Search

Objective: This study aimed to identify what proportion of middle-ear surgery patients utilise the internet for information and to characterise which resources and media formats are used and for what durations. Method: A single-arm, retrospective cohort study was performed using an online survey of English-speaking patients who underwent middle-ear surgery over a three-year period across two otology practices. Results: Of 260 invitees, 165 responded. A total of 122 used online resources: 9.8 per cent used online resources for less than 15 minutes, 27.0 per cent used them for 15 to 29 minutes, 27.0 per cent used them for 30 to 59 minutes and 36.1 per cent used them for 60 minutes or more. Of online users with complete responses (108 of 122), the most used resources (used for 12 minutes or more) were: written information (73.1 per cent); surgeons' websites (55.6 per cent); pictures, diagrams or photos (42.6 per cent); videos (37.0 per cent); and social media (10.2 per cent). Conclusion: At least 46.9 per cent of patients undergoing elective ear surgery use online resources. Most time is spent using written information, pictures, diagrams, photos and videos. Therefore, it is increasingly essential that accurate and informative resources in these formats are readily available online. [ABSTRACT FROM AUTHOR]

Objectives: An anatomical study was performed to describe the endoscopic anatomy and variations of the protympanum, including classification of the protiniculum and subtensor recess. Methods: A retrospective review was conducted of video recordings of cadaveric dissections and surgical procedures, which included visualisation of the protympanum, across 4 tertiary university referral centres over a 16-month period. A total of 97 ears were used in the analysis. Results: A quadrangular conformation of the protympanum was seen in 60 per cent of ears and a triangular conformation in 40 per cent. The protiniculum was type A (ridge) in 58 per cent, type B (bridge) in 23 per cent and type C (absent) in 19 per cent. The subtensor recess was type A (absent) in 30 per cent, type B (shallow) in 48 per cent and type C (deep) in 22 per cent. Conclusion: The protympanum is an area that has been ignored for many years because of difficulties in visualising it with an operating microscope. However, modern endoscopic equipment has changed this, providing detailed anatomical knowledge fundamental to ensuring the safety of endoscopic surgical procedures in the region. [ABSTRACT FROM AUTHOR]

Objective:Totally endoscopic ear surgery is a relatively new method for managing chronic ear disease. This study aimed to test the null hypothesis that open and endoscopic approaches have similar direct costs for the management of attic cholesteatoma, from an Australian private hospital setting.Methods:A retrospective direct cost comparison of totally endoscopic ear surgery and traditional canal wall up mastoidectomy for the management of attic cholesteatoma in a private tertiary setting was undertaken. Indirect and future costs were excluded. A direct cost comparison of anaesthetic setup and resources, operative setup and resources, and surgical time was performed between the two techniques.Results:Totally endoscopic ear surgery has a mean direct cost reduction of AUD$2978.89 per operation from the hospital perspective, when compared to canal wall up mastoidectomy.Conclusion:Totally endoscopic ear surgery is more cost-effective, from an Australian private hospital perspective, than canal wall up mastoidectomy for attic cholesteatoma. [ABSTRACT FROM PUBLISHER]

Objective:To investigate the evidence for balloon dilatation of the eustachian tube using a transtympanic approach.Methods:A systematic search of several databases was conducted (using the search terms ‘dilation’ or ‘dilatation’, and ‘balloon’ and ‘eustachian tube’). Only studies that used a transtympanic approach for the procedure were included. These studies were then assessed for risk of bias.Results:Three studies were included. Each of these studies was a limited case series, with two performed on human subjects and one on human cadavers. Results of safety and efficacy are conflicting. There is a high risk of bias overall.Conclusion:At present, there is a very narrow evidence base for transtympanic balloon dilatation of the eustachian tube. There are a number of advantages and disadvantages of the technique. Previously identified and theoretical safety concerns will need to be addressed thoroughly in future studies prior to wider clinical use. [ABSTRACT FROM AUTHOR]

