Publications by authors named "Elliott D Kozin"

141 Publications

Transcanal Computed Tomography Views for Transcanal Endoscopic Lateral Skull Base Surgery: Pilot Cadaveric Study.

J Neurol Surg B Skull Base 2021 Jun 7;82(3):338-344. Epub 2019 Nov 7.

Department of Otolaryngology, Massachusetts Eye and Ear, Boston, Massachusetts, United States.

 Transcanal endoscopic operative approaches provide for a minimally invasive surgical portal to the lateral skull base. Traditional preoperative imaging evaluation involves computed tomography (CT) acquisition in the axial and coronal planes that are not optimized for the transcanal surgical corridor. Herein, we describe a novel CT-based "transcanal view" for preoperative surgical planning and intraoperative navigation.  Present study is a cadaveric imaging study.  Cadaveric temporal bones (  = 6) from three specimens underwent high-resolution CT (0.625 mm slice thickness). Using three-dimensional (3D) Slicer 4.8, reformatted "transcanal" views in the plane of the external auditory canal (EAC) were created. Axial and coronal reformats were used to compare and measure distances between anatomic structures in the plane of the EAC.  The degree of oblique tilt for transcanal CT reformats was 6.67 ± 1.78 degrees to align the EAC in axial and coronal planes. Anticipated critical landmarks were identified easily using the transcanal view. Mean values were 8.68 ± 0.38 mm for annulus diameter, 9.5 ± 0.93 mm for isthmus diameter, 10.27 ± 0.73 mm for distance between annulus and isthmus, 2.95 ± 0.13 mm for distance between annulus and stapes capitulum, 5.12 ± 0.35 mm for distance between annulus and mastoid facial nerve, and 19.54 ± 1.22 mm for EAC length.  This study is the first to illustrate a novel "transcanal" CT sequence intended for endoscopic lateral skull base surgery. Future studies may address how incorporation of a transcanal CT reformat may influence surgical decision making.
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http://dx.doi.org/10.1055/s-0039-3400219DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8133816PMC
June 2021

Further Research Needed to Understand Relationship Between Tubarial Glands and Eustachian Tube Dysfunction.

Otolaryngol Head Neck Surg 2021 Apr 13:1945998211004256. Epub 2021 Apr 13.

Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA.

The pathophysiology of eustachian tube dysfunction (ETD) remains poorly characterized, and it may result in significant patient morbidity. A recent study has identified a collection of previously unidentified salivary glands in the nasopharynx that overlay the torus tubarius. While salivary gland tissue has been described in the nasopharynx, the newly discovered salivary gland tissue has been denoted tubarial glands (TGs) and theorized to be a distinct organ. The TGs have been suggested to aid in lubrication of the oropharynx and nasopharynx. However, the exact clinical significance of TGs is unknown. Given the proximity of the TG to the eustachian tube, it is possible that the TGs may be related to the development of ETD. Future studies of the TGs and related pathophysiology may improve approaches to developing future ETD treatments.
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http://dx.doi.org/10.1177/01945998211004256DOI Listing
April 2021

Histopathology of the Incudomalleolar Joint in Cases of "Indeterminate" Presbycusis.

Otolaryngol Head Neck Surg 2021 Feb 23:194599821993813. Epub 2021 Feb 23.

Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard University, Boston, Massachusetts, USA.

Level Of Evidence: Retrospective study.
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http://dx.doi.org/10.1177/0194599821993813DOI Listing
February 2021

Three-dimensional (3D) Printed Vestibular Schwannoma for Facial Nerve Tractography Validation.

Otol Neurotol 2021 06;42(5):e598-e604

Eaton-Peabody Laboratories, Massachusetts Eye and Ear.

Objectives: Predicting the course of cranial nerve (CN) VII in the cerebellopontine angle (CPA) on preoperative imaging for vestibular schwannoma (VS) may help guide surgical resection and reduce complications. Diffusion MRI based tractography has been used to identify cranial nerve trajectory, but intraoperative validation of this novel approach is challenging. Currently, validation is based on operative report descriptions of the course of cranial nerves, but yields a simplified picture of the three-dimensional (3D) course of CN VII. In this study, we investigate the accuracy of tractography with detailed patient-specific 3D-printed VS tumors.

Design: Retrospective case review.

Setting: Tertiary referral center.

Participants: Twenty adult VS surgical candidates.

Main Outcome Measures: We compared tractography with intraoperative 3D course of CN VII. The surgeons were blinded to tractography and drew the intraoperative course of the CN VII on a patient specific 3D-printed tumor model for detailed comparison with tractography.

Results: Of 20 patients, one was excluded due to subtotal removal and inability to assess CN VII course. In the remaining 19 patients, 84% (16/19) tractography was successful. In 94% of tumors with tractography (15/16), the intraoperative description of CN VII course matched the tractography finding. The maximum distance, however, between tractography and intraoperative course of CN VII was 3.7 mm ± 4.2 mm.

Conclusion: This study presents a novel approach to CN VII tractography validation in VS. Although descriptions of CN VII intraoperatively match tractography, caution is warranted as quantitative measures suggest a clinically significant distance between tractography and CN VII course.
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http://dx.doi.org/10.1097/MAO.0000000000003058DOI Listing
June 2021

Association of Pediatric Hearing Loss and Head Injury in a Population-Based Study.

Otolaryngol Head Neck Surg 2021 Jan 26:194599820982904. Epub 2021 Jan 26.

Department of Otolaryngology, Massachusetts Eye and Ear, Boston, Massachusetts, USA.

Traumatic brain injury (TBI) is the leading cause of acquired long-term disability during childhood, and it may result in wide range of negative developmental consequences. Auditory dysfunction is generally recognized to be a possible sequela of pediatric TBI. Unfortunately, few contemporary studies have quantified the association between head injury and hearing loss in the pediatric population. The National Survey of Children's Health (NSCH) for the combined years 2017-2018 was used to determine the association of hearing loss with TBI. Deafness or problems with hearing were more commonly reported in children with a history or current brain injury/concussion compared to those without any such history (3.2% [70,000] and 1.2% [830,000] children, respectively; odds ratio, 2.67; .001). Findings suggest a notable association between TBI and hearing loss. Children with a history of TBI are 2.67 times more likely to have concurrent hearing complaints. IV.
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http://dx.doi.org/10.1177/0194599820982904DOI Listing
January 2021

Single-surgeon parotidectomy outcomes in an academic center experience during a 15-year period.

