Auditory Brainstem Implantation in Chinese Patients With Neurofibromatosis Type II: The Hong Kong Experience.

Objective: To describe our experience and outcomes of auditory brainstem implantation (ABI) in Chinese patients with Neurofibromatosis Type II (NF2). Study Design: Retrospective case review. Setting: Tertiary referral center. Patients: Patients with NF2 who received ABIs. Results: Between 1997 and 2014, eight patients with NF2 received 9 ABIs after translabyrinthine removal of their vestibular schwannomas. One patient did not have auditory response using the ABI after activation. Environmental sounds could be differentiated by six (75%) patients after 6 months of ABI use (mean score 46% [range 28-60%]), and by five (63%) patients after 1 year (mean score 57% [range 36-76%]) and 2 years of ABI use (mean score 48% [range 24-76%]). Closed-set word identification was possible in four (50%) patients after 6 months (mean score 39% [range 12-72%]), 1 year (mean score 68% [range 48-92%]), and 2 years of ABI use (mean score 62% [range 28-100%]). No patient demonstrated open-set sentence recognition in quiet in the ABI-only condition. However, the use of ABI together with lip-reading conferred an improvement over lip-reading alone in open-set sentence recognition scores in two (25%) patients after 6 months of ABI use (mean improvement 46%), and five (63%) patients after 1 year (mean improvement 25%) and 2 years of ABI use (mean improvement 28%). At 2 years postoperatively, three (38%) patients remained ABI users. Conclusion: This is the only published study to date examining ABI outcomes in Cantonese-speaking Chinese NF2 patients and the data seems to show poorer outcomes compared with English-speaking and other nontonal language-speaking NF2 patients. Environmental sound awareness and lip-reading enhancement are the main benefits observed in our patients. More work is needed to improve auditory implant speech-processing strategies for tonal languages and these advancements may yield better speech perception outcomes in the future. Copyright (C) 2016 by Otology & Neurotology, Inc. Image copyright (C) 2010 Wolters Kluwer Health/Anatomical Chart Company

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Long-term Results of ABI in Children with Severe Inner Ear Malformations.

Objective: To report the long-term outcomes of children who received auditory brainstem implant (ABI) because of severe inner ear malformations. Study Design: Retrospective chart review. Setting: Tertiary referral otolaryngology clinic. Subjects and Methods: Between July 2006 and October 2014, 60 children received ABI at Hacettepe University. Preoperative work up included otolaryngologic examination, audiological assessment, radiological evaluation together with assessment of language development and psychological status. The surgeries were performed via retrosigmoid approach with a pediatric neurosurgeon. Intraoperatively, electrical auditory brainstem response was utilized. Initial stimulation was done 4 to 5 weeks postoperatively. Outcomes were evaluated with Categories of Auditory Performance (CAP), speech intelligibility rate (SIR), functional auditory performance of cochlear implant (FAPCI) and Manchester Spoken Language Development Scale scores; receptive and expressive language ages were determined. Results: Sixty children who received ABI were between ages of 12 and 64 months. Thirty-five patients with follow up period of at least 1 year, were reported in means of long-term audiological and language results. The most prevelant inner ear malformation was cochlear hypoplasia (n = 19). No major complication was encountered. Majority of the patients were in CAP 5 category, which implies that they can understand common phrases without lip reading. SIR was found out to be better with improving hearing thresholds. Children with ABI were performing worse than average cochlear implantation (CI) users when FAPCI scores were compared. Patients with the best hearing thresholds have expressive vocabulary of 50 to 200 words when evaluated with Manchester Spoken Language Development Scale. There was no relationship between the number of active electrodes and hearing thresholds. The type of inner ear anomaly with the best and the worst hearing thresholds were common cavity and cochlear aperture aplasia, respectively. Patients with additional handicaps had worse outcomes. Among 35 children, 29 had closed set discrimination and 12 developed open set discrimination above 50%. It was determined that, progress of the patients is faster in the initial 2 years when compared with further use of ABI. Conclusion: ABI is an acceptable and effective treatment modality for pediatric population with severe inner ear malformations. Bilateral stimulation together with CI and contralateral ABI should be utilized in suitable cases. Copyright (C) 2016 by Otology & Neurotology, Inc. Image copyright (C) 2010 Wolters Kluwer Health/Anatomical Chart Company

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The Impact of Smoking on Ossiculoplasty Outcomes.

Objectives: To assess the impact of tobacco smoking on outcomes after ossiculoplasty. Study Design: Case series with chart review. Setting: Tertiary care center. Patients: Adult patients (16-88 yr of age) undergoing ossiculoplasty with cartilage tympanoplasty. Outcome Measures: Patients were classified as smokers (TOB+) or nonsmokers (TOBN). Comparisons were then made between these two groups with regard to early and late audiometric outcomes, rate of cure of conductive hearing loss, rate of successful graft healing, and incidence of complications after surgery. Results: There was no significant difference between the two groups with regard to postoperative [DELTA]PTA-ABG (change in pure-tone average air-bone gap) (-14.4 dB vs. -14.6 dB for TOBN vs. TOB+, respectively, p = 0.946) or final audiometric outcome ([DELTA]PTA-ABGfinal) (-13.6 dB vs. -11.7 dB for TOBN vs. TOB+, respectively, p = 0.315), cure of conductive hearing loss, defined as closure of the PTA-ABG to

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Flat-Panel CT Imaging for Individualized Pitch Mapping in Cochlear Implant Users.

