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ObjectiveTo evaluate the treatments’ consequences for unilateral hearing loss in children.DesignSystematic review and meta-analysis (CRD42018109417). The MEDLINE, CENTRAL, ISRCTN and ClinicalTrials databases were searched between September 2018 and May 2019. Articles were screened and data were collected independently by two authors following the Cochrane and Preferred Reporting Items for Systematic review and Meta-Analysis guidelines. The risk of bias was evaluated using the Cochrane tool, the Newcastle-Ottawa Scale, the National Institute of Health, USA tool and considering the risk of confounding. In the studies with the lowest risk of bias, a meta-analysis was conducted.InterventionsValidated hearing rehabilitation devices.Patients6–15 years old children with moderate to profound unilateral hearing loss.Main outcome measuresThe primary study outcome was children’s quality of life. Academic performances were studied as an additional outcome.Results731 unique articles were identified from the primary search. Of these, 18 articles met the Population, Intervention, Control, Outcomes and Study design selection criteria. In the eight studies with the lowest risk of bias, two meta-analysis were conducted. There was not enough data on academic results to conduct a meta-analysis. In 73 children included in a fixed effect meta-analysis (two studies), no effect of treatment could be shown (g=−0.20, p=0.39). In 61 children included in a random-effect meta-analysis (six studies), a strong positive effect of hearing treatment on quality of life was demonstrated (g=1.32, pConclusionsThe treatment of unilateral hearing loss seems to improve children’s quality of life. Further research is needed to identify the most effective treatment and its corresponding indications.

Humanitarian action, in the broad sense, including global outreach missions by ENT physicians, has been effective for many years. These volunteer missions have not had any specific regulatory framework, be it medical, social or above all ethical. The testimony of ENT physicians in certain "recipient" countries, in particular during the 2017 Paris Congress of the International Federation of Otorhinolaryngological Societies (IFOS), revealed the importance of adequate coordination between "provider" and "recipient" teams. Several ethical reports have been made, but few specifically focused on ENT outreach. The present review is based on feedback from several missions given to the French Society of OtoRhinoLaryngology and Head and Neck Surgery (SFORL) and IFOS, and on a review of the literature. A specific charter of global outreach and humanitarian missions in ENT has been drawn up. This review is essential for optimizing the sharing of knowledge and training in otorhinolaryngology across the world while respecting mandatory sociocultural and ethical rules.

Objective To describe the long-term clinical vertigo control along with measured lateral canal vestibular function in patients with unilateral refractory Meniere's disease (MD) treated with gentamicin transtympanic injections (TTI). Study design Retrospective analytic study. Setting Tertiary referral center. Patients Thirty-eight patients treated by TTI for medically refractory unilateral MD, defined by the 1995 AAO-HNS criteria, between May 2006 and December 2012. Intervention(s) One-year course of treatment with gentamicin TTI following a low dose on-demand protocol. TTI were repeated in new courses of treatment when MD recurrence occurred. Main outcome measure(s) AAO-HNS class of control, caloric tests (CalT), recurrence rate. Results After an average clinical follow-up of 71 months, all patients entered a class of control A (78%) or B (22%), with an average of 2.3 TTI received. The mean maximal obtained deficit was 88.5%, and the mean long-term deficit was 85.5%. Ten (26%) patients had disease recurrence requiring a new course of treatment. A value of the first CalT in the 3 months following the first TTI strictly higher than 78% was significantly associated with disease control and the absence of symptom recurrence (p≤0.01). In the "recurrence" group, four patients had a significantly lower mean value of all CalT performed after the first TTI when compared with other patients (p≤0.001), indicating gentamicin resistance CONCLUSION:: Achieving a sustainable vestibular deficit on caloric testing is key for MD symptom control after gentamicin TTI. Gentamicin resistance must be diagnosed early to adapt therapeutic strategies.

Introduction: Cochlear implantation is a recent approach proposed to treat single-sided deafness (SSD) and asymmetric hearing loss (AHL). Several cohort studies showed its effectiveness on tinnitus and variable results on binaural hearing. The main objective of this study is to assess the outcomes of cochlear implantation and other treatment options in SSD/AHL on quality of life. Methods: This prospective multicenter study was conducted in 7 tertiary university hospitals and included an observational cohort study of SSD/AHL adult patients treated using contralateral routing of the signal (CROS) hearing aids or bone-anchored hearing systems (BAHSs) or who declined all treatments, and a randomized controlled trial in subjects treated by cochlear implantation, after failure of CROS and BAHS trials. In total, 155 subjects with SSD or AHL, with or without associated tinnitus, were enrolled. After 2 consecutive trials with CROS hearing aids and BAHSs on headband, all subjects chose any of the 4 treatment options (abstention, CROS, BAHS, or cochlear implant [CI]). The subjects who opted for a CI were randomized between 2 arms (CI vs. initial observation). Six months after the treatment choice, quality of life was assessed using both generic (EuroQoL-5D, EQ-5D) and auditory-specific quality-of-life indices (Nijmegen Cochlear implant Questionnaire [NCIQ] and Visual Analogue Scale [VAS] for tinnitus severity). Performances for speech-in-noise recognition and localization were measured as secondary outcomes. Results: CROS was chosen by 75 subjects, while 51 opted for cochlear implantation, 18 for BAHSs, and 11 for abstention. Six months after treatment, both EQ-5D VAS and auditory-specific quality-of-life indices were significantly better in the “CI” arm versus “observation” arm. The mean effect of the CI was particularly significant in subjects with associated severe tinnitus (mean improvement of 20.7 points ± 19.7 on EQ-5D VAS, 20.4 ± 12.4 on NCIQ, and 51.4 ± 35.4 on tinnitus). No significant effect of the CI was found on binaural hearing results. Before/after comparisons showed that the CROS and BAHS also improved significantly NCIQ scores (for CROS: +7.7, 95% confidence interval [95% CI] = [4.5; 10.8]; for the BAHS: +14.3, 95% CI = [7.9; 20.7]). Conclusion: Cochlear implantation leads to significant improvements in quality of life in SSD and AHL patients, particularly in subjects with associated severe tinnitus, who are thereby the best candidates to an extension of CI indications.

Objectives: To describe the treatment choice in a cohort of subjects with single-sided deafness (SSD) and asymmetric hearing loss (AHL). To assess the reliability of the treatment trials. Design: In this national, multicentre, prospective study, the choice of subjects was made after two consecutive trials of Contralateral Routing Of the Signal (CROS) hearing aids and a Bone Conduction Device (BCD) on a headband. Subjects could proceed with one of these two options, opt for cochlear implantation or decline all treatments. Setting: Seven tertiary university hospitals. Participants: One hundred fifty-five subjects with SSD or AHL fulfilling the candidacy criteria for cochlear implantation, with or without associated tinnitus. Main outcome measures: After the two trials, the number of subjects choosing each option was described. Repeated assessments of both generic and auditory-specific quality of life were conducted, as well as hearing assessments (speech recognition in noise and horizontal localization). Results: CROS was chosen by 75 subjects, followed by cochlear implantation (n = 51), BCD (n = 18) and abstention (n = 11). Patients who opted for cochlear implantation had a poorer quality of life (P = .03). The improvement of quality of life indices after each trial was significantly associated with the final treatment choice (P = .008 for generic indices, P = .002 for auditory-specific indices). The follow-up showed that this improvement had been overestimated in the CROS group, with a long-term retention rate of 52.5%. Conclusions: More than one third of SSD/AHL subjects are unsatisfied after CROS and BCD trials. Repeated quality of life assessments help counselling the patient for his/her treatment choice.