Laryngoscope Investig Otolaryngol 2020 Dec 21;5(6):1096-1103. Epub 2020 Oct 21.

Department of Otolaryngology Harvard Medical School Boston Massachusetts USA.

Objective: As large single-surgeon series in the literature are lacking, we sought to review a single-surgeon's experience with parotidectomy in an academic center, with a focused analysis of pathology, technique, and facial nerve (FN) weakness. Benchmark values for complications and operative times with routine trainee involvement and without continuous FN monitoring are offered.

Materials And Methods: All patients who underwent parotidectomy, performed by D. G. D., for benign and malignant disease between January 2004 and December 2018 at an academic center were reviewed.

Results: A total of 924 parotidectomies, with adequate evaluatable data were identified. The majority of patients had benign tumors (70.9%). Partial/superficial parotidectomy was the most common approach (65.7%). Selective FN branch sacrifice was rare (12.3%), but significantly more common among patients with malignant pathology (33.8% vs 3.5% for benign,  < .0001). Among patients with intact FN, post-operative short- and long-term FN weaknesses were rare (6.5% and 1.7%, respectively). These rates were lower among patients with benign tumors (5.4% and 1.3%). Partial/superficial parotidectomy for benign tumors was associated with a low rate of short- and long-term FN weaknesses (2.7% and 0.9%). Mean OR time was 185 minutes.

Conclusion: This is the largest single-surgeon series on parotidectomy, spanning 15 years. We demonstrate excellent long- and short-term FN paresis rates with acceptable operative times without regular use of continuous FN monitoring and with routine trainee involvement. These findings may provide valuable insight into parotid tumor pathology, FN outcomes, and feasibility and expectations of performing parotidectomy in an academic setting.

Level Of Evidence: 4.
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http://dx.doi.org/10.1002/lio2.480DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7752052PMC
December 2020

A Quantitative Analysis of Social Media to Determine Trends in Brain Tumor Care and Treatment.

Cureus 2020 Nov 17;12(11):e11530. Epub 2020 Nov 17.

Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, USA.

Background Approximately 80,000 primary brain tumors are diagnosed annually. Social media provides a source of information and support for patients diagnosed with brain tumors; however, use of this forum for dissemination of information about brain tumors has not been evaluated. The objective of this study was to evaluate social media utilization and content related to brain tumors with an emphasis on patients' trends in usage. Methods Social media platforms were systematically evaluated using two search methods: systematic manual inquiry and a keyword-based social media tracker. The search terms included brain tumor, glioblastoma, glioma, and glioblastoma multiforme. Social media content (which includes Facebook pages and groups, YouTube videos, and Twitter or Instagram accounts) and posts were assessed for activity (as quantified by views of posts) and analyzed using a categorization framework. Results The manual and keyword searches identified 946 sources of social media content, with a total count of 7,184,846 points of engagement. Social media platforms had significant variations in content type. YouTube was the largest social media platform for sharing content related to brain tumors overall, with an emphasis on surgical videos and documented patient experiences. Facebook accounted for the majority of patient-to-patient support, and Twitter was the most common platform for scientific dissemination. Overall social media content was mostly focused on treatment overviews and patient experience. When evaluated by search term, most social media posts by the "brain tumor" community shared illness narratives, and searches specific to "glioma" and "glioblastoma" demonstrated a higher proportion of educational and treatment posts. Conclusions This study presents novel observations of the characteristics of social media utilization for the online brain tumor community. A robust patient community exists online, with an emphasis on sharing personal narratives, treatment information, patient-to-patient support, treatment options, and fundraising events. This study provides a window to the role of social media utilization by patients, their families, and health professionals. These findings demonstrate the different roles of Facebook, YouTube, and Twitter in the rapidly changing era of social media and its relationship with neurosurgery and neuro-oncology.
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http://dx.doi.org/10.7759/cureus.11530DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7746327PMC
November 2020

Getting Started with Endoscopic Ear Surgery.

Otolaryngol Clin North Am 2021 Feb;54(1):45-57

Department of Otolaryngology-Head and Neck Surgery, Lewis Katz School of Medicine, 7604 Central Avenue, Friends Hall, Suite 100, Philadelphia, PA 19111, USA.

Because endoscopic technology has matured over the past several decades, ear surgeons have increasingly used endoscopy to address some of the limitations of operative microscopy. The wide field of view and high-resolution images provided by endoscopes allow for improved visualization of the tympanic cavity using minimally invasive surgical portals compared with the standard operative binocular microscope. The endoscope is becoming an essential tool in the otologist's armamentarium. In this article, the authors discuss rationale for endoscopic ear surgery, terminology and classification, surgical indications, essential equipment, surgical ergonomics, and practical steps to incorporate endoscopic ear surgery into practice.
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http://dx.doi.org/10.1016/j.otc.2020.09.009DOI Listing
February 2021

Impact of COVID-19 on Presentation of Sudden Sensorineural Hearing Loss at a Single Institution.

Otolaryngol Head Neck Surg 2020 Nov 24:194599820974685. Epub 2020 Nov 24.

Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, Massachusetts, USA.

The coronavirus disease 2019 (COVID-19) pandemic resulted in widespread unprecedented changes to the health care system. Herein, we sought to assess the impact of the viral outbreak on clinical presentations of sudden sensorineural hearing loss (SSNHL) at a single academic center. Our results demonstrate a decrease in the absolute number of patients presenting with SSNHL to our institution during the initial onset of the COVID-19 pandemic compared to an analogous time frame 1 year prior. However, the ratio of patients with SSNHL compared to total patients evaluated was largely similar during the 2 time periods. Based on data from our institution, the COVID-19 virus does not appear to confer a significantly increased risk for the development of SSNHL.
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http://dx.doi.org/10.1177/0194599820974685DOI Listing
November 2020

A Systematic Review of Nonautologous Graft Materials Used in Human Tympanoplasty.

