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Kosaraju N, Moore LS, Mulders JY, Blevins NH. Sporadic vestibular schwannoma in a pediatric population: a case series. Childs Nerv Syst 2024; 40:635-645. [PMID: 37889276 DOI: 10.1007/s00381-023-06184-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 10/10/2023] [Indexed: 10/28/2023]
Abstract
PURPOSE To describe the characteristics, management, and outcomes of pediatric patients with sporadic vestibular schwannoma (sVS). METHODS This was a case series at a tertiary care center. Patients were identified through a research repository and chart review. Interventions were microsurgery, stereotactic radiosurgery (SRS), and observation. Outcome measures were tumor control, facial nerve function, and hearing. RESULTS Eight patients over 2006-2022 fulfilled inclusion criteria (unilateral VS without genetic or clinical evidence of neurofibromatosis type 2 (NF2); age ≤ 21) with a mean age of 17 years (14-20). Average greatest tumor length in the internal auditory canal was 9.7 mm (4.0-16.1). Average greatest tumor dimension (4/8 tumors) in the cerebellopontine angle was 19.1 mm (11.3-26.8). Primary treatment was microsurgery in five (62.5%) patients, observation in two (25%), and SRS in one (12.5%). Four (80%) surgical patients had gross total resections, and one (20%) had regrowth post-near total resection and underwent SRS. One observed patient and the primary SRS patient have remained radiographically stable for 3.5 and 7 years, respectively. The other observed patient required surgery for tumor growth after 12 months of observation. Two surgical patients had poor facial nerve outcomes. All post-procedural patients developed anacusis. Mean follow-up was 3 years (0.5-7). CONCLUSIONS We describe one of the largest reported cohorts of pediatric sVS in the USA. Diligent exclusion of NF2 is critical. Given the high likelihood of eventually requiring intervention and known adverse effects of SRS, microsurgery remains the preferred treatment. However, observation can be considered in select situations.
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Affiliation(s)
- Nikitha Kosaraju
- Division of Otology/Neurotology, Department of Otolaryngology - Head & Neck Surgery, Stanford University School of Medicine, 801 Welch Rd, Palo Alto, Stanford, CA, 94305-5739, USA
- David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Lindsay S Moore
- Division of Otology/Neurotology, Department of Otolaryngology - Head & Neck Surgery, Stanford University School of Medicine, 801 Welch Rd, Palo Alto, Stanford, CA, 94305-5739, USA
| | - Jip Y Mulders
- Division of Otology/Neurotology, Department of Otolaryngology - Head & Neck Surgery, Stanford University School of Medicine, 801 Welch Rd, Palo Alto, Stanford, CA, 94305-5739, USA
- Leiden University Medical Center, Leiden, The Netherlands
| | - Nikolas H Blevins
- Division of Otology/Neurotology, Department of Otolaryngology - Head & Neck Surgery, Stanford University School of Medicine, 801 Welch Rd, Palo Alto, Stanford, CA, 94305-5739, USA.
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Liu GS, Cooperman SP, Neves CA, Blevins NH. Estimation of Cochlear Implant Insertion Depth Using 2D-3D Registration of Postoperative X-Ray and Preoperative CT Images. Otol Neurotol 2024; 45:e156-e161. [PMID: 38270174 DOI: 10.1097/mao.0000000000004100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2024]
Abstract
OBJECTIVE To improve estimation of cochlear implant (CI) insertion depth in postoperative skull x-rays using synthesized information from preoperative CT scans. STUDY DESIGN Retrospective cohort. SETTING Tertiary referral center. PATIENTS Ten adult cochlear implant recipients with preoperative and postoperative temporal bone computed tomography (CT)scans and postoperative skull x-ray imaging. INTERVENTIONS Postoperative x-rays and digitally reconstructed radiographs (DRR) from preoperative CTs were registered using 3D Slicer and MATLAB to enhance localization of the round window and modiolus. Angular insertion depth (AID) was estimated in unmodified and registration-enhanced x-rays and DRRs in the cochlear view. Linear insertion depth (LID) was estimated in registered images by two methods that localized the proximal CI electrode or segmented the cochlea. Ground truth assessments were made in postoperative CTs. MAIN OUTCOME MEASURES Errors of insertion depth estimates were calculated relative to ground truth measurements and compared with paired t t ests. Pearson correlation coefficient was used to assess inter-rater reliability of two reviewer's measurements of AID in unmodified x-rays. RESULTS In postoperative x-rays, AID estimation errors were similar with and without registration enhancement (-1.3 ± 20.7° and -4.8 ± 24.9°, respectively; mean ± SD; p = 0.6). AID estimation in unmodified x-rays demonstrated strong interrater agreement (ρ = 0.79, p < 0.05) and interrater differences (-15.0 ± 35.3°) comparable to estimate errors. Registering images allowed measurement of AID in the cochlear view with estimation errors of 14.6 ± 30.6° and measurement of LID, with estimate errors that were similar between proximal electrode localization and cochlear segmentation methods (-0.9 ± 2.2 mm and -2.1 ± 2.7 mm, respectively; p = 0.3). CONCLUSIONS 2D-3D image registration allows measurement of AID in the cochlear view and LID using postoperative x-rays and preoperative CT imaging. The use of this technique may reduce the need for postimplantation CT studies to assess these metrics of CI electrode position. Further work is needed to improve the accuracy of AID assessment in the postoperative x-ray view with registered images compared with established methods.
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Affiliation(s)
- George S Liu
- Stanford University, Department of Otolaryngology-Head and Neck Surgery, 801 Welch Road, Stanford, CA 94305
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Liu GS, Berry GJ, Soltys SG, Blevins NH. Glomangiopericytoma Presenting as a Middle Ear Mass. Laryngoscope 2024; 134:1426-1430. [PMID: 37615366 DOI: 10.1002/lary.30987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 08/06/2023] [Accepted: 08/09/2023] [Indexed: 08/25/2023]
Abstract
We describe an unusual case of glomangiopericytoma presenting as a mass filling the middle ear, enveloping the ossicles, and extending into the mastoid antrum without bony destruction. Management involved three surgeries and stereotactic radiosurgery, which achieved short-term local control with no evidence of disease on MRI imaging 12 months after radiation. Facial nerve function and hearing were preserved. This is the first report to our knowledge of a glomangiopericytoma presenting as a primary temporal bone lesion. Treatment with surgery and stereotactic radiosurgery for residual or recurrent disease is a reasonable approach to achieve local control and functional preservation. Laryngoscope, 134:1426-1430, 2024.
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Affiliation(s)
- George S Liu
- Department of Otolaryngology-Head and Neck Surgery, Stanford University, Stanford, California, U.S.A
| | - Gerald J Berry
- Department of Pathology, Stanford University, Stanford, California, U.S.A
| | - Scott G Soltys
- Department of Radiation Oncology, Stanford University, Stanford, California, U.S.A
| | - Nikolas H Blevins
- Department of Otolaryngology-Head and Neck Surgery, Stanford University, Stanford, California, U.S.A
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Fitzgerald MB, Ward KM, Gianakas SP, Smith ML, Blevins NH, Swanson AP. Speech-in-Noise Assessment in the Routine Audiologic Test Battery: Relationship to Perceived Auditory Disability. Ear Hear 2024:00003446-990000000-00258. [PMID: 38414136 DOI: 10.1097/aud.0000000000001472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/29/2024]
Abstract
OBJECTIVES Self-assessment of perceived communication difficulty has been used in clinical and research practices for decades. Such questionnaires routinely assess the perceived ability of an individual to understand speech, particularly in background noise. Despite the emphasis on perceived performance in noise, speech recognition in routine audiologic practice is measured by word recognition in quiet (WRQ). Moreover, surprisingly little data exist that compare speech understanding in noise (SIN) abilities to perceived communication difficulty. Here, we address these issues by examining audiometric thresholds, WRQ scores, QuickSIN signal to noise ratio (SNR) loss, and perceived auditory disability as measured by the five questions on the Speech Spatial Questionnaire-12 (SSQ12) devoted to speech understanding (SSQ12-Speech5). DESIGN We examined data from 1633 patients who underwent audiometric assessment at the Stanford Ear Institute. All individuals completed the SSQ12 questionnaire, pure-tone audiometry, and speech assessment consisting of ear-specific WRQ, and ear-specific QuickSIN. Only individuals with hearing threshold asymmetries ≤10 dB HL in their high-frequency pure-tone average (HFPTA) were included. Our primary objectives were to (1) examine the relationship between audiometric variables and the SSQ12-Speech5 scores, (2) determine the amount of variance in the SSQ12-Speech5 scores which could be predicted from audiometric variables, and (3) predict which patients were likely to report greater perceived auditory disability according to the SSQ12-Speech5. RESULTS Performance on the SSQ12-Speech5 indicated greater perceived auditory disability with more severe degrees of hearing loss and greater QuickSIN SNR loss. Degree of hearing loss and QuickSIN SNR loss were found to account for modest but significant variance in SSQ12-Speech5 scores after accounting for age. In contrast, WRQ scores did not significantly contribute to the predictive power of the model. Degree of hearing loss and QuickSIN SNR loss were also found to have moderate diagnostic accuracy for determining which patients were likely to report SSQ12-Speech5 scores indicating greater perceived auditory disability. CONCLUSIONS Taken together, these data indicate that audiometric factors including degree of hearing loss (i.e., HFPTA) and QuickSIN SNR loss are predictive of SSQ12-Speech5 scores, though notable variance remains unaccounted for after considering these factors. HFPTA and QuickSIN SNR loss-but not WRQ scores-accounted for a significant amount of variance in SSQ12-Speech5 scores and were largely effective at predicting which patients are likely to report greater perceived auditory disability on the SSQ12-Speech5. This provides further evidence for the notion that speech-in-noise measures have greater clinical utility than WRQ in most instances as they relate more closely to measures of perceived auditory disability.
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Affiliation(s)
- Matthew B Fitzgerald
- Department of Otolaryngology-Head and Neck Surgery, Stanford University, Palo Alto, California, USA
| | - Kristina M Ward
- Department of Otolaryngology-Head and Neck Surgery, Stanford University, Palo Alto, California, USA
| | - Steven P Gianakas
- Department of Otolaryngology-Head and Neck Surgery, Stanford University, Palo Alto, California, USA
- Department of Speech-Language-Hearing, Boys Town National Research Hospital, Omaha, Nebraska, USA
| | - Michael L Smith
- Department of Speech-Language-Hearing Sciences, University of Minnesota, Minneapolis, MN
| | - Nikolas H Blevins
- Department of Otolaryngology-Head and Neck Surgery, Stanford University, Palo Alto, California, USA
| | - Austin P Swanson
- Department of Otolaryngology-Head and Neck Surgery, Stanford University, Palo Alto, California, USA
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Lai C, Lui JT, de Lotbiniere-Bassett M, Chen JM, Lin VY, Agrawal SK, Blevins NH, Ladak HM, Pirouzmand F. Virtual Reality Simulation for the Middle Cranial Fossa Approach: A Validation Study. Oper Neurosurg (Hagerstown) 2024; 26:78-85. [PMID: 37747333 DOI: 10.1227/ons.0000000000000915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Accepted: 07/22/2023] [Indexed: 09/26/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Virtual reality (VR) surgical rehearsal is an educational tool that exists in a safe environment. Validation is necessary to establish the educational value of this platform. The middle cranial fossa (MCF) is ideal for simulation because trainees have limited exposure to this approach and it has considerable complication risk. Our objectives were to assess the face, content, and construct validities of an MCF VR simulation, as well as the change in performance across serial simulations. METHODS Using high-resolution volumetric data sets of human cadavers, the authors generated a high-fidelity visual and haptic rendering of the MCF approach using CardinalSim software. Trainees from Neurosurgery and Otolaryngology-Head and Neck Surgery at two Canadian academic centers performed MCF dissections on this VR platform. Randomization was used to assess the effect of enhanced VR interaction. Likert scales were used to assess the face and content validities. Performance metrics and pre- and postsimulation test scores were evaluated. Construct validity was evaluated by examining the effect of the training level on simulation performance. RESULTS Twenty trainees were enrolled. Face and content validities were achieved in all domains. Construct validity, however, was not demonstrated. Postsimulation test scores were significantly higher than presimulation test scores ( P < .001 ). Trainees demonstrated statistically significant improvement in the time to complete dissections ( P < .001 ), internal auditory canal skeletonization ( P < .001 ), completeness of the anterior petrosectomy ( P < .001 ), and reduced number of injuries to critical structures ( P = .001 ). CONCLUSION This MCF VR simulation created using CardinalSim demonstrated face and content validities. Construct validity was not established because no trainee included in the study had previous MCF approach experience, which further emphasizes the importance of simulation. When used as a formative educational adjunct in both Neurosurgery and Otolaryngology-Head and Neck Surgery, this simulation has the potential to enhance understanding of the complex anatomic relationships of critical neurovascular structures.
