic regression models were created (6-FPTA and AAO). Into these base models, WR variables (WR, sWR, WR asymmetry [WRΔ], and sWR asymmetry [sWRΔ]) were added. Tumor detection performance for each regression model was compared twice: first, using all qualifying cases (61 tumor cases; 2332 reference group cases), and second, using a data set filtered to exclude hearing asymmetries greater than would be expected from noise-related or age-related hearing loss (25 tumor cases; 2208 reference group cases). The area under the curve and the DeLong test for significant receiver operating curve differences were used as outcome measures.

RESULTS

The 6-FPTA model significantly outperformed the AAO model-with or without the addition of WR or WRΔ variables. Including sWR into the AAO base regression model significantly improved disease detection performance. Including sWR into the 6-FPTA model significantly improved disease detection performance when large hearing asymmetries were excluded. In the data set that included large pure-tone asymmetries, area under the curve values for the 6-FPTA + sWR and AAO + sWR models were not significantly better than the base 6-FPTA model.

CONCLUSIONS

The results favor the superiority of the sWR computational method in identifying reduced WR scores in retrocochlear cases. The utility would be greatest where undetected tumor cases are embedded in a population heavily representing age- or noise-related hearing loss. The results also demonstrate the superiority of the 6-FPTA model in identifying tumor cases. The 2 computational methods may be combined (ie, the 6-FPTA + sWR model) into an automated tool for detecting retrocochlear disease in audiology and community otolaryngology clinics. The 4-frequency AAO-based regression model was the weakest detection method considered. Including raw WR scores into the model did not improve performance, whereas including sWR into the model did improve tumor detection performance. This further supports the contribution of the sWR computational method for recognizing low WR scores in retrocochlear disease cases.

New bone formation over dehiscent semicircular canal with cartilage cap

PURPOSE

Cartilage cap resurfacing is a method to seal a superior semicircular canal dehiscence. The purpose of this study was to evaluate the detection of new bone formation after surgical placement of a cartilage cap over a dehiscent semicircular canal.

METHODS

In this retrospective review, two neuroradiologists blinded to each other's interpretation reviewed the temporal bones of 20 patients, five of which had a pre-operative computed tomography (CT) exam which was interpreted as unilateral superior semicircular canal dehiscence and with new bone formation following repair on follow-up CT. There were also 15 control subjects. Each neuroradiologist was blinded to history, including post-operative changes, and asked to determine if there was a dehiscence or no dehiscence.

RESULTS

Out of the 15 controls, there was 100% inter-observer agreement. On the five post-operative patients, there was agreement in 4/5 that there was no dehiscence post-operatively and 1/5 agreement of dehiscence post-operatively, but ectopic bone adjacent to the dehiscence.

CONCLUSION

Our results indicate that new bone formation can be seen at the site of cartilage cap placement over the dehiscence and be interpreted as bony closure of the dehiscence.

Supralabyrinthine air cell is not present in superior semicircular canal dehiscence

Objectives:

Superior semicircular canal dehiscence (SSCD) is defined as a defect in the bone overly the superior semicircular canal (SSC). The purpose of this study is to evaluate the pre-operative imaging examinations of patients who have undergone SSCD repair. We hypothesize that these patients will not have a supralabyrinthine air cell on the side of surgery.

Material and Methods:

Our group retrospectively reviewed 50 consecutive pre-operative computed tomography (CT) temporal bone examinations who had confirmed SSCD on intraoperative examination and underwent repair for the presence of a supralabyrinthine air cell.

Results:

100% of patients who had confirmed SSCD on intraoperative examination had no supralabyrinthine air cell on pre-operative CT of the temporal bone.

Conclusion:

This study shows that a supralabyrinthine air cell is not present in SSCD. When a supralabyrinthine air cell is present, the roof of the SSC is intact. CT and magnetic resonance imaging (MRI) are often performed together to evaluate for SSCD and exclude other etiologies. We propose that if a supralabyrinthine air cell is seen on MRI, no CT is necessary, thus avoiding unnecessary radiation exposure and additional imaging costs to the patient.

