Otology & Neurotology

Prevalence of Asymmetric Hearing Among Adults in the United States Objective: To estimate the national prevalence of asymmetric hearing among adults through applying two distinct audiometric criteria. Study Design: National cross-sectional survey. Setting: Ambulatory examination centers within the National Health and Nutrition Examination Survey (NHANES). Patients: Non-institutionalized adults in the United States from the 2001 to 2012 cycles of NHANES aged 20 years and older with pure tone audiometric and tympanometric data (n = 6,190). Intervention: Standardized protocol for pure tone audiometry and tympanometry. Main Outcome Measure: Proportion of asymmetric hearing according to two distinct audiometric criteria. One criterion (American Academy of Otolaryngology–Head and Neck Surgery [AAO-HNS]) specifies asymmetry as a difference between pure tone averages (PTA) greater than 15 dB, and the other (Veterans Affairs [VA]) specifies asymmetry as a difference greater than/equal to 20 dB across two contiguous frequencies or 10 dB across three contiguous frequencies. Analyses included sampling weights to account for the epidemiologic survey's complex sampling design. Results: Using a definition from the AAO-HNS, overall prevalence was 2.77 and 9.46% when calculating the PTA with 0.5 to 4 kHz and 4 to 8 kHz, respectively. In contrast, through a working definition used within the VA, overall prevalence was 25.05% across 0.5 to 8 kHz. Estimates differed across sex and age, with men and older age cohorts exhibiting higher prevalence. Conclusions: A nationally-representative sample of US adults indicates higher prevalence of asymmetric hearing among men and older adult cohorts. There is currently no standard audiometric criterion for defining asymmetry, and prevalence estimates vary markedly depending on which audiometric criteria is used. Given the potentially high prevalence of asymmetry depending on criterion, clinicians should also consider other supplementary clinical data when recommending medical referral. Address correspondence and reprint requests to Jonathan J. Suen, AuD, Johns Hopkins Cochlear Center for Hearing and Public Health, 2024 East Monument Street, Suite 2-700, Baltimore, MD 21205; E-mail: suen@jhmi.edu Funding: J.J.S.: Supported by the Johns Hopkins School of Nursing. J.B.: None declared related to submitted work. N.S.R.: Supported by the Cochlear Center for Hearing and Public Health at the Johns Hopkins Bloomberg School of Public Health. J.A.D.: NIH/NIA K01AG054693. F.R.L.: None declared related to submitted work. A.M.G.: None declared related to submitted work. This manuscript is supported in part by funding from the Eleanor Schwartz Charitable Foundation and the Cochlear Center for Hearing and Public Health at the Johns Hopkins Bloomberg School of Public Health Conflicts of Interest: J.J.S. declares no conflicts. J.B. declares no conflicts. N.S.R. reports being a scientific board member (non-financial) for SHOEBOX Ltd., Ottawa, Ontario, Canada and a consultant to Helen of Troy. J.A.D. declares no conflicts. F.R.L. reports being a nonprofit board member for Access HEARS, a consultant for Boehringer Ingelheim and Amplifon, receiving speaker honoraria from Caption Call, receiving reimbursed travel from Cochlear Ltd., and being the director of a research center at the Johns Hopkins Bloomberg School of Public Health funded in part by a philanthropic gift from Cochlear Ltd.. A.M.G. reports being a consultant to Cochlear Ltd and Auditory Insight. Copyright © 2020 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

