Treatment of Acute Otitis Media with Inner Ear Involvement in Adults

Inner ear involvement (IED) is a rare local complication of the very common acute otitis media (AOM). The most beneficial treatment for IED remains a matter of debate. The aim of this study is to analyze different treatment modalities based on hearing outcomes to contribute to the discussion of therapy for IED in AOM. This retrospective study includes 112 adult patients diagnosed with AOM with IED between 2000 and 2020. Patients either received conservative (systemic antibiotic and systemic steroid therapy), interventional (conservative plus myringotomy and tympanic tube) or operative (interventional plus antrotomy) treatment. Pre- and post-treatment pure tone audiometry was performed. The hearing outcome was compared, and hearing recovery was analyzed based on modified Siegel's criteria. The pre-treatment pure tone average (PTA) was significantly (p < 0.05) higher in the operative group than in the other groups. All treatment modalities led to a significant hearing improvement (p < 0.001). The pre- and post-treatment hearing loss was predominantly observed in high frequencies 2-4 kHz. The operative group showed the highest rate of complete hearing recovery. While all treatment modalities led to a significant improvement in hearing, the operative group showed the most beneficial hearing results in patients with high pre-treatment hearing loss. It remains to be shown if the findings in patients with high pre-treatment hearing loss can be generalized to patients with mild or moderate pre-treatment hearing loss.

Effects of preloads on middle-ear transfer function and acoustic reflex in ossiculoplasty with PORP

INTRODUCTION

Surgical outcomes in ossiculoplasty with partial ossicular replacement prostheses (PORPs) are greatly influenced by the amount of preload imposed on the PORP. In this study, the attenuation of the middle-ear transfer function (METF) was experimentally investigated for prosthesis-related preloads in different directions, with and without concurrent application of stapedial muscle tension. Different PORP designs were assessed to determine functional benefits of specific design features under preload conditions.

METHODS

The experiments were performed on fresh-frozen human cadaveric temporal bones. The effect of preloads along different directions were experimentally assessed by simulating anatomical variance and postoperative position changes in a controlled setup. The assessments were performed for three different PORP designs featuring either a fixed shaft or ball joint and a Bell-type or Clip-interface. Further, the combined effect of the preloads towards the medial direction with tensional forces of the stapedial muscle was assessed. The METF was obtained via laser-Doppler vibrometry for each measurement condition.

RESULTS

The preloads as well as the stapedial muscle tension primarily attenuated the METF between 0.5 and 4 kHz. The largest attenuations resulted from the preload towards the medial direction. The attenuation of the METF with stapedial muscle tension was reduced with concurrent PORP preloads. PORPs with a ball joint resulted in reduced attenuation only for preloads along the long axis of the stapes footplate. In contrast to the clip interface, the Bell-type interface was prone to lose coupling with the stapes head for preloads in the medial direction.

CONCLUSIONS

The experimental study of the preload effects indicates a direction-dependent attenuation of the METF, with the most pronounced effects resulting from preloads towards the medial direction. Based on the obtained results, the ball joint offers tolerance for angular positioning while the clip interface prevents PORP dislocations for preloads in lateral direction. At high preloads, the attenuation of the METF with stapedial muscle tension is reduced, which should be considered for the interpretation of postoperative acoustic reflex tests.

Three-dimensional quasi-static displacement of human middle-ear ossicles under static pressure loads: Measurement using a stereo camera system

The time delay and/or malfunctioning of the Eustachian tube may cause pressure differences across the tympanic membrane, resulting in quasi-static movements of the middle-ear ossicles. While quasi-static displacements of the human middle-ear ossicles have been measured one- or two-dimensionally in previous studies, this study presents an approach to trace three-dimensional movements of the human middle-ear ossicles under static pressure loads in the ear canal (EC). The three-dimensional quasi-static movements of the middle-ear ossicles were measured using a custom-made stereo camera system. Two cameras were assembled with a relative angle of 7° and then mounted onto a robot arm. Red fluorescent beads of a 106-125 µm diameter were placed on the middle-ear ossicles, and quasi-static position changes of the fluorescent beads under static pressure loads were traced by the stereo camera system. All the position changes of the ossicles were registered to the anatomical intrinsic frame based on the stapes footplate, which was obtained from µ-CT imaging. Under negative ear-canal pressures, a rotational movement around the anterior-posterior axis was dominant for the malleus-incus complex, with small relative movements between the two ossicles. The stapes showed translation toward the lateral direction and rotation around the long axis of the stapes footplate. Under positive EC pressures, relative motion between the malleus and the incus at the IMJ became larger, reducing movements of the incus and stapes considerably and thus performing a protection function for the inner-ear structures. Three-dimensional tracing of the middle-ear ossicular chain provides a better understanding of the protection function of the human middle ear under static pressured loads as immediate responses without time delay.

Wave propagation across the skull under bone conduction: Dependence on coupling methods

This study is aimed at the quantitative investigation of wave propagation through the skull bone and its dependence on different coupling methods of the bone conduction hearing aid (BCHA). Experiments were conducted on five Thiel embalmed whole head cadaver specimens. An electromagnetic actuator from a commercial BCHA was mounted on a 5-Newton steel headband, at the mastoid, on a percutaneously implanted screw (Baha^® Connect), and transcutaneously with a Baha^® Attract (Cochlear Limited, Sydney, Australia), at the clinical bone anchored hearing aid (BAHA) location. Surface motion was quantified by sequentially measuring ∼200 points on the skull surface via a three-dimensional laser Doppler vibrometer (3D LDV) system. The experimental procedure was repeated virtually, using a modified LiUHead finite element model (FEM). Both experiential and FEM methods showed an onset of deformations; first near the stimulation area, at 250-500 Hz, which then extended to the inferior ipsilateral skull surface, at 0.5-2 kHz, and spread across the whole skull above 3-4 kHz. Overall, stiffer coupling (Connect versus Headband), applied at a location with lower mechanical stiffness (the BAHA location versus mastoid), led to a faster transition and lower transition frequency to local deformations and wave motion. This behaviour was more evident at the BAHA location, as the mastoid was more agnostic to coupling condition.