Objective: This study aims to identify electrode contact location and to assess frequency deviation between predicted and actual frequency allocation maps in cochlear implant (CI) users. Study Design and Methods: This is a retrospective clinical study. Flat-panel computed tomography (FPCT) scans were collected for 17 CI users. Cochlear length was measured using three-dimensional curved multiplanar reconstruction on high-resolution secondary reconstructions. Each electrode's percentage of distance from the base of the helicotrema was measured, and a modified Greenwood's function was applied. The patients' frequency allocation maps were retrieved from electronic medical records and compared with their calculated characteristic frequencies. Results: Our results revealed that reprogramming based on FPCT imaging findings might improve 83% (n = 216) of 260 electrode contacts. The most basal and apical electrodes (12, 11, 10, 5, 4, 3, 2, and 1) most consistently deviated (>83% of the time) from their theoretical characteristic frequencies; the basal electrodes undershot and the apical electrodes overshot their theoretical values. Frequency mismatch between the characteristic frequencies of auditory neurons and programmed center frequencies ranges from 0.41 to 1.51 in octave bands. Conclusions: Using FPCT imaging and a modified Greenwood's function, we identify a mathematical discrepancy between theoretical and actual CI placement with respect to frequency-place mapping. We demonstrate a clinically reproducible and direct assessment of frequency-place mismatch. Our individualized calculations account for inter-individual variability in cochlear lengths, operative differences in insertion depths, and electrode array kinking within the cochlea. The benefits of allocating electrode contact frequencies to their tonotopy-derived locations in the cochlea were not investigated in this study, and future prospective trials are needed to demonstrate the consequences of personalized pitch mapping for CI users with respect to speech and pitch perception. Copyright (C) 2016 by Otology & Neurotology, Inc. Image copyright (C) 2010 Wolters Kluwer Health/Anatomical Chart Company

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The Tightrope Facial Nerve-An Unsupported Mastoid Segment After Resection of Recidivistic Cholesteatoma.

Objectives/Hypothesis: Cholesteatomas are epidermal inclusion cysts containing stratified squamous epithelium that arise in the middle ear and mastoid cavities resulting in a persistent inflammatory state. Complications include chronic otorrhea, granulation tissue, and bony erosion. Cholesteatoma growth patterns predict frequent involvement of the Fallopian canal of the facial nerve. Extensive disease may extend to the posterior and middle fossa dura, the otic capsule, the carotid artery, and the jugular bulb. Dehiscence of the Fallopian canal and direct involvement of the facial nerve epineurium by cholesteatoma are risk factors for intraoperative facial nerve injury during tympanomastoid surgery by exposing the facial nerve to mechanical trauma and inflammation during microdissection. We present two cases of recidivistic cholesteatoma with unusual medial involvement of the vertical segment of the facial nerve that resulted in an unsupported mastoid segment after resection. The outcomes from these two patients suggest that facial nerve function may be preserved despite circumferential exposure with appropriate preoperative planning and intra-operative techniques. Study Design: Case studies. Methods: Two patients undergoing revision tympanomastoidectomy for extensive recidivistic cholesteatoma with medial involvement of the facial nerve in the mastoid segment. In each case, the facial nerve was circumferentially exposed during the resection of the cholesteatoma. Results: Normal facial nerve function after surgery was confirmed in both patients at 18 months and 6 years, respectively. Conclusions: Surgical resection of extensive cholesteatoma with medial involvement of the vertical segment of the facial nerve resulted in an unsupported mastoid segment in two patients with normal postoperative facial nerve function. Copyright (C) 2016 by Otology & Neurotology, Inc. Image copyright (C) 2010 Wolters Kluwer Health/Anatomical Chart Company

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Magnetic Resonance Imaging Compatibility of a New Generation of Active Middle Ear Implant: A Clinically Relevant Temporal Bone Laboratory Study.

Objective: Magnetic resonance imaging (MRI) has become an essential tool of modern medical imaging and disease diagnosis. In November 2014, a new MRI-conditional (up to 1.5 T) generation of an active middle ear implant (AMEI) was released to the market. The aim of the study was to test the MRI compatibility of the new implant system in a clinical-anatomical study. Design: Experimental cadaver head model. Setting: Temporal bone laboratory. Participants: AMEIs were implanted in 28 fixed temporal bones at three different floating mass transducer (FMT)-coupling positions (N = 8 short process of the incus, N = 16 long process of the incus, N = 4 round window). Main Outcome Measures: The position of the FMT and the integrity of the ossicular chain was monitored through microscopy, microendoscopy, and computed tomography (CT) scans before and after the MRI (1.5 T) was conducted. Proper function of the implant was tested with reverse transfer function (RTF) measurements. Results: Neither positional nor functional changes after MRI were observed. Conclusion: The new generation of the AMEI is a MRI-compatible system, which features an easier and quicker implant fixation method. The option of MRI in patients with AMEI should be taken into consideration during the preoperative discussion with potential candidates. Copyright (C) 2016 by Otology & Neurotology, Inc. Image copyright (C) 2010 Wolters Kluwer Health/Anatomical Chart Company

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Relationship Between Clinical Test Results and Morphologic Severity Demonstrated by Sitting 3-D CT in Patients With Patulous Eustachian Tube.