Superior Semicircular Canal Dehiscence : Covering Defects in Understanding from Clinical to Radiologic Evaluation

Superior semicircular canal dehiscence alters the normal fluid mechanics of the vestibulocochlear system and can be a debilitating condition. This article reviews the current understanding of the bony labyrinthine defect, including symptoms, etiology, surgical approach, as well as preoperative and postoperative imaging pearls.

Takotsubo Cardiomyopathy and Canalith Repositioning Procedure for Benign Paroxysmal Positional Vertigo

Background: Takotsubo cardiomyopathy, also known as left ventricular apical ballooning syndrome, ampulla cardiomyopathy, or transient left ventricular dysfunction is characterized by chest pain, electrocardiographic changes, transient left ventricular apical aneurysm, and normal coronary arteries. Tako-tsubo is a round-bottomed, narrow-necked Japanese octopus trap and lends its name to takotsubo cardiomyopathy because of its resemblance to echocardiographic and ventricular angiographic images of the left ventricle in this condition. This appearance takes its source from peculiar, transient regional systolic dysfunction involving the left ventricular apex and mid-ventricle with hyperkinesis of the basal left ventricular segments. Benign paroxysmal positional vertigo (BPPV) is the most common cause of vertigo caused by peripheral vestibular dysfunction. The symptoms of BPPV are attributed to intralabyrinthine particles, presumed displaced otoconia. Thus, the treatment recommended for BPPV is head repositioning maneuvers.

Purpose: To present the first takotsubo cardiomyopathy case in the English literature related to BPPV undergoing canalith repositioning procedure.

Conclusion: This report will provide additional information for physicians encountering acute-onset chest pain and vertigo. It will also expand the spectrum of clinical correlates of the increasingly well recognized but poorly understood syndrome, takotsubo cardiomyopathy.

Facial Nerve Schwannomas: Review of 80 Cases Over 25 Years at Mayo Clinic

OBJECTIVE

To elucidate the long-term clinical behavior, treatment, and outcomes of sporadic facial nerve schwannoma (FNS) in a large cohort of patients managed in the post-magnetic resonance imaging era.

PATIENTS AND METHODS

Retrospective review at a single tertiary health care system (January 1, 1990, through December 31, 2015), evaluating 80 consecutive patients with sporadic FNS.

RESULTS

Ninety-eight patients with FNS were identified; 10 with incomplete data and 8 with neurofibromatosis type 2 were excluded. The remaining 80 patients (median age, 47 years; 58% women) were analyzed. Forty-three (54%) patients presented with asymmetrical hearing loss, 33 (41%) reported facial paresis, and 21 (26%) reported facial spasm. Seventeen (21%) exhibited radiologic features mimicking vestibular schwannoma, 14 (18%) presented as a parotid mass, and 5 (6%) were discovered incidentally. Factors predictive of facial nerve paresis or spasm before treatment were female sex and tumor involvement of the labyrinthine/geniculate and tympanic facial nerve segments. The median growth rate among growing FNS was 2.0 mm/y. Details regarding clinical outcome according to treatment modality are described.

CONCLUSION

In patients with FNS, female sex and involvement of the labyrinthine/geniculate and tympanic segments of the facial nerve predict a higher probability of facial paresis or spasm. When isolated to the posterior fossa or parotid gland, establishing a preoperative diagnosis of FNS is challenging. Treatment should be tailored according to tumor location and size, existing facial nerve function, patient priorities, and age. A management algorithm is presented, prioritizing long-term facial nerve function.

Identifying and Prioritizing Diseases Important for Detection in Adult Hearing Health Care

PURPOSE

The purpose of this research note is to identify and prioritize diseases important for detection in adult hearing health care delivery systems.

METHOD

Through literature review and expert consultation, the authors identified 195 diseases likely to occur in adults complaining of hearing loss. Five neurotologists rated the importance of disease on 3 dimensions related to the necessity of detection prior to adult hearing aid fitting.

RESULTS

Ratings of adverse health consequences, diagnostic difficulty, and presence of nonotologic symptoms associated with these diseases resulted in the identification of 104 diseases potentially important for detection prior to adult hearing aid fitting.