Multicenter Results With an Active Transcutaneous Bone Conduction Implant in Patients With Single-sided Deafness

OBJECTIVE

To evaluate the audiological and subjective benefit from hearing rehabilitation with an active bone conduction implant in subjects with single-sided sensorineural deafness (SSD).

STUDY DESIGN

Prospective, multicenter, single-subject repeated measures.

SETTING

Tertiary referral center, five clinics in Germany and Switzerland.

PATIENTS

Seventeen subjects aged 18 years and older with severe to profound unilateral sensorineural hearing loss and contralateral normal hearing were followed up for 24 months.

INTERVENTION

Active bone conduction implant.

MAIN OUTCOME MEASURES

Speech understanding in noise was assessed in three situations: with signal from front, deaf, or normal hearing side (with noise from front in all set-ups). Subjective benefit was evaluated using the Speech, Spatial, and Qualities of Hearing (SSQ-B) and Bern Benefit in Single-Sided Deafness (BBSS) questionnaire.

RESULTS

When the signal was coming from the deaf side the mean improvement of the speech reception threshold in noise ranged from 1.5 up to 2.2 dB with the device and was statistically and clinically significant at all tested timepoints. No significant difference between the aided and unaided situation was found when signal and noise were coming from the front. With the signal from the normal hearing side no clinically significant difference, that is, greater than 1 dB between the aided and unaided situation was found. The SSQ-B and BBSS questionnaire showed an overall improvement with no significant difference between time points.

CONCLUSIONS

The study demonstrates long-term efficacy and benefit of the device in adults with SSD. Patients reported substantial and persistent subjective benefit from the active bone conduction implant.

Cost Effectiveness of Cochlear Implantation in Single-Sided Deafness

OBJECTIVE

To analyze the cost effectiveness of cochlear implantation (CI) for the treatment of single-sided deafness (SSD).

STUDY DESIGN

Cost-utility analysis in an adapted Markov model.

SETTING

Adults with single-sided deafness in a high-income country.

INTERVENTION

Unilateral CI was compared with no intervention.

MAIN OUTCOME MEASURE

Incremental cost-effectiveness ratios were compared with different cost-effectiveness thresholds ($10,000 to $150,000) for different age, sex, and cost combinations. The calculations were based on the quality-adjusted life year (QALY), national life expectancy tables, and different cost settings. The health utility values for the QALY were either directly collected from published data, or, derived from published data using a regression model of multiple utility indices (regression estimate).

RESULTS

The regression estimate showed an increase of the health utility value from 0.62 to 0.74 for SSD patients who underwent CI. CI for SSD was cost effective for women up to 64 years ($50,000 per-QALY threshold), 80 years ($100,000 per-QALY threshold), and 86 years ($150,000 per-QALY threshold). For men, these values were 58, 77, and 84, respectively. Changing the discount rate by up to 5% further increased the cutoff ages up to 5 years. A detailed cost and age sensitivity analysis is presented and allows testing for cost effectiveness in local settings worldwide.

CONCLUSIONS

CI is a cost-effective option to treat patients with SSD.

Transcutaneous and percutaneous bone conduction sound propagation in single-sided deaf patients and cadaveric heads

OBJECTIVE

To investigate transcranial transmission (TT) and the dampening effect of the skin in patients and cadaver heads.

DESIGN

In patients a pure tone bone conduction audiogram for ipsilateral and contralateral stimulation was performed. The TT was defined as the difference between ipsilateral and contralateral hearing thresholds. In cadaver heads ipsilateral and contralateral promontory motion was measured using a three-dimensional Laser Doppler Vibrometer system.

STUDY SAMPLE

Seven single-sided deaf patients fitted with a Baha^® Connect, fifteen single-sided deaf patients without a bone conduction hearing aid and five Thiel-embalmed cadaver heads were included.

RESULTS

The TT decreased with increasing frequency in patients and cadaver heads. No significant difference was seen between patients and cadaver heads. Measurements on patients and cadaver heads showed increasing skin attenuation with increasing frequency. However, the dampening effect was 3-12 dB higher in patients than in cadavers at all frequencies.

CONCLUSION

The TT was not significantly different for patients compared to cadaver heads. The value of promontory motion to estimate TT in patients need to be further evaluated. The skin attenuates a BC stimulus by 10-20 dB in patients and by a smaller amount in cadaver heads, probably due to changes in the properties of the Thiel-conserved skin.

Contribution of the flexible incudo-malleal joint to middle-ear sound transmission under static pressure loads

The incudo-malleal joint (IMJ) in the human middle ear is a true diarthrodial joint and it has been known that the flexibility of this joint does not contribute to better middle-ear sound transmission. Previous studies have proposed that a gliding motion between the malleus and the incus at this joint prevents the transmission of large displacements of the malleus to the incus and stapes and thus contributes to the protection of the inner ear as an immediate response against large static pressure changes. However, dynamic behavior of this joint under static pressure changes has not been fully revealed. In this study, effects of the flexibility of the IMJ on middle-ear sound transmission under static pressure difference between the middle-ear cavity and the environment were investigated. Experiments were performed in human cadaveric temporal bones with static pressures in the range of +/- 2 kPa being applied to the ear canal (relative to middle-ear cavity). Vibrational motions of the umbo and the stapes footplate center in response to acoustic stimulation (0.2-8 kHz) were measured using a 3D-Laser Doppler vibrometer for (1) the natural IMJ and (2) the IMJ with experimentally-reduced flexibility. With the natural condition of the IMJ, vibrations of the umbo and the stapes footplate center under static pressure loads were attenuated at low frequencies below the middle-ear resonance frequency as observed in previous studies. After the flexibility of the IMJ was reduced, additional attenuations of vibrational motion were observed for the umbo under positive static pressures in the ear canal (EC) and the stapes footplate center under both positive and negative static EC pressures. The additional attenuation of vibration reached 4~7 dB for the umbo under positive static EC pressures and the stapes footplate center under negative EC pressures, and 7~11 dB for the stapes footplate center under positive EC pressures. The results of this study indicate an adaptive mechanism of the flexible IMJ in the human middle ear to changes of static EC pressure by reducing the attenuation of the middle-ear sound transmission. Such results are expected to be used for diagnosis of the IMJ stiffening and to be applied to design of middle-ear prostheses.

