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Purpose During insertion of the cochlear implant electrode array, the tip of the array may fold back on itself and can cause serious complications to patients. This article presents a sensing system for cochlear implantation in a cochlear model. The electrode array fold-over behaviors can be detected by analyzing capacitive information from the array tip. Method Depending on the angle of the array tip against the cochlear inner wall when it enters the cochlear model, different insertion patterns of the electrode array could occur, including smooth insertion, buckling, and fold-over. The insertion force simulating the haptic feedback for surgeons and bipolar capacitance signals during the insertion progress were collected and compared. The Pearson correlation coefficient (PCC) was applied to the collected capacitive signals to discriminate the fold-over pattern. Results Forty-six electrode array insertions were conducted and the deviation of the measured insertion force varies between a range of 20% and 30%. The capacitance values from electrode pair (1, 2) were recorded for analyzing. A threshold for the PCC is set to be 0.94 that can successfully discriminate the fold over insertions from the other two types of insertions, with a success rate of 97.83%. Conclusions Capacitive measurement is an effective method for the detection of faulty insertions and the maximization of the outcome of cochlear implantation. The proposed capacitive sensing system can be used in other tissue implants in vessels, spinal cord, or heart.

Objectives: To compare outcomes of telephone and face-to-face consultations for new otology referrals and discuss the wider use of telemedicine in otology. Design: Retrospective cohort study. Setting: UK secondary/tertiary referral unit. Participants: New adult otology referrals to our unit, sampled consecutively between March 2021 and May 2021, reviewed in either a face-to-face or telephone clinic. Main outcome measures: Primary outcome measure was the proportion of patients with a definitive management outcome (discharged or added to waiting list for treatment) versus the proportion of patients requiring follow-up for further assessment or review. Results: 150 new patients referred for a routine otology consultation (75 telephone, 75 face-to-face) were included. 53/75 patients (71%) undergoing a face-to-face consultation received a definitive outcome following initial review, versus 22/75 (29%) telephone patients (2

Treating twenty-five cases of chronic resistant otitis externa with fluticasone propionate (Flixonase®): a case series Utilising Flixonase® in treatment of chronic otitis externaKey points:Chronic cases of otitis externa, resistant to conventional treatments are notoriously difficult to treat, with resolution in these cases challenging.Guidelines suggest the use of corticosteroid in chronic otitis externa, however, there is no specific advice on which corticosteroid to utilise.Our case-series demonstrates the potential benefit of fluticasone propionate in patients who have previously failed a multitude of conventional management options.Despite the limitations of our study, our experience highlights a gap in the literature and suggest fluticasone propionate as an exciting and potentially important tool in the arsenal of the otolaryngologist.

Cochlear Implant provides an electronic substitute for hearing to severely or profoundly deaf patients. However, postoperative hearing outcomes significantly depend on the proper placement of electrode array (EA) into scala tympani (ST) during cochlear implant surgery. Due to limited intra-operative methods to access array placement, the objective of the current study was to evaluate the relationship between EA complex impedance and different insertion trajectories in a plastic ST model. A prototype system was designed to measure bipolar complex impedance (magnitude and phase) and its resistive and reactive components of electrodes. A 3-DoF actuation system was used as an insertion feeder. 137 insertions were performed from 3 different directions at a speed of 0.08 mm/s. Complex impedance data of 8 electrode pairs were sequentially recorded in each experiment. Machine learning algorithms were employed to classify both the full and partial insertion lengths. Support Vector Machine (SVM) gave the highest 97.1% accuracy for full insertion. When a real-time prediction was tested, Shallow Neural Network (SNN) model performed better than other algorithms using partial insertion data. The highest accuracy was found at 86.1% when 4 time samples and 2 apical electrode pairs were used. Direction prediction using partial data has the potential of online control of the insertion feeder for better EA placement. Accessing the position of the electrode array during the insertion has the potential to optimize its intraoperative placement that will result in improved hearing outcomes.