Vertigo and dizziness are a frequent reason for medical consultation. However, diagnostic and therapeutic management is sometimes limited, and clinicians are faced with many unmet needs. The purpose of this study was to identify and prioritize these needs.A questionnaire methodology was used to determine the need for innovation in vestibular disorder management. The questionnaire was sent to 19 teams in French-speaking ENT centers. We measured the concordance of the panel of experts on 56 questions related to the different vestibular pathologies encountered and the desired modalities of innovations.Thirteen questions were identified as priorities. The needs expressed by the experts had better knowledge of the pathophysiological mechanisms of the main diseases encountered and the development of new treatment modalities. Particular attention was paid to inner ear imaging techniques and the development of specific electrophysiology techniques.Some of the anticipated innovations are already under development, such as new inner ear fluid imaging techniques (hydrops visualization using MRI) or in situ treatments (transtympanic dexamethasone or gentamicin injections). Others, such as new electrophysiological techniques, are still not fully developed CONCLUSION: This study provides a snapshot of the needs of the medical profession in vestibular disorder management. It highlights a real concern of the attending personnel, as well as a critical need to optimize the means of diagnosing and treating patients with vestibular disorders.

Normal-hearing subjects listening to acoustic simulations of cochlear implants (CI) can obtain sentence recognition scores near 100% in quiet and in 10 dB signal-to-noise ratio (SNR) noise with acute exposure. However, average sentence recognition scores for real CI listeners are generally lower, even after months of experience, and there is a high degree of heterogeneity. Our aim was to identify the relative importance and strength of factors that prevent CI listeners from achieving early, 1-mo scores as high as those for normal-hearing-listener acoustic simulations.Sentence recognition scores (100 words/list, 65 dB SPL) using CI alone were collected for all adult unilateral CI listeners implanted in our center over a 5-yr period. Sentence recognition scores in quiet and in 10 dB SNR 8-talker babble, collected from 1 to 12 mo, were reduced to a single dependent variable, the "initial" score, via logarithmic regression. "Initial" scores equated to an improved estimate of 1-mo scores, and integrated the time to rise above zero score for poorer performing subjects. Demographic, device, and medical data were collected for 118 subjects who met standard CI candidacy criteria. Computed tomography of the electrode array allowing determination of the insertion depth as an angle, and the presence or absence of scala dislocation was available for 96 subjects. Predictive factors for initial scores were selected using stepwise multiple linear regression. The relative importance of predictive factors was estimated as partial r with a low bias method, and statistical significance tested with type II analysis of variance.The etiologies chronic otitis and autoimmune disease were associated with lower, widely variable sentence recognition scores in the long-term. More than 60% of CI listeners scored50/100 in quiet at 1 mo. Congenital hearing loss was associated with significantly lower initial scores in quiet (r 0.23, p0.001), as was longer duration of hearing loss (r 0.12, p0.001, -0.76 pts per year). Initial scores were negatively correlated with insertion depth (r 0.09, p0.001, -0.1 pts per degree), with the highest initial scores being obtained for insertion depths of 300° to 400°. A much greater proportion of scala dislocations was found for perimodiolar arrays compared with straight arrays. Scores were negatively correlated with the proportion of the active electrode array found in scala vestibuli for Nucleus perimodiolar devices (r 0.14, p0.01, coefficient -25). Similar overall results were obtained for sentence recognition scores in noise (+10 dB SNR). The intercept value for the obtained regression functions indicated that CI listeners with the least limiting factors generally scored ~95/100 in quiet and ~90/100 in noise. In addition, CI listeners with insertion angles as low as 315° to 360° could obtain sentence recognition scores80/100 even at 1 day after activation. Insertion depths of 360° were estimated to produce frequency-place mismatches of about one octave upward shift.Patient-related factors etiology and duration of deafness together explained ~40% of the variance in early sentence recognition scores, and electrode position factors ~20%. CI listeners with insertion depths of about one turn obtained the highest early sentence recognition scores in quiet and in noise, and these were comparable with those reported in the literature for normal-hearing subjects listening to 8 to 12 channel vocoder simulations. Differences between device brands were largely explained by differences in insertion depths. This indicates that physiological frequency-place mismatches of about one octave are rapidly accommodated by CI users for understanding sentences, between 1 day to 1 mo postactivation, and that channel efficiency may be significantly poorer for more deeply positioned electrode contacts.

Single-sided deafness (SSD) and asymmetric hearing loss (AHL) have recently been proposed as a new indication for cochlear implantation. There is still no recommended treatment for these hearing deficits, and most options considered rely on the transfer of sound from the poor ear to the better ear, using Contralateral Routing of the Signal (CROS) hearing aids or bone conduction (BC) devices. In contrast, cochlear implantation allows the poor ear to be stimulated and binaural hearing abilities to be partially restored. Indeed, most recently published studies have reported an improvement in the spatial localisation of an incoming sound and better speech recognition in noisy environments after cochlear implantation in SSD/AHL subjects. It also provides consistent relief of tinnitus when associated. These encouraging hearing outcomes raise the question of the cost-utility of this expensive treatment in an extended indication. The final endpoint of this national multicentre study is to determine the incremental cost-utility ratio (ICUR) of cochlear implantation in comparison to the current standard of care in France through simple observation, using a randomised controlled trial. Firstly, the study comprises a prospective and descriptive part, where 150 SSD/AHL subjects try CROS hearing aids and a BC device for three weeks each. Secondly, the choice is made between CROS hearing aids, BC implanted device and cochlear implantation. Hearing outcomes and quality of life measurements are described after 6 months for the subjects who chose CROS, BC or declined any option. The subjects who opt for cochlear implantation are randomised between one group where the cochlear implant is inserted without delay and one group of simple initial observation. Hearing outcomes and quality of life measurements are compared after 6 months. The present study was designed to assess the efficiency of cochlear implantation in SSD/AHL. A favourable cost-utility ratio in this extended indication would strengthen the promising clinical results and justify a reimbursement by the health insurance. The efficiency of other options (CROS, BC) will also be described. This research has been registered in ClinicalTrials.gov ( http://www.clinicaltrials.gov/ ), the 29th July 2014 under the n°NCT02204618.