Assessment of Surgical Complications With Respect to the Surgical Indication: Proposal for a Novel Index

Introduction: The Clavien–Dindo classification is a broadly accepted surgical complications classification system, grading complications by the extent of therapy necessary to resolve them. A drawback of the method is that it does not consider why the patient was operated on primarily.

Methods: We designed a novel index based on Clavien–Dindo but with respect to the surgical indication. We surveyed an international panel of otolaryngologists who filled out a questionnaire with 32 real case-inspired scenarios. Each case was graded for the surgical complication, surgical indication, and a subjective rating whether the complication was acceptable or not.

Results: Seventy-seven otolaryngologists responded to the survey. Mean subjective rating and surgical complication grading for each scenario showed an inverse correlation (r² = 0.147, p = 0.044). When grading the surgical complication with respect to the surgical indication, the correlation with the subjective rating increased dramatically (r² = 0.307, p = 0.0022).

Conclusion: We describe a novel index grading surgical complications with respect to the surgical indication. In our survey, most respondents judged a complication as acceptable or not according to its grade but kept in mind the surgical indication. This subjective judgment could be quantified with our novel index.

Pre-habilitation Before Vestibular Schwannoma Surgery-Impact of Intratympanal Gentamicin Application on the Vestibulo-Ocular Reflex

Background: Patients with vestibular schwannoma that show residual peripheral-vestibular function before surgery may experience sudden and substantial vestibular loss of function after surgical resection. To alleviate the sudden loss of peripheral-vestibular function after vestibular-schwannoma (VS) resection, pre-surgical intratympanic gentamicin application was proposed. Objective: We hypothesized that this approach allows for a controlled reduction of peripheral-vestibular function before surgery but that resulting peripheral-vestibular deficits may be canal-specific with anterior-canal sparing as observed previously in systemic gentamicin application. Methods: Thirty-four patients (age-range = 27-70 y) with unilateral VS (size = 2-50 mm) were included in this retrospective single-center trial. The angular vestibulo-ocular reflex (aVOR) was quantified before and after (29.7 ± 18.7 d, mean ± 1SD) a single or two sequential intratympanic gentamicin applications by use of video-head-impulse testing. Both aVOR gains, cumulative saccadic amplitudes, and overall aVOR function were retrieved. Statistical analysis was done using a generalized linear model. Results: At baseline, loss of function of the horizontal (20/34) and posterior (21/34) canal was significantly (p < 0.001) more frequent than that of the anterior canal (5/34). After gentamicin application, loss of function of the horizontal (32/34) or posterior (31/34) canal remained significantly (p ≤ 0.003) more frequent than that of the anterior canal (18/34). For all ipsilesional canals, significant aVOR-gain reductions and cumulative-saccadic-amplitude increases were noted after gentamicin. For the horizontal canal, loss of function was significantly larger (increase in cumulative-saccadic-amplitude: 1.6 ± 2.0 vs. 0.8 ± 1.2, p = 0.007) or showed a trend to larger changes (decrease in aVOR-gain: 0.24 ± 0.22 vs. 0.13 ± 0.29, p = 0.069) than for the anterior canal. Conclusions: Intratympanic gentamicin application resulted in a substantial reduction in peripheral-vestibular function in all three ipsilesional canals. Relative sparing of anterior-canal function noted at baseline was preserved after gentamicin treatment. Thus, pre-surgical intratympanic gentamicin is a suitable preparatory procedure for reducing the drop in peripheral-vestibular function after VS-resection. The reasons for relative sparing of the anterior canal remain unclear.

[Experimental Evaluation of the Adhear, a Novel Transcutaneous Bone Conduction Hearing Aid]

OBJECTIVE

Different bone conduction hearing aids (BCHA) are commercially available. They are attached to the head in different ways. The aim of this work is an experimental evaluation of the performance of a new transcutaneous (surface mounted via adhesive pad) actuator of a BCHA.

MATERIAL AND METHODS

Experiments were conducted on a Thiel embalmed whole head cadaver specimen. The electromagnetic actuators from a commercial BCHA (Adhear) was used to provide stepped sine stimulus in the range of 0.1-10 kHz. The BCHA was coupled to a skin surface adhesion that was placed on the mastoid. The response was monitored as motions of the ipsi- and contralateral promontory, and as motions of the ipsi-, top- and contralateral skull surface. Promontory motion was quantified via a three-dimensional laser Doppler vibrometer (3D LDV) system. Analogously, surface motion was registered by sequentially measuring ~200 points on the skull surface (~ 15-20 mm pitch) via 3D LDV. The data were compared to corresponding measurements obtained with a Baha Power that was coupled to skin on the Mastoid via a 5 Newton steelband.

RESULTS

Ipsilateral and contralateral promontory vibration for stimulation with the Adhear are comparable to stimulation with the Baha Power on the 5 Newton steelband with regard to frequency dependent amplitude and phase, as well as the contribution of the motion components. The surface motion of the skull experiences a similar complex motion for both stimulation modes.

CONCLUSIONS

Although the Adhear is coupled without any pressure to the skin over the mastoid whereas the Baha power is attached with a 5 Newton steelband, the vibration parameters investigated are comparable.