Background:Imaging the Eustachian tube has proven difficult as it has an anatomical orientation that is not aligned with standard planes. In addition, the Eustachian tube is a dynamic structure, opening briefly during a variety of physiological manoeuvres.Case report:A 54-year-old healthy and asymptomatic man underwent computed tomography utilising an area detector scanner. Multiplanar reconstruction was performed at 1 mm intervals. In addition, dynamic clips were constructed to demonstrate air and its movement in the field. Images and video were acquired whilst a Valsalva manoeuvre was being performed.Conclusion:Although imaging techniques have been able to visualise the Eustachian tube well in the closed state, it may be more useful to have it imaged whilst open. Area detector computed tomography scanners can be used to acquire four-dimensional images. This allows dynamic imaging of the region, to assist in the diagnosis of various types of Eustachian tube dysfunction. [ABSTRACT FROM PUBLISHER]

Objectives:To investigate the effectiveness of benzodiazepine use for subjective tinnitus and to consider this in the context of the concomitant side effects.Methods:A systematic search of several databases using the terms ‘tinnitus’ and ‘benzodiazepines’ was conducted to find clinical trials of benzodiazepines and comparators in tinnitus patients. These studies were then assessed for risk of bias.Results:Six clinical trials were included. Clonazepam was found to be effective in three studies, but these studies had limitations regarding adequate blinding. The effectiveness of alprazolam was equivocal. Diazepam was not effective in two studies and oxazepam was effective in one study.Conclusion:Benzodiazepine use for subjective tinnitus does not have a robust evidence base. Clonazepam has the most evidence to support its use and is relatively less likely to lead to abuse because of its longer half-life, but caution is still needed given the other serious side effects. [ABSTRACT FROM PUBLISHER]

Introduction: Cholesteatoma is common chronic ear condition that usually requires surgical treatment and long-term follow-up. The Internet helps patients find information about their medical conditions and assists in shared clinical decision making. This work aims to assess the quality of information on YouTube for cholesteatoma. We aim to assess the quality of the most popular cholesteatoma videos on YouTube using recognized scoring systems and determine if quality correlated with video likes and views., Methods: The YouTube website was systematically searched on separate days with a formal search strategy to identify videos relevant to cholesteatoma. Each video was viewed and scored by three independent assessors using a novel Essential and Ideal Video Completeness criteria for cholesteatoma and the validated DISCERN tool. Popularity metrics were analyzed and compared with video popularity., Results: A total of 90 YouTube videos were analyzed with an average 55,292 views per video with an average of 271 likes and 22 dislikes. The interrater correlation was moderate with Fleiss kappa score 0.42 ( p < 0.01) using the Essential and Ideal Video Completeness criteria for cholesteatoma and interrater correlation coefficient was 0.78 (95% confidence interval, 0.58-0.90), indicating good reliability for DISCERN scores. The overall video quality was poor with higher DISCERN scores found from academic institutions., Conclusion: YouTube content with regard to cholesteatoma is of poor quality. Videos with unclassified sources or more dislikes correlated with poor quality. Otology societies should be encouraged to publish high-quality YouTube videos on cholesteatoma and other ear conditions., Competing Interests: The authors disclose no conflicts of interest., (Copyright © 2023, Otology & Neurotology, Inc.)

Objective: To investigate the degree to which transnasal eustachian tube (ET) dilation balloon catheters are able to be passed through the ET in a cadaver model., Patients and Interventions: A cadaveric study of 8 cadaver heads (16 ears), which underwent transnasal ET insertion with a 3 × 20-mm balloon catheter with transtympanic endoscopic visualization and grading., Results: Catheter tip incursion into the protympanum or mesotympanum occurred in all ears. Radiological validation was obtained with correlation to published ET length data., Conclusion: Middle ear incursion of balloon catheter tips can be demonstrated in a cadaver model and highlights the ongoing need for both caution in novel surgical techniques and evolution in device design., (Copyright © 2022, Otology & Neurotology, Inc.)

