How Was Your Otology Training? A Survey of Recent Otolaryngology Residents

Objective: To survey graduating residents or recent graduates of otolaryngology residency programs to evaluate their Otology/Neurotology (ON) experience in residency and discern if they had received adequate training in time to decide whether to pursue a fellowship in Otology or Neurotology. Study Design: Internet-based survey. Methods: A survey was distributed to all US otolaryngology residency programs to distribute to 5th year residents and recent graduates in last 4 years. The survey assessed satisfaction in ON experience, presence of ON fellows, adequacy of experience to decide on ON fellowship, post-graduate year (PGY) year at which residents observed, performed, and proficiently performed five procedures (tympanoplasty, mastoidectomy, ossiculoplasty, stapedectomy, and cochlear implant), and plan for performing these surgeries in practice. Results: 89/106 (84%) of respondents felt they had adequate training in Otology in time to decide whether or not to pursue a fellowship and were found to observe and perform surgeries significantly earlier in training by PGY including: mastoidectomy (observed PGY 1.9 versus PGY 2.3, performed PGY 2.9 versus PGY 3.5), ossiculoplasty (observed 2.1 versus 3.0, performed 3.6 versus 4.3), stapedectomy (observed 2.3 versus 3.0, performed 3.9 versus 4.5), and cochlear implant (observed 2.1 versus 2.8, performed 3.4 versus 4.1) all p 

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Morphological Characteristics of Osseous External Auditory Canal and Its Relationship With External Auditory Canal Cholesteatoma in Patients With Congenital Aural Stenosis

Objective: To investigate the characteristics of stenotic external auditory canal (EAC) (e.g., shape, length, orientation, and curvature) and to compare them with those of the cholesteatoma and no cholesteatoma groups, which may help to explain cholesteatoma formation to a certain degree. Methods: Computed tomography scans of two groups of patients (with and without EAC cholesteatoma) were analyzed. We determined the degree of microtia, the stenosis of EAC, radius and curvature of osseous EAC bending (abbreviated as OEB-r and OEB-c, respectively), and other anatomic parameters of EAC by using Mimics and Matlab. Results: There was no significant difference in the degree of microtia between the cholesteatoma and no cholesteatoma groups using the Marx grading system. Additionally, no significant difference was found in the stenosis of EAC between the two groups. The OEB-r was smaller in the cholesteatoma group (4.62 ± 0.62 mm) than in the no cholesteatoma group (7.41 ± 0.50 mm), and the OEB-c was found to be larger in the cholesteatoma group (1.55 ± 0.05 × 10 mm−1) than in the no cholesteatoma group (1.10 ± 0.10 × 10 mm−1). Moreover, the OEB-c (OR, 8.60; 95% CI, 2.67–27.75) was associated with EAC cholesteatoma formation. Conclusion: The curvature of osseous EAC in the cholesteatoma group was significantly larger than that in the no cholesteatoma group. It is suggested that the curvature of osseous EAC was a risk factor for EAC cholesteatoma formation.

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Do Measurements of Inner Ear Structures Help in the Diagnosis of Inner Ear Malformations? A Review of Literature

Objective: We conducted an extensive review of the literature relevant to inner ear measurements in normal and malformative conditions to select reproducible methods and normative ranges that may be used in clinical practice. Data Sources and Study Selection: A review of the published literature was performed in the English language using PubMed with appropriate keywords. We selected only those articles containing normative values of inner ear structures. Data Extraction and Data Synthesis: The following measurements were identified as reproducible and sensitive for the diagnosis of inner malformations: cochlear height in coronal plane; maximal diameter of bony island of lateral semicircular canal; width of vestibular aqueduct: 1) at midpoint; 2) at operculum in axial plane; cochlear canal and cochlear width in multiplanar reconstructions (MPR)/axial; cochlear length. The following cutoffs for normal inner ears are proposed based on the comparative analysis of the literature: cochlea height: >4.3 mm; lateral semicircular canal bony island: >3 mm; vestibular aqueduct: 1.4 mm and 5.4 mm. Conclusion: Measurements of inner ear structures can help in the interpretation of computed tomography images. They increase the sensitivity in detecting inner ear malformations, especially cochlear hypoplasia now considered more common than previously thought.