Active Middle Ear Implant Patient Outcomes With Adaptive Feedback Canceller Objective: Evaluation of the audiological patient performance with an upgrade of the firmware from the fixed feedback canceller (FFC) to the adaptive feedback canceller (AFC) on an active middle ear implant. Study Design: Retrospective observational nonrandomized group study. Setting: Private hospital. Patients/Intervention(s): From March 2018 to September 2019, 15 patients implanted with an active middle ear implant, with 6 or more months of experience with a FFC system, were upgraded to an AFC algorithm. Main Outcome Measure(s): Functional gain, speech perception in silence and in noise, and sound localization capacities were examined. Feedback reduction was also analyzed. Results: Thirteen patients were analyzed. Pure tone audiometric evaluation with FFC (mean value of 48.02 dB) compared with AFC at 1 (mean value of 49.12 dB) and 6 months (mean value of 42.75 dB) revealed no statistically significant differences (p = 0.889 and p = 0.358 respectively). In speech discrimination in silence, clinically relevant improvements were observed with AFC at 1 and 6 months, with a mean value of 41.5 and 38.3 dB, respectively (p = 0.03 and p = 0.021 correspondingly). In speech discrimination in noisy environments, we observed an improvement of the different conditions tested. No differences were found in localization capacities between FFC and AFC at the two different moments of evaluation. Conclusions: AFC is more effective than FFC in cancelling feedback and improving sound quality, allowing for better speech understanding in silence and in noise. Address correspondence and reprint requests to Maria Conceição Peixoto, M.D., Serviço de Otorrinolaringologia - Hospital Cuf Porto, Estrada da Circunvalação 14341, 4100-180 Porto, Portugal; E-mail: maria.peixoto@jmellosaude.pt Financial Disclosure Information: This work was supported by Choclear®. The authors disclose no conflicts of interest. Copyright © 2020 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

Precise Evaluation of the Cochlear Duct Length by Flat-panel Volume Computed Tomography (fpVCT)—Implication of Secondary Reconstructions Hypothesis: Flat-panel volume computed tomography (fpVCT) and secondary reconstruction allow for more accurate measurements of two-turn length (2TL), cochlear duct length (CDL), and angular length (AL). Background: Cochlear geometry is a controversially debated topic. In the meantime, there are many different studies partly reporting highly divergent values. Our aim is to discuss the differences and to propose a radiological possibility to improve cochlear measurements using 3D-curved multiplanar reconstruction and fpVCT. Methods: Performing different image modalities and settings, we tried to find a clinically usable option that allows for a high degree of accuracy. Therefore, we tested them against reference values of high-definition micro-computed tomography. Results: Comparison of 99 μm slice thickness secondary reconstruction of fpVCT and reference showed no significant differences for 2TL and CDL (p ≥ 0.05). Accordingly, ICC (intraclass correlation) values were excellent (ICC ≥ 0.75; lower limit of confidence interval [CI] ≥ 0.75; Cronbach's alpha [α] ≥ 0.9). Evaluating AL, there was a significant difference (difference: −17.27°; p = 0.002). The lower limit of the CI of the ICC was unacceptable (ICC = 0.944; lower limit of CI = 0.248; α = 0.990). Regarding the Bland-Altman plots, there were no clinically unacceptable errors, but a systematic underestimation of AL. Conclusion: Secondary reconstruction is a suitable tool for producing reliable data that allow the accurate measurement of 2TL and CDL. The option of generating these reconstructions from raw data limits the need for higher radiation doses. Nevertheless, there is an underestimation of AL using secondary reconstructions. Address correspondence and reprint requests to Kristen Rak, M.D., Department of Oto-Rhino-Laryngology, Plastic, Aesthetic and Reconstructive Head and Neck Surgery and the Comprehensive Hearing Center, University of Wuerzburg, Josef-Schneider-Straße 11, D-97080 Wuerzburg, Germany; E-mail: Rak_K@ukw.de P.S. and L.I. contributed equally to this work. The authors disclose no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (www.jcraniofacialsurgery.com). Copyright © 2020 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

