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OBJECTIVE To review our hearing preservation rates and speech recognition outcomes in patients undergoing cochlear implantation with a recently developed lateral wall electrode. STUDY DESIGN Retrospective cohort study. METHODS Retrospective case series of all patients, both pediatric and adult, undergoing cochlear implantation with the Advanced Bionics Hifocus™ SlimJ electrode between December 2017 and January 2020. Main outcomes included hearing preservation rates using several definitions, speech recognition testing primarily through Arizona Biosciences (AzBio) and Consonant-Nucleus-Consonant (CNC) testing, intra- and postoperative complications. RESULTS Sixty-one ears underwent implantation with the new electrode. Hearing preservation rates were 13.0% to 36.0% depending on the definition used. Speech recognition testing showed significant increases from pre- to postoperative condition (Implant-only AzBio: 24.1 to 48.3, P = .004, binaural AzBio: 46.1 to 65.9, P = .002, Implant-only CNC: 9.7 to 35.1, P

Objective/hypothesis This study aimed to determine the clinical and cost-effectiveness of endoscopes during cholesteatoma surgery. More specifically, this study hypothesized that endoscope use would reduce cholesteatoma recurrence rates and cost. Study design Case series involving the prospective enrollment of 110 consecutive cholesteatoma patients over a 2-year period. Methods Patients underwent cholesteatoma surgery with microscopy. During dissection, the location of the cholesteatoma was assessed. At the end of dissection and before reconstruction, the same subunits were visualized with straight and angled endoscopes for residual cholesteatoma. Hearing was analyzed before surgery and at the last possible examination. Costs were analyzed using Medicare reimbursement rates from the Centers for Medicare and Medicaid Services. Results Intraoperative endoscopic surveillance was able to detect residual cholesteatoma in 18 patients. With a 0° endoscope, residual cholesteatoma was noted in the epitympanum (two patients), sinus tympani (one patient), and the supratubal air cells (one patient). With a 45° endoscope, residual cholesteatoma was noted in the epitympanum (three patients), sinus tympani (nine patients), the supratubal air cells (two patients), and the mesotympanum (two patients). From a cost analysis, endoscopic surveillance ($6110.36 per patient) are less expensive than second look surgeries ($11,829.83 per patient), observation ($7097.20 per patient), and observation with annual magnetic resonance imaging studies ($9891.95 per patient). The patients hearing improved after surgery, consistent with previous studies. No complications were noted from the use of endoscopes. Conclusions Intraoperative endoscopic surveillance reduced recurrence in our series of 110 patients. Endoscopes are particularly useful in evaluating the epitympanum, mesotympanum, sinus tympani, and supratubal air cells. Moreover, endoscopic surveillance is cost-effective. Level of evidence 4 Laryngoscope, 128:2867-2871, 2018.

Objectives/Hypothesis The aims of this study were to investigate short- and long-term rates of hearing preservation after cochlear implantation and identify factors that impact hearing preservation. Study Design Retrospective review. Methods Patients undergoing cochlear implantation with conventional-length electrodes and air-conduction thresholds ≤80 dB HL at 250 Hz preoperatively were included. Hearing preservation was defined as air-conduction thresholds ≤80 dB HL at 250 Hz. Results The sample included 196 patients (225 implants). Overall, the rate of short-term hearing preservation was 38% (84/225), with 18% (33/188) of patients preserving hearing long term. Multivariate analysis showed better preoperative hearing was predictive of hearing preservation at short (odds ratio [OR]: 0.93, 95% confidence interval [CI]: 0.91-0.95, P < .001) and long-term follow-up (OR: 0.94, 95% CI: 0.91-0.97, P < .001). Lateral wall electrodes and mid-scala electrodes had 3.4 (95% CI: 1.4-8.6, P = .009) and 5.6-times (95% CI: 1.8-17.3, P = .003) higher odds of hearing preservation than perimodiolar arrays at short-term follow-up, respectively. Long-term data revealed better hearing preservation for lateral wall (OR: 7.6, 95% CI: 1.6-36.1, P = .01), but not mid-scala (OR: 3.1, 95% CI: 0.4-23.1, P = .28), when compared to perimodiolar electrodes. Round window/extended round window (RW/ERW) approaches were associated with higher rates of long-term hearing preservation (21%) than cochleostomy approaches (0%) (P = 0.002) on univariate analysis. Conclusions Better preoperative residual hearing, lateral wall electrodes, and RW/ERW approaches are predictive of higher rates of long-term functional hearing preservation. Level of Evidence 4 Laryngoscope, 2017

