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The history of vascularization of the human cochlea began with the first anatomical description of the cochlea in the 16th century. Three different periods are recognizable in the development of knowledge concerning this subject: the macroscopic period, with the description of the structure of the cochlea from the 16th to the 19th century; the microscopic period, with the description of the part of the organ of Corti in the 19th century; and the injection period, with the description of the fine vascularization of the cochlea in the 20th century. Various techniques were used during these three periods, which will be presented here, using only original references. This historical study reveals the ingenuity of the researchers in using different aspects of technological progress to enhance their performance in research. [ABSTRACT FROM AUTHOR]

Objective: To investigate the effect of day-case stapes surgery on hearing results, quality of life, patient satisfaction, and complications rates, compared with inpatient stapes surgery., Study Design: A single-center, nonblinded, randomized controlled trial in a tertiary referral center., Methods: One hundred twelve adult patients planned for primary or revision stapes surgery were randomly assigned to either the day-case or inpatient treatment group. The effect on hearing outcomes (primarily), hearing benefits, quality of life, patient satisfaction, postoperative complications, and causes of crossover or readmission (secondarily) were assessed using auditory evaluations, questionnaires, and patients' charts over a follow-up period of 1 year., Results: Audiometric measurements and postoperative success rates were not different between the inpatient and day-case group. There were no statistically significant differences between both groups regarding the overall quality of life (QoL) (HUI3), disease-specific QoL (GHSI), change in postoperative health status (GBI), and postoperative complications rate. We found a high patient satisfaction toward the day-case approach. Six patients allocated to the inpatient group requested same-day discharge. Of the day-case patients, there was a crossover rate to inpatient care of 38% (20 patients), mainly due to postoperative nausea and vomiting (25%), vertigo (20%), or dizziness (40%)., Conclusion: We found no significant differences in outcomes of audiometric measurements, QoL, patient satisfaction and postoperative complications following day-case, and inpatient stapes surgery. Therefore, stapes surgery in a day-case setting seems to be a feasible approach in terms of postoperative outcome, safety, and desirability when taking patient selection and surgical planning into account. Besides this, the familiarity with a day-case approach of both patient and the surgical team, will increase the acceptance and feasibility of day-case stapes surgery., Competing Interests: None declared., (Copyright © 2022 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of Otology & Neurotology, Inc.)

Objectives: To evaluate pure-tone audiometric results in otosclerosis patients undergoing revision stapes surgery following previous middle ear interventions., Methods: A retrospective cohort study was performed in a tertiary referral center. Consecutive otosclerosis patients who underwent revision stapes surgeries, following previous middle ear interventions, for persistent conductive hearing loss, recurrent conductive hearing loss, or vertigo and had available postoperative pure-tone audiometry were included. Mean pre- and postoperative air conduction, bone conduction, and air-bone gap averaged over 0.5, 1, 2, and 3 kHz were obtained. Audiometric outcomes were obtained at 7 weeks postoperatively., Results: In total, 63 consecutive otosclerosis patients who underwent 66 revision stapes surgeries were included. Air-bone gap improved significantly with a mean gain of 19 dB (95% CI, 15-22). Air conduction improved significantly with a mean gain of 18 dB (95% CI, 14-23). Bone conduction did not change significantly, with a mean deterioration of 0 dB (95% CI, -2 to 1). Air-bone gap closure to 10 dB or less was achieved in 38% of cases and to 20 dB or less in 80% of cases. Indication for surgery, previous type of procedure, primary cause of failure, and current surgical technique were not significantly associated with air-bone gap closure to 10 dB or less. Indication for surgery and primary cause of failure were associated with one another., Conclusions: Compared to the available literature, a slightly larger gain in air conduction and air-bone gap was achieved in our study. Air-bone gap closure to 10 dB or less was achieved less often in our study.

Objectives/hypothesis: To investigate hearing capabilities and self-reported benefits of simultaneous bilateral cochlear implantation (BiCI) compared with unilateral cochlear implantation (UCI) after a 2-year follow-up and to evaluate the learning effect of cochlear implantees over time., Study Design: Multicenter randomized controlled trial., Methods: Thirty-eight postlingually deafened adults were included in this study and randomly allocated to either UCI or simultaneous BiCI. Our primary outcome was speech intelligibility in noise, with speech and noise coming from straight ahead (Utrecht-Sentence Test with Adaptive Randomized Roving levels). Secondary outcomes were speech intelligibility in noise with spatially separated sources, speech intelligibility in silence (Dutch phoneme test), localization capabilities and self-reported benefits assessed with different quality of hearing and quality of life (QoL) questionnaires. This article describes the results after 2 years of follow-up., Results: We found comparable results for the UCI and simultaneous BiCI group, when speech and noise were both presented from straight ahead. Patients in the BiCI group performed significantly better than patients in the UCI group, when speech and noise came from different directions (P = .01). Furthermore, their localization capabilities were significantly better. These results were consistent with patients' self-reported hearing capabilities, but not with the questionnaires regarding QoL. We found no significant differences on any of the subjective and objective reported outcomes between the 1-year and 2-year follow-up., Conclusions: This study demonstrates important benefits of simultaneous BiCI compared with UCI that remain stable over time. Bilaterally implanted patients benefit significantly in difficult everyday listening situations such as when speech and noise come from different directions. Furthermore, bilaterally implanted patients are able to localize sounds, which is impossible for unilaterally implanted patients., Level of Evidence: 1b Laryngoscope, 127:1161-1168, 2017., (© 2016 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypotheses: In 1884, Johann Constantin August Lucae (1835-1911), a German otologist from Berlin, introduced a new "method to mechanically treat chronic troubles of the mobility of the hearing organ transmission apparatus." It consisted in the use of a springy pressure probe to directly mobilize the handle of the malleus. The aim of this study is to trace the invention, clinical use, technological modifications, and ultimate extinction of this instrument., Method: Review of Lucae's publications, comments by his colleagues, and trade catalogues published between 1880 and 1940., Results: Lucae presented at least six different models of his springy pressure probe during his career. Some of his colleagues modified it. The success rate was much disputed, and the instrument died with Lucae., Conclusion: Lucae's spring pressure probe is another example of the ingenuity of man to try to find a solution when confronted with an unclear and unresolved otological problem.