CONCLUSIONS

Current and evolving health care delivery systems, including direct-to-consumer sales, involve inconsistent means of disease detection vigilance prior to device fitting. The first steps in determining the safety of these different delivery methods are to identify and prioritize which diseases present the greatest risk for poor health outcomes and, thus, should be detected in hearing health care delivery systems. Here the authors have developed a novel multidimensional rating system to rank disease importance. The rankings can be used to evaluate the effectiveness of alternative detection methods and to inform public health policy. The authors are currently using this information to validate a consumer questionnaire designed to accurately identify when pre- fitting medical evaluations should be required for hearing aid patients.

Pure-tone hearing asymmetry: a logistic approach modeling age, sex, and noise exposure history

BACKGROUND

Asymmetric hearing loss (AHL) can be an early sign of vestibular schwannoma (VS). However, recognizing VS-induced AHL is challenging. There is no universally accepted definition of a "medically significant pure-tone hearing asymmetry," in part because AHL is a common feature of medically benign forms of hearing loss (e.g., age- or firearm-related hearing loss). In most cases, the determination that an observed AHL does not come from a benign cause involves subjective clinical judgment.

PURPOSE

Our purpose was threefold: (1) to quantify hearing asymmetry distributions in a large group of patients with medically benign forms of hearing loss, stratifying for age, sex, and noise exposure history; (2) to assess how previously proposed hearing asymmetry calculations segregate tumor from nontumor cases; and (3) to present the results of a logistic regression method for defining hearing asymmetry that incorporates age, sex, and noise information.

RESEARCH DESIGN

Retrospective chart review.

STUDY SAMPLE

Five thousand six hundred and sixty-one patients with idiopathic, age- or noise exposure-related hearing loss and 85 untreated VS patients.

DATA COLLECTION AND ANALYSIS

Audiometric, patient history, and clinical impression data were collected from 22,785 consecutive patient visits to the audiology section at Mayo Clinic in Florida from 2006 to 2009 to screen for eligibility. Those eligible were then stratified by VS presence, age, sex, and self-reported noise exposure history. Pure-tone asymmetry distributions were analyzed. Audiometric data from VS diagnoses were used to create four additional audiograms per patient to model the hypothetical development of AHL prior to the actual hearing test. The ability of 11 previously defined hearing asymmetry calculations to distinguish between VS and non-VS cases was described. A logistic regression model was developed that integrated age, sex, and noise exposure history with pure-tone asymmetry data. Regression model performance was then compared to existing asymmetry calculation methods.

RESULTS

The 11 existing pure-tone asymmetry calculations varied in tumor detection performance. Age, sex, and noise exposure history helped to predict benign forms of hearing asymmetry. The logistic regression model outperformed existing asymmetry calculations and better accounted for normal age-, sex-, and noise exposure-related asymmetry variability.

CONCLUSIONS

Our logistic regression asymmetry method improves the clinician's ability to estimate risk of VS, in part by integrating categorical patient history and numeric test data. This form of modeling can enhance clinical decision making in audiology and otology.

Selective embolization of glomus jugulare tumors

Four patients with grade C or D(1) glomus jugulare tumors who underwent preoperative highly selective embolization followed by infratemporal fossa removal of their tumors were compared to three patients undergoing surgery alone with respect to intraoperative blood loss, operative time, cranial nerve palsy, length of hospitalization, and perioperative complications. Embolized patients demonstrated a marked reduction in blood loss (650 vs 1375 cc) compared with the nonembolized group. Operative time was shortened (by 51 minutes). Facial nerve function did not appear related to embolization but was directly related to intraoperative nerve manipulation. Hospital stay, perioperative complications, and lower cranial nerve palsies were not related to embolization.

Bilateral multicanal benign paroxysmal positional vertigo coexisting with a vestibular schwannoma: case report

We describe a rarely encountered case of coexisting bilateral multicanal benign paroxysmal positional vertigo (BPPV) and vestibular schwannoma in a 56-year-old woman. The patient had presented with a 10-year history of dizziness and imbalance, and her vestibular findings were perplexing. We decided on a working diagnosis of BPPV and began treatment. After several months of canalith repositioning maneuvers had failed to resolve her symptoms, we obtained magnetic resonance imaging, which revealed the presence of the vestibular schwannoma. This case serves as a reminder of the importance of differentiating between central and peripheral vestibular disorders, as well as central and anterior canal BPPV-induced down-beating nystagmus in order to establish the correct diagnosis and initiate appropriate treatment.