Measuring health-related quality of life in chronic otitis media in a Chinese population: cultural adaption and validation of the Zurich Chronic Middle Ear Inventory (ZCMEI-21-Chn)

Background

The demand for assessing health-related quality of life (HRQoL) in chronic otitis media (COM) is increasing globally. The currently available Chinese-language patient-reported outcome measurement (PROM) specific for COM includes merely a limited range of related symptoms and dimensions. Hence, in this study, we aim to translate, culturally adapt, and validate the Zurich Chronic Middle Ear Inventory (ZCMEI-21) in Chinese, to enable a comprehensive evaluation of the patients’ subjective health outcome in COM.

Methods

We sampled and surveyed 223 COM patients at three tertiary referral centers in China, using the Chinese translation of ZCMEI-21 (ZCMEI-21-Chn) and the EQ-5D questionnaire, a generic measure of HRQoL. Confirmatory factor analysis (CFA) was performed to investigate the structural model fit to the dataset. Cronbach’s α and test-retest reliability coefficient were calculated to establish reliability, and correlation was tested between ZCMEI-Chn scores and EQ-5D scores for convergent validity.

Results

A total of 208 adult patients with COM were included, with a mean age of 46 years (SD 14 years) and a male proportion of 41% (85/208). A modified bifactor model with ω_H of 0.65 and ECV of 0.47 was found to fit the scale scores, indicating fair general factor saturation and multidimensionality of the instrument. ZCMEI-21-Chn demonstrated good reliability (Cronbach’s α = 0.88, test-retest reliability = 0.88). The total scores of ZCMEI-21-Chn had a moderate correlation with a question directly addressing HRQoL (r = 0.40, p < 0.001), EQ-5D descriptive system score (r = 0.57, p < 0.001), and EQ-5D visual analogous scale (r = 0.30, p < 0.001).

Conclusions

The ZCMEI-21-Chn is valid, reliable and culturally adapted to Chinese adult patients with COM. This study offers clinicians an efficient and comprehensive instrument to quantify COM patients’ self-reported health outcomes, which could facilitate the standardization of HRQoL data aggregation in COM on a global scale.

Human Cochlear Nucleus on 7 Tesla Diffusion Tensor Imaging: Insights Into Micro-anatomy and Function for Auditory Brainstem Implant Surgery

OBJECTIVE

The cochlear nucleus (CN) is the target of the auditory brainstem implant (ABI). Most ABI candidates have Neurofibromatosis Type 2 (NF2) and distorted brainstem anatomy from bilateral vestibular schwannomas. The CN is difficult to characterize as routine structural MRI does not resolve detailed anatomy. We hypothesize that diffusion tensor imaging (DTI) enables both in vivo localization and quantitative measurements of CN morphology.

STUDY DESIGN

We analyzed 7 Tesla (T) DTI images of 100 subjects (200 CN) and relevant anatomic structures using an MRI brainstem atlas with submillimetric (50 μm) resolution.

SETTING

Tertiary referral center.

PATIENTS

Young healthy normal hearing adults.

INTERVENTION

Diagnostic.

MAIN OUTCOME MEASURES

Diffusion scalar measures such as fractional anisotropy (FA), mean diffusivity (MD), mode of anisotropy (Mode), principal eigenvectors of the CN, and the adjacent inferior cerebellar peduncle (ICP).

RESULTS

The CN had a lamellar structure and ventral-dorsal fiber orientation and could be localized lateral to the inferior cerebellar peduncle (ICP). This fiber orientation was orthogonal to tracts of the adjacent ICP where the fibers run mainly caudal-rostrally. The CN had lower FA compared to the medial aspect of the ICP (0.44 ± 0.09 vs. 0.64 ± 0.08, p < 0.001).

CONCLUSIONS

7T DTI enables characterization of human CN morphology and neuronal substructure. An ABI array insertion vector directed more caudally would better correspond to the main fiber axis of CN. State-of-the-art DTI has implications for ABI preoperative planning and future image guidance-assisted placement of the electrode array.

Dependence of skull surface wave propagation on stimulation sites and direction under bone conduction

In order to better understand bone conduction sound propagation across the skull, three-dimensional (3D) wave propagation on the skull surface was studied, along with its dependence on stimulation direction and location of a bone conduction hearing aid (BCHA) actuator. Experiments were conducted on five Thiel embalmed whole head cadaver specimens. Stimulation, in the 0.1-10 kHz range, was sequentially applied at the forehead and mastoid via electromagnetic actuators from commercial BCHAs, supported by a 5-N steel band. The head response was quantified by sequentially measuring the 3D motion of ∼200 points (∼15-20 mm pitch) across the ipsilateral, top, and contralateral skull surface via a 3D laser Doppler vibrometer (LDV) system, guided by a robotic positioner. Low-frequency stimulation (<1 kHz) resulted in a spatially complex rigid-body-like motion of the skull that depended on both the stimulation condition and head support. The predominant motion direction was only 5-10 dB higher than other components below 1 kHz, with no predominance at higher frequencies. Sound propagation direction across the parietal plates did not coincide with stimulation location, potentially due to the head base and forehead remaining rigid-like at higher frequencies and acting as a large source for the deformation patterns across the parietal sections.

Predictive Value of Pretherapeutic Maximum Standardized Uptake Value (Suvmax) In Laryngeal and Hypopharyngeal Cancer

The aim of the study was to evaluate whether pretherapeutic metabolic tumor parameters from 18-fluorodeoxyglucose positron emission tomography (FDG-PET) imaging could predict larynx preservation in laryngeal and hypopharyngeal cancer patients prior to primary chemoradiation. Tumor metabolic parameters [maximum standardized uptake value (SUV_max), metabolic tumor volume (MTV), and total lesion glycolysis (TLG)] were retrospectively assessed in a consecutive cohort of laryngeal and hypopharyngeal cancer patients undergoing primary (chemo-)radiation. Main outcome measures were larynx preservation and survival. The study included 97 patients with a median follow-up of 32 months (IQR 20-54.5). For hypopharyngeal cancer, multivariable analysis showed that patients with a primary tumor's SUV_max > 9.5 entailed a higher risk of undergoing salvage pharyngolaryngectomy after chemoradiation (HR = 8.64, 95% CI = 1.1-67.3, P = 0.040). In laryngeal cancer, SUV_max did not predict the need for salvage laryngectomy. The only predictor for larynx preservation in laryngeal cancer patients was T-classification at initial diagnosis (HR = 6.67, 95% CI = 0.82-53.9, P = 0.039). In conclusion, SUV_max of primary tumor could be used as a predictor of larynx preservation prior to primary chemoradiation in hypopharyngeal cancer patients. This information may be important for patient counseling, as high SUV_max was correlated with reduced probability of larynx preservation. However, in laryngeal cancer patients, SUV_max does not seem to be predictive of outcome.