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Affiliation(s)
- Carolyn Lai
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto , Ontario , Canada
| | - Justin T Lui
- Section of Otolaryngology-Head & Neck Surgery, Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary , Alberta, Canada
| | - Madeleine de Lotbiniere-Bassett
- Section of Neurosurgery, Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary , Alberta, Canada
| | - Joseph M Chen
- Department of Otolaryngology-Head & Neck Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto , Ontario , Canada
| | - Vincent Y Lin
- Department of Otolaryngology-Head & Neck Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto , Ontario , Canada
| | - Sumit K Agrawal
- Department of Otolaryngology-Head & Neck Surgery, London Health Sciences Centre-University Hospital, Western University, London , Ontario , Canada
| | - Nikolas H Blevins
- Department of Otolaryngology-Head & Neck Surgery, Stanford University, Palo Alto , California , USA
| | - Hanif M Ladak
- Department of Medical Biophysics, Western University, London , Ontario , Canada
- Department of Electrical & Computer Engineering, Western University, London , Ontario , Canada
| | - Farhad Pirouzmand
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto , Ontario , Canada
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Jason Qian Z, Vaisbuch Y, Gianakas SP, Tran ED, Ali NES, Blevins NH, Fitzgerald MB. Evaluation of Asymmetries in Speech-in Noise Abilities in Audiologic Screening for Vestibular Schwannoma. Ear Hear 2023; 44:1540-1547. [PMID: 37707393 PMCID: PMC10583925 DOI: 10.1097/aud.0000000000001397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 05/23/2023] [Indexed: 09/15/2023]
Abstract
OBJECTIVES Measures of speech-in-noise, such as the QuickSIN, are increasingly common tests of speech perception in audiologic practice. However, the effect of vestibular schwannoma (VS) on speech-in-noise abilities is unclear. Here, we compare the predictive ability of interaural QuickSIN asymmetry for detecting VS against other measures of audiologic asymmetry. METHODS A retrospective review of patients in our institution who received QuickSIN testing in addition to a regular audiologic battery between September 2015 and February 2019 was conducted. Records for patients with radiographically confirmed, unilateral, pretreatment VSs were identified. The remaining records excluding conductive pathologies were used as controls. The predictive abilities of various measures of audiologic asymmetry to detect VS were statistically compared. RESULTS Our search yielded 73 unique VS patients and 2423 controls. Receiver operating characteristic curve analysis showed that QuickSIN asymmetry was more sensitive and specific than pure-tone average asymmetry and word-recognition-in-quiet asymmetry for detecting VS. Multiple logistic regression analysis revealed that QuickSIN asymmetry was more predictive of VS (odds ratio [OR] = 1.23, 95% confidence interval [CI] [1.10, 1.38], p < 0.001) than pure-tone average asymmetry (OR = 1.04, 95% CI [1.00, 1.07], p = 0.025) and word-recognition-in-quiet asymmetry (OR = 1.03, 95% CI [0.99, 1.06], p = 0.064). CONCLUSION Between-ear asymmetries in the QuickSIN appear to be more efficient than traditional measures of audiologic asymmetry for identifying patients with VS. These results suggest that speech-in noise testing could be integrated into clinical practice without hindering the ability to identify retrocochlear pathology.
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Affiliation(s)
- Z. Jason Qian
- Department of Otolaryngology-Head and Neck Surgery, Stanford University, Palo Alto, California, USA
| | - Yona Vaisbuch
- Department of Otolaryngology-Head and Neck Surgery, Stanford University, Palo Alto, California, USA
- Department of Otolaryngology-Head and Neck Surgery, Rambam Medical Center, Haifa, Israel
| | - Steven P. Gianakas
- Department of Otolaryngology-Head and Neck Surgery, Stanford University, Palo Alto, California, USA
- Department of Speech-Language-Hearing Science, University of Minnesota, Minneapolis, Minnesota, USA
| | - Emma D. Tran
- Department of Otolaryngology-Head and Neck Surgery, Stanford University, Palo Alto, California, USA
- Department of Otolaryngology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Noor-E-Seher Ali
- Department of Otolaryngology-Head and Neck Surgery, Stanford University, Palo Alto, California, USA
- Department of Otolaryngology, Southern Illinois University, Springfield, Illinois, USA
| | - Nikolas H. Blevins
- Department of Otolaryngology-Head and Neck Surgery, Stanford University, Palo Alto, California, USA
| | - Matthew B. Fitzgerald
- Department of Otolaryngology-Head and Neck Surgery, Stanford University, Palo Alto, California, USA
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El Chemaly T, Athayde Neves C, Leuze C, Hargreaves B, H Blevins N. Stereoscopic calibration for augmented reality visualization in microscopic surgery. Int J Comput Assist Radiol Surg 2023; 18:2033-2041. [PMID: 37450175 DOI: 10.1007/s11548-023-02980-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Accepted: 05/26/2023] [Indexed: 07/18/2023]
Abstract
PURPOSE Middle and inner ear procedures target hearing loss, infections, and tumors of the temporal bone and lateral skull base. Despite the advances in surgical techniques, these procedures remain challenging due to limited haptic and visual feedback. Augmented reality (AR) may improve operative safety by allowing the 3D visualization of anatomical structures from preoperative computed tomography (CT) scans on real intraoperative microscope video feed. The purpose of this work was to develop a real-time CT-augmented stereo microscope system using camera calibration and electromagnetic (EM) tracking. METHODS A 3D printed and electromagnetically tracked calibration board was used to compute the intrinsic and extrinsic parameters of the surgical stereo microscope. These parameters were used to establish a transformation between the EM tracker coordinate system and the stereo microscope image space such that any tracked 3D point can be projected onto the left and right images of the microscope video stream. This allowed the augmentation of the microscope feed of a 3D printed temporal bone with its corresponding CT-derived virtual model. Finally, the calibration board was also used for evaluating the accuracy of the calibration. RESULTS We evaluated the accuracy of the system by calculating the registration error (RE) in 2D and 3D in a microsurgical laboratory setting. Our calibration workflow achieved a RE of 0.11 ± 0.06 mm in 2D and 0.98 ± 0.13 mm in 3D. In addition, we overlaid a 3D CT model on the microscope feed of a 3D resin printed model of a segmented temporal bone. The system exhibited small latency and good registration accuracy. CONCLUSION We present the calibration of an electromagnetically tracked surgical stereo microscope for augmented reality visualization. The calibration method achieved accuracy within a range suitable for otologic procedures. The AR process introduces enhanced visualization of the surgical field while allowing depth perception.
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Affiliation(s)
- Trishia El Chemaly
- Department of Bioengineering, Stanford University, Stanford, CA, USA.
- Department of Otolaryngology, Stanford School of Medicine, Stanford, CA, USA.
- Department of Radiology, Stanford School of Medicine, Stanford, CA, USA.
| | - Caio Athayde Neves
- Department of Otolaryngology, Stanford School of Medicine, Stanford, CA, USA
- Faculty of Medicine, University of Brasília, Brasília, Brazil
| | - Christoph Leuze
- Department of Radiology, Stanford School of Medicine, Stanford, CA, USA
- Wu Tsai Neurosciences Institute, Stanford University, Stanford, CA, USA
| | - Brian Hargreaves
- Department of Bioengineering, Stanford University, Stanford, CA, USA
- Department of Radiology, Stanford School of Medicine, Stanford, CA, USA
- Department of Electrical Engineering, Stanford University, Stanford, CA, USA
| | - Nikolas H Blevins
- Department of Otolaryngology, Stanford School of Medicine, Stanford, CA, USA
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Neves CA, Liu GS, El Chemaly T, Bernstein IA, Fu F, Blevins NH. Automated Radiomic Analysis of Vestibular Schwannomas and Inner Ears Using Contrast-Enhanced T1-Weighted and T2-Weighted Magnetic Resonance Imaging Sequences and Artificial Intelligence. Otol Neurotol 2023; 44:e602-e609. [PMID: 37464458 DOI: 10.1097/mao.0000000000003959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
OBJECTIVE To objectively evaluate vestibular schwannomas (VSs) and their spatial relationships with the ipsilateral inner ear (IE) in magnetic resonance imaging (MRI) using deep learning. STUDY DESIGN Cross-sectional study. PATIENTS A total of 490 adults with VS, high-resolution MRI scans, and no previous neurotologic surgery. INTERVENTIONS MRI studies of VS patients were split into training (390 patients) and test (100 patients) sets. A three-dimensional convolutional neural network model was trained to segment VS and IE structures using contrast-enhanced T1-weighted and T2-weighted sequences, respectively. Manual segmentations were used as ground truths. Model performance was evaluated on the test set and on an external set of 100 VS patients from a public data set (Vestibular-Schwannoma-SEG). MAIN OUTCOME MEASURES Dice score, relative volume error, average symmetric surface distance, 95th-percentile Hausdorff distance, and centroid locations. RESULTS Dice scores for VS and IE volume segmentations were 0.91 and 0.90, respectively. On the public data set, the model segmented VS tumors with a Dice score of 0.89 ± 0.06 (mean ± standard deviation), relative volume error of 9.8 ± 9.6%, average symmetric surface distance of 0.31 ± 0.22 mm, and 95th-percentile Hausdorff distance of 1.26 ± 0.76 mm. Predicted VS segmentations overlapped with ground truth segmentations in all test subjects. Mean errors of predicted VS volume, VS centroid location, and IE centroid location were 0.05 cm 3 , 0.52 mm, and 0.85 mm, respectively. CONCLUSIONS A deep learning system can segment VS and IE structures in high-resolution MRI scans with excellent accuracy. This technology offers promise to improve the clinical workflow for assessing VS radiomics and enhance the management of VS patients.
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Affiliation(s)
| | - George S Liu
- Department of Otolaryngology-Head and Neck Surgery, Stanford University
| | | | - Isaac A Bernstein
- Department of Otolaryngology-Head and Neck Surgery, Stanford University
| | - Fanrui Fu
- Department of Otolaryngology-Head and Neck Surgery, Stanford University
| | - Nikolas H Blevins
- Department of Otolaryngology-Head and Neck Surgery, Stanford University
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Liu GS, Shenson JA, Farrell JE, Blevins NH. Signal to noise ratio quantifies the contribution of spectral channels to classification of human head and neck tissues ex vivo using deep learning and multispectral imaging. J Biomed Opt 2023; 28:016004. [PMID: 36726664 PMCID: PMC9884103 DOI: 10.1117/1.jbo.28.1.016004] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 01/06/2023] [Indexed: 05/09/2023]
Abstract
SIGNIFICANCE Accurate identification of tissues is critical for performing safe surgery. Combining multispectral imaging (MSI) with deep learning is a promising approach to increasing tissue discrimination and classification. Evaluating the contributions of spectral channels to tissue discrimination is important for improving MSI systems. AIM Develop a metric to quantify the contributions of individual spectral channels to tissue classification in MSI. APPROACH MSI was integrated into a digital operating microscope with three sensors and seven illuminants. Two convolutional neural network (CNN) models were trained to classify 11 head and neck tissue types using white light (RGB) or MSI images. The signal to noise ratio (SNR) of spectral channels was compared with the impact of channels on tissue classification performance as determined using CNN visualization methods. RESULTS Overall tissue classification accuracy was higher with use of MSI images compared with RGB images, both for classification of all 11 tissue types and binary classification of nerve and parotid ( p < 0.001 ). Removing spectral channels with SNR > 20 reduced tissue classification accuracy. CONCLUSIONS The spectral channel SNR is a useful metric for both understanding CNN tissue classification and quantifying the contributions of different spectral channels in an MSI system.