Stensen duct injury has been reported in the medical literature following penetrating injuries of the cheek or by exeresis of tumors of the cheek or of the oral mucosa. This type of physical trauma often arises from injuries as a result being assaulted (e.g. with knife) or from road accidents. The complexity of the damage to the anatomical structures and the causative agent sometimes makes the diagnosis difficult. We report on a clinical case of managemenent Stensen duct injury secondary of goring by a cow horn.

ObjectTo report the morbidity and long term results in the treatment of paragangliomas by transarterial embolization with ethylene vinyl alcohol (Onyx), either as preoperative or palliative treatment.MethodsBetween September 2005 and 2012, 18 jugulotympanic, 7 vagal, and 4 carotid body paragangliomas (CBPs) underwent Onyx embolization, accordingly to our head and neck multidisciplinary team's decision. CBPs were embolized preoperatively. Jugulotympanic and vagal paragangliomas underwent surgery when feasible, otherwise palliative embolization was carried out alone, or in combination with radiotherapy or tympanic surgery in the case of skull base or tympanic extension. Treatment results, and clinical and MRI follow-up data were recorded.ResultsIn all cases, devascularization of at least 60% of the initial tumor blush was obtained; 6 patients underwent two embolizations. Post-embolization, 8 patients presented with cranial nerve palsy, with partial or complete regression at follow-up (mean 31 months, range 3–86 months), except for 2 vagal and 1 hypoglossal palsy. 10 patients were embolized preoperatively; 70% were cured after surgery and 30% showed residual tumor. 19 patients received palliative embolization, of whom 5 underwent radiotherapy and 3 received tympanic surgery post-embolization. Long term follow-up of palliative embolization resulted in tumor volume stability (75%) or extension in intracranial or tympanic compartments. Onyx embolization of CBPs resulted in more difficult surgical dissection in 2 of 4 cases.ConclusionsOnyx embolization is a valuable alternative to surgery in the treatment of jugulotympanic and vagal paragangliomas; tympanic surgery or radiosurgery of the skull base should be considered in selected cases. Preoperative Onyx embolization of CBPs is not recommended.

Background: Large animal models of implantable hearing devices are needed to assess innovative technologies before using them in humans. The rhesus macaque has cognitive abilities close to humans and has been used in the past but with noncommercial implants or no detailed radiologic descriptions of the surgical procedures. The aim of this study was to evaluate the feasibility of cochlear implantation in this animal model. Methods: We present detailed radiologic data (CT scan and Cone beam computed tomography) from 7 heads of rhesus macaque monkeys coming from autopsy materials. Several comparative measurements were performed with 10 human temporal bones to emphasize similarities and differences between the macaque and the human inner ear. The radiologic analyses helped planning the surgical approach for cochlear implant insertion in the macaque. Results: We managed to perform one full (720 degrees) and 3 partial insertions (190Y330 degrees) of cochlear implants in 4 rhesus macaque cochleae, documented by cone beam computed tomography reconstructions. We confirm that the procedure is facilitated in this animal because the cochlea dimensions are close to humans. However, marked differences in the orientation of the external auditory canal and the basal turn must be taken into account. We suggest that the removal of the inferior wall of tympanal bone provides the optimal axis for electrode array insertion. Conclusion: The rhesus macaque monkey is a valid and closeto-human animal model for cochlear implants insertion. Because this species is widely used in both behavioral and physiologic studies, we expect that functional implants can be coupled with electrophysiologic recordings to study the mechanisms of auditory compensation. Key Words: Animal modelVCochlear implantVCochlea sizeVTemporal bone anatomy. Otol Neurotol 34:e76Ye81, 2013.

International audience; Due to signal distortion, speech comprehension in cochlear-implanted (CI) patients relies strongly on visual information, a compensatory strategy supported by important cortical crossmodal reorganisations. Though crossmodal interactions are evident for speech processing, it is unclear whether a visual influence is observed in CI patients during non-linguistic visual-auditory processing, such as face-voice interactions, which are important in social communication. We analyse and compare visual-auditory interactions in CI patients and normal-hearing subjects (NHS) at equivalent auditory performance levels. Proficient CI patients and NHS performed a voice-gender categorisation in the visual-auditory modality from a morphing-generated voice continuum between male and female speakers, while ignoring the presentation of a male or female visual face. Our data show that during the face-voice interaction, CI deaf patients are strongly influenced by visual information when performing an auditory gender categorization task, in spite of maximum recovery of auditory speech. No such effect is observed in NHS, even in situations of CI simulation. Our hypothesis is that the functional crossmodal reorganisation that occurs in deafness could influence nonverbal processing, such as face-voice interaction; this is important for patient internal supramodal representation.

Objective: The pathogenesis of idiopathic sudden sensorineural hearing loss (ISSHL) remains unknown, but vascular involvement is one of the main hypotheses. The main objective of this study was to investigate the association between ISSHL and cardiovascular and thromboembolic risk factors. Study Design: Multicentric case-control study. Methods: Ninety-six Caucasian patients with ISSHL and 179 sex- and age-matched controls were included. Patients were evaluated on the day of the inclusion and 1 week, 3 weeks and 3 months later. Clinical information concerning personal and familial cardiovascular and thromboembolic risk factors and concerning the ISSHL was collected. Blood samples were collected for genetic analysis of factor V Leiden and G20210A polymorphism in the factor II gene. The severity of the hearing loss was classified as mild (21–40 dB), moderate (41–70 dB), severe (71–90 dB) and profound or total (>90 dB). Hearing improvement was calculated as a relative improvement of hearing thresholds using the contralateral ear as baseline. Results: Systolic blood pressure was higher in patients (130 ± 1.7 mm Hg) than in controls (124 ± 1.1 mm Hg, p = 0.003). The personal/familial history of cardiovascular events was also more prevalent in patients (p = 0.023 and p = 0.014, respectively), whereas no difference was found in the prevalence of personal cardiovascular risk factors (hypertension, diabetes mellitus, hyperlipidemia, smoking habits). There was no correlation between the audiogram type, the hearing outcome and the presence of cardiovascular risk factors. No significant difference was observed in the personal/familial history or in the presence of thromboembolic risk factors. The prothrombin and factor V mutations were uncommon in both patients and controls. The final hearing threshold was only correlated with the severity of the initial hearing loss (p < 0.001), but not influenced by the presence of vertigo, audiogram type, time elapsed from onset of ISSHL to hospitalization or failure of a previous oral therapy. Hearing stabilization was obtained at 21 days in 92% of patients. Conclusion: These results support the theory of vascular involvement as the etiology of some cases of ISSHL. The sole predictive factor of poor final hearing is the severity of the initial hearing loss.