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Value of T1-weighted Magnetic Resonance Imaging in Cholesteatoma Detection

Objective: To reveal the usefulness of T1-weighted (T1W) imaging on diagnostic magnetic resonance (MR) imaging for cholesteatoma. Study Design: A retrospective case review. Setting: Tertiary referral center. Patients: Fifty-three patients (57 ears) suspected to have cholesteatomas and treated (6–82 yr of age). Intervention: Preoperative MR imaging, including non-echo planar (non-EP) diffusion-weighted (DW) and T1W imaging. Main Outcome Measures: Primary outcome measures included the comparison between the diagnostic accuracy for the detection of cholesteatomas using non-EP DW imaging alone (criterion 1) and non-EP DW imaging along with T1W imaging (criterion 2). Diagnostic accuracy was evaluated in each case by comparing MR imaging with surgical findings. Secondary outcome measures included the comparison of the rates of cases showing a high T1W signal between cholesteatomas and noncholesteatomas which showed a high non-EP DW signal. Results: The sensitivity, specificity, and accuracy according to criterion 1 were 93.5, 63.6, and 87.7% and those according to criterion 2 were 89.1, 100, and 91.2%, respectively. Of 43 cholesteatoma cases indicating a high non-EP DW signal, only 2 cases showed a high T1W signal (5%). On the other hand, all four noncholesteatoma cases indicating high non-EP DW signal showed a high T1W signal (100%), and these rates were significantly different (p 

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The Etiological Relationship Between Migraine and Sudden Hearing Loss

Objectives: To investigate the relationship between sudden sensorineural hearing loss (SSNHL) and migraine, assess the prevalence of migraine in patients with idiopathic SSNHL, and determine a possible common vascular etiopathogenesis for migraine and SSNHL. Study Design: Prospective cohort study. Setting: Tertiary referral center. Patients: This study initially assessed 178 SSNHL cases obtained from the Head and Neck Surgery Clinic patient database at a tertiary hospital in Turkey between January 2011 and March 2016. Ultimately, a total of 61 idiopathic SSNHL patients participated in the present study. İnterventions: Diagnostic. Main Outcome Measures: Cases with inflammation in the middle or inner ear; a retro cochlear tumor; autoimmune, infectious, functional, metabolic, neoplastic, traumatic, toxic, or vascular causes; Meniere's disease; otosclerosis; multiple sclerosis; and/or cerebrovascular diseases were excluded. Results: Of the 61 idiopathic SSHNL patients, 34 were women (55.74%); and 24 (39.34%) had migraine, according to the criteria of the International Headache Society (IHS). The mean age of the migraine patients (Group 1) was 43.83 ± 13.16 years, and that of those without migraine (Group 2) was 51.05 ± 16.49 years. The groups did not significantly differ in terms of age, sex, or SSNHL recovery rates according to the Siegel criteria (p > 0.05). Ten of the migraine patients experienced visual aura, and the recovery rates of this group were higher. Additionally, the rate of total hearing loss was lower in Group 1 (n = 3, 12.5%) than in Group 2 (n = 10, 27%). Conclusion: SSNHL patients had a higher prevalence of migraine. Although those with migraine had higher recovery rates, the differences were not statistically significant.