Objective: To investigate the incidence of middle ear cholesteatoma surgery and assess trends in mastoidectomy procedures in Australia., Study Design: Cross-sectional population-based study using data from the National Hospital Morbidity Database., Methods: Admitted care episodes containing the principal diagnosis of middle ear cholesteatoma were analyzed for two 12-month periods of 2007-2008 and 2017-2018. Surgical admissions involving mastoidectomy were identified by procedure codes. Incidence rate per 100,000 person-years were compared between study periods., Results: Of the 3855 middle ear cholesteatoma admissions, 3558 (92.3%) involved surgery, with the incidence rate for cholesteatoma surgical admissions estimated at 8.6 per 100,000 (95% CI: 8.2-9.0) and 8.1 per 100,000 (95% CI: 7.7-8.5) for 2017-2018 and 2007-2008, respectively. Population aged 10-19 years had the highest age-specific incidence rate at 12.5 per 100,000 (95% CI: 11.3-13.9) for 2017-2018. The 60 years and over age groups had the highest decennial percentage increase. Mastoidectomy procedures were consistently used in over half of all surgical admissions. An increase in the rate of canal wall up (CWU) mastoidectomy procedure related admissions was observed (rate ratio of 1.62 [95%CI: 1.41-1.86], P <.001) and was offset by a decreased rate of canal wall down (CWD) procedure associated admissions (0.69 [95% CI: 0.61-0.78], P <.001])., Conclusions: The incidence rate of cholesteatoma surgery in Australia is estimated at 8.6 per 100,000. Mastoidectomy continues to play an essential role in cholesteatoma surgery with a trend favoring CWU over CWD mastoidectomy. Level of evidence: 4., Competing Interests: The authors declare no potential conflict of interest., (© 2021 The Authors. Laryngoscope Investigative Otolaryngology published by Wiley Periodicals LLC on behalf of The Triological Society.)

Objectives: Stapes surgery has evolved from its origins in 1956. Microscopic assisted stapedotomy remains the most common technique but the introduction of endoscopic ear surgery has led to some units using this new approach. The endoscope delivers a wide angled, contextual view of the stapes, and associated pathology. This systematic review provides a critical analysis of the current published endoscopic data, allowing comparison to the established microscopic technique., Data Sources: Six databases (PubMed, Medline, Cochrane database, AMED, EMBASE, and CINAHL) were searched for studies within the last 10 years., Study Selection and Data Extraction: English language articles including 5 or more cases were included. Primary outcomes included audiological results and reported complications. Data was extracted according to PRISMA guidelines., Results: Thirteen papers were identified comprising 361 endoscopic stapes surgeries. Postoperative temporary facial nerve weakness was reported in 3 patients (0.8%) which all resolved within 4 weeks. Chorda tympani injury occurred in 21 cases (5.8%) and vertigo in 61 (16.9%). The audiometric outcomes of endoscopic stapes surgery were available for 259 patients and showed air bone gap closure rates of 71.4% (0-10 dB), 25.9% (11-20 dB), 2.3% (21-30 dB), and 0.4% (>30 dB)., Conclusions: Endoscopic stapes surgery has similar audiometric outcomes compared to the traditional microscopic approach with air bone gap closure values of <20 dB in 97.3% of cases. However, the complication rates of chorda tympani damage, postoperative dysguesia, and tympanic membrane perforation for endoscopic stapes surgery are high. Caution should therefore be taken before undertaking stapes surgery with the endoscopic technique. Further studies are required to prove superiority over well established existing microsurgical methods., Competing Interests: All authors have read and approved this manuscript and there are no conflicts of interest regarding publication of this article., (Copyright © 2021, Otology & Neurotology, Inc.)