Background: Chronic otorrhoea after canal wall down mastoidectomy can be a clinical challenge. Basic principles for canal wall down surgery include establishing a large meatus. Several meatoplasty techniques have been reported. This paper describes this new indication for Todd's meatoplasty with surgical improvements., Study Design: Retrospective review., Setting: Academic tertiary referral centre., Methods: Modifications of transposition postauricular flap meatoplasty are reported. This technique was applied in a series of patients with chronic otorrhoea after a canal wall down mastoidectomy., Results: In general, a dry radical cavity was successfully created within six weeks and follow-up visits at the out-patient clinic were reduced. Only minor complications occurred, which are all reported., Conclusion: The postauricular flap meatoplasty is a valuable tool in the management of chronic otorrhoea after an open cavity approach for cholesteatoma.

Objectives/hypothesis: To determine the effect of cochlear implantation on tinnitus perception in patients with severe bilateral postlingual sensorineural hearing loss and to demonstrate possible differences between unilateral and bilateral cochlear implantation., Study Design: Prospective study., Methods: Thirty-eight adult patients were included in this prospective study, as part of a multicenter randomized controlled trial investigating the benefits of bilateral cochlear implantation versus unilateral cochlear implantation. Pre- and postoperative tinnitus perception scores were evaluated, before and 1 year after implantation on three tinnitus questionnaires; the Tinnitus Handicap Inventory (THI), the Tinnitus Questionnaire (TQ), and a visual analogue scale for tinnitus burden., Results: Before implantation, the tinnitus prevalence was 42.1% (16 of 38) in the whole study group. One year after implantation, the tinnitus questionnaire scores had decreased in 71.4% according to the TQ and 80.0% according to the THI. Tinnitus was induced after cochlear implantation in six patients, five in the bilateral and one in the unilateral group., Conclusions: Our study shows that cochlear implantation is effective in the reduction of tinnitus in patients with bilateral sensorineural hearing loss who suffered from preoperative tinnitus. Conversely, tinnitus may also increase or even be induced by the cochlear implantation itself. Cochlear implant candidates should be well informed about these possible consequences before undergoing surgery., Level of Evidence: 2b., (© 2015 The American Laryngological, Rhinological and Otological Society, Inc.)

Importance: The cost of bilateral cochlear implantation (BCI) is usually not reimbursed by insurance companies because of a lack of well-designed studies reporting the benefits of a second cochlear implant., Objective: To determine the benefits of simultaneous BCI compared with unilateral cochlear implantation (UCI) in adults with postlingual deafness., Design, Setting, and Participants: A multicenter randomized clinical trial was performed. The study took place in 5 Dutch tertiary referral centers: the University Medical Centers of Utrecht, Maastricht, Groningen, Leiden, and Nijmegen. Forty patients eligible for cochlear implantation met the study criteria and were included from January 12, 2010, through November 2, 2012. The main inclusion criteria were postlingual onset of hearing loss, age of 18 to 70 years, duration of hearing loss of less than 20 years, and a marginal hearing aid benefit. Two participants withdrew from the study before implantation. Nineteen participants were randomized to undergo UCI and 19 to undergo BCI., Interventions: The BCI group received 2 cochlear implants during 1 surgery. The UCI group received 1 cochlear implant., Main Outcomes and Measures: The primary outcome was the Utrecht Sentence Test with Adaptive Randomized Roving levels (speech in noise, both presented from straight ahead). Secondary outcomes were consonant-vowel-consonant words in silence, speech-intelligibility test with spatially separated sources (speech in noise from different directions), sound localization, and quality of hearing questionnaires. Before any data were collected, the hypothesis was that the BCI group would perform better on the objective and subjective tests that concerned speech intelligibility in noise and spatial hearing., Results: Thirty-eight patients were included in the study. Fifteen patients in the BCI group used hearing aids before implantation compared with 19 in the UCI group. Otherwise, there were no significant differences between the groups' baseline characteristics. At 1-year follow-up, there were no significant differences between groups on the Utrecht Sentence Test with Adaptive Randomized Roving levels (9.1 dB, UCI group; 8.2 dB, BCI group; P = .39) or the consonant-vowel-consonant test (median percentage correct score 85.0% in the UCI group and 86.8% in the BCI group; P = .21). The BCI group performed significantly better than the UCI group when noise came from different directions (median speech reception threshold in noise, 14.4 dB, BCI group; 5.6 dB, BCI group; P <.001). The BCI group was better able to localize sounds (median correct score of 50.0% at 60°, UCI group; 96.7%, BCI group; P <.001). These results were consistent with the patients' self-reported hearing capabilities., Conclusions and Relevance: This randomized clinical trial demonstrates a significant benefit of simultaneous BCI above UCI in daily listening situations for adults with postlingual deafness., Trial Registration: trialregister.nl Identifier: NTR1722.

