Otology & Neurotology

Altered Gray Matter Volume and White Matter Integrity in Sensorineural Hearing Loss Patients: A VBM and TBSS Study Objective: The purpose of the present study was to detect structural changes in the brains of patients with sensorineural hearing loss (SNHL) by combining voxel-based morphometry (VBM) and tract-based spatial statistics (TBSS). Methods: Thirty-five patients with SNHL (mean age: 39.72 ± 1.81 yr) and 23 age-matched control subjects (mean age: 39.83 ± 1.96 yr) were assessed using three-dimensional, T1-weighted imaging, and diffusion tensor imaging. TBSS and VBM analyses were performed to evaluate grey matter (GM) volume changes and white matter (WM) alternations, as measured by mean diffusivity (MD), fractional anisotropy (FA), axial diffusivity (AD), and radial diffusivity (RD). Results: VBM showed decreased GM volume in patients with SNHL in the fusiform gyrus of the right temporal lobe and right middle occipital gyrus. TBSS revealed WM integrity changes, including decreased FA and RD and increased RD in several WM regions. However, MD showed no significant difference between patients with SNHL and age-matched controls. Conclusion: Patients with SNHL showed smaller GM volume and WM integrity changes in several regions. Address correspondence and reprint requests to Liwei Zou, Department of Radiology, the Second Hospital of Anhui Medical University, Hefei 230601, Anhui Province, China; E-mail: nike6621@sina.com; Suisheng Zheng, M.D., Department of Radiology, the Second Hospital of Anhui Medical University, Hefei 230601, Anhui Province, China; Medical Image Research Center, Anhui Medical University, Hefei 230601, Anhui Province, China; E-mail: zhengss0509@sina.com This work is currently receiving a grant from Anhui Provincial Public Linkage Projects (1604f0804025), University natural science research project of Anhui province (KJ2018A0201), Science research foundation of Anhui medical university (2017xkj037), and Anhui Provincial General Medicine Clinical Scientific Projects (2016QK089). The authors declare no conflicts of interest. Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

Standardization of the Punch Technique for the Implantation of Bone Anchored Auditory Devices: Evaluation of the MIPS Surgical Set Objective: To describe and assess intraoperative and postoperative outcomes in the insertion of osseointegrated auditory implants with a newly designed surgical instrumentation set through a punch type technique. Study Design: Retrospective case series. Methods: Patients who underwent bone anchored auditory implant surgery using the Minimally Invasive Ponto Surgery (Oticon Medical, Somerset, NJ) surgical set through a punch technique at nine neurotology tertiary referral based practices were identified. Demographic data, skin thickness at implant site, implant used, duration of surgery, adverse intraoperative events, and postoperative outcomes were recorded. Results: Seventy-five patients comprised the study cohort (32 males, 43 females). Most patients (57. 3%) were aged 51 to 75 years while 30.7% of the cohort comprised those aged 18 to 50 years and 12% were over 75 years. All but two patients received 4 mm fixtured implants and 68% received the Oticon Medical BioHelix implant. Two patients received 3 mm fixture implants and 32% received the Oticon Medical Wide Ponto implant. Mean surgical time was 12.2 minutes (6–45 min, standard deviation of 6.88 min). In three instances, surgery was converted to a linear incision to control brisk bleeding. Skin condition was Holgers 0 to 1 in 91.8%, while 5.5% had Holgers 2, and 2.7% had Holgers 3 at the first postoperative visit. At second postoperative visit, 94.3% had Holgers 0 to 1, 4.3% had Holgers 2, and 1.4% had Holgers 3. All instances of adverse skin reactions were treated with topical or systemic antibiotics and/or local debridement. There were no instances of implant loss. One patient had his implant traumatically displaced to a 45-degree angle necessitating implant replacement at a second site. Conclusion: Punch technique placement of osseointegrated auditory implants using the Minimally Invasive Ponto Surgery surgical set represents a safe technique that further simplifies a progressively minimally invasive surgery. Address correspondence and reprint requests to Harold Hyon Soo Kim, M.D., NW Ear Institute, 2230 NW Pettygrove Street, Suite 120, Portland, OR 97214; E-mail: galbey@yahoo.com H.H.S.K. is a consultant for Oticon Medical (Somerset, NJ). The authors disclose no conflicts of interest. Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