Laryngoscope 2021 02 27;131(2):392-400. Epub 2020 Jul 27.

Eaton-Peabody Laboratories, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, U.S.A.

Objectives: Nonautologous graft materials may solve several dilemmas in tympanoplasty by obviating the need for graft harvest, facilitating consistent wound healing, and permitting graft placement in the clinical setting. Prior studies of nonautologous grafts in humans have shown variable outcomes. In this systematic review, we aim to 1) summarize clinical outcomes and 2) discuss limitations in the literature regarding nonautologous grafts for tympanoplasty in humans.

Methods: A literature review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations. The study size, etiology and duration of perforation, type of nonautologous graft, and postoperative closure rate were assessed.

Results: The PRISMA approach yielded 61 articles, including 3,247 ears that met inclusion criteria. Studies evaluated nonautologous grafts including paper patch, gelatin sponge, growth factors, porcine small-intestinal submucosa, among others. Traumatic perforations (62.3%) were most commonly studied, whereas postinfectious perforations (31.9%) and other etiologies (5.8%) comprised a minority of cases. Acute perforations of <8 weeks duration constituted just over half of all treated ears. Overall closure rate was 82.1%, with significantly higher closure rates in acute (89.9%) versus chronic perforations (64.9%, P < .01), regardless of material. A median postoperative air-bone gap of 5.6 dB was found in the 23% of studies reporting this metric.

Conclusions: The majority of publications reviewing nonautologous materials in tympanoplasty evaluate acute or traumatic perforations, and few rigorously report hearing outcomes. Given available data, porcine submucosa and basic fibroblast growth factor may hold promise for chronic perforation closure. Future studies should report closure rates and hearing outcomes in perforations >8 weeks duration. Laryngoscope, 131:392-400, 2021.
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http://dx.doi.org/10.1002/lary.28914DOI Listing
February 2021

Systematic Review of Endoscopic Ear Surgery Outcomes for Pediatric Cholesteatoma.

Otol Neurotol 2021 01;42(1):108-115

Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA.

Objective: Endoscopic ear surgery (EES) has been increasingly adopted to enhance visualization during otologic surgery including pediatric cholesteatoma resection. The purpose of this study is to systematically review the current literature reporting rates of residual cholesteatoma to evaluate outcomes of EES in the pediatric population.

Data Sources: PubMed, Embase, Cochrane.

Study Selection: Using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis recommendations (PRISMA), we systematically reviewed studies that reported outcomes for cholesteatoma surgery in children using the endoscope. Studies were included if they described the use of the endoscope for middle ear surgery and measured outcomes following cholesteatoma resection in pediatric patients.

Data Extraction: Identified articles were assessed for study design, sample size, inclusion of pediatric population, the presence of a comparison group, outcomes measured such as: residual disease rate, recurrent cholesteatoma, audiologic outcome, quality of life measures, and complications.

Data Synthesis: Fourteen articles in the literature discussed cholesteatoma outcomes in children when the endoscope was employed. Residual disease rate ranged from 0 to 22% when endoscope was used for dissection compared with 11 to 55% when endoscope was used for inspection or not at all. A meta-analysis was conducted on 11 studies. There was a significant risk reduction in residual disease rates for endoscopic dissection when compared with microscope (RR = 0.48, 95% CI = 0.37-0.63, p < 0.001).

Conclusion: Among the studies included in this review, EES was associated with lower rates of residual cholesteatoma compared with traditional microscopic techniques. Additional prospective studies are needed to further assess these findings.
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http://dx.doi.org/10.1097/MAO.0000000000002876DOI Listing
January 2021

Georg von Békésy and Bruce Mer: Early Pioneers of Endoscopic Ear Surgery.

Otolaryngol Head Neck Surg 2021 May 29;164(5):1065-1067. Epub 2020 Sep 29.

Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA.

The binocular operative microscope has been the workhorse of otologic and neurotologic surgeons since the 1950s. Since its advent, however, surgeons recognized that the operative microscope could not "look around corners" and its line-of-sight technology required soft tissue and bony dissection to enable light to reach the surgical plane. Endoscopic technology has evolved to address many of the limitations of operative microscopy. While the endoscope is often viewed as a recent development in otologic surgery, in the following historical article, we highlight the contributions of two mid-20th century pioneers of endoscopic ear surgery: Georg von Békésy and Bruce Mer. In the 1940s, Dr von Békésy envisioned an endoscope for determining stapes mobility. Dr Mer, with a team of engineers, created an otoendoscope to perform some of the first endoscopic ear procedures in the 1960s. Lessons gleaned from von Békésy and Mer's research include the need for counterculture thinking and the challenges of pioneering ideas beyond technical capacity.
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http://dx.doi.org/10.1177/0194599820957307DOI Listing
May 2021

Demonstration and Mitigation of Aerosol and Particle Dispersion During Mastoidectomy Relevant to the COVID-19 Era.

Otol Neurotol 2020 10;41(9):1230-1239

Department of Otolaryngology - Head and Neck Surgery, Massachusetts Eye and Ear.

Background: COVID-19 has become a global pandemic with a dramatic impact on healthcare systems. Concern for viral transmission necessitates the investigation of otologic procedures that use high-speed drilling instruments, including mastoidectomy, which we hypothesized to be an aerosol-generating procedure.

Methods: Mastoidectomy with a high-speed drill was simulated using fresh-frozen cadaveric heads with fluorescein solution injected into the mastoid air cells. Specimens were drilled for 1-minute durations in test conditions with and without a microscope. A barrier drape was fashioned from a commercially available drape (the OtoTent). Dispersed particulate matter was quantified in segments of an octagonal test grid measuring 60 cm in radius.