Objective: To investigate the correlation of sitting 3-D computed tomography (CT) scans of the Eustachian tube (ET) with subjective and objective findings in patients with patulous Eustachian tube (PET). Study Design: Retrospective. Setting: Tertiary referral center. Subjects: A retrospective survey of medical records in Sen-En Hospital identified 40 patients and 62 ears with PET between September 2014 and June 2015. Method: Diagnosis of PET was based on the presence of three characteristic aural symptoms (autophony of voice or breathing sounds, and aural fullness), as well as verification of synchronous movement of the tympanic membrane in response to forced breathing under an endoscope. Any pressure changes in the external auditory canal (EAC) elicited by deep breathing and sniffing were detected by tubotympanoaerodynamography (TTAG). In addition, sonotubometry was performed where two parameters were used determined to evaluate ET function. Patients were examined by 3-D CT (Accuitomo; Morita, Kyoto, Japan) in the sitting position. The length of the closed ET lumen section was measured. Ears were divided into three groups as follows: completely open, closed-short (3 mm or less), and closed-long (longer than 3 mm). Results: The median length of the closed section of the ET lumen was 1.85 +/- 2.69 mm in positive findings of PET. The three groups were significantly different in both aural fullness (p = 0.023) and, similarly, the difference in tympanic membrane movement (p = 0.032) among these three groups was also significantly different (p = 0.032). However, for autophony of breathing sounds, there was no significant difference with regard to autophony of breathing sounds among these three groups (p = 0.324). Although TTAG findings were did not reveal any significantly difference among these three groups (p = 0.589), the difference was significant (p = 0.001) in degree of EAC pressure change in TTAG. The difference among the three groups was significant (p = 0.001) based on sonotubometry findings. Conclusion: Under resting conditions, the lengths of the closed area of the ETs in PET groups are clearly shorter than in groups without PET based on sitting position CT scans in resting condition. Among the symptoms and clinical test findings including the ET function test results, the presence of tympanic membrane movement induced by respiration, the high degree of EAC pressure change in TTAG, as well as the positive results of sonotubometry are significantly correlated with the positive findings of sitting CT revealing the open ET. Copyright (C) 2016 by Otology & Neurotology, Inc. Image copyright (C) 2010 Wolters Kluwer Health/Anatomical Chart Company

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Primary Epidermoid Tumors of the Cerebellopontine Angle: A Review of 47 Cases.

Objective: To analyze disease presentation, treatment, and clinical course of a consecutive series of patients with primary cerebellopontine angle (CPA) epidermoids. Patients: Forty-seven consecutive patients with previously untreated CPA epidermoids. Intervention(s): Observation and microsurgery. Main Outcome Measures: Disease- and treatment-associated morbidity, recurrence. Results: Forty-seven patients (mean age 39 years; 53% women) were analyzed and the average duration of follow-up was 42 months. The most common presenting symptom was headache (27; 57%); 13 (28%) exhibited preoperative asymmetric sensorineural hearing loss, 3 (6%) facial nerve paresis, and 3 (6%) hemifacial spasm. Thirteen patients (28%) were initially observed over a mean interval of 56 months; however, five experienced disease progression requiring operation. Thirty-nine patients (83%) underwent surgical resection; 18 (46%) received gross total, 5 (13%) near total, and 16 (41%) aggressive subtotal resection. Three patients (8%) recurred at a median of 53 months; two after subtotal and one after gross total resection. Ninety-three percent of patients with useful hearing maintained serviceable hearing following treatment and one patient (3%) experienced mild long-term postoperative facial nerve paresis (HB II/VI). All patients with preoperative facial nerve paresis recovered normal function postoperatively. There were no episodes of stroke or death. Conclusions: Surgical intervention is effective in alleviating symptoms of cranial neuropathy and brainstem compression from CPA epidermoids. Gross total resection is preferred; however, aggressive subtotal removal should be considered with adherent or extensive disease as reoperation rates are low, even in the setting of aggressive subtotal resection. Conservative observation with serial imaging is a viable initial strategy in asymptomatic or minimally symptomatic patients. Copyright (C) 2016 by Otology & Neurotology, Inc. Image copyright (C) 2010 Wolters Kluwer Health/Anatomical Chart Company

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Asymmetrical Hearing Loss in Cases of Industrial Noise Exposure: A Systematic Review of the Literature.