International audience; IMPORTANCE: The association between hearing impairment and cognitive decline has been established; however, the effect of cochlear implantation on cognition in profoundly deaf elderly patients is not known. OBJECTIVE: To analyze the relationship between cognitive function and hearing restoration with a cochlear implant in elderly patients. DESIGN, SETTING, AND PARTICIPANTS: Prospective longitudinal study performed in 10 tertiary referral centers between September 1, 2006, and June 30, 2009. The participants included 94 patients aged 65 to 85 years with profound, postlingual hearing loss who were evaluated before, 6 months after, and 12 months after cochlear implantation. INTERVENTIONS: Cochlear implantation and aural rehabilitation program. MAIN OUTCOMES AND MEASURES: Speech perception was measured using disyllabic word recognition tests in quiet and in noise settings. Cognitive function was assessed using a battery of 6 tests evaluating attention, memory, orientation, executive function, mental flexibility, and fluency (Mini-Mental State Examination, 5-word test, clock-drawing test, verbal fluency test, d2 test of attention, and Trail Making test parts A and B). Quality of life and depression were evaluated using the Nijmegen Cochlear Implant Questionnaire and the Geriatric Depression Scale-4. RESULTS: Cochlear implantation led to improvements in speech perception in quiet and in noise (at 6 months: in quiet, 42% score increase [95% CI, 35%-49%; P \textless .001]; in noise, at signal to noise ratio [SNR] +15 dB, 44% [95% CI, 36%-52%, P \textless .001], at SNR +10 dB, 37% [95% CI 30%-44%; P \textless .001], and at SNR +5 dB, 27% [95% CI, 20%-33%; P \textless .001]), quality of life, and Geriatric Depression Scale-4 scores (76% of patients gave responses indicating no depression at 12 months after implantation vs 59% before implantation; P = .02). Before cochlear implantation, 44% of the patients (40 of 91) had abnormal scores on 2 or 3 of 6 cognition tests. One year after implant, 81% of the subgroup (30 of 37) showed improved global cognitive function (no or 1 abnormal test score). Improved mean scores in all cognitive domains were observed as early as 6 months after cochlear implantation. Cognitive performance remained stable in the remaining 19% of the participants (7 of 37). Among patients with the best cognitive performance before implantation (ie, no or 1 abnormal cognitive test score), 24% (12 of 50) displayed a slight decline in cognitive performance. Multivariate analysis to examine the association between cognitive abilities before implantation and the variability in cochlear implant outcomes demonstrated a significant effect only between long-term memory and speech perception in noise at 12 months (SNR +15 dB, P = .01; SNR +10 dB, P \textless .001; and SNR +5 dB, P = .02). CONCLUSIONS AND RELEVANCE: Rehabilitation of hearing communication through cochlear implantation in elderly patients results in improvements in speech perception and cognitive abilities and positively influences their social activity and quality of life. Further research is needed to assess the long-term effect of cochlear implantation on cognitive decline.

Contains fulltext : 152325.pdf (Publisher’s version ) (Open Access) OBJECTIVE: Recommendation for cochlear implant (CI) treatment for individuals with severe to profound single-sided deafness (SSD) and asymmetrical hearing loss (AHL) is on the rise. This raises the need for greater consistency in the definition of CI candidacy for these cases and in the assessment methods of patient-related benefits to permit effective comparison and interpretation of the outcomes with both conventional and implantable options across studies. METHOD: During a dedicated seminar on implant treatment in AHL patients, the panellists of the closing round table reviewed the clinical experience presented with the aim to define clear audiometric characteristics for both AHL and SSD cases, as well as a common data set enabling consistent evaluation of hearing benefits in this population. CONCLUSIONS: The panellists agreed on a clear differentiation between AHL and SSD CI candidates, defining average pure-tone thresholds up to 4 kHz for better and poorer ears. Agreement was reached on a minimum set of assessment procedures, and included the necessity of trials with conventional CROS/BICROS hearing aids and bone conduction devices before considering CI treatment. Objective assessment of sound localisation abilities was identified as the most relevant criterion to quantify performance before and after treatment. In parallel, subjective assessment of overall hearing ability was recommended via the Speech, Spatial and Qualities of hearing questionnaire. Longitudinal follow-up of these parameters and the hours of daily use were considered essential to reflect the potential treatment benefits for this population. The consistency in the data collection and its report will further support health authorities in their decision on acceptable gains from available hearing loss treatment options.

Objectives: To compare speech perception outcomes between bilateral implantation (cochlear implants [CIs]) and bimodal rehabilitation (one CI on one side plus one hearing aid [HA] on the other side) and to explore the clinical factors that may cause asymmetric performances in speech intelligibility between the two ears in case of bilateral implantation.Design: Retrospective data from 2247 patients implanted since 2003 in 15 international centers were collected. Intelligibility scores, measured in quiet and in noise, were converted into percentile ranks to remove differences between centers. The influence of the listening mode among three independent groups, one CI alone (n = 1572), bimodal listening (CI/HA, n = 589), and bilateral CIs (CI/CI, n = 86), was compared in an analysis taking into account the influence of other factors such as duration of profound hearing loss, age, etiology, and duration of CI experience. No within-subject comparison (i.e., monitoring outcome modifications in CI/HA subjects becoming CI/CI) was possible from this dataset. Further analyses were conducted on the CI/CI subgroup to investigate a number of factors, such as implantation side, duration of hearing loss, amount of residual hearing, and use of HAs that may explain asymmetric performances of this subgroup.Results: Intelligibility ranked scores in quiet and in noise were significantly greater with both CI/CI and CI/HA than with a CI-alone group, and improvement with CI/CI (+11% and +16% in quiet and in noise, respectively) was significantly better than with CI/HA (+6% and +9% in quiet and in noise, respectively). From the CI/HA group, only subjects with ranked preoperative aided speech scores >60% performed as well as CI/CI participants. Furthermore, CI/CI subjects displayed significantly lower preoperative aided speech scores on average compared with that displayed by CI/HA subjects. Routine clinical data available from the present database did not explain the asymmetrical results of bilateral implantation.Conclusions: This retrospective study, based on basic speech audiometry (no lateralization cues), indicates that, on average, a second CI is likely to provide slightly better postoperative speech outcome than an additional HA for people with very low preoperative performance. These results may be taken into consideration to refine surgical indications for CIs.

The aim of this study was to assess the effect of corticosteroids administered intra- and postoperatively on the occurrence of facial palsy after a cerebellopontine angle (CPA) tumor resection, and to investigate pre- and intraoperative prognostic factors. A multicenter, prospective, randomized, double-blind and versus-placebo study was conducted between 2006 and 2010. Three hundred and ten patients operated on for a CPA tumor (96% vestibular schwannomas, 4% miscellaneous) were included by five participating centers. The population was stratified into patients with small (≤15 mm CPA on axial MRI views) and large tumors. In each group, patients were randomized to receive corticosteroid (1 mg/kg/day i.v. methylprednisolone intraoperatively and at postoperative days 1-5) or placebo. Steroids did not affect the facial function at postoperative days 1, 8 and 30 in patients with small or large tumors as evaluated by House and Brackmann grading.