Results: Drilling without a microscope dispersed fluorescent particles 360 degrees, with the areas of highest density in quadrants near the surgeon and close to the surgical site. Using a microscope or varying irrigation rates did not significantly reduce particle density or percent surface area with particulate. Using the OtoTent significantly reduced particle density and percent surface area with particulate across the segments of the test grid beyond 30 cm (which marked the boundary of the OtoTent) compared with the microscope only and no microscope test conditions (Kruskall-Wallis test, p = 0.0066).

Conclusions: Mastoidectomy with a high-speed drill is an aerosol-generating procedure, a designation that connotes the potential high risk of viral transmission and need for higher levels of personal protective equipment. A simple barrier drape significantly reduced particulate dispersion in this study and could be an effective mitigation strategy in addition to appropriate personal protective equipment.
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http://dx.doi.org/10.1097/MAO.0000000000002765DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7497894PMC
October 2020

American Neurotology Society, American Otological Society, and American Academy of Otolaryngology - Head and Neck Foundation Guide to Enhance Otologic and Neurotologic Care During the COVID-19 Pandemic.

Otol Neurotol 2020 10;41(9):1163-1174

Department of Otolaryngology, Harvard Medical School.

: This combined American Neurotology Society, American Otological Society, and American Academy of Otolaryngology - Head and Neck Surgery Foundation document aims to provide guidance during the coronavirus disease of 2019 (COVID-19) on 1) "priority" of care for otologic and neurotologic patients in the office and operating room, and 2) optimal utilization of personal protective equipment. Given the paucity of evidence to inform otologic and neurotologic best practices during COVID-19, the recommendations herein are based on relevant peer-reviewed articles, the Centers for Disease Control and Prevention COVID-19 guidelines, United States and international hospital policies, and expert opinion. The suggestions presented here are not meant to be definitive, and best practices will undoubtedly change with increasing knowledge and high-quality data related to COVID-19. Interpretation of this guidance document is dependent on local factors including prevalence of COVID-19 in the surgeons' local community. This is not intended to set a standard of care, and should not supersede the clinician's best judgement when managing specific clinical concerns and/or regional conditions.Access to otologic and neurotologic care during and after the COVID-19 pandemic is dependent upon adequate protection of physicians, audiologists, and ancillary support staff. Otolaryngologists and associated staff are at high risk for COVID-19 disease transmission based on close contact with mucosal surfaces of the upper aerodigestive tract during diagnostic evaluation and therapeutic procedures. While many otologic and neurotologic conditions are not imminently life threatening, they have a major impact on communication, daily functioning, and quality of life. In addition, progression of disease and delay in treatment can result in cranial nerve deficits, intracranial and life-threatening complications, and/or irreversible consequences. In this regard, many otologic and neurotologic conditions should rightfully be considered "urgent," and almost all require timely attention to permit optimal outcomes. It is reasonable to proceed with otologic and neurotologic clinic visits and operative cases based on input from expert opinion of otologic care providers, clinic/hospital administration, infection prevention and control specialists, and local and state public health leaders. Significant regional variations in COVID-19 prevalence exist; therefore, physicians working with local municipalities are best suited to make determinations on the appropriateness and timing of otologic and neurotologic care.
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http://dx.doi.org/10.1097/MAO.0000000000002868DOI Listing
October 2020

Do high-frequency air-bone gaps persist after ossiculoplasty?

Laryngoscope Investig Otolaryngol 2020 Aug 26;5(4):734-742. Epub 2020 Jun 26.

Eaton-Peabody Laboratories Massachusetts Eye and Ear Infirmary Boston Massachusetts USA.

Objectives: Conventional reporting of postoperative hearing outcomes utilizes a pure-tone averaged air-bone gap (ABG) that is biased toward low frequencies. Consequently, a high-frequency ABG after otologic surgery may go unnoticed. In this study, we evaluate changes in low- and high-frequency ABG following ossiculoplasty.

Study Design: Retrospective review.

Subjects And Setting: Consecutive series of patients who underwent ossiculoplasty at a single tertiary care center. Patients with pre- and postoperative audiograms were included.

Methods: Low-frequency ABG was calculated as the mean ABG at 250, 500, and 1000 Hz. High-frequency ABG was calculated at 4 kHz. Pre- and postoperative ABGs were compared.

Results: Thirty-seven consecutive patients were included. Mean age at surgery was 38 years (range, 7-77 years). Reconstruction materials included: cartilage (N = 4), hydroxyapatite cement (N = 5), and partial or total ossicular replacement prostheses (N = 20 and N = 8, respectively). Postoperatively, the mean low-frequency ABG improved by 11.9 ± 15.1 dB ( < .0001) and the mean high-frequency ABG improved by 5.9 ± 16.0 dB ( = .030). Low-frequency ABG closure was significantly larger than high-frequency ABG closure ( = .007). Mean postoperative persistent high-frequency ABG was 22.0 ± 13.8 dB.

Conclusion: In this series, ossiculoplasty improved ABG across all frequencies, but greater improvements were observed at low frequencies when compared to high frequency. Current reporting standards may not identify persistent high-frequency ABG. Additional study of the mechanisms of high-frequency sound conduction in reconstructed middle ears is needed to improve high-frequency hearing outcomes in ossiculoplasty.

Level Of Evidence: Level 4.
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http://dx.doi.org/10.1002/lio2.418DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7444777PMC
August 2020

Hearing Vital Signs: Mobile Audiometry in the Emergency Department for Evaluation of Sudden Hearing Loss.

Otolaryngol Head Neck Surg 2020 11 28;163(5):1025-1028. Epub 2020 Jul 28.

Department of Otolaryngology, Massachusetts Eye and Ear, Boston, Massachusetts, USA.