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Affiliation(s)
- George S. Liu
- Stanford University, Department of Otolaryngology — Head and Neck Surgery, Palo Alto, California, United States
| | - Jared A. Shenson
- Stanford University, Department of Otolaryngology — Head and Neck Surgery, Palo Alto, California, United States
| | - Joyce E. Farrell
- Stanford University, Department of Electrical Engineering, Stanford, California, United States
| | - Nikolas H. Blevins
- Stanford University, Department of Otolaryngology — Head and Neck Surgery, Palo Alto, California, United States
- Address all correspondence to Nikolas H. Blevins,
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Lai C, Lui JT, Chen JM, Lin VY, Agrawal SK, Blevins NH, Ladak HM, Pirouzmand F. High-Fidelity Virtual Reality Simulation for the Middle Cranial Fossa Approach—Modules for Surgical Rehearsal and Education. Oper Neurosurg (Hagerstown) 2022; 23:505-513. [DOI: 10.1227/ons.0000000000000387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 06/12/2022] [Indexed: 11/16/2022] Open
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Goff L, St. Croix R, Jing JW, Ferri D, Sivanathan M, Harris C, Pelletier F, Bénard F, Sédillot-Daniel È, Fleiszer D, Bhandari A, White A, Shah A, Zhang Y, Akbari P, Fugaru I, Aggarwal I, Zhang Y, Gold MS, Belliveau S, Lai C, Daud A, Hamdan NA, Carr L, Fazlollahi AM, Retrosi G, Del Fernandes R, Roberts S, Botelho F, Micallef J, Rathagirishnan R, Stachura N, Grewal K, Yilmaz R, Mahmood S, Tee T, Qiu R, Hindi MN, AlTinawi B, Qiu R, Tanya SM, Greene H, Munn A, Furey A, Smith N, Moffatt-Bruce S, Lefebvre G, Harvey EJ, Reindl R, Al Badi H, Berry GK, Martineau PA, Koucheki R, Lex JR, Morozova A, Hauer TM, Mirzaie S, Ferguson PC, Ballyk B, Micallef J, Franco LY, Drennan IR, Button D, Dubrowski A, Thorburn C, Skanes C, Kennedy R, Smith C, Torres A, Meloche-Dumas L, Guérard-Poirier N, Kaviani A, Kapralos B, Mercier F, Dubrowski A, Patocskai E, Habti M, Meloche-Dumas L, Bérubé S, Cadoret D, Arutiunian A, Papas Y, Torres A, Kapralos B, Mercier F, Dubrowski A, Patocskai E, Melkane A, Chiesa C, Fakhry N, Young V, Smith L, Lechien J, Guertin L, Olivier MJ, Maniakas A, Jun Lin R, Bissada É, Christopoulos A, Ayad T, Leclerc AA, Posel N, Rosenzveig A, Gariscsak P, Kemp L, Haji F, Reid A, Sidhu S, Moon M, Turner S, Zheng B, Wolfstadt JI, Hall J, Ward S, Jad A, Yee N, Ross TD, Ferguson P, Zheng B, Valiquette C, Brathwaite S, Hawley G, Martou G, Hendry M, Schouela V, Aubé-Peterkin M, Kemp L, Winthrop A, Zheng B, Belliveau S, Gold M, Lui JT, de Lotbiniere-Bassett M, Chen JM, Lin VY, Agrawal SK, Blevins NH, Ladak HM, Pirouzmand F, Hauer T, Wolfstadt J, Ferguson P, Almansouri A, Yilmaz R, Eskandari M, Tee T, Agu C, Pachchigar P, Giglio B, Balasubramniam N, Gueziri HE, Del Maestro R, McKechnie T, Hatamnejad A, Chan J, Beattie A, Yilmaz R, Alsayegh A, Bakhaidar M, Del Maestro RF, Dharamsi N, de Vries I, Mann S, McEwen L, Phillips T, Zevin B, Robart A, Brennan H, Conway J, Patey C, Harley J, Poenaru D, Sivanathan M, Clarke K, Habti M, Roy MÈ, Bedwani S, Patocskai É, Dubrowski A, Valiquette C, Zhu J, Adibfar A, Snell L, Nayak R, Malthaner R, Fortin D, Inculet R, Qiabi M, Azher S, Moreno M, Melo LP, Pekrun R, Wiseman J, Fried GM, Lajoie S, Brydges R, Hadwin A, Sun NZ, Khalil E, Harley JM, Bakhaidar M, Alsayegh A, Hamdan NA, Fazlollahi AM, Agu C, Pachchigar P, Del Maestro R, Almas S, Ryan J, Anderson B, Pachchigar P, Tarabay B, Yilmaz R, Del Maestro R, Lan L, Mao R, Kay J, Darren de SA, Blair G, Noorani A, Noorani S, Mak M, Ibrahim G, Hodaie M, van Kampen K, Domerchie E, Farrugia P, Joly-Chevrier M, Nguyen AXL, Pur DR, Power RJ, Sharma S, Costello F, Kherani F. C-CASE 2022: Competence to Excellence01. The Queen Bee phenomenon in Canadian surgical subspecialties: an evaluation of gender biases in the resident training environment02. Barriers to surgical peer coaching — What have we learned, and where do we go from here?03. Shared decision-making and evidence-based medicine: Pivotal or trivial to patient care in orthopedic trauma?04. Immersive virtual reality and cadaveric bone are equally effective in skeletal anatomy education: a randomized crossover noninferiority trial05. Development of simulators for decentralized simulation-based education IO training using design thinking and Delphi — a novel approach06. The impact of feedback on laparoscopic skills for surgical residents during COVID-1907. The role of collaborative feedback and remote practice in the acquisition of suturing skills by medical students at Université de Montréal08. Efficacy testing of an affordable and realistic small bowel simulator for hand-sewn anastomosis09. The LASER rating scale: a new teaching tool in otolaryngology10. Virtual patient case simulations: their role in undergraduate and postgraduate surgical training11. Evaluating the effectiveness of video-assisted informed consent in surgery: a systematic review12. Communication patterns in the cardiac surgery operating room are affected by task difficulty: a simulation model13. Improving adherence to postcall departure guidelines in orthopedics: a quality-improvement initiative14. Increasing familiarity among team members helps to reduce laparoscopic procedure time15. The effectiveness of a self-directed online learning module on trainee knowledge and confidence during plastic surgery clinical rotations16. Implementing an orientation handbook before a surgical rotation in urology17. An examination of equity-related experiences of surgical trainees at academic centres across Ontario: design of a targeted needs assessment18. Viewing differences between experts and trainees: implication for surgical education19. Assessment of medical student exposure to and satisfaction with surgical subspecialty education20. Assessment of student exposure to climate impacts of surgical personal protective equipment in the undergraduate medical curriculum21. Virtual reality simulation for the middle cranial fossa approach — a face, content and construct validation study22. Evaluating the Canadian Orthopaedic Surgery Medical Education Course (COSMEC)23. Subpial resection in a novel ex vivo calf brain epilepsy simulation model24. Effectiveness of the Eyesi augmented reality simulator for ophthalmology trainees: a systematic review and meta-analysis25. Learning beyond the objectives: an evidence-based analysis of AI-selected competencies in surgical simulation training26. Virtual compared with in-person surgical grand rounds: participants’ perceptions, preferences and directions for the future27. Quality of narrative feedback for entrustable professional activities assessed in the operating room: analysis of 4. years of assessments in the surgical foundations curriculum at Queen’s University28. SimOscopy: an accessible 3D-printed and laser-cut laparoscopic surgical simulator developed for a mobile device29. A debriefing tool to acquire nontechnical skills in trauma courses30. Capacity building using a hub-and-spokes model to produce customizable simulators for surgical education31. Exploring skin tone diversity in a plastic surgery resident education curriculum32. Video-based assessments of thoracic surgery trainees’ operative skills as adjuncts in competency-based medical education33. How do you feel? An examination of team leaders’ and members’ emotions in surgical simulations34. Comparing the efficacy of a real-time intelligent coaching system to human expert instruction in surgical technical skills training: randomized controlled trial35. Empowering women to pursue surgery: launching a pilot gender-congruent mentorship program for medical students36. Affective and cognitive responses to a virtual reality spine simulator37. Immersive virtual reality for patient-specific preoperative planning: a systematic review38. The categorization of surgical problems by junior and senior medical students39. The application of microlearning modules in surgical education to enhance procedural skills and surgical training40. Authorship gender disparity and trends in female authorship in 5 high-impact orthopedic journals from 2002 to 202241. The landscape of Canadian academic surgery: analysis of gender representation, academic rank, and research productivity. Can J Surg 2022. [DOI: 10.1503/cjs.014622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Thai A, Tran E, Swanson A, Fitzgerald MB, Blevins NH, Ma Y, Smith ML, Larky JB, Alyono JC. Outcomes in Patients Meeting Cochlear Implant Criteria in Noise but Not in Quiet. Otol Neurotol 2022; 43:56-63. [PMID: 34889839 DOI: 10.1097/mao.0000000000003351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Evaluate outcomes in cochlear implant (CI) recipients qualifying in AzBio noise but not quiet, and identify factors associated with postimplantation improvement. STUDY DESIGN Retrospective cohort study. SETTING Tertiary otology/neurotology clinic. PATIENTS This study included 212 implanted ears. The noise group comprised 23 ears with preoperative AzBio more than or equal to 40% in quiet and less than or equal to 40% in +10 signal-to-noise ratio (SNR). The quiet group included 189 ears with preoperative AzBio less than 40% in quiet. The two groups displayed similar demographics and device characteristics. INTERVENTIONS Cochlear implantation. MAIN OUTCOME MEASURES AzBio in quiet and noise. RESULTS Mean AzBio quiet scores improved in both the quiet group (pre-implant: 12.7%, postimplant: 67.2%, p < 0.001) and noise group (pre-implant: 61.6%, postimplant: 73.8%, p = 0.04). Mean AzBio +10 SNR also improved in the quiet group (pre-implant: 15.8%, postimplant: 59.3%, p = 0.001) and noise group (pre-implant: 30.5%, postimplant: 49.1%, p = 0.01). However, compared with the quiet group, fewer ears in the noise group achieved within-subject improvement in AzBio quiet (≥15% improvement; quiet group: 90.3%, noise group: 43.8%, p < 0.001) and AzBio +10 SNR (quiet group: 100.0%, noise group: 45.5%, p < 0.001). Baseline AzBio quiet (p < 0.001) and Consonant-Nucleus-Consonant (CNC) scores (p = 0.004) were associated with within-subject improvement in AzBio quiet and displayed a higher area under the curve than either aided or unaided pure-tone average (PTA) (both p = 0.01). CONCLUSIONS CI patients qualifying in noise display significant mean benefit in speech recognition scores but are less likely to benefit compared with those qualifying in quiet. Patients with lower baseline AzBio quiet scores are more likely to display postimplant improvement.
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Affiliation(s)
- Anthony Thai
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
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Cooperman SP, Aaron KA, Fouad A, Tran E, Blevins NH, Fitzgerald MB. Influence of electrode to cochlear duct length ratio on post-operative speech understanding outcomes. Cochlear Implants Int 2021; 23:59-69. [PMID: 34590531 DOI: 10.1080/14670100.2021.1979289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To assess whether the pre-operative electrode to cochlear duct length ratio (ECDLR), is associated with post-operative speech recognition outcomes. STUDY DESIGN A retrospective chart review study. SETTING Tertiary referral center. PATIENTS The study included sixty-one adult CI recipients with a pre-operative computed tomography scan and a speech recognition test 12 months after implantation. INTERVENTIONS The average of two raters' cochlear duct length (CDL) measurements and the length of the recipient's cochlear implant electrode array formed the basis for the electrode-to-cochlear duct length ratio (ECLDR). Speech recognition tests were compared as a function of ECDLR and electrode array length itself. MAIN OUTCOME MEASURES The relationship between ECDLR and percent correct on speech recognition tests. RESULTS A second order polynomial regression relating ECDLR to percent correct on the CNC words speech recognition test was statistically significant, as was a fourth order polynomial regression for the AzBio Quiet test. In contrast, there was no statistically significant relationship between speech recognition scores and electrode array length. CONCLUSIONS ECDLR values can be statistically associated to speech-recognition outcomes. However, these ECDLR values cannot be predicted by the electrode length alone, and must include a measure of CDL.