Super-resolution Diffusion Tensor Imaging for Delineating the Facial Nerve in Patients with Vestibular Schwannoma

Objectives  Predicting the course of cranial nerves (CNs) VII and VIII in the cerebellopontine angle on preoperative imaging for vestibular schwannoma (VS) may help guide surgical resection and reduce complications. Diffusion magnetic resonance imaging dMRI is commonly used for this purpose, but is limited by its resolution. We investigate the use of super-resolution reconstruction (SRR), where several different dMRIs are combined into one dataset. We hypothesize that SRR improves the visualization of the CN VII and VIII. Design  Retrospective case review. Setting  Tertiary referral center. SRR was performed on the basis of axial and parasagittal single-shot epiplanar diffusion tensor imaging on a 3.0-tesla MRI scanner. Participants  Seventeen adult patients with suspected neoplasms of the lateral skull base. Main Outcome Measures  We assessed separability of the two distinct nerves on fractional anisotropy (FA) maps, the tractography of the nerves through the cerebrospinal fluid (CSF), and FA in the CSF as a measure of noise. Results  SRR increases separability of the CN VII and VIII (16/17 vs. 0/17, p  = 0.008). Mean FA of CSF surrounding the nerves is significantly lower in SRRs (0.07 ± 0.02 vs. 0.13 ± 0.03 [axial images]/0.14 ± 0.05 [parasagittal images], p  = 0.00003/ p  = 0.00005). Combined scanning times (parasagittal and axial) used for SRR were shorter (8 minute 25 seconds) than a comparable high-resolution scan (15 minute 17 seconds). Conclusion  SRR improves the resolution of CN VII and VIII. The technique can be readily applied in the clinical setting, improving surgical counseling and planning in patients with VS.

The Role of Non-Echoplanar Diffusion-Weighted Magnetic Resonance Imaging in Diagnosis of Primary Cholesteatoma and Cholesteatoma Recidivism as an Adjunct to Clinical Evaluation

Introduction:

The aim of this study was to analyze the sensitivity and specificity of non-echoplanar (non-EPI) diffusion-weighted (DW) magnetic resonance imaging (MRI) for the detection of cholesteatoma, with a focus on its value as an adjunct to clinical examination.

Methods:

In a prospective cohort study, 92 cases were divided into 2 groups: “clinically cholesteatoma” ( n = 79) and “clinically no cholesteatoma” ( n = 13). Non-EPI DW MRI was performed preoperatively in all cases. The presence of a cholesteatoma was assessed by clinicians otoscopically, by neuroradiologists on non-EPI DW MRI, by the surgeon intraoperatively, and finally by the pathologist postoperatively. Data analysis was performed for specificity, sensitivity, positive predictive value, negative predictive value, and interrater variability.

Results:

The sensitivity and specificity were 89.3% and 75%, respectively, in the “clinically cholesteatoma” group and 0% and 100% in the “clinically no cholesteatoma” group. Non-EPI DW MRI had a positive predictive value of 98.5% when cholesteatoma was suspected clinically and a negative predictive value of 84.6% when cholesteatoma was not suspected clinically.

Conclusion:

If cholesteatoma is suspected clinically, non-EPI DW MRI is not necessary. If there is no clinical suspicion of cholesteatoma in second-look situations, sensitivity is low and serial follow-up MRI with long intervals is advised.

Japanese translation, cross-cultural adaption and multicentre validation of the Zurich chronic middle ear inventory (ZCMEI-21-Jap)

OBJECTIVE

In the assessment of chronic otitis media (COM) and its treatment, patient-reported outcomes are becoming increasingly important. The aim of the present study was to translate and validate the Zurich chronic middle ear inventory (ZCMEI-21) in Japanese in order to provide the first Japanese-language instrument for measuring health-related quality of life (HRQoL) in COM.

METHODS

The ZCMEI-21 was translated into Japanese according to published guidelines. In order to assess validity, the ZCMEI-21-Jap total score was compared to a question directly addressing HRQoL as well as the five-level version of the EQ-5D questionnaire, a generic measure of HRQoL.

RESULTS

Demographic data and validity were assessed in a total of 91 COM patients. The ZCMEI-21-Jap total and subscale scores were well comparable to those of the original validation study. Cronbach's α of the ZCMEI-21-Jap was 0.85, indicating an excellent internal consistency. The ZCMEI-21-Jap total score showed a strong correlation (r=0.68, p<0.0001) to the question directly addressing HRQoL and, as expected, only a moderate correlation to the EQ-5D scores (r=0.49, p<0.0001 for descriptive system score and r=0.44, p<0.0001 for VAS score).

CONCLUSION

We successfully translated the ZCMEI-21 into Japanese and were able to obtain sufficient information during the validation process for the use of the ZCMEI-21-Jap to quantify HRQoL in patients with COM. With the current study, we aim to take a step forward towards an international standardization of reporting HRQoL in COM.

Biologic therapies for refractory juvenile dermatomyositis: five years of experience of the Childhood Arthritis and Rheumatology Research Alliance in North America

BACKGROUND

The prognosis of children with juvenile dermatomyositis (JDM) has improved remarkably since the 1960's with the use of corticosteroid and immunosuppressive therapy. Yet there remain a minority of children who have refractory disease. Since 2003 the sporadic use of biologics (genetically-engineered proteins that usually are derived from human genes) for inflammatory myositis has been reported. In 2011-2016 we investigated our collective experience of biologics in JDM through the Childhood Arthritis and Rheumatology Research Alliance (CARRA).