Treating twenty-five cases of chronic resistant otitis externa with fluticasone propionate (Flixonase®): a case series Utilising Flixonase® in treatment of chronic otitis externaKey points:Chronic cases of otitis externa, resistant to conventional treatments are notoriously difficult to treat, with resolution in these cases challenging.Guidelines suggest the use of corticosteroid in chronic otitis externa, however, there is no specific advice on which corticosteroid to utilise.Our case-series demonstrates the potential benefit of fluticasone propionate in patients who have previously failed a multitude of conventional management options.Despite the limitations of our study, our experience highlights a gap in the literature and suggest fluticasone propionate as an exciting and potentially important tool in the arsenal of the otolaryngologist.

Objective To investigate the disturbance induced in the cochlea during cochleostomy using conventional drill and a hand guided robotic drill. Study design The study is based on experimental measurements using the Laser Doppler Vibrometer during the drilling processes converted to Sound Pressure Levels (SPL) for comparison. Setting The study is based on experimental results of three sets of cochleostomies on human cadaver heads. Main outcome measure(s) Robotic drilling, in comparison to the conventional drilling method, creates a consistently lower level of disturbance in cochlea across the hearing frequency range. Results Robotic drilling, in comparison to the conventional drilling method, creates a consistently lower level of disturbance in cochlea across the hearing frequency range. Conclusions It is reasonable to conclude that robotic drilling has a lower possibility of creating acoustic trauma in cochlea that endangers the residual hearing of patients.

For centuries it has been humankind's instinct to cover the mouth and nose when coughing or sneezing. Common sense would dictate this instinctively reduces the dispersion of aerosol and droplets and thus the spread of contact and airborne infections.

Human evaluation and judgement may include errors that can have disastrous results. Within medicine and healthcare there has been slow progress towards major changes in safety. Healthcare lags behind other specialised industries, such as aviation and nuclear power, where there have been significant improvements in overall safety, especially in reducing risk of errors. Following several high profile cases in the USA during the 1990s, a report titled "To Err Is Human: Building a Safer Health System" was published. The report extrapolated that in the USA approximately 50,000 to 100,000 patients may die each year as a result of medical errors. Traditionally otolaryngology has always been regarded as a "safe specialty". A study in the USA in 2004 inferred that there may be 2600 cases of major morbidity and 165 deaths within the specialty. MEDLINE via PubMed interface was searched for English language articles published between 2000 and 2012. Each combined two or three of the keywords noted earlier. Limitations are related to several generic topics within patient safety in otolaryngology. Other areas covered have been current relevant topics due to recent interest or new advances in technology. There has been a heightened awareness within the healthcare community of patient safety; it has become a major priority. Focus has shifted from apportioning blame to prevention of the errors and implementation of patient safety mechanisms in healthcare delivery. Type of Errors can be divided into errors due to action and errors due to knowledge or planning. In healthcare there are several factors that may influence adverse events and patient safety. Although technology may improve patient safety, it also introduces new sources of error. The ability to work with people allows for the increase in safety netting. Team working has been shown to have a beneficial effect on patient safety. Any field of work involving human decision-making will always have a risk of error. Within Otolaryngology, although patient safety has evolved along similar themes as other surgical specialties; there are several specific high-risk areas. Medical error is a common problem and its human cost is of immense importance. Steps to reduce such errors require the identification of high-risk practice within a complex healthcare system. The commitment to patient safety and quality improvement in medicine depend on personal responsibility and professional accountability.

Background Our aims were to determine the usability and practicality of the endoscope-i system, a novel mobile attachment for aural endoscopy. This incorporated assessing the ease of use of the endoscope-i for different professionals, and ultimately improving the system by receiving constructive feedback. Objective Our objectives were to assess the ease of the endoscope-i system in conducting an aural examination and to assess its feasibility for integrating its use into clinical practice. We looked to assess its ease, effectiveness, and efficiency; to compare this to current practices with otoscopes; and to determine whether participants perceived the system to be able to produce an image of sufficient quality to make a clinical assessment. Finally, we wanted to assess the usefulness of the current training given for using the system, and we sought to gain feedback for the product from the differing specialists. Methods A formative usability study of the endoscope-i system was conducted with 5 health care professionals. Each session lasted 40 minutes and involved audio/video consent, a hands-on session, a private semistructured interview, and an option to discuss the device with a company representative. Results All participants found the endoscope-i system easy to use. The image quality was perceived to be greater than that achieved by current otoscopes. The ability to record images and view them retrospectively was also seen as a positive. Conclusions This study has not identified any significant issues relating to the design, functionality, or application of the endoscope-i. Participants perceived the system as superior to current options with a directly positive impact on their clinical practice.

