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Image-guided robots have been widely used for bone shaping and percutaneous access to interventional sites. However, due to high-accuracy requirements and proximity to sensitive nerves and brain tissues, the adoption of robots in inner-ear surgery has been slower. In this paper the authors present their recent work towards developing two image-guided industrial robot systems for accessing challenging inner-ear targets. Features of the systems include optical tracking of the robot base and tool relative to the patient and Kalman filter-based data fusion of redundant sensory information (from encoders and optical tracking systems) for enhanced patient safety. The approach enables control of differential robot positions rather than absolute positions, permitting simplified calibration procedures and reducing the reliance of the system on robot calibration in order to ensure overall accuracy. Lastly, the authors present the results of two phantom validation experiments simulating the use of image-guided robots in inner-ear surgeries such as cochlear implantation and petrous apex access. [ABSTRACT FROM AUTHOR]

We conducted a study to estimate the number of mastoidectomy procedures performed annually in the United States. Our results are based on state-specific healthcare utilization data and Medicare-funded procedural data from 2002. The utilization data were obtained from the State Ambulatory Surgery Database, which is made available through the Healthcare Cost and Utilization Project. Statistical Package for the Social Sciences (SPSS) statistical software was used to quantify the number of mastoidectomy procedures performed during 2002 in Maryland, New Jersey, New York, and Florida. Information was also obtained from the Federated Ambulatory Surgery Association on the number of Medicare-funded mastoidectomy procedures performed in 2002. State and U.S. population statistics were obtained from the U.S. Census Bureau. These data were extrapolated to obtain a nationwide estimate of the number of mastoidectomies performed annually in the U.S. With 99% confidence, we determined that 0.73 to 0.94 mastoidectomy procedures were performed per 10,000 population in Maryland and 2.55 to 2.74/10,000 in New York. Estimates for both New Jersey and Florida fell in between. Medicare patients underwent between 1.68 and 1.79 procedures per 10,000 population. Based on these data, we estimate that between 30,000 and 60,000 mastoidectomies are performed each year in the U.S., although we suspect that our range may be an underestimation of the actual number because of some limitations inherent in the data collection process. Although mastoidectomy is a common outpatient procedure, to the best of our knowledge, no report on the annual frequency of mastoidectomy procedures in the U.S. has ever been published in the English-language literature. We hope that our report will serve to motivate further research into technological and surgical advancements surrounding this procedure. [ABSTRACT FROM AUTHOR]

Objective: To assess whether preferential hiring practices, particularly self-hiring, are present in academic otolaryngology departments. Setting: A list of academic Otolaryngology-Head and Neck Surgery (O-HNS) departments ranked #1-40 was generated from the Doximity 2021 rankings. The educational background and training information of clinical faculty members and departmental leadership was extracted from each department's online directories. Methods: Descriptive statistics were used to examine inter/intradepartmental relationships and affiliations of included clinical faculty and departmental leadership based on current employment and medical training sites. A "prior affiliation ratio" was calculated to assess the degree of self-hiring and account for multiple possible prior affiliations (medical school, residency, and fellowship) by dividing all prior self-hired affiliations of faculty by the total number of faculty at each department. Results: A total of 1344 clinical faculty were identified, and 596 (44.35%) had at least 1 prior affiliation with their department. The overall prior affiliation ratio was 0.6, and 7 departments had a value >0.8, with the highest being 1.27 (>1.0 indicating multiple prior affiliations per individual such as both residency and fellowship). A network map of departments #1-10 showed heavy intradepartmental faculty recruitment with 24% of faculty having completed a #1-10 residency, 24% a #11-20 residency, 13% a #21-30 residency, and 11% a #31-40 residency. Totaling this data, 76% of faculty at departments ranked #1-10 had completed training at a program ranked #1-40. Furthermore, our data shows high rates of self-hiring among departmental leadership, (40% of Departmental Chairs and 62.5% of Program Directors) though rates are not significantly higher than self-hiring among faculty overall. Conclusion: The top 40 ranked O-HNS departments have high rates of self-hiring, relying on prestige of training programs and prior affiliation in hiring decisions. The effect on departmental productivity and training is unclear., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Dr Robert F. Labadie is a consultant for Spiral Therapeutics and receives NIH funding for other projects.

Objective: To prospectively evaluate the association between hearing preservation after cochlear implantation (CI) and intracochlear electrocochleography (ECochG) amplitude parameters., Study Design: Multi-institutional, prospective randomized clinical trial., Setting: Ten high-volume, tertiary care CI centers., Patients: Adults (n = 87) with sensorineural hearing loss meeting CI criteria (2018-2021) with audiometric thresholds of ≤80 dB HL at 500 Hz., Methods: Participants were randomized to CI surgery with or without audible ECochG monitoring. Electrode arrays were inserted to the full-depth marker. Hearing preservation was determined by comparing pre-CI, unaided low-frequency (125-, 250-, and 500-Hz) pure-tone average (LF-PTA) to LF-PTA at CI activation. Three ECochG amplitude parameters were analyzed: 1) insertion track patterns, 2) magnitude of ECochG amplitude change, and 3) total number of ECochG amplitude drops., Results: The Type CC insertion track pattern, representing corrected drops in ECochG amplitude, was seen in 76% of cases with ECochG "on," compared with 24% of cases with ECochG "off" ( p = 0.003). The magnitude of ECochG signal drop was significantly correlated with the amount of LF-PTA change pre-CI and post-CI ( p < 0.05). The mean number of amplitude drops during electrode insertion was significantly correlated with change in LF-PTA at activation and 3 months post-CI ( p ≤ 0.01)., Conclusions: ECochG amplitude parameters during CI surgery have important prognostic utility. Higher incidence of Type CC in ECochG "on" suggests that monitoring may be useful for surgeons in order to recover the ECochG signal and preventing potentially traumatic electrode-cochlear interactions., (Copyright © 2024, Otology & Neurotology, Inc.)