To allow for enhanced quality while reducing machining time, machines have become increasingly complex, thus leading to an increase in purchase, running and operator training costs. In what follows in the present paper, we shall firstly show how a virtual machine tool can be developed. Secondly, we shall study the influence this tool can have on teaching methods..

To assess the conservation of residual hearing in recipients of the Nucleus 24 Contour Advance cochlear implant (CI) and the benefits of combined electrical and acoustic stimulation.Prospective multicenter study.CI clinics in Western Europe.Adult candidates for conventional cochlear implantation with a minimum preoperative word recognition score of 10% in the ear to be implanted."Soft-surgery" protocol, including a 1- to 1.2-mm anterior and inferior cochleostomy hole with the electrode array, inserted 17 mm using the "advance-off-stylet" technique. Patients with postoperative pure-tone hearing threshold levels (HTLs) of 80 dB hearing loss or less at 125 and 250 Hz and 90 dB hearing loss or less at 500 Hz were refitted with an in-the-ear hearing aid for combined ipsilateral electrical and acoustic (El-Ac) stimulation.A questionnaire to collect information regarding surgery. Pure-tone HTLs measured at intervals. Word recognition tested in quiet and sentence recognition tested in noise at 10 and 5 dB signal-to-noise ratio (SNR). HEARING CONSERVATION RESULTS: HTL data were available for 27 patients. HTLs were conserved within 20 dB of preoperative levels for 33, 26, and 19% of patients for 125, 250, and 500 Hz, respectively. However, the recommended soft-surgery protocol was strictly followed in only 12 of 27 patients. For these 12 patients, hearing thresholds were conserved within 20 dB for 50, 50, and 33% of patients. Median threshold increases were 40 dB (range, 250-500 Hz) for the whole group and 23 dB for the strict surgery group. Ten patients retained sufficient HTLs to enter the El-Ac user group. SPEECH RECOGNITION RESULTS: Group mean recognition scores for nine El-Ac users for words presented at 65 dB sound pressure level were 45% for CI alone and 55% for CI + ipsilateral hearing aid (p0.05, paired t). For sentences presented in noise at 5 dB SNR, mean word scores were 46% CI alone and 56% CI + ipsilateral hearing aid (p0.01, paired t).Hearing was conserved for conventional candidates for cochlear implantation where the recommended soft-surgery protocol was strictly adhered. Combined ipsilateral electrical and acoustic stimulation provided considerable benefits for speech recognition in noise, equivalent to between 3 and 5 dB SNR, compared with CI alone.

Objectives To describe the hearing outcomes in patients with far-advanced otosclerosis and to identify the best initial approach based on preoperative word recognition scores (WRS), pure tone averages (PTA), and radiological classification. Study design Retrospective case review. Setting Academic neurotology tertiary referral center. Patients All patients (n = 58) with preoperative air conduction PTA less than 85 dB (HL), disyllabic WRS less than or equal to 50% at 60 dB (HL) with well-fitted hearing aids, and evidence of otosclerosis on CT scan, treated in our department over the past 20 years. Interventions Stapedotomy, cochlear implantation, or both. Main outcome measures Postoperative WRS after a minimum of 12 months' follow-up, percentage of patients with WRS greater than 50%. Reliability of air and bone conduction PTAs and WRS in predicting failure of stapedotomy. Results Fifty-eight patients were divided into three groups: group I, primary stapedotomy (n = 32); group II, primary cochlear implantation (n = 9); and group III, secondary cochlear implantation (with a previous history of stapedotomy) (n = 25). The mean postoperative WRS were 50.6% (± 34), 75% (± 17), and 72% (± 20), respectively. Sixty percent of patients in the stapedotomy group had a postoperative WRS greater than 50% requiring no further treatment, compared to 85% for cochlear implant recipients. No specific predictive factors for stapedotomy outcome could be identified. Surgical difficulties during cochlear implantation were significantly higher in patients with advanced radiological stage. Conclusion Although cochlear implantation gives better overall results, stapedotomy with hearing aids can still be very effective in the management of patients with far-advanced otosclerosis. It should therefore be proposed as a first-line treatment.

A four-channel device may enhance the sensitivity of electromyography (EMG). Determination of stimulation thresholds (STs) below 0.05 mA improves facial prognostic information after vestibular schwannoma (VS) surgery. To compare intraoperative observations with electromyographic data for predicting the immediate facial function outcome after VS surgery.A total of 111 VS patients operated on and intraoperatively monitored using four-channel facial EMG between October 2002 and September 2003 were included in this multicentre, prospective study. Mascular activity detection was performed in the frontal, orbicularis oculi, orbicularis oris and platysma muscles. Intraoperative observations were made concerning adhesion and nerve stretch, and facial function was graded (House-Brackmann classification) at postoperative Days 1 and 8.Facial function at postoperative Days 1 and 8 was related to the intraoperative nerve STs at the brainstem and in the adhesion zone (range 0.01-3 mA for a response100 microV). At postoperative Day 8, good facial function (Grades 1 or 2) was observed in 93% of cases for STs in the adhesion zone of 0.01-0.04 mA, 85% for STs of 0.05-0.3 mA and 79% for STs0.3 mA. These STs were related to the degree of tumor adhesion and not to the nerve stretch. The maximal EMG response was detected in the frontal or platysma muscles in 26% of cases, and in the orbicularis oris and orbicularis oculi muscles in 74%.

Objective: This study aimed to evaluate the long-term speech perception and speech intelligibility of congenitally and prelingually deaf children after cochlear implantation. It was a longitudinal study following 63 congenitally or prelingually deaf children up to 5 years after implantation. They each received a nucleus multichannel cochlear implant before they were 10 years old. Methods: Perception is evaluated using the Test for the Evaluation of Voice Perception and Production (TEPP) and concerns closed- and open-set word and sentence perception without lip-reading. The intelligibility is classified according to the Speech Intelligibility Rating (SIR). The evaluations have been made every 3 months for 1 year, then at 18 months, 2 years, 3 years and 5 years after the cochlear implantation. Results: After 5 years of implantation, the median percentage of closed-words speech perception (CSW) is 95.5%—93.67% for closed-sentence speech perception (CSS) and 76.3% for open-sentence speech perception (OSS); the median Speech Intelligibility Rating is 3.83. Conclusions: Congenitally and prelingually deaf children who receive cochlear implant before the age of 10 years develop speech perception and speech intelligibility abilities. The closed-set perception progresses quickly and seems to reaching a plateau at 5 years post implantation. The improvement of open-sentence perception is not significant until the first year post implantation. The speech intelligibility improves regularly the five first year post implantation.