To establish whether criteria can be used to identify patients who do not need high resolution computed tomography (HRCT) scans before cochlear implant operations, by retrospectively applying a preoperative selection pathway, the Cambridge Cochlear Implant Protocol (CCIP).Retrospective case series.Tertiary referral center, Queen Elizabeth Hospital, Birmingham, UK (QEHB).One hundred adult patients receiving primary cochlear implantation (CI) operations from April 2015 to July 2016 performed at the QEHB who received preoperative HRCTs.Etiology of hearing loss and anatomical abnormalities were collected by reanalyzing HRCT scans. Patients were retrospectively grouped according to criteria to restrict HRCT use derived from the Cambridge Cochlear Implant Programme (CCIP). The two main outcomes, recorded management change and significant abnormalities, were compared between the two CCIP groups, scanned and not scanned.Twenty-six patients had significant abnormalities detected on imaging, 16 in the scanned group and 10 in the not scanned group (p = 0.152). Five patients had a recorded management change as a result of HRCT scan, four scanned group, one not scanned group (p = 0.107). Significant abnormalities and recorded management change were seen across all etiological subgroups of hearing loss.The anatomy within the temporal bone is variable amongst CI recipients. Recorded management change and significant abnormalities occurred in both CCIP groups and across many etiologies of hearing loss patients. No specific group, based on the etiology of their hearing loss could be identified that do not require preoperative HRCT. Therefore, it is recommended that all CI patients should continue to receive preoperative HRCT imaging.

To study the effectiveness of Type 1 tympanoplasty for chronic tympanic membrane perforations in the pediatric age group and to investigate factors influencing its success.Searches were conducted of the MEDLINE database and the Cochrane Database of Systematic Reviews using terms focused around tympanoplasty and children. Searches were performed on June 23, 2014 and limited to English language entries since January 1, 1997.Studies reporting tympanoplasty closure rates in children 18 years and younger, with a minimum follow-up of 6 months, were included. Studies focusing on more advanced forms of tympanoplasty and revision surgery were excluded.Five hundred sixty-four articles were screened identifying 2,609 cases from 45 eligible studies. Data were collected by consensus of the first two authors with the third author arbitrating disparities of opinion. Success was taken as the closure rate at 12 months where possible.Forest plots with Mantel-Haenszel analyses were used to compare closure rates with respect to perforation size, adenoidectomy, status of contralateral ear, Eustachian tube function, active infection, and graft position. Linear regression and Fisher's exact were used to analyze closure rate with respect to age.The mean weighted closure rate for pediatric tympanoplasty was 83.4%. Subgroup analysis found age not to be a significant factor affecting the closure rate. Tympanoplasties performed on larger perforations or in children with abnormal contralateral ear findings were more likely to fail. Surgery may be best delayed until contralateral otitis media with effusion has settled.

Objective Cochlear implantation is a clinical and cost-effective treatment for severe hearing loss. Cochlear nerve size assessment by magnetic resonance imaging (MRI) has been investigated for use as a prognostic indicator following cochlear implantation. This study aimed to further that research by assessing nerve size in normal-hearing adults for symmetry. Materials and methods Patients with tinnitus presenting to our center retrospectively had their nerve size assessed by MRI. Results The study found no significant differences between right and left cochlear nerves in normal-hearing adults, supporting our hypothesis of symmetry in these individuals. This was a previously unproven and uninvestigated hypothesis. Conclusion Nerve size assessment should remain an active area of research in otological disease.