Background: Eustachian tube dysfunction (ETD) is a common clinical condition encountered by otolaryngologists. The severity and duration of symptoms range from the mild and transient to the chronic and severe along with secondary pathologies. Balloon dilation eustachian tuboplasty (BDET) as a treatment, was first described in 2010 and has been studied extensively. This study evaluates the efficacy and safety of BDET in an Australian cohort., Methods: Retrospective chart review on all patients who underwent BDET from September 2016 to March 2020 was performed. The Eustachian Tube Dysfunction Patient Questionnaire (ETDQ-7) was chosen as the primary outcome measure. Secondary outcome measures included subjective global assessment of presenting symptoms, ability to perform Valsalva maneuver and tympanometry. Any complications related to the procedures were reported., Results: One hundred and nineteen eustachian tube operations were included in this study. The patient cohort showed statistically significant improvement of mean EDTQ-7 score from 0.7 to 2.9. Improvement in EDTQ-7 was achieved in 83.9% of the cases. All patients in the baro-challenge-induced subgroup achieved improvement in ETDQ-7 score. Complete resolution of symptoms with an ETDQ <2.1 was achieved in 37.1% of the cohort. There were no adverse safety events associated with the procedures., Conclusion: BDET resulted in improvement of the EDTQ-7 score in most of patients in this Australian cohort with no reported complications. BDET was most successful in baro-challenge-induced subgroup with universal improvement. Lower success rates were seen in patients with secondary pathology from their ETD., (© 2021 Royal Australasian College of Surgeons.)

Technological advancement in computed tomography (CT) and MRI has improved cholesteatoma detection rates considerably in the past decade. Accurately predicting disease location and extension is essential for staging, planning, and preoperative counseling, in particular in the newer approach of endoscopic ear surgery. Improved sensitivity and specificity of these radiological methods may allow the surgeon to confidently monitor patients, therefore avoiding unnecessary surgery. This article outlines recent advances in CT and MRI technology and advantages and disadvantages of the newer techniques. Emphasis on improving the feedback loop between the radiologist and surgeon will increase the accuracy of these new technologies., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Introduction: Endoscopic stapes surgery is a technically demanding procedure that is increasing in popularity. Surgical outcomes and complication rates have been demonstrated to be comparable to traditional microscopic techniques. The surgical outcomes for patients undergoing stapes surgery performed by the Sydney Endoscopic Ear Surgery Research Group are presented., Study Design: Retrospective review from prospectively gathered database., Setting: Tertiary referral centers., Patients: A retrospective case review of patients undergoing endoscopic stapes surgery performed by four surgeons between February 2015 and July 2019 was carried out. Sixty nine patients were identified, and assessed for demographics, functional results, and postoperative complications., Intervention: Endoscopic stapedotomy., Main Outcome Measure: Postoperative hearing results., Results: Sixty eight of 69 patients (98.6%) achieved an air-bone gap (ABG) closure of less than 20 dB. Sixty of 69 patients (87%) achieved and ABG closure of less than 10 dB. The average improvement of the ABG over four frequencies achieved was 26.5 dB (range, 0-61). Postoperative complications were infrequent and self-limiting. Six patients experienced dysgeusia without obvious chorda tympani injury, four patients developed short lived vertigo, and two patients experienced tinnitus., Conclusions: Endoscopically assisted stapes surgery represents a safe alternative to traditional microscopic techniques, with similar morbidity and audiological outcomes.

Objectives: The stapedius muscle, tendon, and pyramidal eminence are structures within the retrotympanum. In cholesteatoma surgery, the retrotympanum is a common site of residual disease. The removal of the pyramidal eminence during surgery is sometimes necessary to obtain better visualization of the superior retrotympanum during surgery. Understanding the relational anatomy of structures in the region to the facial nerve allows the surgeon to safely access regional disease. This study aims to better understand the anatomical relationship between the mastoid portion of the facial nerve, the pyramidal eminence, and the stapedius muscle. A secondary aim is to demonstrate that removal of the stapedius muscle in the cadaver model, can increase exposure to the retrotympanic space., Study Design: Anatomical cadaveric observation study., Methods: Endoscopic dissection of cadaveric heads was undertaken. Classification of the superior and inferior retrotympanic area was performed. The anatomy of the stapedius muscle was described including relationships, depth, course, and angle with respect to the facial nerve. The pyramidal eminence and stapedius muscle were removed in all specimens and the exposure of the retrotympanum re-evaluated to determine if exposure of the region was increased., Results: In all cases (11 ears), the stapedius muscle was located medial and anterior to the mastoid portion of the facial nerve, with the second genu superior. The mean antero-posterior distance from the apex of the pyramidal eminence, which the stapedius tendon enters, to the stapes itself was 4.10 mm (range, 2.92-5.73 mm; standard deviation [SD] 0.90 mm). In all cases, irrespective of sinus tympani conformation, removal of the pyramidal eminence and stapedial bony crest in proximity to the facial nerve allowed exposure of the whole retrotympanic region, using a 0-degree endoscope., Conclusions: The pyramidal eminence and stapedius muscle have a relatively constant relationship to the facial nerve. Removal of the stapedius muscle in the human cadaver model increases the exposure of the sinus tympani and subpyramidal space. Increased visualization in this region, may reduce risk of residual cholesteatoma in patients.