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Patterns of Extended High-frequency Hearing Loss Following Stapes Surgery

Objective: Thresholds in the extended high-frequency (EHF) range (> 8 kHz) often worsen after otherwise successful stapedectomy. The aims of this study were to document the prevalence of hearing loss from 0.25 to 16 kHz after stapedectomy and the relative rates of transient and permanent EHF hearing loss. Study Design: Prospective, observational, longitudinal. Setting: Tertiary referral center. Patients: Thirty-nine patients who underwent 44 primary or revision stapes surgeries. Intervention: Hearing thresholds were measured at 0.25 to 16 kHz preoperatively, and at approximately 1 week, 1, 3, 6, and 12 months postoperatively. Main Outcome Measures: Average threshold changes in bands of frequencies (0.25–1, 2–8, 9–11.2, 12.5–16 kHz) and the percentage of patients with a change in the highest frequency at which a hearing threshold could be measured were evaluated at each assessment. Results: A mean hearing loss was documented in the EHF range at all postoperative assessments. There was a decrease in the highest frequency at which a hearing threshold was measureable in 77% of patients at the first postoperative assessment, and despite some improvement over time, in 50% of patients 12 months postoperatively. Conclusion: There is a significant incidence of EHF loss after stapedectomy. Although partial recovery often occurs, more than half of patients retain an EHF hearing loss 12 months postoperatively. As hearing loss in the EHF range is more common than loss at 4 kHz, EHF measurements may be a more sensitive model to compare surgical factors and evaluate pharmacologic interventions.

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Effectiveness in Rehabilitation of Current Wireless CROS Technology in Experienced Bone-Anchored Implant Users

Objective: To compare the effectiveness of current contralateral routing of signal technology (CROS) to bone-anchored implants in experienced bone-anchored implant users with unilateral severe-profound sensorineural hearing loss. Design: Prospective, within-subject repeated-measures comparison study. Setting: Tertiary referral center. Patients: Adult, English-speaking patients (n = 12) with severe-profound unilateral sensorineural hearing loss implanted with a bone-anchored implant for the indication of single-sided deafness. Intervention: Subjects were fitted with contralateral routing of signal amplification and tested for speech in noise performance and localization error. Outcome Measures: Speech perception in noise was assessed using the BKB-SIN test materials. Localization was assessed using narrow band noises centered at 500 and 4000 Hz, as well as a broadband speech stimulus presented at random to the front hemifield by 19 speakers spatially separated by 10 degrees. Results: There was no improvement in localization ability in the aided condition and no significant difference in performance with CROS versus bone-anchored implants (BAI). There was a significant improvement in speech in noise performance for monaural listeners in the aided condition for speech poorer ear/noise better ear, speech front/noise front, and speech front/noise back. No significant difference was observed on performance with CROS versus BAI subjects. Conclusion: Contrary to earlier studies suggesting improved performance of BAIs over CROS, the current study found no difference in performance in BAI over CROS devices. Both CROS and BAI provide significant benefit for monaural listeners. The results suggest that noninvasive CROS solutions can successfully rehabilitate certain monaural listening deficits, provide improved hearing outcomes, and expand the reach of treatment in this population.

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High Incidence of Bell's Palsy After Mastoidectomy: A Longitudinal Follow-up Study

Objective: The objective of this study was to compare the prevalence of Bell's palsy in participants who underwent mastoidectomy (to treat chronic otitis media) and nonmastoidectomy participants (control). Methods: Using the national cohort study from the Korean Health Insurance Review and Assessment Service, mastoidectomy patients (2,045) and control participants (8,180) were matched 1:4 for age, sex, income, and region of residence. The prevalence of Bell's palsy in both the groups was measured from 0 to 10 years postoperation. Results: In a sample of 1,025,340 Korean individuals, 7,070 were diagnosed or treated with Bell's palsy between 2002 and 2013; the annual incidence of Bell's palsy was 0.057%. The overall prevalence of Bell's palsy was three times higher in the mastoidectomy group (1.27%) than control group (0.49%) (p 

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Prospective Evaluation of Patients Undergoing Translabyrinthine Excision of Vestibular Schwannoma with Concurrent Cochlear Implantation