Background: Otosclerosis is characterized by bony deposits in the otic capsule, resulting in stapes fixation and progressive hearing loss. It can be treated effectively by surgically removing (part of) the stapes and replacing it with a prosthesis. Increasingly, stapes surgery is performed as a day-case procedure. The major drive towards day-case surgery has been out of economic considerations. However, it is also increasingly an explicit patient request and leads to shorter waiting times for surgery, a reduced risk of infection and most likely positively influences the patient's quality of life as a result of rapid discharge and rehabilitation. Even though stapes surgery seems well suited to a day-case approach, given the low complication rates and early recovery, evidence is scarce and of low quality., Methods and Design: A single-center unblinded randomized controlled trial was designed to (primarily) investigate the effect of hearing outcomes of day-case stapes surgery compared to inpatient stapes surgery and (secondarily) investigate the effect of both methods on quality of life, tinnitus, vertigo and cost-effectiveness. One hundred and twelve adult otosclerosis patients who are eligible for stapes surgery will be randomly assigned to either the day-case or inpatient treatment group. The primary and secondary outcome measures will be assessed using pure-tone audiometry (at approximately 2 months and 1 year follow-up), questionnaires (at 3 months and 1 year follow-up) and costs diaries (weekly the first month after which once a month until 1 year follow-up)., Discussion/conclusion: This trial allows for a comparison between day-case and inpatient stapes surgery to investigate the hypothesis that day-case stapes surgery is associated with a higher quality of life and higher cost-effectiveness, while maintaining equal hearing results, compared to inpatient stapes surgery., Trial Registration: Netherlands Trial Register (www.trialregister.nl): NTR4133, registration date 21(st) August 2013.

Objective: To assess hearing results and complications following primary stapedotomy in otosclerosis patients, comparing different laser types., Data Sources: Pubmed, Embase, The Cochrane Library, CINAHL, and Scopus., Study Selection: A systematic bibliographic search was conducted to identify all original articles, comparing hearing outcome between different lasers used for fenestration in stapedotomy., Data Extraction: Directness of evidence and risk of bias of the selected articles were assessed. Studies with low or moderate directness of evidence, or high risk of bias, were not further analyzed., Data Synthesis: The absolute risks, risk differences, and 95% confidence intervals were extracted only for the studies with high directness of evidence and moderate to low risk of bias., Conclusion: A total of 383 unique articles were retrieved. Four studies provided direct evidence, whereas all studies carried moderate to high risk of bias. After exclusion of the studies that did not provide direct evidence and/or carried high risk of bias, 2 studies were considered eligible for data extraction. This best available evidence shows a slightly better air-bone gap closure for CO2 laser compared to potassium titanyl phosphate laser, but the clinical relevance is unclear. The risk difference of 28.1% [95% confidence interval, 22.8, 33.4] between CO2 and erbium yttrium aluminium garnet favors CO2 laser. Unfortunately, this current best available evidence is insufficient to draw any definitive conclusions on which laser to use for fenestration in stapedotomy.

Objectives/hypothesis: To assess hearing results and complications following primary stapedotomy in otosclerosis patients comparing the use of laser and conventional techniques for fenestration., Study Design: Systematic literature review., Methods: A systematic bibliographic search was conducted in PubMed, Embase, the Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, and Scopus. Studies reporting original data on the effect of laser fenestration, compared to conventional techniques, on closure of air-bone gap in patients undergoing primary stapedotomy were included. Directness of evidence and risk of bias of the selected articles were assessed. Studies with low directness of evidence, high risk of bias, or both were not further analyzed. The absolute risks, risk differences, and 95% confidence intervals were extracted only for studies with moderate to high directness of evidence and moderate to low risk of bias., Results: In total, 383 unique studies were retrieved. Eight of these (including 999 procedures) provided high or moderate directness of evidence and carried a moderate risk of bias, and were considered eligible for data extraction. The included studies show no consistent difference in postoperative air-bone gap closure or immediate postoperative vertigo., Conclusions: Both footplate fractures and sensorineural hearing loss appear to occur more frequently in the conventional group than in the laser group. Therefore, we prefer laser above conventional methods for footplate fenestration in primary stapedotomy., Level of Evidence: NA., (© 2013 The American Laryngological, Rhinological and Otological Society, Inc.)

The goal of this work was to review the pre-and postsurgical auditory thresholds of two surgical implantation techniques, namely the mastoidectomy with posterior tympanotomy approach (MPTA) and suprameatal approach (SMA), to determine whether there is a difference in the degree of preservation of residual hearing. In a series of 430 consecutive implanted patients 227 patients had measurable pre-operative hearing thresholds at 250, 500, and 1,000 Hz. These patients were divided into two groups according to the surgical technique that was used for implantation. The SMA approach was followed for 84 patients in Amsterdam, whereas the MPTA technique was adhered to 143 patients in Maastricht. The outcome variables of interest were alteration of pre-and postoperative auditory thresholds after cochlear implantation. Complete or partial preservation of residual hearing was obtained in 21.4 and 21.7% in the SMA and MPTA group, respectively. No statistical differences could be found between the SMA and MPTA group (p = 0.96; Chi-square test). The SMA technique is correlated with a similar degree of hearing loss after cochlear implantation compared to the MPTA technique. However, both techniques were not able to conserve a measurable amount of hearing in patients with a substantial degree of residual hearing. Therefore, both surgical techniques need to be refined for patients in which residual acoustical hearing is pursued.

Objective: Vestibular symptoms are seen variably in patients with otosclerosis, both in patients with the disease and in patients after treatment with stapes surgery. The goal of this study was to objectify any changes of the bone-conducted (BC) ocular vestibular evoked myogenic potentials (oVEMPs) in patients with otosclerosis before and after stapes surgery., Study Design: Twenty-six healthy subjects and 27 patients with otosclerosis were tested in a tertiary care center, and 11 of the patients were tested preoperatively and postoperatively. The ears of patients were divided in 4 groups: normal ears, otosclerotic ears, ears after primary stapes surgery, and ears after revision surgery. The stimulus used in oVEMP testing was a BC stimulus delivered by a mini-shaker at stimulus frequencies of 250 and 500 Hz. oVEMP characteristics were the n1 and p1 latencies, n1 - p1 amplitude, and threshold., Results: No significant differences were seen in all oVEMP characteristics between the 4 groups of ears without surgery nor in the ears that were tested preoperatively and postoperatively., Conclusion: No or undetectably little damage to the utricle is caused by both otosclerotic disease and stapes surgery. There is no additive value of screening with BC oVEMPs perioperatively in otosclerotic patients.