Objective The Vibrant Soundbridge is an active semi-implantable middle ear implant for the rehabilitation of patients with a sensorineural hearing loss who are not able to derive adequate benefit from conventional hearing aids. A retrospective study was performed to assess the overall level of satisfaction of implanted patients and to investigate the potential determinants of postoperative success. Study design A retrospective survey of audiological data from repeated measures and subjective data from self-assessment scales administered postoperatively was conducted to determine the degree of benefit and satisfaction for Vibrant Soundbridge implantees. Setting Twenty-one tertiary referral and teaching hospitals. Subjects The first 125 VSB implantees implanted in France between August 1997 and May 2001 were included in the study. Results No clinically significant change was observed for residual hearing postoperatively. Most patients (83%) reported they were either satisfied or very satisfied with the Vibrant Soundbridge. Analysis of correlation revealed a moderate correlation (Pearson coefficient r = 0.59) between the degree of benefit reported via the patient survey and the degree of benefit reported via the Glasgow Benefit Inventory. A moderate correlation (Pearson coefficient r = 0.66) was observed between speech comprehension scores in quiet for the preoperative unaided condition and the postoperative aided Vibrant Soundbridge condition. No correlation was observed between subjective reports of satisfaction postoperatively and performance on preoperative objective tests or patient characteristics. Conclusion The results indicate a high level of satisfaction with the VSB as a treatment of sensorineural hearing impairment in patients with a wide range of characteristics. Preoperative scores for unaided speech comprehension tests in quiet may be a potential indicator of success on aided Vibrant Soundbridge speech comprehension tests postoperatively but do not reflect patient satisfaction with the device reported on self-assessment scales.

This study was designed to investigate the perceptual benefits and potential risks of implanting the Nucleus(R) multichannel auditory brainstem implant.Between September 1992 and October 1997 a total of 27 subjects received a Nucleus 20- or 21-channel Auditory Brainstem Implant (ABI). All subjects involved in the trial had bilateral acoustic tumour as a result of neurofibromatosis type 2 (NF2) resulting in complete dysfunction of the VIIIth nerve. The study used each subject as their own control without a preoperative baseline because residual hearing, if existing, was destroyed at surgery by tumour removal. A battery of speech tests was conducted to evaluate each patient's performance and communication abilities. Tests were conducted, where possible, in the auditory-only, visual-only, and auditory-visual conditions at 3 days postoperatively (baseline), at 3-mo intervals for the first year and every 12 mo thereafter. A subjective performance questionnaire was administered together with an extensive neurological examination at each test interval.27 subjects involved in this trial were successfully implanted with a Nucleus ABI. One subject died 2 days postoperatively due to a lung embolism unrelated to the device. Twenty-six subjects underwent device activation and all but one patient received auditory sensation at initial stimulation (96.2%). On average 8.6 (+/-4.2) of the available 21 electrodes were used in the patients' MAPs. Performance evaluation measures showed that the majority of users had access to auditory information such as environmental sound awareness together with stress and rhythm cues in speech that assist with lipreading. Although most subjects did not achieve any functional auditory-alone, open-set speech understanding, two subjects from this series (7.4%) did receive sufficient benefit to be able to use the ABI in conversation without lipreading.Although the medical risks and surgical complexity associated with ABI device implantation are far greater than those for a cochlear implant, the clinical results from this trial show that the Nucleus multichannel ABI is capable of providing a significant patient benefit over risk ratio for subjects suffering loss of hearing due to bilateral retrocochlear lesions.

OBJECTIVES The detection of fundamental frequency (F0) variations plays a prominent role in the perception of intonation. Cochlear implant (CI) users with residual hearing might have access to these F0 cues. The objective was to study if and how residual hearing facilitates speech prosody perception in CI users. DESIGN The authors compared F0 difference limen (F0DL) and question/statement discrimination performance for 15 normal-hearing subjects (NHS) and two distinct groups of CI subjects, according to the presence or absence of acoustic residual hearing: one "combined group" (n = 11) with residual hearing and one CI-only group (n = 10) without any residual hearing. To assess the relative contribution of the different acoustic cues for intonation perception, the sensitivity index d' was calculated for three distinct auditory conditions: one condition with original recordings, one condition with a constant F0, and one with equalized duration and amplitude. RESULTS In the original condition, combined subjects showed better question/statement discrimination than CI-only subjects, d' 2.44 (SE 0.3) and 0.91 (SE 0.25), respectively. Mean d' score of NHS was 3.3 (SE 0.06). When F0 variations were removed, the scores decreased significantly for combined subjects (d' = 0.66, SE 0.51) and NHS (d' = 0.4, SE 0.09). Duration and amplitude equalization affected the scores of CI-only subjects (mean d' = 0.34, SE 0.28) but did not influence the scores of combined subjects (d' = 2.7, SE 0.02) or NHS (d' = 3.3, SE 0.33). Mean F0DL was poorer in CI-only subjects (34%, SE 15) compared with combined subjects (8.8%, SE 1.4) and NHS (2.4%, SE 0.05). In CI subjects with residual hearing, intonation d' score was correlated with mean residual hearing level (r = -0.86, n = 11, p < 0.001) and mean F0DL (r = 0.84, n = 11, p < 0.001). CONCLUSION Where CI subjects with residual hearing had thresholds better than 60 dB HL in the low frequencies, they displayed near-normal question/statement discrimination abilities. Normal listeners mainly relied on F0 variations which were the most effective prosodic cue. In comparison, CI subjects without any residual hearing had poorer F0 discrimination and showed a strong deficit in speech prosody perception. However, this CI-only group appeared to be able to make some use of amplitude and duration cues for statement/question discrimination.

Objective: To analyze predictive factors of cochlear implant outcomes and postoperative complications in the elderly. Study Design: Prospective, longitudinal study performed in 10 tertiary referral centers. Methods: Ninety-four patients aged 65-85 years with a profound, postlingual hearing loss were evaluated before implantation, at time of activation, and 6 and 12 months after cochlear implantation. Speech perception and lipreading were measured using disyllabic word recognition in quiet and noise, and lipreading using disyllabic words and sentences. The influence of preoperative factors on speech perception in quiet and noise at 12 months was tested in a multivariate analysis. Complications, presence of tinnitus and of vestibular symptoms were collected at each evaluation. Results: The effect of age was observed only in difficult noisy conditions at SNR 0 dB. Lipreading ability for words and sentences was negatively correlated with speech perception in quiet and noise. Better speech perception scores were observed in patients with shorter duration of hearing deprivation, persistence of residual hearing for the low frequencies, the use of a hearing aid before implantation, the absence of cardiovascular risk factors, and in those with implantation in the right ear. General and surgical complications were very rare, and the percentage of vestibular symptoms remained stable over time. Conclusion:This study demonstrates that cochlear implantation in the elderly is a well-tolerated procedure and an effective method to improve communication ability. Advanced age has a low effect on cochlear implant outcome. Analyses of predictive factors in this population provide a convincing argument to recommend treatment with cochlear implantation as early as possible in elderly patients with confirmed diagnosis of a severe-to-profound hearing loss and with only limited benefit from hearing aid use in one ear.

