Faculty Bibliography

OBJECTIVE:To describe extracochlear extension of revision cochlear implant arrays into the Fallopian canal. PATIENTS:Two adult patients with extension of revision cochlear implant arrays into the Fallopian canal. INTERVENTIONS:Computed tomography (CT), selective deactivation of non-functional electrodes. MAIN OUTCOME MEASURES:Facial nerve function, facial nerve stimulation, cochlear implant electrode position, radiography, functional hearing. RESULTS:Two patients presented with failure of their long-standing cochlear implants (CIs). One patient with presumed postviral hearing loss presented with declining function and increasing facial stimulation from an implant placed 30 years previous. A second with postmeningitic hearing loss presented with a draining mastoid fistula from an implant placed 7 years before. Both patients were reimplanted with minimal insertion resistance via the established electrode tract, yet demonstrated facial nerve stimulation during intraoperative telemetry and on device activation. Postoperative CTs of each patient showed exit of the electrode from the cochlea into the tympanic or labyrinthine Fallopian canal. Both patients can use their devices effectively with selective electrode deactivation. CONCLUSIONS:Our cases illustrate the potential association of long-standing electrodes with otic capsule changes, allowing extracochlear malposition of subsequent arrays. This can occur despite apparently uneventful reinsertion of a flexible array without undue force. Previously reported histopathology confirms the potential for a reactive osteitis from arrays that may contribute to this phenomenon. Intraoperative facial stimulation with neural telemetry testing can raise suspicion of a malpositioned array involving the Fallopian canal. Such cases can be effectively managed with selective deactivation of malpositioned electrode contacts.

Objective To evaluate the effect of anatomy-specific virtual reality (VR) surgical rehearsal on surgeon confidence and temporal bone dissection performance. Study Design Prospective pre- and poststudy of a novel virtual surgical rehearsal platform. Setting Academic otolaryngology-head and neck surgery residency training programs. Subjects and Methods Sixteen otolaryngology-head and neck surgery residents from 2 North American training institutions were recruited. Surveys were administered to assess subjects' baseline confidence in performing 12 subtasks of cortical mastoidectomy with facial recess. A cadaver temporal bone was randomly assigned to each subject. Cadaver specimens were scanned with a clinical computed tomography protocol, allowing the creation of anatomy-specific models for use in a VR surgical rehearsal platform. Subjects then rehearsed a virtual mastoidectomy on data sets derived from their specimens. Surgical confidence surveys were administered again. Subjects then dissected assigned cadaver specimens, which were blindly graded with a modified Welling scale. A final survey assessed the perceived utility of rehearsal on dissection performance. Results Of 16 subjects, 14 (87.5%) reported a significant increase in overall confidence after conducting an anatomy-specific VR rehearsal. A significant correlation existed between perceived utility of rehearsal and confidence improvement. The effect of rehearsal on confidence was dependent on trainee experience and the inherent difficulty of the surgical subtask. Postrehearsal confidence correlated strongly with graded dissection performance. Subjects rated anatomy-specific rehearsal as having a moderate to high contribution to their dissection performance. Conclusion Anatomy-specific virtual rehearsal improves surgeon confidence in performing mastoid dissection, dependent on surgeon experience and task difficulty. The subjective confidence gained through rehearsal correlates positively with subsequent objective dissection performance.

OBJECTIVE:Review otolaryngology literature for awareness of neurotoxicity from general anesthesia in children. Recently, there has been increasing focus in anesthesia literature on the long-term effects of general anesthesia on neurodevelopment. Multiple animal models have demonstrated evidence of neurotoxicity from both inhalational and intravenous anesthetics. Cohort studies also have revealed modestly increased risk of adverse neurodevelopmental outcomes in children exposed to a single episode of general anesthesia prior to 3 to 4 years of age, with stronger evidence for multiple exposures in this age range. Otolaryngologists may subject children to general anesthesia via procedures or tests, including computed tomography, magnetic resonance imaging, and auditory brainstem response. DATA SOURCES:PubMed, Embase, Scopus, and Web of Science Review. METHODS:A scoping review using the above databases was performed limited to January 2005 through December 2015. Articles were screened and reviewed based on predefined inclusion and exclusion criteria. RESULTS:Initial search generated 3,909 articles. After 72 full text articles were reviewed, only seven articles mentioned neurotoxicity as a risk of general anesthesia in pediatric patients. CONCLUSION:Despite the high volume of pediatric otolaryngologic procedures performed annually, there remains limited awareness in our literature discussing neurotoxicity as an outcome. Prospective data from anesthesia literature is still pending; therefore, specific recommendations cannot be made at this time. Otolaryngologists should be aware of the concerns and work toward defining elective procedures, combining surgical procedures with other procedures or imaging, and reassessing the timing and frequency of various interventions under general anesthesia in young children. Laryngoscope, 127:1930-1937, 2017.