Age Dependent Cost-Effectiveness of Cochlear Implantation in Adults. Is There an Age Related Cut-off? Objective: To analyze the impact of age at implantation on the cost-effectiveness of cochlear implantation (CI). Study Design: Cost-utility analysis in an adapted Markov model. Setting: Adults with profound postlingual hearing loss in a "high income" country. Intervention: Unilateral and sequential CI were compared with hearing aids (HA). Main Outcome Measure: Incremental cost-effectiveness ratio (ICER), calculated as costs per quality adjusted life year (QALY) gained (in CHF/QALY), for individual age and sex combinations in relation to two different willingness to pay thresholds. 1 CHF (Swiss franc) is equivalent to 1.01 USD. Results: When a threshold of 50,000 CHF per QALY is applied, unilateral CI in comparison to HA is cost-effective up to an age of 91 for women and 89 for men. Sequential CI in comparison to HA is cost-effective up to an age of 87 for women and 85 for men. If a more contemporary threshold of 100,000 CHF per QALY is applied, sequential CI in comparison to unilateral CI is cost-effective up to an age of 80 for women and 78 for men. Conclusions: Performing both sequential and unilateral CI is cost-effective up to very advanced ages when compared with hearing aids. Address correspondence and reprint requests to Roman D. Laske, M.D., Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Zurich, Frauenklinikstr. 24, 8091 Zürich, Switzerland; E-mail: laske@gmx.ch R.D.L. and M.D. have contributed equally for this manuscript. Sources of support: None. Disclosure of funding: None. The authors disclose no conflicts of interest. Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

Temporal Bone Histopathology Case of the Month: Basal Cell Carcinoma of the Middle Ear Following Chemoradiation to the Head and Neck No abstract available

Audiologic and Otologic Complications of Cryptococcal Meningoencephalitis in Non-HIV Previously Healthy Patients Objective: To identify audiologic and otologic outcomes in previously healthy non-HIV patients with cryptococcal meningoencephalitis (CM). Study Design: Retrospective case review of a subset of patients recruited in a prospective observational study following previously healthy individuals who developed CM. Setting: Tertiary referral center, National Institutes of Health Clinical Center. Patients: Previously healthy adult patients with CM without immune suppressive therapy before disease onset. Interventions: Diagnostic evaluations included audiometry, acoustic immittance, otoacoustic emissions, and auditory brainstem response studies, in addition to neurotologic assessment. Results: Twenty-nine patients (58 years) underwent audiologic evaluation between 6 months and 3.5 years after CM diagnosis; 21 patients were seen for longitudinal assessment with an average duration of follow up of 20.3 months. Nearly three-quarters (73%) of the cohort presented with hearing loss, most commonly (90%) sensorineural in origin. The most frequent degree of loss was mild and then moderate, although some patients had severe or profound impairment. Hearing loss improved (43%) or remained stable (38%) in most cases. Ears with internal auditory canal enhancement on magnetic resonance imaging (MRI) had significantly more hearing loss than those without enhancement, although a similar finding was not observed with gyral enhancement or the presence of ependymitis or ventricular volume expansion. Hearing loss was not associated with reduced cerebrospinal fluid (CSF) glucose, CSF total protein, cryptococcal antigen, or total cell count. Conclusions: Hearing loss is a common manifestation of cryptococcal meningitis in previously healthy patients and may involve a cochlear or neural site of lesion, or both. Routine surveillance of hearing in patients is recommended, regardless of symptomatology, to ensure early and appropriate intervention and care. Address correspondence and reprint requests to Peter R. Williamson, 9000 Rockville Pike, Bldg. 10, Rm. 11C208, Bethesda, MD, 20892; E-mail: williamsonpr@mail.nih.gov. Sources of Support: NIAID/NIH intramural program, AI001123 and AI001124, NIDCD/NIH intramural program ZIA-DC000064, and the Clinical Center at the National Institutes of Health. The authors disclose no conflicts of interest. Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

Histopathologic Characteristics of Internal Auditory Canal Diverticula Hypothesis: We hypothesize that internal auditory canal (IAC) diverticula occur independent of otosclerosis as demonstrated by temporal bone histopathology. Background: Diverticula at the anterior-inferior aspect of the IAC have been described histologically in the setting of cavitary otosclerosis. Recent radiographic studies show the prevalence of IAC diverticula that is higher than what can be accounted for by cavitary otosclerosis alone. Methods: We examined hematoxylin and eosin temporal bone histopathology slides with otosclerosis involving the IAC. We also examined bones from normal hearing subjects with normal histologic findings. Temporal bones were included if donors were more than 18 years of age at time of death and adequate horizontal cuts were available to evaluate the area of interest. Results: IAC diverticula were found in 33 of 47 (70%) temporal bones with IAC otosclerosis and in 5 of 20 (25%) normal temporal bones. The difference in mean pure tone averages (PTA) in the normal temporal bones with (PTA 7.3 ± 7) and without (PTA 8 ± 2) diverticula was not statistically significant (p = 0.86). Conclusion: IAC diverticula which have been previously demonstrated to occur in the setting of cavitary otosclerosis can also occur independent from otosclerosis. Subjects with diverticula but without other temporal bone pathology have normal hearing thresholds. Address correspondence and reprint requests to Thomas Muelleman, M.D., House Ear Clinic, 2100 West 3rd Street Ste 111, Los Angeles, CA 90057; E-mail: tmuelleman@houseclinic.com National Institute on Deafness and Other Communication Disorders grant 1U24DC015910-01. The authors disclose no conflicts of interest. Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