Cochlear implantation (CI) has developed from its origins in the 1980s. Initially, CI was for profound bilateral hearing impairment. However, candidacy for CI have become more widespread in recent years with unilateral implantation and an emphasis on hearing preservation. Evidence supports full electrode insertion in an atraumatic fashion into the scala tympani (ST) provides optimal hearing outcomes. The main aim of this systematic review was to elucidate the degree of trauma associated with CI insertion.A systematic literature search was undertaken using PubMed Medline. A grading system described by Eshraghi was used to classify cochlear trauma. Both radiological and histological studies were included.Twenty one papers were identified which were relevant to our search. In total, 653 implants were inserted and 115 (17.6%) showed evidence of trauma. The cochleas with trauma had basilar membrane elevation in 5.2%, ruptured in 5.2%, the electrode passed from the ST to the SV in 84.4% and there was grade 4 trauma in 5.2%. The studies used a variety of histological and radiological methods to assess for evidence of trauma in both cadaveric temporal bones and live recipients.Minimizing cochlear trauma during implant insertion is important to preserve residual hearing and optimize audiological performance. An overall 17.6% trauma rate suggests that CI insertion could be improved with more accurate and consistent electrode insertion such as in the form of robotic guidance. The correlation of cochlea trauma with post-operative hearing has yet to be determined.

Cholesteatoma is a condition describing the accumulation of squamous epithelium and keratinocytes within the middle ear space. There is conflicting evidence regarding the influence of socioeconomical status on the prevalence of cholesteatoma. Hospital episode statistics (HES) data detailing the numbers of cholesteatoma surgeries performed per area were compared with the Index of Multiple Deprivation 2010 (IMD 2010) data that give a statistical measure of deprivation per local health authority in the UK. Statistical analysis of this data was performed to identify correlations between prevalence of cholesteatoma and deprivation. A trend was identified showing that health authorities associated with an overall low IMD 2010 value indicating more deprived, had higher numbers of mastoid operations. Our results have found that increasing levels of deprivation are associated with greater numbers of mastoid operations and thus greater numbers of cholesteatomas. Our work suggests that there is a need for additional input in deprived areas to accommodate the increased numbers of mastoid operations and chronic middle ear disease.

Fungal malignant otitis externa (FMOE) is a serious and potentially life-threatening condition that is challenging to manage. Diagnosis is often delayed due to the low sensitivity of aural swabs and many antifungal drugs have significant side effects. We present a case of FMOE, where formal tissue sampling revealed the diagnosis and the patient was successfully treated with voriconazole, in addition to an up to date review of the current literature. We would recommend tissue biopsy of the external auditory canal in all patients with suspected FMOE in addition to routine microbiology swabs.

Copyright © 2014 Tom Williamson et al. Robotic assistance in the context of lateral skull base surgery, particularly during cochlear implantation procedures, has been the subject of considerable research over the last decade. The use of robotics during these procedures has the potential to provide significant benefits to the patient by reducing invasiveness when gaining access to the cochlea, as well as reducing intracochlear trauma when performing a cochleostomy. Presented herein is preliminary work on the combination of two robotic systems for reducing invasiveness and trauma in cochlear implantation procedures. A robotic system for minimally invasive inner ear access was combined with a smart drilling tool for robust and safe cochleostomy; evaluation was completed on a single human cadaver specimen. Access to the middle ear was successfully achieved through the facial recess without damage to surrounding anatomical structures; cochleostomy was completed at the planned position with the endosteum remaining intact after drilling as confirmed by microscope evaluation.