Objective: Translabyrinthine (TL) vestibular schwannoma (VS) resection may be accomplished with preservation of the cochlear nerve, permitting successful, concurrent cochlear implantation. In this single institution, Food and Drug Administration-approved feasibility study, we wished to determine the success and outcomes of concurrent cochlear implantation at the time of TL resection of VS. Study Design: Prospective cohort. Setting: Tertiary referral center. Patients: Patients with small VS less than 1.5 cm in size. Intervention: Concurrent TL VS resection and cochlear implantation. Main Outcome Measure: Sound localization and speech understanding. Results: All cochlear nerves were anatomically preserved. Five out of seven patients had auditory precepts at the time of activation. At 1 month following surgery, AzBio scores (0 dB SNR, with sound front, noise to normal ear) were improved by an average of 10% with implant on, persisting to 6 months out from surgery. Localization 1 month after surgery was markedly improved with root mean square 78 degrees ±13 in the “implant off” condition and 41 ± 9 degrees in the “implant on” condition. Average tinnitus severity was reduced in subjects and speech and spatial hearing was improved on speech, spatial and qualities of hearing scale (SSQ). Conclusions: These data demonstrate preservation of electrical hearing in TL VS surgery is consistently possible, and although speech outcomes do not achieve the same levels seen with other etiologies of hearing loss, excellent improvement in sound localization, improved speech understanding, and substantial reductions in tinnitus are achieved.

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Dizziness Handicap Inventory Score Is Highly Correlated With Markers of Gait Disturbance

Objective: To evaluate the association between Dizziness Handicap Inventory—Screening version (DHI-S) score and spatiotemporal gait parameters using SoleSound, a newly developed, inexpensive, portable footwear-based gait analysis system. Study Design: Cross-sectional. Patients: One hundred eighteen patients recruited from otology clinic. Intervention(s): Subjects completed the DHI-S survey and four uninterrupted walking laps wearing SoleSound instrumented footwear on a hard, flat surface for 100 m. Main Outcome Measure(s): For each subject, mean and coefficient of variation (CV) of stride length, cadence, walking speed, foot-ground clearance, double-support time, swing period, and stance-to-swing were computed by considering 40 strides of steady-state walking within each lap. Linear regression models were employed to study correlations between these variables and DHI-S scores after adjusting for age, sex, and race/ethnicity. Results: Patients with higher DHI-S score took shorter steps and less steps per minute (−0.017 m and −1.1 steps/min per every four-point increase in DHI-S score, p 

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Mastoid and Inner Ear Measurements in Patients With Menière's Disease

Objective: To determine the relationship between radiographic temporal bone anatomy of patients with Menière's disease in medically and surgically managed populations versus controls. Study Design: Retrospective chart review. Setting: Two tertiary referral centers. Patients: Adults older than 18 years with Menière's disease treated with endolymphatic sac decompression (ESD) or medical management (non-ESD) versus controls. Interventions: Magnetic resonance imaging and computed tomography imaging studies of the temporal bones were reviewed by blinded radiologists. Main Outcome Measures: Radiographic temporal bone dimensions were measured in Menière's disease and control patients. Age, sex, symptoms, audiogram data, academy classification of Menière's disease, and follow-up were recorded. Statistical analysis was performed to compare outcome measures across groups and demographics. Results: A total of 90 imaging studies were reviewed (ESD = 22; non-ESD = 30; control = 38). ESD and non-ESD groups had similar pure-tone averages (33.9 ± 20.6 versus 41.6 ± 22.6 dB HL; p = 0.21) and frequency of definite Menière's disease (59.1% versus 53.3%; p = 0.68). There was no significant trend between groups for any measurement. One nonsignificant trend existed in mean vestibule length, increasing from the control (5.45 ± 0.54 mm), non-ESD (5.80 ± 0.97 mm), and ESD (5.94 ± 0.81 mm) group. In a combined Menière's group, mean vestibule length was significantly greater than controls (5.86 ± 0.89 versus 5.45 ± 0.54 mm; p = 0.008) and mean vestibule width significantly less (2.99 ± 0.46 versus 3.19 ± 0.39 mm; p = 0.024). Conclusion: Medical and surgical Menière's patients were similar utilizing academy classification. There was no significant trend between medical and surgical Menière's patients versus controls for any measurement. In a combined Menière's group, the longer and narrower vestibule anatomy may suggest an anatomical basis for endolymphatic hydrops.

