Gurgel, Richard Klaus

ABSTRACT Objective To evaluate intracochlear electrocochleography (ECochG) amplitude parameters during cochlear implantation (CI) using a novel multi‐frequency ECochG algorithm. Methods A multi‐institutional, prospective cohort study was performed at 18 high‐volume CI centers. The inclusion criteria were adults with sensorineural hearing loss and audiometric thresholds of ≤ 90 dB hearing level at 500 Hz undergoing CI with Advanced Bionics (Valencia, CA) Ultra 3D devices between 2024 and 2025. ECochG recordings were performed with simultaneous multi‐frequency stimulation of four frequencies between 125 and 4000 Hz during cochlear implant insertion. Concurrent multi‐frequency recording allowed extraction of amplitude and phase of each frequency individually. Post hoc analysis was performed to determine the difference in the number of drop alarms between single‐ and multi‐frequency ECochG. An ECochG amplitude drop of 6 dB was defined as a drop alarm. Insertion track patterns were compared between single‐ and multi‐frequency ECochG. Results One hundred ninety‐five ears were included. Mean number of drop alarms for the single‐frequency algorithm was 1.72 (95% CI: 1.52, 1.92; median 1) compared to 0.42 (95% CI: 0.31, 0.53; median 0) for multi‐frequency; p < 0.001. The number of Type C patterns (rise in amplitude during insertion followed by a drop) decreased with the multi‐frequency ECochG algorithm compared to the single‐frequency ECochG algorithm. The number of Type D patterns (no‐response) decreased, indicating that multi‐frequency ECochG generated more responses across the cochlea than single‐frequency ECochG. Conclusions A novel multi‐frequency ECochG algorithm during CI is associated with fewer drop alarms and altered insertion track patterns, which may provide a more accurate assessment of the cochlear microenvironment. Level of Evidence 3.

ABSTRACT Objectives To characterize the structure, resources, and educational practices of temporal bone laboratory training across ACGME‐accredited U.S. otolaryngology residency programs. Methods A national cross‐sectional survey was distributed to program directors and faculty responsible for temporal bone education. Survey domains included curriculum structure, training frequency, faculty involvement, assessment practices, and access to laboratory resources. Descriptive statistics and univariable regression analyses were performed to explore associations between program characteristics and neurotology fellowship pursuit. Results Thirty‐seven programs responded (28.2%). Laboratory structure varied widely, including longitudinal (monthly or weekly) and condensed (annual or 2–3 courses/year) formats. Programs with longitudinal sessions reported more annual lab hours than condensed formats (median 42 vs. 16 h/year, p = 0.003). All programs had access to cadaveric temporal bones (mean 2.25 ± 1.13 bones per resident/year), though five reported fewer bones than residents. The mean drill‐to‐resident ratio was 0.59, with 10.8% reporting a 1:1 ratio. Formal performance evaluation was used by 43.2% of programs. On exploratory univariable analysis, longer otology rotation duration was associated with having at least one neurotology fellow within five years ( p = 0.025). Larger resident cohort size ( p = 0.048) and older laboratory instruments ( p = 0.043) were associated with producing more than one fellow. Conclusion There is substantial variability in temporal bone education across U.S. otolaryngology training programs. Programs differ in curricula, resources, and access to cadaveric and simulation‐based training. Standardization of core components may improve educational equity and training consistency. Level of Evidence N/A.

Objective: To examine the benefit of cochlear implantation (CI) in pediatric patients with a history of temporal bone fracture resulting in single-sided deafness (SSD). Study design: Retrospective chart review. Setting: Two tertiary academic centers. Patients: Pediatric patients less than 18 years of age with SSD secondary to temporal bone fracture who underwent CI from 2012 to 2022. Intervention(s): CI. Main outcome measure(s): Postoperative audiometric testing. Results: Seven subjects were identified (median age: 10 years (y); Q1 to Q3: 5 to 16 y). Median time from temporal bone trauma to CI was 7 months (mo) (Q1 to Q3: 3 to 7 mo) and 85% had otic capsule involvement. Subjects were followed for a median length of 12 months (Q1 to Q3: 6 to 24 mo) after CI. All patients achieved full electrode insertion, though 2 required scala vestibuli insertion due to ossification of the scala tympani (one of whom had a history of meningitis after temporal bone fracture). Postoperative audiometric testing revealed variable speech perception outcomes with 4 of 7 obtaining open or closed set speech perception and 3 of 7 obtaining only sound awareness. No postoperative complications occurred. Conclusions: CI is a feasible intervention for SSD following pediatric temporal bone fractures, but outcomes are variable. Early evaluation and timely CI, ideally within 6 months of temporal bone fracture, may optimize outcomes. Cochlear ossification, either as a result of otic capsule fracture or subsequent meningitis, may lead to suboptimal outcomes.

