Faculty Bibliography

This article highlights variables that affect cochlear implant performance, emerging factors warranting consideration, and variables shown not to affect performance. Research on the outcomes following cochlear implantation has identified a wide spectrum of variables known to affect pos0timplantation performance. These variables relate to the device itself as well as individual patient characteristics. Factors believed to affect spiral ganglion cell survival and function have been shown to influence postoperative performance. Binaural hearing affects performance. Social and educational factors also affect postoperative performance. Novel variables capable of affecting performance continue to emerge with increased understanding of auditory pathway development and neural plasticity

OBJECTIVES/HYPOTHESIS: To analyze existing evidence regarding utility of laryngeal electromyography (LEMG) for prognosis in cases of vocal fold palsy (VFP). STUDY DESIGN: Meta-analysis of studies reporting LEMG results and clinical outcomes in 503 patients with of VFP identified by literature search. METHODS: Studies were identified by literature search. Method of diagnosis, interval to LEMG, criteria for prognostication, and outcome were assessed. Criteria for prognosis were standardized to the extent possible across all studies, and studies were checked for consistency in outcome measures and assessments. Pooled data were subjected to statistical analysis. RESULTS: A total of 296/503 patients (58.8%) had findings predictive with poor prognosis, whereas 207/503 (41.2%) had findings of recovery. According to laryngoscopic examination, 269/296 patients with predicted poor recovery had poor recovery (positive predictive value = 90.9%), whereas 27/296 (9.1%) had good recovery. In patients with findings consistent with recovery, 115/207 (negative predictive value = 55.6%) noted return of motion, whereas 88/207 (44.4%) did not. The odds ratio was 11.56 with 95% confidence interval of 7.10-18.81. CONCLUSIONS: LEMG is a good predictor of poor recovery in patients with VFP and is clinically useful in identifying candidates for early definitive intervention

OBJECTIVES: To determine the efficacy of cochlear implantation (CI) in prelingually deafened adolescent children and to evaluate predictive variables for successful outcomes. DESIGN: Retrospective medical record review. PARTICIPANTS: Children aged 10 to 17 years with prelingual hearing loss (mean length of deafness, 11.5 years) who received a unilateral CI (mean age at CI, 12.9 years). Intervention Unilateral CI. MAIN OUTCOME MEASURES: Standard speech perception testing (Consonant-Nucleus-Consonant [CNC] monosyllabic word test and Hearing in Noise [HINT] sentence test) was performed preoperatively, 1 year postoperatively (year 1), and at the last follow-up/end of the study (EOS). RESULTS: There was a highly significant improvement in speech perception scores for both HINT sentence and CNC word testing from the preoperative testing to year 1 (mean change score, 51.10% and 32.23%, respectively; P < .001) and from the preoperative testing to EOS (mean change score, 60.02% and 38.73%, respectively; P < .001), with a significantly greater increase during the first year (P < .001). In addition, there was a highly significant correlation between improvements in performance scores on the CNC word and HINT sentence speech perception tests and both age at CI and length of deafness at the year 1 testing (P </=.009) but not from the year 1 testing to EOS testing. Adolescents with progressive deafness and those using oral communication before CI performed significantly better than age-matched peers. CONCLUSIONS: Adolescents with prelingual deafness undergoing unilateral CI show significant improvement in objective hearing outcome measures. Patients with shorter lengths of deafness and earlier age at CI tend to outperform their peers. In addition, patients with progressive deafness and those using oral communication have significantly better objective outcomes than their peers

OBJECTIVE: To generate an evidence-based algorithm for the use of intraoperative testing during cochlear implantation (CI). STUDY DESIGN: Retrospective review. SETTING: Tertiary referral center. PATIENTS: A total of 277 children (aged 6 mo to 17 yr) and adults 18 years and older with normal cochlear anatomy who underwent primary and revision cochlear implantation at a single center between 2005 and 2010 were included. INTERVENTION: Intraoperative electrophysiologic monitoring and intraoperative Stenver's view plain film radiography. MAIN OUTCOME MEASURE: Intraoperative testing included the following: 1) individual electrode impedance measurements; 2) neural response telemetry (tNRT) levels for electrodes E20, E15, E10, and E5; and 3) plain film radiograph assessment of electrode position. RESULTS: No patient demonstrated abnormalities on all 3 modalities. Open or short electrodes on impedance testing were found in 6% of patients; half of these normalized when remeasured. Absent tNRT responses on 1 or more electrodes occurred in 14% of patients, although complete lack of response was rare (1.4%) and did not correlate with a dysfunctional device. Spread of excitation was performed in 1 patient and was consistent with a tip rollover. Intraoperative radiography identified tip-rollover and extracochlear electrode placement in all cases (n = 5, 1.8%) and prompted the use of the backup device. CONCLUSION: Immediate intraoperative determination of device functionality and optimal electrode placement is advantageous. Of the modalities tested, including electrode impedance, tNRT, and plain radiograph, only the radiographic results impacted intraoperative surgical decision making and led to the use of the backup device