Conventional computed tomography (CT) imaging is the standard imaging technique for temporal bone diseases, whereas cone-beam CT (CBCT) imaging is a very fast imaging tool with a significant less radiation dose compared with conventional CT. We hypothesize that a system for intraoperative cone-beam CT provides comparable image quality to diagnostic CT for identifying temporal bone anatomical landmarks in cadaveric specimens.Cross-sectional study.University tertiary care facility.Twenty cadaveric temporal bones were affixed into a head phantom and scanned with both a prototype cone-beam CT C-arm and multislice helical CT. Imaging performance was evaluated by 3 otologic surgeons and 1 head and neck radiologist. Participants were presented images in a randomized order and completed landmark identification questionnaires covering 21 structures.CBCT and multislice CT have comparable performance in identifying temporal structures. Three otologic surgeons indicated that CBCT provided statistically equivalent performance for 19 of 21 landmarks, with CBCT superior to CT for the chorda tympani and inferior for the crura of the stapes. Subgroup analysis showed that CBCT performed superiorly for temporal bone structures compared with CT. The radiologist rated CBCT and CT as statistically equivalent for 18 of 21 landmarks, with CT superior to CBCT for the crura of stapes, chorda tympani, and sigmoid sinus.CBCT provides comparable image quality to conventional CT for temporal bone anatomical sites in cadaveric specimens. Clinical applications of low-dose CBCT imaging in surgical planning, intraoperative guidance, and postoperative assessment are promising but require further investigation.

OBJECTIVE Evaluate the type, content, and quality of information available via the Internet for patients with common otological conditions. METHODS The Google search engine was used to generate responses for the following search terms: glue ear, otitis media, otosclerosis, Meniere's disease, cholesteatoma, and ear perforation. The first 10 websites for each search term were selected for analysis. Websites were evaluated with the validated DISCERN instrument (Institute of Health Sciences, University of Oxford, UK), the LIDA tool (Minervation Ltd, Oxford, UK), the Flesch Readability Formula, the Simple Measure Of Gobbledygook (SMOG) readability score, and against the Journal of the American Medical Association (JAMA) criteria. Comparisons were made with a similar study assessing quality of information in nonotological conditions. RESULTS Mean SMOG score was 12.19 years of education (range, 6.2-22.8). The health on the net (HON) symbol appeared on 15 of 49 websites (30.61%). Pearson's r was used to identify interactions between variables and demonstrated a significant correlation between LIDA score and Google ranking (R = -0.1195, p = 0.002); between university/hospital affiliation and JAMA score (R = -1.7889, p = 0.0182) and commercial affiliation and JAMA score (R = 1.0561; p = 0.01). Multivariate linear regression analysis showed LIDA to be the strongest predictor of Google ranking (Page rank decreasing by 0.10572 per LIDA score; p = 0.01). CONCLUSION As websites with better Google ranking were only weakly associated with higher quality rankings patients would benefit from being directed to reliable websites by clinicians. There is currently a gap in the available resources for a high quality repository of otological information aimed at patients.

The authors wish to acknowledge financial support by Cochlear Ltd., Australia, and clinical support from Queen Elizabeth Hospital, Birmingham, UK in this work and the advice and enthusiasm of Mechtron Design Ltd, UK.

Aim:(1) To assess hypersensitivity to bismuth iodoform paraffin paste impregnated ribbon gauze following its use in packing canal wall down mastoidectomy cavities; (2) to determine if isolation of the skin and mucosa from the pack, using thin Silastic sheeting and Cortisporin ointment, reduces hypersensitivity reactions, compared with a previous series; and (3) to review the literature and to determine if bismuth iodoform paraffin paste hypersensitivity precludes the consumption of seafood (due to its high iodine content).Materials and methods:All patients undergoing canal wall down mastoidectomy with intra-operative bismuth iodoform paraffin paste packing between 1985 and 2009 were identified and reviewed.Results:Of 587 patients identified, the overall bismuth iodoform paraffin paste reaction rate was 1 per cent. All reactions were in patients undergoing revision mastoidectomy procedures, giving a reaction rate for revision procedures of 2.4 per cent.Conclusion:Reactions are an uncommon event following post-operative mastoid cavity packing using bismuth iodoform paraffin paste. Reaction rates may be lowered by preparing the cavity with Silastic sheeting and Cortisporin ointment prior to packing, thus isolating the skin and mucosal surfaces. Development of such a reaction does not preclude the consumption of seafood.