Emergency departments (EDs) are a common location for patients to present with sudden hearing loss (SHL). Unfortunately, high-quality, rapid quantitative measurement of hearing loss is challenging. Herein, we aim to evaluate the accuracy of tablet-based audiometry in patients complaining of SHL. Prospective tablet-based testing was completed in the ED in patients complaining of SHL. Air conduction thresholds (ACTs) obtained via tablet-based audiometry were compared to same-day measurements with a clinical-grade audiometer. Hearing loss (HL) was defined as >20 dB ACT for any frequency. In participant-level analysis, 30+ dB HL in 3 consecutive frequencies was used to define SHL. In the ED, mobile audiogram ACTs were within 5 dB (77%) and 10 dB (89.6%) of those determined by conventional audiometry. The sensitivity and specificity for mobile audiometry to detect 3 or more consecutive thresholds with 30+ dB HL were 100% and 62.5%, respectively. Findings have implications for increasing access to high-quality audiometry.
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http://dx.doi.org/10.1177/0194599820935420DOI Listing
November 2020

Telemedicine Services Provided to Medicare Beneficiaries by Otolaryngologists Between 2010 and 2018.

JAMA Otolaryngol Head Neck Surg 2020 Sep;146(9):816-821

Department of Otolaryngology, Massachusetts Eye and Ear, Boston.

Importance: Clinicians are increasingly adopting telemedicine in an effort to expand patient access and efficiently deliver care. However, the extent to which otolaryngologists provide telemedicine services is unclear.

Objective: To characterize recent trends in the use of telemedicine by otolaryngologists to deliver care to Medicare beneficiaries.

Design, Setting, And Participants: A retrospective cross-sectional analysis was conducted between January 1, 2010, and December 31, 2018, using publicly available Medicare Physician/Supplier Procedure Summary data on physicians practicing in the field of otolaryngology and benchmark specialties (dermatology and psychiatry) that provided telemedicine services to Medicare beneficiaries.

Main Outcomes And Measures: Primary outcomes were the mean annual number of telemedicine services delivered per active physician and mean annual payment per active physician for these services. Secondary outcomes included the number, setting, and complexity of telemedicine services.

Results: Between 2010 and 2018, otolaryngologists provided 2127 total telemedicine services (7 unique service types) to Medicare beneficiaries and received $88 574 in total payment for these services. During this period, the mean number of telemedicine services increased at a compound annual growth rate (CAGR) of 11.0%, and the mean Medicare payment per otolaryngologist increased at a CAGR of 21.8%. In comparison, telemedicine use during this period generally increased at a higher rate in the fields of dermatology (mean number of services per active physician at CAGR of 13.0%; mean Medicare payment per active physician at CAGR of 12.5%) and psychiatry (mean number of services per active physician at CAGR of 25.8%; mean Medicare payment per active physician at CAGR of 26.6%). In 2018, outpatient evaluation and management visits accounted for most telemedicine services provided (337 of 353 [95.5%]) and the payments received ($17 542.13 of $18 470.47 [95.0%]) by otolaryngologists. In contrast, physicians in other specialties also provided substantial portions of telemedicine services in the inpatient (psychiatry, 18 403 of 198 478 [9.3%]; dermatology, 231 of 1034 [22.3%]) and skilled nursing facility settings (psychiatry, 14 690 of 198 478 [7.4%]; dermatology, 46 of 1034 [4.4%]).

Conclusions And Relevance: This study suggests that the extent to which otolaryngologists used telemedicine to deliver care to Medicare beneficiaries between 2010 and 2018 was rare. Although there was relative growth in the use of telemedicine by otolaryngologists during this period, absolute growth remained low. Policy makers and provider organizations should support otolaryngologists in the adoption of telemedicine technologies, especially while coronavirus disease 2019 (COVID-19) viral suppression efforts necessitate prolonged restriction of physical clinic throughput.
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http://dx.doi.org/10.1001/jamaoto.2020.1911DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7378874PMC
September 2020

Effect of Powered Air-Purifying Respirators on Speech Recognition Among Health Care Workers.

Otolaryngol Head Neck Surg 2021 01 21;164(1):87-90. Epub 2020 Jul 21.

Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA.

Powered air-purifying respirators (PAPRs) are used as personalized protective equipment for health care personnel. PAPRs offer health care workers added protection when dealing with patients who have high-risk infectious disease such as COVID-19. Unfortunately, PAPRs can produce notable levels of background noise. We hypothesize that PAPR use may be associated with increased hearing thresholds and impaired word discrimination and may ultimately have a negative impact on effective communication. Herein, we (1) determined sound levels generated by PAPRs and (2) measured hearing thresholds and word discrimination with and without operational PAPRs. All participants had normal hearing. When the PAPR was operational, mean ± SD thresholds increased from 4.5 ± 3.6 to 38.6 ± 5.6 dB HL ( < .001). Word discrimination dropped from 100% in all participants in quiet to a mean 48% ± 14% with operational PAPR ( < .001). Thus, we find that use of PAPR hoods results in hearing impairment comparable to moderate to severe hearing loss, and we suspect that users will experience communication difficulties as a result. Prospective study.
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http://dx.doi.org/10.1177/0194599820945685DOI Listing
January 2021

Aerosol Dispersion During Mastoidectomy and Custom Mitigation Strategies for Otologic Surgery in the COVID-19 Era.

Otolaryngol Head Neck Surg 2021 01 14;164(1):67-73. Epub 2020 Jul 14.

Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA.

Objective: To investigate small-particle aerosolization from mastoidectomy relevant to potential viral transmission and to test source-control mitigation strategies.

Study Design: Cadaveric simulation.

Setting: Surgical simulation laboratory.

Methods: An optical particle size spectrometer was used to quantify 1- to 10-µm aerosols 30 cm from mastoid cortex drilling. Two barrier drapes were evaluated: OtoTent1, a drape sheet affixed to the microscope; OtoTent2, a custom-structured drape that enclosed the surgical field with specialized ports.