Objective: Asymmetrical hearing thresholds are common in people claiming compensation for noise-induced hearing loss (NIHL). When present and otherwise unexplained, there is some controversy as to whether such asymmetry can be attributed to occupational noise exposure. In this review, our main objectives were to collate the overall prevalence of this finding in subjects with NIHL, and further, to provide a balanced argument regarding causality. Data Sources: MEDLINE, CINAHL, EMBASE, Cochrane, Google Scholar. No date or language restrictions. Study Selection and Data Extraction: A systematic review of the literature was performed and data on noise exposure, pure tone audiometry, and lateralized hearing outcomes were reviewed. Newcastle-Ottawa (N-O) criteria were employed to assess quality of studies where applicable. Data Synthesis: N/A Conclusion: Six studies met the inclusion criteria giving a total of 4,735 individual cases with NIHL. Asymmetrical hearing loss accounted for between 2.4% and 22.6% of NIHL cases (L-R difference >15 dB for any frequency 0.5-8 kHz). However, the overwhelming majority of subjects in this review have symmetrical hearing loss when adjusted for other significant variables, e.g., age, sex, and binaural hearing deterioration. Subjects considered for noise exposure remuneration were men (94.3% SE +/- 2.7), aged 52.9 years (inter-quartile range, 46.1-58.4), and from a broad range of industrial backgrounds. Future research will be needed to establish the influence of other factors such as smoking status, exposure to chemical agents, specific drugs, or genetic predisposition. Copyright (C) 2016 by Otology & Neurotology, Inc. Image copyright (C) 2010 Wolters Kluwer Health/Anatomical Chart Company

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The Association of Valsalva Status With Smoking and Its Impact on Ossiculoplasty Outcomes and Complications.

Objectives: To assess the association of a patient's ability to perform a clinically observed Valsalva maneuver with tobacco smoking and post-ossiculoplasty outcomes. Study Design: Case series with chart review. Setting: Tertiary referral, university-based otology practice. Patients: Adult patients (16-88 years of age) undergoing ossiculoplasty with tympanoplasty or tympanomastoidectomy using cartilage tympanic membrane grafts, retrograde mastoidectomy with canal wall reconstruction, or mastoid obliteration techniques. Outcome Measures: Patients were classified as Valsalva negative (ValN) or positive (Val+). Comparisons were then made between these two groups for smoking status, final audiometric outcomes, rate of cure of conductive hearing loss, anatomic outcomes, and incidence of significant complications after otologic surgery involving ossiculoplasty. Results: Tobacco smoking is not significantly correlated with the inability to insufflate the middle ear with the Valsalva maneuver (p = 0.557). An insignificant difference in final pure-tone average air-bone gap (PTA-ABG) was observed between the ValN and Val+ groups (20.2 dB HL versus 18.2 dB HL, respectively; p = 0.152). Similarly, the rate of successful PTA-ABG closure to

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Botulinum Toxin Treatment of Objective Tinnitus Because of Essential Palatal Tremor: A Systematic Review.

Introduction: In contrast to subjective tinnitus, objective tinnitus can be heard by the examiner as well as by the patient. It can be triggered by, among many other etiologies, idiopathic muscular tremor in the soft palate, the essential palatal tremor (EPT). Many treatment modalities have been investigated, of which only Botulinum toxin (BT) injections have shown promising results. Goal: The aim of this study was to evaluate the effect of BT treatment on objective tinnitus due to EPT by a systematic review of the literature. Methods: In accordance with PRISMA guideline a systematic literature search in three databases was performed. Results: Twenty-two studies fulfilled the inclusion criteria, mainly case reports and case series. A total of 51 BT treated patients diagnosed with EPT were identified in the literature. The studies were evaluated with focus on diagnostics, injection technique and BT dose, follow-up, effect on objective tinnitus, complications, and adverse effects. Conclusions: The included studies suffer from an extremely low evidence level with several sources of bias. When optimally injected, BT seems to be an effective treatment of objective tinnitus due to EPT, with few adverse effects and complications. We suggest BT injections as first choice in case of EPT and present a guideline regarding diagnostics, treatment, and follow-up. Copyright (C) 2016 by Otology & Neurotology, Inc. Image copyright (C) 2010 Wolters Kluwer Health/Anatomical Chart Company

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A Systematic Review on Complications of Tissue Preservation Surgical Techniques in Percutaneous Bone Conduction Hearing Devices.

Objective: To investigate skin-related postoperative complications from tissue preservation approaches in percutaneous bone conduction device (BCD) implantations. Data Sources: PubMed, Embase, and Cochrane Library. Study Selection: We identified studies on BCDs including the opted surgical technique and derived complications. Retrieved articles were screened using predefined inclusion criteria. Critical appraisal included directness of evidence and risk of bias. Studies that successfully passed critical appraisal were included. Data Extraction: Outcome measures included patient demographics, surgery time, follow-up time, and complications reported by Holgers classification. Data Synthesis: We selected 18 articles for data extraction; encompassing 381 BCDs implanted using non-skin thinning approaches. Four studies reported an implantation technique using the punch method (81 implants), 13 studies applied the linear incision technique without soft tissue reduction (288 implants) and one study used the Weber technique (12 implants). Holgers 3 was described in 2.5% following the punch technique, in 5.9% following the linear incision technique, and in no implants following the Weber technique. One patient was mentioned having Holgers 4, skin overgrowth was reported in 6 patients, and 10 studies compared their non-skin thinning technique with a skin-thinning technique. Overall, the soft tissue preservation technique had a similar or superior complication rate, shorter surgical time, and better and faster healing, compared with the soft tissue reduction technique. Conclusion: Tissue preservation surgical techniques for percutaneous BCDs have limited postoperative skin complication rates. Moreover, these techniques are suggested to have at least similar complications rates compared with skin-thinning techniques. Copyright (C) 2016 by Otology & Neurotology, Inc. Image copyright (C) 2010 Wolters Kluwer Health/Anatomical Chart Company

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Petroclival Chondrosarcoma: A Multicenter Review of 55 Cases and New Staging System.