METHODS

The JDM biologic study group developed a survey on the CARRA member experience using biologics for Juvenile DM utilizing Delphi consensus methods in 2011-2012. The survey was completed online by the CARRA members interested in JDM in 2012. A second survey was similarly developed that provided more opportunity to describe their experiences with biologics in JDM in detail and was completed by CARRA members in Feb 2013. During three CARRA meetings in 2013-2015, nominal group techniques were used for achieving consensus on the current choices of biologic drugs. A final survey was performed at the 2016 CARRA meeting.

RESULTS

One hundred and five of a potential 231 pediatric rheumatologists (42%) responded to the first survey in 2012. Thirty-five of 90 had never used a biologic for Juvenile DM at that time. Fifty-five of 91 (denominators vary) had used biologics for JDM in their practice with 32%, 5%, and 4% using rituximab, etanercept, and infliximab, respectively, and 17% having used more than one of the three drugs. Ten percent used a biologic as monotherapy, 19% a biologic in combination with methotrexate (mtx), 52% a biologic in combination with mtx and corticosteroids, 42% a combination of a biologic, mtx, corticosteroids (steroids), and an immunosuppressive drug, and 43% a combination of a biologic, IVIG and mtx. The results of the second survey supported these findings in considerably more detail with multiple combinations of drugs used with biologics and supported the use of rituximab, abatacept, anti-TNFα drugs, and tocilizumab in that order. One hundred percent recommended that CARRA continue studying biologics for JDM. The CARRA meeting survey in 2016 again supported the study and use of these four biologic drug groups.

CONCLUSIONS

Our CARRA JDM biologic work group developed and performed three surveys demonstrating that pediatric rheumatologists in North America have been using multiple biologics for refractory JDM in numerous scenarios from 2011 to 2016. These survey results and our consensus meetings determined our choice of four biologic therapies (rituximab, abatacept, tocilizumab and anti-TNFα drugs) to consider for refractory JDM treatment when indicated and to evaluate for comparative effectiveness and safety in the future. Significance and Innovations This is the first report that provides a substantial clinical experience of a large group of pediatric rheumatologists with biologics for refractory JDM over five years. This experience with biologic therapies for refractory JDM may aid pediatric rheumatologists in the current treatment of these children and form a basis for further clinical research into the comparative effectiveness and safety of biologics for refractory JDM.

Development and validation of the Zurich chronic middle ear inventory (ZCMEI-21): an electronic questionnaire for assessing quality of life in patients with chronic otitis media

Because existing patient-reported outcome measures (PROMs) specific for chronic otitis media (COM) are lacking certain relevant symptoms and dimensions of health-related quality of life (HRQoL), we aimed to develop and validate a new questionnaire for comprehensively measuring HRQoL in adult patients with COM. An expert panel and patients were involved in developing the first version of the Zurich chronic middle ear inventory, containing 33 items (ZCMEI-33). An electronic application was chosen not only to provide maximal data quality, but also to facilitate and accelerate data analysis. Item reduction was performed by testing the questionnaire in a first cohort (n = 85). Using sequential statistical analysis, the ZCMEI-33 was reduced to 21 items (ZCMEI-21). Subsequently, the ZCMEI-21 was validated in a second cohort (n = 76). Validation revealed a Cronbach's α of 0.91, indicating excellent internal consistency. Moreover, the ZCMEI-21 was able to discriminate between patients with COM and healthy participants (p < 0.0001), thus possessing good discrimination validity. Assessing criterion validity, the ZCMEI-21 total score was compared to a question directly addressing HRQoL and the EQ-5D descriptive system score, a generic measure of HRQoL. Whereas the ZCMEI-21 total score and the EQ-5D descriptive system score were only moderately correlated (r = 0.60, p < 0.0001), the ZCMEI-21 total score and the question directly addressing HRQoL showed a strong correlation (r = 0.74, p < 0.0001). In conclusion, sufficient information on reliability and validity was obtained to propagate the application of the ZCMEI-21 to quantify HRQoL in patients with COM.

Extra- and Intracochlear Electrocochleography in Cochlear Implant Recipients

Objective: To monitor cochlear function by extra- and intracochlear electrocochleography (ECoG) during and after cochlear implantation and thereby to enhance the understanding of changes in cochlear function following cochlear implantation surgery. Methods: ECoG responses to acoustic stimuli of 250, 500 and 1,000 Hz were recorded in 9 cochlear implant recipients with presurgical residual hearing. During surgery extracochlear ECoG recordings were performed before and after insertion of the cochlear implant electrode array. After insertion of the electrode array, intracochlear ECoG recordings were conducted using intracochlear electrode contacts as recording electrodes. Intracochlear ECoG recordings were performed up to 6 months after implantation. ECoG findings were correlated with findings from audiometric tests. Results: Extra- and intracochlear ECoG responses could be recorded in all subjects. Extracochlear ECoG recordings during surgery showed moderate changes. Loss or reduction of the ECoG signal at all three frequencies did not occur during cochlear implantation. During the first week following surgery, conductive hearing loss, due to middle ear effusion, led to a decrease in intracochlear ECoG signal amplitudes. This was not attributable to changes of cochlear function. All persistent reductions in ECoG response magnitude after normalization of the tympanogram occurred during the first week following implantation. Thresholds of ECoG signals were at or below hearing thresholds in all cases. Conclusion: Gross intracochlear trauma during surgery appears to be rare. In the early postoperative phase the ability to assess cochlear status by ECoG recordings was limited due to the regular occurrence of middle ear effusion. Still, intracochlear ECoG along with tympanogram recordings suggests that any changes of low-frequency cochlear function occur mainly during the first week after cochlear implantation. ECoG seems to be a promising tool to objectively assess changes in cochlear function in cochlear implant recipients and may allow further insight into the mechanisms underlying the loss of residual hearing.

