Patel, Neil S.

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.

BACKGROUND: Surgical intervention remains an important option in the management of vestibular schwannoma (VSs). Development of a systematic approach to choose the most appropriate route for this intervention, based on existing published evidence, is an important goal. OBJECTIVE: To review the literature published since the 2018 Congress of Neurological Surgeons Guideline on surgical intervention for patients with sporadic VSs and use this information to update that set of recommendations. METHODS: The literature in the PubMed and MEDLINE databases from January 2015 through May 20, 2022, was searched for manuscripts pertaining to surgical intervention for VSs. Those manuscripts meeting inclusion criteria were then analyzed for creation of recommendations in response to a set of updated questions. RESULTS: The resultant findings included a considerable amount of data that did not alter the recommendations form the 2018 publication on this topic. Thus, recommendations stating hearing preservation surgery through the middle fossa or retrosigmoid approach may be considered in individuals with good preoperative hearing as an alternative to simple observation remain. In addition, if microsurgical resection is necessary after stereotactic radiosurgery, it is recommended that patients be counseled that there is an increased likelihood of a subtotal resection and decreased facial nerve function. In some questions, insufficient data were present to create an answer and that is stated. CONCLUSION: This guideline demonstrates surgical intervention for VSs and represents a range of options, and the choice of the intervention depends on the specific aspects of the lesion and the individual that harbors them. Objective refinement of those choices will require thoughtful research design by investigations that wish to address those items for which we still have insufficient information. The full guideline can be seen online at https://www.cns.org/guidelines/treatment-adults-vestibular-schwannoma/7-surgical-resection-treatment-of-patients-with-ve-2

BACKGROUND: Intraoperative neuromonitoring (IONM) has become vital in the management of vestibular schwannoma (VS) with the paradigm shift from tumor eradication to functional preservation. Several facial nerve (FN) monitoring strategies have been explored over the past few decades ranging from free-running electromyography, direct nerve stimulation, continuous nerve stimulation, facial motor evoked potentials, blink reflex, and others. Hearing preservation surgery is guided primarily by far-field auditory brainstem response and real-time cochlear nerve action potentials. Given the heterogeneity in tumor and patient factors, it remains very difficult to accurately predict cranial nerve outcomes, regardless of the monitoring strategy. OBJECTIVE: To critically appraise literature regarding IONM during VS surgery and update the previous evidence-based clinical practice guideline. METHODS: This is a systematic review of the literature, incorporating articles from March 2015 to May 2022. Literature published before 2015 that would have been included in the previous Congress of Neurological Surgeons guideline was not searched again in this update. RESULTS: FN monitoring provides better functional outcomes compared with anatomic dissection alone and may guide the extent of tumor resection. While facial motor evoked potentials and free-running electromyography can provide continuous noninvasive FN monitoring, there are insufficient data to determine which more strongly correlates with facial function outcomes. Both electrophysiological data and tumor size correlate with facial function outcomes. The ideal hearing monitoring strategy remains unclear as there are insufficient data comparing cochlear nerve action potentials with far-field auditory brainstem response. All studies were graded as Class III evidence. CONCLUSION: IONM should be used in all VS cases. While the optimal FN and hearing monitoring strategy remains elusive, available data support the use of a combination of strategies, including preoperative tumor size, to maximize sensitivity and specificity. There remains a significant need for high-quality comparative studies to determine which intraoperative monitoring scheme can provide intraoperative guidance and predict postoperative outcome. The full guideline can be seen online at https://www.cns.org/guidelines/treatment-adults-vestibular-schwannoma/3-intraoperative-cranial-nerve-monitoring-in-manag

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.

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

AbstractObjectiveLimited evidence guides the optimal timing of treatment after the detection of tumor growth during the observation of sporadic vestibular schwannoma (VS). The current work aimed to inform the timing of radiosurgical intervention based on an analysis of patient outcomes among those who ultimately failed stereotactic radiosurgery (SRS) and underwent salvage microsurgery.Study DesignA historical cohort study.SettingSeven centers across the United States and Norway.MethodsAdults with sporadic VS who underwent salvage microsurgery following failed primary SRS were included. The primary outcome of interest was the association between tumor size at the time of primary SRS and the ability to achieve gross total resection (GTR) and maintain postoperative House–Brackmann (HB) facial nerve grade I at the last follow‐up after salvage microsurgery.ResultsAmong 96 patients, the median (interquartile range [IQR]) cerebellopontine angle (CPA) tumor size at primary SRS was 14.5 mm (10.0‐19.0). Each 1‐mm increase in CPA tumor size at the time of primary SRS was associated with a 13% increased likelihood of near‐total/subtotal resection or most recent postoperative HB grade >I (odds ratio [OR] 1.13, 95% confidence interval [CI] 1.05‐1.21, P = .001), with an optimal tumor size threshold to distinguish this outcome of 12 mm of CPA extension (c‐index 0.73). Similarly, for each 1‐mm increase in CPA tumor size at the time of primary SRS, a 9% increase in any postoperative complication with salvage microsurgery was observed (OR 1.09, 95% CI 1.02‐1.15, P = .009).ConclusionCorroborated by size threshold surveillance data informing the timing of primary microsurgical resection, the current study suggests that VS outcomes are optimized when primary radiosurgical intervention is undertaken on growing tumors when they harbor 10–15 mm of cerebellopontine angle extension or less.