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Risk Factors of Recurrence in Pediatric Congenital Cholesteatoma

Objective: To examine the risk factors of recurrence in pediatric congenital cholesteatoma. Study Design: Retrospective chart review. Setting: University hospital. Patients: Sixty-seven patients having tympanic type of congenital cholesteatoma under 15-years old at surgery. Interventions: Canal wall-up tympanomastoidectomy (n = 30) or transcanal atticotomy/tympanoplasty (n = 37) was performed depending on cholesteatoma extension, 16 of which were followed by second-look surgery. Preoperative computed tomography (CT) before second-look surgery or follow-up CT was performed to detect residual recurrence 1 year after the surgery. Cholesteatoma found at the second surgery was also included in the recurrence. All patients had no recurrent cholesteatoma at the last follow-up (median, 61 mo after surgery). Main Outcome Measures: Possible predictive factors were compared between the groups. Results: Residual cholesteatoma and retraction cholesteatoma occurred in 21 and 6%, respectively. There was no significant difference in age, sex, and type of cholesteatoma (open or closed) between the groups; however, Potsic stage and status of stapes involvement were more advanced in the residual cholesteatoma group. All residual lesions could be detected by follow-up CT or by second-look surgery. All of four retraction cholesteatoma patients were male, young at the surgery and in stage IV. Conclusion: Recurrence mostly occurred as residual cholesteatoma, suggesting that CT is recommended as a follow-up tool for congenital cholesteatoma. Advanced lesions had the risk of residual cholesteatoma, suggesting that complete removal of epithelium is important. Although rare, young advanced-stage patients had risk of retraction cholesteatoma and therefore normal mucosa should be preserved as much as possible for these patients.

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Pain Free 3 T MRI Scans in Cochlear Implantees

Objective: For cochlear implant recipients, undergoing magnetic resonance imaging (MRI) scans is associated with safety risks and potential side effects. Even following safety guidelines, potential complications (e.g., pain, magnet dislocation, image artifacts) are possible during 1.5 Tesla (T) MRI scans. The stronger static magnetic field of a 3.0 T scanner is associated with further risks of complication, including implant demagnetization. These complications led to the recent development of rotatable internal receiver magnets with a diametrical magnetization. The aim of this study was to evaluate the potential occurrence of pain during 3.0 T MRI scans for cochlear implant recipients with a rotatable, diametrically magnetized implant magnet. Patients: Five patients implanted with a cochlear implant diametrically magnetized magnet. Intervention: MRI scanning at 3 T. Main Outcome Measure: In the prospective patient study an MRI scan was performed on five implantees and the degree of pain was evaluated by a visual analog scale. Scans were performed initially with a magnet-supporting headband, and depending on the degree of discomfort/pain, repeated without the headband. Results: In all the patients, all the MRI scans were performed without any pain, even without the use of the supportive headband. Demagnetization was clinically not observed. Conclusion: 3.0 T MRI scanning can be performed on cochlear implant recipients with a rotatable diametrically magnetized internal magnet without risk of the most frequent cochlear-implant-related MRI complication: pain. This finding enables the expansion of MRI scanning indications up to 3.0 T without complication. Limitations in terms of MRI artifact still persist.