Objectives: To comprehensively examine the characteristics and prognosis of bilateral sudden sensorineural hearing loss (BSSHL) and its subtypes compared to unilateral sudden sensorineural hearing loss (USSHL)., Data Sources: PubMed, Scopus, and CINAHL., Review Methods: Databases were searched from inception to December 5, 2023, for studies reporting patient characteristics and audiometric outcomes for BSSHL and its simultaneous (Si-BSSHL) and sequential (Se-BSSHL) subtypes. Meta-analysis of continuous measures, proportions (%), mean differences (Δ), and odds ratio (OR) were performed., Results: Eleven studies were included, consisting of 368 patients with BSSHL and 2,705 patients with USSHL. The pooled prevalence among all SSHL cases was 88.1% (95% CI: 81.2%-93.6%) for USSHL and 11.9% (95% CI: 6.4% to 18.8%) for BSSHL. PTA improvement following treatment with steroids was significantly worse in patients with BSSHL (Δ15.3 dB; 95% CI: 14.6 to 15.9; p < 0.0001) compared to patients with USSHL. There was no significant difference in post-treatment PTA improvement between the BSSHL subtypes. Patients with Si-BSSHL were significantly less likely to have an idiopathic etiology (OR: 0.4; 95% CI: 0.2 to 0.8; p = 0.01) and significantly more likely to have an autoimmune disease etiology (OR: 27.4; 95% CI: 2.2 to 336.1; p = 0.01), comorbid cardiovascular disease (OR: 2.3; 95% CI: 1.1 to 5.1; p = 0.03), and comorbid hypertension (OR: 2.5; 95% CI: 1.6 to 3.8; p < 0.0001) compared to patients with USSHL., Conclusions: BSSHL is a considerably rarer form of SSHL with worse prognosis compared to USSHL. BSSHL, and Si-BSSHL in particular, has significantly greater associations with systemic pathologies compared to USSHL. Laryngoscope, 134:3883-3891, 2024., (© 2024 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives: To assess the clinical utility of spread of excitation (SOE) functions obtained via electrically evoked compound action potentials (eCAP) to 1) identify electrode array tip fold-over, 2) predict electrode placement factors confirmed via postoperative computed tomography (CT) imaging, and 3) predict postoperative speech recognition through the first year post-activation in a large clinical sample., Study Design: Retrospective case review., Setting: Cochlear implant (CI) program at a tertiary medical center., Patients: Two hundred seventy-two ears (238 patients) with Cochlear Ltd. CIs (mean age = 46 yr, range = 9 mo-93 yr, 50% female) implanted between August 2014 and December 2022 were included., Main Outcome Measures: eCAP SOE widths (mm) (probe electrodes 5, 11, and 17), incidence of electrode tip fold-over, CT imaging data (electrode-to-modiolus distance, angular insertion depth, scalar location), and speech recognition outcomes (consonant-nucleus-consonant [CNC], AzBio quiet, and +5 dB SNR) through the first year after CI activation., Results: 1) eCAP SOE demonstrated a sensitivity of 85.7% for identifying tip fold-over instances that were confirmed by CT imaging. In the current dataset, the tip fold-over incidence rate was 3.1% (7 patients), with all instances involving a precurved electrode array. 2) There was a significant positive relationship between eCAP SOE and mean electrode-to-modiolus distance for precurved arrays, and a significant positive relationship between eCAP SOE and angular insertion depth for straight arrays. No relationships between eCAP SOE and scalar location or cochlea diameter were found in this sample. 3) There were no significant relationships between eCAP SOE and speech recognition outcomes for any measure or time point, except for a weak negative correlation between average eCAP SOE widths and CNC word scores at 6 months post-activation for precurved arrays., Conclusions: In the absence of intraoperative CT or fluoroscopic imaging, eCAP SOE is a reasonable alternative method for identifying electrode array tip fold-over and should be routinely measured intraoperatively, especially for precurved electrode arrays with a sheath., Competing Interests: Sources of support and disclosure of funding: Dr. Gifford is on the audiology advisory boards for Advanced Bionics and Cochlear Americas and is a consultant for Skylark Bio. The remaining authors disclose no conflicts of interest., (Copyright © 2024, Otology & Neurotology, Inc.)