Objective: To examine the performance of diffusion-weighted magnetic resonance imaging (DW-MRI) in the detection of residual and recurrent cholesteatoma in children., Methods: A systematic review and meta-analysis was conducted as per PRISMA guidelines using the following databases from their date of inception: MEDLINE, PubMed, Embase, Cochrane Library, Web of Science. Bivariate meta-analysis using a random effects model was used to calculate summarized pooled estimates of sensitivity, specificity, and diagnostic odds ratios, using second-look surgery as the gold standard comparison., Results: A total of ten articles (141 cases) were included for qualitative and quantitative analysis. Pooled sensitivity and specificity of non-echo planar imaging (non-EPI) DW-MRI were 89.4% (95%CI 51.9%-98.5%) and 92.9% (95%CI 81.4%-97.5%) respectively. DW-MRI appears limited in its ability to detect lesions less than 3 mm in size., Conclusion: Non-EPI DW-MRI is highly specific but carries uncertain sensitivity in the detection of residual and recurrent cholesteatoma in children. Further research is warranted to determine the specific role of DW-MRI in this patient group, namely when and how often children should be referred for imaging and in which cases the method can be used to completely replace second-look surgery., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Objective: Minimally Invasive Ponto Surgery (MIPS) was recently described to facilitate the placement of percutaneous bone anchored hearing devices. As early adopters of this new procedure, we sought to perform a quality assurance project using our own small prospective cohort to justify this change in practice. We chose to examine device stability and to gauge our patients' perspective of the surgery and their overall satisfaction with the process., Methods: A total of 12 adult patients who underwent MIPS between 2016 and 2017 with a minimum post-operative follow-up of 12 months were included in this study. A prospective MIPS research clinic was used to follow patients, assess the implant site soft tissue status and gather qualitative information through patient interviews and surveys., Results: The mean (SD) soft tissue status score averages using the IPS Scale were low for inflammation 0.1 (0.1), pain 0.1 (0.1), skin height 0.2 (0.1) and total IPS score 0.4 (0.3) indicating minimal soft tissue changes. Patient experiences with MIPS were overwhelmingly positive in reports through the MIPS modified SSQ-8. All patients reported speedy recoveries and no long-term complications. There were zero device losses., Conclusion: The series presented in this paper represents the first MIPS cohort with long term follow-up to be published to date in North America. Our findings conclude both device stability and patient satisfaction with no loss of fixtures. Consequently, we have adopted MIPS as our procedure of choice for the placement of all percutaneous BAHDs.

Objective: To conduct a systematic review of the published evidence relating to the prevention of otic barotrauma in aviation. In particular, this review sought to identify procedures, techniques, devices, and medications for the prevention of otic barotrauma as well as evaluate the evidence relating to their efficacy., Data Sources: Ten databases including Embase, MEDLINE, the Cochrane Database of Systematic Reviews, and the Cochrane Central Register of Controlled Trials were searched using the full historical range., Study Selection: English language articles including more than or equal to five participants or cases were included. Outcomes of interest were reduced severity or the successful prevention of otic barotrauma in participants undergoing gradual changes in pressure during air travel or its simulation., Data Extraction: Articles and data were extracted and analyzed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses and other international guidelines., Conclusions: This review highlights the lack of published evidence relating to what is a significant and increasingly common problem in otology. There is level 1 evidence that supports the efficacy of oral pseudoephedrine (120 mg) in preventing otic barotrauma in adults. However, oral pseudoephedrine (1 mg/kg) does not appear to be effective in children. There is insufficient evidence to support the efficacy of either nasal balloon inflation or pressure-equalizing ear plugs for the prevention of otic barotrauma. A recently reported, novel technique for insertion of temporary tympanostomy tubes is promising but requires further evaluation.