Objective: To evaluate the effectiveness of primary stapes surgery with and without a vein graft in patients with otosclerosis and to determine the differences in the postoperative gain in air-bone gap (ABG) and air-conduction (AC)., Study Design: A nonrandomized multicenter clinical evaluation., Setting: Two tertiary referral centers in The Netherlands and France., Patients: Otosclerosis patients that underwent primary stapedotomy surgery., Intervention: Primary stapedotomy surgery without a vein graft (n = 939, first center) compared with primary stapedotomy surgery with a vein graft (n = 3691, second center)., Main Outcome Measures: Preoperative and postoperative audiometric results were compared. An analysis of variance was performed to evaluate differences in postoperative ABG and AC gains between surgeries with and without a vein graft, adjusted for potential confounders., Results: The postoperative ABG was 10 dB or lesser in 72.1% of the patients without a vein graft and in 93.2% of patients with a vein graft. After adjustments for differences at baseline, the mean gain in ABG was 18.6 dB (95% CI, 18.1-19.1) in the group without vein graft, compared with 24.2 dB (95% CI, 23.9-24.6) in the group with vein graft (mean difference, 5.6 dB; 95% CI, 5.0-6.2). The mean gain in AC was 19.5 dB (95% CI, 18.7-20.3) in the group without vein graft, compared with 24.3 dB (95% CI, 23.7-24.7) in the group with vein graft (mean difference, 4.8 dB; 95% CI, 3.8-5.7)., Conclusion: Patients with otosclerosis undergoing primary stapes surgery may benefit more from a vein graft interposition., Level of Evidence: 2B.

Objectives/hypothesis: An increasing number of patients with low-frequency residual hearing are fitted with a cochlear implant. The challenge is to optimize cochlear implant device properties and develop atraumatic surgical techniques to preserve residual hearing. In view of the ongoing debate about the optimal procedure for opening the cochlea during cochlear implantation, we reviewed the evidence on the round window and the cochleostomy insertion techniques and compared their effects on postoperative residual hearing., Design: Systematic review., Methods: Electronic databases were systematically searched for relevant studies published up to January 2012. All studies reporting on residual hearing and hearing preservation surgery were included., Results: Sixteen studies, with a total of 170 patients, were included. There were no studies directly comparing both surgical insertion techniques. The methodologic quality of the studies was poor and might be subjected to a high risk of bias. Because there were no studies directly comparing the 2 techniques and controlling for possible influencing factors, differences between studies might also be influenced by intersurgeon variance in many facets regarding cochlear implantation surgery. The available data show a postoperative low-frequency hearing loss ranging from 10 to 30 dB at 125, 250, and 500 Hz, regardless of surgical technique. The number of patients with a postoperative complete hearing preservation ranged from 0% to 40% for the cochleostomy group and from 13% to 59% in the round window group., Conclusion: The available data do not show that there is a benefit of one surgical approach over the other regarding the preservation of residual hearing. To provide solid evidence, a double-blind randomized trial is needed, which compares the clinical outcomes, notably the degree of hearing preservation, of both surgical approaches.

Objectives/hypothesis: Our study was designed to compare two surgical approaches that are currently employed in cochlear implantation., Methods: There were 315 patients who were divided into two groups according to the surgical technique used for implantation. The suprameatal approach (SMA) was followed for 104 patients (107 implantations) in Amsterdam, whereas the mastoidectomy with posterior tympanotomy approach (MPTA) was adhered to for 211 (214 implantations) in Maastricht. The outcome variables of interest were duration of surgery and peri- or postoperative complications., Results: In the SMA group the incidence of major and minor complications was 3.7% (4/107) and 23.4% (25/107), respectively, whereas it was 6.5% (14/214) and 22.4% (48/214), respectively, in the MPTA group. A chi-square statistic of 1.096 (P = .295) and 0.021 (P = .884) for minor and major complications, respectively, indicated no statistically significant differences between the two techniques. Mean duration of surgery was significantly shorter (P < .0005) in the SMA (111.7 minutes) than in the MPTA (132.2 minutes) group., Conclusions: The suprameatal approach is clearly a good alternative to the classical surgery technique for cochlear implantation.

Objective: To evaluate the hearing results of stapes surgery with two different titanium stapes prostheses. A crimping and a non-crimping prosthesis., Methods: Retrospective analyses were carried out on the pre- and postoperative hearing results obtained after 126 primary stapedotomies with two different prostheses in patients with otosclerosis. Sixty-three patients had a stapedotomy with a K-piston Titanium (No. 1006107) type and 63 patients received a CliP-piston àWengen Titanium (No. 1006807) type after stapedotomy. The results were compared according to mean audiometrical parameters. A Chi-square Test analysis (a contingency table) was performed with odds ratio to analyze this retrospective case-control study., Results: The hearing results of both titanium stapes prostheses were comparable. There was no difference in the final hearing results between the two pistons studied. No statistically significant difference between the postoperative air-bone gap closures by the two titanium stapes prostheses studied could be demonstrated., Conclusions: Because of the different properties of the two titanium piston studied (CliP-piston àWengen Titanium type, no crimping and K-piston Titanium crimping necessary) a difference in the closure of the air-bone gap could be suspected. This comparative study could not demonstrate a statistical better air-bone gap closure for one of the titanium pistons. Both stapes prostheses showed good results in reconstruction of the hearing loss due to otosclerosis.