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Affiliation(s)
- Shayna P Cooperman
- Department of Otolaryngology-Head & Neck Surgery, Stanford University, Stanford, CA, USA
| | - Ksenia A Aaron
- Department of Otolaryngology-Head & Neck Surgery, Stanford University, Stanford, CA, USA
| | - Ayman Fouad
- Department of Otolaryngology-Head & Neck Surgery, Stanford University, Stanford, CA, USA.,Otolaryngology Department, Tanta University, Tanta, Egypt
| | - Emma Tran
- Department of Otolaryngology-Head & Neck Surgery, Stanford University, Stanford, CA, USA
| | - Nikolas H Blevins
- Department of Otolaryngology-Head & Neck Surgery, Stanford University, Stanford, CA, USA
| | - Matthew B Fitzgerald
- Department of Otolaryngology-Head & Neck Surgery, Stanford University, Stanford, CA, USA
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Neves CA, Tran ED, Cooperman SP, Blevins NH. Fully Automated Measurement of Cochlear Duct Length From Clinical Temporal Bone Computed Tomography. Laryngoscope 2021; 132:449-458. [PMID: 34536238 DOI: 10.1002/lary.29869] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 08/24/2021] [Accepted: 08/31/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVES/HYPOTHESIS To present and validate a novel fully automated method to measure cochlear dimensions, including cochlear duct length (CDL). STUDY DESIGN Cross-sectional study. METHODS The computational method combined 1) a deep learning (DL) algorithm to segment the cochlea and otic capsule and 2) geometric analysis to measure anti-modiolar distances from the round window to the apex. The algorithm was trained using 165 manually segmented clinical computed tomography (CT). A Testing group of 159 CTs were then measured for cochlear diameter and width (A- and B-values) and CDL using the automated system and compared against manual measurements. The results were also compared with existing approaches and historical data. In addition, pre- and post-implantation scans from 27 cochlear implant recipients were studied to compare predicted versus actual array insertion depth. RESULTS Measurements were successfully obtained in 98.1% of scans. The mean CDL to 900° was 35.52 mm (SD, 2.06; range, [30.91-40.50]), the mean A-value was 8.88 mm (0.47; [7.67-10.49]), and mean B-value was 6.38 mm (0.42; [5.16-7.38]). The R2 fit of the automated to manual measurements was 0.87 for A-value, 0.70 for B-value, and 0.71 for CDL. For anti-modiolar arrays, the distance between the imaged and predicted array tip location was 0.57 mm (1.25; [0.13-5.28]). CONCLUSION Our method provides a fully automated means of cochlear analysis from clinical CTs. The distribution of CDL, dimensions, and cochlear quadrant lengths is similar to those from historical data. This approach requires no radiographic experience and is free from user-related variation. LEVEL OF EVIDENCE 3 Laryngoscope, 2021.
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Affiliation(s)
- Caio A Neves
- Faculty of Medicine, University of Brasilia, Brasilia, Brazil
| | - Emma D Tran
- Department of Otolaryngology-Head & Neck Surgery, Stanford University School of Medicine, Stanford, California, U.S.A
| | - Shayna P Cooperman
- Department of Otolaryngology-Head & Neck Surgery, Stanford University School of Medicine, Stanford, California, U.S.A
| | - Nikolas H Blevins
- Department of Otolaryngology-Head & Neck Surgery, Stanford University School of Medicine, Stanford, California, U.S.A
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Neves CA, Tran ED, Blevins NH, Hwang PH. Deep learning automated segmentation of middle skull-base structures for enhanced navigation. Int Forum Allergy Rhinol 2021; 11:1694-1697. [PMID: 34185969 DOI: 10.1002/alr.22856] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 05/26/2021] [Accepted: 06/03/2021] [Indexed: 12/24/2022]
Affiliation(s)
- Caio A Neves
- Faculty of Medicine, University of Brasilia, Brasília, Brazil
| | - Emma D Tran
- Department of Otolaryngology-Head & Neck Surgery, Stanford University School of Medicine, Stanford, California, USA
| | - Nikolas H Blevins
- Department of Otolaryngology-Head & Neck Surgery, Stanford University School of Medicine, Stanford, California, USA
| | - Peter H Hwang
- Department of Otolaryngology-Head & Neck Surgery, Stanford University School of Medicine, Stanford, California, USA
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Cooperman SP, Aaron KA, Fouad A, Tran E, Blevins NH, Fitzgerald MB. Assessment of Inter- and Intra-Rater Reliability of Tablet-Based Software to Measure Cochlear Duct Length. Otol Neurotol 2021; 42:558-565. [PMID: 33492059 DOI: 10.1097/mao.0000000000003015] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The objective of this study is to build upon previous work validating a tablet-based software to measure cochlear duct length (CDL). Here, we do so by greatly expanding the number of cochleae (n = 166) analyzed, and examined whether computed tomography (CT) slice thickness influences reliability of CDL measurements. STUDY DESIGN Retrospective chart review study. SETTING Tertiary referral center. PATIENTS Eighty-three adult cochlear implant recipients were included in the study. Both cochleae were measured for each patient (n = 166). INTERVENTIONS Three raters analyzed the scans of 166 cochleae at 2 different time points. Each rater individually identified anatomical landmarks that delineated the basal turn diameter and width. These coordinates were applied to the elliptic approximation method (ECA) to estimate CDL. The effect of CT scan slice thickness on the measurements was explored. MAIN OUTCOME MEASURES The primary outcome measure is the strength of the inter- and intra-rater reliability. RESULTS The mean CDL measured was 32.84 ± 2.03 mm, with a range of 29.03 to 38.07 mm. We observed no significant relationship between slice thickness and CDL measurement (F1,164 = 3.04; p = 0.08). The mean absolute difference in CDL estimations between raters was 1.76 ± 1.24 mm and within raters was 0.263 ± 0.200 mm. The intra-class correlation coefficient (ICC) between raters was 0.54 and ranged from 0.63 to 0.83 within raters. CONCLUSIONS This software produces reliable measurements of CDL between and within raters, regardless of CT scan thickness.
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Affiliation(s)
- Shayna P Cooperman
- Department of Otolaryngology-Head and Neck Surgery, Stanford University, Stanford, California, USA
| | - Ksenia A Aaron
- Department of Otolaryngology-Head and Neck Surgery, Stanford University, Stanford, California, USA
| | - Ayman Fouad
- Department of Otolaryngology-Head and Neck Surgery, Stanford University, Stanford, California, USA
- Otolaryngology Department, Tanta University, Tanta, Egypt
| | - Emma Tran
- Department of Otolaryngology-Head and Neck Surgery, Stanford University, Stanford, California, USA
| | - Nikolas H Blevins
- Department of Otolaryngology-Head and Neck Surgery, Stanford University, Stanford, California, USA
| | - Matthew B Fitzgerald
- Department of Otolaryngology-Head and Neck Surgery, Stanford University, Stanford, California, USA
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Losorelli S, Kaneshiro B, Musacchia GA, Blevins NH, Fitzgerald MB. Factors influencing classification of frequency following responses to speech and music stimuli. Hear Res 2020; 398:108101. [PMID: 33142106 DOI: 10.1016/j.heares.2020.108101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 09/25/2020] [Accepted: 10/19/2020] [Indexed: 01/08/2023]
Abstract
Successful mapping of meaningful labels to sound input requires accurate representation of that sound's acoustic variances in time and spectrum. For some individuals, such as children or those with hearing loss, having an objective measure of the integrity of this representation could be useful. Classification is a promising machine learning approach which can be used to objectively predict a stimulus label from the brain response. This approach has been previously used with auditory evoked potentials (AEP) such as the frequency following response (FFR), but a number of key issues remain unresolved before classification can be translated into clinical practice. Specifically, past efforts at FFR classification have used data from a given subject for both training and testing the classifier. It is also unclear which components of the FFR elicit optimal classification accuracy. To address these issues, we recorded FFRs from 13 adults with normal hearing in response to speech and music stimuli. We compared labeling accuracy of two cross-validation classification approaches using FFR data: (1) a more traditional method combining subject data in both the training and testing set, and (2) a "leave-one-out" approach, in which subject data is classified based on a model built exclusively from the data of other individuals. We also examined classification accuracy on decomposed and time-segmented FFRs. Our results indicate that the accuracy of leave-one-subject-out cross validation approaches that obtained in the more conventional cross-validation classifications while allowing a subject's results to be analysed with respect to normative data pooled from a separate population. In addition, we demonstrate that classification accuracy is highest when the entire FFR is used to train the classifier. Taken together, these efforts contribute key steps toward translation of classification-based machine learning approaches into clinical practice.
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Affiliation(s)
- Steven Losorelli
- Department of Otolaryngology Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, CA, USA.
| | - Blair Kaneshiro
- Department of Otolaryngology Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, CA, USA.
| | - Gabriella A Musacchia
- Department of Otolaryngology Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, CA, USA; Department of Audiology, University of the Pacific, San Francisco, CA, USA.
| | - Nikolas H Blevins
- Department of Otolaryngology Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, CA, USA.
| | - Matthew B Fitzgerald
- Department of Otolaryngology Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, CA, USA.
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Shenson JA, Liu GS, Farrell J, Blevins NH. Multispectral Imaging for Automated Tissue Identification of Normal Human Surgical Specimens. Otolaryngol Head Neck Surg 2020; 164:328-335. [PMID: 32838646 DOI: 10.1177/0194599820941013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Safe surgery requires the accurate discrimination of tissue intraoperatively. We assess the feasibility of using multispectral imaging and deep learning to enhance surgical vision by automated identification of normal human head and neck tissues. STUDY DESIGN Construction and feasibility testing of novel multispectral imaging system for surgery. SETTING Academic university hospital. SUBJECTS AND METHODS Multispectral images of fresh-preserved human cadaveric tissues were captured with our adapted digital operating microscope. Eleven tissue types were sampled, each sequentially exposed to 6 lighting conditions. Two convolutional neural network machine learning models were developed to classify tissues based on multispectral and white-light color images (ARRInet-M and ARRInet-W, respectively). Blinded otolaryngology residents were asked to identify tissue specimens from white-light color images, and their performance was compared with that of the ARRInet models. RESULTS A novel multispectral imaging system was developed with minimal adaptation to an existing digital operating microscope. With 81.8% accuracy in tissue identification of full-size images, the multispectral ARRInet-M classifier outperformed the white-light-only ARRInet-W model (45.5%) and surgical residents (69.7%). Challenges with discrimination occurred with parotid vs fat and blood vessels vs nerve. CONCLUSIONS A deep learning model using multispectral imaging outperformed a similar model and surgical residents using traditional white-light imaging at the task of classifying normal human head and neck tissue ex vivo. These results suggest that multispectral imaging can enhance surgical vision and augment surgeons' ability to identify tissues during a procedure.
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Affiliation(s)
- Jared A Shenson
- Department of Otolaryngology-Head and Neck Surgery, Stanford University, Stanford, California, USA
| | - George S Liu
- Department of Otolaryngology-Head and Neck Surgery, Stanford University, Stanford, California, USA
| | - Joyce Farrell
- Department of Electrical Engineering, Stanford University, Stanford, California, USA
| | - Nikolas H Blevins
- Department of Otolaryngology-Head and Neck Surgery, Stanford University, Stanford, California, USA
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Tran ED, Swanson A, Sharon JD, Vaisbuch Y, Blevins NH, Fitzgerald MB, Steenerson KK. Ocular Vestibular-Evoked Myogenic Potential Amplitudes Elicited at 4 kHz Optimize Detection of Superior Semicircular Canal Dehiscence. Front Neurol 2020; 11:879. [PMID: 32982915 PMCID: PMC7477389 DOI: 10.3389/fneur.2020.00879] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 07/09/2020] [Indexed: 02/04/2023] Open
Abstract
Introduction: High-resolution temporal bone computed tomography (CT) is considered the gold standard for diagnosing superior semicircular canal dehiscence (SCD). However, CT has been shown over-detect SCD and provide results that may not align with patient-reported symptoms. Ocular vestibular-evoked myogenic potentials (oVEMPs)—most commonly conducted at 500 Hz stimulation—are increasingly used to support the diagnosis and management of SCD. Previous research reported that stimulation at higher frequencies such as 4 kHz can have near-perfect sensitivity and specificity in detecting radiographic SCD. With a larger cohort, we seek to understand the sensitivity and specificity of 4 kHz oVEMPs for detecting clinically significant SCD, as well as subgroups of radiographic, symptomatic, and surgical SCD. We also investigate whether assessing the 4 kHz oVEMP n10-p15 amplitude rather than the binary n10 response alone would optimize the detection of SCD. Methods: We conducted a cross-sectional study of patients who have undergone oVEMP testing at 4 kHz. Using the diagnostic criteria proposed by Ward et al., patients were determined to have SCD if dehiscence was confirmed on temporal bone CT by two reviewers, patient-reported characteristic symptoms, and if they had at least one positive vestibular or audiometric test suggestive of SCD. Receiver operating characteristic (ROC) analysis was conducted to identify the optimal 4 kHz oVEMP amplitude cut-off. Comparison of 4 kHz oVEMP amplitude across radiographic, symptomatic, and surgical SCD subgroups was conducted using the Mann-Whitney U test. Results: Nine hundred two patients (n, ears = 1,804) underwent 4 kHz oVEMP testing. After evaluating 150 temporal bone CTs, we identified 49 patients (n, ears = 61) who had radiographic SCD. Of those, 33 patients (n, ears = 37) were determined to have clinically significant SCD. For this study cohort, 4 kHz oVEMP responses had a sensitivity of 86.5% and a specificity of 87.8%. ROC analysis demonstrated that accounting for the inter-amplitude of 4 kHz oVEMP was more accurate in detecting SCD than the presence of n10 response alone (AUC 91 vs. 87%). Additionally, using an amplitude cut-off of 15uV reduces false positive results and improves specificity to 96.8%. Assessing 4 kHz oVEMP response across SCD subgroups demonstrated that surgical and symptomatic SCD cases had significantly higher amplitudes, while radiographic SCD cases without characteristic symptoms had similar amplitudes compared to cases without evidence of SCD. Conclusion: Our results suggest that accounting for 4 kHz oVEMP amplitude can improve detection of SCD compared to the binary presence of n10 response. The 4 kHz oVEMP amplitude cut-off that maximizes sensitivity and specificity for our cohort is 15 uV. Our results also suggest that 4 kHz oVEMP amplitudes align better with symptomatic SCD cases compared to cases in which there is radiographic SCD but no characteristic symptoms.