Simultaneous acute superior nerve neurolabyrinthitis and benign paroxysmal positional vertigo

An acutely vertiginous 47-year-old woman presented to the emergency department with simultaneous acute left neurolabyrinthitis and left posterior canal benign paroxysmal positional vertigo (BPPV). Gaze nystagmus from the neurolabyrinthitis hampered diagnosis of the BPPV. However, once the BPPV was identified and treated, the patient's subjective vertigo improved rapidly. Concomitant BPPV should not be overlooked when a diagnosis of acute neurolabyrinthitis is made in the emergency department.

Pediatric and adult cochlear implantation

The frequency of cochlear implantation has increased tremendously over the past decade. Cochlear implantation is often performed as an outpatient procedure and is considered an acceptable treatment for severe to profound sensorineural hearing loss in patients who are refractory to conventional hearing augmentation. Imaging plays an important part in the work-up of cochlear implant candidates, and an understanding of imaging evaluation procedures is essential. The radiologist must be familiar with imaging findings that contraindicate implantation (absence of the cochlea or cochlear nerve) and with those that could significantly alter surgery (facial nerve dehiscence, cochlear ossification). It is also imperative to be familiar with the growing number of imaging options (particularly magnetic resonance [MR] imaging pulse sequences) to optimize evaluation of cochlear implant candidates. Imaging choices will be substantially influenced by the manufacturer of the computed tomographic scanner or MR imager. Radiologists will assume an expanding role in evaluating affected patients as the frequency of cochlear implantation continues to increase.

Tympanic membrane perforation in adults. How to manage, when to refer

Tympanic membrane perforation is a common and potentially serious condition. One of the most important aspects of primary care for perforations is deciding which patients need to be seen by an otolaryngologist and how urgently they need to be referred. There are several indications for surgical repair, but most cases can be managed with conservative care and require no referral.

Early post-laser stapedotomy hearing thresholds

OBJECTIVE

Auditory testing is not routinely performed within 4-6 weeks after stapedotomy, because hearing acuity is thought to be transiently depressed. In rare circumstances, postsurgical auditory and vestibular complaints may lead one to test hearing soon after stapedotomy. The early postoperative effects of carbon dioxide (CO2) and potassium titanyl phosphate (KTP) lasers, which now are routinely used to perform stapedotomies, have not been reported. The purpose of this report is to present normative data for auditory thresholds measured within 2 weeks of laser stapedotomy.

STUDY DESIGN

The study design was a prospective, unblinded study.

SETTING

The study was conducted at three academic medical centers.

PATIENTS

Thirty-six subjects undergoing 38 stapedotomies for otosclerosis by 5 surgeons participated.

MAIN OUTCOME MEASURES

Behavioral audiometry was performed using standard techniques beginning before surgery and continuing through > 1 year after surgery.

RESULTS

The CO2 laser was used in 26 stapedotomies and the KTP laser was used in 12. Nine cases were revision procedures. Bone conduction pure-tone averages and speech discrimination scores did not worsen during the early postoperative period. Bone conduction at 250 and 4,000 Hz dropped slightly within the first 2 weeks (-4.3 and -6.7 dB) but recovered thereafter. Bone conduction at 1,000 Hz actually improved within the first week after surgery (+6.2 dB, p = 0.021). Significant improvements in air conduction thresholds (and air-bone gap) were seen at the second week and late audiometry. The results for CO2 and KTP laser-treated groups were not significantly different.

CONCLUSIONS

Cochlear function is not significantly depressed in the early postoperative period after laser (CO2 or KTP) stapedotomy.

Mechanical versus CO2 laser occlusion of the posterior semicircular canal in humans

The purpose of this study was to compare the effectiveness of mechanical and laser-assisted posterior semicircular canal occlusion (PCO) for the treatment of intractable benign paroxysmal positional vertigo (BPPV). Twelve consecutive patients with intractable BPPV underwent PCO by three surgeons, six with mechanical PCO and six with CO2 laser-assisted PCO. PCO eliminated positional vertigo in all patients treated with the laser and five of six patients treated without the laser. Dysequilibrium was present in all patients immediately postoperatively. This resolved in all patients treated with the CO2 laser but in only two of six patients treated without the laser (p = 0.03). Patients were hospitalized for dysequilibrium for an average of 5.2 and 2.8 days for the mechanical and laser-assisted groups, respectively. Preoperative and postoperative hearing was not significantly different between the groups. No clinically significant postoperative hearing loss was encountered in either group. These results suggest that PCO is an effective treatment for intractable BPPV. The incidence of dysequilibrium that persists following PCO may be reduced by using the CO2 laser to seal the membranous canal prior to occluding the bony canal.