ImportanceManagement of sporadic vestibular schwannoma with radiosurgery is becoming increasingly common globally; however, limited data currently characterize patient outcomes in the setting of microsurgical salvage for radiosurgical failure.ObjectiveTo describe the clinical outcomes of salvage microsurgery following failed primary stereotactic radiosurgery (SRS) or fractionated stereotactic radiotherapy (FSRT) among patients with sporadic vestibular schwannoma.Design, Setting, and ParticipantsThis was a cohort study of adults (≥18 years old) with sporadic vestibular schwannoma who underwent salvage microsurgery following failed primary SRS/FSRT in 7 vestibular schwannoma treatment centers across the US and Norway. Data collection was performed between July 2022 and January 2023, with data analysis performed between January and July 2023.ExposureSalvage microsurgical tumor resection.Main Outcomes and MeasuresComposite outcome of undergoing less than gross total resection (GTR) or experiencing long-term facial paresis.ResultsAmong 126 patients, the median (IQR) age at time of salvage microsurgery was 62 (53-70) years, 69 (55%) were female, and 113 of 117 (97%) had tumors that extended into the cerebellopontine angle at time of salvage. Of 125 patients, 96 (76%) underwent primary gamma knife SRS, while 24 (19%) underwent linear accelerator-based SRS; the remaining patients underwent FSRT using other modalities. Postoperative cerebrospinal fluid leak was seen in 15 of 126 patients (12%), hydrocephalus in 8 (6%), symptomatic stroke in 7 (6%), and meningitis in 2 (2%). Each 1-mm increase in cerebellopontine angle tumor size was associated with a 13% increased likelihood of foregoing GTR (64 of 102 patients [63%]) or long-term postoperative House-Brackmann grade higher than I (48 of 102 patients [47%]) (odds ratio, 1.13; 95% CI, 1.04-1.23). Following salvage microsurgery, tumor growth–free survival rates at 1, 3, and 5 years were 97% (95% CI, 94%-100%), 93% (95% CI, 87%-99%), and 91% (95% CI, 84%-98%), respectively.ConclusionsIn this cohort study, more than half of patients who received salvage microsurgery following primary SRS/FSRT underwent less than GTR or experienced some degree of facial paresis long term. These data suggest that the cumulative risk of developing facial paresis following primary SRS/FSRT by the end of the patient’s journey with treatment approximates 2.5% to 7.5% when using published primary SRS/FSRT long-term tumor control rates.

Objective The objective of the current study was to present the results of an international working group survey identifying perceived limitations of existing facial nerve grading scales to inform the development of a novel grading scale for assessing early postoperative facial paralysis that incorporates regional scoring and is anchored in recovery prognosis and risk of associated complications. Study Design Survey. Setting A working group of 48 multidisciplinary clinicians with expertise in skull base, cerebellopontine angle, temporal bone, or parotid gland surgery. Results House-Brackmann grade is the most widely used system to assess facial nerve function among working group members (81%), although more than half (54%) agreed that the system they currently use does not adequately estimate the risk of associated complications, such as corneal injury, and confidence in interrater and intrarater reliability is generally low. Simplicity was ranked as the most important attribute of a novel postoperative facial nerve grading system to increase the likelihood of adoption, followed by reliability and accuracy. There was widespread consensus (91%) that the eye is the most critical facial region to focus on in the early postoperative setting. Conclusions Members were invited to submit proposed grading systems in alignment with the objectives of the working group for subsequent validation. From these data, we plan to develop a simple, clinically anchored, and reproducible staging system with regional scoring for assessing early postoperative facial nerve function after surgery of the skull base, cerebellopontine angle, temporal bone, or parotid gland.