Objective: Voice rehabilitation after total laryngectomy is challenging. In order to investigate and understand the function of the neoglottis sophisticated measurements need to be made. During voice production, aerodynamic energy is transformed into sound energy. In non-laryngectomized patients, the voice production efficiency is called the vocal efficiency. Vocal efficiency is an indication of how efficient the transformation of energy takes place. Vocal efficiency is calculated by dividing the output sound power by the aerodynamic power., Patients and Methods: In a group of eight laryngectomees with tracheoesophageal voice, we measured aerodynamic and acoustic quantities and calculated vocal efficiency. We used a computer setup with airflow transducers, pressure transducers, mikrotip transducers and sound intensity measurement to allow calculation of the needed parameters., Results: The tables show the results of the power used and produced in various phonatory tasks. Relatively high levels of aerodynamic power are interpreted as increased effort to speak., Conclusion: The aerodynamic power is an indication of the effort needed for voice generation. The efficiency of TE-voice production is lower compared to laryngeal voice production but does show an increase when sound intensity increases, a known phenomenon in healthy laryngeal voice production.

Objective: To review the postoperative radiographic investigations of patients implanted with a cochlear implant., Study Design: Retrospective case series., Patients: Thirty-nine patients (22-77 yrs old) implanted for sensorineural deafness in the cochlear implants program of the Academic Medical Center of Amsterdam., Intervention: Cochlear implantation with Cochlear Nucleus 24 Contour and Cochlear Nucleus Freedom (Cochlear Corp., Lane Cove, New South Wales, Australia) implant., Results: This retrospective analysis of the postoperative computed tomographic scans showed that, in a large number of the implantations, the external ball electrode of the cochlear implant migrated from the insertion place toward the magnet of the receiver/stimulator unit of the implant. It seems that this migration of the external ball electrode does not influence the function of the cochlear implant and the result of the hearing rehabilitation in the short term., Conclusion: Because of the magnetic field of the receiver/stimulator unit of the cochlear implant and the magnet of the external transmitting coil of the speech processor, it seems to be possible that the extracochlear ball electrode can migrate in the space between the temporal bone and the temporal muscle during the postoperative healing phase. The importance of our observation is still not clear.

Background: In laryngectomized patients, tracheoesophageal voice generally provides a better voice quality than esophageal voice. Understanding the aerodynamics of voice production in patients with a voice prosthesis is important for optimizing prosthetic designs and successful voice rehabilitation., Objectives: To measure the aerodynamics and sound intensity in tracheoesophageal voice production., Study Design and Methods: We built a special setup, which consisted of a Pentium 200 MHz computer with an AD-DA interface card and Labview 4.01 software. In an oral/nasal mask we constructed several mass flow sensors and a microphone. This measured both the oral airflow and the level of sound. For the measurement of endotracheal pressure, which is the driving force behind the airflow, we used a transducer which was connected to the tracheostoma. The endoesophageal pressure was measured at the level of the prosthesis in the esophagus by a Mikrotip transducer. Using this we could determine how much the voice prosthesis contributes to the overall pressure drop of the phonatory tract. Furthermore, the average airflow rate as a function of the sound pressure levels could be determined., Results: In our population, 6 out of 7 patients showed a positive relationship between trans-source airflow and generated sound intensity. We compared our prosthesis pressure drop values with in vitro data and found that there are some differences, possibly due to difference in age of the prosthesis and physiological circumstances in vivo. The overall contribution of the voice prosthesis to the airway resistance depends on the level of phonation and the type of device. In our patient group it is apparent that the pharyngoesophageal (PE) segment has the greatest share of the total pressure drop, especially at higher airflow rates. We measured a 27% pressure drop in airflow over the voice prosthesis. Different tracheostoma occlusion methods did not have any effect on the aerodynamics and sound intensity. One patient that had had a jejunal graft for reconstruction showed, not unexpectedly, extremely different aerodynamic values. We were unable to define optimal airflow rates or optimal resistance values for sound production in the PE segment., Conclusion: The aerodynamic characteristics of voice production in laryngectomized patients with voice prostheses are determined by both prosthetic factors and PE segment tissue factors. In our patient group the PE segment is responsible for the greatest pressure drop. We found no significant difference in pressure drop and sound intensity for different tracheostoma occlusion methods.

This paper discusses a rare complication of an intracochlear misdirection of the electrode of a cochlear implant in a 55-year-old male. The patient received a cochlear implant using the mastoid-saving surgical approach. Intraoperative measurements showed impedance and NRT reactions suggesting a reasonable function of the inner ear and the implant. Postoperatively our patient suffered from passing vertigo. Postoperative CT scans revealed a misdirection implantation of the cochlear implant into the vestibular part of the inner ear. A deformed implant was removed and a reimplantation was successfully performed after enlarging and reshaping the cochleostomy. Our patient now enjoys all the benefits of an optimal functioning cochlear implant. Intracochlear misdirection of the electrode can occur even when intraoperative measurements seem to be normal. When a patient suffers from unexplained vertigo after cochlear implantation with a poor function of the implant a misdirection of the active electrode must be considered. New high resolution peroperative three-dimensional imaging techniques can probably help to avoid such insertion failures.