The effect of rocking stapes motions on the cochlear fluid flow and on the basilar membrane motion

The basilar membrane (BM) and perilymph motion in the cochlea due to rocking stapes motion (RSM) and piston-like stapes motion (PSM) is modeled by numerical simulations. The full Navier-Stokes equations are solved in a two-dimensional box geometry. The BM motion is modeled by independent oscillators using an immersed boundary technique. The traveling waves generated by both stimulation modes are studied. A comparison of the peak amplitudes of the BM motion is presented and their dependence on the frequency and on the model geometry (stapes position and cochlear channel height) is investigated. It is found that the peak amplitudes for the RSM are lower and decrease as frequency decreases whereas those for the PSM increase as frequency decreases. This scaling behavior can be explained by the different mechanisms that excite the membrane oscillation. Stimulation with both modes at the same time leads to either a slight increase or a slight decrease of the peak amplitudes compared to the pure PSM, depending on the phase shift between the two modes. While the BM motion is dominated by the PSM mode under normal conditions, the RSM may lead to hearing if no PSM is present or possible, e.g., due to round window atresia.

[NiTiBOND an optimized self-crimping stapes prosthesis for treatment of otosclerosis]

BACKGROUND

Compared to traditional stapes prostheses, self-crimping prostheses have been shown to result in similar, if not better, closure of the air bone gap in patients undergoing stapedotomy for otosclerosis. To achieve self-crimping, nitinol, a shape memory alloy, has been used for several years but concerns have been raised regarding possible damage to the incus and its muco-periosteum. We investigate these concerns with regard to the newer NiTiBOND stapes prosthesis in an observational multi-centre study.

MATERIAL AND METHODS

In a multicentre, prospective observational study, 76 patients undergoing stapedotomy with the NiTiBond prosthesis across 4 centres were compared to 75 -retrospectively selected control SMart patients. Complications, intra-operative user-friendliness and audiological results at 3 months were documented.

RESULTS

Audiological improvement and the rate of complications were similar in both groups. Non inferiority was shown at all frequencies and in the pure-tone average. The NiTiBOND prosthesis was described as very user-friendly.

CONCLUSIONS

By eliminating manual crimping, stapedotomy using the NiTiBOND prosthesis can be facilitated and standardized. Furthermore, intraoperative handling characteristics of the prosthesis are very good which may further reduce operative risk. Importantly, we show that these benefits are not to the detriment of audiological outcome. Larger and longer-term studies are required to further evaluate results.

The development of bone mineral lateralization in the arms

Bone mineral content (BMC) is known to be greater in the dominant arm after the age of 8 years. We studied a group of children and found that BMC sidedness gradually increased up to the age of 6 years and then remained stable into late adolescence.

INTRODUCTION

Bone mineral content (BMC) exhibits sidedness in the arms after the age of 8 years, but it is not known whether BMC is greater in the dominant arm from birth or whether lateralization develops in early childhood. To address this, we examined bone mineral status in relation to handedness and age.

METHODS

Subjects (N = 158) were children recently initiating glucocorticoids for underlying disease (leukemia 43 %, rheumatic conditions 39 %, nephrotic syndrome 18 %). Handedness was determined by questionnaire and BMC by dual-energy X-ray absorptiometry.

RESULTS

Median age was 7.2 years (range, 1.5 to 17.0 years), 49 % was male, and the spine BMD Z-score was -0.9 (SD, 1.3). By linear regression, BMC sidedness in the arms was significantly related to age (r = 0.294, p = 0.0005). Breakpoint analysis revealed two lines with a knot at 6.0 years (95 % CI, 4.5-7.5 years). The formula for the first line was: dominant:nondominant arm BMC ratio = 0.029 × age [in years] + 0.850 (r = 0.323, p = 0.017). The slope of the second line was not different from 0 (p = 0.332), while the slopes for the two lines were significantly different (p = 0.027).

CONCLUSIONS

These results show that arm BMC sidedness in this patient group develops up to age 6 years and then remains stable into late adolescence. This temporal profile is consistent with mechanical stimulation of the skeleton in response to asymmetrical muscle use as handedness becomes manifest.

Facial nerve motor evoked potentials during skull base surgery to monitor facial nerve function using the threshold-level method

Object

During surgeries that put the facial nerve at risk for injury, its function can be continuously monitored by transcranial facial nerve motor evoked potentials (FNMEPs) in facial nerve target muscles. Despite their advantages, FNMEPs are not yet widely used. While most authors use a 50% reduction in FNMEP response amplitudes as a warning criterion, in this paper the authors' approach was to keep the response amplitude constant by increasing the stimulation intensity and to establish a warning criterion based on the “threshold-level” method.

Methods

The authors included 34 consecutive procedures involving 33 adult patients (median age 47 years) in whom FNMEPs were monitored. A threshold increase greater than 20 mA for eliciting FNMEPs in the most reliable facial nerve target muscle was considered a prediction of reduced postoperative facial nerve function, and subsequently a warning was issued to the surgeon. Preoperative and early postoperative function was documented using the House-Brackmann grading system.

Results

Monitoring of FNMEPs was feasible in all 34 surgeries in at least one facial nerve target muscle. The mentalis muscle yielded the best results. The House-Brackmann grade deteriorated in 17 (50%) of 34 cases. The warning criterion was reached in 18 (53%) of 34 cases, which predicted an 83% risk of House-Brackmann grade deterioration. Sensitivity amounted to 88% (CI 64%–99%) and specificity to 82% (CI 57%–96%). Deterioration of FNMEPs and a worse House-Brackmann grade showed a high degree of association (p < 0.001). The impact of FNMEP monitoring on surgical strategy is exemplified in an illustrative case.