Objective: To evaluate the treatment efficacy of neuromodulation versus sham for the treatment of tinnitus., Data Sources: Cochrane Library, CINAHL, PubMed, Scopus., Review Methods: The Cochrane Library, CINAHL, PubMed, and Scopus were searched from inception through May 2023 for English language articles documenting "neuromodulation" and "tinnitus" stratified by sham-controlled randomized control trials with 40 or more patients. Data collected included Beck Anxiety Inventory, Beck Depression Inventory (BDI), Tinnitus Handicap Inventory (THI), Tinnitus Questionnaire, and Visual Analog Scale. A Meta-analysis of continuous measures (mean) and proportions (%) were conducted., Results: A total of 19 randomized control trials (N = 1186) were included. The mean age was 48.4 ± 5.3 (range: 19-74), mean duration of tinnitus was 3.8 ± 3.4 years, 61% [56.2-65.7] male, and 55.7% [46-65] with unilateral tinnitus. The short-term effect of transcutaneous electrical nerve stimulation and transcranial direct current stimulation on THI score is -16.2 [-23.1 to -9.3] and -19 [-30.1 to -7.8], respectively. The long-term effect of repetitive transcranial magnetic stimulation on THI score is -8.6 [-11.5 to -5.7]. Transcranial direct current stimulation decreases BDI score by -11.8 [-13.3 to -10.3]., Conclusion: As measured by the Tinnitus Handicap Index, our findings suggest the effects of transcutaneous electrical nerve stimulation and transcranial direct current stimulation reach significant benefit in the short term, whereas repetitive transcranial magnetic stimulation reaches significant benefit in the long term. Based on the BDI, transcranial direct current stimulation significantly reduces comorbid depression in patients with tinnitus., (© 2024 American Academy of Otolaryngology–Head and Neck Surgery Foundation.)

Objective: To assess image artifact when imaging a cochlear implant (CI) with a conventional 3T MRI machine compared with a very low-field (0.064T) MRI., Patients: None., Intervention: Diagnostic study., Main Outcome Measure: Image artifact size associated with the CI affixed to an MRI phantom at very low-field 0.064T MRI versus 3T MRI., Results: The longest diameter of the image artifact was 125 mm for the 3T MRI and 86 mm for the 0.064T MRI, representing 45% longer image artifact generated in the 3T MRI. The actual volume of the imaging phantom was 1371 cm 3 . The volume of the image artifact was measured as 379 cm 3 in the 3T MRI, representing a loss of 27.6% of the actual volume of the imaging phantom. The volume of image artifact was measured as 170 cm 3 in the 0.064T MRI, representing a loss of 12.4% of the phantom volume., Conclusions: 3T MRI had better image quality. This result was not surprising given that larger magnetic field strength is known to provide higher resolution. There was 15% less image artifact generated in the very low-field MRI machine compared with a conventional 3T device. And there was also subjectively increased distortion of the imaging phantom at 3T MRI compared with the 0.064T MRI. With minimized safety concerns and a much lower cost than conventional 3T machines, very low-field scanners may find expanded clinical uses. This preclinical study explores the potential utility of very low-field MRI in scanning CI recipients., Competing Interests: None declared., (Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of Otology & Neurotology, Inc.)

Background: Cochlear-implant electrode arrays (EAs) are currently inserted with limited feedback, and impedance sensing has recently shown promise for EA localisation., Methods: We investigate the use of impedance sensing to infer the progression of an EA during insertion., Results: We show that the access resistance component of bipolar impedance sensing can detect when a straight EA reaches key anatomical locations in a plastic cochlea and when each electrode contact enters/exits the cochlea. We also demonstrate that dual-sided electrode contacts can provide useful proximity information and show the real-time relationship between impedance and wall proximity in a cadaveric cochlea for the first time., Conclusion: The access resistance component of bipolar impedance sensing has high potential for estimating positioning information of EAs relative to anatomy during insertion. Main limitations of this work include using saline as a surrogate for human perilymph in ex vivo models and using only one type of EA., (© 2024 John Wiley & Sons Ltd.)

Cochlear implants (CIs) are neuroprosthetics that can provide a sense of sound to people with severe-to-profound hearing loss. A CI contains an electrode array (EA) that is threaded into the cochlea during surgery. Recent studies have shown that hearing outcomes are correlated with EA placement. An image-guided cochlear implant programming technique is based on this correlation and utilizes the EA location with respect to the intracochlear anatomy to help audiologists adjust the CI settings to improve hearing. Automated methods to localize EA in postoperative CT images are of great interest for large-scale studies and for translation into the clinical workflow. In this work, we propose a unified deep-learning-based framework for automated EA localization. It consists of a multi-task network and a series of postprocessing algorithms to localize various types of EAs. The evaluation on a dataset with 27 cadaveric samples shows that its localization error is slightly smaller than the state-of-the-art method. Another evaluation on a large-scale clinical dataset containing 561 cases across two institutions demonstrates a significant improvement in robustness compared to the state-of-the-art method. This suggests that this technique could be integrated into the clinical workflow and provide audiologists with information that facilitates the programming of the implant leading to improved patient care.