Objective: Totally endoscopic ear surgery is a relatively new method for managing chronic ear disease. This study aimed to test the null hypothesis that open and endoscopic approaches have similar direct costs for the management of attic cholesteatoma, from an Australian private hospital setting., Methods: A retrospective direct cost comparison of totally endoscopic ear surgery and traditional canal wall up mastoidectomy for the management of attic cholesteatoma in a private tertiary setting was undertaken. Indirect and future costs were excluded. A direct cost comparison of anaesthetic setup and resources, operative setup and resources, and surgical time was performed between the two techniques., Results: Totally endoscopic ear surgery has a mean direct cost reduction of AUD$2978.89 per operation from the hospital perspective, when compared to canal wall up mastoidectomy., Conclusion: Totally endoscopic ear surgery is more cost-effective, from an Australian private hospital perspective, than canal wall up mastoidectomy for attic cholesteatoma.

Background: Endoscopic transcanal approaches to the facial nerve allow excellent exposure of the tympanic facial nerve. This approach becomes limited when access is required to the more proximal geniculate ganglion and labyrinthine portion of the facial nerve. The aim of this report was to determine the feasibility of a transmastoid endoscopically assisted approach to the geniculate ganglion and labyrinthine facial nerve. This is an endoscopic cadaveric dissection and video review at a university anatomical laboratory., Methods: A total of 12 endoscopic cadaveric dissections were performed. A cortical mastoidectomy and perilabyrinthine air cell removal was performed using an operating microscope. Beyond this, dissection was performed with an endoscope., Results: In all dissections, an endoscopically assisted transmastoid approach allowed complete access to the geniculate ganglion, and at least 1.5 mm of the distal labyrinthine facial nerve. Further transcrusal drilling through the anterior crus of the superior semicircular canal allowed access to the entire labyrinthine facial nerve., Conclusions: The entire geniculate ganglion and labyrinthine facial nerve is difficult to access with microscopic techniques. Adding endoscopic visualization allows for complete visualization of the geniculate ganglion. Clinical reports will further strengthen these preliminary cadaveric results.

Background: Minimally Invasive Ponto Surgery (MIPS) was recently described as a new technique to facilitate the placement of percutaneous bone anchored hearing devices. The procedure has resulted in a simplification of the surgical steps and a dramatic reduction in surgical time while maintaining excellent patient outcomes. Given these developments, our group sought to move the procedure from the main operating suite where they have traditionally been performed. This study aims to test the null hypothesis that MIPS and open approaches have the same direct costs for the implantation of percutaneous bone anchored hearing devices in a Canadian public hospital setting., Methods: A retrospective direct cost comparison of MIPS and open approaches for the implantation of bone conduction implants was conducted. Indirect and future costs were not included in the fiscal analysis. A simple cost comparison of the two approaches was made considering time, staff and equipment needs. All 12 operations were performed on adult patients from 2013 to 2016 by the same surgeon at a single hospital site., Results: MIPS has a total mean reduction in cost of CAD$456.83 per operation from the hospital perspective when compared to open approaches. The average duration of the MIPS operation was 7 min, which is on average 61 min shorter compared with open approaches., Conclusion: The MIPS technique was more cost effective than traditional open approaches. This primarily reflects a direct consequence of a reduction in surgical time, with further contributions from reduced staffing and equipment costs. This simple, quick intervention proved to be feasible when performed outside the main operating room. A blister pack of required equipment could prove convenient and further reduce costs.