There has been a reduction in the number of modified radical mastoidectomy and revision mastoidectomy surgeries per head of population in Ontario between 1987 and 2007, we believe that this represents a true reduction in prevalence of cholesteatoma. The increase of cases performed at the University Hospital Network, Toronto (UHN) may represent a shift to subspecialization in the treatment of chronic ear disease.To analyze the trends in mastoid operations for chronic middle ear disease in the Canadian province of Ontario between 1987 and 2007 and to determine whether an increasing proportion of these procedures are being performed in tertiary referral centres.The year on year population and number of mastoid procedures performed per year in Ontario and at the UHN between 1987 and 2007 were obtained from Statistics Canada and the Ministry of Health and Long-Term Care, Ontario, respectively. Population-adjusted rates of mastoid surgery for Ontario and the UHN. These data were collated and graphically represented for trend analysis.The population-adjusted number of mastoid procedures for Ontario declined from 7.1 cases per 100,000 in 1986 to 4.1 cases per 100,000 in 2006. During this time the number of both modified radical mastoidectomies and revision mastoid surgeries at UHN increased.

The standard current treatment of an otogenic brain abscess is drainage via neurosurgical burr hole or complete excision, followed by an otological procedure to eradicate the primary pathology – often at a later date. We describe the drainage of otogenic brain abscess via a transtemporal approach. We present a retrospective study of six cases, five children and one adult. All the children had acute middle ear disease while the adult patient had a petrous apex cholesteatoma. All cases had an otogenic intracranial abscess either in the posterior cranial fossa or in both posterior and middle cranial fossae. Diagnosis was confirmed by computed axial tomography (CT) scan. All the patients were treated by mastoidectomy and needle aspiration to drain the abscesses. In all cases the brain abscess and the ear pathology were successfully treated by a single stage transmastoid approach. The five paediatric patients had an extended cortical mastoidectomy approach to both intracranial pathology and ear disease except one patient who required a burr hole to drain a posteriorly located subdural posterior fossa abscess. The adult patient underwent petrosectomy, followed by transtemporal abscess drainage. There was postoperative pus recollection in one patient who required further aspiration. We conclude that transtemporal drainage of an otogenic brain abscess can successfully treat otological and intracranial pathology in a single operation. It has a low complication rate and avoids the need for a craniotomy or subsequent operations.

Background In this paper we consider two relatively frequently performed operations in the field of ear, nose and throat (ENT) surgery and consider how they could be improved by using robotic applications. We consider currently available robots and propose theoretical robotic solutions. Methods The application of robotic systems for both cochlear implantation and endoscopic sinus surgery was considered. Currently available robotic systems were reviewed and those with potential use in ENT surgery were identified. For aspects of operations where there is no available technology, hypotheses are presented on how robots could help. Results Three robotic systems were identified with potential usage in ENT: the Pathfinder™ neurosurgical robot, the Acrobot® knee replacement system and the autonomous smart drill for drilling a cochleostomy. Conclusions The challenge for the future of ENT is being able to perform tasks beyond the level of human perception and abilities. The examples presented here demonstrate that microtechnologies could be used to reduce complications, decrease operating time and improve clinical results. Copyright © 2007 John Wiley & Sons, Ltd.

A mechatronic surgical micro-drill applied in practice has enabled new techniques for measurement in otology to understand the dynamic response of the cochlea hearing organ. In the interest of reducing trauma and to reinforce preservation of residual hearing during surgery, results point to choices in technique as mechatronic devices offer significantly less disturbance than conventional surgical tools used in cochlear electrode implantation. The cochlea transforms mechanical disturbances induced from incident ambient sound to electrical neuro-signals interpreted in the brain as sound, and is a closed volume of fluids and delicate membranes. The mechatronic drilling technique can expose consistently sized membranes at the base of a hole drilled through the bone tissue shell of the cochlea. The dynamic deflection of membrane windows, in response to fluid pressure transients, enables contrast between intra-cochlear disturbances at different locations within the cochlea, and between normal hearing disturbance amplitude and disturbances induced by surgical processes.