This study describes audiometric patterns of ototoxicity in a consecutive series of patients uniformly treated with intra-arterial high-dose cisplatin chemoirradiation for advanced cancer of the head and neck. Air conduction thresholds were measured from 0.125 to 16 kHz and bone conduction thresholds were measured from 0.5 to 4 kHz. The overall audiometric pattern was characterized by maximum threshold shifts after the 2nd cisplatin infusion and a maximum total threshold shift at 8 kHz, irrespective of gender, age, pretreatment sensorineural hearing loss (SNHL) or subjective complaints during therapy. A hearing deterioration gradient was observed from (ultra-) high to low frequencies, worse with increasing pre-existent SNHL and with increasing cumulative dose of cisplatin chemoradiation. Cisplatin chemoradiation-induced hearing loss seemed to reach a plateau at higher levels (75-80 dB HL) for frequencies above 8 kHz compared to frequencies up to 8 kHz (45-60 dB HL). Recovery of SNHL was found after therapy in 27 ears characterized by extensive hearing loss at frequencies 1, 2 and 4 kHz., (Copyright 2006 S. Karger AG, Basel.)

There are many reports in the literature on the outcome of ear surgery. However, it is difficult to make comparisons from these reports because of a lack of uniformity in the way in which outcomes are reported. At the same time, the general public expects doctors to provide them with information regarding the benefits and risks of surgery. Many ear surgeons will not be able to provide this information because few have an up-to-date database. A group of otologists in Europe has attempted to establish a common otology database. The aim is to create a framework whereby surgeons in Europe can contribute to a common ear database using a web-based system. The proposed methodology involves two levels of data entry. Level 1 is a minimal database where the main outcomes are included. Level 2 is a comprehensive database where detailed information on pathologies, risk factors, and surgical procedures is also recorded. As both databases share the same core data, clinicians using database 1 can still compare their outcomes with those using database 2. Clinicians will be able to input and retrieve ear data onto or from the web-based database. There has already been an international consensus on the content of the common ear database. The website address is www.ear-audit.net. The international project has now been in operation for more than 6 months, and Ear UK has already given its endorsement. The founder members include 27 otologists from 12 European countries. The cumulative outcome from this group of surgeons will be used as the benchmark for the purpose of comparative audit. These benchmark sites will be subjected to regular external validation. The web-based system is interactive and gives instant feedback to individual surgeons who wish to compare their results to the benchmark. Therefore, it can be a good learning tool for trainees or less experienced surgeons. The common data entry system also provides an opportunity for clinicians to collaborate in clinical research.

Objective: Hearing results after 23 implantations of a newly designed titanium-clip stapes piston prosthesis (the àWengen Clip Piston prosthesis) in patients with otosclerosis were evaluated. This new type of stapes piston was designed to avoid the crimping onto the incus in stapedotomy. This one clip fits all designs and enables solid fixation by clicking the prosthesis onto the long process of the incus without crimping., Study Design: A retrospective pilot study was carried out by microcomputer of the preoperative and postoperative audiological results of patients in whom the titanium-clip stapes piston prosthesis was implanted., Setting: Ear, nose and throat department of Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands., Patients: 23 Patients underwent a stapedotomy for hearing improvement suffering from otosclerosis. implantations of a newly designed titanium-clip stapes piston prosthesis (the àWengen Clip Piston prosthesis) in patients with otosclerosis were evaluated., Intervention(s): The stapedotomy was performed with the àWengen Clip Piston prosthesis., Main Outcome Measure(s): Pre and postoperative audiograms were used to evaluate the hearing gain improvement with the new stapes piston. Especially we looked at the airbone gap closure and the sensorineural hearing after the surgical procedure and compared these with the ones before surgery., Results: The hearing results showed a closure of the pure-tone average air-bone gap to within 10 dB in 56.6% of cases (10 of 23 implantations) and to within 20 dB in 100% (23 of 23 implantations). A residual air-bone gap of greater than 20 dB was seen in the present pilot study. Postoperative overclosure of bone-conduction thresholds was discovered only for the frequency of 2 kHz. Sensorineural hearing loss greater than 10% did not occur, and there was no decline in the speech discrimination., Conclusions: The use of a newly designed titanium-clip stapes piston prosthesis with a diameter of 0.4 mm gives good results in cases of stapedotomy for otosclerosis. The titanium-clip design is a new development in the evolution of stapes piston prostheses. Surgical introduction, placement, and fixation are not always easy, depending on the anatomy of the middle ear and the thickness of the fixation area on the long process of the incus.

Objective: The objective of this study was to evaluate the hearing results of stapes surgery with 2 different full metal stapes prostheses., Study Design: Retrospective analyses were carried out on the pre- and postoperative hearing results obtained after primary stapedotomy with 2 different prostheses., Patients: We studied 106 patients with otosclerosis treated by stapes surgery., Intervention: Fifty-three patients had a stapedotomy with a gold piston and 53 patients received a titanium piston after stapedotomy., Main Outcome Measures: The results were compared according to mean audiometric parameters. Furthermore, the individual audiologic results were demonstrated with the Amsterdam Hearing Evaluations Plot (AHEP). This method is a visual presentation of the hearing result for each operated ear., Results: These AHEPs showed that the heavier gold piston (shaft Ø 0.4 mm and weight 10192.0 microg) gives more overclosure gain (28.3%) than the lightweight (shaft Ø 0.4 mm and weight 2541.0 microg) titanium piston (9.4% cases of overclosure)., Conclusions: Because of the different properties of the 2 pistons (gold very malleable, titanium rather stiff), a choice can be made for different anatomic or pathologic situations in the operated middle ear. The "overclosure effect" of the gold piston is higher compared with the titanium piston.