Objective Vestibular Test Battery and Patient Reported Outcomes in Cochlear Implant Recipients Objective: Cochlear implantation (CI) may have undesired effects on the vestibular apparatus. However, the literature holds no consensus on vestibular affection and the testing tools applied to test for vestibular dysfunction after cochlear implantation are inconsistent. We aimed to investigate the impact of CI on vestibular function by an extensive test battery including patient-reported outcomes. Study Design: Prospective observational study. Setting: University hospital. Patients: Forty adult unilateral first-time CI recipients. Intervention: Vestibular function was evaluated pre- and post-implantation with the video head impulse test (VHIT), the caloric test and cervical vestibular evoked myogenic potentials (cVEMPs), and the patient-reported dizziness handicap inventory (DHI). Results: Mean VHIT gain decreased from preoperative 0.92 to 0.84 postoperative (p = 0.018); mean caloric unilateral weakness increased from 20.5% preoperative to 42.9% postoperative (p < 0.0001); cVEMP responses were present on 10 operated ears preoperative and five ears postoperative, and compared with non-implanted ears, cVEMP responses on implanted ears were impaired (p = 0.023). 50% of patients reported early postoperative dizziness, but the mean DHI score remained unchanged (p = 0.94). The DHI scores correlated poorly with the objective outcomes (rs = 0.19 and rs = –0.22). Conclusion: Vestibular function is significantly affected after cochlear implantation, but vestibular hypofunction varies with the test used. Although early dizziness after implantation is common, later DHI scores are not significantly higher than before the implantation, indicating that central compensation plays a major role for these patients. Address correspondence and reprint requests to Niels West, M.D., Department of Otorhinolaryngology Head & Neck Surgery and Audiology, Rigshospitalet, Blegdamsvej 9, DK-2100 Copenhagen Ø, Denmark; E-mail: niels.west.christensen@regionh.dk Disclosure: Nothing to disclose. Funding: N.W. has received a research grant from William Demant Foundation. The contents of this paper have not been published or presented previously. The authors disclose no conflicts of interest. Copyright © 2020 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

Auditory Brainstem Implant in Adult Patient With Cochlear Ossification From Otosclerosis Objective: The objective is to describe auditory brainstem implantation in a case of extensive cochlear otosclerosis. Patient, Intervention, and Results: A case is presented of a 65-year-old male with bilateral cochlear otosclerosis and profound sensorineural hearing loss. Imaging studies showed distorted cochlear anatomy bilaterally and ossification of cochlear ducts. He underwent successful placement of an auditory brainstem implant using a retrosigmoid craniotomy approach. Conclusions: Extensive cochlear otosclerosis may distort cochlear anatomy such that cochlear implantation is expected to have a poor outcome. Auditory brainstem implantation may be an additional treatment option in these patients. Address correspondence and reprint requests to Gregory P. Lekovic, M.D., Ph.D., Division of Neurosurgery, House Clinic, 2100 West Third Street, Los Angeles, CA 90057; E-mail: glekovic@houseclinic.com The authors disclose no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (www.jcraniofacialsurgery.com). Copyright © 2020 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

Cochlear Implantation in Adults With Single-Sided Deafness: Outcomes and Device Use Objective: To describe our experience with adults undergoing cochlear implantation (CI) for treatment of single-sided deafness (SSD). Study Design: Retrospective case review. Setting: Tertiary referral center. Patients: Fifty-three adults with SSD. Intervention(s): Unilateral CI. Main Outcome Measure(s): Speech perception testing in quiet and noise, tinnitus suppression, and device usage from datalogs. Results: The mean age at CI was 53.2 years (SD 11.9). The mean duration of deafness was 4.0 years (SD 7.8). The most common etiology was idiopathic sudden SNHL (50%). Word recognition improved from 8.7% (SD 15) preoperatively to 61.8% (SD 20) at a mean follow-up of 3.3 years (SD 1.8) (p < 0.0001). Adaptive speech recognition testing in the "binaural with CI" condition (speech directed toward the front and noise toward the normal hearing ear) revealed a significant improvement by 2.6-dB SNR compared to the preoperative unaided condition (p = 0.0002) and by 3.6-dB SNR compared to when a device to route sound to the contralateral side was used (p < 0.0001). Tinnitus suppression was reported to be complete in 23 patients (43%) and improved in 20 patients (38%) while the device was on. The addition of the CI did not lead to a decrement in hearing performance in any spatial configuration. Device usage averaged 8.7 (SD 3.7) hours/day. Conclusions: Cochlear implantation in adult SSD patients can suppress tinnitus and achieve speech perception outcomes comparable with CI in conventional candidates. Modest improvements in spatial hearing were also observed and primarily attributable to the head shadow effect. Careful patient selection and counseling regarding potential benefits are important to optimize outcomes. Address correspondence and reprint requests to David R. Friedmann, M.D., M.Sc., Division of Otology, Neurotology and Skull Base Surgery, Department of Otolaryngology–Head & Neck Surgery, New York University School of Medicine, 530 1st Avenue, Skirball Suite 7Q, New York, NY 10016; E-mail: david.friedmann@nyulangone.org Financial material & support: No commercial sponsorship or support. Conflict(s) of interest to declare: This study discusses off-label use of cochlear implants. J.T.R. and W.S. are on the advisory board for Cochlear Limited. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (www.jcraniofacialsurgery.com). Copyright © 2020 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