OBJECTIVES/OBJECTIVE:Paradoxical vocal fold motion (PVFM) consists of intermittent adduction of the vocal folds during inspiration, resulting in stridor and worsened by anxiety and stress. The purpose of this study was to assess the impact of PVFM on quality of life in our pediatric patient population. STUDY DESIGN/METHODS:This is a prospective, descriptive survey study. METHODS:Thirty-nine consecutive patients (ages 12-17 years) presenting with a PVFM diagnosis for respiratory retraining sessions with speech-language pathology were recruited. Patients completed a brief demographic questionnaire and the Short Form 36, version 2, a validated tool for measuring health-related quality of life. RESULTS:There were 31 (79%) girls and 8 (21%) boys with a mean age of 15.5 years. Subjects reported regular participation in competitive extracurricular activities, including track or cross country (30.8%), swimming (17.9%), and cheerleading or dancing (15.4%). Of the patients in the study, 46.2% were straight-A students. On the SF-36 (population averages normalized to a score of 50), the general health of patients with PVFM was better than that of the general population (53.27); however, their physical health limited their role activities more severely (42.82). In addition, a greater proportion of the group with PVFM was at risk for first-stage depression screening when compared with the general population (28% versus 18%). CONCLUSIONS:We demonstrate a measurable detrimental impact of PVFM on health-related quality of life. This is consistent with previously published literature showing a preponderance of females with PVFM, most of whom are high achievers academically and athletically.

OBJECTIVES/HYPOTHESIS:Acute supraglottitis is a potentially life-threatening condition due to rapid onset upper airway obstruction. The study aimed to characterize adult acute supraglottitis patients and to recognize factors associated with an aggressive disease course. STUDY DESIGN:Retrospective chart review. METHODS:All adult acute supraglottitis patients admitted to a single academic medical center between 2000 and 2014 were included and their medical charts reviewed. The main outcome measures were airway intervention and mortality. RESULTS:Three hundred fifty-eight patients were enrolled. Mean age was 53 years (range, 16-92 years), with 62.8% males. Sore throat (79%) and dysphagia (70.9%) were the most common symptoms. Stridor (3.6%), tachypnea (5.7%), and dyspnea (6.4%) were uncommon but significantly associated with airway intervention. The epiglottis was most commonly involved (67%). Involvement of the epiglottis and aryepiglottic folds showed a trend of correlation to airway intervention. Blood glucose levels, C-reactive protein (CRP) levels, and relative neutrophilia were significantly higher in patients admitted to the intensive care unit or requiring airway intervention. Thirty-four patients (9.5%) required intensive care unit admission. Sixteen patients (4.4%) required airway intervention. Recurrent episodes of supraglottitis, seen in 19 patients, were more common in males (P = .048), and tended to have a more severe clinical course, requiring more airway interventions (P = .005) and intensive care unit admissions (P = .016). CONCLUSIONS:The typical high risk patient-a male, with dyspnea and stridor, presenting with edema of the epiglottis and aryepiglottic folds, elevated CRP, hyperglycemia, and a history of recurrent episodes-should warrant more aggressive treatment and closer observation. LEVEL OF EVIDENCE:4 Laryngoscope, 127:2106-2112, 2017.

BACKGROUND:Contemporary cochlear implants (CIs) use cathodic-leading, symmetrical, biphasic current pulses, despite a growing body of evidence that suggests anodic-leading pulses may be more effective at stimulating the auditory system. However, since much of this research on humans has used pseudomonophasic pulses or biphasic pulses with unusually long interphase gaps, the effects of stimulus polarity are unclear for clinically relevant (i.e., symmetric biphasic) stimuli. PURPOSE/OBJECTIVE:The purpose of this study was to examine the effects of stimulus polarity on basic characteristics of physiological spread-of-excitation (SOE) measures obtained with the electrically evoked compound action potential (ECAP) in CI recipients using clinically relevant stimuli. RESEARCH DESIGN/METHODS:Using a within-subjects (repeated measures) design, we examined the differences in mean amplitude, peak electrode location, area under the curve, and spatial separation between SOE curves obtained with anodic- and cathodic-leading symmetrical, biphasic pulses. STUDY SAMPLE/METHODS:Fifteen CI recipients (ages 13-77) participated in this study. All were users of Cochlear Ltd. devices. DATA COLLECTION AND ANALYSIS/METHODS:SOE functions were obtained using the standard forward-masking artifact reduction method. Probe electrodes were 5-18, and they were stimulated at an 8 (of 10) loudness rating ("loud"). Outcome measures (mean amplitude, peak electrode location, curve area, and spatial separation) for each polarity were compared within subjects. RESULTS:Anodic-leading current pulses produced ECAPs with larger average amplitudes, greater curve area, and less spatial separation between SOE patterns compared with that for cathodic-leading pulses. There was no effect of polarity on peak electrode location. CONCLUSIONS:These results indicate that for equal current levels, the anodic-leading polarity produces broader excitation patterns compared with cathodic-leading pulses, which reduces the spatial separation between functions. This result is likely due to preferential stimulation of the central axon. Further research is needed to determine whether SOE patterns obtained with anodic-leading pulses better predict pitch discrimination.