The oval window region has recently been identified as a potential route for drug diffusion into the inner ear. Locally applied gadolinium and trimethylphenylammonium (TMPA) have been shown to directly diffuse into the vestibule through the oval window region. Given the potential importance of the oval window region in the diffusion of substances into the inner ear, this work aimed to use micro-CT to obtain a data set of anatomical characteristics of the annular ligament of the stapes in the human temporal bone, a region thus far poorly studied. Twenty-one temporal bones were micro-dissected to preserve the otic capsule and allow perfusion of fixative stains into the inner ear. The specimens were scanned with micro-CT methods to provide 3D reconstructions and measurement. The 3D reconstructions were able to demonstrate an undisturbed stapes footplate and annular ligament from which measurements could be taken. This study found a wide variance in the volumes and thicknesses of the stapedial ligaments. There was a positive correlation between the size of the stapes footplate and the annular ligament.

Background: Imaging the Eustachian tube has proven difficult as it has an anatomical orientation that is not aligned with standard planes. In addition, the Eustachian tube is a dynamic structure, opening briefly during a variety of physiological manoeuvres., Case Report: A 54-year-old healthy and asymptomatic man underwent computed tomography utilising an area detector scanner. Multiplanar reconstruction was performed at 1 mm intervals. In addition, dynamic clips were constructed to demonstrate air and its movement in the field. Images and video were acquired whilst a Valsalva manoeuvre was being performed., Conclusion: Although imaging techniques have been able to visualise the Eustachian tube well in the closed state, it may be more useful to have it imaged whilst open. Area detector computed tomography scanners can be used to acquire four-dimensional images. This allows dynamic imaging of the region, to assist in the diagnosis of various types of Eustachian tube dysfunction.

The round window region is of critical importance in the anatomy of the middle ear. The aim of this paper is to describe its anatomy from an endoscopic point of view, emphasizing structures that have important surgical implications, in particular the fustis and the subcochlear canaliculus. The fustis, a smooth bony structure that forms the floor of the round window region, is a constant and important structure. It seems to indicate the round window membrane and the correct position of scala tympani. A structure connecting the round window region to the petrous apex, named the subcochlear canaliculus, is also described. A retrospective review of video recordings of endoscopic dissection and surgical procedures, carried out between June 2014 and February 2015, was conducted across two Tertiary university referral centers. A total of 42 dissections were analyzed in the study. We observed the fustis in all the cases and we identify two different anatomical conformations. The subcochlear canaliculus was found in 81.0 %, with a pneumatization direct to the petrous apex in 47.7 %. Conformation and limits of the round window niche may influence the surgical view of the round window membrane. Endoscopic approaches allow a very detailed view, which enables a comprehensive exploration of the round window region. Accurate knowledge of the anatomical relationships of this region has important advantages during middle ear surgery.

The protympanum, a final common pathway between the tympanic cavity and external environment, is gaining relevance due to the ease and completeness of visualization with angled endoscopes. Two primary conformations are described, quadrangular and triangular, and new anatomic structures such as the protiniculum, subtensor recess, and protympanic spine are defined. Surgical relevance of the protympanum is described with respect to ventilation, cholesteatoma, cerebrospinal fluid leak, otic neuralgia, and surgical access to the eustachian tube., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: To assess the acoustic transmission characteristics of the Eustachian tube (ET) in living subjects in verified patent and closed ET states to facilitate the detection and quantification of ET function using acoustic measures such as sonotubometry., Patients: The two subjects in this study had no history of ear disease nor previous ear surgery and were capable of volitionally opening and closing their ET., Interventions: Tympanometry and otologic examinations were used to confirm ET patent and closed states by observing tympanic membrane movement with respiration and by acoustic immitance measurements during forced respiration. A series of 500-ms long chirps containing frequencies from 100 Hz to 10 kHz were introduced into the nasal cavity during both ET states and recorded by microphones in both the contralateral naris and external auditory canal., Main Outcome Measures: Acoustic energy transmission through the ET across the 0.1 to 10 kHz frequency range in the closed state versus the patent state., Results: An increase in acoustic energy transmission occurs across the frequencies of 1 to 4 kHz between the closed and patent ET states, particularly in frequencies below 2.5 kHz., Conclusions: Results support sonotubometry as a potential diagnostic tool for ET dysfunction. Acoustic differences between the ET states manifest as a general increase in transmitted signal amplitude. Characterizing the acoustic properties in the verified patent and closed ET states allows investigators to more reliably interpret sonotubometric tests of ET function.