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Affiliation(s)
- Emma D Tran
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, United States
| | - Austin Swanson
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, United States
| | - Jeffrey D Sharon
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Yona Vaisbuch
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, United States.,Department of Otolaryngology-Head and Neck Surgery, Rambam Medical Center, Haifa, Israel
| | - Nikolas H Blevins
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, United States
| | - Matthew B Fitzgerald
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, United States
| | - Kristen K Steenerson
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, United States
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Neves CA, Vaisbuch Y, Leuze C, McNab JA, Daniel B, Blevins NH, Hwang PH. Application of holographic augmented reality for external approaches to the frontal sinus. Int Forum Allergy Rhinol 2020; 10:920-925. [PMID: 32362076 DOI: 10.1002/alr.22546] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 01/11/2020] [Accepted: 02/05/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND External approaches to the frontal sinus such as osteoplastic flaps are challenging because they require blind entry into the sinus, posing risks of injury to the brain or orbit. Intraoperative computed tomography (CT)-based navigation is the current standard for planning the approach, but still necessitates blind entry into the sinus. The aim of this work was to describe a novel technique for external approaches to the frontal sinus using a holographic augmented reality (AR) application. METHODS Our team developed an AR system to create a 3-dimensional (3D) hologram of key anatomical structures, based on CT scans images. Using Magic Leap AR goggles for visualization, the frontal sinus hologram was aligned to the surface anatomy in 6 fresh cadaveric heads' anatomic boundaries, and the boundaries of the frontal sinus were demarcated based on the margins of the fused image. Trephinations and osteoplastic flap approaches were performed. The specimens were re-scanned to assess the accuracy of the osteotomy with respect to the actual frontal sinus perimeter. RESULTS Registration and surgery were completed successfully in all specimens. Registration required an average of 2 minutes. The postprocedure CT showed a mean difference of 1.4 ± 4.1 mm between the contour of the osteotomy and the contour of the frontal sinus. One surgical complication (posterior table perforation) occurred (16%). CONCLUSION We describe proof of concept of a novel technique utilizing AR to enhance external approaches to the frontal sinus. Holographic AR-enhanced surgical navigation holds promise for enhanced visualization of target structures during surgical approaches to the sinuses.
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Affiliation(s)
- Caio A Neves
- Department of Otolaryngology-Head & Neck Surgery, Stanford University School of Medicine, Stanford, CA.,Faculty of Medicine, University of Brasília, Brasilia, Brazil
| | - Yona Vaisbuch
- Department of Otolaryngology-Head & Neck Surgery, Stanford University School of Medicine, Stanford, CA.,Department of Otolaryngology-Head & Neck Surgery, Rambam Medical Center, Haifa, Israel
| | - Christoph Leuze
- Department of Radiology, Stanford University School of Medicine, Stanford, CA
| | - Jennifer A McNab
- Department of Radiology, Stanford University School of Medicine, Stanford, CA
| | - Bruce Daniel
- Department of Radiology, Stanford University School of Medicine, Stanford, CA
| | - Nikolas H Blevins
- Department of Otolaryngology-Head & Neck Surgery, Stanford University School of Medicine, Stanford, CA
| | - Peter H Hwang
- Department of Otolaryngology-Head & Neck Surgery, Stanford University School of Medicine, Stanford, CA
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21
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Musacchia G, Hu J, Bhutani VK, Wong RJ, Tong ML, Han S, Blevins NH, Fitzgerald MB. Frequency-following response among neonates with progressive moderate hyperbilirubinemia. J Perinatol 2020; 40:203-211. [PMID: 31263204 DOI: 10.1038/s41372-019-0421-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 05/01/2019] [Accepted: 05/23/2019] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To evaluate the feasibility of auditory monitoring of neurophysiological status using frequency-following response (FFR) in neonates with progressive moderate hyperbilirubinemia, measured by transcutaneous (TcB) levels. STUDY DESIGN ABR and FFR measures were compared and correlated with TcB levels across three groups. Group I was a healthy cohort (n = 13). Group II (n = 28) consisted of neonates with progressive, moderate hyperbilirubinemia and Group III consisted of the same neonates, post physician-ordered phototherapy. RESULT FFR amplitudes in Group I controls (TcB = 83.1 ± 32.5µmol/L; 4.9 ± 1.9 mg/dL) were greater than Group II (TcB = 209.3 ± 48.0µmol/L; 12.1 ± 2.8 mg/dL). After TcB was lowered by phototherapy, FFR amplitudes in Group III were similar to controls. Lower TcB levels correlated with larger FFR amplitudes (r = -0.291, p = 0.015), but not with ABR wave amplitude or latencies. CONCLUSION The FFR is a promising measure of the dynamic neurophysiological status in neonates, and may be useful in tracking neurotoxicity in infants with hyperbilirubinemia.
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Affiliation(s)
- Gabriella Musacchia
- Department of Audiology, University of the Pacific, San Francisco, CA, 94103, USA. .,Department of Otolaryngology - Head and Neck Surgery, Stanford University, Stanford, CA, 94305, USA.
| | - Jiong Hu
- Department of Audiology, University of the Pacific, San Francisco, CA, 94103, USA
| | - Vinod K Bhutani
- Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University, Stanford, CA, 94305, USA
| | - Ronald J Wong
- Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University, Stanford, CA, 94305, USA
| | - Mei-Ling Tong
- Department of Pediatrics, Nanjing Maternal and Child health Hospital of Nanjing Medical University, Nanjing, China
| | - Shuping Han
- Department of Pediatrics, Nanjing Maternal and Child health Hospital of Nanjing Medical University, Nanjing, China
| | - Nikolas H Blevins
- Department of Otolaryngology - Head and Neck Surgery, Stanford University, Stanford, CA, 94305, USA
| | - Matthew B Fitzgerald
- Department of Otolaryngology - Head and Neck Surgery, Stanford University, Stanford, CA, 94305, USA
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22
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Ali NES, Alyono JC, Song Y, Kouhi A, Blevins NH. Postoperative Venous Thromboembolism after Neurotologic Surgery. J Neurol Surg B Skull Base 2019; 82:378-382. [PMID: 34026416 DOI: 10.1055/s-0039-3400223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 09/28/2019] [Indexed: 10/25/2022] Open
Abstract
Objective This study aimed to determine the incidence of postoperative venous thromboembolism (VTE) in adults undergoing neurotologic surgery at a single center. Methods The records of adults undergoing neurotologic surgery from August 2009 to December 2016 at a tertiary care hospital were reviewed for VTE within 30 postoperative days. Particular attention was focused on postoperative diagnosis codes, imaging, and a keyword search of postoperative notes. Caprini risk scores were calculated. Results Among 387 patients, 5 experienced postoperative VTE including 3 cases of pulmonary embolism (PE) and 2 cases of isolated deep vein thrombosis (DVT). All patients were given sequential compression devices perioperatively, and none received preoperative chemoprophylaxis. Patients with Caprini score > 8 had a significantly higher rate of VTE compared with those < 8 (12.5 vs. 1%, p = 0.004). Receiver operating characteristic analysis revealed the Caprini risk assessment model to be a fair predictor of VTE, with a C-statistic of 0.70 (95% confidence interval [CI]: 0.49-0.92). Conclusion While no specific validated VTE risk stratification scheme has been widely accepted for patients undergoing neurotologic surgery, the Caprini score appears to be a useful predictor of risk. The benefits of chemoprophylaxis should be balanced with the risks of intraoperative bleeding, as well as the potential for postoperative intracranial hemorrhage.
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Affiliation(s)
- Noor-E-Seher Ali
- Department of Otolaryngology, Stanford University, Stanford, California, United States
| | - Jennifer C Alyono
- Department of Otolaryngology, Stanford University, Stanford, California, United States
| | - Yohan Song
- Department of Otolaryngology, Stanford University, Stanford, California, United States
| | - Ali Kouhi
- Department of Otolaryngology, Stanford University, Stanford, California, United States
| | - Nikolas H Blevins
- Department of Otolaryngology, Stanford University, Stanford, California, United States
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23
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Santa Maria PL, Shi Y, Gurgel RK, Corrales CE, Soltys SG, Santa Maria C, Murray K, Chang SD, Blevins NH, Gibbs IC, Jackler RK. Long-Term Hearing Outcomes Following Stereotactic Radiosurgery in Vestibular Schwannoma Patients-A Retrospective Cohort Study. Neurosurgery 2019; 85:550-559. [PMID: 30247723 PMCID: PMC7137466 DOI: 10.1093/neuros/nyy407] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 08/01/2018] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND An understanding of the hearing outcomes is needed for treatment counseling for patients with vestibular schwannomas (VS). OBJECTIVE To determine long-term hearing results following stereotactic radiosurgery (SRS) for VS and identify any influential variables. METHODS Tertiary hospital retrospective cohort. RESULTS There were 579 tumors (576 patients) treated with SRS. Eighty-two percent (473) of tumors had ≥1 yr and 59% (344 ≥3 yr follow-up. In the 244 tumor ears, with measurable hearing before SRS who were followed ≥1 yr, 14% (31) had improved hearing, 13% (29) unchanged hearing, and 74% (158) had worsened hearing. In 175 patients with ≥3 yr follow-up and who had measurable hearing pretreatment, 6% (11 ears) improved hearing, 31% (54 ears) unchanged hearing, and 63% (110 ears) had worsened hearing. Patients with tumors with larger target volumes (P = .040) and with neurofibromatosis type 2 (NF2; P = .017) were associated with poorer hearing (P = .040). Patients with word recognition scores (WRS) of 50% or poorer had tumors with a larger volume (P = .0002), larger linear size (P = .032), and NF2 (P = .045). Traditionally reported hearing outcomes using the Gardner Robertson maintenance of PTA ≤50 db or WRS ≥50% were 48% at 3 yr, which overestimates hearing outcomes compared to the above reporting standards. CONCLUSION Hearing declines over time in VS treated with SRS in a high proportion of cases. The frequency and magnitude of long-term hearing decline following SRS argues against prophylactic radiation for small tumors in hearing ears with undetermined growth behavior.
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Affiliation(s)
- Peter L Santa Maria
- Department of Otolaryngology, Head and Neck Surgery, Stanford University, Palo Alto, California
- Department of Ear Sciences, The University of Western Australia, Nedlands, Australia
- Ear Science Institute Australia, Subiaco, Australia
| | - Yangyang Shi
- Department of Otolaryngology, Head and Neck Surgery, Stanford University, Palo Alto, California
| | - Richard K Gurgel
- Department of Otolaryngology, Head and Neck Surgery, University of Utah, Salt Lake City, Utah
| | - C Eduardo Corrales
- Division of Otolaryngology—Head and Neck Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Scott G Soltys
- Department of Radiation Oncology, Stanford University, Palo Alto, California
| | - Chloe Santa Maria
- Department of Otolaryngology, Head and Neck Surgery, Stanford University, Palo Alto, California
- Department of Ear Sciences, The University of Western Australia, Nedlands, Australia
- Ear Science Institute Australia, Subiaco, Australia
| | - Kevin Murray
- School of Population and Global Health, The University of Western Australia, Nedlands, Australia
| | - Steven D Chang
- Department of Neurosurgery, Stanford University, Stanford, California
| | - Nikolas H Blevins
- Department of Otolaryngology, Head and Neck Surgery, Stanford University, Palo Alto, California
- Department of Neurosurgery, Stanford University, Stanford, California
| | - Iris C Gibbs
- Department of Radiation Oncology, Stanford University, Palo Alto, California
| | - Robert K Jackler
- Department of Otolaryngology, Head and Neck Surgery, Stanford University, Palo Alto, California
- Department of Neurosurgery, Stanford University, Stanford, California
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24
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Won TB, Cho SW, Sung MW, Paek SH, Chan S, Salisbury K, Blevins NH, Vaisbuch Y, Hwang P. Validation of a rhinologic virtual surgical simulator for performing a Draf 3 endoscopic frontal sinusotomy. Int Forum Allergy Rhinol 2019; 9:910-917. [PMID: 31012526 DOI: 10.1002/alr.22333] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Revised: 02/17/2019] [Accepted: 02/24/2019] [Indexed: 11/09/2022]
Abstract
BACKGROUND We recently introduced a patient-specific rhinologic virtual surgical environment (VSE) that has shown potential for surgical rehearsal of various skull base lesions. Our aim in this study was to validate the usefulness of the rhinology VSE in performing the Draf 3 procedure. METHODS An outside-in Draf 3 procedure was performed on 4 cadaver heads. Computed tomography (CT) scans were obtained before and after cadaver dissection (CD). Pre-dissection CT scans were used to construct a cadaver-specific VSE. A virtual Draf 3 dissection (VD) was performed using the same technique. Validation was conducted by comparing the final common frontal outflow tract. A subjective comparison of the post-dissection endoscopic findings (CD vs VD) and an objective measurement using the post-dissection CT scan for the CD and the reconstructed CT scan obtained from the data after the VD was performed. RESULTS Subjective overall resemblance of the 2 dissections (CD vs VD) assessed by the 4-point Likert scale (0-3) was 2.5 (median interquartile range [IQR], 0.25) for the 4 cadavers. The median difference for the anteroposterior dimension of the frontal neo-ostium (CD vs VD) assessed in the midsagittal view was 0.11 mm, whereas the median difference for the lateral dimension assessed in the coronal view was 2.71 mm. Thus, no statistical difference was observed. CONCLUSION VD showed nearly matching results with the actual cadaver dissection. With further validation, our rhinologic VSE may be used for presurgical planning and rehearsal before the actual Draf 3 procedure is performed in the operating room.