Objectives 1) Examine angular insertion depths (AID) and scalar location of Med-El (GmbH Innsbruck, Austria) electrodes; and 2) determine the relationship between AID and audiologic outcomes controlling for scalar position. Study Design Retrospective review. Methods Postlingually deafened adults undergoing cochlear implantation with Flex 24, Flex 28, and Standard electrode arrays (Med-El) were identified. Patients with preoperative and postoperative computed tomography scans were included so that electrode location and AID could be determined. Outcome measures were 1) speech perception in the cochlear implant (CI)-only condition, and 2) short-term hearing preservation. Results Forty-eight implants were included; all electrodes (48 of 48) were positioned entirely within the scala tympani. The median AID was 408° (interquartile [IQ] range 373°–449°) for Flex 24, 575° (IQ range 465°–584°) for Flex 28, and 584° (IQ range 368°–643°) for Standard electrodes (Med-El). The mean postoperative CNC score was 43.7% ± 21.9. A positive correlation was observed between greater AID and better CNC performance (r = 0.48, P < 0.001). Excluding patients with postoperative residual hearing, a strong correlation between AID and CNC persisted (r = 0.57, P < 0.001). In patients with preoperative residual hearing, mean low-frequency pure-tone average (PTA) shift was 27 dB ± 14. A correlation between AID and low-frequency PTA shift at activation was noted (r = 0.41, P = 0.04). Conclusion Favorable rates of scala tympani insertion (100%) were observed. In the CI-only condition, a direct correlation between greater AID and CNC score was noted regardless of postoperative hearing status. Deeper insertions were, however, associated with worse short-term hearing preservation. When patients without postoperative residual hearing were analyzed independently, the relationship between greater insertion depth and better performance was strengthened. Level of Evidence 4. Laryngoscope, 127:2352–2357, 2017

Objective Patients with incidental or minimally symptomatic superior semicircular canal dehiscence (SSCD) are usually observed, without surgical repair. However, it remains unknown whether a labyrinthine fistula of the superior semicircular canal is associated with progressive conductive or sensorineural hearing loss over time. Study Design Retrospective review at two tertiary care academic referral centers. Methods Adults analyzed were diagnosed with SSCD by high-resolution temporal bone computed tomography and vestibular evoked myogenic potential testing and observed with a minimum of two sequential audiograms. Patients with other potential causes of hearing impairment were excluded. Results A total of 40 ears in 30 adult patients (median age: 59 years; 63% female) were analyzed. Median audiometric follow-up was 23 months (range 1–136 months). None experienced a sudden hearing loss over the follow-up period. In patients with audiometric follow-up of at least 20 months (median 34 months), the median change in air-conduction pure tone average and air–bone gap was 0.9 decibels (dB) per year (interquartile range [IQR] 0–2.1) and 0.7 dB per year (IQR 0–2.0), respectively. Speech discrimination scores did not differ when comparing median initial (100%) and median final (98%) scores (P = 0.77). There was no statistically significant change in bone-conduction thresholds at 0.5, 1, 2, and 4 kHz over the period of observation. Conclusion The risk of progressive hearing loss with observed SSCD is low during short- and intermediate-term follow-up. Further studies are necessary to determine whether late hearing loss occurs. Such information may be critical toward patient counseling regarding the need for and timing of surgery. Level of Evidence 4. Laryngoscope, 127:1181–1186, 2017

Objectives To test the hypothesis that bipolar electrical impedance measurements in perimodiolar cochlear implants (CIs) may be used to differentiate between perimodiolar insertion technique favoring proximity to the modiolus or lateral wall. Study Design and Methods Bipolar impedances are a measure of electrical resistance between pairs of electrode contacts in a CI. Stimulation is through biphasic pulses at fixed frequency. Impedance measurements were made in real time through sequential sampling of electrode pairs. Perimodiolar electrodes were inserted in temporal bones using one of two techniques: 1) In the standard insertion technique (SIT), the electrode array slides along the lateral wall during insertion. 2) In the Advance Off Stylet (Cochlear Ltd. Sydney) technique (AOS), the electrode maintains modiolar contact throughout the insertion process. A set of 22 insertions were performed in temporal bone specimens using perimodiolar electrode arrays with both AOS and SIT. Buffered saline was used as a substitute for natural perilymph based on similar electrical conductivity properties. Impedance with and without stylet removal were recorded with a 30-second sampling window at final insertion depth. Results There is a significant difference in bipolar impedance measures between AOS and SIT, with impedances rising in measurements with stylet removal. Evaluation was based on two-sided analysis of variance considering technique and electrode with P < 0.025. Conclusion Bipolar electrical impedance can be used to detect relative motion toward the modiolus inside the cochlea. This detection method has the potential to optimize intraoperative placement of perimodiolar electrode arrays during implantation. We anticipate that this will result in lower excitation thresholds and improved hearing outcome. Level of Evidence N/A. Laryngoscope, 2016