OBJECTIVE: To further define the spectrum of clinical presentation and explore the histologic sequelae of jugular bulb abnormalities (JBAs). DESIGN: Retrospective review. SETTING: Academic medical center. PATIENTS: Thirty patients with radiologic evidence of inner ear dehiscence by JBA. MAIN OUTCOME MEASURE: Thirty patients with radiologic inner ear dehiscence by JBA and 1579 temporal bone specimens were evaluated for consequences from JBA. RESULTS: We found that JBA-associated inner ear dehiscence could be identified on computed tomography of the temporal bone but not on magnetic resonance imaging scan. Jugular bulb abnormalities eroded the vestibular aqueduct most often (in 25 patients), followed by the facial nerve (5 patients) and the posterior semicircular canal (4 patients). Half of the patients (15) were asymptomatic. Results from vestibular evoked myogenic potential (VEMP) tests were positive in 8 of 12 patients with inner ear dehiscence. Histologically, only 2 of 41 temporal bones with dehiscence of the vestibular aqueduct demonstrated endolymphatic hydrops. CONCLUSIONS: Jugular bulb abnormalities can erode into the vestibular aqueduct, facial nerve, and the posterior semicircular canal. While symptoms may include pulsatile tinnitus, vertigo, or conductive hearing loss, in contrast to earlier reports, half of the patients were asymptomatic. Dehiscence of vestibular aqueduct rarely leads to clinical or histologic hydrops. The VEMP testing was useful in confirming the presence of inner ear dehiscence due to JBAs. Because the natural history of JBAs is unknown, these patients should be followed closely to evaluate for progression of the JBA or development of symptoms

Cochlear implants have a remarkable history and a promising future. As the cochlear implant has evolved, so has the surgical technique. This review encompasses a history of the cochlear implant, a summary of the evolution of the implant incision and the methods used to secure the device and the electrode, the cochleostomy versus round window debate, and a discussion of the validity of intraoperative tests. Advanced technology, new surgical techniques, and refining established techniques are hallmarks of cochlear implant surgery. Advancements, including image-guided surgery, hearing preservation with full insertion, and telemetry-based advanced programming, are expected to be standard in the future

BACKGROUND:Temporary remission of primary hyperparathyroidism (PHPT) following fine-needle aspiration (FNA)-induced hemorrhage of a parathyroid adenoma is extremely rare. The purpose of this report was to illustrate that parathyroid adenomas can masquerade as thyroid nodules and that these patients must be monitored closely following remission as their hyperparathyroidism may recur. PATIENT FINDINGS/METHODS:This report describes a patient who presented with a neck mass and was incidentally found to have PHPT. Ultrasound (US) evaluation revealed a lesion that was diagnosed as a thyroid nodule. After a nondiagnostic FNA, she developed a large neck hematoma and her PHPT went into remission. Soon thereafter, her hyperparathyroidism recurred, and she underwent parathyroidectomy and thyroid lobectomy, which confirmed a large parathyroid adenoma. SUMMARY/CONCLUSIONS:This report illustrates that remission of PHPT can occur because of FNA-induced hemorrhage leading to autoinfarction of a parathyroid adenoma. Following autoinfarction, the patient's parathyroid hormone and calcium levels must be monitored closely as the remission of PHPT may be temporary. Further, although US is a fast, inexpensive, often reliable modality for diagnosing neck masses, it does not always accurately identify parathyroid adenomas. CONCLUSION/CONCLUSIONS:Clinicians must be cognizant of the possibility that parathyroid adenomas can masquerade as thyroid nodules on US, especially as most patients with parathyroid adenomas are asymptomatic at presentation.

BACKGROUND:Currently described endoscopic techniques for subtotal resections of the maxilla include endoscopic medial maxillectomy and extended endoscopic medial maxillectomy; however, a complete resection of the maxilla is sometimes warranted. We describe a combined transoral and endoscopic technique for total and subtotal maxillectomy in an attempt to decrease the morbidity of traditional approaches. METHODS:Technical note, Feasibility, Human cadaveric dissection. RESULTS:Ten total and subtotal maxillectomies were performed in human specimens without the need of facial incisions or transfixion of the nasal septum. The pterygopalatine and infratemporal fossas were accessed and dissected in all cases. CONCLUSIONS:A combined transoral and endoscopic approach is feasible and can be used in selected patients when other minimally endoscopic techniques are not indicated. The benefits of no facial incisions and/or transfixion of the nasal septum, potential improvement in hemostasis, and visual magnification may help to decrease the morbidity of traditional open approaches.