Objective: To analyze clinical outcomes after treatment of petroclival chondrosarcoma and to propose a novel staging system. Study Design: Retrospective case review, 1995 to 2015. Setting: Multicenter study. Patients: Consecutive patients with histopathologically proven petroclival chondrosarcoma. Intervention(s): Microsurgery, endoscopic endonasal surgery, radiation therapy, observation. Main Outcome Measures: Disease- and treatment-associated morbidity, recurrence, mortality. Results: Fifty-five patients (mean age 42 years; 56% women) presenting with primary or recurrent petroclival chondrosarcoma were analyzed. The mean duration of follow-up was 74 months. Among 47 primary cases, the most common presenting symptoms were headache (55%) and diplopia (49%) and the mean tumor size at diagnosis was 3.3 cm. Subtotal resection was performed in 33 (73%) patients and gross total resection in 12 (27%). Adjuvant postoperative radiation was administered in 30 (64%) cases. Preoperative cranial neuropathy improved in 13 (29%), worsened in 11 (24%), and remained stable in 21 (47%) patients; notably, 11 preoperative sixth nerve palsies resolved after treatment. Nine recurrences occurred at a mean of 42 months. The 1-, 3-, 5- and 10-year recurrence-free survival rate for all 45 patients who underwent primary microsurgery with or without adjuvant radiation therapy was 97%, 89%, 70%, and 56%, respectively. Higher tumor stage, larger categorical size (=4 cm), lack of adjuvant radiation, and longer duration of follow-up were associated with greater risk of recurrence. The overall mortality rate was 2% for patients presenting with primary disease. Analyzing the cohort of 17 cases with 20 recurrences, 3 received salvage surgery alone, 5 radiation therapy alone, 11 multimodality treatment, and one patient has been observed. Tumor control was ultimately achieved in 15 of 17 patients with recurrent disease. One patient (6%) with grade 3 petroclival chondrosarcoma died as a result of rapidly progressive disease within 6 months of salvage treatment. The overall mortality rate was 6% for patients with recurrent disease. Conclusion: Gross total or subtotal resection with adjuvant radiation provides durable tumor control with minimal morbidity in most patients. Surgery may improve preoperative cranial nerve dysfunction, particularly in the case of cranial nerve 6 paralysis. Copyright (C) 2016 by Otology & Neurotology, Inc. Image copyright (C) 2010 Wolters Kluwer Health/Anatomical Chart Company

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TeleAudiology in the Veterans Health Administration.

Objective: To assess effectiveness of TeleAudiology for hearing aid services. Study Design: Retrospective case-control. Setting: Ambulatory Veterans Health Administration and Community-Based Outpatient Clinics (CBOCs). Patients: 42,697 veterans who received hearing aids from January through September, 2014. Intervention(s): TeleAudiology (TA) and conventional in-person (IP) audiology care. Main Outcome Measure(s): International Outcome Inventory for Hearing Aids (IOI-HA) outcomes data. The IOI-HA is a 7-item survey used to assess hearing aid effectiveness. Scored from 7 to 35 points, higher scores are more favorable. Results: Among veterans nationwide who received hearing aids and completed the IOI-HA survey, 1,009 received TA and 41,688 received IP care. TA and IP groups have comparable mean IOI-HA values (TA = 29.6, SD = 3.9; IP = 28.7, SD = 4.2). Although comparison showed a statistically significant difference (p 0.05, t test). Conclusion: TA and IP encounters to provide hearing aid services to veterans are comparable, as both are highly effective based on IOI-HA results. The noninferiority of TA suggests its adoption to non-veterans may improve access while preserving high satisfaction. Financial impact of migration to TA will require future econometric analysis. Copyright (C) 2016 by Otology & Neurotology, Inc. Image copyright (C) 2010 Wolters Kluwer Health/Anatomical Chart Company

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Type I Tympanoplasty Meta-Analysis: A Single Variable Analysis.

Objective: To determine which independent variables influencing the efficacy of type I tympanoplasty in adult and pediatric populations. Data Sources: A search of the PubMed database and Cochrane Database of Systematic Reviews using the key words "tympanoplasty OR myringoplasty" from January 1966 to July 2014 was performed. Study Selection: Studies reporting outcomes of myringoplasty or Type I tympanoplasty in primary non-cholesteatomatous chronic tympanic membrane (TM) perforation were included. Data Extraction: Of 4,698 abstracts reviewed, 214 studies involving 26,097 patients met our inclusion criteria and contributed to meta-analysis. Data Synthesis: The primary outcome of success was defined as closure rate at 12 months. The independent variables analyzed were age, follow-up period, approach, graft material, perforation cause, size, location, ear dryness, and surgical technique. Only those studies providing data on a given parameter of interest could be included when comparing each variable. Conclusion: The weighted average success rate of tympanic closure was 86.6%. Based on this meta-analysis, pediatric surgery has a 5.8% higher failure rate than adults and there is no correlation between follow-up period and success. Other variables associated with improved closure rates include perforation with a size less than 50% of total area (improved by 6.1%) and the use of cartilage as a graft (improved by 2.8% compared with fascia), while ears that were operated on while still discharging, those in different locations of the pars tensa, or using different surgical approaches or techniques did not have significantly different outcomes. Copyright (C) 2016 by Otology & Neurotology, Inc. Image copyright (C) 2010 Wolters Kluwer Health/Anatomical Chart Company

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Cochlear Histopathology as Observed in Two Patients With a Cochlear Implant Electrode With Positioner.