Objective: To investigate the impact of the surgical indication on posttonsillectomy bleed rates., Data Sources: PubMed, Scopus, CINAHL., Review Methods: A systematic review was performed searching for articles published from the date of inception to July 6, 2022. English language articles describing posttonsillectomy hemorrhage rates in pediatric patients (age ≤ 18) stratified by indication were selected for inclusion. A meta-analysis of proportions with comparison (Δ) of weighted proportions was conducted. All studies were assessed for risk of bias., Results: A total of 72 articles with 173,970 patients were selected for inclusion. The most common indications were chronic/recurrent tonsillitis (CT/RT), obstructive sleep apnea/sleep-disordered breathing (OSA/SDB), and adenotonsillar hypertrophy (ATH). Posttonsillectomy hemorrhage rates for CT/RT, OSA/SDB, and ATH were 3.57%, 3.69%, and 2.72%, respectively. Patients operated on for a combination of CT/RT and OSA/SDB had a bleed rate of 5.99% which was significantly higher than those operated on for CT/RT alone (Δ2.42%, p = .0006), OSA/SDB alone (Δ2.30%, p = .0016), and ATH alone (Δ3.27%, p < .0001). Additionally, those operated on for a combination of ATH and CT/RT had a hemorrhage rate of 6.93%, significantly higher than those operated on for CT/RT alone (Δ3.36%, p = .0003), OSA/SDB alone (Δ3.01%, p = .0014), and ATH alone (Δ3.98%, p < .0001)., Conclusion: Patients operated on for multiple indications had significantly higher rates of posttonsillectomy hemorrhage than those operated on for a single surgical indication. Better documentation of patients with multiple indications would help further characterize the magnitude of the compounding effect described here., (© 2023 American Academy of Otolaryngology-Head and Neck Surgery Foundation.)

Objective: To investigate whether revision surgery with the same device results in a change in three key indicators of electrode positioning: scalar location, mean modiolar distance ( M ¯ ), and angular insertion depth (AID)., Methods: Retrospective analysis of a cochlear implant database at a university-based tertiary medical center. Intra-operative CT scans were obtained after initial and revision implantation. Electrode array (EA) position was calculated using auto-segmentation techniques. Initial and revision scalar location, M ¯ , and AID were compared., Results: Mean change in M ¯ for all ears was -0.07 mm (SD 0.24 mm; P  = 0.16). The mean change in AID for all ears was -5° (SD 67°; P  = 0.72). Three initial implantations with pre-curved EAs resulted in a translocation from Scala Tympani (ST) to Scala Vestibuli (SV). Two remained translocated after revision, while one was corrected when revised with a straight EA. An additional five translocations occurred after revision., Conclusions: In this study examining revision cochlear implantation from a single manufacturer, we demonstrated no significant change in key indicators of EA positioning, even when revising with a different style of electrode. However, the revision EA is not necessarily confined by the initial trajectory and there may be an increased risk of translocation.

Purpose: Cochlear implants (CIs) have been shown to be highly effective restorative devices for patients suffering from severe-to-profound hearing loss. Hearing outcomes with CIs depend on electrode positions with respect to intracochlear anatomy. Intracochlear anatomy can only be directly visualized using high-resolution modalities, such as micro-computed tomography ( μ CT ), which cannot be used in vivo . However, active shape models (ASM) have been shown to be robust and effective for segmenting intracochlear anatomy in large scale datasets of patient computed tomographies (CTs). We present an extended dataset of μ CT specimens and aim to evaluate the ASM's performance more comprehensively than has been previously possible., Approach: Using a dataset of 16 manually segmented cochlea specimens on μ CTs , we found parameters that optimize mean CT segmentation performance and then evaluate the effect of library size on the ASM. The optimized ASM was further evaluated on a clinical dataset of 134 CT images to assess method reliability., Results: Optimized parameters lead to mean CT segmentation performance to 0.36 mm point-to-point error, 0.10 mm surface error, and 0.83 Dice score. Larger library sizes provide diminishing returns on segmentation performance and total variance captured by the ASM. We found our method to be clinically reliable with the main performance limitation that was found to be the candidate search process rather than model representation., Conclusions: We have presented a comprehensive validation of the ASM for use in intracochlear anatomy segmentation. These results are critical to understand the limitations of the method for clinical use and for future development., (© 2023 Society of Photo-Optical Instrumentation Engineers (SPIE).)

Purpose: This study investigated the relationship between the number of active electrodes, channel stimulation rate, and their interaction on speech recognition and sound quality measures while controlling for electrode placement. Cochlear implant (CI) recipients with precurved electrode arrays placed entirely within scala tympani and closer to the modiolus were hypothesized to be able to utilize more channels and possibly higher stimulation rates to achieve better speech recognition performance and sound quality ratings than recipients in previous studies., Method: Participants included seven postlingually deafened adult CI recipients with Advanced Bionics Mid-Scala electrode arrays confirmed to be entirely within scala tympani using postoperative computerized tomography. Twelve conditions were tested using four, eight, 12, and 16 electrodes and channel stimulation rates of 600 pulse per second (pps), 1,200 pps, and each participant's maximum allowable rate (1,245-4,800 pps). Measures of speech recognition and sound quality were acutely assessed., Results: For the effect of channels, results showed no significant improvements beyond eight channels for all measures. For the effect of channel stimulation rate, results showed no significant improvements with higher rates, suggesting that 600 pps was sufficient for maximum speech recognition performance and sound quality ratings. However, across all conditions, there was a significant relationship between mean electrode-to-modiolus distance and all measures, suggesting that a lower mean electrode-to-modiolus distance was correlated with higher speech recognition scores and sound quality ratings., Conclusion: These findings suggest that even well-placed precurved electrode array recipients may not be able to take advantage of more than eight channels or higher channel stimulation rates (> 600 pps), but that closer electrode array placement to the modiolus correlates with better outcomes for these recipients.