Conclusions

In surgeries that put the facial nerve at risk, the intraoperative increase in FNMEP stimulation threshold was closely correlated to postoperative facial nerve dysfunction. Monitoring of FNMEPs is a valid indicator of facial nerve function in skull base surgery. It should be used as an adjunct to direct electrical facial nerve stimulation and continuous electromyographic monitoring of facial nerve target muscles.

Characterization of stapes anatomy: investigation of human and guinea pig

The accuracy of any stapes model relies on the accuracy of the anatomical information upon which it is based. In many previous models and measurements of the stapes, the shape of the stapes has been considered as symmetric with respect to the long and short axes of the footplate. Therefore, the reference frame has been built based upon this assumption. This study aimed to provide detailed anatomical information on the dimensions of the stapes, including its asymmetries. High-resolution microcomputed tomography data from 53 human stapes and 11 guinea pig stapes were collected, and their anatomical features were analyzed. Global dimensions of the stapes, such as the size of the footplate, height, and volume, were compared between human and guinea pig specimens, and asymmetric features of the stapes were quantitatively examined. Further, dependence of the stapes dimensions on demographic characteristics of the subjects was explored. The height of the stapes relative to the footplate size in the human stapes was found to be larger than the corresponding value in guinea pig. The stapes showed asymmetry of the footplate with respect to the long axis and offset of the stapes head from the centroid of the medial surface of the footplate for both humans and guinea pigs. The medial surface of the footplate was curved, and the longitudinal arches of the medial surface along the long axis of the footplate were shaped differently between humans and guinea pigs. The dimension of the footplate was gender-dependent, with the size greater in men than in women.

Pre-, per- and postoperative factors affecting performance of postlinguistically deaf adults using cochlear implants: a new conceptual model over time

OBJECTIVE

To test the influence of multiple factors on cochlear implant (CI) speech performance in quiet and in noise for postlinguistically deaf adults, and to design a model of predicted auditory performance with a CI as a function of the significant factors.

STUDY DESIGN

Retrospective multi-centre study.

METHODS

Data from 2251 patients implanted since 2003 in 15 international centres were collected. Speech scores in quiet and in noise were converted into percentile ranks to remove differences between centres. The influence of 15 pre-, per- and postoperative factors, such as the duration of moderate hearing loss (mHL), the surgical approach (cochleostomy or round window approach), the angle of insertion, the percentage of active electrodes, and the brand of device were tested. The usual factors, duration of profound HL (pHL), age, etiology, duration of CI experience, that are already known to have an influence, were included in the statistical analyses.

RESULTS

The significant factors were: the pure tone average threshold of the better ear, the brand of device, the percentage of active electrodes, the use of hearing aids (HAs) during the period of pHL, and the duration of mHL.

CONCLUSIONS

A new model was designed showing a decrease of performance that started during the period of mHL, and became faster during the period of pHL. The use of bilateral HAs slowed down the related central reorganization that is the likely cause of the decreased performance.

Inversion-recovery single-shot cardiac MRI for the assessment of myocardial infarction at 1.5 T with a dedicated cardiac coil

OBJECTIVE

The aim of this study was to assess the diagnostic accuracy of imaging myocardial infarction with a two-dimensional (2D) single-shot inversion-recovery (IR)-gradient-echo (GE) sequence compared with a standard 2D segmented IR-GE sequence at 1.5 T using a dedicated cardiac coil.

METHODS

22 patients with myocardial infarction documented in the past 3-12 months were examined at 1.5 T using a 5 channel cardiac coil. Imaging of delayed enhancement was performed 15 min after administration of 0.2 mmol of gadopentetate dimeglumine per kilogram of body weight. Immediately after completion of the single-shot sequence, which allows for coverage of the entire ventricle during a single breath-hold with nine slices, the segmented IR sequence was started. Infarct volumes, infarct transmurality and contrast-to-noise ratios (CNRs) of infarcted and healthy myocardium were compared between both techniques.

RESULTS

Despite a moderate, non-significant loss of CNR (CNR(single-shot IR)=31.2±4.1; CNR(segmented IR)=37.9±4.1; p=0.405), the 2D single-shot technique correctly determined infarct size when compared with the standard 2D segmented IR-GE sequence. Assessment of both infarct volume (r=0.95; p<0.0001) and transmurality (r=0.97; p<0.0001) is possible, with excellent correlation of both techniques.

CONCLUSION

Single-shot delayed enhancement imaging during a single breath-hold is feasible at 1.5 T with the use of a dedicated cardiac coil. Despite a moderately lower CNR, the single-shot technique allows for fast and accurate determination of infarct size with high spatial resolution and has the potential to reduce electrocardiogram and breathing artefacts.

Assessment of a direct acoustic cochlear stimulator

This study aimed to assess the functional results of a new, active, acoustic-mechanical hearing implant, the Direct Acoustic Cochlear Stimulation Partial Implant (DACS PI), in a preclinical study. The DACS PI is an electromagnetic device fixed to the mastoid by screws and coupled to a standard stapes prosthesis by an artificial incus (AI). The function of the DACS PI-aided reconstruction was assessed by determining: (1) the maximum equivalent sound pressure level (SPL) of the implant, which was obtained from measurements of the volume displacement at the round window in normal and implanted ears, and (2) the quality at the coupling interface between the AI of the DACS and the stapes prosthesis, which was quantified from measurements of relative motions between the AI and the prosthesis. Both measurements were performed with fresh temporal bones using a scanning laser Doppler interferometry system. The expected maximum equivalent SPL with a typical driving voltage of 0.3 V was about 115-125 dB SPL up to 1.5 kHz in reconstruction with the DACS PI, and decreased with a roll-off slope of about 65 dB/decade, reaching 90 dB SPL at 8 kHz. The large roll-off relative to a normal ear was presumed to be a relatively high inductive impedance of the coil of the DACS PI actuator at higher frequencies. Good coupling quality between the AI and the prosthesis was achieved below the resonance (∼1.5 kHz) of the DACS PI for all tested stapes prostheses. Above the resonance, the SMart Piston, which is composed of a shape-memory alloy, had the best coupling quality.