Hypothesis: This study reports the cochlear histopathology of two patients who during life underwent cochlear implantation with a positioner. Background: A silastic positioner introduced by the Advanced Bionics Corporation in 1999 was designed to position the electrode of the cochlear implant close to the modiolus. The positioner was recalled in the United States in July 2002 because of an apparent higher incidence of bacterial meningitis in patients in whom the positioner had been placed. Methods: Four celloidin-embedded temporal bones from two patients with cochlear implants with a positioner from the temporal bone collection of the Massachusetts Eye and Ear Infirmary were included in the study. In a previous study, we reported histopathologic findings in Patient 1, and in this report, we present the findings in a second case in a 94-year-old woman (Patient 2), and the similarities and differences between the two patients. All four specimens were prepared for histologic study by conventional techniques and 2-D reconstruction. Results: Evidence of insertion trauma was observed in all three implanted specimens. More significant trauma was found in Patient 2 than in Patient 1 including disruption of the osseous spiral lamina and the basilar membrane. In addition, there was more new fibrous tissue and bone in Patient 2 than in Patient 1. There was a large fluid space in all three implanted temporal bones around the electrode and positioner. Conclusion: The findings observed in the two patients may help to explain the increased risk of meningitis in patients implanted with a positioner. Copyright (C) 2016 by Otology & Neurotology, Inc. Image copyright (C) 2010 Wolters Kluwer Health/Anatomical Chart Company

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Cochlear Implantation in Patients With Intracochlear and Intralabyrinthine Schwannomas.

Objective: Schwannomas may arise primarily within the inner ear, or invade the cochlea or labyrinth from the distal internal auditory canal through transmodiolar or transmacular extension, respectively. To date, very limited data exists regarding cochlear implant (CI) outcomes in this unique population. Study Design: Retrospective case review. Patients: Ten ears (nine patients) with inner ear schwannomas that underwent CI at a single tertiary referral center. Intervention(s): Cochlear implantation. Main Outcome Measure(s): Surgical approach, CI performance. Results: Ten ears (nine patients) were implanted with conventional CI arrays. Three cases had primary inner ear schwannomas, while seven were in patients with neurofibromatosis type 2 (NF2) having transmodiolar invasion of the inner ear from a vestibular schwannoma (VS). In all cases, intracochlear tumor was left in situ to preserve cochlear anatomy and a full electrode insertion was achieved. Use of a styleted electrode with late deployment aided advancement through the intracochlear tumor. In all cases, the ipsilateral internal auditory canal and inner ear could be visualized on postoperative magnetic resonance imaging (MRI) for tumor surveillance. Eight ears achieved good open-set word recognition (median, Consonant-Nucleus-Consonant [CNC] 50% [range, 28-88%], median, AzBio 73% [range, 60-91%]); two patients with NF2 and prolonged deafness (15 and 22 years) received limited benefit. Conclusions: Cochlear implantation in patients with inner ear schwannomas and an intact cochlear nerve is feasible. Leaving intracochlear schwannoma in situ preserves cochlear architecture and use of a styleted electrode may aid in achieving a full insertion when obstructing tumor is present. Postoperative MRI surveillance is still adequate after CI and a high percentage of patients achieve good open-set speech perception performance. Copyright (C) 2016 by Otology & Neurotology, Inc. Image copyright (C) 2010 Wolters Kluwer Health/Anatomical Chart Company

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Focal Endolymphatic Hydrops as Seen in the Pars Inferior of the Human Inner Ear.

Hypothesis: Endolymphatic hydrops of the human inner ear may be localized focally in the pars inferior of the human inner ear. Background: Endolymphatic hydrops may be found in the human inner ear in patients who in life had suffered from Meniere's syndrome or a variety of other disorders. The degree of endolymphatic hydrops may differ based on location in the inner ear. Methods: A computer-assisted search of all cases in the collection of the Massachusetts Eye and Ear Infirmary in which endolymphatic hydrops was found in the inner ear yielded 13 specimens in which there was good evidence for focal endolymphatic hydrops in the pars inferior. Temporal bones were prepared for light microscopy. Semi-serial sections were reviewed to generate localization data for endolymphatic hydrops and also to search for evidence of a previous inflammatory process, including fibrosis or new bone formation. Results: Endolymphatic hydrops was present in the saccule in 10 of 13 specimens. In the cochlear duct, there were segments of the cochlea in which there was no cochlear hydrops juxtaposed to other regions in which there was severe endolymphatic hydrops. Transition between hydropic and non-hydropic status in the cochlear duct was often abrupt. Evidence for a previous inflammation process was found in 6 of 13 specimens including fibrosis because of temporal bone fracture, or traumatic stapedectomy and in those cases in which the cause of hearing loss was idiopathic, fibrosis, and osteoid between the labyrinthine surface of the footplate and the hydropic saccular wall, and/or osteoid in the scala vestibuli, or in the proximate Rosenthal's canal. Evidence of a previous inflammatory process was uniformly seen in the perilymphatic compartment. Conclusions: Endolymphatic hydrops of the pars inferior in the human may have a focal distribution. This study suggests that the pathogenesis of endolymphatic hydrops is unlikely to be because of distal obstruction of longitudinal flow and was more consistent with the hypothesis that homeostasis of the endolymphatic and perilymphatic volumes occurs all along the cochlear duct. Other factors including variable distensibility of Reissner's membrane or disturbance of local solute homeostatic mechanisms may be responsible for wide variations in the degree of hydrops. A focal inflammatory process during life may be one cause of focal endolymphatic hydrops as seen histopathologically. Copyright (C) 2016 by Otology & Neurotology, Inc. Image copyright (C) 2010 Wolters Kluwer Health/Anatomical Chart Company