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Affiliation(s)
- Tae-Bin Won
- Department of Otorhinolaryngology-Head & Neck Surgery, Seoul National University Bundang Hospital, Seongnam, Korea.,Center for Minimally Invasive Skull Base Surgery, Seoul National University Hospital, Seoul, Korea
| | - Sung-Woo Cho
- Department of Otorhinolaryngology-Head & Neck Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Myung-Whun Sung
- Department of Otorhinolaryngology-Head & Neck Surgery, Seoul National University Hospital, Seoul, Korea
| | - Sun Ha Paek
- Center for Minimally Invasive Skull Base Surgery, Seoul National University Hospital, Seoul, Korea.,Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea
| | - Sonny Chan
- Department of Computer Science, University of Calgary, Calgary, AB, Canada
| | | | - Nikolas H Blevins
- Department of Otolaryngology-Head & Neck Surgery, Stanford University, Stanford, CA
| | - Yona Vaisbuch
- Department of Otolaryngology-Head & Neck Surgery, Stanford University, Stanford, CA
| | - Peter Hwang
- Department of Otolaryngology-Head & Neck Surgery, Stanford University, Stanford, CA
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25
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Abstract
OBJECTIVE To determine the incidence of postoperative venous thromboembolism (VTE) in adults undergoing otologic surgery. STUDY DESIGN Cross-sectional retrospective study. SETTING Single tertiary academic center. SUBJECTS AND METHODS Adults undergoing nononcologic, extracranial otologic surgery from August 2009 to December 2016. Patients with postoperative diagnosis VTE codes were identified. Imaging and clinical documents were searched for VTE evidence within the first 30 postoperative days. Methods of thromboprophylaxis were documented, and Caprini risk scores were calculated. RESULTS In total, 1213 otologic surgeries were evaluated. No postoperative VTE events were identified (0/1268). Mean age was 51.0 ± 17.3 years (range, 18.1-93.4 years). Average length of surgery was 136.0 ± 79.0 minutes (range, 5-768 minutes). The average Caprini score in all patients was 4.0 ± 1.7 (range, 1-15). Eighty-five percent of patients had a Caprini score ≥3, the threshold at which chemoprophylaxis has been recommended in general surgery patients by the American College of Chest Physicians 2012 guidelines. Six patients had documented preoperative chemoprophylaxis and a Caprini score of 4.8 ± 1.7. This was not significantly different from that of patients who did not receive preoperative chemoprophylaxis (t test, P = .3). The literature would estimate a rate of 3.7% VTE in adults with similar Caprini scores undergoing general surgery procedures with no VTE prophylaxis. CONCLUSION The Caprini risk assessment model may overestimate VTE risk in patients undergoing extracranial otologic surgery. Postoperative VTE following otologic surgery is rare, even in patients traditionally considered moderate or high risk. Chemoprophylaxis guidelines in this group should be balanced against the potential risk of increased intraoperative bleeding and its associated effects on surgical visualization and morbidity.
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Affiliation(s)
- Yohan Song
- 1 Department of Otolaryngology-Head and Neck Surgery, Stanford University, Stanford, California, USA
| | - Jennifer C Alyono
- 1 Department of Otolaryngology-Head and Neck Surgery, Stanford University, Stanford, California, USA
| | - Noor-E-Seher Ali
- 1 Department of Otolaryngology-Head and Neck Surgery, Stanford University, Stanford, California, USA
| | - Nikolas H Blevins
- 1 Department of Otolaryngology-Head and Neck Surgery, Stanford University, Stanford, California, USA
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26
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Liu GS, Boursiquot BC, Blevins NH, Vaisbuch Y. Systematic Review of Temporal Bone-Resurfacing Techniques for Pulsatile Tinnitus Associated with Vascular Wall Anomalies. Otolaryngol Head Neck Surg 2019; 160:749-761. [PMID: 30667295 DOI: 10.1177/0194599818823205] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To systematically review literature evidence on temporal bone-resurfacing techniques for pulsatile tinnitus (PT) associated with vascular wall anomalies. DATA SOURCES We searched PubMed, Embase, and the Cochrane Database. The period covered was from 1962 to 2018. REVIEW METHODS We included studies in all languages that reported resurfacing outcomes for patients with PT and radiographic evidence or direct visualization of sigmoid sinus wall anomaly, jugular bulb wall anomaly, or dehiscent or aberrant internal carotid artery. RESULTS Of 954 citations retrieved in database searches and 5 citations retrieved from reference lists, 20 studies with a total of 141 resurfacing cases involving 138 patients were included. Resurfacing outcomes for arterial sources of PT showed 3 of 5 cases (60%) with complete resolution and 2 (40%) with partial resolution. Jugular bulb sources of PT showed 11 of 14 cases (79%) with complete resolution and 1 (7%) with partial resolution. Sigmoid sinus sources of PT showed 91 of 121 cases (75%) with complete resolution and 12 (10%) with partial resolution. Symptoms occurred more in females and on the right side. Most cases (94%) used hard-density materials for resurfacing. Material density did not appear to be associated with resurfacing outcomes. Use of autologous materials was associated with improved outcomes for arterial sources resurfacing. Major complications involving sigmoid sinus thrombosis or compression were reported in 4% of cases without long-term morbidity or mortality. CONCLUSIONS Resurfacing surgery is likely effective and well tolerated for select patients with PT associated with various vascular wall anomalies.
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Affiliation(s)
- George S Liu
- 1 Department of Otolaryngology-Head and Neck Surgery, Stanford University, Stanford, California, USA
- 2 School of Medicine, Stanford University, Stanford, California, USA
| | | | - Nikolas H Blevins
- 1 Department of Otolaryngology-Head and Neck Surgery, Stanford University, Stanford, California, USA
| | - Yona Vaisbuch
- 1 Department of Otolaryngology-Head and Neck Surgery, Stanford University, Stanford, California, USA
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27
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Jackler RK, Santa Maria PL, Blevins NH. In reference to Evidence against the mucosal traction theory in cholesteatoma. Laryngoscope 2018; 128:E269-E270. [PMID: 29392724 DOI: 10.1002/lary.27097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Accepted: 11/08/2017] [Indexed: 11/12/2022]
Affiliation(s)
- Robert K Jackler
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Peter L Santa Maria
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Nikolas H Blevins
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
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28
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Patel VS, Choby GW, Thamboo A, Blevins NH, Hwang PH. Nasoseptal flap closure of the eustachian tube for recalcitrant cerebrospinal fluid rhinorrhea. Laryngoscope 2017; 128:1523-1526. [PMID: 29152752 DOI: 10.1002/lary.26988] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Revised: 09/12/2017] [Accepted: 10/05/2017] [Indexed: 11/09/2022]
Affiliation(s)
- Vishal S Patel
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, California, U.S.A
| | - Garret W Choby
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, California, U.S.A.,Department of Otorhinolaryngology, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Andrew Thamboo
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, California, U.S.A.,Department of Otolaryngology-Head and Neck Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Nikolas H Blevins
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, California, U.S.A
| | - Peter H Hwang
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, California, U.S.A
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29
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Monfared A, Corrales CE, Theodosopoulos PV, Blevins NH, Oghalai JS, Selesnick SH, Lee H, Gurgel RK, Hansen MR, Nelson RF, Gantz BJ, Kutz JW, Isaacson B, Roland PS, Amdur R, Jackler RK. Facial Nerve Outcome and Tumor Control Rate as a Function of Degree of Resection in Treatment of Large Acoustic Neuromas: Preliminary Report of the Acoustic Neuroma Subtotal Resection Study (ANSRS). Neurosurgery 2017; 79:194-203. [PMID: 26645964 DOI: 10.1227/neu.0000000000001162] [Citation(s) in RCA: 83] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Patients with large vestibular schwannomas are at high risk of poor facial nerve (cranial nerve VII [CNVII]) function after surgery. Subtotal resection potentially offers better outcome, but may lead to higher tumor regrowth. OBJECTIVE To assess long-term CNVII function and tumor regrowth in patients with large vestibular schwannomas. METHODS Prospective multicenter nonrandomized cohort study of patients with vestibular schwannoma ≥2.5 cm who received gross total resection, near total resection, or subtotal resection. Patients received radiation if tumor remnant showed signs of regrowth. RESULTS Seventy-three patients had adequate follow-up with mean tumor diameter of 3.33 cm. Twelve received gross total resection, 22 near total resection, and 39 subtotal resection. Fourteen (21%) remnant tumors continued to grow, of which 11 received radiation, 1 had repeat surgery, and 2 no treatment. Four of the postradiation remnants (36%) required surgical salvage. Tumor regrowth was related to non-cystic nature, larger residual tumor, and subtotal resection. Regrowth was 3 times as likely with subtotal resection compared to gross total resection and near total resection. Good CNVII function was achieved in 67% immediately and 81% at 1-year. Better immediate nerve function was associated with smaller preoperative tumor size and percentage of tumor left behind on magnetic resonance image. Degree of resection defined by surgeon and preoperative tumor size showed weak trend toward better late CNVII function. CONCLUSION Likelihood of tumor regrowth was 3 times higher in subtotal resection compared to gross total resection and near total resection groups. Rate of radiation control of growing remnants was suboptimal. Better immediate but not late CNVII outcome was associated with smaller tumors and larger tumor remnants. ABBREVIATIONS CNVII, cranial nerve VIIGTR, gross total resectionHB, House-BrackmannMRI, magnetic resonance imageNTR, near total resectionSTR, subtotal resection.