Hearing loss is a highly prevalent disease state affecting almost 1 in 5 individuals globally. Growing research shows that untreated or undertreated hearing loss carries significant long-term sequelae, including increased risk of social isolation, depression, and cognitive decline, among other ramifications. Limited awareness and common misperceptions among the general US adult population and primary care providers contribute to low rates of referral to hearing specialty clinics and underutilization of hearing aids, cochlear implants, and other rehabilitative devices. Comprised of diverse membership, the Hearing Health Collaborative (HHC) was formed in May 2021 to identify and overcome challenges impacting good health care practices and public policy on hearing care in connection with healthy aging. This editorial documents a recent outcome of the HHC derived from a structured A3 process. Specifically, initiative 2, a proposal to develop a simple, clinically anchored staging system primarily for use by frontline providers and patients, is presented. Unlike other common disorders that harbor long-term health sequelae, a corresponding pragmatic clinical staging system—leveraging precedent disease staging convention, based on clinically meaningful outcomes and prognosis for acquired hearing loss—does not exist. The development of this staging system will potentially allow for improved communication across providers and patients, facilitate referral pathways, and ultimately enable patient access to timely and appropriate care.

Objective Literature is limited regarding the relationship between cochlear magnetic resonance imaging fluid-attenuated inversion recovery (FLAIR) signal and hearing preservation after resection of vestibular schwannoma (VS). We hypothesize that increased preoperative FLAIR signal is associated with decreased odds of hearing preservation. Study Design Retrospective cohort study. Setting Single academic tertiary/quaternary care center. Patients Subjects with histologically confirmed intracanalicular VS (without extension into the cerebellopontine angle). Intervention Microsurgical resection via middle fossa approach. Main Outcome Measures A review of demographic, clinical, radiographic, and audiometric outcomes were performed. Hearing preservation was defined as American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS) class A or B hearing. Binary logistic regression analysis was performed with SPSS version 29. Results Twenty-seven subjects met inclusion criteria with median age at time of surgery of 47 (interquartile range [IQR]: 38–54) years; 92.60% were White; 66.67% had AAO-HNS class A, and 33.33% had class B hearing. Postoperatively, at median (IQR) of 11.50 (2.10–38.50) months, 44.40% had class A or B hearing. On logistic regression analysis, a ratio of cochlea-to-brainstem FLAIR signal greater than 0.6 was associated with decreased odds of hearing preservation at 11.50 months—odds ratio, 0.13; 95% confidence interval, 0.02–0.84. Age, sex, surgery duration, tumor volume and linear dimension, fundal cap of cerebrospinal fluid, and extent of resection were not associated with hearing preservation. Conclusion Increased cochlear FLAIR signal on preoperative imaging is associated with decreased likelihood of hearing preservation after resection of intracanalicular, sporadic VS via middle fossa approach.

Objective: To determine the impact of modifiable surgical factors on ossiculoplasty outcomes after controlling for ear environment risk. Study Design: Multi-institutional retrospective review. Setting: Six tertiary care centers from 2011 to 2019. Patients Adults and children. Interventions: Ossiculoplasty, including synthetic ossicular replacement prosthesis, autograft interposition, bone cement repair, and mobilization. Main Outcome Measure: Correlation between modifiable surgical factors and pure-tone average air-bone gap (ABG) at most recent audiogram after controlling for preoperative risk using the statistically validated Ear Environment Risk (EER) score. Results: A total of 1,679 cases were included with a median follow-up time of 20 months (IQR, 5–51). After controlling for EER score, malleus engagement of prosthesis yielded favorable ABG versus direct contact to tympanic membrane without malleus engagement (beta = −2.4 dB [−3.8, −1.1], p < 0.001). For total ossicular replacement prostheses (TORP), use of a footplate prosthesis yielded favorable ABG as compared with no footplate prosthesis (−3.6 dB [−6.1, −1.1], p = 0.005). For synthetic prostheses, polyethylene prostheses had a less favorable ABG compared with full titanium or titanium with hydroxyapatite prostheses ( p < 0.05). In cases where the malleus was not engaged in reconstruction, amputation of the malleus head yielded worse ABG (+3.9 dB [1.2, 6.7], p = 0.005). There was no significant difference ( p > 0.05) in ABG for single-stage versus multistaged approach, use of a cartilage cap over the prosthesis versus no cartilage, use of bone cement to secure a PORP to the stapes versus no cement, mastoid cavity obliteration versus no obliteration, and incudostapedial joint reconstruction with joint prosthesis/bone cement versus synthetic PORP. Conclusions: With statistical correction for ear environment risk, several modifiable surgical factors are noted to impact ossiculoplasty hearing outcomes. Level of Evidence: 4.