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Secondary Acquired Cholesteatoma: Presentation and Tympanoplasty Outcomes.

Objective: Comparing the clinical features and surgical outcomes of patients undergoing tympanoplasty for secondary acquired cholesteatoma (SAC) versus non-complicated tympanic membrane perforation (TMP). Study Design: Retrospective patient review. Setting: Tertiary-care, academic center. Patients: All 41 patients with diagnosis of SAC confirmed at surgery between January 1, 2007 and June 30, 2014, and an age-matched cohort consisting of patients with TMP. Intervention(s): Tympanoplasty using either medial or lateral graft techniques. Main Outcome Measure(s): Resolution of perforation, SAC, and symptoms. Results: Comparison between the two cohorts failed to reveal significant differences in otologic symptomology, or presentation. There was no significant difference in the resolution of SAC (p = 0.7) between the medial and lateral tympanoplasty techniques. Both techniques also had similar rates of success in the TMP cohort. The medial graft technique was significantly (p = 0.008) more likely to result in a successfully repaired tympanic membrane in the TMP cohort compared with the SAC cohort. The Lateral graft technique demonstrated no significant difference in the likelihood of TMP and SAC resolution. Conclusion: The presentation of SAC is similar to that of TMP despite being a separate clinical entity. A clinician's ability to distinguish the two is important to mitigate the destructive potential of untreated SAC and correctly council patients on tympanoplasty success rates. This study was unable to demonstrate a significant difference in disease control between the medial and lateral tympanoplasty techniques, although potential advantages of each technique are discussed. Copyright (C) 2016 by Otology & Neurotology, Inc. Image copyright (C) 2010 Wolters Kluwer Health/Anatomical Chart Company

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Study Finds Support for Classroom Acoustics Standards (ANSI/ASA, 2010)

A recently-published study by Frank Ingelhart evaluated the speech perception performance of 23 children with cochlear implants and 23 children with normal hearing through the speech frequencies (500-4000 Hz). Speech perception testing was completed in a classroom environment at three different reverberation times—0.9 seconds, 0.6 seconds, and 0.3 seconds.

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“Children with cerebral palsy experience greater levels of loading at the low back during gait compared to healthy controls”

Publication date: Available online 6 June 2016
Source:Gait & Posture
Author(s): D. Kiernan, A. Malone, T. O’Brien, C.K. Simms
Excessive trunk motion has been shown to be characteristic of cerebral palsy (CP) gait. However, the associated demands on the lower spine are unknown. This study investigated 3-dimensional reactive forces and moments at the low back in CP children compared to healthy controls. In addition, the impact of functional level of impairment was investigated (GMFCS levels). Fifty-two children with CP (26 GMFCS I and 26 GMFCS II) and 26 controls were recruited to the study. Three-dimensional thorax kinematics and reactive forces and moments at the low back (L5/S1 spine) were examined. Discrete kinematic and kinetic parameters were assessed between groups. Thorax movement demonstrated increased range for CP children in all 3 planes while L5/S1 reactive forces and moments increased with increasing level of functional impairment. Peak reactive force data were increased by up to 57% for GMFCS I and 63% for GMFCS II children compared to controls. Peak moment data were increased by up to 21% for GMFCS II children compared to GMFCS I and up to 90% for GMFCS II compared to control. In addition, a strong correlation was demonstrated between thorax side flexion and L5/S1 lateral bend moment (r=0.519, p<0.01) and medial/lateral force (r=0.352, p<0.01). Children with CP demonstrated increased lower spinal loading compared to TD. Furthermore, GMFCS II children demonstrated significantly more involvement. Intervention should be aimed at reducing excessive thorax movement, especially in the coronal plane, in order to reduce abnormal loading on the spine in this population.