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Affiliation(s)
- Ashkan Monfared
- *Departments of Otolaryngology and Neurosurgery, George Washington University, Washington, DC; ‡Departments of Otolaryngology-Head and Neck Surgery and Neurosurgery, Stanford University, Palo Alto, California; §Department of Otolaryngology-Head and Neck Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; ¶Department of Neurosurgery, University of Cincinnati, Cincinnati, Ohio; ‖Department of Neurosurgery, University of California San Francisco, San Francisco, California; #Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, Texas; **Department of Otolaryngology-Head and Neck Surgery, Weill Cornell School of Medicine, New York, New York; ‡‡Department of Statistics, California State University, Northridge, Northridge, California; §§Department of Otolaryngology-Head and Neck Surgery, University of Utah, Salt Lake City, Utah; ¶¶Department of Otolaryngology-Head and Neck Surgery, University of Iowa, Iowa City, Iowa; ‖‖Department of Otolaryngology-Head and Neck Surgery, Indiana University, Indianapolis, Indiana; ##Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern, Dallas, Texas
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30
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Won TB, Hwang P, Lim JH, Cho SW, Paek SH, Losorelli S, Vaisbuch Y, Chan S, Salisbury K, Blevins NH. Early experience with a patient-specific virtual surgical simulation for rehearsal of endoscopic skull-base surgery. Int Forum Allergy Rhinol 2017; 8:54-63. [DOI: 10.1002/alr.22037] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2017] [Revised: 09/28/2017] [Accepted: 10/10/2017] [Indexed: 12/28/2022]
Affiliation(s)
- Tae-Bin Won
- Department of Otorhinolaryngology-Head and Neck Surgery; Seoul National University Hospital; Seoul Korea
- Center for Minimally Invasive Skull Base Surgery; Seoul National University Hospital; Seoul Korea
| | - Peter Hwang
- Department of Otolaryngology-Head and Neck Surgery; Stanford University; Stanford CA
| | - Jae Hyun Lim
- Department of Otorhinolaryngology-Head and Neck Surgery; Seoul National University Hospital; Seoul Korea
| | - Sung-Woo Cho
- Department of Otorhinolaryngology-Head and Neck Surgery; Seoul National University Hospital; Seoul Korea
| | - Sun Ha Paek
- Center for Minimally Invasive Skull Base Surgery; Seoul National University Hospital; Seoul Korea
- Department of Neurosurgery; Seoul National University Hospital; Seoul Korea
| | - Steven Losorelli
- Department of Otolaryngology-Head and Neck Surgery; Stanford University; Stanford CA
| | - Yona Vaisbuch
- Department of Otolaryngology-Head and Neck Surgery; Stanford University; Stanford CA
| | - Sonny Chan
- Department of Computer Science; University of Calgary; Calgary AB Canada
| | | | - Nikolas H. Blevins
- Department of Otolaryngology-Head and Neck Surgery; Stanford University; Stanford CA
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31
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Locketz GD, Lui JT, Chan S, Salisbury K, Dort JC, Youngblood P, Blevins NH. Anatomy-Specific Virtual Reality Simulation in Temporal Bone Dissection: Perceived Utility and Impact on Surgeon Confidence. Otolaryngol Head Neck Surg 2017; 156:1142-1149. [DOI: 10.1177/0194599817691474] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective To evaluate the effect of anatomy-specific virtual reality (VR) surgical rehearsal on surgeon confidence and temporal bone dissection performance. Study Design Prospective pre- and poststudy of a novel virtual surgical rehearsal platform. Setting Academic otolaryngology–head and neck surgery residency training programs. Subjects and Methods Sixteen otolaryngology–head and neck surgery residents from 2 North American training institutions were recruited. Surveys were administered to assess subjects' baseline confidence in performing 12 subtasks of cortical mastoidectomy with facial recess. A cadaver temporal bone was randomly assigned to each subject. Cadaver specimens were scanned with a clinical computed tomography protocol, allowing the creation of anatomy-specific models for use in a VR surgical rehearsal platform. Subjects then rehearsed a virtual mastoidectomy on data sets derived from their specimens. Surgical confidence surveys were administered again. Subjects then dissected assigned cadaver specimens, which were blindly graded with a modified Welling scale. A final survey assessed the perceived utility of rehearsal on dissection performance. Results Of 16 subjects, 14 (87.5%) reported a significant increase in overall confidence after conducting an anatomy-specific VR rehearsal. A significant correlation existed between perceived utility of rehearsal and confidence improvement. The effect of rehearsal on confidence was dependent on trainee experience and the inherent difficulty of the surgical subtask. Postrehearsal confidence correlated strongly with graded dissection performance. Subjects rated anatomy-specific rehearsal as having a moderate to high contribution to their dissection performance. Conclusion Anatomy-specific virtual rehearsal improves surgeon confidence in performing mastoid dissection, dependent on surgeon experience and task difficulty. The subjective confidence gained through rehearsal correlates positively with subsequent objective dissection performance.
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Affiliation(s)
- Garrett D. Locketz
- Department of Otolaryngology–Head and Neck Surgery, Stanford University, Stanford, California, USA
| | - Justin T. Lui
- Division of Otolaryngology–Head and Neck Surgery, Department of Surgery, University of Calgary, Calgary, Canada
| | - Sonny Chan
- Department of Computer Science, University of Calgary, Calgary, Canada
| | - Kenneth Salisbury
- Department of Computer Science, Stanford University, Stanford, California, USA
| | - Joseph C. Dort
- Division of Otolaryngology–Head and Neck Surgery, Department of Surgery, University of Calgary, Calgary, Canada
| | - Patricia Youngblood
- Division of Clinical Anatomy, Department of Surgery, Stanford University School of Medicine, Stanford, California, USA
| | - Nikolas H. Blevins
- Department of Otolaryngology–Head and Neck Surgery, Stanford University, Stanford, California, USA
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Locketz GD, Li PMMC, Fischbein NJ, Holdsworth SJ, Blevins NH. Fusion of Computed Tomography and PROPELLER Diffusion-Weighted Magnetic Resonance Imaging for the Detection and Localization of Middle Ear Cholesteatoma. JAMA Otolaryngol Head Neck Surg 2016; 142:947-953. [DOI: 10.1001/jamaoto.2016.1663] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Garrett D. Locketz
- Department of Otolaryngology–Head and Neck Surgery, Stanford University, Stanford, California
| | - Peter M. M. C. Li
- Department of Otolaryngology–Head and Neck Surgery, Stanford University, Stanford, California
| | - Nancy J. Fischbein
- Department of Otolaryngology–Head and Neck Surgery, Stanford University, Stanford, California2Department of Radiology, Stanford University, Stanford, California
| | | | - Nikolas H. Blevins
- Department of Otolaryngology–Head and Neck Surgery, Stanford University, Stanford, California
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Chan S, Li P, Locketz G, Salisbury K, Blevins NH. High-fidelity haptic and visual rendering for patient-specific simulation of temporal bone surgery. Comput Assist Surg (Abingdon) 2016; 21:85-101. [DOI: 10.1080/24699322.2016.1189966] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Affiliation(s)
- Sonny Chan
- Department of Computer Science, University of Calgary, Calgary, AB, Canada
| | - Peter Li
- Department of Otolaryngology – Head and Neck Surgery, Stanford University, Stanford, CA, USA
| | - Garrett Locketz
- Department of Otolaryngology – Head and Neck Surgery, Stanford University, Stanford, CA, USA
| | - Kenneth Salisbury
- Departments of Computer Science and Surgery, Stanford University, Stanford, CA, USA
| | - Nikolas H. Blevins
- Department of Otolaryngology – Head and Neck Surgery, Stanford University, Stanford, CA, USA
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Jackler RK, Maria PLS, Varsak YK, Blevins NH, Nguyen A. In response to A new theory on the pathogenesis of acquired cholesteatoma: Mucosal traction. Laryngoscope 2015; 126:E133. [PMID: 26421689 DOI: 10.1002/lary.25699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Accepted: 09/01/2015] [Indexed: 11/06/2022]
Affiliation(s)
- Robert K Jackler
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Peter Luke Santa Maria
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Yasin K Varsak
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Nikolas H Blevins
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Anh Nguyen
- Department of Otolaryngology-Head and Neck Surgery, University of Oregon Health and Science University, Portland, Oregon
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Jackler RK, Maria PLS, Varsak YK, Blevins NH, Nguyen A. In response to a new theory on the pathogenesis of acquired cholesteatoma: Mucosal traction. Laryngoscope 2015; 126:E131. [PMID: 26372503 DOI: 10.1002/lary.25654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/10/2015] [Indexed: 11/12/2022]
Affiliation(s)
- Robert K Jackler
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Peter Luke Santa Maria
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Yasin Kursad Varsak
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Nikolas H Blevins
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Anh Nguyen
- Department of Otolaryngology-Head and Neck Surgery, University of Oregon Health and Science University, Portland, Oregon
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Jackler RK, Santa Maria PL, Varsak YK, Blevins NH, Nguyen A. In reference to A new theory on the pathogenesis of acquired cholesteatoma: Mucosal traction. Laryngoscope 2015; 126:E50. [PMID: 26267761 DOI: 10.1002/lary.25542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Accepted: 06/11/2015] [Indexed: 11/11/2022]
Affiliation(s)
- Robert K Jackler
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Peter Luke Santa Maria
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Yasin K Varsak
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Nikolas H Blevins
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Anh Nguyen
- Department of Otolaryngology-Head and Neck Surgery, University of Oregon Health and Science University, Portland, Oregon
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Jackler RK, Santa Maria PL, Varsak YK, Nguyen A, Blevins NH. A new theory on the pathogenesis of acquired cholesteatoma: Mucosal traction. Laryngoscope 2015; 125 Suppl 4:S1-S14. [PMID: 26013635 DOI: 10.1002/lary.25261] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Accepted: 02/20/2015] [Indexed: 01/16/2023]
Abstract
OBJECTIVES/HYPOTHESIS Although the migration of its squamous outer surface of the tympanic membrane has been well characterized, there is a paucity of data available concerning the migratory behavior of its medial mucosal surface. Existing theories of primary acquired cholesteatoma pathogenesis do not adequately explain the observed characteristics of the disease. We propose a new hypothesis, based upon a conjecture that mucosal membrane interactions are the driving force in cholesteatoma. STUDY DESIGN A retrospective chart review and a prospective observational cohort study in rats. METHODS After developing the new theory, it was tested through both clinical and experimental observations. To evaluate whether impairment of middle ear mucociliary migration would influence cholesteatoma formation, a retrospective chart review evaluating cholesteatoma occurrence in a sizable population of patients with either primary ciliary dyskinesia (PCD) or cystic fibrosis (CF) was performed. To study mucosal migration on the medial aspect of the tympanic membrane, ink tattoos were monitored over time in a rat model. RESULTS No cholesteatomas were identified in either PCD patients (470) or in CF patients (1,910). In the rat model, mucosa of the posterior pars tensa migrated toward the posterior superior quadrant, whereas the mucosa of the anterior pars tensa migrated radially toward the annulus. CONCLUSION Mucosal coupling with traction generated by interaction of migrating opposing surfaces provides the first comprehensive theory that explains the observed characteristics of primary acquired cholesteatoma. The somewhat counterintuitive hypothesis that cholesteatoma is fundamentally a mucosal disease has numerous therapeutic implications.
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Affiliation(s)
- Robert K Jackler
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, California, U.S.A
| | - Peter L Santa Maria
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, California, U.S.A
| | - Yasin K Varsak
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, California, U.S.A
| | - Anh Nguyen
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland, Oregon, U.S.A
| | - Nikolas H Blevins
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, California, U.S.A
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Alyono JC, Corrales CE, Huth ME, Blevins NH, Ricci AJ. Development and characterization of chemical cochleostomy in the Guinea pig. Otolaryngol Head Neck Surg 2015; 152:1113-8. [PMID: 25779472 DOI: 10.1177/0194599815573703] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Accepted: 01/29/2015] [Indexed: 01/14/2023]
Abstract
OBJECTIVES Creation of an atraumatic, hearing-preservation cochleostomy is integral to the future of minimally invasive inner ear surgery. The goal of this study was to develop and characterize a novel chemical approach to cochleostomy. STUDY DESIGN Prospective animal study. SETTING Laboratory. METHODS Experimental animal study in which phosphoric acid gel (PAG) was used to decalcify the otic capsule in 25 Hartley guinea pigs. Five animals in each of 5 surgical groups were studied: (1) mechanically opening the auditory bulla alone, (2) PAG thinning of the basal turn otic capsule, leaving endosteum covered by a layer of bone, (3) micro-pick manual cochleostomy, (4) PAG chemical cochleostomy, exposing the endosteum, and (5) combined PAG/micro-pick cochleostomy, with initial chemical thinning and subsequent manual removal of the last osseous layer. Preoperative and postoperative auditory brainstem responses and otoacoustic emissions were obtained at 2, 6, 10, and 16 kHz. Hematoxylin and eosin-stained paraffin sections were compared. RESULTS Surgical and histologic findings confirmed that application of PAG provided reproducible local bone removal, and cochlear access was enabled. Statistically significant auditory threshold shifts were observed at 10 kHz (P = .048) and 16 kHz (P = .0013) following cochleostomy using PAG alone (group 4) and at 16 kHz using manual cochleostomy (group 3) (P = .028). No statistically significant, postoperative auditory threshold shifts were observed in the other groups, including PAG thinning with manual completion cochleostomy (group 5). CONCLUSION Hearing preservation cochleostomy can be performed in an animal model using a novel technique of thinning cochlear bone with PAG and manually completing cochleostomy.
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Affiliation(s)
- Jennifer C Alyono
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine Stanford, California, USA
| | - C Eduardo Corrales
- Department of Otology and Laryngology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Markus E Huth
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, University of Bern, Freiburgstrasse, Bern, Switzerland
| | - Nikolas H Blevins
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine Stanford, California, USA
| | - Anthony J Ricci
- Department of Otolaryngology-Head and Neck Surgery and Department of Molecular and Cellular Physiology, Stanford University School of Medicine Stanford, California, USA
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Monfared A, Taheri MR, Gurgel RK, Blevins NH, Jackler RK. Temporal Bone Radiology: Beyond the Basics. Otolaryngol Head Neck Surg 2014. [DOI: 10.1177/0194599814538403a67] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Program Description: Through this interactive presentation, the audience is exposed to challenging temporal bone radiology cases and offered strategies to improve their interpretation. We will cover key findings for chronic ear disease and conductive hearing loss, lateral skull base lesions, and the petrous apex. The emphasis is placed on subtle but pertinent findings on computed tomography and magnetic resonance imaging examinations and their importance in creating and narrowing a differential diagnoses. We will present guidelines to aid in the efficient acquisition and interpretation of imaging for patients with common otologic symptoms such as vertigo, sudden hearing loss, and pulsatile tinnitus. Educational Objectives: (1) Interpret key radiographic findings for common pathologic conditions of the temporal bone. (2) Order appropriate radiographic tests to evaluate common conditions and understand the strengths and limitations of various imaging modalities.