Hypothesis: This study evaluated the utility of the pull-back technique in improving perimodiolar positioning of a precurved cochlear implant (CI) electrode array (EA) with simultaneous insertion force profile measurement and direct observation of dynamic EA behavior., Background: Precurved EAs with perimodiolar positioning have improved outcomes compared with straight EAs because of lowered charge requirements for stimulation and decreased spread of excitation. The safety and efficacy of the pull-back technique in further improving perimodiolar positioning and its associated force profile have not been adequately demonstrated., Methods: The bone overlying the scala vestibuli was removed in 15 fresh cadaveric temporal bones, leaving the scala tympani unviolated. Robotic insertions of EAs were performed with simultaneous force measurement and video recording. Force profiles were obtained during standard insertion, overinsertion, and pull-back. Postinsertion CT scans were obtained during each of the three conditions, enabling automatic segmentation and calculation of angular insertion depth, mean perimodiolar distance ( Mavg ), and cochlear duct length., Results: Overinsertion did not result in significantly higher peak forces than standard insertion (mean [SD], 0.18 [0.06] and 0.14 [0.08] N; p = 0.18). Six temporal bones (40%) demonstrated visibly improved perimodiolar positioning after the protocol, whereas none worsened. Mavg significantly improved after the pull-back technique compared with standard insertion (mean [SD], 0.34 [0.07] and 0.41 [0.10] mm; p < 0.01)., Conclusions: The pull-back technique was not associated with significantly higher insertional forces compared with standard insertion. This technique was associated with significant improvement in perimodiolar positioning, both visually and quantitatively, independent of cochlear size., Competing Interests: The authors disclose no conflicts of interest., (Copyright © 2023, Otology & Neurotology, Inc.)

Purpose: During traditional insertion of cochlear implant (CI) electrode arrays (EAs), surgeons rely on limited tactile feedback and visualization of the EA entering the cochlea to control the insertion. One insertion approach for precurved EAs involves slightly overinserting the EA and then retracting it slightly to achieve closer hugging of the modiolus. In this work, we investigate whether electrical impedance sensing could be a valuable real-time feedback tool to advise this pullback technique., Methods: Using a to-scale 3D-printed scala tympani model, a robotic insertion tool, and a custom impedance sensing system, we performed experiments to assess the bipolar insertion impedance profiles for a cochlear CI532/632 precurved EA. Four pairs of contacts from the 22 electrode contacts were chosen based on preliminary testing and monitored in real time to halt the robotic insertion once the closest modiolar position had been achieved but prior to when the angular insertion depth (AID) would be reduced., Results: In this setting, the open-loop robotic insertion impedance profiles were very consistent between trials. The exit of each contact from the external stylet of this EA was clearly discernible on the impedance profile. In closed-loop experiments using the pullback technique, the average distance from the electrode contacts to the modiolus was reduced without greatly affecting the AID by using impedance feedback in real time to determine when to stop EA retraction., Conclusion: Impedance sensing, and specifically the access resistance component of impedance, could be a valuable real-time feedback tool in the operating room during CI EA insertion. Future work should more thoroughly analyze the effects of more realistic operating room conditions and inter-patient variability on this technique., (© 2022. CARS.)

Title: Facial Paralysis in Skull Base Osteomyelitis - Comparison of Surgical and Nonsurgical Management., Objective: To compare outcomes of surgical and nonsurgical management in cases of facial paresis secondary to skull base osteomyelitis., Methods: A 14 patients presenting with skull base osteomyelitis complicated by facial nerve paresis at a single tertiary referral center from 2009 to 2019 were retrospectively reviewed. Patients were treated with medical therapy with or without surgical intervention, consisting of mastoidectomy and debridement with or without facial nerve decompression. House-Brackmann (HB) Grade was the main outcome measure., Results: A 14 patients (average age 68 years, range 58-82 years, 71% male) were analyzed, with 5 undergoing facial nerve decompression (36%), 5 undergoing mastoidectomy without facial nerve decompression (36%), and 4 undergoing medical management alone (28%). Of the 4 patients who underwent medical therapy alone, none experienced significant improvement in facial function. Of the 5 patients who underwent facial nerve decompression, 3 patients experienced improved facial function. Of the 5 patients who underwent mastoidectomy without decompression, 4 experienced improved facial function. There was no clear link between the severity of infection and the severity of facial paresis. When comparing HB score changes before and after treatment across groups, there was no statistically significant difference seen (p = 0.47)., Conclusions: Mastoidectomy and debridement with or without facial nerve decompression may improve facial nerve outcomes when compared to isolated medical management, although differences were not of statistical significance. The best facial nerve recoveries occurred in patients undergoing surgery within 14 days of the onset of paralysis., Level of Evidence: 4 - Case Series Laryngoscope, 133:179-183, 2023., (© 2022 The American Laryngological, Rhinological and Otological Society, Inc.)