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“Children with cerebral palsy experience greater levels of loading at the low back during gait compared to healthy controls”

Publication date: Available online 6 June 2016
Source:Gait & Posture
Author(s): D. Kiernan, A. Malone, T. O’Brien, C.K. Simms
Excessive trunk motion has been shown to be characteristic of cerebral palsy (CP) gait. However, the associated demands on the lower spine are unknown. This study investigated 3-dimensional reactive forces and moments at the low back in CP children compared to healthy controls. In addition, the impact of functional level of impairment was investigated (GMFCS levels). Fifty-two children with CP (26 GMFCS I and 26 GMFCS II) and 26 controls were recruited to the study. Three-dimensional thorax kinematics and reactive forces and moments at the low back (L5/S1 spine) were examined. Discrete kinematic and kinetic parameters were assessed between groups. Thorax movement demonstrated increased range for CP children in all 3 planes while L5/S1 reactive forces and moments increased with increasing level of functional impairment. Peak reactive force data were increased by up to 57% for GMFCS I and 63% for GMFCS II children compared to controls. Peak moment data were increased by up to 21% for GMFCS II children compared to GMFCS I and up to 90% for GMFCS II compared to control. In addition, a strong correlation was demonstrated between thorax side flexion and L5/S1 lateral bend moment (r=0.519, p<0.01) and medial/lateral force (r=0.352, p<0.01). Children with CP demonstrated increased lower spinal loading compared to TD. Furthermore, GMFCS II children demonstrated significantly more involvement. Intervention should be aimed at reducing excessive thorax movement, especially in the coronal plane, in order to reduce abnormal loading on the spine in this population.



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“Children with cerebral palsy experience greater levels of loading at the low back during gait compared to healthy controls”

Publication date: Available online 6 June 2016
Source:Gait & Posture
Author(s): D. Kiernan, A. Malone, T. O’Brien, C.K. Simms
Excessive trunk motion has been shown to be characteristic of cerebral palsy (CP) gait. However, the associated demands on the lower spine are unknown. This study investigated 3-dimensional reactive forces and moments at the low back in CP children compared to healthy controls. In addition, the impact of functional level of impairment was investigated (GMFCS levels). Fifty-two children with CP (26 GMFCS I and 26 GMFCS II) and 26 controls were recruited to the study. Three-dimensional thorax kinematics and reactive forces and moments at the low back (L5/S1 spine) were examined. Discrete kinematic and kinetic parameters were assessed between groups. Thorax movement demonstrated increased range for CP children in all 3 planes while L5/S1 reactive forces and moments increased with increasing level of functional impairment. Peak reactive force data were increased by up to 57% for GMFCS I and 63% for GMFCS II children compared to controls. Peak moment data were increased by up to 21% for GMFCS II children compared to GMFCS I and up to 90% for GMFCS II compared to control. In addition, a strong correlation was demonstrated between thorax side flexion and L5/S1 lateral bend moment (r=0.519, p<0.01) and medial/lateral force (r=0.352, p<0.01). Children with CP demonstrated increased lower spinal loading compared to TD. Furthermore, GMFCS II children demonstrated significantly more involvement. Intervention should be aimed at reducing excessive thorax movement, especially in the coronal plane, in order to reduce abnormal loading on the spine in this population.



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Time reversal for localization of sources of infrasound signals in a windy stratified atmosphere

Time reversal is used for localizing sources of recorded infrasound signals propagating in a windy, stratified atmosphere. Due to the convective effect of the background flow, the back-azimuths of the recorded signals can be substantially different from the source back-azimuth, posing a significant difficulty in source localization. The back-propagated signals are characterized by negative group velocities from which the source back-azimuth and source-to-receiver (STR) distance can be estimated using the apparent back-azimuths and trace velocities of the signals. The method is applied to several distinct infrasound arrivals recorded by two arrays in the Netherlands. The infrasound signals were generated by the Buncefield oil depot explosion in the U.K. in December 2005. Analyses show that the method can be used to substantially enhance estimates of the source back-azimuth and the STR distance. In one of the arrays, for instance, the deviations between the measured back-azimuths of the signals and the known source back-azimuth are quite large (−1° to −7°), whereas the deviations between the predicted and known source back-azimuths are small with an absolute mean value of

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A study of ribbing effect on the vibration response and transmission of an L-shaped platea)

This paper presents an analytical solution for the vibration response of a ribbed L-shaped plate using a modal expansion solution approach. The analytical model is then employed to study the ribbing effect on vibration reduction and transmission between the two plate components of the L-shaped plate. It is found that for the system considered in the study, a rib inserted between the excitation force and the source plate can lead to a large vibration reduction for both source and receiving plates except at a frequency band near the fundamental resonant frequency of the rib where the rib's flexural stiffness is negligible. A reduced vibration transmission to the receiving plate can also be achieved by placing a rib near the plate/plate junction, attributed to the increased moment impedance at the coupling after the rib insertion. Increasing the rib's flexural stiffness under this condition can further reduce vibration transmission in the low frequency bands while increasing the rib's mass can lead to a reduced vibration transmission in the higher frequency bands. The insights obtained from this study are relevant to vibration control of structures such as transformer tanks and machine covers.

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How the demographic makeup of our community influences speech perception

Speech perception is known to be influenced by listeners' expectations of the speaker. This paper tests whether the demographic makeup of individuals' communities can influence their perception of foreign sounds by influencing their expectations of the language. Using online experiments with participants from all across the U.S. and matched census data on the proportion of Spanish and other foreign language speakers in participants' communities, this paper shows that the demographic makeup of individuals' communities influences their expectations of foreign languages to have an alveolar trill versus a tap (Experiment 1), as well as their consequent perception of these sounds (Experiment 2). Thus, the paper shows that while individuals' expectations of foreign language to have a trill occasionally lead them to misperceive a tap in a foreign language as a trill, a higher proportion of non-trill language speakers in one's community decreases this likelihood. These results show that individuals' environment can influence their perception by shaping their linguistic expectations.

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