Results: Mastoid drilling without a barrier drape, with or without an aerosol-scavenging second suction, generated large amounts of 1- to 10-µm particulate. Drilling under OtoTent1 generated a high density of particles when compared with baseline environmental levels ( < .001, = 107). By contrast, when drilling was conducted under OtoTent2, mean particle density remained at baseline. Adding a second suction inside OtoTent1 or OtoTent2 kept particle density at baseline levels. Significant aerosols were released upon removal of OtoTent1 or OtoTent2 despite a 60-second pause before drape removal after drilling ( < .001, = 0, n = 10, 12; < .001, = 2, n = 12, 12, respectively). However, particle density did not increase above baseline when a second suction and a pause before removal were both employed.

Conclusions: Mastoidectomy without a barrier, even when a second suction was added, generated substantial 1- to 10-µm aerosols. During drilling, large amounts of aerosols above baseline levels were detected with OtoTent1 but not OtoTent2. For both drapes, a second suction was an effective mitigation strategy during drilling. Last, the combination of a second suction and a pause before removal prevented aerosol escape during the removal of either drape.
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http://dx.doi.org/10.1177/0194599820941835DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7361126PMC
January 2021

Telemedicine Algorithm for the Management of Dizzy Patients.

Otolaryngol Head Neck Surg 2020 11 30;163(5):857-859. Epub 2020 Jun 30.

Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, Massachusetts, USA.

As a result of the COVID-19 pandemic, telemedicine has been thrust to the forefront of health care. Despite its inherent limitations, telemedicine offers many advantages to both patient and physician as an alternative to in-person evaluation of select patients. In the near term, telemedicine allows nonpandemic care to proceed while observing appropriate public health concerns to minimize the spread of pandemic pathogens. Thus, it behooves practitioners to use telemedicine consultations for common otolaryngology complaints. Assessment of the dizzy patient is well-suited to an algorithmic approach that can be adapted to a telemedicine setting. As best practices for telemedicine have yet to be defined, we present herein a practical approach to the history and limited physical examination of the dizzy patient in the telemedicine setting for the general otolaryngologist. Indeed, once the acute crisis has abated, we suspect that this approach will continue to be an effective way to manage dizzy patients.
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http://dx.doi.org/10.1177/0194599820935859DOI Listing
November 2020

Auditory Quality-of-Life Measures in Patients With Traumatic Brain Injury and Normal Pure Tone Audiometry.

Otolaryngol Head Neck Surg 2020 12 30;163(6):1250-1254. Epub 2020 Jun 30.

Department of Otolaryngology, Massachusetts Eye and Ear, Boston, Massachusetts, USA.

Auditory complaints are commonly reported following traumatic brain injury (TBI). However, few studies have examined patient-reported auditory symptomatology and quality-of-life metrics in individuals with TBI. We hypothesize that following TBI, individuals can experience auditory symptoms even with hearing thresholds in the normal range. Adult patients with normal auditory thresholds and a history of TBI were evaluated for subjective hearing loss, tinnitus, aural fullness, hyperacusis, and autophony. Hearing Handicap Inventory for Adults, Tinnitus Handicap Inventory, and Hyperacusis Questionnaire were administered. Thirty-one patients were prospectively recruited. Twenty-eight TBI participants (90%) reported ≥1 auditory symptoms at the time of survey intake. Mild to severe handicap in the Hearing Handicap Inventory for Adults and Tinnitus Handicap Inventory was reported in 71.4% and 40% of the participants with hearing loss and tinnitus, respectively. Hyperacusis handicap was considered significant in 41.1% of the participants who complained of hyperacusis and completed the survey. Despite normal hearing thresholds, individuals with TBI experience decrements in auditory quality-of-life metrics. Level of evidence: 3.
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http://dx.doi.org/10.1177/0194599820933886DOI Listing
December 2020

Otopathologic Analysis of Patterns of Postmeningitis Labyrinthitis Ossificans.

Otolaryngol Head Neck Surg 2021 01 30;164(1):175-181. Epub 2020 Jun 30.

Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA.

Objective: Labyrinthitis ossificans (LO) may occur following meningitis and, in cases where cochlear implantation is indicated, complicate electrode insertion. LO is critical to identify for successful cochlear implantation, and histopathology is more sensitive than imaging for identification of LO. Herein we utilize otopathologic techniques to study the timing and location of intracochlear tissue formation following meningitic labyrinthitis (ML).

Study Design: Retrospective review.

Setting: Academic institution.

Methods: Temporal bone specimens with a history of bacterial ML were histologically evaluated. The location and extent of intracochlear tissue formation within the scala tympani (ST) and scala vestibuli (SV) were graded, and spiral ganglion neurons were counted.

Results: Fifty-one temporal bones were identified: 32 with no intracochlear tissue formation, 9 with fibrosis alone, and 10 with LO. Fibrosis was identified as early as 1.5 weeks after ML, while ossification was found only in specimens that survived multiple years after ML. All LO cases showed ossification of the ST at the round window membrane (RWM) with continuous extension throughout the basal turn. Extent of SV ossification correlated with that in the ST but showed frequent isolated distal involvement of the cochlea. Spiral ganglion neuron counts were lower than those in age-matched controls.

Conclusion: In this human temporal bone study, we found that postmeningitic LO results in ossification at the RWM with continuous extension into the ST of the basal turn and variable involvement of the SV. Identification of a patent basal turn beyond RWM ossification of the ST should permit full electrode insertion.

Level Of Evidence: Retrospective review.
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http://dx.doi.org/10.1177/0194599820934748DOI Listing
January 2021

Long-term cochlear implantation outcomes in patients following head injury.

Laryngoscope Investig Otolaryngol 2020 Jun 21;5(3):485-496. Epub 2020 Apr 21.

Department of Otolaryngology Massachusetts Eye and Ear Boston Massachusetts USA.

Objective: In cases of a severe to profound sensorineural hearing loss following head injury, the cochlear implant (CI) is the primary option for auditory rehabilitation. Few studies, however, have investigated long-term CI outcomes in patients following head trauma, including those without temporal bone fracture (TBF). Herein, the aim of this study is to examine CI outcomes following cases of head injury with and without TBF.