Cochlear implantation with acoustic hearing preservation is becoming increasingly prevalent allowing cochlear implant (CI) users to combine electric and acoustic stimulation (EAS) in the implanted ears. Despite a growing EAS population, our field does not have definitive guidance regarding EAS technology optimization and the majority of previous studies investigating hearing aid (HA) and cochlear implant (CI) programming for EAS listeners have been mixed. Thus, the purpose of this exploratory study was to explore the effects of various EAS crossover frequencies-defined as the low-frequency (LF) CI cutoff-relative to the underlying spiral ganglion (SG) characteristic frequency associated with the most distal or apical electrode in the array. Speech recognition in semi-diffuse noise and subjective estimates of listening difficulty were measured for 15 adult CI recipients with acoustic hearing preservation in three listening conditions: 1) CI-alone, 2) bimodal (CI+HA), and best-aided EAS (CIHA+HA). The results showed no effect of LF CI cutoff for any of the three listening conditions such that there was no trend for increased performance or less subjective listening difficulty across LF CI cutoffs, referenced to underlying SG-place frequency. Consistent with past studies, the current results were also consistent with significant speech recognition and subject listening difficulty benefits for both bimodal (CI+HA) and best-aided EAS (CIHA+HA) as compared to CI-alone listening as well as significant additional benefits for best-aided EAS (CIHA+HA) compared to bimodal hearing (CI+HA). Future studies are necessary to investigate the efficacy of SG-place-based fittings for i) large samples of experienced EAS listeners for whom perceptual adaptation has occurred to the frequency mismatch provided by standard CI frequency allocations, and ii) EAS users at or close to CI activation as place-based approaches may ultimately yield greater outcomes, particularly for newly activated CI users for whom SG-place-based approaches may afford a steeper trajectory to performance asymptote., (Copyright © 2022. Published by Elsevier B.V.)

Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Objective . The cochlear implant is a neural prosthesis designed to directly stimulate auditory nerve fibers to induce the sensation of hearing in those experiencing severe-to-profound hearing loss. After surgical implantation, audiologists program the implant's external processor with settings intended to produce optimal hearing outcomes. The likelihood of achieving optimal outcomes increases when audiologists have access to tools that objectively present information related to the patient's own anatomy and surgical outcomes. This includes visualizations like the one presented here, termed the activation region overlap image, which is designed to decrease subjectivity when determining amounts of overlapping stimulation between implant electrodes. Approach . This visualization uses estimates of electric field strength to indicate spread of neural excitation due to each electrode. Unlike prior visualizations, this method explicitly defines regions of nerves receiving substantial stimulation from each electrode to help clinicians assess the presence of significant overlapping stimulation. A multi-reviewer study compared this and an existing technique on the consistency, efficiency, and optimality of plans generated from each method. Statistical significance was evaluated using the two-sided Wilcoxon rank sum test. Main results . The study showed statistically significant improvements in consistency ( p  < 10 -12 ), efficiency ( p  < 10 -15 ), and optimality ( p  < 10 -5 ) when generating plans using the proposed method versus the existing method. Significance . This visualization addresses subjectivity in assessing overlapping stimulation between implant electrodes, which currently relies on reviewer estimates. The results of the evaluation indicate the provision of such objective information during programming sessions would likely benefit clinicians in making programming decisions., (© 2022 IOP Publishing Ltd.)

Objectives: To evaluate the utility of intracochlear electrocochleography (ECochG) monitoring during cochlear implant (CI) surgery on postoperative hearing preservation., Study Design: Prospective, randomized clinical trial., Setting: Ten high-volume, tertiary care CI centers., Patients: Adult patients with sensorineural hearing loss meeting the CI criteria who selected an Advanced Bionics CI., Methods: Patients were randomized to CI surgery either with audible ECochG monitoring available to the surgeon during electrode insertion or without ECochG monitoring. Hearing preservation was determined by comparing preoperative unaided low-frequency (125-, 250-, and 500-Hz) pure-tone average (LF-PTA) to postoperative LF-PTA at CI activation. Pre- and post-CI computed tomography was used to determine electrode scalar location and electrode translocation., Results: Eighty-five adult CI candidates were enrolled. The mean (standard deviation [SD]) unaided preoperative LF-PTA across the sample was 54 (17) dB HL. For the whole sample, hearing preservation was "good" (i.e., LF-PTA change 0-15 dB) in 34.5%, "fair" (i.e., LF-PTA change >15-29 dB) in 22.5%, and "poor" (i.e., LF-PTA change ≥30 dB) in 43%. For patients randomized to ECochG "on," mean (SD) LF-PTA change was 27 (20) dB compared with 27 (23) dB for patients randomized to ECochG "off" ( p = 0.89). Seven percent of patients, all of whom were randomized to ECochG off, showed electrode translocation from the scala tympani into the scala vestibuli., Conclusions: Although intracochlear ECochG during CI surgery has important prognostic utility, our data did not show significantly better hearing preservation in patients randomized to ECochG "on" compared with ECochG "off.", (Copyright © 2022, Otology & Neurotology, Inc.)