Comparison of Cochlear Implant Device Fixation—Well Drilling Versus Subperiosteal Pocket. A Cost Effectiveness, Case–Control Study Objective: To compare surgical characteristics and complications between well drilling (WD) and subperiosteal pocket techniques (SPT) for receiver/stimulator (R/S) fixation of cochlear implant (CI), and conduct cost-effectiveness analysis. Study Design: Retrospective clinical study, decision-analysis model. Setting: Tertiary referral center. Patients: Three-hundred and eighty-eight CI recipients with a minimum of 6-months follow-up. Interventions: CI surgery using either WD or SPT for R/S fixation. A decision-analysis model was designed using data from a systematic literature review. Main Outcome Measures: Surgical operation time, rates of major and minor long-term complications were compared. Incremental cost-effectiveness was also estimated, comparing the two methods of fixation. Results: We compared 179 WD with 209 SPT. Surgery time was significantly shorter in SPT (148 versus 169 min, p = 0.001) and remained significant after adjustment for possible confounders. Higher rates of major complications requiring surgical intervention were found with SPT (10.5% versus 4.5%, p = 0.042), however, the difference was not significant after adjusting for follow-up time (47.8 versus 32.5 months for SPT, WD respectively; p < 0.001). The incremental cost-effectiveness ratio for WD (compared with SPT) was $48,795 per major complication avoided, which was higher than the willingness-to-pay threshold of $47,700 (average cost of 2 h revision surgery). Conclusions: SPT was found to be faster but potentially risks more complications, particularly relating to device failure. Further long-term studies are required to validate these differences. Based on data from the current literature, neither of the methods is compellingly cost-effective over the other, and surgeons can base their choice on personal preference, comfort, and previous training. Address correspondence and reprint requests to George Alexiades, M.D., Clinical Otolaryngology, Weill Cornell Medical College, Cornell University, New York, NY 10021; E-mail: gea9039@med.cornell.edu Funding: None. The authors disclose no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (www.jcraniofacialsurgery.com). Copyright © 2020 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