The aims of this study were to investigate short- and long-term rates of hearing preservation after cochlear implantation and identify factors that impact hearing preservation.Retrospective review.Patients undergoing cochlear implantation with conventional-length electrodes and air-conduction thresholds ≤80 dB HL at 250 Hz preoperatively were included. Hearing preservation was defined as air-conduction thresholds ≤80 dB HL at 250 Hz.The sample included 196 patients (225 implants). Overall, the rate of short-term hearing preservation was 38% (84/225), with 18% (33/188) of patients preserving hearing long term. Multivariate analysis showed better preoperative hearing was predictive of hearing preservation at short (odds ratio [OR]: 0.93, 95% confidence interval [CI]: 0.91-0.95, P.001) and long-term follow-up (OR: 0.94, 95% CI: 0.91-0.97, P.001). Lateral wall electrodes and mid-scala electrodes had 3.4 (95% CI: 1.4-8.6, P = .009) and 5.6-times (95% CI: 1.8-17.3, P = .003) higher odds of hearing preservation than perimodiolar arrays at short-term follow-up, respectively. Long-term data revealed better hearing preservation for lateral wall (OR: 7.6, 95% CI: 1.6-36.1, P = .01), but not mid-scala (OR: 3.1, 95% CI: 0.4-23.1, P = .28), when compared to perimodiolar electrodes. Round window/extended round window (RW/ERW) approaches were associated with higher rates of long-term hearing preservation (21%) than cochleostomy approaches (0%) (P = 0.002) on univariate analysis.Better preoperative residual hearing, lateral wall electrodes, and RW/ERW approaches are predictive of higher rates of long-term functional hearing preservation.4. Laryngoscope, 128:482-489, 2018.

Keywords: Meningoencephalocele; encephalocele; cerebrospinal fluid leak; transmastoid; middle cranial fossa; brain hernia

Objectives/Hypothesis: We have previously described a novel, automated, nonrigid, model-based method for determining the intrascalar position of cochlear implant (CI) electrode arrays within human temporal bones using clinically available, flat-panel volume computed tomography (fpVCT). We sought to validate this method by correlating results with anatomic microdissection of CI arrays in cadaveric bones. Study Design: Basic science. Methods: Seven adult cadaveric temporal bones were imaged using fpVCT before and after electrode insertion. Using a statistical model of intracochlear anatomy, an active shape model optimization approach was employed to identify the scalae tympani and vestibuli on the preintervention fpVCT. The array position was estimated by identifying its midline on the postintervention scan and superimposing it onto the preintervention images using rigid registration. Specimens were then microdissected to demonstrate the actual array position. Results: Using microdissection as the standard for ascertaining electrode position, automatic identification of the basilar membrane coupled with postintervention fpVCT for electrode position identification accurately depicted the array location in all seven bones. In four specimens, the array remained within the scala tympani; in three, the basilar membrane was breached. Conclusions: We have anatomically validated this automated method for predicting the intrascalar location of CI arrays using CT. Using this algorithm and pre- and postintervention CT, rapid feedback regarding implant location and expected audiologic outcomes could be obtained in clinical settings. Laryngoscope, 2010

To test the hypothesis that bipolar electrical impedance measurements in perimodiolar cochlear implants (CIs) may be used to differentiate between perimodiolar insertion technique favoring proximity to the modiolus or lateral wall.Bipolar impedances are a measure of electrical resistance between pairs of electrode contacts in a CI. Stimulation is through biphasic pulses at fixed frequency. Impedance measurements were made in real time through sequential sampling of electrode pairs. Perimodiolar electrodes were inserted in temporal bones using one of two techniques: 1) In the standard insertion technique (SIT), the electrode array slides along the lateral wall during insertion. 2) In the Advance Off Stylet (Cochlear Ltd. Sydney) technique (AOS), the electrode maintains modiolar contact throughout the insertion process. A set of 22 insertions were performed in temporal bone specimens using perimodiolar electrode arrays with both AOS and SIT. Buffered saline was used as a substitute for natural perilymph based on similar electrical conductivity properties. Impedance with and without stylet removal were recorded with a 30-second sampling window at final insertion depth.There is a significant difference in bipolar impedance measures between AOS and SIT, with impedances rising in measurements with stylet removal. Evaluation was based on two-sided analysis of variance considering technique and electrode with P0.025.Bipolar electrical impedance can be used to detect relative motion toward the modiolus inside the cochlea. This detection method has the potential to optimize intraoperative placement of perimodiolar electrode arrays during implantation. We anticipate that this will result in lower excitation thresholds and improved hearing outcome.NA. Laryngoscope, 127:1413-1419, 2017.