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Usefulness of Electrical Auditory Brainstem Responses to Assess the Functionality of the Cochlear Nerve Using an Intracochlear Test Electrode

Objective: To use an intracochlear test electrode to assess the integrity and the functionality of the auditory nerve in cochlear implant (CI) recipients and to compare electrical auditory brainstem responses (eABR) via the test electrode with the eABR responses with the CI. Setting: Otolaryngology department, tertiary referral hospital. Patients: Ten subjects (age at implantation 55 yr, range, 19–72) were subsequently implanted with a MED-EL CONCERTO CI on the side without any useful residual hearing. Interventions: Following identification of the round window (RW), the test electrode was inserted in the cochlea previous to cochlear implantation. Main Outcome Measures: To assess the quality of an eABR waveform, scoring criteria from Walton et al. (2008) were chosen. The waveforms in each session were classified by detecting waves III and V by the algorithm and visual assessment of the waveform. Speech performance was evaluated with monosyllables, disyllables, and sentence recognition tests. Results: It was possible to evoke electrical stimulation responses along with both the test electrode and the CI in all subjects. No significant differences in latencies or amplitudes after stimulation were found between the test electrode and the CI. All subjects obtained useful hearing with their CI and use their implants daily. Conclusions: The intracochlear test electrode may be suitable to test the integrity of the auditory nerve by recording eABR signals. This allows for further research on the status of the auditory nerve after tumor removal and correlation with auditory performance.

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A Multivariate Analytic Approach to the Differential Diagnosis of Apraxia of Speech

Purpose

Apraxia of speech (AOS) is a consequence of stroke that frequently co-occurs with aphasia. Its study is limited by difficulties with its perceptual evaluation and dissociation from co-occurring impairments. This study examined the classification accuracy of several acoustic measures for the differential diagnosis of AOS in a sample of stroke survivors.

Method

Fifty-seven individuals were included (mean age = 60.8 ± 10.4 years; 21 women, 36 men; mean months poststroke = 54.7 ± 46). Participants were grouped on the basis of speech/language testing as follows: AOS-Aphasia (n = 20), Aphasia Only (n = 24), and Stroke Control (n = 13). Normalized Pairwise Variability Index, proportion of distortion errors, voice onset time variability, and amplitude envelope modulation spectrum variables were obtained from connected speech samples. Measures were analyzed for group differences and entered into a linear discriminant analysis to predict diagnostic classification.

Results

Out-of-sample classification accuracy of all measures was over 90%. The envelope modulation spectrum variables had the greatest impact on classification when all measures were analyzed together.

Conclusions

This study contributes to efforts to identify objective acoustic measures that can facilitate the differential diagnosis of AOS. Results suggest that further study of these measures is warranted to determine the best predictors of AOS diagnosis.

Supplemental Materials

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Right-Ear Advantage for Speech-in-Noise Recognition in Patients with Nonlateralized Tinnitus and Normal Hearing Sensitivity

Abstract

Despite having normal hearing sensitivity, patients with chronic tinnitus may experience more difficulty recognizing speech in adverse listening conditions as compared to controls. However, the association between the characteristics of tinnitus (severity and loudness) and speech recognition remains unclear. In this study, the Quick Speech-in-Noise test (QuickSIN) was conducted monaurally on 14 patients with bilateral tinnitus and 14 age- and hearing-matched adults to determine the relation between tinnitus characteristics and speech understanding. Further, Tinnitus Handicap Inventory (THI), tinnitus loudness magnitude estimation, and loudness matching were obtained to better characterize the perceptual and psychological aspects of tinnitus. The patients reported low THI scores, with most participants in the slight handicap category. Significant between-group differences in speech-in-noise performance were only found at the 5-dB signal-to-noise ratio (SNR) condition. The tinnitus group performed significantly worse in the left ear than in the right ear, even though bilateral tinnitus percept and symmetrical thresholds were reported in all patients. This between-ear difference is likely influenced by a right-ear advantage for speech sounds, as factors related to testing order and fatigue were ruled out. Additionally, significant correlations found between SNR loss in the left ear and tinnitus loudness matching suggest that perceptual factors related to tinnitus had an effect on speech-in-noise performance, pointing to a possible interaction between peripheral and cognitive factors in chronic tinnitus. Further studies, that take into account both hearing and cognitive abilities of patients, are needed to better parse out the effect of tinnitus in the absence of hearing impairment.

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