Methods: Audiometric outcomes of patients who received a CI due to a head injury resulting in severe to profound hearing loss at two tertiary care hospitals were analyzed. Patients were divided into those who received a CI in a fractured temporal bone (group A, n = 11 patients corresponding to 15 ears) and those who received a CI in a non-fractured temporal bone (group B, n = 8 patients corresponding to nine ears). Primary outcomes included duration of deafness prior to CI and postoperative consonant-nucleus-constant whole word (CNC) scores.

Results: Nineteen patients (84% male), corresponding to 24 CIs, were identified. Fifteen CI were performed on ears with TBF (group A), and nine CI were performed on ears without TBF (group B). No patients had an enlarged vestibular aqueduct (EVA). The mean duration of deafness was 5.7 and 11.3 years in group A and group B, respectively. The mean duration of CI follow-up (CI experience) was 6.5 years in group A and 2.1 years in group B. The overall mean postoperative CNC score for all subjects was 68.6% (±21.2%, n = 19 with CNC testing). There was no difference in CNC score between group A and group B (69.8% and 66% respectively, = .639).

Conclusion: The study is among the largest series examining long-term outcomes of CI after head injury. CI is an effective method for auditory rehabilitation in patients after head injury.

Level Of Evidence: IV.
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http://dx.doi.org/10.1002/lio2.378DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7314488PMC
June 2020

Review of Audiovestibular Symptoms Following Exposure to Acoustic and Electromagnetic Energy Outside Conventional Human Hearing.

Front Neurol 2020 28;11:234. Epub 2020 Apr 28.

Department of Otolaryngology, Harvard Medical School, Boston, MA, United States.

We aim to examine the existing literature on, and identify knowledge gaps in, the study of adverse animal and human audiovestibular effects from exposure to acoustic or electromagnetic waves that are outside of conventional human hearing. A review was performed, which included searches of relevant MeSH terms using PubMed, Embase, and Scopus. Primary outcomes included documented auditory and/or vestibular signs or symptoms in animals or humans exposed to infrasound, ultrasound, radiofrequency, and magnetic resonance imaging. The references of these articles were then reviewed in order to identify primary sources and literature not captured by electronic search databases. Infrasound and ultrasound acoustic waves have been described in the literature to result in audiovestibular symptomology following exposure. Technology emitting infrasound such as wind turbines and rocket engines have produced isolated reports of vestibular symptoms, including dizziness and nausea and auditory complaints, such as tinnitus following exposure. Occupational exposure to both low frequency and high frequency ultrasound has resulted in reports of wide-ranging audiovestibular symptoms, with less robust evidence of symptomology following modern-day exposure via new technology such as remote controls, automated door openers, and wireless phone chargers. Radiofrequency exposure has been linked to both auditory and vestibular dysfunction in animal models, with additional historical evidence of human audiovestibular disturbance following unquantifiable exposure. While several theories, such as the cavitation theory, have been postulated as a cause for symptomology, there is extremely limited knowledge of the pathophysiology behind the adverse effects that particular exposure frequencies, intensities, and durations have on animals and humans. This has created a knowledge gap in which much of our understanding is derived from retrospective examination of patients who develop symptoms after postulated exposures. Evidence for adverse human audiovestibular symptomology following exposure to acoustic waves and electromagnetic energy outside the spectrum of human hearing is largely rooted in case series or small cohort studies. Further research on the pathogenesis of audiovestibular dysfunction following acoustic exposure to these frequencies is critical to understand reported symptoms.
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http://dx.doi.org/10.3389/fneur.2020.00234DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7199630PMC
April 2020

Labyrinthine concussion: Historic otopathologic antecedents of a challenging diagnosis.

Laryngoscope Investig Otolaryngol 2020 Apr 16;5(2):267-277. Epub 2020 Mar 16.

Department of Otolaryngology Harvard Medical School Boston Massachusetts.

Objective: The term "labyrinthine concussion" has evolved to mean audiovestibular dysfunction in the absence of a temporal bone fracture (TBF). Despite a multitude of case descriptions of labyrinthine concussion, the precise pathophysiology remains poorly understood. Herein, we explore the historical otopathologic underpinnings of the diagnosis of labyrinthine concussion with a focus on the auditory pathway during the late 19th to the mid-20th centuries and conclude with a discussion of its contemporary relevance.

Methods And Data Sources: A review of primary and secondary medical sources written in English, German, and French on otopathology labyrinthine concussion studies from the late-19th to the mid-20th centuries.

Results: Around the turn of the 20th century, otopathologists identified histologic changes in the temporal bones of individuals that sustained head injury without TBFs. Based on these otopathologic findings in humans, early experiments investigating the pathophysiology of labyrinthine concussion were performed in animals through either the delivery of blows to the head or direct introduction of a pressure wave into the labyrinthine fluid. Collectively, otopathologists hypothesized that predominant mechanisms for labyrinthine concussion included inner ear hemorrhage, cochleovestibular nerve traction injury, direct damage from a labyrinthine fluid pressure wave, or vasomotor dysfunction.

Conclusion: Historical study shows a variety of inner ear pathologies potentially responsible for auditory dysfunction following head injury. Understanding the history and otopathology of labyrinthine concussion may help clinicians focus on new pathways toward novel research and improved patient care.
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http://dx.doi.org/10.1002/lio2.360DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7178453PMC
April 2020

Histopathological changes to the peripheral vestibular system following meningitic labyrinthitis.

Laryngoscope Investig Otolaryngol 2020 Apr 14;5(2):256-266. Epub 2020 Feb 14.

Department of Otolaryngology Massachusetts Eye and Ear Boston Massachusetts.

Objective: While cochlear ossification is a common sequalae of meningitic labyrinthitis, less is known about the effects of meningitis on peripheral vestibular end organs. Herein, we investigate histopathologic changes in the peripheral vestibular system and cochlea in patients with a history of meningitic labyrinthitis.