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40
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Alyono JC, Corrales E, Blevins NH, Ricci A. Development and Characterization of Chemical Cochleostomy in the Guinea Pig. Otolaryngol Head Neck Surg 2014. [DOI: 10.1177/0194599814541627a167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives: Creation of an atraumatic, hearing-preservation cochleostomy is integral to the future of minimally invasive inner ear surgery. Current techniques generally take 1 of 2 approaches: mechanical or thermal. The goal of this study was to develop and characterize a novel chemical approach to cochleostomy. Methods: Experimental animal study in which phosphoric acid gel (PAG) was used to decalcify the otic capsule in 25 Hartley guinea pigs. Five animals in each of 5 groups were studied: (1) mechanically opening the auditory bulla alone, (2) PAG thinning of the basal turn otic capsule, leaving endosteum covered by a layer of bone, (3) micro-pick manual cochleostomy, (4) PAG chemical cochleostomy, exposing the endosteum, and (5) combined PAG/micro-pick cochleostomy, with initial chemical thinning and subsequent manual removal of the last osseous layer. Preoperative and postoperative auditory brainstem responses and otoacoustic emissions were obtained at 2, 6, 10, and 16 kHz. Hematoxylin and eosin stained paraffin sections were compared. Results: Surgical and histologic findings confirmed that application of PAG provided reproducible local bone removal, and cochlear access was enabled. Statistically significant auditory threshold shifts were observed at 10 and 16 kHz following cochleostomy using PAG alone (group 4), and at 16 kHz using manual cochleostomy (group 3) ( P < .05). No statistically significant postoperative auditory threshold shifts were observed in the other groups, including PAG thinning with manual completion cochleostomy (group 5). Conclusions: Hearing preservation cochleostomy can be performed in an animal model using a novel technique of thinning cochlear bone with PAG and manually completing cochleostomy.
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Monfared A, Blevins NH, Lalwani AK, Lustig LR, Tucci DL. Managing the Unexpected in Otologic Surgery. Otolaryngol Head Neck Surg 2014. [DOI: 10.1177/0194599814538403a62] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Program Description: Sponsored by the American Neurotology Society, this interactive presentation aims to provide general practitioners tips and techniques employed by experts in management of intraoperative complications encountered during common otology cases such as tympanoplasty, tympanomastoidectomy, and stapedotomy. The panelists will present illustrative cases and discuss best practice approaches to intraoperative cerebrospinal fluid (CSF) leak and encephaloceles, facial nerve injury, vascular complications, stapedotomy challenges, ossicular chain and external auditory canal damage, and inner ear violation. Educational Objectives: (1) Recognize unexpected circumstances and anatomic variations that could lead to complications in otologic surgery. (2) Manage intraoperative complications such as facial nerve palsy, vascular injury, encephaloceles, CSF leaks, postoperative sensorineural hearing loss, and vertigo.
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Santa Maria PL, Abuzeid WM, Nayak JV, Chang SD, Blevins NH. A case of stereotactic radiation in skull base solitary fibrous tumor: more harm than good? J Neurol Surg Rep 2014; 75:e214-6. [PMID: 25485216 PMCID: PMC4242816 DOI: 10.1055/s-0034-1387196] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2014] [Accepted: 06/08/2014] [Indexed: 10/31/2022] Open
Abstract
Objective Due to its location, total resection of a skull base solitary fibrous tumor (SFT) can lead to morbidity with injury to lower cranial nerves, and a decision must be made between subtotal resection with possible stereotactic radiotherapy or total resection with cranial nerve morbidity. We report the long-term outcomes and review the literature of a case of stereotactic radiation in SFT to provide evidence for making this decision. Design A retrospective case review. Setting An academic tertiary referral center. Results We present a case with > 10 years follow-up of radiation following skull base SFT, initially misdiagnosed as schwannoma, where radiotherapy did not improve recurrence or metastatic behavior and led to complications during subsequent surgical resection. Conclusions SFT often masquerades as schwannoma, especially in the skull base. Careful immunohistochemistry, including CD34 expression, is critical to the diagnosis and management. This case highlights that total tumor resection of SFT remains the gold standard of treatment. Stereotactic radiation is not recommended in the management of skull base SFT.
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Affiliation(s)
- Peter L Santa Maria
- Department of Otolaryngology, Head and Neck Surgery, Stanford University Hospital and Clinics, Stanford, California, United States
| | - Waleed M Abuzeid
- Department of Otolaryngology, Head and Neck Surgery, Stanford University Hospital and Clinics, Stanford, California, United States
| | - Jayakar V Nayak
- Department of Otolaryngology, Head and Neck Surgery, Stanford University Hospital and Clinics, Stanford, California, United States
| | - Steven D Chang
- Department of Neurosurgery, Head and Neck Surgery, Stanford University Hospital and Clinics, Stanford, California, United States
| | - Nikolas H Blevins
- Department of Otolaryngology, Head and Neck Surgery, Stanford University Hospital and Clinics, Stanford, California, United States
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43
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Monfared A, Taheri MR, Jackler RK, Blevins NH, Gurgel RK. Temporal Bone Radiology: Beyond the Basics. Otolaryngol Head Neck Surg 2013. [DOI: 10.1177/0194599813493390a68] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Program Description: Through this interactive presentation, the audience is exposed to challenging temporal bone radiology cases and offered strategies to improve his or her interpretation. We will cover key findings for chronic ear disease and conductive hearing loss, lateral skull base lesions, and the petrous apex. The emphasis is placed on subtle but pertinent findings on computed tomography (CT) and MRI examinations and their importance in creating and narrowing a differential diagnosis. We will present guidelines to aid in the efficient acquisition and interpretation of imaging for patients with common otologic symptoms such as vertigo, sudden hearing loss, and pulsatile tinnitus. Educational Objectives: 1) Interpret key radiographic findings for common pathologic conditions of the temporal bone. 2) Order appropriate radiographic tests to evaluate common conditions and understand the strengths and limitations of various imaging modalities.
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Forsslund J, Chan S, Selesnick J, Salisbury K, Silva RG, Blevins NH. The effect of haptic degrees of freedom on task performance in virtual surgical environments. Stud Health Technol Inform 2013; 184:129-135. [PMID: 23400144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Force and touch feedback, or haptics, can play a significant role in the realism of virtual reality surgical simulation. While it is accepted that simulators providing haptic feedback often outperform those that do not, little is known about the degree of haptic fidelity required to achieve simulation objectives. This article evaluates the effect that employing haptic rendering with different degrees of freedom (DOF) has on task performance in a virtual environment. Results show that 6-DOF haptic rendering significantly improves task performance over 3-DOF haptic rendering, even if computed torques are not displayed to the user. No significant difference could be observed between under-actuated (force only) and fully-actuated 6-DOF feedback in two surgically-motivated tasks.
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Affiliation(s)
- Jonas Forsslund
- Computer Science Department, Stanford University, Stanford, CA, USA
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Li PMMC, Linos E, Gurgel RK, Fischbein NJ, Blevins NH. Evaluating the utility of non-echo-planar diffusion-weighted imaging in the preoperative evaluation of cholesteatoma: A meta-analysis. Laryngoscope 2012; 123:1247-50. [DOI: 10.1002/lary.23759] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2012] [Revised: 08/15/2012] [Accepted: 09/05/2012] [Indexed: 11/11/2022]
Affiliation(s)
- Peter M. M. C. Li
- Department of Otolaryngology-Head and Neck Surgery; Stanford; California
| | - Eleni Linos
- Department of Dermatology; University of California San Francisco; San Francisco; California; U.S.A
| | - Richard K. Gurgel
- Department of Otolaryngology-Head and Neck Surgery; Stanford; California
| | | | - Nikolas H. Blevins
- Department of Otolaryngology-Head and Neck Surgery; Stanford; California
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Deutsch ES, Blevins NH, Shapiro JA, Malekzadeh S, Reickert C. Simulation: Disruptive Innovation and Our Quest to Excel. Otolaryngol Head Neck Surg 2012. [DOI: 10.1177/0194599812449008a30] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Gurgel RK, Popelka GR, Oghalai JS, Blevins NH, Chang KW, Jackler RK. Is It Valid to Calculate the 3-Kilohertz Threshold by Averaging 2 and 4 Kilohertz? Otolaryngol Head Neck Surg 2012; 147:102-4. [DOI: 10.1177/0194599812437156] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Many guidelines for reporting hearing results use the threshold at 3 kilohertz (kHz), a frequency not measured routinely. This study assessed the validity of estimating the missing 3-kHz threshold by averaging the measured thresholds at 2 and 4 kHz. The estimated threshold was compared to the measured threshold at 3 kHz individually and when used in the pure-tone average (PTA) of 0.5, 1, 2, and 3 kHz in audiometric data from 2170 patients. The difference between the estimated and measured thresholds for 3 kHz was within ±5 dB in 72% of audiograms, ±10 dB in 91%, and within ±20 dB in 99% (correlation coefficient r = 0.965). The difference between the PTA threshold using the estimated threshold compared with using the measured threshold at 3 kHz was within ±5 dB in 99% of audiograms ( r = 0.997). The estimated threshold accurately approximates the measured threshold at 3 kHz, especially when incorporated into the PTA.
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Affiliation(s)
- Richard K. Gurgel
- Department of Otolaryngology–Head and Neck Surgery, Stanford University, Stanford, California, USA
| | - Gerald R. Popelka
- Department of Otolaryngology–Head and Neck Surgery, Stanford University, Stanford, California, USA
| | - John S. Oghalai
- Department of Otolaryngology–Head and Neck Surgery, Stanford University, Stanford, California, USA
| | - Nikolas H. Blevins
- Department of Otolaryngology–Head and Neck Surgery, Stanford University, Stanford, California, USA
| | - Kay W. Chang
- Department of Otolaryngology–Head and Neck Surgery, Stanford University, Stanford, California, USA
| | - Robert K. Jackler
- Department of Otolaryngology–Head and Neck Surgery, Stanford University, Stanford, California, USA
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Gurgel RK, Oghalai JS, Chang KW, Blevins NH, Jackler RK, Popelka RK. Correlation of Measured vs Averaged 3kHz Pure Tone Averages. Otolaryngol Head Neck Surg 2011. [DOI: 10.1177/0194599811416318a156] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective: AAO-HNS reporting guidelines for hearing results recommend a pure tone average (PTA) using thresholds at 0.5, 1, 2, and 3 kHz. 3 kHz measurements, however, are not always included in routine audiometry. We determined the magnitude of PTA errors using 3 kHz thresholds interpolated from 2 and 4 kHz measurements. Method: Retrospective analysis of audiogram data from an academic, tertiary referral center from April to August 2010. All patients (N = 1,204) in our clinic having audiograms for any reason were eligible for inclusion. Audiograms missing threshold data at any of the frequencies evaluated were excluded. Results: The difference between calculated and measured 3 kHz was within 5 dB, 10dB, and 20dB in 89.5%, 68.9%, and 98.6% of audiograms respectively. When the 3kHz level varied more than 10 dB from actual, the error underestimated the degree of hearing loss by a 3:1 margin (7.9% vs 2.6%). The steeper the slope of the hearing loss, the greater the divergence of the interpolated value from actual. When factored into the PTA, however, measured verses interpolated thresholds at 3 kHz showed a difference within 5 dB in 98.6%, R = 0.996, with a mean difference of 0.6 dB (SD = 1.7dB). Conclusion: While interpolation of 3 kHz introduces a degree of error in measurement of this specific frequency, the effect on PTA is minor. These data suggest that 3 kHz thresholds can be reliably interpolated using available 2 and 4 kHz thresholds when utilized in PTAs.
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Li PM, Bergeron C, Monfared A, Agrawal S, Blevins NH. Superior semicircular canal dehiscence diagnosed after failed stapedotomy for conductive hearing loss. Am J Otolaryngol 2011; 32:441-4. [PMID: 20888070 DOI: 10.1016/j.amjoto.2010.07.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2010] [Accepted: 07/17/2010] [Indexed: 10/19/2022]
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