The concept of a hand guided robotic drill has been inspired by an automated, arm supported robotic drill recently applied in clinical practice to produce cochleostomies without penetrating the endosteum ready for inserting cochlear electrodes. The smart tactile sensing scheme within the drill enables precise control of the state of interaction between tissues and tools in real-time. This paper reports development studies of the hand guided robotic drill where the same consistent outcomes, augmentation of surgeon control and skill, and similar reduction of induced disturbances on the hearing organ are achieved. The device operates with differing presentation of tissues resulting from variation in anatomy and demonstrates the ability to control or avoid penetration of tissue layers as required and to respond to intended rather than involuntary motion of the surgeon operator. The advantage of hand guided over an arm supported system is that it offers flexibility in adjusting the drilling trajectory. This can be important to initiate cutting on a hard convex tissue surface without slipping and then to proceed on the desired trajectory after cutting has commenced. The results for trials on phantoms show that drill unit compliance is an important factor in the design.

An inflammatory pseudotumour of the temporal bone is a rare, idiopathic, fibro-inflammatory lesion which mimics malignancy. Although such a lesion is known to occur elsewhere in the body such as the liver, abdominal viscera, pelvis, thorax and the upper respiratory tract, the involvement of the temporal bone is extremely unusual. We present such a case in a 60-year-old man, which provided a great diagnostic challenge. We review the key radiological and histological results that confirmed the diagnosis and demonstrated for the first time that oral steroids alone may completely resolve the condition.

During cochlear implantation, hearing preservation is a concern. Minimizing disturbances to the cochlea and protection of the underlying endosteal membrane during the formation of a cochleostomy are considered important factors. The robotic micro-drill system tested in this article is the first example of an autonomous surgical drill successfully producing a cochleostomy, which keeps the underlying endosteal membrane intact. This study compares induced disturbances within the cochlea during formation of cochleostomy using the robotic micro-drill with that of conventional manual drilling. The disturbance of the endosteal membrane is measured using a Microscope Scanning Vibrometer at a third window, produced in the cochlea. Results show that the highest velocity amplitude measured was associated with manual drilling technique. The robotic micro-drill technique produced only about 1% of the peak velocity amplitude seen in manual drilling and exhibited much more uniform behaviour, while keeping the underlying membrane intact. The technique applied when using the robotic drill could be a major step in reducing the trauma to the cochlea, by reducing disturbance levels.

A single-stage fitting of a bone-anchored hearing aid (BAHA) implant and abutment with mastoid obliteration both obviates the need for two separate procedures and utilises the BAHA soft tissue reduction in the mastoid obliteration. Such a procedure has good outcomes in terms of osseointegration and achieving a dry ear. We present a 6-patient case series report highlighting the technique of combined BAHA insertion and mastoid obliteration in six patients. All patients at twelve-month followup have a good degree of sound localisation and hearing thresholds with their BAHA and are free from the social stigma associated with a foul smelling discharging ear.

To conduct a survey of the antiseptic preparations used for ear surgeries among otolaryngologists in Canada.An electronic survey was sent to active members of the Canadian Society of Otolaryngology-Head and Neck Surgery via e-mail. Questions included the use of antiseptic, choice of preparation solution, duration of preparation, use of a barrier method, and compliance with hospital protocol changes.The e-mail was received by 253 otolaryngologists, and 85 completed the survey. Four of 85 respondents did not perform tympanoplasty surgery and were not included in the analysis. Of those who performed tympanoplasty (n = 81), 78 of the 81 respondents (96%) used an antiseptic preparation solution at surgery, whereas 3 respondents (4%) did not. Sixty-six of the 77 respondents (86%) used aqueous povidone-iodine, 4 (5%) used a chlorhexidine-based preparation, 3 (4%) used an alcohol-based solution, 3 (4%) used others, and 1 answered "I don't know." Thirty-eight of 75 (29%) respondents used a barrier method, 23 (31%) answered "always," 18 (24%) answered "sometimes," and 5 (7%) answered "I don't know." When asked if they would comply with a hypothetical hospital policy to use chlorhexidine in ear surgery, 15 of 79 (19%) respondents agreed, whereas 64 (81%) disagreed. Among the aqueous povidone-iodine users (n = 66), 7 (11%) agreed to change to chlorhexidine.There is a wide variation in practice in the use of surgical preparation solution among otolaryngologists performing ear surgery. Surgeons must be vigilant to avoid ototoxicity. A national society consensus on appropriate preparation solutions for ear surgery would minimize patients' risk and minimize future medicolegal actions.