Objective: To evaluate the early postoperative hearing results of a new titanium stapes prosthesis (K-Piston) implanted in patients with otosclerosis., Study Design: A retrospective analysis of preoperative and early postoperative hearing thresholds., Setting: One tertiary referral and teaching hospital., Patients: Eighteen men and 40 women, mean age 47 years, with otosclerosis., Intervention: Primary stapedotomy., Main Outcome Measure: Main outcome measures were the mean gains in bone-conduction and air-conduction pure-tone thresholds, and pure-tone averages for different frequency combinations. Success and failure of the individual cases were presented using Amsterdam Hearing Evaluation Plots., Results: The overall postoperative air-bone gap for the frequency combination 0.5-1-2-4 kHz was 8.4 (standard deviation: 5.2) dB. In 79% of the patients the postoperative air-bone gap was less than 10 dB. Air-conduction improved even in higher frequencies, while the Carhart effect was not seen in most cases. In three patients a deterioration of bone-conduction was observed ranging from 11 to 16 dB sound pressure level (SPL), and in four patients the gain in air-conduction was insufficient (3-29 dB SPL) to close the preoperative air-bone gap to within 20 dB., Conclusion: The new low-weight, full-titanium stapes prosthesis with its slight rough surface and its good mechanical stability and biocompatibility can safely and successfully restore the function of the middle ear when implanted in patients with otosclerosis.

During the last century, hundreds of studies have been performed to identify factors that are involved in the aetiology of otosclerosis. These studies include a variety of aetiological factors and, although many theories have been postulated, the process of the development of the disease remains unclear. A historical overview and analysis of the literature dealing with the aetiology of otosclerosis is presented. The role of collagen disorders, genetic linkage studies, associations with the HLA system and measles virus infection as causal factors is discussed. From an epidemiological point of view, the disease has an autosomal dominant mode of inheritance. Therefore, since the introduction of new genetic research techniques over the last decades, more studies have been performed to find evidence of a genetic factor that initiates the development of otosclerosis. In this review, we tried to categorize the most prominent studies in sections according to their subjects within the diversity of aetiological factors that have been studied.

Objective: to determine the occurrence of the unusual side effect of a reparative granuloma after the implantation of a pure gold piston in cases of otosclerosis., Study Design: a retrospective case review study of 475 stapes operations with a pure gold piston., Setting: Department of Otorhinolaryngology of the University of Amsterdam, The Netherlands and the HNO clinic in Luenen (Brambauer) in Germany., Patients: four hundred and seventy five patients (328 women, 147 men, average age: 45.2 years), who clinically and per-operatively had otosclerosis, underwent a stapedotomy using a pure gold piston prosthesis. Therapeutic intervention: in cases of suspicion of a reparative granulomas or those cases that did not have improvement of the hearing after the stapedotomy, a re-operation by transcanal approach was performed., Results: in seven cases a reparative granuloma was diagnosed by this revision surgery. The postoperative incidence of these granulomas following stapedotomy using the pure gold piston turned out to be 1.5%., Conclusion: reparative granulomas can occur after stapedotomy with a pure gold stapes piston although the incidence is low. The role of grafting material to seal the oval window niche and the treatment of these reparative granulomas following stapes surgery are discussed.

Objectives: The long-term results of the implantation of glass ionomer cement in the human mastoid and middle ear were studied., Study Design: A prospective study of the survival of bone cement in the middle ear., Methods: Ionocem (IONOS, Medizinische Produkte Gmbh & Co., Seefeld/Obb, Germany), a two-compound bone material that forms a stable, water-proof junction with bone, was implanted in 23 middle ears of 23 patients (13 male and 10 female patients). Closure of the dehiscence of the tegmen was performed in 7 cases, obliteration of the mastoid cavity in 10 cases, and ossicular chain reconstruction in 6 cases., Results: The follow-up period was 5.1 years. Complications attributable to operation were not seen, but adverse tissue reaction with severe middle ear infection and abundant otorrhea occurred in six cases after 12 months, requiring repeat operation. In three more cases, a spontaneous extrusion of the bone cement was seen after 4 years. The bone cement was totally extruded in nine cases. The mean survival time was 28 months., Conclusions: The use of Ionocem for obliteration of the mastoid cavity or for the closure of dehiscence of the tegmen has a high risk of extrusion. Therefore, it is not the first-choice material to use for obliteration or tegmen defect closure in the middle ear.

The Committee on Hearing and Equilibrium of the American Academy of Otolaryngology-Head and Neck Surgery proposed guidelines to provide more uniformity in reporting hearing results after middle ear surgery. One of the proposals was to include the hearing thresholds at 0.5, 1, 2, and 3 kHz in a 4-frequency pure-tone average (PTA) and to use post-operative bone-conduction (BC) levels rather than preoperative BC levels in describing postoperative air-bone gaps (ABGs). The hearing results of 451 stapes operations were evaluated to analyze to what extent the choice of different audiologic criteria affects success rates. It appeared that choice of PTA significantly affects postoperative gain in air-conduction thresholds and ABG levels. If one takes the improvements in speech-reception thresholds as the gold standard, the gain in air-conduction correlates best with a gain in speech-reception threshold if a higher frequency, such as 3 or 4 kHz, is included in a 4-frequency PTA. Also, choice of preoperative or postoperative BC in computing postoperative ABGs had a significant effect on the mean postoperative ABG levels, showing more favorable results with the use of preoperative BC thresholds.

To standardize the reporting of hearing results after middle ear surgery, the Committee on Hearing and Equilibrium of the American Academy of Otolaryngology-Head and Neck Surgery proposed 2 levels of guidelines: level 1 for reporting summary data and level 2 for reporting raw data. The Committee encourages the reporting of raw data from each individual case. However, in studies in which the examined population is too large, this can yield difficulties. With respect to this point, we designed a method for a simple visual presentation of hearing results in an attempt to provide data from each individually operated ear in a patient group. In this method the relation between the preoperative and postoperative bone-conduction levels is evaluated to assess overclosure and iatrogenic cochlear damage, and the relation between postoperative gain in air conduction and the preoperative air-bone gap is evaluated as a measure of technical success rate. This results in 2 plots, which we called the Amsterdam Hearing Evaluation Plots. Audiometric data from 451 stapes operations were used to demonstrate the use of the Amsterdam Hearing Evaluation Plots.