The Vibrant Soundbridge (VBS; Symphonix Devices, Inc., San Jose, CA, U.S.A.) is an active, semi-implantable, middle ear hearing device that directly drives the ossicular chain and is used in the treatment of patients with mild to severe sensorineural hearing loss. The benefits of the VBS and the effects of surgery were examined and compared with the preoperative aided condition in 25 patients with implants.Single-subject repeated-measures evaluations were performed with each patient acting as his or her own control. Objective audiologic measures and subjective questionnaires also were used.Five tertiary referral and teaching hospitals.Adult patients had bilateral sensorineural hearing loss (average hearing loss, 56 dB; range, 33-80 dB). Twenty-one patients had worn a conventional hearing aid before surgery (11 binaurally, 10 monaurally). Four patients had not used a conventional hearing aid before surgery.Rehabilitative.No significant change in residual hearing after surgery was observed. Functional gain was significantly superior with the VBS. No significant differences were observed for aided speech recognition in quiet. A significant improvement in communication in various listening conditions was reported with the VBS as compared with conventional hearing aids.The VBS surgical implantation procedure does not affect the residual hearing level in the implanted ear, nor does it present any unacceptable risk. Measurable benefit from the VBS in comparison with conventional amplification was demonstrated with regard to the provision of superior usable amplification and greater ease in communication in daily listening environments for the majority of patients.

The Vibrant Soundbridge, a semi-implantable hearing device for subjects with moderate to severe sensorineural hearing impairment was introduced commercially. First audiologic results are presented on 63 patients from 10 European implant centers. Hearing loss was at 0.5, 1, 2, and 4 kHz varying between 43 and 81 dB HL. The patients used the analogue audio processor, type 302. Measured sound-field gain was compared with NAL-R target values. For most patients an acceptable agreement was found. There was a subgroup of patients, however, with relatively low gain. The results suggest that this was related to the suboptimal positioning and fixation of the transducer to the incus.

Cochlear implantation in elderly patients is a questionable subject. The purpose of this study was to evaluate the procedure and its outcome, the postoperative course, and the audiologic and social benefits of cochlear implantation in this population. Twenty-seven patients older than 60 years were compared with a control group of 15 adult patients. This retrospective study analyzed data concerning the outcome of the procedure, postoperative course, postoperative orthophonic test results, and answers of a questionnaire assessing the changes in communication, perception, and social outcomes. The procedure was uneventful in both groups. Minor complications were not more frequent in elderly patients. Orthophonic test results were comparable in both groups. At 12 months, 83% of the elderly patients had an open-set speech discrimination score above 60%. The benefits of cochlear implantation in terms of the quality of life are not statistically different with younger patients. Cost-utility analysis might support these findings.

Objective: To investigate the evolution of cochleovestibular symptoms before, during, and after microvascular decompression (MVD) of the facial nerve in hemifacial spasm. Study Design: Prospective study in patients with hemifacial spasm. Among our 13 patients who underwent MVD of the facial nerve from 1995 to 1997, 6 had associated cochleovestibular disorders confirmed by neurotologic tests. Results: In four of these patients, a concomitant compression of the eighth and facial nerves was found at surgery. Preoperative magnetic resonance angiography studies had shown three cases of this double neurovascular compression. Intraoperative auditory brainstem response monitoring showed that interposition of Teflon between vessel and facial nerve was highly critical to the auditory function. Auditory brainstem response monitoring was used to guide the surgeon during this critical phase. Surgery improved at least one cochleovestibular symptom in each patient. Conclusions : The authors propose two pathophysiologic hypotheses. First, the concomitant facial and cochleovestibular symptoms may be due to a hyperactivity of both the facial and vestibular nuclei. According to theories about cryptogenic hemifacial spasm, the origin of this hyperactivity could be an ectopic excitation focus. However, the two nerves may have different sites of ectopic excitation. According to the second hypothesis, a pulsatile compression of the facial nerve may be transmitted to the eighth nerve. This could take place even if only the facial nerve is in contact with a vascular loop.

Postoperative imaging plays a growing role in clinical studies concerning prognostic factors in cochlear implantation. Indeed, intracochlear position of the cochlear implant has recently been identified as a contributor in functional outcomes and radiological tools must be accurate enough to determine the final placement of the electrode array. The aim of our study was to validate cone beam computed tomography as a reliable technique for scalar localization of the electrode array. We performed therefore a temporal bone study on ten specimens that were implanted with a perimodiolar implant prototype. Cone beam reconstructions were performed and images were analyzed by two physicians both experienced in cochlear implant imaging, who determined the scalar localization of the implant. Temporal bones then underwent histological control to document this scalar localization and hypothetical intracochlear lesions. In four cases, a dislocation from scala tympani to scala vestibuli was suspected on cone beam reconstructions of the ascending part of the basal turn. In three of these four specimens, dislocation in pars ascendens was confirmed histologically. In the remaining temporal bone, histological analysis revealed an elevation with rupture of the basilar membrane. Histological assessment revealed spiral ligament tearing in another bone. We conclude that cone beam is a reliable tool to assess scalar localization of the selectrode array and may be used in future clinical studies.

Objective: To test the influence of multiple factors on cochlear implant (CI) speech performance in quiet and in noise for postlinguistically deaf adults, and to design a model of predicted auditory performance with a CI as a function of the significant factors.Study Design: Retrospective multi-centre study.Methods: Data from 2251 patients implanted since 2003 in 15 international centres were collected. Speech scores in quiet and in noise were converted into percentile ranks to remove differences between centres. The influence of 15 pre-, per- and postoperative factors, such as the duration of moderate hearing loss (mHL), the surgical approach (cochleostomy or round window approach), the angle of insertion, the percentage of active electrodes, and the brand of device were tested. The usual factors, duration of profound HL (pHL), age, etiology, duration of CI experience, that are already known to have an influence, were included in the statistical analyses.Results: The significant factors were: the pure tone average threshold of the better ear, the brand of device, the percentage of active electrodes, the use of hearing aids (HAs) during the period of pHL, and the duration of mHL.Conclusions: A new model was designed showing a decrease of performance that started during the period of mHL, and became faster during the period of pHL. The use of bilateral HAs slowed down the related central reorganization that is the likely cause of the decreased performance. Citation: Lazard DS, Vincent C, Venail F, Van de Heyning P, Truy E, et al. (2012) Pre-, Per- and Postoperative Factors Affecting Performance of Postlinguistically Deaf Adults Using Cochlear Implants: A New Conceptual Model over Time. PLoS ONE 7(11):e48739. doi:10.1371/journal.pone.0048739

Objectives To describe the clinical and radiologic features of associated spontaneous tegmen defects (STDs) with semicircular canal dehiscences (SCCDs) and to postulate a novel etiopathogenic hypothesis of these pathologic conditions. Methods Medical records of all patients with surgically confirmed STD between 2001 and May 2010 were reviewed. We excluded all secondary tegmen defects. Clinical, audiological, and radiologic data were analyzed. Results Twenty-three patients matched the inclusion criteria. Semicircular canal dehiscence was associated to STD in 13 patients. Of these patients, 12 (95%) had protruding superior semicircular canals in the middle cranial fossa versus only 3 (30%) of 10 patients for the nondehiscent cases. Twenty-two patients complained of hearing loss. Cerebrospinal fluid leak was found in 13 patients. Four patients had history of meningitis. Vestibular symptoms were present in 8 patients. Conclusion This is the largest series of reported coexistence of STD and SCCD in the literature. Protrusion of the superior semicircular canal in the middle cranial fossa is probably an additional factor underlying STD and SCCD etiopathogeny. Semicircular canal dehiscence should always be looked for when STD is present.