Methods: Temporal bone (TB) specimens from patients with a history of meningitis were evaluated and compared to age-matched controls. Specimens were evaluated by light microscopy and assessed for qualitative changes, including the presence of vestibular and/or cochlear endolymphatic hydrops, presence and location of inflammatory cells, new bone formation, and labyrinthitis ossificans; and quantitative changes, including Scarpa's ganglion neuron (ScGN) and spiral ganglion neuron (SGN) counts.

Results: Fifteen TB from 10 individuals met inclusion and exclusion criteria. Presence of inflammatory cells and fibrous tissue was found in 5 TB. Of these, evidence of labyrinthitis ossificans was found in 2 TB. In the peripheral vestibular system, mild to severe degeneration of the vestibular membranous labyrinth was identified in 60% of cases (n = 9 TBs). There was a 21.2% decrease (range, 3%-64%) in the mean total count of ScGN in patients with meningitis, compared to age-matched controls. In the cochlea, there was a 45% decrease (range, 25.3%-80.9%) in the mean total count of SGN compared to age-matched controls (n = 14 TBs).

Conclusions: Otopathologic analysis of TB from patients with a history of meningitic labyrinthitis demonstrated distinct peripheral vestibular changes. Future research may help to delineate potential mechanisms for the observed otopathologic changes following meningitis.

Level Of Evidence: N/A.
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http://dx.doi.org/10.1002/lio2.349DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7178454PMC
April 2020

Three-Dimensional Surface Reconstruction of the Human Cochlear Nucleus: Implications for Auditory Brain Stem Implant Design.

J Neurol Surg B Skull Base 2020 Apr 22;81(2):114-120. Epub 2019 Feb 22.

Department of Otolaryngology - Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, United States.

 The auditory brain stem implant (ABI) is a neuroprosthesis placed on the surface of the cochlear nucleus (CN) to provide hearing sensations in children and adults who are not candidates for cochlear implantation. Contemporary ABI arrays are stiff and do not conform to the curved brain stem surface. Recent advancements in microfabrication techniques have enabled the development of flexible surface arrays, but these have only been applied in animal models. Herein, we measure the surface curvature of the human CN and adjoining regions to assist in the design and placement of next-generation conformable clinical ABI arrays. Three-dimensional (3D) reconstructions from ultrahigh T1-weighted brain magnetic resonance imaging (MRI) sequences and histologic reconstructions based on postmortem adult human brain stem specimens were used.  This is a retrospective review of radiologic data and postmortem histologic axial sections.  This is set at the tertiary referral center.  Data were acquired from healthy adults.  The main outcome measures are principal curvature values (Kmin and Kmax) and global radius of curvature.  The CN was successfully extracted and rendered as a 3D surface in all cases. Significant curvatures of the CN in both histologic and radiographic reconstructions were found with global radius of curvature ranging from 2.08 to 8.5 mm. In addition, local curvature analysis revealed that the surface is highly complex.  Detailed rendering of the human CN is feasible using histology and 3D MRI reconstruction and highlights complex surface topography that is not recapitulated by contemporary stiff ABI arrays.
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http://dx.doi.org/10.1055/s-0039-1677863DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7082162PMC
April 2020

Reframing Our Approach to Facial Analysis.

Otolaryngol Head Neck Surg 2020 May 24;162(5):595-596. Epub 2020 Mar 24.

Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA.

Facial analysis is a foundational aspect of facial plastic and reconstructive surgery. Unfortunately, ideal proportions of beauty are commonly discussed without much thought regarding their historical derivation and associated cultural implications. Facial analysis often is limited to narrow ethnic and gender-normative aesthetics. As we evolve as a specialty that treats disparate patient populations and embraces a diverse community of surgical trainees, it may be time to reframe our approach to facial analysis education.
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http://dx.doi.org/10.1177/0194599820912031DOI Listing
May 2020

Human Cochlear Nucleus on 7 Tesla Diffusion Tensor Imaging: Insights Into Micro-anatomy and Function for Auditory Brainstem Implant Surgery.

Otol Neurotol 2020 04;41(4):e484-e493

Eaton-Peabody Laboratories, Massachusetts Eye and Ear.

Objective: The cochlear nucleus (CN) is the target of the auditory brainstem implant (ABI). Most ABI candidates have Neurofibromatosis Type 2 (NF2) and distorted brainstem anatomy from bilateral vestibular schwannomas. The CN is difficult to characterize as routine structural MRI does not resolve detailed anatomy. We hypothesize that diffusion tensor imaging (DTI) enables both in vivo localization and quantitative measurements of CN morphology.

Study Design: We analyzed 7 Tesla (T) DTI images of 100 subjects (200 CN) and relevant anatomic structures using an MRI brainstem atlas with submillimetric (50 μm) resolution.

Setting: Tertiary referral center.

Patients: Young healthy normal hearing adults.

Intervention: Diagnostic.

Main Outcome Measures: Diffusion scalar measures such as fractional anisotropy (FA), mean diffusivity (MD), mode of anisotropy (Mode), principal eigenvectors of the CN, and the adjacent inferior cerebellar peduncle (ICP).

Results: The CN had a lamellar structure and ventral-dorsal fiber orientation and could be localized lateral to the inferior cerebellar peduncle (ICP). This fiber orientation was orthogonal to tracts of the adjacent ICP where the fibers run mainly caudal-rostrally. The CN had lower FA compared to the medial aspect of the ICP (0.44 ± 0.09 vs. 0.64 ± 0.08, p < 0.001).

Conclusions: 7T DTI enables characterization of human CN morphology and neuronal substructure. An ABI array insertion vector directed more caudally would better correspond to the main fiber axis of CN. State-of-the-art DTI has implications for ABI preoperative planning and future image guidance-assisted placement of the electrode array.
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http://dx.doi.org/10.1097/MAO.0000000000002565DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7392811PMC
April 2020

Inaugural Otology and Neurotology "Video Report".

Otol Neurotol 2020 04;41(4):429-430

Department of Otolaryngology-Head and Neck Surgery, Columbia University Medical Center, New York Presbyterian Hospital, New York, New York.

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http://dx.doi.org/10.1097/MAO.0000000000002560DOI Listing
April 2020