Study Objective: To determine whether allergic sensitisation occurs more frequently in young children with an acquired cholesteatoma in comparison with young children without ear diseases., Design: In this retrospective case-control study the allergic sensitisation of 43 children (age 0-10 years) who were operated for an acquired cholesteatoma was compared with the allergic sensitisation of children without ear pathology., Setting: Otology department of the ORL clinic of the Academic Medical Centre of University of Amsterdam in the Netherlands., Measurements: From all subjects a complete history examination was performed and stored in a database. To assess for the presence of allergic sensitisation in patients who underwent radical ear surgery because of an acquired cholesteatoma, and the control group a multiantgen radioallergosorbent test (RAST) was performed. The GraphPad Prism v 2.0. statistical software was used to perform the analyses., Results: Eighteen subjects (41.8%) demonstrated sensitivity to allergens and this is statistically significant (P < 0.0047) higher than the control group and expected for the general paediatric population. 80% of the patients with a positive multiantgen radioallergosorbent test were boys. In all positive cases an allergy for the house dust mite was determined., Conclusion: Allergy is statistically frequently present in paediatric patients with an acquired cholesteatoma. The house dust mite seems to be the most important allergen when allergy is involved with an acquired cholesteatoma. Cholesteatoma with an positive allergy test occurs much more often in boys than girls. This could mean that young boys with a series of inflammatory middle ear diseases and allergic sensitisation are probably more at risk to develop an acquired cholesteatoma in childhood.

Purpose: Evaluation of hearing results after implantation of a Teflon piston (type Causse; Xomed Surgical Products, Jacksonville, FL) and of a pure gold piston (K-piston; Heinz Kurz GmbH Medizintechnik, Dusslingen, Germany), both with a shaft diameter of 0.4 mm in cases of otosclerosis requiring stapedotomy. An important difference between both prostheses is the difference in mass: the gold piston is three times heavier than the Teflon piston., Methods: Retrospective analyses were carried out of the presurgery and postsurgery audiologic results obtained after primary stapedotomy by implantation of 62 Teflon pistons and 66 gold pistons. The results were compared according to mean values of several audiometric parameters. Furthermore, individual audiometric results have been evaluated with the "Amsterdam Hearing Evaluation Plots" (AHEPs) as a method for visual presentation of hearing results from each operated ear. With this method, "unsuccessfully" and "successfully" inserted prostheses can be recognized easily and a more realistic comparison between prostheses is possible., Results: It was found that in the overall group the heavier gold prosthesis gives a significantly larger gain in air-conductive hearing at 2 kHz (p < 0.05) and in the speech frequency range 0.5 to 2 kHz (p < 0.05). There were no significant intergroup differences with regard to change in bone-conduction and air-bone gaps. Analysis of the hearing results of the subgroup that included only the "successfully" implanted prostheses according to the criteria of the AHEPs had mainly consequences for improvement of air-conduction thresholds: none of the intergroup differences were statistically significant., Conclusions: For a fair comparison between prostheses, it is necessary to take only the prostheses into account that are inserted properly and that are functioning under normal conditions with regard to transmission of sound vibrations. After analysis of the hearing results of these "successfully" implanted prostheses, a trend was noticed that the heavier gold piston gives more gain in the low- and mid-frequency range and the light-weighted Teflon piston gives more gain in the high-frequency range, although none of the differences were significant.

This study reports the evaluation of the results after 72 stapedotomies in patients with bilateral otosclerosis. All pre- and postoperative audiological data, together with all relevant information of the operations, were stored in a data base and analyzed retrospectively. The Glasgow benefit plot (GBP) is a useful method to evaluate the hearing results of each individual ear after stapes surgery in a more functional way rather than from a technical standpoint. Therefore, it has been used to assess the benefit obtained after second-ear stapedotomy. From the results it appears that a second operation on the contralateral side increases the chances of achieving at least one 'normal'-hearing ear, and it makes symmetrical 'normal' hearing possible in the majority of the cases.

Tinnitus is still a phenomenon with an unknown pathophysiology with few therapeutic measures. During the last two decades, hyperbaric oxygenation therapy (HBO) has been used in the treatment of sudden deafness and chronic distressing tinnitus. In this study, we prescribed HBO to 20 patients who had had severe tinnitus for more than one year and who had already had other forms of tinnitus therapy with unsatisfactory results. Four patients could not cope with the pressure gradient. The effect of HBO was assessed using subjective evaluation and VAS scores before and after HBO. Follow-up continued until one year after treatment. Six patients had a reduction of tinnitus and accompanying symptoms, eight patients did not notice any change and two patients experienced an adverse effect. Any outcome persisted with minor changes until one year after treatment. HBO may contribute to the treatment of severe tinnitus, but the negative effect on tinnitus should be weighed carefully.

This study reports the evaluation of the hearing results after 62 implantations of a pure gold (99.9%) piston in cases of otosclerosis. A retrospective analysis of the pre- and postsurgery audiological results of these patients was carried out by microcomputer. This study shows that the use of a pure gold piston ((K-piston) with a diameter of 0.4 mm gives good results in cases of stapedotomy for otosclerosis. The hearing results show a closure of the pure-tone average (PTA) air-bone gap to within 10 dB was 70.9% (44/62) and to within 20 dB in 95.1% (59/62). A residual airbone-gap of > 20 dB was seen in three cases (4.8%). A postoperative overclosure of bone conduction thresholds was discovered for all frequencies measured. Sensorineural hearing loss (> 10%) did not occur and there was no decline in the speech discrimination. The future for this new generation of stapes pistons seems to be promising.