Objective To assess integration of a single-use robotic-assisted cochlear implant (RA-CI) electrode array insertion system into surgical workflows, identify potential challenges, and inform best practices. Study Design Survey. Setting Survey data from 16 surgeons across 10 US hospitals. Patients CI candidates 12 years and older with radiographically normal cochleae. Intervention CI surgery with single-use RA-CI insertion system during electrode array insertion. Main Outcome Measures Number of RA-CI to achieve proficiency, estimated additional time for RA-CI, and best practices to successfully incorporate the RA insertion system into CI surgery. Results A total of 121 RA-CI cases were performed. All surgeons completed the survey. Most surgeons (62.5%) reported they would feel comfortable using the device within five cases. Eight (50%) reported use of the RA system added 5 to 10 minutes to the case, and seven (44%) reported an added 10–15 minutes. Providing adequate incision size to secure the unit base superior to the temporal line and maximizing exposure of the facial recess were the most recommended best practices. Additional recommendations included pulling the receiver/stimulator forward within the pocket to facilitate a full electrode array insertion and considering drive head placement and mastoidectomy size to maximize overall visibility during electrode array insertion. Conclusions Proficiency with an RA electrode array insertion system during CI surgery can be achieved with minor adjustments to the surgical approach, within relatively few use cases (generally <5) and with minimal time addition (between 5 and 15 min). Training to specific best practices is important before initial clinical use.

Objective Present the rationale for the development of a new, patient-facing vital sign for adult hearing. Study Design Structured A3 process. Setting Fourteen virtual meetings and two in-person meetings held between May 2021 and June 2022. Main Outcome Measure(s) Identification and refinement of a countermeasure to develop and imbed a hearing health vital sign for adult hearing. Results Through a rigorous, structured A3 process, the Hearing Health Collaborative identified and refined the rationale for and the qualities associated with a public-facing vital sign for adult hearing loss. Specifically, such a vital sign must embody five qualities: simple, accessible, stable, inclusive, and meaningful. These qualities together would ensure that a hearing health vital sign would be useful not only as a screening tool but also as an instrument to guide next steps in workup and potentially treatment. Conclusions Successful identification and implementation of a hearing metric or “vital sign” for the presence of adult hearing loss, using precedent convention of other medical diseases, may help reframe public perceptions surrounding hearing loss, improve awareness and literacy regarding the presence of the disease, and prompt action to seek diagnostic assessment.

Objectives Evaluate the training background of surgeons performing high volumes of cochlear implants (CIs) and estimate the ratio of providers trained in otology/neurotology (O&N) to the number of traditional CI candidates and audiologists. Methods A retrospective review of US surgeon registration data from a single CI manufacturer was performed to determine CI volume based on surgeon training. The prevalence of traditional candidates for CIs was estimated from US census population data and compared with the number of O&N providers. The ratio of audiologists to O&N providers was estimated from the Bureau of Labor and Statistics and American Speech‐Language‐Hearing Association databases. Results From 2021 to 2023, a mean of 88% of providers performing ≥25 CIs per year and 90% performing ≥40 per year had training in O&N. All surgeons registering ≥100 implants per year were O&N providers. The mean percentage of O&N providers performing ≥25 CIs per year and ≥ 40 per year was higher than the percentage of General and Pediatric Otolaryngology providers performing the same volume: mean difference = 76%, p < 0.001 and mean difference = 79%, p < 0.001, respectively. The mean estimated prevalence of traditional CI candidates per O&N provider is 3,354 with an estimated mean of 32 audiologists (3.5 trained in CIs) per O&N provider. Conclusion 88% of high‐volume CI surgeons have fellowship training in O&N. To meet the current state of CI underutilization and anticipated growing population of CI candidates, we propose increasing the surgical capacity of O&N providers and the number of surgeons proficient in CIs. Level of Evidence NA Laryngoscope , 135:2146–2153, 2025