Objective: To enhance understanding of the possible dangers of large vestibular schwannomas and their potential to cause sudden death through rare situations such as brain herniation precipitated by cerebrospinal fluid pressure shifts., Patient: An otherwise healthy 32-year-old woman with a magnetic resonance imaging demonstrating a cystic cerebellopontine angle mass, presumptive for vestibular schwannoma, experienced sudden onset of headaches, nausea, and vomiting., Intervention: The patient was admitted to the intensive care unit, started on anticonvulsants, investigated with serial computed tomography (CT) scans, and then elective intubation and ventriculostomy when her condition worsened., Main Outcome Measure(s): Clinical and radiological findings, as well as outcome of interventions., Results: In the first hours of admission, the patient underwent serial CT scans that demonstrated fourth ventricle compression and hydrocephalus. When the patient's condition worsened, elective intubation was undertaken and an external ventricular drain was inserted. Very high intracranial pressures were noted despite cerebrospinal fluid drainage. Postoperative CT and magnetic resonance imaging demonstrated ascending transtentorial and tonsillar herniation as well as scattered cortical infarcts. Brain death was determined and care was withdrawn 5 days later., Conclusion: This is a very rare patient report of sudden death caused by a large vestibular schwannoma despite assertive emergent management. There was no intratumoral or intracranial haemorrhage. Brain death was likely a result of ascending transtentorial herniation that can occur with large posterior fossa tumors and be exacerbated by cerebrospinal fluid shifts after ventriculostomy.

Objective: To assess the feasibility, safety, and efficacy of transtympanic balloon catheter dilatation of the Eustachian tube (ET) in a cadaver model., Patients and Interventions: A cadaveric study of 10 cadaver heads, which underwent unilateral transtympanic dilatation of the ET with a 3 × 20 mm balloon catheter with full endoscopic guidance and visualization., Results: Procedural safety was demonstrated, with no damage to any essential structures found. Feasibility of the procedure was demonstrated in all cadavers with 100% success rate, despite a small number of encountered difficulties. Statistically significant efficacy was also demonstrated in both radiologic and manometric data., Conclusion: With full endoscopic visualization, the transtympanic approach to balloon catheter dilatation of the ET seems to be a feasible and safe procedure in the cadaver model.

Objective: The aim of our study was to assess quality of life (QOL) among patients who underwent microsurgical excision of vestibular schwannoma (VS) compared with those managed conservatively., Study Design: Retrospective study., Setting: Tertiary care center., Patients: There was a total sample population of 376 patients diagnosed with a unilateral VS., Intervention: A total of 223 patients with unilateral VS returned the mailed questionnaires. These were then divided into two groups-78 that had undergone microsurgical excision and 145 that were managed conservatively. Subgroups within these primary groups were created for analysis., Main Outcome Measure: The primary outcome measure was the Medical Outcomes Study 36 Items Short Form (SF-36). The Dizziness Handicap Inventory test, Hearing Handicap Inventory test, and Tinnitus Handicap Inventory were also used., Results: The surgically managed group had a worse QOL when compared with the conservatively managed group using SF-36, significantly so in the domains of physical role limitation and social functioning. Trends were seen toward a better QOL in some domains in the subgroups of male patients and patients younger than 65 years. Worse QOL scores in the Tinnitus Handicap Inventory were seen in the subgroups with larger tumor size. Finally, on correlation analysis between all handicap inventories and SF-36, handicap due to disequilibrium had the strongest correlation with worsening of QOL. In SF-36, the vitality domain showed the greatest correlation with otologic handicap overall, whereas the role emotional domain showed the least., Conclusion: This study found that worse QOL scores for surgically managed versus conservatively managed VS patients are most significant in the areas of physical role limitation and social functioning. In some areas, patients who are male and younger report better QOL. Handicap due to disequilibrium seems to have the greatest negative impact on QOL. These factors should be considered when counseling patients regarding approach to VS, in the context of an experienced management program.