To estimate the impact of race on disease presentation and treatment of vestibular schwannoma (VS) in the United States.Analysis of a national population-based tumor registry.Analysis of the Surveillance, Epidemiology, and End Results database was performed, including all patients identified with a diagnosis of VS. Associations between race, disease presentation, treatment strategy, and overall survival were analyzed in a univariate and multivariable model.A total of 9,782 patients with VS were identified among 822 million person-years. Of these, 7,400 (75.6%) claimed white, 807 (8.2%) Hispanic, 755 (7.7%) Asian, 397 (4.1%) black, and 423 (4.3%) patients reported other race. The median annual incidence of disease was lowest among black (0.43 per 100,000 persons) and Hispanic populations (0.45 per 100,000 persons) and highest among white (1.61 per 100,000 persons) populations (P0.001). Overall, Hispanic patients were diagnosed at the youngest age, and white patients were diagnosed at the oldest age (mean of 50.0 vs. 56.0 years, respectively; P0.001). Compared to white populations, black, Hispanic, and Asian populations were more likely to present with larger tumors (P0.001). After controlling for tumor size, age, and treatment center in a multivariable model, Hispanic patients were more likely than white patients to undergo surgery (P = 0.010); however, there were no differences between white, black, and Asian populations with regard to treatment modality. Hispanic and black patients had the poorest overall survival following surgery compared to other groups.Racial differences among patients with VS exist within the United States. Further studies are required to determine which factors drive differences in tumor size, age, annual disease incidence, and overall survival between races.3. Laryngoscope, 126:2128-2133, 2016.

Objectives/Hypothesis Three surgical approaches: cochleostomy (C), round window (RW), and extended round window (ERW); and two electrodes types: lateral wall (LW) and perimodiolar (PM), account for the vast majority of cochlear implantations. The goal of this study was to analyze the relationship between surgical approach and electrode type with final intracochlear position of the electrode array and subsequent hearing outcomes. Study Design Comparative longitudinal study. Methods One hundred postlingually implanted adult patients were enrolled in the study. From the postoperative scan, intracochlear electrode location was determined and using rigid registration, transformed back to the preoperative computed tomography which had intracochlear anatomy (scala tympani and scala vestibuli) specified using a statistical shape model based on 10 microCT scans of human cadaveric cochleae. Likelihood ratio chi-square statistics were used to evaluate for differences in electrode placement with respect to surgical approach (C, RW, ERW) and type of electrode (LW, PM). Results Electrode placement completely within the scala tympani (ST) was more common for LW than were PM designs (89% vs. 58%; P

A 74-year-old female presented to an outside medical facility with gradual decline in neurological status over a period of 6 to 8 weeks. The patient’s symptoms began with headache and progressed to confusion, altered sensorium, escalating ataxia, and expressive aphasia. The patient was transferred to our medical center. Review of the patient’s past medical history was negative for head trauma, prior neurosurgical or otologic procedures, neoplasms of the skull base, or chronic infections of the middle ear or mastoid. Secondary to the presence of a pacemaker, magnetic resonance imaging (MRI) was contraindicated; therefore, CT of the head was obtained and revealed a 5 by 3 cm pneumatocele in the area of the posterior fossa. Imaging showed evidence of compression of the right middle cerebellar peduncle and posterior right upper pons with associated hydrocephalus. (Fig. 1) The mastoid appeared to be hyperpneumatized and a small bony dehiscence was identified in the right posterior mastoid air cells just superior to the vestibular aqueduct. (Figs. 2A and 2B) The intracranial compartment and temporal bones were otherwise unremarkable. Medical workup revealed no other etiology for the patient’s neurological decline. The patient was initially observed as an inpatient, but showed no improvement in her neurological status.