Isaacson, Brandon

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 describe histologic and radiographic findings associated with insertion of a new lateral wall electrode in human temporal bones, as well as quantify the ease of insertion as characterized by multiple cochlear implant surgeons. Setting: Multi-institutional cadaveric study. Methods: The Slim J electrode was inserted in cadaveric temporal bones via a standard mastoidectomy and facial recess approach. Insertion was performed by five cochlear implant surgeons with no previous experience with the Slim J electrode array. Electrode array insertion was performed via a round window, an extended round window, or a cochleostomy approach. Intracochlear trauma, and angular insertion depth was assessed histologically and radiologically, respectively, after placement of the Slim J electrode array. Results: Scala tympani insertion was accomplished in all 40 specimens. Thirty-eight specimens (95%) showed minimal trauma (Esrhaghi grade 0 or 1). One patient had rupture of basilar membrane (grade 2 trauma) at 380 degrees. One patient had grade 4 trauma with scalar translocation beginning at 210 degrees. The mean angular insertion depth was 416.4 degrees (range: 338.7–509.2 degrees, SD 44 degrees). Surgical handling was described as easy in 38 cases (95%). Conclusion: In a human cadaveric model the lateral wall Slim J electrode produced minimal intracochlear trauma that was positioned completely within the scala tympani in 97.5% of cases.

Objective: To date, less than 150 cases of middle ear adenomatous neuroendocrine tumors (MEANTs) have been reported in the English literature. The objective of this study was to provide a contemporary analysis of these rare lesions and develop a consensus-driven staging system. Study Design: Multi-institutional retrospective histopathologic, radiologic, and clinical review. Setting: Six tertiary referral centers. Patients: Thirty-two patients with pathologically confirmed MEANT. Intervention: Surgical resection, adjuvant therapy. Main Outcome Measures: Clinical manifestations, outcomes, staging system. Results: Patients commonly presented with progressive conductive or mixed hearing loss (90%), aural fullness (50%), and tonal tinnitus (46%). Pulsatile tinnitus (16%), carcinoid syndrome (4%), and facial nerve paresis (4%) were less commonly observed. MEANTs frequently mimicked temporal bone paraganglioma (31%) and cholesteatoma (15%) at presentation. According to a novel T/N/M/S staging system (S = secretory tumor) proposed herein, there were 6 (19%) T1, 19 (59%) T2, and 7 (22%) T3 MEANTs. T3 tumors were significantly more likely to undergo subtotal or near total resection compared with lower staged tumors secondary to adherence to critical neurovascular structures such as the petrous internal carotid artery and facial nerve (p = 0.027). Patients with T3 MEANTs were more likely to experience multiple recurrences, require adjuvant therapy with a somatostatin analogue, or develop permanent facial nerve paresis compared with lower staged tumors. At last follow up, no patients with T1 MEANTs had developed recurrence, whereas 37% (7/19) of patients with T2 MEANT and 57% (4/7) of patients with T3 MEANT experienced either disease recurrence after gross total resection (GTR) or regrowth of known residual tumor requiring additional surgery at a median duration of 72 months (95% CI, 24–84). Conclusions: Patients with MEANTs can present with nonspecific symptomatology that overlaps with more commonly encountered middle ear lesions. MEANT exhibits a proclivity for recurrence according to T-stage and long-term clinical follow up is necessary, particularly for advanced stage tumors.