Audiologic Improvement Following MCF Approach for Spontaneous Cerebrospinal Fluid Leaks Objective: To determine the audiologic improvement after middle cranial fossa (MCF) approach to repair spontaneous cerebrospinal fluid (sCSF) leaks. Study Design: Retrospective cohort study. Setting: Tertiary referral center. Patients: Twenty-four consecutive patients (27 ears) with temporal bone sCSF leak over a 4-year period. Patient age, sex, ethnicity, body mass index (BMI), location of CSF leak, recurrence of CSF leak, and presence of encephalocele(s) were recorded. Intervention: Audiometric testing in patients undergoing MCF repair of temporal bone sCSF leak. Main Outcome Measures: Comparison of preoperative and postoperative pure-tone average (PTA), air-bone gap (ABG), and word recognition score (WRS) in the sCSF leak ear. Results: Out of 27 ears, 55% had multiple tegmen defects and 82% had more than or equal to 1 encephaloceles. There were no recurrent CSF leaks at a median follow up of 4 months. The mean (SD) preoperative PTA and ABG were 40.58 [15.67] and 16.44 [6.93] dB, respectively. There was significant improvement in mean PTA (10.28 [8.01] dB; p < 0.001; Cohen d = 0.95) and ABG (9.31 [7.16] dB; p < 0.001; Cohen d = 0.88) after sCSF repair. Mean WRS improved (by 3.07 [6.11] %; p = 0.024; Cohen d = 0.46) from a mean preoperative WRS of 93.16 [9.34]% to a mean postoperative WRS of 96.26 [6.49]%. Conclusions: MCF approach for repair of sCSF leaks yields significant improvement in conductive hearing loss and is highly effective in management of the entire lateral skull base where multiple bony defects are often identified. Address correspondence and reprint requests to Rick F. Nelson, M.D., Ph.D., Department of Otolaryngology–Head and Neck Surgery, Indiana University Health, 1130W. Michigan Street|Fesler Hall 400, Indianapolis, IN 46202; E-mail: ricnelso@iupui.edu Financial disclosures: none. Authors disclose no conflict of interest. Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

In Response To Letter To The Editor Regarding: Increased Risk of Benign Paroxysmal Positional Vertigo in Patients With A History of Sudden Sensorineural Hearing Loss Based On A Longitudinal Follow-Up Study Using A National Sample Cohort No abstract available

Acute Otitis Media and Associated Complications in United States Emergency Departments No abstract available

Malignant Hyperthermia During Translabyrinthine Acoustic Neuroma Surgery After Previous Uneventful Surgery Objective: Review current literature and guidelines for malignant hyperthermia in the context of neurotologic surgery. Patient: A case of malignant hyperthermia during vestibular schwannoma surgery, in a patient previously exposed to anesthesia. Interventions: Excision of vestibular schwannoma, acute management of malignant hyperthermia. Main Outcome Measures: Knowledge of the basic pathophysiology, clinical manifestations, and treatment protocols for malignant hyperthermia. Results: Rapid termination of the procedure and appropriate modifications in surgical technique permitted expeditious treatment of malignant hyperthermia and prevented its lethality. Conclusions: Malignant hyperthermia is a rare and lethal condition that may arise in neurotologic surgery, even in patients who have previously received general anesthesia. The neurotologic surgeon has a role in early recognition and expeditious termination of surgery to help reduce its mortality. Address correspondence and reprint requests to Moises A. Arriaga, M.D., Division of Neurotology, Department of Otolaryngology, Louisiana State University Health Sciences Center, 7777 Hennessy Blvd., Ste 709 Baton Rouge, LA 70808; E-mail: Maa@neurotologic.com Isaac Erbele received a consulting fee from Medical Advisory Services for manuscript production performed between July, 2014 and September, 2015. The authors report no conflicts of interest Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

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