Objective: To analyze the relationship of electrode array (EA) type and position on hearing preservation longevity following cochlear implantation., Study Design: Retrospective chart review., Setting: Tertiary referral center., Patients: Adult cochlear implant recipients between 2013 and 2019 with hearing preserved postoperatively and postoperative CT scans., Interventions: CT scan analysis of EA position. Stepwise regression to determine influence of EA position, EA type, and patient demographics on postoperative low frequency hearing., Main Outcome Measures: Low frequency pure tone average (LFPTA), LFPTA shift, angular insertion depth, base insertion depth, scalar position, mean perimodiolar distance., Results: Of 792 cochlear implant recipients, 121 had preoperative LFPTA <80 dB HL with 60 of the 121 (49.6%) implanted with straight, 32 (26.4%) with precurved, styletted, and 29 (24.0%) implanted precurved, nonstyletted EA. Mean follow up was 28.6 months (range 1-103). There was no statistically significant difference in activation, 6- and 12-month, and last follow-up LFPTA (125, 250, and 500 Hz) shift based on EA type (straight p = 0.302, precurved, styletted p = 0.52, precurved, nonstyletted p = 0.77). Preoperative LFPTA and age of implantation were significant predictors of LFPTA shift at activation, accounting for 30.8% of variance ( F [2, 113] = 26.603, p < 0.0001). LFPTA shift at activation, scalar position, and base insertion depth were significant predictors of variability and accounted for 39.1% of variance in LFPTA shift at 6 months ( F [3, 87] = 20.269, p < 0.0001). Only LFPTA shift at 12 months was found to be a significant predictor of LFPTA shift at last follow up, accounting for 41.0% of variance ( F [1, 48] = 32.653, p < 0.0001)., Conclusions: Patients had excellent long-term residual hearing regardless of EA type. Age, preoperative acoustic hearing, and base insertion depth may predict short term preservation, while 12-month outcomes significantly predicted long-term hearing preservation., Competing Interests: The authors disclose no conflicts of interest., (Copyright © 2022, Otology & Neurotology, Inc.)

This study investigated the number of channels needed for maximum speech understanding and sound quality in 15 adult cochlear implant (CI) recipients with Advanced Bionics (AB) Mid-Scala electrode arrays completely within scala tympani. In experiment I, CI programs used a continuous interleaved sampling (CIS)-based strategy and 4-16 active electrodes. In experiment II, CI programs used an n-of-m strategy featuring 16 active electrodes with either 8- or 12-maxima. Speech understanding and sound quality measures were assessed. For CIS programs, participants demonstrated performance gains using up to 4-10 electrodes on speech measures and sound quality ratings. For n-of-m programs, there was no significant effect of maxima, suggesting 8-maxima is sufficient for this sample's maximum performance and sound quality. These results are largely consistent with previous studies using straight electrode arrays [e.g., Fishman, Shannon, and Slattery (1997). J. Speech Lang. Hear. Res. 40, 1201-1215; Friesen, Shannon, Baskent, and Wang (2001). J. Acoust. Soc. Am. 110, 1150-1163; Shannon, Cruz, and Galvin (2011). Audiol. Neurotol. 16, 113-123; Berg, Noble, Dawant, Dwyer, Labadie, and Gifford (2020). J. Acoust. Soc. Am. 147, 3646-3656] and in contrast with recent studies looking at cochlear precurved electrode arrays [e.g., Croghan, Duran, and Smith (2017). J. Acoust. Soc. Am. 142, EL537-EL543; Berg, Noble, Dawant, Dwuer, Labadie, and Gifford (2019b). J. Acoust. Soc. Am. 145, 1556-1564], which found continuous improvements up to 16 independent channels. These findings suggest that Mid-Scala electrode array recipients demonstrate similar channel independence to straight electrode arrays rather than other manufacturer's precurved electrode arrays.

Clinics are treating a growing number of patients with greater amounts of residual hearing. These patients often benefit from a bimodal hearing configuration in which acoustic input from a hearing aid on 1 ear is combined with electrical stimulation from a cochlear implant on the other ear. The current guidelines aim to review the literature and provide best practice recommendations for the evaluation and treatment of individuals with bilateral sensorineural hearing loss who may benefit from bimodal hearing configurations. Specifically, the guidelines review: benefits of bimodal listening, preoperative and postoperative cochlear implant evaluation and programming, bimodal hearing aid fitting, contralateral routing of signal considerations, bimodal treatment for tinnitus, and aural rehabilitation recommendations., Competing Interests: CONFLICT OF INTEREST M.A.H. holds the position of Associate Editor for Otology & Neurotology Open and has been recused from reviewing or making decisions for the article. J.T.H., H.S., and R.H.G. are on the Editorial Board for Otology & Neurotology Open and have been recused from reviewing or making decisions for the article. The remaining authors disclose no conflicts of interest.