Word and Nonword Reading Efficiency in Postlingually Deafened Adult Cochlear Implant Users Hypothesis: This study tested the hypotheses that 1) experienced adult cochlear implants (CI) users demonstrate poorer reading efficiency relative to normal-hearing controls, 2) reading efficiency reflects basic, underlying neurocognitive skills, and 3) reading efficiency relates to speech recognition outcomes in CI users. Background: Weak phonological processing skills have been associated with poor speech recognition outcomes in postlingually deaf adult CI users. Phonological processing can be captured in nonauditory measures of reading efficiency, which may have wide use in patients with hearing loss. This study examined reading efficiency in adults CI users, and its relation to speech recognition outcomes. Methods: Forty-eight experienced, postlingually deaf adult CI users (ECIs) and 43 older age-matched peers with age-normal hearing (ONHs) completed the Test of Word Reading Efficiency (TOWRE-2), which measures word and nonword reading efficiency. Participants also completed a battery of nonauditory neurocognitive measures and auditory sentence recognition tasks. Results: ECIs and ONHs did not differ in word (ECIs: M = 78.2, SD = 11.4; ONHs: M = 83.3, SD = 10.2) or nonword reading efficiency (ECIs: M = 42.0, SD = 11.2; ONHs: M = 43.7, SD = 10.3). For ECIs, both scores were related to untimed word reading with moderate to strong effect sizes (r = 0.43–0.69), but demonstrated differing relations with other nonauditory neurocognitive measures with weak to moderate effect sizes (word: r = 0.11–0.44; nonword: r = (−)0.15 to (−)0.42). Word reading efficiency was moderately related to sentence recognition outcomes in ECIs (r = 0.36–0.40). Conclusion: Findings suggest that postlingually deaf adult CI users demonstrate neither impaired word nor nonword reading efficiency, and these measures reflect different underlying mechanisms involved in language processing. The relation between sentence recognition and word reading efficiency, a measure of lexical access speed, suggests that this measure may be useful for explaining outcome variability in adult CI users. Address correspondence and reprint requests to Terrin N. Tamati, Ph.D., Department of Otolaryngology, The Ohio State University, 915 Olentangy River Road, Suite 4000, Columbus, OH 43212; E-mail: terrin.tamati@osumc.edu A.C.M. and C.R. received grant support from Cochlear Americas for an unrelated investigator-initiated study of aural rehabilitation. Development of measures used in this study was supported by the National Institutes of Health, National Institute on Deafness and Other Communication Disorders Career Development Award 5K23DC015539-02 and the American Otological Society Clinician-Scientist Award to A.C.M. Preparation of this manuscript was supported in part by VENI Grant No. 275-89-035 from the Netherlands Organization for Scientific Research and funding from the President's Postdoctoral Scholars Program at The Ohio State University awarded to T.N.T. The authors disclose no conflicts of interest. Copyright © 2020 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

Robot-assisted Cochlear Implant Electrode Array Insertion in Adults: A Comparative Study With Manual Insertion Objective: To describe the first cochlear array insertions using a robot-assisted technique, with different types of straight or precurved electrode arrays, compared with arrays manually inserted into the cochlea. Study Design: Retrospective review. Setting: Tertiary otologic center. Patients: Twenty cochlear implantations in the robot-assisted group and 40 in the manually inserted group. Interventions: Cochlear implantations using a robot-assisted technique (RobOtol) with straight (eight Cochlear CI522/622, and eight Advanced Bionics Hifocus Slim J) or precurved (four Advanced Bionics Hifocus Mid-Scala) matched to manual cochlear implantations. Three-dimensional reconstruction images of the basilar membrane and the electrode array were obtained from pre- and postimplantation computed tomography. Main Outcome Measures: Rate and localization of scalar translocations. Results: For straight electrode arrays, scalar translocations occurred in 19% (3/16) of the robot-assisted group and 31% (10/32) of the manually inserted group. Considering the number of translocated electrodes, this was lower in the robot-assisted group (7%) than in the manually inserted group (16%) (p < 0.0001, χ2 test). For precurved electrode arrays, scalar translocations occurred in 50% (2/4) of the robot-assisted group and 38% (3/8) of the manually inserted group. Conclusion: This study showed a safe and reliable insertion of different electrode array types with a robot-assisted technique, with a less traumatic robotic insertion of straight electrode arrays when compared with manual insertion. Address correspondence and reprint requests to Hannah Daoudi, M.D., Service ORL, Unité fonctionnelle Implants auditifs, GHU Pitié-Salpêtrière, Bâtiment Babinski, 52 boulevard Vincent Auriol, 75013 Paris, France; E-mail: hannah.daoudi@aphp.fr Source of funding: Fondation pour l'Audition (Hearing institute starting grant); ANR Robocop ANR-19-CE19-0026-02. The authors disclose no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (www.jcraniofacialsurgery.com). Copyright © 2020 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

EFFECT OF INTRATYMPANIC DEXAMETHAZONE ON BELL'S PALSY: LETTER TO THE EDITOR No abstract available

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Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00302841026182,00306932607174,alsfakia@gmail.com,

Telephone consultation 11855 int 1193,