International audience; HYPOTHESIS: : Bilateral stimulation through cochlear implants induces a brain activity pattern closer to the normal one than unilateral stimulation. BACKGROUND: : Although it has been shown that speech comprehension through bilateral cochlear implants leads to better performances than after unilateral implantation, the existence of neural underpinnings of this improvement remains to be studied. METHODS: : We performed an H2O positron emission tomographic study of word recognition in 5 patients with bilateral cochlear implants and 5 normal-hearing controls. Subjects had to distinguish words from nonwords in binaural and monaural conditions. RESULTS: : There was no overactivation in patients for binaural stimulation, with a hypoactivation in the right temporal cortex. For monaural stimulation, patients demonstrated more activation contralaterally to the stimulation side in the posterior temporal cortex and in the cerebellum. CONCLUSION: : Binaural stimulation through cochlear implants is advantageous compared with the monaural at the neurofunctional level because the pattern of brain activity is closer to the normal one.

Conclusion: High-resolution computed tomography (CT) scan may reveal an isolated fenestral form of otosclerosis, and an extensive form, which involves multiple foci around the otic capsule. Pre- and postoperative hearing thresholds are poorer in patients with extensive otosclerosis and their chance of overclosure is reduced by 90%. Objectives: To evaluate the relationship between CT scan extension of otosclerotic foci and hearing thresholds in the operated ear, before and after stapedotomy. Methods: A preoperative CT scan was performed in 200 patients suspected of having otosclerosis. CT scan findings were categorized as negative, isolated fenestral otosclerosis, and extensive otosclerosis. Preoperative and 2 months postoperative air-conduction (AC) and bone-conduction (BC) thresholds were collected. Results: In the operated ear, 150 CT scans (75%) revealed an isolated fenestral otosclerosis; 35 (17.5%) were classified as extensive otosclerosis. Mean preoperative BC was significantly poorer in extensive otosclerosis (30.3 dB) than in isolated fenestral otosclerosis (24.6 dB). Mean postoperative BC remained lower in extensive otosclerosis (30.3 dB) than in isolated fenestral otosclerosis (21.2 dB). An overclosure greater than 10 dB was found in 20% of isolated fenestral otoscleroses and in 2.85% of extensive otoscleroses (chi-square: 5.5; p = 0.02).

Objective: The need for revision stapes surgery has many causes, and among these, we describe a particular displacement of the piston: the Blateralized piston syndrome.[ The goal of this study is to define criteria and surgical management of this syndrome. Study Design: Retrospective study over 13 years. Setting: Tertiary reference center. Patients: A review of 1,289 consecutive stapes operations revealed 119 revisions (9%) from which 22 cases (18.5%) could be classified under the lateralized piston syndrome. Intervention: Revision stapedotomy. Main Outcome Measures: Medical files, preoperative and postoperative audiograms, computed tomographic scans, and operative reports. Results: The 22 cases presented as a delayed conductive hearing loss in 95.5% of cases. Preoperative computed tomographic scans showed a lateralized piston out of the stapedotomy in 81% of cases and touching the tympanic membrane in 54.5% of cases. Revisions revealed a lateral displacement of the piston out of the entire oval window in 86% of cases, with closure of the stapedotomy in all cases and incus necrosis in 77% of cases. Conventional pistons were fitted in 12 cases. In case of a significantly eroded incus, total prostheses (TORPs) in 6 cases and offset pistons in 4 cases were placed. Air-bone gap (ABG) was closed to within 20 dB in 82% of cases. Air-conduction puretone audiometry improvement was 17.2 dB (standard deviation [SD], 19.2), with a mean postoperative ABG of 16.2 dB (SD, 12.7). Only 1 ear, operated with TORP, had a sensorineural deterioration of 20 dB. With offset pistons, ABG was closed to within 20 dB in 100% of cases with a mean postoperative ABG of 8.8 dB (SD, 7.2). Conclusion: The lateralized piston syndrome was found in 18.5% of stapes surgery revisions. Surgical management was effective in correcting the conductive hearing loss. In the event of significant eroded incus, we observed better results with offset pistons than with TORPs. Key Words: Computed tomographic scanVOtosclerosisVProsthesis malfunctionV RevisionVStapedotomy. Otol Neurotol 30:1138Y1144, 2009.

To assess the reliability of high-resolution computed tomographic scan (HRCT scan) for the diagnosis of otosclerosis and to determine its usefulness to predict hearing deterioration and surgical difficulties.Prospective study.Tertiary reference center.Two hundred nine ears (200 patients) presenting progressive conductive hearing loss with normal tympanic membrane, abnormal stapedial reflex, and scheduled for stapes surgery. The mean age was 47.3 years.All patients underwent HRCT scan before surgery (slice thickness of 0.6 to 1 mm). Stapedotomy was performed in 99% of cases.High-resolution computed tomographic scan results were categorized as positive, doubtful, or negative. We classified a CT scan as positive for otosclerosis when a hypodense focus was seen around the otic capsule. Preoperative and postoperative air- and bone-conduction thresholds were collected.Of 209 HRCT scans, 84.2% were classified positive, 8.6% doubtful, and 7.2% negative. In all patients with positive CT scan, otosclerosis was confirmed in surgery. Among 15 negative cases, we found 4 minor malformations and 1 fracture of the stapes. Footplate incidents (mobilized, floating, or fractured footplate; 5.3%) occurred significantly more frequently when an HRCT scan was negative or doubtful (p = 0.05). Mean preoperative air-bone gap was 27.7 dB (standard deviation, 10). Mean postoperative air-bone gap was within 10 dB in 65% and within 20 dB in 92% of cases. Greater than 10 dB deterioration of bone-conduction thresholds occurred in 2% of cases. Mean preoperative and postoperative bone-conduction thresholds were significantly lower in cases of round window obliteration, pericochlear, or internal auditory canal hypodensities (p0.005 and p0.0001, respectively).In our series, the sensitivity of HRCT scan to otosclerosis was 95.1%. Hypodense otosclerotic foci were mostly localized at the anterior part of footplate. Negative or doubtful cases were associated with the highest incidence of stapes footplate complications. Foci involving otic capsule, internal auditory canal, or round window led to a significantly higher risk of sensorineural hearing loss.