Objective: Electrode array tip fold-over is a complication of cochlear implant surgery that results in poor hearing outcomes and often leads to revision surgery. However, tip fold-over can be corrected immediately if identified through intraoperative computed tomography, which also potentially provides information about final intracochlear positioning. Our objective was to provide the first economic analysis of intraoperative computed tomography by generating models in fee-for-service and bundled payment reimbursement structures of payer and institutional cost-effectiveness of this technology used in cochlear implantation over 1, 5, and 10-year time periods., Methods: Cost data specific to a commerically available intraoperative computed tomography machine was obtained from the manufacturer, Xoran Technologies. Institutional tip fold-over rate was obtained from already published data. Medicare reimbursement rate for cochlear implantation was obtained from institutional accountants. Private payer reimbursement for and cost of revision cochlear implantation were estimated based on available data., Results and Conclusion: At large volume centers, cost-effectiveness of this technology is possible in both fee-for-service and bundled payment reimbursement structures at various time points dependent on payer mix. Even low volume cochlear implantation centers (<150 per year) can financially benefit from intraoperative computed tomography in bundled payment models at 5- and 10-year periods regardless of payer mix. This model demonstrates key factors at play in determining cost-effectiveness of this technology including institutional factors and payer type and suggests this technology can align incentives both to improve patient care and outcomes with institutional and payer financial well-being.

Objective: Surgeons have no direct objective feedback on cochlear-implant electrode array (EA) positioning during insertion, yet optimal hearing outcomes are contingent on placing the EA as close as feasible to viable neural endings. This paper describes a system to non-invasively determine intracochlear positioning of an EA, without requiring any modifications to existing commercial EAs themselves., Methods: Electrical impedance has been suggested as a way to measure EA proximity to the inner wall of the cochlea that houses auditory nerve endings-the modiolus. In this paper, we extend prior work and demonstrate for the first time the relationship between bipolar access resistance and proximity of the EA to the modiolus (E-M proximity). We also evaluate two methods for producing direct, real-time estimates of E-M proximity from bipolar impedance measurements., Results: We show that bipolar access resistance is highly correlated with E-M proximity and can be approximately modeled by a power law function. This one dimensional model is shown to be capable of producing accurate real-time estimates of E-M proximity, but its simplicity also limits the potential for future improvement. To address this challenge, we propose a new prediction approach based on a recurrent neural network, which generated an overall prediction accuracy of 93.7%., Conclusion: Bipolar access resistance is highly correlated with E-M proximity, and can be used to estimate EA positioning., Significance: This work shows how impedance sensing can be used to localize an EA during insertion into the small, enclosed cochlear environment, without requiring any modifications to existing clinically used EAs.

Objective: Demonstrate the ability of a novel steerable distal chip endoscope to traverse the Eustachian tube and provide diagnostic quality images of the human middle ear., Patients: Three cadaveric temporal bone specimens were used in this work., Intervention: Diagnostic transeustachian endoscopy of the middle ear was performed., Main Outcome Measure: Diagnostic image quality., Results: A novel 1.62 mm steerable endoscope successfully cannulated the Eustachian tube of three human cadaveric temporal bone specimens to reveal intact middle ear anatomy with high optical clarity., Conclusions: A steerable endoscope can be designed to traverse the human Eustachian tube and provide diagnostic quality images of middle ear anatomy., Competing Interests: The authors disclose no conflicts of interest., (Copyright © 2021, Otology & Neurotology, Inc.)

Introduction: Translocation of precurved cochlear implant (CI) electrodes reduces hearing outcomes, but it is not known whether it is possible to correct scalar translocation such that all electrodes reside fully in the scala tympani (ST)., Methods: Six cadaveric temporal bones were scanned with CT and segmented to delineate intracochlear anatomy. Mastoidectomy with facial recess was performed. Precurved CI electrodes (CI532; Cochlear Limited) were implanted until scalar translocation was confirmed with postoperative CT. Then, electrodes were removed and replaced. CT scan was repeated to assess for translocation correction. Scalar position of electrode contacts, angular insertion depth (AID) of the electrode array, and M- (average distance between each electrode contact and the modiolus) were measured. An in vivo case is reported in which intraoperative translocation detection led to removal and replacement of the electrode., Results: Five of 6 cadaveric translocations (83%) were corrected with 1 attempt, resulting in full ST insertions. AID averaged 285 ± 77° for translocated electrodes compared to 344 ± 28° for nontranslocated electrodes (p = 0.109). M- averaged 0.75 ± 0.18 mm for translocated electrodes and 0.45 ± 0.11 mm for nontranslocated electrodes (p = 0.016). Reduction in M- with translocation correction averaged 38%. In the in vivo case, translocation was successfully corrected in a single attempt., Conclusion: Scalar translocation of precurved CI electrodes can be corrected by removal and reinsertion. This significantly improves the perimodiolar positioning of these electrodes. There was a high rate of success (83%) in this cadaveric model as well as a successful in vivo attempt., (© 2021 S. Karger AG, Basel.)