Chlorhexidine is a common antiseptic used to prevent surgical infection. However, its exposure to the middle ear may lead to deafness. The mechanisms of the ototoxicity of chlorhexidine are reviewed. The importance of recognizing its toxicity cannot be overstated in preventing injury to patients undergoing ear surgery.A systematic literature search was performed looking at data from human and animal studies. Search engines included MEDLINE, EMBASE, The Cochrane Library, CENTRAL, CINAHL, and Web of Science to November 1, 2010, for relevant studies published in all languages. Two independent reviewers (P.L. and D.D.P.) screened the references from published articles for additional relevant studies. Medical Subject Headings and key words including intervention (chlorhexidine, antiseptic), exposure (myringoplasty, intratympanic), and adverse effects (sensorineural hearing loss, ototoxicity, vestibular toxicity) were used.Twelve studies were identified, two of which were non-English and were excluded. Only 2 articles on human subjects and 12 articles on animal models concerning chlorhexidine ototoxicity were identified.Chlorhexidine in both human studies and animal models demonstrates ototoxicity if it reaches the inner ear. The toxicity of chlorhexidine appears to be related to its concentration and probable contact time with the round window membrane intraoperatively. It is conceivable that the incidence of chlorhexidine toxicity may be higher than stated if unrecognized or has resulted in subsequent medicolegal actions. From the evidence available, safer preparation solutions are available without clinical risks for ototoxicity should surgeons continue with this practice.

In this paper, a surgical robotic micro-drill is described that has been applied in the preparation of cochleostomies. The critical point of the procedure requires the penetration of the bone tissue of the cochlea while preserving the endosteal membrane tissue at the inner interface. This gives robotic technology the edge over manual approaches as there are benefits relating to the preservation of hearing and reduced possibilities for complications achieved through particularly precise control of the tool-point with respect to moving and deforming tissues. Using a novel approach to interpreting force sensory data the micro-drill operates autonomously guided by the state of the tissue/ tool interaction in order to discriminate tissue types and to detect the tissue interface before penetration occurs. The device also uses standard drill-bits.

An inflammatory pseudotumour of the temporal bone is a rare, idiopathic, fibro-inflammatory lesion which mimics malignancy. Although such a lesion is known to occur elsewhere in the body such as the liver, abdominal viscera, pelvis, thorax and the upper respiratory tract, the involvement of the temporal bone is extremely unusual. We present such a case in a 60-year-old man, which provided a great diagnostic challenge. We review the key radiological and histological results that confirmed the diagnosis and demonstrated for the first time that oral steroids alone may completely resolve the condition.

Objectives. Cochlea implantation involves drilling a cochleostomy through which the electrode array can be inserted. This is a freehand procedure requiring great accuracy. On breaking through the medial bony cochlea wall the drill penetrates through the endosteal membrane traumatizing the basilar membrane and scala tympani and contaminates them with bone dust. This probably causes a destruction of any residual hearing. Our objective was to produce an autonomous surgical drilling robot capable of drilling a cochleostomy but stopping prior to disrupting the endosteal membrane. Method. The autonomous surgical robot senses the force and torque at the tool point and uses this information to predict the start of breaking through the medial bony cochlea wall. Drilling is stopped prior to penetrating the endosteal membrane. The autonomous robot was used to drill a cochleostomy in 5-porcine cochlea's. Results. In all 5 procedures the autonomous surgical drilling robot stopped at the point of breakthrough. The endosteal membrane was not perforated in any of the specimens. The intact membrane was visible at the base of the cochleostomy. Conclusions. The autonomous surgical robot can drill a cochleostomy that minimizes damage to the membranous cochlea. The effect of this increased accuracy on residual hearing and post-operative infection is under further investigation.