Temporal bone encephalocele and cerebrospinal fluid leaks

Nineteen cases of temporal bone brain herniation and cerebrospinal fluid (CSF) leaks in 17 adult patients since 1987 are reviewed. Of these 19 cases, 11 were spontaneous CSF leaks, 6 were related to chronic otitis media, and 2 were posttraumatic. Among the 10 women and 7 men, the average age was 51.2 years, with average follow-up time of 2 years, 7 months. Two cases were repaired by a middle fossa craniotomy approach, 1 case by a transmastoid approach, and 16 by a combined transmastoid and middle fossa approach. Ten cases utilized the preferred technique of fascia-bone-fascia to repair the defects. The diagnosis was made on clinical grounds in 18 of the 19 cases, with ancillary diagnostic test providing little useful information. There were no postoperative surgery-related complications, and definitive repair was accomplished in one stage in all cases.

Otosclerosis update

The use of lasers for primary and revision stapes surgery has many applications and potential advantages over mechanical techniques. It should be emphasized, however, that the laser is simply a tool, albeit a sophisticated one, and not a substitute for knowledge, experience, judgment, or ability. A laser will not "make" a good stapes surgeon, any more than a scalpel "makes" a good surgeon. There are limitations as well as benefits to lasers. Excellent results for stapes surgery were obtained for years prior to the advent of lasers, which is testimony to the skill and understanding of nonlaser stapes surgeons.

Facial Nerve Monitoring: Principles and Practical Applications

Educational objectives: To critically assess the strengths and weaknesses of available monitoring units and to directly apply the basic principles of facial nerve monitoring to surgical procedures.

Small Fenestra Laser Stapedotomy

Educational objectives: To understand the indications and techniques of laser stapedotomy and to discuss the pros and cons of different laser modalities.

Ototoxicity and ototopical medications: a survey of otolaryngologists

In an attempt to define the clinical parameters and relevance of ototopical medications, including their usefulness in permanent inner ear damage, a questionnaire survey was sent to 7463 otolaryngologists within the United States, of which 2235 responded. The four main categories were demographic data, patterns of practice, factors influencing use of ototopicals, and opinions/impressions of ototopicals under various circumstances. The vast majority of respondents use ototopical preparations in the presence of a draining perforation (84.1%), in the presence of drainage through a ventilation tube (93.7%), and in the presence of an open, draining tympanomastoid cavity (92.8%). A significant number of clinicians use ototopicals with intraoperative packing (75.3%) and postoperative prophylaxis against infection (57.9%). Eighty percent of respondents indicate that the risks for ototoxicity of otitis media is as great as, or greater than, the risks for ototoxicity of an ototopical preparation. Seventy-five percent of respondents stated that ototopicals are safe in a fresh postoperative ear. Some respondents (3.4%) reported that they had witnessed irreversible inner ear damage unquestionably related to ototopicals.

Facial nerve outcome in acoustic neuroma surgery

Patients consider facial paralysis the most concerning sequelae following acoustic tumor resection. Surgical and anesthetic refinements have lowered operative mortality to allow the surgeon to focus on preserving facial nerve function. Tumor size, microsurgical technique, and intraoperative monitoring are the most important factors that define the risk of postoperative facial paralysis. A protocol for uniform surgical reporting is proposed.

Condylar neck fractures of the mandible

Despite the effectiveness and many advantages of closed reduction of condylar neck fractures, open reduction techniques offer the advantage of anatomic repositioning of the fracture, which may reduce resultant deformities, malocclusion, and temporomandibular joint derangements in patients with complex subcondylar fractures. This objective is best achieved with rigid plate and screw fixation to obtain the stability required for immediate function. This article presents guidelines for the experienced surgeons who wish to address this controversial problem.